Bellack, Hersen - Kazdin (Eds.) (1990) - International Handbook of Behavior Modification End Therapy

International Handbook of
Behavior Modification
and Therapy
SECOND EDITION
International Handbook of
Behavior Modification
and Therapy
SECOND EDITION
Edited by
Alan s. Bellack
Medical College of Pennsylvania at EPPI
Philadelphia, Pennsylvania
Michel Hersen
Western Psychiatric Institute and Clinic
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
and
Alan E. Kazdin
Yale University
New Haven, Connecticut
PLENUM PRESS • NEW YORK AND LONDON

International ~ an dbook of behavior l od l f l cat lon and ther~py I edited
by Alan S. Billac k, Mich e l Herse n. Ind Alan E. Klldln. 2nd ed.
p. c•.
Inc lude s b lbllogra ph lc,l raferenc es .
I S8N .J): 97l!-14612-7S4!!-1 c-1SHN-13: 918-1-4613.()523-1
001: 10.IOO11978-1-4613-<l523-1
I . Beh,V lor therapy--Handbooks. IInu a l s. etc. 2. Beh,vlor
l od lflclt l0n --Hl ndb ooks •• anviis . ote. I. Bel lic k. All n S.
n. Hersen. Mlchl l. III. Kazal n. Alln E.
t DNJol: I . Behlvlor Th.rlpy--hlndbooks. 1+1 34 1611,
RC489. B4154 1990
6 16 . 89 · 142--dc20
DNJoI/DLC
fer Llb~lry of Con~~ls, 90-6900
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© 1990, 1982 Plenum Press, New York

Sofu.mtrrcpint ofthc hanJcover 2odcditioo 1990
A Division of Plenum Publishing Corporation

233 Spring Street, New York , N.Y. 10013
AU rights reserved
No part of this book may be reproduced, stored in a r etrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
To Barbara, Jonathan, and Adam
Victoria, Jonathan, and Nathaniel
Alan, Michael, Steven, and Daniel
Contributors
Vincent J. Adesso Laura Cleere

Department of Psychology School of Social Work
University of Wisconsin-Milwaukee Boston University
Milwaukee, Wisconsin 53201 Boston, Massachusetts 02215
Gregory M. Alberts Denise D. Davis

Department of Psychology Affective Disorders Unit
West Virginia University Department of Psychiatry
Morgantown, West Virginia 26506-6040 Vanderbilt University
Nashville, Tennessee 37240
Robert T. Ammerman
Western Pennsylvania School for Blind Children Barry A. Edelstein
Pittsburgh, Pennsylvania 15213 Department of Psychology
West Virginia University
BiUy A. Barrios
Morgantown, West Virginia 26506-6040
Department of Psychology
University of Mississippi
Andrew L. Egel
University, Mississippi 38677
Department of Special Education
Susan T. Bell University of Maryland at College Park
Graduate School of Education College Park, Maryland 20742
University of Pennsylvania
Paul M. G. Emmelkamp
Philadelphia, Pennsylvania 19104
Department of Clinical Psychology
Alan S. BeUack Academic Hospital
Department of Psychiatry Groningen, The Netherlands
Medical College of Pennsylvania at EPPI
Philadelphia, Pennsylvania 19129 Greta Francis
Department of Psychiatry and Human Behavior
Kent Burnett Bradley Hospital
Department of Counseling Psychology Brown University
University of Wisconsin East Providence, Rhode Island 02915
Madison, Wisconsin 53706
Arthur Freeman
Marjorie H. Charlop Department of Psychiatry
Department of Psychology University of Medicine and Dentistry of New Jersey
Claremont McKenna College School of Osteopathic Medicine
Claremont, California 91711 Cherry Hill, New Jersey 08002
vii
...
Vll1 CONTRIBUTORS
David M. Gamer University of Ottawa

Department of Psychiatry Ottawa, Ontario
Michigan State University Canada KIN 6N5
East Lansing, Michigan 48824
Roger J. Ingham
Dorothy Ginsberg Department of Speech and Hearing Sciences
Department of Psychiatry University of California at Santa Barbara
University of California at San Francisco Santa Barbara, California 93106
San Francisco, California 94143 Rick E. Ingram
Gerald Goldstein San Diego State University
Veterans Administration Medical Center San Diego, California 92182
Pittsburgh, Pennsylvania 15206
Gail Ironson
Robert G. Hall Department of Psychiatry
Palo Alto Veterans Administration Stanford University School of Medicine
Medical Center I Stanford, California 94305
Palo Alto, California 94304
Allen C. Israel
Sharon M. Hall Department of Psychology
Department of Psychiatry State University of New York at Albany
University of California at San Francisco Albany, New York 12222
San Francisco, California 94143 Nadine J. Kaslow
Departments of Psychiatry, Psychology,
Cynthia Harbeck and Child Study Center
Department of Psychology Yale University
University of Missouri-Columbia Yale Psychiatric Institute
Columbia, Missouri 65211 New Haven, Connecticut 06520
Donald P. Hartmann Alan E. Kazdin
Department of Psychology Department of Psychology
University of Utah Yale University
Salt Lake City, Utah 84112 New Haven, Connecticut 06520
Michel Hersen Robert L. Koegel

Department of Psychiatry Department of Speech and Hearing Sciences
Western Psychiatric Institute and Clinic University of California at Santa Barbara
University of Pittsburgh School of Medicine Santa Barbara, California 93106
Pittsburgh, Pennsylvania 15213 Leonard Krasner
Laboratory for Behavioral Medicine
Richard E. Heyman
Stanford University
Stanford, California 94305
University of Oregon
Eugene, Oregon 97403 Donald J. Levis
Gary W. Holden State University of New York at Binghamton
School of Social Work Binghamton, New York 13905
Columbia University
New York, New York 10025 Joseph LoPiccolo
John Hunsley University of Missouri
School of Psychology Columbia, Missouri 65211
CONTRIBUTORS IX
Ronald A. Madle Clifford R. O'Donnell

Laurelton Center Department of Psychology
Laurelton, Pennsylvania 17835; and University of Hawaii at Manoa
Department of Human Development Honolulu, Hawaii 96822
and Family Studies
Roger L. Patterson
Pennsylvania State University
Veterans Administration Outpatient Clinic
University Park, Pennsylvania 16802
Daytona Beach, Florida 32117
William L. Marshall
Lizette Peterson
Queen's University
University of Missouri-Columbia
Kingston, Ontario
Columbia, Missouri 65211
Canada K7L 3N6
Gary R. Racusin
EricJ. Mash
Department of Psychiatry and Child Study Center
Yale University
University of Calgary
New Haven, Connecticut 06519
Calgary, Alberta
Canada T2N 1N4 Todd R. Risley
Department of Psychiatry
Nathaniel McConaghy
University of Alaska
School of Psychiatry
Anchorage, Alaska 99508
University of New South Wales
Sydney, Australia Lionel W. Rosen
Department of Psychiatry
Michael A. Milan Michigan State Uniyersity
East Lansing, Michigan 48824
Georgia State University
Atlanta, Georgia 30303 Thomas E. Rudy
Department of Anesthesiology, and
Michael S. Moncher Pain Evaluation and Treatment Institute
School of Social Work University of Pittsburgh School of Medicine
Columbia University Pittsburgh, Pennsylvania 15213
New York, New York 10025
Steven P. Schinke
Randall L. Morrison School of Social Work
Department of Psychiatry Columbia University
Medical College of Pennsylvania at EPPI New York, New York 10025
Laura Schreibman
Kim T. Mueser Department of Psychology
Department of Psychiatry University of California at San Diego
Medical College of Pennsylvania at EPPI La Jolla, California 92093
Walter D. Scott
John T. Neisworth Department of Psychology
Department of Special Education San Diego State University
Pennsylvania State University San Diego, California 92182
University Park, Pennsylvania 16802
Zindel V. Segal
Michael T. Nietzel Cognitive Behavior Therapies Section
Department of Psychology Clarke Institute of Psychiatry
University of Kentucky Toronto, Ontario
Lexington, Kentucky 40506 Canada M5T 1R8
x CONTRIBUTORS
Jan B. Sheldon Dennis C. Turk

Department of Human Development Department of Psychiatry, and
University of Kansas Pain Evaluation and Treatment Institute
Lawrence, Kansas 66045 University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania 15213
Lori A. Sisson
Western Pennsylvania School for Blind Children Vincent B. Van Hasselt
Pittsburgh, Pennsylvania 15213 Department of Psychiatry and Human Behavior
Linda C. Sobell University of California at Irvine, and
Addiction Research Foundation, and Fairview Developmental Center
Departments of Psychology and Behavioral Science Costa Mesa, California 92626
University of Toronto
Vicki Veitch Wolfe
Toronto, Ontario
Canada M5S 2S 1
Children's Hospital of Western Ontario
Mark B. Sobell London, Ontario
Addiction Research Foundation, and Canada N6A 4G5
Departments of Psychology and Behavioral Science
University of Toronto Thomas A. Wadden
Toronto, Ontario Department of Psychiatry
Canada M5S 2S1 University of Pennsylvania School of Medicine
Gail Steketee
School of Social Work Robert L. Weiss
Boston University Department of Psychology
Boston, Massachusetts 02215 University of Oregon
Eugene, Oregon 97403
David T. Susman
Department of Psychology D. Adrian Wilkinson
University of Kentucky Addiction Research Foundation, and
Lexington, Kentucky 40506
C. Barr Taylor York University
Department of Psychiatry Toronto, Ontario
Stanford University School of Medicine Canada M3J IP3
Stanford, California 94305
David D. Wood
Ronald G. Tharp Tulare County Children's Mental Health
Department of Psychology Consortium
University of Hawaii at Manoa Turning Point of Central California
Honolulu, Hawaii 96822 Disalia, California 93277
Preface to the Second Edition
It is particularly gratifying to prepare a second edition of a book, because there is the necessary impli-
cation that the first edition was well received. Moreover, now an opportunity is provided to correct the
problems or limitations that existed in the first edition as well as to address recent developments in the field.
Thus, we are grateful to our friends, colleagues, and students, as well as to the reviewers who have expressed
their approval of the first edition and who have given us valuable input on how the revision could best be
structured.
Perhaps the first thing that the reader will notice about the second edition is that it is more extensive than the
first. The volume currently has 41 chapters, in contrast to the 31 chapters that comprised the earlier version.
Chapters 3, 9, 29, and 30 of the first edition either have been dropped or were combined, whereas 14 new
chapters have been added. In effect, we are gratified in being able to reflect the continued growth of behavior
therapy in the 1980s. Behavior therapists have addressed an ever-increasing number of disorders and behavioral
dysfunctions in an increasing range of populations. The most notable advances are taking place in such areas as
cognitive approaches, geriatrics, and behavioral medicine, and also in the treatment of childhood disorders. Of
special note is the fact that Part V, Intervention and Behavior Change: Child and Adolescents, has been expanded
from 6 to 13 chapters. Also, the current volume reflects the meteoric development of cognitive behavior therapy.
Consequently, a chapter on cognitive behavior therapy has been added to Part I, Foundations, and the influence of
cognitive strategies is well reflected in the content of several other chapters, including Chapter 16, Depression,
and Chapter 23, Marital Distress.
In keeping with the ongoing developments in the field and because of the availability of numerous basic
sources on individual topics, we have elected not to have our contributors simply reprise typical reviews of each
topic. Rather, we have invited them to "step back" and provide a critical evaluation of where their respective
field has been, its current strengths and shortcomings, and the direction it must go if it is to continue to grow and
develop. Thus, the current volume is not simply a cosmetic update of the first edition, in which a handful of new
references have been added to the same basic text. To the contrary, most of the contributors from the first edition
have written completely new chapters, whereas the contributors who are new to this volume are providing a fresh
perspective. In some ways, therefore, the two editions can indeed complement each other, rather than having the
second edition make the first instantly obsolete.
Our secretarial staffs can document the problems involved in putting together a work of this size and scope.
Anyone else who has ever been involved in such a task can also document that it cannot be done without dedicated
and conscientious personnel. Once again, we would like to thank Mary Newell, who now is familiar with the
preparation of second editions, and we also appreciate the efforts of Mary Dulgeroff. We owe special thanks and a
xi
xu PREFACE
hearty welcome to Joan Gill, who recently joined Alan S. Bellack's staff, thereby inheriting a file cabinet drawer
full of manuscripts and a lot of work. Finally, we appreciate the support and patience of Eliot Werner at Plenum
Press.
Alan S. Bellack
Michel Hersen
Alan E. Kazdin
Philadelphia, Pittsburgh, and New Haven
Contents
PART I FOUNDATIONS
Chapter 1 History of Behavior Modification 3

Leonard Krasner
Introduction ............................................................ 3
Behaviorism: As Paradigm and as Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
On the Nature of Behaviorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Concept of "Learning" ............................................... 7
On Labels and Terminology ............................................... 8
Historical Perspectives on Behavior Modification/Therapy . . . . . . . . . . . . . . . . . . . . . . . 10
The Clinical Psychology Context ........................................... 11
Target Behaviors ........................................................ 13
Behavioral Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
On Later Terminology-The Second Wave ................................... 19
Onward and Upward? .................................................... 21
References ............................................................. 21
Chapter 2 The Experimental and Theoretical Foundations of

Behavior Modification ........................................ 27
Donald J. Levis
Introduction ............................................................ 27
Basic Experimental Learning Paradigms and Principles ......................... 30
Classical Conditioning ................................................... 30
Operant or Instrumental Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Avoidance Learning: A Combination of Procedures ............................ 32
Implication of Conditioning Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Theoretical Foundations .................................................. 33
The Function of Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Skinner's Antitheoretical Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
The Impact of Formal Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Excitation and Inhibition Models of Behavior Change .......................... 35
xiii
XIV CONTENTS
Counterconditioning Models of Behavior Change .............................. 36

Behavior Change via Emotional Extinction ................................... 38
Cognitive Models of Behavior Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Methodological Foundations ............................................... 44
The Present State of Affairs ............................................... 47
A Future in Question ..................................................... 47
References ............................................................. 48
Chapter3 Cognitive Behavior Therapy ................................... 53

Rick E. Ingram and Walter D. Scott
Introduction ............................................................ 53
Historical Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Description ............................................................ 55
Current and Future Directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Summary and Conclusions ................................................ 63
References ............................................................. 63
Chapter4 Applied Behavior Analysis ........ '" . . .. . .. ... . .. . ... . .. . . . .. . 67

Michael A. Milan
Introduction ............................................................ 67
Radical Behaviorism ..................................................... 67
Characteristics of Applied Behavior Analysis ................................. 68
Principles of Applied Behavior Analysis ..................................... 70
Summary .............................................................. 81
References ............................................................. 82
PART II ASSESSMENT AND RESEARCH
Chapter 5 Behavioral Assessment: A Contemporary Approach... . . . .. . . . .... 87

Eric J. Mash and John Hunsley
Introduction ............................................................ 87
Contemporary Behavioral Assessment ....................................... 88
Models of Behavioral Assessment .......................................... 89
Traditional Issues in Behavioral Assessment .................................. 94
Emerging Issues and Directions ............................................ 97
Summary .............................................................. 100
References ............................................................. 101
Chapter 6 Observational Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Donald P. Hartmann and David D. Wood
Introduction ............................................................ 107

Designing an Observation System .......................................... 108
CONTENTS XV
Observers: Errors and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 117

Reliability ............................................................. 121
Validity ............................................................... 126
Final Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 128
References ............................................................. 129
Chapter 7 Behavioral Neuropsychology 139

Gerald Goldstein
Introduction ............................................................ 139

The Problem of Generalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 141
Specific Problem Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 143
Summary .............................................................. 147
References ............................................................. 148
Chapter 8 Experimental Design in Group Outcome Research. . . . . . . . . . . . . . . .. 151

Billy A. Barrios
Introduction ............................................................ 15 1
Aims ................................................................. 152
Assumptions ........................................................... 153
Applications ............................................................ 154
Assessment ............................................................ 160
Analytical Techniques .................................................... 167
Arguments ............................................................. 168
Admissions and Admonitions .............................................. 169
A Plea for Standardization and Quantification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170
Summary .............................................................. 171
References ............................................................. 171
Chapter 9 Single-Case Experimental Designs 175

Michel Hersen
Introduction ............................................................ 17 5
History ................................................................ 1 76
Group Comparison Designs ............................................... 177
Experimental Analysis of Behavior ......................................... 178
General Issues .......................................................... 178
General Procedures ...................................................... 181
Basic A-B-A Designs .................................................... 187
Extensions of the A-B-A Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 191
Drug Evaluations ........................................................ 194
Additional Designs ...................................................... 197
Statistical Analysis ...................................................... 203
Replication ............................................................. 204
References ............................................................. 207
XVI CONTENTS
PART III GENERAL ISSUES AND EXTENSIONS
Chapter 10 Training in Behavior Therapy ................................ . 213

Gregory M. Alberts and Barry A. Edelstein
Introduction 213
History of Behavior Therapy Training ...................................... . 214
Defining Behavior Therapy ............................................... . 215
Behavior Therapy Knowledge and Skills .................................... . 216
Models for Training Behavior Therapy Competencies .......................... . 218
Training Evaluation ..................................................... . 220
Summary and Conclusions ............................................... . 223
References ............................................................ . 224
Chapter 11 Balancing Clients' Rights: The Establishment of

Human Rights and Peer Review Committees .................... . 227
Jan B. Sheldon and Todd R. Risley
Introduction 227
Establishing Protective Mechanisms ........................................ . 229
The Human Rights Committee ............................................ . 232
The Peer Review Committee ............................................. . 239
Conclusion ............................................................ . 245
Appendixes ........................................................... . 246
Appendix 1: Human Rights Committee "Due Process" Summary Report 246
Appendix 2: Summary of Human Rights Committee Review of
Client Individual Habilitation Plan 246
Appendix 3: Peer Review Committee Summary Report ..................... . 247
References ............................................................ . 248
Chapter 12 Community Intervention Guided by Theoretical Development ..... . 251

Clifford R. O'Donnell and Roland G. Tharp
Introduction 251
Unit of Analysis ....................................................... . 252
Outcomes of Participation in an Activity Setting .............................. . 256
Intervention ........................................................... . 258
Means of Assistance .................................................... . 261
Principles and Guidelines for Community Psychology Consultants ............... . 263
Final Comment ........................................................ . 264
References 265
Chapter 13 Drugs Combined with Behavioral Psychotherapy ................ . 267

William L. Marshall and Zindel V. Segel
Introduction ........................................................... . 267

Anxiety Disorders ...................................................... . 268
Depression ............................................................ . 273
CONTENTS XVll
Summary .............................................................. 276

References ............................................................. 276
PART IV INTERVENTION AND

BEHAVIOR CHANGE: ADULTS
Chapter 14 Anxiety and Fear ........................................... . 283

Historical Perspective ................................................... . 283

Current Empirical Status ................................................. . 284
Agoraphobia .......................................................... . 285
Panic ................................................................ . 291
Social Phobia .......................................................... . 293
Posttraumatic Stress Disorder ............................................. . 295
Generalized Anxiety Disorder ............................................. . 296
Concluding Remarks .................................................... . 299
References ............................................................ . 300
Chapter 15 Obsessional-Compulsive Disorders ............................ . 307

Gail Steketee and Laura Cleere
Description and Classification ............................................ . 307

Assessment ........................................................... . 309
Behavioral Theory ...................................................... . 310
Behavioral Treatment ................................................... . 311
Cognitive Theory and Treatment .......................................... . 321
Combined Behavioral and Pharmacological Treatment ......................... . 322
Predictors of Outcome of Behavioral Treatment .............................. . 324
Further Considerations .................................................. . 326
References 326
Chapter 16 Cognitive Therapy of Depression ............................. . 333

Arthur Freeman and Denise D. Davis
Introduction ........................................... : ............... . 333

The Basic Cognitive Therapy Model ....................................... . 335
General Treatment Approach ............................................. . 338
Strategies for the Initial Sessions .......................................... . 340
Summary ............................................................. . 349
References ............................................................ . 349
Chapter 17 Schizophrenia ............................................. . 353

Alan S. Bellack and Kim T. Mueser
Introduction 353
Assessment 357
...
XVl11 CONTENTS
Behavioral Interventions for Schizophrenia ................................... 359

References ............................................................. 366
Chapter 18 Adult Medical Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

C. Barr Taylor, Gaillronson, and Kent Burnett
Introduction 371
Historical Perspective ................................................... . 372
Cardiovascular Disorders ................................................ . 374
Coronary Artery Disease ................................................. . 376
Gastrointestinal System .................................................. . 378
Respiratory Disorders ................................................... . 379
Pain Syndromes ........................................................ . 380
Cancer ............................................................... . 381
Psychoneuroimmunology ................................................ . 384
Acquired Immune Deficiency Syndrome .................................... . 386
Computers in Behavioral Medicine ......................................... . 388
Future Perspectives ..................................................... . 390
Summary ............................................................. . 391
References ............................................................ . 391
Chapter 19 Pain ...................................................... . 399

Dennis C. Turk and Thomas E. Rudy
Introduction ............................................................ 399

Respondent Conditioning Model of Chronic Pain .............................. 400
Operant Conditioning Model of Chronic Pain ................................. 403
Cognitive-Behavioral Perspective on Chronic Pain ............................. 405
References ............................................................. 411
Chapter 20 Alcohol and Drug Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 415

Mark B. Sobell, D. Adrian Wilkinson, and Linda C. Sobell
Introduction ............................................................ 415

The Evolution of Behavioral Treatments for Alcohol and Drug Problems ........... 417
Major Areas of Progress or Investigation since 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . .. 419
Conclusions and Future Directions .......................................... 430
References ............................................................. 431
Chapter 21 Cigarette Dependence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 437

Sharon M. Hall, Robert G. Hall, and Dorothy Ginsberg
Tolerance and Dependence ................................................ 437

Measurement of Smoking Behavior ......................................... 438
The Range of Treatments and Their Effectiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 439
Relapse Prevention ...................................................... 443
CONTENTS XIX
Thoughts for the Future .................................................. , 444

References ............................................................. 445
Chapter 22
.
Obesity.................................................... 449
Thomas A. Wadden and Susan T. Bell
Definition and Epidemiology .............................................. 449

Complications .......................................................... 450
The Multiple Causes of Obesity: Biological Factors ............................ 450
The Multiple Causes of Obesity: Behavioral Factors ............................ 453
Interaction of Biology and Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 454
Classification and Assessment ............................................. 455
Treatment of Mild Obesity ................................................ 457
Treatment of Moderate Obesity ............................................ 461
Improving Maintenance of Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 464
Future Directions ........................................................ 467
A Final Recommendation ................................................. 468
References ............................................................. 468
Chapter 23 Marital Distress ............................................ , 475

Robert L. Weiss and Richard E. Heyman
Introduction and Overview ................................................ 475

Conceptual Developments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 475
Affect Research ......................................................... 477
Cognitive Factors .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 482
Spouse Behaviors ....................................................... 487
Measuring Therapeutic Effectiveness ........................................ 492
References ............................................................. 496
Chapter 24 Interpersonal Dysfunction 503

Randall L. Morrison
Social Skills: Conceptual/Theoretical Issues .................................. 504

Assessment of Social Skill ................................................ 509
Social Skills Training .................................................... 514
References ............................................................. 519
Chapter 25 Crime and Aggression/Child and Spouse Abuse. .. .. . . . .. . .. . . . .. 523

Michael T. Nietzel and David T. Susman
Assessment of Crime and Delinquency ...................................... 525

Summary .............................................................. 539
References ............................................................. 540
xx CONTENTS
Chapter 26 Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 547

Joseph LoPiccolo
Treatment of Sexual Dysfunction ........................................... 547

Treatment Techniques .................................................... 552
References ............................................................. 562
Chapter 27 Sexual Deviation ............................................ 565

Nathaniel McConaghy
Assessment of Paraphilias ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 565

Treatment of Paraphilias .................................................. 568
Treatment of Other Sexual Disorders ........................................ 576
Treatment of Gender Identity Disorders ...................................... 577
Summary .............................................................. 577
References ............................................................. 578
Chapter 28 Geriatric Populations 581

Roger L. Patterson
Social Behavior ......................................................... 581

Anxiety ............................................................... 585
Behavioral Medicine ..................................................... 585
Behavior Associated with Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 588
Home Management...................................................... 590
Depression ............................................................. 590
Dependency and Self Care ................................................ 591
ADL Training .......................................................... 592
Future Applications ................................... '. . . . . . . . . . . . . . . . . .. 592
References ............................................................. 593
PART V INTERVENTION AND BEHAVIOR CHANGE:

CHILDREN AND ADOLESCENTS
Chapter 29 Stuttering ................................................. . 599

Roger J. Ingham
Introduction ........................................................... . 599

Describing Stuttering .................................................... . 600
Onset and Development of Stuttering ....................................... . 601
The Search for Distal and Proximal Causes of Stuttering ....................... . 603
Stuttering Variability Research ............................................ . 610
Stuttering Therapy ...................................................... . 613
Conclusion ............................................................ . 623
References 623
Chapter 30 Anxiety Disorders...... ....... .... .......... . .. ..... . ....... 633

Greta Francis
CONTENTS XXI
Classification ........................................................... 633

Assessment Issues ....................................................... 634
Assessment Instruments .................................................. 636
Treatment .............................................................. 639
Summary .............................................................. 645
References ............................................................. 645
Chapter 31 Childhood Depression: Current Status and Future Directions 649

Nadine J. Kaslow and Gary R. Racusin
Introduction ............................................................ 649

Assessment ............................................................ 650
Deficits in Functional Domains ............................................ , 655
Treatment .............................................................. 657
Current Directions for Treatment Outcome Research ........................... 659
Concluding Comments ................................................... 662
References ............................................................. 662
Chapter 32 Conduct Disorders 669

Alan E. Kazdin
Introduction ........................................................... . 669

Characteristics of Conduct Disorder ........................................ . 669
Current Treatments ..................................................... . 674
Operant Conditioning Techniques .......................................... . 674
Parent- and Family-Based Treatment ....................................... . 685
Cognitively Based Treatment ............................................. . 691
Approaches to Treatment: Exemplary Studies ................................ . 696
Current Issues ......................................................... . 699
Conclusions ........................................................... . 701
References 702
Chapter 33 Sexual Abuse of Children . ................................... . 707

Vicky Veitch Wolfe
Primary Prevention and Early Disclosure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 707

Disclosure Crisis ........................................................ 717
Treatment .............................................................. 720
Summary .............................................................. 725
References ............................................................. 726
Chapter34 Mental Retardation ......................................... , 731

Ronald A. Madle and John T. Neisworth
Introduction ............................................................ 731

Current Empirical Status and Developments .................................. 734
Future Perspectives and Directions .......................................... 749
Summary .............................................................. 752
References ............................................................. 753
XXll CONTENTS
Chapter35 Infantile Autism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 763

Laura Schreibman, Robert L. Koegel, Marjorie H. Charlop, and
4ndrew L. Egel
Overview .............................................................. 763

Diagnosis .............................................................. 764
Etiology and Past Treatment Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 767
Behavior Modification ................................................... 768
Eliminating Behavioral Excesses ........................................... 769
Acquisition of New Behaviors and Stimulus Functions .......................... 772
Motivation ............................................................. 774
Generalization .......................................................... 776
Treatment Environments .................................................. 778
Teaching Homes ........................................................ 781
Social Validation of Treatment Effects and Targets ............................. 782
Conclusion ............................................................. 783
References ............................................................. 783
Chapter 36 Medical Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791

Lizette Peterson and Cynthia Harbeck
Behavioral Interventions in Pediatric Psychology .............................. 791

Response Enhancing Techniques ........................................... 792
Response Reduction Techniques ............................................ 794
Issues for the Future ..................................................... 801
References ............................................................. 802
Chapter 37 Anorexia Nervosa and Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . .. 805

David M. Garner and Lionel W. Rosen
Introduction ............................................................ 805

Assessment Framework ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 806
General Treatment Principles .............................................. 808
Intervention Strategies .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 80g
Prominent Themes in Cognitive Restructuring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 811
Conclusion ............................................................. 815
References ............................................................. 815
Chapter 38 Childhood Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 819

Allen C. Israel
Definition and Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 819

Prevalence and Significance ............................................... 820
Research Findings ....................................................... 820
Closing Comments ...................................................... 828
References ............................................................. 828
CONTENTS XXl11
Chapter39 Physically Disabled Persons .................................. . 831

Vincent B. Van Hasselt, Robert T. Ammerman, and Lori A. Sisson
Behavior Problems ..................................................... . 832

Adaptive Living Skills ................................................... . 838
Vocational Skills ....................................................... . 843
Social Skills ........................................................... . 844
Family Adjustment ..................................................... . 846
Conclusion ............................................................ . 849
References 850
Chapter 40 Habit Disorders ............................................ . 857

Vincent 1. Adesso
Nailbiting .............................................................. 857

Thumbsucking ............................... '. . . . . . . . . . . . . . . . . . . . . . . . . .. 861
Trichotillomania ........................................................ 864
Concluding Comments ........................................ ,.......... 865
References ............................................................. 865
Chapter 41 Substance Abuse ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 869

Gary W. Holden, Michael S. Moncher, and Steven P. Schinke
Introduction 869
Overview ............................................................. . 869
Effects of Substance Abuse ............................................... . 871
Theoretical Etiological Models ............................................ . 872
Life Skills Training ..................................................... . 874
Summary and Conclusions ............................................... . 877
References ............................................................ . 877
Index ................................................................. 881

PART I
Foundations
CHAPTER 1
History of Behavior Modification

Leonard Krasner
Introduction expanded to such an extent that an adequate all-encom-

passing history would require a two- or three-volume
The opening chapter in an International Handbook of encyclopedia. Kazdin (1982) authored an excellent
Behavior Modification and Therapy should place the comprehensive history chapter in the first edition of
late 1980s' version of behavior modification/therapy this handbook.
in appropriate conceptual contexts-the history, phi- Having acknowledged that we can only scratch the
losophy, and sociology of science; the histories of psy- surface, we will now present our biased view based on
chology, clinical psychology, and psychiatry; the personal involvement in this exciting (and sometimes
broader developments of behaviorism; and the intel- frustrating) field of human endeavor (Krasner, 1982).
lectual, social, economic, and political developments
of twentieth-century society. Of course, these various
contexts are not independent of each other but are mu- Behaviorism: As Paradigm and as
tually interactive. Context
My purpose in this chapter is to present the broad
framework in which behavior modification/therapy As far back as ancient times, human beings have
(as well as the subsequent chapters in this handbook) been involved in creating concepts that could explain
can be placed so that this model/theory/paradigm of the vast intricacies of human behavior. It was not until
human behavior can be better appreciated, com- comparatively very recently (as time goes) that a for-
prehended, utilized, and developed even further. Note mal discipline of knowledge-psychology-devel-
at this point that we are using behavior modifica- oped with a number of theoretical approaches about
tion/therapy as the generic term because, except for the nature of human nature. It is the history of one of
some very minor differences, the labels behavior mod- these models, behaviorism, that we are exploring.
ification and behavior therapy have been used almost The story of behaviorism should be placed within a
interchangeably in the literature. number of broader intellectual contexts, such as that of
The field of behavior modification/ therapy, in terms science, of psychology, and of society itself to be un-
of research, applications, publications, organizations, derstood, appreciated, or even reviled. In doing so, we
journals, conferences, training programs, and indi- will be setting the context for approaching the behavior
viduals identified with it (and against it) has grown and of the individual behaviorists and the reactions to them
by other individuals in our society. We are approaching
Leonard Krasner • Laboratory for Behavioral Medicine, behaviorism as both a social and theoretical movement
Stanford University. Stanford, California 94305 within the academic and professional fields of psy-
3
4 PART I • FOUNDATIONS
chology and psychiatry. We start with the very broad A major element in Kuhn's approach involves an
framework of historiography, paradigmatic revolu- analysis of the "scientific" community at any given
tions, philosophy of science, the nature-nurture con- time. Basic to the development of Kuhn's ideas is an
troversy, and the history of psychology itself. First, we analysis of community structure: the origins, educa-
attempt to delineate the parameters of the concept of tion, and professional initiation of members, and the
behaviorism by putting it in the broader context of type of working consensus they bring to bear in ap-
historiography, the issues involved in the science or art proaching their subject matter. Such an account calls for
of writing history. an explication of the ways a group fosters a particular
There are issues in the history of science and of practice and perception of problems such that judg-
psychology that may well affect any interpretation of ments and recognition of achievement are possible (Pe-
behaviorism. Current applications of behaviorism in- terson, 1981). Another important element in Kuhn's
dicate the concept has become reified as an entity and approach is its emphasis on the relationship between the
divorced from its philosophical and psychological researcher and that which is being researched. In effect,
roots. It is of major importance that those individuals this is not a problem to be "controlled" but rather to be
who identify themselves as practitioners of modern- the focus of skilled observation and description. The
day versions of behaviorism, such as behavior modifi- researcher influences and, in tum, is influenced by the
cation/therapy, understand and appreciate that they are problems being studied. The researcher indeed is a
dealing with a broad philosophy of human behavior, participant-observer. Thus, the factor of subjectivity in
and thus they are not merely technicians. The broadest science that Kuhn noted was not considered a criticism
and most pertinent context for the historical develop- or taint but rather an integral aspect of scientific
ment of behavior therapy is that of "science." Vir- practice.
tually all researchers and practitioners of the various It is important to place behaviorism in a broader
versions of behaviorism, from the Watsonian brand of social, political, and economic context. By its very
the 1920s to the multimodel brands of the 1980s, iden- nature, the concept of "paradigm" implies such a con-
tify with the concept of science, which, socially, eco- text. However, we are actually dealing with two sepa-
nomically, politically, and intellectually has grown to rate but interrelated contexts: that of the society and
the point where the term symbolizes the highest pres- that of the profession. Even though a professional con-
tige in Western society. text was implicit in Kuhn's usage of the term "commu-
The model of historiography that an individual his- nity of scholars," it has only been fairly recently that
torian espouses is simply the conceptual framework real attention has been paid to the social, political, and
within which the task of reexamining the past is ap- economic context of the "profession " (e. g. , Mahoney,
proached. My own belief is that, to a very large extent, 1976). Even now, generally, there is a reluctance on the
the process of looking back and examining the past, part of those professions that view themselves as "sci-
even of as illustrious a field as behaviorism, is a pro- entific," particularly psychology, to accept or ac-
cess of creating and recreating the past. knowledge that there is a social, political and eco-
In effect, we will be dealing with the behavior of nomic aspect to the "profession" that influences the
individuals. It is a frequent tendency of writers of all theory, methodology, and approach to the actual con-
sorts to refit metaphors and to write or talk or concep- tent of the field.
tualize in terms of psychology or behaviorism, as if In dealing with behaviorism, we are looking at a
they were real entities of their own. Psychology does view, a belief system, about the nature of human
not speak, but John B. Watson, or John Dewey, or B. F. nature. There are many historians and psychologists
Skinner, or Sigmund Freud speaks or writes, although who contend that the basic views about the nature of
admittedly they sometimes sound as if they do indeed human beings held at any period of time, even by the
speak for psychology. professionals and scholars, are influenced by the
A continuing controversy in psychology about the broader zeitgeist of the society, and, in tum, influence
growth of behaviorism as a scientific movement fits the society as expressed in books, newspapers, the
within Thomas Kuhn's (1970) view of revolutions in media, and the pop culture of the period.
science through broad paradigmatic shifts. Controver- Behaviorism was a human creation and a very sig-
sy abounds as to whether or not psychology itself is at a nificant one. It is not possible to discuss it out of the
paradigmatic stage (i.e., has a broad model of "human context of its creators or out of the societal context in
nature" which is generally accepted in the profession). which they functioned. The behavioral movement in
CHAPTER 1 • HISTORY OF BEHAVIOR MODIFICATION 5
American or British psychology and society can be nication). He termed his approach as offering a "so-
approached as a scientific/ social movement influenced ciorationalist meta theory." It seems to us, in effect,
by, and, in turn, influencing, the broader society in that this is a restatement of Kuhn's paradigmatic ap-
which it developed (Ullmann, 1969). Behaviorism proach, which also refers to a community belief sys-
evolved in the context of the social, political, cultural, tem at any given point.
educational, economic, and intellectual history of the One of the widely held stereotypes about behav-
twentieth century. Conversely, as the pragmatic phi- iorism is that it does not involve a philosophy at all
losophy of the behavioral movement spread beyond because it represents an "objective" approach to be-
the bounds of the psychology laboratory, it influenced havior. Any question about the relationship between
virtually every aspect of social life. Perhaps no other behaviorism and philosophy is quickly settled by refer-
systematic approach to human behavior has been as ring to the views of B. F. Skinner.
vilified, praised, used, and misused as behaviorism Skinner (1974) made a flat declaration as to the
(except, perhaps, that of psychoanalysis). nature of behaviorism, which is of major importance
Behaviorism, in the form of behavior modifica- because it comes from the more current version of the
tion/therapy, represented a break with authority, a behaviorist. "Behaviorism is not the science of human
break with the traditions of its own history, and it was, behavior; it is the philosophy of that science. Some of
in effect, something new and exciting. The profes- the questions it asks are these: Is such a science really
sionals of the period who were identifying either with possible? Can it account for every aspect of human
"humanism" or with behaviorism (or both) were ad- behavior? What methods can it use? Are its laws as
vocating an open society in which human behavior valid as those of physics and biology? Will it lead to
could be a function of what individual human beings technology, and if so, what role will it play in human
did, felt, and believed now and were not victims of a affairs?" (p. 2).
mechanical history of the society or of their own life.
The philosophical roots of behavior modifica-
tion/therapy are generally traced to the positivistic phi- On the Nature of Behaviorism
losophy system founded by Comte, which radically
rejected all metaphysics-the inquiry into the ultimate Defining the nature of behaviorism is both a game
causes and nature of things. The objective of science and a large projective technique. Everyone, in and out
was to discover facts, their relations, and the laws of psychology, can and has played the game. An entire
governing them. Positivism strongly reinforced the book could be written on the various attempts to delin-
antimentalistic and anti-introspectionist tendencies in eate just what it is and what is not, and mutual contra-
psychology. The behaviorist tenets in psychology dictions abound. Changes occur even in the views of
seemed very much in agreement with positivistic the same individuals over time. This links up with our
views. The controversy as to whether science is value- point that we are dealing with an idea (expressed in
free or value-laden has been an integral part of the verbal behavior) about human nature, and thus confu-
behavior modification/therapy history (Krasner & sion, duplicity, certainty, doubt, and so forth have been
Houts, 1984). the name of the game throughout human history as to
Perhaps the most important of the historiographic what a human being is and could become.
issues is that of discovery versus invention. Is the his- As is true of every aspect of psychology, controver-
torian, or any writer on' a particular subject, discover- sy abounds as to the origins and prehistory of behav-
ing new "facts" about the particular subject, or is he iorism (Burnham, 1968). Historians of psychology
creating (inventing) new material on the subject by the who were contemporaries of Watson (e.g., Boring,
very act of investigating it? Thus, to understand an Heidbreder, Woodworth) clearly credit Watson as
approach to human behavior as behaviorism it would being the founder of behaviorism. More recent writers
be necessary to study the behavior of the investigators of history (e.g., Kazdin, 1978b; Samelson, 1981) tend
of behaviorism. to credit Watson as being the catalyst of a movement
Gergen (1982) nicely captured the position of in- (toward "objectivism" and away from "conscious-
vention in noting that "truth is the product of the col- ness") that was already well in progress. They note
lectivity of truth makers" (p. 207). He placed the loci that Watson was not unique in this new approach which
of knowledge not in the minds of single individuals but he called "behaviorism," not only in the terminology
in the "collectivity" (i.e., a social process of commu- but in what it stood for. "Criticism of introspection
was not new, neither was the use of objective methods iorism could well be the opening paragraph of a paper
or the advocacy of the study of behavior, as references John B. Watson published in 1913:
to other authors like Mayer, Parmelee, and Thorndike
indicate" (Samelson, 1981, p. 404). Psychology as the behaviorist views it is a purely objective ex-
A reasonable place to start our approach to behav- perimental branch of natural science. Its theoretical goal is the
prediction and control of behavior. Introspection forms no essen-
iorism would be a straightforward dictionary defini- tial part of its methods, nor is the scientific value of its data
tion: "The psychological school holding that objec- dependent upon the readiness with which they lend themselves to
tivity observable organismic behavior constitutes the interpretation in terms of consciousness. The behaviorist, in his
efforts to get a unitary scheme of animal response, recognizes no
essential or exclusive scientific basis of psychological dividing line between man and brute. The behavior of man, with
data and investigation and stressing the role of envi- all of its refinement and complexity, forms only a part of the
ronment as a determinant of human and animal behav- behaviorist's total scheme of investigation. (p. 158)
ior" (American Heritage Dictionary, 1969, p. 220).
An even more basic starting point in approaching In that paragraph, there seems to be all of the ele-
the various convolutions in the usage of terminology is ments in the verbal armory of behaviorism: "objec-
a straightforward dictionary definition of the ubiq- tive," "experimental," "science," "prediction,"
uitous word behavior (behaviour, the British spelling). "control of behavior," "no dividing line between man
Senn (1966) has traced the change in the usage of the and brute." Further, it contains a clear disavowal of
term and has emphasized that the definition of even "introspection" and "consciousness." We could prob-
such a basic word as behavior changes, and in the ably stop at this point and say, "That's it; behaviorism
twentieth century even the dictionary definition of the in a nutshell."
term "seems to have stemmed from developments of But it is not that simple. Nothing is, and the word
the fields of psychology, social psychology, and so- behaviorism has had projected onto it a multitude of
ciology" (p. 109). Thus, the apparently simple defini- meanings, some flattering, some derogatory.
tions of behavior used by the American Heritage Dic- At this time, as is the case in every aspect of psy-
tionary (1969), "the manner in which one behaves; the chology, controversy abounds even as to the origins
actions or reactions of persons or things under specific and prehistory of behaviorism (Burnham, 1968). At
circumstances" (p. 120), may well be the reflections of least there can be agreement in crediting John B. Wat-
the influence of the history of behaviorism rather than son with "catalyzing a movement toward objectivism
an immutable basic fact. that was already well in progress" (Kazdin, 1978b, p.
Other theorists of the time also categorized types of 64).
behaviorism. Calkins (1921) distinguished between Apparently, the only material of actual observation,
"radical" or "extreme" behaviorism and "modified or data, on which Watson based his writing was the
behavioristic psychology." The major difference ap- case of Albert and the rat. There is now much contro-
pears to be whether "consciousness" is denied or ac- versy about the case as to the techniques and pro-
cepted as an element to be studied. Lashley (1923) cedures and subsequent difficulty in replication. There
made this same distinction in labeling his two catego- are, of course, various interpretations of Watson's role
ries of behaviorism as "extreme" and "meth- in the origins of behaviorism. Burnham, for example,
odological." The extreme label has evolved into the contends that viewing the development of behaviorism
modern day "radical behaviorists." They are de- as a Kuhnian paradigmatic shift, Watson is then
scribed as generally identifying themselves with the viewed as the "charismatic leader" of behaviorism
works of Skinner and view behaviorism as a social and rather than as its founder.
intellectual movement. The methodology of this group It is the issue of control of behavior that, more than
focuses on data that are based on behavior taking place any other, was to pervade the psychology and society
in a natural setting, and large samples of behavior pri- scene of the last part of the century. In his first major
marily based on one individual organism collected book, Skinner (1938) expressed considerable doubt
over long periods of time. The aim of the study is not to about the possibility or even desirability of prediction
understand or to control the behavior. In effect, the and control of behavior: "Confronted with the sheer
investigator becomes part of the experiment. Thus, the expansiveness of the topography of behavior, we must
control relationship between investigator and subject concede the impossibility of any whosesale prediction
is itself being analyzed. of stimulus or response that could be called exact" (p.
A relevant starting place for a definition of behav- 10).
It is a thread of the control of behavior for "social Kazdin (1978b) noted that behaviorism still re-
betterment," or "Utopianism," in the behaviorism mained close to stimulus-response theory and, indeed,
stream that has throughout created the most controver- provided elaborate theoretical accounts with multiple
sy, enthusiasm, and criticism of behaviorism. If your levels of intervening variables to handle phenomena
goal as a psychologist is the prediction and control of that might better have been handled by cognitive or
behavior, the immediate question is "for what perceptual theories. Much of the first 30 years of be-
purpose?" haviorism in America was devoted to formulating laws
of behavior based primarily upon animal research,
which could help to illuminate the processes of human
The Concept of "Learning" learning.
The research and theoretical formulations of the ear-

ly investigators, particularly Watson, in their emphasis
Animal Psychology
on environmental influences on behavior brought to
the fore the concepts of "learning," which became the There seemed to have been an affinity and mutual
central focus of experimental psychology through the influence between the development of behaviorism as
subsequent decades. A series of investigators (Edward embodied in Watson and the field of animal psychol-
L. Thorndike, Edwin R. Guthrie, Edward C. Tolman, ogy. It was relatively easy to point to Watson's rural
Clark L. Hull, Kenneth W. Spence, O. Hobart background, which meant contact with animals, tin-
Mowrer, B. F. Skinner, Albert Bandura, and others) kering with machinery, and emphasis on behavior as
attempted to construct theories or models of learning against verbalizations or consciousness. Further, ani-
and postulated a variety of different principles and mal psychology was presumably objective in the sense
mechanisms to explain "learning." that the observer, like the astronomer, the physicist, or
In the 1970s, a concept that emerged (or reemerged, the botanist, necessarily stands outside the material he
depending on how long a historical perspective one studies.
takes) was that of "cognition" or "cognitive pro- Yet the more recent scholarship of early behav-
cesses." Kazdin (1978a,b) linked the evolution of be- iorism, particularly that of Samelson (1980, 1981),
haviorism in its relationship to cognitive processes labels it a myth that behaviorism developed out of ani-
through three stages. The first stage involved the nega- mal psychology because the situation of working with
tive reaction to introspectionism typified by Watson. animals forced researchers into behavioral studies. For
In the second stage of behaviorism, investigators (such example, the major animal psychologists of the peri-
as Hull, Tolman, and Mowrer) introduced concepts of od, Yerkes and Washburn, rejected Watson and his
"intervening variables" to explain what went into the theories. It is true that Watson liked rural life and loved
relationship between stimulus and response. In effect, animals, but this was not unique to behaviorism. There
variables within the organism (0) were postulated and already was a trend in psychology, especially in animal
S-R psychology became S-O-R psychology. psychology, to question the usefulness of the concept
In the third stage, investigators, such as Bolles, of "consciousness." It now seems clear that animal
Bower, and Neisser, approached the human-learning (comparative) psychology was getting nowhere in try-
process as it involved thinking, perception, and coming to do functional analysis of the minds of the con-
plex motivational processes. Tolman is credited with sciousness of animals. The concept of "mind" seemed
being the first to make explicit the central role of cog- to do less and less for the life of the animal, whereas it
nition in learning, in emphasizing that the individual began to be generally accepted that the real influences
learned strategies of responding and perceived general seemed to be in the environment. Thus, the concept of
relationships in the environment, symbolized by the "consciousness" began to be dropped, and the empha-
concept of "cognitive maps." One of the most interest- sis shifted to the environment and behavior. It should
ing and influential of attempts to reconcile cognitive be noted that the same kind of analysis also held for the
processes with the earlier S-R behaviorism was that of difficulty in analyzing minds of the retarded and the
G. A. Miller, Galanter, and Pribram in their 1960 book abnormal. This development in psychology was occur-
on Plans and the Structure of Behavior. containing an ring prior to and contemporaneously with Watson.
approach which they aptly describe as a "subjective Logue (1978) unequivocally pointed out that" John B.
behaviorism. " Watson, the original and most vocal behaviorist, did
not support the extrapolation of animal data to prin- mental laboratory, usually based on learning theory
ciples of human psychology" (p. 77). and applied in a social influence situation. Thus, be-
havior therapy, according to this view, is a technology
built upon a base of behavior influence. What Lazarus
On Labels and Terminology (1971) labeled the "non-specific" factors, which oth-
ers call "placebo effect," actually involves very spe-
There are various terms that have become syn- cific social psychological variables, such as expectan-
onymous with clinical applications of behaviorism. cy, prestige, demand characteristics, set, experimenter
There are a series of "behavioral" labels or terms that bias, and so forth. The technology of behavior therapy
abound, each of which has somewhat different origins becomes effective in modifying behavior only within
and meanings attached to them: behavior therapy, be- the context of maximum social influence. It is impor-
havior modification, behavioral engineering, behavior tant to emphasize that behavior therapy involves both
influence, behavior analysis, cognitive behavior modi- the technology and its social influence base. Some of
fication, conditioning, operant conditioning, S-R ap- the behavior therapy investigators have been clearly
proach, social learning, vicarious learning, reinforce- cognizant of this, but most have ignored it. The behav-
ment, contingency management, stimulus control, and ior therapist is a compound, social reinforcing, and
multimodal therapy. Initially, we will focus on the ori- discriminative stimulus. He or she is viewed as the
gins of the usage of the two most widely used labels: source of meaningful stimuli that alter, direct, and
behavior therapy and behavior modification. maintain another individual's behavior. There have
The first use of the term behavior therapy in the been a multitude of variations of meaning attached to
literature was in a 1953 status report on their NIMH behavior therapy after these early approaches.
grant by Ogden Lindsley, B. F. Skinner, and Richard In interpreting behavior therapy in the context of
Solomon, referring to their application of operant con- broader conceptual "helping" models, Ullmann and
ditioning (of a plunger-pulling response) research with Krasner (1965) described behavior therapy as "treat-
psychotic patients. Lindsley suggested the term to ment deducible from the sociopsychological model
Skinner, based on its simplicity (what could be simpler that aims to alter a person's behavior directly through
than "behavior") and the linkage (via that ubiquitous application of general psychological principles." This
term therapy) to other treatment procedures. was contrasted with "evocative psychotherapy,"
Despite this early usage, Lazarus (1958) used "be- which is "treatment deducible from a medical or psy-
havior therapy" to refer to his mentor, Joseph Wolpe's choanalytic model that aims to alter a person's behav-
application of his "reciprocal inhibition" technique to ior indirectly by first altering intrapsychic organiza-
neurotic patients. Hans 1. Eysenck (1959) used the tions" (p. 244).
term to refer to the application of what he termed The breadth and need for an integrative theoretical
"modem learning theory" to the behavior of neurotic model was illustrated by Kanfer and Phillips (1970),
patients based, ~n large part, on the procedures of a who classified four types of behavior therapy: "in-
group of investigators then working at the Maudsley teractive therapy" (methods requiring an extended se-
Hospital in London. This influential group of early ries of personal interviews using the therapist's verbal
investigators consistently defined behavior therapy in behavior to catalyze changes in the patient); "instiga-
terms of learning theory, for example, Wolpe (1973): tion therapy" (using suggestions and tasks to teach the
"behavior therapy, or conditioning therapy, is the use patient to become his own therapist); "replication ther-
of experimentally established principles oflearning for apy" (changing behavior by replicating a critical seg-
the purpose of changing unadaptive behavior. Unadap- ment of the patient's life within the therapy setting);
tive habits are weakened and eliminated; adaptive hab- and "intervention therapy" (disruption by the therapist
its are initiated and strengthened" (p. xi). of narrow response classes as they appear in the pa-
By the early 1970s, the literature on behavior thera- tient's interactions with his natural environment).
py had grown to the point where it warranted a whole They called for establishing a well-integrated frame-
chapterin the Annual Review ofPsychology, a sure sign work from which practitioners could derive new tech-
of having "made it big." In this initial chapter, Krasner niques with clearly stated rationales, predictable ef-
(1971) conceptualized behavior therapy as comprising fects, and with well-defined criteria for examining
a series of specific techniques derived from the experi- their efficacy. They argued that a consistent behav-
ioristic view requires an understanding of the entire therapy: "It was a psychologist, Carl Rogers, who in
range of psychological principles that can be brought 1942, through a book ... and an article ...
to bear on the problems of an individual client. launched the research approach in behavioral modifi-
The term behavior modification. which was to rep- cation through psychotherapy (pp. 20-21). It often
resent the pop behaviorism of the 1970s and the 1980s. comes as a surprise (for some a shock) that the origins
has been used interchangeably with behavior therapy. of behavior modification are attributed (credited?
or to refer solely to the application of operant condi- blamed?) to Carl Rogers, the personification of "hu-
tioning to distinguish it from the behavior therapy de- manism" (Krasner, 1978).
rived from the work of Wolpe. It initially was used to A favorite pastime of psychologists (including me as
describe research studies of those investigators who well) is to attempt definitions of these labels, and we
were approaching the modification of behavior via the cite those of Bandura, Kazdin and Wilson.
systematic application of social learning principles de- Bandura (1969), in a most influential and widely
rived from sociopsychological research (Bandura. cited book, placed "the principles of behavior modifi-
1969; Franks. 1964; Kanfer & Phillips, 1970). cation" within the "conceptual framework of social
The two volumes of collected papers on research learning."
and case studies in behavior modification (Krasner &
Ullmann, 1965; Ullmann & Krasner, 1965) repre- By requiring clear specification of treatment conditions and ob-
jective assessment of outcomes. the social learning ap-
sented the first use of that term in a book title. The
proach . . . contains a self-corrective feature that distinguishes
introduction to the "research" collection placed the it from change enterprises in which interventions remain iII-
work of the investigators involved (e.g., Ferster, defined and their psychological effects are seldom objectively
Staats, Bijou, Salzinger, Goldiamond, Patterson, evaluated. (p. v)
Krasner, Sarason. Kanfer, Hastorf, Saslow, Colby,
Bandura, and Sarbin) within the context of the broader Bandura integrated the, by then, greatly expanded
field of behavior influence (Krasner, 1962; Krasner & investigations derived from the influence of Skinner,
Ullmann, 1973), which included: "Investigations of Wolpe, and the British group (e.g., Eysenck).
the ways in which human behavior is modified, A very broad view is taken by Kazdin (1978b) in his
changed, or influenced. It includes research on operant history of behavior modification:
conditioning, psychotherapy, placebo, attitude
Behavior modification can be defined as the application of basic
change, hypnosis, sensory deprivation, brainwashing, research and theory from experimental psychology to influence
drugs, modeling, and education" (p. 1). behavior for purposes of resolving personal and social problems
We then adopted the description of behavior modifi- and enhancing human functioning. (p. ix)
cation offered by R. I. Watson (1962). (It should be
noted that this reference is to Robert I. Watson, the Wilson (1978) made a useful and functional distinc-
historian of psychology, and not John B. Watson, the tion between the two terms in using behavior therapy
behaviorist.) In presenting a historical introduction to to refer to individual treatment of a single client and
Bachrach's (1962) collection of research on the "ex- behavior modification to cover efforts to change social
perimental foundations of clinical psychology," Wat- institutions or groups of people without regard to indi-
son used the term "behavior modification" to cover a vidual learning theories.
multitude of approaches. It is doubtful there is any current satisfactory defini-
tion of the model of human behavior called behavior
It includes behavioral modification as shown in the structured modification/therapy. Unfortunately, many of the de-
interview, in verbal conditioning, in the production of experi- velopments of the past have been based on the assump-
mental neuroses, and in patient-doctor relationships. In a broader
tion that behavior modification/therapy does indeed
sense, the topic of behavior modification is related to the whole
field oflearning. Studies of behavior modification are studies of "exist" (as if there was a reality to it separate from the
learning with a particular intent-the clinical goal of treatment. behavior of the individuals endorsing it or condemning
(p. 19) it). Few investigators have focused on the reification
process whereby a metaphoric label takes on a life and
Watson included among the historical forebears of reality of its own rather than being viewed as a set of
"behavior modification" those investigators who were explanatory hypotheses about human behavior.
doing systematic research into the process of psycho- For a considerable period of time, both the propo-
nents and opponents of behavior modification/therapy therapy" published in the Annual Review of Psychol-
really believed in the myth of its existence. There were ogy, Krasner (1971) argued that 15 streams of develop-
some difficulties in defining it, but that did not prevent ment within the "science" of psychology came to-
people from trying. Thus, we get hung up on such gether during the 1950s and 1960s to form the
controversies as to whether aversive procedures are or approach to behavior change generally known as "be-
are not really part of behavior modification/therapy. havior therapy." These streams may be briefly sum-
We would argue that there is indeed a field of behavior marized as follows:
modification/therapy that is defined by the behavior of
those professionals who identify with it and by the 1. The concept of behaviorism in experimental
historical context within which these people work. psychology (e.g., Hilgard & Marquis, 1940;
Historical contexts include social, political, eco- Kantor, 1969)
nomic, philosophical, professional, and personal 2. The instrumental (operant) conditioning re-
elements. search of Thorndike (1931) and of Skinner
The link between the zeitgeist of an era and the (1938, 1953, 1957) and Keller and Schoenfeld
theoretical and practical development of models of (1950)
human behavior, particularly behavioral, is person- 3. The development of the technique of reciprocal
ified by the experiences of Paul Fuller. The first report inhibition as a "treatment" procedure (Wolpe,
of the application of the concept of "operant condi- 1958). Wolpe noted the influence of James Tay-
tioning" to changing a "maladaptive" human behav- lor and Leo Reyna on his research.
ior was presented by Fuller (1949) in a paper entitled: 4. The experimental studies of a group of investi-
"Operant Conditioning of a Vegetative Human Orga- gators at Maudsley Hospital in London under
nism." Fuller described the influence on his own the direction of H. J. Eysenck (1960, 1964)
behavior: 5. The investigations (from the 1920s through the
1950s) applying conditioning/learning con-
I regularly read the Bulletin of Atomic Scientists and a variety of cepts to human behavior problems (e. g., W. H.
nonpsychology. I had come to psychology from geology and
physics, through political theory. I kept up in some of these
Burnham, 1924; Dunlap, 1932; Guthrie, 1935;
fields. A reaction to World War II experiences led me to the Hollingworth, 1930; M. C. Jones, 1924a,b; O.
applications of the principles and methods of experimental psy- H. Mowrer & W. M. Mowrer, 1938; Pascal,
chology to current problems. (personal communication, 1974) 1959; Pavlov', 1927; Phillips, 1956; J. B. Wat-
son & Rayner, 1920)
The themes that Fuller touches upon recur again and 6. Interpretations of psychoanalysis in learning
again in this period, namely, the influence of ideas theory terms (e.g., Dollard & Miller, 1950),
from physical science, particularly physics, and the hence, enhancing learning theory as a respect-
impact of World War II in generating a strong desire to able base for clinical work
create a better world by the application of whatever 7. The concept of classical conditioning as the
"scientific" principles might be available. basis for explaining and changing both normal
and deviant behavior (e.g., Pavlov, 1928)
8. Theoretical concepts and research studies of so-
Historical Perspectives on Behavior cial role learning and interactionalism in social
Modification/Therapy psychology and sociology (e.g., Homans,
1961; Mead, 1934; Parsons, 1959; Sarbin,
Kazdin's (1978b) comprehensive history traces the 1954)
scientific foundations of modem-day behavior modifi- 9. The stream of research in the field of develop-
cation/therapy into general areas of research: condi- mental and child psychology exemplified by
tioning and reflexology in Russia (e.g., Sechenov, the contributions of Baer, Bandura, Bijou, Dol-
Pavlov, and Bechterev); comparative psychology lard, Gewirtz, N. Ellis, N. Miller, Sears, and
(stimulated by Darwin and Lloyd Morgan); the behav- Suinn
iorism of John B. Watson; and the psychology of learn- 10. Social influence studies of demand charac-
ing in America (e.g., Thorndike, Hull, Guthrie, teristics, experimenter bias, hypnosis, and
Tolman, and Mowrer). placebo (Frank, 1961, 1973; Rosenthal, 1966)
In the first article devoted to the topic of "behavior 11. An environmentally based social learning
model as an alternative to the disease model of attributes of scientific investigation including control of vari-
human behavior (Ullmann & Krasner, 1965; ables, presentation of data, replicability, and a probabilistic view
of behavior. (pp. 457-458)
Bandura, 1969)
12. Dissatisfaction with psychotherapy and the
psychoanalytic model as evidenced by strong
critiques (e.g., Eysenck, 1952)
13. The development of the clinical psychologist The Clinical Psychology Context
within the scientist-practitioner model
(Shakow, 1965) We are pursuing the theme of behavioral movements
14. A movement within psychiatry away from the in the context of the growth of the largest subdivision
then orthodox focus on internal dynamics and of psychology, and perhaps the field that has had the
pathology toward concepts of human interac- most impact on society, clinical psychology. Since its
tion and environmental manipulators (e. g. , Ad- inception, the behavior modification/therapy move-
olph Meyer and Harry Stack Sullivan) ment has been linked with the field of clinical psychol-
15. A Utopian emphasis on the planning of social ogy on theoretical and applied levels. Many of the
environments to elicit and maintain the best of postwar behavior therapists also identify themselves as
human behavior (e.g. , Skinner's, 1948: Walden clinical psychologists.
Two) One of the major hallmarks of the behavioral move-
ment has been the integration of experimental research
The streams, of course, were not independent of with clinical procedures (Bachrach, 1962). An influ-
each other and were continually in the process of in- ential paper in the postwar period was Shaw's (1946)
teracting, changing, and developing. The elements of "A StimUlus-Response Analysis of Repression and In-
the belief system common to behavior therapy ad- sight to Psychotherapy," which was one of the first to
herents included the statement of concepts so that they apply systematically principles, of learning based on
can be tested experimentally; the notion of the "labo- animal work (primarily that of O. H. Mowrer) to the
ratory" as ranging from animal mazes through the clinical process of psychotherapy.
basic human learning studies to hospitals, school- Another important early linkage of psychotherapy
rooms, homes, and the community; research as treat- with "learning theory" was Shaffer's (1947) article
ment-and treatment as research; and an explicit strat- emphasizing the effects of theories of behavior on the
egy of therapy change. therapist. Shaffer contended that "psychotherapy's
There were numerous theoretical papers, research great need for a substantial scientific basis is not fulfill-
studies, and applications in a variety of settings that ed with entire adequacy by any of the existing system-
exemplified this behavioral model and set the basis for atic approaches" (p. 461). He focused on the one at-
the subsequent growth in the 1980s of behavior modifi- tempt to define psychotherapy in researchable terms,
cation/therapy as the predominant approach to influ- that of O. H. Mowrer (1939) who "applied stimulus-
encing human behavior (e.g., Agras, Kazdin, & response concepts to the study of adjustment mecha-
Wilson, 1979; Bijou & Baer, 1961, 1965; Breger & nisms" (p. 462).
McGaugh, 1965; Cautela, 1967; Davison, 1968; Ek- Shaffer conceptualized psychotherapy in terms very
man & Friesen, 1969; Franks, 1964; Greenspoon, similar to that used by current behavior therapists, for
1955; Heller, 1969; Hersen, 1968; Hersen & Bellack, example, "psychotherapy can be approached as a
1976; Keller, 1968; Krasner, 1962; Levis, 1970; Lon- learning process through which a person acquires an
don, 1969; Lovaas, 1968; Lovibond, 1964; Marks, ability to speak to himself in an appropriate way so as
1969; Paul, 1966; Rachman, 1963; Risley, 1968; to control his own conduct" (p. 463). (Over a period of
Staats, 1964; Wolf, Risley, & Mees, 1964; Wolpe & 40 years the cycle goes from self-control to self-con-
Lazarus, 1966; Yates, 1970). trol.) Another similar major influence was the 1949
Krasner (1971) noted the following unity to the paper by Shoben, which also attempted an integration
field: of the "learning therapy" approach of O. H. Mowrer
with the field of psychotherapy.
On the other hand, the kind of research studies that
The unifying factor in behavior therapy is its basis in derivation
from experimentally established procedures and principles. The were to become the hallmark of early behavior modifi-
specific experimentation varies widely but has in common all the cation/therapy, the operant baseline (N= 1) studies,
which combined laboratory procedures with subjects Perhaps the most important of these commonalties was
outside the laboratory and the concept of "research as the role-model identification of the investigators them-
therapy," had not yet appeared on the postwar scene. selves. Those interested in basic research saw socially
They would begin to develop later on in the 1950s. important applications for their work. Those involved
Influences in this period on the psychiatrist Joseph in applications viewed their work as derived from
Wolpe reflect some of the experimental-clinical link- more basic scientific, or laboratory, or experimental
ages we are describing, as well as the role of social research studies. They conceived of themselves as be-
networking in the diffusion of innovative ideas: havioral scientists who were investigating and apply-
ing the basic processes of human behavior change.
1946 was the tail end of the period (1943-1946) when I was Thus, clinical phenomena were investigated through
learning from conversations with professionals and from person-
al experiences with narcoanalysis that psychoanalytic principles operationally defined and experimentally tested re-
were of very little use in the treatment of neuroses. . . . Leo search studies.
Reyna arrived as a gift from heaven at the end of 1946 . . . he The effect of environmental stimulation in directing
spent three years in South Africa and we met on countless occa- the individual's behavior was continually emphasized.
sions .... One thing he did was to encourage me to rework for
publication my M.D. thesis based on the cat experiments. Hypothetical "inner" concepts, such as the uncon-
(Wolpe, personal communication, 1974) scious, ego, cognition, and internal dynamics (even
such concepts as heredity and maturation), were totally
Another important influence in the 1940s on the eschewed or at least consistently deemphasized.
clinical-experimental linkage was the work of a group The approach to "maladaptive" behavior as to all
of investigators at Yale (Sears, Miller, Mowrer, and behavior was through a psychological rather than a
Doob) who attempted to develop a "learning theory" "medical" model. Hence, the behavior therapist dealt
basis for psychoanalytic formulations. E. Lakin Phil- directly with behavior rather than indirectly with un-
lips is prototypical of a small group of investigators derlying or "disease" factors that "cause" symptoms.
who were influenced by psychoanalysis in the late The psychological model may have been labeled as
1940s, as well as being influenced by learning theo- "social learning" or as "social reinforcement," terms
rists of the period (e.g., Hull Guthrie, Spence, the Yale used to emphasize the observation that other human
Group), and eventually shifted away from the psycho- beings are a source of meaningful stimuli that alter,
analytic into a behavioral-learning application in psy- direct, or maintain the individual's behavior.
chotherapy. Phillips' 1956 book, Psychotherapy: A The major commonalty in these investigators was
Modern Theory and Practice, illustrated a learning "the insistence that the basis of treatment stems from
theory approach independent ofthe Skinnerian or Wol- learning theory, which deals with the effect of experi-
pean streams. Salter's (1949) book also offered a be- ence on behavior. . . . The basis of behavior modifica-
havioral theory of maladaptive behavior and specific tion is a body of experimental work dealing with the
therapeutic procedures. relationship between changes in the environment and
Eysenck (1949) published an important article on changes in the subject's responses" (Ullmann &
training in clinical psychology from the English point Krasner, 1965, p. I).
of view. He criticized an American Psychological As- In effect, the terms behavior modification and be-
sociation Committee on Training because of their rec- havior therapy were used "to denote the modification
ommendation of including "psychotherapy" as a part of clinical and maladaptive behavior." Since the focus
of the training of clinical psychologists, in addition to was on behavior that was observable and definable, the
diagnoses and research. The reason for his concern concern of the therapist started with the question,
was that psychotherapy, as then practiced, was totally "What do we wish to accomplish through our applica-
Freudian; hence, according to Eysenck, "unscien- tion of learning theory?"
tific." Here was a clearly self-identified behavioral A classic review of the field of learning by Leo
scientist arguing for clinical psychology as a "sci- Postman (1947) started with the following observation
ence." Eysenck, of course, was to have a major role in which could be, and often is, repeated today:
the subsequent development of the behavioral
movement. Through history those concerned with the control of human be-
havior-parents and educators, businessmen and lawmakers-
It is useful to attempt to see the commonalties and
have acted on the belief that rewards and punishment are power-
general principles that have characterized the work of ful tools for the selection and fixation of desirable acts and the
those early post-World War II behavioral investigators. elimination of undesirable ones. This common sense view of
the nature of learning has not received undivided support from series of programs to develop community relevant be-
the professional students of behavior. Almost forty years after haviors, such as seeking jobs, attending social func-
the first enunciation of the law of effect as a formal doctrine of
learning, the problem of reinforcement is still the subject of tions, and living in halfway houses and other commu-
heated controversy among the proponents of rival theories nity facilities.
of learning. (p. 489) Implicit in the behavioral approach has been a re-
conceptualization of the group of behaviors generally
Postman then went on to what may well represent labeled as schizophrenia from that of being a product
the first usage of the term behavior modification in of disease to that of a product of social learning . Three
print: "Mowrer's interpretation of effect or a satisfying facets of the research in this area have been (1) to
state of affairs is frankly and emphatically hedonistic. demonstrate the modifiability of specific schizo-
Ultimately all behavior modification is mediated by phrenic behaviors, such as abstract thinking; (2) to
pleasure (tension reduction)" (p. 500). analyze the behavior of schizophrenic patients in terms
In experimental psychology, the studies of such in- of their success in "impression management" and ma-
vestigators as Skinner, Hull, Spence, and Guthrie were nipulative tactics; and (3) to demonstrate that "schizo-
beginning to have influence not only within the re- phrenic" behavior can be produced in "normal"
search field but also extending toward clinical applied individuals.
areas. In the "neurotic" category, "anxiety" and "depres-
sion" were among the first behaviors with which be-
havioral investigators reported success. It was Ferster
Target Behaviors (1965) who first noted that the loss of a close friend or
relative constitutes a sudden shift or reduction in the
An important aspect of the behavior modifica- schedule of reinforcements maintaining many behav-
tion/therapy movement has been the notion of "target iors of an individual, and that a reduction in the rate of
behavior" being changed, modified, and treated. a person's behavior would be a logical consequence
There is virtually no human behavior that has not been following the death of a close relative or the loss of the
studied or systematically influenced by one or more source of his social reinforcers. Lazarus (1958) con-
behavioral-intervention procedures. We will focus on a ceptualized depression as a response to "inadequate or
broad overview of the problems, populations, and insufficient reinforcers." The studies of these investi-
techniques that have been investigated with emphasis gators was the forerunner to the later behavioral ap-
on the early studies that have served as the basis for the proach to depression.
more recent enormous growth of applications. An early trend in the application of behavior thera-
It was in the area of the most seriously disturbed and py, insofar as populations served were concerned, was
deviant of human behaviors that the behaviorists of the to go in an opposite direction from traditional psycho-
applied behavior analysis type first initiated their therapy. In contrast with the initial focus of evocative
work. The 1949 Fuller Study, previously cited, illus- therapy on the YAVIS (young, attractive, verbal, intel-
trated the initial approach to those considered (in the ligent, successful), the behavior therapist started with
1940s) least approachable-the retardates. The first the unattractive, mute, retarded person, the one on
usage of the behavior therapy terminology was by whom everyone else had given up. For example, it is in
Lindsley, Skinner, and Solomon (1953) in conjunction the field of working with mentally retarded individuals
with institutionalized "psychotics." Later studies that behavior therapy first had a major impact and has
focused on the development of adaptive behavior in the advanced to the point where now it is "the treatment of
hospital environment, such as self-care, performing choice." In contrast, it has only been relatively late in
jobs on and off the ward, taking medication, participat- behavioral history that the YAVIS are getting their just
ing in various activities, cleaning one's room, decreas- due as behavior therapy moved into the counseling
ing reports of delusions and hallucinations, altering a area, as desensitization became appropriate to the full
large variety of bizarre and antisocial behaviors, such range of "neurotic" disorders, as token economies
as aggression, screaming, crying, not eating, hoard- moved into the home, school, and community, and as
ing, compulsive hand washing, and the like. The focus the social-psychological views predominated in the
has been on increasing skills in what was severely approaches to the problem behaviors of everyday life.
deficit areas, such as speech, social interaction, and The field of physical rehabilitation was also strongly
communication. Then came an extension to a whole influenced by behavioral techniques. Developments in
behavioral medicine have extended the behavioral or clinic and hoping that it will "carry over" to another
concepts to virtually the entire population as profes- situation, such as the home.
sionals deal with the full range of human behaviors A series of studies were developed that were de-
implicit in the concept of "health." signed to enhance and develop behavioral procedures
in the real environment. Ferster and Simmons (1966)
stressed the use of natural reinforcers available in the
Behavioral Techniques environment (determined by careful observation) in
shaping new behavior of young children, in contrast
There are many "helping" techniques that derive with the more rigid dependence upon food, which was
from behaviorist theory, and they are constantly being derived from animal experimentation. Patterson
expanded and revised. The techniques that involve the (1970) presented an overview of behavioral-interven-
systematic presentation of positive consequences to tion procedures in the home and in the classroom. He
influence behavior derive primarily from the early op- offered a key element in behavior therapy by viewing
erant conditioning studies. As we have noted, Fuller intervention as "attempting to modify the dispensers
(1949) was the flrst investigator to present a report of which provide" reinforcement contingencies in the so-
the deliberate application of operant conditioning in a cial environment. Most of the studies that used
clinical setting by shaping arm movements with a positive reinforcement also involved training indi-
warm sugar-milk solution in an 18-year-old "vege- viduals in the techniques of reinforcement, including
tative idiot." how to observe and how to reinforce behavior. Such
Subsequent research was strongly influenced by the training was done individually and in groups with the
previously mentioned Lindsley et al. (1953) studies at aid of training devices, such as fIlms, closed circuit
Metropolitan State Hospitai. The studies reported TV, and "bug-in-the-ear," in the laboratory, in the
within this framework were increasingly characterized home, and in the schoolroom. The training itself was
by greater ingenuity (artistry) in techniques, a greater done by the psychologists, by technicians, by parents,
range of problem behaviors tackled, and greater so- and by teachers.
phistication of design. Those studies which demon-
strated experimentally that the stimulus manipulations
Verbal Conditioning
were responsible for the behavioral change that was
produced were distinguished from the studies which Research in the area of verbal conditioning has been
used operant techniques in a nonexperimental manner. one of the major and earliest linkages between the
These latter did not conclusively demonstrate that rein- experimental laboratory and clinical applications
forcement techniques were functional in causing the (Krasner, 1958). The importance of this aspect of be-
behavioral change. havior therapy lies in the nature of the behavior in-
The research studies based on operant conditioning volved, namely, human verbalization. The first verbal
placed major emphasis on the use of contingent rein- conditioning study to attract widespread attention was
forcement to strengthen speciflc behavior. Generally, that of Greenspoon (a doctoral dissertation in 1949 and
the studies failed to emphasize the social influence published in 1955) in which he used a simple verbal
base to which the speciflc operant training procedures response to influence the frequency of emission of the
were added. One exception were the studies of Agras, verbal response class of plural nouns. From such hum-
Leitenberg, Barlow, and Thompson (1969), which in- ble beginnings have grown reams of research, doctoral
dicated that reinforcement is necessary for, and adds dissertations, controversy, and an approach to key is-
to, the social influencing effects of instructions, thus sues of social influence. In fact, Dollard and Miller
linking their operant work to the social influence (1950) seized upon the early reports of Greenspoon's
process. flndings to demonstrate their belief that changes in
In a paper that later became a "citation classic," verbalization in psychotherapy were "automatic and
Baer, Wolf, and Risely (1968) made the astute and unconscious." Whether this assessment was accurate
highly relevant comment that "generalization should or not (still a major controversy) Dollard and Miller
be programmed rather than expected or lamented." did anticipate the theoretical importance of verbal con-
This view represented an alternative to the usually ditioning for clinical psychology.
futile approach of changing behavior in the laboratory In an early review of this fleld, Kanfer (1968) ar-
gued that research on verbal conditioning has under- were interested in the process of psychotherapy, which
gone four stages: (1) demonstration, (2) reevaluation, during the early 1950s was primarily of the evocative
(3) application, and (4) expansion. This was a useful model. Here, at last, it seemed as if operant condition-
way of summarizing these studies particularly as they ing offered a technique for setting up an analogue of
are related to behavior therapy research. The four psychotherapy in a rigorously objective manner. It is
stages were prototypical of the development of most of clear now that verbal conditioning and psychotherapy
the behavioral techniques. The studies in the first stage are not the same identical process nor is one an ana-
demonstrated that verbal behavior could be brought logue of the other. However, some verbal conditioning
under control of environmental stimuli and that verbal does take place in evocative psychotherapy, and some
behavior followed the same principles as human motor of the relationship variables of the latter cannot and
behavior and that of animal behavior. It became clear should not be eliminated from the former.
that reinforcement, under certain conditions, can sys- Almost every conceivable variable in the psycho-
tematically influence verbal behavior. The second therapy situation has been investigated in hundreds of
stage, that of reevaluation, demonstrated that what studies, often with contradictory findings. The major
was being dealt with was a far more complex phe- uncontrolled variable has been the examiner: his or her
nomenon than at first was evidenced by a simple oper- expectancies, biases, and the complex interactions of
ant explanation. Responsivity to verbal conditioning his or her reinforcing characteristics with other situa-
was affected by variables, such as social settings, pre- tional variables. It has been the sensitivity of verbal
vious experience with the examiner, expectancy, varia- conditioning to the many variables of human interac-
tions in the meaning of reinforcing stimuli, and other tion which has emphasized its usefulness as a research
interpersonal variables. In the third stage, that of ap- tool.
plication, operant conditioning was used to specifical-
ly change verbal behavior with a therapeutic intent
Token Economy
(e.g., Williams & Blanton, 1968, reported a study in
which verbal conditioning was used as a deliberate One of the techniques emerging from the early oper-
"therapeutic" technique and found to be as effective as ant studies has been the use of tokens in place of pri-
traditional psychotherapeutic procedures). The fourth, mary reinforcers. A. W. Staats, C. K. Staats, Shutz,
or expansion, stage of development involves those and Wolf (1962) were the first to utilize a back-up
studies investigating theoretical issues related to the reinforcement system in a reading discrimination pro-
capability of human beings for self-regulation. These gram. They used tokens exchangeable for a variety of
included such processes as vicarious learning, the role edibles and toys. This meant that the therapist, or ex-
of awareness in learning, self"reinforcement and self- perimenter, was no longer dependent upon the mo-
control, and the associative relationship of words. mentary desirability of an object, for example, M &
Investigators focused on the environmental cues Ms. Tokens opened up an almost limitless world of
that may serve as reinforcers (i.e., food, cigarettes, reinforcers.
smiles, toys, tokens, head nods, "very good," etc.) as The first report of a token program in a psychiatric
well as what kind of verbal behavior may serve as a hospital was that of Ayllon and Azrin (1965, 1968).
response class. Salzinger (1967) reviewed the many This program evolved from previous techniques of
studies on defining the response class in verbal condi- Ayllon and his associates that applied the earlier Skin-
tioning and offered several ways of describing the ner-Lindsley principles of contingent reinforcement to
"complexities" involved in determining what a re- shape desirable behavior. The early work of Ayllon
sponse class is. and Michael (1959) in training the psychiatric nurse as
Goldiamond and Dyrud (1968) explicitly extended a behavioral engineer, and the use of satiation as an
the operant investigation of verbal behavior into the aversive procedure, opened the way for the introduc-
area of behavior analysis of the psychotherapy pro- tion of the more encompassing token program. The
cess. They made the same observation that many of the Ayllon and Azrin token program functioned at a ward
early verbal conditioning experimenters had; namely, in a mid-Western state hospital with a population of
that there is a similarity between the operant condition- long-term female patients.
ing strategy in research technique and clinical interest In a later study, Atthowe and Krasner (1968) re-
in verbal behavior. Many of the early investigators ported the successful use of a token economy program
in a Veterans Administration hospital in California stitution and the community itself with adults who had
with patients of up to 24-years hospitalization. serious disturbed behaviors.
Schaefer and Martin (1969) reported the effectiveness An early example of a token program extended into
of a token program in modifying a specific behavior, the home with relatively intact individuals was re-
that of "apathy." The significance of this program lies ported by Stuart (1969) who worked with four separate
in its reconceptualization of traditional patient with- couples who had sought help for marital problems.
drawal as "apathy," operationally specifying the spe- Labeling his approach "operant interpersonal," Stuart
cific behaviors that are included in this more general stressed the importance of constructing situations that
category, and the shaping of alternative, mutually ex- could increase the intensity of interpersonal reinforce-
clusive behaviors that are prosocial. Since these early ment. He trained his clients in the gamelike procedure
token programs, similar techniques have been ex- called "prostitution," of setting up a token program in
tended to other hospital wards, institutions for retar- the home facilitating the exchange of such items as
dates, delinquents, the schoolroom, and the communi- relevant talk and sexual intimacy.
ty (Kazdin, 1977).
Winkler (1971) reported a series of research on
Desensitization
token economy programs that extends this technique
into an important new dimension, that of testing pre- In terms of sheer output of research, the desensitiza-
dictions from economic theory, thus studying the core tion branch of behavior modification/therapy ranks
of token programs. He investigated the complex rela- close to that of positive reinforcement. As a technique
tionships between the variables of prices, wages, and that involves the gradual substitution of a favorable
savings, and how they influence individual behavior. (i.e., relaxation) response that is incompatible with an
Token economies were found to operate according to unfavorable (i.e., anxiety) response to a stimuli, de-
principles similar to those that economists have found sensitization has had many diverse clinical forebears.
in national, money-based economies. Token econo- These include techniques labeled as deconditioning,
mies not only look like "real" economies, they func- reconditioning, associative inhibition, and autogenic
tion like them, and research in this field has linked training. However, it was Wolpe's (1958) version of
behavior therapy with social and "Utopian" planning. reciprocal inhibition that eventually stimulated the
The use of reward itself in the classroom is, of outburst of research and clinical application, which
course, not new, but the systematic use of contingent was to characterize the next several decades.
reinforcement by a teacher trained in the procedure The term systematic desensitization has become
does represent a basic change. The principles behind widely used to designate the technique to achieve the
the use of tokens in the classroom-contingency rein- goal of response substitution. Wolpe (1958) conceived
forcement of desirable alternative behaviors-is the of systematic desensitization as "the breaking down of
same as in mental hospitals, but there are problems neurotic anxiety" (p. 91). Based on the "conditioned
unique to the nature of the classroom. O'Leary and inhibition" notions of Hull, Wolpe devised a series of
Becker (1967) introduced the first use of a token rein- animal experiments that resulted in the development of
forcement program to control a large class (n= 17) of a technique of replacing an anxiety response by a relax-
emotionally disturbed children. The utilization of a ation response. Jacobson's (1938) technique of pro-
token program resulted in a decrease of average disrup- gressive relaxation offered the possibility of a response
tive behavior (talking, noise, pushing, and ,eating) that could be influenced by the therapist and that, when
from 76% in the baseline period to 10% during the 2- developed, would be incompatible with anxiety.
month token period. Wolpe paired muscular relaxation with visualized
A major development was the extension of the token scenes and objects to which inappropriate anxiety re-
programs beyond the hospital and schoolroom directly sponses had been made. Paul (1966) described a relax-
into the community. L. K. Miller and O. L. Miller ation procedure that can be taught in half an hour. The
(1970) introduced the notion of freedom money, a potentially threatening situations with which relaxa-
token economy approach to organizing self-help action is paired range in a series of hierarchies moving
tivities among low-income families. Henderson and from the least to the most threatening. There have been
his group at Spruce House (1968) reported a token a number of early "explanations" of systematic desen-
program that bridged the gap between residential in- sitization that attributed change to "habituation"
CHAPTER I • HISTORY OF BEHAVIOR MODIFICATION 17
(Lader & Mathews, 1968), to operant conditioning ther assumed that these arousal processes, operating
(Leitenberg, Agras, Thompson, & Wright, 1968), to primarily at the central level, exercise some degree of
attribution theory (Val ins & Ray, 1967), to interper- control over instrumental avoidance responding" (p.
sonal strategies, and to a Jungian analysis (Weitzman, 173). Bandura's (1977, 1986) research and general
1967). theories of identification have forged a major link be-
tween the experimental laboratory and real-life modi-
fication of behavior.
Modeling
The deliberate use of the behavior of the therapist (or
Modeling and the use of vicarious processes in the an individual trained by him or her) as an example,
acquisition and modification of patterns of behavior illustration, or model to influence the behavior of an-
have become important techniques of behavior thera- other person has occurred in the one-to-one interview,
py. Bandura (1969) summarized a large range of re- has been combined with reinforcement in training a
search, which through the efforts of investigators, such retarded child, has been used as an "observational
as Bandura, Kanfer, Lovaas, Baer, and their collab- learning opportunity" with juvenile delinquents, has
orators, became an integral part of behavior been used via a film depicting social interaction be-
modification/ therapy: tween children to enhance social behavior in preschool
isolates, has helped alleviate fear of dogs in preschool
Research conducted within the framework of social-learning the- children by filmed models, and has been used in treat-
ory demonstrates that virtually all learning phenomen:. resulting
from direct experiences can occur on a vicarious basis through ing snake phobias.
observation of other persons' behavior and its consequences for
them .... Modeling procedures are, therefore, ideally suited
for effecting diverse outcomes including elimination of behav- Control of Autonomic Functions
ioral defects, reduction of excessive fears and inhibitions, trans-
mission of self-regulating systems, and social facilitation of be- One of the most important early developments, both
havioral patterns on a group-wide scale. (Bandura, 1969, p. 118) theoretically and practically, was the demonstration
that selected autonomic responses could be strength-
Research investigators in this area have used a vari- ened by reinforcement after their emission. Tech-
ety of labels under which to classify their work, such as niques were developed for the direct training of auto-
modeling, imitation, vicarious learning, vicarious re- nomic systems through exteroceptive feedback and
inforcement, identification, and contagion. The ap- operant shaping techniques. Lang (1970), in the first
plication of modeling procedures to the modification comprehensive review of the research of autonomic
of specific kinds of behavior has occurred within two control, credited Shearn (1962) with first demonstrat-
different but not mutually exclusive conceptual frame- ing the operant conditioning of heart -rate acceleration.
works. Those working within the operant framework Shapiro, Tursky, Gershon, and Stem (1969) suggested
have tended to view the introduction of modeling pro- that blood pressure may be brought under control via
cedures as an additional training technique to elicit feedback and reinforcement. Lang, Stroufe, and Hast-
behaviors. Baer (1968) summarized the approach to ings (1967) also reported that heart rate may be sta-
the use of imitation, particularly in its use in eliciting bilized within narrow limits when feedback is
verbal behavior in children. Baer described the initia- provided.
tion of his research "not from a basis of clinical ambi- States of psychophysiological relaxation were pro-
tion to improve behavior, but rather out of a curiosity duced by the use of electromyograph feedback from
about the fundamental nature of imitation. Is imitation striate muscles. Stoyva (1968) and Kamiya (1968)
a type of learning qualitatively different from operant demonstrated that people can be taught to control some
conditioning, or only a more complex organization of of their own brain wave patterns by hearing a feedback
the results of operant conditioning than is the simple buzzer whenever the desired pattern is occurring. They
discriminated operant?" (p. 12). learn to associate their subjective mental state with the
On the other hand, a study of Bandura, Blanchard, buzzing so that by reproducing that mental state they
and Ritter (1969) is placed within the "dual-process can reproduce the brain wave patterns whether or not
theory of avoidance behavior." According to this view, the buzzer is on.
"threatening stimuli evoke emotional arousal which The animal experiments of N. E. Miller and his
has both autonomic and central components. It is fur- associates (N. E. Miller and Dieara, 1967) on cura-
rized rats provided the first sophisticated and convinc- ment or self-improvement, as well as the formation of
ing demonstrations of operant control of autonomic thousands of new mutual-aid organizations in which
functions. Miller argued that psychosomatic condi- people could discuss their problems with others who
tions may develop through contingent attention and were similarly in trouble." This development was
other reinforcing consequences. It should then be pos- based on the studies that "showed that individual well-
sible to modify the visceral responses that occur in being depends more on behavior than on miracle cures,
psychosomatic disorders by extinction and differential giving people renewed reason to diet, exercise, and
reinforcement. quit smoking." Although the influence of the behav-
The work of this group of investigators was to pro- ioral movement was not the sole effect on the develop-
vide some of the basic experimental underpinning of ment, it certainly was a major one.
the current field of behavioral medicine. Glasgow and Rosen (1978, 1979) reviewed "self-
help behavior therapy manuals" and noted the great
proliferation of materials in this area. They cate-
Aversive Procedures
gorized the materials in terms of the behavior problems
Aversion therapy was, and may still be, the most on which the various manuals are designed to focus:
controversial of the major behavioral techniques in phobias, smoking, obesity, sexual dysfunctions, as-
terms of theory and ethical implications. Individuals sertiveness, child behavior problems, study skills,
have always used noxious stimuli to influence the be- physical fitness, academic performance, depression,
havior of other individuals, sometimes to coerce them, and marital and interpersonal problem-solving skills.
sometimes to treat them, sometimes one under the The reviewers covered approximately 150 "commer-
guise of the other. Within the context of behavior ther- cially published or empirically evaluated behaviorally
apy, there are two broad types of aversive methods, oriented books." They pointed out that there are, of
those derived from operant and those derived from course, many more self-help articles in newspapers
classicalleaming theory. and magazines, and a growing number of audio and
Bandura (1969) categorized "aversive control" into video tapes that train you on doing it "yourself."
the use of negative reinforcers, the use of aversive
contingency systems, and the removal of positive rein-
Social Problems and Social Change
forcers. Kanfer and Phillips (1970) distinguished be-
tween punishment (an aversive stimulus contingent on Developing from the Utopian stream of behaviorism
a response expected to decrease its frequency) and es- has been an extension of the usage of behavior modifi-
cape and avoidance (an organism that is under noxious cation/therapy to an increasing usage to bring about an
stimulation is reinforced in any act which terminates amelioration of social and ecological problems in the
the stimulus). natural environment. In Walden II (1948), the pro-
totypical behavioristic Utopia, Skinner tackled the de-
sign of a total society. Subsequent investigators, influ-
Self-Control and Self-Help
enced primarily by the applied behavior analysis
The term self-control has found increasing use approach, focused directly on specific problem situa-
among behavior therapists. One way of utilizing it has tions of life in highly complex industrial societies. Just
been to represent internal mediating events. However, to mention the areas in which these applications have
in a broad sense, all of the behavior therapy procedures occurred is tantamount to offering a catalog of societal,
may be viewed as training in self-control conceived of social, and environmental problems in the second half
as the individual regulating his own behaviors by ar- of the twentieth century: pollution control; energy con-
ranging appropriate contingencies. Kanfer (1970) of- servation; littering; recycling waste material; mass
fered a slight variation in terminology by describing transportation; stress; noise; job performance; obtain-
his research as self-regulation. ing employment; community self-government; racial
In its review of developments in science in the dec- integration; and military training. The quantity and
adeof the 1970s, the New York Times (January 1, quality of studies in these areas have grown at an accel-
1980, p. 14) noted under Behavior that "more than erating pace, particularly in the decade of the 1970s
anything else in the 1970's people helped themselves." (e.g., Geller, 1973; Hayes & Cone, 1977; R. 1. Jones
The concept of "self-help encompasses the enormous & Azrin, 1973; Kazdin, 1975; Pierce & Risley, 1974;
number of books and courses promoting enlighten- Winett & Nietzel, 1975). In effect, a new field of be-
havioral community psychology has emerged (Glen- search, such as reinforcement, stimulus control,
wick & Jason, 1980; Martin and Osborne, 1980; punishment, and extinction. Many, if not most, of the
Nietzel, Winett, Mcdonald, & Davidson, 1977). techniques used in community applications illustrate
Behaviorists ofthis period were stressing a new/old applied behavior analysis.
theme; namely, the urgency of the solution of environ- The neo-behavioristic mediational S-R model in-
mental problems in Society and the belief that the be- volves the application of the principles of classical
haviorists may have the skill to contribute to the solu- conditioning derived from the earlier work of Pavlov,
tion. The postwar theme of developing a "better Hull, Guthrie, Mowrer, Miller, and Wolpe and has
society" as the goal of the behaviorists thus returned, been most responsible for integrating this material into
although it actually has been part of the behavioral a systematic treatment approach. Concepts of inter-
stream throughout its history. vening variables and hypothetical constructs, particu-
Attempts to influence littering behavior (Geller, larly those of Hull (1943, 1951) and O. H. Mowrer
1973) were the first systematic research of the behav- (1939, 1960), warrant the usage of a mediational ter-
iorist in the environmental area, and these have be- minology. This is further exemplified by the usage of
come prototypical of later extensions to other environ- unobservable processes, such as the use of the imag-
mental problems. Such studies have generally ined representation of anxiety-eliciting stimuli in sys-
emphasized either prevention of littering by investigat- tematic desensitization. Although the applied behavior
ing antecedent events or more generally have focused analyst would not accept the purity of this approach,
on reinforcing litter removal. The related area of recy- those influenced by Wolpe still consider themselves as
cling (a specific and important aspect of the proper good behaviorists since the mediational processes are
disposal of litter) has also been systematically investi- placed within a stimulus-response context. The Wol-
gated by the behavior analysis group (Geller, Chaffe, peans, despite the use of symbolic processes such as
& Ingram, 1975). images, still vehemently eschew (as, of course, do the
Skinnerians) the utilization of cognitive formulations.
It is the newest group of behavior therapists who
On Later Terminology-The Second proudly utilize the term and concept cognition to de-
Wave note their approach to intervention procedures (Ma-
honey, 1974; Meichenbaum, 1977). These investiga-
Developments in behaviorism since 1975 can be re- tors emphasize the importance of, and focus on,
ferred to as the "second wave." The emphasis in this cognitive processes and private events as mediators of
period was on ways of categorizing behavior therapy, behavior change. Key concepts of this group include
which increasingly was becoming fractionated. [The assumptive models of reality, attributions of one's own
ways of describing the different approaches in the be- behavior and that of others, thoughts, images, self-
haviortherapy scene are in terms of "applied behavior statements, self-instruction, sets, response strategies,
analysis," a "neo-behavioristic mediational model," and other similar terminology to account for "cog-
"social learning theory," "cognitive behavior modifi- nitive processes."
cation," and "multimodal behavior therapy" (Kazdin The social learning approach to behavior therapy
& Wilson, 1978).] has been most clearly and comprehensively concep-
Applied behavior analysis is used to describe those tualized by Bandura (1969, 1976, 1977b). Behavioral
investigators whose application of operant principles response patterns are influenced by external stimulus
derived from the Skinnerian influence in a wide range events (primarily through classical conditioning), by
of clinical and social institutions. These are the "radi- external reinforcement and, most importantly, by cog-
cal behaviorists" whose basic assumption is that be- nitive mediational processes. Behavior change is ef-
havior is a function of its consequence. Intervention fected primarily through a symbolic modeling process
procedures are evaluated in terms of single-case ex- in which learning occurs through observation and the
perimental design in which the subject serves as his or coding of representational processes based upon these
her own control. observations or even upon imagined material. Social
Applied behavior analysts utilized environmental learning theory emphasized the reciprocal interaction
variables to effect behavioral changes. A wide range of between the individual's behavior and the environ-
intervention techniques have been developed based ment. The individual is considered to be capable of
upon principles generally derived from laboratory re- self-directed behavior change. Bandura (1977a) has
integrated the social learning approach in the concept Medicine (Schwartz & Weiss, 1978a,b), supported by
of "self-efficacy," which emphasized the individual's the National Institute of Health, which really gave birth
expectations about his or her own behavior as he or she to this new social research movement.
is influenced by performance-based feedback, vi- This conference set up the definition, scope, bound-
carious information, and psychological changes. aries, and guidelines for this new field. It touched upon
Lazarus's (1971) concept of multimodal behavior organizational and publication outlets. Very quickly
therapy remains highly controversial as to whether it two organizations were formed in 1978 and 1979, the
really belongs within the fold of behavior therapy or Academy of Behavioral Medicine Research, and the
goes "beyond." Krasner (1980) and his collaborators Society of Behavioral Medicine (with the psychiatrist
utilize the concept of "environmental design" in an Stewart Agras as first president). Soon a publication
approach to behavior change which links applied be- appeared on the scene-the Journal of Behavioral
havior analysis and social learning concepts with ele- Medicine. Finally, to give full governmental sancti-
ments of environmental psychology, "open educa- fication of this new development, there was organized
tion," architecture, and social planning. a "Behavioral Medicine Branch" of the National
Thus, in the 1970s, the self-identified behaviorists Heart, Lung, and Blood Institute of the National In-
emerged from the laboratory, the clinic, and the mental stitutes of Health. Behavioral medicine had, indeed,
hospital to the "natural" social environment. They made it big!
were guided by earlier applications of behavioral prin- In addition to the multitude of research publications,
ciples in schoolrooms and hospitals and were also in- there appeared a considerable number of books (P. O.
fluenced by national concerns and debates on the so- Davidson & S. M. Davidson, 1980; Ferguson & Tay-
cial issues of the 1960s. A new generation of lor, 1980; Melamed & Siegel, 1980; Pomerleau &
behaviorists began to take on the total natural and man- Brady, 1979; Stuart, 1982). As might be expected,
made environment as the focus for investigation and with the outpouring of publications reflecting the
social change with a purpose-namely, a "better en- views of the major investigators in a new field, there
vironment" for members of society. soon was considerable controversy over the definition,
identity, and key issues in this latest manifestation of
behaviorism.
Behavioral Medicine
It must be noted that in the very same time-frame
Of all of the areas in which behaviorism historically within which behavioral medicine developed, another
has affected human behavior the most is in the field of new field was also in the process of developing, using
"health." We have described the manifestation of be- the label of health psychology. Was this to be a genu-
haviorism in the form of behavior modification and inely differentiated field, with an aspect of human be-
behavior therapy, and their interaction with Society in havior of its very own to study, or were we to be deal-
the 1960s and 1970s. In the mid-1970s and early ing with issues of professional territoriality?
1980s, the term behavioral combined itself with medi-
cine (Agras, 1982; Brownell, 1984).
Behavioral Community Psychology
Edward Blanchard (1982), in the introduction to a
special issue of the Journal of Consulting and Clinical The postwar brand of behaviorism, initially in the
Psychology devoted completely to behavioral medi- laboratory, and developed as we have described,
cine, noted that he first became aware of the term moved on into the clinic, the mental hospital, and the
behavioral medicine in the title of Lee Birk's (1973) schoolroom in the 1950s and 1960s. Then, in the early
edited book, Biofeedback: Behavioral Medicine. So at 1970s, the self-identified behaviorists (labeled as be-
least for the moment, Birk appears to warrant the man- havior modifiers or applied behavior analysts)
tle of term originator. emerged from the laboratory or mental hospital to the
The next development of this significant label came "natural" social environment. This new generation of
in 1974 when John Paul Brady and Ovide Pomerleau behaviorists were influenced by national concerns and
established the first clinical research center to use the debates of the social issues of the 1960s. They began to
term, Center for Behavioral Medicine, at the Univer- tackle the total natural and man-made environment as
sity of Pennsylvania. In 1975, the Laboratory for the they focused on systematic investigation. Their goal
Study of Behavioral Medicine was formed at Stanford. was to develop a better environment for members of
In 1977, it was the Yale Conference on Behavioral society. The Utopian influence was still at work.
For example, Nietzel et al. (1977) provided a chap- its well-documented record of success in the treatment
ter (in a book appropriately entitled Behavioral Ap- of the neuroses, behavior therapy is little taught in
proaches to Community Psychology) on "environmen- departments of psychiatry because of an inaccurate
tal problems" covering the topics of "litter control, image based on misinformation" (p. 192). In effect,
recycling, energy conservation, transportation, archi- according to Wolpe, the theoretical and practical his-
tectural design and population change" (p. 310). torical roots of behavior modification/therapy have
They confidently concluded that "the research on been deviated from, misunderstood, and misrepre-
littering and recycling has focused on procedures that sented.
are simple, inexpensive, and can be applied on neigh- As in every aspect of every issue in the field of
borhood and community levels. Their successful dis- behavior modification/therapy, there are mixed, con-
semination . . . will depend on both economic contradictory sets of views. Perhaps that in itself is what
siderations and the skillful use of the media to promote makes this such an exciting field. In contrast to the
such programs. The next step likely will involve the pessimism of Skinner and Wolpe, there are, of course,
development of more powerful reinforcers and the many positive, optimistic views of the current status of
demonstration that a large-scale environmental protec- the behavior modification/therapy field. Franks and
tion program can be implemented and supported by Rosenbaum (1983) in the introduction to their Perspec-
communities" (p. 310). tives on Behavior Therapy in the Eighties contend that
Here indeed was a new theme from the behaviorists,
namely, the urgency of the solution of environmental Behavior therapy as it now stands, then, is healthy despite, or
perhaps because of, its variations and complexity. But it does
problems of society and the belief that the behaviorists present certain problems for the practitioner as well as the re-
may have the skill to contribute to the solution. searcher. How the behavior therapist practices, what techniques
to use, the approach to problems of strategy, and even the matter
of patient/therapist relationships will inevitably depend upon the
explicit theoretical orientation of the clinician concerned and the
Onward and Upward? implicit philosophical and cultural milieu prevailing at the time.
(p.8)
One important current development is the recent
concerns and criticisms of two of the most influential This view nicely expresses cautious optimism and is
of the creators of the original behavior modifica- an appropriate note on which to conclude this history
tion/therapy paradigm, Fred Skinner and Joe Wolpe. of behavior modification/therapy.
Their views have been expressed in recent publica-
tions.
The title of Skinner's (1987) American Psychologist References
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CHAPTER 2
The Experimental and Theoretical

Foundations of Behavior
Modification
Donald J. Levis
Introduction Crocetti (1958) estimated that between 14 and 20 of

every 1,000 children born will be hospitalized in a
Critical issues related to the area of psychological as- mental institution within their lifetime. Srole and his
sessment and treatment of human psychological distur- co-workers (Srole, Langner, Michael, Olper, & Rin-
bance, which are topics of this volume, have been nie, 1962) reported that fewer than one out of four
addressed numerous times in an already vast and ex- persons was judged to be psychologically healthy, and
tensive published literature. Yet, despite these past nearly one out of five persons was considered to be
efforts, the scholarly search to establish integrative "incapacitated" by psychological disturbance. Recent
lawful statements about human psychopathology, attention has also been devoted to the possibility that
which lead to increased precision in assessment and between two thirds to three quarters of presenting
treatment, is still an ongoing process. The quest to physical problems may be affected by and related to
identify, establish, and develop effective methods of psychological factors. Further, the field's past tenden-
treatment has been retarded, in part, by a mental health cy to rely heavily on chemotherapy as an immediate
field plagued by conceptual diversity, training inade- solution has undergone a serious challenge as an ap-
quacies, and a lack of consensus in the need to objec- proach which, at best, is simply providing a "holding"
tify the validity of a given theoretical model and treat- period and, at worst, an approach that results in actu-
ment approach. ally delaying or preventing an individual from dealing
Compounding the above problem is an enormous with the issues that prevent corrective behavioral
pressure placed on the mental health field resulting change.
from a dramatic increase in the number of individuals Society'S demand for an immediate solution to the
requesting solutions to their psychological problems. growing crisis in the mental health field for effective
The cost to society in terms of human suffering, loss of service has put an enormous pressure on an already
productivity, and dollars is staggering. Lernkow and disjointed profession. Responses to this crisis have
been characterized as slow, inefficient, and ineffec-
tual. Existing psychotherapy movements that have
Donald J. Levis • Department of Psychology, State Univer-
sity of New York at Binghamton, Binghamton, New York dominated the field throughout most of this century,
13905. such as psychoanalytic, Gestalt, existential, human-
27
istic, and cognitive approaches, have produced the- fears of failing, losing control, taking responsibility,
oretical structures that lack operational specificity and expressing anger, or showing love and affection.
ease of testability. Treatment techniques from these Given the above diversity of unusual and puzzling be-
positions are costly, lengthy, and of dubious effect. havior, it is little wonder that the scientific search for
Claims of therapeutic efficacy frequently are not ac- the causes of abnormal behavior, for the conditions
companied by sufficient research support, and the sup- that maintain such behavior, and for effective methods
port that is available generally falls short of incorporat- of treatment represent a task, which at first glance,
ing even a minimum degree of methodological appears to be insoluable.
sophistication. Eysenck (1960, 1966), perhaps more
than others, has cogently and at times tendentiously
The Behavior Therapy Movement
championed this viewpoint. Newer approaches, like
the old, appear in large part to be unconcerned by the A serious attempt to recognize and resolve the above
critic's cry for objective assessment and for scientific critical issues resulted in the development in the late
evaluation of treatment effectiveness. Rather, it ap- 1950s and early 1960s of a new movement labeled
pears that many therapists have bent to the expedient behavioral therapy or modification. By the 19708, the
philosophy of the day that is unconcerned with such impact of this approach had gained full momentum.
matters and by the profit motivate that is greatly under- History would suggest, given the already existing
mining the humanistic values and principles histor- abundance of unproven theoretical and treatment ap-
ically associated with the mental health field. proaches, that the advent of yet another therapeutic
An additional factor compounding the current crises orientation should be viewed with a healthy skep-
is the recognition that the phenomena that are the ticism. Yet, despite the attempts of the behavioral ap-
province of psychopathology represent a diversity of proach to foster a particular viewpoint, something
mystifying behaviors that have challenged scholarly unique and previously unoffered was suggested. The
and scientific efforts for centuries. For example, confounding fathers recognized that if the existing chaos
sider a woman who is so terrified of water that she within the mental health field were to be resolved, a
wears a life preserver when she takes a bath, or a man new strategy was needed. The path chosen was to link
who abandoned his professional career because he was directly the applied clinical field with the basic re-
afraid to leave his home out of fear that dog feces might search fields of psychology, most notable that of the
be present in his yard. For the latter, the thought of field of learning. The vision was that such a marriage
becoming contaminated became so frightening that he would produce a solid experimental and theoretical
repeatedly engaged in washing his clothes, hands, and foundation upon which treatment techniques could be
body to obtain partial relief from his obsessive, anx- developed, assessed, and improved. This objective to
iety-electing thoughts. In a similar case, a woman be- mold clinical psychology into a scientific discipline
came so panic stricken by the fear of dirt and disease represents the central strength of the behavioral move-
that she required her husband to shower immediately ment, and the main reason this author (Levis, 1970a)
after he entered the house. Some individuals break out tentatively labeled this movement the "Fourth Psycho-
in a cold sweat at the sight of a car, tall building, therapeutic Revolution." (The first recognized psy-
airplane, or elevator, whereas others experience panic chotherapy movement was morale therapy; the second
when they leave their home, enter their basement, or was psychoanalysis; and the third, being the communi-
are exposed to crowds. Many people are so afraid of ty mental health movement; see Tourney, 1967.) Al-
their sexual feelings that they avoid the opposite sex, though the term behavior therapy actually encom-
become obsessed with the thought that they have can- passes a variety of different techniques and theoretical
cer or will hurt their own children, or are convinced justifications, each can attribute its origin to an attempt
they will die and be sent to hell. Or consider the behav- to extrapolate to the applied area basic research prin-
ior of hospitalized individuals who report that their ciples established in the learning and conditioning lit-
food contains captive people and worms, that they are erature. As a result, the uniqueness of this approach is
God, the Virgin Mary, or Jesus Christ, or lie huddled in reflected in its emphasis on behavior and its measure-
a fetal position, mute and unresponsive, occasionally ment, in its isolation of relevant environmental vari-
eating their own feces. Finally, it should be recognized ables, in its attempt to develop precise definitions and
that the behavior of many individuals labeled "nor- specifiable operations, and in its stress on experimen-
mal" are regularly altered or modified by anticipatory tal control (Greenspoon, 1965).
CHAPTER 2 • FOUNDATIONS OF BEHAVIOR MODIFICATION 29
The fruits of this approach have resulted in signifi- ment of related applied sciences can be shown to be a
cant contributions over the last 30 years to the clinical direct function of the practitioner's ability to draw on
treatment area reflected in the introduction of objective the established principles developed by basic re-
assessment procedures (see Hersen & Bellack, 1988) searchers in the area. Prior to the development of the
and a variety of new and promising treatment ap- behavioral approach to treatment, this strategy was
proaches at both the outpatient and inpatient levels (see largely ignored by the mental health field. The obliv-
Goldstein & Foa, 1980; Kalish, 1981; Kazdin, 1978). iousness of clinicians to the potentially huge volume of
Included in this arsenal are such established techniques human and subhuman data has markedly reduced com-
as token economy, biofeedback, stress management, munication among psychological areas within the
relaxation training, assertive and social skills training, field. As Ford and Urban (1967) suggested:
systematic desensitization, implosive (flooding) thera-
py, and behavioral medicine, to name a few. The be- One index of the viability and growth potential of a particular
havioral movement is also responsible for broadening therapeutic approach may well be the extent to which it exposes
itself to influences from, and attempts to utilize knowledge from,
the span of clinical intervention to areas previously Qther domains. If the psychotherapy community does not adopt
largely ignored by psychology, such as weight control, the responsibility for "bridge building," the therapy subject may
smoking addiction, stress management, social and in- be the victim. (p. 338)
terpersonal skill training, and physical health-related
problems. Such lack of integration will be perpetuated as long
Although considerable attention has been given to as the clinician remains deficient in scientific training
behavior therapy's treatment success, caution is still and unconcerned about the need for a common lan-
advised until the test of time is met. Considerably more guage to facilitate this communication. The behavior
research is needed on a variety of homogeneous patient modification approach to clinical problems is an at-
populations with long-term evaluations before any tempt to break down both of the above barriers and
concrete conclusions can be reached about the efficacy clearly represents one of its major contributions to the
of any given technique. However, for this author, what field.
may prove to be of critical importance, even revolu-
tionary, is the potential fruitfulness of the philosophy, The Nature of Theory Construction. The
orientation, and strategy behind this movement and its strategy common to most nonbehavioral approaches
impact on the rest of the mental health field. Three of has been to develop complex, all-encompassing theo-
these potential assets particularly stand out and are ries that are designed to explain the whole and com-
discussed below. plete human organism. This objective has been
achieved by sacrificing clarity, precision, and predict-
ability. Although these theories are occasionally rid-
The Resulting Assets
dled with creative and potentially fruitful ideas, the
Emphasis on Learning and Conditioning meshing and interlacing of so many surplus meaning
Principles. Few clinicians would object to the state- concepts makes experimental analysis difficult, if not
ment that learning plays an important role in the devel- impossible. Unfortunately, these theories provide their
opment of psychopathological behavior. In fact, most followers with only a comforting set of terminology
nonbehavioral explanations of psychopathology ac- and an illusory sense of understanding.
knowledge the role of conditioning and learning in In contrast, the strategy of a behavioral viewpoint is
early childhood, the effects of punishment and with- to start from a descriptive, better defined, and more
drawal of love by the parents, and the importance of controllable account of behavior and then systemat-
anxiety and fear in motivating human symp- ically and progressively work to build on this founda-
tomatology. Yet, prior to the advent of the behavior tion. The objective is to produce clarity in communica-
therapy approach, no systematic attempt was made to tion and operational specificity of variables, which, in
develop treatment approaches by drawing on the estab- tum, permits the systematic manipulation and evalua-
lished principles of conditioning and learning. tion of critical variables.
Perhaps the clinical field's inability to show system-
atic growth is related to the reluctance of other ap- Commitment to Assessment. The last asset to be
proaches to utilize the tools and procedures of basic discussed is perhaps the most important and yet the
researchers in the field of psychology. The develop- most ignored factor in the development of the mental
health field. The concern about evaluation in most tionallight on the development and treatment of psy-
therapeutic approaches has rarely moved beyond the chopathology. In order to facilitate a better understand-
case history level. Those studies that have attempted ing of the rationale underlying the various strategies
experimental analysis have fallen far short of the rigor adopted by contemporary behavior therapists, a review
required of a discipline striving for scientific respecta- of some of the basic experimental paradigms will be
bility. The behavioral modification movement has presented here, followed by an outline of some of the
been the only psychotherapeutic approach that has theoretical positions that influenced the field's growth.
been committed to objective outcome evaluation from
its inception. It is well known that therapeutic tech-
niques frequently are reported to be more effective Classical Conditioning
initially (Tourney, 1967), but their effectiveness dimin-
ishes eventually. Although the data suggest that one Changing behavior can be achieved in the laboratory
should be cautious in making therapeutic claims, un- through the use of one of two distinct conditioning
supported enthusiastic claims of success still dominate procedures, which are commonly referred to as result-
the field. ing in the development of classical or instrumental
The behavioral movement is also not free of making learning. Descriptively, the classical conditioning par-
premature claims of success, displaying inadequate adigm differs from the instrumental procedure in that
methodological sophistication, and committing errors the sequence of events presented is independent of the
of overgeneralization. However, the commitment of subject's behavior. The typical sequence consists of an
the behavioral field to a scientific analysis has resulted unconditioned stimulus (UCS), a stimulus known to
in an open system of checks and balances and of self- evoke a regular and measurable response (UCR), and
criticism that in time should result in the establishment the conditioned stimulus (CS), a stimulus that at the
of reliable and valid contributions. The existing crisis outset of an experiment does not evoke the UCR. The
in the mental health field can be resolved only by an usual order of the sequence used to produce condition-
objective evaluation of treatment approaches. ing is to present the CS followed closely in time by the
UCS. The regular and measurable response elicited by
the UCS is called an unconditioned response (UCR).
Basic Experimental Learning Conditioning is said to have occurred if the CS presen-
Paradigms and Principles tation follows pairings of the CS-UCS results in the
elicitation of a conditioned response, which usually
The systematic application of learning principles to resembles the UCR. Pavlov's (1927) work with the
applied areas has unfortunately been a relatively slow conditioning of salivation of dogs illustrates the pro-
development, gaining impetus only in the last 20 cedure used in classical conditioning.
years. The main factors contributing to this delay have The effects of classical conditioning can be demon-
been the tendency of psychologists to separate theory strated at almost all levels of animal life. Furthermore,
and application, a reluctance to use the clinic as a it is just as easily established in primitive animals as in
laboratory, and the acceptance of the traditional psy- human beings, which suggests that conditioning may
chodynamic methods as the model for psychotherapy involve the same mechanism in all species.
(Kalish, 1965). The learning psychologist's retreat to Pavlov and his colleagues were responsible for iso-
the laboratory during the first half of this century was lating some of the most basic phenomena of classical
not without its value, because it was during this period conditioning learning. These phenomena include:
that the groundwork for the development of the prin-
ciples and theories utilized by behavior theorists was 1. Conditioning-the acquisition of a stimulus-
laid and well documented. The literature generated on response relationship
issues of acquisition, response maintenance, extinc- 2. Generalization-the tendency of the organism
tion, counterconditioning, generalization and discrim- to transfer as a function stimulus similarity its
ination learning, schedules of reinforcement, punish- acquired response t'J new stimulus situations
ment, and social imitation and reinforcement proved 3. Conditioned discrimination-the learning to re-
extremely helpful in the development of applied tech- spond only to a specified stimulus or to respond
niques. Furthermore, the theoretical contributions of in two different ways to two different stimuli
Pavlov, Hull, Guthrie, Mowrer, and Tolman shed addi- 4. Higher-order conditioning-a conditioning se-
quence in which a neutral stimulus is condi- rat's pressing a bar increases following the presenta-
tioned by being paired with a previously condition of food, the food can be labeled a positive rein-
tioned CS forcement; if such behavior increases following the
5. Extinction-the training procedure in which the cessation of shock, shock can be viewed as a negative
CS is presented in the absence of the DCS, with reinforcer.
the resulting effect being a loss in the strength of 2. Punishment. Punishment refers to an event that is
theCR made contingent on a response that results in a de-
6. Inhibition-a hypothetical process that actively crease in the probability of the response's occurrence.
prevents the performance of the CR during Stimuli that can be classified as punishers can be divid-
extinction ed into two classes: those that result in a decrease in
7. Spontaneous recovery-the partial reap- responding following the onset of the stimulus event
pearance of an extinguished CR following a (e.g., electric shock paired with a bar-press response)
lapse of time and without any new conditioning and those that produce the same result following the
withdrawal of an event (e.g., withdrawal of food fol-
lowing a response).
Operant or Instrumental Learning It should be noted that the effects of reward and
punishment have important implications for helping us
Following the work of Thorndike (1911) and Skin- meet the objective of modifying maladaptive human
ner (1938), learned responses have also been devel- behavior. However, controversy still exists over the
oped by procedures labeled operant or instrumental effects of punishment on behavior-a source of confu-
learning. With the operant procedure, the DCS or re- sion reflected in Thorndike's early work (1911). His
ward presentation is made dependent (not indepen- original position was that learning is a reversible pro-
dent, as in the classical conditioning procedure) on the cess, that reward strengthens behavior, and that
subject's behavior. An essential aspect of this pro- punishment weakens it. Later, he reversed this posi-
cedure is that reward (whether negative or positive) tion (1931) and concluded that although reward does
follows the subject's response in some systematic strengthen behavior, punishment does not weaken it; it
manner. For example, every time a rat pressed a bar only results in the suppression of responding. Al-
(CR), a food pellet is dispensed (DCS). though recent data provide some support for Thorn-
Although operant responses can refer to the selec- dike's original position, the issue is far from resolved
tion of isolated responses, the term usually refers to the (Church, 1963; Mowrer, 1960). Such a resolution will
conditioning of a class of behavior, which, in tum, is have important implications for applied behavior
defined by the requirements for reinforcement set by modification.
the experimenter or by the environment in a given 3. Extinction. As is the case with classical condi-
situation. Thus, unlike the classical conditioning pro- tioning, extinction refers simply to a procedural ma-
cedures, which is usually confined to the study of iso- nipulation: the removal of a reinforcer. Although ex-
lated responses, operant conditioning widens the range tinction usually results in a decrease or an elimination
of behaviors that can be studied, including the majority of responding, it differs from a punishment procedure
of human behaviors. Thus, as Kazdin (1978) noted, in that reinforcement is simply discontinued, and its
the principles explaining the development, mainte- negative effects are not made directly contingent on the
nance, and elimination of operants are likely to have occurrence or nonoccurrence of a given response
wide generality. Some of the basic principles of oper- class.
ant conditioning are outlined below. 4. Stimulus control. Stimulus control is related to
1. Reinforcement. Reinforcement of a behavior is the concept of discrimination and to the empirical find-
determined operationally by noting whether an ining that antecedent events (stimuli) can also control
crease in the frequency of a response occurs following behavior by associating different reinforcement conse-
certain consequences that are labeled reinforcers. If quences for a particular response class across different
behavior increases following presentation of an event stimuli. For example, if Stimulus A is reinforced in one
after a response, the reinforcing state of affairs is re- situation and not in another, or if Stimulus A is rein-
ferred to as being positive. If a behavioral response forced in one situation and Stimulus B is not, differen-
increases following the removal of an event, the event tial stimulus control over behavior can be established.
is labeled a negative reinforcement. For example, if a Thus, stimulus control refers to the extent to which
antecedent stimuli determine the probability of re- makes an appropriate response (e.g., bar press) within
sponse occurrence. the fixed interval, the noxious stimulus is postponed
5. Schedules of reiriforcement. It has been estab- and is therefore avoided for a specified time interval
lished that behavior changes and maintenance can be (e.g., 10 sec). In such a procedure, organisms do learn
markedly affected by manipulating the ways in which and develop high rates of responding.
discriminative or reinforcing stimuli are presented in Another procedure closely related to avoidance con-
relation to responses. For example, by varying the fre- ditioning and requiring no external warning stimulus is
quency and magnitude of reinforcement density, re- escape training. In this procedure, the subject can turn
sponse output can be regulated at high, medium, or off (escape) an aversive UCS (e.g., electric shock) by
low rates of responding. An analysis of certain sched- emitting an operant or instrumental response. For ex-
ules of reinforcement has resulted in important ad- ample, Mowrer (1940) conditioned a rat to terminate
vances in our understanding of what stimulus rein- electric shock by pressing a pedal arrangement located
forcement consequences maintain behavior as well as at one end of the conditioning chamber.
what changes are needed to alter behavior. The clinical
application of such principles has important implica-
tions for our quest to alter maladaptive behavior. Implication of Conditioning Principles
6. Superstitious behaviors. By the repeated presen-
tation of a reinforcer independent of any given re- The preceding discussion of conditioning pro-
sponse class, one can demonstrate that such noncon- cedures and principles represents only a cursory re-
tingent delivery can increase the rate of responding of view of the topic. To provide an adequate description
behavior performed at the time of reinforcement of the relevant principles and techniques involved
dispensing. would require a separate volume. A detailed discus-
sion of these topics can be found in Kimble (1961) and
in Mackintosh (1974).
Avoidance Learning: A Combination of Until the advent of the behavior therapy movement,
Procedures implications of learning principles for the understand-
ing of human maladaptive behavior received only spo-
Bekhterev (1928) provided the reference experi- radic historical attention. One of the most influential
ment for the avoidance paradigm by conditioning to a applications of conditioning principles to an under-
signal the withdrawal response of a hand or foot. In standing of human fear behavior was reported by Wat-
this experiment, which represents the usual form of the son and Rayner in 1920. These investigators attempted
avoidance training, the subject could prevent the oc- to determine whether they could condition a startle
currence of a noxious stimulus, such as electric shock, reaction in a child to a previously neutral stimulus. A
by responding to a signal. What makes this paradigm white rat, which elicited no fear, was paired with a
of interest is that it includes both a classical and an loud, fear-producing noise in the presence of an 11-
operant procedure. The paradigm is designed to pre- month-old infant named Albert. After seven such pair-
sent CS-UCS presentations (a classical conditioning ings, the presentation of the rat alone elicited avoid-
procedure), which can be altered if a designated re- ance and fearful behavior in the child. This condi-
sponse (operant) is emitted to the CS. If such an oper- tioned reaction generalized to other similar stimuli,
ant response is made within the required time period such as a rabbit, a dog, a fur coat, and cotton. The fear
(CS-UCS interval), the UCS is not presented on that response was not elicited by inanimate objects, such as
trial. Thus, the term avoidance learning comes into blocks. Extending Watson's work, Mary Cover Jones
being. (1924) attempted to determine whether learning prin-
Most of the laboratory studies of avoidance condi- ciples could help remove children's fears. Among the
tioning use a trial-by-trial procedure in which a dis- techniques employed were principles of extinction,
crete warning stimulus is presented. Sidman (1953), counterconditioning, and social imitation. The impact
however, developed an avoidance procedure within the of the above work is critical in that it suggested the
context of a free-responding situation in which a dis- possibility that learning principles may be involved in
crete external signal was not provided. In the Sidman the development, maintenance, and removal of mal-
procedure, a noxious stimulus is presented at a fixed adaptive behavior.
interval (e.g., every 20 sec). If the subject (e.g., rat) Despite the importance of this early work, the sys-
tematic application of learning principles to treat mal- tion that certain clinical phenomena seem to contradict
adaptive behavior has unfortunately developed rela- the laboratory findings on which existing learning the-
tively slowly until recently. It took the behavior ory is based. Mowrer (1950) was one of the first theo-
therapy movement to facilitate the use of learning par- rists to recognize that human "neurotic" behavior ap-
adigms and principles. Classical conditioning, punish- pears to represent a paradox in that it is self-punitive,
ment, escape-avoidance, extinction, and operant par- self-defeating, and perhaps self-perpetuated. Patients
adigms have each been used with apparent success frequently report being fully aware at a cognitive level
over a wide range of behaviors , including social, sexu- that their maladaptive behavior is "irrational" and
al, addictive, eating, self-destructive, psychotic, and counterproductive. Such an observation seems con-
criminal behaviors. General treatment techniques de- trary to most learning positions, which are essentially
signed to deal with a wide variety of maladaptive be- hedonistic, stressing what Thorndike (1911) called the
haviors have also emerged, based on such learning "law of effect" and Skinner (1938) the "law of rein-
principles as emotional extinction (implosive and forcement." From a learning viewpoint, the symp-
flooding therapy), counterconditioning (systematic tomatic behavior of the neurotic is functioning in the
desensitization), and higher order conditioning (covert absence of a ues. In essence, this is why such behav-
sensitization procedures). ior is labeled irrational, in that failure to exhibit a
This initial success in applying laboratory principles symptom will not result in any biological harm. Yet
to the human situation should strengthen even further human maladaptive behavior maintains itself over long
the links between experimental and applied psychol- periods of time in the absence of a biological threat. On
ogy. As this relationship becomes stronger, so should the other hand, laboratory data strongly suggest that
there be an increase in the sophistication, applicability, whether the behavior in question is overt or emotional,
and success of the approach. But for behavioral thera- unlearning or extinction will follow rather rapidly once
py to remain viable, it must also provide a conceptual the UCS is removed (Mackintosh, 1974).
framework for understanding, predicting, and even- Classical and modern learning theory have been
tually preventing maladaptive behaviors. Basic learn- concerned largely with isolating and explaining gener-
ing theory has already proved helpful in providing an al laws of behavior. They have not, as yet, fully ad-
initial conceptual framework from which to start. dressed the exceptions to these laws reflected in the
unusual and puzzling behaviors labeled psycho-
pathological. Applied behavior therapists as a group
Theoretical Foundations have also not undertaken this task seriously. It is this
writer's opinion that such a state of affairs exists be-
Without question, formal theory construction has cause behavior therapists have been poorly trained in
played a major and critical role in the development and the areas of theory construction and existing learning
advancement of the experimental learning field. In the theory. It is the further belief of this writer that the
quest to develop a science of behavior, learning theory existing theories of learning do provide an important
has kept critical issues at the forefront, has heightened starting point from which laws of psychopathology
controversy, has resulted in differential predictions, and treatment can be developed and that such a devel-
and has stimulated a variety of new research areas. The opment is critical to the future survival of the behavior
applied behavior therapy movement has also profited therapy movement. Therefore, in this section, the pur-
from the development of learning theory, because the pose and basic principles of theory construction will be
rationale for a number of its techniques is based di- outlined, along with a brief description of those clas-
rectly on classical laboratory theories. However, the sical and modern learning positions, that may well
direct extrapolation of learning theory to justify ap- provide the stepping stones for the development of
plied treatment techniques and to aid us in understand- viable models of psychopathology and treatment.
ing psychopathology has not proved as successful as
the transfer of learning paradigms. Critics (e. g. ,
Breger & McGaugh, 1965) have been correct in their
assessment that behavior therapists are working with The Function of Theory
antiquated models and have yet to establish a direct
relationship between theory and treatment techniques. The scientist's task in regard to theory construction
Part of the above problem stems from the observa- has been succinctly stated by Spence (1951):
Briefly, it may be said that the primary aim of the scientist is to quantitative science the exactitude of the concepts is enormously
develop an understanding or knowledge of a particular realm of enhanced through the application of the techniques of measure-
events or data. Such scientific understanding consists in for- ment. (p. 12)
mulating relationships between concepts that have reference to
the particular event under observation. Thus, beginning with the
sense or events provided by observation, the scientist abstracts Precision of psychological terms requires that they be
out of them certain ones on which he concentrates. To particular capable of operational analysis. As Skinner (1945)
descriptive events and pattern of events he assigns, arbitrarily, warned, "we must explicate an operational definition
language symbols (concepts) and then formulates the rela-
for every term unless we are willing to adopt the vague
tionship observed to hold between these events (or concepts) in
the form of laws. These observed regularities or laws provide at usage of the vernacular" (p. 270).
least partial explanation of the particular event under considera- Learning theory attempts to meet the tenets of good
tion, for explanation in science basically consists of nothing theory construction, and herein lie its distinct advan-
more than a statement of relations of a particular event to one or
more events. (p. 239) tage and potential explanatory and predictive power.
The issue, of course, is whether it is feasible to apply
existing learning or conditioning laws in our quest to
In other words, the function of theory is to provide a
understand human psychopathology. Eysenck (1960)
systematic expansion of knowledge mediated by spe-
perhaps said it best when he reasoned:
cific empirical propositions, statements, hypotheses,
and predictions that are subject to empirical tests. It If the laws which have been formulated are not necessarily true,
should be noted that it is only the derivations of propo- but at least partially correct, then it must follow that we can make
sitions derived from the theory that are open to em- the deductions from them to cover the type of behavior repre-
sented by neurotic patients, construct a model which will dupli-
pirical test. The theory itself is assumed; acceptance or
cate the important and relevant features of the patient and suggest
rejection of it is determined by its utility, not by its new and possible helpful methods of treatment along lines laid
truth or falsity (Hall & Lindzey, 1957, p. 13). The down by learning theory. (p. 5)
utility of a theory lies essentially in its ability to serve
as a guide for empirical studies. Unguided experimen- The issue is, of course, an empirical one, and, for-
tation usually results in an organized mass of data. tunately, Eysenck's suggestion has already mate-
Although the ordering and interpretation of data are rialized. Learning theory has been responsible for gen-
important functions of theory, history supports the erating a number of new ideas and treatment proce-
claim that a viable theory is one that predicts and ex- dures.
plains in advance laws or results that were unknown
before. Important theories in science have satisfied this
test. Skinner's Antitheoretical Position
Nonbehavioral theories of psychopathology clearly
have not met the above boundary conditions for theory Skinner, who himself has made important contribu-
construction. However, the argument is made that tions to the advancement of learning theory (Skinner,
human behavior is complex and in need of explanation 1938), changed his position and became one of the
by postulating a variety of constructs. The language of most eloquent critics of formal theory construction.
the laboratory is viewed as inadequate and nondescrip- For Skinner (1950), a science of behavior must
tive of human interactions. Unfortunately, the model eventually deal with behavior in its relation to certain
of human behavior generated by the psychoanalytic, manipulable variables. He stated that theories in the
humanistic, and existential movements, although ade- field generally deal with the intervening steps in these
quate in postdiction, lacks prediction. Relationships relationships. Therefore, instead of prompting us to
among constructs are not adequately explained, and search for and explore more relevant variables, these
terms and propositions generated by the theories are intervening steps frequently serve only to provide ver-
unclear and full of surplus meaning. For theory to aid bal answers in place of the factual data we might find
in the advancement of knowledge, definitional preci- through further study. Such a state, from Skinner's
sion of terms is essential. As Feigl (1953) suggested: viewpoint, can easily create a false sense of security.
Skinner further argued that research designed in rela-
This obvious standard scientific method requires that the con- tion to theory was likely to be wasteful, because con-
cepts used in the formulation of scientific knowledge-claims be siderable energy and skill most likely would be de-
as definitely delimited as possible. On the level of the
qualitative-classificatory sciences this amounts to the attempt to voted to its defense. This energy, he felt, could be
reduce all border-zone vagueness to a minimum. On the level of directed toward a more "valuable" area of research.
Skinner's position will not be rebutted here, since It is the opinion of this reviewer that applied behav-
his viewpoint was mainly taken as a stance against the ioral theorists should also move away from using the
movement in the 1940s to provide an all-encompass- classical theories as a foundation for their techniques.
ing general theory of behavior. Today, learning theory Contemporary learning positions may well provide a
is much more specific and problem-oriented. Skin- much stronger base for extrapolating to psycho-
ner's own attempt to provide an inductive data base for pathology. The need for the applied behavior field to
psychology is reflected in the large volume of em- upgrade and sharpen its theoretical foundation is clear-
pirical data published by Ferster and Skinner (1957). ly evident. Therefore, only a cursory review of the
This volume, which reports important findings, reads a classical theories is provided here, followed by a de-
little like a phone book and falls far short of Skinner's scription of a couple of contemporary models that may
own expectations. The failure of the purely inductive prove of use to the behavior therapy field.
approach has largely been a failure to provide the orga- Theories of learning can be grouped under a variety
nizational and integrative structure that theory offers. of different headings. The subdivisions frequently
Today, this point is well recognized by Skinner's fol- used are one-factor versus two-factor theories, rein-
lowers in the basic research areas. Operant research forcement versus nonreinforcement theories, drive
has clearly moved from an inductive analysis to a func- versus nondrive theories, and inhibition versus non-
tional theoretical structure. inhibition theories. It is possible for a given theory to
Skinner's antitheoretical stance has influenced and be cross-indexed under more than one heading (e.g., a
is still influencing many behavior therapists. These reinforcement, drive position). For the purposes of this
individuals, referred to as operant behavior modifiers, review, the strategy was adopted of grouping theories
are mainly interested in the question of what tech- along the lines of how they conceptualize changing or
niques will shape a patient's behavior to the desired extinguishing established behaviors. Applied behavior
outcome, rather than attempting to understand why therapy techniques are designed to emphasize the prin-
and how the techniques operate. This strategy has al- ciple believed responsible for such changes. Thera-
ready resulted in the development of some important peutic techniques have already been developed that
and interesting techniques, which have greatly en- emphasize the role of excitation and inhibition, coun-
hanced the behavior modification movement. But as terconditioning, nonreinforced emotional extinction,
the data base of the field increases, the need exists, as and changes in cognitive expectancies. It should be
was the case in the basic research areas, for better noted, however, that these divisions are neither mutu-
organizational structure, which perhaps can be best ally exclusive nor all-inclusive.
achieved from this orientation by a functional the-
oretical analysis.
Because formal models of learning also have played Excitation and Inhibition Models of
a significant role in the development of this new ap- Behavior Change
plied field, these implications for the behavior therapy
movement are now addressed. Concepts of excitation and inhibition play both a
historical and a contemporary role in theory develop-
ment. Under this heading, only Pavlov's classic theory
The Impact of Formal Models is discussed here, but it should be noted that Hull's
theory can also be labeled an excitation-inhibition
The classical theories of learning developed by model.
Pavlov, Hull, Guthrie, and Tolman played a major
heuristic role in providing the initial foundations for
Pavlov's Physiological Theory of the Cerebral
the development of many of the behavioral modifica-
Cortex
tion techniques. It should be understood that these ap-
proaches were designed as general theories of behavior Pavlov's (1927) theory was one of the first major
and not as models of psychopathology. Today, learning approaches to have an impact on both the learning and
theorists have moved away from such general theories the behavior therapy fields. He viewed conditioning as
to providing more explicit and detailed models of vari- a function of cortical extinction and ~ortical inhibition.
0us empirical findings. However, the influence of the According to this position, when a "neutral" stimulus
masters can still be felt. (for example, a tone) is presented to a subject, the
afferent stimulation elicited by the tone produces an from an excess of inhibition, thus blocking his or her
excitatory process at some definite point in the cortex. normal output of excitation. Therapy is therefore de-
At the point of cortical stimulation, the excitatory pro- signed to encourage the patient to express feelings di-
cess is believed to spread gradually over the entire rectly. Wolpe's (1958) "assertive" response approach
sensory area. The intensity of the spreading effect or represents a very similar technique and conceptualiza-
"irradiation" of excitation is hypothesized to decrease tion.
as the distance from the point of origin increases. With However, learning theorists long ago abandoned
onset of the UCS (for example, shock), this process is Pavlov's theoretical thinking, partly because of the
repeated, but at a different point in the cortex. Because lack of direct experimental support and partly because
of the differences in intensity, the irradiation is consid- neurophysiologists are committed to the concept of
ered greater for the UCS than for the neutral stimulus. synaptic transmission of neural impUlses. Neverthe-
Following repeated presentations of the neutral stim- less, the role of the concepts of excitation and inhibi-
ulus and the UCS (CS-UCS pairings), the cortical tion have been incorporated into other more modem
stimulation elicited by the tone is expected to gravitate theories, such as those proposed by Hull (1943), by
toward the stronger cortical stimulation of the shock Amsel (1958), and, more recently, by Rescorla (1969),
until the locus of the neutral stimulus is of sufficient Rescorla and LoLordo (1965), and Rescorla and
intensity to elicit a CR. Wagner (1972).
According to Pavlov, one can reduce the strength of
the CS by presenting it in the absence of the UCS
(extinction). Under these conditions, the cortical pro-
cess of excitation is changed to inhibition, which like
Counterconditioning Models of
the previous excitation irradiates to the surrounding
Behavior Change
region of the cortex. The assumption is further made
Counterconditioning theories of extinction have
that when the elicitation of either cortical excitation or
held both historical and contemporary interest. Under
cortical inhibition occurs, the surrounding areas of the
this heading, the classical models of Hull and Guthrie
cortex concurrently produce the opposite process. Bor-
are described briefly, along with Denny's more recent
rowing a term suggested by E. Hering and C. S. Sher-
extension of Hullian theory.
rington, Pavlov called the effect "induction." Excita-
tion in one area of the cortex leads to increased
inhibition in another area (negative induction), while
Hull's Monistic Reinforcement Theory
inhibition is believed to lead to increased excitation
(positive induction). Hull (1943, 1952) attempted to synthesize the data
obtained from Pavlov's classical conditioning pro-
cedure and Thorndike's trial-and-error learning into a
Implications
unitary concept of reinforcement (viz., drive reduc-
Pavlov was the first and one of the few classical tion). Briefly, the theory states that whenever any re-
theorists to extend his model to explain psycho- ceptor activity (a stimulus) and effector activity (a re-
pathology. He reasoned that when cortical irradiation sponse) occur in close temporal contiguity, and this
ofthe inhibitory process is extreme, the resultant effect temporal contiguity is closely associated with the di-
is sleep, whereas extreme excitation is believed to pro- minution of a need (drive reduction), there will result
duce alert, active behavior. A functional breakdown an increment in the tendency of that afferent impulse to
leading to psychopathology can occur with the active evoke that reaction on later occasions. These incre-
clashing of the excitatory and inhibitory processes or ments of successive reinforcements are believed to
with the presentation of intense stimulation. Accord- summate and to yield a combined habit strength (sHR)'
ing to this model, such excessive cortical excitation or which is hypothesized to be a simple positive growth
inhibition can result in such symptoms as hysteria, function of the number of reinforcements received.
neurasthenia, depression, mania, and catatonia. Motivational variables, such as drive, are believed to
Pavlov's theory inspired a number of applied behav- interact in a multiplicative manner with habit strength
ior therapists, most notably Andrew Salter (1949, to produce performance (D x sHR ).
1965), who developed his conditioned-reflex therapy. Concurrently with the development of excitatory be-
For Salter the neurotic individual is suffering basically havior, Hull, like Pavlov, drew on inhibition theory. In
brief, the assumption is made that every response, behavior modifiers to be more useful and reflective of
whether reinforced or not, results in an increment of the process underlying their techniques.
reactive inhibition (IR)' which according to Hull is a
primary negative drive resembling fatigue. The mag-
Denny's Elicitation Theory
nitude of IRis considered an increasing function of the
rate of response elicitation and the effortfulness of the Denny (1971, 1976) has offered a countercondition-
response. In short, as IR builds up, the strength of the ing model of behavior that stresses concepts like relief
response just preceding it becomes weakened, a func- and relaxation for the explanation of behavior involv-
tion of the direct incompatibility of the two responses. ing aversive stimuli. In his theory, the removal of a
It follows that since IR (fatigue) is a drive, the reduc- ues in an established behavior sequence also serves as
tion of this state is reinforcing and therefore is capable a ues or eliciting stimulus for a class of response that
of strengthening any response that precedes it closely is typically antagonistic to the responses that were elic-
in time. Since I R leads to cessation of activity, a resting ited by the original ues. For example, in situations
response is conditioned-or, more appropriately, that involve aversive stimuli, the removal of these
counterconditioned-to the es. Hull referred to this stimuli elicit relief and relaxation, which Denny views
latter process as conditioned inhibition (siR). The total as being antagonistic to fear and fear-related behavior.
inhibition in the situation results from an additive com- The countercondition effect, then, mediates approach
binationofbothlRandslR. Thus, behavior equals D X rather than withdrawal behavior. Relief is a construct
sliR - (IR + siR)· With the removal of the ues (rein- that is viewed as essentially autonomic and as occur-
forcement), inhibition can exceed strength of excita- ring almost immediately after the termination of an
tion resulting in the extinction or the countercondition- aversive stimulus. Relaxation is a construct that is
ing of the previous learned response. viewed as essentially musculoskeletal and as reaching
The implications of the Hullian counterconditioning a peak of responding about 2Y2 min after aversive stim-
model of extinction for psychotherapy were first noted ulation ends. Relief and relaxation, which make a sit-
by Shoben (1949) and Dollard and Miller (1950), who uation positive and safe, become dominant when the
retranslated existing insight therapy into a learning, situation is no longer aversive and bring about the ex-
reinforcement framework. However, the applied im- tinction of fear-related behavior.
portance of Hullian theory was not fully realized until A critical aspect of Denny's elicited relaxation theo-
Joseph Wolpe (1958) extrapolated from the model to ry is that relief and relaxation automatically occur
develop new behavioral techniques that launched the when the aversive stimulus is removed or remains
behavior therapy movement. harmless. From this model, direct methods for produc-
Wolpe, borrowing theoretical notions from Hull ing relaxation, as used in Wolpe's desensitization pro-
(1943), Sherrington (1947), and Jacobson (1938), de- cedure, would not be required to produce extinction.
veloped the counterconditioning approach of system- Of course, such a procedure from this viewpoint
atic desensitization that is designed to reciprocally in- should facilitate the extinction procedure. Denny has
hibit anxiety-eliciting stimulus. He also rekindled also suggested that his theory may be useful in explain-
interest in assertive training, as well as developing ing the effects of flooding or implosive therapy
conditioning techniques to reduce sexual inhibition. (Stampfl & Levis, 1967).
Hullian theory, however, may not be the best con-
ceptual framework from which to view Wolpe's re-
Guthrie's Contiguous Conditioning Theory
ciprocal inhibition therapy. Wolpe interpreted symp-
toms as avoidance behavior motivated by fear-eliciting Guthrie's (1935) theory provides a completely dif-
stimuli. Although Hull's theory is a general theory of ferent counterconditioning viewpoint of extinction.
behavior, he never directly applied his theory to the According to his contiguity position, all that is neces-
area of avoidance and fear conditioning. Miller (1948) sary for learning to occur is the pairing of a stimulus
finally made the appropriate extrapolations, but a clas- and a response. Unlike in Hull's theory, reinforcement
sical Hullian interpretation of avoidance responding or reward does not strengthen the learned connection.
has long since lost the interest of researchers in this Rewards are important only in that they change the
area. A recent theoretical extension of Hull's theory stimuli or the situation so that no new response can be
that does directly address avoidance behavior has been associated with the previous stimulus. In other words,
offered by Denny (1971) and may be found by applied a reward removes the organism from the stimulus to
which the response was conditioned, thus ensuring posed by Mowrer (1947, 1960), who emphasized the
that unlearning will not take place. The best predictor principle of es exposure in the unlearning of emo-
of learning is the response in the situation that last tional responses, which, in turn, leads to the extinction
occurred. According to Guthrie, learning is permanent of overt behavior. As will be seen, Mowrer's model
unless interfered with by new learning. Therefore, and the existing extensions by Eysenck and Stampfl
from this model, extinction always occurs as asso- and Levis are believed to have important theoretical
ciative inhibition (i.e., through the learning of an in- implications for our understanding and treatment of
compatible response). psychopathology.
To weaken activities (S-R connections) or remove
undesirable behavior, Guthrie suggested three ap-
Mowrer's Two-Factor Theory of Avoidance
proaches. The first technique involves a gradual stim-
ulus-approximation approach, in which one introduces Although Mowrer (1947) was influenced by Hull,
the stimulus that one wishes to have disregarded, but he broke away from a one factor or monistic reinforce-
only in such a faint degree that it will not elicit a re- ment position because of the awkwardness of Hull's
sponse. For example, if a person is afraid of a dog, one theory in handling problems associated with avoidance
could introduce furry objects such as stuffed dogs, then learning. For Mowrer, avoidance learning involved
pictures of dogs, then a very small dog, and so forth. two types of learning: one based on the procedure of
The second method is to repeat the stimulus until the classical conditioning, which incorporates only a con-
original response is fatigued and then to continue the tiguity principle, and one based on operant or instru-
sequence until new responses to the signal are learned. mental learning, which includes both a contiguity and
For exarnple, if one is afraid of tall buildings, she or he a drive-reduction notion of reinforcement. In the typ-
should repeatedly climb the stairs to the top of a tall ical discrete-trial avoidance paradigm, a es (e.g., a
building until fatigue and exhaustion counteract the tone) is presented, say, for a five-sec period and is
fear behavior (a point similar to Hull's prediction). followed by a ues (e.g., shock). With repeated es-
Finally, Guthrie suggested that behavior can be ues pairing, fear or anxiety is believed to become
changed by presenting the stimulus that elicits the unconditioned to the es and is mediated by the autonom-
desirable response but then inhibiting the response by ic nervous system. The conditioning of fear is simply a
presenting a stronger stimulus that elicits an incom- result ofthe above classical-conditioning pairing, with
patible response. For example, one can let an exhibitor drive reduction playing no part in this learning. Fear is
expose himself in the stimulus situation that elicits conceptualized as having activation or drive properties
such behavior and then shock him prior to sexual that result in energizing or increasing the organism's
arousal. activity. These activation properties are also elicited by
The implications of Guthrie's suggestions for ap- ues onset, resulting in the organism's escaping the
plied behavior change are apparent, but his model in shock. The escape response involves motor behavior
this context has unfortunately been neglected. It clear- that is viewed as being mediated by the central nervous
ly deserves attention. system and reinforced by pain reduction. As fear be-
comes conditioned to the es, it also activates motor
behavior, which results in a response prior to ues
Behavior Change via Emotional onset. This response is labeled an avoidance response
Extinction and is believed to be learned because it results in the
termination of the aversive es and in a subsequent
It should be noted that all major learning positions reduction of fear, which strengthens the avoidance be-
predict that nonreinforced (UeS absence) presentation havior. For the avoidance behavior to become un-
of the es will result in extinction or the unlearning of a learned, one need only extinguish the fear stimuli elic-
previous conditioned response. This is true whether iting the avoidance behavior. To achieve this objective,
the behavior in question be overt-motor or emotional. all one must do is present the es in the absence of the
As has already been seen, differences exist at a the- ues (Pavlovian extinction). Nonreinforced es ex-
oreticallevel about whether the underlying extinction posure will result in a weakening of the fear behavior.
process is facilitated by inhibition, countercondition- Once fear is sufficiently weakened, it will cease to
ing, or simple weakening of the previous response. activate the avoidance behavior.
The major position described in this section was pro- In 1960, Mowrer revised the above two-factor theo-
ry and extended it to explain appetitive (approach) as UCS. First, presentation of the CS alone may be fol-
well as avoidance theory. In his new model, Mowrer lowed by a decrement or an extinction of the CR,
concluded that all learning by implication was a result which is the law of Pavlovian extinction. Second, and
of the classical conditioning or internal states. The new contrary to the position of Mowrer and others, CS
version remains "two-factor" only in terms of whether presentation in the absence of the UCS may lead to an
the form of reinforcement is incremental (punishment) enhancement of the CR. The implication of this latter
or decremental (reward). statement with respect to fear conditioning is that
Mowrer's 1947 version of avoidance behavior, how- somehow exposure to the CS alone can enhance or add
ever, still seems to be the preferred interpretation (see new fear to the situation despite the fact that the UCS
Rescorla & Solomon, 1967). The basic tenets of the has been removed. According to Eysenck, incubation
model have received considerable empirical support of the CS is more probable when conditioning involves
(Brown & Jacobs, 1949; Brown, Kalish, & Farber, a drive (emotions), a strong UCS, and short CS ex-
1951; Levis, 1989; Miller, 1948). Although not free of posure periods when the UCS is removed. Eysenck's
criticism (Hernstein, 1969), two-factor theory has sur- theory clearly has important implications for those be-
vived the test of time and is still considered a very havior theorists interested in developing a viable con-
viable explanatory model for infrahuman and human ditioning model of neurosis. However, his position has
avoidance behavior (Levis, 1989; Mackintosh, 1974). not been free of serious criticism (see the commen-
For theorists who view human psychological symp- taries following the Eysenck, 1979, article).
toms as avoidance behavior, Mowrer's two-factor the-
ory provides an initial theoretical framework that has Stampfl and Levis's Extension. Stampfl and
already proved profitable to build on. Two such exten- Levis (1967, 1969, 1976) not only have extended
sions, which clearly illustrate this point, are briefly Mowrer's two-factor theory to the area of psycho-
described below. pathology but also have suggested the use of a new
treatment technique developed by Stampfl, which is
Eysenck's Extension. Concerned with the issues called implosive or flooding therapy. In agreement
involved in the "neurotic paradox," Eysenck (1968, with Eysenck, Stampfl and Levis believe that the crit-
1976, 1979) has modified Mowrer's theory to explain ical question from a learning position is why human·
clinical observations that appear to contrast with the symptoms (avoidance behaviors) resist extinction for
laws of classical learning theory. Three major areas are such long periods of time in the absence of any real
addressed in this reformation. danger. Laboratory examples of extreme resistance to
First, an attempt is made to explain why certain extinction are rare. However, unlike Eysenck, these
classes of phobic behavior are much more prevalent authors do not believe that two-factor theory has to be
than others. To do this, Eysenck challenged the doc- so drastically modified by adding such concepts as
trine of equipotentiality, which states that stimuli that preparedness or incubation (see Levis, 1979).
are equated for sensory input should be of equal condi- Extrapolating from the laboratory model, Stampfl
tionability when paired with a UCS. He argued that a and Levis see most psychopathology as resulting from
notion, such as Seligman's (1971) concept of "CS pre- past specific experiences of punishment and pain,
paredness", is required to be connected more readily which confer strong emotional reactions to initially
with anxiety responses than others. nonpunishing stimuli (classical conditioning). The re-
Eysenck's second modification centers on his obser- sulting conditioned stimuli provide the motivational
vation that basic personality differences are believed to source for developing symptom behavior designed to
affect conditionability. This conclusion helps to ex- escape or avoid the source of the conditioned aversive
plain differences among nosologies. stimulation (instrumental conditioning). Furthermore,
And third, and perhaps more importantly, Eysenck the past specific conditioning experiences are believed
reasoned that if we are to explain why symptoms per- to be encoded in memory and on recall may function as
sist for so long in the absence of UCS presentation, the a conditioned emotional stimulus.
laws of extinction have to be amended and the law of According to Stampfl and Levis, the issue of symp-
incubation or enhancement of fear needs to be added. tom maintenance is best conceptualized by extending
According to Eysenck's (1979) reformulation of the the Solomon and Wynne (1954) conservation of anx-
law of Pavlovian extinction, two consequences may iety hypothesis to encompass complex sets of condi-
follow presentation of the CS in the absence of the tioned cues, ordered sequentially in terms of their ac-
cessibility and aversive loadings. Briefly, Solomon psychopathology involves conflict learning paradigms
and Wynne postulated that exposing an organism to a that are more complex than that suggested by the sim-
long es exposure results in an increase in fear level ple avoidance model. Levis and Hare (1977) outlined
because of more es exposure, and that on subsequent four possible conflict paradigms that may be directly
trials, such an increase in fear could recondition the related to the development of psychopathology.
avoidance response, resulting in shorter latency re-
sponding. Furthermore, the more short-latency avoid- Interaction 0/ Fear and Hunger Drives. The hunger
ance responding that occurs, the less es exposure ex- drive and the strong responses it excites may pave the
perienced and the greater the conservation of fear to way under certain circumstances for important learn-
the unexposed segments of the es interval. ing, especially in childhood developmental patterns.
If the es interval comprises a series of complex As Dollard and Miller (1950, p. 132) pointed out, if a
stimuli that differ on a stimulus dimension from the child is repeatedly left to "cry out" when hungry, the
preceding set, then such conditions should greatly en- child may learn that no matter what it tries, it can do
hance or maximize the conservation of anxiety princi- nothing that will alleviate the painful experience of
ple. Therefore, from this analysis, the onset of en- hunger. Such training may lay the basis for apathy or
vironmental stimulus eliciting symptoms for human helplessness, the behavior of not trying to avoid when
clients is believed to represent only the initial part (S 1) in pain (Seligman, 1975). Furthermore, if an intensive
of a chain of stimuli being avoided (S2' S3' S4). As hunger develops, the responses involved can attach
noted earlier, many of these avoided stimuli are as- fearfulness to situational cues, like the bedroom,
sumed to be encoded in memory and capable of func- darkness, quietness, being alone, or the absence of the
tioning on exposure as higher-order, conditioning parents. An approach-avoidance conflict may develop
stimuli. As S) is extinguished, S2 is released from between two primary drives (hunger and externally
memory, markedly increasing the level of fear and re- induced pain) if the child cries when hungry and is
sulting in the reestablishment of avoidance responding subsequently punished for crying or is directly
to the S) segment. As long as the organism is capable punished for certain eating behaviors that meet with
of protecting itself or controlling the amount and dura- the displeasure of the parents. Thus, by pitting two
tion of es exposure through avoidance behavior, ex- drives against each other, the desire to eat and the fear
tinction will be retarded considerably (see Levis & of being punished for eating, the resulting conflict can
Boyd, 1979; Levis & Hare, 1977). heighten fearfulness and the conditionability of situa-
For human symptoms to become unlearned, all that tional cues associated with the stressful situation.
one need do is to extinguish the emotional response by
presenting the total es complex in the absence of the Interaction 0/ Fear and Sex Drives. Probably no
ues. Since the ues is believed to be long since re- other primary drive is so severely inhibited in our soci-
moved, all that is required is to present an approxima- ety as sex. Research has indicated that the sex drive can
tion of the es. Thus, like Pavlov, Hull, and Mowrer, produce positive reinforcement effects early in life.
Stampfl and Levis argued that extinction is a direct For example, Kinsey, Pomeroy, and Martin (1948)
function of nonreinforced es exposure, which is the concluded that small boys acquire the capacity for
main principle on which the implosive or flooding orgasm long before they become able to ejaculate. Yet
technique is based. many parents view such reinforcement as "nasty,"
"dirty," and "eviL" Even in the present "en-
Extension to Conflict Theory. Fear theorists are lightened" age, it is not uncommon for parents to in-
drive theorists and thus are cognizant that more than a hibit their childrens' sexual play by directly punishing
single drive may be present in a learning situation. If such behavior or threatening to administer punish-
the drive states elicited results in the simultaneous ment, such as cutting off the penis, if the undesired
arousal of competitive tendencies, then conflict is said behavior reoccurs. It is also not uncommon for parents
to exist. Miller (1959) has studied this problem exten- to create an approach-avoidance conflict by directly
sively, and Dollard and Miller (1950) have provided stimulating their children sexually and then punishing
numerous examples illustrating the important role that the child's response. It is little wonder that sexual inhi-
conflict plays in the development and maintenance of bitions play such an important role in the development
psychopathology. Because human learning can be mo- of many cases of psychopathology. Because sex is a
tivated by more than a single drive, it is likely that relatively weak primary drive, a frequent learned re-
sponse is to remove the conflict and guilt associated Interaction if"Fear, Anger, and Frustration Drives.
with the response by the avoidance (repression) of sex- As previous models have suggested, the excessive or
ual feelings and thoughts. Such conflicts frequently severe use of punishment as a behavioral controller
reemerge in adult life, when society partially removes leads to the conditioning of fear to previously nonfear-
its taboos and places strong pressure on the individual ful stimuli. Punishment can also have the effect of
to be active in this area. inhibiting ongoing, goal-directed behavior. The block-
ing of such responses frequently creates a state of frus-
Interaction of Fear and Positive Reinforcing Drives tration, which has been shown experimentally to lead
Labeled "Affection" or "Love." Stimuli made contin- to an increase in drive (anger) and to behavior labeled
gent on positive reinforcement can acquire the capaci- as aggression (Amsel, 1958). The affects of the in-
ty to elicit a positive emotional response in the same teraction of these two emotions (fear and anger) on the
manner as described for stimuli conditioned to elicit development of psychopathology are well documented
negative affect. To describe an individual as feeling in the clinical literature. It is not surprising that Dollard
good emotionally, or as having a feeling of well-being and Miller (1950) concluded, "Lift the veil of repres-
and of security, is to say in learning terms that environ- sion covering the childhood mental life of a neurotic
mental and internal cues previously conditioned to person and you come upon the smoking responses of
produce positive affect are currently being elicited. A anger" (p. 148).
decrease in the positive emotional state experienced is The conflict resulting from the interaction of fear
considered a direct function of eliminating or reducing and anger frequently leads, in theory, to behavior best
the cues eliciting the positive affect. This is true described in the context of a multiprocess approach-
whether they are labeled conditioned or unconditioned avoidance paradigm (see Stampfl & Levis, 1969). The
stimuli. If the loss of positive affect is of sufficient first stage consists of conditioned anxiety's being asso-
magnitude, the experience generates a negative emo- ciated with cues correlated with a desired approach
tional state resulting in the aversive conditioning of response. This is achieved by pairing the goal-directed
those situational cues correlated with the reduction in response with punishment (pain). Because the goal-
stimulation of the positive affective cues. Depending directed behavior is thwarted, frustration is elicited, in
on the individual's previous conditioning history, such addition to pain, and may lead to aggressive behavior.
a sequence of events can elicit additional cues Especially in the case of children, such aggressive ten-
(thoughts, images, memories) representing similar dencies are usually followed by more punishment, in-
conditioning sequences. The resulting compounding hibiting the aggressive responses. With sufficient rep-
of negative affective stimuli can generate the strong etition of the above sequence, aggressive responses
negative emotional states frequently described by will, in tum, become inhibited by conditioned anxiety.
clinicians as representing feelings of guilt, worth- By channeling the aggressive behavior into internal
lessness, and depression (Stampfl & Levis, 1969). cues involving thoughts, images, or ruminations con-
Thus, goal-directed behavior designed to elicit a cerning the punishing agent, a partial discharge of the
positive emotional state may become inhibited be- anger response can occur. However, if the punishing
cause of the presence of previously conditioned stimuli agent is a source of considerable positive primary and
that were associated with a reduction in the positive secondary reinforcement, such as in the case of a
emotional state (e.g., rejection). The presence of such mother who plays a protective, nurturant role, the
aversive stimuli may result in the anticipation that such stage is set for an additional conflict. By the child's
negative consequences may occur again if the positive harboring aggressive impulses toward such a figure,
goal-directed behavior is carried out. This, in tum, the strength and positive reinforcement obtained from
should result in an inhibition of such behavior in an viewing the mother as a supportive, loving figure is
attempt to avoid the possible negative outcome. decreased.
Whether such behavior is engaged in depends on the The above conflict can be resolved by avoiding
conditioning and the motivational strength of the two (suppressing) the aggressive fantasies and responses
sets of approach-avoidance stimuli (Miller, 1951). For associated with the aggressive behavior. Such behav-
a fairly typical conditioning sequence depicting the ior is engaged in so as to avoid diminishing the positive
above process and believed to reflect a common child- reinforcement associated with the child's concep-
hood occurrence, the reader is referred to an article by tualization of the punishing agent and to reduce addi-
Stampfl and Levis (1969). tional secondary anxiety (guilt) over expressing the
internal aggressive cues. lithe avoidance pattern is not behavior route leading from sign to significate. In
completely successful in removing the conflict, de- Tolman's language, a sign-gestalt is equivalent to an
fense mechanisms, such as displacement, reaction for- expectation by the organism that the sign, if behaved to
mation, and projection, may develop. A depressive in such and such a way (the behavior route), will lead to
reaction is also believed to be a frequent outgrowth of this or that significate.
such conditioning sequences. When signs (certain sets of stimuli) become inte-
Depression can play added functional roles in that grated within the nervous system with certain sign-
the self-punitive effects of the reaction may help re- gestalt expectations, learning occurs. Hypotheses are
duce the secondary anxiety of guilt as well as setting created and rejected. When one is confirmed, it (the
the stage for the attainment of positive responses from expectation) is learned. Unlearning, or extinction, re-
the punisher or other individuals (secondary gain). Fur- quires the disconfirmation of a previously learned hy-
thermore, such conditioning experience usually leads pothesis. In Tolman's viewpoint, reinforcement, in the
to a decrease in assertive behavior in an effort to avoid sense of an S-R position, is not essential for learning
increasing the probability of additional conditioning to occur.
trials.
The above four conditioning models are only sug-
Breger and McGaugh's Informational
gestive of some possible interactions that can occur to
Analysis
produce symptoms. Clearly, the models are spec-
ulative in nature and in need of scientific evaluation at Tolman's theory had little impact on the develop-
the human level of analysis. Yet such speculation may ment of the behavior modification movement, largely
prove to be useful in determining the directions in because of its cognitive emphasis. Behavior therapy's
which therapy might proceed. identity initially resided in its emphasis on changing
overt behavior and freeing itself of mentalistic con-
cepts. However, a few earlier attempts were made to
Cognitive Models of Behavior Change introduce cognitive notions into the behavioral move-
ment. Breger and McGaugh (1965), for example, sug-
Historically, cognitive models of learning have not gested that the problem of neurosis may be better un-
been popular with those who hold an S-R, behav- derstood by incorporating concepts of information
ioristic viewpoint. Issues of contention have largely storage and retrieval. From this viewpoint, neurosis is
focused on the lack of theoretical precision and par- seen as a learned set of central strategies that guide the
simony and on the difficulty of establishing an em- person's adaptation to his or her environment. There-
pirical framework. Nevertheless, cognitive interpreta- fore, neurosis is not viewed as symptoms, and therapy
tions have become more popular in the recent learning is conceived of as involving the learning of a new set of
literature and have had a similar impact on the behavior strategies via a new language, that is, a new syntax as
therapy movement. In the following section, Tolman's well as a new vocabulary.
classic theory is discussed along with some recent
contributions.
Rotter's Expectancy-Reinforcement Theory
A cognitive influence can also be found in Rot-
Tolman's Sign Learning
ter's (1954, 1970) "expectancy-reinforcement" theo-
Tolman (1932) departed from the traditional stim- ry, which was also designed to provide a different
ulus-response orientation of conditioning in an at- learning framework within which the clinician could
tempt to develop a theoretical system that would be operate. Although Rotter was influenced by Hull and
applicable to all of psychology. Tolman attempted to others, Tolman's impact is clearly seen in Rotter's
integrate into one theory the facts of classical condi- position. Behavior for Rotter is goal-directed, and the
tioning, trial-and-error learning, and "inventive" or directional aspect of behavior is inferred from the ef-
higher learning processes. fect of the reinforcing conditions. An individual's be-
According to Tolman, learning is sign-gestalt learn- haviors, needs, and goals are viewed as belonging to a
ing, or the acquiring of bits of "knowledge" or "cog- functionally related system. The behavior potential is
nitions." Sign-gestalts can be conceptualized as con- considered a function of both the individual's expec-
sisting of three parts: a sign, a significate, and a tancy of the goal and the reinforcement value of the
external reinforcement. Emphasis is placed on a per- Seligman and Johnston's Expectancy Theory
son's social interactions as opposed to his or her inter-
1\vo other models developed from infrahuman ex-
nal feelings as an explanation or criterion for pa-
perimentation are worthy of note. Seligman and John-
thology. It is not so much the underlying motivation
ston (1973) have proposed a cognitive-expectancy
that needs to be altered or removed according to Rotter
model of avoidance conditioning . Avoidance behavior
as it is the manner in which the patient has learned to
is initially learned via a process of fear conditioning
gratify needs. The question asked is, "What is the
similar to that in the models previously outlined. How-
patient trying to obtain by a given behavior," rather
ever, unlike traditional S-R theorists, Seligman and
than "What is being avoided?" Once the answer to this
Johnston have argued that once the UCS is removed,
question has been ascertained, the assumption is made
fear extinction will be rapid. Yet they noted that in
that the present mode of responding is viewed by the
some cases, avoidance responding is quite resistant to
patient as the best way to obtain the desired goal. In
extinction. At the clinical level, this clearly appears to
addition, more efficient behaviors for achieving the
be the normal state of affairs. From their viewpoint,
same goal are either not available in the patient's reper-
fear has long since extinguished, and what is motivat-
toire or are believed to lead to punishment or the frus-
ing responding is a cognitive expectancy that if re-
tration of another need. The task of the therapist then
sponding is stopped, pain will follow. From this
becomes one of manipulating expectancies and rein-
model, extinction results only if the expectancy is
forcement values in such a way as to bring about new
changed to one in which absence of responding will
behaviors.
not be followed by an aversive consequence. If one
The cognitive viewpoints of Rotter and Breger and
extrapolates this model to a therapeutic situation, then
McGaugh have provided mainly a framework from
the task of therapy is not to extinguish fear-producing
which to operate rather than providing alternative be-
cues but to change the expectancies of response-con-
havioral techniques. This point, plus the fact that the
tingent outcomes.
behavior modification movement initially was in large
part a reaction against cognitive, insight-oriented
therapies, minimized the influence of any learning- Seligman'S Learned-Helplessness Theory
based cognitive positions. However, recently there has
been a renewed interest in a cognitive-based behav- In a related theoretical development, Maier and Se-
ioral viewpoint that has become a substantial influence ligman (1976) attempted to explain why infrahuman
within the behavioral therapy movement (Mahoney, subjects under certain experimental manipulations
1977). The position that changing cognitions are cen- failed to learn to avoid or escape aversive conse-
tral to changing overt behavior has led to the develop- quences. This position is referred to as learned-help-
ment of a variety of new techniques focusing on chang- lessness theory and has been extended by Seligman
ing thought processes (e.g., cognitive restructuring, (1975) to explain human depression. Three stages are
thought stopping, and covert assertion). postulated in the development oflearned helplessness.
S-R-oriented behavior therapists (Levis, 1980; The first stage consists of the organism's receiving
Wolpe, 1978) have been quick to criticize this new information that the probability of the outcome is inde-
development, suggesting that an emphasis on chang- pendent of performing a given response class. The
ing cognitions will not only remove the identity of the distinction between controllable and unco~trollable re-
behavioral movement but result in a return to the less inforcement is central to the theory. The concept of
objective, insight-oriented treatment approaches. controllability is operationally defined within a re-
Whatever the final outcome of this new debate, cog- sponse-reinforced contingency space. If the condi-
nitive-behavioral therapy is here to stay, at least in the tional probability of that outcome (i.e., reinforce-
immediate future. However, even supporters of this ment), given a specific response, does not differ from
movement should recognize that the theoretical foun- the conditional probability of that outcome in the ab-
dations on which cognitive-behavioral therapy is based sence of that response, then the outcome is indepen-
are deplorably weak. Clearly, what is needed is to up- dent of responding , and, by definition, uncontrollable.
date the cognitive-behavioral approach by incorporat- On the other hand, if the conditional probability of the
ing the theoretical thinking of modem-day cognitive outcome, given a specific response, is not equal to the
psychology. An excellent start in this direction has conditional probability of the outcome in the absence
been offered by Bower (1978). of that response, then the outcome is controllable. A
person or infrahuman is "helpless" with respect to tween behavioral science and the application of this
some outcome when the outcome occurs independent- knowledge.
ly of all voluntary responses.
The critical stage of the theory involves the orga-
nism's registering and processing cognitively the in- Methodological Foundations
fonnation obtained from the contingency exposure in
which responding was independent of outcome. This The behavior modification movement's reliance on
event can be subdivided into two processes for the the principles and theories of experimental psychology
organism subject to helplessness: (1) learning that a has also resulted in this field's adoption or acceptance
contingency exists concerning the independence of re- of the validity of certain research strategies. For exam-
sponding and outcome, and (2) developing the expec- ple, many of the established principles that fonn the
tation that responding and outcome will remain inde- foundation of various behavioral techniques are·based
pendent on future trials. Coinciding with the second on infrahuman or human laboratory research. Further-
stage is a reduction in the motivation (activity) to con- more, its identification with experimental psychology
trol the outcome and thus the designation of non- has also required that the behavioral movement adopt
motivational theory once depression or helplessness is the methodological principles of the behavioral scien-
learned. The final stage includes the generalization tist. Although at times a source of controversy, the
and transference of the expectation that responding acceptance of each of the points of heritage has
and outcome are independent of new learning situa- strengthened and clarified the rationale and commit-
tions. The behavioral outcome of this generalization is ment of this new applied science. The following dis-
referred to as the learned-helplessness effect or depres- cussion attempts to highlight some ofthe positive fall-
sion (see Levis, 1976, for a critical analysis). out of such a strategy.
Abramson, Seligman, and Teasdale (1978) have ex-
tended Seligman's earlier position to include attribu-
Infrahuman Analogue Research
tion theory. They have added to the model the response
class of self-esteem, which is considered orthogonal to Most of the behavior principles and theories just
controllability, presumably being dependent on lit- reviewed were initially and sometimes solely devel-
tributional considerations. For these writers, the ex- oped from research data that utilized laboratory ani-
pectation of response-outcome perfonnance is re- mals, especially the rat, as subject material. Skep-
garded only as a sufficient condition for depression. ticism naturally arises concerning the applicability of
Other factors like physiological and honnonal states, these laws to human behavior, because marked dif-
postpartum conditions, chemical depletions, and loss ferences are apparent between rat behavior and a
of interest in reinforcers may also produce depression human being's social and verbal development. Never-
in the absence of expectations of uncontrollability. theless, many of the principles developed at the in-
From the above discussion of theory and its applied frahuman level have been shown to operate at the
implications, it should be recognized that fonnal theo- human level. It may also turn out that data collected
ry aids in the scientist's quest to heighten diversified from infrahuman species will prove more useful for
viewpoints, strategies, and predictions. It should also generalizing than the vast amount of research now
be noted that many important theoretical models have being conducted with human beings. If, say, maladap-
not been presented here that may at some point also tive behavior is tied to the conditioning of emotional or
contribute in a significant way to the applied behavior autonomic responses, and if mediated internal cues,
therapy movement (see Hilgard & Bower, 1966; such as words, thoughts, images, and memories in the
Mackintosh, 1974). For example, experimental work human being turn out to follow essentially the same
on modeling and imitation learning at the infrahuman conditioning laws as exteroceptive stimuli, the argu-
level stimulated Bandura (1962) to develop and re- ment for the implications of infrahuman research be-
search important principles that have resulted in behav- comes much stronger. Not only does the rat provide a
ior techniques usable at the human level. As was noted less complex organism, which may be more advan-
in relation to the value of extrapolating learning prin- tageous for deciphering basic laws, it is also equipped
ciples and paradigms, theory also plays an important with an autonomic nervous system not unlike that
role in making a workable and profitable marriage be- found in human beings. Further, animals are expend-
able and can be used in experimentation that for ethical critical principles of behavior change associated with a
reasons cannot be carried out on human beings. They given technique, for developing and testing ideas or
also have the advantage of being less complex than a hypotheses in a controlled setting, for clarifying the-
human being, which increases the probability of isolat- oretical issues, and for establishing the validity and
ing basic principles of behavior. In fact, if infrahuman reliability of previous findings. The laboratory setting
experimentation provides a vehicle for illustration and using nonpatient populations is useful because it per-
confirmation of suspected hypotheses about the human mits the selection of an adequate sample of homoge-
being, the effort is more than worthwhile. neous target behaviors, the equation of avoidance ten-
Despite the various arguments pro and con and the dencies, the operational definition of independent and
obvious need for confirmation at the human level, the dependent measures, and the selection of appropriate
value of infrahuman research in developing other sci- control conditions. Such experimental precision is ex-
ences like biology, behavioral genetics, and medicine ceedingly difficult, if not impossible, when one is
is beyond debate. And as far as behavior therapy is using patient populations (Levis, 1970b).
concerned, animal research has been directly responsi- The value of the analogue population is based on
ble for influencing the development of the applied be- essentially the same strategy that led investigators to
havioral movement. Both Wolpe and Stampfl's re- study the rat so intensively. Studying less complex sets
search with animals was instrumental in developing of behaviors under more contrglled conditions may
their respective theories, and Skinner's work with ani- well be more advantageous for deciphering basic laws.
mals has had a profound influence on the operant con- This strategy has clearly helped the behavioral therapy
ditioning approach. Justified or not, these infrahuman movement to isolate and develop important principles
findings have given impetus to the development of in the areas of assessment, treatment, and theory (see
treatment techniques that previously were un- Bandura, 1978, an excellent article on this subject).
developed or unhighlighted. This is certainly no small
accomplishment (Levis, 1970a; Stampfl, 1987).
Patient Research
Perhaps the most important aspect of the behavior
Human Analogue Research
therapy movement is its continual commitment to ob-
Human laboratory or analogue research has also be- jective assessment and scientific analysis. Not only
come an ingrained part of the methodological arsenal have behavioral therapists embraced the meth-
of the applied behavioral movement. These studies, odological techniques developed by behaviorism and
usually carried out in a laboratory setting with college experimental psychology, but they have also built on
students, mainly involve studying the fears and avoid- these, adding to the arsenal available to applied scien-
ance behaviors of nonpatient populations. Cooper, tists. However, more advances in this area are badly
Furst, and Bridger (1969) were one of the first to crit- needed. Experimental precision is exceedingly diffi-
icize this strategy by suggesting that the treatment of cult to achieve when using a clinical population to
nonclinical fears may be irrelevant to an understanding assess therapeutic techniques. Anyone who has con-
of treating clinical neuroses. Cooper et ai. were quite ducted therapy-outcome research is aware of the nu-
correct then, and, unfortunately, the criticism still ap- merous problems that continually confront the re-
plies today. Too much of the analogue research was searcher. Difficulty with administrative interference,
and is used by behavior therapists to validate their cooperation of staff, control over patient selection and
techniques (a major error of over-generalization). The drug administration, issues of ethics, and sample size
naIvete of some behavior therapists in attempting to are only a few of the frustrations facing the investiga-
justify the validity of their techniques without docu- tors (Levis, 1970b).
menting them with clinical populations is disconcert- The complexity of the therapeutic interaction also
ing. Even today, reviews frequently fail to discrimi- necessitates the use of numerous control groups to deal
nate between research performed with analogue and with such issues as the therapist's skill, experience,
with clinical populations. commitments, and potential extratherapeutic factors,
Human analogue research, however, has been such as the patient's expectations or uncontrolled de-
proved of value as a vehicle for obtaining information mand effects. It is precisely because of this lack of
about various treatment manipulations, for isolating experimental control that outcome research has not
even begun to consider the questions raised at the ana- that may have merit involves the combination of a
logue level of analysis. In fact, it is because of the between-group design with a within-group analysis.
control problem that patient research has not had much One major difficulty in evaluating any therapeutic
of an impact on the scientific community. Appropriate technique is the lack of control over how effectively
design and statistical techniques for evaluation are the technique is administered. The therapist's skill and
readily available, but the issue is one of implementa- expertise, personality interaction, and suggestive ef-
tion. fects are currently allowed to vary, greatly increasing
In an attempt to resolve the problem of the large error variance. Control groups can be added to the
sample sizes required by the traditional between-group design, but they are costly and imprecise.
analysis, a number of behavior therapists have adopted One of the key advantages of the behavioral ap-
the philosophy developed by Skinner and other oper- proaches is that the procedural technique used and the
ant researchers of using within-group analysis of small principles outlined for creating behavioral change can
samples. In such a design, each subject serves as his or be operationalized. However, this is rarely done on a
her own control. Such a strategy has already been subject-by-subject basis or, for that matter, even on a
proved of value in establishing useful behavioral prin- group basis. For example, systematic desensitization
ciples at the infrahuman level of analysis, and it ap- maintains that for therapy to work, the relaxation re-
pears to be the only methodological solution with those sponse must be dominant over the anxiety response.
populations for whom adequate sample size or homo- Implosive therapy argues that therapy will be effective
geneous behavioral patterns cannot be obtained. if the cues introduced elicit a high level of anxiety and
However, the use of these designs with human if extinction of this response results from continual
beings creates new methodological problems that are repetition. Error variance would be markedly reduced
not a factor when conducting animal research. For one if the boundary condition of the technique used were
thing, the within-group analysis of a small sample established on a subject-by-subject basis. That is to
(ABA design) is based on the assumption that large say, the technique administration needs to be
numbers of subjects are not required if environmental monitored by an objective dependent measure of the
variance can be eliminated or controlled. This kind of construct considered to be the changed agent.
control may be readily achieved by using the rat or For systematic desensitization, a measure of the
pigeon Skinner box, but it is almost impossible or too construct relaxation (e.g., electromyogram) and anx-
costly to maintain within the clinical setting. For an- iety (e.g., galvanic skin response) would be needed.
other thing, the experimental manipulation (e. g. , rein- For implosive therapy, a measure of anxiety is re-
forcement administration) is free of bias at the in- quired. Thus, with appropriate monitoring, it can be
frahuman level because it is usually programmed by an empirically established whether the boundary condi-
apparatus. At the human level, such manipulations are tions for a given technique were met by the subject.
usually made with the aid of other human beings or in When it has been established that they have been met, a
the presence of an experimenter. Drug research has direct correspondence should be achieved with symp-
overwhelmingly documented the methodological tom reduction. If symptom reduction does not occur,
point that such manipulations, unless done on a com- the principle suggested by the therapy is not effective
pletely blind basis, can result in subtle communica- with the population tested. If the boundary conditions
tions (suggestive and demand effects) to patients, re- are not met and behavior changes occur, such changes
sulting in the alteration of behavior in the absence of must be attributed to a principle other than that sug-
any experimental effect (the so-called placebo effect). gested by the therapy.
Such dangers must be considered when evaluating re- Because of space limitations, all of the implications
search of this type (Stampfl, 1970). of the above design cannot be addressed. But it is the
writer's conclusion that only two groups would be re-
quired initially: an experimental group and a non-
The Construct Design
treated, control-baseline group. With adequate rep-
It should be clear from the above comments that new lications, such a design would provide a quantitative
designs are needed at the applied level that reinforce index for establishing whether a relationship exists be-
the feasibility of conducting patient research. Ideally, tween meeting the boundary conditions of the tech-
these designs should permit research on small samples nique and symptom reduction and for determining
while addressing the issue of control. One possibility whether extratherapeutic factors are effectively operat-
ing. Whether or not the above ideas are workable reappears to rest. Stampfl noted that these so-called be-
quires testing. But the objective of an economical de- havior therapists assert with virtually dogmatic insis-
sign is correct, and the future of the clinical areas is tence that neither the origin nor the maintenance of
dependent on reaching an adequate solution. The be- neurotic behavior can be understood in terms of clas-
havioral therapy movement is committed to achieving sical fear theory. He noted these same individuals also
this objective and enhancing scientific rigor. relegate the role of operant principles in the Skinnerian
tradition as being equally useless, suggesting a ring of
finality for the learning theory era of behavior therapy.
The Present State of Affairs Stampfl found it ironic that this state of affairs should
exist precisely at a time when marvelous opportunities
The above review covers over 30 years of issues for solidly based theoretical innovations to the human
since the behavior approach got its modern-day start. condition may readily be inferred from the contempo-
Today, the movement has mushroomed to the point rary learning and conditioning literature. Stampfl
where numerous journals, books, workshops, and so- stated, in no uncertain terms, that as far as the anti-
cieties are solely devoted to the topic of behavior thera- learning movement goes the arguments offered are
py. Research articles abound and new techniques flour- based on a number of dubious assumptions, simplistic
ished but the field in its development has broadened to interpretations, questionable assertions, misleading
such a point that its current eclectic nature questions, and inaccurate references, misleading definition of the
too frequently, the appropriateness of the term behav- problem, and critical omissions of the relevant liter-
ior. Once the movement became popular, those associ- ature. He then concluded, "It can safely be asserted
ated with nonbehavioral approaches rechristened that seldom has so much been claimed based on so
themselves as "behavioral." As the membership little" (p. 529).
broadened, a deemphasis on extrapolating basic learn- The reasons for the existing trend away from build-
ing and conditioning principles developed, and the ing upon conditioning and learning principles are
identity to the underlying philosophy of behaviorism many and varied. The reasons, however, are not based
started to erode. The need to be relevant within psy- upon data, on the lack of the fruitfulness of the ap-
chological circles spurred many to alter the behavior proach, or on a replaced and better scientific philoso-
movement in the direction of the ongoing movement in phy. Rather, the problem appears to reflect more a
cognitive psychology. The founding fathers, alarmed problem of training, or lack of it, that retards the ability
by the recent trends, repeatedly expressed their con- to provide a critical analysis. As a result many clini-
cerns (Skinner, 1984; Stampfl, 1983; Wolpe, 1978). cians are influenced by the "fad" of the day. This
Skinner (1984) in commenting on the influence of the sentiment is echoed by Dinsmoor (1983):
cognitive movement warned:
There is a strong tendency in contemporary writings, from the
research report to the undergraduate text, to follow the fashion of
Cognitive psychology is frequently presented as a revolt against the moment, to abandon-almost frivolously-well established
behaviorism, but it is not a revolt; it is a retreat. Everyday English principles in favor of whatever fits the spirit of the time. This,
is full of terms derived from ancient explanations of human however, is not the way to construct a strong and orderly science,
behavior. We spoke the language when we were young. When one capable of bending nature to its will. (p. 704)
we went out into the world and became psychologists, we
leamed to speak in other ways but made mistakes for which we
were punished. But now we can relax. Cognitive psychology is
Old Home Week. We are back among friends speaking the lan- A Future in Question
guage we spoke when we were growing up. We can talk about
love and will and ideas and memories and feelings and states of Given the current state of affairs, it is very possible
mind, and no one will ask us what we mean; no one will raise an
eyebrow. (pp. 949-950) that historians will view behavior therapy as one of
those many passing, fashionable fads. This possibility
was recently highlighted by Steward Agras, in his
Stampfl (1983), perhaps more to the point, in re-
1986 Association for the Advancement of Behavior
viewing the volume that was edited by Boulougouis on
Therapy Presidential address (see Agras, 1987). In his
learning approaches to treatment, concluded that the
opening statement he states:
thrust of chapters by certain well-known behavior ther-
apists formed the panoply on which the "growing dis- In the past few years, despite the ever-strengthening evidence for
satisfaction" thesis with learning theory formulations the efficacy of behavioral treatments, and the widening applica-
tions of such therapies, a theme of discontent has been sounded dealt with such clinical relevant topics as conflict (Mil-
in the writings of many experts in the field. Krasner (1985) in his ler, 1959) aggression (Logan, 1971), anger and frus-
review of the thousand page "International Handbook of Behav-
ior Modification and Therapy" asks where do we go from here? tration (Amsel, 1971), fear (Mower, 1948), and self-
This handbook brings to a focus the crisis in the behavior modifi- punitive behavior (Brown, 1969) were either ignored
cation field. It has lost its initial unity and theoretical cohesion. or arbitrarily dismissed. In place of these well-estab-
There is no coherent overall picture of the field or where it is
lished theories, many behavior therapists offered their
going. I have no specific recommendations to remedy the situa-
tion other than to call attention to the obvious and to suggest that own theories that all too often were poorly concep-
we all focus some attention on these major problems of the tualized and constructed and not very germane to
behavioral movement, overload and fractionization. (Agras, clinical realities. Unfortunately, the super-scien-
1987, p. 203)
tifically trained behavior therapists never emerged, but
rather those who could be characterized as showing
Thus, a strong case could be made that the behav- little depth in the field of learning, possessing limited
ioral movement is in danger of losing its identity. The knowledge of the literature outside of the behavior
founding fathers envisioned the developing field of therapy field, and having limited exposure to the intri-
behavioral therapy as a revolutionary movement of im- cacies of psychopathology. Ironically, the end result is
mense potential and historical importance (Levis, that many of the second and third generations of behav-
1970a). We were at a threshold of a great new develop- ior therapists, who became leaders of the behavioral
ment, the uniting of two disciplines of psychology- therapy movement, were also responsible for moving
clinical and learning. It was hoped that this marriage the behavioral field away from a learning interpreta-
would remove the existing schizophrenia between the tion (Levis, 1988).
applied and its experimental fields of psychology, If the revolution envisioned by the founding fathers
providing each partner with a sense of direction and and this author is to continue, we must return to the
purpose. This relationship was blessed with a common philosophy of science upon which behaviorism is
communication system devoid of surplus meaning based. Our training programs are badly in need of re-
concepts, a shared philosophy of science, and a strong vitalization (see Turner et al., 1988). The power of
commitment to the values of radical behaviorism and basic learning principles and behavioral theory is in
neobehaviorism. However, for this marriage to flour- need of reemphasis, as is the need to illustrate and train
ish, a new breed of scientifically trained clinicians had students how to combine creatively basic principles to
to be developed (Levis, 1974). As previously argued explain clinical phenomena (e. g., see Stampfl, 1987).
(Levis, 1988), the goal was not to only produce an An effort should also be made to enhance communica-
expert in the field of learning, but a master of clinical tion between the applied clinician and the basic re-
experience and knowledge. Unfortunately, too many searcher. If these seeds and those suggested by others
of the behavioral techniques offered today appear con- (Agras, 1987; Krasner, 1985; Turneretal., 1988) are
ceptually shallow, oversimplistic, and unrelated to planted and nurtured into full development, the revolu-
clinical experience (see Turner, Hersen, & Beidel, tion for an objective, critical, and growing behavioral
1988). Many of these techniques appear to be devel- science will continue in an ongoing and significant
oped in an academic vacuum and are based on learning fashion.
principles and theory that are too often naive, sim-
plistic, and lacking in integration.
It is clear that the vision of what might have been
never really materialized to the extent of generating a References
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CHAPTER 3
Cognitive Behavior Therapy

Rick E. Ingram and Walter D. Scott
Introduction aimed specifically at the empirical study of cognition).

Additionally, publication of a number of volumes de-
Behavior therapy has traditionally been viewed as a set voted to cognitive-behavioral approaches to theory, as-
of therapeutic procedures, derived from basic research sessment, and treatment also attests to the vitality of
on human learning, that analyzes and targets for modi- these approaches (e.g., Beck & Emery, 1985; Beck,
fication the stimulus variables that cause and maintain Rush, Shaw, & Emery, 1979; Dobson, 1988; Ingram,
maladaptive behaviors. Historically, cognitive pro- 1986; Kendall & Hollon, 1979, 1981; Mahoney, 1974;
cesses had little place in orthodox approaches to behav- Meichenbaum, 1977; Merluzzi, Glass, & Genest,
ior change. In both a conceptual and procedural sense, 1981; Michelson & Ascher, 1987; Turk, Meichen-
however, the increasing recognition of the importance baum, & Genest, 1983). As evidenced by the prolifer-
of cognitive variables within behavior change has led ation of applied workshops offered through numerous
to the hybrid known as "cognitive behavior" therapy. organizations, cognitive-behavioral approaches have
Conceptually, for example, most theoretical rationales also captured the interest of everyday practitioners.
as to both the change processes effected by behavior Perhaps most noteworthy in appraising the expand-
therapy procedures as well as the causal agents in dys- ing role of cognition in behavior therapy is the increas-
functional behavior now embody significant cognitive ing publication of empirical data evaluating the effi-
elements. Similarly, therapeutic methods designed cacy of cognitive-behavioral approaches. Such data
specifically to impact on cognitive variables are now have been reported in a myriad of investigations, and
standard and essential components of virtually every currently a variety of excellent summaries, both meta-
contemporary behavioral approach to treatment. analytic and qualitative, are available (e.g., Hollon &
Clearly, cognitive processes and procedures in behav- Beck, 1986; Kendall, 1987; Kendall & Bemis, 1983;
ior change represent mainstream behavior therapy. Mahoney & Amkoff, 1978; Steinbrueck, Maxwell, &
There are a variety of ways to document the growing Howard, 1983). Although there is a diversity of specif-
emphasis and influence of cognition in behavior thera- ic cognitive-behavioral approaches in existence (along
py. Kendall (1987), for example, noted a number of with significant variations in definitions and duration
significant milestones in the development of cognitive of outcome criteria, disparate skill levels of study ther-
behavior therapy (e.g., the appearance of journals apists, different disorders treated, and varying meth-
odological adequacy precluding simple statements re-
garding the "effectiveness" of cognitive-behavioral
Rick E. Ingram and Walter D. Scott • Department of Psy-
chology, San Diego State University, San Diego, California therapy), cognitive and cognitive-behavioral pro-
92182. cedures appear to have "generally established their
53
efficacy in a variety of disorders" (Hollon & Beck, Finally, analytical behaviorism views cognitive var-
1986, p. 476). Although not uniform, the empirical iables as simply another category of behavior that oper-
data are certainly quite promising. ates according to the same laws and principles that
Given the current stature of cognitive processes and govern all behaviors. Cognitive responses, then, are
procedures in behavior therapy, our aim in the present merely a subset of behavioral responses, and, conse-
chapter has several objectives. First, we will review quently, cognitive treatments are merely a subset of
the historical development of cognition in behavior behavioral treatments (Wolpe, 1980). Such assump-
therapy. Second, we will attempt to elucidate the de- tions place peculiar constraints on the language used to
fining features and critical underlying assumptions of describe cognition; according to this view, cognition
cognitive-behavioral approaches. Finally, we will dis- and perception are most appropriately referred to as
cuss the current as well as future issues in the continued "cognitive behaviors" and "perceptual behaviors" to
development and evaluation of cognitive-behavioral denote their status as subsets of behavioral constructs.
approaches as we see them. We should note that since Such distinctions are not just semantic, however, in
the efficacy of cognitive-behavioral procedures has that they have important implications for how treat-
been rigorously reviewed elsewhere (e.g., Hollon & ment is conducted and how cognitive variables are
Beck, 1986; Kendall & Bemis, 1983), we will restrict incorporated into theoretical frameworks. Changes in
our comments to primarily definitional and theoretical cognitive variables, for instance, should follow estab-
issues. lished principles of learning and conditioning (e.g.,
cognitive reinforcement, punishment, and extinction).
"Covert conditioning" (e.g., Cautela, 1967), which
Historical Foundations was an early attempt to apply conditioning principles
to cognitive phenomena, nicely illustrates such ap-
As with most paradigmatic changes (Kuhn, 1970), proaches; by merely connecting aversive cognitions to
the acknowledgment and incorporation of cognition in problematic cognitions, these later "cognitive behav-
behavior therapy has represented a gradual shift rather iors" should simply extinguish.
than an abrupt change. To fully understand this shift, it
is helpful to comprehend the conceptual evolution of
Evolution of Cognitive Concepts in
behaviorism. "Behaviorism" is not a monolithic entity
Behaviorism
but is rather a spectrum of views that share several
common assumptions. Given these assumptions, Ma- There seem to be three reasonably distinct stages in
honey (1974) indicated that three "kinds" of behav- the conceptual shift to cognitive concepts. Although
iorism can be identified: metaphysical, meth- behaviorism dominated psychology for many years, in
odological, and analytic. the late 1960s a growing dissatisfaction with non-
Metaphysical (or radical) behaviorism asserts that mediational approaches led several prominent re-
mental events do not exist per se. Instead, all experi- searchers to begin to move away from a strictly behav-
ence can be reduced to glandular secretions, muscular ioral conceptual paradigm (Dobson & Block, 1988).
movements, and exclusive environmental determin- At first, given the belief of many learning theorists that
ism. Thus, both philosophically and procedurally, the study of cognition was not scientific, such shifts
metaphysical behaviorism rejects mediational ac- were of necessity quite subtle. For instance, in devel-
counts of behavior in favor of strictly observable stim- oping the tenets of social learning theory that empha-
Ulus-response analyses. Methodological behav- sized vicarious learning processes, Bandura (1969)
iorism, on the other hand, does not deny or affirm and Mischel (1973) suggested the importance of cog-
mental events but asserts that since such events are not nitive variables, but placed them within the context of
directly observable, they cannot be studied scien- covert behavior. It was this context that allowed them
tifically. Therefore, methodological behaviorism access to "legitimate" scientific status. These social
maintains that cognitive variables cannot be the source learning approaches thus represented the early ante-
of scientific data and, consequently, have little place in cedents of analytical behavioral paradigms.
the science of behavior change. 1 This gradual inclusion of cognitive variables into
1It should be noted that writers have occasionally referred to

"methodological behaviorism" to denote an emphasis in cog- (e.g .• Ingram & Kendall. 1986). Such definitions deal with a
nitive clinical research on the objective scientific inquiry and substantially different concept than is being discussed in the
methodological rigor that are the hallmarks of behaviorism present context.
CHAPTER 3 • COGNITIVE BEHAVIOR THERAPY 55
the realm of scientific respectability was followed by a edly, investigators continue to examine empirically the
group of primarily clinical psychologists who were effectiveness of cognitive-behavioral approaches, but
interested in the development of effective treatment with an increased precision that reflects the meth-
procedures. As such, they focused considerable atten- odological advances in the field (see Hollon & Beck,
tion on explicitly cognitive targets and developed both 1986). Finally, at both the conceptual and empirical
cognitive and behavioral procedures designed to im- levels, efforts are also underway to broadly integrate
pact upon these targets. The emphasis at this second cognitive-behavioral interventions with other diverse
stage was on effective treatment development rather psychotherapeutic approaches to human change
than on refinement and development of cognitive con- (Goldfried, 1980, 1982; Haaga, 1986; Wolfe & Gold-
ceptual frameworks. Nevertheless, these researchers fried, 1988). Interventions that integrate cognitive and
moved away from the notion of cognitions as simply behavioral approaches may be a part of this larger
internal behaviors and accepted the fact that cognitions trend, or, alternately, may have stimulated the trend.
could be considered to operate according to sets of
principles that were substantially different from tradi-
tionalleaming principles. Moreover, such cognitions Description
were viewed as having legitimate causal implications
in dysfunctional behavior. Thus, emphasis was gener- In discussing the foundations of cognitive-behav-
ally on how individuals cognitively structure their ex- ioral treatment, it is helpful to offer some ideas as to
perience (Davison, 1980), and, in particular, on modi- what constitutes the basic nature of cognitive-behav-
fying specific dysfunctional cognitions. Employing ioral therapy. Such defining features not only allow for
the term cognitive-behavioral for probably the first distinguishing between what constitutes cognitive-be-
time, this group included influential works by Kendall havioral treatment from what does not, but also for
and Hollon (1979, 1981), Mahoney (1974), Lazarus identifying the key commonalities and distinctions be-
(1981), and Meichenbaum (1977), Additionally, Beck tween various cognitive-behavioral approaches. In
(1976; Beck et al., 1979), and Ellis (1962) were also considering what it is that constitutes cognitive-behav-
among this group, although they came from traditions ioral therapy, however, it is important to guard against
that were not originally behavioristic. extending uniformity myths (Kiesler, 1966) to this ap-
The third stage is represented by contemporary proach. Such myths would imply that all cognitive-
work in cognitive-behavioral psychology. Work here is behavioral treatments are essentially the same in both
too diverse to identify a particular focus at this time. procedures and underlying theoretical cognitive con-
Instead, it is necessary to distinguish among several ceptualizations of psychological disturbance (Hollon
general themes. One theme in contemporary cog- & Beck, 1986; Kendall & Bemis, 1983). Uniformity
nitive-behavioral theory and research is characterized myths can be discarded by examining the definitions,
by an increased emphasis on the conceptual develop- assumptions, and features that characterize the family
ment of models of cognition and cognitive dysfunc- of cognitive-behavioral treatments.
tion. Given that many previous cognitive construct~ in
cognitive-behavioral psychology developed indepen-
Definitions
dently of ongoing efforts in basic cognitive psychology
(Winfrey & Goldfried, 1986), much current concep- It is useful to begin a description of cognitive behav-
tual work has focused on adaptation of the methods, ior therapy with a quite fundamental definition from
data, and constructs from experimental psychology to which an examination of assumptions and features fol-
cognitive-behavioral psychology (e. g., Ingram, 1986; lows. As a core definition, we view cognitive-behav-
Merluzzi et al., 1981). An additional theme has to do ioral therapy in a manner that emphasizes both the-
with the conceptual understanding and modification of oretical and procedural elements. Specifically,
emotion in cognitive-behavioral therapy paradigms cognitive-behavioral therapy is defined as those sets of
(e.g., Greenberg & Safran, 1987; Guidano & Liotti, therapeutic procedures that (1) embody theoretical
1983). An emphasis on elucidating the disordered pro- conceptualizations of change that place primary im-
cesses that are modified by cognitive-behavioral inter- portance on cognitive process, and that (2) pro-
ventions and thus responsible for therapeutic improve- cedurally target at least some therapeutic maneuvers
ment is also a current focus of contemporary theory specially at altering aspects of cognition.
and research efforts (Hollon, DeRubeis, & Evans, Such a definition, while admittedly simple, has sev-
1987; Simons, Garfield, & Murphey, 1984). Relat- eral functions. For example, it suggests certain im-
plications for conceptualizations of human change 7. Both cognitive and behavioral therapeutic
processes, and, consequently, for translating these the- change methods are desirable and can be
oretical ideas into further therapeutic development, integrated.
modifications, and refinements. Additionally, such a
definition provides a basis for discriminating between
Features
cognitive-behavioral and noncognitive-behavioral ap-
proaches. Approaches solely concerned with the mod- Although we have offered what we view as the de-
ification of behavior, for instance, would not qualify as fining features of cognitive-behavioral therapy (i.e.,
cognitive-behavioral even though they may target the theoretical importance of cognitive causal factors
some cognitive processes. In this regard, Hollon and and methods intended specifically to alter these cog-
Beck (1986) point out that systematic desensitization nitive variables), therapies falling within this class of
would not be considered a cognitive-behavioral ap- therapeutic procedures may vary on a number of differ-
proach because behavior rather than cognitive change ent dimensions, thus making it more difficult to dis-
is the therapeutic goal as well as the presumed causal tinguish what constitutes a cognitive-behavioral thera-
mechanism. Similarly, as Dobson and Block (1988) py. In further attempting to clarify the nature of
noted, approaches employing operant techniques with cognitive-behavioral therapy, a construct borrowed
the sole purpose of modifying behavior, even though from experimental cognitive psychology-cognitive
they may alter some aspect of cognitive functioning, prototypes-is quite helpful. According to Rosch
would clearly not be cognitive-behavioral any more (1973, 1975), prototypes represent abstractions of su-
than would approaches emphasizing childhood trau- perordinate natural categories. The degree of "related-
mas and cathartic expression. ness" of category members depends on the number of
features these members share with the category.
Hence, if the natural category is "bird," a robin is seen
Assumptions
as more typical than a penguin because it shares more
Cognitive-behavioral procedures can also be dis- features with the prototypical bird, although both
tinguished by virtue of their underlying assumptions. qualify as birds. Such prototype constructs have pre-
Although there are no universally agreed upon as- viously been employed in psychopathology research to
sumptions, the following list, which is based on Dob- facilitate diagnosis (see Horowitz, French, Lapid, &
son (1988), Kendall and Bemis (1983), Kendall and Weckler, 1982; Horowitz, Weckler, & Doren, 1983;
Hollon (1979), and Mahoney and Amkoff (1978), Nasby & Kihlstrom, 1986).
seems reasonable with regard to current theory and In determining therapy class membership, as in all
data. We suggest that virtually all cognitive-behavioral cases of natural categories, it is helpful to examine the
therapies share these assumptions. number of features that the particular case has in com-
mon with the prototype. The prototype construct sug-
1. Individuals respond to cognitive representations gests that it is possible to distinguish not only what
of environmental events rather than to the events clearly is and is not cognitive-behavioral therapy, but
per se. also among varying cognitive-behavioral degrees. Al-
2. Learning is cognitively mediated. though some therapies may represent prototypical cog-
3. Cognition mediates emotional and behavioral nitive-behavioral approaches, others may approximate
dysfunction. It should be noted that this assump- this to a much lesser degree and be considered only
tion does not imply a linear focus where cogni- "somewhat" cognitive-behavioral. Although we sug-
tion is primary, but rather that cognitive vari- gest that any therapeutic set of procedures possessing
ables are interrelated with affective and beha- the two core assumptions that we earlier defined can be
vioral variables and thus affect these variables considered cognitive-behavioral, the greater the num-
(and vice versa). ber of other features present, the "more" cognitive-
4. At least some forms of cognition can be moni- behavioral a given therapy can be considered.
tored. As with the assumptions underlying cognitive-be-
5. At least some forms of cognition can be altered. havioral therapy, there is no universally agreed upon
6. As a corollary to numbers 3, 4, and 5, altering set of defining features. However, we think the follow-
cognition can change dysfunctional patterns of ing list is both reasonably accurate and comprehen-
emotion and behavior. sive. As we have noted before, the first two features
represent the core characteristics of any therapy con- validity of the cognitive-behavioral "model" of
sidered to be cognitive-behavioral. dysfunction in order to modify dysfunctional
cognition and behavior.
1. Cognitive variables are assumed to be important
causal mechanisms. This does not imply that
The Varieties of Cognitive-Behavioral
there are not other meaningful casual mecha-
Experience
nisms as well, but that cognitive variables are
important in the constellation of processes that By virtue of the aforementioned features, there are
elicit the onset and course of a disorder. undoubtedly over 20 specific procedures that qualify
2. Following from the assumption that cognitive as cognitive-behavioral therapies. Although it is out-
variables are presumed to be causal agents, at side the scope of the present chapter to describe these
least some of the methods and techniques of the specific interventions, it is worthwhile to consider
intervention are aimed specifically at cognitive some of the major categories of cognitive-behavioral
targets. therapies (excellent summaries and reviews of specific
3. A functional analysis of the variables maintain- interventions can be found in Dobson, 1988; Hollon &
ing the disorder, particularly cognitive variables, Beck, 1986; Kendall, 1987).
is undertaken. Dobson and Block (1988) and Mahoney and Arn-
4. Cognitive-behavioral approaches employ both koff (1978) have noted three general classes of cog-
cognitive and behavioral therapeutic tactics. nitive-behavioral interventions that vary according to
Typically, even behavioral tactics, however, are the general goal of the therapy. Such approaches are
aimed at cognitive objectives, such as in the case not seen as exclusive but rather differ in terms of em-
of Beck's (Beck et aI., 1979) approach to depres- phasis. Coping skills approaches are those that focus
sion, which employs behavioral homework as- on helping individuals develop skills for adapting to
signments intended to help modify dysfunctional stressful circumstances that are largely out of their
thoughts and beliefs. control. Meichenbaum's (1977) stress inoculation
5. There is a strong emphasis on empirical verifica- training is a relevant example of coping skills ap-
tion. This emphasis is manifested in two differ- proaches. Alternatively, cognitive restructuring meth-
ent domains. The first is in empirical research ods focus upon altering some aspect of the individual's
designed to establish the efficacy of the thera- cognitive structures or processes, presumably to in-
peutic procedures and help determine the pro- crease the individual's accurate appraisal of informa-
cesses by which these procedures function. The tion. Examples of cognitive restructuring methods in-
second is in an emphasis within actual therapy clude Beck's (Beck et al., 1979) cognitive therapy
upon employing objective assessment to exam- approach. Problem-solving approaches, as the name
ine therapeutic progress. Again turning to treat- implies, are those that are aimed at helping clients to
ment for depression, Beck (Beck et aI., 1979) develop effective problem-solving behaviors. Prob-
recommended a session-by-session client Beck lem-solving therapy as described by D'Zurilla and
Depression Inventory (BD!) to help assess ob- Goldfried (1971) represents such an approach.
jectively the range and degree of the client's de- In noting that treatments can also vary as a function
pressive symptoms. of procedural rather than therapeutic goal emphasis,
6. Cognitive-behavioral approaches are typically Hollon and Beck (1986) have described three related
time limited, or at least not considered long-term but different categories of cognitive-behavioral
therapy in the classic sense. therapies. For example, they suggested that some
7. Cognitive-behavioral approaches are collab- therapies are characterized as emphasizing rationality.
orative enterprises (e.g., "collaborative em- Ellis's (1962) rational-emotive therapy is the best ex-
piricism") where the client and therapist form a ample of an approach that is designed to alter the cli-
working alliance to alleviate dysfunctional ent's irrational beliefs through logic and persuasion.
thinking and behavior. Procedures emphasizing empiricism include Beck's
8. Cognitive-behavioral therapists are active and approach to depression (Beck et al., 1979) and anxiety
directive rather than passive and nondirective. (Beck & Emery, 1985); these focus upon both cog-
9. Cognitive-behavioral approaches are educa- nitive and behavioral hypothesis-testing procedures to
tional in nature. That is, clients, must accept the help clients' assess the accuracy of their thoughts and
S8 PART I • FOUNDATIONS
beliefs. Procedures emphasizing repetition are those quite differently because of a variety of factors, such as
that rely on a structured sequence to help clients re- their particular personal attributes and backgrounds,
place dysfunctional cognitions with particular func- training backgrounds, and the vicissitudes of client
tional cognitions. Meichenbaum's (1977) stress inocu- circumstances and behaviors. With very few excep-
lation training approach represents an intervention that tions, it is simply not realistic to assume that a method
underscores repetition. or technique found effective in experimentally rigor-
ous outcome studies can be employed in the same way
in actual practice. It is unlikely that we will ever be
Scientific Considerations
able to prescribe certain treatments for certain disor-
An often heard axiom is that the goal of therapy ders, at least in the manner that the treatments are
outcome research is to determine which methods are actually tested. Does this then suggest that empirical
effective for treating which clients with which prob- research that tests the effectiveness of various treat-
lems: "Which specific procedures obtain which results ment strategies is unimportant or not useful? Abso-
with which patients, in what amount of time, and are lutely not; a strong emphasis on empirical testing is the
these differential results equally enduring" (Bergin & hallmark of both behavioral and cognitive-behavioral
Lambert, 1978, p. 162). In principle, this proposal approaches and is unequivocally essential. The prob-
suggests that is should one day be possible, based on lem, however, revolves around whether applied clini-
the empirical literature, to catalog effective treatment cal psychology is a conceptual or a prescriptive sci-
techniques for specific problems so that specific inter- ence. We argue strongly that it is a conceptual science.
ventions can presumably be registered for prescriptive What empirical research can realistically do is to in-
use. Behavioral and cognitive-behavioral approaches form therapists regarding human change principles,
have been seen as offering the greatest promise for and how these principles tend to be effected by various
achieving this goal. For instance, the emphasis on em- classes of therapist behaviors. These data then allow
ploying specific techniques or methods in these ap- therapists to put this knowledge into practice, not in a
proaches conforms nicely to the premises underlying prescriptive sense, but in a scientific sense. Indeed, we
this philosophy. In addition, the reliance on rigorous view therapists as applied scientists who bring to bear
empirical verification of therapeutic efficacy implies a their empirically derived knowledge of basic science
mechanism for eventually being able to reach the goal (the functioning of various change variables) on partic-
of empirical cataloging. ular scientific (client) problems to be solved. Thus,
It is worthwhile to examine briefly the assumptions these scientist-practitioners are characterized by a
of this prescriptive philosophy. Earlier we suggested flexibility to apply their basic scientific knowledge in a
that cognitive-behavioral approaches have generally way that fits best with their personalities and back-
proven their worth in the outcome literature, and it grounds, with clients' personalities and backgrounds,
might thus be suggested that clinical science is steadily and with the multitude of problems clients bring to
progressing toward a body of knowledge that allows therapy. It follows, then, that outcome research that
for clear recommendations regarding particular thera- tells us most about scientific change principles will be
peutic methods for specific problems. There are two the most effective in helping clients. On the other
interrelated problems with this assumption, however. hand, "horse race" studies comparing different meth-
The first has to do with the prescriptiveness of em- ods to see what is the most effective are of less value in
pirical findings, and the second concerns what is actu- day-to-day practice unless they can provide mean-
ally demonstrated when an approach has been found to ingful information about the processes underlying the
be effective for a psychological problem. A prescrip- changes effected by the different treatments. Ultimate-
tive philosophy assumes something analogous to a ly, outcome research that explicitly examines ques-
medical treatment model. For example, different psy- tions of process will be of the greatest use in such a
chopharmacological doses of a medication prescribed conceptual science as clinical psychology.
by different practitioners for a disorder represent an
identical treatment; the methods based on a medical
model can be applied in a uniform fashion with largely Current and Future Directions
predictable results. The same cannot be said for psy-
chological treatment. Even using the "same" methods Earlier we alluded to a number of important direc-
for the same disorder, different therapists will behave tions in cognitive-behavioral research. Although space
does not pennit a detailed examination of these trends, (Bower, 1981; Greenberg & Safran, 1987; Ingram,
we will elaborate on several that we believe are most 1984a,b; Leventhal, 1980). However, a fact often un-
promising. In particular, we will focus on the growing noticed by many cognitive-behavioral researchers is
trend to establish theoretical models of the dysfunc- that the study of emotion has been pursued with some
tional cognitive variables that are affected by cog- success outside the standard journal publications of
nitive-behavioral procedures. Further, we will attempt cognitive-behavioral psychology. In some instances,
to integrate these cognitive theoretical constructs with the findings can be seen as complementary to areas of
current perspectives on affect. current activity in cognitive-behavioral research, al-
In order to examine these trends, it is helpful to have though they may hold some variant and distinct implica-
a conceptual framework to guide discussion. Else- tions for the practice of cognitive-behavioral therapy.
where, a "cognitive taxonomy" has been described as Although empirically established models of emotion
a means to classify diverse levels of cognitive analysis have yetto be established, nevertheless, there has been a
(Ingram & Hollon, 1986; Ingram & Kendall, 1986, proliferation of first attempts that are to be commended
1987; Ingram & Wisnicki, in press; Kendall & Ingram, for both the light they do shed on the role of emotion and
1987). Briefly, this taxonomy suggests that cognitive in the heuristic value they serve in the further study of an
variables can be classified according to which level of obviously relevant and critical intervening variable
cognitive analysis they describe. Structural variables (see, for example, Greenberg & Safran, 1987). Indeed,
refer to the "architecture" of the cognitive system; if we can study the topic of emotion with the same
those variables that describe how infonnation is repre- rigorous empirical prerequisites that have traditionally
sented, organized, and connected into meaningful characterized cognitive-behavioral research, the poten-
units. Propositions, on the other hand, refer to the tial benefits to the treatment and modification of psy-
infonnation itself that is stored within cognitive struc- chopathology are self-evident and numerous.
tures. Schema constructs are usually a function of hy- There is a body of emotion theory and research that
pothesized structural and propositional variables (In- not only complements some current cognitive-behav-
gram & Kendall, 1986) in that they describe certain ioral theoretical paradigms but potentially offers some
kinds of infonnation structured in a certain fashion unique implications for the practice of cognitive-be-
(e.g., the depressive self-schema; Beck, 1976). Oper- havior therapy. For instance, the cross-cultural facial
ational variables are those that describe the processes studies of Ekman and others (Ekman, 1972, 1973;
by which the system operates (e.g., encoding and re- Ekman, Friesen, & Ellsworth, 1972; Emde, Gaens-
trieval processes, attention). Finally, product variables bauer, & Harmon, 1976; Izard, 1971, 1977) have dem-
pertain to the results of infonnation processing within onstrated universality with a few basic emotional ex-
the system; these are the cognitions that are experi- pressions, including interest, happiness, surprise,
enced, such as self-statements, thoughts, decisions, disgust, fear, anger, and sadness. The establishment of
and images. cross-cultural expressions of emotions supports the
Employing the cognitive taxonomic system as our thesis that humans possess an emotional "hard-wir-
guiding or paradigmatic structure, we shall examine ing" or innate neural programming. This hard-wiring
some current trends and future directions in the study of emotions is further indicated by a study that found
of cognitive and affective mediational constructs. that Americans identified with equal accuracy ante-
Given that these trends seem most evident within the cedents to emotion provided by both American and
structural, propositional, and operational categories, Malaysian subjects (Boucher & Brandt, 1981). Al-
we will limit our discussion to these areas. though the authors recognize that additional research is
needed with other non-Western cultures before claims
of universality in emotional antecedent meanings can
Cognitive Structural/Propositional
be established, this study and the body of research on
Constructs
pan-cultural expression strongly suggest that human
Considering cognitive-behavioral therapy's empha- beings possess common prototypical affective struc-
sis on rationality, it is not surprising that conceptual tures.
approaches to emotion have not received much atten- More interestingly perhaps, this line of research ap-
tion in the past. It is therefore noteworthy that cognitive pears to support an evolutionary or functional theory of
psychology has recently begun an attempt to include emotion. Originally proposed by Charles Darwin
affective variables in cognitive-behavioral paradigms (1872/1965), functional theories of affect have since
been presented in alternative forms by such theorists as Rummelhart, 1975) and adjoined to it the concept of a
Tomkins (1962, 1963, 1984), Izard (1977), Plutchik "primary emotion node." Briefly, he postulated the
(1980), and Ekman (1984). Essentially, the functional existence of memory structures (called "nodes") rep-
approach views emotion as an organizing and sustain- resenting basic emotions, such as joy, fear, and sad-
ing process that motivates adaptive behaviors that are ness. He viewed these nodes as having neural connec-
intended to accomplish some desired and needed effect tions to associated propositions and aspects character-
upon the environment; that is, fear motivates running istic of each specific emotion. For instance, the sad-
to escape from a threat stimulus just as distress moti- ness node is a unit in memory posing associative links
vates crying to elicit empathy from a group member to verbal labels, evoking appraisals, expressive behav-
(Tomkins, 1984). Discrete or "primary" emotions fur- iors, and autonomic reactions characteristic of sad-
ther function to direct a selective attentional process ness. When these nodes become activated (or overacti-
that focuses available capacity on the relevant stimuli vated) through physiological or symbolic verbal
and thus provides specific information that is more means, the resulting spread of activation has two pri-
readily processed and integrated than the type of infor- mary effects: (1) it arouses and evokes the associated
mation provided by simple undifferentiated arousal characteristics of the particular emotion, and (2) it de-
(Izard, 1977). This body of emotion research and theo- creases the threshold of consciousness for the affec-
ry appears to be quite consistent and compatible with tively related propositions, cognitions, and memories.
the "schema" or "network" models predominant in As previously noted, a network theory of emotion
the current cognitive perspectives. and cognition is quite compatible with an evolutionary
and functional perspective on emotion. For instance,
Cognitive Structure/Proposition Constructs the fact that arousal of a specific mood evokes a
Integrating Affect. A great deal of current research spreading activation process, whereby affectively rele-
in cognitive psychology continues to grapple with sev- vant cognitions, memories, as well as other emotional
eral versions of "network theory" that specify a rela- characteristics, such as action tendencies and behav-
tionship between cognition, affect, perceptual, and iors, become immediately accessible, seems to sug-
memory processes (Bower, 1981; Ingram, 1984a,b). gest an important survival function (Bower, 1981). If a
Originally proposed by Bower (1981) to account for stimulus is appraised as dangerous and fear is felt, for
experimental findings in such phenomena as memory instance, it behooves the chances for survival if there is
retrieval, state-dependent learning, and mood-con- immediate access to stored memories of similar dan-
gruent effects, network theory models potentially hold gerous situations containing accurate or inaccurate ap-
several important implications for therapeutic inter- praisals and successful or unsuccessful behavioral re-
vention strategies. However, it should be noted that sponses. Although there have been relatively few
although network constructs have generally been suc- attempts to integrate functional theories of affect with
cessful in conceptualizing and accounting for a variety network theories of emotion and cognition-notable
of the effects that mood has on memory (see Ellis & exceptions being Leventhal's perceptual-motor theory
Ashbrook, 1988) and for many of the typical symp- (1979, 1980, 1982, 1984) and Lang's bio-informa-
toms of clinical depression (see Ingram, 1984a), there tional theory (1983)-it appears to us that a combina-
have also been some hypothesized effects that experi- tion can yield benefits as a heuristic model for the
mental research has found especially difficult to repli- examination of the affect-cognition interface as well
cate (see Blaney, 1986; Ellis & Ashbrook, 1988). Ellis the relationship of cognition and affect to other mental
and Ashbrook (1988), however, suggested that the processes, such as memory and perception.
problem lies not necessarily with the network model Several similar versions of network theory have ap-
itself but possibly results from inadequate design fea- peared that also explicate mood, memory, and percep-
tures inherent in many of the nonconfirrnatory studies. tual biasing effects, particularly as these occur in rela-
Conceptually similar to a variety of schema con- tion to depression (Clark & Isen, 1982; Ingram,
structs commonplace in cognitive clinical and social 1984a,b; Isen, 1984; Teasdale, 1983). Since these
cognitive psychology, network approaches are some- models view depression as primarily the result of a
what novel in that they posit a specific role for emo- highly activated and elaborate depressed emotion
tion. Essentially, Bower (1981) adapted a proposi- structure, cognitive-behavioral treatment could have
tional network theory of memory (Anderson, 1976; several different effects: (1) the negative content of the
Anderson & Bower, 1973; Kintsch, 1974; Norman & depressed structure could be modified, (2) compen-
satory structures could be created or existent structures that the effect upon the client of gaining knowledge
that are incompatible with the activation of depressed about depression leads the client to experience less
emotion networks further developed, or (3) the de- "depression about depression." Specifically, rather
pressed emotion structure could simply be deactivated than viewing the aversive and uncontrollable aspects
(Ingram & Hollon, 1986; Kendall & Ingram, 1987). Of of experiences as evidence of personal inadequacy,
these approllches, the prevalent goal in cognitive-be- selfishness, and so on, clients recognize them as symp-
havioral therapy has been to attempt to correct the toms of a well-known psychological disorder with pre-
distorted or "irrational" negative cognitions and be- dictable and understandable effects. In effect, then, the
liefs of the depressed client and, hence, to modify the therapist is assisting the client to develop a "coping
elaborate depressive structure itself (Beck et aI., network" that can become activated through con-
1979). Although this approach makes good intuitive trolled processing procedures during depressive expe-
sense and provides a foundation for many theoretical riences. As treatment progresses, however, the client
proposals on cognitive change processes (e. g. , Beck et is then provided with the additional behavioral coping
aI., 1979; Winfrey & Goldfried, 1986), some investi- mechanisms to further increase perceived control-
gators have argued that treatments may not necessarily lability and reduce the aversiveness of future experi-
succeed by minimizing the content of depressive struc- ences. In this way, the coping structure is further solid-
tures (Ingram & Hollon, 1986). For example, they note ified, and vulnerability to future depressive episodes is
that high relapse rates in treated depressed individuals decreased.
may indicate that negative cognitive structures have
not in fact been altered. Alternatively, several theorists Further Therapeutic Implications of Affec-
(Ingram & Hollon, 1986; Teasdale, 1985) have sug- tive Approaches. An integration of functional emo-
gested that some cognitive-behavioral interventions tion theory with network theory would seem to suggest
may accomplish the majority of their effects by devel- some alternative approaches to the treatment of psy-
oping and activating incompatible network structures, chological problems. It has been widely recognized
whereas others may accomplish their effects by deac- that the modification of affect is an important practical
tivating negative structures. In effect, treatment ac- goal for treatment (Greenberg & Safran, 1987;
cording to this view consists of providing cognitive- Rachman, 1981). Typically, however, such modifica-
behavioral knowledge/action systems that enable the tion has been approached by purely cognitive pro-
client to cope with, or compensate for, this otherwise cedures. Rachman (1981) suggested that if Zajonc
negative impact of the information processing of the (1980) is correct in arguing that the affective system is
depressed network. both independent and primary, then it becomes imper-
Teasdale (1985) also suggested a compensatory ative that methods be developed that allow for entry
schema approach, and recognizing that various cog- into the affective system. Although most researchers
nitive behavior therapies with disparate rationales are recognize a certain degree of interrelationship between
equally effective in the treatment of depression, solved affect and cognition, they are in agreement that they
this apparent dilemma by postulating that these various may indeed compose separate systems and, therefore,
therapies succeed because they possess common meth- may require different procedures for modifications.
ods that alleviate the factors involved in the mainte- Interestingly, a network-functional approach to af-
nance of depression. Briefly, as a result of the overac- fect and cognition suggests that by accessing affective-
tive depressive network, clients perceive current cognitive structures the modification of maladaptive
experiences as highly aversive and uncontrollable. cognitions can be improved. As one example of such a
Rather than attempt a difficult alteration of the de- method, Greenberg and Safran (1987) have developed
pressive structure itself, Teasdale argued that treat- a procedure that attempts to "combat" self-critical or
ment ought to provide clients with information ex- negative cognitions by evoking the structural networks
plaining the symptoms and cycling effects known to be of basic biologically adaptive emotions. These emo-
an inherent aspect of the psychological dysfunction. In tions are selected because of their incompatibility with
this way, Teasdale argued, clients are less over- the negative network structures. For example, when a
whelmed with the aversiveness and uncontrollability depressed client reveals some anger at a hypercritical
of the experiences and view their symptoms as part of side of him- or herself, the therapist induces further
one underlying problem rather than more stable and arousal of the essentially adaptive emotional response
pervasive personal weaknesses. Teasdale maintained of anger so that the client is able to assist him- or
herself against these negative onslaughts. By support- terest in the present context, studies have observed a
ing and accessing the emotion node or network of an- relationship between the disposition of private self-
ger, the therapist improves the likelihood that the client consciousness and the experience of affective states.
will be capable of processing more adaptive cognitions Specifically, individuals high in private self-con-
(e.g., "I'm not perfect. And I can't be therefor every- sciousness experience an increase in affect and are thus
body") (p. 293). These cognitions are consistent with more likely to express such affect in behaviors (Scheier
the activated structure and, hence, are processed at & Carver, 1977; Scheier, Carver, & Gibbons, 1981).
deeper levels allowing for a more meaningful integra- Studies have also suggested that chronically self-
tion. focused individuals are more affectively reactive to life
The effectiveness of such "access" procedures has a events (Ingram, 1990). These findings suggest an
degree of empirical support. Ingram (1984b), for in- important principle that may be utilized in developing
stance, found that mood influenced the cognitive pro- methods to access cognitive-affective structures prior
cessing of favorable and unfavorable personal informa- to implementation of cognitive-behavioral procedures.
tion. Specifically, subjects who first received a Namely, the directing of attentional capacities inter-
negative mood experience and then unfavorable feed- nally upon salient emotions appears to be an effective
back recalled more of the negative feedback than did means of evoking and accessing affect.
positive and control mood subjects. It appeared, then, In a therapeutic setting, the reflection of feelings
that a negative mood experience primed or accessed employed in a very directive fashion appears to insti-
the relevant network structures so that subjects pro- gate this internal focusing process and therefore may
cessed mood-congruent feedback more deeply and be valuable as an access strategy to prime cognitive-
therefore integrated the unfavorable feedback at more affective structures. Although establishment of a
meaningful levels. If structures must be accessed prior "working alliance" is viewed by some to be the pri-
to persuasive or rational presentation of information, a mary function of empathic techniques, many empathic
primary problem for cognitive-behavioral therapy be- theorists suggest that empathic responding intensifies
comes one of developing methods for priming these emotional experiencing (Gladstein, 1983; Rice, 1974;
cognitive-affective structures. A few strategies that Rogers, 1961). Thus, before employing the coping
suggest some promise include music (see Clark & skill, restructuring, or problem-solving methods stan-
Teasdale, 1985; Sutherland, Newman, & Rachman, dard in cognitive-behavioral interventions, the thera-
1982), Velten-like techniques, and evocative-empathic pist might first empathic ally reflect the specified emo-
methods (Rice, 1974), although these would obviously tion that is related to the targeted cognitions (this ap-
need to be adapted for the special circumstances of the proach is similar to the "combating cognitions" strat-
therapeutic structure. egy of Greenberg and Safran (1987), except that empa-
thy is proposed as the procedure to evoke the emotional
state). In this way, the effectiveness of these cognitive-
Cognitive Operations
behavioral procedures might be improved through
We defined cognitive operations as those procedures priming the relevant cognitive-affective structures.
by which the various components of the cognitive sys- Even though cognitive-behavioral therapists are
tem interact to function in the processing of informa- more inclined to favor a strictly rational approach, it is
tion. Regarding current research in the study of cog- possible that such methods themselves only succeed in
nitive operations, there seem to us to be two principal effecting the awareness of the maladaptive cognitive
areas of current activity that hold special relevance to content and do not actually access the belief structure
cognitive-behavioral treatment: (1) those studies ex- itself. Indeed, the client may well possess a precise
amining the role of self-focused attentional processes intellectual awareness that "x" is irrational but may
in affective states, and (2) research and theory on auto- still "feel" that x is nevertheless true. By enhancing
matic and controlled information processing. self-focused attention through the use of empathic
priming methods in combination with such methods as
Attentional Constructs: Self-Focused Atten- countering, perceptual shifting, logical analysis, iden-
tion. Researchers have examined the effects of self- tifying underlying assumptions, and conditioning pro-
focused attention (or "private self-consciousness") on cedures, therapists might be more successful in access-
a variety of processes (e.g., Carver & Scheier, 1981; ing and altering the cognitive-affective structures in
Fenigstein, Scheier, & Buss, 1975). Of particular in- which the targeted cognitive content is embedded.
Automatic and Controlled Processing. It has switch to a more controlled mode when they experi-
been observed that information can be processed in ence a negative affective reaction and, consequently,
either an automatic or a controlled fashion. Although vitiate the maintaining and exacerbating by-products
definitions vary somewhat, automatic processing re- of the negative cycling effect.
fers to information that is processed in a habitual man-
ner and that individuals do not "choose" to think about
or attend to, but find themselves doing anyway (In- Summary and Conclusions
gram & Hollon, 1986). This stands in contrast to a
more controlled form of processing in which the indi- In order to elucidate some of the basic foundations
vidual chooses to exert some control over the informa- of cognitive-behavioral approaches, we have noted in
tion thought about and attended to. this chapter some of the origins, assumptions, and fea-
Several theorists have suggested that such disorders tures of contemporary cognitive-behavioral psychol-
as depression are characterized by an automatic style ogy. Additionally, we have attempted to describe some
of processing information (e.g., Beck, 1976; Beck et of the current as well as future trends in cognitive-
al., 1979; Ingram, 1984a; Rehm, 1977). In therapy, behavioral perspectives. Researchers have gone be-
therefore, one of the treatment effects may include the yond a relatively simple interest in demonstrating the
cessation of negative automatic cycling in favor of a effectiveness of therapy to an examination of issues
more controlled processing style. Ingram and Hollon concerning the theoretical structure of cognition and
(1986), for instance, have hypothesized that many of its relationship to dysfunction, the processes impacted
the commonly used cognitive-behavioral intervention by cognitive-behavioral treatment, and the explicit in-
strategies attain their success in part by interrupting corporation of affect into cognitive-behavioral models
this automatic recycling of negative cognitions in de- and interventions. In a Kuhnian sense, these activities
pression and by forcing a more controlled mode of have the decided appearance of "normal science."
processing. They suggest that many behavioral and Even though cognitive-behavioral psychology may not
cognitive intervention strategies, including activity yet be considered mature in this same Kuhnian sense, it
scheduling, graded task assignments, scheduling spe- can certainly be considered to be enjoying a healthy
cific activities, identifying automatic thoughts, identi- adolescence. Indeed, the 10 to 15 years that have
fying cognitive distortions, identifying underlying be- passed since explicit references to cognitive-behav-
liefs, and evaluating belief validity, accomplish their ioral approaches were first made have seen an extraor-
success, at least in part, because they interrupt this dinary amount of progress. The next 10 to 15 years
depressive automatic processing sequence and precipi- promise to be every bit as impressive.
tate a switch to a controlled processing mode. In-
terestingly, this creates a paradox in that automatic
processing is usually a functional and ordinary infor-
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CHAPTER 4
Applied Behavior Analysis

Michael A. Milan
Introduction implies, radical behaviorism differs from the tradi-

tional and methodological forms of behaviorism with
Skinner (1974) noted that behaviorism is not a science which it is often confused. However, the term radical
of behavior but, instead, is the philosophy of that sci- is not used to signify that the difference is one of
ence. Behavior analysis is a science of behavior that is amount or degree. Radical behaviorism is not an ex-
based upon that philosophy. The science has two major treme form of the more common varieties of behav-
divisions. The first division, the experimental analysis iorism. Instead, the term radical is properly used to
of behavior, is concerned primarily with basic research signify that the approach is thoroughgoing. That is,
and the discovery and elaboration of fundamental prin- radical behaviorists hold that all psychological phe-
ciples of behavior in laboratory settings. The second nomena, including such private events as thoughts and
division, applied behavior analysis, is concerned pri- feelings, are amenable to behavior analysis, and that
marily with applied research and the extension and such an analysis will increase our ability to under-
further elaboration of fundamental principles of behav- stand, predict and, when it is socially desirable to do
ior in natural settings. The two divisions complement so, control those phenomena. Indeed, Skinner has dis-
each other, and both share the philosophy of science cussed the potential benefits of a behavioral analysis of
called radical behaviorism that has been articulated by a range of subjects of interest to psychology, including
Skinner(1938, 1953, 1969, 1971, 1974, 1987) and his social behavior, religion, and psychotherapy (Skinner
colleagues (e.g., Keller & Schoenfeld, 1950). A basic 1953); freedom, dignity, and values (Skinner, 1971);
understanding of radical behaviorism is therefore nec- thinking, knowing, and emotion (Skinner, 1974); and
essary for an appreciation of applied behavior analysis. language (Skinner, 1957).
Perhaps the difference between traditional and radi-
cal behaviorism that many of those who have not read
the radical behavioral literature for themselves find
Radical Behaviorism most surprising is radical behaviorism's position on the
importance of private events (e.g., thoughts, feelings)
In general, radical behaviorism involves the ap- in a science of behavior. The origins of behaviorism lie
plication of the philosophies of the natural sciences to in large part in the revolt against the mentalism and
the study of psychological phenomena. As its name introspection of early twentieth-century psychology.
Those origins led to the rejection by traditional and
Michael A. Milan • Department of Psychology, Georgia methodological behaviorism of private events as natu-
State University, Atlanta, Georgia 30303. ral (real) phenomena or as phenomena that are suitable
67
for scientific investigation. However, radical behav- of behavior because they can provide valuable clues
iorism does not exclude private events from the study about the causes of the behavior. However, radical
of behavior. Radical behaviorism views thoughts, feel- behaviorism then goes on to explore the learning histo-
ings, and other private events as important natural phe- ry of the individual to gain a better understanding of all
nomena that are suitable for scientific investigation the dimensions of the behavior that are in need of
(Skinner, 1974, pp. 16-18). For the radical behav- explanation.
iorist, the individual is considerably more than an im- 1)rpically, radical behaviorism first explores the past
penetrable black box! consequences of the behavior within the context of the
A second difference between radical and other forms individual's current situation (Hersen & Bellack,
of behaviorism is radical behaviorism's position on the 1981), as when it is determined that taking aspirin in
importance of stimuli in the explanation of operant the past has been followed by quick headache relief.
(instrumental) behavior. For traditional or meth- However, other aspects of the individual's learning
odological behaviorism, the primary unit of analysis is history are not ignored. It may well be, for example,
the stimulus-response (S-R) relationship. Responses that the individual's physician has prescribed the as-
are said to occur in response to the stimuli that precede pirin, or the individual has recently viewed a series of
them, and those stimuli are said to be the causes of the aspirin commercials. Indeed, it is common for behav-
responses. Stimulus-response relationships are seen ior to have a mUltiplicity of causes or determinates, all
by traditional behaviorisms as the necessary ingredients of which may also be subjected to a radical behavioral
in an understanding of most behavior. For radical behav- analysis as the circumstances necessitate.
iorism, the primary unit of analysis is the relationship
between responses and their consequences. Responses Characteristics of Applied Behavior
are said to occur now because of the events that followed Analysis
them in the past, and the consequences of those re-
sponses now will influence whether, when, and where Applied behavior analysis was described eloquently
those responses will occur in the future. Response- by Baer, Wolf, and Risley (1968) in the first issue of
consequence relationships are seen by radical behav- the journal that today continues to bear its name and
iorism as the necessary ingredients in an understanding define its character. At that time, applied behavior
of most behavior. Radical behaviorism is certainly not a analysis was said to consist of the application of some-
form of S-R psychology! times tentative principles of behavior to the improve-
Radical behaviorism's emphasis on behavior and its ment of socially important behavior in such areas as
consequences should not be mistaken for teleology or mental illness, crime, education, or retardation, while
purposivism. Teleology is the general tenet that pre- simultaneously evaluating whether observed changes
sent events are controlled by a final, future cause or in behavior may be attributable to the action of those
ultimate outcome. Purposivism is a form of teleology principles. Applied behavior analysis remains so to-
that posits people do things in the present in order to day. Baer et at. also discussed seven characteristics of
obtain the products of those things in the future, as applied behavior analysis: not only must the approach
when we are told that a person is taking aspirin because be applied, behavioral, and analytical, but the applica-
it will reduce a headache. Although explanations such tions should be technological, conceptually systemat-
as this are popular in Western culture, it is generally ic, effective, and display generality. Although these
accepted by science and philosophy that events which characteristics may appear obvious, they set the behav-
mayor may not occur in the future can in no way ior analytic approach apart from other, approaches in
control events taking place in the present. Teleogical or important ways. The applied nature of the approach
purposive explanations of behavior, no matter how signifies that the phenomena studied by applied behav-
popular or commonsensical they may be, are therefore ior analysts are relevant directly to important concerns
rejected as inadequate or misleading. Similarly, the of society or its individual members, rather than ap-
individual's stated expectation that the aspirin will replicable primarily to the development or elaboration of
duce the headache is rejected as an inadequate or mis- some theory.
leading explanation of why the individual is taking the The phenomena studied by applied behavior analy-
aspirin. Instead, the expectation is viewed as addi- sis are typically the behaviors of individuals and the
tional behavior that is in need of explanation. Radical factors or variables that influence or control them.
behaviorism takes note of these popular explanations These may be both public and private events. Public
CHAPTER 4 • APPLIED BEHAVIOR ANALYSIS 69
events occur in the natural environment where they continue to grow as an organized discipline and, as a
may be perceived (seen, heard, smelled, felt) by the second effect, contributes to the continued growth of
social community in general. Private events occur in behavior theory (Skinner, 1969, pp. vii-xii). The ef-
the inner environment of the body where they may be fects of behavioral procedures should be of practical
perceived only by the person so behaving and, in some value, for if they are not, they are of little or no use in
instances, by members of the social community with the applied setting. Even though small but reliable or
the assistance of special instruments, as when a ther- statistically significant results may be of considerable
mometer is used to measure skin temperature during value in basic research, large and clinically significant
the assessment of anxiety (e.g., Kolko & Milan, change in socially relevant public and private behavior
1980). Both radical and more traditional behaviorists is the goal of applied behavior analysis. Finally, behav-
agree that public and private events do not appear to ioral procedures should have generality in that they
differ in any other important way (Skinner, 1953, pp. apply to a range of related behaviors and a variety of
257-258, Wolpe, 1976, p. 59). similar individuals, and that their effects endure over
The variables that influence or control the public time and across settings.
and private behavior of an individual typically lie in the The Baer et al. (1968) defining characteristics of
individual's social environment. These are the ways applied behavior analysis have been elaborated and
that others behave toward the individual and react to extended by subsequent writers. Azrin (1977) noted
his or her behavior. To the degree that it is possible to that the approach is learning based. At their core, the
identify the relationships between an individual's be- principles and constructs that applied behavior ana-
havior and the variables that influence or control it, it is lysts rely upon most heavily to understand behavior
possible to understand that behavior. To the degree that and develop treatment procedures come from basic
it is possible to observe and quantify those rela- learning theory, primarily operant and respondent con-
tionships, it then is possible to predict behavior. Final- ditioning. This does not mean that behavior analysts
ly, to the degree that it is possible to influence those believe that all psychological problems are a product
relationships by changing the behavior of the indi- of learning or that they may be eliminated through
vidual or the members of the social environment, it is learning, although at times it may appear otherwise.
possible to influence behavior. And the influencing of This is because applied behavior analysis is optimistic
public and private behavior is, of course, what all in its efforts to help individuals overcome their prob-
forms of psychotherapy, behavior-analytic or other- lems and develop into the people they want to become.
wise, are all about. One manifestation of this orientation is a reluctance to
The analytical nature of the approach requires clear impose on individuals unproven limitations that are
demonstrations that the procedures employed or the said to be inherent in actual or hypothesized biological
variables manipulated by applied behavior analysts are factors (e.g., heredity, neuroanatomy, physiology). In-
responsible for any observed changes in behavior. This stead, behavior analysts allow individuals to define
is typically accomplished through the use of single- their own limits by working with them to achieve all
case experimental designs (see Chapter 9 in this vol- that can be achieved.
ume). The technological requirement of applied be- Biological factors certainly underlie the problems in
havior analysis means that when one behavior analyst living that some individuals experience. However,
reports upon or describes a procedure or technique, the learning interacts with those biological factors in
details of the treatment program are presented in a important ways to determine both the nature of the
manner that allows other comparably trained and expe- problems that these individuals experience and the de-
rienced behavior analysts to duplicate the treatment gree to which they may be overcome. Psychologists
program and produce the same effects. Moreover, the and other members of the helping professions have, at
resulting direct and systematic replication (Sidman, best, only limited access to the heredity, neuroana-
1960) of procedures and techniques enables the early tomy, and physiology of their clients, and even when it
identification and correction of ineffective practices is possible to determine that biological factors underlie
that initial research incorrectly found to be effective. a particular problem, it is often impossible to change
Descriptions of procedures and result are also relat- those factors. In these situations, behavior analysts
ed systematically to the basic concepts or general prin- concentrate upon the factors that have contributed to
ciples of the approach. This conceptual integration of and are maintaining problems that can be more readily
knowledge ensures that applied behavior analysis will identified and changed. Diagnosis goes beyond a spec-
ification of biological factors when they do exist and was a symptom of an Oedipal complex (Freud,
analyzes the individual's learning history and current 1909/1955), both radical and more traditional behav-
situation to more fully understand the problem. The iorists would consider the more parsimonious explana-
treatment plan then accounts for but goes beyond those tion that it was a result of Little Hans's terrifying expe-
biological factors by providing for changes in the cur- rience of being nearly run down by an out-of-control
rent situation and the development of a new learning horse van (Wolpe & Rachman, 1960) and the condi-
history (today's learning experience is tomorrow's tioning possibilities that this entailed. Equally impor-
learning history) in order to better attenuate orremedi- tantly, applied behavior analysts would question
ate the problems experienced. whether the treatment of choice for such a problem is
Azrin (1977) pointed out that treatment plans for- an indirect one that seeks to modify hypothesized psy-
mulated by applied behavior analysts are considerably chodynamic constructs and processes or a direct one
more complex than a straightforward extension of a designed to decondition conditioned anxiety. It is diffi-
principle of learning from the laboratory, where it was cult for the behaviorist to accept that designing treat-
discovered and examined, to the applied setting, ment programs to modify things that do not exist (the
where it is now to be used to benefit persons in distress. hypothetical) is an effective way of influencing things
Instead, even the earliest applied behavior analysis that do exist (the behavioral). Instead, behaviorists
treatment procedures typically involved combinations doubt the influence of things that do not exist and
of different principles, as in the controlled breathing design treatment programs to modify things that do
treatment of stuttering (Azrin & Nunn, 1974), pros- exist.
thetic aids, as in the bell-and-pad-assisted treatment of
enuresis (Azrin, Sneeds, & Fox 1973), interacting sets
of contingencies, as in learning-based marital counsel- Principles of Applied Behavior
ing (Azrin, Naster, & Jones, 1973) and continuing in- Analysis
novations to compensate for unforeseen obstacles and
happenings, as in the development and refinement of Behavior analysts distinguish between what are
the token economy with schizophrenic patients (Ayl- called respondent and operant forms of acquired be-
Ion & Azrin, 1968). The complex nature of applied havior (Fantino & Logan, 1979). Respondent behavior
behavior analysis is even more apparent today, as other is similar to reflexive behavior, in which the learned
chapters in this handbook document. response is clearly tied to or elicited by a preceding
Ullmann (1979) made it clear that behavior analysts stimulus. The occurrence of a respondent is deter-
are concerned with understanding and treating the real, mined by the occurrence of the stimulus that elicits it.
not the hypothetical, the inferred, or the imagined. A Examples of respondent behavior include the salivary
basic premise of the behaviorist is that behavior, be it response of Pavlov's (1927) familiar dog and the fear
public or private, is real, that it is problematic behavior response of Wolpe 's (1982) phobic client. Operant be-
that brings the client to the therapist, and that it is the havior is not at all like reflexive behavior in that it is not
therapist's task to assist the client to alter problematic tied to or elicited by a preceding stimulus. Instead, an
behavior and replace it with more appropriate, more operant is emitted by the individual and "is studied as
fulfilling alternative behavior. Behaviorists agree with an event appearing spontaneously with a given fre-
their nonbehavioral colleagues that some people can- quency" (Skinner, 1938, p. 21). Although stimuli may
not recall unpleasant memories, that others have great set the occasion for operant behavior, as when a traffic
difficulty distinguishing between "b" and "d" while light sets the occasion for crossing the street, other
learning to read, and that still others develop irrational variables determine whether the response will be emit-
fears of horses. However, behaviorists question whe- ted and the street will be crossed. Examples of operant
ther such behavioral phenomena are caused by the op- behavior range from the bar-press response of the rat in
eration of a hypothesized defense mechanism, an in- Skinner's experimental chamber (Skinner, 1938) to the
ferred minimal brain disfunction, or an imagined academic performance of prison inmates in the token
desire to kill the father and possess the mother. In- economies of Ayllon and Milan (Ayllon, Milan,
stead, behaviorists would look to the operation of the Roberts, & McKee, 1979).
principles of behavior to understand the development To date, behavior analysts have emphasized the
of behavioral phenomena. For example, before the- study of public operant behavior and the examination
orizing that Little Hans's well-known horse phobia of the variables of which it is a function in their applied
activities. This section will describe the most com- behavior actually occurs. This qualification of the defi-
mon principles and procedures applied behavior ana- nition of reinforcers and reinforcing events is so much
lysts make use of in their understanding and modifica- a part of applied behavior analysis that it is typically
tion of operant behavior: (1) reinforcement; (2) punish- left unsaid to avoid unnecessary redundancy.
ment; (3) establishing operations; (4) extinction, Some clarification of the general terms in this sec-
differential reinforcement, and shaping; (5) condition is required. The stimuli and conditions that may
tioned reinforcement and token economies; (6) disfunction as positive and negative reinforcers are vir-
crimination training and fading; (7) generalization tually limitless and can include smiles, attention,
training and maintenance; and (8) language and rule- praise, conversation, submission, acceptance, music,
governed behavior. food, water, money, warmth, sexual stimulation,
frowns, pestering, jeering, rejection, opposition, loud
noise, putrid odors, long lines, traffic jams, cold, elec-
Reinforcement
trical stimulation, and so forth. Moreover, both the
Reinforcement is the central principle of behavior presentation and prolongation of positive reinforcers
analysis. Reinforcement is defined as the occurrence and the termination and prevention of negative reinfor-
of an event following behavior that results in an in- cers serve as reinforcing events. Indeed, the two forms
crease in the occurrence of that behavior in the future. of negative reinforcement have their own names. Es-
Nothing can be added to this definition that will enable cape conditioning denotes the response-contingent ter-
an a priori identification of reinforcing events. Behav- mination of a negative reinforcer, and avoidance con-
ior analysts are well aware that different events may ditioning denotes the response-contingent postpone-
and may not be reinforcing for different behaviors of ment or prevention of a negative reinforcer. That the
different individuals at different times. The defining responses that are reinforced and the responses that
characteristic of a reinforcer is only that it reinforces a then occur with greater frequency or probability in the
particular behavior of a particular individual at a par- future are not in fact the same responses should be
ticular time. This definition of reinforcement is not obvious but is also in need of emphasis. In a strict
circular, for the function of the definition is the objec- sense, it is rare that one response is ever identical to
tive identification of events that are reinforcing. The another. Instead, these responses are members of the
definition does not imply that an event serves as rein- same response class; that is, they are equivalent func-
forcement because it is reinforcing, as a circular defi- tionally in terms of topography and impact upon the
nition would. An event serves as reinforcement be- social environment.
cause of an individual's biological endowment, Finally, Michael (1975) has questioned the distinc-
learning history, and current situation. tion made by Skinner (1953) between positive and
Skinner (1938, 1953) distinguished between two negative reinforcement. The presentation of praise or
types of reinforcing events and, by extension, two the termination of pestering contingent, perhaps, on
types of reinforcers. A reinforcing event that consists taking the trash to the dumpster, appear to be clear
of the presentation of some stimulus or condition fol- examples of positive and negative reinforcement, re-
lowing a response is called positive reinforcement. A spectively. However, in other instances the distinction
reinforcing event that consists of the removal of some is clouded. For example, when an individual manipu-
stimulus or condition following a response is called lates a thermostat, is the reinforcing event more
negative reinforcement. The stimuli or conditions that warmth (positive reinforcement) or less cold (negative
are presented and removed are called positive reinfor- reinforcement)? Michael argued that the distinction
cers and negative reinforcers, respectively. It is there- between positive and negative reinforcement is an ar-
fore common practice to define the positive reinforce- bitrary and frequently confusing one that should be
ment procedure as the presentation of a positive discarded. Instead, Michael would merely define an
reinforcer contingent upon a response, and to define event as reinforcement if it strengthened behavior and
the negative reinforcement procedure as the termina- would then go on to describe the observable charac-
tion of a negative reinforcer contingent upon a re- teristics of that event. The case for the elimination of
sponse. However, whether a stimulus is indeed a rein- the imposed distinction between positive and negative
forcer and whether its presentation or termination is reinforcement is compelling. Nonetheless, the major-
indeed reinforcement for a particular response depends ity of the early work and much of the current work in
upon whether an increase or strengthening of future applied behavior analysis attempts to distinguish be-
tween positive and negative reinforcement, and that and a rebate of $5 of the cost of the program for each
practice will be continued as a heuristic in this chapter. exercise session which conformed to the requirements
An early example of the use of positive reinforce- of the treatment package, up to a maximum of $100.
ment was provided by Hart, Reynolds, Baer, Brawley, The results of this study revealed that all five clients
and Harris (1968), who were working with Martha, a remained in the program and adhered to the require-
socially-withdrawn, 5-year-old female student who ments of the exercise regimen. Although the program
often taunted her peers and refused to play with them did not include a continuing maintenance component,
when invited to do so. However, Martha appeared re- four of the five clients were still exercising at a 3-
sponsive to her teachers' comments and attention. month follow-up, and three were still exercising at a 6-
Teacher approval and attention were therefore identi- month follow-up. In addition, four of the five clients
fied as potential reinforcers, and their effects on coop- reported decreases in vascular headache activity as
erative play during three experimental conditions were aerobic fitness increased, and three clients began re-
assessed. The three experimental conditions were: (1) porting headache-free weeks during the latter half of
baseline, during which teachers interacted with Mar- the program.
tha in their routine manner; (2) noncontingent rein- An early example of negative reinforcement was
forcement, during which teachers approved and spent provided by Whaley and Tough (1970), who were
time with Martha at randomly selected times, indepen- working with a 6-year-old Down syndrome boy with
dent of her behavior; and (3) contingent reinforcement, an IQ of 15 who engaged in high rates of self-injurious
during which teachers approved and spent time with head banging and ear pounding. When first seen by the
Martha when she was playing cooperatively with her authors, the client was spending the whole day in a
peers while refraining from so doing when Martha was modified straightjacket and a football helmet to pre-
engaged in solitary or noncooperative activities. The vent serious self-injury. The treatment program con-
results indicated that the rate of cooperative play was sisted of negative reinforcement of a response that was
very low during baseline, was not different from base- incompatible with the self-injurious behavior. The
line during noncontingent reinforcement, and in- negative reinforcer was a harmless but painful electric
creased to an appropriate level during contingent shock of the lower calf. The response that was rein-
reinforcement. Although the use of the term noncon- forced by the termination or prevention of the shock
tingent reinforcement is incorrect technically because was touching or holding a toy. Treatment began with
the definition of reinforcement specifies a contingency escape conditioning, during which the shock was pre-
between responses and consequences, it is common sented, the client's hands were quickly guided to a toy,
practice to apply the term noncontingent reinforcement and the shock was terminated. When the client let go of
to control conditions in which potentially reinforcing the toy, the shock was again presented and the guid-
events are scheduled independent of behavior. Numer- ance procedure repeated. The results of this study indi-
ous replications of these findings have confirmed the cated that the client began quickly to make the escape
roles of both teacher attention in fostering appropriate response without guidance, and then came to avoid the
student behavior and "contingent" reinforcement as a shock by holding on to and carrying the toy about for
necessary ingredient in behavior change programs. progressively longer periods of time. Self-injurious re-
A more recent study by Fitterling, Martin, Gram- sponses were virtually eliminated by the end of treat-
ling, Cole, and Milan (1988) showed how positive ment, and follow-up indicated that the client ap-
reinforcement is employed routinely within multicom- proached and showed affection for staff, including the
ponent treatment packages. The purpose of the study author who had conducted the treatment, was active on
was to develop and test an exercise adherence package the ward, and was making progress in other treatment
so that the effects of improved aerobic fitness on vas- programs.
cular headache activity could be evaluated. Clients No negative side effects of the electric shock were
were five adult females with long histories of severe reported in the Whaley and Tough (1970) study. None-
vascular headaches that had not yielded to routine theless, programs that employ stimuli or conditions
medical treatment. The treatment package consisted of that the public or professional community would con-
a 14-week aerobic training regimen. The positive rein- sider to be aversive or noxious should be evaluated
forcement component of the program consisted of carefully before, during, and after their use. At the
praise for progress during weekly group meetings at very least, programs using aversive or noxious stimuli
which each client's performance was posted publicly, should not be employed capriciously, with unimpor-
tant behaviors, or in the absence of adequate treatment following behavior that results in a decrease in the
staff, professional supervision, and continuous occurrence of that behavior in the future. Skinner
monitoring. Programs that employ aversive stimuli or (1953) distinguished between two classes of punishing
noxious conditions should be considered only when events. The first class of punishing events consists of
more positive and less intrusive programs have failed, the termination of stimuli or conditions, such as turn-
and when their use is in accord with accepted legal and ing off the favorite television program of a child who is
ethical standards (e.g., R. Martin, 1975). provoking a sibling or breaking off a conversation with
A more recent example of the use of negative rein- an adult who is making racist statements. Skinner
forcement is provided by Allen and Stokes (1987), noted that the stimuli or conditions whose termination
who were working with five children who experienced serves as a punishing event are often the same as those
severe anxiety and who exhibited serious resistant and whose presentation serves as a reinforcing event,
disruptive behavior during dental treatment. The treat- thereby implying that this type of punishment consists
ment package consisted of negative reinforcement of of the termination of positive reinforcers. Punishment
increasing periods of exposure to six simulated dental of this type is sometimes called punishment by con-
procedures, supplemented by praise and encourage- tingent withdrawal and consists of three subclasses:
ment. The negatively reinforced response was appro- time out, time out from positive reinforcement, and
priate behavior in the dentist's chair during the simulat- response cost. Time out involves terminating a rein-
ed dental procedures. The negative reinforcer was the forcing condition or removing the individual from a
dental procedure that was being practiced. That is, reinforcing situation, as when a disruptive youth is
progressively longer periods of tolerance of the simu- placed in a barren time-out room for a brief period of
lated dental procedures were reinforced by the termi- time. Time out from positive reinforcement involves a
nation of the procedures and a pause before the simula- brief period of time during which an individual's abil-
tion was begun again. Treatment resulted in a ity to earn positive reinforcers is suspended, as when
clinically significant decrease in disruptive and re- an employee is suspended without pay. Response cost
sistant behavior, and the dentist and the dental assistant involves the requirement that an individual relinquish
rated all clients as more cooperative and less anxious accumulated reinforcers, as when a traffic fine is im-
after the program than before. posed upon a left lane bandit.
The second class of punishing events consists of the
presentation of stimuli or conditions, such as spanking
Punishment
the disruptive child or chastising the racist adult. Skin-
If reinforcement is the most important principle ner (1953) also noted that the stimuli or conditions
studied by applied behavior analysis, punishment is whose presentation serves as a punishing event were
perhaps the principle of second greatest importance. often the same as those whose termination serves as a
This is not because behavior analysts rely heavily on reinforcing event, thereby implying that this type of
punishment procedures in intervention programs. In- punishment consists of the presentation of negative
stead, the study of punishment is important because reinforcers. Punishment of this type is sometimes
the social community sanctions and relies heavily on called punishment by contingent stimulation and is
punishment in raising children, managing employees, typically the procedure to which behavior analysts re-
practicing religion, dealing with criminals, formulat- fer when they use the term punishment without further
ing foreign policy, and the like. Consequently, a thor- qualification. A second type of punishment by con-
ough knowledge of punishment and of its desirable and tingent stimulation is overcorrection (Foxx & Azrin,
undesirable effects contributes to our understanding 1973), in which clients are required to practice an alter-
both of why many of society's practices fail, and of native to the undesirable response, repetitively and
how much disturbed public and private behavior devel- with physical guidance when necessary, immediately
ops and is maintained. A thorough knowledge of following each instance of the behavior. As discussed
punishment also allows the design of effective and previously, Michael (1975) noted that attempting to
fast-acting punishment programs when alternative distinguish between two types of punishment in terms
strategies have failed, thereby minimizing both the of the termination or presentation of positive or nega-
amount of punishment clients experience and punish- tive reinforcers involves the same difficulties as are
ment's undesirable effects. involved in attempting to distinguish between two
Punishment is defined as the occurrence of an event types of reinforcement, and for that reason they should
also be abandoned. Nonetheless, the distinction be- while denying others what may well be their only re-
tween two types of punishment remains a common one maining form of effective treatment, continue to be
in the behavior analysis literature. debated.
Skinner (1974) has examined the undesirable effects An early example of the therapeutic use of punish-
of punishment and has offered numerous examples of ment was provided by Lovaas and Simmons (1969),
how punishment can give rise to a variety of problems who were working with three psychotic and retarded
in living. He observed that the way individuals feel children. The clients engaged in such high rates of
when they are in situations in which they have been severe self-mutilating and destructive behavior that
punished previously or engage in behavior for which continuous physical restraint was required to protect
they have been punished previously depends on the them from themselves. Treatment was conducted
types of punishment experienced and the individuals while the clients were out of restraints and consisted of
or social institutions delivering the punishment. For punishment in the form of a I-sec electric shock on the
example, feelings of shame and sin are often the prod- leg that was administered immediately following each
ucts of punishment by peers and religion, respectively. self-destructive act. Results indicated that punishment
When punishment is particularly severe, these emo- quickly reduced the self-destructive behavior to near-
tions may be accompanied by anger, frustration, anx- zero or zero rates, and that this was accomplished with
iety, or depression. Skinner (1953) also noted that ter- five or less administrations of shock for all clients.
mination or prevention of the feeling states associated Moreover, positive side effects of punishment were
with punishment may serve as a reinforcing event. For observed as the frequency of other inappropriate be-
example, some individuals may cease thinking about haviors also declined, and the clients became less with-
or recalling activities that were punished in the past drawn and more responsive to staff.
and, for this reason, may be described as repressing A more recent example of punishment is provided
painful memories. Others may blunt those feelings by by Luce, Delquadri, and Hall (1980), who were work-
turning to alcohol or drugs. Other individuals may find ing with two severely emotionally disturbed children
ways to escape from the individuals or organizations in a classroom setting. One of the clients engaged in
that deliver the punishment, such as being truant from physical aggression and the other engaged in verbal
school. Finally, Skinner posits that the development aggression. Punishment consisted of "contingent ex-
and maintenance of many psychosomatic disorders, ercise, " a variant of the overcorrection procedure
such as functional paralysis or deafness, may be at- wherein the clients were required to perform physical
tributed to punishment and then escape and avoidance. exercises involving 10 rapid cycle3 of standing and
More recently, Balsam and Bondy (1983) supported then sitting on the floor in the classroom, immediately
Skinner's (1953) early concerns about the social and following each aggressive act. The program resulted in
therapeutic use of punishment. They identified 10 a rapid decrease of aggressive behavior to near-zero
classes of undesirable side effects of punishment and levels within 3 days for both clients.
cited over 30 clinical reports documenting the occur-
rence of such effects. However, the prevalence of un-
desirable side effects when punishment is used as a
Establishing Operations
planned therapeutic intervention has been challenged.
Punishment has been shown to be effective in the treat- The reinforcing or punishing properties of events can
ment of clinical problems (Axelrod & Apsche, 1983), vary from occasion to occasion, and what may be a
and it has been argued that none of the undesirable side reinforcing or punishing event today mayor may not be
effects attributed to punishment are seen in punishment so tomorrow. As the reinforcing or punishing properties
programs that are designed properly and administered of the consequences of behavior increase and decrease,
carefully (Johnston, 1985). Punishment continues to so does the frequency or probability of the behaviors
be used, albeit considerably less frequently than rein- that result in those consequences. An understanding of
forcement, as a therapeutic intervention, in accord the general factors that influence the properties of po-
with prescribed legal safeguards, and typically only tential reinforcers and punishers is therefore important
after an array of alternative programs have been tried for our understanding of why behavior does and does
and have been shown not to be effective. The effects not occur, and for our ability to maximize the effective-
and side effects of punishment, and the ethics of pro- ness of reinforcers and punishers in treatment pro-
tecting some individuals from unnecessary discomfort grams. Although many variables influence the strength
of reinforcers and punishers, one class of variables is of more towels accumulated in her room, the positive
particular importance. These "motivational" factors reinforcing value of the towels appeared to decline, as
have been described as setting factors by Kantor (1958), the patient ceased her stealing of towels and became
as setting events by Wahler and Fox (1981), and, more reluctant to accept more towels from staff. By the
broadly, as establishing operations by Michael (1982). fourth week of treatment, it appeared that the towels
The latter term will be used in this chapter. had become negative reinforcers, as the patient refused
In general, establishing operations involve a condi- to accept additional towels and began to throw towels
tion that increases or decreases the strength of potential out the door of her room and finally removed the sever-
reinforcing or punishing events, and evokes or sup- al hundred towels that she had accumulated. By the
presses the behavior that those events have followed in end of treatment, she, like the other patients, kept only
the past. Deprivation and satiation are two common one towel in her room.
types of establishing operations. For example, food A more recent example of the use of establishing
deprivation increases the value of food as a reinforcing operations in the form of reframing and paradoxical
event and evokes responses that have been followed by instruction is provided by Kolko and Milan (1983).
access to food in the past. Satiation in the form of The clients in this study were three predelinquent
eating the food then results in a decrease in the value of youths who were referred to a community-based coun-
the food as a reinforcing event, and the responses that seling program because of their truancy problems.
have been followed by access to the food eventually When they failed to respond to contingency contract-
cease. The deprivation-satiation cycle then repeats. ing procedures, additional behavior analysis suggested
For this reason, treatment sessions utilizing food as that they were resisting the program because the
reinforcement are conducted just prior to scheduled strength of reinforcers that were being offered did not
meals rather than after them. Deprivation and satiation outweigh the reinforcing effects of the signs of frustra-
also influence the strength of punishment. For exam- tion and discomfort exhibited by thwarted parents,
ple, the likelihood that the removal of food will serve teachers, and counselors. An establishing operation
as punishment and that behavior punished previously designed to increase the reinforcing value of thwarting
by the removal of food will be suppressed is consider- the counselor and to decrease the reinforcing value of
ably greater under conditions of food deprivation than truancy was then superimposed on the continuing con-
under conditions of satiation. tingency contracting program. This consisted of as-
Another common class of establishing operations serting the expertise of the therapist and reframing tru-
consists of conditions that are responsible for emo- ancy as a sign of immaturity. Finally, the therapist gave
tional reactions, such as affection, anxiety, or anger. the paradoxical instruction to not attend school that the
Skinner (1953) noted that for the individual made fear- clients could thwart only by attending school. Reinfor-
ful, the opportunity to escape from or avoid the feared cers offered by the contingency contracts were avail-
situation has great reinforcing value. Similarly, for the able to maintain any changes in behavior evoked by the
enraged person, signs of pain or distress by the target establishing operations. Results indicated that the pro-
of the anger have great reinforcing value. Not only is gram produced marked increases in school attendance
the reinforcing value of some condition or event en- rates for each client and that by the end of the program
hanced by the establishing operation, but relevant be- the clients' attendance rates were within normal limits.
haviors, such as fleeing or attacking, are also clearly Moreover, the improvements were maintained in fol-
evoked by the establishing operations. Much of the low-up at the end of the school year, and the clients'
variability seen from day to day and from situation to grades had, on the average, increased from the un-
situation in clinical cases is undoubtedly due to the satisfactory to the satisfactory range.
operation of establishing operations.
An early example of the use of establishing opera-
Extinction, Differential Reinforcement, and
tions was provided by Ayllon (1963). The client in this
Shaping
study was a hospitalized female psychiatric patient
who had a 9-year history of stealing towels from other Extinction, differential reinforcement, and shaping
patients on her ward and hiding them in her room. are related procedures. Extinction, within the context
Treatment consisted of "stimulus satiation," wherein of operant behavior, is often described as the failure to
the patient was allowed to keep the towels she stole and deliver a reinforcer following a response that had been
was given additional towels by staff. As progressively previously followed by that reinforcer (e.g., Poling,
1985}. The effect of this operation is a reduction in the only the behavior that is to be decreased. Reinforce-
frequency or probability of the response. Even though ment is then delivered while the response does not
this definition is correct, it implies that only behavior occur, and is not delivered while the response does
maintained by positive reinforcement may be extin- occur. Differential reinforcement of low-rate behavior
guished. However, behavior maintained by negative (DRL) involves the specification of one behavior and
reinforcement may also be subjected to the extinction then reinforcing responses occurring at or below a pre-
procedure. This is done by no longer terminating a determined rate while extinguishing responses occur-
negative reinforcer following responses that had pre- ring above that rate. Differential reinforcement ofhigh-
viously been followed by that consequence. More- rate behavior (DRH) is similar to the DRL procedure
over, the suppressive effects of punishment may also but reinforces behaviors occurring at or above a pre-
be extinguished by no longer presenting negative rein- determined rate while extinguishing behaviors below
forcers or terminating positive reinforcers following that rate. The goal of the DRL and DRH procedures is
previously punished behavior. The effect of the latter not to replace one behavior with another but instead to
two extinction procedures is an increase in the frequen- replace one rate of behavior with another.
cy or probability of behavior. A more encompassing Differential reinforcement plays a central role in the
definition of extinction is therefore called for. Extinc- development of a range of important skills. One exam-
tion is the breaking of the contingent relationship be- ple involves modeling and imitation. Our ability to
tween a response and its consequence. In accord with learn to do things by watching others or by following
this definition, previously reinforced responses are no their instructions is undoubtedly taught to us starting in
longer followed by reinforcing events, and previously our earliest years by a social community that models
punished responses are no longer followed by punish- desired behaviors both physically and verbally, and
ing events. The expected outcomes of these operations reinforces correct imitative responses while ex-
are a decrease in the occurrence of the previously rein- tinguishing incorrect imitative responses. Whether
forced responses, and an increase in the occurrence of modeled behavior continues to be imitated then de-
the previously punished responses. pends on the consequences of imitation (Baer & Sher-
Differential reinforcement consists of reinforcing man, 1964). Behavior analysts typically first employ
one response or set of responses while simultaneously modeling, imitation, and reinforcement when they
extinguishing another response or set of responses wish to instigate behavior change. That is, they show
(Holland & Skinner, 1961). The effect of this operation or tell the client what is appropriate or expected, pro-
is an increase in the occurrence of the reinforced re- vide the client the opportunity to do it, and reinforce
sponses and a decrease in the occurrence of the non- when it is done. Unfortunately, this is not always effec-
reinforced responses. One important use of differential tive and alternative, more effortful procedures must
reinforcement is as an alternative to punishment in the then be employed.
elimination of inappropriate behavior. Four general Shaping is often used to develop new behavior when
strategies are employed: differential reinforcement of modeling and imitation is ineffective. Shaping consists
incompatible behavior, differential reinforcement of of the differential reinforcement of successive behav-
zero behavior, differential reinforcement of low-rate iors that are closer approximations of the to-be-devel-
behavior, and differential reinforcement of high-rate oped new behavior and for this reason is also known as
behavior (S. M. Dietz, Repp, & D. E. D. Dietz, 1976; the method of successive approximations (Wolf,
Singh, Dawson, & Manning, 1981). Risley, & Mees, 1964). Shaping relies on behavioral
Differential reinforcement of incompatible behavior variability. As was noted previously, two responses are
(DRI) involves the specification of both the behavior rarely, if ever, the same. As responses occur, some will
that is to be decreased and its incompatible opposite as be more like the to-be-developed or final behavior than
the behavior that is to be increased. Incompatible op- others, be this in terms of topography, quality, or quan-
posites are simply two behaviors that cannot occur tity. Differential reinforcement of the first approxima-
simultaneously, such as standing up and sitting down. tion begins as responses that are more like the final
Care is then taken to ensure that reinforcement follows behavior are reinforced while the responses that are
the appropriate response and does not follow the inap- less like the final behavior are extinguished. The result
propriate response. Differential reinforcement of zero of this first step in the shaping procedure is the move-
behavior (DRO), also known as differential reinforcement of behavior in the direction of the final response;
ment of other behavior, involves the specification of as the extinguished responses decrease, the reinforced
responses increase, and behavioral variability leads to the establishment of the second previously neutral
the emergence of new responses that are even more stimulus as a conditioned stimulus. This new condi-
like the final behavior. The cycle is repeated until the tioned stimulus may then be used as an unconditioned
final response emerges and is reinforced in the last step stimulus by pairing it with a neutral stimulus in yet
of the shaping procedure. another replication of the respondent conditioning pro-
cedure. Higher order conditioning is said to provide a
basis for the explanation of how stimuli that are far
Conditioned Reinforcement and Token
removed from pairings with biological unconditioned
Economies
stimuli have acquired their conditioned respondent and
Very little of the day-to-day behavior of humans is operant properties (Schwartz, 1984, p. 60). However,
controlled by biological reinforcers, such as the con- laboratory research indicates that higher order condi-
sumption of food and drink or the avoidance of phys- tioning becomes ineffective when successive pairings
ical harm. Instead, the bulk of human behavior is con- are two or at most three steps removed from a biolog-
trolled by acquired reinforcers that are, at most, only ical unconditioned stimulus (Rachlin, 1976, p. 176).
indirectly related to their biological counterparts. The operant conditioning framework provides an alter-
Stimuli, such as praise and scolding, that have ac- native explanation of how neutral stimuii acquire con-
quired their positive or negative reinforcing properties ditioned properties.
are called conditioned reinforcers. Knowledge of how The operant explanation of how neutral stimuli be-
neutral stimuli come to serve as conditioned reinfor- come conditioned reinforcers is more complex than the
cers is important for an understanding of behavior as it respondent explanation. The operant explanation
exists in the social environment and for the develop- focuses on the development of discriminative stimuli
ment of programs to change that behavior. Respondent (Fantino & Logan, 1979). As discussed previously,
and operant conditioning both provide explanations of discriminative stimuli are those that set the occasion
how stimuli can acquire reinforcing properties. The for a response in that behavior occurring in their pres-
respondent explanation is the most common and is ence is reinforced while behavior occurring in their
typically described as the pairing of a neutral stimulus absence is extinguished. Discriminative stimuli have a
with an unconditioned stimulus (Schwartz, 1984), as second important property, in that their presentation
when entering an elevator is followed by a three-story will serve as a reinforcing event. That is, stimuli that
plunge. As a result of the pairing, the previously neu- become discriminative for responses that produce rein-
tral stimulus is said to become a conditioned stimulus forcement also become reinforcers for responses that
that takes on properties of the unconditioned stimulus, produce them. For example, praise may become a con-
as when the elevator comes to elicit some of the same ditioned reinforcer because it sets the occasion for re-
classes of affective, behavioral, and cognitive reinforcement ill that requests made of other individuals
sponses as the plunge. Equally importantly, the condi- are more likely to be honored when those individuals
tioned stimulus will also mimic the effects of the un- are providing praise than when they are not. When this
conditioned stimulus with which it has been paired state of affairs exists, behavior that results in the praise
when its presentation or termination is made con- of others may well be strengthened.
tingent upon a response, as when an individual turns Chaining is the operant equivalent of higher order
away from an elevator and instead climbs the stairs. conditioning and explains how the conditioned proper-
Clearly, the stimuli with which neutral stimuli are ties of stimuli not discriminative for biological rein-
paired should be viewed as both the unconditioned forcement are acquired and maintained (Cooper, Her-
stimuli of respondent conditioning and either the on, & Heward, 1987). In the laboratory, the process
positive or negative reinforcers of operant condition- begins with the conditioning of a response through the
ing. Through pairing, the previously neutral stimuli use of positive reinforcement using a biological rein-
become both conditioned stimuli for respondent be- forcer such as food. Next, a stimulus is made discrimi-
havior and either conditioned reinforcers or punishers native for that response through the use of discrimina-
for operant behavior. Moreover, a conditioned stim- tion training. Finally, a second response is conditioned
ulus may be used as an unconditioned stimulus in the through the use of positive reinforcement using the
respondent conditioning paradigm by pairing it with a newly established discriminative stimulus as the rein-
neutral stimulus in a process called higher order condi- forcer. The procedure may then be repeated, with each
tioning. The expected effect of this second pairing is successive replication moving the newly established
conditioned reinforcers further from the biological that stimulus. The effect of discrimination training is
reinforcer. the occurrence of the response in the presence of the
Chaining may be used to develop long sequences of stimulus and the nonoccurrence of the response in the
responses and conditioned reinforcers that are much absence of the stimulus. This outcome is called stim-
further removed from biologically reinforcing stimuli ulus control. Controlling stimuli are said to set the
than is possible through the pairing of stimuli in the occasion for responses. They do not elicit responses.
respondent conditioning procedure. For example, The ringing of the telephone is a familiar example of a
Thcker and Berry (1980) used chaining to teach se- controlling stimulus. Answering the phone when it is
verely multihandicapped children to put on their hear- ringing is reinforced by the opportunity to talk with the
ing aids. An analysis of the requirements of the task led caller; answering the phone when it is not ringing has
to the identification of 31 steps that were taught as a no such consequence. Thus, people typically answer
chain beginning with the sight of the hearing aid con- the phone only when it is ringing. However, the ring-
tainer, which was a discriminative stimulus for opening of the telephone does not elicit an "irresistible
ing the container, and ending with setting the gain urge" to answer it. Whether you answer your phone
control of the hearing aid, which was reinforced by when it rings is influenced by a range of other vari-
aided hearing. ables, such as what you are doing and with whom you
The token economy (Ayllon & Azrin, 1968) is also are doing it.
an example of the use of chaining in an applied set- Discrimination training differs from differential re-
tings. In a token economy, clients engage in behavior inforcement in that in their most basic forms, discrimi-
that earns tokens, and the client then exchanges the nation training is concerned with one response that is
tokens for the commodities and amenities offered to be emitted in the presence of a stimulus and not
through the economy. To accomplish this, Ayllon and emitted in its absence, whereas differential reinforce-
Azrin first identified a variety of effective reinforcers ment is concerned with increasing the emission of one
for their schizophrenic patients, such as food and response and decreasing the emission of a second re-
drink, for their withdrawn clients. Next, theyestab- sponse independent of the stimuli present. However,
lished a token, such as a poker chip, as a discriminative the two are combined in most applications. For exam-
stimulus by giving clients a supply of tokens and ple, learning to say "b" when presented with the stim-
providing the reinforcers only when the clients had ulus "b" and learning to say "d" when presented with
tokens to offer in exchange. Finally, Ayllon and Azrin the stimulus "d" involves differential reinforcement to
stopped giving tokens on a noncontingent basis and increase the emission of each letter response and dis-
began using them as conditioned reinforcers by requir- crimination training to ensure each response is con-
ing that clients earn them by engaging in therapeutic trolled by the appropriate letter. The stimuli of concern
activities and behaviors. Their procedures produced in most applications of discrimination training are also
clinically significant improvements in a variety of more complex than the ringing of the telephone and the
problems experienced by schizophrenic patients and, letters of the alphabet. For example, Roales-Nieto
since that time, others have and continue to use token (1988) combined discrimination training and external
economy procedures across a range of settings, cli- cues to improve the accuracy with which three insulin-
ents, and problems with similar success (Kazdin, dependent diabetic patients estimated their blood-
1977). glucose levels. Moreover, training in blood-glucose
discrimination was associated with improved general
diabetic control, which was maintained by two of the
Discrimination Training and Fading
three clients at a 3-month follow-up.
The effects of the principles and procedures dis- Fading may be used to transfer stimulus control
cussed previously have been to increase or decrease from a stimulus that does control a response to a stim-
behavior, with little regard for when or where that ulus that does not control the response. This is done by
behavior occurred. Discrimination training and fading gradually changing the stimulus from the one that ini-
are concerned primarily with the way the antecedents tially controls behavior to the stimulus that is to control
of behavior come to influence when and where behav- behavior. The procedure is often used when indi-
ior occurs. Discrimination training involves reinforc- viduals fail to learn discriminations through discrimi-
ing a response in the presence of a particular stimulus nation training alone. A variety of strategies may be
and extinguishing the same response in the absence of used. For example, Sidman and Stoddard (1967) used
fading to teach retarded children to discriminate be- very least revolve more slowly than it now does (Paul
tween different forms by starting with stimuli that were & Lentz, 1977). Perhaps the reason that critics have
discriminated easily and then making the discrimina- mistakenly concluded that behavior analysis has ex-
tion progressively more difficult while providing guid- traordinary problems with generalization and mainte-
ance and reinforcement for correct choices. This strat- nance is because many behavior analysts concern
egy of starting training with an easy discrimination and themselves with it, study it, and discuss it in the pro-
then progressing to successively more difficult dis- fessionalliterature, whereas many nonbehaviorists ei-
criminations was a variant of Terrace's (1963) errorles ther ignore the problem or have chosen to keep to
discrimination training procedure, so named because themselves what they have learned about the gener-
it minimizes the occurrence of errors throughout alization and maintenance of their own treatment
training. procedures.
Milan, Mitchell, Berger, and Pierson (1982) used Behavior analysts have directed their attention to
fading as part of a treatment program to eliminate the three general areas to ensure the effects of their inter-
bedtime temper tantrums of emotionally disturbed and vention procedures: stimulus generalization, response
physically handicapped children. The fading compo- generalization, and maintenance over time. Stimulus
nent of the program involved first identifying the time generalization occurs when a response that has been
at which the children began to show signs of sleep- developed or reinforced in one stimulus situation oc-
iness, then implementing a sequence of bedtime ac- curs in other stimulus situations, as when a social skill
tivities that culminated in sleep, and finally instructing taught by and practiced with a therapist in an office
the parent(s) to gradually fade the onset of the se- occurs with other people and in other settings. Re-
quence of activities back from the time at which the sponse generalization occurs when teaching or rein-
children showed signs of sleepiness to the time at forcing one response has the effect of increasing the
which the parent(s) wanted the children to go to sleep. occurrence of not only that response but related re-
The program was effective in eliminating bedtime responses as well, as when a client who has been taught a
sistance without the prolonged occurrence of tantrum- specific example of an appropriate social skill begins
ing that is characteristic of programs that emphasize to generate new examples of that skill without the aid
the extinction of temper tantrums through the with- of the therapist. Both stimulus and response gener-
holding of attention. The fading program was subse- alization are desired in most applications, as when the
quently replicated with two nonhandicapped sisters. client who is being provided social skills training
comes to create new variations on the skill theme (re-
sponse generalization) that are appropriate to the de-
mands of new situations (stimulus generalization).
Generalization Training and Maintenance
Maintenance occurs when the effects of training or
The generalization and maintenance of behavior reinforcement at one time are seen at a later time, as
change is of concern to all of psychology. Applied when an individual who has completed a social skills
behavior analysis is sometimes criticized on the training program is found to be still using those skills at
grounds that the results of its programs do not gener- a I-year follow-up.
alize or are not maintained after clients leave behavior Stokes and Baer (1977) outlined the major strategies
analysis programs. Although it may be true that behav- behavior analysts use to ensure the generalization and
ior analysts are sometimes not satisfied with the degree maintenance of intervention effects. Two of the most
to which their accomplishments generalize and are common generalization strategies are stimulus and re-
maintained, it may very well be that the results of sponse generalization training. In stimulus generaliza-
behavioral programs generalize more and are main- tion training, behavior is taught and practiced in sever-
tained for longer periods of time than the results of al of the stimulus situations in which it is to occur.
nonbehavioral programs. For example, while the "re- When feasible, common aspects of the various stim-
volving door" of the psychiatric hospital is an ac- ulus situations in which the behavior is to occur may be
knowledged problem, behavior analysis is far from identified or arranged and included in the training reg-
being the most prevalent form of treatment provided in imen (Ayllon, Kuhlman, & Warzak, 1982). In re-
those hospitals. Indeed, there is good reason to believe sponse generalization training, several responses that
that if behavioral procedures were more widely de- fall within the general class of acceptable responses are
ployed in psychiatric hospitals, the door would at the taught and practiced. Clients may also be taught to
generalize by presenting situations in which stimulus response-dependent and those that are said to be time-
and response generalization are called for, providing dependent. In response-dependent schedules, rein-
prompts and instructions as necessary, and then reinforcement is a function of the number of responses the
forcing generalization when it occurs. At the same individual makes, as when an employee paid on a
time, what constitutes acceptable behavior should be piecework basis consistently earns $10 for every 7
defined loosely so that variability within acceptable units assembled. When the ratio of responses to rein-
limits is encouraged, thereby contributing to the ac- forcement is fixed at some value as it is in this exam-
quisition of generalization as a metaresponse appropri- ple, aflXed ratio (FR) schedule of reinforcement is said
ate to new situations. Finally, individuals may be to be in effect. The ratio of responses to reinforcement
taught self-control strategies (Skinner, 1953) that they can also vary around some average value, such as the
may use to control their behavior in other situations ratio of lever-pulls to pay-offs for a Las Vegas slot
and at later times (Marlatt & Gordon, 1985). machine. When ratios vary in this manner, a variable
To the degree that training is followed by stimulus ratio (VR) schedule of reinforcement is said to be in
and response generalization, some maintenance has effect.
occurred. Additional strategies may be used to In time-dependent schedules, the availability of re-
strengthen maintenance effects and better ensure that inforcement is a function of the passage of time, after
as the time between training and performance oppor- which one response must be emitted if reinforcement is
tunities increases, maintenance of what has been to occur. Clock watching is an example of a time-
learned will continue. Perhaps the most important dependent schedule of reinforcement, for glancing at
maintenance strategy entails an analysis of what is the clock (response) is reinforced by seeing that it is 10
called for in the situations in which the behavior is to A.M. (coffee break), noon (lunch hour), 3 P.M. (coffee
occur, and then teaching the behavior that is appropri- break), and 5 P.M. (leave work). When the intervals of
ate in those situations. By so doing, the behavior ana- time preceding the availability of reinforcement are
lyst increases the likelihood that the new behavior will constant from reinforcement to reinforcement, as they
be occasioned and reinforced by the naturally occur- are in this example, aflXed interval (FI) schedule of
ring contingencies of the individual's social environ- reinforcement is said to be in effect. The intervals of
ment. When behavioral trapping (Baer & Wolf, 1970) time preceding the availability of reinforcement can
such as this occurs, the maintenance of behavior is also vary around some average value, as when glanc-
virtually assured. The trapping of behavior may be ing out the office window is reinforced by the sight of
facilitated by utilizing in training the same patterns of attractive passers-by who appear on the average every
reinforcement that exist in the individual's social en- 10 min. When time intervals vary in this manner, a
vironment. Although behavior change is best accom- variable interval (VI) schedule of reinforcement is said
plished by the reinforcement of each appropriate re- to be in effect. Comparable schedules of punishment
sponse, the natural environment more typically also exist. A thorough knowledge of the schedules of
reinforces behavior on an irregular basis. Conse- reinforcement is important in planning for a gradual
quently, behavior analysts typically reinforce each re- transition from the continuous reinforcement of the
sponse during training and then move to progressively early stages of treatment to the intermittent reinforce-
more irregular patterns of reinforcement so that by the ment of the social environment. In addition, knowl-
end of training the patterns of reinforcement in the edge of schedule effects enables the behavior analyst to
training setting and the natural environment are develop desirable patterns of new behavior and to bet-
indistinguishable. ter understand existing patterns of established behavior
The relationships between responses and conse- as they occur in the natural environment.
quences are called schedules of reinforcement and
schedules ofpunishment. Five basic schedules of rein-
Language and Rule-Governed Behavior
forcement will be described here. When each response
is reinforced, a continuous schedule of reinforcement Behavior analysts are aware that they talk with their
(CRF) is said to be in effect. All other schedules of clients and tell them things. Behavior analysts are also
reinforcement wherein some, but not all, responses are aware that clients talk with themselves and tell them-
reinforced are called intermittent schedules of rein- selves things. Finally, behavior analysts are aware that
forcement. There are two main types of intermittent what clients are told and what clients tell themselves
schedules of reinforcement: those that are said to be can influence their behavior. Behavior analysts are
therefore aware that a knowledge of language and the attractive person, then signs of anxiety, verbal dis-
role it plays in influencing behavior is important in fluencies, and rebuke will follow. The directions to the
understanding client behavior and in developing effec- restaurant are then followed or the conversation with
tive treatment programs. Much of what transpires in the attractive individual is then not initiated.
verbal psychotherapy involves the use of language in People learn and continue to follow rules because of
the process of undoing the undesirable effects of the the consequences of rule following. If the directions
individual's learning history (Skinner, 1953). To ac- provided by an individual are consistently correct,
complish this, behavior analysts have typically worked then directions from that individual will be solicited
with their clients to develop a behavioral concep- and followed. If directions provided by an individual
tualization of the problems experienced and then for- are consistently incorrect, then directions from that
mulate a course of treatment based upon the principles individual may then be neither solicited nor followed.
described in this chapter (e.g., Kaplan, 1986). More Similarly, if individuals consistently refrain from or
recently, however, behavior analysts have begun to fail at an activity that they tell themselves they cannot
focus upon the role of language itself in the develop- do, they will continue to refrain from that activity and
ment, maintenance, and treatment of psychopathology tell themselves that they cannot do it. If individuals can
(e.g., Zettle & Hayes, 1982). be induced to engage in that activity and succeed, they
Radical behaviorism views language as verbal be- may then engage in that activity more frequently and
havior (Skinner, 1957) that is amenable to behavior cease telling themselves that they cannot do it.
analysis and may be understood in terms of the same Zettle and Hayes (1982) have discussed how verbal
principles as is other forms of behavior. Although behavior and rule-governed behavior may act together
some linguists have questioned whether a radical be- in the development and maintenance of various forms
havioral analysis of language will prove to be either of psychopathology, such as anxiety, mood, and ad-
appropriate or productive (e.g., Chomsky, 1959), justment disorders. The basis of their formulation is
some behaviorists have questioned whether those lin- that dysfunctional rule formation can lead to psycho-
guists comprehend the radical behavioral view of lan- pathology, and that the dysfunctional rules may be
guage (e.g., MacCorquodale, 1970) and have sug- even more powerful in maintaining pathological be-
gested that those linguists' criticisms of the radical havior than is the disconfirming contact with the con-
behavioral analysis oflanguage are by and large irrele- tingencies of reinforcement that they incorrectly de-
vant to the endeavor (e.g., MacCorquodale, 1969). scribe. The approach to treatment that Hayes (1987)
Verbal behavior contributes to the development of recommends does not attempt to directly replace that
rules (cognitions) that contribute to much adaptive and dysfunctional rule with an incompatible, functional
maladaptive behavior. Radical behaviorist views rules rule. Instead, Hayes recommends that therapists work
as descriptions of contingencies of reinforcement. with clients to transform gradually the rules control-
Rule-governed behavior (Skinner, 1969, 1974) is be- ling their behavior so that they describe more accu-
havior that is controlled by descriptions of contingen- rately the operative contingencies. The transformed
cies rather than the contingencies that are described. rules then make it possible to teach and encourage the
Rules may be verbal, such as instructions, or rules may performance of behavior that was inhibited by the dys-
be nonverbal, such as maps. Rules may be given by functional rule. Finally, engaging in the behavior al-
others or given by oneself. Rules may be said aloud or lows clients to experience and come to terms with the
said silently. Rules may be detailed, as when someone contingencies of reinforcement as they really are.
describes how to get to a particular restaurant while
drawing a corresponding map, or rules may be abbre-
viated, as when individuals repeatedly say to them- Summary
selves that they "cannot do it" when preparing to
strike up a conversation with an attractive person. In The principles that have been reviewed in this chap-
each case, however, the contingencies of reinforce- ter provided a basis for behavioral formulations of such
ment to which the rules refer imply that if certain be- diverse phenomena of interest to psychology as per-
haviors are engaged in under certain conditions, cer- sonality (Krasner & Ullmann, 1973), intelligence
tain consequences will follow. That is, if the directions (Staats, 1971), and psychopathology (Ullmann &
to the restaurant are followed, then the restaurant will Krasner, 1969), and for interventions at the individual,
be located, or if a conversation is initiated with the social group, and community levels (Glenwick & Jas-
on, 1980; Morris & Braukmann, 1987; Nietzel, Win- Ayllon, T., & Azrin, N. H. (1968). The token economy: A moti-
ett, MacDonald, & Davidson, 1977). The small sam- vational system for therapy and rehabilitation. New York:
Appleton-Century-Crofts.
ple of studies cited in this chapter has demonstrated the Ayllon, T., Milan, M. A., Roberts, M. D., & McKee, J. M.
successful application of behavior analysis to a repre- (1979). Correctional rehabilitation and management: A psy-
sentative cross-section of the disorders included in the chological approach. New York: Wiley.
Diagnostic and Statistical Manual of Mental Disor- Ayllon, T., Kuhlman, C., & Warzak, W. 1. (1983). Programming
resource room generalization using lucky charms. Child and
ders the American Psychiatric Association; in schools, Family Behavior Therapy, 4, 61-67.
homes, and institutions; and with psychiatrically im- Azrin, N. H. (1977). A strategy for applied research: Learning
paired, mentally retarded, and nonhandicapped indi- based but outcome oriented. American Psychologist, 33, 140-
149.
viduals. Applied behavior analysis continues to devel- Azrin, N. H., & Nunn, R. G. (1974). A rapid method of elim-
op its principles and procedure and to extend them to inating stuttering by a regulated breathing approach. Behavior
the understanding and treatment of more complex phe- Research and Therapy, 12, 279-286.
nomena. The dynamic nature of the approach is seen Azrin, N. H., Naster, B. 1., & Jones, R. 1. (1973). Reciprocity
counseling: A rapid learning-based procedure for marital
clearly when one compares the first and current vol- counseling. Behaviour Research and Therapy, 11, 365-382.
umes of The Journal ofApplied Behavior Analysis and Azrin, N. H., Sneed, T. 1., & Foxx, R. M. (1973). A rapid
the other journals that publish behavior analytic work, method of eliminating bed-wetting (enuresis) of the retarded.
Behaviour Research and Therapy, 11, 427-434.
such as Behavior Modification, Behaviour Research
Baer, D. M., & Sherman, J. A. (1964). Reinforcement control of
and Therapy, Behavior Therapy, and Behavior Thera- generalized imitation. Journal ofExperimental Child Psychol-
py and Experimental Psychiatry. ogy, 1, 37-49.
Reviews of comparative outcome studies across Baer, D. M., & Wolf, M. M. (1970). The entry into natural
contingencies of reinforcement. In R. Ulrich, T. Stachnik, &
types of clients and problems reveal that, with few if J. Mabry (Eds.), Control of human behavior (Vol. 2, pp. 319-
any exceptions, behavior therapy is no less effective 324). Glenview, IL: Scott-Foresman.
than the alternative forms of treatment to which it is Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current
compared; that behavior therapy is often marginally to dimensions of applied behavior analysis. Journal of Applied
Behavior Analysis, 1, 91-97.
considerably more effective than alternative treat- Balsam, P. D., & Bondy, A. S. (1983). The negative side effects
ments; and that for some problem areas behavior thera- of reward. Journal of Applied Behavior Analysis, 16, 283-
py is the only effective treatment available (G. Martin 296.
Chomsky, N. (1959). A review of B. F. Skinner's "Verbal Be-
& Pear, 1983). The same may be said of comparisons
havior." Language, 35, 26-58.
between applied behavior analysis and other forms of Cooper,1. 0., Heron, T. E., & Heward, W. L. (1987). Applied
behavior therapy. It is not surprising, therefore, that behavior analysis. Columbus, OH: Merrill.
behavior therapy is commonly used as the standard to Dietz, S. M., Repp, A. C., & Dietz, D. E. D. (1976). Reducing
inappropriate classroom behavior of retarded students through
which other forms of therapy are compared, and be- three procedures of differential reinforcement. Journal of
havior analysis is commonly used as the standard to Mental Deficiency Research, 20, 155-170.
which other forms of behavior therapy are compared. Fantino, E., & Logan, C. A. (1979). The experimental analysis
The implicit acknowledgment that the behavior thera- of behavior. San Francisco: W. H. Freeman.
Fitterling, 1. M., Martin, J. E., Gramling, S. C., Cole, P., &
pies are today the standards of comparison in psycho- Milan, M. A. (1988). Behavioral management of exercise
therapy outcome research highlights the vigor, scope, training in vascular headache patients: An investigation of
and effectiveness of the behavioral approach. This exercise adherence and headache activity. Journal of Applied
Behavior Analysis, 21,9-19.
condition is unlikely to change in the foreseeable Ferster, C. B., & Skinner, B. F. (1957). Schedules ofreinforce-
future. ment. Englewood Cliffs, NJ: Prentice-Hall.
Fox, R. M., & Azrin, N. H. (1973). Reduction of self-stimulato-
ry behavior by overcorrection. Journal of Applied Behavior
Analysis, 6, 1-15.
Freud, S. (1955). Analysis of a phobia in a five-year-old boy. The
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PART II
Assesstllent and Research

CHAPTER 5
Behavioral Assessment
A CONTEMPORARY APPROACH
Eric J. Mash and John Hunsley
Introduction As witnessed by the coverage in this and other re-

cent volumes (e.g., Mash & Terdal, 1981, 1988a),
Despite its relatively short history, behavioral assess- behavioral assessment in the 1980s continues to playa
ment has evolved rapidly and has been widely incorpo- dominant role in the assessment and treatment of the
rated into the practices of many clinicians and re- entire spectrum of psychological disorders in adults
searchers. Born out of the growing dissatisfaction with and children. But, despite the apparent acceptance and
psychodynamic and psychometric approaches to as- growth of behavioral assessment, many workers in the
sessment, the recognition that behavior is typically sit- field have become "disillusioned" by its perceived
uationally determined (Mischel, 1968), and the growth shortcomings (Nelson, 1983). Moreover, although the
of behavioral treatments (Wolpe & Lazarus, 1966), growth of the field is undeniable, researchers are be-
behavioral approaches to the assessment of psycholog- coming increasingly concerned that this growth is
ical functioning began to take shape in the late 1960s lacking in focus and conceptual clarity (Evans &
(e.g., Kanfer & Saslow, 1969). For many years, be- Nelson, 1986; McFall, 1986); similar concerns areevi-
havioral assessors labored not only to develop their dent in the growth of behavior therapy (Agras, 1987).
techniques and tools, but also to demonstrate the scien- In response to these problems, some researchers have
tific basis of behavioral assessment in order to con- vociferously held on to orthodox behavioral views,
vince the psychological establishment of its merit in rejecting any deviations from their learning and condi-
assessing psychological problems, formulating treat- tioning roots. In contrast to this approach, others have
ment goals, and evaluating treatment outcome. As called for the continued broadening of the focus of
noted by many authors (e.g., Goldfried, 1982; Nelson, behavioral assessment based on theoretical and em-
1983), the 1970s were a period of growth and excite- pirically verifiable rationales (e.g., Cone, 1988; Ken-
ment for behavioral researchers and clinicians, as be- dall, 1987; Mash & Terdal, 1988b; McFall, 1986;
haviorally based assessment, research, and treatment McFall & McDonel, 1986).
proliferated. Set against this historical backdrop, the purpose of
this chapter is to provide an overview of the present
status of behavioral assessment. In doing so, we ad-
EricJ.Mash • Department of Psychology, University of Cal-
gary, Calgary, Alberta, Canada T2N IN4. John Hunsley
dress the purposes, methods, and problems of behav-
• School of Psychology, University of Ottawa, Ottawa, On- ioral assessment; the nature of the various "models" of
tario, Canada KIN 6N5. behavioral assessment; the "traditional" issues that
87
88 PART II • ASSESSMENT AND RESEARCH
continue to affect the field, such as standardization, Methods of Behavioral Assessment

psychometrics, and the idiographic/nomothetic de-
Because ample information on the specific meth-
bate; the current issues, such as treatment utility, the
odology of behavioral assessment is provided in a mul-
targeting of problem behaviors, and clinical decision
titude of sources, we will present only a brief summary
making that are influencing the direction and the future
of these methods. For more details, interested readers
face of behavioral assessment; and, finally, we provide
are directed to the chapters on adult and child interven-
recommendations regarding the development and
tion and behavior change in this volume, journals such
evaluation of behavioral assessment.
as those appearing in our chapter's reference list, and
recent books by Ciminero, Calhoun, and Adams
(1986), Bellack and Hersen (1988), Mash and Terdal
Contemporary Behavioral Assessment (1988a), and Michelson and Ascher (1987).
Briefly then, behavioral assessment methods in-
The Purposes of Behavioral Assessment clude: structured (DiNardo et al., 1983; Edelbrock &
Costello, 1984) and unstructured interviews (Bier-
A hallmark of behavioral assessment is the utiliza-
man, 1983; Gross, 1984; Turkat, 1986); behavioral
tion of assessment strategies that are individually tai-
checklists and questionnaires (Barkley, 1987; Finch &
lored to meet the needs of specific clients and
Rogers, 1984; Himadi, Boice, & Barlow, 1986; Jensen
situations. Even when a standard set of measures is
& Haynes, 1986; McMahon, 1984); self-monitoring
employed for all clients presenting with a given prob-
procedures (Bornstein, Hamilton, & Bornstein, 1986);
lem, the way in which they are used is compatible with
analogue methods (Hughes & Haynes, 1978; Nay,
an idiographic approach to assessment. For example,
1986); psychophysiological methods (Kallman &
in the assessment of clients' presenting with agorapho-
Feuerstein, 1986; Williamson, Waters, & Hawkins,
bic symptoms, a standardized diagnostic interview,
1986); and direct observations of behavior (Foster &
fear survey, a depression inventory, and a measure of
Cone, 1980, 1986; Grotevant& Carlson, 1987). Thus,
marital adjustment are commonly administered (Bar-
behavioral assessment encompasses a wide variety of
low & Waddell, 1985). However, in addition to
techniques and strategies and should not simply be
providing a diagnosis, standardized diagnostic inter-
equated with the use of direct observational methods
views can provide information on a client's history of
(Jacobson, 1985a; Mash & Terdal, 1988b).
panic attacks, the frequency of various associated
symptoms, the fear and avoidance associated with a
range of activities when alone or accompanied by a
In Search of a Definition
friend or family member, and the coping strategies
used to deal with fear and panic (DiNardo, O'Brien, Behavioral assessment is more than just a collection
Barlow, Waddell, & Blanchard, 1983). of techniques-it is an approach to assessment that
Although behavioral assessment measures and strat- relies upon multiple sources of data gathered in multi-
egies are selected and modified to suit the demands of a ple situations (Mash & Terdal, 1988b; Nelson, 1983).
particular clinical context, it is possible to delineate But because of the diversity of theoretical orientations
purposes that all behavioral assessments have in com- and assessment repertoires encompassed within the
mon (Bornstein, Bornstein, & Dawson, 1984; Cone & rubric of behavioral assessment, a precise definition of
Hawkins, 1977; Hawkins, 1979; Hayes, Nelson, & behavioral assessment continues to be an elusive entity
Jarrett, 1986; Kanfer & Nay, 1982; Mash & Terdal, (Cone, 1988; Mash & Terdal, 1988b; Strosahl & Line-
1976, 1980). Broadly conceived, these purposes in- han, 1986). For example, behavioral assessment has
clude diagnosis, or assessment activities focusing on been defined as the identification and description, for
determining the nature or cause of the client's problem; the purposes of understanding and modification, of
prognosis, or generating predictions concerning future human responses that are controlled by contempo-
behavior under specified conditions; treatment design, raneous environmental events (Cone & Hoier, 1986;
or the gathering of information that will assist in the Hayes et al., 1986). However, behavioral assessment
development and implementation of effective inter- has also been defined as a deliberate and ongoing prob-
ventions; and evaluation, or assessments intended to lem-solving/hypothesis-testing approach to under-
evaluate treatment effectiveness and/or acceptability standing and altering human behavior (Kanfer, 1985;
(Mash & Terdal, 1988b). Mash & Terdal, 1988b).
CHAPTER 5 • BEHAVIORAL ASSESSMENT 89
In a very real sense, the growing acceptance and modalities include a description of potential behavioral
incorporation of behavioral assessment strategies into targets; the conditions of the occurrence of these target
the armamentarium of researchers and clinicians have behaviors; historical information regarding the client;
compounded this "identity" problem. "Traditional" an assessment of internal and external client resources;
behavioral concepts, such as the utilization of perfor- and an assessment of client motivation for change.
mance data, the attempt to minimize inferential pro- Theoretically, these modalities can be assessed by
cessing of assessment data, and, especially, the linking means of four methods: interview, written informa-
of assessment to treatment, are increasingly becoming tion, observation, and physiological recordings. More
central concerns in various approaches to assessment recently, Cone (1986, 1988) has presented a model for
and treatment. This rapprochement with other forms of classifying approaches to behavioral assessment that
assessment and treatment means that the field of be- utilizes both descriptive and epistemological dimen-
havioral assessment is constantly evolving, thus lead- sions. This model considers the scientific approach
ing to a blurring of the boundaries between "behav- underlying the strategy (deductive or inductive), the
ioral" assessment and other approaches to assessment assessment focus (idiographic or nomothetic), the sub-
(cf. Mash & Terdal, 1988b). ject matter of the assessment (behavior or trait), the
primary source of variation in the assessment target
(intrasubject or intersubject), and the environmental
Models of Behavioral Assessment emphasis of the assessment (interactive or noninterac-
tive).
Behavioral assessment means different things to dif- In their recent exposition of behavioral assessment,
ferent people and, although such pluralism may indi- Mash and Terdal (1988b) have taken a different ap-
cate the vitality and flexibility of the field, it makes the proach in presenting a model of behavioral assess-
description of behavioral assessment a difficult task. ment. In an attempt to overcome the disagreements
Theorists have taken several different tacks in their about the definition of behavioral assessment, they
attempts to formulate a taxonomy of behavioral ap- presented a "prototypic" view (e.g., Cantor, Smith,
proaches. Some authors have presented classification French, & Mezzich, 1980; Clarkin, Widiger, Frances,
systems based upon epistemological distinctions, such Hurt, & Gilmore, 1983) of behavioral assessment, by
as the extent to which operationally definable internal documenting a selection of theoretical and pragmatic
mediators of behavior are employed and the extent to features that are common to most forms of behavioral
which cognitive mediators can be reduced to behav- assessment. An advantage of this approach is that,
ioral or environmental terms (Hillner, 1984; Marx & although there may be disagreement about whether
Hillix, 1979). their prototype represents the manner in which behav-
Classification systems based upon descriptive fea- ioral assessment should be conducted, there will at
tures of assessment strategies have also been proposed. least be agreement that the prototype represents the
For example, Cone (1978) developed the Behavioral current practices of most behavioral assessors.
Assessment Grid (BAG) to classify behavioral assess- Our goal in the present chapter is to illustrate the
ment instruments and research. BAG simultaneously many heuristic models subsumed within this prototype
considers three dimensions of assessment: content that have guided, and continue to guide, the field. To
(cognitive, motor, or physiological data); methods structure our presentation, we have grouped together
(ranging from indirect methods, such as interviews, conceptually similar models on the basis of an admit-
self-report, and ratings by significant others, to direct tedly informal and somewhat intuitive "cluster analy-
methods, such as self-observation, analogue role play, sis." These clusters are: operant-based models, re-
analogue free behavior, naturalistic role play, and natu- sponse-class models, and systems-based models. Al-
ralistic free behavior); and types of generalizability though our presentation is far from all-inclusive, it
(across scorers, items, time, setting, methods, and di- should nonetheless serve to illustrate the diversity of
mension) possessed by a given assessment strategy. the past and current models of behavioral assessment.
Similarly, Nay's (1979) multimethod clinical assess-
ment involves a two-dimensional system to describe
Operant-Based Models
the "what" and "how" of behavioral assessment (cf.
Bomstein et al .• 1984). Nay's model utilizes five cate- Functional Analysis. Early behavioral assessment
gories of information, termed "modalities." These endeavors were based upon the learning principles en-
compassed under the operant, classical, and observa- of a functional analysis may overcome the narrow ap-
tionallearning paradigms (Ullmann & Krasner, 1965). plicability of the original version (Evans & Nelson,
The cardinal feature of these approaches was the idi- 1986), it does not address all the criticisms that have
ographic assessment of an observable problematic tar- been levied at the functional analysis. For example, a
get behavior and the observable antecedent and conse- functional analysis is frequently conducted by means
quent environmental events that were deemed relevant of an informal, subjective, and unsystematic process
to the target behavior (Bijou & Peterson, 1971; Bijou, of unknown reliability (Haynes, 1986). Indeed, the
Peterson, Harris, Allen, & Johnston, 1969; Lindsley, term functional analysis is somewhat of a misnomer in
1964). Following such an assessment, treatment that a functional analysis is rarely functional, for the
focused on altering or rearranging the antecedent and controlling variables are usually hypothetical con-
consequent stimuli that elicited or reinforced the prob- structs and no independent test is made to determine
lematic behavior. The term functional analysis was whether these variables actually control the target be-
proposed to describe this operant-based assessment ap- havior (Nelson & Hayes, 1986). Moreover, the clinical
proach (Peterson, 1968) that consisted primarily of utility of the functional analysis has yet to be em-
obtaining frequency, rate, and duration measures de- pirically substantiated. Specifically, it must be shown
scribing the behaviors of interest. that a functional analysis increases the effectiveness of
an intervention beyond what would have been obtained
SORKC. Kanfer and colleagues (Kanfer & Phil- by a standardized intervention and, furthermore, that
lips, 1970; Kanfer & Saslow, 1969) added an impor- this incremental increase in treatment efficiency war-
tant dimension to the functional-analysis approach to rants the time and effort required to conduct a func-
assessment by incorporating information regarding the tional analysis (Haynes, 1986).
individual whose behavior was being assessed. The
acronym SORKC summarizes the classes of assess- Radical Behavior Analysis. Not all behavioral
ment information relevant to their assessment model: S assessors have responded favorably to an expansion of
refers to the stimulus in the external or internal en- the functional analysis, and because they are cognizant
vironment that elicits the target behavior; 0 refers to of the limitations of functional analysis as it is com-
the organism, or biological status of the client (includ- monly practiced, they have called for a return to the
ing genetic, physiological, neurological, biochemical, operant-based roots of behavioral assessment. As a
and mechanical variables);R refers to the target behav- result, a radical behavioral analysis has been suggested
ior, encompassing motor behavior, cognitive-verbal as the proper form of behavioral assessment (Barrett,
behavior, and physiological-emotional behavior; K re- Johnston, & Pennypacker, 1986; Cone & Hoier,
fers to the contingency relations between the target 1986). The six defining characteristics (Cone & Hoier,
behavior and its consequences, including the frequen- 1986) of a radical behavioral analysis are: (1) a focus
cy and timing of response outcomes and schedules of on behavior in which behavior is viewed as a form of
reinforcement; finally, C refers to the consequences of "matter in motion"; (2) the application of measure-
the target behavior and may include a variety of social ment principles that deal with the motion of matter that
and nonsocial events that vary in their valence. are based upon absolute and standard units of measure-
ment (e.g., the dimensions offrequency, duration, la-
An Expanded Functional Analysis. The func- tency, and intensity); (3) the inductive gathering of
tional analysis continues to form the backbone of most information about behavior; (4) the use of an idi-
behavioral assessments, but it has undergone some ographic approach to assessment designed to detect
changes in the last two decades, including a further intraindividual behavioral organization; (5) assess-
expansion on the SORKC model and its extension into ment that is criterion-referenced and behavior thus in-
a process analysis of high-risk situations (L. Peterson, terpreted solely in terms of its effects; and (6) accuracy
Farmer, & Mori, 1987). Haynes (1986), for example, that is used as the ultimate criterion of measurement
suggested that a functional analysis should take into adequacy. A major advantage of the radical behavioral
account multiple target behaviors, multiple media- approach is that it is sensitive enough to evaluate subtle
tional variables, multiple etiologic factors, the client's treatment effects that might otherwise be overlooked
social system and cognitions, response classes, and or masked if assessed by means of the group statistical
complex response-response and response-environ- tests (Barrett et al., 1986). On the other hand, the
ment stimulus chains. Although this expanded version utility and power of this approach tends to be overs tat -
ed in claims that it "bypasses human observer error diagnostic categories within the scope of behavioral
and permits behavior to speak for itself' (Barrett et at. , assessment does not indicate the rejection or abandon-
1986, p. 159). ment of basic behavioral principles-it only requires
an acknowledgment that there may be stable covaria-
tions among some behaviors which can best be as-
From Responses to Response Classes
sessed at a superordinate level rather than by a focus on
As behavioral assessment progressed, researchers individual behaviors (Strosahl & Lineham, 1986).
began to attend to constellations of behaviors that tend- Although there are drawbacks to diagnoses that are
ed to co-occur and to commonalities across situations based upon form, topography, or structural properties
in which these behaviors were evident. This broadened of behavior rather than upon functional properties of
focus was present within the SORKC model, for Kan- behavior (Nelson & Hayes, 1986), this need not lead to
fer and Saslow (1969) called for the use of functional a general indictment of the use of diagnostic catego-
analysis as part of a behavioral diagnosis. Specifically, ries. Diagnostic systems developed from an empirical
they suggested seven components of a client's life that basis can provide a standardized means of describing
should be assessed in order to develop a comprehen- clients and their problems and should be able to pro-
sive understanding of the presenting problem and to vide both treatment and prognostic information (Hay-
construct a treatment that would be sensitive to these nes, 1986; Kazdin, 1983). Even the third edition of the
individual features of the client. These components Diagnostic and Statistical Manual of Mental Disor-
are: (1) an initial analysis of the problem situation in ders (DSM-III) and its successor DSM-III-R, with all
terms of behavioral excesses, deficits, and assets; (2) of their flaws (e.g., Mclemore & Benjamin, 1979;
the clarification of problem situation (i.e., who objects Millon, 1983; Vaillant, 1984), can still be useful to
to the behaviors and the consequences of the behavior behavioral assessors (Harris & Powers, 1984; C. Peter-
and its removal for the client); (3) a motivational analy- son & Rahrer, 1986; Powers, 1984; Taylor, 1983) be-
sis in order to determine important incentives and aver- cause they appear to possess some discriminant valid-
sive stimuli for the client; (4) a developmental analysis ity with respect to treatment indications (e.g., Wad-
that focuses on biological, sociological, and behav- dell, Barlow, & O'Brien, 1984).
ioral changes which have occurred that are relevant to
the problem; (5) an analysis of self-control (i.e., under Triple Response System. A second trend toward
what conditions can the client control the behavior and an examination of response covariation is the assess-
to what extent can such control be used in the treatment of the triple-response system (Lang, 1968,
ment); (6) an analysis of social relationships, including 1985). This tripartite assessment model, also known as
a determination of the people who are most influential the triple-response mode (Cone, 1979) and the three-
in the client's environment and the expectations these response system (Kozak & Miller, 1982), examines
people and the client have of each other; and (7) an verbal, somatic, and behavioral dimensions of a disor-
analysis of the social-cultural-physical environment, der. Although originally designed to assess the dimen-
including the norms for behavior, and any limitations sions of anxiety, the assessment of the triple-response
in the environment that reduce opportunities for the system has been presented as a general framework for
client to experience reinforcement. selecting target behaviors in behavioral assessment
(Nelson & Hayes, 1979)-thus, it has broadened the
Disorder-Based Assessment. Kanfer and Sas- scope of what is considered to be a target behavior and
low's work served to set the stage for the movement has promoted the use of multiple-assessment tech-
from a behavioral assessment that narrowly focused on niques to measure the different response domains
single behaviors to a behavioral assessment that (Kratchowill, 1985).
focuses on a constellation of problem behaviors. Al- Even though the assessment of the triple-response
though, in the past, behavioral assessment research system has been advocated in the context of anxiety
tended to focus on single, isolated responses (cf. and anxiety disorders (Barlow & Maser, 1984; Himadi
Evans, 1986; Voeltz & Evans, 1982), researchers are etal., 1986; Maser, 1984; Turner & Michelson, 1984),
now attending to covariations among behaviors by psychophysiological measurements are all too often
focusing on syndromes (e.g., Kazdin, 1982) and psy- not gathered during an assessment (Michelson, 1987).
chiatric diagnostic categories (cf. Mash & Terdal, However, this state of affairs may change as relatively
1988b). Importantly, the inclusion of syndromes and inexpensive technologies, for example, ambulatory
heart-rate monitors, become more widely available. that could be successfully applied to all clients, re-
Practical concems aside, there are many conceptual gardless of the idiographic nature of the three-systems'
issues that have impeded the proper utilization of the responses.
triple-response system approach to assessment. For
example, the boundaries between the three dimensions
The Expansion into Systems Models
are often ambiguous: should speech be considered a
cognitive response or a motoric response (Evans, In recent years, behavioral assessment has become
1986) or can verbal reports be equated with the experi- increasingly systems-focused and behavioral assessors
ence of emotions (Kozak & Miller, 1982)? Moreover, have begun to describe and to elucidate the nature of
by treating physiological responses as a unitary dimen- the structural organizations and functional relations
sion, assessment may overlook meaningful differences that exist between situations, behaviors, physiological
between responses in the hormonal system, the auto- functioning, thoughts, and emotions (Evans, 1985;
nomic nervous system, and the skeletal muscle system Kanfer, 1985; Mash, 1985, 1987; Mash & Terdal,
(Evans, 1986) and thus misrepresent the nature of in- 1988b). Moreover, because the client is seen as part of
traorganismic responses and their organization (Stro- a complex and dynamic system containing many po-
sahl & Linehan, 1986). tential controlling variables, problem behaviors and
Importantly, there is frequently a lack of concor- psychological disorders are assumed to be multiply
dance across the three systems during a given assess- determined (Mash & Terdal, 1988b). As such, a sys-
ment (Williams, 1985); indeed, it may be naive to tems perspective rejects any a priori assumptions re-
expect substantial correlations across self-report, garding the primacy of controlling variables that affect
physiological, behavioral, and other public response a client's problems. Thus, it is no longer sufficient to
measures (Evans, 1986; Kaloupek & Levis, 1980) be- focus only on discrete behaviors or environmental
cause of intrasubject variability in the structure of re- events, for complex behavior chains and behavioral
sponse classes. Therefore, caution should be exercised interrelations must be assessed (Haynes, 1986) in
in interpreting either significant or nonsignificant cor- order to accurately evaluate the nature of a problem
relations across systems, and nonsignificant correla- and the context in which it occurs. In addition, a sys-
tions should not simply be treated as an error (Jacob- tems perspective requires that an assessor recognize
son, 1985b). The assessment of sexual arousal nicely that the variables that originally led to the development
illustrates this point: a lack of correlation between a of the problem may no longer be relevant to the treat-
self-report of arousal and a measure of penile circum- ment of the problem and that a comprehensive assess-
ference does not provide evidence of discordance be- ment must include information on the variables that
tween cognitive and physiological systems; it may in- currently serve to maintain the target behavior (Kanfer,
dicate that the client's self-report is inaccurate or that 1985).
the client assigns only a minimal weighting to in-
teroceptive cues in assessing his level of arousal BASIC ID. Lazarus' BASIC ID model (1973,
(Evans, 1986). Finally, the covariation of the three 1976), along with the work on the triple-response sys-
systems may vary across assessments; such temporal tem, provided some of the impetus toward the devel-
incongruency is known as desynchrony (Michelson, opment of a systems perspective in behavioral assess-
1984, 1987). Although desynchronous responding ap- ment. According to Lazarus, effective behavior
pears to be associated with a poorer prognosis for treat- therapy is possible only if the correct target behaviors
ment outcome (Michelson & Mavissakalian, 1985; and the contexts surrounding those behaviors have
Michelson, Mavissakalian, & Marchione, 1985), not been adequately assessed and the resulting information
all researchers agree that clinicians need to be con- used to develop the treatment plan. The acronym
cerned about desynchrony as it may only reflect ar- BASIC ID is an assessment heuristic that is used to
tifacts in measurement (Kaloupek & Levis, 1983). In specify the aspects of a client's life that should be
any event, even if desynchrony is an important clinical thoroughly assessed prior to, during, and following
consideration and treatment effectiveness is specific to treatment. B refers to the characteristics of the target
a certain response dimension (Cone, 1988; Kratcho- behaviors, such as duration, frequency, and intensity
will, 1985), it should be feasible to develop a treatment and the antecedents and consequences of the behav-
package comprised of response-specific components iors; A refers to the affective domain, with particular
attention to the events that result in strong emotional (e.g., schematic memory). Although a full discussion
responses; S refers to the physical complaints and sen- of cognitive assessment procedures is beyond the scope
sory experiences that are part of the presenting prob- of this chapter, suffice it to say that the field of cognitive
lems or that are functionally related to the target behav- assessment has rapidly grown in recent years (cf. Ken-
iors; I refers to the assessment of imagery, including dall & Braswell, 1982), resulting in a proliferation of
any mental pictures that are functionally related to the disorder-specific assessment devices (Chambless, Ca-
problem and the client's ability to imagine his or her puto, Bright, & Gallagher, 1984; Glass, Merluzzi,
life situation if the problems were overcome; C refers Biever, & Larsen, 1982; Hollon & Kendall, 1980), new
to cognitive features of the problem, including any methodologies for assessing cognitive processes
misconceptions, mistaken beliefs, inaccurate attribu- (Davison, Robins, & Johnson, 1983; Ickes, Robertson,
tions, or faulty reasoning that maintain the problem; I Tooke, & Teng, 1986; Schwartz & Garamoni, 1986),
refers to interpersonal relationships, including the so- and innovative models of human cognitive processes
cial context in which the client lives and the gathering (e.g., Wyer&Srull, 1986).
of information regarding the nature of the interactions Concomitantly, researchers have been appropriately
the client has with significant others; and D refers to critical of the theoretical bases and methodological
drugs, which is interpreted broadly to include an as- underpinnings of cognitive assessment procedures,
sessment of the client's physical well-being (e.g., ap- questioning the causal status of cognitive phenomena
pearance, health, exercise, and diet). The BASIC ID is (Coyne, 1982; Gotlib & Cane, 1987), the disorder-
first and foremost a framework for assessment-it specificity of hypothesized cognitive processes (Coyne
provides no theoretical or empirical basis to assist in & GotIib, 1983; Hollon, Kendall, & Lumry, 1986), the
determining the interrelations between the various do- stability (Dobson & Shaw, 1987; Last, Barlow, &
mains outlined above. O'Brien, 1985) and cross-situational consistency (Cut-
rona, Russell, & Jones, 1985) of cognitive measure-
Multidimensional/Systems Assessment. The ments, and the functional inequivalence of seemingly
trend toward a systems perspective is readily apparent, comparable assessment methods (Blackwell, Galassi,
both in psychology (e.g., Bandura, 1978, 1983, 1984, Galassi, & Watson, 1985; Heimberg, Nyman, &
1986; Schwartz, 1982; but see Phillips & Orton, 1983, 0' Brien, 1987; Hunsley, 1987). Given the vigor of the
and Staddon, 1984) and in the broader context of the current research programs investigating cognitive as-
biological and social sciences (Engel, 1977; Maturana pects of psychological disorders, in the next several
& Varela, 1980; Miller, 1978; von Bertalanffy, 1968, years we should witness further growth in the develop-
1975). Although, at present, there is no single ap- ment of methodologically sound cognitive assessment
proach to a systems assessment nor is there agreement procedures.
regarding what constitutes a sufficient systems assess-
ment, in general, behavioral assessors tend to examine Affect. Increasingly, researchers and clinicians are
the nature of both intraorganismic and social systems evaluating affective variables in their behaviorally ori-
and the ways in which these various systems interact. ented assessments. These efforts appear especially
The systems perspective has led to a renewed interest important when assessing disturbances in close rela-
in the assessment of cognition, emotion, and family re- tionships, such as marriage (Bradbury & Fincham,
lationships. 1989a,b; Gottman & Levenson, 1985), for consistent
affective patterns have emerged in the marital research
Cognition. The assessment of cognitive processes is literature. Specifically, compared to maritally satisfied
a key aspect of many behaviorally and cognitive-behav- couples, in maritally distressed couples there is more
iorally oriented treatments (Barlow, 1985; Beck & negative affect, a spouse is more likely to respond to
Emery, 1985; Beck, Rush, Shaw, & Emery, 1979; In- his or her spouse's expression of negative affect with a
gram, 1986; Michelson & Ascher, 1987; Turk, negative affective response, and affective interactions
Meichenbaum, & Genest, 1983). Cognitive assessment are more structured, rigid, and predictable (Gottman &
can be subdivided (Kendall, 1987) into the assessment Levenson, 1986).
of cognitive contents (e.g., internal dialogue), cog- Importantly, in the past few years, two diametrically
nitive processes (e. g. , biases and distortions), cognitive opposed trends have appeared in the assessment of
products (e.g., attributions), and cognitive structures affect. Whereas some researchers have suggested that
94 PART n • ASSESSMENT AND RESEARCH
there are clear biological and social differences be- ander, Johnson, & Carter, 1984; Oliveri & Reiss,
tween the various negative emotions (e.g., Ekman, 1984).
Friesen, & Ellsworth, 1972; Ekman, Levenson, &
Friesen, 1983), others have concluded that there is so
Traditional Issues in Behavioral
much overlap between negative emotional states, such
Assessment
as depression and anxiety, at least among nonpsychi-
atrically distressed individuals (Gotlib, 1984), that
As our overview of behavioral assessment models
they should best be conceptualized as exemplars of a
indicates, behavioral assessment is a multifaceted and
relatively stable and pervasive emotional state known
heterogeneous discipline. The rich variety of epis-
as negative affectivity (Tellegen, 1985; Watson &
temological positions and assessment methodologies
Clark, 1984; Watson & Tellegen, 1985). Part of the
has led to difficulties in parsimoniously defining the
discrepancy between these theoretical views may be
field of behavioral assessment, which, in tum, has led
due to methodological artifacts in the assessment of
to the promulgation of definitions about what the field
emotional states. Specifically, the concept of negative
is not. Definitions that are based on contrasts with
affectivity stems from the common empirical finding
traditional approaches to assessment are fraught with
that self-report measures (state and trait) of various
theoretical pitfalls, for they tend to foster the blanket
negative affective characteristics are highly intercorre-
acceptance or rejection of certain ideas or procedures
lated. These findings are not surprising, because this
when such categorical decisions are often unnecessary
line of research systematically ignores any possible
or undesirable. Additionally, the practices of clinicians
situational or contextual effects that might impinge on
and researchers do not conform strictly to these global
a subject's emotional functioning. An accurate assess-
definitions, and the boundaries between traditional
ment of affective distress must take into account the
and behavioral approaches are becoming increasingly
social context in which emotions arise, for the factors
less clear (Haynes, 1983). For example, a recent sur-
that govern the organization and function of emotio~al
vey of members of the Association for Advancement
states are largely interpersonal in nature (cf. Avenll,
of Behavior Therapy found that approximately one
1983; de Rivera & Grinkis, 1986).
third of the sample believed that clinical psychologists
should be competent in the administration and in-
Family Systems. The focus on systems models has
terpretation of such traditional personality measures as
led to a heightened interest in the social context in
the Thematic Apperception Test (TAT) and the Ror-
which psychological disorders occur and the assess-
schach (Piotrowski & Keller, 1984).
ment of family (Forman & Hagan, 1984; Holman,
Behavioral assessors are increasingly cognizant of
1983; Patterson, 1982; Rodick, Henggeler, & Hanson,
the fact that behavioral assessment is often as subjec-
1986) and broader sociocultural variables (Barling,
tive as traditional assessment (Barrios & Hartmann,
1986; Dunst & Trivette, 1986; Parke, MacDonald,
1986) and that there is need to include some aspects of
Beital, & Bhavnagri, 1989), which may influence the
traditional assessment if behavioral assessment is to be
maintenance and alteration of behavioral problems.
more broadly used in research and clinical work (Bar
The trend to evaluate the effects of interpersonal sys-
rios & Hartmann, 1986; Mash & Terdal, 1988b). To
tems on psychological functioning is especially notice-
this end, several concepts (e.g., nomothetic data, as-
able in the child psychopathology literature. For exam-
sessment standardization and norming, and psycho-
ple, parent-child interactions have been found to be
metrics) that had previously been anathema to behav-
adversely affected by parental social isolation (e.g.,
ioral assessors are now considered quite relevant and
Wahler, 1980), parental stress (e.g., Passman &
necessary to the growth of behavioral assessment. Ad-
Mulhern, 1977), parental psychopathology (e.g., Lee
ditionally, central tenets of behavioral assessment,
& Gotlib, 1988), and marital satisfaction (e.g., Brody,
such as the level of inferential processes required in
Pillegrini, & Sigel, 1986). Although many interper-
interpreting behavioral data, are now being ques-
sonally based assessment measures have been devel-
tioned.
oped recently (Humphrey & Benjamin, 1986;
Kinston, Loader, & Miller, 1987; Margolin, Talovic,
The Idiographic/Nomothetic Distinction
& Weinstein, 1983; Moos & Moos, 1981; Schaefer &
Olson, 1981), this emerging field is still struggling Traditional psychological research and assessment
with conceptual and methodological difficulties (Alex- have tended to be nomothetic in nature, in that large
numbers of subjects are assessed in order to facilitate 1985). Standardized measures facilitate the develop-
the development of general laws or principles of ment of norms, allow cross-study comparisons, and
human behavior and to determine the relation between increase the applicability of measures to a wide variety
universally applicable variables (Cone, 1986). In con- of clinical settings. In spite of the recognition that stan-
trast, the idiographic approach to assessment and re- dardized measures should be used, there has been a
search is centered on the individual, with the focus on proliferation of assessment methods (Evans & Nelson,
the intrasubject organization of psychological phe- 1986) that are idiosyncratic to the situation in which
nomena. Behavioral assessors, with their interest in they are used, unstandardized, and of unknown relia-
functional analyses and situational contexts, have gen- bility and validity (Strosahl & Linehan, 1986). All too
erally espoused an idiographic approach to assessment often this is due to the belief that improvised and non-
and have shunned nomothetic approaches as aids to standardized assessment is congruent with an idi-
assessing an individual because of the hazards associ- ographic approach to assessment (Barrios & Hart-
ated with deductive reasoning and the emphasis on mann, 1986).
cross-situational consistency (cf. Cone & Hoier, One of the major impediments to the development
1986). More recently, however, a rigid distinction be- of standardized measures in the behavioral assessment
tween these two seemingly disparate approaches has field is that the conceptual meaning of standardization
been questioned (McFall & McDonel, 1986) because is often misconstrued. Frequently, standardization is
all behavioral assessments inevitably involve aspects interpreted as implying that there is one true method
of both approaches. All clinicians approach clients (or sets of methods) to be used in assessing a behavior
with a set of hypotheses that are influenced by experi- and that the same measures should be applied in all
ence and the relevant empirical literature on response contexts, regardless of the nature of the presenting
covariations, normative functioning, and diagnostic problem (e.g., Hayes et aI., 1986). Standardization,
categories (Cone, 1986; Hawkins, 1986; Nelson & however, refers simply to the uniform application of a
Hayes, 1986). The issue, therefore, is not whether to measure across conditions of administration-the as-
use nomothetic principles and data, but rather, to select sessment device, time limits, instructions, and scoring
the nomothetic strategies that are most useful for de- criteria must be held constant across all individuals,
scribing, predicting, and explaining the behaviors that and occasions (Anastasi, 1982; Barrios & Hartmann,
are of interest (McFall & McDonel, 1986). 1986). It does not require that all clients receive the
same "test battery" and it does not imply that problem-
specific measures cannot be constructed.
Norms and Standardization
Although behavioral assessors have typically re-
jected the use of norms in the assessment enterprise Psychometrics: Boon or Bane?
(Nelson & Hayes, 1979), criterion-referenced norms
can be of inestimable value in assessing behavioral Many behavioral assessors have dismissed psycho-
competence (Goldfried & D'Zurilla, 1969). Indeed, metric principles, deeming them irrelevant and inap-
Hartmann, Roper, and Bradford (1979) have outlined a plicable to behaviorally based assessment strategies.
number of potential uses for such normative com- The reasons for this outright rejection of psycho-
parisons, including the identification of deficient or metrics are that the level of analysis is on group data,
excessive behaviors, educating clients and their signif- not the individual (Barrett et ai., 1986; Hayes et at.,
icant others when their expectations differ markedly 1986) and that psychometric concepts, such as internal
from existing norms for the behavior of interest, facili- consistency, test-retest reliability, and concurrent va-
tating decisions regarding treatment in cases in which lidity are incommensurate with behavioral assessors'
norms exist that suggest that certain presenting prob- views of behavior as being situation-specific (Hayes et
lems are transient in nature, and facilitating the com- aI., 1986; Kazdin, 1979; Nelson, 1983). Recently,
parison of studies using differing samples of subjects. however, the tide seems to have turned, for many be-
Obviously though, a prerequisite for the develop- havioral assessors are now calling for the rigorous use
ment of meaningful norms is the use of standardized of psychometrics in evaluating behavioral assessment
assessment measures, and the need for standardized (Barrios & Hartmann, 1986; Haynes, 1986; Mash &
measures in behavioral assessment has been frequently Terdal, 1988b; Strosahl & Linehan, 1986) and for the
discussed (Goldfried, 1982; Kanfer, 1972; Mash, development of techniques to apply the results of psy-
chometrically sound tests to the assessment of indi- The Inferential Level of Behavioral
viduals (Cone, 1988). Assessment
Much of the furor regarding the applicability of psy-
chometric principles appears to have stemmed from an Goldfried and Kent's (1972) influential review of
overly rigid distinction between idiographic and the methodological and theoretical bases of traditional
nomothetic assessment and from some misconceptions and behavioral assessment has been instrumental in the
of the theoretical basis of psychometrics. For example, promulgation ofthe assumption that behavioral assess-
some behavioral researchers have stated that psycho- ment procedures require only low levels of inference.
metric principles are based on the notion that "stable Goldfried and Kent described three levels of inference
internal entities" (Nelson, 1983) guide our behavior that may be involved in an assessment: (1) concluding
and that events can be explained by the "structure of that the obtained data is representative of the "true"
the mind" (Hayes et al., 1986). These views are only test response or criterion behavior; (2) concluding that
partially correct, for although psychometric tech- the data are representati ve of the relevant aspects of the
niques allow researchers to measure constructs, and population of "true" responses or criterion behaviors;
although much of psychology has tended to measure and (3) concluding that the data are indicative of some
internal constructs known as "traits," psychometrics hypothetical construct which is postulated to account
should not be confused with trait psychology. Psycho- for individual differences in responses or behaviors.
metric techniques are simply tools that must be applied Traditional approaches to assessment, they argued,
judiciously-no one would argue that all psycho- rely upon the explanatory power of personality con-
metric principles are applicable to all forms of data structs to account for behavioral acts and thus require
collection. Thus, a measure of stressful life events all three levels of inferential reasoning. In contrast,
should not be expected to possess split-half reliability because behavioral assessment is not dependent upon
(Hayes, Nelson, & Jarrett, 1987). On the other hand, such hypothetical constructs, responses and behaviors
the situational specificity and temporal instability of are not viewed as signs of a construct but, rather, are
behavior should not simply be assumed by behavioral seen as samples of the criterion behavior. Behavioral
assessors, it must be demonstrated empirically, for assessment, therefore, involves only two levels of
there are some behaviors that are cross-situationally inference.
consistent and temporally stable (cf. Barrios & Although many behavioral assessors continue to be-
Hartmann, 1986; Kenrick & Funder, 1988). lieve that a behavioral approach to assessment requires
There are other mistaken assumptions that are often only a low level of inference, this assumption is receiv-
used as justifications for the avoidance of psycho- ing a substantial amount of criticism. For example,
metric rigor. According to some behavioral re- although behavioral assessors may be unlikely to as-
searchers, the concept of measurement error is not rel- cribe causal status to hypothetical constructs (Mes-
evant to behavioral assessment (Hayes et al., 1986). sick, 1981), it is clear that constructs are frequently
Clearly though, behavioral assessors should be con- used in behavioral assessment (Barrios & Hartmann,
cerned about various factors that contribute to mea- 1986; Evans, 1986; McFall, 1986). Additionally, there
surement error, including method variance, reactivity, is a growing recognition of the tendency for observed
observer drift, and observer bias (Hawkins, 1986). behaviors to be interpreted as signs of underlying con-
Moreover, contrary to some suggestions (Hayes et aI., structs (Jacobson, 1985a). Indeed, the distinction be-
1986; Nelson, 1983), the "group" data that forms the tween the use of behaviors as signs or samples has
basis of the psychometric approach can and should be become blurred as behavioral assessors have begun to
applied to the individual case. Jacobson, Follette, and explore behaviors that can only be evaluated in a sub-
Revenstorf (1984), and more recently, Christensen and jective manner (Weiss & Frohman, 1985).
Mendoza (1986) have developed methods for assess- The issue appears to be one of the degree of in-
ing change in single-subject designs using standard- ference required in behavioral assessment, for few
ized, psychometrically sound measures. Their tech- would argue that no inferences are required. It is
niques use group norms, the standard error of the important to recall that Goldfried and Kent's proposi-
measurement of the measure, and pre- and posttherapy tions regarding the low level of inferences associated
scores of the client on the measure to determine if with behavioral assessment were stated in a relative
significant change has occurred because of treatment sense, not an absolute sense. Although behavioral as-
(for a case example, see Hunsley, 1988). sessment may require less inference than traditional
assessment, a very high level of inferential reasoning forcement community of the client; and is essential for
is required nonetheless. Anyone who has selected tar- physical and psychological development.
gets for observation; defined behavioral categories; Unfortunately, the very breadth and variety of such
collapsed data across coding categories; used a sum- guidelines may reduce the likelihood of high interrater
mary score from a behavior checklist, assertiveness reliability in selecting targets for behavioral change.
questionnaire, or fear survey schedule; or targeted Furthermore, the complexity of selecting target behav-
such constructs as social skill, marital satisfaction, iors is compounded by two other considerations. First,
problem solving, or coping strategies has engaged in a the factors that were instrumental in the development
high-level inferential process (Kanfer, 1985; Mash & of the problem may not be the same factors that serve
Hunsley, 1987). Although the inferences drawn by a to maintain the problem (Kanfer, 1985). Hence, a
behavior therapist may differ from those drawn by a functional analysis of the target behavior must attend
psychodynamically oriented therapist (PIous & Zim- to current influences on the behavior. Second, a focus
bardo, 1986), in the final analysis they are still infer- on a specific behavior rather than on response classes
ences. or response covariations may lead to the formulation of
a less than optimal treatment strategy (Barlow, 1986;
Kazdin, 1985; Voeltz & Evans, 1982). Accordingly,
Emerging Issues and Directions behavioral assessors must begin to define a problem
space for the behaviors that are targeted for change
(Mash, 1985). Such definitions can best be developed
In the previous section, we reviewed several major
through the use of theory-driven empirically based
issues that have been, and continue to be, an integral
models of human functioning. Patterson's work with
part of the evolution of a scientific, behaviorally based
children and families exhibiting antisocial behavior
approach to assessment. In the following section, we
problems is a fine exemplar of this process (Patterson,
will review some of the constructs and issues that have
1982, 1986; Patterson & Bank, 1986).
recently emerged, but which will likely exert strong
influences on the future direction and growth of behav-
ioral assessment. The topics we will consider include:
The Treatment Utility of Assessment
the selection of target behaviors, treatment utility, ac-
curacy, the process of clinical decision making, and
Behavioral assessors have consistently argued that
computer applications in behavioral assessment.
the value of behavioral assessment strategies should be
determined functionally; that is, evaluations should
The Selection of Target Behaviors address the issues of whether the assessment strategy
fulfills its intended purpose and whether it does so to a
Given that a functional analysis of specific target greater extent than do other comparable instruments
behaviors has long been a hallmark of behavioral as- (Barrios & Hartmann, 1986; Evans & Nelson, 1986;
sessment, the finding that behavioral assessors fre- Mash, 1979; Nelson, 1983). Although several evalua-
quently disagree on the selection of behaviors to be tion models, such as Kazdin's (1985) validation
targeted for change (Wilson & Evans, 1983) has led model, have been proposed, the most promising ap-
researchers to examine this process more closely. To proach to a functional assessment of behavioral assess-
aid assessors in the selection of target behaviors, re- ment appears to be the strategy of treatment utility
searchers have provided summaries of conceptual (Hayes et al., 1986, 1987; Nelson & Hayes, 1979).
guidelines (Mash & Terdal, 1988b; Nelson & Hayes, Rejecting the applicability of psychometric theory to
1979, 1986), including whether the behavior is phys- behavioral assessment, Hayes and colleagues pro-
ically dangerous to the client or to others; is aversive to posed that the adequacy of an assessment technique
others; will be maintained by the environment after should be judged by its ability to influence treatment
treatment; falls within the aegis of the therapist's treat- outcome. Thus, if an assessment measure is demon-
ment repertoire; is relatively easy to change; will pro- strated to effect a positive treatment outcome, the mea-
duce therapeutically beneficial response generaliza- sure should be included in future clinical work. For
tion; is an early element of more complex response example, if subjects are classified on the basis of target
chains; is positive, in order to avoid a problem focus in behaviors and differential treatment responses occur
treatment; provides an entry point into the natural reinfor the various classes of subjects, then the classifica-
tion scheme has been demonstrated to have treatment curacy of measurement is more important than mea-
utility. surement reliability (Nelson & Hayes, 1986) and
To date, however, the adequacy of the treatment should be the ultimate criterion in behavioral assess-
utility strategy as a replacement for psychometric prin- ment (Cone, 1981; Cone & Hoier, 1986; Foster &
ciples is unknown, for there have been few empirical Cone, 1980). Conceptually distinct from treatment
studies directly testing this approach. It is clear that utility, an assessment instrument is accurate to the ex-
research efforts need to be directed at the link between tent that it produces objectively verifiable data (Cone,
assessment and treatment, but, importantly, there do 1989). The necessary prerequisites for establishing ac-
appear to be at least two potential problems with the curacy include a set of rules or procedures for instru-
use of the treatment utility approach to address such ment use and an "incontrovertible" index against
issues. which scores from the instrument can be compared
First, there has been a tendency for behavioral as- (Cone, 1988; Cone & Hoier, 1986). The major diffi-
sessors to be guided more by data than by theory culty in clinically implementing the concept of ac-
(Goldfried, 1982; Kazdin, 1985; Mash & Terdal, curacy is the infrequent availability of such an index.
1988b). The treatment utility approach may further Rarely do we have an incontrovertible measure of "re-
encourage the proliferation of blind empiricism (cf. ality" to use as a standard (Hayes et al., 1986); indeed,
Kazdin, 1985) by leading researchers to collect assess- some would argue that such indices of reality cannot
ment data in a "shot-gun manner." This may be done exist (Watzlawick, 1984).
in order to increase the potential for uncovering a mea- As presented in the behavioral assessment literature,
sure that possesses treatment utility and to focus pri- accuracy is a unitary concept grounded in the ability of
marily on the pragmatic implications of the clinical use a measure to correspond to reality. However, in the
of such a measure rather than attempting to determine person perception literature, accuracy is a much more
its theoretical relevance to the process of treatment. complex and multifaceted concept. Swann (1984), for
Although the treatment utility approach has the poten- instance, distinguished between circumscribed and
tial to contribute greatly to the development of models global accuracy. Circumscribed accuracy is measured
based on an integration of empirical and conceptual by the extent to which people are able to predict the
information, it also has the potential to reify em- behavior of individuals in their presence (personal ac-
piricism devoid of theoretical underpinnings. curacy), within a limited number of contexts (con-
Second, the role psychometric theory plays in treat- textual accuracy), and for a relatively brief period
ment utility seems uncertain. Psychometric principles, (brief accuracy). Of more relevance to clinicians, how-
such as reliability and validity, are frequently dis- ever, is global accuracy-the ability for the "per-
missed as antithetical to behavioral practices, a stance ceiver" to predict the behavior of a "target" individual
which we indicated previously is typically derived in the presence of all perceivers that the target encoun-
from equating psychometrics with trait psychology. ters (transpersonal accuracy), across all the contexts
However, Hayes et al. (1987) recently argued that psy- that the target enters (transcontextual accuracy), and
chometric procedures can add valuable information to across a lang span oftime (extended accuracy). Thus,
treatment utility research. For example, once a mea- the standard of accuracy is not some form of "reality
sure has been shown to have treatment utility, it seems index" but rather the pragmatic standard of predicta-
inevitable that one would examine certain psycho- bility. Funder (1987) further expanded upon this dis-
metric properties of the measure, such as its interrater tinction by differentiating between errors and mistakes
reliability, stability, or generalizability. The task rein social judgment. According to Funder, an error is a
maining for those who would use treatment utility judgment of a stimulus that d~viates from how the
strategies appears to be the development of rationales judgment should be made. In the context of social
for when to use psychometric principles and how to interactions, an error becomes a mistake only when it
interpret or resolve any theoretical discrepancies that results in an invalid belief or an inappropriate action.
may occur (e.g., a measure that is unreliable but ap- This explicitly leaves open the possibility that a judg-
pears to have treatment utility). ment or measure may be erroneous (i.e., inaccurate)
without having any consequences in the "real world."
Accuracy in Behavioral Assessment From this perspective, it would seem overly stringent
Stemming from the perceived inadequacies of psy- to have accuracy, rather than utility or functionality, as
chometrics, some authors have suggested that the ac- the ultimate criterion of behavior assessment.
The Process of Clinical Decision Making to determine how skilled clinicians actually make deci-
sions and whether phenotypically different decisions
Throughout the chapter we have illustrated the di- can be equally effective.
verse range of theoretical models and psychological Discussion of these issues may cause many readers
constructs that serve to infonn behavioral assessors. to harken back to Meehl's (1954) discussion of clinical
Given such diversity, it should not be surprising to find versus statistical prediction. We are not challenging
that there is little consistency in the ways in which Meehl's thesis that the statistical synthesis of clinical
behavior therapists fonnulate client problems and de- data is typically superior to the clinical synthesis of the
sign treatments (Mash, 1985; Wilson & Evans, 1983). same infonnation. Rather, we are suggesting that, be-
However, if behavioral treatments are to be used most cause much of the clinical process must by necessity
efficaciously, we must ensure that both novice and ex- rely upon human decision-making abilities (see Holt,
perienced therapists possess not only technical skills, 1970, and Meehl's 1954 discussion ofthe "context of
but also the metacognitive skills necessary for sound discovery"), the onus is upon researchers to elucidate
clinical work. Accordingly, the task facing behav- the nature of the processes that underlie most clinical
iorally oriented clinicians and researchers is to begin to work. There is now ample evidence to indicate that
develop scientifically sound models of clinical deci- clinicians and other decision makers often make errors
sion-making processes in order to effectively train in their judgments (Kahneman, Slovic, & lVersky,
practitioners to become consummate clinicians. 1982; Nisbett & Ross, 1980). Perhaps it is now time to
The process of clinical decision making has often detennine the mechanisms that are responsible for
been represented metaphorically as a funnel (e.g., these errors (cf. Kunda, 1987) and to detennine the
Hawkins, 1986), in which the scope of infonnation parameters that cause an "error" or a bias in decision
gathered and the range of treatment options narrows as making to become a "mistake" (cf. Funder, 1987).
therapy progresses. For example, as the specific nature
of the presenting problem becomes apparent and is
Computer Applications in Behavioral
defined in concrete, behavioral tenns, the suitability of
Assessment
various treatment modalities and fonnats for altering
the problem behavior becomes clearer. Although this There has been a dramatic increase in the use of
metaphor may capture some elements of the process of computer technology in the assessment and treatment
target behavior selection and treatment design, it is of psychological disorders. Although not without po-
almost certainly an oversimplification. It ignores not tential drawbacks (Hofer & Green, 1985; Matarazzo,
only the subtleties of the cognitive skills required to 1986), computer programs are frequently used for the
select as a target for change a specific behavior or presentation, scoring, and interpretation of interviews
response class, but also the common clinical fact that and self-report psychometric tests (Erdman, Klein, &
clients frequently reveal "new" and important prob- Griest, 1985; French & Beaumont, 1987), the assess-
lems during the course of therapy (Sorenson, Gorsuch, ment of target complaints and behaviors (Angle, Ellin-
& Mintz, 1985). wood, Hay, Johnsen, & Hay, 1977; Carr & Ghosh,
Conceptualizing the clinician's activities as a recur- 1983b; Farrell, Camplair, McCullough, 1987; Hol-
sive, iterative problem-solving and decision-making born, Hiebert, & Bell, 1987), and treatment delivery
process (Kanfer, 1985) would appear to be a much (e.g., Binik, Servan-Schreiber, Freiwald, & Hall,
more satisfying and accurate depiction of clinical 1988; Ghosh & Marks, 1987). Moreover, the wide-
work. Researchers (Hayes, 1986; Kanfer, 1985) have spread availability of microcomputers makes it feasi-
described some of the many factors that influence ble to develop large-scale multisite data bases (Mash,
clinicians' decisions regarding how best to treat pre- 1985; McCullough, Farrell, & Longabaugh, 1986) and
senting problems, including diagnosis, severity of to provide ample opportunities for scientist-practi-
problem, etiologic and mediational considerations, tioners to conduct both quantitative and qualitative
consequences of selecting and altering target behav- analyses of single-subject designs (Todd, 1987). Im-
iors, competing problem behaviors, expected proba- portantly, current evidence suggests that clients react
bility and degree of success, motivational and client positively to computerized questionnaires and treat-
resource issues, ethical considerations, and pos- ment programs (Carr & Ghosh, 1983a; Farrell et al.,
sibilities for posttreatment maintenance of behavioral 1987; French & Beaumont, 1987).
change. Clearly though, empirical research is required Lambert (1987) recently developed a computer sim-
ulation program for use in behavior therapy training. tional analysis, the target behavior, is embedded. Di-
The simulation presents information on the referral, agnostic and classification data, if based upon em-
assessment, and treatment of an anxious patient. The pirically verifiable and clinically relevant information,
user is able to request various forms of information, may well prove to greatly enhance our ability to pro-
including the results of a behavioral interview, the in- vide for each client the most appropriate and effective
terpretations gathered from psychometric tests, and an treatment available.
analysis of the patient's motoric behavior. Based upon 3. As the scope of behavioral assessment continues
this information, the user is able to implement various to expand, there is an ever-increasing need for assess-
forms of treatment (e.g., systematic desensitization, ment techniques that are objective, standardized, nor-
cognitive restructuring, flooding). The "outcome" of med, and psychometrically sound. Importantly, such
the treatment selected for the patient is based upon the instruments must be sensitive to the situational vari-
empirical evidence for the efficacy of the treatment. ability that exists within disorders, for despite the
Programs such as this hold great potential for supple- longstanding emphasis on the importance of context in
menting the training of behavior therapists. Further- behavioral assessment, there has been insufficient at-
more, in light of the previous discussion of clinical tention to the design of assessment instruments that are
decision making, computer-based simulations would sensitive to situational and developmental parameters.
appear to be ideally suited to the collection of informa- 4. The emergent emphasis on systems models with-
tion regarding the nature of the clinical data required in behavioral assessment must be examined cautiously
by experienced therapists, how that information is and judiciously. Too often such models are vague and
used to formulate treatment plans, and how the resul- unwieldy abstractions that can leave the clinician and
tant changes (or lack of changes) in client behavior researcher frustrated and confused. For example, we
may modify treatment plans and goals. Thus, comput- need to know how concordance and synchrony among
er technology holds much promise not only for training the parameters of the triple-response system affect
purposes but also for disentangling the subtle pro- treatment selection and outcome. More broadly, there
cesses that are part of the clinical enterprise. is a need for investigations into the reciprocal influ-
ences among cognition, affect, physiology, and inter-
personal behavior and for research that provides infor-
mation regarding the most appropriate level(s) at
Summary which to target clinical interventions (e.g., family-
focus or individual-focus, skills remediation or cog-
Throughout this chapter we have described the nitive restructuring).
methods, models, and issues that are part of the multi- 5. A wealth of data indicates that clinicians are not
faceted clinical enterprise known as behavioral assess- immune to the various biases and heuristics that shape
ment. Based upon our review of this literature, we human decision-making processes. Perhaps it is now
offer for consideration the following recommendations time to stop bemoaning this state of affairs and to start
regarding the development and evaluation of behav- examining when such cognitive processes lead to
ioral assessment. clinically relevant "mistakes." Although it is unlikely
1. Despite the longstanding association between the to be a simple or easy task, it is necessary for us to train
strategy of functional analysis and the conduct of be- clinicians and researchers to be aware of these poten-
havioral assessment, there is astonishingly little infor- tial pitfalls. Where such biases cannot be overcome, it
mation on the process, reliability, or utility of func- may prove to be possible to circumvent them by means
tional analysis. A clear priority for research in of strategies, such as structured interviews or comput-
behavioral assessment is the investigation of these fea- er-assisted assessments.
tures. If functional analysis is indeed shown to have
treatment utility, we must then determine the nature of ACKNOWLEDGMENTS. During the preparation of this
the process involved in conducting a functional analy- chapter, Eric Mash was supported by a Sabbatical Fel-
sis in order to increase its utility and to set about train- lowship from the University of Calgary. The admin-
ing therapists to conduct sound functional analyses. istrative support of the Crippled Children's Division,
2. Relatedly, there is a pressing need for research Oregon Health Sciences University, also facilitated
into the problem space in which the focus of a func- work on this chapter and is gratefully acknowledged.
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CHAPTER 6
Observational Methods
Donald P. Hartmann and David D. Wood
Introduction Weick, 1968), and clinical psychology (Cone & fos-

ter, 1982; Wasik, 1984).
Behavioral observation is the recording of the observ- Despite the widespread popUlarity of observation
able responses of individuals. This approach to assess- methodologies, their association with behavioral psy-
ment has been variously described as the "hallmark," chology is unique. The work by Watson and his stu-
the "sine qua non, " and "the greatest contribution" of dents (e.g., Jones, 1924; Watson & Raynor, 1920)
behavior modification to the treatment of human prob- provided an important early stimulus to observational
lems (Hartmann & Wood, 1982, p. 109). Although studies, particularly with children (Arrington, 1939).
these descriptions may contain some hyperbole (cf. Child behavioral researchers subsequently developed
Jacobson, 1985a,b), direct observation is an important observation procedures to a level of technical sophis-
behavioral assessment technique. Surveys indicate tication only recently equaled by contemporary ap-
that observation procedures are employed in over 70% plied behavior analysts (see the reviews of early obser-
of the research articles published in major behavioral vation studies by Arrington, 1939, 1943). Compared
journals (Bass & Aserlind, 1984; Bomstein, Bridg- with other assessment methods, direct observation is
water, Hickey, & Sweeney, 1980; Kelly 1977). Direct more consistent with behaviorism's epistemological
observations are reported to occupy a similarly impor- emphasis on overt behavior, public events, quantifica-
tant role in the clinical practice of behavior therapists tion, low levels of inference, and assumptions of en-
(Gottman, 1985; Swan & MacDonald, 1978; Wade, vironmental causality (e.g., Goldfried & Kent, 1972;
Baker, & Hartmann, 1979). In addition, observational Haynes, 1978; Kendall, 1982; Schlundt, 1985).
methods of assessment are used frequently by re- Apart from ideology, direct observation has other
searchers in other fields, including anthropology (e. g. , strengths that cause it to be preferred to alternative
B. B. Whiting&J. W. M. Whiting, 1973), childdevel- assessment methods (e.g., Cairns & Greene, 1979;
opment (e.g., Cairns, 1979; Lytton, 1971), education Hartmann & Wood, 1982). The strengths of behavioral
(e.g., Boyd & DeVault, 1966), ethology (e.g., S. J. observations include (1) their flexibility in providing
Hutt & C. Hutt, 1970), social psychology (e.g., varied forms of data, ranging from narrative descrip-
tions of complex interactions to quantitative summa-
ries of individual behavior; (2) their relative simplicity
Donald P. Hartmann • Department of Psychology, Univer- and, hence, their economy of use by lay or paraprofes-
sity of Utah, Salt Lake City, Utah 84112. David D. sional observers; and (3) their wide range of ap-
Wood • Tulare County Children's Mental Health Consor-
tium, Turning Point of Central California, Disalia, California plicability across populations, behaviors, and settings.
93277. For example, observations can be particularly useful in
107
assessing young children and other verbally deficient discussions of these issues may refer to the technical
or unsophisticated subjects. They also can provide references we list, many of which are outside of the
measures of responses that most subjects cannot accu- traditional behavioral literature.
rately describe, such as behavior rates, expressive
movements, and fleeting movement, and for events
that subjects may be unwilling to report or else may Designing an Observation System
distort as a function of the event's social undesirability
or of the effort required for adequate description. Addi- An observation system is a more-or-less formalized
tional advantages of observational procedures are dis- set of rules for extracting information from the stream
cussed by methodological experts, including Fiske of behavior. These rules specify the target events or
(1978), P. Martin and Bateson (1986), Mischel (1968), behaviors, the observation settings, and the observers;
Messick (1983), and Wiggins (1973). they also specify how the events are sampled, the di-
The purpose of all assessment is to aid in decision mensions of the events that are assessed, and how the
making, including the selection and classification of data are recorded. Furthermore, observation rules may
individuals, the evaluation of interventions, and the specify how the resulting data are combined to form
testing of scientific hypotheses (Cronbach, 1960; scores. Thus, the unique set of rules defining a specific
Cronbach & Gieser, 1965). Hawkins (1979) has observation system also determines the cost, the de-
grouped the many functions served by behavioral as- tail, and the generality of the resulting information, as
sessment data into two broad categories: data that in- well as the questions to which the information is rele-
fluence treatment decisions and data that influence vant. The alternative rules that may be adopted to de-
policy decisions, program evaluation, and scientific fine an observation system and the consequences of
knowledge. The specific treatment-related assessment their adoption are reviewed elsewhere (Altman, 1974;
functions served by observational procedures are de- Boyd & DeVault, 1966; Gellert, 1955; P. Martin &
scribed by Hawkins (1979), Haynes (1978), and Mash Bateson, 1986; McCall, 1984; Weick, 1968; Wright,
and Terdal (1976), and are discussed more recently by 1960). Our discussion of these issues draws heavily on
Gottman (1985), as well as by Weiss and Frohman these sources as well as on more recent contributions to
(1985). These functions include (1) identifying target the behavioral assessment literature. Many of these
behaviors and their controlling stimuli; (2) designing issues are interrelated and deserve consideration at the
interventions; and (3) monitoring treatment progress preliminary stages of an investigation (e. g., Filsinger,
and outcome. A well-constructed and carefully evalu- 1983).
ated observation system is required to serve these pur-
poses effectively.
Developing Behavioral Categories
This chapter focuses on issues relevant to selecting
or developing behavioral observation systems. Major The behavioral categories included in an observa-
topics include the factors important in designing an tional system can vary in a number of ways. Because
observation system, selecting and training observers, these categories determine the research questions that
and assessing the reliability and the validity of obser- can be addressed, they should be selected with care
vation data. Our discussion of these issues focuses on (e.g., Reid, Baldwin, Patterson, & Dishion, 1988).
observations conducted in naturalistic settings by inde- Category or taxonomic systems differ in the breadth
pendent observers, when the descriptions of behavior of information they provide. Observation systems
require little inference and the recordings are made that provide information on a broad set of catego-
during the time the events occur, or soon after (cf. ries-broad-bandwidth (Cronbach, 1960) or exten-
Jones, 1977). However, much of this material is ap- sive (Crano & Brewer, 1973) observation systems-
plicable to other circumstances, such as observations often do so by sacrificing measurement precision or
conducted in contrived settings by participant-observ- fidelity. Simultaneous breadth and precision of obser-
ers or self-observations. Because each of the general vations are possible in those unusual settings where
topics surveyed rightfully deserves its own separate observers are abundant and subjects are both acces:.i-
chapter, many of the important details necessary to an ble and tolerant of extensive observation (e.g., Paul
adequate understanding of the issues have had to be & Lentz, 1977). Generally, the use of broad-band-
treated briefly. Readers interested in more extensive width observation categories is restricted to such sit-
CHAPTER 6 • OBSERVATIONAL METHODS 109
uations as the preliminary phases of assessment, "look" are the two categories in an exclusive (or mutu-
when the information they provide is used for generally exclusive) category system not having priority
ating hypotheses that subsequently will be tested with rules, the additional code, "smile and look," must be
more precise information (e.g., Bijou, Peterson, & added and used when the two behaviors co-occur. With
Ault, 1968; Hawkins, 1979; Scott & Hatfield, 1985). exhaustive observation categories, some behavior
More narrowly focused observation categories are ap- code must be scored for each observation unit. Sackett
propriate for formal hypothesis testing, as when one (1978) described the advantages of using mutually ex-
or more target behaviors are monitored for the pur- clusive and exhaustive behavior categories, particu-
pose of establishing the causal effects of a treatment larly when behavioral sequences or social interactions
intervention (e.g., Barlow & Hersen, 1984). are the focus of interest.
Categories in behavioral observation systems may Categories can also vary in other ways that may be
be either molar or molecular. Molar categories are relevant to behavior analysts. Categories may be
used to code global units of behavior, such as "ag- qualitative (e.g., yes/no) or may involve quantitative
gresses" or "plays," that often define functional re- judgments along some response dimension (e.g., Gel-
sponse classes. Molecular categories are used to code fand & Hartmann, 1984). A single set of categories
more narrowly defined units of behavior, such as may be appropriate for all subjects, particularly ifthey
"bites" or "smiles," that are often defined in terms of share the same problem behavior. Alternatively, differ-
specific sequences of motor movements (e.g., S. 1. ent sets of observation categories may be required for
Hutt & c. Hutt, 1970). Although molar categories are different subjects, when, for example, the intent is to
intended to code events into psychologically mean- investigate patients having widely varying problem be-
ingful categories, the empirical evidence that they do haviors, such as smoking and out-of-seat behavior. Ul-
so effectively is often lacking (e.g., Hartup, 1979; but timately, decisions about properties of behavioral cate-
see Foster & Cone, 1986, p. 261, for examples of gories depend on the functions that the observations
carefully validated molar observation categories). In are to serve. Regardless of assessment goals, behav-
addition, molar codes may be troublesome since they ioral taxonomies and classification schemata are cen-
require observers to make inferences about events. In tral to applied behavior analysis (cf. Adams, Doster, &
contrast, molecular observation categories may be Calhoun, 1977; Begelman, 1976; Menzel, 1979; Ro-
more difficult to interpret subsequent to data collec- senblum, 1978). They often are developed by first con-
tion, but they are relatively easy for observers to use ducting pilot observations.
(e.g., Hollenbeck, 1978). Molecular categories can
also be collapsed into molar categories for summary Pilot Observations. Useful paradigms for con-
data analyses, but molar categories cannot be broken ducting pilot observations have been described by in-
down into smaller, more molecular units. Because of vestigators with ethological perspectives (e.g., Blur-
the advantages of molecular categories-their ease of ton Jones & Woodson, 1979; S. 1. Hutt & c. Hutt,
use and the flexible manner in which they can be col- 1979; P. Martin & Bateson, 1986). The general pro-
lapsed into molar categories after the data are col- cedure is initially to obtain narrative observational ac-
lected-it may be advisable to collect data at a more counts of behavior in the assessment setting. Since this
molecular level than the intended level of analysis may prove demanding (Gellert, 1955), observers
(e.g., Bakeman & Gottman, 1986; Paul, Mariotto, & should use the simplest descriptive synonyms (with the
Redfield, 1986). least number of syllables) possible for accurately de-
Observation categories also differ in exclusiveness scribing behavior (S. 1. Hutt & C. Hutt, 1970). These
and exhaustiveness. Exclusive observation categories narrative data can then be reviewed with the intent of
are used when only one act or series of acts can be developing a more restrictive list of potentially impor-
scored for each unit of observation. When behaviors tant target behaviors. Subsequent field testing and
occur simultaneously, a priority coding rule must be refinement may be conducted as indicated. This pro-
developed to determine which behavior is recorded cedure represents a refinement from initial, unstruc-
and which behaviors are ignored, or, alternatively, the tured descriptive data to more structured, evaluative
system must be constructed so that a separate coding data (e.g., Boyd & DeVault, 1966; Scott & Hatfield,
category is available for each possible combination of 1985). When important observation targets have been
jointly occurring behaviors. Thus, if "smile" and identified, the investigator can then generate formal
operational definitions. These definitions should rep- in the length of time required to perform them, and
resent discrimination rules for coding targets, thereby when timing devices are available. Frequency is mea-
facilitating observer accuracy and consistency. sured when the incidence of a response is targeted,
when behaviors are of constant duration, and when
Operational Definitions. Hawkins and Dobes individuals are themselves the measurement unit, such
(1977) suggested that adequate operational definitions as the number of individuals who litter, overeat, or are
should possess at least three characteristics. First, a in their assigned seats at some designed time (e. g. ,
definition should be objective and should refer to di- Kazdin, 1982b). Novice behavior modifiers some-
rectly observable components of the target. Second, times record the wrong response characteristic, as
the definition should be clear, unambiguous, and easi- when "attending" is targeted for intervention but fre-
ly understood, so that any experienced observer can quency rather than duration of eye contact is recorded.
accurately paraphrase it. Third, the operational defini- Typical rules of parsimony and simplicity are rea-
tion should require little or no inference, even when sonable guidelines when determining response dimen-
used across a variety of observation settings. Accord- sions of target behaviors (e.g., Hamilton & Hunter,
ing to Hawkins (1982), operational definitions should 1985; Jay & Elliott, 1984; Jacobson, 1985b; Saudargas
ideally include a descriptive name, a general definition & Lentz, 1986). Moreover, in most investigations, the
(as in a dictionary), an elaboration that describes the appropriate response characteristic will be apparent.
critical parts of the behavior, typical examples of the When it is not, the examination of decision flowcharts
behavior, and questionable instances-borderline or provided by Alevizos, Campbell, Callahan, and Berek
difficult examples of both occurrences and nonoccur- (1974) and by Gelfand and Hartmann (1975) may be
rences of the behavior. One test for the adequacy of useful. If a qualitative dimension of responding is re-
operational definitions is to provide naive observers quired, such as the creativity of block constructions
with a written copy of the definitions. Then, without (Goetz & Baer, 1973), standard references on the con-
any formal training, observers should use the defini- struction of rating scales should be consulted (e. g. ,
tions to independently observe the same subject(s) for Anastasi, 1976; also, see Cone & Foster, 1982). Many
one or more sessions. Provided there are adequate con- investigators may be a~le to adopt or easily modify
trols for timing errors (Gelfand & Hartmann, 1975), behavior observation codes already reported in the lit-
the extent of observer consistency obtained by this erature (see Haynes, 1978, pp. 119-120, for a sample
method is an index of the relative adequacy of the listing; Simon & Boyer, 1974, for an anthology; and
operational definitions (Hawkins & Dobes, 1977). Re- topic-area reviews as surveyed in Ciminero, Calhoun,
lated considerations in developing operational defini- & Adams, 1977, 1986; Hersen & Bellack, 1976, 1981;
tions and behavior codes have been outlined previously McIntyre et al., 1983). While meaningful observation
(Arrington, 1939; Gelfand & Hartmann, 1984; Gel- targets and their dimensions (or relevant published ob-
lert, 1955; Heyns & Lippitt, 1954; S. 1. Hutt & c. servation codes) are selected, the investigator should
Hutt, 1970). During the development of operational also determine the context or sampling of settings
definitions, it is also helpful to specify response di- where the observations will be conducted.
mensions that can be accurately and easily monitored
[cf. discussions of target behavior selection in Behav-
Selecting Observation Settings
ioral Assessment (1985, pp. 1-78); also see Halle &
Sindelar (1982)]. The settings used for conducting behavior observa-
tions have been limited only by the creativity of inves-
Response Dimensions. The choice of response tigators and the location of subjects. Although most
dimension(s) is ordinarily based on the nature of the observations are conducted in homes, schools, clinics,
response, the availability of suitable measurement de- and laboratories, relevant settings may include bars,
vices, and, again, the purpose of the study (e.g., Alt- public restrooms, factories, summer camps, muse-
mann, 1974; Bakeman, 1978; Johnston & Penny- ums, and shopping centers (e.g., Bickman, 1976;
packer, 1980; Sackett, 1978). Duration, or one of its Haynes, 1978; Weick, 1968). The number, locale, and
derivatives, such as latency orpereentage of time spent correspondence between observation settings and
in some activity, is assessed when a temporal charac- important naturalistic settings require careful consid-
teristic of a response is targeted, when behaviors vary eration by the investigator.
Sampling of Settings. Observations conducted in employed with standard behavioral avoidance tests.
a single setting are appropriate when problems are lim- Haynes (1978) and others (e.g., McFall, 1977; Nay,
ited to a specific environment, such as school prob- 1977, 1979) have provided examples of representative
lems and discrete phobias, or when the rate of problem studies that employed various levels and types of struc-
behavior is uniform across settings, as may be the case turing in observation settings; these authors also dis-
with some forms of seizure activity. Because many cuss the potential advantages of structuring, including
behaviors are dependent on specific environmental cost-effectiveness and measurement sensitivity.
stimuli, behavior rates may well vary across settings Clues in observation settings may also be affected
containing different stimuli (e.g., Kazdin, 1979a). by the type of observers used and their relationship to
More representative data may therefore be obtained by the persons observed. Observers can vary in their level
conducting observations in a number of settings (e.g., of participation with the observed. At one extreme are
Ayllon & Skuban, 1973; S. 1. Hutt & c. Hutt, 1970). nonparticipant (independent) observers whose only
Sampling of observational settings also is critical if role is to gather data. At the.other extreme are self-
variation in setting control is to be used to suggest observations conducted by the target subject. Inter-
stimuli that might effectively be used to generate con- mediate levels of participant-observation are repre-
trol over responding, or if generalization of treatment sented by significant others, such as parents, peers,
effects is to be demonstrated (Gelfand & Hartmann, siblings, spouses, teachers, aides, and nurses, who are
1984). Given the infrequency with which settings are normally present in the setting where the observations
typically sampled (Bomstein et at., 1980), behav- take place (e.g., Bickman, 1976). The major advan-
iorists must either be assessing targets that do not re- tages of participant-observers result from their pres-
quire the sampling of settings or they are disregarding ence at times that may otherwise be inconvenient for
possible situational specificity in their data. The issue independent observers and the possibility that their
of specificity or generalizability of behavior across set- presence may be less obtrusive. On the other hand,
tings is especially important, as the observation setting they may be less dependable, more subject to biases,
may differ somehow from important naturalistic set- and more difficult to train and evaluate than are inde-
tings. Indeed, even naturalistic sites, such as bars pendent observers (Nay, 1979; also see discussions by
(e.g., Geller, Russ, Nasow, & Altomari, 1986) or uni- Jacobson & Moore, 1981; Jarrett & Nelson, 1984).
versity cafeterias (e.g. Krasner, Brownell, & Stunk- Unless self-observations are employed, ethical is-
ard, 1979; LeBow, Chipperfield, & Magnusson, sues related to informed consent must be considered as
1985), may fail to yield observational data that could well as the need to verify the level of awareness of the
appropriately be generalized beyond those immediate assessment by the subjects (Wiggins, Renner, Clore,
locales. & Rose, 1971). The specific problems associated with
self-observation are described by Nelson (1977) and
Control of Settings. The correspondence be- by Nay (1979).
tween observation and naturalistic settings varies as a When observation settings vary from natural life
function of similarities in their physical charac- settings because of either the presence of external ob-
teristics, in the persons present, and in the control ex- servers or the imposition of structure, the ecological
erted by the observation process (Nay, 1979). Observa- validity of the observations is open to question (e.g.,
tions may be conducted in contrived settings of Barker & Wright, 1955; Rogers-Warren & Warren,
minimal naturalistic importance to most clients, or 1977). Kazdin (1979a,b, 1982a) suggested thatthreats
they may be conducted in primary living environ- to ecological validity may require greater use of non-
ments, such as homes or schools. Even if observations obtrusive measures (e.g., Webb, Campbell, Schwartz,
are conducted in naturalistic settings, the observations & Sechrest, 1966) or increased reliance on reports
may produce variations in the cues that are normally from informants who are a natural part of the client's
present in these settings (e.g., Oei & Mewett, 1987). interpersonal environment.
Setting cues may vary when structure is imposed on Settings are just one of a number of technical aspects
observation settings. Structuring may range from pre- of observations that involve sampling issues. Although
sumably minor restrictions in the movement and ac- sampling of observation settings is an important issue,
tivities of family members during home observations investigators must also determine how best to schedule
to the use of highly contrived situations such as are observations within these settings.
Scheduling Observations vations are to be conducted on more than one subject,

decisions must be made concerning the length of time
Behavior cannot be observed and recorded continu- and the order in which subjects will be observed. Se-
ously unless the targets are low-frequency events in quential methods, in which subjects are observed for
captive populations (see, for example, the Clinical brief periods in a previously randomized, rotating
Frequency Recording System employed by Paul & order, are apparently superior to fewer but longer ob-
Lentz, 1977), or when self-observation procedures are servations or to haphazard sampling (e. g., Thomson,
employed (see Nelson, 1977). Otherwise, partial re- Holmberg, & Baer, 1974).
cords must suffice and the time in which observations
are conducted must be sampled. If sampling is re-
Selecting a Recording Technique
quired, decisions must be made about the number of
observation sessions to be scheduled and the basis for Decisions about sampling dimensions should also
scheduling. Haynes (1978) suggested that more sam- take into account the type of recording technique best
ples are required when behavior rates are low, variable, suited to the purposes of the investigation. Altmann
and changing (either increasing or decreasing); when (1974) and others (e.g., Sacket, 1978, 1979; Wright,
events controlling the target behaviors vary substan- 1960) have described a variety of different recording
tially; and when observers are asked to employ com- procedures (traditionally called sampling procedures),
plex coding procedures. These suggestions should be at least five of which seem particularly relevant to
taken as tentative, because sampling issues have not applied behavioral researchers. Selection of one of
attracted the attention of most behavioral researchers these procedures will determine which response char-
(Linehan, 1980; see Alevizos, DeRisi, Liberman, acteristics are recorded as a function of how the behav-
Eckman, & Callahan, 1978, for a notable exception). ioral stream is segregated or divided.
Observation sessions may be scheduled on the basis Ad lib sampling, also called nonsystematic sampling
of time, events, or both time and events. When com- or informal observation, hardly deserves formal rec-
plex observation codes are employed, or if the target ognition because of its nonrigorous nature. Such casu-
behavior is a free operant, such as crying or smoking, al method of informal note taking may be particularly
sessions are often scheduled on a temporal basis. If suitable for the preliminary mapping of a behavioral
time is the scheduling basis, the observations may be domain, for obtaining a crude estimate of the frequen-
scheduled at fixed intervals, at random intervals, or on cy or duration of the target responses, for identifying
a stratified random basis. For discriminated operants, potential problems in implementing a more formal re-
such as responding to requests, sessions are scheduled cording procedure, and for developing preliminary
on either an event or a combined temporal-event basis definitions (e.g., Rosenblum, 1978). Although this
(Gelfand & Hartmann, 1975). Finally, observation method may serve pilot observation functions well, it
sessions may occur without regard to scheduling rules. is not recommended as a method for gathering formal
Such ad lib scheduling (Altmann, 1974) is probably data in the course of a structured investigation (cf.
appropriate only for observations conducted during the Scott & Hatfield, 1985).
formative stages of an investigation. Although the ad lib method is the least rigorous
Once a choice has been made about how frequently observation procedure, real-time observations are the
and on what basis to schedule sessions, a session dura- most rigorous and powerful. With these latter pro-
tion must be established. In general, briefer sessions cedures, both event frequency and duration are re-
are necessary to limit observer fatigue when a complex corded on the basis of their occurrence in the noninter-
coding system is used, when coded behaviors occur at rupted, natural time flow (e.g., Bakeman & Gottman,
high rates, and when more than one subject must be 1986). Data from real-time recording are the most flex-
observed simultaneously. Ultimately, however, ses- ible; they can be used for such purposes as sequential
sion duration as well as the number of observation analysis that may not be well served by other methods
sessions should be chosen to minimize costs and to (Bakeman, 1978). Ifthe observation code used in real-
maximize the representativeness and reliability of the time recording is not mutually exclusive, the initiation
data as well as the output of information per unit of and termination time of each behavior category must
time. For an extended discussion of these issues as they be noted. When the code is mutually exclusive and
apply to scheduling, see Arrington (1943), Smith exhaustive, only initiations are recorded, because the
(1933), and Olson and Cunningham (1934). If obser- onset of a new category automatically signals the off-
set, or end, of the preceding coded event (Sackett, popular recording methods (Kelly, 1977) and one of
1978). The real-time method and event recording (the the most troublesome (e.g., Altmann, 1974; Kraemer,
technique we discuss next) are the only two procedures 1979). With this technique, an observation session is
commonly employed to obtain unbiased estimates of divided into brief observe-record intervals, and the
response frequency, to determine the rate of responses, observation category is scored if the relevant target
and to calculate conditional probabilities. behavior occurs within any part of the interval. Powell,
Event recording-sometimes called frequency re- Martindale, and Kulp (1975) have distinguished be-
cording, the tally method, or trial scoring when it is tween two variants of interval recording: whole-inter-
applied to discrete trial behavior-is used when fre- val recording, in which a behavior is scored only when
quency is the response dimension of interest. With it occurs during the entire interval, and partial-interval
event recording, initiations of the target behavior are recording, in which a behavior is scored even though it
scored for each occurrence in an observation session or occurs during just part of the interval. Even though
during brief intervals within a session (Wright, 1960). interval-recording procedures have been recom-
Event recording is a commonly used method in applied mended for their ability to measure both response fre-
behavior analysis (Kelly, 1977), and examples can be quency and response duration, recent research indi-
found in most issues of major applied behavioral jour- cates that this method may seriously misrepresent
nals. Because event sampling breaks up the continuity results by providing distorted estimates of both of
of behavior, it is sometimes supplemented with nar- these response characteristics (see Hartmann & Wood,
rative recording. This may be particularly helpful in 1982, p. 115; also, see Bass & Aserlind, 1984; Green,
the early phases of assessment to assist in identifying McCoy, Burns, & Smith, 1982; Harrop & Daniels,
antecedent and consequent stimuli that may exert some 1986; Karweit & Slavin, 1982; Macdonald, Craig, &
control over the target behavior. Other advantages, as Warner, 1985; Mansell, 1985; Moskowitz, 1986;
well as limitations, of event recording are described by Moskowitz & Schwartz, 1982; Smith, Madsen, &
Nay (1979) and by Cone and Foster (1982). For exam- Cipani, 1981).
ple, event recording may be difficult with infrequent According to the work by Ary and Suen (Ary &
events of low salience, and when the initiation and Suen, 1983; Suen & Ary, 1984), as a measure of fre-
termination of behaviors are difficult to discriminate. quency, the rate of interval recorded data varies de-
Scan sa,!,pling, also referred to as instantaneous pending on the duration of the observation interval.
time sampling, momentary time sampling, and discon- With long intervals, more than one occurrence of a
tinuous probe-time sampling, is particularly useful response may be observed, yet only one response
with behaviors for which duration is a more mean- would be scored. With short intervals, a single re-
ingful dimension than frequency. With scan sampling, sponse may extend beyond an interval and thus would
the observer periodically scans each subject and notes be scored in more than one interval. As a measure of
whether or not the behavior is occurring at that instant. response duration, interval-recorded data also present
The duration of observed responses is then estimated problems. For example, duration is overestimated
on the basis of the proportion of time samples during whenever responses are scored yet occur for only a
which occurrences of the target behaviors are noted. portion of any observation interval. The interval meth-
Momentary time sampling has been used to code an od provides a good estimate of duration only when the
individual's location, facial expressions, activities, observation intervals are very short in comparison with
and a variety of appropriate and inappropriate behav- the mean duration of the target behavior. Under these
iors in groups as diverse as students and chronic mental conditions, the interval method becomes procedurally
patients (e.g., Paul, 1986). An alternative to scan sam- similar to scan sampling. Ary (1984), using sampling
pling in assessing one or more temporal aspects of a theory, described how the error in interval-recorded
response (duration, latency, or interresponse times) is data may be estimated, and Suen and Ary (1986) sug-
referred to as duration recording. Duration recording gested methods for assessing the a priori probability
requires nothing more than a watch, or similar timing that interval recording will provide accurate informa-
device, to time the relevant temporal characteristic of tion on response frequency and duration. Discussions
responding. of the suitability of interval-recording procedures, par-
The final procedure, interval recording, is also re- ticularly for sequential analysis, are presented by
ferred to as time sampling, one-zero recording, and the Sackett (1979), by Bakeman (1978), and by Sanson-
Hansen system. It is at the same time one of the most Fisher, Poole, Small, and Fleming (1979).
In view of the numerous liabilities of interval-re- Table 1. Levels of Observation Technology and
cording, behavior analysts would be well advised to Sample References
consider alternative observation procedures. If real-
Type Sample references
time sampling is not required or is prohibitively expen-
sive, adequate measures of response duration and fre- Written records
quency can be obtained from scan sampling or event Behavior checklists Walls, Werner, Bacon, &
Zane (1977)
recording. Economical measures of both response fre-
"Countoons" Kunzelman (1970)
quency and duration can result from combining the Narrative accounts Barker & Wright (1955)
scan- and event-recording techniques. However, data Inventories Caldwell-Colbert & Lav-
produced by combining these two methods do not have orne Robinson (1984)
the same range of applications as data obtained by the Questionnaires Haynes (1978)
real-time procedure. Rating forms P. Martin & Bateson
Human observers using one of these five observation (1986); Nay (1976)
Discussions Nay (1977, 1979)
procedures will undoubtedly continue to serve as the
primary" apparatus" for obtaining observational data. Electromechanical equipment
However, various technologies are available to aid or Actometers Eaton (1983); Redmond &
even supplant observers in recording behavioral data. In Hegge (1985); Tryon
(l984a,b)
some instances, the new observation technologies far
Event recorders Alban & Nay (1976)
exceed the limits of more traditional procedures, conse- Stenography equipment Carter, Haythorn,
quently allowing much more sophisticated analyses of Meirowitz, & Lanzetta
highly complex behavioral phenomena (see Lamb, (1951); Heimstra &
Suomi, & Stephenson, 1979). Davis (1962)
Timing devices Washburn (1936); Wolach,
Roccaforte, & Breuning
Selecting Technological Aids (1975)
Discussions Rugh & R. L. Schwitz-
The technologies available to assist in collecting ob- gebel (1977); R. K.
servation data range from simple pencil-and-paper re- Schwitzgebel & R. L.
cording forms to complicated computer-assisted Schwitzgebel (1973)
sensing, recording, and retrieval systems. Selection Audio recording
from among existing technologies can determine the Automatic speech Jaffe & Feldstein (1970)
obtrusiveness and efficiency of data collection, the processing
representativeness of sampling, the ease of data man- Computer analysis of ver- Cassota, Jaffe, Feldstein, &
bal material Moses (1964)
agement (storage and retrieval), and the feasibility of
For narrative observation S. J. Hutt & C. Hutt
conducting various statistical analyses. These logis- (1970); Schoggen (1964)
tical problems are basic considerations that should be For unobtrusive observation Bernal, Gibson, William,
reviewed before commitment to any given technology & Pesses (1971); Chris-
(Sykes, 1977). Table 1 presents the major classes of tensen (1979); Lichstein
technologies typically used by applied behavior & Hoelscher (1986)
analysts. From radio transmitters Purcell & Brady (1965);
Soskin & John (1963)
Typescripts from: Powell & Jackson (1964);
Written Records. Pencil-and-paper media remain Thelen (1950)
popular today because of their general simplicity and Voice prosody Alpert, Merewether,
inexpensiveness as well as their importance in generat- Homel, Martz, &
ing a preliminary observation code (see discussions of Lomask (1986)
ethograms and the relevance of ethological perspec- Voice spectrometer Hargreaves & Starkweather
(1963)
tives and procedures in Blurton Jones, 1972; S. 1. Hutt
& C. Hutt, 1970; P. Martin & Bateson, 1986). How- Film and Videotape Records
ever, hand-written records may prove cumbersome or Computer analysis Futrelle (1973); Ledley
ill-suited to complex observation methodologies, such (1965)
as sequential analysis (Sidowski, 1977). When pencil- Time-lapse photography Delgado (1964); Withall
(1956)
and-paper recording procedures are used, careful at-
Table 1. (Continued) and the numbered observation intervals. The record
form could also include the observation code or sym-
Type Sample references
bols and ample space to write descriptive or narrative
Discussions Berger (1978); Collier comments, which can help clarify the obtained data.
(1967); S. J. Hutt & c. Sample record forms are given in a variety of sources
Hutt (1970)
(e.g., Arrington, 1939; Haynes, 1978; Nay, 1979;
Computers Wright, 1960).
Observer-to-computer links Sanson-Fisher, Poole, When recording data using written records or key-
Small, & Fleming
boards, observers should be protected from mechan-
(1979); Simpson (1979);
Tobach, Schneirla, Aron-
ical errors by employing a redundant coding procedure
son, & Laupheimer (e.g., Sykes, 1977) or other simple methods, such as
(1962) single-letter abbreviations or a minimum number of
Data analysis options Dodd, Bakeman, Loeber, writing movements (e.g., Gelfand & Hartmann,
& Wilson (1981); Quera 1975). Pictograms are particularly useful since they
& Estany (1984); are unique and easily discriminated shorthand symbols
Schlundt (1982); White-
for behavior (e.g., using the letter V or U for smile).
hurst, Fischel, De-
baryshe, & Caulfield
Since recording often takes place during brief intervals
(1986) following a period of observation, some signaling de-
Discussions Borko (1962); Stephenon vice, such as an electronic beeper, may be used to
(1979) signal the beginning and the end of each interval. A
Direct observations compared to: tape recorder with previously recorded interval num-
Videotape or film Boyd & DeVault (1966); bers ("interval 1, observe ... interval 1, record") is
Eisler, Hersen, & Agras a preferable method as it can be used not only to signal
(1973) the beginning and the end of the observation and re-
One-way mirror; live video Kent, O'leary, Dietz, & cording intervals but also to identify each interval
monitor observations Diament (1979); also see
uniquely. By means of this procedure, it is relatively
Knapp (1978)
Audio- or typescript- Steinzor (1949) easy to ensure that the data will be recorded in the
recorded interactions proper space on a data sheet (Gelfand & Hartmann,
1975). Similar data entry precautions are enumerated
Note: For additional material on audio recording, see ASHA Reports
(1970); Lass (1976); and recent issues of the Journal of Speech and by P. Martin and Bateson (1986) in their review of
Hearing Disorders: Journal of Speech and Hearing Research; and Folio keyboard-recording formats.
Phioniatrica. Additional observation technology is described in Be-
havior Research Methods and Instrumentation (1979, 403-455; 1982, It is surprising to note that relatively little empirical
227-253; 1984, 154-164), in the Journal of Applied Behavior Analysis, evaluation has been conducted to evaluate data sheets
and in P. Martin and Bateson (1986).
and record forms. Ellis and Wilson (1973) and Wood,
Callahan, Alevizos, and Teigen (1979) have demon-
tention to the construction of record forms may spare strated significant gains in reported behavioral data
investigators considerable grief during data collection, simply by modifying the traditional record formats
storage, retrieval, and analyses (Bakeman, 1978; used in psychiatric settings. More recent investiga-
Heyns & Lippitt, 1954; Weick, 1968). In fact, the de- tions contrasting paper-and-pencil recording forms tQ
velopment of appropriate record forms should coin- computerized observation media suggest that while
cide with the piloting stages of a behavioral observa- computers offer unique applications, some reliable and
tion system; mutual refinements can allow more cost-effective properties of simpler recording remain
efficient assessment and increase subsequent data- (Greenfield, 1985; Klesges, Woolfrey, & Vollmer,
management capability. Procedures for engineering 1985). These results should remind us that our final
effective record forms are described by Gelfand and data are only as good as our records (Sykes, 1977).
Hartmann 0975), by P. Martin and Bateson (1986),
and by Weick (1968). In general, a record form should Electromechanical Equipment. Keyboard and
be designed for convenience in data collection, stor- event recorders are now commonplace data-collection
age, and retrieval. Adequate identifying information aides. These devices enable observers to spend a great-
should be included on the form, such as the date of the er proportion of their time observing behavior with less
observation session, the target subject(s), the observer, distraction imposed by recording requirements; both
the occurrence and the duration of events can be more make analyses increasingly detailed and, accordingly,
easily recorded; and the records are time-locked, thus time-consuming. This may result in what has been
facilitating reliability analysis (e.g., Simpson, 1979). aptly called data tyranny (Bakeman, Cairns, & Ap-
The availability of sophisticated transducers has fur- plebaum, 1979). S. 1. Hutt and C. Hutt (1970) sug-
ther allowed behavior analysts precise and continuous gested that film or videotape is preferable when behav-
access to such events as gradations in noise level that ioral events of interest occur quickly, are highly
previously were only crudely measured (Rugh & complex, and present subtle changes or sequential
Schwitzgebel, 1977). Useful reviews of electrome- changes in complex behavior, and when precise mea-
chanical equipment initially were provided by the Sch- surement is required of brief, complex events. For de-
witzgebels and their associates (Rugh & R. L. Sch- tailed analysis requiring slow and/or mUltiple projec-
witzgebel, 1977; R. L. Schwitzgebel, 1976; R. K. tion, film is more durable and generally superior to
Schwitzgebel & Kolb, 1974; R. L. Schwitzgebel & R. videotape; 16-mm film is characterized by better reso-
K. Schwitzgebel, 1973). More recent descriptions can lution, definition, durability, and higher cost than 8-
be found in Booth, Lyons, and Barnard (1984), Briem mm film. Videotape may be preferable to film in set-
(1983), and Pamment and Stephens (1981). tings where obtrusive cameras, lights, and technicians
The major advantages to using electromechanical should be avoided. Investigators may also wish to con-
devices include increased data-collection capabilities, sider the time-sampling observation properties of
adaptability to automated data analysis, and the pos- time-lapse photography (e.g., Anderson et al., 1985;
sibility of less obtrusive assessment than is typically Delgado, 1964). Finally, videotape or film observa-
associated with live observers using clipboards, stop- tions should not be ruled out if there are efficient data-
watches, and awkward signaling devices to identify management procedures to cope with the substantial
observation intervals. Major limitations include in- amount of information they provide. Promising initial
creased downtime and data loss because of equipment steps have been made in combining film records with
failure, data overload caused by injudiciously adding computer technologies (e.g., Duncan & Fiske, 1977;
performance measures, and limited generality within S.1. Hutt & c. Hutt, 1970).
and across studies because of poor standardization of
procedures and nomenclature (e.g., P. Martin & Bate- Computers. The accessibility of computers is cer-
son, 1986; Rugh & R. L. Schwitzgebel, 1977). tainly the most promising (and perhaps to many the
most threatening) development in behavior observa-
Audio and Visual Recording Devices. Standar- tion technology. Early discussions of this topic were
dization may prove less of a problem with audio and provided by Lang (1969), Sackett (1978), Cairns
visual recorders, which are often used as an intermedi- (1979), and Lamb et al. (1979). Pencil-and-paper ob-
ate step in data collection, but may prove helpful in servation media have been adapted to computer tech-
their own right (e.g., Helmchen & Renfordt, 1981). nology for some time (e.g., Heyns & Lippit, 1954),
Auditory and visual stimuli are first recorded on tape and other researchers (e.g., Tobach, Schneirla, Aron-
and later coded by trained observers. These devices son, & Laupheimer, 1962) have anticipated direct ob-
may be useful when the presence of observers would server-to-computer links in behavior assessment (cf.
be reactive or when the events to be coded are so com- Sanson-Fisher et al., 1979; Simpson, 1979). More re-
plex that the observational stimuli require repeated ex- cent discussions of microcomputers and associated
amination. Nay (1979) cogently reviewed the ethics of technologies are available in a variety of sources, in-
using such recording techniques and made recommen- cluding Ager (1985), Behavior Research Methods and
dations for informed consent and subject-controlled Instrumentation (1982, 1984), Klepac (1984), and
editing of tapes. Clients should be allowed to turn off Maclean, Tapp, and Johnson (1985). Despite the con-
the recording device and even to "censor" the records siderable merits of computer technologies for behavior
(e.g., Christensen, 1979). observation, the wary consumer might consider that
Comparisons of audiovisual recording procedures such media may require considerable investments in
(film and videotape) with live observations reveal few equipment, observer training, and software and pro-
differences in results because of differences in media gramming(e.g., Sykes, 1977). Furthermore, the data-
(Boyd & DeVault, 1966; Eisler, Hersen, & Agras, management capabilities of computers are not a
1973; Kent, O'Leary, Dietz, & Diament, 1979). How- substitute for the data-interpretation capabilities of in-
ever, with film or tape media, there is the temptation to vestigators. Thus, computer applications are useful
only when researchers ask meaningful questions, ob- Brody, Stoneman, & Wheatley, 1984; Haynes, 1978;
tain appropriate data, plan relevant analyses, and in- Willis & Nelson, 1982). Adults, for example, display
terpret their results correctly. higher rates of positive interactions with children dur-
ing direct observations (e.g., Baumetal., 1979). Ifwe
can assume that accuracy and consistency are
Observers: Errors and Training positively valenced by observers, then reactivity due
to social desirability may also be illustrated when ob-
Although observers are a critical component of most server performance improves in the presence of a sec-
observation systems, their performance is fallible and ond observer (e. g., Taplin & Rein, 1973; see review by
may result in seriously flawed data (e.g., Heyns & Kazdin, 1977).
Lippitt, 1954; Menzel, 1979). The field of applied
behavior analysis has typically assumed that most po- Subject Characteristics. Young children under the
tential observer effects may be overcome or controlled age of 6 and subjects who are open and confident or
by adequate training. Observer training is therefore perhaps merely insensitive may react less to direct ob-
usually conducted with the intent to control error by servation than subjects who do not share these charac-
standardizing the observation procedures across teristics (e.g., Arrington, 1939; Gellert, 1955). Al-
raters. though numerous suggestions of observation reactivity
are discussed in reference to more socially adept or
older subjects, these hypotheses await empirical con-
Sources of Observer Effects
firmation (Kent & Foster, 1977; Wildman & Erickson,
Observer effects represent a conglomerate of the 1977).
systematic or directional errors in behavior observa-
tions that may result from using human observers. Our Conspicuousness of Observation. The most exten-
discussion of observer effects highlights the important sively researched contributing factor to reactivity is the
sources of errors also identified in previous reviews of level of obtrusiveness or conspicuousness of observa-
the literature (e.g., Foster & Cone, 1986; Johnson & tion. The obtrusiveness of observation can be manipu-
Bolstad, 1973; Kent & Foster, 1977; Wildman & lated by varying the activity level of the participant-
Erickson, 1977). observers (e.g., Melbin, 1954; Mizes, Hill, Boone, &
Lohr, 1983); by instructions that alert subjects to the
Reactivity. Behavior observation often is an intru- observation conditions (e.g., Bales, 1950); by the ob-
sive assessment procedure (e.g., Weick, 1968). The server's proximity to the subject (S. G. O'Leary & K.
presence of an observer may represent a novel stimulus D. O'Leary, 1976); by the presence of observation
that can evoke atypical responses from the observed instrumentation (Roberts & Renzaglia, 1965); and by
subjects (Haynes, 1978). This reaction to observation the length of exposure to observation (Haynes, 1978).
is the basis for the term reactivity (Lambert, 1960). The more obtrusive or obvious the assessment pro-
The outcomes of research conducted on the potential cedure, the more likely it is to evoke reactive effects.
reactive effects of observation have not been uniform; However, numerous contrary findings have been ob-
nevertheless, five factors appear to contribute to reac- tained, and none of these obtrusive factors necessarily
tivity (e.g., Arrington, 1939; Baum, Forehand, & guarantees that subjects will react to observations in an
Zegiob, 1979; Goodrich, 1959; Harris & Lahey, 1982; atypical manner (see the reviews previously noted).
Haynes, 1978; Haynes & Hom, 1982; Johnson & Perhaps somewhat more disquieting is the finding
Bolstad, 1973; Kazdin, 1977, 1982a; Wildman & reported by Harris and Lahey (1982) that conspicuous
Erickson, 1977). These factors are the valence or so- conditions of observation can interact with treatment
cial desirability of target behaviors, subject charac- phases to produce a form of reactivity that mimics a
teristics, conspicuousness of observation, observer at- treatment effect. Further investigation is required to
tributes, and the rationale for observation. assess the Ubiquitousness of this validity threat (Cook
& Campbell, 1979).
Valence ofthe Behavior. Socially desirable or appro-
priate behaviors may be facilitated while socially un- Observer Attributes. When behavior assessment is
desirable or "private" behaviors may be suppressed conducted by observers in natural settings, sex, ac-
when subjects are aware of being observed (e.g., tivity level or responsiveness, and age appear to be
important observer attributes that influence reactivity comparison to the evaluations performed by others
in children (e.g., Connolly & Smith, 1972; M. F. Mar- (e.g., Nelson, Hayes, Felton, & Jarrett, 1985).
tin, Gelfand, & Hartmann, 1971). Appearance, tact,
and public-relations skills can also affect the level of Observer Bias. Observer bias is a systematic error
reactivity, as when rather casually attired observers in assessment usually associated with the observers'
invade an upper-middle-class household (e.g., Hay- expectancies and prejudices as well as their informa-
nes, 1978) or when scientific detachment prevents ap- tion-processing limitations. Campbell (1958), in a rare
propriate supervision of aggressive interactions be- conceptual review of observer bias (also, see Haynes
tween children (e.g., Spiro, 1958). Other attributes of & Hom, 1982), described a number of cognitively
observers, such as race, socioeconomic class (Rosen- based distortions, including a "bias toward central ten-
thal, 1966), and professional status (Wallace 1976) dency." Thus, observers may impose patterns of reg-
may also contribute to reactivity (Johnson & Bolstad, ularity and orderliness on otherwise complex and un-
1973). ruly behavioral data (Hollenbeck, 1978; Mash &
Makohoniuk, 1975). Methodological solutions to
Rationale for Observation. Goodrich (1959) has de- these cognitively based biases were described by
scribed the role of the observer as "helpless" Heyns and Lippitt (1954) and by Weick (1968). The
scapegoat or even one of representing potential danger clinical judgment literature also may provide sug-
to subjects. Although this description may seem overly gestions useful for evaluating and moderating observer
dramatic, it followed an investigation where ambigu- bias effects (e.g., Cooper, 1981; Friedlander & Phil-
ity about observer roles was met with aggression lips, 1984; Hogarth, 1981; Rock, Bransford, Maisto,
against observers by delinquent boys (Polansky et al., & Morey, 1987; Rock, Bransford, Morey, & Maisto,
1949). Thus, the manner in which an observer joins a 1988).
group may be very important (see discussion by Other systematic errors are due to observer expec-
Weick, 1968). Johnson and Bolstad (1973) recom- tancies, including explicit or implicit hypotheses
mended providing a thorough rationale for observation about the purposes of an investigation, how subjects
procedures in order to reduce subject concerns and should behave, or perhaps even what might constitute
potential reactive effects that are due to the observation "appropriate" data (e.g., Haynes, 1978; Kazdin,
process. 1977; Nay, 1979). The observer may develop an im-
Other methods of reducing reactivity are also avail- plicit bias during training as a function of seren-
able to investigators. Rules for observer dress, eti- dipitous factors. For example, the characteristics of
quette, and other ways to minimize reactivity were the behavioral coding schema may prompt the ob-
discussed by Gelfand and Hartmann (1975), by server to search out specific targets to the exclusion
Haynes (1978), and by Weick (1968). It is possible that of less salient events (Rosenblum, 1978). Observers
reactivity represents a problem only with data obtained may also develop biases on the basis of more overt
early in an investigation; subjects may be expected to expectations resulting from a knowledge of experi-
habituate to observations with repeated assessment mental hypotheses, subject characteristics, and preju-
(Haynes, 1978). The length of time or the number of dices conveyed explicitly or implicitly by the investi-
observation sessions required for habituation is still an gator (e.g., E. E. Jones, Schwartz, & Gilbert, 1983).
empirical question. Littman, Pierce-Jones, and Stem Several studies have been specifically designed to
(cited in Haynes, 1978) recommended a 6-hour adapt- evaluate the role of observer expectancies in contribut-
ion period for home observations, whereas other re- ing systematic bias to behavioral assessments (see Fos-
searchers have recommended even less time for obser- ter & Cone, 1986). Although the results of applied
vations of young children (e.g., Bijou, Peterson, Har- behavioral studies directed to the issue of observer
ris, Allen, & Johnson, 1969; Werry & Quay, 1969). If expectations are not entirely consistent (see Foster &
none of these options proves satisfactory, investigators Cone, 1986, p. 334f.), the following conclusions seem
may elect to employ covert assessments using con- warranted. First, the accuracy of quantitative mea-
cealed recording procedures (Kent & Foster, 1977). sures is not much affected by observer expectancies,
For the special case of self-observation and reactivity, especially when stringent training criteria are coupled
Nelson (1977) provided a summary of relevant re- with a low-inference observation code (Redfield &
search. In general, this research indicates that self- Paul, 1976); the absence of these conditions, however,
observations reflect a pervasive self-deprecation in can produce biased reporting (e.g., Shuller & McNa-
mara, 1976, 1980). Second, when observer expectan- steps to evaluate the presence of observer drift by hav-
cies are strengthened by social reinforcement from the ing observers periodically rate prescored videotapes
investigator, the combination of expectancy and feed- (sometimes referred to as criterion videotapes), by
back produces obvious bias in the observational data conducting reliability assessment across rotating
(K. D. O'leary, Kent, & Kanowitz, 1975). members of observation teams, and by using indepen-
A variety of methods have been proposed for con- dent reliability assessors (also, see V. V. Wolfe, Cone,
trolling biases in observational reporting (e.g., & D. A. Wolfe, 1986).
Hartmann, 1984). Among these are using professional
observers; videotape recording the target events and Observer Cheating. Outright observer fabrica-
rating the sessions in random order; maintaining ex- tion of data has been reported by Azrin, Holz, Ulrich,
perimental naIvete among observers; cautioning ob- and Goldiamond (1961); observers have also been
servers about the potential lethal effects of bias; em- known to calculate inflated reliability coefficients
ploying stringent training criteria; and using precise, (Kent et al., 1974). However, these calculation mis-
low-inference operational definitions (Harris & Lahey, takes are not necessarily the result of intentional fabri-
1982; Haynes, 1978; Kazdin, 1977; Redfield & Paul, cation (e.g., Rusch, Walker, & Greenwood, 1975),
1976; Rosenthal, 1966; also, see Weick, 1968). If even though unsupervised observers obtain higher reli-
there is any reason to doubt the effectiveness with ability when alone than when joined by a supervisor
which observer bias is being controlled, investigators (K. D. O'Leary & Kent, 1973). Precautions against
should assess the nature and extent of bias by systemat- observer cheating include making random, unan-
ically probing their observers (Hartmann, Roper, & nounced reliability spotchecks, collecting data forms
Gelfand, 1977; Johnson & Bolstad, 1973; Weinrott, immediately after an observation session ends, re-
Reid, Bauske, & Brummett, 1981). stricting data analysis and reliability calculations to
individuals who did not collect the data, and providing
Observer Drift. Another source of error in behav- raters with pens rather than pencils (obvious correc-
ioral investigations is measurement decay in observer tions might then be evaluated as an indirect measure of
performance (Cook & Campbell, 1979). Observer cheating). In addition, observers might be repeatedly
consistency and accuracy may decrease, sometimes warned that cheating will bring about dire conse-
precipitously, from the end of training to the beginning quences (e.g., K. D. O'leary & Kent, 1973). Collat-
offormal data collection (e.g., Taplin & Reid, 1973). eral sources, such as nurses in the observation setting,
Reductions in accuracy have been described as instru- might be asked to report periodically on observer be-
ment decay or observer drift (Johnson & Bolstad, havior, thereby providing the investigator with both
1973; K. D. O'leary & Kent, 1973). When interob- valuable feedback and the confidence of the institu-
server consistency remains high yet observer accuracy tional staff (also, see McCall, 1984).
fails, the phenomenon is labeled consensual observer
drift (Johnson & Bolstad, 1973). Consensual observer
Selecting and Training Observers
drift occurs when a recording-interpretation bias has
gradually evolved over time (Arrington, 1939, 1943; The preceding discussion considered sources of er-
Gellert, 1955) or when response definitions or mea- ror in observation data, at least some of which may be
surement procedures are informally altered to suit partially controlled by adequate observer training. Sur-
novel changes in the topography of some target behav- prisingly little effort has been devoted to the systematic
ior (Doke, 1976). Reduction in observer consistency evaluation of observer characteristics that may help or
(drift) can also result from observer satiation or hinder such training.
boredom (Weick, 1968; Weinrott & Jones, 1984), or
even simple inattention (Elston, Schroeder, & Rojahn, Selecting Observers. Certain aptitudes and per-
1982). ceptual motor skills of observers may prove directly
According to Hartmann (1984), drift can be limited relevant to training efficiency and to the maintenance
or its effects reduced by providing continuing training of desired levels of observer performance (e.g., Nay,
throughout a project, by training and recalibrating all 1979). Skindrud (1973) used testing to screen potential
observers at the same time, and by inserting random observers on the basis of above-average verbal and
and covert reliability probes throughout the course of clerical skills (cf. Salthouse, 1986). Additional ob-
an investigation. Alternatively, investigators can take server attributes may also be important, including mor-
ale (Guttman, Spector, Sigal, Rakoff, & Epstein, cedures and problems. Observers should also be famil-
1971); motivation (Dancer et al., 1978); and even so- iarized with the Ethical Principles in the Conduct of
cioeconomic status (Alvevizos et aI., 1978). Yarrow Research with Human Participants (1973), with partic-
and Waxler (1979) suggested that good observers have ular emphasis placed on confidentiality. Proper ob-
the ability to sustain attention without habituation and server screening may eliminate some potential train-
to manage high levels of environmental stimulations ees, without penalty, at this step.
without confusion, have a compulsive regard for detail
and precision and an overriding commitment to scien- STEP 2. Learning the observational manual
tific detachment, and are "intense," analytical, and Trainees should learn the'operational definitions and
introspective. Applied behavior analysts interested in scoring procedures of the observation system as pre-
improving observer performance may wish to supple- sented in a formal observation training manual (sug-
ment these hypotheses with others gleaned from the gestions for observation manuals are discussed by Nay,
literature on information processing and applied deci- 1979, p. 237). After pilot observations, trainees might
sion making (e.g., R. Lachman, J. L. Lachman, & help to develop the code and the related definitions
Butterfield, 1979; Ostrom, Werner, & Saks, 1978; (Heyns & Lippitt, 1954). Observer trainees at this step
Weick, 1968; see also the citations to the clinicaljudg- are required to memorize the operational definitions
ment literature in the section "Observer Bias"). (see Hawkins & Dobes, 1977, for a discussion of oper-
ational definitions) as well as to learn examples and the
Observer Training. Unusually thorough models rules for scoring the target behaviors. Investigators
of observer training aimed at reducing timing and in- should utilize appropriate instructional principles,
terpretation errors have been available for approx- such as successive approximations and ample positive
imately 50 years (Arrington, 1932; Jersild & Markey, reinforcement, in teaching their observer trainees ap-
1935; Thomas, Loomis, & Arrington, 1933). Previous propriate observation, recording, and interpersonal
reviews of the observer-training literature (e.g., Boice, skills.
1983; Haynes, 1978; Johnson & Bolstad, 1973; Kaz-
din, 1977; Kent & Foster, 1977; Nay, 1979; Paul, STEP 3. First criterion check
1986; Reid, 1982; Wildman & Erickson, 1977) and After studying the observational manual, observers
our own evaluation of this literature suggest a seven- should pass a pencil-and-paper test or score a written
step general model for observer training. protocol presenting sample target events (e.g., Bertuc-
ci, Huston, & Perloff, 1974). In this phase, the trainee
STEP 1. Orientation is required to have a working knowledge of the obser-
A. Pilot observations (optional). Prior to training, vation system in order to code the test items accurately.
observers might be exposed to the observation setting
(cf. Stephens, 1970) and might attempt to record be- STEP 4. Analogue observations
haviors without the benefit of formal instruction or the Having passed the written test, observers should
aid of any coding schema. This procedure may be next be trained to criterion accuracy and consistency
useful in convincing observers of the need for training on a series of analogue assessment samples, such as
and the value of a structured observation system film clips (e.g., Loomis, 1931) or role-plays. Train-
(Heyns & Zander, 1953). ing should be based on varied and representative sam-
B. Sensitization to research issues. Even if pilot ob- ples of the target behaviors (Nay, 1979). If response
servations are not conducted, some form of prelimi- topographies can be expected to change over the
nary observer orientation should take place (cf. Zeren course of the investigation, then the trainees should
& Makosky, 1986):. It is important that observers re- be exposed to both earlier and later response variants.
main naive about the purposes of the investigation and Film or videotape is particularly useful in this regard
any experimental hypotheses. A suitable rationale and (Arrington, 1939), especially if sample vignettes
introduction should cover these issues, while empha- meet several important requirements. First, vignettes
sizing the continued need for experimentally blind and should present rather complex interaction sequences
objective assessment throughout the entire course of (Kent & Foster, 1977). Second, the sample interac-
the investigation. Observers should be warned against tion sequences should be unpredictable and variable
attempts to generate their own hypotheses and in- in response patterning (Mash & Makohoniuk, 1975;
structed to avoid private discussions of coding pro- Mash & McElwee, 1974). Third, observers should be
overtrained on these difficult vignettes in order to on the observation manual (see Paul & Lantz, 1977;
minimize decrements in performance from training to Paul, 1986) and reviews of sample observation events.
in vivo observations (Kazdin, 1977; Wildman & Perhaps an alternate set of criterion vignettes on film or
Erickson, 1977). Computerized interactive training videotape might be developed for just these purposes.
with videotapes may prove useful (e. g., Bass, 1987; Nay (1974) suggested that observers attain predeter-
see Cipani & McLaughlin, 1981; Power, Paul, Licht, mined criteria for reliability across multiple partners,
& Engel, 1982; Wilson, 1982, for other training and Haynes (1978) recommended that observers be
models). Discussion of procedural problems and con- rotated to constitute various teams or pairs during the
fusions should be encouraged throughout this training investigation. Another strategy is to train a second,
phase, provided all observers are informed of (and, independent observer group to provide reliability
ideally, present during) such discussions and the re- cross-checks (Kent et aZ., 1974).
sulting clarifications. Decisions should be posted in
an observer log or noted in the observation manual STEP 7. Postinvestigation debriefing
that each observer carries (Gelfand & Hartmann, At the end of the investigation, observers should be
1975). interviewed to assess any biases or potential mistakes
that may have influenced their observations (Hartmann
STEP 5. In situ practice et aZ., 1977; Johnson & Bolstad, 1973). Following
Observers should next attain some criterion perfor- these interviews, observers should be extended the
mance accuracy, such as 90% during "live" practice in professional courtesy of being informed about the
the observation setting (Conger & McLeod, 1977). nature and results of the investigation and should re-
Practice in the observation setting can serve the dual ceive footnote acknowledgment in technical reports or
purpose of desensitizing observers to fears about set- publications.
tings, such as inpatient psychiatric units, and allowing In reporting on observers in technical reports, re-
the subjects to habituate to the observation procedures. searchers should describe the observers' charac-
The training considerations outlined in Step 4 are also teristics, including the selection factors, the length and
relevant here. In addition, regular accuracy feedback type of training to attain criterion, and the criterion-
should be provided throughout training. House (1980) level accuracy and consistency that were selected. A
has described a quick and convenient statistical pro- method section that omits these details could be con-
cedure for monitoring systematic errors in observation sidered deficient in describing one of the most signifi-
data; this procedure may be useful in monitoring ob- cant methods in any observation study.
server performance during training and could serve as
a useful format to provide feedback to observers. It is
important to remember that feedback about accuracy
improves accuracy, whereas feedback about consisten-
Reliability
cy (e.g., interobserver agreements during coding) im-
proves consistent scoring tendencies and not neces- Reliability issues are relevant to scores from any
sarily accuracy (DeMaster, Reid, & Twentyman, assessment method, including direct observations. Di-
1977). Observer feedback must avoid social reinforce- mensions of reliability include scorer consistency
ment for ratings consistent with the outcome expectan- (sometimes referred to as observer agreement), tem-
cies of the investigation (K. D. O'Leary et aZ., 1975). poral stability, and internal as well as situational con-
Observers should also be informed either that all obser- sistency. Poor reliability on any of these dimensions
vation sessions will be checked for reliability or that would not necessarily rule out the use of an observa-
reliability will be checked covertly at unannounced tion system (Nelson, L. R. Hay, & W. M. Hay, 1977;
times. Reliance on periodic overt reliability checks Hayes, Nelson, & Jarett, 1986). However, poor relia-
should be avoided (see Kazdin, 1977). bility in one or more of these respects indicates limita-
tions in the extent to which the observation scores
STEP 6. Retraining-recalibration sessions could be generalized. The explicit relationship be-
During the course of the investigation, periodic re- tween reliability and the generalizability of observa-
training and recalibration sessions should be con- tions stems from the theory of generalizability pro-
ducted with all observers (Johnson & Bolstad, 1973; posed by Cronbach and his associates (Cronbach,
Kazdin, 1977); recalibration could include spot tests GIeser, Nanda, & Rajaratnam, 1972).
Generalizability Theory alizability should be assessed, and methods of sum-

marizing these data (e.g., generalizability formulas).
The theory of generalizability offers a detailed con-
These problems are not new; they have a long and often
ceptual analysis of the components of a score, methods
times overlooked history dating back in psychology
for analyzing those components, statistics for sum-
almost 50 years (e.g., Arrington, 1943). Our discus-
marizing the analysis, and an interpretive framework
sion here focuses primarily on definitions of basic con-
for evaluating the limits of score generalizability. The
cepts and a consideration of generalizability formulas
components of a score are determined by the specific
referred to as summary statistics.
conditions under which the score was obtained, in-
cluding time, context, scoring system, and observer.
Definitions. Observer agreement, observer relia-
The contributions of these conditions of measurement,
bility, and observer accuracy are the three terms that
calledfacets in generalizability theory, are determined
have been used with some frequency to describe in-
by analysis-of-variance procedures. The results of the
terobserver generalizability. Observer agreement and
analysis are summarized by estimates of variance com-
observer reliability are often used interchangeably to
ponents, intraclass correlation coefficients, and mea-
describe consistency of ratings among two or more
surement error statistics. Large variance components
observers who score the same behavior independently.
associated with a facet or an interaction of facets serve
When the two terms are distinguished, observer agree-
as a warning that the generalizability of the observa-
ment refers to consistency indexed by an agreement
tions may be limited along those dimensions. fur ex-
statistic, whereas observer reliability refers to con-
ample, a large variance component associated with the
sistency indexed by a correlation coefficient (e. g. ,
facet of observers may suggest that a replication of
Tinsley & Weiss, 1975). These indices should not be
similar results is unlikely with a change in observers.
considered interchangeable since they access different
The conceptualization and applied procedures of
properties of the same data (e.g., Hartmann, 1982).
generalizability theory are readily accessible to as-
Agreement statistics measure the degree to which ob-
sessors who employ direct observations. Nontechnical
servers assign the same score to an event or a person,
descriptions of the theory and illustrations of its ap-
and correlation coefficients measure the degree to
plicability to observational data are given in Berk
which observers assign the same standard score to an
(1979), Coates and Thoresen (1978), Cone (1977), R.
event or a person. When observations require di-
R. Jones (1977), R. R. Jones, Reid, and Patterson
chotomous judgments (occurrence/nonoccurrence),
(1975), Mitchell (1979), and Wiggins (1973). In addi-
the two approaches tend to merge.
tion, R. R. Jones (1977) has described some of the
Observer accuracy, sometimes called criterion-ref-
computational limitations of the generalizability theo-
erenced agreement (Frick & Semmel, 1978), refers to
ry approach for individual subject data. Strossen,
consistency between the ratings of an observer and a
Coates, and Thoresen (1979) have discussed possible
criterion rating. The three observer generalizability
solutions to these problems. Our discussion here
conceptions do not typically produce the same results
focuses on the facet of observation score gener-
when applied to the same observer data. Tinsley and
alizability that is most often considered by applied be-
Weiss (1975) demonstrated that observer agreement
havior analysts: generalizability across observers.
can vary independently from observer reliability. They
also described conditions in which independence be-
Interobserver Generalizability tween these two statistics might be expected. De-
Master et al. (1977) demonstrated that consistency and
Since early discussions of the methodology of be- accuracy can also vary independently.
havior analysis (Baer, Wolf, & Risely, 1968; Bijou et As an applied issue, Frick and Semmel (1978) and
al., 1968), applied behavioral researchers have fo- Cone (e.g., 1981) argued for an increased use of ac-
cused on the observer facet of generalizability in obser- curacy measures, and Nay (1979) and Boykin and
vation scores (Kelly, 1977). Despite this attention, as- Nelson (1981) provided useful suggestions for the con-
sessment of the generaIizability of results across struction of criterion videotapes, which are the com-
observers has been plagued by a number of problems. mon standard used for assessing accuracy. However,
These problems include disagreements about the defi- the development of criterion ratings may be infeasible
nition of basic concepts (e.g., Suen, 1988), decisions in many situations. Even if feasible, criterion ratings
regarding the level of data at which observer gener- may provide unrepresentative estimates of accuracy if
observers can discriminate between accuracy assess- agreement category before calculating an agreement
ment trials and more typical observations. In such a statistic (e.g., Hawkins & Dotson, 1975), whereas
case, users of observational systems are left with ob- other procedures provide formal correction for chance
server consistency as an indirect measure of accuracy agreements. These latter statistics sometimes are re-
(Hartmann, 1979a). Tinsley and Weiss (1975) argued ferred to as kappa-like statistics because of their sim-
that both agreement and correlational measures of con- ilarity to their precursor, Cohen's kappa (Cohen,
sistency should be calculated on observational data. In 1960). Kappa-like statistics have been discussed and
contrast, Hartmann (1977, 1982) suggested that the illustrated by many behavioral investigators, including
two approaches may be differentially relevant, de- Hartmann (1977, 1982), Hollenbeck (1978), and John-
pending on the purpose of the study and the form of the ston and Pennypacker (1980). A useful technical bibli-
major data analysis. Some of the statistics that can be ography on kappa-like statistics is given by Hubert
calculated are discussed in the next section. (1977), while the limitations of kappa are reviewed by
Uebersax (1988). Kappa also may be used for sum-
Summary Statistics. Following the choice of marizing observer accuracy (Light, 1971), for deter-
method for assessing interobserver generalizability, mining consistency among many raters (Fleiss, 1971),
selection from well over 20 statistical measures are and for evaluating scaled (partial) consistency among
available for summarizing the reliability data that are observers (Cohen, 1968). Potentially useful computer
collected. Berk (1979) described 22 different summary programs for determining kappa and other "reliability
statistics, and Tinsley and Weiss (1975), Frick and statistics" are given by Bloor (1983) and by Burns and
Semmel (1978), Wallace and Elder (1980), and A. E. Cavallar (1982).
House, B. 1. House, and Campbell (1981) listed still A percentage-of-agreement statistic for quantitative
others. Although some of these methods are equivalent data also has been reported frequently in applied be-
under special conditions (e.g., Fleiss, 1975), it is ap- havioral research. This statistic, sometimes called
parent that different summary statistics provide differ- marginal agreement (Frick & Semmel, 1978), is the
ent-sometimes substantially different-results when ratio of the smaller value (frequency or duration) to the
applied to the same data (e. g., Frick & Semmel, 1978; larger valued obtained by two observers multiplied by
Hartmann, 1977, 1982; A. C. Repp, D. E. D. Dietz, 100. It, too, has been criticized for potentially inflating
Boles, S. M. Dietz, & C. F. Repp, 1976). reliability estimates (Hartmann, 1977). Flanders
Observation data are typically obtained in one or (1967) and Garrett (1972) offered chance-corrected
both of two forms: categorical data, such as oc- formulas for marginal agreement statistics.
cur/nonoccur, correct/incorrect, or yes/no, that might Berk (1979) advocated the use of generalizability
be observed in brief time intervals or scored in re- coefficients as an alternative to the above-described
sponse to discrete trials; and quantitative data, such as statistics. He argued that the generalizability approach
response frequency, rate, or duration (Gelfand &
Hartmann, 1984; Hartmann, 1977). Somewhat differ- produces estimates of the reliability of a single observation and
ent agreement and correlational statistics have been sets of observations, ... provides data for deciding the number
and assignment of observers in the principle experiment, [and]
developed for the two kinds of data. permits researchers to choose between the inclusion and exclu-
The percentage-of-agreement statistic is the most sion of observer bias as part of the error variance term. (p. 464)
common index for summarizing the interobserver con-
sistency of categorical judgments (Kelly, 1977). Per- In all, Berk listed 11 advantages associated with the
centage of agreement is the ratio of the number of generalizability approach to assessing reliability.
agreements to the total number of observations (agree- Some investigators, however, have argued that gener-
ments plus disagreements) multiplied by 100. This alizability and related correlational approaches should
agreement statistic has been repeatedly criticized, es- be avoided. The reasons for this avoidance include
pecially since inflated estimates may result when the fears that such procedures "cook numbers to provide
target behavior occurs at extreme rates (Costello, highly abstract outcomes" (Baer, 1977, p. 117) or that
1973; Johnson & Bolstad, 1973; Hartmann, 1977; such mathematical approaches may inhibit applied be-
Hopkins & Hermann, 1977; Mitchell, 1979). A havior analysis from becoming a "people's science"
number of statistical techniques have been suggested (Hawkins & Fabry, 1979, p. 546).
to remedy this problem. Some procedures exclude en- Disagreement about procedures for summarizing
tries in either the occurrence or the nonoccurrence observer reliability also are related to differing recom-
mendations for "acceptable values" of observer relia- reported a similar neglect of other facets of gener-
bility estimates. Given the variety of available statis- alizability in her review of observation studies pub-
tics-with various statistics based on different metrics lished in Child Development and Developmental Psy-
and employing different conceptions of error-a com- chology. Thus, it seems that with few exceptions (e.g.,
mon standard for satisfactory reliability or gener- Johnson & Bolstad, 1973; Jones et al., 1975; Paul,
alizability seems unlikely. In general, values closer to 1986; Paul & Lentz, 1977), the effects of items, time,
the maximum value ofthe statistic (e.g., 100% or 1.0) and settings have not been the subject of systematic
are preferable to values less close to the maximum, methodological investigations.
although Frick and Semmel (1978) warned about over- This one-sided treatment of reliability may reflect
ly high observer consistency for field observations. the belief of some investigators that behavior is highly
Kelly (1977) recommended a minimum value of 90% discriminated across response modes, time, and situa-
for percentage of agreement, and Jones et al. (1975) tions (e.g., Nelson et al., 1977). Although this belief
suggested 70% agreement as an acceptable level of in response specificity seems appropriate for some be-
observer consistency when complex coding schemes haviors (Mischel, 1968), for many other responses the
are used. Gelfand and Hartmann (1975) recommended issues of stability and generality either have been dem-
80% agreement, and .60 for kappa-like statistics and onstrated (Epstein & Brady, 1985), or remain em-
reliability coefficients. Some investigators (e.g., pirical questions (Wiggins, 1973). Because of the ap-
Birkimer & Brown, 1979a; Yelton, 1979) have sug- parent importance of temporal and situational consis-
gested that the statistical significance of the reliability tency to applied behavioral practices, these gener-
summary statistics should be considered the minimally alizability facets deserve more systematic attention.
acceptable level of interobserver consistency. This ap- Behavioral researchers must also be concerned
proach has been criticized for the unusual reason that about another aspect of generalizability: adequacy of
statistical significance is dependent on sample size the sample of behavior available for observation and,
(Hopkins & Hermann, 1977). hence, analysis. This form of generalizability is partic-
A more serious concern is that significance levels ularly relevant to exploratory or descriptive analyses,
based on traditional inferential tests may be grossly in or treatment investigations in which direct observa-
error when they are applied to serially dependent time- tions provide the major source of data (see examples in
series data (Hartmann & Gardner, 1982). In general, it Paul & Lentz, 1977). In order for these analyses to
is not possible to stipulate an acceptable level of in- produce meaningful results, the scores must be based
terobserver consistency without additional informa- on adequate (reliable, stable) samples of behavior.
tion concerning the variability of the data, the magni- This demand is analogous to the demand imposed on
tude of effect to be detected, and the risk of Type II traditional psychometric assessors to develop tests of
error (or level of power) that the investigator finds adequate length. In the case of scores derived from
acceptable. A novel graphic approach focusing on dis- observations, the samples of behaviors that are ob-
agreement rather than agreement between observers served must be sufficient in both number and duration.
has been proposed by Birkimer and Brown (1979b). Investigators can attempt to meet the demands for ade-
Unfortunately, this approach fails to consider any of quate data by trusting their luck, their intuition, or their
the aforementioned factors, such as variability prior experience-alternatives associated with some
(Hartmann & Gardner, 1979). risk-or they may base their decisions on the results of
a generalizability analysis. Additional advantages that
may accrue to a more extensive investigation of other
Other Facets of Generalizability generalizability facets are described by Cone (1977),
Other facets of generalizability relevant to the relia- Hartmann, Roper, and Bradford (1979), and Mitchell
bility of observations include items (subclasses of be- (1979).
havior), time, and settings (e.g., Cone, 1977; Jones, As behavioral researchers increase their focus on
1977; Wiggins, 1973). These facets apparently have generalizability facets other than observers, they
not engaged the attention of behavioral researchers in- would be well advised to consult the existing literature
terested in observation systems, as writings on behav- before engaging in extensive research and develop-
ior observation typically limit their reliability consid- ment. The alternative approach, that of reinventing a
erations to observer generalizability. Mitchell (1979) technology, as has been done with observer reliability
(Hartmann, 1979a,b; Peterson & Hartmann, 1975), is (Reid, 1970; Taplin & Reid, 1973) indicates that relia-
substantially less efficient even though it may be tem- bility assessments are themselves reactive. As a result,
porarily more rewarding. overt interobserver reliability checks can produce spu-
rious estimates of observer generalizability. Finally,
generalizability assessments should be conducted
Recommendations for Reporting and Using
throughout the investigation and particularly in each
Reliability Information
part of multiphase behavior-change investigations
A variety of recommendations have been advanced (e.g., Hawkins & Dobes, 1977).
for reporting reliability information (e.g., Hartmann,
1977; Hawkins & Dotson, 1975; Hopkins & Hermann, Generalizability for Which Scores? The third
1977; Johnson & Bolstad, 1973; Kratochwill & Wet- set of recommendations specifies the scores for which
zel, 1977; Mitchell, 1979; Tinsley & Weiss, 1975; generalizability should be reported. Generalizability
Uebersax, 1988). The recommendations range from (or reliability in the generic sense) should be reported
the suggestion that investigators embellish their pri- for each variable that is the focus of a substantive anal-
mary data with disagreement ranges and chance agree- ysis. Thus, if analyses are conducted on each of five
ment levels (Birkimer & Brown, 1979b) to advocacy observed behaviors, reliability should be reported for
of what appear to be cumbersome tests of statistical each of the five behaviors. Some investigators violate
significance (Yelton, Wildman, & Erickson, 1977). this principle by reporting a single overall measure of
We suggest a collection of what appear to be the most generalizability, such as interobserver agreement, for
reasonable recommendations. an entire multicategory observation system. This ap-
proach can be troublesome, particularly when the
Types of Generalizability to Report. The first overall measure is not representative of each category
set of recommendations concerns the type(s) of gener- or behavior in the system.
alizability that should be reported. For most purposes, If analyses are conducted on composite variables,
generalizability estimates should be reported on in- such as difference scores (e. g., postscores minus pre-
terobserver accuracy and/ or consistency as well as on scores) or sum scores (e.g., total deviant behaviors),
the reliability or adequacy of the data sample. In the reliability analyses should be conducted on the com-
case of interobserver consistency or accuracy assessed posite variables, and perhaps also on the more elemen-
with percentage-of-agreement statistics, either a tary component behaviors that make up the composite.
chance-corrected index or the chance level of agree- Even though composite variables based on sums of
ments for the index used should be reported. The ade- positively correlated components are typically more
quacy of the data sample may be assessed by either reliable than their components (Nunnally, 1978), com-
internal consistency or test-retest reliability. If the posite variables based on differences between positive-
Cronbach et at. (1972) generalizability approach is ly correlated components may be substantially less re-
employed for estimating any design facet, the compo- liable than their components (McNemar, 1969). This
nents that contribute to error should be indicated. If potential discrepancy between composite and compo-
unusual statistics are employed for reliability pur- nent score reliabilities underlies our recommendation
poses, a convenient reference should be cited. for evaluating the generalizability of both.
Further consideration of composite scores forms the
Data for Assessing Generalizability. The sec- basis for another recommendation: generalizability as-
ond set of recommendations concerns the sources of sessments should be performed at the temporal level at
the data on which generalizability calculations should which the data are analyzed (e.g., Heyns & Lippit,
be based (see also the section on "Observers"). First, 1954). Thus, if weekly behavior rate is the focus of
both subjects and observers should be given time to analysis, the reliability of the rate measure should be
acclimate to the observational setting before gener- assessed for the data summed over the seven days in a
alizability-or any other-data are collected. Second, week. Reliability assessed at the level of monthly rate
observers should be separated and, if possible, kept would almost certainly overestimate the reliability of
unaware both of when generalizability assessments are the weekly rate scores, while reliability assessed at the
scheduled and of the purpose of the study. As we pre- level of daily rate would very likely underestimate
viously noted, the research by Reid and his associates their reliability. In some situations, as we previously
suggested, reliability assessed at a finer level of data 1979). This relative neglect of validity issues is ironic,
then that at which the analysis is conducted may be as behavior analysts have repeatedly criticized tradi-
useful (e.g., Bakeman & Gottman, 1986). For exam- tional assessment methodologies for their limited reli-
ple, reliability assessed at the level of brief intervals ability and validity (Linehan, 1980). In fact, observa-
within a session may be useful for identifying observer tions have been considered inherently valid insofar as
difficulties with a coding schema even if the data are they are based on direct sampling of behavior and re-
analyzed at the level of daily session totals (e.g., quire minimal inferences on the part of observers
Hartmann, 1977). Reliability assessments conducted (Goldfried & Linehan, 1977). Observation data have
on brief intervals, however, will almost certainly pro- been excused from the requirements of external valida-
vide a conservative estimate of the reliability of daily tion, yet they often serve as the criteria for validating
session totals (Hartmann, 1976). other types of assessment data (e.g., Mash & Terdal,
1976). This assumption of inherent validity in observa-
Modifying the Data Collection Plan Based tions involves a serious epistemological error (Haynes,
on GeneralizabiIity Data. If preliminary estimates 1978). Clearly, the data obtained by human observers
of generalizability suggest that the quality of data is may not be veridical descriptions of behavior (e.g.,
unsatisfactory, a number of options may be available to Uebersax, 1988).
the investigator. Consider the case in which an obser- Accuracy of observations can be attenuated by vari-
vation session of some particular Itmgth produces in- ous sources of unreliability and contaminated by reac-
sufficiently stable data based upon a split session gen- tivity effects and other sources of measurement bias as
eralizability assessment. First, the observation system we have indicatedearlier(e.g., Kazdin, 1977, 1979a).
may be modified. Stability sometimes can be im- The occurrence of such measurement-specific sources
proved by removing distracting stimuli from the set- of variation provides convincing evidence for the need
ting, or by adding a brief habituation period to each ob- to validate observation scores (Campbell & Fiske,
servation session. Second, the investigator may be 1959; Cook & Campbell, 1979). Validation is further
able to extend the observation session or increase the indicated when observations are combined to measure
number of sessions until a practical combination of some higher level construct or when observation
session duration and number is achieved that produces scores are used as predictors (Hartmann et at., 1979;
consistent data. Third, modifications can be made in Hawkins, 1979). Even though the theory of gener-
other, indirectly related aspects of the experimental alizability formulated by Cronbach et at. (1972) can
plan. For example, the statistical power lost by an un- accommodate discussion of validity issues relevant to
reliable data sample may be recovered by increasing behavior observation (Cone, 1977), our discussion re-
the number of participating subjects, and summary sta- views traditional validity categories that are generally
tistics that are degraded by instability can be adjusted better known and similarly applicable. The categories
by correcting them for attenuation (Nunnally, 1978). include content, criterion-related (concurrent and pre-
See Hartmann (1982) for further discussion of meth- dictive), and construct validity.
ods of modifying the plan of experiments suffering
from other forms of inadequately generalizable data.
Content Validity
In advocating a conservative and thorough analysis
of generalizability facets, our primary concern is to Although each of the traditional types of validity is
prompt investigators to describe the characteristics of relevantto observation systems (e. g. , Hartmann et at. ,
their data at least as well as they describe the charac- 1979), content validity is especially important in the
teristics of subjects, target behaviors, intervention pro- initial development of a behavior-coding schema (cf.
cedures, and assessment methods. McCall, 1984; Moskowitz, 1986). Content validity is
determined by the adequacy with which an observation
Validity instrument samples the behavioral domain of interest
(Cronbach, 1971). According to Linehan (1980), three
Validity, the extent to which a score measures what it requirements must be set to establish content validity.
is intended to measure, has not received much atten- First, the universe of interest (Le., domain of relevant
tion in observation research (e.g., Cone, 1982; John- events) must be completely and unambiguously de-
son & Bolstad, 1973; Kendall, 1982; K. D. O'Leary, fined. Depending on the nature and purposes of an
observation system, this demand for specifications 1979). Other recent predictive validity evaluations of
may apply to the behaviors of the target subject, to observation systems are presented by Ballard (1981)
antecedent and consequent events provided by other and by Reed and Edelbrock (1983), the latter study
persons, or to settings and temporal factors. Next, also reporting generalizability coefficients.
these relevant factors should be representatively or ex- Predictive validity studies are susceptible to numer-
haustively sampled for inclusion in the observation ous methodological difficulties. Thus, investigators
system. Finally, the method for evaluating and com- should be sensitive to issues of subject sampling, con-
bining observations to form scores should be speci- trol of irrelevant variables, and methods of establish-
fied. ing incremental validity when decisions involve ex-
Most observation systems have generally con- treme base rates. Additional considerations include the
formed to the operational requirements of content va- seemingly inevitable problems of chance findings and
lidity by specifying sampling and analysis procedures. cross-validation which frequently occur in multivari-
However, less attention has been devoted to defini- ate prediction studies based on small numbers of sub-
tional requirements, particularly in the case of multi- jects (see related discussions by Kupke, Calhoun, &
purpose observation systems when definition of the Hobbs, 1979; Kupke, Hobbs, & Cheney, 1979). For-
relevant behavior domain or universe assumes particu- tunately, these problems have been identified and spec-
lar importance (e.g., Haynes & Kerns, 1979). Thor- ified, and effective solutions have been developed by
ough enumeration of the stimuli, the responses, and traditional assessment researchers (Megargee, 1966;
other important elements in the domain (analogous to Wiggins, 1973; Journal of ConSUlting and Clinical
performing a task analysis) could promote more ade- Psychology, 1978).
quate sampling of the appropriate observation dimen- A second criterion-related validity issue is the de-
sions. This procedure would also clearly sp~cify the gree to which one source of behavioral assessment data
limits of applicability of an observation system as, for can be substituted for another. This issue is particularly
example, in recent discussions of classroom observa- important in evaluating treatment outcomes, as when
tion systems (e.g., Merrett & Wheldall, 1986; Sau- assessing the effects of social skills training (e.g.,
dargas & Lentz, 1986). Bellack, 1979). Although the literature on the con-
sistency between alternative sources of assessment
data is modest, it is safe to conclude that the cross-
Criterion-Related Validity
method generalizability of observational data is vari-
The criterion-related validity of observation scores able (e.g., reviews by Cone, 1981; Cone & Foster,
refers to their usefulness or accuracy in predicting 1982; Kazdin, 1979a,b). The highest convergence is
some performance criterion (predictive validity) or in found when precisely the same behavior at the same
substituting for some other established measure (con- level of specificity is assessed by the methods being
current validity). The two criterion-related validity compared with direct observations (Cone, 1982). The
paradigms are both potentially important for behav- variable outcomes on convergence suggest that behav-
ioral observation (Hawkins, 1979; Kazdin, 1979b), as ioral outcome data might have restricted gener-
they are central to two currently prominent issues in alizability. Moreover, these results further underscore
behavioral assessment. the desirability of concurrent validity studies when be-
The first issue is the determination of the validity of havioral and alternative data sources are used to assess
observation and other behavior assessment data when treatment outcome (cf. Chamberlain & Reid, 1987;
they are used to identify problem behaviors and con- Hoge, 1985).
trolling stimuli and to select treatment interventions
(e.g., Haynes, 1978; Mash & Terdal, 1974). In this
Construct Validity
instance, the utility of observations for such classifica-
tion decisions must be determined by predictive valid- Construct validity is indexed by the degree to which
ity studies. Noteworthy work in this direction has been observations accurately measure some psychological
performed by Paul and his associates in the validation construct. The need for construct validity is most ap-
of three observation systems used to assess chronically parent when observation scores are combined to yield
hospitalized psychiatric patients (Paul, 1986; Paul & a measure of some molar behavior category or con-
Lentz, 1977; Journal of Behavioral Assessment, struct, such as "deviant behavior." Patterson and his
colleagues (e.g., Johnson & Bolstad, 1973; Jones et of assessment data, are subject to errors and biases. In
al., 1975) have exemplified construct validation pro- addition, they may be logistically difficult or impossi-
cedures with their Total Deviancy score, which is de- ble (Goldfried & Davison, 1976), and only relate to
rived by combining scores for a number of behaviors targets of change indirectly, as in the cases of marital
included in their Behavioral Coding System (BCS). dissatisfaction or subjective feelings of depression
Separate construct validation studies have demon- (Jacobson, 1985a,b; but compare with Weiss & Froh-
strated that (1) parents consider behaviors included in man, 1985; Gottman, 1985). Indeed, ratings (Cairns &
the Total Deviancy score more noxious than other be- Green, 1979), self reports (Jacobson, 1985a), and per-
haviors included in the BCS; (2) that the Total Devian- manent products (e.g., Webb, Campbell, Schwartz,
cy score is susceptible to fake-bad instructional sets Sechrest, & Grow, 1981) may be data sources of
(e.g., Johnson & Bolstad, 1973); and (3) that the Total choice for specific purposes.
Deviancy score discriminates between clinical and A second and somewhat related issue is the apparent
nonclinical groups of children and is sensitive to the independence of the behavioral observation literature
social-learning intervention strategies for which it was both from its precursors in behavioral child psychol-
initially developed. Thus, the construct validity of this ogy and from the observation literatures in an-
measure subsumes two additional validity categories thropology, education, ethology, and social psychol-
proposed by Nelson and Hayes (1979); the BCS and its ogy (see a related criticism by Boyd & DeVault, 1966).
measure of Total Deviancy can be used to promote an The insular qualities of behavioral psychology in gen-
experimental analysis (theoretical validity) and to as- eral and of behavior assessment in particular have been
sist in the development of effective treatments (treat- previously noted by Krantz (1971) and by Peterson and
ment validity). In general, the sensitivity of observa- Hartmann (1975). The consequences of this isolation,
tions in evaluating treatment outcomes has provided including restrictions on methodology and on concep-
the most impressive evidence for their construct valid- tual models as well as the conduct of needlessly redun-
ity (Haynes, 1978). dant investigations, hardly seem worth the effort
To conclude, it is important to realize that validity is spared by such "scholarly selectivity" (see earlier and
not a general or absolute property of an assessment similar discussions by Hare, 1962; Withall, 1960).
instrument (Anastasi, 1976). Observations may have Our third observation is again reminiscent of "qual-
impressive validity for evaluating the effectiveness of ity-of-science" issues. Most of the observation liter-
behavioral interventions, but they may be only moder- ature and the reviews of it are limited in their level of
ately valid or even invalid measures for other assess- conceptual analysis. Notable exceptions are Camp-
ment purposes. Observations may be used for various bell's (1958) communication system analogy for ob-
assessment functions, and the validity of observation servation error and Heyns and Lippitt's (1954) solu-
data for each of these functions must be independently tions to these problems derived from the laws of
verified (e.g., Hartmann etal., 1979; Hawkins, 1979; psychophysics. The conceptual power of information-
Kazdin, 1979b; Mash & Terdal, 1974). Behavior ana- processing theory, theories of instruction (see Bass &
lysts, no less than other clinician-investigators, are Aserlind, 1984), person perception, vigilance, atten-
responsible for establishing the validity and utility of tional processes, self-presentation, and perception
their assessment systems. have yet to be consistently applied to problems of ob-
server training (Boice, 1983); this may be one reason
Final Observations that observer training has not substantially changed
over the course of 50 years. (See Cochrane & Sobol,
Our review of the observation literature prompts six 1976, for similar concerns about the entire behavior
concluding observations on apparent trends. therapy field.)
First, direct behavior observation no longer appears A fourth issue involves the increasing availability of
to have the elevated status it once held. As Jacobson sophisticated observational technology. Compact key-
has stated (1985b), "we cannot assume that observa- board and data storage devices with easy access to
tional measures are superior to other types of measures computers for data processing and analysis are now
simply because they are observational" (p. 324). available and within many investigators price range
While observations continue to be the preferred source (see section on "Technological Aids"). Even though
of behavioral assessment data, they, like other sources these developments simplify the work of observers and
allow more complex and molecular analyses ofbehav- ACKNOWLEDGMENTS. Special thanks for technical as-
ioral phenomena, potential problems with such tech- sistance to Gene Izatt, Maureen McKee, Renee Ortiz,
nologies are apparent (e.g., Simpson, 1979; Sykes, and Sandy Sommer.
1977). The use of these devices will require caution by
investigators to ensure that they do not lose contact
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CHAPTER 7
Behavioral Neuropsychology
Gerald Goldstein
Introduction management, and related procedures, show promise of

being effective in the remediation of behavioral defi-
The tenn behavioral neuropsychology may appear to cits and disorders commonly associated with structural
be a tautology because neuropsychology itself is the brain damage. That belief represents a distinct position
discipline that has to do with relationships between the within neuropsychology because, as in other areas of
nervous system and behavior. However, in recent psychology, at least some remnants of the old
years, the tenn has been generally understood as hav- "schools" persist, and not every neuropsychologist is
ing to do with the interdisciplinary relationship that has an advocate of behaviorism. However, the differences
been established by neuropsychologists and behavior in actual practice are not as clear-cut as would be the
therapists. Some years ago, Horton (1979) defined the case for functional disorders, probably largely because
field as follows: the field of brain damage rehabilitation has not yet
reached the stage at which there are clearly established
Essentially, Behavioral Neuropsychology may be defined as the remediation techniques for various disorders. It is
application of Behavior Therapy techniques to problems of
organically impaired individuals while using a neuropsycholo-
therefore sometimes difficult to detennine whether a
gical assessment and intervention perspective. (p. 20) particular method of brain damage rehabilitation is
"behaviorally" oriented or not. However, as in other
Clearly, the emphasis of the field is on the re- areas of application, the behavioral neuropsycholo-
habilitative aspects of neuropsychology rather than on gists would tend to be oriented toward modification of
its basic science or assessment components. Within specific behaviors, whereas others in the field would
the circle of those interested in the rehabilitative as- be more inclined to attempt to restore generic abilities
pects of neuropsychology, the behavioral neuropsy- that would be applied, it is hoped, to specific behav-
chologists are ideologically aligned with behaviorism iors. The debate involving specific versus generic re-
rather than with other epistemologies associated with mediation has been an active one in the field of cog-
psychology in general (i.e., specifically with re- nitive rehabilitation (Goldstein, 1987).
habilitation of brain damaged patients). Initially, it was assumed that the aftereffects of brain
Behavioral neuropsychologists believe that behav- damage were irreversible because central nervous sys-
ior therapy techniques, such as modeling, contingency tem tissue does not regenerate. Treatment of brain-
damaged patients was viewed, therefore, primarily as
a management issue in which emphasis was placed on
Gerald Goldstein • Veterans Administration Medical Cen- environmental supports, reduction of demand, and
ter, Pittsburgh. Pennsylvania 15206. various efforts to minimize secondary consequences of
139
brain damage, such as contractures and decubitus ul- training should help the patient with skills needed in
cers. Thus, great emphasis was placed on nursing care everyday life, such as reading or using instruments.
and physical therapy. Observation of brain-damaged Perhaps this trend developed because neuropsycholo-
patients following hospitalization frequently indicated gists tend to think in terms of functional constructs,
that these patients were unable to return to their pre- such as memory and language, rather than of specific
vious employment or could not complete their educa- behaviors, such as shopping or driving a car. Were that
tion successfully. Rehabilitation was frequently suc- not the case, the trend in rehabilitation might have been
cessful in restoring use of impaired limbs or sensory toward such specific behaviors. Neuropsychologists
function, and in maintaining the patient outside of an would be training patients in driving or shopping or
institutional setting; however, full return to premorbid other specific tasks. That is, the training would be
function was a rare exception. It was recognized that much more content-oriented than it is at present. In
these patients not only often had physical difficulties, recent years, efforts have been made to make formal
such as partial paralysis or blindness, but cognitive training more "practical," but the nature of the train-
difficulties as well, including impairment of language, ing itself has still remained relatively formal.
previously acquired academic skills, motor skills, ca- Content-oriented approaches have become in-
pacity to attend and remember, and spatial orientation. creasingly attractive in recent years because of the
The impairment of language that sometimes occurs, common finding that generic neuropsychological re-
called aphasia, was recognized since the nineteenth habilitation frequently did not generalize to activities
century at least, but other cognitive deficits were spe- of daily living. It has become apparent that improve-
cifically identified far more recently. The observation ment in memory, for example, can readily be achieved
that people do not appear to be as intelligent or alert in laboratory or clinical settings, but that achievement
after brain damage as they were premorbid no doubt does not appear to generalize well to everyday life
goes back to antiquity, but specification of the actual situations in which problems with remembering
changes remains an area of active research. emerge. Indeed, some of the earlier attempts at "cog-
There is no question that, in many cases, the conse- nitive rehabilitation" seemed like little more than tra-
quences of brain damage are permanent and devastat- ditional experimental psychology laboratory studies in
ing. In some cases, they are also progressive, and there memory and learning. Other efforts might have been
is no known way of arresting that progression. Disor- characterized as teaching the patient to pass some psy-
ders such as Alzheimer's and Huntington's disease are chological test. This generic form of retraining may be
of that type. Nevertheless, there is frequently spon- placed in contrast with efforts of behavior therapists to
taneous recovery from some types of brain damage, teach basic skills, such as eating, toileting, appropriate
such as stroke, and certainly not all forms of brain social behavior and such practical matters as handling
damage are progressive. Thus, many brain-damaged money or grooming, to psychiatric and mentally re-
patients live long lives after they sustain their original tarded patients (Hersen & Bellack, 1978). Treatment
insult, and the clinical problem becomes one of mak- successes in these matters led to the question of
ing their lives as functional and productive as possible. whether or not these techniques would be effective
Thus, the field of rehabilitation becomes a matter of with brain-damaged patients. There is a growing liter-
optimizing spontaneous recovery, capitalizing on re- ature providing reports of successful applications of
sidual capacities, and finding ways of compensating behavior therapy methods to brain-damaged patients
for capacities that are permanently lost. (Goldstein & Ruthven, 1983; Horton & Sautter, 1986),
The goals of neuropsychologically oriented cog- and reviewers of this literature have indicated that there
nitive rehabilitation have traditionally been posed in are reasons for optimism.
terms of restoration of functions rather than of specific In effect, there are two forms of application of be-
behaviors. Thus, methods employed were designed to havior therapy techniques to brain-damaged patients.
improve memory, visual perception, or motor skills in One of them involves the more-or-less direct applica-
a general sense. It was hoped that these formal training tion of established techniques. An example would be a
procedures would generalize to relevant activities of study by Sellick and Peck (1981), who used a flooding
daily living. Thus, memory training should help the procedure to treat fear in a child with cerebral palsy.
patient in keeping appointments or remembering a list Brain-damaged patients may develop phobias, depres-
of items to be purchased, whereas perceptual or motor sion, habit disorders, and essentially all of the behav-
CHAPTER 7 • BEHAVIORAL NEUROPSYCHOLOGY 141
ioral disorders that afflict nonbrain-damaged indi- are examined and manipulations are made to optimize
viduals. The question is whether or not standard functioning of impaired individuals. Goldstein et at.
application of established techniques for these various (1985) used a multiple-baseline design to evaluate the
conditions are directly applicable to brain-damaged teaching of severely amnesic patients a limited set of
patients. Will they respond well to social skills train- items, such as the names of significant people that
ing, desensitization, modeling, and the like? We sug- were felt to be of importance for adaptive functioning.
gested earlier (Goldstein, 1979) that behavior thera- This study also demonstrated the utility of simple
pists and neuropsychologists could form a productive learning by repetition, even in the absence of specified
alliance around the interface of rehabilitation. In the reinforcers, in achieving meaningful rehabilitation
case of this direct application of behavioral therapies, goals. There are numerous other examples in the liter-
the neuropsychologist may be helpful with regard to ature that would support the conclusion that behavioral
specifying the perceptual or cognitive limitations the techniques can achieve usually modest, but often
patient has that may compromise treatment outcome, clinically significant goals with regard to remediation
and may also be able to recommend optimal stimulus of neuropsychological deficits.
and response modalities.
The second interface between behavior therapy and
neuropsychology has to do with the application of be- The Problem of Generalization
haviorally oriented treatment to the direct conse-
quences of brain damage themselves. There have been Although the term generalization is used in many
several attempts to use such methods directly in the ways in psychology, what is usually meant by it in the
treatment of rehabilitation of language, memory, per- field of rehabilitation has to do with the extent to which
ceptual, conceptual, and other disorders of the type the training received in the clinic or laboratory is ap-
that commonly result from the acquisition of structural plied to everyday life situations. As Seron (1987) has
brain damage. In these cases, the neuropsychologist, suggested, transfer of training demonstrated in the
through application of appropriate testing, describes clinic or laboratory may not transfer to everyday life.
the pattern and severity of deficits, whereas the behav- Perhaps the major issue in the field of cognitive re-
ior therapist, utilizing the repertoire of available inter- habilitation has to do with whether the many newly
vention methods, designs, implements, and monitors a developed computer-assisted training programs actu-
treatment program. An early example of this interac- ally improve the capacity of brain-damaged patients to
tion may be found in the efforts made by speech-lan- function in their natural environments. Demonstration
guage therapists to apply operant methods to the treat- of efficacy in the laboratory or clinic, or even demon-
ment of aphasia (Holland, 1969, 1970). At the time of stration of transfer in those settings, may not guarantee
this work, the "teaching machines" or programmed transfer to real life. For example, it is unclear that the
instruction methods inspired by B. F. Skinner and col- many recently developed computer-assisted methods
laborators were in vogue, and procedures were devised of memory training actually help patients in learning
such that aphasic patients could use these devices and new information.
programs in their treatment (Holland & Levy, 1969; Possibly a unique problem in the reeducation of
Naeser, 1975). Since that time, efforts have been made brain-damaged patients is that successful learning of
to apply research designs developed within a behavior specific materials may have little or no implications for
therapy framework, such as the multiple-baseline de- other related materials. Thus, agrammatic aphasics
sign, as well as specific methods, such as operant con- may learn to say drilled sentences, but that learning
ditioning, to remediation of various neuropsycholo- does not appear to help much with undrilled sentences
gical deficits. (Helm-Estabrooks, Fitzpatrick, & Barresi, 1981).
A representative example of this research is the Amnesics may learn one set of items to criterion, but
study reported by Diller and Gordon (1981), in which that learning does not seem to increase the efficiency
wives were trained to be behaviorally oriented "speech with which a similar set of items is subsequently
therapists" for purposes of helping their aphasic hus- learned (Goldstein et at., 1985). It would appear that
bands reacquire certain language skills. This method the cognitive structures these patients retain, while
was described as representing an engineering model of supporting new learning, may not support generaliza-
rehabilitation in which environmental contingencies tion of the lessons learned from that learning to new
materials and situations. This phenomenon creates rate on prosthetic approaches to rehabilitation here,
major difficulties for clinic- or laboratory-based train- but would point out that in such approaches, gener-
ing of brain-damaged patients, since apparent suc- alization would appear to be "built-in" as long as the
cesses within the confines of those settings may be of patient is in the presence of the prosthetic. A poten-
no major therapeutic consequence. tially useful application of behavior therapy in this
The state of the art in neuropsychological rehabilita- regard has to do with teaching patients to accept and
tion still reflects major problems with the generaliza- use prosthetics. It is well understood that prosthetics
tion matter. However, there have been several efforts for physical disabilities are sometimes rejected by pa-
made to deal with it that warrant discussion. One meth- tients, despite the fact that they do their intended jobs
od involves development of a transition between the effectively. In the case of external memory aids, more
therapist and the caretaker, such that the caretaker severely amnesic patients forget to use the aids them-
learns the therapeutic technique and continues to use it selves, and some preliminary training is often neces-
in the community. The example cited above of teach- sary to teach the patient to remember to use the device.
ing wives to be therapists for their aphasic husbands is Often, neuropsychological assessment can be help-
a good one (Diller et al., 1974). The wives were pro- ful in determining whether an educational or prosthetic
vided with earphones during therapy sessions so that strategy should be employed with a particular patient.
they could be coached to give feedback regarding the For example, in the case of Korsakoff's syndrome, a
adequacy of communications. They were also taught severe, neurologically irreversible form of amnesia, a
reinforcement principles to reward adequate commu- prosthetic strategy would appear to be particularly ap-
nication. In the case of severely aphasic patients, res- propriate, since even very limited restoration of mem-
toration of normal language is not feasible, and a rea- ory through formal training is not likely to occur. We
sonable solution would appear to be to teach the patient are not suggesting that Korsakoff patients are entirely
an artificial, nonverbal language, usually through the incapable of new learning. The literature on this disor-
use of pictures of objects or forms (Gardner, Zurif, der indicate that they are, in fact capable of certain
Berry, & Baker, 1976). The difficulty with this ap- types of learning (Cohen & Squire, 1980). What we
proach is that though that language may be effectively are indicating is that the established methods of memo-
taught to patients, people in the environment do not ry training in which strategies such as chunking, use of
understand it. The solution appears to be to teach the visual imagery, and chaining are productively used by
language to the families and acquaintances of patients normal individuals (and perhaps people with milder
so that they may communicate with each other. The forms of memory loss) are not likely to be effective
approach is quite similar to teaching sign language to with patients that suffer the severity of memory loss we
acquaintances of the deaf. typically see in Korsakoff's syndrome. However, cer-
The problem of generalization may be associated tain aspects of preserved function in these patients,
with an implicit or explicit educational model of cog- such as relatively intact language and general intel-
nitive rehabilitation. Educators generally wonder ligence, as well as their spared memory capacities,
about whether what is learned in the classroom will be may suggest that a prosthetic approach could be pro-
used in the outside world. With regard to working with ductive. Similarly, children with certain very profound
brain-damaged patients, there is certainly the hope that basic language deficits, such as the incapacity to make
carefully planned programs that take into cognizance grapheme to phoneme transformations, would not be
the nature of the deficits and residual abilities associ- ideal candidates for traditional remedial reading ap-
ated with the type of brain damage involved will lead to proaches, and might gain more benefit from a compre-
significant restoration of function. However, despite hensive rehabilitation program that bypasses reading
our best efforts, certain functions do not return, or do as an important issue.
so to only a very limited extent. In these cases, it is Ideally, cognitive retraining provided to patients in
often useful to think in terms of prosthetic approaches clinical settings should be of assistance to them in
in which the environment takes over some of the func- adapting to their environments after suffering from
tions normally carried out by the person. We are al- brain damage. Apparent success in such treatment can
ready hearing a great deal about prosthetic or external clearly not be taken to mean that what was learned will
memory aids (Harris, 1978) and about "smart" tech- be used productively. It would probably be fair to say
nologies in the designs of homes for physically and that, in general, neuropsychological rehabilitation re-
cognitively impaired individuals. We will not elabo- search has not yet succeeded in finding methods that
assure this kind of transfer. However, the view that the Spevack, 1980; Webster & Scott, 1983), and comput-
problem is with the training methods themselves may erized training methods have been devised for re-
not be entirely correct, since the pattern of what abili- mediation of attentional deficits (Bracy, 1982; Sand-
ties individual patients have preserved and perma- ford & Browne, 1987). However, probably the most
nently impaired varies greatly, and the phenomenon of comprehensive system currently available is described
improvement in treatment without generalization may in a chapter by Ben-Yishay, Piasetsky, and Rattok
relate substantially to the patient's neuropsychological (1987). These investigators developed a system called
profile. Thus, a proposed solution to the generalization the "Orientation Rehabilitation Module (ORM)," con-
problem might involve a continuity of treatment, rang- sisting of five procedures for retraining of attention at
ing from purely educational to purely prosthetic in varying levels of complexity. Beginning with dealing
nature. In such a scheme, the environment gradually with basic wakefulness, the system progresses to those
takes over all or portions of the responsibility for gen- areas in which attention merges into the higher cortical
eralization. In an earlier era of behavior therapy, it was functions. The most basic element of the system in-
suggested that rather than lament the absence of gener- volves training in visual reaction time, while the most
alization, it is more productive to build it into the de- advanced element involves having the patient listen to
sign of the treatment. In neuropsychology, it can be rhythmic patterns formed by tone sequences and re-
said that we hoped for generalization following gener- produce those patterns by pressing a telegraph key in
ic treatment, but may not have been actively involved the proper pattern. Utilizing a sample of 40 head-in-
in assuring it. Our suggestion in that regard is that jured patients in a rehabilitation program, it was found
treatment need not be terminated at the door of the that training was associated with significant improve-
clinic, but should pursue the patient into the communi- ment on posttesting with all of the five tasks. Actually,
ty with the support of prosthetic technology as it be- the posttesting mean scores were all within normal
comes available. limits. Generalization was also considered and was
studied by means of clinical observation and examina-
tion for improvement on psychometric tests of atten-
Specific Problem Areas tion. Significant posttraining improvement was found
on a visual reaction time task, a picture description
task, and the Wechsler Adult Intelligence Scale
The Problem of Attention
(WAlS) Digit Span and Picture Completion subtests. It
The remediation of attention deficits in brain- was also found that training effects were stable at a 6-
damaged patients, particularly those suffering from the month follow-up.
effects of traumatic head injury, can be viewed as a These results would suggest that there is some hope
precursor to other forms of remediation, because any for significant amelioration of attention deficits in
form of productive interaction with the environment head-injured patients. Application of the ORM in
would appear to be predicated upon the presence of a other settings may aid in confirming the Ben-Yishay
reasonable level of alertness and ability to focus on group's initially positive findings, perhaps resulting in
objects of interest. Patients with various forms of brain a useful procedure for remediation of attentional
damage may develop basic disturbances of arousal, deficits.
such that they may often not be in a state of full
wakefulness. They may fluctuate in level of attention
Memory Training
and may be unusually distractible. Sustained con-
centration is often impaired, limiting the capacity to Impairment of memory is probably the most com-
complete tasks that require extended effort over time. mon symptom resulting from brain damage. Some-
Because slowness of thought, or speed of information times the problem is transitory and self-resolving, as in
processing, is an extremely common phenomenon, the case of posttraumatic amnesia, but sometimes it is
there have been several major studies of reaction time persistent. The prospects of restoring some degree of
in head-injured patients (Levin, Benton, & Grossman, memory function to brain-damaged patients has been
1982; Van Zomeren, 1981). Having documented these widely discussed and studied. In planning of memory
phenomena, the question has been raised concerning training programs for brain-damaged patients, it is first
their remediation with behavioral methods. Several of all important to note that there are many forms of
case studies have been reported (Gerber, Richard, & memory disorder, and that programs appropriate for
one form may not be suitable for others (Butters, preservation oflanguage, motor skills, and other over-
1984). In the field of aphasia, it is generally taken for learned materials in Korsakoff patients. Goldstein et
granted that there should be specific treatments for al. (1985), using this distinction as a conceptual ra-
various forms of the disorder, since the language defi- tionale, were able to teach Korsakoff patients sets of
cits seen in aphasia may be remarkably different from items (using a repetitive drill procedure), such as
each other. Thus, there are treatments for agram- names of people or locations, which were retained for
matism, global aphasia, Broca's aphasia, and so forth lengthy periods of time. The learning of the items did
(Albert, Goodglass, Helm, Rubens, & Alexander, not generalize to new material, nor did these patients
1981). However, development of a nosology for am- benefit from conventional memory training in which
nesia has only occurred recently (Butters & Cermak, visual imagery mnemonics were used. Thus, memory
1980), and the treatment implications of that develop- training for Korsakoff patients realistically seems lim-
ment have barely begun to be realized. Without going ited to the teaching of specific items of information.
into detail here, it is important to note that certain However, prosthetic memory approaches that have not
amnesic patients, notably those with Korsakoff's syn- been explored yet may prove to be helpful.
drome, have extremely severe amnesias that are not Head-injured patients with persistent amnesia show
reversible. The amnesia is generally so severe in these more promise of being able to benefit from more ad-
individuals that they are disoriented, and usually can- vanced forms of training, resembling the training nor-
not provide accurate descriptions of their personal cir- mal individuals may take to improve their memories.
cumstances, their age, or their location. Head-injury Many of these procedures are described in Wilson
patients, on the other hand, are often not that severely (1986) and Wilson and Moffat (1984). Such tech-
impaired, and may only have more than normal diffi- niques as the peg method, the method of loci, chain-
culty in recalling recent events or in learning new infor- ing, verbal elaboration, and visual-imagery-based
mation. Patients with stroke or other forms of uni- methods have been described in the literature, and
lateral brain damage may experience a so-called many of them have been tried out with head-injured
modality specific memory deficit, in which only mem- patients. There seems little question that they may be
ory functions mediated by the affected hemisphere are used to improve memory in the clinic or laboratory,
impaired. Thus, damage to the left hemisphere would but, as indicated above, documentation of generaliza-
be associated with impaired verbal relative to nonver- tion to real life has not yet been well established. On
bal memory, while the reverse would be true for the other hand, these methods do work in the clinic or
the right hemisphere. Memory disorders associated laboratory with amnesic head-injured patients, but not
with cerebral infections, Huntington's disease, and with Korsakoff patients. Goldstein et al. (1988) re-
Alzheimer's disease also each have unique character- cently demonstrated that head-injured patients, util-
istics. izing a ridiculously imaged story technique originally
To briefly summarize a great deal of work, memory studied with amnesic patients by Kovner, Mattis, and
training for Korsakoff's syndrome patients typically Goldmeier (1983), improved their capacity for free
exploits a memory system that appears to be relatively recall of lengthy lists of words, with improvement oc-
well preserved in these patients. The system is gener- curring over training sessions even when the lists were
ally defined as procedural memory, which is dis- changed. Thus, there appeared to be generalization to
tinguished from declarative memory. The distinction is new items within the context of the training itself.
similar to the one between semantic and episodic Studies of this type demonstrate that head-injured pa-
memory, but differs in some details. It has been noted tients with significant memory problems can learn
that Korsakoff patients may be capable of learning new mnemonic strategies that they can apply to the learning
skills, or procedures, but without awareness on their of new material. The next steps would appear to be to
part that such learning has taken place. Thus, incre- determine the extent to which they apply what they
mental learning can be documented over trials, while have learned in everyday life, and to develop support
the patient may claim complete unfamiliarity with the systems that promote that application.
situation in which the material is being learned. The The most commonly discussed approach to patients
new learning is thought to be mediated by the pro- with modality-specific memory disorders involves use
cedural memory system, in the virtual absence of a of the intact modalities in training. The widely cited
declarative memory system. It is apparently the pro- study by Gasparrini and Satz (1979) provided an ex-
cedural or semantic memory system that allows for plicit application of this idea. Patients with left hemi-
sphere stroke were provided with memory training Doyle, Goldstein, and Bourgeois (1987) involving
based on a "right hemisphere" strategy utilizing visual syntax training, maintenance was evaluated with ex-
imagery and a "left hemisphere" strategy using verbal emplars of a common sentence form, such as de-
elaboration. The "right hemisphere" strategy was clarative transitive (e.g., "He plays baseball "). Gener-
more effective, ostensibly because it exploited the rel- alization was evaluated by probing with different
atively intact capacity of the right hemisphere to pro- sentence types (e.g., passive, "The class was can-
cess nonverbal information in the form of visual celled"). In this same study, the investigators also
images. looked at social validation of this training through hav-
In summary, different kinds of memory training ing blind judges rate the adequacy and accuracy of
have been formulated for patients with different kinds communications made by aphasic subjects before and
of amnesia. There is some evidence for specificity of after treatment.
these methods, since they do not seem to work when A second important trend in language therapy re-
they are inappropriately applied. The future of research has to do with the application of single-case
habilitation of memory for densely amnesic patients of research designs. The multiple-baseline design is often
the Korsakoff type would appear to lie in the develop- used since it avoids the difficulties that may be encoun-
ment of prosthetic technologies, whereas patients with tered with return to baseline-type designs. The debate
amnesia resulting from head injury or stroke may ben- continues as to the efficacy of therapy for aphasia,
efit from the development of increasingly sophisti- since following stroke or head injury there is often
cated strategy training methods that provide cognitive some degree of spontaneous recovery. Recent studies
supports for impaired memory abilities. utilizing clinically stable patients as well as group
studies involving samples of treated and untreated pa-
tients have tended to demonstrate that treatment may
Rehabilitation of Language
be efficacious independently of spontaneous recovery
An extended review of behavioral methods of lan- (Helm-Estabrooks & Holland, 1984). A third impor-
guage therapy has recently been provided by Seron tant trend appears to be a thrust in the direction of
(1987), and Kent-Udolf (1984) wrote a review cover- focusing treatment on functional communication as
ing assessment and treatment of communication disor- opposed to the formal specifics of the aphasia (Davis &
ders resulting from traumatic brain injury. We will not Wilcox, 1981; Holland, 1978). Encouraging the pa-
repeat that material here, but rather will briefly review tient to communicate adequately by whatever means,
some major issues. First, it is important to note that rather than resolving the specific aphasic deficits, has
efforts to develop new treatments for aphasia are con- become a significant emphasis in treatment.
tinuing to be actively made, as are attempts to demon-
strate the efficacy of those methods (Helm-Estabrooks
Treatment of Behavioral Difficulties
& Holland, 1984). lYpically, the new treatments being
Associated with Brain Damage
developed are quite specific and relate to a variety of
aspects of language, such as grammar, word finding, It has been recognized for some time that one of the
reading, writing, and auditory comprehension (Albert more significant effects of brain damage is major per-
et al., 1981). Behavioral methods continue to be used sonality change. The Diagnostic and Statistical Man-
by many investigators, but, as we read the literature, ual of Mental Disorders (DSM-III-R) (American Psy-
there appears to have been a diminution of interest in chiatric Association, 1987) lists the diagnoses of
programmed instruction. As in the case of memory organic delusional, mood, anxiety, and personality
training, there is increasing interest in generalization disorders. In order to make these diagnoses, there has
of treatment accomplished in clinical settings to every- to be evidence of a specific, etiologically related
day life. An important distinction is often made be- organic factor. Aside from these separate disorders,
tween maintenance and generalization. Maintenance there are other major adjustment problems associated
may be evaluated by probes made following comple- with sustaining brain damage. Loss of self-esteem,
tion of a component of treatment. The probes may be depression, and impaired motivation are common.
different in content from what was used in the treat- There also are behavioral changes that may be more
ment, but must belong to the same response class. directly associated with the brain damage itself. Disin-
Generalization is evaluated with probes that involve hibition, apathy, impaired modulation of affect, and
different response classes. fur example, in a study by inappropriate affect are examples.
146 PART U • ASSESSMENT AND RESEARCH
Application of behavioral methods to treatment of of inappropriate behavior, but only in the context of
these disorders has become a major component of having to perform a perceptual-motor task in a shel-
treatment at several rehabilitation centers. The major tered workshop. The patient had right hemisphere
focus has been on head injury, but patients with other brain damage, and the task turned out to be one that
disorders may receive such treatment as well. Perhaps required relatively intact function in his area of great-
the major formulations of this area of treatment have est weakness. Had he received a more suitable assign-
been accomplished by Ben-Yishay and Diller (1983) ment, the inappropriate behavior may never have
and Prigatano (1987). In Ben-Yishay's head-injury reemerged.
habilitation program, there has been extensive empha-
sis on support 'groups and maintenance of motivation
The Problem of Learning Disability in Adults
by staff and family. Social skills training of various
types is frequently employed, as are contingency man- The study of brain-behavior relationships in learn-
agement programs for specific behaviors (Goldstein & ing disability has become a major subspecialty of
Ruthven, 1983). Prigatano (1987) has suggested that clinical neuropsychology (Gaddes, 1985; Rourke,
the most common disturbances following brain 1985). The major emphasis of this research has been
damage are anxiety and the catastrophic reaction, de- on school children, with a major practical application
nial of illness (anosognosia), paranoia, psychomotor of the research being that of recommending interven-
agitation, and depression. He indicates that these con- tion strategies based upon neuropsychological assess-
ditions are potentially treatable through cautious ap- ment results to special education teachers. There has
plication of psychopharmacological agents and psy- been major interest in defining subtypes of learning
chotherapy involving, where possible, both the patient disability and formulating different kinds of remedia-
and the family. tion for the different sUbtypes. There are several exten-
We would view as a major problem in this area the sive reviews of this literature (Gaddes, 1985; Hynd,
matter of whether and to what extent established be- Obrzut, Hayes, & Becker, 1986; Rourke, 1985), and
havior therapy techniques can be applied to the brain- we will not comment extensively on it here. The point
damaged population. As indicated above, there have we wish to emphasize as representing a recent devel-
been numerous instances in which the single-case de- opment is that it now seems apparent that learning
sign has been used to evaluate the efficacy of cognitive disability is not always outgrown. Indeed, it may per-
rehabilitation (Webster, McCaffrey, & Scott, 1986), sist far into adulthood. There is additional evidence
but there have been few examples of the success of that several of the SUbtypes identified in children also
these methods for treating social, motivational, and persist into adulthood (McCue, Goldstein, Shelly, &
emotional disorders. However, there have been some Katz, 1986; Spreen & Haaf, 1986). In recent years, the
studies: for example, Cincirpini, Epstein, and Ko- U.S. Rehabilitation Services Administration has rec-
tanchik (1980) treated self-stimulatory and attending ognized adult learning disability as a disorder of suffi-
behavior in a child with cerebral palsy, and Turner, cient severity to permit allocation of educational bene-
Hersen, and Bellack (1978) demonstrated the efficacy fits to people suffering from it.
of social skills training with a brain-damaged patient. The particular challenge to behavioral neuropsy-
Nevertheless, a great deal more needs to be known chology regarding learning-disabled adults has to do
about the usefulness of behavioral methods in treat- with the development of treatment and management
ment of the anxiety, agitation, denial, and depression plans. These people are typically no longer in school,
that frequently afflict brain-damaged patients, as well and so the availability of special education facilities is
as about the treatment of the loss of social behaviors highly limited. Furthermore, many of these indi-
these individuals often develop. Also, as has been viduals, if they had been identified as learning disabled
pointed out by Horton and Sautter (1986) and by Gold- during their school years, may have been in special
stein and Ruthven (1983), inappropriate behaviors education programs for lengthy periods of time. Most
may often be induced when brain-damaged patients often, they have difficulties in gaining or maintaining
are placed into situations that overtax their cognitive employment because of their limited academic skills.
capacities. Often, the neuropsychologist can provide We would suggest that a major challenge for behav-
important advice regarding the nature of such situa- ioral neuropsychology, in collaboration with members
tions. For example, Horton and Sautter (1986) briefly of the rehabilitation and educational disciplines, is the
reviewed the case of a patient who exhibited episodes development of viable programs for adult learning dis-
abled individuals. In planning such programs, it is evaluate the vocational impacts of those difficulties,
generally useful to think in tenns of remediation and and to propose appropriate compensations, accom-
accommodation. Remediation has to do with direct modations, and remediation strategies. For example,
efforts to correct the disability (e.g., remedial read- the poor reader may have difficulty in comprehending
ing), whereas accommodation refers to alterations written instructions. The vocational impacts would in-
made in the environment that assist people with dis- volve an inability to perfonn jobs that require action
abilities to function more adequately. The accom- based upon the reading of infonnation, or that require
modation concept is more widely understood in tenns following of written instructions. The suggested com-
of physical disability, and involves alterations, such as pensations and strategies include giving instructions
provision of wheelchair access, or adjusting work set- orally or by tape recorder, pairing the learning-dis-
tings so that they can be used by blind or deaf people. abled individual with a co-worker who reads nonnally,
In the case of learning disability, accommodation may or teaching a highly specific job-related vocabulary.
be seen in tenns of pennitting adequate functioning in The extent to which neuropsychologically based
the presence of stable academic-cognitive deficits. In cognitive rehabilitation methods are effective with
the case of the adult with learning disability, accom- learning-disabled adults has not yet been evaluated.
modation may be more appropriate than it would be in These methods are generally tailored to the various
the case of children. As indicated above, many learn- neuropsychological subtypes, adopting the general hy-
ing-disabled adults have achieved maximum benefit pothesis that the different subtypes will respond better
from remedial efforts accomplished in school, but are or worse to different treatment strategies (Lyon, 1985).
still handicapped from the points of view of advanced Pursuit of this area could provide productive methods
education and employment. Many learning-disabled for assisting learning-disabled adults.
individuals seek jobs that do not require much reading
or use of other academic skills. Often their situation
becomes problematic when they lose such jobs and Summary
must seek employment elsewhere.
It is not being suggested that remediation efforts The tenn behavioral neuropsychology is currently
should be abandoned once the learning-disabled indi- commonly understood to refer to coordinated efforts
vidual has reached adolescence. Indeed, several edu- made by behavior therapists and neuropsychologists.
cational methods have been developed specifically for It has a particular focus in the area of rehabilitation of
adolescent students. Some of them involve the teach- brain-damaged patients. Its advocates believe that
ing of learning strategies, such as the "Multipass" methods developed within the theoretical framework
method of Schumaker, Deshler, Alley, Warner, and of behaviorism and the clinical framework of behavior
Denton (1982). This method was designed to assist therapy may be highly appropriate for such rehabilita-
learning-disabled students in gaining infonnation from tion efforts when the application of the method chosen
textbook chapters through reviewing the material sev- is guided by the results of a neuropsychological assess-
eral times: once to get the main ideas, once to gain ment. The literature now contains numerous reports of
specific infonnation, and once for purposes of self- successful application of this approach to brain-
testing. Towle (1982) has proposed a similar scheme damaged patients.
that divides learning into the steps of processing infor- In this review, we considered the general problem of
mation, organizing, rehearsing, and recall/applica- generalization of clinic- or laboratory-based rehabilita-
tion. In effect, efforts have been made to structure tion training to everyday life, and noted that success in
study skill development such that learning-disabled in- meeting training criteria does not necessarily assure
dividuals can use such structures to improve classroom generalization. Suggestions were made to promote ap-
perfonnance. Accommodation efforts have used such plication of training through use of prosthetics and
means as extensive utilization of tape recording of instruction to caretakers. Brief summaries were also
lessons, elimination of time limits on examinations, offered of several major areas of cognitive rehabilita-
more than usual repetition and rephrasing, and what tion, including remediation of deficits in the areas of
has been characterized as reasonable modifications of attention, memory, language, affect, and social behav-
academic requirements. Recently, Dowdy (1987) has ior, and adult-learning disability. Although the sub-
made an extensive effort to characterize difficulties stantive contribution of this aspect of neuropsychology
often encountered by learning-disabled individuals, to has not yet led to the establishment of any definitive
treatments, the field nevertheless appears to continue problems in left hemisphere CVA patients. Journal ofClinical
to show promise. Neuropsychology, 1, 137-150.
Gerber, G., Rivard, C., & Spevack, M. (1980, December). In-
creasing compliance and attention in a severely brain
damaged patient using behavioral intervention. Paper pre-
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CHAPTERS
Experimental Design in Group

Outcome Research
Billy A. Barrios
Introduction examination of the component questions have been

proposed. Three such schemes are presented in the text
Behavior modification research has been and con- that follows.
tinues to be the search for the answer to the question, In Paul's (1969) blueprint for behavior modification
"What treatment, by whom, is most effective for this research, within-and between-subjects' strategies are
individual with that specific problem, under which'set arranged according to the level of product they yield.
of circumstances?" (Paul, 1967, p. 111). It is a ques- That is, they are organized according to the tenability
tion within which numerous questions are embedded; and generality of the causal inferences they allow for.
thus, the search is not for one answer but for numerous Case studies-a specific within-group strategy-and
answers. And the search is a continuous process in single-group studies-a specific between-subjects'
which the answering of a specific question alters the strategy-are seen as yielding low-level products.
nature of said question and all subsequent questions; That is, they are seen as allowing for causal inferences
consequently, the answering of a question is never pre- of only questionable credibility and generality. Incapa-
cise but always provisional. ble of establishing cause-and-effect relationships, case
The first step in the ongoing attempt to address the studies and single-group studies are, however, quite
above-cited, complex question has been to carve the capable of identifying possible cause-and-effect rela-
question with respect to type of problem. Having done tionships. Thus, they are seen as useful in the genera-
so, the next step has been to cast and classify questions tion and formulation of hypotheses about the
along the dimensions of clients, techniques, thera- efficacious treatment of the particular problem of in-
pists, and settings. And having done so, the third step terest. And as such, they constitute the first step in
has been to address each of the component questions determining which treatment is most effective for the
by means of a within-subject strategy or between-sub- problem of interest among the populations of interest
jects strategy or some combination of the two (e.g., under the conditions of interest. Single-case experi-
Barlow & Hersen, 1984; Kazdin, 1980, 1982; Kra- mental studies-a specific within-subject strategy-
tochwill, 1978; Mahoney, 1978). Several schemes for and control-group studies-a specific between-sub-
the orderly use of these three strategies in the orderly ject strategy-are both viewed as yielding high-level
products. Thus, they serve as the second step in the
BiUy A. Barrios • Department of Psychology, University of research scheme, rigorously testing the merits of our
Mississippi, University, Mississippi 38677. hypotheses and firmly establishing the cause-and-ef-
151
fect relationships that do exist. Comparative factorial ascertained. All three types of studies may take the
studies-another specific between-subjects' strat- form of either single-case experiments or group ex-
egy-also yield high-level products. Serving as the periments. Such studies are then followed by field tests
third step in this research scheme, these studies help to comparing the effectiveness of laboratory-proven
specify the mechanisms of therapeutic change, the treatments-tests which like their predecessors may
generality of therapeutic change, and the parity or dis- take the form of either a series of single-case experi-
parity in therapeutic change produced by different ments or a series of group experiments.
treatments. Although separated by several years, the three
A similar intermingling of within- and between-sub- schemes just summarized are strikingly similar. All
jects' strategies is present in Agras and Berkowitz's put forth a similar sequence of research activities that
(1980) model of behavior modification research. First, both emanate and culminate in the clinical setting. All
promising treatments are generated from exploratory advocate a similar intermixture of within- and be-
investigations, which may take the form of either case tween-subjects' strategies in the pursuit of those ac-
studies or single-group studies. Second, short-term tivities. And all assign between-subjects' strategies a
outcome studies of the form of either single-case ex- similar role in the answering of the question, "What
periments or control-group experiments are carried out treatment, by whom, is most effective for this indi-
to determine the effectiveness of these promising treat- vidual with that specific problem, under which set of
ments. Third, short-term comparative outcome studies circumstances?" (Paul, 1967, p. 111). The present
of the form of either between-group experiments or chapter looks closely at the unique place between-sub-
factorial experiments are conducted to delineate the jects' or group strategies occupy in behavior modifica-
parameters of the treatments' effects. Fourth, long- tion research. Specifically, the chapter discusses the
term outcome studies of the form of control-group ex- aims, assumptions, and applications of group strat-
periments are undertaken to ascertain the permanence egies in behavior modification research. It also touches
of the treatments' effects. And finally, field tests of the upon the objections and obstacles to the use of such
form of either case studies or single-case experiments strategies in behavior modification research. And, in
are performed to find out the generality of the treat- conclusion, the chapter offers several simple proposals
ments' effects to the clinical setting. for the systematic use of group strategies in the system-
In Kazdin's (1987) outline for behavior modifica- atic development of the practice of behavior
tion research, the progression is from global questions modification.
requiring few controls and comparison conditions to
specific questions requiring stringent controls and sev-
eral comparison conditions. The sequence begins with Aims
treatment package studies that evaluate the effects of
treatments as they are typically used. The treatments The aims of group research strategies are many.
themselves are developed from uncontrolled case re- Simply stated, they are to aid in the identification and
ports; the expectations that the treatments may be ef- establishment of a therapeutic effect, to aid in the iden-
fective are derived from case reports or single-group tification and establishment of the agent of said thera-
reports; and the effectiveness of these treatments is peutic effect, to aid in the identification and establish-
determined through either single-case experiments or ment of the generality of said therapeutic effect, to aid
control-group experiments. Upon finding treatments in the identification and establishment of the relative
to be effective, the next agenda is to identify the treat- effects of different therapeutic agents, and to aid in the
ments' active ingredients and optimum instigation. identification and establishment of the generality of
This is done through dismantling, constructive, and their relative effectiveness. In essence, group strat-
parametric studies. In dismantling studies, treatments egies are looked upon for assistance in drawing in-
are broken down into their component parts, and the ferences about therapeutic effects-inferences about
effects of these component parts are examined in isola- their actuality, causality, and generality (e.g., Beck,
tion and in combination. In constructive studies, treat- Andrasik, & Arena, 1984). From such inferences, we
ments are built up by the adding of components until look to build a set of empirical guidelines for treatment
optimum complexity and efficacy are achieved. And in selection. The soundness of such a set of guidelines
parametric studies, treatments are varied along dimen- will, of course, be dependent upon the soundness of
sior:s of administration until maximum efficiency is the inferences on which the set is based. Thus, in our
CHAPTER 8 • EXPERIMENTAL DESIGN 153
research pursuits in behavior modification, we look to 1977). In viewing subjects as replicas of one another,
group strategies for assistance in the drawing of tena- group strategies provide for efficient replication of pur-
ble inferences about therapeutic effects. ported cause-and-effect relationships; thus, they con-
tribute greatly to the establishment of causal rela-
tionships for therapeutic effects.
Assumptions To be sure, no two subjects are ever exact copies of
each other along all possible dimensions. To assume
Although the aims of group strategies are many, the such an equivalence would be restrictive and
assumptions are few. All, however, are quite critical to ridiculous. In group strategies, the assumption is only
proper and profitable use of group strategies. The first that subjects are equivalent along all relevant dimen-
of these assumptions is that the subjects serve as an sions. What the relevant dimensions are is at this time
adequate representative of the population of interest. largely a matter of what researchers say they are. And
Whether or not the subjects do so is determined by a since at this time researchers are not in complete agree-
logical appraisal of the methods of subject selection, ment on the list of all relevant dimensions, we cannot
the characteristics of the subjects selected, and the state all of the specific characteristics across which
match between the characteristics of the subjects se- subjects are assumed to be homogeneous. However,
lected and the characteristics of the population of in- we can state some of them, for there is strong consen-
terest. Also entering into this logical appraisal of the sus on what some of the critical dimensions are. Fore-
adequacy of the subject sample are two types of cir- most among them are those pertaining to the problem
cumstantial evidence: (1) the correspondence between condition-the symptom profile and the severity of
the characteristics of the present subject sample and the symptoms. In the later section on assessment, we
those of previous subject samples of presumably thr discuss in detail the issues involved in certifying and
same population of interest, and (2) the responsiveness verifying equivalence among subjects with respect to
of subjects to presumably an active treatment. From the problem condition of interest.
such a rational appraisal comes a judgment of the ade- The final assumption of group strategies is that of
quacy with which the subject sample represents the independence among the subjects. Here we are claim-
population of interest-a judgment which is rendered ing that the behavior of anyone subject does not influ-
not in terms of absolutes but in terms of degree. ence the behavior of any other subject in the study. To
This assumption of the adequacy of the subject sam- have a situation in which the behavior of anyone sub-
ple is pivotal to the adequacy with which the aims of ject influences the behavior of any other subject is
group strategies are achieved. Recall that the ultimate tantamount to subjects not serving as replicas of the
aim of group strategies is to assist in the formation of a effects of treatment. For when the behavior of a subject
set of empirical guidelines for treatment selection. Al- is affected by the behavior of another subject, those
though general in nature, these guidelines are derived effects are intermixed with the effects of treatment.
from the use of particular group strategies with particu- The posttreatment behavior of the former is a reflection
lar persons, and are then used to direct us in the selec- of the joint influence of treatment and another subject,
tion of a particular treatment for a particular person. whereas the posttreatment behavior of the latter is a
The sureness of this extrapolation from the particular reflection of only the influence of treatment. These
to the general and prescription from the general to the subjects, therefore, cannot legitimately serve as rep-
particular hinges upon the sureness of the sample as a licas of one another of the effects of treatment. This
representative of the population and, thus, the impor- also means that group strategies cannot efficiently as-
tance of the assumption of the adequacy of the subject sist in the identification and establishment of causal
sample. relationships regarding the effects of our treatments.
A second assumption is that of homogeneity of sub- Whether or not subjects are independent of one an-
jects along all relevant dimensions. Recall that a pri- other rests ultimately on a rational appraisal of the
mary aim of group strategies is to assist in the estab- administration of treatment and the activities outside
lishment of various cause-and-effect relationships of treatment. If treatment is conducted in such a way as
regarding therapeutic effects. Hypothesized cause- to minimize contact among subjects both within and
and-effect relationships are elevated to the status of between sessions, then the assumption of subject inde-
established causal relationships in large part through pendence is a reasonable one. If, however, there is
the process of replication (e.g., Dawis, 1984; Weimer, reasonable cause to believe that there is considerable
interaction among subjects either within or between common forces that compete with our treatment as the
sessions, then the assumption of subject independence agent of influence are history, maturation, testing, in-
is a questionable one. In cases such as this one, steps strumentation, statistical regression, selection, in-
must be taken to acknowledge and accommodate the stability, and experimental mortality (Campbell &
violation of the assumption of subject independence. Stanley, 1966; Glass etal., 1975; Kratochwill, 1978).
The plausibility of these forces as agents of influence is
a direct function of the study's arrangement of mea-
Applications surement and manipulation, with certain arrangements
rendering the forces less likely agents of influence than
All group strategies take the form of an arrangement others. Certain arrangements, then, allow us to assert
of measurement and manipulation. All differ, how- with more certainty than others that a particular pattern
ever, in terms of the exact form this arrangement of of responding is due to a particular treatment. In the
measurement and manipulation takes. Certain ar- sound selection of a group strategy, the second step,
rangements allow us to infer certain types of rela- then, is to select a group strategy that allows us to
tionships with certain degrees of confidence. Group assert with sufficient certainty that our treatment is
strategies differ, therefore, in terms of the type and responsible for the effects observed.
tenability of the inferences they allow for. Various To repeat, the choice of an arrangement of measure-
names have been coined for the various arrangements ment and manipulation is based upon the nature of the
of measurement and manipulation. For a sample of relationship in which we wish to infer and the sureness
these names, see Campbell and Stanley (1966), Cook with which we wish to infer it. Various arrangements
and Campbell (1979), Paul (1969), and Mahoney of measurement and manipulation have been used to
(1978). examine and establish the various relationships of in-
Sound selection of the specific strategy to use is terest to us. In the text that follows, we describe several
predicated on the specific relationship we wish to infer specific group strategies that have been used in the
and the certainty with which we wish to infer it. Recall study of the treatment of a specific problem condi-
that in behavior modification research we are in- tion-children's fears and anxieties. We discuss the
terested in determining the actuality, causality, and strategies in terms of the type of relationship we wish
generality of therapeutic effects. To wit, we are in- to infer and the strength with which the strategies per-
terested in identifying and establishing the occurrence mit us to infer it. And we do so in order to illustrate the
of therapeutic effects, the agents of those effects, the diversity and diverse merits of the group strategies
generality of those effects, the relative standing of available for use in behavior modification research.
those effects, and the generality of their relative stand-
ing. Identification and establishment of each one of
A Therapeutic Effect
these relationships is a two-step process: inferring the
relationship from a pattern of responses and arguing Determining what treatment is most effective for a
for the propriety of the inference over competing ex~ particular child suffering from a particular fear first
planations (e.g., Campbell & Stanley, 1966; Cook & involves determining whether or not a particular treat-
Campbell, 1979; Glass, Willson, & Gottmann, 1975). ment reliably produces a therapeutic effect. That is, it
The different relationships require different patterns of must be determined whether or not there is a consistent
responses for their ready inference; the different group relationship between a given intervention and thera-
strategies allow for the obtainment of different patterns peutic change. To assist them in making such a deter-
of responses. Thus, the first step in the sound selection mination about their home-based intervention for chil-
of a group strategy is selecting a group strategy that dren's nighttime fears, Graziano and his associates
allows for the obtainment of the desired pattern of (Graziano, Money, Huber, & Ignasik, 1979) used a
responses. group strategy of the form of assessment prior to treat-
Arguing for the propriety of a particular inference is ment' assessment immediately following treatment,
done by reducing the plausibility of competing in- and assessment 1 year following treatment. Seven
ferences. In behavior modification research, we are children ranging in age from 8V2 to 12Vz years and
interested in claiming that a particular pattern of re- suffering from fears of 3- to 6-years' duration partici-
sponding is due to the influence of a particular treat- pated in the study. All received the home-based treat-
ment and not to the influence of other forces. The most ment, consisting of training in relaxation, pleasant im-
agery, and coping self-talk. And all evidenced This arrangement of repeated measurement before,
reductions in their fears from pre- to posttreatment during, and after treatment allows for more certain
assessment and maintained these reductions at I-year claims about the treatment and the therapeutic effects
follow-up. These results led Graziano and his associ- observed than does the arrangement of measurement-
ates to conclude that their home-based intervention manipulation-measurement-measurement. It does so
may have been effective in reducing the nighttime fears because it reduces the plausibility of many of the
of the children. forces that compete with the treatment as the agent of
Graziano and his associates could not claim with influence, and, in doing so, it enhances the plausibility
greater conviction that a reliable relationship exists of a reliable relationship between the treatment and the
between their intervention and therapeutic change be- therapeutic effects observed. A case in point is the
cause the group strategy they employed does not per- competing force of testing. In the arrangement of mea-
mit them to do so. A logical analysis of the arrange- surement-manipulation-measurement-measurement,
ment of measurement and manipulation readily reveals the act of being tested on one occasion (i.e., pretreat-
why this is so. The arrangement does not control for or ment) is a very credible explanation for any change
rule out any of the common forces that compete with evidenced in responding on a subsequent occasion
the intervention as the agent of influence. In other (i.e., posttreatment). It is, however, not a very credible
words, the arrangement does not reduce the plau- explanation of therapeutic effects when the arrange-
sibility of history, testing, maturation, or any of the ment is one of repeated measurement before, during,
others as the agent responsible for the therapeutic ef- and after treatment. Having repeated assessments at all
fects observed. And because it does not do so, the critical junctures in the study eliminates testing as a
arrangement does not enhance the plausibility of a reli- plausible explanation for improvements in responding
able relationship between the intervention and the ther- from one juncture (i.e., pretreatment) to the next (i.e.,
apeutic effects observed. posttreatment). Thus, it elevates the plausibility of the
Take for example the competing forces of history treatment as the agent responsible for the changes
and testing. In the arrangement of measurement-ma- displayed.
nipulation-measurement-measurement, the possibility This arrangement of repeated measurement before,
of an extratherapeutic event coinciding with treatment during, and after treatment does not, however, control
and instigating the changes observed is a very real one. for all of the forces that compete with treatment as the
So too is the possibility of the initial assessment's dic- agent of influence. Specifically, it does not control for
tating the nature of responding on all subsequent as- the competing force of history. And because it does
sessments. The group strategy of measurement-ma- not, a coincidental therapeutic event is as reasonable
nipulation-measurement-measurement does nothing an explanation for the therapeutic effects observed as is
to refute or reduce either one of these possibilities. the treatment itself. Consequently, this particular
Thus, the group strategy does not allow us to assert group strategy does not allow us to claim with utmost
with any certainty that a consistent relationship exists certainty a consistent relationship between our inter-
between the treatment and the changes evidenced. vention and the therapeutic effects observed.
Barlow and Seidner (1983) employed a slightly dif- One particular group strategy that does allow for
ferent strategy in their study of their treatment of chil- such claims is illustrated by Graziano and Mooney
dren's fears of being alone and being away from home, (1980) in their study of their home-based treatment for
and as such were able to put forth slightly stronger children's nighttime fears. Thirty-three children, rang-
claims about the ties between their treatment and thera- ing in age from 6 to 13 years and suffering from fears of
peutic change. Three children, ranging in age from 15 1- to lO-years' duration, participated in the study. Ap-
to 17 years and suffering from fears of 14- to 48- proximately half of the children were randomly as-
months' duration, participated in the study. All re- signed to a treatment of training in muscle relaxation,
ceived a treatment package consisting of panic-man- pleasant imagery, and coping self-talk; the other half
agement training, cognitive restructuring, and gradu- were randomly assigned to a condition of waiting for
ated exposure to the feared situations. All underwent such treatment to be available. All were assessed at the
repeated assessments preceding, during, and follow- same five points in time: prior to treatment, upon com-
ing treatment. And all but one showed improved per- pletion of treatment, and 2, 6, and 12 months follow-
formance with the onset of treatment and maintenance ing treatment. Thus, the arrangement of measurement
of said performance upon the completion of treatment. and manipulation took the form of measurement-treat-
ment-measurement-measurement-measurement-mea- the optimum arrangement of those elements is a com-

surement for half of the children, and measurement-no plex affair (Barrios, 1984; Barrios & Hartmann,
treatment-measurement-measurement-measurement- 1988b; Paul, 1969). First, it entails carving the com-
measurement for the other half. Prior to treatment, plete treatment into distinct components; second, com-
each group of children was as fearful as the other. bining different subsets of components into coherent
Upon completion of treatment, the group of children treatment packages; and third, comparing the effects of
receiving the treatment was less fearful than the group the different subsets of components to one another and
of children waiting to receive the treatment, and they to those of the complete treatment. In essence, we are
remained so at each of the three successive trying to separate the wheat of our treatment from the
assessments. chaff of our treatment. And to assist us in doing so, we
Of the many possible reasons for the reductions in draw upon several specific group strategies-the me-
the nighttime fears of these children, the most plausi- chanics and merits of which are discussed next.
ble is the receiving of the home-based intervention. In their study of the active ingredients of their cog-
Such forces as testing, history, and maturation are all nitive-behavioral treatment for generalized anxiety,
less plausible explanations by virtue of the pattern of Miller and Kassinove (1978) assigned 96 fourth gra-
measurement and manipulation employed and the pat- ders to one of four conditions: (1) the complete treat-
tern of responding obtained. Take, for example, the ment package of rational emotive therapy, behavioral
competing force of maturation. For naturally occurring rehearsal, and in vivo practice; (2) the component sub-
maturational processes to be a likely reason for the set of rational emotive therapy and behavioral rehears-
reductions in fear among treated children, similar real; (3) the component of rational emotive therapy; or
ductions in fear must be evidenced among untreated (4) no-treatment. All children were assessed prior to
children. Since they were not, maturation is a most and upon completion of treatment. Children receiving
unlikely candidate as the agent responsible for the ther- the complete treatment and the component treatment
apeutic effects obtained. A similar logic renders all of rational emotive therapy and behavioral rehearsal
other competing forces to be improbable agents of in- showed the greatest improvement, with no appreciable
fluence, thus rendering treatment the most probable differences between the two of them.
cause of the effects observed. On the basis of these findings, one would be tempt-
ed to designate the components of rational emotive
therapy and behavioral rehearsal as the active ingre-
The Therapeutic Agent
dients of Miller and Kassinove's cognitive-behavioral
Once we have established a consistent causal rela- treatment. What is more, one would be tempted to
tionship between an intervention and a therapeutic ef- delimit their cognitive-behavioral treatment to the ap-
fect, our next task is to identify the active ingredients plication of those two components. To do so, however,
of that intervention. In other words, our next task is to would be premature. For the group strategy employed
pinpoint those aspects of the intervention that are in the study does not give strong backing to such a
needed to produce the therapeutic effect. Implicit here conclusion and such a course of action. Missing from
is the assumption that the intervention is complex and this arrangement of measurement and manipulation
that some of this complexity is not necessary for thera- are the components of behavioral rehearsal and in vivo
peutic change. Of the behavioral treatments developed practice-in isolation and in tandem-and the compo-
to date, virtually all appear to be complex in nature; nent combination of rational emotive therapy and in
that is, virtually all appear to be comprised of two or vivo practice. Thus, missing from this arrangement is a
more components (cf. Bellack, Hersen, & Kazdin, thorough analysis of the treatment's active elements
1982; Mash & Barkley, 1989; Masters, Burish, Hol- and the optimum combination of those elements.
lon, & Rimm, 1987). Thus, for nearly all behavioral A group strategy that allows for a more precise iden-
treatments, the first part of this assumption holds true. tification of an intervention's essential elements is il-
The validity of the second part of this assumption- lustrated by 0' Connor (1972) in his study of his com-
that some treatment components are superfluous-is pound treatment for children's social fears. Thirty-
the subject of study in this the second stage of behavior three young children were randomly assigned to one of
modification research. four conditions: (1) the complete compound treatment
Identifying the active elements of a treatment and of symbolic modeling and contingency management,
(2) the component of symbolic modeling, (3) the com- symbolic modeling or the component of guided in vivo
ponent of contingency management, or (4) an attention practice, but only to the combination of the two. The
control. All children were assessed immediately be- third is that there are no superfluous components in the
fore and after treatment and 3 and 6 weeks following complete treatment package. All components contrib-
treatment. Showing the greatest improvement overall ute to the treatment's therapeutic effects; thus, all com-
were those children receiving either the complete components are active ingredients of the treatment. And
pound treatment of symbolic modeling and contingen- the fourth is that the treatment should remain intact.
cy management or the component treatment of sym- No components of the treatment should be removed,
bolic modeling, with no appreciable differences for to do so would reduce the treatment's therapeutic
between the two conditions. benefits. All of these statements can be put forth with
The findings of the study point to symbolic model- great confidence, for the study's arrangement of mea-
ing as the agent behind the therapeutic effects of surement and manipulation allows us to do so. The
O'Connor's compound intervention, which in turn, design provides for an examination of all of the treat-
points to the simplification of O'Connor's compound· ment's components, in isolation and in combination;
intervention from a treatment of symbolic modeling the design controls for all of the forces that compete
and contingency management to a treatment of sym- with the treatment-be the treatment a component or
bolic modeling. Both inference and action are justified combination of components-as the agent of influ-
given the arrangement of measurement and manipula- ence. Thus, the design gives great tenability to the
tion employed in the study. All components were ex- inferences that underlie our statements, great validity
amined in isolation and in all possible combinations; to the actions that spring from our statements.
all competing forces were attended to and controlled. From our discussion of these three studies, it is evi-
Thus, the inference of symbolic modeling as the active dent that the more complicated our treatment, the more
ingredient in O'Connor's compound intervention is a complicated will be the search for our treatment's ac-
tenable one, the business of reducing the treatment to tive ingredients. That is, the more complicated will be
symbolic modeling a sensible one. the arrangement of measurement and manipulation
Another example of a good group design is found in needed for a thorough examination of all treatment
the study by Lewis (1974) of her participant modeling components-in isolation and in all possible combina-
treatment for children's fear of water. Forty children, tions. A quick comparison of the strategies needed to
ranging in age from 5 to 12 years, were randomly identify the active elements of the O'Connor (1972)
assigned to one of four conditions: (1) the complete and Miller and Kassinove (1978) treatments bears this
participant modeling treatment consisting of symbolic out. For the two-component treatment of O'Connor,
modeling and guided in vivo practice, (2) the compo- four different manipulations or conditions are re-
nent treatment of symbolic modeling, (3) the compo- quired: the two components in separation, the two
nent treatment of guided in vivo practice, and (4) an components together, and the absence of both. For the
attention control. All children were assessed at three three-component treatment of Miller and Kassinove,
points in time: immediately preceding treatment, im- eight different manipulations or conditions are re-
mediately following treatment, and 5 days following quired: the three components in separation, the three
treatment. Children receiving the complete participant components in couplets, the three components to-
modeling treatment showed significantly greater im- gether, and the absence of all three.
provement than children receiving the component of What is also evident from our discussion is that for
symbolic modeling, the component of guided in vivo some interventions there are no extraneous compo-
practice, or the attention control. nents. That is, for some interventions our search for the
Based on these findings, several statements can be active ingredients takes us back to where we started-
made about Lewis's participant modeling treatment for the complete treatment package. Lewis's (1974) study
children's fear of water. The first is that the combina- of her participant modeling treatment bears this out.
tion of the components of symbolic modeling and in What may not be so evident from the Lewis (1974)
vivo practice is more effective than either one of the study and others like it is that such studies have value.
two components in isolation. The second is that the Such studies bring us back to where we started, but
therapeutic effects of the complete participant model- they do so leaving us much more certain about the
ing treatment cannot be attributed to the component of active ingredients of our interventions. And it is with
this greater certainty about our interventions-the intervening event is responsible for the maintenance of
necessary and sufficient conditions for their therapeu- treatment gains. This makes it all the more likely that
tic effects-that we take on the next research task. the treatment is responsible for the therapeutic effects
observed at the follow-up assessment. In fact, the de-
sign makes such an interpretation the most plausible
The Generality of the Therapeutic Effect
explanation of the findings.
Once we have established a reliable relationship be- An often-cited study by Kanfer, Karoly, and New-
tween our treatment and a therapeutic effect and have man (1975) serves as an example of the assessment of
pinpointed the operations needed to produce the said the spread of treatment effects across untreated set-
effect, our next task is to identify the generality of this tings. Forty-five children, ranging in age from 5 to 6
treatment-outcome relationship. In other words, in the years and suffering from fear of darkness, were ran-
third stage of behavior modification research, we are domly assigned to one of three conditions: (1) a coping
asked to determine the conditions under which our self-talk treatment, (2) an information control, or (3)
treatment effects generalize. Among the dimensions an attention control. All children were assessed for
across which we are most interested in studying the fear of darkness both before and after treatment. This
spread of a therapeutic effect are time, setting, behav- took the form of having the children seated in a fully
ior, person, therapist, and procedure. Generalization illuminated room with a rheostat device in hand and
across the former dimension of time defines the du- asking them to lower the lighting of the room to a level
rability of the therapeutic effect; generalization across they could tolerate. At the completion of the posttreat-
the five latter dimensions defines the expanse of the ment assessment, all children were also tested for fear
therapeutic effect. of darkness in a slightly different situation. Seated in a
In our study of the spread of a therapeutic effect, our fully darkened room with a rheostat device in hand, the
aim is twofold: to detect the presence of therapeutic children were asked to raise the lighting of the room to
benefits where no treatment has been in operation and a level they found comfortable. Prior to treatment, the
to attribute said therapeutic benefits to our intervention three groups of children were quite similar in the level
(Barrios & Hartmann, 1988b). The adequacy with of lighting they selected as tolerable; at the completion
which we do so is a function of the tenability of the oftreatment, they were quite dissimilar, with the group
underlying inferences, which, in turn, is a function of of children receiving the coping self-talk treatment se-
the nature of the study. To aid us in the sound determin- lecting a much lower level of illumination as tolerable
ation of the spread of a therapeutic effect are several than the two groups of children receiving the control
group strategies-the mechanics and merits of which conditions. The same pattern of findings emerged for
are discussed next. the novel testing situation, thus suggesting the spread
A study by Keller and Carlson (1974) illustrates the of treatment effects to an untreated setting.
assessment of the generalization of treatment effects Investigations by Melamed and Siegel (1975) and
across time. Nineteen children, ranging in age from 3 Klorman and his colleagues (Klorman, Hilpert,
to 10 years and suffering from fear of social situations, Michael, LaGana, & Sveen, 1980) further illustrate
were randomly assigned to one of two conditions: a the use of group strategies in the delineation of the
modeling treatment or an attention control. All chil- generality of a therapeutic effect. Melamed and Siegel
dren were assessed immediately before, immediately (1975) examined the generalization of their modeling
after, and 3 weeks following treatment. Children as- treatment's effects across untreated behaviors, where-
signed to the modeling condition were as fearful as as Klorman and his colleagues (Klorman et at., 1980)
children assigned to the control condition prior to treat- examined the generalization of their modeling treat-
ment, but less fearful upon completion of treatment ment's effects across minor variations in the treatment
and 3 weeks following treatment. This leads to the procedure. Specifically, 60 children, ranging in age
conclusion that the therapeutic effects of the modeling from 4 to 12 years and reporting fear of the hospital
treatment were maintained over or generalized across situation, served as subjects in the Melamed and Siegel
the 3-week time period. It is a compelling conclusion (1975) investigation. The children were randomly as-
by virtue of the study's arrangement of measurement signed to one of two conditions-a modeling treat-
and manipUlation. The interval between the complement or an attention control-and were assessed for
tion of treatment and the follow-up assessment is suffi- both fear of the hospital situation and fear of a compila-
ciently short enough to make it most unlikely that some tion of situations (i.e., generalized anxiety) both prior
to and upon completion of treatment. With respect to ments for children's fears and anxieties are systematic
the focal or treated fear toward the hospital situation, desensitization and prolonged exposure (cf. Barrios &
children receiving the modeling treatment showed O'Dell, 1989). In a study by Johnson, Tyler,
greater improvement than children receiving the atten- Thompson, and Jones (1971), the effects of the two
tion control. The same held true for the nonfocal or treatments were directly compared. Twenty-four sixth,
untreated fears, thus extending the range of behaviors seventh, and eighth graders suffering from fear of pub-
affected by the modeling treatment. lic speaking were randomly assigned to one of three
In a series of three studies, Klorman and his col- conditions: (1) systematic desensitization, (2) pro-
leagues examined the effect certain changes in the longed exposure, or (3) no-treatment. All children
model's behavior has on their modeling treatment for were assessed immediately before and after treatment.
children's fear of the dental situation. A total of 136 The three groups of children were comparable to one
children, ranging in age from 3 to 14 years and varying another prior to treatment, different upon completion
in experience with the dental situation, participated in of treatment-the difference being that the systematic
the three studies. In each, children were randomly as- desensitization and prolonged exposure groups were
signed to one of three conditions: (1) the standard mod- less fearful than the no-treatment group, but no more
eling treatment showing a peer in discomfort in the so than one another. Thus, in terms of the treatment of
dental situation, coping with that discomfort, and public speaking anxiety among these sixth-, seventh-'
calmly completing the dental procedure; (2) a variant and eighth-grade children, systematic desensitization
of the standard modeling treatment showing a peer in and prolonged exposure proved to be equally effective.
no discomfort in the dental situation, calmly complet- A much different outcome was obtained by Cra-
ing the dental procedure; or (3) an attention control. dock, Cotler, and Jason (1978), when they compared
And in each study, assessments were carried out before the therapeutic effects of systematic desensitization to
and after treatment. In general, the children receiving the therapeutic effects of their self-management pro-
either the standard treatment or its variant improved gram in the treatment of public speaking anxiety. Spe-
more than the children receiving the attention control, cifically, 40 14-year-old females were randomly as-
but no more so than one another. The therapeutic ef- signed to one of three conditions: (1) self-management
fects of the standard treatment, then, proved to be in- training, (2) systematic desensitization, or (3) no-
variant across this particular alteration in the treatment treatment control. Assessments were carried out prior
procedure. to and upon completion of treatment. Showing the
greatest treatment gains were those subjects receiving
the self-management training, followed by those sub-
The Relative Effectiveness of Different
jects receiving systematic desensitization, followed by
Treatments
those subjects receiving no-treatment. Given the pat-
In our search for a powerful treatment for a particu- tern of findings obtained and the pattern of measure-
lar problem condition, we eventually find ourselves ment and manipulation employed, the researchers
with two or more treatments of known effectiveness. judged the therapeutic effects of self-management
When we do so, we enter into the fourth stage ofbehav- training to be superior to those of systematic desensi-
ior modification research, the task of which is to deter- tization-a judgment which one would find difficult to
mine the relative effectiveness of our different treat- refute.
ment alternatives. Note that at this point in our study of
a particular treatment for a particular problem we have
The Generality of the Relative Effectiveness
established a reliable relationship between the treat-
of Different Treatments
ment and a therapeutic effect, pinpointed the treat-
ment's active ingredients, streamlined the treatment to When we compare the therapeutic effects of two or
its essential operations, and delineated the generality more treatments, we do so under a certain set of cir-
of the treatment's effects. What awaits us now is a cumstances. That is, we select certain persons suffer-
direct comparison of our treatment with one or more ing from certain levels of a specific problem condition
other treatments for which as much is known. To aid us as our subjects. We expose these subjects to a certain
in this process, we draw upon several specific group form of one of two or more treatments in a certain
strategies and now describe their application. setting. And we assess the performance of these sub-
Two of the most widely employed behavioral treat- jects on certain occasions. Having done so, our next
task is to determine how well the findings hold up behavior modification research. Instead, we have as
under different sets of circumstances. In other words, many different group strategies as there are different
our task in this the fifth stage of behavior modification arrangements of measurement and manipulation. This
research is to delineate the generality of the relative is good, given that we are interested in inferring and
effects of our different treatments. establishing many different relationships regarding the
There are numerous dimensions across which we treatment of a given problem condition. It is also ob-
can examine the regularity of the relative effects of our vious that we have no uniformily useful group strategy
different treatments. Of greatest interest to us are the for behavior modification research. Instead, we have
dimensions of time, persons, settings, and procedure. particular arrangements of measurement and manip-
We are interested in the consistency of the relative ulation that are of use to us in inferring and establishing
effects of our different treatments across different particular relationships regarding the treatment of a
points in time, across different types of treatment set- given problem condition. The usefulness of these
tings (e.g., laboratory, clinic), across different types of group strategies is a function of how well they allow
treated persons (e.g., age, race, gender, problem se- for tenable inferences and valid conclusions, which, in
verity), and across different types of procedural varia- turn, is in part a function of how well they rule out
tions (e.g., therapist, schedule of sessions). And we competing agents of influence (i.e., those variables
look to group strategies for assistance in determining that compete with the treatment as the agent responsi-
each one of these relationships. A description of one ble for the therapeutic effects observed). The
such group approach is offered below. usefulness of these strategies is also a function of how
Of the many studies of behavioral treatments for well the measurements and manipulations are carried
children's fears and anxieties, few have examined the out. What makes for sound and sensitive measurement
generality of the relative effectiveness of the different and implementation of treatment is discussed in the
treatments (cf. Barrios & O'Dell, 1989). One that has next section.
is the Bandura, Blanchard, and Ritter (1969) com-
parative study of three much-used behavioral tech-
niques. Specifically, persons ranging in age from 13 to Assessment
59 years and suffering from a longstanding fear of
snakes were randomly assigned to one of four condi- A host of assessment issues is tied up in the use of
tions: (1) systematic desensitization, (2) symbolic group designs in behavior modification research.
modeling, (3) participant modeling, or (4) no-treat- Chief among them are specifying the problem space,
ment. All subjects were assessed for their fears of specifying the patient population, diagnosing the prob-
snakes and other stimuli at three points in time: (1) lem condition, defining treatment outcome, determin-
immediately before treatment, (2) immediately after ing instrument integrity, and determining treatment in-
treatment, and (3) I-month following treatment. The tegrity. We will now discuss each one of these key
study's arrangement of measurement and manipula- assessment issues.
tion allowed for both a determination of the relative
effects of the treatments and a determination of the
Specifying the Problem Space
consistency of those effects across the dimensions of
time and persons. To be exact, the study's design al- As stated earlier, the first step in addressing the
lowed for a determination of the consistency of the global question of "What treatment, by whom, is most
relative effects of the treatments across a time span of 1 effective for this individual with that specific problem,
month and an age span of 46 years. In sum, the three under which set of circumstances?" (Paul, 1967, p.
treatments were superior to no-treatment; the partici- 111) is to break the question up into smaller units along
pant modeling treatment was superior to the systematic the lines of the different problem conditions. To do so,
desensitization and symbolic modeling treatments. we must first specify the problem space-the universe
And this superiority of the participant modeling treat- of events that are said to legitimately constitute a prob-
ment was constant across both time and persons. lem condition (Mash, 1985). Having done so, we are
then able to enumerate and investigate the various
problem conditions.
Summary
To date, the problem space has been traced along
From the many examples cited in this section, it is three different lines: the symptom, the syndrome, and
obvious that we have no monolithic group strategy for the system (Barrios, 1988). In the problem space of the
symptom, an individual behavior is seen as sufficient of interest, we must do so with utmost explicitness.
to serve as a problem condition. That is, discrete be- Failure to do so only leads to confusion over who are
haviors, such as clinging, grimacing, and trembling, the rightful recipients of our treatment, which, in turn,
are all viewed as distinct problem conditions. In the only leads to corruption in who are selected to receive
problem space of the syndrome, a cluster of behaviors our treatment. Together, this confusion and corruption
is seen as forming a problem condition. That is, indi- work against the orderly determination of the effec-
vidual behaviors, such as clinging, grimacing, and tiveness of our treatment for the patient population of
trembling in concert but not in isolation, are viewed as primary interest and the patient populations of ancil-
a problem condition. And in the problem space of the lary interest. Heretofore, we have not been very pre-
system, a combination of behaviors on the part of two cise in specifying the popUlation of interest and as such
or more individuals is seen as making up a problem we have had great difficulties in judging the adequacy
condition. That is, behaviors on the part of say a child of our subject samples-the adequacy with which our
or his mother would be insufficient to serve as a prob- subject samples serve as representatives of the popula-
lem condition; behaviors on the part of both, however, tion of interest. Suggestions as to how we could avoid
would be adequate to stand as one. such difficulties are offered in a later section.
To conceptualize the problem space is to begin to
designate the suitable targets for treatment. As such,
Diagnosing the Problem Condition
the three conceptualizations of the problem space as
symptom, syndrome, and system hold very definite Be the condition of interest a symptom, a syndrome,
and very different implications for behavior modifica- or a system, we are in essence concerned with the
tion research. The three different conceptualizations responses of a person or persons. The question is:
point to the development of very different interven- What level of responding constitutes a problem condi-
tions and very different assessment instruments. What tion? To date, three general approaches have been used
is more, they put forth very different criteria for the to designate a problem condition: client-referenced,
evaluation of treatment outcome and instrument criterion-referenced, and norm-referenced. In the cli-
soundness. Such diversity obviously works against the ent-referenced approach, the client per se functions as
development of a cumulative science of behavior mod- the backdrop against which current performance is
ification. Such diversity unfortunately characterizes deemed either problematic or nonproblematic. This
much of today's research on behavior modification. backdrop may take a number of different forms. For
Suggestions for less diversity and more unity in our example, the past performance of the client or the de-
investigative efforts are offered in a later section of the sired performance of the client may serve as the refer-
chapter. ent against which the current performance of the client
is appraised. Another example would be a backdrop
comprised of multiple aspects of the person's life situa-
Specifying the Patient Population
tion. For the syndrome of separation anxiety, such a
Be it the problem of interest symptom or syndrome mosaic might be made up of the following pieces of the
or system, our next task is to identify the persons of child's life situation: disruption offamily functioning,
interest. These are persons whom we are most intent disruption of classroom functioning, constriction of
on treating and for whom our treatment is specifically social activities, obstruction of goal attainment, and
intended. As a whole, these persons constitute the pa- magnitude of subjective discomfort.
tient popUlation of interest. The patient population In the criterion-referenced approach, a set standard
may be defined along any of a number of different of performance serves as the backdrop against which
lines-developmental, racial, cultural, sexual, or the person's performance is deemed either problematic
some combination of the four. For example, a patient or nonproblematic. This standard is put forth by those
population defined along developmental lines would of us who are familiar with the performance pattern of
be one made up of similar age persons; a patient popu- interest and is typically a product of our clinical obser-
lation defined along sexual lines would be one made up vations or empirical investigations or both. Take, for
of same-sexed persons; and a patient population de- example, children's fear of darkness. At the level of
fined along combined developmental-sexual lines the symptom as problem condition, the criterion might
would be one made up of same-sexed persons of the be fleeing from a dark room upon 30 sec of entering
same age. said room. Thus, any child who does so within 30 sec
Whatever way we choose to specify the population or less will be said to be responding at a problematic
level. At the level of syndrome as problem condition, norm-referenced approach, the principal strength is
the criterion might be fleeing from a dark room upon likewise a simplified and standardized handling of the
30 sec of entering said room, sobbing and screaming as complex issue of problem diagnosis. Its principal
one does so, with one's heart racing at 120 or more weakness, though, is its generation of numerous con-
beats per min. Thus, any child who flees sobbing and .ceptual and ethical quandaries. Again consider the
screaming from a dark room upon 30 sec or less of fears of children. Among preschoolers, fear of imagi-
entry and whose heart is pounding 120 or more beats nary creatures, such as ghosts and goblins and witches,
per min as he does so will be judged to be responding at is quite common (e.g., Bauer, 1976; lersild &
a problematic level. Finally, at the level of system as Holmes, 1935). A preschooler, then, who displayed no
problem condition, the criterion might be both mother such fear would deviate dramatically from the norm.
and child fleeing from a dark room upon 30 sec of The question is: Should behavior so praiseworthy be
entering said room, sobbing and screaming as they do designated changeworthy? A strict adherence to the
so, with their hearts racing at 120 or more beats per norm-referenced approach tells us yes. Our good
min. Given such a criterion, it follows that any mother sense, though, tells us no.
and child meeting or exceeding said criterion will be Of these three strategies for problem diagnosis, the
judged to be responding at a problematic level. criterion-referenced approach appears most commen-
In the norm-referenced approach, the performance surate with the goal of a cumulative science of behav-
of the person's peers serves as the backdrop against ior modification (e.g., Barrios, 1988; Barrios &
which the person's performance is deemed either prob- Hartmann, 1988a; Barrios & Shigetomi, 1985).
lematic or nonproblematic. Deviations from the aver- Shared standards for problem designation foster the
age responding of the peer group-be they in either collective study of the effectiveness of our treatments;
direction-are seen as problem responding. As an il- shared standards for problem designation allow us to
lustration of the approach, once again consider the benefit from and build upon one another's work. Of
fears of children. Two children are frightened of the course, nothing of the sort will happen if the standards
imaginary Halloween creatures of ghosts and goblins we put forth are vague and imprecise. Vague and im-
and witches. One child is 4 years old; the other child is precise criteria for problem performance sabotage our
12 years old. According to the norm-referenced ap- efforts to study the effectiveness of our treatments in a
proach, the behavior of the 4-year-old would not be unified and orderly fashion; vague and imprecise crite-
viewed as a problem, whereas the behavior of the 12- ria retard the steady growth of a cumulative science of
year-old would. For according to epidemiological behavior modification. Slow growth is, unfortunately,
studies, fear of imaginary creatures, such as ghosts and the state of affairs of much of this past decade's study
goblins and witches, is quite common among 4-year- of behavior modification techniques. Rectifying this
olds, but most uncommon among 12-year-olds (e.g., situation calls for refining the standards we put forth
Bauer, 1976; Jersild & Holmes, 1935; Mauer, 1965; for problem performance. Suggestions as to how we
Ollendick, 1983; Scherer & Nakamura, 1968). might go about doing so are offered in a later se.::tion.
Each of the three approaches to problem diagnosis
comes with certain strengths and weaknesses. The ob-
Defining Treatment Outcome
vious strength of the client-referenced approach is its
sensitivity to the subtleties and idiosyncrasies of the All treatment can be conceptualized as incurring
individual case, whereas the obvious weakness of the costs and yielding benefits. Given this simple view, the
approach is its incompatibility with traditional modes not-so-simple task is to specify the costs of treatment,
of test construction, test evaluation, and data aggrega- the benefits of treatment, and the computation of their
tion. The primary advantage of the criterion-refer- difference (i.e., the net gains from treatment). To this
enced approach is its straightforward and standard- end, many proposals have been put forward (e.g., Bar-
ized method to problem designation-a method most rios & O'Dell, 1989; Kazdin, 1980, 1987; Kazdin &
compatible with the goal of a cumulative science of Wilson, 1978; Mash & Barkley, 1989). In the text that
behavior modification. Its primary disadvantage is, follows, we describe a broad integrative framework
however, a tendency toward pseudospecificity-a ten- for the assessment of treatment outcome.
dency most incompatible with the goal of a cumulative The costs of treatment can be viewed from three
science of behavior modification (e.g., Barrios & different perspectives: the individual, the household,
Hartmann, 1988a; Taylor, 1983). And finally with the and the community. And within each perspective, the
costs of treatment can be grouped into two types: fi- for the household and the community of that indi-
nancial and psychological. As way of an example, vidual. To wit, treatment of an individual brings with it
again consider the treatment of a child's fear. From the certain costs and benefits for the household and com-
perspective of the individual (i.e., the child), the finan- munity of the said individual. For both the household
cial costs of treatment will in almost all cases be mini- and the community, the costs associated with treatment
mal; for in almost all cases it will be someone other of an individual are both financial and psychological in
than the child who will pay the fee for services. Psy- nature. In the case of the treatment of a child's fear, an
chological costs are, however, another matter. All be- obvious financial expense for the household is the fee
havioral programs for the treatment of children's fears for therapeutic services; a not-so-obvious one is the
call for the expenditure of effort and endurance of dis- loss of income resulting from participation in the treat-
comfort. A treatment, such as implosion, calls for the ment process. There is loss of income because vir-
child to imagine an unrealistic yet nevertheless horrific tually all of the treatments for a child's fear assign
scenario involving the feared stimulus, and to do so certain duties to the members of the household (cf.
repeatedly until he or she is no longer disturbed by the Barrios & O'Dell, 1989). To carry outthese duties is to
images (e.g., Ollendick & Gruen, 1972; R. E. Smith forego opportunities to add to the household income.
& Sharpe, 1970). To undergo such a treatment ob- Thus, to participate in the treatment process is to pass
viously entails the expenditure of considerable effort up potential household earnings. Participation in the
and the endurance of considerable discomfort on the treatment process also exacts a certain psychological
part of the child. Other treatments, such as systematic toll upon the members of the household. Assisting in
desensitization and symbolic modeling, make far the administration of treatment calls for the expendi-
fewer demands upon the child (cf. Barrios & O'Dell, ture of effort and the endurance of discomfort. What is
1989); they do, however, make some demands. And as more, treatment of one member of a household for a
such, they like all other behavioral treatments carry problem condition identifies the entire household as
with them some psychological costs for the child. having a problem condition, which, in turn, subjects
A third type of psychological cost incurred with everybody in the household to some degree of scorn
treatment is that of scorn. For in this day and age, there and ridicule. Treatment, then, carries with it the same
is still some stigma surrounding psychotherapy in gen- kinds of psychological costs for the household as it
eral and behavior modification in particular. A child, does for the individual-energy, discomfort, and
then, receiving treatment for a fear will, to some de- scorn.
gree, be singled out as a child with a problem and, as The same breakdown of treatment costs holds for
such, will be subjected to some degree of ridicule or the community of which the household is a constitu-
rejection or both. The amount of scorn experienced is ent. The community, as represented by the therapist,
likely to be a function of the conspicuousness with suffers certain financial and psychological costs in
which the child is singled out as having a problem, providing a particular treatment to a particular indi-
which, in tum, is likely to be a function of the conspic- vidual from a particular household suffering from a
uousness of treatment. Certain treatments, such as particular problem condition. There are costs in invest-
large-scale, group-administered modeling programs, ing therapist time and labor and equipment to the treat-
neatly coalesce with the ongoing events of the child's ment of one individual with a problem condition as
daily life (e.g., school); consequently, they cast little opposed to the treatment of another individual with
attention toward the child as someone having a prob- another problem condition. There is effort expended as
lem in need of correction. Other treatments, such as well as discomfort experienced in preparing and im-
systematic desensitization, clash with the ongoing plementing a treatment for a given individual. What is
events of the child's daily life; consequently, they draw more, there is criticism received for treating an indi-
attention to the child as someone having a problem in vidual with a certain problem condition as opposed to
need of correction. None of the treatments, though, treating another individual with another problem con-
completely conceal the child as someone with a prob- dition. In sum, the community bears the same kinds of
lem. Therefore, all of the treatments carry with them financial and psychological costs in treating an indi-
some stigmatization of the child. vidual as do the individual and the members of his
All individuals are members of households and all household.
households are members of communities. Treatment The benefits of treatment can also be viewed from
of an individual therefore holds certain implications the three perspectives of individual, household, and
community. And within each perspective, the benefits worth of our treatments will most probably come down
of treatment can be viewed as being of three types: to matters of dollars and cents. That is, if we are to
improvements in the problem condition per se, im- have a common metric of treatment costs and treatment
provements in nontreated problem conditions, and im- benefits, the metric is most likely to be that of money.
provements in projected problem conditions. At pre- This is not a metric we would choose; it is, however, a
sent, assessment of each type of benefit is most metric we believe will be imposed. Given such an
straightforward at the level of the individual, least anticipated state of affairs, our task is to begin assign-
straightforward at the level of the community. For ex- ing a monetary value to each and every one of the
ample, in the case of a fear reaction of a child, the psychological costs and benefits of treatment-a most
benefits of treatment for the child are reflected in the awesome and uneasy task.
following: changes in subjective, motoric, and physio- And much to our discomfort, our work does not end
logical responses to the feared stimulus (Le., improve- here. For once we have determined the net gains of our
ments in the problem condition per se); changes in treatments, we must then determine the significance of
SUbjective, motoric, and physiological responses of those gains. In other words, we must develop models
nontreated fear reactions (i.e., improvements in non- and methods for evaluating the significance and worth
treated problem conditions); and changes in expected of the net gains of our treatments. Such models and
subjective, motoric, and physiological responses to methods have already begun to be developed. For ex-
expected fear stimuli (Le., improvements in projected ample, Kazdin (1977) has put forth a number of pro-
problem conditions). cedures which he refers to collectively as social valida-
The treatment of an individual also holds benefits tion. They call for interpreting the performance of
for the household and community of said individual. treated subjects against a backdrop of the performance
With treatment, energy that had been directed to the of nontroubled peers, interpreting the performance of
management and modification of the individual's treated subjects against a backdrop of the performance
problem condition can now be directed elsewhere; of exemplary peers, having relevant persons in the sub-
with treatment, discomfort that had been experienced jects' household judging the subjects' performance,
and endured in the management of the individual's having relevant persons in the subjects' community
problem condition can now be displaced by comfort; judging the subjects' performance, or some combina-
and with treatment, scorn that had been experienced tion of the above. A much more statistical approach to
and endured simply for having a member with a prob- determining the significance of treatment gains has
lem condition can now be replaced by acceptance. been proposed by Jacobson, Follette, and Revenstorf
Such benefits appear with regard to not only the prob- (1984). Simply stated, the procedure first calls for
lem condition per se but also the nontreated problem computing a reliable change index-the posttest score
conditions and the projected problem conditions. minus the pretest score, divided by the standard error
Determining the net gains of treatment for the indi- of measurement. Such an index indicates whether the
vidual, the household, and the community is simply a change from pretest to posttest is a chance or non-
matter of subtracting their aforementioned costs from chance phenomenon. Second, the procedure calls for
their aforementioned benefits. Doing so in practice, interpreting the posttest performance of treated sub-
though, is far from a simple matter. The main stum- jects against a backdrop of the performance of all non-
bling block is the lack of a common metric for costs treated persons suffering from the same problem con-
and benefits. In practice, what we typically do is index dition (Le., the performance distribution of the patient
the financial costs of treatment by means of one scale, population of interest) or a backdrop of the perfor-
the psychological costs of treatment by means of an- mance of all persons not suffering from the problem
other scale, and the benefits of treatment by yet still condition (i.e., the performance distribution of the
another scale. The measures from the different scales normal population of interest) or a backdrop of some
cannot legitimately be added to or subtracted from one combination of the two. Specifically, the procedure
another. And if they are added to or subtracted from calls for determining whether or not the posttest perfor-
one another, their sums or remainders cannot be mean- mance of treated subjects falls beyond two standard
ingfully interpreted. Thus, we have heretofore been deviations above the mean for the patient population of
unable to determine the net gains of our behavior modi- interest or within two standard deviations below the
fication programs. mean for the normal population of interest or both.
Given the nature of our society, judgments about the Neither the social validation model of Kazdin nor
the statistical validation model of Jacobson et al. is scores on the instrument with scores on a different
sufficient for determining the significance of the net instrument addressing a criterion of interest; or we
gains of our treatments. Both models make no mention correlate scores on the instrument with scores on a
of the matter of treatment costs; both models make no different instrument addressing a different but presum-
mention of the matter of aggregating individual costs ably related phenomenon of interest (e.g., Guion,
and benefits and subtracting the former from the latter. 1980; Nunnally, 1978).
The two models bear mention because they offer us Insomuch as there is no one way of estimating relia-
frameworks that we can build upon-frameworks that bility and validity, there is no one index of the sound-
we can fashion into sound and sensitive models for ness and sensitiveness of an instrument. The various
determining the worth of treatment gains. ways of estimating reliability and validity represent
various types of reliability and validity, which, in tum,
represent various types of intra- and interinstrument
Determining Instrument Integrity
inferences. In our study of the therapeutic effects of our
Sound and sensitive measures are needed to draw interventions, we wish to draw different types of in-
sound and sensitive inferences and conclusions about ferences at different stages of investigation. Whether
the effects of our treatments. Without sound measures, or not an instrument is sound and sensitive, therefore,
we cannot be certain that our measures reflect the be- depends upon whether or not it helps in the drawing of
haviors of interest; thus, we cannot be certain about the the inferences of interest.
therapeutic effects of our treatments. Without sound A similar method of appraising the soundness and
measures, we cannot be certain that changes in our sensitiveness of our instruments is put forth by the
measures reflect changes in the behaviors of interest; generalizability model (e.g., Cone, 1978; Cronbach,
thus, we cannot be certain about the therapeutic effects GIeser, Nanda, & Rajaratnam, 1972). The model as-
of our treatments. And without sensitive measures, we sumes that all measurement is a function of the condi-
cannot be certain that the absence of changes in our tions in which it is determined and that all variability in
measures reflect the absence of changes in the behav- measurement is a function of one or more of these
iors of interest; thus, we cannot be certain about the conditions. Of greatest interest to us are the measure-
therapeutic effects of our treatments. To date, we have ment conditions of test item, scorer, method, setting,
drawn upon four models to gauge the soundness and time, and response dimension (Cone, 1978), for these
sensitiveness of our assessment instruments: the psy- are the measurement conditions we are most interested
chometric model, the generalizability model, the ac- in generalizing across in our study of the therapeutic
curacy model, and the treatment validity model. All effects of our interventions. We estimate the soundness
are discussed below. of an instrument by correlating scores across the differ-
Basic to the psychometric model is the assumption ent items, by correlating scores obtained across differ-
that all measurement involves error; that is, all measure- ent scorers, by correlating scores obtained across dif-
ment reflects both phenomena of interest and phe- ferent points in time, or by correlating scores with
nomena of noninterest. The more a measure reflects the scores from other instruments presumably addressing
former as opposed to the latter, the more sound or the same phenomenon. We estimate the sensitiveness
reliable the measure is said to be. To estimate the relia- of an instrument by correlating scores across different
bility of an instrument, we correlate scores on one half settings or by correlating scores with scores from other
of the instrument with scores on the other half of the instruments addressing other aspects of presumably
instrument; we correlate scores on one form of the same phenomenon. The various ways of estimating
the instrument with scores on an alternative form of the the soundness and sensitiveness of an instrument de-
instrument; or we correlate scores on the instrument at note various types of intra- and interinstrument gener-
one occasion with scores on the instrument at another alizations or inferences. Whether or not a particular
occasion (e.g., Nunnally, 1978). The more that scores instrument is sound and sensitive, then, depends upon
on an instrument generalize to scores on a different the type of generalization or inference we are in-
instrument, the more sensitive or valid the instrument is terested in making.
said to be (e.g., Guion, 1980). To estimate the validity In the accuracy model, soundness and sensitiveness
of an instrument, we correlate scores on the instrument are synonymous with veridicality (Cone, 1981). The
with scores on a different instrument presumably ad- more veridical the representation of the phenomenon
dressing the same phenomenon of interest; we correlate of interest, the more sound and sensitive the measure-
ment is said to be. To determine the accuracy of an effects of our treatments must include a careful assess-
instrument, we compare its scores to those of an in- ment of the integrity of our treatments.
controvertible index of the phenomenon of interest. In At present, there is much controversy surrounding
other words, we compare scores on the instrument to the theoretical mechanisms of most behavioral tech-
those of some indisputable standard for the phe- niques. And, in all probability, there always will be.
nomenon of interest. There is, however, much consensus as to the mechan-
In the treatment validity model, soundness and sen- ics of most behavioral techniques. Thus, at present, the
sitiveness are synonymous with usefulness (Hayes, situation is such for us to begin assessing the integrity
Nelson, & Jarrett, 1986; Nelson & Hayes, 1981). The of our behavioral treatments. For example, in the area
more helpful an instrument is in implementing a treat- of children's fears and anxieties, all behavioral treat-
ment or enhancing the outcome of treatment, the more ments come with a protocol (cf. Barrios & O'Dell,
sound and sensitive the instrument is said to be. Ac- 1989). The protocol specifies the tasks that must be
cording to the model, we estimate the usefulness of an performed in order for the treatment to be operative-
instrument by comparing the efficiency of treatment the tasks that the therapist must perform, the tasks that
when the instrument is employed to the efficiency of the child must perform, and, in some cases, the tasks
treatment when the instrument is not employed. that the parent or teacher must perform. An interven-
The four aforementioned models for determining tion, such as imaginal desensitization, assigns the ther-
the integrity of our measures put forth different defini- apist the tasks of instructing the child in deep muscle
tions for the soundness and sensitiveness of our instru- relaxation exercises, constructing an anxiety hierarchy
ments. In the psychometric and generalizability mod- from the child's list of anxiety-provoking situations,
els, soundness and sensitiveness are equated with presenting each hierarchy scene to the relaxed child,
generalizability; in the accuracy model, they are equa- and re-presenting each hierarchy scene until success-
ted with veridicality; and in the treatment validity fully mastered by the child. To the child, the interven-
model, they are equated with efficiency. Each model tion of imaginal desensitization assigns the tasks of
has attracted a large body of followers who have been following the therapist's instructions to tense and relax
busy creating and implementing and evaluating assess- various muscles, compiling a list of various situations
ment instruments according to the tenets of the model. involving the feared stimulus, rank-ordering the vari-
As such, each model has contributed a sizeable ous situations according to the fear they engender,
number of studies to the literature on the therapeutic imagining each scene clearly while in a relaxed state,
effects of our behavioral interventions. Problems arise and eliminating the image of each scene when upset by
when we try to combine the different studies of the said scene. For the treatment of imaginal desensitiza-
different models. In other words, problems arise when tion to be operative, then, both therapist and child must
we try to convert the findings from the different studies faithfully perform their duties.
of the different models into a cumulative science of Assessing the integrity of imaginal desensitization
behavior modification. Recommendations for remedy- or any other behavioral treatment of a child's fears and
ing this situation are offered in a later section. anxieties should, therefore, be a rather straightforward
affair. All that is called for is to make note of the
fidelity with which the therapist and child and parent or
Determining Treatment Integrity
teacher perform their assigned duties, ruling on
Sound and sensitive inferences and conclusions whether or not the therapist and child and parent or
about the therapeutic effects of our treatments hinge teacher have performed their assigned duties faithfully.
upon the arrangement of measurement and manipula- It is as simple as that. Assessment of the integrity of
tion as well as the soundness and sensitiveness of the our behavioral treatments for children's fears and anx-
instruments we employ. They also hinge upon the ieties has, however, proven to be far from simple.
soundness and sensitiveness with which we carry out Assessment of the integrity of our behavioral treat-
our treatments (e.g., Cook & Campbell, 1979; ments for children's fears and anxieties has, in fact,
Sechrest, West, Phillips, Redner, & Yeaton, 1979). proven to be virtually nonexistant (cf. Barrios &
The degree to which we implement our treatments as O'Dell, 1989). We have failed to assess the integrity of
they are intended to be implemented is referred to as our treatments primarily because we have constructed
treatment integrity (Yeaton & Sechrest, 1981). It is no instruments for carrying out such assessments. This
obvious, then, that any careful study of the therapeutic is true not only of our treatments for children's fears
and anxieties but also of our treatments for virtually all often graphed the data from instruments of suspect
problem conditions. To remedy this situation, then, we soundness and sensitiveness; and as such we have
need to begin to develop and implement sound and often reached suspect conclusions regarding the thera-
sensitive instruments for the assessment of treatment peutic effects of our treatments. We have also on many
integrity. We need to do so in order to carry out careful occasions used statistical procedures with not so many
studies of the therapeutic effects of our treatments. In a subjects -a situation referred to as low power (Co-
later section, we will reiterate this plea for sound, sen- hen, 1977). Statistical procedures of little power have
sitive, and standardized assessment of the integrity of little precision in identifying the relationship between
our treatments. responding and treatment. As such, on many occa-
sions, we have been imprecise in identifying and delin-
eating the therapeutic effects of our treatments (e. g. ,
Analytical Techniques Kazdin, 1986). A sensible tact for us to begin taking is
to use the two types of procedures in conjunction with
As mentioned earlier, all studies of the effects of our each other when appropriate. That is, when we have
treatments consist of an arrangement of measurement sound measures from sufficient numbers of subjects, it
and manipulation. The arrangement of measurement may be profitable to employ both types of data analytic
and manipulation yields a pattern of responses; the procedures. Albeit redundant, the joint use of visual
pattern of responses yields a series of interpretations; and statistical techniques will corroborate the findings
and the series of interpretations yields a set of in- from either one of the techniques in isolation-offer-
ferences about the therapeutic effects of our treating us greater certainty as to the exact nature of the
ments. Identifying and delineating the therapeutic ef- pattern of responding obtained.
fects of our treatments begin, then, with delineating There are also two types of procedures for detecting
and identifying the pattern of responses obtained. To the pattern of responding across a series of studies:
aid us in doing so, we draw upon various data analyti- rational analysis and meta-analysis. Rational analytic
cal techniques. procedures are the traditional ways we have gone about
All of our data analytical procedures can be classi- reviewing the literature on the therapeutic effects of
fied into one of two groups: those that assist in the our treatments. That is, we first retrieve all of the stud-
delineation and identification of a pattern of responses ies of the effects of a particular treatment. Second, we
within a single study or those that assist in the delinea- organize the studies along a number of presumably key
tion and identification of a pattern of responses across dimensions. Third, we compare the outcomes of stud-
a series of studies. Procedures for use in a single study ies at various points on these dimensions. And fourth,
are oftwo types: visual and statistical. The visual pro- we draw conclusions about the cross-study effects of
cedures provide us with graphic displays of the study's the treatment on the bases of these comparisons. Our
data; the graphic displays are inspected according to recent review of the literature on the behavioral treat-
logical guidelines; and from the logical inspection of ment of children's fears and anxieties serves as an ex-
these graphic displays, the relationship between re- ample of the rational analytic method (Barrios &
sponding and treatment is discerned (e.g., Gelfand & O'Dell, 1989). One hundred and twenty-two studies
Hartmann, 1984; Huitema, 1986; Tukey, 1977). The from the years 1924 to 1985 were gathered and
statistical procedures provide us with quantitative grouped first in terms of the type of treatment (e.g.,
statements about the study's data. They provide us systematic desensitization, modeling, contingency
with estimates of the direction and degree of associa- management). All studies of a particular treatment
tion between treatment and responding, with estimates were then classified along a number of subject, prob-
of the probability of obtaining such association by lem, and procedural dimensions. The subject dimen-
chance, and with estimates of the probability of such sions were number, gender, and age; the problem di-
association's deviating from some comparison value mensions were nature and duration of fear reaction;
(e.g., Wampold, 1987). and the procedural dimensions were number of ses-
To date, we have viewed and used the visual and sions and duration of treatment. Comparisons of the
statistical procedures as if they were antithetical to one outcomes of the studies at different points along each
another, which, of course, they are not. To date, we dimension were made; comparisons of the outcomes of
have abused the two types of procedures by using them studies of different treatments at similar points along
when it is inappropriate to do so. For example, we have each dimension were also made.
Rational analytic procedures yield qualitative state- that use of meta-analytic procedures will detract much
ments about the pattern of responding across studies; needed attention away from the much needed tasks of
meta-analytic procedures yield quantitative statements developing sound assessment instruments, defining
about the pattern of responding across studies (e.g., the outcome of treatment, assessing the integrity of
Garfield, 1983; Michelson, 1985; M. L. Smith & treatment, and so forth. What is worse, there is the fear
Glass, 1977). Like the rational analytic procedures, that use of meta-analytic procedures will delude us into
the meta-analytic procedures first call for the gathering thinking that we have already completed the tasks of
of all studies on the effects of a particular treatment. developing sound assessment instruments, defining
An effect size is then computed for each of the studies, the outcome of treatment, assessing the integrity of
with the effect size serving as both a quantitative index treatment, and so forth.
and common metric of treatment outcome across the Despite these reservations of ours, we would do
different studies. Next, the studies are classified along well to begin using meta-analytic procedures in the
a number of key subject, problem, and procedural di- systematic study of the effects of our treatments. Meta-
mensions. Effect sizes of various studies at various analytic procedures do not preclude the use of rational
points along a dimension are then compared statis- analytic procedures; in fact, careful use of meta-ana-
tically. Through such statistical comparisons, we end lytic procedures is predicated on the use of certain
up with a set of probability statements-statements rational analytic procedures (e.g., Strube & Hart-
about the probability of the differences between the mann, 1983). For example, the studies we include for
effect sizes of different studies being a function of analysis are selected on the bases of certain rational
chance. criteria. The dimensions we include for classification
To date, we have made frequent use of rational ana- of the studies are also selected on a rational basis. The
lytic procedures in our inspection and integration of main advantages of meta-analytic procedures are two:
findings from different studies; we have made infre- they render explicit what heretofore has been a rather
quent use of meta-analytic procedures in the service of implicit process and they quantify the process of com-
these same activities. This is quite odd given behavior paring and combining studies (Kazdin, 1987). In other
modification's longstanding emphasis on measure- words, meta-analytic procedures allow for standard-
ment. The reasons for our preference for rational ana- ization and quantification-two necessary conditions
lytic methods over meta-analytic methods appear to be for a cumulative science of behavior modification. For
four. First is the recency with which the meta-analytic these reasons, we recommend their increased usage.
procedures have appeared on the scene. Most of us
have yet to be educated in the mechanics and merits of
the many different meta-analytic procedures. Second Arguments
is the incredulity of the findings of early meta-analytic
studies (cf. Wilson & Rachman, 1983). Most of the The many arguments against the use of group strat-
early meta-analytic studies found no differences in the egies in behavior modification research are of three
effectiveness of various behavioral interventions, no types: ethical, practical, and interpretive (cf. Barlow
differences in the effectiveness of various behavioral & Hersen, 1984). Ethical objections center around the
and nonbehavioral interventions-findings quite at withholding of treatment for some subjects while ad-
odds with the experience of most behavior modifica- ministering treatment to other subjects. For those sub-
tion experts. Third is the tendency on the part of users jects from whom treatment is withheld, suffering per-
of meta-analytic techniques to disregard differences in sists; whereas for those subjects to whom treatment is
data quality among the studies they combine and com- administered, suffering is alleviated. Such an arrange-
pare (Eysenck, 1978). Because sound inferences and ment is seen by some behavior modifiers as morally
conclusions are predicated in part on sound measure- unacceptable, thus the ethical objections to the use of
ment, most of us are suspicious of inferences and con- group strategies in behavior modification research. On
clusions drawn from a summary of measures of sus- a practical level, group strategies call for an enormous
pect soundness. To wit, most of us are suspicious of investment in time, energy, and resources. Subjects
findings based on the combining and comparing of need to be recruited and selected; assessors need to be
measures of mixed quality. And fourth is the fear that trained and monitored; therapists need to be trained
meta-analyses will retard rather than advance the study and monitored; and so on and so forth. To many, this
ofthe effectiveness of our treatments. There is the fear investment is so great as to make the strategies prohib-
itive. And then there are the interpretive objections to though, is the size of the potential yield. With group
group strategies. Most data analytic techniques used in strategies, there is the possibility of great gains-great
conjunction with group strategies combine the scores gains in the establishment of a therapeutic effect, great
of individual subjects into a single score for the entire gains in the identification of the agents of said effect,
group of subjects. Such a group score is seen as having great gains in the determination of the generality of
unknown meaning for any individual subject; thus, said effect, and great gains in the determination of the
such a group score is seen as of questionable relevance relative effects of different treatments (e.g., Kazdin,
for any individual subject. For example, the pattern of 1980; Paul, 1969). Whether or not such gains are real-
responding of the group across the course of treatment ized depends upon the precision with which the group
may not mimic the pattern of responding of any indi- strategies are carried out. To the question, then, of
vidual subject across the course of treatment; the net whether or not the potential yield of group strategies
gains of treatment for the group may not match the net warrant the sizable investment, we answer "It de-
gains of treatment for any individual subject; and the pends." If the prospects of carrying out the group strat-
treatment findings of the group may not generalize to egy with precision are good, then certainly the poten-
any individual outside of said group. In sum, the argu- tial yield of said strategies would justify the
ment is that group findings tell us little about the treat- investment. If, however, the prospects of carrying out
ment of the individual. the group strategies with precision are poor, then the
For each of the aforementioned arguments against prospects of realizing the potential yield of said strat-
group strategies, there is a compelling counterargu- egies would also be poor; thus, the investment would
ment. First, let us consider the ethical objection. Dur- not be justified.
ing the early stages of the investigation of a treatment, Third is the interpretive objection. Recall that an
we are interested in establishing the presence of a ther- ultimate objective of ours is the derivation of a set of
apeutic effect and attributing said effect to our treat- general empirical guidelines for treatment selection,
ment. To do so, we compare responding when the and that it is by classifying and combining the findings
treatment is in operation to responding when the treat- from individual subjects that we arrive at such a set of
ment is not in operation. This is true, be the strategy guidelines. With group strategies, much classifying
employed a group or a single-case one. Thus, group and combining of individual subject data are explicit;
strategies are not the only research strategies that are whereas with single-case strategies, this classifying
guilty of withholding treatment from subjects; all re- and combining of individual subject data are implicit
search strategies do; thus, all research strategies are (i.e., replication). Be it our custom to overlook the
subject to the same criticism. This criticism is applica- individual when using group strategies, there is noth-
ble to group strategies only during the early stages of ing inherent in the nature of group strategies that pro-
investigation of a treatment. Once we have established hibits our looking at the individual subject. In fact,
a causal relationship between our treatment and a ther- judicious use of group strategies calls for examination
apeutic effect, our aim is to determine the specific of the individual (Ross, 1981). Through inspection of
therapeutic agents behind said effect, the generality of the individual, insights are gained into the optimum
said effect, and the relative effectiveness of our treat- ways of classifying and combining the data from indi-
ment and other treatments. To this end, we draw upon vidual subjects. Through inspection of the individual,
group strategies for assistance-none of which neces- information is gained on the accuracy of a given set of
sarily involves the withholding of treatment (e.g., guidelines for treatment selection. Thus, judicious use
Kazdin, 1986). of group strategies does not exclude attention to the
Second is the practical objection. It is true that group individual subject; judicious use of group strategies
strategies call for an enormous investment of time, includes attention to the individual subject.
energy, and money. It is also true that all research calls
for some commitment of time, energy, and money. To
think otherwise is to delude ourselves about the real- Admissions and Admonitions
ities of research. What is more, it is true that all re-
search involves some yield. The issue, then, is not the There are many matters in the study of the effects of
size of the investment per se but the size of the invest- our treatments in which group strategies are of great
ment in relation to the size of the yield. With group help to us. We have made mention of these many mat-
strategies, the size of the investment is great; so, teo, ters throughout the course of this chapter (e.g., estab-
lishment of a therapeutic effect, identification of the do well to invest in reaching an agreement among our-
agents of said effect, determination of the generality of selves on the definition of the problem space, the defi-
said effect). There are many matters, though, in which nition of the outcome of treatment, and so forth. And
group strategies are of no help to us at all. For example, having done so, we behavior modifiers would do well
group strategies are of no help to us in defining the to limit our comparisons of different treatments to
problem space or defining the population of interests those that clearly fall within the behavioral paradigm
or defining the outcome of treatment. What is more, (cf. Bellack & Hersen, 1985). For doing so is what is
group strategies are of no help to us in selecting assess- needed if we are ever to have a cumulative science of
ment instruments or in determining the soundness and behavior modification.
sensitivity of those assessment instruments. Of help to
us in these matters is theory. It is theory that guides us
in performing each one of these tasks. Group strategies
assist in determining the wisdom of such guidance, but
A Plea for Standardization and
they do not and cannot offer such guidance per se. Quantification
Thus, we should not look to group strategies for help in
performing these tasks. Two hallmarks of science are standardization and
We also should not look to group strategies for help quantification. Both contribute to the detection and
in assimilating the findings of research into clinical delineation of lawful relationships among variables.
practice. Group strategies are a means of producing Through standardization, repeatable and replicable
findings regarding the effectiveness of our treatment; observations of variables are possible; through quan-
they are not a means of producing changes in clinical tification, careful and exact specification of their rela-
practice in light of said findings. Other strategies are tionship is possible (Nunnally, 1978). Little stand-
called for (e.g., Backer, Liberman, & Kuehnel, 1986). ardization and quantification can be found, though, in
Thus, it is to these other strategies we should look to our studies of the effects of our behavior modification
for help in assimilating research into practice. techniques. For example, we have no standardized sys-
There are instances in which group strategies can be tem of classification of problem conditions or stan-
of much assistance to us, but that would be much better dardized procedure for assessment of each of the prob-
postponed for now. One such instance is the com- lem conditions. We have no standardized treatments
parison of the effects of conceptually diverse treat- for each of the problem conditions nor do we have
ments (e.g., behavior therapies vs. insight-oriented standardized instruments for assessing the integrity of
therapies). For a comparison of, say, the effects of a the treatments. What is more, we have no standardized
behavior therapy to the effects of an insight-oriented decision rules for combining the various costs and ben-
therapy to be a valid one, there first must be concur- efits of these treatments (e.g., Mash, 1985). All are
rence on the definition of the problem space. Next, needed, though, if we are to have a cumulative science
there must be concurrence on the definition of the pop- of behavior modification.
ulation of interest and the definition of the outcome of Also needed is a shift away from the study of di-
treatment. Finally, there must be concurrence on the chotomous variables to the study of continuous vari-
instruments for assessing treatment outcome and treat- ables. Heretofore, we have dichotomized the variable
ment integrity. Given such concurrence and a powerful of performance into problematic and nonproblematic,
group strategy, a valid comparison of the effects of the the variable of manipulation into treatment and non-
two conceptually diverse treatments is possible (e.g., treatment, and the variable of outcome into success
Kazdin, 1986). At present, such a comparison is not and failure. And having done so, we have sought to
possible, for there is very little concurrence among specify the relationships among them. Such a tact
different schools of psychotherapy on the definition of yields a very gross sketch of the relationships among
the problem space, the definition of the population of the variables. For a finer picture, finer discriminations
interest, and so forth. What is worse, at present there is are needed of the different levels of the different vari-
little consensus within the school of behavior modifi- ables. Such discriminations are obtainable through
cation on these same issues (e.g., Barrios, 1988; Kra- more sophisticated scales of measurement (e.g., inter-
tochwill, 1985). We behavior modifiers, then, would val). The need, then, is for us to develop more precise
do well not to invest in comparisons of conceptually quantitative indices of the variables of performance,
diverse treatments. No, we behavior modifiers would manipulation, and outcome.
Summary To continue with the metaphor of the factory is to
continue widening the division between labor and
There is no end to the search for an answer to the product, laboratory and clinic, and theory and prac-
question, "What treatment, by whom, is most effec- tice. A more unifying metaphor is needed. To this end,
tive for this individual with that specific problem, un- we suggest the family farm. In the metaphor of the
der which set of circumstances?" (Paul, 1967, p. 11). family farm, we have the sense of history and con-
Thus, there is no end to research on the effects of our tinuity and care that is needed to carry out research
behavior modification treatments. Our studies on the indefinitely. In the metaphor of the family farm, we
effects of our behavior modification treatments will have the virtues and values of independence, interde-
continue to make use of group strategies or single-case pendence, cooperation, patience, perseverance, and
strategies or combined strategies. What will inspire perspective-the virtues and values needed to stimu-
and sustain us, though, in our continued study of the late and support us in our never ending study of the
effects of our behavior modification treatments? effects of our behavior modification treatments.
The answer is a metaphor. It is a metaphor that has Whether we adopt the metaphor of the factory or the
seen us to this point and it is a metaphor that will see us metaphor of the family farm, progress in the develop-
into the future. The question is: Do we wish to con- ment of a set of sound, empirical guidelines for treat-
tinue drawing upon the same metaphor for guidance ment selection will be slow. Such is the nature of be-
and sustenance? In other words, do we wish to con- havior modification research. Be it slow, progress in
tinue looking to the metaphor of the factory to drive the study of our behavior modification treatments does
and direct our investigative efforts? For it is the meta- not have to be unsystematic. The framework described
phor of the factory that has served to organize and in these pages is one that will facilitate systematic
guide our research efforts to date (e.g., Agras & gains in our understanding of the effects of our behav-
Berkowitz, 1980). And it is the metaphor of the factory ior modification treatments, systematic gains in our
that has had grave consequences for the field of behav- development of a set of sound, empirical guidelines for
ior modification. treatment selection. It will do so for it will lend proper
Behavior modification research as factory has led to focus and scale and significance to our research
many destructive divisions-division of labor, divi- efforts. And proper focus and scale and significance
sion between product and process, division between are what are very much needed at this juncture in our
laboratory and clinic, and division between theory and study of behavior modification treatments.
practice. Research on the effects of our treatments has
been dismembered into a number of different tasks-
assessment, treatment, and data analysis. And the dif-
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of Consulting Psychology, 31, 109-118.
CHAPTER 9
Single-Case Experimental Designs

Michel Hersen
Introduction 1986; Guyatt et al., 1986; Louis, Lavori, Bailar, &

Polansky, 1984; Mcleod, Cohen, Taylor, & Cullen,
Behavior modification and therapy perhaps are best 1986; Robin & Burke, 1986). Thus, the widespread
distinguished from other therapeutic and educational application attests to both its popularity and its utility.
approaches by their dependence on the experimental- The importance of the single-case experimental
empirical methods for solving human problems. Thus, study to behavior therapy was best illustrated by Yates
in evaluating the efficacy of emerging therapeutic and (1970). Indeed, he felt compelled to define behavior
educational techniques, a large variety of experimental therapy specifically in relation to single-case meth-
strategies has been carried out by behavioral re- odology. He argued that
searchers. Included, of course, are both group-com-
parison designs (cf. Kazdin, 1980) and single-case ex- behavior therapy is the attempt to utilize systematically that
perimental designs (Barlow & Hersen, 1984; Hersen body of empirical and theoretical knowledge which has resulted
from the application of the experimental method in psychology
& Barlow, 1976). and its closely related disciplines (physiology and neu-
Although group comparison and single-case design rophysiology) in order to explain the genesis and maintenance
strategies are both well within the armamentarium of of abnormal patterns of behavior; and to apply that knowledge
to the treatment or prevention of those abnormalities by means
behavioral researchers, the single-case design ap-
of controlled experimental studies of single cases, both descrip-
proach to evaluating technical efficacy is almost tive and remedial. (p. 18).
uniquely tied in with the behavioral movement of the
least two decades. That is, the single-case research This strong link between behavior therapy and re-
approach has been followed not only in clinical psy- search is reflected in the single-case publications in
chology (Hayes, 1981), psychiatry (Barlow & Hersen, psychological (e.g., Journal of Consulting and Clini-
1973), and education (Risley & Wolf, 1972; Thoresen, cal Psychology), psychiatric (American Journal ofPsy-
1972), but also in the practice of social work (Thomas, chiatry. Archives of General Psychiatry), and, of
1978), rehabilitation (Martin & Epstein, 1976; Van course, the behavioral journals (e.g., Behavior Modifi-
Hasselt & Hersen, 1981), behavioral medicine (Bar- cation, Behaviour Research and Therapy, Behavior
low, Blanchard, Hayes, & Epstein, 1977), and, most Therapy, Journal ofApplied Behavior Analysis, Jour-
recently, internal medicine (Anonymous Editorial, nal of Behavior Therapy and Experimental Psychia-
try).
In this chapter, we first briefly trace the history of
Michel Hersen • Department of Psychiatry, Western Psychi-
atric Institute and Clinic, University of Pittsburgh School of the single-case approach, particularly as it relates to
Medicine. Pittsburgh, Pennsylvania 152l3. the problems and limitations of the group comparison
175
method. This is to be followed by a discussion of more brains of experimental animals were systematically
general issues involved in research, such as variability, excised (i.e., the extirpation of parts). The relationship
intrasubject averaging, and the generality of findings. of such surgical excisions and subsequent behavioral
Next, we outline the basic procedures followed in sin- changes in single organisms was meticulously studied,
gle-case evaluations: repeated measurement, choice of thus providing "an anatomical map of brain func-
a baseline, changing of one variable at a time, length of tions." The critical point to be underscored here is that
phases, distinction between reversal and withdrawal, findings of wide generality were gleaned on the basis
and evaluation of irreversible procedures. Then we of experimental work with very few research subjects.
discuss and illustrate A-B-A designs and their exten- It is generally agreed that Fechner's publication in
sions (e.g., interaction designs, drug evaluations). 1860 of Elemente der Psychophysik heralded the be-
This is followed by our examination of additional de- ginning of experimental psychology. In this treatise,
sign strategies (e.g., the three types of multiple-base- Fechner described studies he had conducted, using in-
line designs, the multiple-schedule and simultaneous- dividual subjects, to determine sensory thresholds and
treatment designs, and the changing criterion design). just-noticeable differences in a variety of sense modal-
Next, we tackle the thorny issue of the role of statis- ities. Although he did apply some statistical methods
tical analyses in evaluating treatment efficacy in sin- in evaluating his work, such statistics were employed
gle-case studies. Highlighted are the arguments in sup- to ascertain variability within a given subject. Follow-
port of and against the use of such statistical ing Fechner's studies in psychophysics, Wundt and his
techniques. Finally, we discuss the importance of rep- colleagues evaluated sensation and perception, while
lication in single-case research. Three types of replica- Ebbinghaus assessed the processes of learning, devel-
tion methods are to be considered: direct, clinical, and oping a new tool for conducting such research: the
systematic. nonsense syllable. Both of these giants in the history of
psychology accomplished their goals by studying indi-
vidual subjects. Later, in the early part ofthe twentieth
History century, Pavlov's classical experiments in physiology,
learning, and conditioning were all conducted with
An historical perusal clearly shows that the single- single organisms.
case approach, as currently applied, owes its heritage With the emergence of the group comparison meth-
to many disciplines (cf. Barlow & Hersen, 1984; ods, bolstered by the statistical genius ofR. A. Fisher
Hersen & Barlow, 1976, Chapter 1; Kazdin, 1978). in the 1930s (i.e., inferential statistics), interest in the
There can be no doubt that the single-case study has single-case approach during the middle part of this
been important in the development of physiology, century waned considerably. Of course, the psycho-
medicine, early experimental psychology, and psychoanalysts did (and continue to) publish their descrip-
analysis. In all of these disciplines, many critical find- tions of protracted treatments of individual patients.
ings have emerged from the careful study of individual Probably the first was Breuer and Freud's case history
organisms and subjects. published in 1895 (1957), describing the systematic
The tradition of single-case research dates back to treatment of Anna O's hysterical symptoms. (Paren-
the 1830s, as exemplified by the work of Johannes thetically, we might note that Hersen and Barlow,
Milller and Claude Bernard in physiology. More 1976, Chapter 1, have likened Breuer and Freud's ap-
important from a historical perspective, however, is proach to the multiple-baseline design across behav-
the contribution of Paul Broca in 1861. At that time, iors.) Nonetheless, these reports, albeit of tremendous
Broca was treating a patient who had suffered a severe therapeutic import, generally had subjective in-
speech loss. However, the patient died while still un- terpretations of results, in that usually no hard data
der his care. Broca subsequently performed an autopsy were presented. However, the psychoanalytic case
and discovered a lesion in the man's cerebral cortex study certainly may be considered one of the anteced-
(i.e., in the third frontal convolution). He correctly ents to the single-case experimental tactic.
assumed that this part of the brain controlled speech In the 1920s and 1930s, there were some sporadic
functions. As pointed out by Barlow and Hersen descriptions of the behavioral treatment of individual
(1984), Broca's clinical method was an extension of cases of unusual interest (cf. Max, 1935; 1. B. Watson
prior work done in laboratories in which parts of the & Rayner, 1920). But these single-case descriptions
CHAPTER 9 • SINGLE·CASE EXPERIMENTAL DESIGNS 177
appear to have had little impact on therapeutic attitudes tients and "spontaneous remission" rates (evaluated
of the day and on subsequent strategies developed to from insurance company records) and concluded that
assess therapeutic efficacy. the effects of psychotherapy (as then practiced) were
There are several other historical antecedents that negligible at best. This finding, of course, sparked a
warrant our attention. Most outstanding, of course, is tremendous controversy in the psychological world,
the operant work of B. F. Skinner and his students in which still rages at times. Bergin (1966) reevaluated
the 1940s and 1950s. Skinner (1966) has stated his the disappointing results of psychotherapy when con·
philosophy of research in very succinct form: "Instead trasted with control group procedures and discovered
of studying a thousand rats for one hour each, or a that some patients improved as a function of treatment,
hundred rats for ten hours each, the investigator is whereas others actually worsened. Indeed, the statis-
likely to study one rat for a thousand hours" (p. 21). tical averaging of results (employing the group com-
The specific experimental strategies used in the experi- parison method) led to a canceling of treatment effects
mental analysis of behavior (with special emphasis on for a fairly substantial number of patients.
research with animals) were compiled and elucidated Bergin's (1966) work in particular clearly indicated
in Sidman's (1960) now-classic tome entitled Tactics some of the limitations of the group comparison ap-
ofScientific Research. However, this book was written proach to studying the efficacy of psychotherapy. As
prior to the plethora of behavior therapy studies that noted by Hersen and Barlow (1976), "These difficul-
appeared in the 1960s, the 1970s, and now in the ties or objections, which tend to limit the usefulness of
1980s. (For a more comprehensive description of the a group comparison approach in applied research, can
use of single-case strategies as applied to humans in be classified under five headings: (1) ethical objec-
therapeutic endeavors, the reader is referred to Hersen tives, (2) practical problems in collecting large num-
and Barlow, 1976, and Barlow and Hersen, 1984). bers of patients, (3) averaging of results over the
In the more clinical realm, the contribution of group, (4) generality of findings, and (5) inter-subject
Shapiro (1966) and Chassan (1967) must not be over- variability" (p. 14).
looked. Both were committed to the intensive study of We briefly comment here on each of these limita-
the single case in a methodologically rigorous manner. tions in turn. First, with regard to ethical concerns, the
Although neither of the two used the current nomen- primary one is that in the group comparison strategy,
clature (e.g., A-B-A) for describing their single-case the control group subjects do not receive treatment
strategies, a number of the reported cases (e.g., and, of consequence, are denied potential benefits.
Shapiro & Ravenette, 1959) bear a striking similarity This objection, naturally, is predicated on the notion
to the prototypical A-B-A design. However, for the (albeit erroneous at times) that the treatment being
most part, the work of Shapiro and Chassan may be evaluated is efficacious in the first place (cf. Eysenck,
described as correlational. That is, the experimental 1952). Second, the practical problems in identifying
control of therapeutic variable over dependent mea- and matching subjects in large-scale group comparison
sures is not as clearly specified as in the reports of studies, in addition to selecting and remunerating suit-
today's behavior analysts (cf. Hersen & Barlow, 1976; able therapists, are overwhelming. Moreover, this ap-
Kazdin, 1975). proach to research is time-consuming and usually re-
quires large federal allocations. It is not at all uncom-
mon for a 3- to 4-year outcome study in psychotherapy
Group Comparison Designs to cost the National Institute of Mental Health upward
of $600,000. Third, already discussed, are the pitfalls
It was in the late 1940s and 1950s that the effects of involved in the statistical averaging of patients who
psychotherapy began to be evaluated in large-scale improve or worsen as a function of treatment. Such
group comparison designs (see Rubenstein & Parloff, problems led Paul (1967) to conclude that psycho-
1959, for a review ofthe issues). However, very quick· therapy researchers should identify the patient who
1y some of the major shortcomings were pointed out in would profit from a specific therapy under very specif-
both the therapeutic techniques themselves (cf. Ey- ic circumstances. Fourth is the issue of generality of
senck, 1952) and the design strategies carried out by findings. Inasmuch as group averaging may "wash
clinical researchers (cf. Bergin, 1966). Eysenck out" the individual effects of particular treatments, the
(1952) compared the improvement rates of treated pa- practicing clinician in the community cannot ascertain
which specific patient characteristics may be corre- With the advent of behavior therapy and the emer-
lated with improvement. Nonetheless, if a study of this gence of a new journal devoted to the experimental
kind is planned prospectively (usually a factorial de- study of the individual in depth (Journal of Applied
sign), such information may be teased out statistically. Behavior Analysis), much of the scientist-practitioner
Fifth is the concern with intersubject variability. Al- split was bridged. Although initially the great majority
though ideally in the group comparison study a fre- ofthe work was operant in nature, more recently other
quent objective is to contrast homogeneous groups of types oftherapeutic strategies (e.g., systematic desen-
patients, in practice this often is neither feasible nor sitization) have also been assessed by means of single-
practicable. (It is obviously impossible to control for case methodology (see Van Hasselt, Hersen, Bellack,
the individual learning histories of patients, irrespec- Rosenblum, & Lamparski, 1979). Generally, single-
tive of whether the presenting symptoms are identical. case research as now practiced is referred to as the
That is, different etiologies may result in identical experimental analysis of behavior (Baer, Wolf, &
symptom patterns.) Thus, again, the unique response Risley, 1968, 1987).
of the individual patient to treatment is lost. Also, in
most group comparison studies, the effects of treat-
ment are indicated on a pre-post basis. As a result, the General Issues
vicissitudes oftherapeutic response throughout the full
course of treatment are not clarified. This certainly is
one area of marked import to every practicing clini- Intrasub;ect Variability
cian, who knows through experience about the "ups To determine the sources of variability in the subject
and downs" of responsivity to treatment, regardless of is probably the most important task of the single-case
the theoretical approach represented. researcher. The assessment of variability, of course, is
facilitated by observing the individual over time under
highly standardized conditions (i.e., repeated mea-
surement). In the quest to determine the causes of vari-
Experimental Analysis of Behavior
ability, the greater the control over the subject's en-
vironment (external and internal), the greater the
In addition to the problems inherent in evaluating likelihood of accurately identifying such variability.
the effects of psychotherapy in group comparison de- As noted by Hersen and Barlow (1976), the task is
signs, some other factors contributed to the growing made easier by studying lower organisms (e.g., the
importance of the single-case approach in the late white rat):
1960s and through the 1980s. First was the then-preva-
lent scientist-practitioner split. That is, many clinical In response to this, many scientists choose to work with lower
life forms in the hope that laws of behavior will emerge more
psychologists pursued esoteric research interests that rapidly and be generalized to the infinitely more complex area of
had little or no bearing on the work they conducted human behavior. Applied researchers do not have this lUXUry.
with their patients. Indeed, often the research carried The task of the investigator in the area of human behavior disor-
out by such clinicians was only of academic import. As ders is to discover functional relations among treatments and
specific behavior disorders over and above the welter of environ-
late as 1972, Matarazzo pointed out that "even after 15 mental and biological variables impinging on the patient at any
years, few of my research findings affect my practice. given time. Given these complexities, it is small wonder that
Psychological science per se doesn't guide me one bit. most treatments, when tested, produce small effects. (p. 35)
I still read avidly but this is of little direct practical
help. My clinical experience is the only thing that has In identifying sources of variability at the human
helped me in my practice to date" (Bergin & Strupp, level, the researcher needs to consider biolog-
1972, p. 340). As earlier argued by Hersen and Barlow ical,cognitive, and environmental variables. Although
(1976), these three systems are obviously interconnected, each
has some unique contributions to the problem. Biolog-
Since this view prevailed among prominent clinicians who were ical or cyclical variability in human beings (and ani-
well acquainted with research methodology, it follows that clini- mals, for that matter) is best represented by the
cians without research training or expertise were largely un-
affected by the promise of substance of scientific evaluation of female's estrus cycle. As is well known clinically and
behavior change procedures. (p. 22) is equally well documented empirically (see Hersen &
CHAPTER 9 • SINGLE-CASE EXPERIMENTAL DESIGNS 179
Barlow, 1976, Chapter 4), the dramatic hormonal absolving him from all household responsibilities)
changes that occur in women throughout the entire while concurrently ignoring any of the few positive
cycle (be it 24, 28, or 30 days) often yield equally verbal and motoric initiatives he did take. It was only
dramatic changes in mood, affect, and behavior. Ap- when the family was instructed and taught to reverse
plied behavioral researchers evaluating effects of ther- the contingencies (i.e., to ignore symptomatic presen-
apeutic interventions, particularly in female subjects tation and to reinforce positive verbal and motor be-
whose menstrual changes in behavior are extreme, haviors) that there was a marked change in the patient's
need to consider this factor when deriving conclusions behavior that maintained itself through a lengthy post-
from their data. Thus, it is quite conceivable that a treatment follow-up period.
behavioral intervention may coincide with a given part
of the cycle, yielding changes in behavior (either im-
provement or worsening) and thus confounding the Intersubject Variability
possible controlling effects of the specific behavioral
technique. Indeed, what behavioral change does take To this point, we have focused our discussion on the
place simply may be due to biological (internal) mech- attempt to ascertain the sources of variability within
anisms. Certainly, in the case of the woman whose the individual subject. However, another type of vari-
post-menses mood typically improves, improved ability that concerns the single-case researcher in-
mood after introduction of a behavioral treatment for volves the differences between and among subjects in
depression may have nothing to do with the behavioral reaction to a therapeutic or educational procedure.
intervention. To the contrary, improved mood most Small and large differences in responding between and
likely is the progression of natural biological events among subjects is termed intersubject variability. We
rather than therapeutic efficacy. have already touched on this issue when discussing the
Although of somewhat more recent interest to ap- limitations and problems of the group comparison ap-
plied behavioral researchers (cf. Bellack & Schwartz, proach to research. There we pointed out how some
1976; Hersen, 1979, 1981; Meichenbaum, 1976), the patients may improve as a function of treatment,
importance of the subject's cognitions can be neither whereas others may worsen. But when the entire treat-
ignored nor discounted. The strict operant interpreta- ment group's data are averaged and contrasted with the
tion of behavior, albeit more parsimonious, probably control condition, no statistically significant dif-
fails to reflect completely what truly distinguishes ferences emerge. From the aforementioned, it is clear
human beings from the lower species. Thus, when that intersubject variability poses an enormous prob-
repeated measurements are conducted, the subject's lem for tile group comparison researcher, even if ho-
emotional-cognitive state requires attention, both as to mogeneous groups are to be contrasted. For tile single-
how he or she feels and thinks over time (a dependent case researcher who is conducting replications of treat-
measure) and also as to how such thinking and feeling ments in a series of patients (presumably homoge-
themselves can be causative agents for alteri!lg overt neous witll regard to a particular disorder), intersubject
behavior. variability is also a problem but may result in subse-
Finally, but hardly least of all, we must consider the quent refinements of procedures. In addition, with ex-
contribution of the external environment (i.e., the con- tensive intersubject variability, the power of a particu-
tingencies of reinforcement) on specific behavioral lar procedure may be determined in addition to an
manifestations. To date, most of the work in single- evaluation of its possible limitations.
case methodology has been devoted to elucidating the More specifically, a behavioral treatment for de-
environmental variables that control directly observ- pression may prove efficacious for botll males and
able motor responses (cf. Kazdin, 1975). For example, females who have had no prior episodes of tile disor-
in a case of conversion reaction where the patient pre- der. On the other hand, for those patients who have
sented himself as unable to walk, Kallman, Hersen, suffered several prior depressive episodes, the same
and O'Toole (1975) clearly documented how the fami- technique may be only partially effective. Under these
ly's reactions to the symptoms resulted directly in the circumstances, the single-case researcher may alter
patient's continued symptomatology. That is, the fami- some aspect of the treatment strategy in the hope of
ly tended to reinforce the patient's verbalizations about getting improved results. As stated in Hersen and Bar-
symptoms (as well as serving him meals in bed and low (1976),
the task confronting the applied researcher at this point is to Generality of Findings
devise experimental designs to isolate the cause of change, or
lack of change. One advantage of single case experimental de-
signs is that the investigator can begin an immediate search for
As will be apparent in the following sections of this
the cause of an experimental behavior trend by altering his ex- chapter, the main objective of the experimental analy-
perimental designs on the spot. This feature, when properly em- sis-of-behavior model (i.e., the single-case design) is
ployed, can provide immediate information on hypothesized to demonstrate the functions of the therapeutic or edu-
sources of variability. (p. 40)
cational strategy that control the target behavior of
interest. However, single-case researchers are intent on
On the other hand, the same behavioral treatment ap- demonstrating this functional relationship not only in
plied to depressives who have had prior episodes may the individual case but also for other individuals who
yield absolutely no change if the patients in addition bear similar characteristics. This, then, is referred to as
are severely obsessive. At this point, the upper limits subject generality. That is, the same therapeutic strat-
of the behavioral strategy may have been discovered, egy should prove effective over a number of patients
and it behooves the single-case researcher to consider with homogeneous features. Such features may relate
either a different behavioral strategy or the combined to sex of the patients, their age, their diagnosis, their
(synergistic) effects of the behavioral-pharmacolog- premorbid personality structure, or the family history
ical approach (cf. Hersen, 1979, 1986). of the disorder under investigation.
A second kind of generality concerns the behavior
change agent (i.e., the therapist or educator). Given
Magnitude of Change the same type of patient and the identical therapeutic
strategy, do the unique characteristics of the therapist
In the section on statistical analysis, we consider in
affect the outcome? More specifically, is the male ther-
some detail the advantages and disadvantages of the
apist who carries out assertion training with an unas-
statistical versus the visual evaluation of data trends.
sertive female client as effective as the female therapist
However, here it is important to consider the magni-
doing the same treatment who is also highly committed
tude of change brought about by a particular interven-
to the goals of the women's movement? This naturally
tion. Because of the frequently exploratory nature of
is an empirical question whose answer can be deter-
single-case work, it is especially important to docu-
mined only via careful replication across different ther-
ment the power of the technique under consideration.
apists (see the sections of direct, clinical, and system-
For example, in the treatment of a depressed indi-
atic replication).
vidual, one may be able to document a statistically
A third type of generality deals with the setting in
significant change if the Beck Depression Inventory
which the therapeutic or educational technique is being
(BDI) score decreases, say, from 20 at baseline to
applied. That is, will a given intervention work as well
about 15 following treatment. However, the question
in one type of setting as in another? For example, if the
to be raised at this juncture is: How meaningful
flooding treatment of an agoraphobic in a rural setting
(clinically and socially) is this 5-point diminution?
appears to work, will the same therapy for an agora-
Certainly, a score of 15 on the BDI still represents a
phobic living in an urban center prove as efficacious?
considerable residue of depression. Thus, although
The three types of generality discussed above are
potentially of statistical significance, the therapeutic
problems for the single-case researcher. Indeed, critics
technique would have to yield a much greater change if
of the single-case approach must often point to gener-
it is to be considered of value to the practicing clini-
ality of findings as one of the weaker features of this
cian. In his incisive review of this issue, Kazdin (1977)
research strategy:
has argued about the importance of providing social
validation. That is, to be given clinical credence a
The most obvious limitation of studying a single case is that one
therapeutic technique should be able to bring about
does not know if the results from this case would be relevant to
sufficient change so that the treated individual ap- other cases. Even if one isolates the active therapeutic variable in
proaches the social norm. Thus, in the case of our a given client through a rigorous single case experimental de-
depressive, the change brought about should lead to a sign, critics . . . note that there is little basis for inferring that
this therapeutic procedure would be equally effective when ap-
posttreatment score of 0-5 on the BDI. Otherwise, the plied to clients with similar behavior disorders (client generality)
norm for the nonpathological population will not have or that different therapists using this technique would achieve the
been closely enough approached. same results (therapist generality). Finally, one does not know if
the technique would work in a different setting (setting gener- more difficult and more time-consuming. It is highly
ality). This issue, more than any other, has retarded the develop- unlikely that the kind of environmental control that one
ment of single case methodology in applied research and has
caused many authorities on research to deny the utility of study-
is capable of obtaining in the animal laboratory will
ing a single case for any other purpose than the generation of ever be possible in the clinical situation, because of the
hypotheses .... Conversely, in the search for generality of ap- multiplicity of variables impinging on human beings
plied research findings, the group comparison approach ap- as well as because of the more obvious ethical
peared to be the logical answer. (Hersen & Barlow, 1976, p. 53)
considerations.
However, as the old adage goes, "Appearances can
be misleading." A careful scrutiny of the group com-
General Procedures
parison strategy reveals that there are limitations here,
too, on establishing generality of findings. These have
Repeated Measurement
been discussed in considerable detail in Barlow and
Hersen (1984, Chapter 2), and the interested reader is The hallmark of the single-case experimental design
referred to that source. However, for purposes of ex- is that dependent measures are repeatedly taken during
position at this point, there are two problems that war- baseline and treatment phases. Such measures may
rant our attention. The first is that one cannot automati- involve the observation of motor behavior (e.g., the
cally infer that the results from a homogeneous group number of social interactions per half hour of free play
of subjects are necessarily representative of the popu- in a socially isolated child), the assessment of physio-
lation of such SUbjects. Second, and probably of para- logical functioning (e. g., the heart rate of a phobic
mount importance, it is difficult to take the average patient on presentation of the feared stimulus), or the
response of a group of subjects and generalize to the evaluation of the cognitive-attitudinal state of the sub-
individual case. In the section on replication (direct, ject (e.g., the score on a self-report anxiety or depres-
clinical, and systematic), we examine how single-case sion scale).
researchers have attempted to document the general Irrespective of the measurement system under con-
applicability of their findings. sideration, "the operations involved in obtaining such
measurements . . . must be clearly specified, observ-
able, pUblic, and replicable in all respects .... Sec-
Variability as Related to Generality
ondly, measurements taken repeatedly, especially over
On the surface, one would think that variability and extended periods of time must be done under exacting
generality are unrelated. However, on closer inspec- and totally standardized conditions with respect to
tion it is clear that by identifying as many sources of measurement devices used, personnel involved, time
variability as possible, single-case researchers are able or times of day, . . . instructions to the subject, and
to improve and refine their techniques so that overall the specific environmental conditions (e.g., location)
treatments have greater applicability to a wider range where the measurement session occurs" (Hersen &
of subjects. Sidman (1960) contended that Barlow, 1976, p. 71).
Each of the measurement systems poses some
tracking down sources of variability is then a primary technique unique challenges to the single-case researcher. When
for establishing generality. Generality and variability are basical-
ly antithetical concepts. If there are major undiscovered sources motoric measures are taken and human observers are
of variability in a given set of data, any attempt to achieve subject used, independent reliability checks are required.
or principle generality is likely to fail. Every time we discover These reliability checks can be expressed either as a
control of a factor that contributes to variability, we increase the percentage of agreement for interval data (with 80%
likelihood that our data will be reproducible with new subjects
and in different situations. Experience has taught us that preci- considered minimally acceptable) or as a correlation
sion of control leads to more extensive generalization of data. for continuous data (with r = .80 considered mini-
(pp. 50-51) mally acceptable). (For a more comprehensive survey
of behavioral assessment strategies, see Hersen &
Of course, Sidman was referring primarily to work Bellack, 1988).
with infrabuman species. Although the same prin- When physiological measures are repeatedly taken,
ciples hold in clinical and educational investigation this too must be done under totally standardized condi-
with human subjects, the methods for achieving con- tions. Here, investigators must be concerned not only
trol and ferreting out sources of variability are both with the functioning of the electronic devices but with
the subject's adaptation to the equipment. In addition, lectors (e. g., nursing personnel) assumes even greater
concern for fatigability is of some importance, particu- importance.
larly if intertrial time periods are not sufficiently long.
In cases where sexual responding in males is being
Choosing a Baseline
repeatedly evaluated, assessment sessions should be
programmed to guarantee maximum possible respond- With the exception of the B-A-B design, where
ing. Thus, the fatigue factor, if not properly attended to treatment precedes baseline assessment, in most sin-
in this instance, might lead to a confounding of conclu- gle-case experimental designs the initial period of ob-
sions. This could occur if decreased deviant sexual servation involves the natural frequency of occurrence
responding to stimuli is erroneously attributed to treat- of the behavior of interest. This initial phase is referred
ment but is, in fact, simply a function of satiation. to as baseline and is labeled A. Baseline serves as the
A major problem in using repeated self-reports of standard by which subsequent treatment phases are
subjects in single-case evaluations of treatments in- contrasted.
volves the external validity of such data. As noted by In the ideal case, the assessment of baseline func-
Hersen and Barlow (1976), "When using this type of tioning yields a stable pattern of data, thus facilitating
assessment technique, the possibility always exists, the interpretation of treatment effects in the B phase.
even in clinical subjects, that the subject's natural re- However, more often than not, such stability of data is
sponsivity will not be tapped, but the data in confor- not to be found. This is less of a problem for the basic
mity to experimental demand are being recorded" (p. animal researcher, who is in a position to program the
73). That is, the subject verbally responds to what he or subject's responding through the application of a vari-
she perceives as the therapist's expectation at that point ety of interval- and ratio-scheduling methodologies. It
in the treatment. Of course, the use of alternate forms is understandable, then, why Sidman's (1960) defini-
of the scale and the establishment of external validity tion of stability is a 5% range of variability. If vari-
by correlating self-report with motoric and physiologi- ability exceeds that range, it is recommended that the
cal indexes are two methods for avoiding some of the experimenter evaluate sources of variability systemati-
pitfalls of attitudinal measures. However, there is am- cally.
ple evidence in the behavioral literature that de- In evaluating human subjects, the experimenter's
synchrony exists among the three response systems flexibility in creating and choosing a baseline is much
(i.e., motoric, physiological, and cognitive) (Hersen, more constricted. Generally, the applied researcher
1973, 1978). Indeed, there is the suggestion that does not have the lUXury of "creating" ideal baseline
clinical subjects' self-reports of how they feel should conditions and is compelled to accept the baseline pat-
be given credence, irrespective of how motoric and tern as a given. Furthermore, the applied researcher is
physiological data change during the course of treat- usually under time constraints; hence, there is less op-
ment (cf. Hersen, 1978). It is assumed that if sufficient portunity to search for the manifold causes of vari-
improvements do not take place in motoric and physio- ability. However, sometimes adjustment in the mea-
logical areas, but the cognitive-attitudinal system re- surement scale being used may reduce extensive
mains unmodified, treatment should be considered variability. That is, at times, the measurement interval
only partially successful. may not be appropriate for the behavior under study
A specific issue faced by the single-case researcher and therefore leads to extraneous variability.
who works in the psychiatric setting (Hersen & Bell- In the following discussion, we illustrate some of
ack, 1978) that obviously can affect the standardiza- the baseline patterns typically encountered when con-
tion of data is the different composition of the staff at ducting applied research with human subjects. Prob-
various times. Not only may variable levels of staff lems inherent in each of the patterns and methods for
cooperation yield a differing quality in the data col- dealing with them are outlined.
lected within a stated time period (e.g., the morning), Hersen and Barlow (1976) have identified and illus-
but the marked staff differences in number and attitude trated eight specific baseline patterns (see Table 1).
during day, evening, and weekend shifts are variables These, of course, are the most representative, but
that may lead to confounded data. Thus, when con- many other possibilities, combinations, and permuta-
ducting single-case research in the psychiatric setting, tions exist. Each of the baseline patterns illustrated
standardization of data collection times and data col- contains six data points. In single-case research, an
Table 1. Baseline Patterns
r: 25
~
1. Stable baseline
2. Increasing baseline (target behavior worsening) ~ 200
3. Decreasing baseline (target behavior improving) i::: 150 _____________
4. Variable baseline
CI
5. Variable-stable baseline
~ 100
6. Increasing-decreasing baseline
•...
7.
8.
Decreasing-increasing baseline
Unstable baseline ...
:. 50
~ 0
oft-raised question is: "How many points do I need for

an appropriate baseline assessment?" Although this is
1 2 3
DAYS
4 5
•
a straightforward question, the answer to it is a bit Figure 1. The stable baseline. Hypothetical data for mean num-
complex. The first issue, of course, is how many data bers of facial tics averaged over three daily 15-min videotaped
points are required in order to ascertain some trend in sessions. (From Fig. 3-1 in Single Case ExperimentaiDesigns by
M. HersenandD. H. Barlow, 1976, New York: Pergamon Press.
the data. Barlow and Hersen (1973) argued that "a
Copyright 1976 by Pergamon Press. Reprinted by permission.)
minimum of three separate observation points, plotted
on the graph, during this baseline phase are required to
establish a trend in the data" (p. 320). Sometimes ment were ineffective, then no difference in the slope
more data points are needed if the baseline is initially of the curve might be noted. On the other hand, if
variable or unstable. But, of course, the exigencies of a treatment were detrimental to the patient, it would be
treatment situation may, at times, demand that the in- difficult to determine whether the data in the interven-
vestigator forego experimental purity and institute tion phase simply represent a continuation of the trend
treatment as rapidly as possible. begun in baseline or whether they indicate further dete-
An upward trend in the data is represented by three rioration because of the treatment itself. However, a
successively increasing points. Conversely, a decreas- marked change in the slope of the curve could be in-
ing trend in the data is represented by three suc- terpreted as a deterioration effect because of the
cessively decreasing points. However, the power of treatment.
the trend is dictated by the slope of the curve, with The third pattern is one where the baseline is de-
steeper slopes indicating greater power. The statistical creasing and the target behavior is improving. This
methods for assessing slopes and trends in single-case pattern is problematic inasmuch as subsequent treat-
research have been reviewed by Kazdin (1976). How- ment application might just result in a continuation of
ever, to date, despite considerable controversy in the the trend begun in baseline. If there were a marked
field (Baer, 1977; Blumberg, 1984; Huitema, 1985; change in the slope of the curve, the improvement
Jones, Vaught, & Weinrott, 1977; Wampold & Work- might be attributed to treatment, but this would be
sham, 1986), most applied behavioral researchers rely difficult to evaluate via visual inspection. Generally, in
on a visual analysis of the data. this instance, treatment would have to be withdrawn
The stable baseline is depicted in Figure 1. As is and reinstituted if its controlling effects are to be estab-
quite apparent, there is some minor variability in tic lished. If treatment were to lead to a worsening of the
frequency, but this variability is minimal, with the data patient's condition, then a reversed trend in the data
essentially representing a straight line (i.e., no upward would be apparent.
or downward trend). The application of treatment fol- The fourth pattern, portrayed in Figure 2, is the
lowing such a baseline would permit an unambiguous variable baseline. We should note that this is a pattern
interpretation of its effect (no change, improvement, frequently encountered in applied clinical research.
or worsening). The figure shows a tic frequency ranging from 24 to
As indicated in Table 1, the second pattern is the 255; no clear trend is apparent in the data. Nonethe-
increasing baseline, where the target behavior is wors- less, there is a clear pattern of alternating low and high
ening. This, of course, is an acceptable pattern that data points. Some investigators who obtain this pattern
could lead to a meaningful interpretation if subsequent block the data by averaging tic frequency over a 2-day
treatment were to reverse the trend. However, if treat- period. This would lead to an apparently stable pat-
184 PART" • ASSESSMENT AND RESEARCH
.. 251 .. 250
.
II
u
i: 211 ...c
j:
200
U
C; 151 ......c 150
...
~
0111
0
~ 100
II
& 51
.:
III
50
I!
~
0
•...
III
0
•
1 2 J
DAYS
• 5
•
2 3
DAYS
4 5
•
Figure 3. The increasing-decreasing baseline. Hypothetical
Figure 2. The variable baseline. Hypothetical data for mean data for mean number of facial tics averaged over three daily 15-
number of facial tics averaged over three 15-min videotaped min videotaped sessions. (From Fig. 3-6 in Single Case Experi-
sessions. (From Fig. 3-4 in Single Case Experimental Designs by mental Designs by M. Hersen and D. H. Barlow, 1976, New
M. Hersen and D. H. Barlow, 1976, New York:: Pergamon Press. York: Pergamon Press, 1976. Reprinted by permission.)
Copyright 1976 by Pergamon Press. Reprinted by permission.)
tern, at least visually. However, this is an artificial The seventh pattern (decreasing-increasing base-
manner of dealing with variability that is "cosmetic" line) is the converse of the sixth: improvement fol-
but does not alter the basic pattern. In light of the lowed by deterioration. In this instance, application of
extreme variability seen in this pattern, subsequent in- treatment that results in a reversal of data trends per-
terpretations of a treatment effect could be quite diffi- mits a clear interpretation of the effect. However, in
cult unless the treatment itself were successful in re- the event that treatment is detrimental to the patient,
ducing both variability and tic frequency. As recom- visual inspection should prove extremely difficult un-
mended by Sidman (1960), if time permits, the re- less there is a marked change in the slope of the curve.
searcher should attempt to identify the source(s) of The final pattern, the unstable baseline, is graphi-
variability. But in the clinical situation, this usually is cally portrayed in Figure 4. In this example, we have
not the case. an extended baseline assessment that fails to reveal any
As can be seen in Table 1, the fifth pattern is the particular pattern in the data. Thus, even the cosmetics
variable-stable baseline. Here, despite initial vari- of blocking would fail to yield visual improvement as
ability, the investigator extends the baseline observa- to stability. As noted by Hersen and Barlow (1976),
tion until the data are less variable. Indeed, this is one "to date, no completely satisfactory strategy for deal-
of the methods for dealing with the fourth pattern: the ing with this type of baseline has appeared; at best, the
variable baseline. After stability is achieved, the in-
stitution of a given treatment should once again lead to
an unambiguous interpretation of the resulting data. ..
II
251
The only problem here is that extensive baseline obser- ...c
j:
210
vation may not be possible or ethical in certain clinical U
......
c 150
situations (e.g., severe head banging or severe depres-
sion where suicidal ideation is present). 0
~ 110
The sixth pattern (increasing-decreasing baseline), II
.:
presented in Figure 3, is one where after an initial
III
~ 50
0
...•
III
period of deterioration, improvement is quite apparent 0
in the subject's condition. But as in the case of the
decreasing baseline, the subsequent treatment applica- 3 5 7 • n 13 15
tion might only result in the continuation of the trend in DIYS
the second part of baseline (i.e., continued improve- Figure 4. The unstable baseline. Hypothetical data for mean
ment). Therefore, here, as in the case of the decreasing number of facial tics averaged over three daily 15-min vid-
eotaped sessions. (From Fig. 3-8 in Single Case Experimental
baseline, withdrawal and reinstatement of treatment Designs by M. Hersen and D. H. Barlow, 1976, New York:
are needed to document the effects controlling the in- Pergamon Press. Copyright 1976 by Pergamon Press. Reprinted
tervention strategy. by permission.)
kinds of strategies for dealing with variable baseline We might also note that in drug evaluations, the one-
are also recommended here" (p. 82). variable rule also holds but has some additional im-
plications. Instead of progressing from a baseline
phase (where no treatment is being administered) to a
Changing One Variable at a Time
treatment phase (active drug), an additional step (i.e.,
One of the basic tenets of the single-case approach is placebo) is needed to control for the mere fact that the
that only one variable is altered at a time when pro- subject is ingesting a substance. Thus, a typical drug
ceeding from one phase to the next (Barlow & Hersen, evaluation accomplished in the experimental single-
1973, 1984; Hersen & Barlow, 1976). It should be case design might involve the following sequence:
noted that if two variables are manipulated simul- (1) no drug, (2) placebo, (3) active drug, (4) placebo,
taneously from one phase to another, then it is impossi- and (5) active drug. This design, labeled A-A' -B-A'-
ble to determine which of the two was responsible for B, allows for evaluation of the contribution of the
or contributed most to behavioral change. This one- placebo over baseline and the drug over and above
variable stricture holds irrespective of whether the be- placebo alone.
ginning, the middle, or the end phase is being
evaluated.
Length of Phases
Let us examine this basic tenet in greater detail. In
the A-B-A-B design, for example, only one variable is A number of factors need to be considered when
changed from one adjacent phase to the next. Baseline determining length of baseline and treatment phases in
is followed by treatment, which is succeeded by base- single-case research. Included are time limitations,
line and then treatment again. If treatment consists of a staff reactions, the relative length of adjacent phases,
single therapeutic strategy-say, social reinforce- and ethical considerations. Johnston (1972) argued
ment-then only one variable is altered from A to B. that
However, many treatments (e. g. , social skills training)
consist of a melange of techniques (Le., instructions, it is necessary that each phase be sufficiently long to demonstrate
stability (lack of trend and constant range of variability) and to
feedback, modeling, and social reinforcement). Thus,
dispel any doubts of the reader that the data shown are sensitive
in an A-B-A-B design involving the application of such to and representative of what was happening under the described
treatment, B represents the full combination of tech- conditions. (p. 1036)
niques. In this analysis, it is not possible to evaluate the
separate contribution of each technique. However, in In the ideal case, of course, the investigator attempts
an A-B-A-B-BC-B design, where A is baseline, B is to secure a relatively equal number of data points per
feedback, and C is social reinforcement, the separate phase. This is especially important in the A-B-A-B
contributions of feedback and social reinforcement to design; otherwise, if, for example, a treatment phase
the overall treatment effect can be determined. were substantially longer than the preceding baseline,
Although the one-variable rule is generally adhered effects could be attributed to the extended time factor
to by behavioral researchers, examples in the literature rather than to the treatment per se (see Hersen & Bar-
may be found where incorrect applications have been low, 1976, p. 101).
carried out and published. Two prime examples are the An excellent example of an A-B-A-B design with
A-B-A-C design, where the investigator erroneously equal phases (with the exception of the last B phase)
assumes that the differential effects of A and C can be was presented by Miller (1973). In this study, the ef-
determined, and the A-B-A-BC design, where the in- fects of retention control training were evaluated in a
vestigator assumes that the combined effects of BC secondary enuretic child, with two targets (number of
may be contrasted with the original B phase. Not only enuretic episodes and frequency of daily urination) se-
is this idea erroneous in terms of the one-variable ten- lected as dependent measures (see Figure 5). The read-
et, but the investigator has failed to consider the addi- er will note the relative stability in the baseline, the
tional factor of the sequencing of possible treatment initial effects of the treatment, the return to baseline
effects and the time lapses between treatment applica- stability, and the renewed effects of the treatment dur-
tions. With respect to these two examples, it should be ing the second B phase. However, the second B phase
pointed out that the experimental error is most fre- was extended to 5 data points (instead of 3) to ensure
quently committed toward the latter part of the experi- the permanence of the treatment effects. This is a pro-
mental analysis. cedure commonly carried out in the last phase of the A-
........
. - . • • • U'f .1 ••• , . . .
~',",.If
•
III
vention it is possible to terminate treatment (with mini-
mal carryover effects, it is hoped, from treatment to
• »
...•
RETENTION
III CONTROL
RETENTION
CONTROL
baseline), in pharmacological applications the biolog-
II BASELINE BASELINE
II
TRAINING TRAINING
ical effects of the drug may actually persist into the
.=
!!II 10 ::
It.
• placebo and baseline phases. Thus, it generally is not
,, ,
,I,
.-..
III
U
, I '. ., ,, II
,c
feasible to evaluate the long-term effects of drugs in
~
•
III
,# .' ....••
single-case studies without the use of additional phases
••
("washout" phases, where there is no intervention)
:I '.~' \. ,....,
......... -.' interposed between treatment and placebo. However,
... r -
III
5 "'\
5~
for the short-term evaluation of drugs, where they are
•4 4 !C rapidly introduced and removed, the single-case strat-
•I II
•• 2
~
III
egy is quite satisfactory (see Liberman & Davis,
2ii
» 1975).
•
:I
I
0:
I~
0
Reversal
1 2 I 4 5 • , I I 10 11 12 11 14
CO.IECUTI'E WEEII In the behavioral literature (e.g., Baer et al., 1968;
Figure 5. Number of enuretic episodes per week and mean Barlow & Hersen, 1973, 1984; Kazdin, 1973), the A-
number of daily urinations per week for Subject 1. (From "An B-A-B design is considered prototypical of the reversal
Experimental Analysis of Retention Control Training in the strategy:
Treatment of Nocturnal Enuresis in Two Institutionalized Ado-
lescents" by P. M. Miller, 1973, Behavior Therapy, 4, 288-294.
When speaking of a reversal, one typically refers to the removal
Fig. 1. Copyright 1973 by Behavior Therapy. Reprinted by
(withdrawal) of the treatment variable that is applied after base-
permission.)
line measurement has been concluded. In practice, the reversal
involves a withdrawal of the B phase (in the A-B-A design) after
behavioral change has been successfully demonstrated. If the
treatment (B phase) indeed exerts control over the targeted be-
B-A-B design, and it has clinical implications, but the havior under study, a decreased or increased trend (depending on
importance of the equality of the data points in the A- which direction indicates deterioration) in the data should follow
B-A phase of the study is clear. its removal. (Hersen & Barlow, 1976, p. 92)
Sometimes, when the targeted behavior is poten-
tially injurious to the subject under study (e.g., head However, although the word reversal is used to de-
banging) and/or the staff in the institution are eager to scribe the A-B-A-B design and the removal of treat-
get the behavior under control very quickly because it ment in the second A phase, Hersen and Barlow (1976)
is annoying, the initial baseline and the subsequent argued that the term withdrawal better describes the
withdrawals of treatment (second and third A phases) technical operation carried out by the applied behav-
may be very brief as contrasted with the intervention ioral research. Hersen and Barlow (1976) contended
phases. Here, it is quite clear that ethical considera- that there is a specific experimental strategy that is to
tions have precedence over experimental rigor. be labeled the reversal design. An illustration of this
Still another factor related to length of phase is the design appears in Figure 6. K. E. Allen, Hart, Buell,
carry-over effects of treatment to baseline. In the A-B- Harris, and Wolf (1964) evaluated the effects of social
A-B design evaluating a behavioral strategy, this oc- reinforcement in a 4Y2-year-old withdrawn girl attend-
curs in the second A phase, where the experimenter is ing a preschool nursery. The target behaviors selected
unable to recover the initial baseline level that ap- for study were the percentage of interaction with adults
peared in the first A phase. This is one of the primary and the percentage of interaction with children. As can
reasons that Bijou, Peterson, Harris, Allen, and John- be seen in Figure 6, during baseline, a greater percent-
ston (1969) stated that "in studies involving stimuli age of social interaction took place with adults than
with reinforcing properties, relatively short experi- with children. In the second phase, the teacher was
mental periods are advocated, since long ones might instructed to reinforce the child socially when she was
allow enough time for the establishment of new condi- interacting with other children and to ignore her when
tioned reinforcers" (p. 202). she was interacting with adults. In the next phase, the
A special problem concerning carry-over effects in- teacher was instructed to reverse the contingencies
volves evaluations of pharmacological treatments in (i.e., to reinforce interaction with adults and to ignore
single-case designs. Whereas with a behavioral inter- interactions with children). Again, interaction with
loo~--------r----------,---------r---------------------------
WIT H ADUL T5
00
z 40
Q
• •
• •
~
u 20
«
a::
w
~ 0
~
u. 100
0
~ WITH CHILDREN
• •
Z 00
w
u
a: 00
• •
w
Q.
40
20
0
o 1 2 3 4 5 6 7 B 9 10 11 17 lB 19 20 21 V 23 24 25 31 384051
BASELINE REINF INTERACT REVERSAL REINF INTERACT WITH POST
WITH CHILDREN CHILDREN CHECKS
DAYS
Figure 6. Daily percentages of time spent in social interaction with adults and with children during approximately 2 hours of each
morning session. (From "Effects of Social Reinforcement on Isolate Behavior of a Nursery School Child" by K. E. Allen et aI., 1964,
Child Development, 35, 511-518, Fig. 2. Copyright 1964 by The Society for Research in Child Development, Inc. Reprinted by
permission.)
adults increased while interaction with children de- here to the physical discontinuation of a drug whose
creased. Indeed, this is a true reversal (of differential biological effect in the body may persist through the
attention) and is vastly different from simple with- placebo and baseline phases of experimentation.
drawal of treatment in the second A phase ofthe A-B- Nonetheless, it is possible to study the very short-term
A-B design. In the fourth phase of the K. E. Allenetal. effects of an instructional set that is periodically intro-
(1964) study, the contingencies were once more reduced and removed (Eisler, Hersen, & Agras, 1973)
versed, this reversal leading to increased interaction and the effects of changing the instructional set from a
with children and decreased interaction with adults. positive to a negative expectation (Barlow, Agras,
We should note parenthetically, however, that de- Leitenberg, Callahan, & Moore, 1972). But usually,
spite this distinction drawn between withdrawal and instructions tend to be maintained as a constant across
reversal, most applied behavioral researchers persist in the various phases of treatment, so that only one thera-
referring to the A-B-A-B design as a reversal strategy. peutic variable is changed at a time (cf. Kallman et al.,
In short, the distinction made has not been reinforced 1975). When this is not possible, alternative experi-
by journal editors. mental strategies, such as the multiple-baseline de-
sign, may be used to evaluate specific instructional
effects on targeted behaviors (e.g., Hersen & Bellack,
Evaluating Irreversible Procedures
1976).
In single-case research, such variables as feedback,
social reinforcement, and a variety of punishment
techniques can be readily introduced and withdrawn in Basic A-B-A Designs
a number of designs (withdrawal and reversal). How-
ever, one variable-instructions-cannot be with-
A-B Design
drawn in the technical sense. That is, once an instruc-
tional set has been given to the subject a number of The A-B design is the simplest of the single-case
times, simply ceasing to remind him or her of the in- strategies, with the exception of the so-called B de-
structions cannot be equated with cessation of feed- sign, where measures are repeatedly taken throughout
back or reinforcement. Indeed, there is an analogy the course of treatment (i.e., in an uncontrolled case
study with repeated measures). On the other hand, in 18 hln. ,, Treat ... nt Follow-up
,,
....
the A-B Design, the natural frequency of the behavior 16
~ ,,
under study is ftrst assessed in baseline (A). Then, in 1~ I!
...I \ iill,
......
I ,
the B phase, treatment is instituted. .. I: 12
I ,
I: -
Of the single-case strategies, the A-B design is one
~i ~~
• .. 10
of the weakest in terms of inferring causality. Indeed,
the design is often referred to as correlational in that .
.c:I
...
....0
8
6
the effects of treatment that control the dependent mea- 4
--- ~~
sures are not completely documented unless treatment : \
: \
is withdrawn subsequent to B (i.e., the A-B-A design). : '
0
: . . . . .
Thus, in the A-B design, it is possible that changes in B 2 ~ 6 8 10 12 1~ 16 18 20 22 24 2 ~ 6 8 1012
are not the direct result of treatment per se but perhaps o HS WEEK 5
of some other factor, such as passage of time, that is Figure 7. Frequency of gagging during baseline treatment and
correlated with the treatment. follow-up. (From "Behavioral Control of Hysterical Gagging"
Nonetheless, the A-B design does have its use and by L. H. Epstein and M. Hersen, 1974, Journal of Clinical
certainly represents a vast improvement over the un- Psychology, 30, 102-104. Fig. 1. Copyright 1974 bytbe Ameri-
can Psychological Association. Reprinted by permission.)
controlled case study. Also, for therapeutic or educa-
tional problems that have long proved recalcitrant, if
intervention in B yields behavioral improvement, then
with some degree of conftdence one may attribute the From a design perspective, the reader should note
effects to the speciftc intervention. However, only by the initial variability in baseline, which then stabilized
demonstrating such change in a withdrawal or reversal to some degree. Further, the length of the treatment
design will dispel the remaining doubts of the more phase was double that of the baseline; it was extended
"hard-headed" operant researcher. for obvious clinical considerations (i.e., renewed
An example of an A-B design that also includes symptomatology on Day 15).
follow-up was presented by Epstein and Hersen Although the treatment appeared to be efficacious, it
(1974). The subject was a 26-year-old psychiatric in- is possible that some unidentifted variable, correlated
patient who had suffered from gagging episodes for with reinforcement procedures, led to behavioral
about 2 years in spite of numerous medical interven- change. But as previously noted, the A-B design does
tions. However, the problem appeared to have no di- not allow for a completely unambiguous interpretation
rect medical etiology; hence, the patient was admitted of causality. However, given the longevity of this pa-
to the psychiatric service of a Veterans Administration tient's disorder and the repeated failure of medical in-
hospital. During baseline (A), the patient was asked to terventions, there is a good likelihood that the treat-
record on an index card the specific time and frequency ment per se caused the improvement.
of each gagging episode. During treatment (B), the
patient was given $2 in canteen books (exchangeable
Pretest-Posttest Design
at the hospital commissary) for an n - 1 decrease in his
gagging rate from the previous day. In treatment, the Thyer and Curtis (1983) have proposed a variant of
emphasis was on the patient's managing his disorder the A-B design that they term the "repeated pretest-
himself, with canteen booklets serving as the incen- posttest" single-subject experiment. This design, to
tive. During the 12-week follow-up, the patient con- date, has not enjoyed widespread popularity, but its
timied recording his gagging rate at home, with self- value to individual practitioners is considerable, given
reports corroborated by his wife. the usual experimental constraints of their practices.
Figure 7 baseline data reveal a gagging frequency of According to Thyer and Curtis, this design does not
8-17 instances per day. Institution of treatment led to a interfere with the delivery of treatment and has "high
marked decrease, to 0 on Day 14. However, renewed internal validity." Basically, the design involves taking
symptomatology was evidenced on Day 15, and treat- measurements of the client's or patient's behavior at
ment was continued, with the criterion for Day 15 reset the beginning and at the end of each treatment session.
to that originally used for Day 13. Improvements were Improvements, of course, can be readily seen from
noted between Days 15 and 18, and treatment was pre- to postmeasurement for self-report, motoric, or
continued an additional 6 days. physiological indices. As noted by Thyer and Curtis,
maintenance of the changes induced in one treatment session are •. - . POlNTS EARNED
assessed by measuring the behavior at the beginning of the next 0 - 0 BEMA VIORAL RATINGS
session. Visual inspection of the data, both pre and post each
30 3
treatment session and across sessions, permits a robust behavior
analysis of the effects of intervention. (p. 312) Q
...Z lit
To illustrate this design, Thyer and Curtis presented •e

...
•
/I
I I
il.
"-e
Z
~
rr
the results of exposure treatment (6 sessions) for a lit 20 I I 2
~
woman suffering from simple phobia, reflecting some
.
Jl
Z
•0e
-e
improvements in pulse rate and very marked improve- 0
ments of subjective units of discomfort (SUDS) when ...0 >
confronted with the phobic object. ....
...Z
•I ~
...•
10
A-B-A Design
.;
I
•
A
Z
...IC
~.'
::) ~
The A-B-A design corrects for one of the major Z

shortcomings of the A-B design: lack of experimental 0 0
control. Removal of treatment in the second A phase is TOKEN
BASELINE I REINFORCEMENT BASELINE
used to confirm experimental control over the depen-
dent measure initially suggested when improvement 2 3 II 5 6 7 8 9 10 11 12
occurs in B. However, the A-B-A design is not com-
Figure 8. Number of points earned and mean behavioral ratings
pletely adequate either, as it terminates in a no-treat- for Subject 1. (From "Effects of Token Economy on Neurotic
ment phase. For very obvious clinical and ethical rea- Depression: An Experimental Analysis" by Michel Hersen et
sons, this is problematic; at times, the experimenter ai., 1973, Behavior Therapy, 4, 392-397, Fig. 1. Copyright
1973 by Behavior Therapy. Reprinted by permission.)
may have intended to follow the more complete A-B-
A-B strategy, but for any number of reasons, the sub-
ject terminates the treatment prematurely. Even under behavioral ratings, suggesting efficacy of the interven-
these circumstances, data from A-B-A designs are of tion. Removal of treatment in the second A phase led
value. to a marked diminution of points earned; decreased
Let us consider an example of an A-B-A designed by behavioral ratings also confirmed the controlling ef-
Hersen, Eisler, Alford, & Agras (1973) some years fects of the treatment.
ago. In this study the investigators evaluated the ef- From a design perspective, the fact that the number
fects of a token economy on neurotic depression in a of points earned in baseline was on the increase makes
married, white, 52-year-old farmer who had become it a bit more difficult to interpret the greater number of
depressed following the sale of his farm. The two de- points earned during token reinforcement. However,
pendent measures selected for study were the number the marked change in the slope of the curve during the
of points earned and the behavioral ratings of depres- token economy phase is highly suggestive. Moreover,
sion (talking, smiling, and motor activity), with higher data in the second A phase (showing a marked de-
ratings indicating less depression. During baseline crease in the number of points earned) confirmed the
(A), the patient was able to earn points, but they had no initial impression of the token economy's controlling
exchange value. In B (token economy), the patient had effects. The data for behavioral ratings, because of the
to purchase privileges on the ward with points earned. specific trends obtained, are definitely less ambiguous
Then, in the third phase (A), baseline procedures were to interpret and clearly indicate the controlling effects
reinstated. of the token economy.
The results of this experimental analysis are present-
ed graphically in Figure 8. Inspection of baseline
A-B-A-B Design
shows that the number of points earned was increas-
ing, whereas decreased behavioral ratings of depres- As previously noted, the A-B-A-B design controls
sion indicated a slight worsening of the patient's condi- for deficiencies inherent in the A-B-A strategy, and
tion. It is quite clear that with introduction of token elsewhere it has been termed the "equivalent time-
reinforcement in the B phase, there was a sharp in- samples design" (Campbell & Stanley, 1966). Not
crease both in the number of points earned and in the only does this design end on a treatment phase (B), but
8.ln Thoughl Slop 8.ln Thoughl Slop Follow - up

500
300
\
OIl
~ 200
i
i ~\
-y: lr
100
*,
20,
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,
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~1~3~~5~7~9~1~1~13~15~1~7~1~9~2~1~2~3~2~5~2~7~2~9~31~3~3~3~5~3~7~~~~12~3~.~5~6~
DAYS
Figure 9. Duration of obsessive ruminations during baseline, treatment, and 6-week follow-up_ (From "Thought-Stopping in the
Control of Obsessive Ruminations" by T. W. Lombardo and S. M. Thmer, 1979, Behavior Modification. 3, 267-272, Fig. 1.
Copyright by Sage Publications. Reprinted by permission.)
it provides two opportunities for showing the control- it softly, and fInally whispering "STOP." The patient then ver-
ling effects of treatment over the dependent measure balized "STOP" in the same manner with an additional fInal step
of saying "STOP" covertly. Depending upon how rapidly the
(B to A and A to B). patient gained control, four to six repetitions of stopping were
Let us now examine an example of the successful used at each voice intensity. (Lombardo & Turner, 1979, p. 269)
use of an A-B-A-B single-case design. Lombardo and
Turner (1979) evaluated the effects of thought stopping Treatment was discontinued on Day 18 and recom-
in a 26-year-old male psychiatric inpatient who was menced on Day 28. In addition, a 6-week follow-up
severely obsessive. Obsessions focused on "imaginal was carried out.
relationships" he had had with other patients on the The results of this study appear in Figure 9. Follow-
ward during previous hospitalizations. Although the ing a period of baseline stability (the model response
patient attempted to control obsessive ruminations was 40 min), thought stopping led to a marked de-
through distraction, this approach failed to reduce the crease of obsessions to a 0 level. When treatment was
disorder's full intensity. then withdrawn in the second A phase (baseline), ob-
In all phases of the experimental analysis, the pa- sessions increased considerably, well over baseline
tient was instructed to note the beginning and ending levels, albeit in a very unstable fashion. However, re-
times of each obsessive episode, thus allowing a deter- introduction of the treatment led to renewed improve-
mination of both the rate of ruminations and the total ment to a 0 level, maintained through Days 33-40.
time per day. Baseline (A) consisted of 6 days of obser- Furthermore, improvement continued throughout the
vation. Treatment (thought stopping) began on Day 7 6-week follow-up period.
and consisted of the patient raising his right index fin- Although the functional effects of treatment ap-
ger whenever he had obtained a vivid obsessive image. peared to be documented, "this conclusion must be
At that point, the therapist shouted, "Stop," and the tempered by the fact that controls were not provided
patient lowered his finger: for the possible therapeutic effects of instructions and
therapist as well as patient expectancies" (Lombardo
Fading of "STOP" intensity and transfer of control from thera- & Turner, 1979, p. 270). This kind of problem is defi-
pist to patient in all training was accomplished as follows. Ini-
tially, the therapist provided the "STOP" fIrst shouting, then nitely more prevalent when self-report data are used as
saying it loudly, then using a normal speaking voice, then saying opposed to motoric and physiological measures. As
noted earlier, motoric and physiological measures are NO

g
I I
less susceptible to such confounding. 50

IIIN~
I
-.....
B-A-B Design
IIIN_IMlNT
CONTINOINT
Although not as complete an experimental analysis UPON
as the A-B-A-B design, the B-A-B design is superior to ..I_MANCI
the A-B-A strategy, as it ends in a treatment phase.

Since the experimental analysis begins in a treatment
phase in the B-A-B design, the natural frequency (i.e.,
rate) of the behavior under investigation is not initially .'
obtained. On the other hand, the B-A-B design may be 10
useful for experimentation in institutional settings,

particularly if the staff are eager to get some disruptive
or unpleasant behavior under quick control. In such 30
instances, the staff will undoubtedly require persua- DAYS

sion with regard to withdrawal of the treatment in the Figure 10. The total number of hours of the on-ward perfor-
second phase (i.e., in A). mance by a group of 44 patients. (From "The Measurement and
Let us consider a historical example of a B-A-B Reinforcement of Behavior of Psychotics" by T. Ayllon and N.
H. Azrin, 1965, Behaviour Research and Therapy, 8, 357-383.
design in which the effects of token economic pro-
Fig. 4. Copyright 1965 by Pergamon Press, Ltd. Reprinted by
cedures on work performance were evaluated for 44 permission. )
chronic schizophrenic patients (Ayllon & Azrin,
1965). In the first phase (B), the patients were awarded
tokens contingently for engaging in a variety of hospi- inhere~t in the traditional group comparison approach (e.g.,
tal-ward work activities. Tokens, of course, were ex- averagmg out of effects, effects due to a small minority while the
changeable for a large menu of "backup" reinforcers. majority remains unaffected by treatment) will be carried over to
the experimental analysis procedure. (p. 190)
In the second phase (A), the patients were given tokens
noncontingently, based on the individual rates ob-
tained in B. In the third phase (B), treatment was
reinstated.
Extensions of the A-B-A Design
The results of this study are depicted in Figure 10.
Extensions of the basic A-B-A design have appeared
During the first B phase, the group of patients averaged
a total of 45 work hours per day. When the contingency in numerous behavioral publications. In this section,
was removed in A, the work level dropped to I hour by we will consider three categories of such extensions.
Day 36. Reinstatement of the treatment in the second B The first involves a more extended replication of the
phase led to a marked increase of work output similar basic A-B pattern (e.g., A-B-A-B-A-B: Mann, 1972)
to that in the first phase. The data in the second B phase or the A-B-A-C-A design, where the controlling ef-
clearly document the controlling effects of the token fects ofB and C on A are examined in one study (e.g.,
economy on the work performance of these chronic Wincze, Leitenberg, & Agras, 1972). However, in the
A-B-A-C-A design, it is not possible to make a com-
schizophrenic patients.
Inasmuch as group data were averaged in this ex- parison of the relative effects of Band C, since these
two interventions are confounded by a third factor:
perimental analysis, Ayllon and Azrin (1965) also pre-
time.
sented individual data, indicating that 36 of the 44
The second category we will look at involves the
patients were affected by the contingency in force; 8 of
the patients did not respond to token economic pro- additive or interactive effects of two therapeutic vari-
cedures. As argued by Hersen and Barlow (1976), ables (e.g., A-B-A-B-BC-B design). Here, given ap-
when group data are presented graphically, the investi- propriate data trends, it is possible to evaluate the con-
gator should also display data for selected subjects: tribution of C above and beyond that of B.
Finally, the third category is concerned with the as-
Individual data presented for selected subjects can be quite sessment of pharmacological treatments. As already
useful, particularly if data trends differ. Otherwise, difficulties noted, there are some unique problems in evaluating
the effects of drugs in a single-case design (e.g., the ment (contingency contracting) led to marked de-
need for placebo phases and the carry-over effects). creases in weight, with interposed baseline data evinc-
Also, it should be noted that at this juncture the use of ing a plateauing effect or an upward trend. In short, the
single-case analyses for pharmacological interven- controlling effects of the contingency contract on
tions is not as widespread as that carried out in evaluat- weight loss were firmly demonstrated several times in
ing behavioral interventions. Thus, in our discussion, this experimental analysis.
we also will highlight possibilities for the future. Wincze et al. (1972) evaluated the effects of feed-
back and token reinforcement on the verbal behavior of
a delusional psychiatric inpatient using an A-B-A-C-
A-B-A-B-A-B and A-B-A-C-A-C' Designs
A-C' -A design. During each of the phases of study, the
Mann (1972) repeatedly evaluated the effects of patient was asked daily to respond to 15 questions
contingency contracting (A-B-A-B-A-B design) in his selected at random from a pool of 105. The proportion
efforts to treat an overweight subject. At the beginning of the responses containing delusional material was
of the study, the subject surrendered a number of recorded for the individual sessions, as was the per-
prized possessions (i.e., variables) to the investigator, centage of delusional talk on the ward monitored by
which could be regained (one at a time), contingent on nurses 20 times a day.
a 2-pound weight loss over a previous low within a During A (baseline), no contingencies were in ef-
designated time period. By contrast, a 2-pound weight fect, and the patient received "free" tokens. Feedback
gain led to the subject's permanent loss of the valuable, (B) involved the patient's being corrected whenever he
to be disposed of by the investigator in equitable fash- responded delusionally. Tokens were still given to him
ion. That is, he did not profit in any way from the noncontingently in this phase. In A, baseline pro-
subject's loss. cedures were reinstituted. In the fourth phase (C),
As can be seen in Figure 11, institution of the treat- tokens were earned contingently for nondelusional
~~
3
1,\1
·
:
.
.. : -
·:
~:
"":".
i~ ~. ..
..
~ 1 ~ i
~ 1 ~ ~ TREATMENT
250 A ··
• B A B A
50 1 0 150 200
DAYS
Figure 11. A record of the weight of Subject 1 during all conditions. Each open circle (connected by the thin solid line) represents a 2-
week minimum-weight loss requirement. Each of the solid dots (connected by the thick solid line) represents the subject's weight on
each of the days he was measured. Each triangle indicates the point at which the subject was penalized by a loss of valuables, eitherfor
gaining weight or for not meeting the 2-week minimum-weight-loss requirement. Note: The subject was ordered by his physician to
consume at least 2,500 calories per day for 10 days, in preparation for medical tests. (From "The Behavior Therapeutic Use of
Contingency Contracting to Control an Adult Behavior Problem: Weight Control" by R. A. Mann, 1972, Journal ofApplied Behavior
Analysis, 5, 99-109, Fig. l. Copyright 1972 by the Society for the Experimental Analysis of Behavior, Inc. Reprinted by
permission. )
2 3 4 5 6 7
~ 100 lIa••line FMdback .....in. Token: "Hline Token:
....Ion. Ionu•
~ 90
\ .~. II. ,P SESSIONS ~--- - - 0
.• 11 'II
o 54 ,..,
P-
WAllO ••- - -••
'1"', :
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00 K
w 40 "
:"0 o
!~JV~d~~n£~
It 7 8 18 19 25 26 32 33 39 40 46 47 53
DAYS
Figure 12. Percentage of delusional talk of Subject 4 during therapist sessions an~ on the ward for eac? experimental. d~~. (From
"The Effects of Token Reinforcement and Feedback on the Delusional Verbal BehaVIOr of Chronic ParanOid SchIZophrenics by J. P.
Wincze et al., 1972, Journal of Applied Behavior Analysis, 5, 247-262, Fig. 4. Copyright 1972 by the Society for the Experimental
Analysis of Behavior, Inc. Reprinted by permission.)
talk. This was followed by a return to baseline condi- struction of complex treatments it becomes necessary to deter-
tions. In C', tokens were awarded contingently for mine the nature of these interactions. (p. 213)
nondelusional talk that exceeded a given criterion As clearly noted in an earlier section, the impor-
(nondelusional talk more than 90%). Finally, in the last tance of the one-variable rule (i.e., changing one vari-
phase (A) ,baseline procedures were reinstated for the able across phases) holds in particular in interaction
fourth time. designs. In some instances, introduction of one thera-
The results of this study appear in Figure 12. These peutic variable will lead to some behavioral change,
data indicate that none of the treatment variables ap- but addition of a second variable will lead to still fur-
plied effected any change in delusional talk on the ther increases, as marked by a significant change in the
ward. Similarly, feedback (B) yielded no effects on slope of the curve (see Hersen & Barlow, 1976, p.
delusional talk in individual sessions. But token ses- 217). In other instances, the first variable may lead to a
sions (Phase 4) and token bonuses (Phase 6) pro- minimal effect, while the second suggests consider-
cedures led to decreased delusional talk in individual able additional effects. Let us consider one such
sessions, thus demonstrating the controlling power of example.
these treatments over the dependent measure. How- Kallman et al. (1975) evaluated the effects of rein-
ever, as has already been underscored, this design does forcing standing and walking on the mean distance in
not permit an analysis of the relative effects of token yards walked per instruction in a white, 42-year-old,
sessions and the token bonus treatment. married patient suffering from a conversion reaction
(i.e., an inability to walk). Figure 13 shows that in the
Interaction Designs first phase, when standing was reinforced with verbal
praise, only minimal efforts were made to walk. In the
As previously pointed out in Hersen and Barlow second phase, when walking and standing were both
(1976), reinforced, a marked linear increase in walking was
noted. In the third phase, standing alone was rein-
most treatments contain a number of therapeutic components.
One task of the clinical researcher is to experimentally analyze forced; the result was a plateauing effect. However,
these components to determine which are effective and which when reinforcement for standing and walking was re-
can be discarded, resulting in a more efficient treatment. Analyz- instituted in the fourth phase, further improvements in
ing the separate effects of single therapeutic variables is a neces-
walking appeared. In the next two phases, reinforce-
sary way to begin to build therapeutic programs, but it is obvious
that these variables may have different effects when interacting ment for standing and walking were maintained, but
with other treatment variables. In advanced states of the con- with the addition of a walker in the fifth phase and its
~350t
I
•
I . . . . .
-
I
a:0( I
~1 40
•••
Z
•WALKER
NO
/
I
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Q 120
~ I
CJ
::> •
a: 100 I
I
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~ I
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a:
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W 60 I
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/ Adm.
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·
~
~
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o 20
I
·
./
Z • ,I
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w / REIN. 14 wk REIN.
10
2wk 6 wk wk. wk.
12
:E 0 ~ STAND STANO' FOL FOL. FOL. FOL.

1
REIN. STAND ~OL. REIN.
STAND "flo
REIN. STAND
WALK REIN. STAND &WALK 110 WALK
......
UP STA~D &WALK UP UP UP UP
123 456 7891011 121314 1516 1718 1920 212223
BLOCKS OF THREE SESSIONS
Figure 13. Mean distances walked during all phases of treatment and follow-up. (From "The Use of Social Reinforcement in a Case
of Conversion Reaction" by W. M. Kallman et al., 1975, Behavior Therapy 6, 411-413, Fig. 1. Copyright 1975 by Behavior
Therapy. Reprinted by permission.)
removal in the sixth. The nomenclature for the first six once again was added to reinforcement in the final
phases of this study is as follows: (1) B; (2) BC; (3) B; phase. In summary, this study failed to document the
(4) BC; (5) BCD; and (6) BC. An evaluation of the controlling effects of reinforcement on weight gain and
analysis clearly indicates the controlling effects of C caloric intake, but it definitely reflects the controlling
(reinforcing walking) over B (reinforcing standing), effects of feedback on these two dependent measures.
but it does not reveal the controlling effects of the
walker (BCD) over no walker (BC), inasmuch as im-
provements in walking continued after the walker was Drug Evaluations
removed.
Let us consider still another example of the interac- So far in this chapter, we have touched on some of
tion design: an evaluation of the effects of feedback the issues related to the evaluation of pharmacological
and reinforcement on the eating behavior of an anorex- agents in single-case designs (viz., the placebo phase
ia nervosa patient (Agras, Barlow, Chapin, Abel, & and the carry-over effects from adjacent phases). A
Leitenberg, 1974). This study was done in an A-B-BC- third important issue in drug research, of course, is the
B-BC design, with A as baseline, B as reinforcement, use of double-blind assessments; that is, neither the
and C as feedback. Throughout the study, the patient patient nor the assessor is aware of whether a placebo
was provided four meals daily, each consisting of or an active drug is being administered. In the single-
1,500 calories. Reinforcement consisted of granting blind assessment, only the patient typically is unaware
the patient privileges, contingent on weight gain. of whether he or she is receiving a drug or a placebo.
Feedback, on the other hand, involved giving the pa- Hersen and Barlow (1976) have pointed out the dif-
tient specific information as to weight, caloric intake, ficulties inherent in conducting the double-blind as-
and actual mouthfuls consumed. sessment in single-case analysis:
The data presented in Figure 14 show a slight in-
crease in weight during baseline but decreased caloric A major difficulty in obtaining a "true" double-blind trial in
intake. When feedback was added to reinforcement in single case research is related to the experimental monitoring of
data (i.e., making decisions as to when baseline observation is to
the third phase, a marked increase in weight and calor- be concluded and when various phases are to be introduced and
ic intake was' noted. This leveled off when feedback withdrawn) throughout the course of investigation. It is possible
was removed in Phase 4, but increased when feedback to program phase lengths on an a priori basis, but then one of the
Reinforcement Reinforcement Reinforcement
ease Line I Reinforcement & Feedback & Feedback
40
4.000
Weight __
Caloric
39 Intake 0----0
3.000
~
DIS
~
38
,o
-5-
-;0
i
·r ~ ,,
1:
, .5 i
~ '0 37
q ,,, .2~
~'O
,,
c:: 2.000
=
~
\
\
OJ
• c::
\X,,
\
\ 0..'
I"'0
I 0, , I"
36 \
l 0
\
I
,0 ? 1.000
, ,O.10' \ \
.
I
I
35
. \
0
0 10 20 30 40 50 80
Days
Figure 14. Data from an experiment examining the effect of feedback on the eating behavior of a patient with anorexia nervosa.
(From "Behavior Modification of Anorexia Nervosa" by W. S. Agras et af., 1974, Archives ofGeneral Psychiatry, 30, 279-286, Fig.
4. Copyright 1974 by the American Medical Association. Reprinted by permission.)
major advantages of the single case strategy (i.e., its flexibility) Listed in Table 2 are some of the possible design
is lost. However, even though the experimenter is fully aware of strategies for assessing drugs. Design 4-15 are all ex-
treatment changes, the spirit of the double-blind trial can be
maintained by keeping the observer . . . unaware of drug and
perimental in that the controlling effects of the drug on
placebo changes .... We might note here additionally that de- targeted behaviors may be ascertained. Also indicated
spite the use of the double-blind procedure, the side effects of is whether a single- or double-blind procedure is pos-
drugs in some cases . . . and the marked changes in behavior sible. Let us consider a published example of one of
resulting from removal of active drug therapy in other cases often
betray to nursing personnel whether a placebo or drug condition the designs (Number 13).
is currently in operation. (p. 206) Liberman et at. (1973) assessed the effects of
placebo and Stelazine on the social interaction of a 21-
In spite of the aforementioned difficulties, which year-old chronic schizophrenic patient who was quite
equally plague the group comparison researcher, there withdrawn. Social interaction was evaluated by noting
are some good examples of single-case work using the patient's willingness to engage in 18 daily half-
drugs. In some, the drug is a constant across phases minute chats with nursing personnel on the ward. Re-
while behavioral strategies are evaluated (cf. Wells, fusals to engage in such chats were labeled asocial
Turner, Bellack, & Hersen, 1978); in others, the addi- responses. In the first phase (A), the patient was with-
tion of a drug to a behavioral intervention is assessed drawn from all medication. In the next phase (A'), he
(Turner, Hersen, & Alford, 1974; Turner, Hersen, was administered a placebo, followed by 60 mg per
Bellack, & Wells, 1979); in still others (Liberman, day of Stelazine (Phase B). Next, he was withdrawn
Davis, Moon, & Moore, 1973; Williamson, CalPin, from Stelazine (Phase A'), and then Stelazine was re-
DeLorenzo, Garris, & Petti, 1981), the primary effects instated (Phase B).
of the drug are evaluated. As can be seen in Figure 15, removal of the drugs in
Table 2. Single-Case Experimental Drug Strategiesa

No. Design b Type Blind possible
1. A-A' Quasi-experimental None

2. A-B Quasi-experimental None
3. A'-B Quasi-experimental Single or double
4. A-A'-A Experimental None
5. A-B-A Experimental None
6. A'-B-A' Experimental Single or double
7. A'-A-A' Experimental Single or double
8. B-A-B Experimental None
9. B-A'-B Experimental Single or double
10. A-A'-A-A' Experimental Single or double
11. A-B-A-B Experimental None
12. A'-B-A'-B Experimental Single or double
13. A-A' -B-A'-B Experimental Single or double
14. A-A' -A-A' -BA'-B Experimental Single or double
15. A'-B-A'-C-A'-C Experimental Single or double
"From Single Case Experimental Designs (Table 6.1, p. 207) by M. Hersen and D. H.
Barlow, 1976. New York: Pergamon Press. Copyright 1976 by Pergamon Press. Re-
printed by permission.
bA = no drug; A' = placebo; B = drug 1; C = drug 2.
the first phase led to increased asocial behavior. With Vaithianathan (1986) evaluated the effects of placebo
the introduction of placebo, there was initial improve- and imipramine in a 22-year-old woman suffering from
ment and then a return of asocial behavior. Introduc- moderate mental retardation and deafness and visual
tion of Stelazine in the third phase led to a marked impairment in one eye as a result of congenital rubella.
improvement, followed by deterioration when Stela- The subject had very limited communication skills and
zine was removed in the fourth phase. Reinstitution of had lived in an institution for 11 years. Problems prior
Stelazine in the fifth phase clearly documents the con- to intervention of particular concern were crying, poor
trolling effects of the drug on improved social appetite, and screaming outbursts.
responding. An A-B-A'-B-A' -B design was followed, with
In a more recent drug trial, Field, Aman, White, and changeover phases between A and B when imipramine
was increased, and on two occasions between B and
A', when imipramine was reduced to O.
NO DRUG PLACEBO STELAZINE PLACEBO STELAZINE
I.
Behaviors targeted were evaluated twice weekly for
I 30 min each in the ward dayroom by two nursing staff
i 12 ,
I
0;
I
members, using lO-sec recording intervals. As can be
.
g 10 I
,.Ji seen in Figure 16, percentage of time crying was low in
0:
,,, baseline (A) and the frrst imipramine phase (B), much
,
I
-'
,, higher (albeit variable) in the placebo phase (AI), low

again in imipramine (B), increasing in the second
,,~
o
z
~ I
placebo phase (AI), and low again in the third im-
UI
:I 2
~-a.
...,, ipramine (B) phase. However, the data are not clear as
to whether crying increased in placebo because of im-
3 8 II 13 15 17 Ie 21 23 25
ipramine withdrawal, especially given the low rate of
SESSIONS
crying during the initial baseline phase (A).
Figure 15. Average number of refusals to engage in a brief con- On the other hand, data for percentage of meals
versation. (From "Research Design for Analyzing Drug-En- consumed clearly show the positive controlling effects
vironmental-Behavior Interactions" by R. P. Liberman et ai, of imipramine (58.7% on placebo; 71.0% on im-
1973, Journal of Nervous and Mental Disease, 156, 432-439,
Fig. 2. Copyright 1973 by Williams & Wilkins. Reprinted by ipramine). Similarly, data for number of screaming
permission.) outbursts show the controlling effects of imipramine
increased or decreased. But a weakness of the study is

that in some of the phases only two data points were
10 plotted, thus allowing for only a partial confirmation
of the data trend.
8
4 Additional Designs
Iv .. _
2
Although the basic A-B-A design and its numerous
o permutations have been used extensively and success-
Ii fully by applied behavioral researchers to evaluate
I 23 4 5 6 7 8 112131415161718182021 many therapeutic and educational problems, at times
some of these designs simply are not appropriate. In-
appropriateness may be due to practical, ethical, or
II II ! design considerations. For example, if a given thera-
I 11/'\'il
0 I
80
w
::I
::I 60
peutic procedure cannot be reversed or withdrawn
1iii (e.g., therapeutic instructions), then a different design
III
z
~Iv
0 70 I· " (such as the multiple-baseline design across behaviors)
u
I• ioj
. : i
could be employed to document the controlling effects
I I
III
-J 60 .1
: t:
t. I:
«
I I
! iii i
!I
of instructions on independent target behaviors. On the
.. i\il
w
::I 50
0: other hand, if an investigator is intent on showing the
""
0
#
40
..I i
I ! ,
I
I
iI
.' .i
:.
1
effects of some kind of shaping procedure where be-
havior is to be accelerated or decelerated, then the
I 2 3 4 5 6 7 6 " 12131415161718182021 changing-criterion design would be more suitable. Fi-
nally, if the relative efficacy of two treatment strategies
is to be contrasted in a single subject, then the simul-
1/'
i f !i
: i:
!I
:
taneous treatment design (sometimes referred to as the
multielement or alternating-treatment design) is the
') :: ,! design strategy of choice.
! !: i i
Let us now consider each of these designs in tum,
! 1"1 11/' beginning with the three varieties of the multiple-base-
:I
if:
~ I
i\!.: .
i iI:
i
:i
~:
I
i
\ line strategy.
o ! iii i Multiple Baseline

! i :: \'
i! i i Baer et al. (1968) first described the multiple-base-
I 2 3 4 5 6 7 8 I 12 1314 15 18 1 718 18 20 2 I
line design as follows:
WEEKS
In the multiple-baseline technique, a number of responses are
Figure 16. Percentage oftime crying, percentage of meals con· identified and measured over time to provide baselines against
sumed and number of screaming outbursts during baseline, im- which changes can be evaluated. With these baselines estab-
ipramine, and placebo periods. There was a I-week transition lished, the experimenter than applies an experimental variable to
phase, providing for dosage changes, between most drug phases one of the behaviors, produces a change in it, and perhaps notes
of the experiment. (From "A Single-Subject Study of Im- little or no change in the other baselines. (p. 94)
ipramine in a Mentally Retarded Woman with Depressive Symp-
toms" by C. J. Field et al., 1986, Journal of Mental Deficiency The investigator subsequently applies treatment to
Research,30, 191-198, Fig. 1. Copyright 1986. Reprinted by
permission.)
succeeding behaviors until some criterion point has
been achieved. Generally, the treatment is then with-
(7.5 per week on placebo; 2.4 per week on held until baseline stability has been achieved.
imipramine). The strategy described above is referred to as the
A nice feature of the Field et al. study is the use of a multiple-baseline design across behaviors. An as-
changeover phase of a week in which drug dosage was sumption, of course, is that the targeted behaviors are
independent of one another. Otherwise, treatment for TRAINING SCENES

one may lead to covariation in a second, thus obfuscat- Social Skills
c:: Bsln. Follow-up
ing the controlling effects of the treatment. In essence, o . Training
~H': .!::.:~
the multiple-baseline design across behaviors is a se-
ries of A-B designs, with every succeeding A phase
continued until treatment has finally been applied to ~ § ~ .40
each. Treatment effects are inferred from the untreated ~ u 8. .20 .
baselines. That is, the controlling effects of treatment VI 0--;
on dependent measures are documented if, and only if,
change occurs when treatment is directly applied. In
this respect, the design certainly is weaker than that in
OIl
OIl
IV
c::
'0
:;,VI
..c::
u
IV
IV
a.
~
L···-1r----
------1
the A-B-A-B design, where the effects of controlling ,3 ...o
variables are directly shown.
Let us consider an example of the multiple-baseline ..................
design across behaviors. Bomstein, Bellack, and ,
,
Hersen (1977) assessed the effects of social skills train-
ing on the role-played performance of an unassertive
8-year-old female third-grader (Jane). During base-
line, specific behaviors were assessed (ratio of eye
contact to speech duration, loudness of speech,
number of requests, and overall assertiveness) in role-
played scenarios requiring assertive responding. As
can be seen in Figure 17, the baseline levels of re-
sponding for target behaviors were low. Treatment ap- 3 5 7 9 11 2- 4·
plied to each baseline under time-lagged and Probe Sessions Weeks
cumulative conditions led to marked increases in re- Figure 17. Probe sessions during baseline, social skills treat-
sponding. The reader should note that only when so- ment, and follow-up for training scenes for Jane. A multiple-
cial skills treatment was directly applied to each of the baseline analysis Of ratio to speech duration of eye contact while
first three targeted behaviors did changes take place. speaking, loudness of speech, number of requests, and overall
assertiveness. (From "Social-Skills Training for Unassertive
There was no evidence that the targeted behaviors were Children: A Multiple-Baseline Analysis" by M. R. Bomstein et
correlated, nor did concurrent change take place in al .• 1977. Journal of Applied Behavior Analysis, 10. 183-195,
untreated target measures. In short, the controlling ef- Fig. l. Copyright 1977 by the Society for the Experimental
Analysis of Behavior, Inc. Reprinted by permission.)
fects of social skills treatment were demonstrated. It
also should be noted that although overall assert-
iveness was not directly treated, independent ratings of
overall assertiveness reflected improvement through- sometimes encountered in applied clinical research.
out the course of treatment, with all treatment gains They argue that
generally maintained in follow-up.
Unless there is a specific theoretical rationale or the in case of ambiguity with the effects of a multiple-baseline de-
investigator has had prior experience working with a sign, it often is possible to include a partial reversal in the design
given set of target behaviors, there is no accurate way for one of the behaviors. The reversal phase, or return to base-
line, need not be employed for all of the behaviors (i.e., base-
to predict whether the three or more targeted behaviors lines) for which data are collected. Indeed, one of the reasons for
selected for treatment truly are independent of one using a multiple-baseline design is to avoid the ABAB design and
another. Following the initial logic of the multiple- its temporary removal of treatment. However, when the specific
baseline design across behaviors, if change in target effect of the intervention is not evident in a multiple-baseline
design, one may have to resort to a temporary withdrawal of the
behaviors 1 and 2 occur as a result of treatment applica- intervention for one of the baselines to determine the effect of the
tion to only the first, then the controlling effects of the intervention. (p. 607)
treatment will not have been demonstrated. The base-
lines are correlated, but that does not necessarily imply A problem with the Kazdin and Kopel solution is
that the treatment in general is ineffective. Kazdin and that in the case of instructions, a true reversal or with-
Kopel (1975) have offered a solution to this dilemma drawal is not possible. Thus, their recommendations
apply best to the assessment of such techniques as ---
!l0 8Dlthne
,
feedback, reinforcement, and modeling.
A second type of multiple-baseline strategy is the
40 --V:
30
one across settings. That is, a given treatment is ap- WALKING ON TRAIL
plied to one subject (or groups of subjects) across sev- 20 EVENING ACTIVITY
eral different settings (e.g., different classroom peri-
10
ods). The logic of the design, however, remains the
same. Baselines for separate settings increase in 0
length, with treatment applied under time-lagged and 40
cumulative conditions. Generally, only one behavior is 30
targeted for time-lagged treatment. But there is no rea- DINING HALL
son that concurrent changes in other behaviors should 20
en
not be monitored. '"enz 10
,
An example of multiple-baseline design across set- 0
0..
en 0
, ...
tings was presented by Allen (1973). In his study, the
subject was an 8-year-old boy with minimal brain '"
II:
40
damage who was attending a special summer camp. '"

II:
II:
30 ,
, CA81N
C(
The target selected for modification was the child's
~
N 20
ii
high rate of bizarre verbalizations in four separate ...0 10
camp settings: walking on a trail, in the dining hall, in I
the cabin, and during education sessions. Treatment ....z

~
0 ,
'----.,
simply involved instructing the camp counselors to '"0
;:)
40
systematically ignore such bizarre verbalizations.
(Previously, these verbalizations had attracted consid- ...'"II: 30
EDUCATION
erable social reinforcement from the counselors.) 20
The results of this experimental analysis appear in
Figure 18. Following 7 days of baseline, treatment was
implemented for walking on the trail, with a resultant 25
decrease in bizarre talk. But no concurrent changes DAYS
were observed in the dining hall. Only when treatment
was specifically applied to the dining hall did bizarre Figure 18. Daily number of bizarre verbalizations in specific
camp settings. (From "Case Study: Implementation of Behavior
talk decrease. Note, however, that when treatment was Modification Techniques in Summer Camp Setting" By G. J.
applied in the dining hall, there were some concurrent Allen, 1973, Behavior Therapy, 4, 570-575, Fig. I. Copyright
decreases in bizarre talk in the cabin. Similarly, when 1973 by Behavior Therapy. Reprinted by permission.)
treatment was applied in the cabin, there were some
concurrent decreases noted during education sessions. length. In contrast to the multiple baseline design across behav-
Thus, the last two baselines were not totally indepen- iors (the within-subject multiple baseline design), in the multiple
dent. Indeed, this was an instance in which Kazdin and baseline across subjects a single targeted behavior serves as the
primary focus of inquiry. However, there is no experimental
Kopel's (1975) recommendation of a partial reversal contraindication to monitoring concurrent . . . behaviors as
(withdrawal) for Baselines 3 and 4 would have added well. (p. 228)
confirmatory evidence to the treatment's effective-
ness. A good example of the multiple-baseline design
A third type of multiple-baseline design strategy is across subjects appeared in a paper by Ortega (1978).
the one across subjects. Although not strictly a single- In this study, Ortega evaluated the effects of relaxation
case study, the general principles of the multiple-base- training on the spasticity level of four cerebral palsied
line strategy apply. As described by Hersen and Bar- adults. The dependent measures involved two timed
low (1976), trials of the Placing Test and the Turning Test from the
Minnesota Rate of Manipulation Tests, which test the
a particular treatment is applied in sequence across matched
subjects presumably exposed to "identical" environmental con-
speed and dexterity of finger, hand, and arm move-
ditions. Thus, as the same treatment variable is applied to suc- ments.
ceeding subjects, the baseline for each subject increases in Figure 19 shows that all four subjects' performance
TREATMENT exposed to the same environment but treated in succes-

FOLLOW·UP
sion in time-lagged fashion. In this manner, the experi-
menter is able to control for the individual's history
(see Campbell & Stanley, 1966). However, under cer-
SUBJECT 2
tain circumstances the possibility of treating several
subjects concurrently may not be possible, especially
if the disorder in question is rare. In order to deal with
• this problem, P. 1. Watson and Workman (1981) have
proposed an alternative strategy, referred to as the non-
SUBJECT 3 current multiple baseline across individuals.
In this research design, the researcher initially determines the

length of each of several baseline phases (e.g. 5, 10, IS days).
When a given subject becomes available (e.g. a client is referred
\®-~ who has the target behavior of interest and is amenable to the use
SUBJECT 4
of a specific treatment of interest), (s)he is randomly assigned to
one of the pre-determined baseline length~. Baseline observa-
tions are then carried out; and assuming that responding has
...
....- - ® - TEST------
TURNING . -------...
reached acceptable stability criteria, treatment is implemented at
.PLACING TEST the pre-determined point in time. Observations are continued
ABSENT
throughout the treatment phase, as in a simple AB design. Sub-
:H>AY PERIODS
jects who fail to display stable responding would be dropped
from the formal investigation; however, their eventual reaction
Figure 19. The time required to complete two trials of both the to treatment might serve as useful replication data. (p. 258)
Placing Test and the Turning Text, from the Minnesota Rate of
Manipulation Tests, during baseline, treatment, and follow-up Although Watson and Workman's strategy repre-
phases of research. Testing sessions, which measured the amount sents a viable approach, it should be used only as a last
of time required to complete various manual manipulations in- resort, since history cannot be controlled. But, of
volving pegs and pegboard, were conducted every third working
day throughout the experiment. During the treatment condition, course, with increased numbers of replications, one's
relaxation exercises were performed every working day. Subject confidence in the procedure under evaluation is
I was absent throughout Test Period 26 because of illness. Sub- enhanced.
ject 4 was vacationing during Periods 5 and 6. Severe cold weath-
er and heavy snows forced the closure of both sheltered work-
Another variation in the basic multiple-baseline de-
shop-facilities for eight working days, so Test Period 30 was sign is the use of the multiple-probe technique (Homer
canceled. (From "Relaxation Exercise with Cerebral Palsied & Baer, 1978). This strategy was designed to deal with
Adults Showing Spasticity" by D. F. Ortega, 1978, Journal of those instances where reactivity may occur simply as a
Applied Behavior Analysis, 11, 447-451. Fig. 1. Copyright
1978 by the Society for the Experimental Analysis of Behavior, result of repetition, of assessment in the successive
Inc. Reprinted by permission.) baselines (e.g., Bellack, Hersen, & Turner, 1976).
Thus, instead of having 8, 12, and 16 assessments in 3
successive baselines, fewer probes may be carried out,
on the two tests was slow, but that slight improvements resulting in, for example, 2, 3, and 4 measurement
generally occurred throughout baseline as a function of points. Of consequence, a somewhat weaker design
repeated trials. However, only when progressive re- results, especially if baseline data are not stable, there-
laxation exercises were practiced by each subject did fore providing suggestive rather than confirmatory evi-
marked changes in speed take place. Moreover, fol- dence of the controlling effects of treatment. Indeed,
low-up data indicate that performance improvement "as in the case of the noncurrent mUltiple baseline
was maintained for at least three weeks. Performance design, it should not be employed as a substitute for·
improvement from baseline to treatment (averaged continuous measurement when that is feasible" (Bar-
over the four subjects) was 28% on the Turning Test low & Hersen, 1984, p. 248).
and 21 % on the Placing Test.
Changing-Criterion Design
Variations in the Multiple Baseline
The changing-criterion design (cf. Hartmann &
In our prior discussion of the multiple-baseline de- Hall, 1976) appears to be ideal for assessing shaping
sign across subjects, each individual treated had been programs to accelerate or decelerate behaviors (e.g.,
PANEL A B c o E F G
55
50
I
I
Ie-~-"';
.'/l........:
!I1
1
I
I
1
I
I
1
I
1
I
1
25 I
DAYS: 1 8 15 29 36 43 50 57 64 71 78 85
PHASES: BASEUNE TREATMENT
Figure 20. Data from a smoking-reduction program used to illustrate the stepwise criterion-change design. The solid horizontaIlines
indicate the criterion for each treatment phase. (From "The Changing Criterion Design" by D. P. Hartmann and R. V. HaIl, 1976,
Journal ofApplied Behavior Analysis, 9, 527-532, Fig. 2. Copyright 1976 by the Society for the Experimental Analysis of Behavior,
Inc. Reprinted by permission.)
increasing activity in overweight individuals; decreas- sign was provided by Hartmann and Hall (1976) in
ing alcohol consumption in heavy drinkers). As a strat- their evaluation of a smoking-deceleration program.
egy, it bears characteristics similar to those of the A-B The baseline smoking level is graphically depicted in
design and has some features of the multiple-baseline Panel A of Figure 20. In B (treatment), the criterion
strategy. Following initial baseline observation, treat- rate was established as 95% of baseline (i.e., 45 ciga-
ment is applied until a given criterion is achieved and rettes per day). An escalating-response cost of $1 was
stability at that level appears. Then, a more rigorous set for smoking Cigarette 47, $2 for Cigarette 48, and
criterion is selected, and treatment is applied until the so forth. If the subject smoked fewer than the criterion
performance level is met. Changes in criterion level as number of cigarettes, an escalating bonus of 10 cents
a result of the second treatment are contrasted with the per cigarette was established. Subsequent treatment in
lower criterion in Treatment 1. Treatment is thereby C through G involved the same contingencies, with the
continued in this stepwise fashion until the final criteri- criterion for each succeeding phase set at 94% of the
on is met. "Thus, each phase of the design provides a previous one.
baseline for the following phase. When the rate of the The experimental analysis clearly shows the
target behavior changes with each stepwise change in efficacy of the contingencies established in reducing
the criterion, therapeutic change is replicated and ex- cigarette smoking by 6% or more from the preceding
perimental control is demonstrated" (Hartmann & phase. In addition, within the individual analysis,
Hall, 1976, p. 527). there were six clear replications of the treatment's ef-
An excellent example of the changing-criterion defect. In short, we agree with Hartmann and Hall (1976)
that "the changing criterion design is capable of TOKEN RFT TOKEN RFT,
BASE (SELF a CLASS)
providing convincing demonstrations of experimental 100 I , (CLASS)
control, seems applicable to a wide range of prob- , I~
II:: 80 I~'
lematic behaviors, and should be a useful addition to 0 ,
I I
60
applied individual subject methodology" (p. 532). ~ ~:
:z: 40
....
III
Simultaneous Treatment Design .... 20

> 0
MAX
~
In the simultaneous treatment design (cf. Kazdin & z
....
~ 100
Geesey, 1977; Kazdin & Hartmann, 1978), there is the
opportunity to compare two or more treatments within
~
c(
~
80 :~:~
I" ..... ~...... .1
_..,
Z 60
a single subject. This, of course, is in marked contrast ....
.' • I ... .... I
to the other strategies we have discussed to this point,

u ~
.. • ' r I
'
....II:: 40 ,
wherein design limitations do not allow for such IL
20 : SELF ••.•
comparisons. 0 ' CLASS<>---<>
As with all single-case designs, there are particular 5 10 15 20
circumstances under which the simultaneous treatment DAYS
design may be implemented. Thus, there must be the
opportunity to evaluate at least two stimulus dimen- Figure 21. Attentive behavior of Max across experimental con-
ditions. Baseline (base): no experimental intervention. Token
sions (e.g., different times of day, locations, or treat- reinforcement (token rft): implementation of the token program,
ment agents). In a classroom study, different time peri- in which tokens earned could purchase events for himself (self)
ods may be the stimulus dimension (morning vs. or the entire class (class). Second phase of token reinforcement
(token rfs 2): implementation of the class exchange intervention
afternoon). During the baseline phase, the targeted be- across both time periods. The upper panel presents the overall
havior is evaluated in each of the stimulus dimensions. data collapsed across time periods and interventions. The lower
Then two (or possibly more) interventions (e.g., indi- panel presents the data according to the time periods across
vidual vs. group contingencies) are applied concur- which the interventions were balanced, although the interven-
tions were presented only in the last two phases. (From "Simul-
rently in each of the stimulus dimensions. In order to taneous-Treatment Design Comparisons of the Effects of Eam-
avoid a possible treatment-stimulus dimension con- ing Reinforcers for One's Peers versus for Oneself" by A. E.
found, each of the two interventions is counter- Kazdin and S. Geesey, 1977, Behavior Therapy, 8, 682-693,
Fig. 2. Copyright 1977 by Behavior Therapy. Reprinted by
balanced across dimensions. For example, on the first permission.)
day, Treatment A is administered in the morning;
Treatment B is administered in the afternoon. On the
second day, treatment B is administered in the morn- 60%. Implementation of the token program for the
ing; Treatment A is administered in the afternoon, and subject alone (i.e., self) led to an average percentage
so forth. The results of the two treatments are plotted of attentive behavior of 72.5%. By contrast, the token
and visually examined. (It is possible to evaluate the program for the subject and the rest of the class (i.e.,
effects of counterbalanced treatment with statistical class: backup reinforcers were earned for himself and
analyses similar to those employed in the analysis of a the entire class) led to 91 % attentive behavior. Thus, in
Latin square design: see Benjamin, 1965.) In the third the third phase, the superior procedure was continued
phase of the study, the most efficacious treatment is across both class periods, with a mean percentage of
applied across each of the stimulus conditions. attentive behavior of 91.2% attained.
Let us look at an example of this design in a study In further considering the simultaneous treatment
carried out by Kazdin and Geesey (1977). In this inves- design, Kazdin and Hartmann (1978) pointed out that
tigation of classroom behavior, the effects of token the behaviors selected for study must be those that can
reinforcement for the subject alone versus token rein- rapidly shift and that do not evince carry-over effects
forcement for the subject and the rest of his class were after termination. By necessity, this would preclude
evaluated, with percentage of attentive behavior as the the evaluation of certain drugs in this kind of design.
dependent measure. This study was done in counter- Also, because of the counterbalancing requirement,
balanced fashion for two separate classroom periods. relatively few behaviors can be evaluated (probably
Figure 21 (bottom part) reveals that percentage of at- not more than three). Finally, "The client must make at
tentive behavior during baseline ranged from 40% to least two sorts of discriminations. First, the client must
discriminate that the treatment agents and time periods Kazdin (1976) has summarized the case against sta-
are not associated with a particular intervention be· tistical analysis in single-subject research as follows:
cause the interventions vary across each of the dimen·
sions. Second, the client must be able to distinguish Individuals who advocate non-statistical criteria for evaluation
caution against "teasing out" subtle effects because these effects
the separate interventions. One would expect that the
are least likely to be replicable. Moreover, involving statistical
greater the discrimination made by the client the more significance as the only criterion for evaluation does not encour-
likely there will be clear effects or discrepancies be- age the investigator to obtain clear unequivocal experimental
tween (among) treatments" (Kazdin & Hartmann, control over behavior. Finally, many investigators believe that in
clinical work statistical evaluation is simply not relevant for
1978, p. 919). assessing therapeutic change. (p. 272)
Statistical Analysis
The Case For
There has probably been no aspect of single-case The advocates of statistical analyses for single-case
research in recent time more fraught with controversy research recommend them for several reasons. The
than that involving statistical analysis (cf. Baer, 1977; most persuasive argument has been presented by Jones
Hartmann, 1974; Huitema, 1985; Jones et al., 1977, et al. (1977). In contrasting the statistical approach
Kazdin, 1984; Keselman & Leventhal, 1974; with visual analysis for a number of studies published
Kratchowill et al., 1974; Michael 1974a, b: Wampold in the Journal of Applied Behavior Analysis, it was
& Workman, 1986). The critics and the advocates of found that in some instances, time-series analyses (cf.
the use of statistics are equally intense about attempt- Glass, Willson, & Gottman, 1975) confirmed the ex-
ing to persuade colleagues and students to their respec- perimenters' conclusions based on visual inspection.
tive positions. In this section, it is not our purpose to In other instances, time-series analyses did not con-
attempt to resolve the controversy. Rather, it is our firm the experimenters' conclusions. In still other
explicit intention to look at the arguments and to ferret cases, time-series analyses indicated the presence of
out the data in relation to these arguments. In so doing, statistically significant findings not identified by the
we will briefly examine the opposing positions while experimenters. Consequently, Jones et al. (1977) con-
considering some of the recommended statistical cluded that
procedures.
all three kinds of supplementary information provided by time-
The Case Against series analysis are useful. It is rewarding to have one's visual
impressions supported by statistical analysis. It is humbling
The basic argument against the use of statistics in and/ or educational to have other impressions not supported. And
single-case research involves the distinction between it is clearly beneficial to have unseen changes in the data detected
by a supplementary method of analysis. It is difficult to see how
clinical and statistical significance. Indeed, one of the operant researchers can lose in the application of time-series
specific arguments against the group comparison analysis to their data. (p. 166)
method is that statistics do not give the experimenter a
"true" picture of the individual pattern of results. That Statistical analysis may prove helpful when baseline
is, positive and negative treatment effects cancel out; stability is difficult to establish and considerable over-
in addition, statistics may possibly yield significance lap exists between the baseline and the treatment
from very weak overall treatment strategies. Thus, if phases. As pointed out by Kazdin (1976), "whereas
the effect of treatment is not sufficiently substantial to visual inspection of the data often entails noting dis-
be detected by visual inspection (i.e., considerable tinct changes in trends across phases, statistical analy-
overlap of data between baseline and treatment sis can scrutinize continuous shift across phases where
phases), then the treatment applied is not clinically there is not change in trend" (p. 270).
potent and its controlling effects have not been clearly A third use advocated for statistical analysis is for
documented. On the other hand, if treatment is of suffi- investigations in so-called new areas of research. Pre-
cient potency to yield considerable clinical change, sumably, in these newer areas, therapeutic techniques
then there is the expectation that such change may are unlikely to be fully refined and developed; hence,
approach the social norm (i. e. , social rather than statis- there is a lesser likelihood that marked clinical dif-
tical validation) (See Kazdin, 1977). This being the ferences will appear on visual inspection. Thus, in the
case, statistical analysis should prove superfluous. early stages of research, it is argued that statistics may
204 PART U • ASSESSMENT AND RESEARCH
reveal small but important differences with clinical account change in the level, change in the slope of the
implications. curve, and the presence or absence of drift or slope in
A fourth reason offered for the use of statistical anal- the curve (see Jones et aI., 1977). Indeed, Figure 22
yses (cf. Kazdin, 1976, 1984) is the increased intra- depicts six illustrative treatment effects that may be
subject variability in uncontrolled research settings ascertained through the use of time-series analyses. As
(e.g., in the natural environment). Again, the argu- noted by Jones et al., in some instances the mere visual
ment put forth is that the statistical approach may de- analysis of such data might yield erroneous conclu-
tect changes that could eventually have some clinical sions.
impact when the specific therapeutic or educational Despite the obvious utility of the time-series ap-
strategy is later refined. proach, it is not without its limitations. First, to meet
the requirements of the analysis, a fairly large number
of observations may be required (Le., 50-100). Al-
T-Test and ANOVA
though feasible in some investigations, this number
A number of t-test and analysis-of-variance would preclude the use of statistics in many others
(ANOYA) techniques have been adapted for use in where short-term treatment effects are being evalu-
single-case research across the different phases of a ated. More recently, Huitema (1985) has presented
given study (cf. Gentile, Roden, & Klein, 1972; Shine evidence questioning whether in many of our single-
& Bower, 1971). If we compare the ANOYAin single- case studies "data have highly autocorrelated re-
case research and group comparison designs, the treat- siduals" (p. 107). Indeed, he argues that complicated
ment factor in the single-case study is analogous to the time-series analyses are neither "appropriate" or nec-
between-group factor. Similarly, the number of obser- essary in such instances. However, Huitema's (1985)
vations within a phase is comparable to the within- assertion has been challenged by Suen (1987; Suen &
group factor. In developing their ANOYA technique, Ary, 1987), who noted "that the findings of no or little
Gentile et al. (1972) assumed that the performance of a autocorrelation in behavior analyses data can best be
response within a phase is independent of each other described as inconclusive" (Suen & Ary, 1987, p.
response. However, it should be noted that they were 113). At this point in time it is safe to say that the
aware of "the high autocorrelation of adjacent obser- philosophical and technical controversies concerning
vations" (Kazdin, 1975, p. 276). To control for this use of statistics in single-case research continue
factor, Gentile et al. suggested combining nonadjacent unabated.
phases in the A-B-A-B design (i.e., A J + A2 ;B J + B2 )
in computing the statistical analysis.
Additional Comments
Despite the correction factor suggested by Gentile et
a!., there are two basic problems in using the ANOYA There can be no doubt that statistical analysis for
model. First and foremost is the issue of dependency. single-case research has its merits and should prolife-
As argued by Kazdin (1976), "combining phases does rate in the future. Also, the reader should keep in mind
not at all affect the problem of non-independent data that many other statistical strategies (not discussed in
points and the decreased variability among observa- this chapter) have appeared and undoubtedly will con-
tions within phases, two factors that can positively bias tinue to appear in the press. (For a more comprehen-
F tests" (p. 277). The second problem is that the sive coverage of the area, the reader is referred to
ANOYA essentially contrasts the means of each phase. Huitema, 1985; Kazdin, 1976; Kratochwill, 1978).
Thus, the statistical model proposed fails to take into
account data trends as represen.ted by the slope of the
curve. In short, it would appear that the criticisms of Replication
applications of traditional group statistics to the single-
case study are warranted (see Hartmann, 1974; Kes- In the previous section, we looked at some of the
elman & Leventhal, 1974). statistical techniques that might serve to confirm (or
even to supplant) the experimenter's visual analysis of
his or her data. The objective in using a statistical
Time-Series Analysis
technique is to guarantee that the visual inspection of
Time-series analysis controls for the problems al- trends indicating controlling effects of treatment vari-
luded to above in that the statistical strategy takes into ables on dependent measures is indeed valid. Assum-
CHAPTER 9 e SINGLE-CASE EXPERIMENTAL DESIGNS 205
to= Itort of lim...rie. w

w
a:: =
t; on int.rruption point a::
o
o tp =.nd of tim...ri•• (.J
I/)
~ ..J
..J «
«
a::
a::
o
o
:> :>
«
«
:t
l:
w
w
~L- ________ ~ _________ ~
t. t. t. t. t. t.
Ia..'in. Trealment Ia..line Trea"".nt
o. Chonte in ,...,. oro trend. b. No change in ,...,. nonzero
no change in tr.nd. tr.nd. no change in trend.
w w
a:: a::
o o
~ ~
..J
..J
« «
a:: a::
Q Q
> >
« «
:t
:t w
w a!
~
t. t. t, t. t.
lcneIine Treatment lcneIine
c. Cho,.. in Ie..,. nonzero d. No cho,.. In level. nonzero
trend. no cho,.. in trend. trend, cho,.. In trend.
w w
a:: a::
o o
~ ~
..J
..J
« «
a::
a:: o
Q
> :>«
«
l: :t
w w
~ ~
~---+----
t. t. t. t. t. t.
IIneIIne TrwIIIIent '-a_ine Treatment
•• Change in _'. nonzero f. No chonte in ....,. zero
trend. chonte in trend. trend. no cho... in trend.
Figure 22. Six illustrative treatment effects: combinations of level and trend changes detectable by time-series analysis. (From
"Time-Series Analysis in Operant Research" by R. R. Jones et al .• 1977, Journal ofApplied Behavior Analysis, 6, 517-531, Fig. 1.
Copyright 1977 by the Society for the Experimental Analysis of Behavior, Inc. Reprinted by permission.)
ing a high concordance between a visual and a statis- Elsewhere, Hersen and Barlow (1976) noted that
tical analysis of the data (thus confirming the
treatment's efficacy for the one subject), the question, Replication is at the heart of any science. In all science, replica-
of course, remains whether the same effect can be re- tion serves at least two purposes: First, to establish the reliability
peated in a different subject. Thus, replication is con- of previous findings and, second, to determine the generality of
these findings under differing conditions. These goals, of course,
cerned with the reliability and the generality of are intrinsically interrelated. Each time that certain results are
findings. replicated under different conditions, this not only establishes
generality of findings, but also increases confidence in the relia- example (H. L. Mills, Agras, Barlow, & 1. R. Mills,
bility of these findings. (p. 317) 1973), there were four successful replications with de-
sign modifications during replications. In still another
The importance of replication in single-case re- series (Wincze et al., 1972), there were mixed results
search should be quite obvious from a strictly scientific in nine replications.
standpoint. Also, however, critics of the single-case When mixed results occur, the investigator should
research approach have chastised applied behavioral search for the causes of failure and refine the treatment
researchers for reporting chance findings in single procedures. According to Hersen and Barlow (1976),
cases, despite the apparent demonstration of experi- if one successful experiment is followed by three suc-
mental control in each. Thus, as in the use of statistics cessful replications, then it is useful to begin a system-
in the experimental analysis of behavior, replication atic replication series, in which different behaviors in
(or its absence) is a controversial point. the same setting or similar behavior in different set-
In this section, we are concerned with the descrip- tings are treated by different therapists. If, on the other
tion of three types of replication strategies referred to hand, one successful treatment is followed by two
in Hersen and Barlow (1976): (I) direct, (2) clinical, failures to replicate, the investigator should carefully
and (3) systematic. For each type of replication series, study the variables that account for the failure. This
the specific issues and guidelines are considered. can be as important as a successful attempt at direct
replication, inasmuch as new hypotheses may be gen-
erated, leading to vastly improved treatments.
Direct Replication
Sidman (1960) has defined direct replication as Clinical Replication
"repetition of a given experiment by the same investi-
gator" (p. 72). This could involve replication of a pro- Hersen and Barlow (1976) have defined clinical rep-
cedure within the same subject or across several sim- lication as the "administration of a treatment package
ilar subjects. As argued by Hersen and Barlow (1976), containing two or more distinct treatment procedures
"while repetition on the same subject increases confi- by the same investigator or group of investigators.
dence in the reliability of findings and is used occa- These procedures would be administered in a specific
sionally in applied research, generality of findings setting to a series of clients presenting similar com-
across clients can be ascertained only by replication on binations of multiple behavioral and emotional prob-
different subjects" (p. 310). Generally, thesameinves- lems, which cluster together" (p. 336). Examples
tigator (or research team) repeats the study in the same might be schizophrenia or childhood autism (e.g.,
setting (e.g., school, hospital, or clinic) with a set of Lovaas, Koegel, Simmons, & Long, 1973).
clients who present with a similar educational or psy-
The usefulness of this effort also depends to some extent on the
chological disorder (e.g., unipolar nonpsychotic de- consistency or reliability of the diagnostic category. If the clus-
pression). Although such clients may differ to some tering of the target behaviors is inconsistent, then the patients
extent on demographic variables, such as age, educa- within the series would be so heterogeneous that the same treat-
ment package could not be applied to successive patients. For
tion, and sex, it is better for a direct replication series if
this reason, and because of the advanced nature of the research
these are closely matched. This is of special impor- effort, clinical replications are presently not common in the liter-
tance for instances where failure to replicate occurs. In . ature. (Hersen & Barlow, 1976, p. 336)
such cases, failure, then, should not be attributed to
differences in demographic variables. Of paramount Guidelines for clinical replication are essentially the
concern is that the identical procedure be applied same as for direct replication. However, interclient
across the different subjects. Otherwise, possible characteristics are, by definition, likely to be more
failures or unusual successes may occur, with attribu- heterogeneous, thus necessitating a longer replication
tion to subject characteristics erroneously assumed. series than in the case of direct replication. Also, suc-
Hersen and Barlow (1976) have described several cessful clinical replication should lead to a systematic
series where direct replications have been undertaken. replication series.
In one, the initial experiment was successful followed
by two replications in the treatment of agoraphobia
Systematic Replication
(Agras, Leitenberg, & Barlow, 1968). (The same held
true for a study reported by Hersen et aI., 1973, on Systematic replication is defined "as any attempt to
token economy and neurotic depression.) In a second replicate findings from a direct replication series, vary-
ing settings, behavior change agents, behavior disor- research strategy, the single-case approach has had a
ders, or any combination thereof. It would appear that long and interesting history. In this chapter, we first
any successful systematic replication series in which examined the historical roots of the current experimen-
one or more of the above-mentioned factors is varied tal analysis-of-behavior model. Then, we considered
also provides further information on generality of find- general issues, such as intrasubject variability, inter-
ings across clients since new clients are usually in- subject variability, generality of findings, and vari-
cluded in these efforts" (Hersen & Barlow, 1976, p. ability as related to generality. We next looked at some
339). of the general procedures that characterize most sin-
As for specific guidelines, systematic replication gle-case research (repeated measurement, choice of a
ideally begins after one successful initial experiment baseline, the changing of one variable at a time, length
and three direct replications have been carried out. of phases, reversal and withdrawal, and evaluation of
However, although the word systematic is included, irreversible procedures). This was followed by a dis-
usually such a series is carried out by researchers, ei- cussion of basic A-B-A designs, their extensions, and
ther concurrently or in succession, in a number of set- the additional designs required when conditions for the
tings. Some researchers may be in direct communica- A-B-A strategies cannot be met. We briefly looked at
tion with one another, but more frequently, it turns out the thorny issue of statistical analysis in single-case
that they are simply working on similar problems; research and ended with a discussion of direct,
hence, the possibility (albeit not really systematic) of clinical, and systematic replication.
replications with variation. Probably the largest such In conclusion, we should point out that the field is
series in the behavioral literature is the one involving not static and that newer design and statistical tech-
dozens of single-case studies showing the efficacy of niques will undoubtedly emerge over the course of the
differential attention procedures for adults and chil- next few years (see Barrios, 1984). This, of course, is a
dren (cf. Hersen & Barlow, 1976, pp. 344-352). healthy phenomenon that we can only applaud. More-
In examining a systematic replication series, it is over, we should acknowledge that there are some in-
important to note differences in therapists, treatment herent limitations in all design strategies, including
settings, and clients. In that sense, the objective of a single-case analysis, that all researchers need to recog-
systematic replication series is to determine exceptions nize (Cavell, Frentz, & Kelley, 1986). Thus, we see
to the rule (i.e., those instances in which a given treat- nothing inherently wrong in, at times, using the single-
ment strategy will not work for a given client or for a case approach to generate treatment hypotheses that
particular therapist). This certainly was the case when subsequently may be refined and then pitted against
Wahler (1969) found that differential attention was not one another in larger scaled group comparison studies.
an effective treatment for dealing with oppositional
children. Thus, the limits of applicability of differen-
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impaired. Journal of Visual Impairment and Blindness, 75, (1978). Effects of cue-controlled relaxation on psychomotor
359-362. seizures: An experimental analysis. Behaviour Research and
Van Hasselt, V. B., Hersen, M., Bellack, A. S., Rosenblum, N., Therapy, 16, 51-53.
& Lamparski, D. (1979). Tripartite assessment of the effects Williamson, D. A., Calpin, 1. P., DeLorenzo, T. M., Garris, R.
of systematic desensitization in a multiphobic child: An ex- P., & Petti, T. A. (1981). Combining dexedrine (dextro-
perimental analysis. Journal ofBehavior Therapy and Experi- amphetamine) and activity feedback for the treatment of hy-
mental Psychiatry, 10, 51-56. peractivity. Behavior Modification, 5, 399-416.
Wahler, R. G. (1969). Oppositional children: A guest for paren- Wincze, J. P., Leitenberg, H., & Agras, W. S. (1972). The
tal reinforcement control. Journal ofApplied Behavior Analy- effects of token reinforcement and feedback on the delusional
sis, 2, 159-170. verbal behavior of chronic paranoid schizophrenics. Journal
Wampold, B. E., & Worsham, N. L. (1986). Randomization of Applied Behavior Analysis, 5, 247-262.
tests for multiple-baseline designs. Behavioral Assessment, 8, Yates, A. 1. (1970). Behavior therapy. New York: Wiley.
135-143.
Watson, J. B., & Rayner, R. (1920). Conditioned emotional
reactions. Journal of Experimental Psychology, 3, 1-14.
PART III
General Issues and

Extensions
CHAPTER 10
Training in Behavior Therapy

Gregory M. Alberts and Barry A. Edelstein
Introduction & BerIer, 1986), college undergraduates (Johnson,

Katz, & Gelfand, 1972), psychiatry residents (Evans,
Behavioral approaches to the assessment and modifi- 1976), parents (Gardner, 1976), teachers (Kazdin,
cation of human psychopathology are entering a fourth 1974), correctional officers (Deibert & Golden, 1973),
decade and have attained a recognized and respected institutional staff (Frazier, 1972), child care workers
position among the mental health disciplines. In a (Schinke & Wong, 1978), and psychiatric nurses
1981 survey of clinical psychologists, 14.4% endorsed (Milne, 1984).
a behavioral orientation, third in rank to eclectic The training provided to these individuals is not
(30.9%) and psychodynamic (30.0%) approaches equivalent in terms of content, format, and objectives.
(Norcross & Prochaska, 1982). Approximately one Training can be conceptualized best as falling on a
third ofthe respondents to Jayaratne's (1978) survey of continuum along which the process and ultimate prod-
clinical social workers indicated behavior therapy as ucts of training vary in degree of sophistication. At one
one of their preferred theoretical orientations. Regreta- end of this continuum are training programs whose
bly, the impact of behavior therapy in psychiatry re- goals are the development of individuals with a broad
mains marginal prompting Franks (1982) to note that range of conceptual, technical, and interpersonal com-
"psychiatric education still deemphasizes behavioral petencies who are qualified, in principle, to function as
training" (p. 15). independent behavior therapy practitioners. On the
Paralleling progress in the development, evalua- other end of the training continuum are educational
tion, and utilization of behavioral treatments have been opportunities designed to instill the skills required to
demands for and opportunities to receive training in apply basic behavioral principles and techniques.
behavior therapy. Behavior therapy training has and Thus, the spectrum of behavior therapy training is rep-
continues to occur in a variety of contexts, including resented, at the one end by program level efforts (e.g.,
undergraduate schools, graduate programs, teaching graduate study in clinical psychology or social work)
hospitals, professional conferences, and postdoctoral to produce sophisticated and comprehensively trained
training institutes. Instruction in behavior therapy has behavior therapists. At the other end, training is deliv-
been provided to virtually every type of human service ered in more focused interventions (e.g., conference
worker. Student-trainee populations have included or in-service workshops), with the goal of equipping
clinical psychology doctoral students (Collins, Foster, trainees with more circumscribed behavior therapy
skills. The number of paraprofessional mental health
Gregory M. Alberts and Barry A. Edelstein • Department
of Psychology, West Virginia University, Morgantown, West workers who participate in this latter form of training
Virginia 26506-6040. has increased significantly the proportion of behav-
213
214 PART III • GENERAL ISSUES AND EXTENSIONS
iorally trained service providers in hospital and other frequently sat in on ... interviews with patients, after which
community-based health service organizations discussion was the rule. The trainee was expected to do a great
deal of reading on his own. (Wolpe & Boynton, 1978, p. 295)
(Graziano & Katz, 1982).
We will confine this current review and discussion to Although a significant portion of behavior therapy
the training of professionals whose primary role in- training was conducted informally, surveys of psy-
volves the provision of mental health services. Follow- chology departments and internship sites revealed that
ing a brief overview of the history and current status of some formal coursework and practicum opportunities
behavior therapy training opportunities, we will re- were being offered (Edwards, 1970; Poser, 1969).
view the domains of therapist skills and competencies Benassi and Lawson (1972) reported the results of a
that have been proposed in the behavioral literature. survey of college and university psychology depart-
Models for imparting behavior therapy competencies ments regarding course offerings in behavior modifica-
will be reviewed as will recent empirical studies de- tion (the term subsumes behavior therapy, condition-
scribing the training of behavior therapy skills. Con- ing therapy, etc.). Two hundred and ninety schools
siderations in training program evaluation will be responded to the survey, of which 180 (62%) of the
highlighted, and future directions in behavior therapy departments stated they offered courses in behavior
training will be addressed. modification at either or both the undergraduate and
graduate levels. Of the 180 schools providing instruc-
tion in behavior modification, 65 offered more than
History of Behavior Therapy Training one course. Further, "nineteen of the schools either
offered graduate degrees [in behavior modification] or
The characteristics of behavior therapy training dur- emphasized behavior modification in their curricu-
ing the early years of the field have not been described, lum" (p. 1068). Although the criteria they used to
except for a few exceptions, in ways that adequately make such a judgment were rather liberal, it is appar-
characterize the content and format of that training. ent that concentrated structured training could be
The editors of the first edition of this volume conveyed obtained.
a flavor for this earlier training in recounting their own The earliest behavior modification course taught
educational experiences: that was noted by the survey respondents was by
Arthur Staats in 1955. No additional courses in behav-
Courses in behavior therapy were then [in the mid to late 1960s1a ior modification were offered between 1955 and 1963;
rarity. Behavioral training was based more on informal tutorials
than on systematic programs of study. The behavioral literature
however, during the period between 1963 and 1971,
was so circumscribed that it could be easily mastered in a few course offerings increased at the rate of 22 per year.
months of study. (Bellack, Hersen, & Kazdin, 1982, p. xi) Course offerings at the time of the study included gen-
eral surveys of the field as well as more specialized
Lazarus (1969) characterized this period as the "do-it- classes covering the application of behavior modifica-
yourself phase of behavior therapy training" and urged tion in such settings as clinics and schools. Surprising-
training institutions to provide formal coursework on ly, some form of practicum experience was provided in
the subject. Wolpe (1969) noted that the professional all but 23 of the courses.
interest in behavior therapy during this period far out- The rnid-1970s witnessed an extraordinary growth
weighed the facilities in which training could be ob- in the number of programs that allegedly trained be-
tained. He stated at the time that the "acquisition of havior therapists. The Association for Advancement of
skills in behavior therapy still rests mainly on episodic Behavior Therapy published its first compendium of
measures like demonstrations and workshops; and graduate training opportunities in behavior therapy
many people have to rely entirely on the printed word" that listed over 200 training programs.
(p. x). This growth in number of training programs has
In 1965, as the sole faculty member in the Behavior continued into the 1980s, with programs increasing in
Therapy Unit at the Department of Psychiatry of the depth of training and breadth of theoretical/ conceptual
Temple University Medical School, Wolpe stated that orientation. A recent publication sponsored jointly by
the Association for Advancement of Behavior Therapy
every applicant was automatically accepted, on the dubious theo- (AABT) and Division 12, Section III, of the American
ry that any apostle [was] better than no apostle. Very little train-
ing of a formal kind was provided. The trainee was assigned Psychological Association (APA) listed 308 programs
patients to treat and was guided in their treatment. [The trainee1 which purport to offer at least one course in behavior
CHAPTER 10 • TRAINING IN BEHAVIOR THERAPY 215
Table 1. Mean Number of Behavioral Courses Table 2. Mean Relative Emphasis (0%-100%)
Offered in Graduate Programs Given to Theoretical/Conceptual Approaches
Master's Doctoral Percentage
degree degree
Clinicala Counseling School
M N M N
I. Methodological 6.3 7.8 10.0
Clinical psychology 4.27 37 5.03 66 behaviorism
Counseling 3.72 25 4.05 20 (e.g., Watson,
School psychology 2.92 26 5.33 24 Hull)
Counseling psychology 4.00 2.75 4 2. Radical 18.5 30.0 33.0
Educational psychology 3.25 4 5.88 9 behaviorism
(e.g., Skinner)
3. Cognitive/cognitive 42.6 36.1 41.0
behavioral
therapy or specified training in the scientist-practi- (e.g., Mahoney,
tioner model. Of these programs, 219 rated the behav- Meichenbaum,
ioral emphasis of their program 3.0 or higher on a 5- Beck)
point scale, where 1 = "none" and 5 = "very great 4. Social learning 28.5 26.1 16.0
(e.g., Rotter,
amount." These programs offered training in clinical
Bandura)
psychology, counseling psychology, school psychol-
a Column does not total 100% as several respondents gave incomplete
ogy, and educational psychology at the masters and
estimates.
doctoral levels . To obtain a rough approximation of the
amount of behavior therapy training available in each
training area, we examined the number of behavioral As evidenced in Table 2, cognitive/cognitive behav-
courses offered across program areas. As shown in ioral approaches received the greatest emphasis,
Table 1, at the master's level, clinical psychology pro- whereas methodological behavioral approaches re-
grams offered the largest number of courses (mean = ceived the least emphasis. These findings are not sur-
4.27), whereas school psychology programs offered prising in light of the relatively smaller contribution of
the fewest (mean = 2.92). At the doctoral level, edu- earlier Hullian and Watsonian formulations to current
cational psychology programs offered the largest models of behavior change.
number of behavioral courses (mean = 5.88) and Surveyed programs were also asked to indicate
counseling psychology offered the fewest (mean = whether the following skills and/or techniques are sys-
2.75). tematically taught and evaluated in their programs.
To obtain additional information on behavior thera- The mean number of programs responding affirma-
py training, we undertook a survey of all graduate tively for each skill area are presented by program area
programs listed in the AABT/APA Division 12 pub- in Table 3. The amount of training of particular tech-
lication whose behavioral emphasis was rated 3.0 or niques is relatively consistent across program areas,
higher on a 5-point Likert-type scale. Of the 219 grad- except where one might expect differences in training
uate programs that met this criterion, 49 programs re- content because of the client population being served.
turned their questionnaires in time for inclusion in this For example, school psychology programs provide rel-
chapter. Programs whose data will be discussed in- atively less training in marital therapies, cognitive
clude 34 clinical psychology, 10 counseling, and 5 therapy, rational emotive therapy, and stress manage-
school psychology programs. ment training.
The surveyed programs were asked to estimate the
relative weight given to the following theoret-
ical/conceptual approaches in their program: meth- Defining Behavior Therapy
odological behavioral (e.g., Watson, Hull), radical be-
havioral/operant (e.g., Skinner), cognitive/cognitive Although the field of behavior therapy and the
behavioral (e.g., Mahoney, Meichenbaum, Beck), and number of training programs have grown and pros-
social learning (e.g., Rotter, Bandura). The means for pered, the conceptualizations of just what constitutes
these relative weights are presented for each of the behavior therapy and behavior modification have also
program areas in Table 2. expanded and evolved. It is important to examine these
Table 3. Percentage of Programs Training and havior therapy, Emmelkamp (1980) concluded that at
Evaluating Skills and Techniques least four types of behavior therapists could be identi-
tied: (1) those who maintain that behavior therapy con-
Percentage
tinues to be the "application of learning theory;" (2)
Clinical Counseling School those who rely more on mediational concepts in ex-
Conducting behavioral 91 100 100 plaining the process of therapeutic change; (3) "multi-
interview model" or technical behavior therapy eclecticists; and
Behavioral conceptual- 91 100 100 (4) experimental-clinical behavior therapists who em-
ization phasize scientific methodology rather than a specific
Direct observation 91 60 100 theoretical orientation.
Self-monitoring 71 80 100
Although one can distinguish several different
Systematic desensitiza- 74 90 80
tion
schools of behavior therapy, behavior therapists, in
Flooding/implosion 40 40 40 principle, tend to
therapy
Relaxation training 91 90 80 (1) focus on current rather than historical determinants of behav-
Assertion/ social skills 83 80 60 ior; (2) emphasize overt behavior change as the main criterion in
training evaluating treatment; (3) rely on basic research from psychology
to generate hypotheses about treatment and specific techniques;
Problem-solving skills 74 90 100
(4) specify treatment in objective and operational terms so that
training the procedures can be replicated; and, (5) specify very carefully
Cognitive restructuring 83 90 60 the target behaviors and the techniques for measuring outcome.
Covert sensitization 43 30 40 (Kazdin, 1982, p. 27).
Behavioral group 37 60 40
therapies
Norcross and Wogan (1983) also emphasized the mul-
Behavioral family 54 60 40
tidimensionality of behavior therapy. They stated that
therapy
Behavioral marital 69 60 20
therapy the contemporary practice of behavior therapy is not a monolithic
structure, rather, it is an ideographic approach that defies reduc-
Cognitive therapy 86 90 20
tion to a few principles or techniques ... In practice, behavior
Rational emotive 54 60 20 therapy seems to be most distinguished by a style of assessment
therapy and intervention (e.g., functional/behavioral analyses, an em-
Stress management 74 90 40 pirical and methodological orientation) that transcends specific
training techniques. (p. 51)
conceptualizations to appreciate the form and content Behavior Therapy Knowledge and
of training advocated by training institutions. Skills
The term behavior therapy first appeared in a report
by Lindsley, Skinner, and Solomon (1953), which de- Consistent with the diversity of opinion regarding
scribed the application of operant conditioning to the what constitutes behavior therapy, there is a diversity
behavior of psychotic patients. Eysenck (1959) used of opinion regarding the essential knowledge and skills
the term behavior therapy to describe the application that establish behavior therapists. Ullmann and
of both classical and operant conditioning principles to Krasner (1965), for example, suggested that these in-
modify maladaptive behavior. Lazarus (1958) used the cluded a broad knowledge in general and experimental
term behavior therapy to "refer to the addition of ob- psychology literatures. In addition to this knowledge,
jective laboratory procedures to traditional psycho- they suggested that the behavior therapist be able to
therapeutic methods" (Franks & Barbrack, 1983, p. objectively and operationally define problem behav-
508). Franks and Wilson (1975) suggested that "be- ior, identify the environmental contingencies that
havior therapy involves primarily the application of maintain maladaptive response patterns, and modify
principles derived from research in experimental and behavior by programming alternative schedules of re-
social psychology for the alleviation of human suffer- inforcement. Finally, they suggested that the therapist
ing and the enhancement of human functioning" be skilled at developing and structuring therapeutic
(p. 1). relationships while simultaneously holding in respect
In surveying the various conceptualizations of be- the individuals with whom they work.
A creative empirically based behavioral problem in professional organizations relevant to behavior ther-
solver is how Wolpe and Boynton (1978) characterized apy" (p. 169).
the behavior therapist. These authors suggested that In a manner nearly as sophisticated as Linehan
therapists (1980), Kanfer and Schefft (1988) have examined the
entire process of psychotherapy from a much broader
know how to derive new methods from the [experimentally es- perspective which, while essentially behavioral, incor-
tablished] principles [of learning] when the occasion requires it, porates more recent concepts from cognitive psychol-
and learn to apply his mind to the possible use of experimental
paradigms not previously put to use. This kind of thinking is the ogy. The authors have divided the therapeutic process
bedrock of behavior therapy. Flexibility, within a framework of into several stages, with each stage having its own
experimentally-based lawfulness, distinguishes behavior therapy objectives and requiring specific therapist skills. The
from other psychotherapeutic systems. (p. 295)
stages include the process of entering therapy, role
structuring and creating a therapeutic alliance with the
Linehan (1980) has offered a detailed specification client, developing a commitment to change, per-
of the skills necessary for well-trained and educated forming the behavioral analysis, negotiating treatment
behavior therapists that extends far beyond the more objectives and methods, implementing treatment
general conceptualizations we have covered thus far. while maintaining motivation, monitoring and eval-
She categorized the skills into overt motor, cognitive, uating progress, and maintenance, generalization, and
and physiological/affective domains. The overt motor termination of treatment. Within each of these stages,
skills needed include (1) procedural skills, (2) interper- the authors offer extensive recommendations for ac-
sonal-clinical skills, (3) behavioral-clinical skills, (4) complishing the respective target goals.
professional skills, and (5) self-development skills. Collins et al. (1986) noted that graduate behavioral
Procedural skills are required to carry out assess- training programs cover, with varying degrees of em-
ment and treatment. Interpersonal skills include those phasis, clinical procedures and techniques, learning
used in communicating warmth and caring for the cli- and behavioral theory, and scientific methodology.
ent while being sensitive to a client's direct and indi- The outcome of this differential emphasis on these
rect communication. In addition, skills in maintaining three domains is that programs will produce profes-
structure in the process are considered very important. sionals with variable skill repertoires.
As Linehan (1980) points out, behavioral-clinical 1. Technique training. "Thus training in the ap-
skills include plication of behavioral techniques must include teach-
ing the therapist to be: a critical consumer of the liter-
the abilities to adequately explain behavioral treatment and as-
ature, to assess the parameters associated with the
sessment rationales to clients, to identify and solve ahead of time
at least some of the problems which may interfere with carrying effectiveness of a given technique, and to reevaluate
out the treatment procedures and to trouble-shoot when a treat- constantly how techniques are used and the types of
ment strategy is not working as well as expected. The therapist techniques that are useful for particular problems" (p.
must also be able to use a wide range of psychological principles
to elicit and maintain the client's participation in the treatment 303).
process .... 2. Training in behaviortheory and philosophy. They
Professional skills include the abilities to engage in profes- suggest that because there is no unified view or defini-
sional consultations with members of the therapist's own or other
tion of the field and approach to behavior therapy,
disciplines; report and progress note writing skills; developing
graphs and charts which will communicate progress to both the students should be acquainted with several theoretical
client and other professionals; self-management behaviors in- conceptualizations that are "essentially behavioral,"
volved in starting and ending therapy sessions on time, complet- such as applied behavior analysis, cognitive-behav-
ing reports when due, and following relevant administrative pro-
cedures; cooperating with peers and other professionals when ioral theory, and social learning theory. What this the-
needed; collecting fees and discussing finances with clients; and oretical training ostensibly equips students to do is
adhering to relevant ethical standards. (p. 168) actively problem-solve to "analyze and revamp unsuc-
cessful interventions with clients, and to develop new
She then goes on to specify that "self-development approaches" (p. 304).
skills are those behaviors which put the trainee into 3. Training in scientific methodology. "The goal of
learning environments other than supervision" (p. training in scientific methodology is to provide stu-
169). "Some behaviors which might be included in dents with widely applicable, broad-based concepts
this category are the trainee's reading, attendance at for analyzing and treating clinical problems. The use
conventions, colloquia, and lectures, and membership of controlled single-case methodology in clinical prac-
tice exemplifies this approach" (p. 304). According to that cover behavioral theory and behavior therapy
McFall (1985), training along these lines will enable techniques. Case demonstrations are presented to il-
students to effectively integrate data from diverse the- lustrate the interplay between theory and technique.
oretical approaches into their own framework and crit- As a means of gaining exposure to direct clinical prac-
ically consume empirical data bearing on the utility of tice, students sit in on behavioral assessments that are
various assessment and treatment methods. conducted by supervisors or advanced trainees. This
period of non participatory observation continues for
some 3 to 4 weeks, at which time student therapists are
Models for Training Behavior Therapy given responsibility for the case and are supervised
Competencies closely by the trainers. Initial cases are assigned on the
basis of complexity, and novice trainees are assigned
The systematic training of individuals to conduct patients who present with relatively "circumscribed"
behavior therapy effectively requires not only the de- problems.
termination oftarget competencies, but also an organi- In addition to managing a small number of cases,
zational framework and set of procedures to impart the trainees are also required to present the following be-
selected skills and knowledge. A number of writers fore group supervision meetings:
have described models regarding the format, sequence
of instruction, and instructional methods to guide the 1. Review the literature for available treatment
training process. Lazarus (1969) has described, in a techniques that have been employed with the par-
personal account, a loosely systematized process of ticular problem category of each client.
training that deserves attention. 2. Develop a comprehensive behavioral formula-
tion of the client's situation.
The most efficient use of training time is to devote attention to 3. Outline a proposed treatment plan.
those methods and procedures that cannot be acquired from 4. Participate in a problem-solving discussion dur-
books. It is useful for trainees to observe several behavior thera-
ing which therapeutic techniques, ethical issues,
pists in action and to participate as co-therapists in both indi-
vidual and group sessions. But even after a year's intensive ap- and other professional concerns as they relate to
prenticeship of this kind. the trainee can cover but a small the client are addressed.
fraction of the many possible clinical encounters and diverse 5. Evaluate the outcome of treatment via a struc-
maladaptive behaviors with which he is likely to be confronted.
The use of behavior rehearsal as a training procedure is a most
tured questionnaire.
useful means of preparing the trainee to cope with an extremely
wide range of likely and unlikely (but possible) therapeutic situa- Wisocki and Sedney (1978) noted that the group
tions. (p. 190). training/supervision format provides students with in-
direct exposure to a large number and variety of clients
Lazarus (1969) goes on to state that in addition to the range of cases they see directly. The
gradual exposure of trainees to cases of greater com-
typically, two or three trainees observe me playing the role of
various kinds of patients with various kinds of problems while plexity may increase the probability that novice thera-
one of the trainees acts the part of the therapist. These sessions pists will have successes early in their applied therapy
are tape recorded. I may act the part of an extremely compliant experiences. Additionally, using advanced trainees as
and acquiescent patient or respond in a belligerent and defensive
supervisors and co-trainers increases the amount and
fashion. I may come on as critical and condemnatory, or test my
trainee's ability to handle vague, confused, and non-specific breadth of training time for each student while afford-
complaints, or portray a phobic patient with an underlying psy- ing those advanced students the opportunity to gain
chosis. After some 10-15 min., the other trainees are invited to valuable supervisory experience.
comment on the overall perfonnance. The recording is then
played back and the strengths and weaknesses of the trainee's
Gelfand (1972) described a behavior modification
responses are underscored. I might demonstrate what I regard as training program consisting of sequences of academic
better ways of handling specific points of emphasis, with one of training, experimental laboratory experience, and ap-
the trainees in the patient's role. In this manner, one can pitch
plied practica. In this 3-month program, designed for
many tricky curves and thus reduce the probability that novice
therapists will be caught unprepared to cope with difficult pa- psychiatry residents, trainees spend the initial part of
tients. (pp. 191-192) their training learning basic principles of operant con-
ditioning through readings and instructional films. As
The training model outlined by Wisocki and Sedney an additional and more "hands on" learning experi-
(1978) has as its first component didactic presentations ence, trainees participate in supervised animal re-
search by running operant experiments incorporating ence, trainees function as primary therapists for these
procedures such as shaping, differential reinforcement clinical cases.
of other behavior (DRO), and extinction. To aid in the Thoresen noted that most clinical and counseling
transition from laboratory demonstrations to the training programs have students devote too much time
clinical application of behavioral procedures, trainees and effort to tasks that have "little to do with the on-
spend time in either a school special education center the-job terminal behaviors of a working counselor or
or on a behavior modification ward of a Veterans Ad- therapist" (p. 55). Therefore, many of the training
ministration hospital. Such limited but intensive expe- experiences in this behavioral systems model consist
riences produce residents who "are not expert behav- of a series of "low-fidelity to high-fidelity" simula-
ior modifiers, [but] most are competent in the use of tions of clinical tasks that students are likely to encoun-
several behavior modification techniques and are ter in their applied endeavors.
equipped to read the technical literature in the area" Munford et at. (1980) discussed a modularized pro-
(p. 15). gram for an interdisciplinary trainee population that
Gray (1974) criticized conventional instructional combines group and individual behaviorally oriented
techniques, such as lectures and individual supervi- instruction. The program is divided into four modules
sion, because they were developed from "non-behav- covering the principles of operant and respondent con-
ioral theories of training and therapy and are not based ditioning, assertiveness training, parent training, and
on knowledge of behavior principles" (p. 19). He ad- behavior therapy procedures for an outpatient adult
vocated that the following activities comprise behavior population. In these modules, trainees acquired skills
therapy training: (1) supervisor-led group demonstra- in procedures, such as systematic desensitization, re-
tions to illustrate therapy procedures, such as relaxa- inforced practice, covert sensitization, flooding and
tion training, covert sensitization, and flooding, (2) implosion treatments, aversive conditioning, and con-
observation of videotaped models to further illustrate tingency contracting. Instructional procedures consist-
various therapeutic techniques, (3) observation of ex- ed primarily of live and videotaped modeling, role-
perienced behavior therapists in-session followed by played graded practice, and in vivo desensitization.
discussion, (4) microcounseling (Ivey & Moreland, Trainees observed ongoing therapy, practiced tech-
1971) to teach relaxation training, hierarchy construc- niques in small groups, and saw clients under the su-
tion, covert sensitization, contingent use of therapist pervision of training leaders.
approval, and (5) observation by experts of trainees' In one of the more comprehensive program descrip-
therapy sessions during which a supervisor consults tions to date, Levine and Tilker (1974) outlined a para-
via a bug-in-the-ear device or through his or her par- digm containing a progression of training experiences
ticipation as a cotherapist. commencing with the didactic presentation of behavior
Thoresen (1972) proposed combining the principles change principles and technology. Once students are
and techniques of systems theory with behavioral or knowledgeable of these domains, the trainees gradu-
"applied social learning" concepts to create a compe- ally begin participation in actual case treatment. The
tency-based program to prepare behavioral coun- list that follows is the sequence of training procedures
selors. Thoresen's behavioral systems approach is di- employed to train behavior therapy skills: (1) Non-
vided into eight subsystems and includes performance participatory observation of therapy is introduced to
areas such as general counseling skills, group counsel- promote "listening" skills and to allow the trainee to
ing skills, and behavior change methodology. Skill de- focus on the nuances of the therapist-client rela-
velopment is achieved through modeling, corrected tionship. (2) Role-playing exercises enable the trainee
practice, immediate feedback, and positive reinforce- to practice information gathering and other clinical
ment. In many of the subsystem modules, trainees' procedures. (3) In vivo observation of trainer-con-
counseling simulations are audiorecorded and later re- ducted therapy sessions is carried out. Trainers can
viewed by the trainee and the supervisor. Further, then model the previously role-played skills and pro-
trainees participate in clinical practica in which they vide a commentary on their own behavior. This situa-
first observe experienced clinicians and advanced tion allows the trainer to provide direct demonstrations
trainees. Following this period of therapy observation, when necessary and directly observe the trainee. The
trainees serve as cotherapists with trained clinicians trainee's involvement and interaction with the client is
and thereby assume a more active role in therapy ses- gradually increased to the point where the trainee
sions. After an unspecified period of cotherapy experi- eventually assumes major responsibility for the con-
duct and content of the sessions. (4) The train- themselves in their empiricism and devotion to out-
er/supervisor gradually fades direct involvement in come evaluation. Unfortunately, virtually no evidence
clinical sessions while maintaining contact with the exists in the research literature to support current be-
trainee via a bug-in-the-ear device. The supervisor is havior therapy curricula and training methods. More-
able to continue to provide prompts and feedback. (5) over, there is no apparent evidence that our current
Finally, as the trainee's competence increases, super- education and training practices result in competent
vision is delivered in a less direct and immediate fash- professional performance.
ion via a review of session recordings. Training programs typically have attended to the
For the most part, the models examined above pro- process and general content of skill and knowledge
vide some blend of didactic and experientialleaming. acquisition (Edelstein, 1985) and have failed to articu-
Although a number of these programs are not de- late, with few exceptions, the specific competencies
scribed in enough detail to identify precisely the in- that are being taught. Even in the behavior therapy
structional components inherent in each one, they do literature there have been few attempts to elaborate
appear to contain many or all of the following ele- some of the competencies (e.g., Hirschenberger,
ments: (1) reading and/or didactic presentation of the- McGuire, & Thomas, 1987; Sulzer-Azaroff, Thaw &
ory, conceptual principles, and techniques; (2) obser- Thomas, 1975) and skills (e.g., Kanfer & Schefft,
vation of in vivo or taped therapy interactions; (3) role- 1988; Linehan, 1980) required for the practice of be-
playing or experiential exercises incorporating demon- havior therapy. In addition, training programs have not
stration, modeling, and feedback; and (4) solo or col- evaluated student performance against validated per-
laborative supervised therapy. formance criteria.
Although didactic methods of instruction appear to Although data are not available on the outcome of
be used to convey information about behavior therapy, training programs, we do have some evidence regard-
the principles and procedures used to change client ing the efficacy of circumscribed training interventions
behavior are applied to promote trainee skill acquisi- focusing on assessment and therapy skill develop-
tion. Behaviorally based procedures to shape trainee ment.
therapy skills include modeling, rehearsal, feedback,
fading, and positive reinforcement. The progression
Skill Training Evaluation
from academic learning to applied behavior therapy
appears to proceed gradually as trainees move from the The behavioral literature contains only a handful of
classroom through observational learning to some studies in which behavior therapy skills are the focus of
form of supervised therapy or cotherapy participation. training. Among these studies, the majority focus on
Supervision appears to be delivered fairly continu- training skills relevant to the assessment component of
ously until trainees acquire some level of basic compe- the behavior therapy process. The training of assess-
tence. Session management is transferred to the train- ment and behavior change skills stands in contrast to
ees as supervisors gradually reduce their level of direct the teaching of process-related responses that were fre-
participation. Unfortunately, these models generally quently the subject of training investigations during
lack suggestions for or procedures by which program the 1960s and 1970s (Ford, 1979).
training goals might be measured. There are few, if In one of the first of the assessment skill studies,
any, references to training standards or outcome crite- Iwata, Wong, Riordan, Dorsey, andLau (1982) trained
ria for performance evaluation. eight students to conduct analogue interviews and then
replicated and extended the training package to an out-
patient clinic with professional therapists. Employing
Training Evaluation a multiple-baseline design across subjects, they ini-
tially trained a set of 25 operationally defined profes-
Although numerous behavior therapy training pro- sional courtesy responses and behavioral assessment
grams and training models exist, little attention has responses by way of written and classroom instruction,
been paid to the evaluation of these programs (Edel- quizzes, and role-play practice with quantitative super-
stein, 1985), including the ones described above. Even visor feedback. Trainees' emission of correct re-
though this problem is not peculiar to behaviorally sponses observed during role-play interviews im-
oriented training (cf. Sechrest & Chatel, 1987), it is proved from an average of 30.1 % during baseline to an
particularly surprising for behaviorists who pride average of76.6% following training. In the replication
and generalization phase of the study, seven practicing sis" interview demonstrated generalization of those
therapists received training on a similar set of courtesy skills from the analogue training situation to a clinical
and assessment responses in a case conference format. setting with actual clients. The results showed that the
Actual clinical interviews were scored for the occur- trained skills maintained across time, settings, and cli-
rence or nonoccurrence of target responses and for ents at 100% criterion mastery for 18 of the 20 gener-
client responses whose content matched the assessors' alization interviews. "Expert" judges' ratings of inter-
questions. Changes in the frequency of therapist target viewer competence paralleled objective increases in
responses corresponded positively with changes in the quantitative skill achievement.
frequency of similar client responses. Such correspon- In one of the few studies that addressed the training
dence provided indirect evidence that therapists' ac- of therapeutic skills, Wright, Mathieu, and McDon-
quired skills were functionally effective. A mainte- ough (1981) examined three different approaches
nance program, consisting of peer observation and to training mental health practitioners to conduct social
feedback, was implemented 4 months following train- skills training (SST). The three instructional ap-
ing and effected increases in therapist and client behav- proaches were labeled (1) structured learning format
ior above those achieved in training. (SLF), (2) seminar format (SF), and (3) workshop for-
As in the aforementioned study, Miltenberger and mat (WF). All subjects received reading material and
Fuqua (1985) taught a repertoire of behavioral assess- viewed videotaped modeling of competent SST deliv-
ment responses to clinician trainees. It was noted that ery. Subjects in the SLF condition received additional
with few exceptions training programs for counselors instructions, rehearsal, and feedback. Subjects in the
and clinicians require highly skilled instructors to im- SF condition discussed issues raised by the readings
plement and monitor training procedures. To address and films, whereas subjects in the WF condition re-
the question of training efficiency, the authors com- ceived instructions alone on how to carry out SST.
pared an instructional manual requiring no direct train- Equivalent and significant training based improve-
er involvement to a training package consisting of in- ments were found across the three conditions on a
structions, modeling, rehearsal, and feedback in questionnaire measuring knowledge of SST. On a vid-
teaching behavioral assessment interviewing skills to eotape measure of therapists' assessment skills, only
eight trainees. Subjects in both groups attained a per- the SLF and WF improved significantly. On a rating
formance criterion of 90% to 100% correct responding scale measure of therapist behavior during a simulated
in 4 to 6 hours of training time regardless of the condi- SST session, subjects in all three training conditions
tion. Effectiveness ratings of selected baseline and showed equivalent and significant improvement on
training interviews provided by four behavioral clini- five of lle six SST components trained (i.e., assess-
cians improved significantly from baseline to treatment, rationale, self-monitoring, role-playing, and
ment across the five qualitative dimensions assessed. feedback).
Brown, Kratochwill, and Bergin (1982) evaluated Wright et at. (1981) suggested that the modeling
an instructional package that contained a written out- component, common to each training group, was re-
line for a structured interview, videotaped modeling, sponsible for the equivalent performance on the rating
feedback, and role-play exercises. The authors as- scale measure of behavioral competence. Noting that
sessed the acquisition of summarization responses and the posttraining scores on this measure were not partic-
verbal skills relevant to a behavioral assessment by ularly high for any of the performance categories, the
school psychology students. Skills increased signifi- authors stated that "there is reason to suggest that none
cantly as a function of treatment. Two-month follow- of the three training formats was optimally effective"
up data on three subjects obtained during analogue (p. 334).
interviews indicated that skills were maintained be- In a second study, Isaacs, Embry, and Baer (1982)
tween 65% and 100% of criterion on each training evaluated a multicomponent program (written manual,
variable. videotaped models, rehearsal, role-plays, and perfor-
In a procedural replication of the above study, Du- mance feedback) to train five family therapists in
ley, Cancelli, Kratochwill, Bergan, and Meredith teaching child management skills to parents. Thera-
(1983) employed the same instructional methods and pists were trained to provide parents with relevant in-
design to train a set of behavior analysis skills derived structions, deliver contingent praise, and impart infor-
from the conceptual framework ofKanfer and Saslow mation about child management issues. Observations
(1969). Subjects trained in this "motivational analy- of parents' behavioral parenting skills and child com-
pliance during in-session parent-child interactions in- Iwata et aI., 1982) or therapist (Isaacs et aI., 1982)
dicated improvement on both of these responses that performance. To address generalization issues, Iwata
corresponded to increases in therapists' target skills. et al. (1982) examined whether methods used to assess
In general, the results of these investigations sug- and train interviewing skills in analogue situations
gest that training interventions containing some com- were equally effective in a clinical setting. Similarly,
bination of instructions, modeling, feedback, and/or Duley et at. (1983) and Isaacs et at. (1982) addressed
rehearsal lead to trainees' acquisition and demonstra- whether skills that were acquired under analogue train-
tion of behavioral assessment and behavior therapy ing conditions generalized to effective performance in
skills. Further, there is evidence that complex behav- nonanalogue environments. The temporal mainte-
iors trained via these conventional training packages nance of trained skills was evaluated in several investi-
promote skills that generalize across clients and set- gations in which follow-up measures were collected
tings and maintain across time. Because only a few from 2 weeks to 2 months posttraining (Brown et al. ,
studies compared or assessed the effects of individual 1982; Duley et aI., 1983; Iwata et at., 1982; Milten-
training components on complex skill acquisition, the berger & Fuqua, 1985). A program to engineer the
relative efficacy of different instructional components maintenance of trained skills was included in one in-
cannot be determined. vestigation (Isaacs et at., 1982).
In this small body of training studies specific atten-
tion was given to remediating pertinent meth-
Addressing the Evaluation Void
odological shortcomings that to date have beset the
training literature (Ford, 1979; Matarazzo, 1978). For Although the above demonstrations of skill acquisi-
instance, instead of training minimal verbal responses tion are encouraging, there remains no evidence of
(e.g., reflection offeeling statements), complex sets of overall training program evaluation. Programs are
responses or skill repertoires were taught (Brown et amenable to evaluation, which can be accomplished
aI., 1982; Duley et al., 1983; Isaacs et aI., 1982; Iwata through examinations of component processes of
et al., 1982; Miltenberger & Fuqua, 1985; Wright et training (Stevenson & Norcross, 1987). Program ob-
aI., 1981). Importantly, these studies defined the re- jectives and goals can be established and trainee per-
sponses to be trained in objective behavioral terms. In formance evaluated periodically. In this manner, one
each of these studies, the description of training and can begin to examine how (or whether) training and
assessment procedures was explicit. The process of education contribute to competence.
dependent variable measurement was characterized by At the student skill and knowledge level, criterion-
steps to minimize sources of bias. For example, ex- referenced, competency-based training in behavior
plicit training of raters was conducted in each study, therapy could be introduced. One could begin with the
and in four cases raters were trained to criterion levels results of previous attempts to elaborate some of the
of performance (Brown et aI., 1982; Duley et aI., competencies (e.g., Thomas & Murphy, 1981; Sulzer-
1983; Miltenberger & Fuqua, 1985; Wright et aI., Azaroff et at., 1975) and skills (e.g., Kanfer & Sche-
1981). Objective response definitions or behavior fft, 1988; Linehan, 1980) required for the practice of
checklists were used to monitor trainee skill acquisi- behavior therapy. Although all of these authors have
tion and performance. When confederate clients were much to offer from their clinical experience and their
used for assessment and/ or training purposes, training attention to the research literature, apparently only
and preparation of these individuals was addressed to Thomas and Murphy (1981) and Sulzer-Azaroff et at.
ensure consistent responding across subjects (Brown (1975) have systematically solicited descriptions of
et al., 1982; Duley et al., 1983; Iwata et at., 1982; competencies from researchers and practicing behav-
Miltenberger & Fuqua, 1985; Wright et aI., 1981). ior therapists/analysts.
With the exception of Wright et al. (1981), each of Although the approach taken by Thomas and Mur-
these investigations employed multiple-baseline de- phy (1981) and Sulzer-Azaroff et at. (1975) has con-
signs to evaluate the effects of training. Admirably, siderable merit and represents the best information we
most of these studies trained students to criterion levels have to date, Schippmann, Smalley, Vinchur, and Pri-
of performance (Brown et at., 1982; Duley et at., en (1988) have offered a more thorough and potentially
1983; Iwata et al., 1982; Miltenberger & Fuqua, valid model for the development of training and eval-
1985). In three studies, clients responses served as an uation specifications that merits our attention. Their
indirect measure of interviewer (Duley et at., 1983; approach, a multidomain analysis, involves describing
the jobs in question and the. attributes or skills required lem-solving skills, a clinical skills examination with a
for successful performance. For the purposes of defin- check list of standards, and a criterion-referenced rat-
ing the jobs of a clinical psychologist, they observed ing scale to assess professional habits and attitudes"
directly psychologists performing their jobs, exam- (p. 195) among medical students.
ined the work setting, and interviewed clinical psy- It should be apparent from the foregoing sug-
chology faculty members, local practitioners, and gestions that behavior therapy training can be evalu-
graduate students. They then performed analyses of ated at the individual skill or competency level as well
the principal tasks of clinical psychologists and identi- as at the program level. All that remains are to engineer
fied the skills necessary to accomplish these tasks. the appropriate contingencies for carrying out the eval-
Examples of tasks identified included "initiate and uation process and for utilizing the results to provide
manage dialogue in group therapy situations to ensure the best quality of training that will promote the com-
that therapy goals are met" (p. 142) and "monitor the petent practice of behavior therapy.
performance and evaluate the progress of assigned in-
dividuals with reference to specified criteria" (p. 142).
Examples of the job skill dimension included "knowl- Summary and Conclusions
edge of psychotropic drugs, their therapeutic action,
interactions and potential side effects, ability to identi- We have reviewed and discussed the behavior thera-
fy behaviors that can be modified and to define the py training literature. In so doing, we have briefly
contingencies to be manipulated when applying behav- traced the history of behavior training, various concep-
ior modification techniques, and ability to demonstrate tualizations of behavior therapy, and the content of
or model the performance behavior involved in differ- training that has evolved from a variety of concep-
ent therapy techniques" (p. 143). tualizations. We then described several training mod-
Once various tasks, skills, and knowledge were els and reviewed the sparse literature regarding the
identified, individuals were asked to rate the "impor- evaluation of behavior therapy skill training. Sug-
tance of various statements of knowledge, skill, or gestions for improving our instruction and evaluation
ability required for performance on the job" (p. 142). methodologies were then offered with the hope that, if
For each step the judge was asked to determine first adopted, they would lead to more valid training and
whether the job skill was required and then, if it was consistent levels of competent performance by behav-
required, how important that job was for full job per- ior therapists.
formance. Judges were asked "where an individual We are not at the point in our knowledge of thera-
would acquire each job skill." Finally, they were asked peutic practice to feel comfortable that newly trained
to "judge whether the job skill is learned on the job or therapists, or even more seasoned veterans, can articu-
before entering the job" (p. 142) and rate how difficult late the effective ingredients of their general practices
it would be to acquire the particular knowledge, skill and those peculiar to particular clients. There is much
or ability. about what behavior therapists do (frequently quite
Behavior therapists could begin to develop valid effectively) that is either ignored in the research liter-
competency measures by employing a methodology ature or considered under the rubric of nonspecific
similar to that of Schippmann et al. (1988). The con- therapeutic processes. The individual therapist cannot
tent of competency measures could be specified as wait for publication of large-scale outcome studies to
operationally defined knowledge and skills. Knowl- guide his or her day-to-day practices. Behavior thera-
edge could be assessed via traditional written or multi- pists can advance their knowledge of the practice of
ple-choice examinations. Skills could be evaluated behavior analysis and therapy by adopting an approach
through simulation techniques (e.g., Berven, 1987; that enables them to begin accounting for their person-
Edelstein, 1985), work samples (Howard, 1987), dial practices and outcomes. In a sense we are proposing
rect observation of criterion performances, and client a cybernetic model that enables therapists to systemat-
ratings of the therapist performance (Stevenson & Nor- ically shape their own behavior through feedback ob-
cross, 1987). The limitations of any single evaluation tained in therapy sessions. We are encouraging teach-
method could be minimized by combining several ing students of behavior therapy to apply an
methods. For example, Anderson and Botticelli idiographic approach to their therapeutic practices by
(1981), as cited in Tonesk (1987), "combined an ob- incorporating the hypothesis-testing model articulated
jective test for knowledge, simulations to assess prob- by Shapiro (1966). In this model, students become
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Champaign, IL: Research Press. havior Therapy and Experimental Psychiatry, 9, 295-300.
Tonesk, Z. (1987). Clinical evaluation of medical students in Wright, 1., & Mathieu, M., & McDonough, C. (1981). An eval-
U.S. medical schools. In B. Edelstein & E. Berler (Eds.), uation of three approaches to the teaching of a behavioral
Evaluation and accountability in clinical training (pp. 183- therapy. Journal of Clinical Psychology, 37, 326-335.
2(0). New York: Plenum Press. Yates, A. 1. (1970). Behavior therapy. New York: Wiley.
Ullmann, L., & Krasner, L. (1965). Preface. In L. Ullmann & L. Yen, S., & McIntire, E. W. (Eds.). (1976. Teaching behavior
Krasner (Eds.), Case studies in behavior modification (pp. v- modification. Kalamazoo, MI: Behaviordelia.
vii). New York: Holt, Rinehart & Winston.
CHAPTER 11
Balancing Clients' Rights

THE ESTABLISHMENT OF HUMAN RIGHTS AND
PEER REVIEW COMMITTEES
Jan B. Sheldon and Todd R. Risley
Introduction right of residential clients to be free from abusive and

harmful procedures and conditions and (2) the right of
In the last two decades, society has witnessed a dra- clients to receive treatment appropriate to their needs.
matic increase in the amount of litigation concerning These two rights are not always compatible and
incarcerated mentally ill and developmentally disabled often may present problems to behavior therapists and
persons. These lawsuits reflect a heightened concern treatment providers (Begelman, 1975, 1978; Fried-
with the conditions and practices to which these people man, 1975; Wexler, 1978). For some severely debili-
have been exposed. Of prime importance in many of tated residents, providing effective treatment may ex-
those cases have been alleged harmful practices, in- pose the person to some risk or potential harm because
cluding such things as physical and mental abuse, unless intrusive treatment procedures have not accom-
sanitary living conditions, and exposure to aversive plished the desired goals (Budd & Baer, 1976; Wexler,
treatment procedures, such as electric shock, psycho- 1973, 1974; Wildgen, 1976). The purpose of this
surgery, physical restraints, and seclusion (Halderman chapter is to describe human rights and peer review
and the United States v. Pennhurst, 1977; Kaimowitz v. committees, mechanisms by which these two rights,
Department of Mental Health, 1973; New York State the right to effective treatment and the right to be free
Associationfor Retarded Children and Parisi v. Carey, from harm, may be balanced and protected. To under-
1975; Wyatt v. Stickney, 1972). Evidence from the stand these protective mechanisms and their impor-
cases indicated that individuals in residential programs tance, it will be helpful to trace briefly the develop-
could also be exposed to harmful conditions because of ment and current state of the two potentially
an absence of appropriate treatment; without appropri- conflicting rights.
ate treatment, many individuals can regress or deterio-
rate in their functioning (Walker & Peabody, 1979). A
number of important conclusions have resulted from Right to Treatment
these lawsuits. Two of the most important are: (1) the
There is no specific constitutional right to treatment;
rather, the "right to treatment" has been found to exist
Jan B. Sheldon • Department of Human Development, Uni- because of the involuntary incarceration of mentally ill
versity of Kansas, Lawrence, Kansas 66045. Todd R.
Risley • Department of Psychiatry, University of Alaska, and developmentally disabled individuals. Relying on
Anchorage, Alaska 99508. the constitutional guarantees of due process and equal
227
protection and the prohibition on cruel and unusual strong dissatisfaction because, after a decade of having
punishment, courts have held that there must be ajusti- mandated that treatment take place, little has occurred
fication for allowing the govrrnment to involuntarily in terms of actually providing residents with much-
confine a person who has not committed a crime needed skills. Whatever the reason, courts now often
(Friedman & Halpern, 1974). This justification, or require specific changes in behavior. Recently, for ex-
quid pro quo, for the deprivation of liberty is the fact ample, a court ruled that a client in a facility had a right
that the government will provide the individual with to a habilitation program that would maximize the cli-
treatment. ent's human abilities, enhance the client's ability to
The first judicial decision to recognize specifically cope with the environment, and create a reasonable ex-
a right to treatment for mental patients was Rouse v. pectation of progress toward the goal of independent
Cameron (1966). The court, relying on a District of community living (Wyatt v. Ireland, 1979). Thus, the
Columbia statute, held that a right to treatment exist- courts recognize that procedures must be employed to
ed by stating: "The purpose of involuntary hospital- produce appropriate changes in the individual's behav-
ization is treatment, not punishment. . . . Absent ior. The type of treatment used to accomplish these
treatment, the hospital is 'transform[ed] ... into a changes, however, has been left, within certain guide-
penitentiary where one could be held indefinitely for lines, to the discretion of the mental health profession
no convicted offence' " (pp. 452-453). Many subse- (Schwitzgebel, 1973).
quent cases have recognized a right to treatment based
on either statutory or constitutional grounds (e.g.,
Right to Be Free from Harm
Covington v. Harris, 1969; Davis v. Watkins, 1974;
Millard v. Cameron, 1966; Nason v. Superintendent of Although recognizing a right to treatment for
Bridgewater State Hospital, 1968; Sinohar v. Parry, incarcerated mentally ill and developmentally disabled
1979; Tribby v. Cameron, 1967; Welsch v. Likins, individuals, the courts simultaneously addressed the
1974; Wuori v. Zitnay, 1978; Wyatt v. Stickney, 1971, issue of the harmful or potentially dangerous condi-
1972; Wyatt v. Adherholt, 1974; Wyatt v. Ireland, tions that existed in institutions and the aversive
1979). In recognizing this right, the courts have also procedures that were being employed as treatment.
referred to "adequate," "appropriate," "effective," The courts found that because of the lack of communi-
"proper," "suitable," "necessary," and "optimal" ty, professional, orjudicial scrutiny, many institutional
treatment, and "a realistic opportunity to be cured or to residents had been subjected to conditions and pro-
improve his or her mental condition" (e.g., Cook v. cedures that raised questions of cruel and unusual
Ciccone, 1979; Clatterbuck v. Harris, 1968; Ecker- punishment, which is prohibited by the Eighth
hart v. Hensley, 1979; In re Jones, 1972; Millard v. Amendment to the Constitution (Wildgen, 1976).
Cameron, 1966; Nason v. Superintendent of Bridge- Many procedures have been critically examined and
water State Hospital, 1968; Rouse v. Cameron, 1966; either have been absolutely forbidden or have been
Welsch v. Likins, 1974; Wyatt v. Stickney, 1972). prohibited unless the resident (or someone acting in the
Although the courts used such terms as appropriate resident's best interest when the resident is incompe-
and optimal treatment, judges have been reluctant to tent) has given expressed, uncoerced, and informed
define exactly what they meant by these terms (Sch- consent. Obviously, most courts have banned the use
witzgebel, 1973). After all, there often appeared to be of corporal punishment and physical abuse (Morales v.
little agreement among mental health professionals as Turman, 1973; Nelson v. Heynes, 1974; New York
to what constituted appropriate treatment. It was there- State Associationfor Retarded Children v. Rockefeller,
fore not unusual that judges, with little or no 1973). Procedures involving physical abuse, such as
psychological training, did not feel competent to spec- slapping, kicking, and tying a resident to a bed for
ify what must take place in order for treatment to have lengthy periods, have been held to degrade human dig-
occurred. In the last few years, however, the courts nity, to serve no necessary purpose, and to be so severe
have been much more willing to specify what goals as to be unacceptable to society (Wheeler v. Glass,
must be attained and what changes must take place in 1973). Other institutional conditions that the courts
order to demonstrate that treatment has been provided. have banned as violating the Eighth Amendment in-
It is debatable whether this change reflects a new re- clude inadequate nutrition or medical services and
spect for the mental health profession in acknowledg- unsanitary living conditions, such as inadequate
ing that professionals can determine when "appropri- plumbing and ventilation or insect infestations (Walker
ate treatment" has occurred, or whether it reflects a & Peabody, 1979).
CHAPTER 11 • BALANCING CLIENTS' RIGHTS 229
The conditions mentioned above have no justifica- (e.g., Horacek v. Exon, 1975; Wyatt v. Stickney,
tion either as treatment procedures or as part of a 1972). Psychotropic drugs, many of which have poten-
humane living environment. Where these conditions tially dangerous side effects, often cannot be used
have existed, it seems clear that the residents have not unless the patient gives informed consent or unless the
been protected from harm, let alone provided with ap- patient presents a clear danger to him- or herself or oth-
propriate treatment. More difficult discriminations are ers. Recent cases have held that a client who is
involved when the courts have had to address the use of nondangerous has a right to refuse treatment that con-
techniques that are accepted as therapeutic but that ex- sists of the use of psychotropic drugs (Rennie v. Klein,
pose the resident to potential harm or detriment. 1978; Rogers v. Okin, 1979).
Clearly, some procedures (e.g., lobotomies and elec- Aversive techniques, which have some potentially
troconvulsive shock treatment) seem much more therapeutic value, present a major problem for courts
intrusive and damaging than others (e.g., psychotropic as well as the mental health profession (Kazdin,
drugs or seclusion). All, however, present the problem 1980a,b, 1981; Lovaas & Favell, 1987; Pictering &
of being open to inappropriate use or misuse, some- Morgan, 1985; Witt & Robbins, 1985). It is necessary
times to the permanent detriment of the resident. The to determine when these techniques are being em-
courts have required that these procedures be used only ployed as part of a comprehensive treatment program
for legitimate therapeutic purposes and only if less re- designed to enable the person to move to the least re-
strictive procedures have failed. For example, one strictive type of environment, as opposed to when they
court ruled that electric shock could be used only in ex- are used for retribution, for the convenience of the
traordinary circumstances to prevent self-mutilation staff, as a substitute for less intrusive treatment, or
that might result in permanent damage (Wyatt v. Stick- simply to accommodate the individual to the existing
ney, 1972). Similarly, physical restraints have been environment. Protective devices must be developed to
closely examined, and restrictions have been placed on ensure that when these techniques are advocated by the
their use (e.g., Inmates ofBoys' Training School v. Af- staff, they are reasonably appropriate and are carefully
fleck, 1972; Welsch v. Likins, 1974; Wheeler v. Glass, and professionally administered so that pauents, es-
1973; Wyatt v. Stickney, (1972). One court stated that pecially the severely debilitated, receive effective, yet
restraints should be applied "only if alternative tech- humane, treatment.
niques have failed and only if such restraint imposes
the least possible restriction consistent with its pur-
pose" and only when absolutely necessary to prevent a
Establishing Protective Mechanisms
client from seriously injuring her- or himself or others
Developing an effective, legally justified, and
(Wyatt v. Stickney, 1972).
ethically sound program i& a difficult task, especially
The use of seclusion has been condemned by some
courts, which have either totally prohibited its use or when a program's clientele are severely debilitated and
difficult to treat. To meet both present legal mandates
strictly limited the situations under which it can be em-
and professional requirements, therapists must pro-
ployed (Inmates of Boys' Training School v. Affleck,
vide appropriate and individualized treatment suitable
1972; Morales v. Turman, 1973; New York State Asso-
to each client's particular needs and at the same time
ciation for Retarded Children v. Rockefeller, 1973;
make sure that the treatment is ethical and humane.
Wyatt v. Stickney, 1972). Many courts (e.g., Wyatt v.
There are two basic problems that a therapist must ad-
Stickney, 1972), however, have made a distinction be-
dress: choosing appropriate goals and designing and
tween the use of seclusion (often defined as locking a
implementing treatment techniques that will allow
resident in a barren room, unsupervised, for long peri-
those goals to be obtained in the most effective, effi-
ods of time) and the use of "therapeutic time-out,"
cient, and professionally appropriate manner possible.
which normally involves placing a person in a room
Additionally, a third consideration, involving the pub-
alone or off to the side of ongoing activities for a short
lic's perspective of what is ethical and humane, must
period of time immediately following the occurrence
be examined.
of an inappropriate behavior. Therapeutic time-out re-
quires constant supervision by the staff to ensure that
the patient does not harm him- or herself while being
Selecting Appropriate Goals
confined (Budd & Baer, 1976). Several authors have addressed the problem of
Additionally, the use of chemical restraints in the selecting appropriate goals (e.g., Davison & Stuart,
form of medication has received widespread attention 1975; Hawkins, 1975; Martin, 1975; Stolz, 1978,a,b;
Wexler, 1978). Clearly, the goals chosen should reflect goals and proper implementation of treatment tech-
individual needs and should be relevant and useful to a niques, effective treatment that will allow a client to
particular client. For example, a person should not be progress to less restrictive environments and activities
subjected to a group training program that is teaching should occur.
skills that the client already possesses or that are of For many programs, establishing effective treatment
little value to the client. The goals should be developed techniques should present few problems, other than
after a comprehensive, but not overly intrusive, as- being creative. Wexler (1973), for example, proposed
sessment has been made. Then, after considering all that instead of depriving people of their "basic rights"
aspects of the client's life, the objectives should be (e.g., food, clothes, bed, closet, outdoor activity, or
prioritized and arranged in terms of short- and long- access to a telephone) in order to use these "rights"as
term goals. They should be organized together to make reinforcers to motivate the person, the therapist should
an integrated program plan for the individual, with the find idiosyncratic or more individualized reinforcers
overall objective of teaching the individual the skills (i.e., something that is very special to that particular
needed to allow removal of restrictions on activities person). Thus, items out of a mail-order catalog, spe-
and opportunities. Examining whether this type of cial trips to favorite places, or the right to engage in
progression 'has taken place is one of the best ways to activities for extended periods of time might be used to
evaluate whether appropriate goals have been estab- reward a person for engaging in appropriate behaviors
lished. Obviously, these kinds of goals may require or to help teach a needed skill. Therapists can no long-
more work for programs that, in the past, have been er rely on the easiest-to-think-of and most convenient
primarily custodial in nature. With some planning and variables, but providing legally sanctioned treatment
organization, however, programs should be able to de- techniques should not present an overwhelming eth-
velop and prioritize goals and treatment plans for the ical, legal, or professional decision for the majority of
clients served. clients.
For severely debilitated individuals, the task of se- With the "hard-to-treat" or the severely debilitated
lecting goals may present some problems. One of the clients, however, problems may arise for a therapist.
primary issues in developing appropriate goals is to as- For example, many of the most debilitated clients have
sure that the goal is established because it will benefit a limited range of items or activities that are reinforc-
the client in some way rather than being beneficial for ing to them. Perhaps because of their limited exposure
only the staff or others in the client's environment. to other reinforcers, only the most basic items (e.g.,
Often, the severely debilitated individuals in a treat- food) may appear to motivate them. Often, therapists
ment program engage in behaviors that the staff or are presented with the problem that if the use of food or
others find particularly disruptive, aggressive, or inap- meals as a reinforcer is limited, it is difficult to teach or
propriate. The staff may wish to eliminate all behaviors train many clients. Another example is clients who are
that they find aversive or that cause them more work. so extremely aggressive, disruptive, or self-abusive
Thus, the treatment may benefit the staff more than it that a limitation on the use of aversive or unpleasant
does the client. Clients must be protected against this treatment techniques may mean that the clients will be
potential problem in addition to being assured of an ap- harmed either physically (because of their self-de-
propriate evaluation, with the relevant goals having structive behavior) or by the lack of treatment (because
been established. of the inability of the therapist to initiate a constructive
form of treatment while the aggressive or disruptive
Establishing Effective Treatment Tech- behavior is being emitted or anticipated) (Baer, 1970;
niques. Effective treatment usually implies that the Stolz, 1975). The therapist is therefore placed in a di-
techniques used are sufficient to give clients an in- lemma. For this type of hard-to-treat client, should
creased latitude in what they are able to do. In deciding treatment programs be implemented that may poten-
what techniques should be used and which will pro- tially deprive the clients of basic rights or expose them
duce the highest probability of being effective, to unpleasant techniques in an attempt to accomplish
treatment providers should rely on the relevant pub- effective treatment and, thus, move them to less re-
lished literature for justifying the techniques and strictive environments and conditions of living? Or,
conditions of use (Risley, 1975). This approach may rather, should these clients be placed in a pleasant en-
require considerable training of staff and supervisors vironment where noncontroversial treatment tech-
before the procedures are implemented. With proper niques are used, even though the techniques have a low
probability of success in accomplishing effective treat- Independent review and protection mechanisms
ment that will allow the client more freedom? need to be developed to assure that the legal, ethical,
and professional decisions being made are in the best
Providing Ethical and Human Safeguards. interest of the clients (Christian, 1981; Egelston,
"Effective" treatment can be defined as the selection Sluyter, Murie, & Hobbs, 1984; Griffith, 1980; May,
of goals and treatment techniques that allow a client Risley, Twardosz, Friedman, Bijou, Wexler et at.,
to progress to less restrictive living conditions. 1976). This procedure would be advantageous to the
Providing effective treatment is normally the concern clients because their interests would be considered and
of the professionals in charge of the treatment pro- protected. There would also be a higher probability
gram. To provide effective treatment, however, may that appropriate treatment would be provided. Inde-
involve procedures or techniques that, because of pendent review mechanisms would also serve to help
their intrusive, controversial, aversive, or restrictive the staff by providing outside professional expertise
nature, are not viewed as acceptable to the general that could be extremely useful. Additionally, if the
public or (to borrow a phrase used by the U.S. Su- mechanisms included some procedures for addressing
preme Court in criminal law cases, e.g., Rochin v. legal and ethical questions, the staff would have as-
California, 1952) that "shock the conscience" of the sistance in determining whether their procedures will
public. Thus, there must be a balance between ac- withstand public or judicial scrutiny.
complishing effective treatment and protecting hu- The protective mechanisms developed need to ad-
man rights (Kazdin, 1980; Reese, 1982). Allowing dress three issues: the development and specification
efficient and effective treatment procedures to exist of appropriate goals; the implementation of effective
without a consideration of how humane and appropri- treatment techniques; and the consideration of whether
ate they are could encourage abuse and misuse of the the goals and treatment procedure are ethical and hu-
procedures that might result in detriment to both the mane. The first two issues involve the judgments of
clients and the treatment program. professionals in the field. The third issue involves
judgments of people who represent the viewpoints of
The Need for Protective Mechanisms
society. Thus, two separate review committees are
Who should make the decisions about whether goals proposed: a peer review committee to address profes-
and treatment techniques are effective and appropri- sional considerations and a human rights committee to
ate? The most convenient method is to allow the address the ethical and humane considerations of
program staff to make these decisions. This approach, society.
however, may not be the most desirable if client and Employing these two types of review mechanisms
staff protection are to be provided. The staff, including can strongly benefit all types of treatment programs,
the therapist, often have a vested interest in having the but especially those serving the severely debilitated,
program operate smoothly and efficiently. One could where professional, legal, and ethical questions could
argue, therefore, that the goals chosen and the tech- constantly be raised as a result of the type of treatment
niques used benefit the staff more than the clients and, programs developed. As pointed out by May et al.
perhaps, could even potentially harm the clients. Pro- (1976), these committees can accomplish the fol-
tective mechanisms need to be developed to ensure that lowing:
goals and treatment procedures are developed for the
benefit of the clients and are ethical and humane. Addi- I. Protect the rights and welfare of . . . clients;
tionally, some method is needed to determine whether 2. Maximize the quality and extent of services provided to
clients;
the staff are using the most up-to-date and profes- 3. Allow conscientious and well-trained persons to admin-
sionally appropriate techniques. It would be prob- ister appropriate treatment procedures with a sense of se-
lematic, for example, if new treatment procedures curity, and
4. Enable institutions to comply as economically and prac-
were developed especially for use with the severely de-
tically as possible, with both the form and spirit of protec-
bilitated client, and the staff were not implementing tive requirements set forth in recent legislation and court
those procedures. The treatment staff may not be in the decisions. (p. 35)
best position to make a decision about the professional
justification of certain procedures because of the pos- Most importantly, these review and protection
sibility of personal bias or potential conflict of mechanisms can ensure that the clients' best interests
interests. are served. Specifically, this means that appropriate
and humane goals and treatment procedures can be Risley & Sheldon-Wildgen, 1980). Described below
implemented in order to accomplish effective and ap- are several considerations that should be addressed
propriate treatment. Thus, each case can be examined when developing a human rights committee that will
individually and treatment plans developed according- operate most effectively to protect clients while ensur-
ly. This procedure is especially relevant for the "hard- ing that they receive appropriate treatment.
to-treat" client, who is an easy target for mistreatment
and nontreatment. This type of client, who once was
Composition
the subject of much abuse, has recently been left un-
treated because only controversial procedures ap- A human rights committee is normally composed of
peared effective. With review and protection mecha- a group of dedicated and concerned people who are
nisms, one can determine whether the controversial willing to give freely of their time and energy to make
techniques are professionally justified, and if they are, sure that the clients of a particular program are treated
protective procedures can be implemented to ensure humanely. Although some authors (e.g., Griffith,
that they are humanely administered. The right to ef- 1980; Mahan etal., 1975; May etal., 1976) advocate
fective treatment can therefore be provided simul- that a behavioral scientist and an attorney should be
taneously to protecting the client from unnecessary or members of this committee, it is not clear that this is
unjustified exposure to harm. The following sections necessary. Although it may be nice to have a behav-
describe in detail how to establish peer review and ioral scientist on the committee, the input that that
human rights committees, what their functions should member would make may be obtained from the peer
be, and how they might most efficiently and effectively review committee. Likewise, although it may be desir-
operate. able to have an attorney (especially one knowledgeable
in the law relating to handicapped people or civilliber-
ties) on the committee, most treatment programs have
The Human Rights Committee an attorney on retainer who can give advice on liability
and legal issues. It is most critical that the members of
Wyatt v. Stickney (1972) was one of the first judicial this committee be genuinely concerned about the cli-
decisions to require the establishment of a human ents and willing to devote considerable time and ener-
rights committee. The court specified that the human gy to investigating and deliberating about indi-
rights committee "review . . . all research proposals vidualized treatment plans as well as treatment
and all habilitation programs to ensure that the dignity techniques.
and human rights of residents are preserved." Addi- Many advocate that consumers of the treatment pro-
tionally, the committee was to guarantee that residents gram be on this committee. Thus, one may want a
would be afforded the legal rights and habilitation that client representative and a relative of a similarly situ-
had been judicially ordered. Thus, the committee was ated client. Depending on the particular person, it may
to advise and assist those residents who felt they had be undesirable to have parents, guardians, or relatives
been denied appropriate treatment or who felt that their of actual clients on the committee, because they may
legal rights had been violated. Unfortunately, the court be too intimately involved with the client to make un-
did not state how the committee was to be formed or biased decisions.
exactly how it was to operate (Mahan, Maples, Mur- Normally, the human rights committee is composed
phy, & Tubb, 1975). Nonetheless, the consequences of of laypersons who represent the sentiments of the com-
the mandate to form a human rights committee were munity, much as ajury is composed. To aid in making
far-reaching. Human rights committees are very com- the committee a credible protective mechanism, the
mon now, and most institutional and residential pro- majority of members should have no affiliation with
grams have one. The problem is that it is still not clear the treatment program. It is not necessary that the
who should be on the human rights committee or, more members of this committee have any professional ex-
importantly, what the function ofthe committee should pertise; rather, the critical qualities that members
be beyond ensuring that clients receive humane treat- should possess are being interested enough to be will-
ment, and, finally, how it should operate (Griffith & ing to dedicate time to examine the functioning of the
Henning, 1981; Repp & Deitz, 1978; Reese, 1982); treatment program and staff, and being able to make
only a few authors have addressed the requirements in independent decisions about whether the treatment
detail (e.g., Brakman, 1985; Mahan et aI., 1975; procedures are humanely justified. The credibility of
the committee can be improved by addressing the is- cerned with aversive techniques; they definitely
sues listed below. should. They also must be concerned with observing
the corollary right to effective treatment in order to
Purpose
remove the restrictions with which the client lives.
The primary purposes of a human rights committee This treatment should be provided in the quickest,
are to provide sufficient and adequate safeguards for most effective, and least restrictive way possible.
the clients of a treatment program to ensure against The human rights committee can function much as a
inhumane or improper treatment and, at the same time, jury does in obtaining and evaluating evidence to pro-
to ensure that appropriate treatment will be accom- tect those who cannot adequately protect themselves.
plished with the greatest speed possible in the least Also, like a jury, the human rights committee can eval-
restrictive manner. The importance of a human rights uate whether due process is followed when implement-
committee is most readily recognized in those pro- ing a treatment program. Thus, the committee mem-
grams that employ controversial procedures. With se- bers will need to develop (or make sure that the
verely debilitated clients, procedures are often imple- treatment staff develops) and implement a fair, inde-
mented that the general public may find objectionable, pendent, and unbiased procedure that examines each
if considered out of context. For example, one may client's treatment plan to determine if it appears justi-
read of a treatment program that shocks small children fied and humane. For example, if the committee ob-
or that squirts lemon juice into their mouths. The gen- served a client who could feed, dress, bathe, and look
eral public, reading only that, may be appalled. The after him- or herself fairly well, the committee might
duty of the human rights committee is to determine if feel that the goal of learning how to dress is unjustified
the procedures are, indeed, objectionable if considered because the client already knows and demonstrates
in the totality ofthe circumstances. Thus, the commit- that skill. Likewise, if none ofthe self-care skills were
tee may not find it objectionable to shock small chil- in a client's repertoire, it may appear unjustified to
dren who are engaging in such serious self-destructive attempt to teach the client to read and write because the
behavior that it threatens their health and welfare. The self-care skills are more fundamental. The committee
committee must consider all the surrounding circum- would also examine the treatment techniques to deter-
stances to decide if the treatment is appropriate. They mine if they are justified and humane. Thus, the com-
must also determine if the same effect could be ob- mittee members may prohibit, for example, the use of
tained by treatment that is less intrusive or aversive. A shock to teach social skills because they feel the pro-
balance must always be considered: the client's right to cedure is inhumane with respect to the behavior being
be free from aversive and intrusive procedures against targeted; they may, on the other hand, allow the use of
the right to obtain effective treatment when all reason- shock to decrease serious self-destructive behavior.
able and less intensive treatment techniques have been The critical element is that the human rights committee
considered. follow a fair procedure that attempts to protect the
One common trap that human rights committees fall clients' rights; that is the key to due process. (A sug-
into is an overpreoccupation with protection from aver- gested procedure will be described later.)
sive or intrusive techniques. Equally important, how- Members of the human rights committee often do
ever, is the need to make steady and rapid progress in not have the expertise to propose or professionally
the treatment. For example, consider severely debili- evaluate procedures. However, they may seek inde-
tated clients who live with many restrictions. The re- pendent professional input as to the guidelines to be
strictions may be determined by the fact that the clients followed in addition to obtaining information on the
have few behaviors in their repertoire or by the fact that effectiveness of certain procedures as compared with
their destructive behavior may require the staff to im- their intrusiveness. The members should remember
pose restrictive forms of treatment in order to protect that their function is not to make professional decisions
them or other clients adequately. Human rights com- but to make decisions, representing the community,
mittees often address only the intrusiveness or re- relating to the justification for selecting goals and
strictiveness of a treatment plan without recognizing treatment procedures and to the humane and ethical
that every day the person goes without effective treat- nature of any treatment plan developed.
ment, the person remains untreated and, thus, in an The human rights committee should write a state-
inherently restricted state. This statement is not to im- ment of purpose that will allow the committee to state
ply that human rights committees should not be con- their overall objective and to outline their goals. Such a
statement makes clear the duties of all the members of tionally, the members should read descriptions in
the committee. More importantly, however, it pro- books and chapters of the ethical and legal issues in
vides a concrete statement that can be used as a source treatment programs (e.g., Berkler, Bible, Boles, De-
of information for others by detailing exactly what itz, & Repp, 1978; Budd & Baer, 1976; Martin, 1974,
objectives the committee is designed to address and the 1975; Roos, 1974). Being more knowledgeable about
procedures the committee follows in making any rec- the key issues will make the members' job easier and
ommendation. Thus, others will be encouraged to their decisions more credible.
bring relevant topics, questions, or grievances to the
committee that could potentially benefit both the client
The Formal Review Process: The Use of
and staff.
Aversive Procedures
In any treatment program, the use of aversive or
Education
unpleasant procedures should be minimized as much
To fulfill their duties adequately, members of the as possible. At times, however, in an attempt to ac-
human rights committee should know what predomi- complish effective treatment, it may be necessary to
nant issues they should be considering. As mentioned use some form of aversive technique. Obviously, since
previously, it is not necessary for committee members the procedure is unpleasant, it easily draws the atten-
to possess professional expertise. If the committee as a tion of the human rights committee, which must con-
whole, or any member, has any question involving a sider whether it is necessary and whether it is humane.
particular professional issue concerning the program, Although protecting clients from the indiscriminate
the committee should contact outside experts (perhaps and inhumane application of aversive procedure is one
someone from the peer review committee) and advo- of the committee's main charges, it is not the only task
cates in this area. It is necessary. however, that the the members have to accomplish. Additionally, it is
members have some knowledge of the types of issues important to be able to provide effective treatment as
they should be addressing. For example, they should quickly as possible (Repp & Deitz, 1978). Therefore,
know about the judicial limitations and the expressed it is useful for the committee to have a formalized
public opinions concerning the use of electrocon- review process that will enable it to address, systemat-
vulsive shock, the denial of basic rights, the use of ically and efficiently, the different types of aversive
psychotropic drugs, or the use of seclusion. They techniques that the staff may employ. Having a stan-
should know that there may be some instances in dard procedure to follow will inform the staff about
which an unpleasant or an aversive technique may be which procedures may and may not be used without
necessary. but they need to know enough to inquire prior approval of the human rights committee.
about less restrictive alternatives and about whether All clients should be protected, since the techniques
the techniques are being used legitimately as a treat- and the procedure to be followed with each technique
ment procedure or, rather, to adapt the individual to the will be explicitly spelled out in advance, and staff ig-
existing environment. A committee member cannot be norance of these procedures would not act as a defense
effective if the member does not fully comprehend to any liability or sanctions that may be imposed. Aver-
what are the duties of the job and what issues must be sive procedures can be categorized into three basic
addressed. Therefore, the members of the human groups (May et al .• 1976), which are outlined below
rights committee should read and acquaint themselves along with the type of review process best suited to the
with the guidelines and standards promulgated by rele- technique. (Although examples of procedures are pro-
vant advocacy groups, including the National Society vided for the first two groups, these are only examples,
for Autistic Children's White Paper on Behavior Modi- and each human rights committee should make its own
fication with Autistic Children (1975), the National decision about which procedures are included in each
Association for Retarded Citizens' Guidelines for the of the three categories.)
Use of Behavioral Procedure on State Programs for 1. Some forms of aversive procedures are mild and
Retarded Persons (May et al.. 1976), the Joint Com- fairly nonintrusive. These procedures might include
mission on Accreditation of Hospitals' Standards for such techniques as the use of some expression of social
Services for Developmentally Disabled Individuals disapproval, for example, the word no (other than
(1978), and the National Teaching-Family Associa- shouting or demeaning, threatening, or abusive com-
tion's Standards of Ethical Conduct (1979). Addi- ments); extinction or ignoring an inappropriate behav-
ior that is not self-destructive or injurious to others; demonstrated that all reasonable, less intensive treat-
and contingent observation and positive-practice over- ment modalities have been tried or would clearly be
correction (when implemented by trained personnel ineffective. Finally, if the technique or procedure has
and only for limited amounts of time). These pro- serious side effects that would be more damaging to the
cedures should be applied only contingent on inap- client than the benefits that the client would receive,
propriate behaviors (e.g., self-mutilation, inappropri- the technique should not be approved. It should be
ate self-stimulation, aggressive, or disruptive noted that although the human rights committee may
behavior). Unless it is observed or reported that these have previously approved the use of a procedure de-
procedures are being abused, they might be approved scribed in this section with one client, prior approval
for use without specific approval of the human rights should be obtained before the procedure may be used
committee before, during, or after their use. It is good with another client or with another problem of the
practice, however, to reevaluate the use of these pro- same client. Once the procedure has been approved for
cedures at least once each year to detennine that they use with a particular client's problem, the human rights
are not being applied inappropriately. committee should review the effect of the procedure on
2. There are some procedures that might be allowed a regular basis.
without the prior approval of the human rights com-
mittee but that require post hoc review. These pro-
The Formal Review Process: Determining
cedures might include such techniques as therapeutic
Individualized Treatment
time-out, fines or response-cost techniques, and dif-
ferential reinforcement of low rates of behavior, all of Human rights committees can become so involved
which should be applied only contingent on inap- in protecting clients from aversive treatment tech-
propriate behaviors. Additionally, there may be some niques and from being deprived of basic privileges that
qualification imposed on their use. For example, the they forget to make sure that clients are provided with
committee might decide that the use of differential appropriate and effective treatment. Additionally, the
reinforcement of other behavior or reinforcement of clients with the most controversial problems and treat-
incompatible behaviors may be used to eliminate an ment techniques are the ones who nonnally receive the
inappropriate behavior only while concurrently rein- committee's attention. Equally important as protecting
forcing an appropriate substitute behavior. Or mini- clients from aversive treatment procedures is evaluat-
meals (without food deprivation) may be allowed to be ing and assessing the treatment and progress of each
used not as a procedure to decrease behavior but rather individual client (including those receiving non-
as a technique to teach appropriate behaviors. The pro- controversial treatment) to detennine if appropriate
cedures delineated in this section could be imple- treatment is being provided. A formal review process
mented by the treatment staff when they felt such pro- should be developed that regularly assesses the treat-
cedures were justified, but their continued use for each ment of all clients. Although staff input should be re-
client would require review by the human rights com- quested in this process, this review and evaluation
mittee and approval at the next meeting of the human should also be conducted independently. In other
rights committee. After approval has been obtained, words, the committee should investigate on its own
reports of the use of the procedure and its effectiveness and make an independent detennination of whether
with a particular client should be presented at each appropriate treatment is being provided. The follow-
subsequent meeting of the human rights committee for ing paragraphs describe a procedure that might be used
the duration of the use of the procedure. to address this issue:
3. Aversive techniques not specified above in (1) or This review process is very similar to a judicial hear-
(2) might require prior approval before they could be ing: at least two opposing sides are considered, a spe-
prescribed for any problem or client. As May et al. cific procedure is followed, evidence is presented, and
(1976) pointed out, there are certain issues that should the burden of proving that a particular type of treat-
be considered before allowing the use of any of these ment is justified rests with the treatment staff. For this
techniques. It should be demonstrated that the client, if review process to function appropriately, it is best if
competent to do so, has given infonned consent (or a one member of the human rights committee is indi-
parent or guardian when the client is unable to do so); vidually assigned to present several clients' cases at a
that the peer review committee has approved this tech- committee meeting (each case would be presented in-
nique as professionally justified; and that the staff has dividually). In doing this, the committee member
236 PART III- GENERAL ISSUES AND EXTENSIONS
would assume the role of a client advocate. Being a procedure for a particular client, they would need to
client advocate includes the following: (1) reviewing present their reasons for desiring this type of treat-
the client's records; (2) observing the treatment that the ment. The designated member of the human rights
client is receiving; and (3) spending time talking with committee, after having reviewed the case, observed
the client (if possible) to understand how the client the present treatment, and talked with the client, would
feels about the treatment that he or she is receiving and advocate a less restrictive type of treatment procedure.
about the living environment. Thus, the committee This opposition would then require the treatment staff
member who is representing or acting as advocate for a to justify their recommendations to the committee. If,
client should know generally what skill deficits the on the other hand, the treatment staff suggested no
client has, what the client needs to learn, what behav- changes in a client's program, the designated commit-
iors should be decreased, and what treatment program tee member could advocate a more intense program
is already in effect for the client. Having this firsthand with the rationale of producing more rapid change, or
information means that the human rights committee if progress was adequate, the member would advocate
need not rely only on the information given to them by a reduction in intrusiveness. In this case, the staff
the treatment staff. would have to provide clear rationales and justifica-
At each meeting of the human rights committee, a tions for advocating no changes.
specified number of client cases should be reviewed. The main objective in the procedure is to consider
Committee members who have been assigned as repre- several alternatives for goals and treatment for each
sentatives or advocates for those clients are responsible client. These different options should be weighed, and
for presenting the information they have obtained the human rights committee, acting much like a jury,
through records and observations. The treatment staff should decide on the best treatment for a client as justi-
or a representative of the staff should also attend this fied by the evidence presented. This is another protec-
meeting. The staff member is responsible for present- tion against the human rights committee's acting mere-
ing the staff's perspective of the client's case. During ly as a "rubber stamp" for the treatment staff. This
this discussion of each client's case, the human rights procedure also requires that the committee peri-
committee, as a whole, must weigh and evaluate the odically review the program for each client, rather
evidence to determine whether the overall goals estab- than reviewing the programs only for clients who are
lished for the client are appropriate, whether the goals receiving aversive techniques. Additionally, the com-
are being reached, and whether the least restrictive or mittee should address and evaluate the ultimate treat-
intrusive form of treatment is being utilized. ment goals every time it reviews a client's program to
So that the committee can make an intelligent and ensure that the skills being taught are relevant to the
fair decision, it is useful that someone present a point reason that the client is receiving treatment. The
of view opposing the desires of the treatment staff. human rights committee may find that they need to
That "someone" should be the member of the human refer to the results of standardized assessment pro-
rights committee who is representing the client. If the cedure to aid in evaluating each client's progress. Re-
committee member assumes a position advocating a cords, however, should not be relied on solely; actual
type of treatment opposite that which the staff is sug- observation and interaction with the client is
gesting, then both sides of the case of issue can be necessary.
heard. Although the treatment staff may have the best
intentions when presenting information about clients, Operating Independently of the
they have a vested interest in the treatment program as
Treatment Staff
it currently exists. Additionally, the treatment staff
may become so involved in a particular client's pro- To function appropriately in a protection and ad-
gram that they can see no alternatives other than what vocacy role and to be viewed as a credible protective
is currently being done. By requiring that an opposite, mechanism, the human rights committee must be able
or at least an alternative, view be considered, other to meet and deliberate as an independent body. Thus,
options are made available. The treatment staff would the committee needs to set its own meeting dates and
then have the "burden of proof" of convincing the periodically meet without the treatment staff present.
human rights committee that the staff's present or pro- The committee, obviously, can ask any staff member
posed treatment is the best for the client. to be present at the meetings whenever necessary. Ad-
The procedure might work as follows: If the treat- ditionally, the committee members must have indepen-
ment staff wanted to institute an aversive or intrusive dent access to the treatment program and the records
and should maintain independent contact with each "Human Rights Committee 'Due Process' Summary
client. Only in this way can the committee retain its Report." This report should be filled out during, or
autonomy and resist undue influence from the treat- directly after, each committee meeting. The main pur-
ment staff. Human rights committees should not be- pose of this report is to have a written record of the
come so intertwined with the treatment staff that they procedures that the committee follows, to determine
lose an independent perspective and are no longer ade- whether the committee acts as a credible, independent
quately able to represent and protect the clients. The review and protection mechanism, and to indicate
human rights committee should not operate in opposi- whether it consistently follows the prescribed
tion to the treatment staff, but it is necessary that the procedures.
two remain very separate entities. The first point listed in Appendix I asks the commit-
tee to note those instances where the committee re-
fused or delayed consent of a treatment procedure and
Public Dissemination of Purpose and
sought additional information concerning less intru-
Procedures
sive procedures. Although it is not expected that this
The human rights committee should disseminate its will occur at each meeting, it would be noteworthy if it
statement of purpose together with a description of its never occurred, thus appearing that the committee ac-
review process. These should be made public so that cepted all the treatment procedures presented to them
any person with questions concerning the ethical or by the staff without question. The second point is con-
humane treatment or care of clients can contact the cerned with outside advice and opinion sought by the
human rights committee. Letters should be sent to all committee. It is not necessary to have such advice
parents, guardians, or the nearest relatives of the cli- reported at every meeting. Again, though. it would be
ents informing them of the existence of the human noteworthy if outside advice were never sought. The
rights committee and stating that parents, guardians, third and fourth points attempt to determine if the
or concerned relatives are welcome to attend the meet- human rights committee functions independently of
ings when the client they are interested in is being the treatment staff or whether it is so directly tied to the
discussed. Additionally, they, along with any other staff by member selection and presence of treatment
people in the community (including treatment staff staff at each meeting that the committee is not a sepa-
personnel), should be able to present, confidentially, rate and independent entity. The issue of notifying the
any questions or criticisms of the program to the public of the committee's existence is addressed in the
human rights committee at any time. To enable more fifth point.
people to know about the human rights committee and The actual "due process" procedure of presenting a
perhaps to utilize it, pictures of the committee mem- client's case and advocating alternative forms of treat-
bers along with names, addresses and phone numbers ment to that proposed by the treatment staff is directly
underneath the pictures should be displayed at the addressed in point 6. Point 7 examines the number of
treatment facility along with the statement of purpose. actual on-site visits made by the committee members.
Making the human rights committee visible helps in Finally, points 8, 9, and 10 involve the review process,
the protection of the clients. Often, it is the relatives of described above, to be used with aversive or intrusive
the client who are most concerned about the client's procedures.
welfare and who have the most contact with the client, In filling out this checklist, when "instances" are
besides the treatment staff. Thus, the relatives may be asked for, the human rights committee should briefly
the ones who are in the best position to know if abuse note what evidence, if any, there is to show that the
has taken place or if the client is making any progress. objective has been partially or fully accomplished. If
In cases of abuse or lack of progress, the relatives or nothing has occurred since the last meeting, "none"
concerned citizens know where to direct questions and should be recorded. As mentioned previously, it is not
can be assured of a specified procedure that will be expected that each item can or should be filled in at
followed in dealing with questions or complaints. each meeting. The credibility of the human rights com-
mittee in providing due-process protection for clients,
however, is strengthened with each entry.
Written Records and Checklists
The second checklist (Appendix 2), the "Summary
Appendixes 1 and 2 contain checklists that the of Human Rights Committee Review of Client Indi-
human rights committee can use to provide a written vidual Habilitation Plan," should be completed for
record of the committee's action. Appendix I is the each client whose program is formally reviewed by the
committee. Since it is desirable that all clients' cases tee for all developmentally disabled clients in that
be periodically reviewed by the committee, it is likely area. Sometimes, the number of clients covered reach-
that this checklist will be completed at least once a year es into the thousands. It would be impossible for a
for each client. This checklist is primarily concerned group of 10-15 citizens on a human rights committee
with identifying treatment goals and techniques and to protect the interests of all those persons. Therefore,
determining how appropriate these goals or treatment it has been recommended that the large area be divided
techniques are. Several issues are considered, and the into smaller regions or catchments and that each area
questions have been taken directly from the Associa- have its own human rights committee.
tion for Advancement of Behavior Therapy's Ethical Another committee with jurisdiction over the entire
Issues for Human Services (1977). As the title might area could serve to make general policy decisions and
imply, the topics address the ethical concerns involved act as an appellate hearing body in cases of disputes
in treatment, including (1) the goals, the method in between staff and clients or between the staff and the
which they have been determined, and the benefit to regional human rights committee. In any event, a
the client in having these goals; (2) the choice of treat- human rights committee should probably not be re-
ment procedures, whether the procedure has been doc- quired to serve more than 100 clients. Any larger
umented as professionally, legally, and ethically justi- number makes it impossible to protect the individual
fied, and the consideration of other treatment methods; needs of each client and to make sure that they are
(3) the client's voluntary participation in the treatment receiving appropriate and humane treatment.
program and whether a range of treatment techniques The opposite type of situation may also occur. Many
were offered; (4) the assurance that the client's best small residential programs in the community serve
interests are still addressed even when the client is only 8-10 clients, or at the most, 20-30. Most of these
incompetent to make treatment decisions; (5) the eval- not-for-profit programs have a board of directors con-
uation of the treatment procedure in general and with sisting of interested persons from the community.
the client in question; (6) the confidentiality of the Rather than attempting to assemble another group of
treatment; (7) the referral of the client to other thera- community persons, the board of directors, reflecting
pists if the therapy is unsuccessful or if the client is the values of the community, can serve as the human
unhappy with the therapy; and (8) the qualifications of rights committee and provide the protective function.
the therapist who is to provide the therapy. This procedure is most useful if the program is not a
Whereas the first checklist is primarily concerned controversial one. If, on the other hand, the program
with the procedures that the human rights committee serves severely debilitated clients and employs contro-
follows in reviewing aversive or intrusive treatment versial techniques, it may be wise to have a separate
techniques as well as in developing treatment plans, human rights committee. In either case, the board or
this second checklist addresses the specific issues in the committee should still address the issues outlined
developing and implementing all treatment programs. in the checklist to be sure that appropriate treatment is
Both checklists are necessary. It is important to know being provided.
that the general procedure the human rights committee
follows is a fair and complete one, independent of staff
Ensuring Staff Compliance
coercion. Additionally, it is important to determine
that when evaluating a particular client's treatment The human rights committee is an advisory group to
program, the committee addresses the critical issues the treatment staff. Should the treatment staff be re-
that will protect that client. By consistently following a quired to follow all recommendations of the human
standard and fair procedure that addresses critical is- rights committee? This is a difficult question, and the
sues, clients' rights should be protected. answer will be influenced by a number of considera-
tions. In some situations, a human rights committee
may be mandated by law or by acceptance of funds
Adapting the Committee to the Size of the
from certain sources. It may still not be clear, however,
Program
that all of the recommendations of this committee need
Depending on the size of the program, what is nor- to be followed. In other cases, institutional policy may
mally thought of as the human rights committee may require compliance with the recommendations of the
need to vary. For instance, some large metropolitan human rights committee. In most cases, whether or not
areas have decided to institute a human rights commit- the recommendations of the human rights committee
are followed will be up to the treatment staff. Thus, the committee (not the treatment staff). No member
discussion, negotiation, and compromise between the could serve consecutive appointments, and at least one
human rights committee and the treatment staff may be or two years should elapse before reappointment to the
necessary. Where systematic and pervasive noncom- committee. Finally, the compensation received by
pliance with recommendations of the human rights each committee member should be reasonable in view
committee exists, however, it would seem that the ap- of the time spent and the prevailing standards of com-
propriate action of the committee members should be pensation in that location. Following procedures sim-
to resign. Continued membership, after pervasive non- ilar to these should allow members to be adequately
compliance with recommendations, would indicate compensated, at the same time allow their tenure on
that the committee believes the program is operating the committee to be protected so that they can operate
properly. Thus, the primary sanction the human rights independently of treatment staff influence, and, addi-
committee can impose is resignation. The resignation tionally, maintain the public credibility of the
of all members would be a public indication of a defi- committee.
nite problem with the program, and, in some in-
stances, the program would be unable to comply with
Benefits to the Program
the legal mandate of having a human rights committee.
Program staff may view the human rights committee
as a burden that they must bear in order to be able to
Compensation
continue their program. The committee, however, can
Most members of a human rights committee serve serve two critically important functions that ultimately
because of their strong commitment to improving con- benefit both the clients and the staff. First and fore-
ditions for clients in the program. Such service, how- most, the committee should exist for the protection and
ever, requires considerable effort and time. Whether or advocacy of all of the program's clients. It should be an
not to compensate committee members is a difficult independent evaluative mechanism that attempts not
issue to resolve. Obviously, it is necessary to pay any only to protect clients from unnecessary aversive tech-
travel or lodging expenses that a member might incur. niques but also to ensure that effective treatment is
The payment of any additional amount, however, has being provided for each client. Second, it serves to
advantages and disadvantages. On the one hand, if the reassure others about the treatment program. Any per-
program pays committee members, it is possible that son or organization questioning whether the treatment
they may not seriously evaluate treatment staff deci- being provided is humane and appropriate may speak
sions because they fear being asked to resign from the directly with the human rights committee. As an inde-
committee and, thereby, losing the money being paid pendent evaluator, this committee can speak without
to them. Further, the public credibility of the commit- bias about the treatment being provided. Thus, the
tee's decisions may be weakened by the fact that the treatment staff, if they comply with the committee's
members are paid by the program. On the other hand, procedures and recommendations, have an advocate
it may be unrealistic to expect people to devote the that protects their public image.
amount of time and energy that are involved in serving
on this committee without some compensation for
their time and efforts, and thus, some guidelines spec- The Peer Review Committee
ify that members should indeed be compensated (e. g. ,
May et al., 1976). Although the human rights committee acts as a rep-
Probably the most critical issue to consider is pro- resentative of society to be sure that clients are treated
tecting the independence of committee members from humanely and ethically, in addition to determining that
undue influence by the treatment staff. It appears that each client is actually receiving treatment, the peer
members could be compensated and at the same time review committee's primary function is to consider the
be able to maintain a protected, independent status professional justification of the procedures being used.
separate from the treatment program. This might be The systematic and critical review of treatment pro-
done by appointing members for a specified term grams by competent professionals has been empha-
(e.g., two or three years), which could be terminated sized as a much needed, but often neglected, process to
only by the member's resigning from the committee or determine the appropriateness, adequacy, and necessi-
by failure to fulfill the responsibilities determined by ty of treatment programs, especially those that involve
240 PART UI • GENERAL ISSUES AND EXTENSIONS
unpleasant or aversive procedures (Serber, Hiller, for publication. This procedure is most useful for pro-
Keith, & Taylor, 1975). grams employing noncontroversial techniques. Addi-
Unfortunately, peer review has not been an easy tionally, other programs involving noncontroversial
process to establish for a variety of reasons. Many techniques may find it useful, as well as educational,
treatment providers have been reluctant to allow out- to periodically ask a group of peers to make an on-site
side professionals to evaluate their programs, often evaluation of their programs. Doing this may be a
because they feel that outside evaluators do not know fresh, innovative method of evaluating problems, in
enough about the operation of the program or about the addition to making sure that the most effective and
clients to make intelligent and reasonable recommen- efficient procedures are being utilized.
dations. In some instances, treatment providers have Finally, there are those programs that employ aver-
been evaluated by professionals with very different sive, or otherwise controversial, procedures. A more
theoretical perspectives, who have made broad, systematic, organized, and intensive peer review
sweeping recommendations to change whole treat- seems required for them. The remainder of this section
ment programs, based on theoretical differences rather of the chapter is devoted to describing this type of peer
than on a consideration of the effectiveness of the pro- review mechanism, how it can be established, and how
cedures being used. Obviously, treatment providers it can best function to safeguard both the client and the
who have experienced this type of peer review have program's interests, in addition to making sure that the
little respect for the system. Likewise, professionals, best treatment procedures available are being pro-
in general, have been reluctant to begin a process of vided.
evaluating one another's programs because of the ca-
maraderie that exists among those in the same disci-
Composition
pline and their reluctance to say anything derogatory
about a fellow therapist or treatment provider (Hare- To be a credible protective mechanism, a peer re-
Mustin, Maracek, Kaplan, & Liss-Levinson, 1979). view committee should consist of independent profes-
The need for peer review, however, cannot be easily sionals who have expertise in using procedures that are
dismissed (Bailey, 1978; Claiborn, 1978; May et aI., of the same theoretical (e.g., behavioral) orientation as
1976; Risley & Sheldon-Wildgen, 1982). If competent those being utilized by the treatment staff or who have
professionals are unwilling or are not allowed to re- a demonstrated competency in working with the type
view treatment programs, especially controversial of client being served by the program. It is necessary
ones, it is unlikely that anyone will be able to deter- that the committee have a representation of both these
mine whether certain procedures are professionally competencies in order to protect the clientele ade-
justified. Once we have recognized the need, there are quately and to protect the program. Ideally, it would be
several ways that peer review can be accomplished, advantageous to have some members who both sub-
depending on the type of program being provided and scribe to the same basic treatment views and who also
the procedures being utilized (Risley & Sheldon-Wild- work with the same clientele, but this is not always
gen, 1982; Spooner & Tyson, 1987). These often range feasible. Thus, the members, in combination, should
from informal review to systematic full-scale evalua- be intimately familiar with the current literature, pro-
tions. Thus, there may be situations in which a thera- grams, and disorders that are relevant to the pro-
pist is presented with a unique situation and desires to cedures used and the clients served in the program. In
discuss this case with another professional who has instances where aversive or controversial treatment
had experience working with the particular type of procedures are being utilized, one may not be able to
client or problem in question. This discussion, al- recruit members for the committee who use exactly the
though informal, provides a type of peer review, since same treatment techniques. Nonetheless, the commit-
the therapist receives professional input from others tee should be comprised of individuals who have either
and does not have to rely solely on his or her o~n the current credentials and involvement with similar
judgment. clients or expertise in using techniques that are derived
Another form of peer review may involve having from the same theoretical basis as the aversive or con-
relevant and competent professionals review the writ- troversial procedure.
ten materials that describe a particular program and its An issue pertaining to the composition of the peer
operation. This type of review could be accomplished review committee that program personnel may want to
in much the same way that journal articles are reviewed consider is whether professionals from different the-
oretical perspectives should serve on this committee mittee members must attend to discrepancies or con-
(Bailey, 1978). Each program must decide indi- cordance between the program practices and the pro-
vidually if this is desirable, but programs should be fessionalliterature. Two considerations are extremely
aware of the type of input that these professionals can important in fulfilling this function. The members
give to the program. Overall program improvement must examine all aversive and controversial pro-
can often be enhanced by having people from other cedures to determine if these techniques are profes-
perspectives on the peer review committee. These sionally justified; normally benign procedures need lit-
people can address general considerations in addition tie, if any, justification (the human rights committee,
to comparing this program with other programs serv- however, should examine even benign procedures to
ing similar clients. These professionals, however, determine if treatment was accomplished by using
would not be the best individuals to address the issue of them). Professionally justified means that they have
procedure improvement because they do not work support in the professional literature, that is, that they
with, nor are they acquainted with the literature on, the have been experimentally evaluated and have been
procedures in question. To obtain the best input regard- shown to be effective as evidenced by published data in
ing the appropriateness of the procedures being util- reputable journals. The committee must also deter-
ized by the treatment staff, it is advisable to have mine if the procedures are justified by current profes-
people who either have used those procedures or are of sional literature. Thus, a controversial procedure at
the theoretical background from which those pro- one time may have been justified, but perhaps more
cedures were derived. effective and less controversial procedures have been
Peer review committees can consist of members developed and evaluated since then. In light of the
chosen both at the national level and from the local evidence of the effectiveness of the new techniques,
area (if available). There are advantages to having both the controversial procedure would no longer be profes-
types of members. Those at the local level have greater sionally warranted. Committee members, therefore,
opportunities to visit the program in operation, while must be familiar with the treatment program as well as
those at the national level can normally provide a with the most current professional literature that is rel-
broader perspective of the program since they do not evant to the techniques used and the clients served in
have as frequent contact. It is critical that all members the program.
be independent of the treatment program and not under Once the peer review committee has examined the
any monetary, professional, or political obligations to program, the members may provide an educational
the program or staff. Members of the peer review com- service to the treatment program personnel by provid-
mittee must feel free to make whatever recommenda- ing a broader knowledge and perspective of the profes-
tions they feel are necessary without fear of reprisal. sionalliterature and practices. Thus, those involved in
Thus, independence, as well as competence, is a crit- making treatment decisions can be advised of the most
ical characteristic of the committee members. current procedures in use with a particular clientele.
The educational purpose of the peer review committee
cannot be overemphasized. It should provide current,
Purpose
as well as new, ways to address problems if it finds that
The peer review committee can serve a twofold pur- the procedures in use are not justified by the profes-
pose. First, the committee can provide independent sional literature.
and explicit advice and consultation to the admin- The second function of the peer review committee is
istrative and treatment staff of the program and also to to answer publicly any questions about the profes-
the human rights committee, if that committee so de- sional justification of the procedures used by the treat-
sires. Second, where appropriate, the peer review ment staff. Often, controversial programs need to re-
committee can provide implicit consent and endorse- spond to questions and criticism from the public and
ment of the treatment program, thus reassuring those governmental officials who are in charge of licensing
outside of the program that the treatment procedures or regulating the programs. Questioning from outside
are justified and that the clients are protected. sources can be good, because it indicates that people
The primary purpose, as mentioned above, is to help are concerned about the welfare of the clients. Unfor-
make sure that the procedures used by the treatment tunately, however, what normally happens is that the
program are in accord with the treatment standards treatment staff and the program administrators spend
found in the current relevant literature. Thus, the com- an inordinate amount of time defending the program.
This can be an emotional and time-consuming battle are carried out as prescribed on a day-to-day basis.
between the "critics" of the program and the staff. In reviewing the program and the procedures used,
Usually, nothing is resolved because the staff is viewed the committee should engage in a two-step process
as being biased and as merely defending their own whereby members examine written treatment plans in
actions. The peer review committee can alleviate some addition to actually observing how the treatment tech-
of the problems caused by the public questioning. The niques are being implemented. When examining writ-
committee should be available to respond knowledgea- ten treatment plans, the committee members can as-
bly, authoritatively, and independently to private or sess whether the techniques advocated by the staff are
public questions or criticism concerning the appropri- justified by the current professional literature. If they
ateness and effectiveness of the treatment program. are not, recommendations should be made that more
The committee will be viewed as a much more credible professionally justifiable techniques be used. If the
source of answers to questions or responses to criticism treatment plans are justified by the current professional
than the treatment staff, who have a vested interest in literature, the committee must then determine if the
the program. The peer review committee is an inde- plans are actually being implemented with the preci-
pendent group, knowledgeable about both the program sion, consistency, and supervision called for by the
and the current professionally justifiable procedures, professional literature. Obviously, the implementation
with no reason to promote or support unjustifiable of the procedures is extremely critical, since many
practices. Thus, the committee members are viewed as aversive techniques are justifiable only if they are
being better able to assess accurately if the treatment is properly implemented.
professionally sound. Since implementation is critical, it may be desirable
to place in the program persons who have direct links
with members of the peer review committee, to work
The Formal Review Process
on a day-to-day basis. This procedure would serve a
Because of the use of aversive, or otherwise contro- function similar to that of having an unannounced vis-
versial, techniques, it is necessary that the peer review it, except that it is more desirable, since the persons
committee make on-site visits and meet together to would be in the program daily. This type of procedure
deliberate about the appropriateness of the general pro- can be most easily utilized when the members of the
gram policy and the individual habilitation programs. peer review committee have faculty positions at uni-
The more controversial the procedures are, the more versities and have students who would like to work as
visits there should be to the program. Here, the local interns or assistants or who would like to carry out
peer review members are most useful. They are more research in the treatment program. These students ulti-
readily available and are able to make more frequent mately report and answer to the peer review committee
visits to the program. Additionally, because of their member who is their faculty adviser, and thus, they are
closeness, they can make unannounced visits to the independent of the treatment staff. The treatment staff
program. Each peer review committee must determine should be aware who the students are so that there are
whether they want to make unannounced visits. When no "undercover" operations going on to make the staff
visits are announced, one can argue that the treatment feel as if people are spying on them. They will know
staff will prepare for the visit and, in essence, act in an that the students can observe what they are doing and
unrepresentative fashion for the benefit of the commit- are presumed to be reporting to the peer review com-
tee. There are certain things that the staff can prepare mittee. Thus, the treatment staff are likely to conform
for and engage in when the peer review committee is their daily behavior to the standards set by the peer
visiting that would not be characteristic of what nor- review committee. If they do not, it will be readily
mally occurs in the program. Other things, however, seen. This procedure can therefore provide one of the
such as lack of staff training (so that the staff does not most credible assurances about the implementation of
know how to implement the treatment procedures the treatment plans.
properly) or lack of client progress, cannot be easily
hidden even with advance warning. In some cases, the
Operating Independently of the Treatment
committee may feel that certain procedures should not
Staff
be used or should be implemented only in a certain
manner with certain safeguards. Unannounced visits To be a credible protective mechanism, the peer
by the peer review committee and the human rights review committee, like the human rights committee,
committee would help make sure that the procedures must be able to meet and deliberate as an independent
entity. It is usually easier for a peer review committee nal distribution. Thus, the peer review committee, in
to maintain its independent status, since this commit- addition to keeping minutes for their own use, should
tee is comprised of professionals who are just as have a summary report that would be acceptable for
knowledgeable about appropriate treatment proce- public dissemination. Appendix 3 contains a sample
dures as is the treatment staff and may be even more "Peer Review Committee Summary Report" that
knowledgeable. Although the peer review committee might be used.
will undoubtedly have considerable contact with the The first question on the "Peer Review Committee
program staff, it is important that they retain their inde- Summary Report" asks the committee to note which
pendent status by meeting without the staff present, so program policies were considered and what recom-
that they can openly and honestly discuss treatment mendations were made at the current meeting, in addi-
procedures and program policy. tion to noting whether previously recommended pol-
icies had been satisfactorily implemented. This
question provides the public with information about
Public Responsiveness
whether the committee is considering critical policy
Like the human rights committee, the peer review decisions as well as whether the staff has complied
committee should publicly make known its existence with the recommendations that have been made.
by disseminating the committee's statement of purpose The second topic may be of importance to much of
together with a description of the review process. Par- the public, since it addresses the use of specific treat-
ents, guardians, and the nearest relatives of the clients ment procedures and provides a public record of which
specifically should be made aware of the existence of procedures were considered and what recommenda-
the peer review committee. They, along with any indi- tions were made for the use of these procedures. It is
vidual in the community, should be encouraged to ask usually wise to include a short statement of the ra-
the committee, either publicly or confidentially, any tionale for any recommendation so that the public can
questions relating to the program's procedures or the understand the justification for the decision. Addi-
implementation of treatment techniques and the pro- tionally, it is critical to document whether previous
fessional justification of them. recommendations were satisfactorily implemented.
After making themselves visible, the peer review The peer review committee should take responsibil-
committee should take an active role in speaking pub- ity not only for reviewing treatment procedures but
licly about the treatment program and in publicly an- also for reviewing clients' individual treatment plans.
swering questions or addressing any criticisms. As Most procedures are normally not evaluated in a
mentioned previously, this committee can be much vacuum; rather, they are considered according to their
more credible in addressing issues raised by the public appropriateness with an individual client. Although
than can the treatment staff, who have a vested interest this committee is not necessarily concerned with either
in the treatment program. Depending on how indepen- the ethical or the humane considerations of the pro-
dently the committee functions and how knowledge- cedures, the members must consider whether a partic-
able the members are about using similar procedures, ular procedure is professionally justified with an indi-
about working with a similar population, or about op- vidual client. If other procedures appeared to be more
erating similar programs, the peer review committee professionally warranted because they are either more
can provide the needed assurances to allow a contro- effective or less intrusive than those the program is
versial, yet professionally appropriate, program to re- currently using, then the committee should recom-
main in operation to serve a difficult-to-treat clientele. mend them. Items 3 and 4 address these issues and
provide a permanent record of the decisions made.
It should be noted that following each of the first
Written Records and Checklists
three points, there is a question asking whether the
The peer review committee may want to keep exten- treatment staff has implemented the peer review com-
sive records or minutes of their meetings. This is an mittee's previous recommendations. If the staff has
acceptable practice and often greatly aids committee not, "No" should be marked, with an explanation
members who live at great distances and are not in given in the "Comments" section. Normally, a "No"
frequent actual contact with the program. Detailed would indicate that the staff is in noncompliance with
minutes can easily refresh a member's memory of what the committee's recommendation, but, in some in-
the critical considerations of the program are. Often stances, this noncompliance may be justified. Any jus-
these minutes, however, are not appropriate for exter- tification could be written in the "Comments" section.
If, on the other hand, the staff routinely disregards the are small or use controversial techniques with only a
committee's recommendations, a problem would be small number of clients. For those programs it may not
indicated and should be addressed. be feasible to have a large peer review committee. It
Items 5-10 help document the credibility of the peer may be more practical to use consultants to advise
review mechanism. Whenever literature or references them on any problems that arise as well as on the
are recommended, the peer review committee is appropriate use of controversial procedures.
providing an educational service to the treatment staff. If individual consultants are being used by a treat-
Direct observation of the program (which is covered in ment program in a peer review role, it is necessary to
topic 6) is essential, and the more that it occurs, the demonstrate that these individuals are, indeed, inde-
more effective and credible the committee will be. As pendent of the staff and able·to make whatever recom-
previously mentioned, the human rights committee mendations they feel are appropriate. Thus, although
should feel free (and should even be encouraged) to the consultant may be compensated with per diem and
consult with the peer review committee. Often, for the travel costs in addition to a consultant's fee, the money
human rights committee to make intelligent and wise earned from this service should be minimal and sup-
decisions, they need information about the profes- plementary to the consultant's normal earnings. In
sional justification of a particular procedure. They other words, if the consultant were no longer to consult
may find that the most appropriate source of this infor- with the program, it should not financially hurt him or
mation is the peer review committee. Keep in mind, her. The consultant should have no personal or profes-
however, that although the peer review committee may sional ties to the program and should not be under any
state that a procedure is professionally justified, the professional, political, or financial obligations to the
human rights committee may decide that the procedure program.
should not be used, for ethical or humane reasons.
They cannot make this decision wisely, though, with-
Ensuring Staff Compliance
out the necessary information from the peer review
committee, and this is the essence of item 7. Like the human rights committee, the peer review
The peer review committee should always record committee is only an advisory group to the treatment
any instances in which a member, or the committee, staff. The committee can make recommendations to
has publicly interpreted or answered questions con- the staff as well as provide educational information.
cerning the treatment program. In recording such in- The treatment staff, however, can choose to comply or
stances, the members should note what the action spe- not. If the staff chooses not to comply, the only sanc-
cifically concerned; to whom it was addressed; when it tion the members of the peer review committee can
occurred; what, in general, the member said; and what impose is to withdraw from the committee. When they
the public's response was. Finally, the committee withdraw, they can state the reason for doing so and
should note what students or interns are working in the thus indicate public disapproval of the program's pro-
program and when the committee meets privately, in cedures. Additionally, they will no longer be available
the absence of the treatment staff. By consistently fill- to respond to public inquiries about the program.
ing out this checklist, an ongoing record of the peer Obviously, a treatment program may not incorpo-
review committee's activities will be available to sub- rate all recommendations made for it by the peer re-
stantiate further that the committee is a credible protec- view committee. Each member of the committee, as
tive mechanism. well as the entire committee, must decide which non-
compliances are acceptable and which are not. When a
point is reached when a member can no longer endorse
Adapting the Committee to the Size of the
the treatment program, it is time for this member to
Program
resign from the committee. Thus, while on the com-
As with the human rights committee, it may be nec- mittee, each member should be willing not only to
essary to vary the structure of the peer review commit- respond to public inquiries but also to generally en-
tee. Since this committee does not have the ultimate dorse the program and the procedures being used.
responsibility of reviewing each client's individual
habilitation plan and progress (that responsibility rests
Compensation
with the human rights committee), the peer review
committee is normally able to review a large program The compensation of peer review committee mem-
that serves many clients. Many programs, however, bers raises the same issues as the compensation of
CHAPTER 11 • BALANCING CLffiNTS' RIGHTS 245
members of the human rights committee and can be terminated. Although it is clear that no one should be
handled in much the same way. Since many of these exposed to treatment techniques that can be labeled as
members may live at a distance from the treatment cruel and unusual punishment, it is also clear that
program, it is necessary that the members receive trav- many techniques that at first blush appear to be cruel
el and per diem expenses. If necessary, compensation are professionally justified for use with certain indi-
for their services can also be provided at much the viduals. To propose a blanket disapproval of them
same rate one would pay any consultant. The same would mean that many severely debilitated individuals
protections to ensure independence from the treatment would never receive the treatment appropriate to their
staff as were described for the human rights committee needs.
might be in effect: Members should receive a specified The critical issue is determining what is appropriate
term of appointment that only they can terminate or and effective treatment and making sure that it is pro-
that the committee can terminate for failure to fulfill vided. Since it is impossible to specify treatment goals
duties, and consecutive terms of appointment should and techniques that would be appropriate and effective
not be allowed. for all individuals, it is necessary to develop mecha-
nisms to ensure that humane and effective treatment
will be provided. Human rights committees and peer
Benefits to the Program review committees have been developed to address the
issue of providing professionally justified and ethically
Normally, the treatment staff and administrators
appropriate treatment, especially for the difficult-to-
view the peer review committee as a beneficial source
of ideas for solving problems and presenting alter- treat. These committees represent both the profes-
native perspectives. The committee's educational sional and the general community view of what type of
treatment should be provided. These committees act to
function can be useful to both the treatment staff and
ensure that treatment will be provided that is appropri-
the human rights committee. In addition to providing
invaluable information, the peer review committee can ate to each individual's needs, professionally war-
ranted, and ethically humane.
serve as an assurance that the goals developed and the
techniques implemented are professionally justified. In addition to monitoring the client's interests, these
Once the committee is satisfied that the treatment pro- committees can also provide protection for treatment
vided by the program is professionally sound, the programs. Acting as independent spokespersons for
members can provide a service to the program that no these programs, the committee members can provide
one else is able to: they can act as public spokespersons public assurance that the goals developed and used are
for the professional aspects of the program, assuring both effective and appropriate. These committees are
the public that the procedures in use are professionally credible, however, only if they consistently follow ap-
warranted. This independent endorsement, by people propriate procedures for evaluating treatment goals
knowledgeable in the area of interest, can often mean and techniques and protecting client rights. Addi-
the difference between a program that is allowed to tionally, they must be independent from the treatment
continue to operate and one that is forced to close. staff.
Establishing credible human rights committees and
peer review committees often means that individuals
who in the past may not have been treated can receive
Conclusion appropriate treatment, and that programs that might
have been closed because of public disapproval of their
Providing appropriate treatment for the severely de- treatment techniques may be allowed to remain open to
bilitated client will always present a challenge to treat- serve those who most desperately need them. Finally,
ment providers. The challenge, however, must be met. the public can be assured that safeguards are con-
Courts, legislatures, and consumer groups have man- tinually in effect to protect those individuals not capa-
dated the right of these people to receive treatment ble of protecting themselves.
appropriate to their needs. Providing this treatment, in
methods acceptable to the public, often requires cre- ACKNOWLEDGMENT. The authors wish to express their
ative thinking. In the past, many programs, whose sincere appreciation to Dr. James A. Sherman for his
goals for treating the difficult-to-treat were admirable, invaluable editorial assistance and his support and con-
have received considerable criticism because of the tributions given throughout the preparation of this
procedures employed. Some programs have even been chapter.
246 PART m • GENERAL ISSUES AND EXTENSIONS
Appendixes statements of the conditions of use, monitoring, and re-

porting that were approved.
The three checklists presented here for use by the 9. a. Instances of any revisions of a statement of approval
human rights committee and peer review committee for procedures that can be implemented on an interim
were developed by the Professional Consultation and basis but that require the human rights committee's
Peer Review Committee of the Association for Ad- review and approval for continuation at the next meet-
vancement of Behavior Therapy (AABT). These ing of the human rights committee.
b. Instances of subsequent review and approval or disap-
checklists are reprinted with the permission of that
proval of procedures in this category.
committee.
10. Instances of the human rights committee's prior review
and approval or disapproval of other procedures.
Appendix 1: Human Rights Committee Signatures of human rights committee members participating:
"Due Process" Summary Report
Persons attending meeting: Date:
I. Instances in which the human rights committee has re-

fused or delayed consent for the initiation of a treatment
Appendix 2: Summary of Human
procedure and has requested additional information,
opinions, or the use of less intrusive procedures.
Rights Committee Review of Client
Individual Habilitation Plan
2. Instances in which the human rights committee has
sought outside opinions and advice. (Note who, when,
Client's initials or identification code:
and topic of concern. Note whether this advice was
sought from the peer review committee; from other out-
Admission date:
side, independent professionals; from the professional
literature; or from a client advocacy group.)
Date of this review:
3. Instances of the human rights committee's deliberations
in the absence of program personnel (Le., executive ses- Name of designated client advocate:
sions). (Note dates and who attended.)
Long-range habilitative goal(s) with target date for each:
4. Instances of independence in selecting new members of
the human rights committee, such as the human rights
Current program goals (one year or less):
committee's providing a list of potential new members
and the program director's choosing from that list. (Char-
Treatment procedures currently in effect:
acterize how the selection was done.)
5. Instances of public display and public awareness of the In reviewing this client's habilitation plan, the human rights
human rights committee, its members, and its activities. committee has addressed each of the following questions and
(Note displays and any approaches to members of the indicates by a "Yes" those questions that have been answered to
human rights committee by staff, outside persons, or the committee's satisfaction. (These questions have been taken
agencies.) directly from the Association for Advancement of Behavior
Therapy's Ethical Issues for Human Services. Please note that
6. Instances of the appointment of (and the subsequent pre-
wherever the term client is used with an asterisk, each of the
sentations made by) one member of the hurna.!l rights
following should also be considered a "client": the person in the
committee for each client or case considered, who acts as
program; the person's parent or guardian; the person or agency
an advocate for that client and whose role is to suggest a
providing funds for the treatment.)
treatment that is the opposite of the treatment the staff is
proposing. (Note the members' names and the clients'
A. Have the goals of treatment been adequately
initials or identifying numbers; note also the dates when
considered?
the appointments were made and the dates when the pre-
sentations were made.) I. To be sure that the goals are explicit, are
they written?
7. Instances of on-site visits made by members of the human
2. Has the client's * understanding of the goals
rights committee to observe program implementation.
been assured by having the client* restate
(Note the names and dates.)
them orally or in writing?
8. Instances of any revisions of a statement of approval for 3. Have the therapist and the client* agreed on
generally used procedures. Also provide any corollary the goals of therapy?
4. Will serving the client's* interests be 2. Have the measures of the problem and its
contrary to the interests of other persons? progress been made available to the client*
5. Will serving the client's * immediate interests during treatment?
be contrary to the client's * long-tenn
interest? F. Has the confidentiality of the treatment
relationship been protected?
B. Has the choice of treatment methods been 1. Has the client* been told who has access to
adequately considered? the records?
1. Does the published literature show the 2. Are records available only to authorized
procedure to be the best one available for that persons?
problem?
2. If no literature exists regarding the treatment G. Does the therapist refer the clients * to other
method, is the method consistent with therapists when necessary?
federally accepted practice? 1. If treatment is unsuccessful, is the client*
3. Has the client* been told of alternative referred to other therapists?
procedures that might be preferred by the 2. Has the client* been told that if dissatisfied
client* on the basis of significant differences with the treatment, referral will be made?
in discomfort, treatment time, cost, or degree
of demonstrated effectiveness? H. Is the therapist qualified to provide treatment?
4. If a treatment procedure is publicly, legally,
or professionally controversial, has fonnal 1. Has the therapist had training or experience
professional consultation been obtained, has in treating problems like the client's?
the reaction of the affected segment of the 2. If deficits exist in the therapist's
public been adequately considered, and have qualifications, has the client* been infonned?
the alternative treatment methods been more 3. If the therapist is not adequately qualified, is
closely reexamined and reconsidered? the client * referred to other therapists, or has
supervision by a qualified therapist been
provided? Is the client* infonned of the
C. Is the client's * participation voluntary?
supervisory relation?
1. Have possible sources of coercion of the 4. If the treatment is administered by mediators,
client's* participation been considered? have the mediators been adequately
2. If treatment is legally mandated, has the supervised by a qualified therapist?
available range of treatments and therapists
been offered? Comments on the above questions:
3. Can the client* withdraw from treatment
without a penalty or financial loss that Outside persons who have been consulted by staff or the human
exceeds actual clinical costs? rights committee in detennining recommended treatment (names
and dates):
D. When another person or an agency is empowered
Based on this review, are any changes indicated in long- or short-
to arrange for therapy, have the interests of the
tenn goals or treatment procedures? (Characterize.)
subordinated client been sufficiently considered?
1. Has the subordinated client been infonned of Signatures of participating members of the human rights
the treatment objectives and participated in committee:
the choice of treatment procedures?
2. Where the subordinated client's competence
to decide is limited, has the client as well as
the guardian participated in the treatment
discussions to the extent that the client's
abilities pennit?
Appendix 3: Peer Review Committee
3. If the interests of the subordinated person and
the superordinate persons or agency conflict, Summary Report
have attempts been made to reduce the
conflict by dealing with both interests? Persons attending meeting: Date:
1. Policies considered and recommendations made:

E. Has the adequacy of treatment been evaluated?
Have previous policy recommendations
1. Have quantitative measures of the problem been implemented to the committee's
and its progress been obtained? satisfaction? No* Yes
2. Procedures considered and recommendations Baer, D. (1970). A case for the selective reinforcement of
made: punishment. In C. Neuringer & 1. S. Michael (Eds.), Behavior
modification in clinical psychology (pp. 243-249). New
Have previous recommendations York: Appleton-Century-Crofts.
concerning procedures been implemented Bailey, B. (1978). Peer review manual for human service pro-
to the committee's satisfaction? No * Yes grams. Nacogdoches, Texas: PCEA, Inc.
Begelman, D. A. (1975). Ethical and legal issues of behavior
3. Clients discussed (initials or identifying modification. In M. Hersen, R. M. Eisler, & P. M. Miller
numbers only) and recommendations made: (Eds.), Progress in behavior modification (Vol. I, pp. 159-
189). New York: Academic Press.
Have previous recommendations Begelman, D. A. (1978). Ethical issues forthe developmentally
concerning clients' programs been disabled. In M. Berkler, G. Bible, S. Boles, D. Deitz, & A.
implemented to the committee's Repp (Eds.), Current trends for the developmentally disabled
satisfaction? No* Yes (pp. 41-66). Baltimore: University Park Press.
Berkler, M. S., Bible, G. H., Boles, S. M., Deitz, D. E., &
Repp, A. C. (Eds.). (1978). Current trends for the develop-
4. Clients receiving complete review of their individual hab-
mentally disabled. Baltimore: University Park Press.
ilitation plan (initials or identifying numbers only): Brakman, C. (1985). A human rights committee in a public
Actions by members of the peer review committee subse- school for severely and profoundly retarded students. Educa-
tion and Training of the Mentally Retarded, 20, 139-147.
quent to the last committee meeting (including actions
Budd, K. S., & Barer, D. M. (1976). Behavior modification and
during present meeting):
the law: Implications of recent judicial decisions. The Journal
of Psychiatry and Law, Summer, 171-244.
5. Literature or references supplied or recommended by the Christian, W. P. (1981). Behavioral administration of the resi-
peer review committee: dential treatment program. The Behavior Therapist, 4, 3-10.
Claiborn, W. (Chair). (1978). APAICHAMPUS outpatient psy-
6. Direct observation of program (names of committee chological peer review manual. Washington: APA.
members and dates): Clatterbuck v. Harris, 295 F. Supp. 84 (D.D.C. 1968).
Cook v. Ciccone, 312 F. Supp. 822 (W.D. Mo. 1970).
7. Consultation with members of the human rights commit- Covington v. Harris, 419 F.2d 617 (D.C. Cir. 1969).
Davis v. Watkins, 384 F. Supp. 1196 (N.D. Ohio 1974).
tee (names of members of peer review committee and
Davison, G. C., & Stuart, R. B. (1975). Behavior therapy and
human rights committee, dates). civil liberties. American Psychologist, 30, 755-763.
Eckerhart v. Hensley, 475 F. Supp. 908 (W.D. Mo. 1979).
8. Actions taken by members of peer review committee sup- Egelston, 1. D., Sluyter, G. v., Murie, S., & Hobbs, T. (1984).
porting or interpreting the program to others Trends in the use of restrictive and aversive procedures in a
(characterize) : facility for developmentally disabled persons. Education and
Training of the Mentally Retarded, 19, 306-311.
9. Peer-review-committee members students, interns, etc., Friedman, P. R. (1975). Legal regulations of applied analysis in
mental institutions and prisons. Arizona Law Review, 17, 39-
recently working in program (name, starting and ending
104.
date, the name of the peer-review-committee member-
Friedman, P., & Halpern, C. (1974). The right to treatment. In
sponsor): B. Ennis & P. Friedman (Eds.), Legal rights of the mentally
handicapped (Vol. I, pp. 273-294). New York: Practicing
10. Peer-review-committee executive session (discussions in Law Institute.
the absence of staff or administrators; persons attending, Griffith, R. (1980). An administrative perspective on guidelines
date): for behavior modification: The creation of a legally safe en-
vironment. Behavior Therapist, 3, 5-7.
Griffith, R. G., & Henning, D. B. (1981). What is a human
rights committee? Mental Retardation, 19, 61-63.
*Comments:
Halderman and the United States v. Pennhurst, 446 F. Supp.
1295 (E.D. Pa. 1977).
Signatures of participating members of the peer review Hare-Mustin, R., Maracek, 1., Kaplan, A., & Liss-Levinson, N.
committee: (1979). Rights of clients, responsibilities of therapists. Ameri-
can Psychologist, 34, 3-16.
Hawkins, R. P. (1975). Who decided that was the problem? Two
stages of responsibility for applied behavior analysts. In W. S.
Wood (Ed.), Issues in evaluating behavior modification (pp.
195-214). Champaign, Ill.: Research Press.
Horacek v. Exon, Civ. No. 72-L-299 (D. Neb., Aug. 6, 1975)
(consent decree).
References Inmates of Boys' Training School v. Affleck, 346 F. Supp. 1354
(D.R.I. 1972).
Association for Advancement of Behavior Therapy. (1977). Eth- In re Jones, 338 F. Supp. 428 (D.D.C. 1972).
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CHAPTER 12
Community Intervention Guided

by Theoretical Development
Clifford R. O'Donnell and Roland G. Tharp
Introduction Whether behaviors learned in an intervention setting

will occur in other settings depends on the charac-
In the first edition of this Handbook we authored a teristics of the settings. Knowledge of these charac-
chapter entitled "Community Intervention and the Use teristics is required to accurately predict transfer; and
of Multidisciplinary Knowledge" (O'Donnell & this knowledge is required to influence the next setting
Tharp, 1982). Our purpose was to suggest a redirection so as to facilitate the occurrence of the desired behav-
in the community applications of behavior modifica- iors. Using behavioral principles, there have been few
tion. We reviewed the considerable accomplishments attempts to analyze the settings of everyday life. But
of community applications of behavior theory in a vari- the understanding of everyday settings has indeed been
ety of different settings, especially in the home and enriched by methods and concepts from other disci-
school. Next, we observed the limits of these accom- plines. An integration of these concepts with behav-
plishments, and two factors were identified as crucial ioral methods in community interventions is not only
barriers to advances in knowledge and practice: (1) the possible, it is crucial for further advance in community
lack of knowledge as to how generalization and main- study and community intervention. Such an integra-
tenance of behavior change may be arranged, and (2) tion does not imply a devaluation of behaviorally de-
the lack of knowledge about everyday settings them- rived strategies. Those other disciplines, whose con-
selves. We suggested that the methods and concepts of structs contribute illumination to the analyses of the
other disciplines are required to overcome these limita- settings of everyday life, do not themselves contain
tions and provided examples of the contributions of prescriptive heuristics. In effect, the task is to incorpo-
some of these methods and concepts. We argued that rate the behavioral means of influence within the con-
this multidisciplinary knowledge provides links with ceptual context of the everyday settings in which we
behavioral methods and thus potentially extends the live.
potential of community programs. Seven years later, Progress on this task can be facilitated best by the
we continue to believe that resolution of generaliza- development of an integrated theory to guide commu-
tion/maintenance problems requires knowledge of nity intervention. The purpose of this current chapter is
everyday settings. to contribute to the development of that theoretical
knowledge. The diversity of interventions, the variety
Clitford R. O'DonneU and Roland G. Tharp • Depart-
ment of Psychology, University of Hawaii at Manoa, Honolulu, of settings for community action, and the diversity
Hawaii 96822. among community and behavioral psychologists' in-
251
tellectual allegiances have all impeded progress to- addressing the basic unit of analysis for community
ward a systematic articulation of crucial theoretical psychology. This will be followed by discussions of
and intervention concepts. Our current effort is per- the process, outcome, and of the implications for com-
haps less that of integration than one shaped step to- munity intervention. We conclude that all types of ef-
ward an integration. fective intervention must affect activity directly by
Our effort has been influenced by the historical fig- changing the components of a target activity setting or
ures and developments in behavioral community psy- indirectly through the macrosystem that is its context.
chology in which we ourselves have played some role. The development of a particular intervention strategy
The more interesting contribution of this chapter, how- should be based on the selection of one of these goals.
ever, may well be the analysis of those writers who
have had the most direct influence on the non-
behavioral concepts presented below: Roger Barker, Unit of Analysis
Urie Bronfenbrenner, and Lev Vygotsky. Barker's de-
velopment of ecological psychology is, of course, a If community psychology is to become a mature
major contribution toward the theoretical considera- field of study, the fundamental challenge is to identify
tion of behavior within a larger system (Barker, 1960; our basic unit of analysis. That unit must meet at least
1968). It is also noteworthy that one of the first at- three criteria: (1) it must encompass objective features
tempts to link behavior analysis was with Barker's the- of setting; (2) it must contain traditional psychological
ory (Rogers-Warren & Warren, 1977; Willems, 1974). aspects of behavior and experience; and (3) its scope
Another major contribution is the work of Bron- must be greater than the individual person, by treating
fenbrenner's ecological theory of human development interactional, social, or community phenomena as fun-
(Bronfenbrenner, 1979). His work has been highly in- damental. The existence of such a unit can be inferred
fluential in developmental psychology, especially in from the overlap among the concepts proposed by pre-
relation to parenting and prevention of child maltreat- vious theoreticians, even though they have discussed it
ment (Belsky, 1980; Belsky & Vondra, 1987). with different terms and with different emphases.
Vygotsky's recently translated work has generated an One of the first proposals for a basic unit was the
extraordinary efflorescence of theoretical and practical behavior setting, as discussed by Barker and his fol-
work in developmental theory, particularly on the in- lowers. The behavior setting is specified by parameters
terface between cognitive development and social proof time and place. In a behavior setting, people are
cesses. This interface has been illuminated by a series engaged in molar behaviors coordinated by a general
of papers by Rogoff and her associates (e.g., Rogoff, activity, such as attending a regular club meeting,
1982; Rogoff & Gardner, 1984; Rogoff, Gauvain, & working in an office, or playing a weekly game of
Ellis, 1984), who have brought the developmental con- summer baseball. The physical features of the behav-
cerns ofVygotsky into conjunction with the contextual ior setting are designed to support the molar behaviors.
analyses of several ecological and community psy- Studies of behavior setting variables have found them
chologists, including Barker, Gibson, and Bron- particularly useful for the analysis of participation and
fenbrenner. Rogoff's focus has been primarily on is- commitment of the people in the setting (O'Donnell,
sues of cognition and cognitive development. In the 1980). This unit has been remarkably productive, even
present chapter, these same conjunctions are used to though it analyzes at the objective level, with little or
address issues within contextual studies themselves, in no treatment of subjective experience.
order to create a more differentiated theoretical struc- O'Donnell (1980, 1984) has proposed to expand the
ture for community psychology. basic unit by adopting the features of the behavior set-
These contributions have also influenced the defini- ting, but expanding the dimensions of concern. His
tion of community psychology that we wish to use microsettings are those in which one can have personal
toward the development of theory to guide interven- contact with the majority of people. Examples include
tion. Our working definition for this purpose is that most schools, homes, gatherings of social groups,
community psychology is the study of the shared ac- stores, and places of work (O'Donnell, 1984, p. 502).
tivity, beyond the capability of a single individual, that O'Donnell's discussions of the microsetting include
occurs through social interaction in specific settings the objective features of the behavior setting, but adds
and the context of these settings within a larger system. such dimensions as skill levels, social role, and social
Our chapter will follow from this definition by first network analyses. The microsetting concept exists in
CHAPTER 12 • COMMUNITY INTERVENTION 253
contrast to the macrosetting that explicitly acknowl- congruent with everyday modes of analysis. For exam-
edges the larger community context in which the basic ple, the life of a school can be described in terms of its
unit of analysis exists. activity settings. Examples of activity settings for stu-
Bronfenbrenner's influential developmental theory dents would include whole-class settings, laboratory
also includes a layering of units by size and scope partnerships, cooperative learning small-groups, de-
(macro-, exo-, meso-, and microsystems). His systems bates, and drama rehearsals. Activity settings for adult
are categorically phenomenological and are described members of school organizations include faculty com-
from the position and point-of-view of the developing mittees, peer coaching groups, workshops, individual
individual. The microsystem, defined as "a pattern of teacher consultation by outside experts, grade-level
activities, roles, and interpersonal relations experi- committee meetings, or curriculum revision groups
enced by the developing person in a given setting with (Tharp & Gallimore, 1988; Tharp & Note, 1989).
particular physical and material characteristics" As can be seen from those examples, it is common
(Bronfenbrenner, 1979, p. 22), is highly similar in its for activity settings to be nested. That is, depending on
structural elements to the concept of behavior setting. the purpose of analysis, one may consider a single
However, the concept of microsystem was designed classroom as an activity setting, or, for finer grained
for analysis of human development, and so empha- analysis, several activity settings can be identified as
sizes the impact of the context on the developing operating within, or nested within, the class-the
person. teacher-led small discussion group, the student clean-
Recently, a fourth nominee for the basic unit has up committee, the worktable for map drawing. In the
emerged from the neo-Vygotskian movement in devel- actual community, these levels sometimes operate in
opmental theory. The activity setting is both phe- such smooth integration that boundaries are not dis-
nomenological and objective. As discussed by cernible; but in other instances, the activity setting can
Vygotsky (1981), and contemporary writers such as reform into nested components with sharp demarca-
Leont'ev (1981), Wertsch (1985a,b), Tharp and Gal- tions, as when the whole cooperating third-grade
limore (1988), and Tharp and Note, (1989), activity classroom adjourns the rehearsal of its Thanksgiving
settings are events in which collaborative interaction, Pageant and begins its science lab groups.
intersubjectivity, and assisted performance occur; they This "nestedness" is characteristic of all communi-
incorporate cognitive and motoric action within the ty institutions, and, indeed, as the community is nested
objective features of the setting (Tharp & Gallimore, within the larger context, all microsettings can be seen
1988). The activity setting differs from both the behav- as nested within macrosettings, which themselves are
ior setting and the microsystem in that the activity is ultimately nested in the concept of the planet Earth.
specific, rather than general-indeed all of the partici- In our interpretation, the activity setting subsumes
pants are interacting within the same activity. For this microsetting, behavior setting, and microsystem.
reason, there may be more than one activity setting in a These three earlier versions of the unit of analysis have
behavior setting. The activity setting is not dependent each made rich contributions to the study of communi-
on the experience of any given person, but is the social ty psychology. The activity setting concept offers two
process common to the participants from which cogni- major advances by providing more inclusive internal
tion develops. The activity setting is the unit in which analysis of processes, and by a more explicit insistence
the development of cognitive processes and structures on the unity of setting, action, and experience. This
of meaning occur, and are therefore the units by which activity setting offers a context for the integration of
community and cultural life are propagated. individual psychology within community psychology.
Activity settings may be described in terms of the However, the activity setting concept-as explica-
who, what, when, where, and whys of everyday life in ted to date-has two clear limitations. The neo-
school, home,community, and workplace. These fea- Vygotskians have not yet provided enough analysis of
tures of personnel, occasion, motivations, goals, its relationship to macrosetting (although it is certainly
places, and times are intertwined conditions that to- philosophically commensurate with such an analysis).
gether comprise the reality of life and learning. Be- Second, the activity setting can be enriched by the
cause social science and psychological practitioners incorporation of some features of traditional Western
have typically separated these features, the activity social science, such as social networks, skill levels,
setting concept requires some practice before its use is and social role concepts. Whether or not these con-
comfortable. However, the activity setting concept is cepts can be made to fit comfortably within the activity
setting unit remains to be seen. Tharp and Gallimore share this motivation, but they are not there by acci-
(1988) have had some success in wedding activity set- dent. They are there as a function of the opportunities
ting concepts with those of Western behaviorism, as and constraints of the ecocultural niche in which every
will be discussed below in the section "Means of As- social group lives and to which it adapts (B. Whiting,
sistance." We provisionally propose the activity set- 1980;B. Whiting&J. Whiting, 1975; Weisner, 1984).
ting as the basic unit of analysis for community psy- These opportunities and constraints can include ways
chology, and in the discussion to follow will attempt to to earn a living, obtain an education, family size, and
relate this unit more clearly to its macrocontext and to rules regarding co-residence, the division of labor by
enrich it by introducing some social science con- age or gender or other ways, religious beliefs and prac-
structs. Will the fundamental assumptions of the two tices, and the norms of the social and political affairs of
traditions mesh without clashing? If so, sharp ad- community life, or many others-all of which serve to
vances in community studies may be possible. motivate the molar behavior of the people in the setting
(Tharp & Gallimore, 1988). However, the organiza-
tion of motives within an individual and within the
Process Analysis
society need not be isomorphic. Portions of an activity
Activity settings may be analyzed in terms of six may be more motivating for one individual than an-
components: a physical environment, time, funds, other, and neither may rank the motive as highly as
positions, people, and symbols. These components are other members of the society or even other members of
the resources among which the activity of the setting is the same activity setting (Leont'ev, 1981; Minick,
generated, maintained, and centered. 1985).
In ordinary community, family, and work life, ac- These people are sources of support, information,
tivity settings exist in a physical environment, are pat- labor, specific skills, and access to other settings.
terned in time, and are supported by funds. Board There are opportunities to learn, develop, and display
meetings are scheduled in the boardroom at particular one's skills. In doing so, one uses the social resources
intervals; tournaments of the chess club occur in the of others and provides these resources for them as one
pavilion only on first Saturdays; the float-building participates in the common activity. The acquired in-
committee works only during December; father and formation, developed skills, and social contacts then
son gather their fishing gear to go fishing at the beach become potential resources for each individual to use
as Sunday dawns. Even though obvious, it is worth and provide in other settings.
attending to the variety of schedules; they may be vir- Finally, there are the symbols. Symbols, including
tually permanent, as in the Sunday worship services of language, reflect the meaning of the activity setting.
the community church, or once may suffice, as when The understanding, explanation, and meaning of the
the congregation raises a new roof over the sanctuary. activity are a part of why activity settings exist and
In everyday life, activity occurs as often and for as long continue. A child who is to participate fully in schol-
as the purpose requires and the resources allow. Re- arly activities must eventually come to share many of
hearsals of the play end when the play is on the boards; the motives of the social system of the school and the
when the stage is struck, the cast stops meeting, even larger sociocultural system that organizes the school
though they may all regret the loss of the society (Leont'ev, 1981; Minick, 1985). The socialized child
(Tharp & Gallimore, 1988). must come to share the cultural meaning of the interac-
Positions are occupied by people with specific roles. tion within the major activity settings of a society
A role refers to a pattern of behavior that is expected of (Cole, 1985).
the person occupying a particular position in the set- All of these components are integral to the activity
ting and that is expected of the others toward that per- setting. The activity cannot exist without each, as
son (cf., Bronfenbrenner, 1979, p. 85). Through these these components form the activity setting in which
expectations, roles serve to coordinate the use of the interaction occurs.
resources of a setting. The coordination of these re- The task of science is to lay some analytic template
sources directly affect the activity. over the raw stuff of events and to describe the reg-
The activity itself is, of course, conducted by ularities observable through the template. In examin-
people. The primary motivation of those who have ing the complex processes in the life of communities,
organized the activity setting is to accomplish their several templates could be used-those that isolate
goals. Other persons present in the setting may not physiological processes, or cognitive processes, or
semiotic processes, or phenomenological processes. tal health reports among older women returning to col-
The crux of this chapter is that another template is lege, a lower rate of angina pectoris among men, and a
crucial for community psychology because it identifies faster recovery and lower death rate from myocardial
the process in which we intervene directly, and is infarction (O'Donnell & Tharp, 1982).
therefore the stuff of our profession. Even if we are Finally, the interaction that occurs in the coordina-
ultimately interested in aspects of human development tion of activities provide opportunities to learn the per-
that involve cognitive, semiotic, or even physiological spectives of others. Cognitive development occurs as
processes, we must act first on that other level. That conflicting perspectives are integrated with one's own
process, foundational for community psychology, is (Piaget, 1948). Adolescent peer groups, for example,
the process of human interaction. provide members with information that must be inte-
grated with that received from parents and teachers to
Interaction. Interaction is the heart of the activity develop their own perspectives. Cognitive develop-
setting. Organized activity cannot impact on commu- ment can also occur when people interact to resolve
nity development in the absence of human interaction. conflicts within the setting. The work of Perret-Cler-
Even the individual working alone, however cre- mont (1980) suggests that this occurs because the reso-
atively, must introduce the fruit of his or her labor to lution of conflict often requires the construction of a
others to influence community development. There- system that can coordinate different ideas. She con-
fore, activity settings always require interaction. ducted several experiments with children on the con-
This interaction in the course of the activity is de- servation of liquid, number, and length, showing how
signed to achieve the goals of the setting. In the prosocial interaction affected the process of cognitive
cess, relationships among people are formed and the structuring resulting in individual cognitive change.
behavioral development of the participants is affected. Emphasizing the central importance of social interac-
For example, interaction has been shown to influence tion in the development of intelligence, she concluded
academic performance, attitudes toward school, that "rooted in biological structures, put to work by the
choice of field of study, delinquency, employment, individual, intelligence itself also appears to be, in
and various personal problems (O'Donnell & Tharp, essence, thefruitofcommunity(p. 179)" (O'Donnell,
1982). How interaction provides the opportunity for 1984, pp. 507-508).
behavior development can be illustrated by consider-
ing social skill, stress reduction, and cognitive change The Pattern of Reciprocal Participation. If
(O'Donnell, 1984). interaction is the key process for social and cognitive
Social skills smooth transactions among people and development, it is also true that interaction with people
facilitate the formation of relationships. Children learn who are more expert in the use of material and concep-
social skills by observing others modeling the appro- tual tools is the most productive form of interaction
priate behavior and being reinforced for it. Preschool (Cole, 1985; Rogoff & Gardner, 1984; Tharp & Gal-
children reinforce specific behaviors (Lamb & Rook- limore, 1988). What is desired is a pattern of reciprocal
arine, 1979), young children imitate the behavior of participation in which each person may both assist and
older children (Abramovitch, Carter, & Lando, 1979), be assisted in the course of the activity. As Bron-
and less dominant children imitate and seek the ap- fenbrenner has noted, this pattern not only fosters the
proval of those who are more dominant (Savin- acquisition of interactive skills, but also stimulates the
Williams, 1979). Interaction with peers is particularly development of the general pattern of interdepen-
important for children to learn the skills necessary to dence, both as a habit of action and as a presumption
control aggression (Hartup, 1979). for problem solving. Thus, interdependency is an
Social skills may also help to reduce stress by mak- important step in cognitive development.
ing the stressful situation a shared experience. Stress Reciprocity also "generates a momentum of its own
can be reduced by using the information, labor, and that motivates the participants not only to persevere
specific skills of other participants to cope with the but to engage in progressively more complex patterns
stressing situation, as, for example, when students of interaction, as in a ping-pong game in which the
with poor study skills benefit by studying with others exchanges tend to become more rapid and intricate as
(Johnson, 1980, p. 131). Social support has been asso- the game proceeds. The result is often an acceleration
ciated with fewer reports of illness following job loss, in pace and an increase in complexity of learning pro-
a lower rate of depression among women, better men- cesses" (Bronfenbrenner, 1979, p. 57).
From the point of view of the child's development, In community psychology interventions, the design
there is a declining proportion of adult responsibility of activity settings in which these exchanges and re-
for task performance, and a reciprocal increase in the ciprocities of assistance occur is a challenge to the
learner's proportion of responsibility. Bruner discusses consultant, a topic to which we will return in the dis-
this reciprocal shift as the "handover principle" -the cussion of intervention below.
child who was a spectator is now a participant (Bruner,
1983, p. 60). The child can begin to use language
exchanges with the adult to provoke assistance.
Outcomes of Participation in an
Wertsch has provided an extensive example drawn
Activity Setting
from joint puzzle solving by an adult and child. The
Several outcomes can be expected of expanded par-
child assists the adult to assist by asking for strategic
ticipation in well-functioning activity settings. These
direction, for example, "Which part do I do next?"
outcomes are aspects of normal process and are reli-
(Wertsch, 1979, p. 19).
able consequences of well-articulated, nested activity
At each stage, the developing child contributes to
settings in ordinary communities. When, through
the success of an activity. Asking for strategic direc-
community interventions, activity settings are brought
tion is, in this sense, no different than the infant's cry
closer to this norm, improvements in these aspects will
that makes locomotion possible. In both cases, the
be the outcome.
child's partial performance provokes adult assistance,
We can consider these improvements in two aspects.
thus permitting an achievement not possible without
In everyday terms, we can say to a participating com-
the collaborating other.
munity member that there will be improvements in two
Reciprocities of assistance also occur in virtually all
ways: who you know, and who you are. And those are
settings of joint productive activity, whether the
two facets of the same unity.
groups consist of adults, children, or mixed age
groups. That is, because any group of people will have
somewhat different skills, strengths, or weaknesses, Who You Are and Who You Know: A
and as long as the group is driven by a common pro- Reciprocal Relationship
ductive goal, each will contribute skills and assist oth- As presented, settings are sites for activity in which
ers, while receiving assistance in areas where the skills human interaction is supported by the available re-
of others are superior. In cooperative learning settings sources. In the course of this activity, participants ac-
in schools, for example, it is common that students quire and develop specific behaviors and initiate and
pool their knowledge and together construct solutions maintain social contact with other participants. Both
to problems. Although no one member can perform a their behavioral repertoires and their social networks
certain task alone, the group, by assisting one another, are affected. The reciprocal nature of the relationship
can elevate the performance to a point further along the between behavioral repertoires and social networks is
developmental path. Furthermore, individual skills rooted in the common seed of activity.
vary by task, so that the "expert" mathematics student The repertoire contributes to successful participa-
in the class may be assisted by an entirely different tion in the activity, participation establishes rela-
"expert" in an art project (Champagne, 1985; Tharp & tionships with others, and these relationships and skills
Gallimore, 1988). provide access to new settings. Participation in the
Nevertheless, in some activities, and for some por- activities of new settings offers the opportunity for the
tions of all activities, some participants are more influ- continued development of both networks and reper-
ential than others. This dimension is important for de- toires. They are the product of activity and, through
velopment in several respects. For a young child, their reciprocal relationship, they germinate new
participation in interaction activities.
Behaviors influence social relationships and these
provides the opportunity for learning both to conceptualize and relationships affect the development of behaviors. In a
to cope with differential power relations. Such learning contrib- review of peer interaction through the life span, Norris
utes simultaneously to cognitive and social development, since and Rubin (1984) found that peers promoted compe-
power relations characterize physical as well as social phe- tent social functioning and that the most important
nomena encountered by the growing person in a variety of eco-
logical settings throughout the life span. (Bronfenbrenner, 1979, component of social functioning was a large behav-
pp.57-58) ioral repertoire used with sensitivity to the social con-
text. In addition when either behaviors or relationships blend one's behavior with the ongoing social interac-
change, the other is likely to change in a consistent tion, (2) initiating and responding positively to others,
direction (O'Donnell, 1984, p. 262; O'Donnell & and (3) a willingness to enter situations indirectly and
Tharp, 1982, pp. 305-308). at an appropriate pace. Family activities that promote
As noted, changes in behaviors and relationships these abilities may be particularly helpful in facilitat-
occur in the activities of settings. The process of ing positive peer relations.
human interaction during these activities is responsible In contrast, families increase the risk of their chil-
for such changes. Behaviors are altered when this in- dren's antisocial behavior through child neglect and
teraction takes the form of assistance. This same pro- may actively support it through child abuse. Ineffec-
cess alters social relationships. Through participation tive supervision is the variable most associated with
in the activity of a setting, the development of social delinquency (Wilson, 1980) and may be the reason
relationships is facilitated. Participation depends on that youths in mother-only households are more likely
the availability of setting resources to provide needed to engage in deviant behavior (Dornbusch et al.,
assistance. When people participate in the activity, 1985). Lack of parental support is associated with
they report a greater sense of obligation and responsi- greater peer orientation and more deviant behavior
bility to others in the group thereby strengthening their (Condry & Siman, 1974; lessor & lessor, 1977). Not
ties to these group members (O'Donnell, 1980). The surprisingly, the least amount of delinquency is found
strength of these ties serves to motivate the behaviors in settings supervised by adults (H. Schwendinger &
supportive of the activity and to discourage deviant 1. Schwendinger, 1982).
behavior (Ekland-Olson, 1982). Morton (1987) has described how activities in prob-
The reciprocal nature of the relationship between lem families can teach children to use coercive behav-
behaviors and relationships has been studied most iors. The marital hostility of parents has been linked to
often among peers. In a review of peer relations, Har- the aggression of their sons and child abuse to child-
tup stressed the importance of the link to the family: hood aggression (Belsky & Vondra, 1987). If these
youths eventually come into contact with the juvenile
secure family relations are the basis for entry into the peer system justice system or are referred to delinquency preven-
and success within it. Family breakdown tends to interfere with
adaption to the peer culture, and good family relations are needed tion programs, they are more likely to develop rela-
throughout childhood and adolescence as the basis for peer relationships with other antisocial youths and to maintain
tions. (Hartup, 1983, p. 172) their problem behavior (O'Donnell, Manos, & Ches-
ney-Lind, 1987).
Several studies have begun to document how ac- Taken together, these studies suggest that the ac-
tivities in family settings can influence peer behavior quisition of socially competent behavior by children
and relationships. A study of parent-child interaction may be facilitated by activities with their parents and
and social competence with preschool peers found that that these socially competent behaviors promote pro-
social peer relationships. In contrast, marital hostility
differential patterns of maternal and paternal behavior were asso- and child abuse facilitate acquisition of aggressive be-
ciated with the social competence of boys and girls. Paternal
physical play, engagement, and maternal verbal behavior were haviors, neglect promotes peer orientation and deviant
positively related to children's peer relations, especially for behavior, and both make relationships with other anti-
boys. Paternal directiveness was negatively related to popUlarity social youths more likely. In this example, behaviors
for boys and girls, while maternal directiveness was positively
linked with popularity for girls. (MacDonald & Parke, 1984, p. and relationships are reciprocal and are rooted in the
1265) common seed of activity with parents.
In summary, behavior and relationships form a cycle
Overall, the promotion of social competence appears linked by activities in which who you know leads to
to be of key importance. Children who lack compe- who you are to who you know, until who you are is
tence and engage in inappropriate behavior are more who you know.
likely to be rejected or neglected (Dodge, 1983),
whereas competent youths may be more able to cap-
Who You Are Is Who You Know:
italize on their opportunities to cease problem behavior
Intersubjectivity
(Mulvey & Aber, 1988).
Asher (1983) noted three dimensions of social com- Duringjoint productive activity, participants tend to
petence of particular importance: (1) the ability to develop more differentiated and pronounced feelings
toward one another. To the extent that they are positive nal of a failure of intersubjectivity. One may argue as a
and reciprocal, they are likely to enhance developmen- corollary that deviant, alienated, nonparticipating
tal processes (Bronfenbrenner, 1979). This affective members of a community almost certainly signal a lack
dimension is one aspect of intersubjectivity, in which of intersubjectivity with the larger unit that defines
individuals come to share "planes of consciousness," them as deviant. They do not define the situation in the
higher-order mental processes, and systems of value same way, do not accept the same process for problem
and meaning. The development of intersubjectivities solving, do not have the same goals or values, and do
is a consequence of profound importance for indi- not accept each other on the same basis.
vidual development, for a satisfying community life, In joint productive activity settings, intersubjec-
and for the perpetuation of culture. tivities are created. Who you are-the intramental,
Intersubjectivity refers to the way that a group of cognitive, value-laden selthood-arises in the social
people think and experience the world in similar basic plane, and is made individual through the processes of
dimensions, processes, and content. To the degree that communication and shared activity. To a major extent,
intersubjectivity is present, that values are alike, and each of us psychologically becomes those people with
that goals are alike, then more cooperation is possible, whom we work, talk, share, and grow. Through the
and thus more harmony. One of the joys of life is the processes of intersubjectivity, culture and cognition
achievement and the experience of intersubjectivity. create each other (Cole, 1985) and community and
And over the long course, productivity (of a group, of a individual create each other.
community, or of an entire culture or nation) will rise
and fall as does intersubjectivity. The intersubjective
dimension of joint activity serves as a reward to its Intervention
members, for it is this aspect to the process which
makes activities memorable, worthwhile, and gratify- Community intervention begins with a desire to
ing to group members, and which motivates members change or create one or more activity settings. In prin-
to continue participation within the group (Tharp & ciple, these "target" settings can range from a single
Note, 1989). classroom to the culture of an entire nation. Regardless
Intersubjectivity is created during joint activity, of the scope of intervention, the purpose is the same: to
through (1) the use of signs and symbols-primarily of affect the interaction among people. It is this interac-
language, (2) the development of a common under- tion that results in behavioral and cognitive develop-
standing of the purposes and meanings of the activity, ment, that sustains human relationships, that fulfills
and (3) the use of common cognitive strategies and setting goals, and that creates the shared meaning of
problem solving. During joint productive activity, intersubjectivity. To affect interaction is to affect ac-
signs and symbols (principally language) are used by tivity settings, for that is where all organized interac-
more knowledgeable members as they assist novices. tion takes place. The foci of community intervention
Peers themselves develop word meanings and dis- are activity settings, both the target activity setting
course routines during their cooperative work. The at- itself, and those that surround it in the context of the
tachment of these symbols to shared events creates a larger community.
plane of meaning and value for activity and a discourse Figure 1 presents an abstract diagram of a targeted
that becomes the binding structures of community life activity setting. The figure portrays the target setting's
and culture. In joint activity-for example, the signs component parts, as well as the larger context in which
and symbols developed through language, the devel- it lies.
opment of common understanding of the purposes and The component parts of an activity setting are pre-
meanings of the activity, and the joint engagement in sented as (1) physical resources, (2) funds, (3) time,
cognitive strategies and problem solving-all these (4) symbols, (5) people, and (6) positions, centered
aspects of interaction influence each participant and around the activity of the setting. The activity and
foster emotional and cognitive commonality. In new these resources constitute the activity setting. The ac-
activity settings, new intersubjectivity is created and, tivity is influenced through the use of these compo-
for individual members, is internalized into a new cog- nents. Therefore, any direct effect on the target activity
nitive development. setting must be through some intervention on these
Most problems in communities provide a clear sig- resources. In the section below, entitled "Conditions
Authority Activity Settings
Policy Perimiter
I
Resource
Positions
"'"
I
Funds
Physical
, / Resources
Activity Target Activity Setting
Settings
I ~ Time
/ pre
Symbols./"
Constituent Activity Settings
Figure 1. The target activity setting in context.
of Assistance," we will discuss examples of interven- tings. Examples are meetings of school alumni or par-
tion in several of these components. For now, how- ents of the children who attend a certain school. Final-
ever, it should be observed that it is also possible to ly, external resource activity settings are all of those
affect the target activity setting indirectly, through settings that have resources that could be obtained for
other activity settings of the context, which will affect the use of the target activity setting. Examples range
the "policy perimeter." from television production studios through child care
The policy perimeter is formed by the balance of the centers to workshops that manufacture products
activity within the setting and the pressures from the needed in the target activity setting.
other settings in its context. The policy perimeter Target activity settings may be affected by many
serves to guide and limit the activity and its use of points of intervention. These points are the levers of
resources. This perimeter should be thought of as a intervention and are depicted by the arrowheads in
permeable membrane that defines the activity setting Figure 1.
from its context and limits the conditions, rules, and As may also be seen in Figure 1, the activity can be
possibilities of the setting, but through which mutual affected directly only through alteration of the resource
influences and components flow. components within the target activity setting. The con-
The context of the target activity setting may be textual settings, however, may serve to influence the
thought of as consisting of other activity settings. policy perimeter and thereby indirectly affect the
These other settings link the target activity setting to its activity.
macrosetting and are of four types: authority, parallel,
constituent, and external resource. Authority activity
Models and Tactics
settings sanction the existence of activity settings.
They may do so by implementation of laws, rules, Several forms of intervention are available to the
regulations, directives, or the authorization of the use community consultant. There are three general models
of specific resources. Parallel activity settings are of intervention, and three general tactics of interven-
those with activities or purposes similar to those of the tion. Table 1 organizes the specific forms of interven-
target setting. Constituent activity settings are those in tion as cells where models and tactics intersect. The
which interaction takes place among those people who form of choice depends on the task of intervention. For
benefit from the target (and its parallel) activity set- example, consultation is the model of intervention
Table 1. Forms of Community Intervention

Models
Tactics Consultation Coordination Creation
Cooperation Working with a target activity Linking with a resource ac- Forming a new resource ac-
setting to assist it tivity setting to assist a tar- tivity setting(s) to assist a
get activity setting target setting
Competition Working with parallel activity Linking with a parallel ac- Forming a new parallel ac-
setting to challenge a target tivity setting to challenge a tivity setting to challenge a
activity setting target activity setting target activity setting
Confrontation Working with a constituent Linking with a constitutent Forming a new parallel ac-
activity setting to oppose a activity setting to oppose a tivity setting to oppose a
target activity setting target activity setting target activity setting
Cooperation, competition Working with an authority ac- Linking authority activity set- Forming a new authority ac-
or confrontation tivity setting to assist, chal- tings to assist, challenge, tivity setting to assist, chal-
lenge, or oppose a target or oppose a target activity lenge, or oppose a target
activity setting setting activity setting
used to direct an existing target activity setting toward The first step in this intervention is an assessment of
an improved goal. Coordination is the model of inter- the process, means, and conditions of assistance in the
vention that links existing activity settings; and cre- setting. The process of assistance refers to the current
ation is the model of intervention that seeks to form a status of assistance in the setting, who may need it,
new activity setting. who may not, who may be able to provide it, and
The purpose of the intervention dictates the tactic. whose performance may be harmed by assistance.
The three general tactics of intervention are coopera- Means refers to the ways that assistance may be pro-
tion, competition. and confrontation. Cooperation is vided, and conditions to those factors that influence
used to assist a target activity setting, competition to whether assistance is likely to occur.
challenge it, and confrontation to oppose it.
Since activity may be directly affected only within
Process of Assistance: The Zone of Proximal
the setting, cooperative consultation is the only direct
Development
form of community intervention shown in Table 1. All
other combinations of models and tactics are attempts A central tenet ofthe theory of Lev Vygotsky is that
to influence a target activity setting through a context development cannot be understood by studying any
activity setting. Typically, authority activity settings individual alone. The external social world in which
are the most effective means of doing so because of that individual life has developed must also be under-
their supervisory function and their ability to organize stood. That is because cognitive and communicative
parallel, constituent, and external resource activity set- skill appears "twice, or in two planes. First it appears
tings. However, the focus of this chapter is the target on the social plane, and then on the psychological
activity setting, and so we will examine the levers of plane. First it appears between people as an inter-psy-
intervention available to directly affect activity chological category, and then within the child as an
through cooperative consultation. intra-psychological category" (Vygotsky, 1978, p.
163). Through participation in activities that require
cognitive and communicative functions, learners are
Cooperative Consultation
drawn into the use of these functions in ways that nur-
Activity is designed to achieve the goals of a setting ture and assist them. In this way, the social processes
and, therefore, is the target of intervention. As noted in that are nurtured and assisted are internalized later, and
the discussion of process, the most productive form of become higher-order cognitive processes. Social prob-
interaction is a pattern of reciprocal participation in lem solving becomes an individual's problem-solving
which each person may both assist and be assisted in heuristic.
the course of the activity. The task of the consultant is These social processes occur in the zone ofproximal
to facilitate this pattern in the target activity setting. development-that phase in the development of an ac-
Recursive Loop
I
Capacity Capacity
Begins Developed
ZONE OF PROXIMAL DEVELOPMENT

.. 1
Assistance Provided by Assistance Internalization Recursiveness through
More Capable Others: Provided by prior stages
theSel! Automatization
Consutlants or Mediators
(De·Automatization)
Parents Teachers Mastery
Experts Peers
TIME---- STAGE I STAGE II STAGE III STAGE IV
Figure 2. The zone of proximal development: The four stages.
tivity where it is only partially mastered, but can be time, it may require assistance once again. Likewise,
performed with the assistance and supervision of a what at one time relied solely on self-assistance may
more capable other-a consultant, a parent, a teacher, regress to require assistance provided by others. Stage
a more capable peer. By one or more of the means of IV illustrates this recursiveness (Tharp & Gallimore,
assistance, the assistor structures the solution to the 1988; Tharp & Note, 1989).
problem, engages the learner in the process, and man-
ages modeling and contingencies to strengthen and
shape competence. Thus, social interaction with Means of Assistance
people who are more expert in the use of material and
conceptual tools is the vehicle for the creation of cog- Most behavioral interventions, at the individual or
nitive processes (Cole, 1985; Rogoff & Gardner, 1984; community level, employ one or more of six means of
Tharp & Gallimore, 1988). assisting performance and facilitating learning. Six
The Zone of Proximal Development has been de- have been studied with enough breadth and time that
scribed in terms of four stages (see Figure 2) (Tharp & the effects are known and dependable (Tharp, 1984;
Gallimore, 1988). In Stage I, the learner requires, in Tharp & Gallimore, 1988, Tharp & Note, 1989). The
order to perform, assistance from more capable others. consultant's task is to arrange situations in such a way
Through this assistance, the learner can perform at a that some of those six means of assistance are brought
higher level than if performing alone. In Stage II, as to bear:
the learner increases in ability, reliance shifts from
assistance provided by others to assistance provided by 1. Modeling: offering behavior for imitation. Mod-
the self, in the form of self-instructing, self-feedback, eling assists by giving the learner information,
self-reinforcement, and so forth. Gradually, the learn- and a remembered image that can serve as a per-
er ceases to rely on any form of assistance; develop- formance standard.
ment has reached a deeper, more internal level. In 2. Feedback: the process of providing information
Stage III, at the point in which assistance is no longer on a performance as it compares to a standard.
necessary, mastery has been achieved, and the task or Feedback is essential in assisting performance
operation is said to be fully developed or automatized. because it allows the performance to be com-
At this point, assistance can actually interfere with pared to the standard, and thus allows self-cor-
accurate performance, because it interrupts the smooth rection. Feedback assists performance in every
automatic integration. domain from tennis to nuclear physics. Ensuring
However, all learning and development is recursive. feedback is the most common and single most
What was at one point a mastered skill may decay- effective form of self-assistance (Watson &
through forgetting, lack of practice, mental or physical Tharp, 1988).
trauma, or simple aging-so that, at another point in 3. Contingency management: the application of the
principles of reinforcement and punishment to the required degree of assistance? Since assistance
behavior. cannot be sustained without sufficient time and fund-
4. Instructing: requesting specific action. It assists ing in some form, those who would organize activity
by selecting the correct response, by providing settings need to provide for them. The use of time and
clarity, information, and decision making. It is funds can be an effective form of intervention either to
most useful when the learner can perform some facilitate specific tasks or to interfere with them by the
segments of the task, but cannot yet analyze the withdrawal of these forms of support.
entire performance, or make judgments about Roles should also be examined. Since roles are a
the elements to choose. pattern of behavior, it may be possible to redefine roles
5. Questioning: a request for a verbal response that so that the desired behavior is more likely to occur.
assists by producing a mental operation that the Roles are likely structured to facilitate the goals of the
learner cannot or would not produce alone. This setting, not necessarily to elicit specific behaviors.
interaction assists further by giving the assistor Other behaviors may also facilitate the goals of the
information about the learner's developing setting. Therefore, one form of community interven-
understanding. tion is to alter the roles of a setting for the purpose of
6. Cognitive structuring: "explanations." Cog- affecting the activity.
nitive structuring assists by providing explanato- An example of this form of intervention was re-
ry and belief structures that organize and justify ported by O'Donnell and Tharp (1982). In a school for
new learning and perceptions and allow the cre- Hawaiian children, individual performance in re-
ation of new or modified schemata. sponse to teacher initiation and the use of Standard
English was expected of students. In contrast, many
Hawaiian youngsters are much more competent in ac-
Conditions of Assistance
tivities that allow cooperation among peers and ex-
The conditions of assistance are determined by the pression in Pidgin English. They typically performed
components of the activity setting: (1) physical re- more competently at home than they did in school
sources, (2) funds, (3) time, (4) symbols, (5) people, because the student role was composed of behaviors in
(6) positions, and the activity itself. To increase the which the youngsters were less proficient. When other
likelihood of a pattern of reciprocal participation, it is interventions failed to affect academic performance,
necessary to use one or more of the components as a Tharp and his colleagues used an alternative interven-
lever of intervention. A change in the component will tion. In effect, they changed the behaviors expected of
directly affect the activity because the components are those in the student role. By redefining the role to
integral to the activity. The change in the activity can permit the use of cooperative, peer-related behavior
create the conditions for a pattern of reciprocal par- and the use of Pidgin English, competent academic
ticipation. To assess whether assistance is likely to performance dramatically increased and thereby facili-
occur, it is necessary to assess the components. tated one of the major goals of the activity setting.
A critical assessment question is whether in the tar- In some situations, assistance may be inadequate
get activity setting those who need assistance are in despite sufficient contact, time, funding, and appropri-
sufficient contact with those who could provide as- ate role definition. In these cases, it may be that some
sistance. The physical environment may not facilitate people are not needed to accomplish the activity be-
contact among these people. For example, studies have cause there are too many people in the target activity
illustrated how the type and availability of toys influ- setting. The ratio of the number of people to the
ence contact among children, and how puzzles and number of roles has been called the manning level
games do the same among those who are institu- (Barker, 1960, 1968; Wicker, 1973; Wicker,
tionalized. The physical design of a setting has been McGrath, & Armstrong, 1972).
shown to structure the proximity among people. Great- Manning level is a dimension of profound conse-
er interaction occurs among those within enclosed quences for the functioning of activity settings because
space, in more central seating locations, and with of its affect on participation. When there are relatively
shorter functional distances between them (O'Don- few people for the number of roles, the demand for
nell, 1980). participation is greater and the standards for accep-
Is sufficient time and funding available to allow for tance lower. In this undermanned situation, assistance
is likely to be offered to those who need it to encourage One intervention goal would be to ensure that every-
their participation and facilitate the functioning of the one works some of the time with others oflower ability
target activity setting. on some task, ensuring, in effect, that the assisted also
The effects of manning levels have been noted in have the opportunity to assist.
numerous studies (O'Donnell, 1980, 1984; Wicker, As our final example, the consultant can institute
1979). In undermanned settings, people interact more changes in activity settings by intervention in symbols.
and report greater obligation and responsibility to oth- Symbols, particularly language, mediate between so-
ers. In overmanned settings, people are encouraged to cial interaction and cognitive process and content;
withdraw and do not develop a commitment to each semiotic processes that link events with symbols are
other. There is also evidence that social networks are the processes that produce motivation, beliefs, affect,
affected. Lower manning levels have been associated and intersubjectivities. Changes in the symbols
with more friends and stronger relationships (Epstein through which events are understood, or changes in the
& Karweit, 1983; O'Donnell & Tharp, 1982). meaning of those symbols, have been critical to the
If assessment indicates that the target activity setting changes sought by social activists from military con-
is overmanned, the goal of intervention is to reduce the querors through labor organizers to psychoanalysts.
number of people or to increase the number of roles. Changing the way that activities are talked about dur-
The purpose is to influence the activity so that those ingjoint productive activity can change the meaning of
who require assistance are needed or to place them in that activity; and when the meaning is changed, all
other activity settings. other dimensions of that activity will be affected.
A similar situation may exist if there are people who These conditions can be designed to increase the
have greater ability relative to others in the same role. likelihood that the means of assistance will occur and
When there are individuals who are more proficient in thus facilitate performance and learning through the
some behavior, performance by others may not be val- zone of proximal development. In this manner, inter-
ued or needed. Acceptable competency is relative to vention in the design of these conditions can contribute
that which is available. The same performance may be toward a pattern of reciprocal participation within the
valued where it is needed and rejected where others are target activity setting. The following principles and
more competent in the expected behavior. Since it is guidelines are offered to assist the consultant in this
difficult to display competence in situations with more task.
highly skilled people, competent performance from
those needing assistance may be being prevented.
This phenomenon may be partially understood by Principles and Guidelines for
the manning level concept, but we suggest that it is Community Psychology Consultants
often useful to consider the specific behaviors required
by the role and the relative competency of these behav- The real client of any consultation is the social sys-
iors among those who are available for the role, rather tem that has produced the problem. Some interven-
than just the number of people who meet the minimum tions will be too narrowly aimed and will produce no
qualifications. Similar to the manning level of set- permanent improvement unless the sustaining context
tings, roles in which relatively few people in the set- is also assisted to change. The consultant's assessment
ting are highly competent may be considered "under- of the context is designed to analyze the dynamics that
skilled," whereas those in which many people are produce and sustain the problem and to locate the le-
competent would be considered "overskilled." The vers of influence that can bring about some reorganiza-
effects noted in studies of manning levels may also tion.
occur among those in under- and overskilled roles. The ultimate goal of the consultant is to increase the
Those in underskilled roles may be valued, may be self-assistance of the community and the growth or
encouraged to participate and interact more, and may development of its members; but the route to that goal
develop a greater sense of obligation and responsibility is through reorganization of activity settings. Through
to the target activity setting. The opposite would be the processes of interaction and assisted performance
expected of those in overskilled roles; they would be in in activity settings, the targeted community members
less demand, have less influence, and be encouraged to can gain greater competence, skill level, and soli-
withdraw (O'Donnell, 1984). darity. It follows that, for the community consultant,
the basic task of intervention is to design activity teraction of social relationships and psychological
settings. processes.
As we analyze the stepwise process of intervention, 1. Each point of contact among consultant and cli-
however, we should not expect the consultant immedi- ents will be in a specific activity setting. Therefore, the
ately to address the design of activity settings for the consultant must attend to all the components of activity
targeted group. The initial intervention work will be settings-time, people, positions, resources, funds,
with some representatives of the community who have and symbols. The influence of the consultant should be
the influence to bring about change. Ordinarily, then, used to generate or organize those resources.
the consultant will design some first-level activity set- 2. The consultant should participate in at least the
ting whose members will consist of those who can do first-level activity settings and engage in joint produc-
the authorizing, planning, or supporting of the tive activity with them. A goal of this first-level ac-
eventual targeted intervention. The members may in- tivity setting is that the consultant and the first-level
clude representatives of authority settings, constituent representatives develop their own intersubjectivities.
settings, or resource settings; they mayor may not This is an irreducible condition for further effective
include identified victims or offenders or "targets" of consultation.
the intervention, and mayor may not include a preex- 3. A goal of the consultant working in the first-level
isting targeted activity setting. An early task of the settings is to assist their members to build the skills that
community psychologist is to participate with these will enable them to assist the ultimate targets of inter-
members in the joint productive activity of organizing vention. The goal of the consultant is not to become a
these new activity settings. That is, the first task, and permanent member of the activities of the client com-
the task of crucial importance, is that the consultant munity, but rather working in the triadic model (Tharp,
organize first-level activity settings with community 1984; Tharp & Note, 1989), exercise the consulting
members, the product of which is to be the design of effects through mediators who are themselves mem-
activity settings for the correction of the target pro- bers of the settings or of the community context.
blem. 4. Those first-level representatives who themselves
These first-level activity settings may be brief and become active in organizing target activity settings
ceremonial, or they may be continuing and evolving; should participate in those activity settings, engage in
they may range from a 15-minute conversation to a full their joint productive activity, and thus move toward
organizational development workup. But, in each in- that intersubjectivity which will ultimately provide the
stance, the consultant must attend to the principles that community bonding.
make activity settings effective-those principles that 5. Each designed activity setting will have as one
have been the substance of this entire chapter. These part of its goal the fostering of the development of
first-level settings can be seen as the activity settings of some capacity, skill, potential, or cognition. There-
consultation. In some instances, the first-level "plan- fore, each activity setting should have a product as its
ning" settings will be sufficient for assessment of the goal; a product that will be motivating for the partici-
problem, but in many others, specific activities will pants and that will require the use of the capacities that
have to be designed to gain assessment information are the focus of development.
before the "planning" setting can begin to formulate
its intentions.
Whatever the number and layering of the activity Final Comment
settings required before the actual intervention com-
mences, in these first-line settings the community con- In this chapter, we have attempted to contribute to
sultant is part of the interaction process, and must pro- the development of theory necessary to guide commu-
gram his or her own participation according to the nity intervention. We believe that theory cannot be
same principles that describe good activity settings based on a psychology ofthe individual, the situation,
generally. Community consulting cannot be under- or of the interaction of individuals and situations
stood outside its own complex social context, any (Cronbach, 1957, 1975). Instead, individuals, situa-
more than can any other interaction. tions, and interactions must be integrated within a
Following Tharp and Note (1989), we can now sug- common context. Contextual views (Lerner & Kauff-
gest some guidelines for setting up this complex in- man, 1985; Sarbin, 1977) offer much promise for com-
munity psychology and for the development of theo- networks. In S. Spitzer & R. 1. Simon (Eds.)., Research in
ries for principled community intervention. A pattern law, deviance and social control: A research annual (Vol 4,
pp. 271-299). Greenwich, CT: JAI Press.
of reciprocal participation among community theorists Epstein, J. L., & Karweit, N. (1983). Friends in school: Patterns
and consultants would serve to advance this promise of selection and influence in secondary schools. New York:
toward accomplishment. Academic Press.
Hartup, W. W. (1979). Peer relations and the growth of social
competence. In M. W. Kent & 1. E. Rolf (Eds.), Primary
ACKNOWLEDGMENT. This chapter benefited from the prevention of psychopathology. Vol. 3: Social competence in
thoughtful comments of four graduate students in com- children (pp. 150-170). Hanover, NH: University Press of
munity psychology: Susan Hippensteele, Mary Note, New England.
Hartup, W. W. (1983). Peer relations. In P. H. Mussen (Ed.),
Justice Shibayama, and Lisa Watkins. We thank them Handbook of child psychology (Vol. 4, pp. 103-196), New
for their participation and assistance. York: Wiley.
Jessor, R., & Jessor, S. L. (1977). Problem behavior and psycho-
social development: A longitudinal study of youth. New York:
Academic Press.
Johnson, D. W. (1980). Group processes: Influences of student-
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CHAPTER 13
Drugs Combined with Behavioral

Psychotherapy
William L. Marshall and Zindel V. Segal
Introduction Klein (1980) expects independent effects of the com-

bination (i. e. , anti panic effects of drugs while behavior
In recent years, behavior therapists who previously therapy is expected to reduce avoidance and anticipato-
appeared antagonistic to the use of drugs in treatment ry anxiety), whereas others have explored the pos-
(e.g., Davison & Valins, 1968) have softened their sibility of interaction effects (Mavissakalian &
views, and some have become advocates of adding Michelson, 1986).
drugs to behavioral programs (e.g., Telch, 1988a,b). Part of the problem in evaluating this literature,
Medications may be used to induce a state deemed then, is to sort out just what is expected of the com-
essential to a behavioral program (e.g., relaxation pre- bination. Apparently no one doubts that drugs alone
paratory to desensitization), to facilitate cooperation in produce rather high refusal rates (particularly among
behavioral programs (e.g., to reduce a patient's fear of phobics but apparently not among obsessive-com-
exposure to anxiety laden cues), or to deal with aspects pulsives; see Marks, 1983) as well as high dropout
of the patient's problem that behavioral programs do rates, and, in addition, it is well known that upon with-
not successfully affect (e.g., panic or depression in drawal, relapse is to be expected in most cases. The
agoraphobics or obsessive-compulsives). There seems value of combining drugs with behavior therapy is,
to be little interest at this time in the first of these therefore, not limited to the issue of whether or not any
alternatives, although such approaches were popular at therapeutic effects are added in those patients who
one time (see Marshall & Segal, 1986, for a review of comply, but also to the issue of whether or not this
this literature). The second alternative has hardly been combination affects refusals, dropouts, and relapses.
explored at all, whereas combining drugs and behavior Unfortunately, the literature is not very helpful on
therapy in the third alternative appears to be the most these issues, since some of the research has simply
popular approach at present. Actually, the thinking focused on immediate changes in cooperative clients,
that guides this latter approach is at times somewhat although when follow-up data are provided it is pos-
muddled. For example, with the anxiety disorders, sible to infer differential relapse rates. Of course, if
outcome data do not favor the combination, then the
other questions become irrelevant.
William L. Marshall • Department of Psychology, Queen's
Drugs have been used in combination with behav-
University, Kingston, Ontario, Canada K7L 3N6. Zindel V.
Segal • Cognitive Behavior Therapies Section, Clarke ioral programs across a wide variety of disorders, but
Institute of Psychiatry. Toronto, Ontario, Canada M5T IR8 the literature is not sufficiently extensive to justify
267
more than a brief comment on all but the anxiety disor- Another point arising from the consideration of the
ders and depression. We will, therefore, restrict our sex offender literature, which also turns out to be rele-
focus to these disorders, but first let us mention one vant to the research on other drug/behavioral combina-
other area of application in order to illustrate more tions, concerns the nature of the psychological compo-
general issues. nent. As we noted, Bradford is a very sophisticated
It is often assumed that sex offenders are driven to researcher, and this shows in the content and scope of
engage in their deviant behavior by an excess of either his adjunctive behavioral program. He includes vari-
testosterone or one or more of the other sex steroids. In ous procedures (e. g. , covert sensitization, masturbato-
this view, it is understood that reducing the sex drive of ry conditioning, satiation, etc.) to alter deviant prefer-
these men will eliminate their propensity to offend. ences, as well as psychotherapeutic strategies aimed at
Indeed, there is evidence that appears to support the correcting the cognitive distortions of these offenders.
therapeutic efficacy of anti androgen therapy of one As far as we can infer, this is a far more extensive
kind or another (Bradford, in press; M. Laschet & L. behavioral component than those employed by other
Laschet, 1975; Money, 1972). However such evidence clinicians using antiandrogens. Even in Bradford's
may not be so clearly indicative of the value of anti- case, however, his program is far from the comprehen-
androgens as a casual reading may suggest. For exam- sive nature of those espoused by behavior therapists
ple, Berlin and Meinecke (1981), reporting on treat- who specialize in such treatment (Abel, Mittleman,
ment outcome with medroxyprogesterone acetate Becker, Rathner, & Rouleau, 1988; Marshall & Barba-
(Provera) administered to various sex offenders, note ree, 1988). In considering the value of adding drugs to
in passing that all patients also received extensive behavior therapy, it adds little to our knowledge to
counseling and psychotherapy. Similarly, M. Laschet compare the combination with either component
and L. Laschet (1975) mentioned that behavior therapy alone, when the behavioral component does not in-
is used in those cases who are not immediately respon- clude the full range of elements that have been em-
sive to antiandrogens. How many other such clients pirically discerned to be maximally beneficial for the
that routinely combine psychological approaches with problem in question.
antiandrogen treatment remain to be determined, but We now turn to a more detailed analysis of anxiety
the rather casual way in which these two groups of disorders and depression.
researchers report the use of additional psychological
procedures encourages the belief that such combina-
tions are not uncommon. Bradford, one of the most Anxiety Disorders
sophisticated researchers in this field, advised us
(Bradford, personal communication April, 1988) that Until recently, the majority of the research in the
in his clinic those offenders who are at high risk to anxiety disorders that examined the value of combin-
reoffend (e.g., high sex drive rapists, exhibitionists, ing drugs with behavior therapy was confined to the
and child molesters) are likely to be given various be- simple phobias (Marshall & Segal, 1986). With these
havioral procedures in addition to cyproterone acetate. circumscribed fears, anxiolytic agents have been used
Fortunately, Bradford is planning a series of careful within behavioral interventions primarily to facilitate
trials to evaluate the usefulness of this combination as exposure (either by way of graduated desensitization
well as the contribution of each component separately. or by a rapid "flooding" approach). Research interest
Other than Bradford's good intentions, however, the in this particular combination of behavior therapy and
outcome of hormonal treatments alone remains some- pharmacotherapy has waned and so apparently has the
what equivocal. As we will see, the confusion over the clinical use.
appraisal of drug therapy, arising from the fact that all Since this earlier literature has been extensively re-
too often there are almost unmentioned psychological viewed elsewhere (Alford & Williams, 1980; Marks,
treatments added to the medication, reappears with the 1982; Marshall & Segal, 1986), we will not examine it
anxiety disorders and may also be true of the pharma- in detail. However, two points are essential to note. In
cological treatment of depression. It appears that the the first place, behavioral procedures requiring pa-
complete acceptance of the medical model by drug tients to confront the stimuli that evoke their fears are
researchers leads them to report the use of psychologi- so effective with the simple phobias (Mavissakalian &
cal treatment but apparently not to the need to utilize Barlow, 1981; Thrner, 1984) that the need for effective
such interventions. facilitating drugs seems unnecessary in all but a lim-
CHAPTER 13 • DRUGS COMBINED WITH BEHAVIORAL PSYCHOTHERAPY 269
ited few patients. Even in these patients, behaviorally it might very well be that where benefits are apparent
based strategies (e. g., training in the use of counter- for the combination of behavior therapy and drugs over
anxiety relaxation or the use of preexposure imaginal behavior therapy alone, these benefits would disappear
procedures) may be sufficient to overcome resistance were maximally beneficial behavioral interventions
to in vivo exposure. Second, there is evidence that used. To make this point clear, let us note some of the
combining drugs with behavior therapy (where both features of treatment that research has shown to in-
are offered as either independent or interactive compo- crease the effectiveness of cognitive-behavioral inter-
nents rather than using drugs to ease the distress in- ventions. For instance, many studies have employed
duced by exposure) for simple phobias is no more ef- brief therapist-assisted in vivo exposure as the behav-
fective than exposure alone (Ballenger, Sheehan, & ioral treatment, and yet few behavior therapists would
Jacobson, 1977; Sheehan, Ballenger, & Jacobson, regard such a limited program to be a satisfactory treat-
1980; Zitrin, Klein, & Woerner, 1978). ment for these complex disorders. Various researchers
Other than the simple phobias, research concerning (e.g., Frame, Turner, Jacob, & Szekely, 1984; Ghosh
the value of using drugs along with behavior therapy & Marks, 1987; Ghosh,Marks, & Carr, 1984; Holden,
has been restricted, for the most part, to the panic- O'Brien, Barlow, Stenson, & Infantino, 1983; Math-
based disorders (panic disorder with and without ago- ews, Gelder, & Johnston, 1981) have demonstrated
raphobia) and to obsessive-compulsive disorders. Al- that self-exposure is more valuable than therapist-as-
though such approaches might be applied equally well sisted treatment. Michelson (1988) provided evidence
to posttraumatic stress disorder or generalized anxiety that the amount of self-exposure engaged in by the
disorder, there are too few evaluations with these prob- patient between therapist-assisted sessions was
lems to make a review worthwhile at this time. Ac- positively related to treatment benefits. In many of the
cordingly, we will restrict ourselves to a consideration comparative studies, little or no control is exercised
of the literature concerned with panic and obsessive- over the degree of patient initiated exposure, although
compulsive patients. some researchers note that this occurred (Pollack &
With the more complex anxiety disorders, drugs Rosenbaum, 1988). Goldstein and Chambless (1978)
have typically been combined with behavior therapy have argued that factors additional to fear and avoid-
on the assumption that the effects of these two compo- ance need to be addressed in the behavioral treatment
nents of treatment will be either multiplicative or ad- of agoraphobics. On this point, Kleiner, Marshall, and
ditive. In these disorders, then, drugs have not been Spevack (1987) demonstrated that addition of a social
used to make it easier for the patient to participate in problem-solving component to exposure therapy
behavioral programs, as has been the case with the markedly enhanced outcome with panic stricken ago-
simple phobias, although they may have served this raphobics. Arnow, Taylor, Agras, and Teich (1985)
purpose inadvertently. Whether the use of drugs with found that exposure effects were improved by provid-
these problems interacts with behavioral procedures to ing agoraphobics and their spouses with marital com-
enhance effects is, of course, the most important ques- munication skills. Finally, cognitive therapists (Beck,
tion, but it is not always easy to make straightforward 1988; Clark, 1986; Salkovskis & Clark, 1986) have
inferences from the research for a variety of reasons shown that exposure to the internal cues of panic is an
that will become clear as we review the literature. Be- important feature of treatment. Chambless, Foa,
fore we tum to the actual studies, however, two general Groves, and Goldstein (1979) provided evidence that
methodological observations must be made. the drug suppression of these cues reduced an other-
Hollon and DuRubeis (1981), for example, noted wise effective exposure procedure. It seems clear that
that those studies that use as controls behavior therapy the majority of researchers who have evaluated com-
plus a placebo drug do not provide a proper estimation binations of drugs and behavior therapy for anxiety
of the effectiveness of behavior therapy alone, as is so disorders have either not been sophisticated in behav-
often assumed in the studies we will review. They ioral approaches or they have employed less than com-
pointed out that the addition of a placebo drug may so plete behavioral programs.
drastically alter the patient's perception of the whole
treatment package as to decrease the effectiveness of
Panic Disorders
the behavioral component.
In addition, a number of comparative studies appear We will now consider the research concerned with
to employ less than optimal behavioral programs, and panic disordered patients who either do or do not en-
gage in extensive avoidance (agoraphobic) behavior. training or flooding) reduced avoidance behavior and
Thus, we will follow the recent revisions to the Diag- the associated anticipatory anxiety. Other researchers
nostic and Statistical Manual of Mental Disorders have found similar results.
(DSM-III-R), but we will continue to use the tenn Ballenger et al. (1977) and Sheehan et al. (1980)
agoraphobia to describe the avoidant patients. found that both imipramine and phenelzine, when
There is extensive evidence indicating that various combined with supportive psychotherapy and instruc-
antidepressants are effective in treating panic-based tion to engage in self-directed exposure, produced
problems (Lydiard & Ballenger, 1988) as well as the marked improvement in agoraphobics who experi-
triazolobenzodiazepine, alprazolam, and the 1, 4-ben- enced panic attacks. Again, these effects involved re-
zodiazepine, clonazepam (Pollack & Rosenbaum, ductions in panics, decreases in avoidance, and less
1988). Research, on the other hand, had shown that the anticipatory anxiety, and these effects were signifi-
earlier benzodiazepines were not useful in the treat- cantly more pronounced than those obtained by com-
ment of these disorders (Rickels & Schweizer, 1986). bining the psychotherapy and exposure with a placebo
However, it is also apparent that a large number of drug. Mavissakalian, Michelson, and Dealy (1983)
panic-disordered patients refuse to take antidepres- found that imipramine plus programmed practice (in-
sants or the new benzodiazepines and many drop out of structions to practice self-exposure between sessions)
treatment, relapse after withdrawal of the medication, was more effective than imipramine alone, and
or suffer distressing side effects (Fyer et at., 1987; Mavissakalian and Michelson (1986) demonstrated
Lydiard, Laraia, Ballenger, & Howell, 1978; Marks, that a similar combination was more effective than the
1983; Rosenbaum, 1986; Sheehan, 1986; Teich, Tear- same procedure where imipramine was replaced by a
nan, & Taylor, 1983; Zitrin, Juliano, & Kahen, 1987). placebo. However, in the studies by Mavissakalian and
Clearly, on their own, these drugs do not represent his colleagues, all patients were given instructions to
effective treatment for panic disorders and are not, expose themselves to their feared situations between
therefore, an alternative to the demonstrably effective treatment contacts, and they were told that such ex-
behavioral programs. The question, then, is whether or posure was crucial to treatment (Michelson, 1988).
not these drugs can add anything to the effectiveness of This is of critical importance, since these authors clear-
behavior therapy. ly showed that the amount of self-exposure predicted
Although behavior therapy is very effective with treated outcome. It is, therefore, difficult to know
complex anxiety disorders, it is true that persistent whether imipramine actually added anything to the
problems remain, including treatment refusals, non- effectiveness of Mavissakalian's combined program.
compliance, and dropouts, as well as clear evidence The same may also be true of the other studies, since
that not all patients who properly complete behavioral Pollack and Rosenbaum (1988) report that, although
programs display satisfactory improvements (Barlow, they begin treatment by administering phar-
O'Brien, & Last, 1984). These observations, how- macotherapy alone, most of their patients initiate ex-
ever, might best be responded to by developing addi- posure practice without any instructions from the
tional features to presently available behavioral pro- therapists.
grams rather than by examining the value of adding In line with this reasoning are the results of three
drug therapies. As we have already noted, recent ex- studies. Marks et al. (1983), in a carefully controlled
tensions to behavioral interventions appear to have in- examination with agoraphobics, found no differences
creased the power of such programs to reduce difficul- in effectiveness for imipramine versus placebo when
ties experienced by panic-disordered patients. both were combined with behavioral procedures (ther-
The earliest evaluations of combining behavior therapist-assisted exposure plus extensive self-exposure),
apy with drugs in the treatment of panic disorders were which were independently demonstrated to be very
reported by Charlotte Zitrin and her colleagues (Zitrin, effective (Ghosh et al., 1984). This study, in particu-
1981; Zitrin, Klein, & Woerner, 1978, 1980; Zitrin, lar, suggests that appropriate behavior therapy pro-
Woerner, & Klein, 1981). Essentially, they showed cedures that are directed by therapists who are well
that each component had independent effects which, grounded in a behavioral approach do not require addi-
when added together, produced complete relief for the tional pharmacological components to overcome the
patients. The antidepressant drug (imipramine in these problems of agoraphobics. Similarly, C. Solyom, L.
early studies) suppressed panics, while the behavioral Solyom, LaPierre, Pecknold, and Morton (1981)
intervention (either desensitization plus assertive could not detect any further benefits in treating agora-
phobics by adding phenelzine to exposure treatment. First, it is assumed that the various antidepressants,
TeIch (1988b) pointed to two criticisms that have been and the more recently available benzodiazepines,
leveled against these studies by those who favor drug function as panic suppressors. As we have noted, the
treatments. The first claim is that unusually low doses evidence may not be as strongly supportive of this
of the drugs were given. However, this is not substanti- notion as it seems, and Marks (1983) was convinced
ated in the case of the Marks et at. study. Their patients from his thorough review of the literature that these
received dosages of imipramine between 124-158 drugs do not exert direct antipanic effects. Second, it is
mg/day,.and Ballenger et al. (1984) found that dose assumed that behavioral interventions are not able to
levels within this range were just as effective in reliev- reduce panics. With respect to this assumption, behav-
ing agoraphobic symptomatology as were higher ior therapists themselves have been at least somewhat
doses. Perhaps the only justifiable criticism that can be responsible for promoting this view.
leveled at the Marks et at and the Solyom et at. studies At a conference that one of us attended (W.L.M.) on
is that they excluded from treatment those patients who the psychological aspects and treatments of panic, held
were also quite depressed. This may be particularly in 1986 under the auspices of the National Institute of
salient, because Marks has argued elsewhere (Marks, Mental Health, several participants (including a num-
1983) that in so far as tricyclics are beneficial in the ber of the world's leading behavior therapists) ex-
treatment of panic-based disorders, it is because of pressed, as a matter of accepted fact, that exposure
their antidepressant effects rather than because these treatment had either a long delayed antipanic effect
drugs have an antipanic effect. Also, of course, it re- (apparent only after 1 year or more) or produced little
mains to be seen whether or not behavioral programs, or no panic suppression. Michelson (1988) presented
particularly those which target a more comprehensive evidence from his studies conducted with Mavis-
set of the dysfunctions (including perhaps depression) sakalian and their colleagues that indicated that their
than just the anxiety and avoidance features, are effec- exposure procedures were not as effective in immedi-
tive with these depressed agoraphobics. ately reducing panics as were the imipramine groups.
The final study relevant to this issue was conducted However, their exposure-only subjects improved over
by TeIch, Agras, Taylor, Roth, and Gallen (1985). In the 2-year follow-up to such as extent that they had
their groups, these researchers gave patients appropri- lower panic scores (frequency and intensity) at that
ate doses of imipramine and specifically instructed point than did subjects treated by antidepressants or
them to avoid exposure. In this group of subjects, there any of the other various procedures Michelson evalu-
were no discernible panic blocking effects. Although ated. It seemed apparent that those behavior therapists
this is the only study that has instructed medicated who were present at the meeting agreed that these data
subjects to abstain from self-managed exposure, it is were typical.
consistent with an earlier finding of Tyer, Candy, and However, this has not always been demonstrated to
Kelly (1973), who found no improvements in panics be true. For example, although Beck (1988) describes
for phenelzine (a monoamine oxidase inhibitor rather his successful treatment program as "cognitive thera-
than a tricyclic) despite improvements in phobias. py," he makes it clear that an essential feature of his
These results suggest the possibility that the earlier treatment is quite extensive exposure to both the inter-
studies, purporting to demonstrate an antipanic effect nal and external cues that elicit a panic. Barlow's ex-
for the antidepressants, may have produced benefits by cellent work with both agoraphobics and other panic-
the inadvertent combination of drugs and exposure (in- disordered patients (Barlow et at., 1984; Barlow,
dependently initiated by the patients without the re- O'Brien, & Last, 1984) has also shown that expanding
searcher's knowledge). Of course, if this is true it sug- the range of behavioral interventions does reduce panic
gests that the effective pharmacological agents may levels. Similarly, our program (Kleiner et aI., 1987),
produce their benefits by facilitating exposure rather which involves therapist-assisted and self-managed
than by adding an otherwise missing effect to behav- exposure (including exposure to the internal cues) and
ioral programs. training in social problem solving (including assert-
The question addressed throughout this part of our iveness training), has been shown to dramatically re-
review has been whether or not there is value to adding duce the frequency and intensity of panics in patients
drugs to a behavioral program for patients with panic- who met the diagnostic criteria (DSM-III-R) for agora-
based disorders. The assumptions underlying the use phobia with panic. In our study, we found that the
of such a combined program are at least two-fold. exposure alone condition reduced panics, but not to the
same degree as the program that included the problem- general inability to cope with stress, does not allow us
solving component. These benefits for panics were to consider such interventions as optimal behavioral
apparent at the end of the treatment and maintained at responses to the complex nature of these disorders.
the 6-month follow-up. Examining the value of adding drugs to the most re-
The conclusions that arise from our consideration of cently developed, optimally effective comprehensive
this literature, then, are that very effective behavioral behavioral programs is the only reasonable research
programs appear to be available for the treatment of approach. Otherwise, we will simply perpetuate the
panic-based disorders; also, there seems to be no need apparently widespread, but unfounded assumption,
to combine these programs with pharmacological that drugs will always be necessary in the treatment of
treatment. Rather, we encourage behavior therapists to complex anxiety disorders. Behavior therapy re-
continue to explore features of these patients which searchers should do what they do best: develop behav-
might be related to either the maintenance of the prob- iorally based interventions. What we know to date in-
lems or to posttreatment relapses, so that additional dicates that there are very effective behavioral
behavioral components can be added to make the over- programs available for the anxiety disorders (see
all program that much more effective. Shear (1988) Marshall & Segal, 1988, for a review) and that adding
has noted that panic-disordered patients have hetero- drugs to behavior therapy increases the number of re-
geneous etiologies; similar heterogeneous features lapses when the patients are eventually withdrawn
probably maintain the difficulties these patients expe- from the medication (TeIch, 1988a; Zitrin et at.,
rience. Shear also points out that in some cases it may 1980), as well as increasing both treatment refusals
be that biological factors are relevant to etiology and and dropouts during treatment (Marks, 1983; TeIch,
maintenance, but this should not be taken to mean (as 1988).
she apparently assumes) that antipanic drug therapy
will be essential in the treatment of these cases. Behav-
Obsessive-Compulsive Disorders
ioral management procedures, such as stress manage-
ment for patients with mitral valve prolapse, may be A considerable body of evidence (see Ananth,
more appropriately added to the usual treatment pro- 1985, for a review) supports the value of various ben-
grams. It seems reasonable, however, from a clinical zodiazepines and antidepressants in the treatment of
perspective, to suggest that there may be occasional obsessive-compulsive disorders (OCD). However,
cases where the patients' fears are so great that an once again relapse rates are high upon withdrawal of
exposure-based strategy may be unacceptable to them. the drugs (Marks, 1983).
In these cases an anxiolytic drug may facilitate cooper- Three studies report an evaluation of the combina-
ation. However, there are behavioral alternatives tion of drugs and behavior therapy in the treatment of
available for such patients (e. g., relaxation training or OCD, whereas one report simply compared these two
other coping skills training) and, in any case, patient forms of treatment. Solyom and Sookman (1977) eval-
refusals can be reduced by properly preparing the cli- uated the independent effects of clomipramine, flood-
ent for exposure (Marshall & Gauthier, 1983). ing, and thought stopping. Flooding was superior to
As we noted earlier, part of the problem in evaluat- the other two treatments in terms of the patients' com-
ing the literature addressing the value of combining pulsive features, and it produced benefits on the ob-
drugs with behavior therapy in the treatment of panic sessive symptoms which were equivalent to
disorders has been the very frequent failure of re- clomipramine.
searchers to utilize a maximally effective behavioral In a series of controlled single-case designs, Thrner,
program. In this respect, some behavior therapists Hersen, Bellack, Andrasik, and Capparell (1950)
have been equally at fault as have our biologically found quite variable results. During response preven-
oriented colleagues. First, the failure to use exposure tion, one patient's rituals decreased while his anxiety
procedures that include internal cues and that require and depression increased. Another patient improved
the patient to do extensive self-exposure practice ex- while taking imipramine, but these benefits disap-
clude the consideration of the behavioral program as peared upon withdrawal of the drug. In yet another
adequate. Second, the failure to address additional case, both imipramine and response prevention exac-
problematic features of the patients, such as deficient erbated the patient's problems, although he was subse-
interpersonal skills (e.g., under assertiveness, marital quently effectively helped by the combination of dox-
difficulties, inadequate problem-solving, etc.), and a epin (a tricyclic) and covert sensitization.
Marks, Stem, Mawson, Cobb, and McDonald Behavior therapists should add components (e.g., as-
(1980) administered clomipramine or a placebo for 4 sertiveness training, marital counseling, training in
weeks before introducing exposure therapy for a fur- problem solving, and treatment for depression) to deal
ther 6 weeks. Exposure plus clomipramine was the with problems additional to the primary features (e.g.,
significantly more effective combination, which was anxiety, fear, panic, obsessions and compulsions) of
similar to an earlier finding by Amin, Ban, Pecknold, these disorders, as well as introducing procedures
and Klinger (1977). In both of these studies, the (e.g., imaginal exposure, coping skills training, etc.)
placebo plus exposure procedure was ineffective. that would properly prepare the patient for in vivo ex-
Since several reviewers (Marshall & Segal, 1988; posure or response prevention treatments.
Mavissakalian, Turner, & Michelson 1985; Rachman Clearly, there has developed over the past few years
& Hodgson, 1980) have concluded that there are now a sentiment among most of those therapists who take a
available very effective behavioral treatment programs biological view of these problems that behavior thera-
for OCD, it is tempting to conclude that either the py can serve at best as an adjunct to drug treatment.
behavioral procedures used by Marks et al. and Amin Such a view is very likely to persist in the near future at
et al. were not optimal, or that adding a placebo de- least, in spite of evidence demonstrating the efficacy of
stroyed the therapeutic value of these procedures. behavioral programs. Similarly, however, there ap-
Typically, these effective behavioral programs have pears to be a well-entrenched view, in some behav-
involved exposure to the external cues, which elicit iorally oriented researchers, that adding drugs to be-
both obsessions and compUlsions, exposure to internal havior therapy will enhance its effectiveness, and
cues (both the actual obsessions and related cata- again this view seems to exist in spite of the evidence.
strophizing thoughts), and response prevention strat- For instance, TeIch and his colleagues (TeIch et al ..
egies aimed at curtailing rituals. As we noted with 1985), as we have noted, found no antipanic effect for
panic disorders, any evaluation of the combination of imipramine when patients were instructed to abstain
drugs and behavior therapy must include the most ef- from exposure, and despite the fact that TeIch (1988a)
fective behavioral program if the resultant data are to discusses this study in detail he proceeds to advocate
be meaningful. To date, such a comparison has not combined programs. He does this apparently on the
been made. If drugs do add anything useful to the basis of two observations: (I) imipramine was ob-
behavioral treatment of OCD, it is apparently through served to reduce depressed mood in these patients, and
their effectiveness in reducing depression (Marks (2) a potentiating effect on panics was observed for the
1983; Turner & Michelson, 1984). However, there is combination. TeIch does not discuss the possibility of
no reason for behaviorists to turn to drugs to overcome using behavioral procedures to deal with the dysphoric
depression, as there are well developed behavioral and mood nor does he entertain the possibility that the ex-
cognitive-behavioral programs for achieving this posure procedure could be enhanced to produce anti-
which could easily be added to exposure and response panic effects, despite his obvious reading of the chap-
prevention programs. In addition, the other problems ters in the same book by Beck, Clark, and Salkovskis,
which, in our experience, OCD patients share in com- which demonstrate an effective procedure for reducing
mon with panic patients (e.g., underassertiveness, de- panics.
pendence, marital difficulties, etc.) could be effective-
ly treated by expanding the behavioral regimen.
Again, we believe that behavior therapists would be Depression
well advised to spend their energies developing their
own approaches to these problems rather than examin-
Behavioral Approaches Combined with
ing the value of adding drugs.
Drugs
Behavioral approaches to the treatment of depres-
Discussion of Anxiety Disorder Studies
sion encompass a wide variety of interventions that
In the treatment of the anxiety disorders, there does emphasize various points: for example, the relative
not appear to be convincing evidence that adding drugs rates of positive reinforcement and punishment in the
to the most effective behavioral procedures enhances patient's environment, dysfunctional styles of self-
outcome. Indeed, there are good reasons for opposing evaluation and self-reinforcement, or social skill defi-
the use of drugs in all but the most resistant patients. cits. The absence of a single approach or a common
core element (such as exposure in the treatment of the improvements. At the 3-month follow-up, both groups
anxiety disorders) has meant that outcome evaluations were shown to have maintained their treatment gains.
are often not readily comparable. However, it does Wilson (1982) reported data from a study in which
seem possible to infer some consistent effects in the 64 depressed patients received either a "task assign-
literature. ment/activity scheduling" program (aimed at increas-
The remediation of the social skills deficits of de- ing social functioning), relaxation training, or minimal
pressives has been one strategy that has received wide- contact, all of which were conducted in combination
spread research interest. Bellack and Hersen and their with either amitriptyline or placebo for a 2-month peri-
colleagues (Bellack, Hersen, & Himmelhoch 1981; od. Marked improvement was observed both at post-
Hersen, Bellack, Himmelhoch, & Thase 1984) have treatment and follow-up (6 months), with these effects
conducted a number of trials in which social skills being independent of the type of intervention. Al-
training has been compared to antidepressant medica- though it may be somewhat surprising that the minimal
tion. In the Bellack et al. (1981) study, 72 unipolar contact and placebo groups displayed significant
depressed female outpatients were equally divided changes from pre- to posttreatment, it is important to
among four treatment groups: social skills training in note that subjects who received amitriptyline had a
combination with amitriptyline; amitriptyline alone; more rapid rate of improvement than those who re-
social skills training plus a placebo; and psychotherapy ceived the placebo. In addition, subjects in both the
plus placebo. Each of the treatments was administered task assignment or relaxation training group sought
by an experienced therapist, who expressed a commit- less additional treatment during the follow-up period
ment to the specific orientations, and each treatment than did those who received minimal contact. No dis-
was found to have produced clinically significant im- tinct advantages were found for the use of amitrip-
provements in mood at termination. Social skills train- tyline in combination with either of the two behavioral
ing plus placebo was found to be as effective as conditions.
amitriptyline alone or psychotherapy plus placebo. Finally, Becker and Heimberg (1987) reported that
The addition of medication to the social skills treat- patients receiving anyone of four different treatments
ment did not enhance treatment effects, but it is impor- did equally well. Patients were given either social
tant to note that patients were more likely to drop out of skills training and nortriptyline, social skills training
the medication-only cell (up to 55%), and that the and placebo, supportive therapy and nortriptyline, or
highest proportion of patients who showed significant supportive therapy and placebo. There was no evi-
improvements received social skills training (70% ver- dence of additive effects for the combined social skills
sus 33% to 50%). Similar findings were reported in the training and nortriptyline condition. Interestingly,
complete trial by Hersen et al. (1984), in which 125 more subjects in the social skills training cells, than in
nonpsychotic, unipolar depressed women were as- the medication cells, completed treatment, corroborat-
signed to the same treatment conditions listed above ing the findings of Bellack et al. (1981) regarding
for a period of 12 weeks, followed by 6 months of dropouts.
booster sessions. No differences were found when the
combined treatment regimen was compared to either
Cognitive Behavior Therapy and Drugs
the drug condition alone, or the skills training alone,
with all programs producing satisfactory benefits. Beck (Beck 1967; Beck, Rush, Shaw, & Emery,
In a related vein, a study by Roth, Bielski, Jones, 1979) has been the major proponent of cognitive thera-
Parker, and Osbord (1982) compared a behavioral in- py for depression, and his approach has been expanded
tervention based on Rehm's (1977) self-control model, over time, both by Beck himself and by others, to
with an antidepressant medication (desipramine hy- include behavioral components. We will refer to this
drochloride). Thirty-two subjects received either self- approach as cognitive-behavior therapy (CBT).
control therapy or a combination of this and the anti- An early report by Beck, Hollon, Young, and Bed-
depressant. Both treatment conditions produced sim- rosian (1979) examined the efficacy of CBT alone ver-
ilar decreases in depressive symptomatology, as mea- sus CBT plus amitriptyline. Both conditions resulted
sured by the Beck Depression Inventory (BOI) and the in similar levels of symptomatic improvement, which
Hamilton Rating Scale (HRSD), although the com- were maintained at the I-year follow-up. In a more
bined treatment resulted in significantly more rapid tightly controlled trial, Blackburn, Bishop, Glen,
Whalley, and Christie (1981) compared combined groups significantly improVed by the end of treatment,
cognitive therapy and pharmacotherapy with each and there was no differential effectiveness among
modality singly. The results were split among the dif- treatments in reducing depressive symptoms. There
ferent groups studied, in that for hospitalized outpa- were, however, differences in dropout rates, with pa-
tients the combination treatment was more effective tients receiving medication alone being the most likely
than either of the individual treatments on 6 out of the 7 to drop out and patients receiving CBT in conjunction
outcome measures. However, in the general practice with either medication or placebo being the least likely
outpatient group, CBT alone was as effective as the to do so. Murphy et al. concluded that CBT was mod-
combination on all measures. Teasdale, Fennell, Hib- erately effective for depression, but they noted that no
bert, and Amies (1984) compared treatment as usual evidence was observed of either additive or interfering
(TAU), delivered by general practice physicians effects arising from combining it with medication. In a
against the same treatment plus CBT. Of the 17 pa- similar vein, Beck et al. (1985) reported the results of
tients receiving TAU alone, 10 were taking antidepres- an outcome trial in which 33 outpatients received treat-
sant medication within the recommended dose range. ment with either CBT alone or CBT plus amitriptyline.
Results indicated that the combined treatment group As is usual in these studies, patients were treated for a
achieved significantly better posttreatment scores on maximum of 20 sessions spaced over a 12-week peri-
all measures of depression. However, by the 3-month od. Both groups showed statistically significant and
follow-up, both groups displayed equal levels of meaningful decreases in depressive symptoms, with
improvement. no differences emerging between groups in terms of
Results from the Cognitive Pharmacotherapy Pro- the magnitude of this decrease. Adding medication to
ject conducted at the University of Minnesota by Hol- CBT did not yield a greater response than that obtained
lon and colleagues (Hollon et al., 1986) are reported by CBT alone. Although a trend suggesting greater
for 106 patients with major depressive disorder, uni- stability of gains for the combined treatment group was
polar type, who were assigned to one of four treatment observed at the I-year follow-up, this may have been
conditions: CBT, imipramine without maintenance, the result of the fact that patients in this group also had
imipramine with maintenance, and combined CBT additional therapy during the follow-up period.
and imipramine without maintenance. Patients were The results from the individual treatment outcome
treated for 12 weeks and then followed over a 2-year studies are essentially mirrored by the findings from
period. Patients in three of the four groups (all but the the studies that have examined CBT given in groups in
imipramine with maintenance group) were tapered off conjunction with medication. Studies by Rush and
all treatments at the end of the 12-week acute treatment Watkins (1981), Covi and Lipman (1987), and Beutler
phase, whereas patients in the imipramine with main- et al. (1987) report no additive effects for the combina-
tenance group were kept on medication for the first tion treatment over CBT alone. In the Beutler et al.
year of the follow-up period. At the end of 12 weeks, (1987) study, for example, 56 elderly adults were treat-
the combined treatment was significantly more effec- ed over a 20-week period by either alprazolam,
tive than imipramine alone but not significantly better placebo, CBT plus placebo, or CBT plus alprazolam.
than CBT alone. Perhaps the most interesting finding Patients receiving CBT in groups showed improve-
is that by the end of the follow-up period, patients who ments in subjective symptoms as well as in sleep effi-
had received CBT with or without medication were ciency. No differences between alprazolam and
less likely to have relapsed or to have sought further placebo were noted regardless of whether or not pa-
treatment than patients receiving the acute imipramine tients received CBT. As was found in previous studies,
therapy (no maintenance). Generally, the treatments CBT patients were less likely than their counterparts to
that included CBT were more likely to bring about terminate treatment prematurely.
sustained remission compared with the medication
only treatment, although these differences did not
Discussion of Depression Studies
reach acceptable levels of statistical significance.
Murphy, Simons, Wetzel, and Lustman (1984) ran- Some studies have found no differences between
domly assigned 87 unipolar depressed outpatients to combinations of behavior therapy and drugs, and ei-
one of four treatments: CBT, nortriptyline, combined ther drugs alone (Hersen et aI., 1984; Wilson, 1982) or
CBT and nortriptyline, and CBT plus placebo. All behavior therapy alone (Becker & Heimberg, 1978;
Hersen et al., 1984; Roth et al., 1982). Combining the treatment response differed among endogenous
CBT with drugs has produced increased effectiveness and nonendogenous depressive subtypes. Specifically,
over one or the other component alone (Blackburn et Thase et al., reported that endogenous patients (who
al., 1981; Hollon et al., 1986; Teasdale et al., 1984), constituted 19% of the overall sample) responded bet-
no greater effects than drugs alone in one study (Mur- terto amitriptyline than to social skills training, where-
phy et al., 1984), and no greater effects than CBT as patients without endogenous features responded
alone in others (Beck et al., 1979, 1985; Blackburn et better to the skills training. In addition, dropout rates
al., 1981; Covi & Lipman, 1987; Murphy et al., 1984; were significantly higher for the endogenous patients
Rush & Watkins, 1981). No doubt these inconsisten- receiving psychosocial treatments without amitrip-
cies arise from the different treatments used within tyline and for nonendogenous patients who were re-
each component. Cognitive behavior therapy seems to ceiving amitriptyline. These types of results highlight
enjoy the greatest popularity at the moment in the non- the need for controlled outcome studies with depressed
drug approaches to depression and, in the hands of its patients in which patient variables are examined in
strongest proponents, seems to be equally as effective interaction with the treatments offered.
as the drug-CBT combination. Again, we suggest that
the energies of behavioral researchers would be best
directed toward increasing the effectiveness of CBT
Summary
either by refining present procedures or by expanding
From our reading of the literature, we are persuaded
the areas targeted in treatment.
that comprehensive behavioral, cognitive, or cog-
When engaging in these types of omnibus com-
nitive-behavioral treatment programs for depression
parisons between clearly defined treatment alter-
and the various anxiety disorders are generally suffi-
natives, it is easy to lose sight of the fact that the typical
ciently effective as to render unnecessary the need for
outcome trial methodology often obscures important
adding drug therapy. When these programs fall short of
patient characteristics that may be common to only a
maximal benefits, we consider the energies of behav-
subsample within the larger pool of patients being in-
ioral researchers will be better spent developing addi-
vestigated. One example of this concerns the sug-
tional behavioral elements or finding ways to enhance
gestion that combined treatment regimens may be
existing procedures, rather than examining the value of
more effective for the severely depressed patient,
adding drugs. Perhaps the only utility of drugs within a
whereas for less severely depressed outpatients, either
behavioral program is to facilitate the occasional re-
medication alone or CBT alone is probably sufficient.
sistant patient entering treatment: for example, the use
This conclusion can be supported by the differential
of an anxiolytic to encourage exposure, or an anti-
outcome for general practice versus psychiatric pa-
depressant to elevate mood in a patient who is so de-
tients in the Blackburn et at. (1981) study as well as by
pressed that he or she cannot muster the will to comply
the results of the studies by Teasdale et at. (1984) and
with the requirements of behavioral procedures. How-
Hollon et al. (1986). Many of the studies that found no
ever, even in these cases, drugs may not always be
differences between a combined treatment regimen
suitable (high refusal rates in phobias, Marks, 1983),
and behavior therapy alone relied on volunteers solic-
and the development of preparatory behavioral tech-
ited from the community who were experiencing de-
niques may be more suitable (Marshall & Gauthier,
pression (e.g., Roth et al., 1982; Wilson, 1982). It
1983). Even when drugs are used to facilitate ex-
may be that subjects in these groups were less severely
posure, therapists should follow the sensible strategy
depressed than those in the studies that found some
adopted by Marks, Viswanathan, Lipsedge, and
extra benefit for the combined treatment.
Gardner (1972), who initiated exposure when drug ef-
Some convergent data on the question of whether
fects were waning so as to avoid state-dependent
severely depressed patients may profit from combined
learning.
programs have come from work that has examined
melancholic depressed patients. Blackburn et al.
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PART IV
Intervention and Behavior

Change
Adults
CHAPTER 14
Anxiety and Fear

Since the first edition of this handbook, behavioral inforcement). According to this theory, anxiety and
research in the field of anxiety disorders has increased avoidance are causally linked, and avoidance behavior
dramatically. Although in the 1970s articles in behav- should be reduced as soon as anxiety is eliminated.
ioral journals concerned mainly analogue studies, in However, the two-stage theory of learning is now un-
the last decade numerous studies have been published tenable as a uniform theory for the functioning of pho-
using clinical phobics as subjects. In addition, a bic behavior (Emmelkamp, 1982).
number of influential volumes on anxiety disorders
have been published (Chambless & Goldstein, 1982;
Systematic Desensitization
Emmelkamp, 1982; Marks, 1987), and at least one
major journal, the Journal of Anxiety Disorders, has In systematic desensitization (Wolpe, 1958), pa-
been founded. The emphasis throughout this chapter tients are first trained in muscular relaxation then move
will be on research with clinical subjects. Because sep- gradually up a hierarchy of anxiety-arousing situations
arate chapters in this volume are devoted to drugs com- while remaining relaxed. Although desensitization
bined with behavior therapy, obsessive-compulsive may be applied either in imagination or in vivo, most
disorders, and anxiety in children and adolescents, studies involved the imaginal variant. According to
these topics will not be dealt with in this chapter. Wolpe (1963), "there is almost invariably a one-to-one
relationship between what the patient can imagine
without anxiety and what he (or she) can experience in
Historical Perspective reality without anxiety" (p. 1063). However, patients
who have been successfully desensitized in imagina-
In the early days of behavior therapy, it was assumed tion nevertheless become anxious when confronted
that anxiety must be inhibited before avoidance behav- with the phobic situation in vivo (e.g., Agras, 1967;
ior could be reduced. This assumption was based on Barlow, Leitenberg, Agras, & Wincze, 1969; Hain,
the two-stage theory of Mowrer (1950). In Mowrer's Butcher, & Stevenson, 1966; Meyer & Crisp, 1966;
view, classically conditioned fear motivates avoidance Sherman, 1972). Several studies have directly com-
behavior, which leads to a reduction of fear and a pared the comparative effectiveness of desensitization
strengthening of the avoidance behavior (negative rein imagination and in vivo and have found in vivo ex-
posure far more effective (Barlow et al., 1969;
Paul M. G. Emmelkamp • Department of Clinical Psychol- Dyckman & Cowan, 1978; Litvak, 1969; Sherman,
ogy, Academic Hospital, Groningen, The Netherlands. 1972).
283
284 PART IV • INTERVENTION AND BEHAVIOR CHANGE: ADULTS
the effects of positive social reinforcement on the ap-

Flooding
proach behavior of phobic patients. This procedure has
Flooding therapies are derived from the work of been called shaping, successive approximation, or re-
Stampfl (Stampfl & Levis, 1967, 1968) on implosive inforced practice. In contrast with imaginally based
therapy. The therapist tries to maximize anxiety procedures, such as systematic desensitization and
throughout treatment, which eventually leads to "ex- flooding, the avoidance behavior is changed directly,
tinction." Sessions are continued until a significant which eventually may lead to a decrease of anxiety
reduction in anxiety is achieved. As in the case of (Leitenberg, Agras, Butz, & Wincze, 1971).
systematic desensitization, it is assumed that if anxiety This treatment approach is illustrated by three case
is inhibited, the avoidance behavior will change ac- studies of agoraphobics described by Agras, Leiten-
cordingly. For a detailed discussion of implosive and berg, and Barlow (1968). The patients had to walk a 1-
flooding procedures the reader is referred to Em- mile "course." Patients were told, "We would like to
melkamp (1982). know how far you can walk by yourself without undue
In the early days of in vivo exposure, guidelines for anxiety. We find that repeated practice in a structured
conducting treatment were derived from implosion situation often leads to progress." The therapist timed
and flooding theory. It was thought to be essential that the duration of each walk. Systematic praise (positive
anxiety should be maximized during in vivo exposure reinforcement), contingent upon progress in distance
before extinction or habituation could occur. In the walked, was introduced, removed, and reintroduced in
first controlled study that included flooding in vivo sequential phases of the experiment with each patient.
with phobic patients (Marks, Boulougouris, & Marset, Social reinforcement (praise by the therapist) led to an
1971), therapists tried to evoke anxiety deliberately. increase in the distance walked. Removal of the rein-
However, subsequent studies indicate that the inclu- forcement led to worsening. Finally, reintroduction of
sion of horrifying stimuli during flooding in imagina- social reinforcement led to improved performance.
tion does not enhance the effectiveness of this pro- Results of these three single-case studies suggested
cedure. Rather, it seems that flooding without such that reinforcement for improved performance was re-
cues is more effective (Emmelkamp, 1982). sponsible for the improvement achieved.
Hafner and Marks (1976) compared in vivo ex- Emmelkamp and Ultee (1974) wondered whether
posure with high anxiety to in vivo exposure with low the social reinforcement contingent upon performance
anxiety. In the high-anxiety condition, the therapist in the feared situation was essential. Rather, they hy-
tried to induce anxiety by such statements as "Imagine pothesized that graded practice in a structured situation
yourself feeling worse and worse, giddy, sweaty, nau- with performance feedback was the essential therapeu-
seated, as if you are to vomit any moment. You fall to tic ingredient in this procedure. These investigators
the floor half-conscious; people gather round you; compared the shaping procedure with "self-observa-
someone calls for an ambulance." Although patients in tion" in a crossover design. In the latter procedure,
the high-anxiety condition experienced more anxiety patients were not reinforced by the therapist but ob-
during treatment than patients in the low-anxiety con- served their progress by timing the duration of each
dition, no differences in improvement were found be- walk. Half of the patients were first treated with self-
tween both conditions. Thus, deliberately inducing observation followed by shaping; with the other half of
anxiety during in vivo exposure did not enhance im- the patients, the reverse order was applied. Results of
provement. Studies into the effects of drug-assisted in this study demonstrated that reinforcement from the
vivo exposure further demonstrate that anxiety therapist was not necessary. Patients showed equal im-
provocation is not necessary for a successful outcome. provement during both the feedback-only and the feed-
Therefore, the term "flooding in vivo" seems less ap- back-pIus-reinforcement phases of the study.
propriate, and more recently this procedure has been
called "prolonged exposure in vivo. "
Current Empirical Status
Shaping
A common element of the various procedures dis-
According to operant theory, reinforcement of ap- cussed so far is exposure, which can be carried out
proach behavior will lead to an increase in that behav- either in imagination or in vivo. Exposure can be either
ior. Leitenberg and his colleagues have investigated self-controlled (as in systematic desensitization and
CHAPTER14 • ANXlliTYANDFEAR 285
shaping) or controlled by the therapist (such as in pro- improvement at the end of the treatment; both rapid
longed exposure in vivo). Modeling, the showing of and slow groups improved to a similar extent.
approach behavior by the therapist or someone else in 4. Frequent practice is more effective than spaced
anxious situations, appears to add little to the effects of practice. Foa, Jameson, 'fumer, and Payne (1980)
exposure in vivo itself (Emmelkamp, 1982). compared 10 sessions of frequent practice with 10 ses-
Systematic research programs carried out over the sions of spaced practice in a crossover design. In the
last 15 years have significantly enhanced our knowl- frequent practice condition, treatment was conducted
edge about optimal treatment conditions. Because on consecutive days, whereas in the spaced condition
most of this research has been reviewed elsewhere sessiollS were held once a week only. Results indicated
(Emmelkamp, 1982), the emphasis here will be on the that frequent practice was more effective than spaced
main conclusions and on more recent developments. practice. Foa et al. (1980) suggested that the superi-
Research will be discussed for agoraphobia, panic, ority of the frequent condition may be due to the fact
social phobia, posttraumatic stress disorder, and gen- that frequent practice provides less opportunity for ac-
eralized anxiety disorder, respectively. cidental exposure between treatment sessions and for
the reinforcement of avoidance or escape behavior.
The latter explanation, however, is less likely, since
Agoraphobia having the opportunity to escape during exposure in
vivo does not have the detrimental effects as once
Exposure
thought (de Silva & Rachman, 1984; Rachman,
Most of the research on agoraphobia has involved Craske, Tallman, & SOlyom, 1986).
investigating effective parameters of exposure treat- 5. Group exposure is about equally effective as in-
ment. The main conclusions include the following: dividually conducted exposure programs. There are
1. Exposure in vivo is superior to imaginal expo- now a number of studies attesting to the clinical effec-
sure. Most studies that investigated this issue found tiveness of in vivo exposure programs conducted in
in vivo exposure superior to imaginal exposure (Em- groups (e.g., Emmelkamp, Brillman, Kuiper, &
melkamp, 1974; Emmelkamp & Wessels, 1975; Stem Mersch, 1986; Emmelkamp, Kuipers, & Eggeraat,
& Marks, 1973; Watson, Mullett, & Pilley, 1973). 1978; Emmelkamp & Mersch, 1982). Studies compar-
Mathews et al. (1976) found both procedures about ing individual and group exposure in vivo found no
equally effective, but their imaginal procedure in- clear differences in effectiveness (Emmelkamp & Em-
volved in vivo exposure homework assignments. Lang melkamp-Benner, 1975; Hafner & Marks, 1976). Be-
(1979) has argued that for imagined treatment to be sides the aspect of saving therapist time, groups may
effective, the image should contain the subject's re- provide the patient with coping models and may lead to
sponse to the situation in addition to symbolic repre- fewer dropouts.
sentation of the stimulus situation. It is the simul- 6. Treatment can be conducted as a self-help pro-
taneous presentation of both stimulus and response gram. The first self-management program was devel-
propositions that results in the emotion-eliciting im- oped by Emmelkamp (1974). Treatment consisted of
age. It should be noted that, at least in clinical studies, self-controlled exposure plus feedback (self-observa-
imaginal exposure usually contained both stimulus and tion). After an instructional phase in the presence of
response propositions. Nevertheless, treatment so the therapist, the patient had to carry on alone. The
conducted was found to be far less effective than in procedure involves a graduated approach by the patient
vivo exposure. in the actual feared situation. The client had to walk
2. Prolonged exposure in vivo is superior to brief alone on a route through the city with instructions to
exposure. Stem and Marks (1973) compared short tum back upon experiencing undue anxiety. The client
(four half-hour sessions) with long (2 hour) sessions. had to record the duration of each trial and to write this
Prolonged in vivo exposure sessions were clearly supe- down in a notebook. Then, he had to enter the phobic
rior to shorter ones. situation in the same way. This procedure was repeated
3. Rapid exposure is more efficient than slow ex- until the 90-min session was over. At the end of each
posure. Yuksel, Marks, Ramm, and Ghosh (1984) session, the patient had to send the results to the thera-
found that faster in vivo exposure led to quicker im- pist. This treatment was found to be equally effective
provement than when exposure was conducted more as therapist-controlled prolonged exposure (Em-
slowly. However, this did not affect the amount of melkamp, 1974).
The effectiveness of self-observation as a self-man- remalm, and Jansson (1984). Exposure in vivo was
agement procedure was further demonstrated in a found to be equally effective for cognitive and noncog-
number of studies reviewed by Emmelkamp (1982). In nitive responders (Mackay & Liddell, 1986) and for
contrast to results found with prolonged exposure in behavioral and physiological reactors (Ost et al.,
vivo, with this self-management program most pa- 1984).
tients went on to make further gains during follow-up
(Emmelkamp, 1974, 1980; Emmelkamp & Kuipers,
Cognitive Therapy
1979).
Mathews, Teasdale, Munby, Johnston, and Shaw The last decade has seen an increasing interest in the
(1977) developed another self-management program cognitive therapy of anxiety problems, but most of the
for agoraphobics. Their program differs from our pro- research has been done on analogue popUlations, usu-
gram in that the patients' spouses were actively in- ally socially anxious or test anxious college students.
volved in planning and encouraging practice attempts. Although these studies generally found cognitive ther-
Furthermore, their patients had to remain in the phobic apy quite effective (Emmelkamp, 1982), more recent
situation long enough for anxiety to decline, rather studies on clinical populations have questioned the
than to return on experiencing undue anxiety as is the usefulness of cognitive approaches with clinical popu-
case with self-observation. Several controlled studies lations. Several studies have shown that agoraphobics
have now been conducted that demonstrate the effec- are characterized by distorted cognitions (Mizes,
tiveness of this program (see Mathews, Gelder, & Landolf-Fritsche, & Grossman-McKee, 1987) and
Johnston, 1981). bias in the interpretation of threat (McNally & Foa,
7. Self-treatment ofpatients can be done through a 1987), but the correlational nature of these studies pre-
self-help book or a computer. Ghosh and Marks (1987) cludes making causal inferences.
compared three ways of giving self-exposure instruc- Cognitive therapy programs for agoraphobia have
tions: therapist instructions, book instructions, and usually employed one or more of the following cog-
computer instructions. Computer-instructed patients nitive strategies: (1) self-instructional training, (2) ra-
planned their exposure treatment by interacting with a tional-emotive therapy, and (3) paradoxical intention.
microcomputer. Instructions for homework practice A fourth cognitive strategy was developed by Beck and
were given by the computer depending on a hier- Emery (1985), but this approach has not yet been eval-
archicallisting of phobic situations by the patient and uated with agoraphobics. Specific cognitive pro-
on the completion of exposure homework assignment cedures to deal with panic attacks are discussed below.
from the previous session. All three groups improved With self-instructional training (SIT), patients are
substantially and retained their gains up to a 6-month instructed to substitute positive coping self-statements
follow-up, with no significant differences between for the anxiety-engendering self-statements. Gener-
them. ally, four stages are differentiated: preparing for a
8. Exposure programs have long-lasting effects. stressor, confronting or handling a stressor, possibly
Follow-up reports ranging from 4 to 9 years after treat- being overwhelmed by a stressor, and, finally, rein-
ment were published by Burns, Thorpe, and Cavallero forcing oneself for having coped (Meichenbaum,
(1986), Emmelkamp and Kuipers (1979), Lelliott, 1975). During treatment sessions, patients cognitively
Marks, Monteiro, Tsakiris, and Noshirvani (1987), rehearse self-instructional ways of handling anxiety by
MacPherson, Brougham, and McLaren (1980), and means of an imagination procedure.
Munby and Johnston (1980). Generally, improvements Ellis (1962) used an A-B-C framework of rational-
brought about by the treatment were maintained or emotive therapy (RET). A refers to an activating event
improved upon. However, results of the behavioral or experience, B refers to the person's belief about the
treatment were variable. Some patients were symptom activating (A) event, and C refers to the emotional or
free, some were moderately improved, and a few pa- behavioral consequence assumed to result from the
tients did not benefit at all. beliefs (B). The critical elements of treatment involve
9. Exposure in vivo is effective irrespective ofindi- determining the (irrational) thoughts that mediate the
vidual response pattern. The importance of individual anxiety and confronting and modifying them so that
response patterns in agoraphobics was examined in undue anxiety is no longer experienced.
studies of Mackay and Liddell (1986) and Ost, Jer- Paradoxical intention is used as a coping procedure
CHAPTER 14 • ANXIETY AND FEAR 287
to reverse the vicious circle of fearful responding. driving disabilities; other fears were not dealt with.
With this approach, patients are instructed to go to a Although both conditions improved on subjective anx-
very difficult phobic situation, to focus on the physio- iety, only the noncognitive group gained significant
logical experiences of anxiety, and to try to increase benefit from treatment on the behavioral measure.
the symptoms in an attempt to court the anticipated Cognitive therapy procedures have differed in the
disastrous consequences. Thus, in vivo exposure emphasis on insight into irrational beliefs and the train-
forms an essential part of this so called cognitive ing of incompatible positive self-statements. The Em-
approach. melkamp et at. (1978) and the Emmelkamp (1982)
studies have included more than one identifiable cog-
RET and SIT. Several studies investigating cognitive procedure in a single-treatment condition. It is
nitive therapy of agoraphobia have been reported. Em- possible, however, that one treatment (e.g., SIT) is
melkamp et at. (1978) compared cognitive therapy helpful whereas the other (e.g., RET) is coun-
(RET + SIT) with prolonged exposure in vivo in a terproductive or vice versa.
crossover design. Exposure in vivo was found to be far Emmelkamp et at. (1986) investigated the differen-
more effective than cognitive therapy both on the be- tial effectiveness of self-instructional training, ra-
havioral measures and on phobic anxiety and avoid- tional-emotive therapy, and prolonged in vivo ex-
ance scales. Treatment was conducted in a relatively posure with agoraphobics. In addition to the short-
short time period (1 week), which, however, might be term effects after 3 weeks of treatment, possibly de-
too short to result in significant cognitive changes. layed effects of treatments were assessed 1 month after
Moreover, the use of a crossover design precluded treatment, during which period patients received no
conclusions about possibly delayed effects of the cog- further treatment. This was done to give patients the
nitive therapy. opportunity to integrate and practice their cognitive
In a subsequent study (Emmelkamp & Mersch, strategies in the natural environment. After this treat-
1982), three treatments were compared in a between- ment-free period, all patients received 3 weeks of pro-
group design: (1) cognitive therapy, (2) prolonged ex- longed exposure in vivo and were reassessed to exam-
posure in vivo, and (3) a combination of self-instruc- ine possible interactions between cognitive strategies
tional training and prolonged exposure in vivo. The and exposure in vivo.
combined therapeutic package was included to investi- The results of this study clearly suggest that in vivo
gate whether self-instructional training would enhance exposure is more effective than the cognitive treat-
the effectiveness of exposure in vivo. Treatment con- ments in reducing anxiety and avoidance of agorapho-
sisted of eight 2-hour sessions spread over 4 weeks. In bics. Although both SIT and RET resulted in statis-
contrast with the Emmelkamp et at. (1978) study, tically significant improvements on most measures,
more emphasis was placed on insight into unproduc- the clinical improvements achieved were generally not
tive thinking: patients had to analyze their own feel- impressive, especially with RET, where most patients
ings in terms of Ellis's A-B-C model. At the posttest, were rated as failures. The lack of clinical improve-
prolonged in vivo exposure and the combined pro- ment in anxiety and avoidance after RET cannot be
cedure were clearly superior to cognitive therapy. At 1- accounted for by inadequate application of the cog-
month follow-up, however, the differences between nitive therapy. RET was the only treatment that led to
the treatments had partly disappeared because of a con- significant changes in irrational beliefs at midtreat-
tinuing improvement in the cognitive therapy condi- ment, thus demonstrating the construct validity of the
tion and a slight relapse in the in vivo exposure condi- cognitive therapy. However, the cognitive changes did
tion. Self-instructional training did not enhance the not result in substantial clinical improvements in anx-
effects of exposure in vivo: the combined procedure iety and avoidance.
was no more effective than the in vivo exposure Another study investigating the relative efficacy of
condition. different cognitive procedures was reported by
A third study that evaluated the effects of cognitive Thorpe, Hecker, Cavallero, and Kulberg (1987). Six-
therapy was reported by Williams and Rappoport teen phobics (including eight agoraphobics) were
(1983). Agoraphobics were assigned to two condi- treated with four sessions of RET and SIT in a
tions: exposure in vivo, or exposure in vivo plus self- crossover design. Few differences emerged, but those
instructional training. Treatment was directed to their that did were in favor of RET. Treatment was short
(eight sessions in toto) and, more importantly, in- resulted in equivalent long-term effectiveness of the
volved exposure in vivo for all subjects; thus, conclu- two treatments. Since an exposure-only group was not
sions with respect to the relative efficacy of the cog- included, it is unclear whether the cognitive strategies
nitive interventions per se are precluded. enhanced the effects of exposure.
Marchione, Michelson, Greenwald, and Dancu Finally, Michelson, Mavissakalian, and Marchione
(1987) compared 16 sessions of cognitive therapy plus (1988) compared paradoxical intention plus exposure
graduated exposure, relaxation plus graduated ex- in vivo, relaxation plus exposure in vivo, and exposure
posure, and graduated exposure alone. All three condi- in vivo alone. Overall, the findings revealed marked
tions led to significant improvements on a number of clinical gains across all three treatment conditions and
clinical variables and psychophysiological indices. On no differential treatment effects on central measures.
the behavioral test, the combined groups were found to Interestingly, all treatments led to beneficial effects for
be more effective than exposure alone, which in the over half the subjects in reducing the presence of spon-
view of the authors suggests that subjects who received taneous panic attacks. Given the large number of sub-
active coping skills (i.e., cognitive therapy or relaxa- jects involved (n = 73), the lack of between-group
tion training) were more effective at controlling their differences cannot be accounted for by lack of power
anxiety. Given the small numbers involved (n = 14 in of the statistical tests. Thus, neither paradoxical inten-
toto), this study awaits replication. tion nor relaxation enhanced the effects of exposure in
vivo.
Paradoxical Intention. Ascher (1981) compared In sum, results of cognitive therapy alone (without
paradoxical intention with graded exposure in vivo and exposure in vivo) with agoraphobics are negative. Fur-
found the former procedure to be superior. More re- thermore, studies that involved a large number of ago-
cently, Ascher, Schotte, and Grayson (1986) investi- raphobics (Emmelkamp & Mersch, 1982; Em-
gated whether adjunctive techniques could enhance melkampetal., 1986; Michelson, etaZ., 1988) did not
the effects of paradoxical intentions. These adjunctive show that cognitive therapy enhanced the effects of
techniques included cognitive techniques derived from exposure in vivo. Although cognitive therapy has not
Ellis and Beck, imaginal exposure, and more explicit proved to be very effective in changing the phobic
exposure in vivo to the physical sensations accompany- behavior of agoraphobics, this does not mean that cog-
ing anxiety. Although results suggested that the ancil- nitive therapy may not be a worthwhile strategy for
lary techniques enhanced the effects of the "classical" other targets. For example, in the Emmelkamp et al.
paradoxical intention procedure, definite conclusions (1986) study, cognitive therapy led to significant
are precluded by a number of methodological prob- changes in irrational beliefs, whereas exposure in vivo
lems in the Ascher (1981) and the Ascher et al. (1986) did not. Also, in the Emmelkamp and Mersch (1982)
studies. First, only behavioral assessment was used, study, cognitive therapy led to significant improve-
results of which can be easily influenced by demand ment at follow-up on depression, assertiveness, and
characteristics (Emmelkamp & Boeke-Slinkers, locus of control, whereas exposure in vivo did not. It is
1977). Second, exposure time was not equated across tempting to assume that cognitive therapy teaches pa-
techniques. Third, numbers in each condition were tients coping skills that they may use in a wide variety
rather small (n = 5). of situations. Such coping skills may be prophylactic
Mavissakalian, Michelson, Greenwald, Kornblith, in the sense that they may prevent relapse in the future.
and Greenwald (1983) investigated the impact of self-
instructional training and paradoxical intention on ex-
Problem-Solving and Assertive Training
posure in vivo. Patients practiced these procedures
twice during each group therapy session and were en- Other strategies that may prevent relapse are prob-
couraged to practice their newly learned cognitive cop- lem-solving training and assertive training. It has been
ing strategies regularly and to apply them in actual suggested (Emmelkamp, 1982; Goldstein & Cham-
anxiety-provoking situations. Treatment consisted of bless, 1978) that agoraphobics are inclined to respond
12 weekly 90-min group sessions. At the end of the to stressful experiences by misattributing physiologi-
treatment period, paradoxical intention resulted in cal arousal associated with panic attacks to external
greater gains than did self-instructional training. How- situational factors, and that they lack adequate prob-
ever, groups that were treated with self-instructional lem-solving skills (Brodbeck & Michelson, 1987;
training continued to improve after the posttest, which Fisher & Wilson, 1985).
Kleiner, Marshall, and Spivack (1987) developed a posure in vivo was found to be more effective on pho-
problem-solving skills program for agoraphobics. The bic measures, whereas assertiveness training was
main targets of this program are to increase the pa- found to be more effective on assertive measures. The
tient's awareness of ongoing interpersonal problems, results of this study indicate that both forms of treat-
to understand the effects of these problems on the pho- ment have something to offer to unassertive agorapho-
bia, and to learn basic skills in dealing with these prob- bics. Exposure in vivo leads to improvement of anxiety
lems, including assertiveness. Both the patients who and avoidance. On the other hand, assertiveness train-
had received exposure in vivo and the patients who had ing leads to more improvement than exposure in vivo
received a combined treatment consisting of exposure with respect to assertiveness. Essentially similar re-
in vivo and problem-solving training improved signifi- sults were found by Thorpe, Freedman, and Lazar
cantly after 12 treatment sessions. Subjects in the in (1985). Since assertive and unassertive agoraphobics
vivo exposure alone condition either failed to show benefited equally from exposure (Emmelkamp, 1980),
further gains at follow-up or relapsed, whereas the the best therapeutic strategy seems to be to start with
group receiving problem-solving training showed fur- exposure in vivo and, if stillnecessary, to continue with
ther improvement at follow-up. Interestingly, the latter assertive training.
patients also showed a significant change in locus of In sum, although problem-solving treatment and as-
control. Jannoun, Munby, Catalan, and Gelder (1980) sertive training alone are not very effective in dealing
investigated the effectiveness of a problem-solving with phobic anxiety and avoidance, both strategies
treatment involving the couple's discussion of life may prevent posttreatment relapse. It may be pre-
stresses and problems. Exposure in vivo was superior mature to dismiss these strategies because of their inef-
to the problem-solving treatment, but one of the two fectiveness as interventions for phobic behavior, while
therapists involved obtained unexpectedly good results ignoring their potential use as relapse prevention tech-
with problem solving. However, in a subsequent study niques. Future studies investigating the prophylactic
(Cullington, Butler, Hibbert, & Gelder, 1984), the fa- use of problem-solving and assertive training are high-
vorable results of problem solving were not replicated. ly needed.
Taken together, the results of Kleiner et al. (1987) and
the studies of the Oxford group suggest that problem
Relational Problems
solving has something to offer when added to exposure
in vivo. When this component is left out of the treat- System-Theoretical Conceptualization of
ment program, problem solving alone has not been an Agoraphobia. A number of therapists have sug-
effective treatment for agoraphobia. gested that interpersonal, particularly marital, difficul-
A number of panic patients and agoraphobics are ties play an important part in the development and
also socially anxious (Arrindell & Emmelkamp, maintenance of patients' phobic symptoms (Goldstein
1987). Although in some cases social anxiety im- & Chambless, 1978; Hafner, 1982). The partners of
proves as a result of improvement of the agoraphobia, phobics have been described as impeding or reversing
in a number of cases the social anxiety has to be dealt the positive effects of treatment or of developing psy-
with more directly. When social anxiety results from a chiatric symptoms themselves. Furthermore, it has
lack of social skills, the appropriate goal of therapy been suggested that a change in phobic symptoms
seems to be to assist patients to acquire the skills that through treatment may have a negative impact upon
they currently lack. Assuming that such lack of social the patient's marriage (e.g., Hafner, 1982). On the
skills provokes anxiety, then anxiety may be overcome basis of such clinical observations, it has been claimed
through social skills training. The aim of such training that a system-theoretic interactional approach is
is to equip agoraphobics with skills designed to facili- needed to understand the etiology and maintenance of
tate better interpersonal relations and to increase re- agoraphobia (Hafner, 1982).
sistance to relapse after termination of treatment. Fry (1962) and Hafner (1982) have suggested that
Two studies evaluated the effects of assertive train- the marital functioning and the development of symp-
ing with agoraphobics. Emmelkamp, Van der Hout, toms of agoraphobics are affected by feelings of in-
and De Vries (1983) contrasted (1) assertiveness train- feriority and inadequacy of their spouses. However,
ing, (2) exposure in vivo, and (3) a combination of findings of a study by Arrindell and Emmelkamp
assertiveness training and exposure in vivo. Only unas- (1985) indicate that partners of agoraphobics cannot be
sertive agoraphobics participated in this study. Ex- characterized as more defensive, more neurotic, more
socially anxious, or more obsessive than controls. This ment of the agoraphobic patient. Also, the male
study showed that the partners of agoraphobics were partner rated the marriage and the sexual relationship
essentially normal individuals. as unaffected by the improvement of his agoraphobic
In a subsequent controlled study, Arrindell and Em- wife.
melkamp (1986) addressed the question whether the In sum, there is little empirical support for the sys-
marital relationship of agoraphobics is qualitatively tem-theoretical conceptualization of agoraphobics. It
different from that of control couples, as suggested by should be noted that the large series of publications by
a number of authors. The results revealed that agora- Hafner (Hafner, 1976, 1977a,b, 1979, 1982, 1983,
phobics and their spouses tend to be more comparable 1984a,b; Milton & Hafner, 1979; Hafner & Ross,
to happily married subjects in terms of intimacy (e.g., 1983), purporting to demonstrate the interactional
marital and sexual adjustment and satisfaction and model of agoraphobia, are all based on only two inde-
quality of communication), whereas nonphobic psy- pendent sets of data. Ironically, their results have not
chiatric patients are more comparable to maritally dis- always been interpreted uniformly, which is rather cu-
tressed couples. Fisher and Wilson (1985) also did not rious given the interdependency of the data sets and the
find any difference in reported marital satisfaction be- relatedness of the hypotheses being tested (Arrindell et
tween agoraphobics and controls. at., 1986). The interpretations of the data in studies by
A third question that was addressed in a number of Hafner have also been heavily criticized by Stern
studies was the impact of the quality of the marital (1977), Monteiro et at. (1985), Wilson (1984), and
relationship on the outcome of behavior therapy. Pre- Kleiner and Marshall (1985).
vious studies in this area found a significant impact of In commenting on the finding of the Hafner and
relationship problems of agoraphobics on the outcome Ross (1983) study that the more friendly the partners
of behavioral treatment (e.g., Bland & Hallam, 1981; were, the less their agoraphobic wives improved,
Emmelkamp & Van der Hout, 1983; Hudson, 1974; Wilson (1984) noted: "In a manner characteristic of
Lelliot et aI., 1987; Milton & Hafner, 1979; Monteiro, Hafner's previous idiosyncratic analyses ... , Hafner
Marks, & Ramm, 1985) but others found no rela- and Ross are able to interpret the husbands' friend-
tionship between initial marital ratings and improve- liness and vigour as reflections of their "capacity to
ment (Cobb, Mathews, Childs-Clarke, & Blowers, deny aspects of their negative feelings" .... One
1984; Emmelkamp, 1980; Himadi, Cerny, Barlow, wonders how these ill-fated husbands would have been
Cohen, & O'Brien, 1986). The studies that evaluated viewed had they been unfriendly and passive" (p. 99).
the impact of marital quality on the outcome of ex- In a similar vein, Kleiner and Marshall (1985) have
posure in vivo are hampered by a number of meth- noted that Hafner seems to interpret a denial of marital
odological problems. In previous studies, the decision dissatisfaction as meaning that agoraphobics may be
to classify couples as maritally satisfied or maritally covering up real problems and have stated that discon-
dissatisfied was based on an arbitrary criterion rather firmation of this hypothesis may be hard to come by.
than on an externally validated cutoff score. Unfortu-
nately, this raises the possibility of classifying subjects Spouse-Aided Therapy. Several studies investi-
or couples erroneously as being satisfied or gated whether the involvement of the spouse as
dissatisfied. cotherapist could enhance treatment effectiveness of
In acknowledging the limitations of previous stud- exposure in vivo. A number of studies found that
ies, Arrindell, Emmelkamp, and Sanderman (1986) spouse-aided exposure therapy was no more effective
used a better alternative to trivial cutoffs for dis- than exposure conducted with the patient alone (Cobb
tinguishing satisfied from dissatisfied marriages et aI., 1984; Emmelkamp, Van Dyck, Bitter, & Heinz,
(Maudsley Marital Questionnaire [MMQ] > 20). Pa- 1990) or with the assistance of a friend (Oatley &
tients were treated by means of prolonged exposure in Hodgson, 1987). In contrast, Barlow, O'Brien, and
vivo. Results indicated that independent observers' Last (1984) found a clear superiority for the spouse-
marital rating and marital self-ratings on the MMQ aided exposure condition when compared to a non-
predicted treatment failure neither at posttest nor at spouse group on measures of agoraphobia. In general,
follow-up. Contrary to expectations from system-theo- such an approach must be discouraged when there is so
rists, agoraphobics' marriage quality and sexual rela- much animosity between the partners that homework
tionship did not deteriorate as a result of the improve- exercises are likely to lead to further arguments and
increased tension. In these instances, it is quite likely melkamp, 1982; Ley, 1985; Rapee, 1987). An increase
that treatment may exacerbate rather than alleviate the of respiratory activity is part of the normal "fight or
problems. flight" response. Because hyperventilation produces
The effects of treatment focusing on the relationship symptoms resembling those of panic attacks, it does
rather than on the phobia was investigated by Cobb, seem that the hyperventilation syndrome and panic
McDonald, Marks, and Stem (1980). Subjects were attacks bear in common the same basic features (Hoes,
both agoraphobics and obsessive-compulsives who Colla, Van Doom, Folgering, & de Swart, 1987). Pa-
also manifested marital discord. Exposure in vivo was tients may hyperventilate for a number of reasons: for
contrasted with marital treatment, and the results indi- instance, during repeated exposure to stressors or
cated that in vivo exposure led to improvements with through a faulty breathing habit. It seems reasonable to
respect to the phobic/obsessive-compulsive problems assume that persons with a bad breathing habit are
and to the marital relationship, whereas marital thera- inclined to hyperventilate when confronted with
py had effect on only the marital relationship and did stressful life events or when emotionally aroused.
not improve the phobic/obsessive-compulsive com- The concept of the vicious-circle effect may be help-
plaints. More recently, Arnow, Taylor, Agras, and ful to understand the course of the hyperventilation. A
TeIch (1985) investigated the effects of communica- hyperventilation attack results in a number of somatic
tion training with agoraphobics. Communication symptoms that are caused by a drop in arterial CO 2
training enhanced the improvement in phobic symp- levels. The individual who is unaware of the connec-
toms resulting from exposure therapy but did not affect tion between overbreathing and somatic symptoms
marital satisfaction. This is not surprising since the may misinterpret these sensations as a sign of a serious
training focused on communications about the phobia disease that leads to increased anxiety, which by itself
rather than on other relationship problems. Further- may provoke hyperventilation in the future. Although
more, only a limited number of subjects were maritally there is now evidence that some patients hyperventi-
distressed. late during panic attacks (e.g., Salkovskis, Warwick,
Clark, & Wessels, 1986), it is unlikely that hyperven-
tilation is the sole cause of these attacks in all patients.
Panic The bodily sensations may also stem from other
sources, including a pathological arousal system, hy-
Panic has received increased attention from re- poglycemia, mitral valve prolapse syndrome, men-
searchers in the behavioral field. Panic attacks have strual cycle, crowding, and (interpersonal) stress (Em-
been defined within the DSM-llI-R (American Psychi- melkamp, 1982). Central to the cognitive concep-
atric Association, 1987) as a sudden episode of fear or tualization of panic is that bodily sensations are
anxiety accompanied by at least 4 of a set of 13 symp- interpreted as dangerous. A positive feedback loop is
toms, such as dizziness, faintness, heart palpitations, postulated between physiological arousal and anxiety
and fear of dying or going crazy. that leads to an ascending "spiral" ending in the full-
In contrast to biological-oriented researchers who blown panic attack (Margraf, Ehlers, & Roth, 1986).
have begun to analyze panic attacks in terms of bio- Although these cognitive formulations of panic are
chemical components, a number of behavioral-ori- relatively new, there is already some evidence to sup-
ented researchers have stressed psychological factors port this hypothesis. For example, Hibbert (1984), Ot-
in accounting for panic attacks (e.g., Clark, 1986; taviani and Beck (1987), and Rapee (1985) found that
Griez & Van den Hout, 1983). In these models, it is cognitions of panic patients centered on illness, death,
assumed that patients misinterpret bodily sensations as loss of breath, and choking. Further, both Hibbert
a sign of a serious physical danger (e. g., a heart at- (1984) and Ley (1985) found that panic attacks usually
tack). The common element is that patients are likely started with physical sensations. Ehlers, Margraf,
to mislabel such bodily sensations and attribute them Roth, Taylor, and Birbaumer (1988) investigated the
to a threatening disease and, as a result, they may positive feedback loop between perceived physiologi-
panic. cal arousal and anxiety by false heart-rate feedback.
A number of authors have proposed that the panic Panic patients were led to believe that their heart rate
attack consists of a synergistic interaction between hy- increased rapidly; as a result, actual heart rate in-
perventilation and fear (Bass & Lelliott, 1989; Em- creased and patients became anxious, leading to a full-
blown panic attack in one patient (Margraf, Ehlers, & investigated whether agoraphobics would benefit from
Roth, 1987). Laboratory studies into the experimental breathing exercises. Breathing exercises led to normal
induction of panic by sodium lactate and CO2 inhala- breathing in the office, but did not affect anxiety and
tion are also relevant in this respect. Lactate infusions avoidance.
and inhalation of carbon dioxide induce physical Griez and Van den Hout (1983) hypothesized that
symptoms that closely resemble those of natural panic repeated exposure to an interoceptive cue by means of
attacks. These agents have been found to induce panic CO 2 inhalation would lead to anxiety reduction in pan-
attacks in panic patients but not in normals, in whom ic patients. In two studies (Griez & Van den Hout,
the effects were less marked. Biologically oriented re- 1986; Van den Hout, Van der Molen, Griez, Lousberg,
searchers argue that panic patients suffer from meta- & Nansen, 1987) CO2-induced subjective anxiety in
bolic disturbances in acid-base regulation and that patients was found to decrease as the number of CO2 -
these pathophysiological mechanisms are triggered by induced exposures to interoceptive anxiety symptoms
lactate infusions and CO2 inhalation. However, Van increased. In the Griez and Van den Hout (1986) study,
der Molen, Merchelbach, Jansen, & Van den Hout repeated CO2 exposure was compared with pro-
(1989) have argued that the different reactions of panic pranolol in a crossover study with 14 panic patients.
patients and normals are due to the fact that panic Propranolol was chosen as the control condition be-
patients typically fear bodily concomitants of arousal. cause it suppresses the interoceptive stimuli through its
For example, whether a person will experience anxiety specific blocking action. The effects of CO2 out-
or not as an effect of these panic-inducing agents seems weighed those of propranolol; the difference between
to be related to cognitive factors, such as expectations the two treatments was significant on fear of autonom-
and recall of previous experiences (Ehlers & Margraf, ic sensations and an agoraphobic avoidance. In the
1989). CO 2 condition, panic attacks declined by 50%. These
These formulations of panic have led to a renewed studies are the first controlled demonstrations of the
interest in the treatment of panic by cognitive and be- effectiveness of exposure to interoceptive stimuli.
havioral methods. The treatment approach of Clark Finally, relaxation procedures have also been evalu-
consists of explanation and discussion of the way hy- ated with panic patients. A number of clinicians are
perventilation induces panic, breathing exercises, and skeptical about the therapeutic value of relaxation with
relabeling of bodily symptoms. This package pro- panic patients because, for a number of patients, relax-
duced a substantial and rapid reduction in panic attack ation resulted in heightened anxiety (Heide &
frequency in two studies with a small number of pa- Borkovec, 1984) and even panic (Cohen, Barlow, &
tients (Clark, Salkovskis, & Chalkley, 1985; Sal- Blanchard, 1985); but in a recent controlled study,
kovskis, Jones, & Clark, 1986). However, both studies such negative effects were not reported (Ost, 1988). In
lacked a formal control group. But, as noted by the this study, 18 patients (14 panic patients and 4 gener-
authors, it is unlikely that the observed improvements alized anxiety disorder [GAD]) were randomly as-
are due to spontaneous remission as, in both studies, a signed across progressive relaxation training and ap-
stable baseline was established before treatment, and plied relaxation training. The purpose of applied
significant improvements from baseline took place in a relaxation is to teach the patient to observe the very
treatment period shorter than the baseline. A clear lim- first signs of a panic attack (small bodily sensation)
itation of this approach is that this treatment can be and to apply a relaxation technique to cope with these
applied only to patients who recognize a marked sim- symptoms before they have developed into a full-
ilarity between the effects of hyperventilation and their blown panic attack. When patients could relax, they
panic symptoms. learned to apply this treatment in vivo in anxiety /panic
Bonn, Readhead, and Timmons (1984) compared situations. With a few patients, anxiety was provoked
the effects of respiratory control treatment plus ex- in anxiety-arousing situations. Applied relaxation
posure in vivo with exposure in vivo alone. Subjects proved to be superior to progressive relaxation and led
were 12 panic patients with agoraphobia. No signifi- to clinically meaningful changes not only in reducing
cant differences were found immediately after treat- panic attacks, but also on measures of general anxiety
ment. At 6-month follow-up, however, a significant and depression.
difference emerged in favor of the combined group. Research into the cognitive-behavioral treatment of
However, the therapeutic value of breathing exercises panic is just beginning, but the results of the few stud-
without any exposure is questionable. Visser (1978) ies that have been conducted are promising. At pre-
sent, there is little evidence that one approach is supe- posure procedures. Emmelkamp, Mersch, Vissia, and
rior to the other. Although the various treatment Van der Helm (1985) compared (1) exposure in vivo,
procedures have been devised from a different the- (2) rational-emotive therapy, and (3) self-instruc-
oretical perspective, they may have more in common tional training with socially anxious outpatients. Treat-
than appears at first glance. Common elements in these ment was conducted in small groups. In the in vivo
procedures are exposure to bodily sensations (e.g., by exposure sessions, patients had to confront their feared
hyperventilating, CO2 inhalation, or direct exposure to situations in the group. For example, patients who
anxiety-arousing situations) and implicit or explicit at- were afraid of blushing had to sit in front of others with
tempts to restructure negative cognitions associated an open-necked shirt until anxiety dissipated. Others
with these bodily sensations, either by information who feared that their hands would tremble had to write
giving or cognitive restructuring. on the blackboard and to serve tea to the group. All
patients had to give speeches in front of the group. An
important part of treatment consisted of actual in vivo
Social Phobia exposure in real social situations in the town center.
Patients had to perform a number of difficult assign-
Social phobia is defined in the DSM-III-R as a per- ments, such as making inquiries in shops and offices,
sistent fear of one or more situations in which the per- speaking to strangers, or visiting bars. Role-playing
son is exposed to possible scrutiny by others and fears was not applied.
that he or she may do something or act in a way that Each of the three therapeutic procedures resulted in
will be humiliating or embarrassing. Exposure to the significant decrements in anxiety at posttesting, which
social situations (such as speaking in public, eating in were either maintained or improved upon at follow-up.
front of others, writing in the presence of others, or In contrast to the results of studies with agoraphobics,
having to answer questions) provokes an immediate where exposure in vivo was found to be significantly
anxiety response, and the situations are avoided or en- superior to cognitive interventions, the results with
dured with intense anxiety. Thus, clinical social anx- social phobics do not reveal many significant
iety is distinguished from the shyness and social anx- differences.
iety many individuals experience by the intensity of Interestingly, only the cognitive treatments revealed
the fears and the avoidance of situations involved. significant changes in cognitions as measured by the
In contrast with the numerous analogue studies that Irrational Beliefs Test, thus demonstrating the con-
deal with social anxiety, speech anxiety, dating anx- struct validity of the cognitive treatment. The differen-
iety, and unassertiveness (reviewed by Emmelkamp, tial effects found after the various treatments make an
1982; Scott, Himadi, & Keane, 1983), relatively few interpretation of the effects in terms of placebo effects
studies in the area of social anxiety have used real unlikely. Exposure was found to lead to a significant
patients. Studies using patients who are socially inade- reduction in pulse rate, which is in line with an expla-
quate or unassertive are included in the present review, nation of the effects of exposure in terms of habitua-
since most patients with social interaction difficulties tion. On the other hand, exposure did not lead to a
experience anxiety in social situations. change in irrational cognitions, although the irrational
beliefs did improve after cognitive treatment. Thus,
changes in dependent measures were restricted to
Exposure and Cognitive Therapy
those consonant with the treatment approach.
A number of studies in the 1970s have evaluated the Scholing and Emmelkamp (1989) evaluated the ef-
effect of systematic desensitization with social phobics fects of exposure in vivo, cognitive therapy, and assert-
(Hall & Goldberg, 1977; Marzillier, Lambert, & Kel- ive training in a within-subject design with nine social
lett, 1976; Shaw, 1979; Trower, Yardley, Bryant, & phobics. Thus, patients received all three treatments,
Shaw, 1978; Van Son, 1978), and the results were not but in a different order. No treatment appeared superior
impressive. In a study by Gelder, Bancroft, Gath, to the other, but each treatment enhanced the effect of
Johnston, Mathews, and Shaw (1973) with a mixed the other treatments, which suggest that a combination
sample of phobics, it was noticed that desensitization of various techniques may be considered.
appeared to lead to a particularly poor response in the Several studies have now been reported that evalu-
social phobics. ated the effects of a combined treatment consisting of a
More recently, emphasis has shifted to in vivo ex- combination of in vivo exposure and (cognitive) cop-
ing techniques. Butler, Cullington, Munby, Amies, skills training and cognitive therapy. This package was
and Gelder (1984) contrasted exposure in vivo, ex- found to result in significant clinical improvements as
posure plus anxiety management, and a waiting list compared to a no-treatment control (Kindness & New-
control group. The anxiety management package in- ton, 1984). The addition of cognitive techniques to
cluded cognitive techniques. Both treatment condi- social skills training did not enhance the effectiveness
tions were superior to controls at posttest and the 6- of social skills training (Frisch, Elliott, Atsaides, Sal-
month follow-up. At the posttest, the only difference va, & Denney, 1982; Hatzenbiihler & Schrooer, 1982;
between the treatment conditions were on two cog- Stravinsky, Marks, & Yule, 1982), but it is question-
nitive measures, which favored the combined group. able whether the subjects in these studies were truly
However, at the 6-month follow-up, the combined phobic rather than socially inadequate.
group was clearly superior to the exposure alone It should be noted that exposure in vivo may account
condition. for part of the effects achieved with social skills train-
Mattick, Peters, and Clarke (1989) investigated the ing. Modeling may be superfluous, and the effects may
effects of (1) exposure in vivo, (2) cognitive therapy, be entirely due to repeated behavior rehearsal in vivo
and (3) a combination of these two techniques. All (exposure) in the group and the structured homework
three treatments proved to be more effective than a practice involving real-life rehearsal of feared situa-
waiting list condition. There were few significant dif- tions. Further studies are needed to resolve this issue.
ferences between the three treatment groups. Results
corroborate the results of the Emmelkamp et al. (1985)
Individual Response Patterns
study in that exposure and cognitive therapy were
found to be equally effective. Interestingly, there was a The clinical studies discussed thus far grouped all
slight superiority for the combined procedure on the socially anxious patients together and ignored the role
behavioral test. In a replication of this study (Mattick of individual differences. To date, three clinical studies
& Peters, 1988), the combined treatment procedure with social phobics have been located that attempted to
was again found to be superior to exposure alone. In identify optimal matches between patient and treat-
both studies, a change between pretest and posttest on ment procedure. A research strategy that underlines
fear of negative evaluation predicted outcome at fol- the importance of individual characteristics of clients
low-up. Thus, the results of the studies by Mattick et is found in experimental designs that examine the in-
al. (1988) suggest that the thought pattern of social teraction between treatment factors and individual
phobics must change if the improvements are to en- characteristics.
dure. An integrative treatment approach addressing Ost, JerremaIm, and Jansson (1984) divided so-
both the irrational beliefs of these patients and their cially anxious outpatients into two groups showing dif-
avoidance behavior looks promising. ferent response patterns: behavioral and physiological
reactors. Within each group, half of the patients were
randomly assigned to treatment that focused on the
Social Skills Training
behavioral component (social skills training), whereas
Anxiety experienced in social situations may be the the other half received treatment that focused primarily
result of inadequate handling of these situations. The on the physiological component (applied relaxation).
skills-deficit model asserts that social anxiety results With applied relaxation, relaxation is taught as a cop-
from a lack of social skills within the patients' behaving response that was applied in vivo in role-play situa-
ioral repertoire. Some patients may lack the skills to tions. Further, patients received homework assign-
initiate conversations or to handle themselves in ments to apply the relaxation in anxiety-arousing
groups. If it is assumed that such lack of social skills situations. Thus, an active ingredient of this procedure
provokes anxiety, then anxiety may be overcome involved exposure in vivo. It was hypothesized that
through social skills training. There is some evidence patients who were treated with a method that matched
that, at least for a number of social phobics, social their response pattern would achieve better results than
skills training leads to more beneficial effects than sys- the group treated with the other method. Generally, the
tematic desensitization (Marzillier et ai., 1976; Van results supported the hypothesis.
Son, 1978) and group psychotherapy (Falloon, In a subsequent study (Jerremalm, Jansson, & Ost,
Lindley, McDonald, & Marks, 1977). 1986), socially anxious patients were classified into
Several studies investigated a combination of social cognitive reactors and physiological reactors. Here,
the hypothesis that matching treatment (cognitive ther- lication of the third edition of the DSM-ITI. PTSD may
apy, self-instructional training, and applied relaxation) follow exposure to any psychological event that is
to the individual response pattern would increase treat- "outside the usual range of experience." In the DSM-
ment effectiveness was not corroborated. Cognitive III-R definition, PTSD is considered a unitary syn-
reactors improved to the same extent with both treat- drome composed ofthree symptom clusters: (1) symp-
ment procedures; also, for physiological reactors, no toms related to reexperiencing of the trauma (night-
differential effectiveness of the procedures was shown. mares, flashbacks); (2) symptoms related to avoidance
Mersch, Bogels, Van der Sleen, and Emmelkamp of stimuli associated with the trauma and numbing of
(1987) divided social phobics into behavioral reactors, responsiveness or reduced involvement in social rela-
and cognitive reactors. Behavioral reactors were cli- tions; and (3) persistent symptoms of increased
ents whose main deficit was in the area of social skills, arousal (American Psychiatric Association, 1987).
as rated by independent raters from a videotaped social In the behavioral formulation, the development of
skills interaction test (the SSIT). Cognitive reactors PTSD is thought to be based on classical and operant
were primarily characterized by dysfunctional co~ni conditioning. According to Keane, Fairbank, Caddell,
tions, as measured by the Rational Behavior Inventory Zimering, and Bender (1985), a traumatic event acts as
(RBI). Half of the patients in each condition received an unconditioned aversive stimulus (UCS) that elicits
social skills training, whereas the other half received extreme levels of autonomic distress. Through a pro-
cognitive therapy. It was hypothesized that skills train- cess of conditioning, previously neutral stimuli that
ing would be superior for behavioral reactors and cog- accompanied the occurrence of the traumatic UCS
nitive therapy would produce better results for the cog- now may serve as conditioned stimuli (CS) capable of
nitive reactors. Contrary to expectation, both eliciting high levels of psychological and physiologi-
treatments were about equally effective on the main cal distress, which leads to escape and avoidance of
measures of social anxiety. However, some differences exposure to conditioned aversive stimuli.
were shown on specific targets on which the treatments Behavioral treatments of PTSD have usually in-
focused. There was a rather small improvement for cluded exposure, either in imagination or in vivo,
both conditions on the behavioral measure, with only sometimes added with stress management procedures.
patients receiving skills training improving signifi- Research will be reviewed separately for combat-relat-
cantly. Interestingly, cognitive reactors benefited more ed PTSD and rape-related PTSD.
from skills training than from RET on this measure.
On the cognitive measure (RBI), the behavioral reac-
Combat-Related PTSD
tors in both treatment conditions did not improve sig-
nificantly. This finding is not surprising because pa- Lang (1979) proposed that emotion is defined by a
tients in this condition already were "rational" specific information structure in memory that is orga-
thinkers. In the cognitive reactor group, however, cog- nized into an associative network. One way to access
nitive restructuring was found to be superior to skills these networks is through the use of imagery. Pitman,
training on the RBI. Orr, Forgue, De Jong, and Claiborn (1987) had Viet-
In sum, cognitive therapy, exposure in vivo, and nam veterans with PTSD and veterans with no mental
social skills training have shown promise as treatment disorder imagine combat experiences. The PTSD sub-
procedures for social phobics. When social phobics do jects' physiologic responses to their combat scenes
possess the necessary social skills, a combination of were markedly higher than the controls responses,
exposure in vivo and cognitive therapy seems to be the which suggests that imagining combat-related scenes
treatment of choice. When social phobics lack the nec- may be used to facilitate habituation. With PTSD suf-
essary social skills, treatment may focus first on the ferers, flooding in imagination (implosive therapy)
teaching of appropriate skills and may add other pro- focuses on memories of traumatic events in order to
cedures if necessary. reduce arousal to cues of the traumatic conditioning
experience. Flooding in imagination was found to be
effective in case studies by Fairbank, Gross! and Keane
Posttraumatic Stress Disorder (1983), Fairbank and Keane (1982), Foy, Donahoe,
Carroll, Gallers, and Reno (1987), Keane et al. (1985),
Posttraumatic stress disorder (PTSD) has been the and Keane and Kaloupek (1983). Johnson, Gilmore,
subject of considerable research since the 1980 pub- and Shenoy (1982) and Kipper (1977) successfully
treated PTSO sufferers with exposure in vivo to stimuli Two controlled studies used random assignment. In
associated with traumatic combat events (e.g., ban- the Frank, Anderson, Stewart, Oancu, Hughes, and
daged persons, war-related sounds). Only one con- West (1988) study, recent rape victims and late treat-
trolled study has been reported (Keane, Fairbank, Cad- ment seekers were randomly assigned to either cog-
dell, & Zimering, 1989). Flooding was found to be nitive behavior therapy or systematic desensitization.
more effective than a waiting-list control group on sub- Approximately 75% of the women applied self-di-
jective distress, not on measures of social adjustment. rected in vivo exposure to the stimuli described in each
SD session. Cognitive therapy was modeled after
Beck's approach. An important element of this treat-
ment consists of graded task assignments (exposure in
Rape-Related PTSD
vivo) to enable gradual involvement in situations or
Rape victims constitute the largest single group of tasks avoided since the assault. Ofthe 138 women who
PTSO sufferers (Steketee & Foa, 1987). Until recently, started treatment, only 84 completed it. Thus, there
therapy for rape victims consisted primarily of crisis was a very high dropout rate. Cognitive-behavioral
intervention counseling. Following the behavioral for- therapy and systematic desensitization were found to
mulation of PTSD in conditioning terms, several be- be equally effective. At the end of therapy, 67%-75%
havioral and cognitive behavioral programs have been of the treated subjects scored within one standard de-
used to treat rape victims. viation of the mean of a never-victimized control sam-
Flooding in imagination proved effective in cases of ple. In addressing the question of why cognitive thera-
sexual assault and incest (Elzinga & Emmelkamp, py and SD were equally effective, Frank et al. (1988)
1989; Haynes & Mooney, 1975; Rychtarik, Silver- noted that one essential feature of both treatments is
man, Van Landingham, & Prue, 1984). However, this the extent to which these treatments give the individual
approach has been criticized by Kilpatrick & Best participating in therapy a sense of control over her
(1984). The main criticisms were that flooding might emotional reactions. Another common element in both
result in a reduction of anxiety to forced sex and that treatments seems to be exposure to avoided situations
flooding failed to enhance coping strategies. Although in vivo.
the latter criticism is probably true, this does not di- Resick, Jordan, Girelli, Hutter, and Marhoeffer-
minish the value of imaginal flooding for rape victims Ovorak (1988) compared the relative efficacy of three
as an anxiety-reducing agent. It simply suggests that types of group therapy: stress inoculation, assertion
more needs to be done beyond anxiety reduction. Fur- training, and supportive psychotherapy. No dif-
ther, there is no evidence that flooding will result in ferences among groups were found; all three condi-
carelessness about one's safety (Steketee & Foa, tions were more effective than a waiting-list group.
1987). Controlled studies have to be conducted before In sum, cognitive-behavioral approaches have
more definite statements can be made about the value shown promise in the treatment of posttraumatic stress
of flooding for rape victims. disorders. Further controlled studies are needed to
To date, three controlled studies have been reported; come to a more balanced evaluation of the contribution
all employed cognitive-behavioral interventions. In a of these approaches to alleviating distress and to im-
study by Veronen and Kilpatrick (1983), the effects of prove social functioning of PTSD sufferers. One point
stress inoculation training (SIT) were compared with of major concern is the high dropout rate in the studies
systematic desensitization (SO) and peer counseling. reported thus far.
Rape victims who remained highly fearful 3 months
after being raped were not randomly assigned to treat-
ments but were allowed to select one of these three Generalized Anxiety Disorder
treatments. More than half of the sample rejected any
type of therapy. Most females chose SIT (n = 11), In recent years, a number of studies have been con-
none elected SO, and only three selected peer counsel- ducted that investigated the effectiveness of behavioral
ing. Notable improvements were found with those and cognitive procedures on patients who suffered
subjects who completed SIT. Clearly, with such a de- from generalized anxiety. The move toward psycho-
sign, any conclusion with respect to the effects of ther- logical treatment for generalized anxiety disorder
apy are precluded. (GAD) has been boosted by the increasing recognition
of dependence problems that are associated with but most patients received additional treatment. Jan-
benzodiazepines. noun, Oppenheimer, and Gelder (1982) investigated
the effects of anxiety management training (AMT) on
anxious outpatients. Results revealed that AMT was
Relaxation
effective in reducing anxiety and led to a marked de-
Positive results of treatment by progressive muscle crease in anxiolytic drug use as compared to a no-
relaxation for generalized anxiety have been reported treatment condition.
in a series of studies by Lehrer and his colleagues. Live AMT consisted of teaching ways of coping with
presentation of relaxation appears to be preferred to anxiety. This method combined relaxation, reassuring
tape-recorded instruction. When relaxation instruction "self-talk," and practice in the use of anxiety-provok-
is tape-recorded, this procedure appears to be ineffec- ing imagery and reassuring imagery (image switch-
tive as a method for teaching relaxation as a skill that ing). Since patients in the study of Jannoun et ai.
can be used across situations (Lehrer, 1982). (1982) found image switching difficult to carry out, in
Hoelscher, Lichtstein, and Rosenthal (1984), using an a more recent study (Butler, Cullington, Hibbert,
unobtrusive measure of compliance, found that only Klines, & Gelder, 1987) from the Oxford group, image
one fourth of the subjects performed relaxation daily. switching was removed from the treatment, and ex-
In several studies, progressive relaxation was con- posure in vivo to deal with "partial" avoidance was
trasted with meditation. Two of these studies found added. Patients in the anxiety management program
both types of relaxation training to be about equally showed highly significant changes in anxiety, depres-
effective (Lehrer, Schoicket, Carrington, & Woolfolk, sion, and problems rating, whereas patients in a wait-
1980; Woolfolk, Lehrer, McCann, & Rooney, 1982), ing list control group improved much less. About half
whereas other studies (Heide & Borkovec, 1984; of the patients had recurrent panic attacks, which fre-
Lehrer, Woolfolk, Rooney, McCann, & Carrington, quency declined substantially with treatment. This
1983) found a relatively more powerful effect of pro- finding suggests that panic attacks are merely an index
gressive relaxation over meditation. The latter studies of severity of anxiety, rather than an indication of a
involved moderately to severely anxious subjects, in distinct form of anxiety disorder.
contrast to the former studies where the anxiety level Treatment in both the Jannoun et at. (1982) and the
of the subject was lower. Finally, Long and Haney Butler, Cullington, Hibbert, Klines, and Gelder
(1988) found progressive relaxation to be no more ef- (1987) studies was individual. In the Powell (1987)
fective than aerobic exercises with working women. and the Eayrs, Rowan, and Harvey (1984) studies,
All studies involved community volunteers rather than AMT was successfully applied in a group format, but
clinical patients. the Powell study was uncontrolled. In the Eayrs et ai.
Other researchers have stressed the importance of (1984) study, AMT was compared with group relaxa-
teaching relaxation as a coping skill. Clients are tion training. Results were equivocal; both AMT and
trained to recognize the physiological cues of tension relaxation groups showed treatment gains.
and to apply relaxation whenever tension is perceived. Finally, Blowers, Cobb, and Mathews (1987) evalu-
A fundamental assumption shared by these various ated the effects of AMT, ·consisting of cue-controlled
relaxation techniques (e.g., applied relaxation, anx- relaxation and cognitive therapy based on Beck and
iety management, and cue-controlled relaxation) is Emery (1985). Although this treatment package was
that patients learn an active coping skill that they can more effective than no treatment, patients who re-
apply in a variety of anxiety-arousing situations in ceived nondirective therapy showed almost equal im-
daily life. Applied relaxation, anxiety management, provements. Results with AMT were less than in the
and cue-controlled relaxation have all been found suc- Butler, Cullington, Hibbert, Klines, and Gelder
cessful in the treatment of generalized anxiety, but (1987) study, where in vivo exposure was added to the
most of these studies have limited clinical relevance treatment package.
since student volunteers were solicited for participa- In sum, AMT has led to clinically significant im-
tion. In the last few years, a number of studies have provements with GAD patients but has not yet been
been reported using GAD patients as subjects. One found to be more effective than relaxation training and
session of applied relaxation proved superior to await- nondirective therapy. The variable results of AMT
ing list control in a study by Tarrier and Main (1986), across studies suggest that exposure may be an impor-
tant ingredient of treatment; when left out, AMT is ment, cognitive therapy, conducted according to the
hardly more effective than other approaches. guidelines given by Beck and Emery (1985), was
found to be equally effective as AMT based on relaxa-
tion. Both treatments were significantly more effective
Cognitive Therapy
than a no-treatment control group. Since clients in the
The cognitive treatment for generalized anxiety is, drug condition were essentially drug free at posttest,
to a large extent, based on research that demonstrates no meaningful comparisons between the drug condi-
the association between anxiety states and cognitions tions and the other groups are possible.
(Beck, Laude, & Bohnert, 1974; Butler, Gelder, Hib- A second study evaluating the effects of Beck and
bert, Cullington, & Klines, 1987; Hibbert, 1984; Emery's cognitive treatment was reported by Durham
Mathews, 1989). Results of these studies suggest that and Turvey (1987). The cognitive therapy included be-
thoughts related to danger are associated with the anx- havioral techniques when appropriate in the context of
iety. This finding has led to the development of treat- the cognitive model of treatment. The behavior thera-
ment approaches that directly challenge cognitions and py condition included behavioral strategies, such as
beliefs associated with anxiety. relaxation, distraction, and graded exposure, but ex-
Woodward and Jones (1980) carried out a controlled cluded any attempt to elicit or modify automatic
clinical trial investigating the effectiveness of cog- thoughts or maladaptive underlying assumptions. Re-
nitive restructuring and a modified systematic desensi- sults were modest. Despite a mean number of 13.4
tization procedure on patients with generalized anx- individual treatment sessions "virtually no patients
iety. In the cognitive restructuring group, the nature of were symptom free at 6 month follow-up, and a third of
self-defeating statements and irrational beliefs was patients at this time were not significantly different
discussed, and patients also cognitively rehearsed self- from their pre-treatment level of functioning" (p.
instructional ways of handling anxiety by means of an 233). At the end of therapy, the cognitive-behavioral
imagination procedure. Clients were asked to imagine approach was equally effective as the dismantled be-
an anxiety-provoking situation as vividly as possible havioral package. By follow-up, however, there were a
and then to replace their negative self-statements with number of significant treatment differences because of
coping self-statements. The desensitization group dif- patients in the cognitive-behavioral condition showing
fered from the cognitive group by the means of coping a tendency to maintain, or improve upon, their post-
that was employed: relaxation was used instead of cop- treatment scores, whereas behavior therapy patients
ing self-statements. In a third treatment group, both either remained at the posttreatment level or tended to
styles of coping (i.e., relaxation and cognitive self- relapse. Given the fact that there were significant pre-
statements) were trained. The combined procedure treatment differences on most measures (anxiety, de-
produced significantly greater improvements than the pression, and target problems) in favor of the cog-
other two active treatments and the control group. nitive-behavioral conditions, this study needs to be
Cognitive restructuring failed to result in any im- replicated before more definite conclusions can be
provement. drawn.
Ramm, Marks, Yuksel, and Stern (1981) also found
meager results from self-instructional training in pa-
Biofeedback
tients with anxiety states. They found only very mod-
est gains after a 6-week period of treatment. Positive A number of studies have investigated the influence
self-statement training was hardly more effective than of various forms of biofeedback (most often EMG) on
negative self-statement training. the anxiety level of anxious patients. Emmelkamp
The emphasis in the cognitive treatment of Wood- (1982) and Rice and Blanchard (1982) reviewed the
ward and Jones (1980) and Ramm et al. (1981) was on literature in this area and concluded that biofeedback
changing self-statements. To date, two studies have does not have a specific value, since other forms of
evaluated more comprehensive cognitive approaches relaxation training tend to yield comparable clinical
that emphasized insight into irrational beliefs. effects. More recent studies also found no superior
Lindsay, Gramsu, McLaughlin, Hood, and Espie effects of biofeedback training over that achieved with
(1987) evaluated the relative efficacy of cognitive-be- relaxation (Banner & Meadows, 1984; Kappes, 1983;
havioral, AMT, and psychopharmacological (Loraze- Schilling & Poppen, 1983). Thus, biofeedback is of
pam) treatment with GAD patients. At the end of treat- little utility in reducing anxiety, because EMG feed-
CHAPTER 14 0 ANXIETY AND FEAR 299
back training is no more effective than other relaxation procedures are responsible for the improvements
techniques. achieved.
Barlow et al. (1984) evaluated the effects of a com-
prehensive treatment consisting of somatically ori-
ented (EMG biofeedback and relaxation) and cog- Concluding Remarks
nitive treatment. The cognitive component of
treatment was based on stress inoculation training and The effects of in vivo exposure procedures have now
Beck and Emery's cognitive-behavioral therapy for been well established. For agoraphobics, cognitive
anxiety disorders. The treatment consisted of 18 ses- techniques have not led to clinically significant results.
sions over a l4-week period. Compared to waiting list With social phobics, however, cognitive procedures
controls, treated patients improved on overall clinical may enhance the effects of exposure procedures, al-
ratings as well as on physiological measures, daily though definite conclusions cannot yet be drawn.
self-monitored measures of background anxiety and Since there is a wide variety of cognitive techniques
panic, and questionnaire measures of anxiety. In- available, careful consideration needs to be given to
terestingly, there were no significant differences in the specific techniques applied. The finding that cog-
outcome across diagnoses, since patients with gener- nitive procedures dealing with irrational beliefs are
alized anxiety disorder and patients with panic disor- effective with socially anxious patients and obsessive-
der responded equally well to treatment. It is unclear compUlsives (Emmelkamp, Visser, & Hoekstra, 1988)
which specific component of the treatment package is but not with agoraphobics and simple phobics (Biran
responsible for the improvement achieved. It should & Wilson, 1981; Emmelkamp & Felten, 1985; Ladou-
be noted that reductions in muscle tension were not ceur, 1983) suggests that irrational beliefs are causally
associated with clinical improvement, which suggests linked with the former but not with the latter
that the somatically oriented treatments (which focus conditions.
on such reductions) did not contribute very much to the In recent years, the interest in the behavioral treat-
overall result of this program. ment of posttraumatic stress disorders has increased.
In sum, results of studies into cognitive therapy with The studies that have been conducted suggest that both
GAD patients are inconclusive. Initial studies pri- (imaginal) exposure procedures and cognitive coping
marily focusing on changing self-statements led to strategies may alleviate the suffering, but at present
meager results. More recent studies using the more only few controlled studies have been reported.
comprehensive cognitive-behavioral approach of Knowledge about the treatment of panic disorder
Beck and Emery (1985) found this approach no more and generalized anxiety disorder is preliminary. Al-
effective than AMT or behavior therapy at the end of though various therapies have shown promise in the
treatment. Only one study found the cognitive-behav- treatment of anxiety states, there is little evidence that
ioral approach superior to a behavioral approach, but one approach is superior to another. Although re-
this effect was found only at follow-up. Unfortunately, searchers have shown an increased inter.::st in these
the groups in this study were not comparable before disorders, the clinical studies that have been conducted
treatment. do not reveal a consistent picture. Different treatments
Terminology in this area is confusing, to say the for generalized anxiety and panic disorders vary in
least. Pure "cognitive" therapy has not yet been tested terms of how readily they can access and modify differ-
with patients with generalized anxiety. Beck and ent features of anxiety. Where and how a treatment
Emery's cognitive therapy is an amalgam of cognitive interacts with the anxiety of a patient to produce the
and behavioral techniques. Behavioral procedures in- most change may be at the level of somatic processes
clude graded task assignments, entering feared situa- (hyperventilation exercises) or at other levels (e.g.,
tions (exposure in vivo), and self-monitoring. These information processing). Change at any level will most
behavioral strategies are selected to help the client dis- likel y be associated with change in other features of the
confirm previously held beliefs. Thus, behavioral anxiety system. As has been noted, some emerging
change is viewed as essential in order to change cogni- developments are promising, but much more research
tions. However, by confounding cognitive and behav- needs to be done in order to understand these disorders
ioral procedures, it becomes impossible to substantiate and to be able to devise specific therapeutic ap-
the claim of proponents of the cognitive approach that proaches.
the cognitive procedures (in contrast to behavioral) The three-system model views fear as an amalgam
of loosely coupled, partially independent tripartite re- licate this finding. Finally, Michelson, Mavissakalian,
sponse systems, which has led to a plea for tripartite and Marchione (1988) found that consonant patients
measurement (TPM) of anxiety. What evidence is improve more than nonconsonant patients. However,
available that TPM is indeed necessary to evaluate the given their definition of consonance (completion of the
treatment of anxiety disorder? It should be noted that a behavioral test, mean subjective anxiety [0-10] during
number of clinical researchers have criticized the ne- the behavioral test :S 3.0 and mean heart rate during
cessity of assessing all three channels routinely with the behavioral test :S 130) this is hardly a surprising
phobics (Emmelkamp, 1982; Mathews et al., 1981). finding. Their analysis simply shows that patients who
Most studies have used electrocardiogram (ECG) as a are improved on these measures are indeed improved
measure of physiological arousal. However, as found on these and other measures that are highly correlated
by Arena, Blanchard, Andrasik, Cotch, and Myers with them. Given the status of research in this area,
(1983), such a measure appears to be highly unrelia- any recommendation with respect to the clinical use of
ble. An even more relevant study, using agoraphobics heart rate, synchrony/desynchrony, and concordance
as subjects, was reported by Holden and Barlow data with respect to anxiety disorders seems prema-
(1986). In measuring heart rate during a standardized ture.
behavioral test, as typically done in outcome studies, Although it is often acknowledged that effective
they found that heart rate decreased significantly, not clinical behavior therapy is only as good as its initial
only with agoraphobics but also with normal controls. behavioral analysis, this issue has been neglected by
This study and research by Fowles (1986) suggest that researchers in the field of anxiety disorders. The pre-
other processes than anxiety or emotional processing dominant type of outcome research involved between-
of fear are measured, for example, novelty effects. group studies that compared different procedures or
Holden and Barlow (1986) found that heart rate was treatment components. In these group designs, within-
quite unreliable, both for agoraphobics and normals, group variance is perceived as an unfortunate occur-
with test-retest coefficients ranging from .40 to .60. rence rather than as a major source of relevant informa-
Although such a low reliability precludes the use of tion (Emmelkamp & Foa, 1983). Controlled single-
heart rate as a measure of clinical change in the anxiety case research (which has hardly been reported in the
disorders and as a predictor of treatment response, a last decade), focusing on the responsiveness of an indi-
number of researchers have used heart rate for such vidual to a given intervention, does not provide infor-
purposes and the results of these studies have, not sur- mati'Jn about the generalizability of the results ob-
prisingly, led to more questions being raised than an- tained. A convergence of the generalization and
swered. Two studies (Michelson & Mavissakalian, individualization approaches is found in some experi-
1985; Michelson, Mavissakalian, & Marchione, 1985) mental designs that examine the interaction between
found that synchrony at pretreatment was associated treatment factors and individual characteristics. The
with greater improvement at posttreatment as well as at results of studies along this line are promising.
follow-up, but others found no such relationship
(Mavissakalian, 1987; Vermilyea, Boice, & Barlow,
1984). Furthermore, Mavissakalian (1987) compared References
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havior Modofication, 2,41-60.
CHAPTER 15
Obsessional-Compulsive Disorders
Gail Steketee and Laura Cleere
Description and Classification Several authors have noted that the content of clinical
obsessions differs little from intrusive thoughts or wor-
Definition ries exhibited by normals, although the former
provoke more anxiety and are less easily dismissed
Clinical accounts of obsessive-compulsive disorders
(Dent & Salkovskis, 1986; Rachman & DeSilva,
(OCD) have appeared in the literature for well over 100
1978; Salkovskis & Harrison, 1984).
years. First described by Esquirol in 1838, OCD was
not formally documented or defined until the begin-
ning of this century (Janet, 1903; Lewis, 1935; Prevalence
Schneider, 1925). Both cognitive and behavioral com-
Although early surveys estimated the prevalence
ponents have traditionally been included in the concep-
rate ofOCD in the general population at .05% (Rudin,
tualization of OCD.
1953; Woodruff & Pitts, 1964), a recent study placed
This disorder is characterized by recurrent obses-
this rate at approximately 2.5% (Robins et al., 1984).
sions or compulsions that cause severe distress or sig-
Women exhibited the disorder slightly more often than
nificantly interfere with the individual's normal level
men, but no difference in racial or age distribution was
of functioning. The Diagnostic and Statistical Manual
observed (Myers et al., 1984).
of Mental Disorders (DSM-III-R) (American Psychi-
atric Association, 1987) defines obsessions as per-
sistent ideas, thoughts, impulses, or images that are Classification
experienced as intrusive and senseless. The individual
recognizes that the obsessions are the product of his or Traditional categories of obsessive-compulsive
her own mind. Compulsions are described as repetitive symptomatology were phenomenological in nature,
intentional behaviors that are performed in response to usually focusing on the ritualistic behaviors or on the
an obsession, and are carried out according to certain content of the ruminative material. This is exemplified
rules or in a stereotyped fashion. These behaviors are in the division of obsessive-compulsive patients into
specifically designed to neutralize discomfort or pre- " was hers, " " chec kers, " " orderers, " "repeaters,"
vent a dreaded event. The activity may not be related to and the like. Although many patients manifest more
what it is designed to prevent, but it is clearly excessive than one type of ritualistic behavior, in most cases one
and the individual recognizes its unreasonableness. type prevails. Washing and cleaning appear to be most
common, with checking rituals also prevalent (Stem &
Gail Steketee and Laura Cleere - School of Social Work Cobb, 1978). "Repeaters" appear to be a subgroup of
Boston University, Boston, Massachusetts 02215. ' checkers who repeat an action, usually a specified
307
"magical" number of times, in order to prevent a par- leviate obsessional fear. Obsessions and compulsions,
ticular disaster from occurring. Unlike checkers, how- then, can be divided into several different kinds. Ob-
ever, their rituals are not related to feared conse- sessions may be prompted by external (environmental)
quences in a direct, rational way. A fourth group of or by internal (thoughts, images) fear cues and mayor
patients manifest ordering rituals in which certain ob- may not include fears of potential disasters. To relieve
jects must be arranged in a particular way to achieve a anxiety, individuals may simply avoid the feared situa-
satisfying state of symmetry or balance. Disturbance tion or stimuli (passive avoidance) or perform overt or
of this order provokes extreme discomfort, but no spe- covert rituals (active avoidance) to restore safety or
cific type of consequences is usually feared. Although prevent harm (Rachman, 1976b). This definition is
Greenberg (1987) differentiated "hoarders" from consistent with the behavioral model of obsessive-
other obsessionals, they can be viewed as another sub- compulsive disorders and the treatment interventions
type of OCD whose rituals are designed to prevent the that have been derived from this model.
loss of potentially important objects or information. A
rare category of "obsessional slowness" has been sug-
Relationship to Other Disorders
gested by Rachman and Hodgson (1980). These pa-
tients carry out every day grooming and other activities Some authors argue that the labeling of OCD as a
with meticulous care and many hours of effort. neurosis has led to the overlooking of the delusion-
Other writers have attempted to provide a classifica- al/psychotic aspects of the syndrome (Insel & Akiskal,
tion system of OCD based on the form or the content 1986; Perse, 1988). These authors hypothesize that
(e. g. , religious, aggressive) of the obsessions (Akhtar, OCD represents a spectrum of psychopathological dis-
Wig, Verma, Pershad, & Verma, 1975; Capstick & orders varying along a continuum, with patients at the
Seldrup, 1973; Dowson, 1977). Such systems have not far end of the spectrum having an "obsessive-com-
generally been adopted. pulsive psychosis." Both Foa (1979) and Perse (1988)
A shortcoming inherent in the above described clas- have reported on OCD patients with overvalued idea-
sifications of OCD is that they fail to bear directly on tion who did not respond to behavior therapy or anti-
treatment strategies. Rather, a classification based on depressant medication. The latter author suggested
the types of cues that evoke anxiety and on the type of that patients like this belong in a separate diagnostic
activity (cognitive or behavioral) that reduces it allows category, somewhere between OCD and delusional
the clinician to relate typology to treatment. Conven- psychoses.
tional formations of OCD have typically referred to OCD should be distinguished from obsessive-com-
thoughts, images, and impulses as obsessions, where- pulsive personality (OCP), which is characterized by
as repetitious overt actions have been defined as com- orderliness, rigidity, indecisiveness, and perfec-
pulsions. This modality-based distinction poses se- tionism. Whereas these traits are not rare in individuals
rious conceptual problems. For example, one number with OCD, they are not characteristic of them, appear-
(e.g., 13) may provoke anxiety, whereas a different ing in 25% or fewer of such patient samples (Black,
number relieves it. Both are mental representations but 1974; Rosenberg, 1967; Steketee, 1988b). A dis-
serve quite different functions. tinguishing feature is that the repetitive acts of patients
To address this problem, Foa and TiIImanns (1980) with OCD are ego alien rather than syntonic, as is
proposed a definition based on the functional rela- characteristic of those with OCP. Some authors also
tionship between obsessive-compulsive symptoms suggest that only some of the compulsive personality
and anxiety. They defined obsessions or ruminations traits may be associated with OCD symptoms
as thoughts, images, or actions that generate anxiety. (Guidano & Liotti, 1983; Steketee & Foa, 1985). So
Compulsions were conceived of as attempts to reduce far, the nature and extent of the relationship between
anxiety aroused by the obsession; they could take the traits and symptoms is unclear (Pollack, 1979; Slade,
form of either overt actions or covert cognitive events. 1974; Steketee & Foa, 1985).
As noted by Rachman (1976a), these two types of re- Hypochondriasis, anorexia nervosa, and bulimia
sponses are functionally equivalent in that both reduce have also been identified as sharing major features
fear. Thus, the obsessive-compulsive syndrome con- with OCD. The mental preoccupation with health/
sists of a set of events that are anxiety evoking and are bodily damage and fatness or fullness is qualitatively
labeled obsessions and a set of behaviors and cogni- similar to obsessional fears of OCD patients. The hy-
tions called compulsions which are performed to al- pochondriac's repeate<i requests for reassurance from
CHAPTER 15 • OBSESSIONAL-COMPULSIVE DISORDERS 309
physicians resembles checking compulsions and may differences increased with the complexity of the task
serve to maintain the obsessive hypochondriacal fears (Beech, Ceiseilski, & Gordon, 1983). Differences
(Salkovskis & Warwick, 1986). The bulimic's vomit- from normals and from other neurotic patients were
ing and purging constitute a type of active avoidance or also evident when other sensory stimuli (visual, au-
ritual which relieves discomfort. Behavioral treat- ditory, and tactile) were employed (Shagass et at.,
ments similar to those found effective for OCD have 1985). A recent study using PET-scan technology
also proven useful for anorexia and bulimia (e.g., clearly differentiated OCD from depressed patients
Rosen & Leitenberg, 1982). and from normals (Baxter et at., 1987).
The above findings regarding brain wave activity
clearly indicate that OCD patients differ from other
Biological Factors
populations. Whether such differences are indicative
Several biological factors have been implicated in of biological causality or are merely consequences of
the development of OCD. The number of reports ap- the disorder cannot be inferred from the data. Re-
pearing in the literature on monozygotic twins concor- gardless of the etiologic pathway, treatment outcome
dant for this disorder points to a possible genetic factor (via drugs or psychological methods) may not neces-
in its etiology (Black, 1974; Marks, 1986), although sarily depend upon the mode of acquisition of the OCD
the influence of environment cannot be extracted from symptoms (Kettl & Marks, 1986). Unfortunately, few
these reports. Parents and siblings of obsessive-com- efforts have been made to determine whether treatment
pulsives show a higher incidence of this disorder in effects vary with the patient's medical history or bio-
contrast to psychiatric controls, but only a small per- logical characteristics.
centage did so: 2% to 10% of parents and siblings
(Marks, 1986). A genetic connection between Gilles
de la Tourette's syndrome and OCD has been clearly Assessment
supported in recent investigations (Pauls, Towbin,
Leckman, Zahner, & Cohen, 1986; Pitman, Green, Ideally, measurement of obsessive-compulsive
Jenike, & Mesulam, 1987), and it has been suggested symptomatology should assess obsessions and com-
that the same genetic factor underlying these disorders pUlsions separately, as well as mood state and general
may be manifested differently depending upon other functioning. Assessment of obsessions should include
biological (e.g., gender, disease processes) and en- information about external sources of fear, internal
vironmental factors. Genetic transmission, then, ac- triggers for fear (thoughts, images, or impulses) and
counts for a small but significant portion of the vari- fears of disastrous consequences that may follow
ance in the development of OCD. failure to carry out compulsions. The amount of pas-
With regard to physical causes, several organic sive avoidance behavior associated with obsessional
manifestations exhibited by OCD patients have been thoughts, as well as behavioral and cognitive compul-
documented, including tremor, facial rigidity, and ex- sions, should also be examined. In order to better un-
cessive hyperactivity (Schilder, 1938). Higher rates of derstand the mechanisms underlying various treatment
birth abnormalities, history of encephalitis (Capstick procedures, measures of specific OCD manifestations
& Sheldrup, 1977; Guirdham, 1972) and neurological are essential. Several instruments to assess obsessional
illnesses (Grimshaw, 1964) compared to normals sug- fear, anxiety, avoidance, and compulsions have been
gest a possible etiological role of early traumatic or developed, although reliability and validity have been
disease processes. investigated for only a few.
Abnormal electroencephalograph (EEG) patterns The main fears associated with obsessions (e.g.,
have been observed in several investigations (e.g., contact with toilets) have been assessed on Likert-like
Flor-Henry, Yendall, Koles, & Howarth, 1979; scales adopted from studies of phobics (Watson &
Pacella, Polatin, & Nagler, 1964; Shagass, Roemer, Marks, 1971). Such measures are more suitable for
Straumanis, & Josiassen, 1985). McCarthy and Foa washers, whose main fear component is contact with
(1989) suggested that these findings point to frontal discrete external stimuli, than for checkers, whose ob-
lobe dysfunction during cognitive processing efforts of sessive thoughts are centered primarily on fears of po-
OCDs. With regard to evoked potentials, obsessional tential catastrophies. Behavioral measures of the de-
patients differed from controls during cognitive ac- gree of passive avoidance (number of steps completed
tivity (Ceiseilski, Beech, & Gordon, 1981), and these and subjective anxiety experienced in specific feared
situations) have been utilized by only a few investiga- versions of 39 items (Marks, Hallam, Connolly, &
tors (e.g., Marks, Hodgson, & Rachman, 1975; Philpott, 1977) and 38 items (Freund, Steketee, & Foa,
Steketee & Foa, 1985). 1987) have been used. The Compulsive Activity
Behavioral measures of the frequency and duration Checklist (CAC), as it has recently been labeled, has
of ritualistic behavior typically request the patient to been found to detect changes following treatment
record the number of minutes spent on compulsive (Freund et al., 1987; Marks, Stem, Mawson, Cobb, &
activity (Emmelkamp & van Kraanen, 1977; Foa, McDonald, 1980) and to meet acceptable validity but
Steketee, & Milby, 1980). However, noncompliance, not reliability criteria (Cottraux, Bouvard, Defayolle,
problems in time sampling, and the reactive effects of & Messy, 1988; Freund et al., 1987). A shortened
self-monitoring by itself render this measure prob- version of the CAC has been proposed (Cottraux et al.,
lematic. Despite problems of reliability and validity 1988), and further tests are currently being carried out.
for research purposes, daily completion of a self- The Maudsley Obsessional Compulsive Inventory
monitoring form provides useful clinical insight into (MOCI) is composed of 30 true/false questions con-
the patient's daily routine and may help generate hy- cerned exclusively with symptom dimensions
potheses about external influences on compulsive (Hodgson & Rachman, 1977). In addition to a general
behavior. obsessive-compulsive score, this inventory yielded
Of the standardized instruments devised to evaluate five subscales (checking, cleaning, slowness, doubt-
OCD symptoms, the Ley ton Obsessional Inventory ing conscientiousness, and ruminating) and was found
(LOI) (Cooper, 1970) has been the most widely used to have adequate validity and reliability (Rachman &
until recently. A card-sorting procedure measuring Hodgson, 1980). Like the CAC, its focus on OCD
symptom, trait, resistance, and interference, this in- symptoms to the exclusion of personality traits has
strument has shown adequate discriminant validity and rendered this instrument useful in the assessment of
test-retest reliability (Emmelkamp, 1982). It has been treatments directed at obsessional and compulsive
criticized for its inadequacy in assessing intrusive symptoms.
thoughts and washing rituals and for the interdepen- The newly developed Padua Inventory (PI) is a 60-
dence of its four scales. A shortened lO-item paper- item measure of common obsessional and compulsive
and-pencil version of this inventory, the Lynnfield Ob- behavior (Sanavio, 1988). Tested on a normal and ob-
sessional Compulsive Questionnaire, was developed sessional Italian population, item consistency and reli-
to circumvent the cumbersome administration pro- ability were satisfactory, and convergent and discrimi-
cedure required by the Ley ton inventory and to better nant validity were demonstrated. Further research
assess obsessional ruminations (Allen & Tune, 1975). using this instrument is needed to determine its utility
Despite evidence of its satisfactory reliability and va- relative to the now widely used MOCI, which to date
lidity, this version has not been widely adopted. has best withstood critical analysis of reliability and
The Sandler Hazari Obsessionality Inventory validity.
(Sandler & Hazari, 1960) assesses both obsessional
traits and symptoms, but has failed to discriminate
patients from controls and has questionable validity Behavioral Theory
(see Emmelkamp, 1982, for review). Similarly, the
obsessive-compulsive subscale of the Hopkins Symp- Mowrer's (1939) two-stage theory for the acquisi-
tom Checklist has been found inadequate with regard tion and maintenance of fear and avoidance behavior
to some aspects of its reliability and validity (Steketee has been commonly adopted to explain phobic and
& Doppelt, 1986). The Minnesota Multiphasic Per- obsessive-compulsive disorders (Dollard & Miller,
sonality Inventory (MMPI) yields what has been la- 1950; Mowrer, 1960). This theory postulates that a
beled an obsessive-compulsive profile, but its validity, neutral event becomes associated with fear by being
too, has been questioned. Doppelt (1983) found that paired with a stimulus that by its nature provokes dis-
neither scale elevation nor code (personality) types of comfort or anxiety. Through an associative process,
the MMPI predicted outcome for obsessive- concrete objects as well as thoughts and images ac-
compulsives. quire the ability to produce discomfort. In the second
Philpott (1975) developed an obsessive compulsive stage of symptom development, escape or avoidance
checklist administered by an assessor to evaluate the responses are developed and maintained by their abil-
degree of impairment in 62 daily activities. Shortened ity to reduce the anxiety or discomfort evoked by the
various conditioned stimuli. Because many of the fear- procedures to reduce anxiety associated with obses-
provoking situations of obsessive-compulsives cannot sions, as well as ways to block ritualistic behavior.
readily be avoided, passive avoidance behaviors are Variants of exposure and blocking procedures have
ineffective in controlling anxiety. Active avoidance been used for both obsessionals and for overt ritu-
patterns in the form of ritualistic behaviors are then alizers. Exposure techniques, such as systematic de-
developed. sensitization, paradoxical intention, flooding, and sa-
Support for the fear acquisition stage of this model is tiation, require the patient to confront anxiety-evoking
inadequate (e.g., Rachman & Wilson, 1980). Many material, either in vivo or in imagination. Blocking, on
patients cannot recall conditioning events associated the other hand, interrupts the patient's ruminations or
with symptom onset, although onset often follows ritualistic behaviors via such procedures as thought
stressful life events. Watts (1971) has suggested that stopping, aversion, distraction, and response preven-
these events may serve to sensitize the individual to tion.
cues that have an innate tendency to elicit fear, and
Teasdale (1974) has proposed that anxiety responses
Exposure Procedures
learned during early experiences may be enhanced by
stress. Similarly, Rachman (1971) posited that for ob- Procedures directed at obsessional anxiety were
sessive-compulsives, a state of heightened arousal based on the rationale that once obsessional cues cease
could lead an individual to associate arousal to to generate anxiety, compulsive behavior will ex-
thoughts that have special significance. It is not unrea- tinguish because it will no longer be reinforced by its
sonable to presume that heightened physiological ability to reduce anxiety. One procedure to reduce anx-
arousal (Boulougouris, 1977) combined with general iety, systematic desensitization, consists of the pairing
stressors and specific fear cues may produce OCD of a relaxed state with presentations of anxiety-evoking
symptoms. items arranged in a hierarchical order (Wolpe, 1958).
Although factors related to the acquisition of an ob- Ritualistic behavior is not addressed. Results of multi-
sessive-compulsive disorder are uncertain, there is ev- ple case studies using desensitization were uniformly
idence to suggest that obsessions give rise to anx- poor: 30% to 40% were improved with imaginal pro-
iety/discomfort and compUlsions reduce it. Rumina- cedures (Beech & Vaughn, 1978; Cooper, Gelder, &
tive thoughts increase heart rate and skin conductance Marks, 1965). In vivo desensitization led to a some-
more than neutra~ thoughts (Boulougouris, Rabavilas, what better rate of improvement, with 7 of 11 patients
& Stefanis, 1977; Rabavilas & Boulougouris, 1974), (64%) showing benefits. A report by Walton and
and contact with contaminants resulted in increased Mather (1963) indicated there may be some justifica-
heart rate and subjective anxiety (Hodgson & tion for the use of desensitization with patients whose
Rachman, 1972), as well as skin conductance onset of symptoms is recent.
(Hornsfeld, Kraaimaat, & van Dam-Baggen, 1979). In Several procedures utilizing more prolonged ex-
most instances, anxiety decreased following the per- posure have been employed with ritualizers. In a single
formance of a ritual (Hodgson & Rachman, 1972; case, Noonan (1971) successfully employed "induced
Hornsveld et al., 1979; Roper & Rachman, 1976; anxiety," which required the patient to experience in-
Roper, Rachman, & Hodgson, 1973). tense anxiety and to describe the images that arose
spontaneously. A related approach, paradoxical inten-
tion, typically involves instructing the patient to delib-
Behavioral Treatment erately increase the frequency or intensity of prob-
lematic thoughts or behaviors; deliberate attempts to
Traditional psychodynamic and hospital milieu evoke humor may be included. Gertz (1966) reported
forms of psychotherapy have proven only moderately that all six of his patients improved or recovered, but
effective in ameliorating obsessive-compulsive symp- Sol yom and his colleagues obtained only a 50% im-
tomatology; improvement rates have ranged from 20% provement rate in 10 patients (L. Solyom, Garza-Per-
to 40%, with slightly higher figures found in outpatient ez, Ledwidge, & C. Solyom, 1972). Another similar
settings (Black, 1974). Improvement in the prognostic procedure, satiation, was studied in comparison to
picture emerged with the use of behavioral techniques thought stopping. In this treatment, patients were
derived from the conceptualization of OCD discussed asked to repeat their ruminations aloud or in writing for
earlier. Treatment based on this model should include I-hour periods. In two series of cases, only one of
three patients (Emmelkamp & Kwee, 1977) and two of Blocking procedures have frequently been em-
seven patients (Stem, 1978) improved with satiation. ployed with obsessionals in an attempt to reduce dis-
Satiation combined with aversion relief led to a better turbing cognitive material. McGuire and Vallance
response according to Solyom, Zamanzadeh, Led- (1964) delivered shock to a patient upon deliberate
widge, and Kenny, (1971). A taped narrative of the elicitation of ruminative material relating to distrust of
obsessions was periodically interrupted by brief si- his wife. Three sessions of treatment followed by 10
lences followed by a mild electric shock. When the days of home practice (self-delivery of shock) were
patient terminated the shock, the taped obsessional quite effective in controlling these obsessions. Single-
material resumed. All four patients were improved and case studies by Bass (1973) and Mahoney (1971) indi-
recovered at follow-up. cated that obsessions could be reduced by using an
Rabavilas, Boulougouris, and Stefanis (1977) em- aversion method that involved instructing patients to
ployed an exposure technique to treat overt rituals snap a rubber band against their wrist whenever obses-
rather than obsessions. Four patients with checking sional thoughts occurred.
rituals were instructed to ritualize repeatedly, beyond Thought stopping is another blocking technique
their urge to do so. Although none of the patients fol- used for obsessions. Stem (1970) successfully treated
lowed the instructions, all showed marked improve- a patient by arranging the obsessions from least to most
ment at follow-up; their rituals decreased by two disturbing and instructing the patient to shout "stop"
thirds. How these instructions succeeded is unclear, upon the evocation of an intrusive rumination. Both
since no actual overexposure occurred, but the results Yamagami (1971) and Gulick and Blanchard (1973)
are sufficiently intriguing to warrant replication. also achieved good results by applying procedures that
In summary, variations of prolonged exposure seem included thought stopping among other treatments.
to have limited effects on obsessions although positive However, the specific contribution of thought stopping
results have been obtained with an aversion-relief pro- to the patient's gains appeared to be limited. Further,
cedure. Residual effects of exposure on ritualistic be- only one third of the patients' in multiple-case reports
havior appear to be limited. and controlled studies have benefitted from this pro-
cedure (Emmelkamp & Kwee, 1977; Stem, 1978;
Stem, Lipsedge, & Marks, 1975), suggesting limited
Blocking Procedures
efficacy of thought stopping with obsessions. By con-
Theoretically, if compulsions are maintained be- trast, aversion techniques have produced a more con-
cause they are effective in decreasing discomfort, they sistent positive picture, with successful outcomes re-
should extinguish if they become associated with an ported in five of six single-case studies and in five of
increase rather than a decrease in discomfort. Lazarus six patients in a controlled trial.
(1958) reported a successful outcome by pairing anx-
iety induction with images of checking rituals. The use
Comparisons between Exposure and Blocking
of an aversion-relief paradigm, in which shock fol-
Procedures
lowed rituals and ended when the patient touched con-
taminants, led to some improvement in case studies, To date, three studies have compared the results of
although compulsions were not entirely eliminated exposure and blocking treatments with obsessionals.
(Marks, Crowe, Drewe, Young, & Dewhurst, 1969; Fifty-one volunteer subjects who scored high on anx-
Rubin & Merbaum, 1971). In a study of aversion pro- iety and on obsessions were treated by five sessions of
cedures with no relief, obsessions and compulsions systematic desensitization, covert sensitization, or
were divided into component steps that were then both (Kazarian & Evans, 1977). All three groups im-
imagined by the patient and followed by shock (Kenny, proved equally on measures of obsessions and were
Mowbray, & Lalani 1978). Three of five patients treat- significantly better than two control groups at post-
ed by this method improved. Blocking techniques with treatment and a 5-week follow-up. Studying actual pa-
the use of aversion, then, have generally yielded good tients, Emmelkamp and Kwee (1977) compared five
results. However, Walton (1960) reported relapse in sessions of thought stopping with five sessions of pro-
cases in which only the behavioral responses were longed imaginal exposure in a crossover design. Three
treated, suggesting that merely punishing the ritu- of their five patients improved equally with either pro-
alistic behavior associated with negative affect may cedure, and the remaining two failed to improve re-
result in relapse. gardless of the treatment applied. Results at variance
with these were reported by Stern (1978), who com- niques have resulted in satisfactory outcome. The con-
pared the efficacy of an intense exposure procedure ceptualization of obsessions as anxiety-evoking phe-
(satiation) with thought stopping. Only two of seven nomena and of rituals as anxiety-reducing efforts
patients who received exposure followed by thought suggests that procedures which reduce anxiety should
stopping improved. Stern attempted to explain the be applied to the former, whereas blocking strategies
poor outcome by suggesting that only horrific obses- are appropriate for the latter. Both strategies should be
sions would be affected by prolonged exposure that required for patients with obsessions and compulsions.
allows for habituation of anxiety. However, Em- In the above research, rarely were treatment methods
melkamp and Kwee's results indicated that their pa- applied differentially and simultaneously.
tients suffered from horrific obsessions and were af-
fected equally by exposure and thought stopping.
Treatment by Exposure and Response
New avenues for the treatment of obsessions have
Prevention
been explored in two studies. Five obsessionals were
trained using biofeedback to generate EEG alpha The combining of exposure for obsessions with re-
waves which were experienced as a relaxed, day- sponse prevention for compulsions was frrst attempted
dreaming, or "blank mind" state (Mills & Solyom, by Meyer in 1966. In this program, rituals were pre-
1974). Four of five patients reported no obsessions, vented while the patient was required to remain in
and the remaining patient reported only a few during circumstances that normally evoked anxiety and con-
the alpha state. However, this effect did not generalize sequent ritualistic activities. Of 15 patients treated in
to ruminations occurring in the nonalpha state, nor did this way by Meyer and his associates (Meyer & Levy,
the amount of alpha waves produced appear to be relat- 1973; Meyer, Levy, & Schnurer, 1974), 10 were rated
ed to success in reducing obsessions. In the second much improved or symptom free and the remaining 5
study, two female volunteers were trained to ruminate were moderately improved. Only 2 relapsed after 5 to
under hypnotic suggestion (Barone, Blum, & Porter, 6 years. These remarkable results generated great in-
1975). Four variants of blocking procedures for reduc- terest in this combined treatment program.
ing obsessions were tested; the blank mind state was Results of research using exposure and response
found to be the most consistently useful in eliminating prevention for obsessions and compulsions are sum-
obsessions and preventing their spontaneous reoccur- marized below and in Table 1. Studies conducted on
rence. Such investigations may eventually provide a inpatients at the Maudsley Hospital in London provide
basis for the development of new procedures. much of the available data about these procedures
(Hodgson, Rachman, & Marks, 1972; Marks et al.,
1975; Rachman, Hodgson, & Marks, 1971; Rachman,
Summary
Marks, & Hodgson, 1973). Variants of exposure in
Included in the foregoing review are numerous re- vivo were compared with relaxation training in con-
ports on the effects of several variants of exposure and junction with response prevention in the treatment of
blocking procedures on ritualizers and obsessionals. 20 obsessive-compulsive inpatients. After 15 sessions
Yet the conclusions that can be derived from this body of the exposure regimen, 8 patients were much im-
of research are at best equivocal. With few exceptions, proved, 7 were improved, and 5 failed to show change.
these investigations have failed to distinguish between By contrast, relaxation training had no effect. At a 2-
effects of the treatment on obsessions and on ritualistic year follow-up, 14 patients remained much improved,
behavior. Without such information, it is difficult to 1 was improved, and 5 were unchanged. Similar re-
determine the differential utility of each procedure. Of sults with 10 washers were reported by Roper,
further concern is the fact that much of the available Rachman, and Marks (1975). In this study, 5 patients
information has been derived from single-case studies. received 15 daily sessions of treatment in which they
Although these are useful for generating hypotheses observed the therapist modeling exposure to disturbing
and developing procedures, they cannot test a treat- objects (passive modeling). The 5 control subjects
ment's efficacy. were treated with 15 sessions of relaxation exercises.
If information from case reports are not included, Both groups were then given 15 additional sessions of
the rather sparse body of literature on the treatment of in vivo exposure (participant modeling) and response
ritualizers with exposure procedures is disappointing. prevention. At the end of treatment, 3 patients were
For obsessionals, neither blocking nor exposure tech- much improved, 5 were improved, and 2 remained
Table 1. Results of Studies Using Variant of Exposure/Response Prevention Treatment
Number of
~
treatment Follow-up I--'
Study Number of cases sessions period Outcome at posttreatment Outcome at follow-up ~
Meyer, Levy, & 15 2 weeks-2 5-6 years 20% no symptoms 17% no symptoms
Schnurer months 47% much improved 50% much improved
(1974) 33% improved 17% improved
17% relapsed
Marks, Hodgson, 20 15 2 years 40% much improved 70% much improved
& Rachman 35% improved 5% improved
(1975) 25% no change 20% no change
Roper, Rachman, 10 15 6 months 30% much improved 40% much improVed
& Marks 50% improved 40% improved
(1975) 20% no change 20% no change
Marks, Bird, & 13 14 (mean) 6 months Statistically significant improvement
Lindley (1978)
Marks, Stem, 20 (of 40) (ex- 15 (10 patients) 1.2 years Statistically significant improvement
Mawson, posure without ~
i-3
Cobb, & drug)
McDonald -<
-
(1980) •
Rabavilas, 12 8 6 months 50% improved 50% improved
Boulougouris, (mean) 33% slightly improved 33% moderately improved
~
trl
& Stefanis 17% no change 17% no change ~
trl
(1976) :z
i-3
Boulougouris 15 (includes 12) 11 (mean) 2.8 years 87% improved 60% improved
(1977) from above ~
-
study) ~
1::1
Boersma, Den 13 15 3 months 54% no symptoms
trl
=
Hengst, Dek- 23% improVed
ker, & Em- 23% no change
melkamp -i~
(1976) (')
Emmelkamp & 13 10 3.5 Statistically significant improvement in group means

van Kraanen ~
C'l
(1977) ~
Emmelkamp, van 15 10 6 months Statistically signficant improvement in group means g
der Helm, van
Zanten, &
~
rI)
Plochy (1980)
Foa & Goldstein 21 10 (18 patients) 3 years Rituals Obsessions Rituals Obsessions
(1978) 15 (3 patients) 85% no symptoms 57% 79% no symptoms 63%
n
10% much improved 10% 0% much improved 5%
0% improved 28% 10% improved 16% >
=
5% no change 5% 11 % no change 16% ~
trl
~
Foa, Steketee, 15 (includes 7 10 9 months Statistically significant improvement in groups means ...
UI
Turner, & from Foa &
Fischer (1980) Goldstein, •
1978) 0
t:=
r;r.,
Foa, Steketee, & 8 20 0 64% much improved 57% much improved trl
r;r.,
Milby (1980) 36% moderately improved 14% moderately improved r;r.,
....
0
20% slightly improved Z
Foa, Grayson, 50 (includes 37 10-20 I year (range 58% much improved 59% much improved
>
t'"'
Steketee, Dop- from preceding 3 months- 38% improved 17% much improved h
0
pelt, Turner, & studies) 3 years) 4% failed 24% much improved ~
Latimer (1983) ~
t'"'
r;r.,
Julien, Riviere, & 18 20 (mean) I year (mean 67% much improved 39% much improved ....
Note (1980) (range 6 28% improved 28% much improved -<
trl
months-3 5% no change 33% no change 1::1
....
r;r.,
years) 0
~
Foa, Steketee, 38 15 16 months 45% much improved 32% much improved 1::1
trl
Kozak, & Mc- (mean 53% improved 50% improved ~
r;r.,
Carthy (1989) (range 9 2% no change 18% no change
months to
2 years)
Emmelkamp, 42 10 3.5 years (2 57% much improved
Visser, & to 6 years) 24% improved
Hoekstra 19% no change
(1988)
Hoogduin & 60 10 78% improved > 30%
Duivenvoorden 22% unimproved
(1988)
Hoogduin & 25 20 (mean) 3-24 months 80% much improved 80% much improved
Hoogduin 3-80 (range) 14.5 months 4% improved 4% improved
(1984) (mean) 16% unimproved 16% unimproved
Marks, Lelliott, 10 (of 49) 10 (mean) 1 year Statistically significant im- 50% much improved
Basoglu, (exposure wlo 4-19 (range) provement in group 30% improved
Noshirvani, drug) for entire means 20% no change U.l
Monteiro, sample of 49 I--'
V1
Cohen, & Kas-
vikis (1988)
unchanged; similar results (4 much improved, 4 im- tients were asymptomatic after treatment; 8 were
proved, 2 unchanged) emerged at follow-up. mildly to moderately symptomatic; and 1 failed to
In two studies by Boulougouris and his associates change. At follow-up, 2 patients relapsed. Their re-
(Boulougouris & Bassiakos, 1973; Rabavilas, Boulou- sults suggest greater efficacy of this treatment with
gouris, & Stefanis, 1976), an average of 11 sessions of compulsions than with obsessions, a finding borne out
in vivo and imaginal exposure plus response preven- in subsequent studies of both exposure therapy and
tion produced good results: 13 patients improved after pharmacotherapy.
treatment, whereas 2 remained unchanged. A long- To date, prolonged exposure and response preven-
term follow-up of these patients proved disappointing: tion have been used to treat well over 200 obsessive-
6 of the 15 patients failed to exhibit treatment gains compulsive ritualizers. Most of the data have been
(Boulougouris, 1977). derived from group studies rather than single-case re-
Emmelkamp and his colleagues conducted three ports, adding confidence to the findings. The remark-
studies with OCD outpatients using 10 to 15 sessions able convergence of results from these studies, con-
of in vivo exposure and blocking of compulsions. In ducted in many centers with numerous therapists,
the first study 7 patients were symptom free, 3 were further attests to the generalizability of the treatment
improved, and 3 were unchanged at posttest, and sim- effects. It seems, then, that exposure and response pre-
ilar findings emerged at follow-up (Boersma, Den vention can be considered the psychological treatment
Hengst, Dekker, & Emmelkamp, 1976). Emmelkamp of choice for obsessive-compulsive ritualizers.
and van Kraanen (1977) reported a significant mean Treatment in most of these studies was conducted
reduction in symptoms for their 13 patients, with 2 daily and often in a hospital setting. Can the mere
failing to benefit and 6 requiring additional sessions. intensity of the treatment account for its superior re-
Emmelkamp, van der Helm, van Zanten, and Plochg suits? This does not seem to be the case. In each of the
(1980) treated 15 OCD patients and obtained gains Maudsley studies, treatment by exposure and response
comparable to those reported in the Maudsley studies. prevention was compared with an equivalent amount
Some relapse was evident at follow-up, and patients of relaxation training. The latter method proved inef-
required additional treatment sessions. In discussing fective in ameliorating obsessive-compulsive symp-
these results, the authors suggested that 10 sessions of tomatology. Still, it is possible that other variables,
exposure and response prevention might not ade- such as expectancy, may have played a role in outcome
quately protect patients against future relapse. in the Maudsley studies which did not assess this issue.
Julien. Riviere, and Note (1980) provided further However, in a study examining the separate and com-
support for the effectiveness of exposure and response bined effects of exposure and response prevention,
prevention: two of their 20 patients dropped out of Steketee, Foa, and Grayson (1982) controlled for ex-
treatment, 12 were much improved, 5 were moder- pectancy as well as the frequency and duration of treat-
ately improved, and 1 remained unchanged. Like the ment. None of these accounted for the superior results
Emmelkamp et al. findings, follow-up assessments obtained by the combined procedure.
conducted 6 months to 3 years after treatment indi- Meyer's original treatment consisted of two basic
cated some relapse. Excellent results were reported by components: exposure to discomfort-evoking stimuli
Catts and McConaghy (1975) with 6 obsessive-com- and prevention of ritualistic responses. Subsequent
pulsives: After treatment 4 were rated as improved on studies have shed some light on the ways in which
ritualistic behavior, 1 was judged much improved, and these two procedures should be administered.
one became asymptomatic. Further improvement in
both rituals and obsessions was noted at follow-up The Form of Exposure: Imaginal versus in
evaluations 9 to 24 months later. Vivo. Early reports on the effect of the modality in
Somewhat more detailed information about the ef- which exposure was delivered to OCD patients were
fects of exposure and response prevention on obses- conflicting. Stampfl (1967) successfully treated a pa-
sions and compulsions separately was provided by Foa tient by imaginally exposing him to his most feared
and Goldstein (1978). After 10 sessions of imaginal situation. Yet. Rachman. Hodgson. and Marzillier
and in vivo treatment, 18 of their 21 patients were (1970) concluded that implosion had no therapeutic
symptom free on measures of rituals, 2 had improved, effect on washing rituals, whereas exposure in vivo
and 1 remained unchanged. At follow-up, 3 relapsed to combined with modeling produced good results. Sub-
various degrees. With regard to obsessions, 12 pa- sequently, Rabavilas et al. (1976) examined the impact
of different fonns of exposure on obsessive-com- However, when exposure was imaginal, the length of
pulsive symptoms in a controlled trial. In vivo ex- time did not produce a different outcome.
posure proved significantly more effective in reducing
obsessive-compulsive symptoms than exposure in fan- Gradual versus Rapid Exposure. Desensitiza-
tasy. Only one study has found imaginal exposure as tion is based on the supposition that anxiety reduction
effective as actual exposure, but this was attributed to is best achieved by gradual exposure to discomforting
the in vivo practice between sessions given to all pa- stimuli so that only low levels of fear are experienced.
tients (Matthews et aI., 1976). However, the speed of presentation of the most dis-
Most of the studies have focused on the modality turbing stimuli has not proved to be a salient variable in
rather than the content of the exposure procedure and the treatment of obsessive-compulsives. Hodgson et
its relevance to the patient's symptomatology. When al. (1972) exposed patients gradually to discomfort-
exposure in fantasy includes only concrete tangible evoking situations after they watched the therapist
cues, it merely mimics exposure in vivo situations. model each step. Other patients were exposed immedi-
Therefore, it is not surprising that the latter technique ately to the most feared situation, again after watching
is often more effective. However, for many neurotic the therapist model exposure. The two procedures
patients, anxiety is generated by both tangible environ- were equally effective, although patients reported feel-
mental cues and thoughts of possible disasters following more comfortable with the graduated approach.
ing exposure to such cues (e.g., death, disease, burgla-
ry, house burning down, etc.) If it is important to Exposure with and without Modeling. Roper
match the content of the exposure to the patient's inter- et al. (1975) found that although some reduction of
nal fear model, as Lang (1977) has suggested, then obsessive-compulsive symptomatology was obtained
checkers whose rituals center around responsibility for with passive modeling, participant modeling and re-
potential catastrophes should improve more when sponse prevention yielded considerably better results.
imaginal exposure to these stimuli is added to in vivo However, these findings are difficult to interpret be-
exposure to external tangible cues. cause this study is confounded by the inclusion of re-
To test this hypothesis, Foa, Steketee, Thrner, and sponse prevention instructions with participant but not
Fischer (1980) assigned 15 patients with checking ritu- with passive modeling. In an earlier study, Rachman et
als and fears of disastrous consequences to one of the al. (1973) compared flooding in vivo with and without
following two conditions: imaginal and in vivo ex- modeling and found no differences between treat-
posure, plus response prevention (Group 1), and ex- ments. Similar results were obtained in a study by
posure in vivo only combined with response prevention Boersma et al. (1976), who found that only the degree
(Group 2). Contrary to their hypothesis, both groups of avoidance related to secondary compulsions was
improved considerably after treatment but did not dif- affected by modeling. As noted by Marks et al. (1975),
fer significantly. However, follow-up data indicated this does not imply that certain individuals cannot ben-
that those who were given imaginal and in vivo ex- efit from modeling. Indeed, some patients have re-
posure retained their gains better than did those who ported that modeling by the therapist assisted them in
received exposure in vivo alone. Thus, exposure to overcoming their resistance and fear of exposure.
disastrous consequences affected maintenance of gains
rather than immediate fear reduction. Imaginal ex- Therapist Role. Therapist qualities of warmth,
posure seems to be a valuable addition to in vivo treat- genuineness, and empathy have long been recognized
ment for patients with fears of disastrous conse- as important components of any psychotherapeutic in-
quences. tervention (e.g., Truax & Carkuff, 1967). Infonnal
observations led Marks et al. (1975) to suggest that
Duration of Exposure. Studies with both animal exposure and response prevention treatment "requires
and volunteer subjects suggest that prolonged ex- a good patient-therapist working relationship and a
posure to fear-provoking stimuli is superior to brief sense of humor helps patients over difficult situations"
exposure. Rabavilas et al. (1976) examined the differ- (p. 360). It is common to find that patients can con-
ential effects of long versus short exposure in fantasy taminate themselves following the therapist's instruc-
and in vivo with obsessive-compulsives. He reported tions but have been unable to do so previously when
that 80 min of continuous in vivo exposure proved urged by their relatives. Research findings by
superior to eight lO-min segments of exposure in vivo. Rabavilas, Boulougouris, and Perissaki (1979) indi-
cated that OCD patients who rated their therapist as variants of response prevention. Some studies (e.g.,
respectful, understanding, interested, encouraging, Meyer et al., 1974) have utilized very strict response
challenging, and explicit improved more. On the other prevention including continuous observation and turn-
hand, gratification of dependency needs, permis- ing water faucets off; others have been more lenient. Is
siveness, and tolerance were negatively related to out- one method more effective? The effect of supervised
come. response prevention versus mere instructions to refrain
Although the personal style of the therapist seems to from ritualizing was studied with five obsessive-com-
be an important variable, his or her presence during pulsive washers (H. L. Mills, Agras, Barlow, & 1. R.
exposure does not appear to have a significant impact Mills, 1973). Instructions alone reduced compulsions,
on outcome. Emmelkamp and van Kraanen (1977) but complete elimination of rituals was not obtained
compared 10 sessions of self-controlled in vivo ex- until strict supervised response prevention was imple-
posure with an equivalent number of sessions in which mented. Indeed, most of the failures reported by
the therapist controlled the exposure. No differences in Rachman et al. (1973) and Marks et al. (1975) were
outcome were found on obsessive-compulsive symp- attributed to patients' inadequate compliance with re-
tomatology, although the latter group required more sponse-prevention instructions. It seems, then, that al-
treatment sessions at follow-up than the former. The though strict supervision may not be necessary for
authors suggested that the self-controlled exposure most patients, it may facilitate adherence to the treat-
group may have gained greater independence in han- ment regimen for some and may result in a more com-
dling their fears. Marks and his colleagues observed plete elimination of ritualistic behavior.
that adding therapist-aided exposure after 8 weeks of A considerably less strict form of response preven-
self-exposure instructions conferred only transient tion has been called "response delay." For a patient
benefits that were lost at week 23 (Marks et al., 1988). who did not respond to in vivo or verbal exposure,
The findings of these studies do not suggest that thera- Junginger and Turner (1987) found that requiring a
pists are dispensible, but do indicate that in vivo ex- waiting period between the occurrence of obsessional
posure may be implemented without their immediate thoughts and compUlsive checking produced positive
presence. results. This response delay procedure was effective in
In view of the evident potency of exposure in treat- eliminating obsessional thinking of ll-years' dura-
ing anxiety-based disorders, the failure to detect dif- tion. Without further controlled study of such a pro-
ferences between variants of exposure may be due to a cedure, it cannot be recommended, though it may
ceiling effect. The number of subjects per cell in the prove helpful for some recalcitrant patients who are
above studies is quite small, permitting only powerful unwilling to engage initially in complete response
effects to be detected. Thus, the results cannot be in- prevention.
terpreted as evidence that variables, such as therapist
presence, rapidity of presentation, and so forth, do not Concomitant Treatments. It is commonly noted
impact at all on treatment outcome, but they do not that obsessive-compulsive symptoms have a negative
appear to be critical. Additionally, response prevention effect on the afflicted person's general functioning,
was implemented simultaneously with deliberate ex- including marital and social adjustment. Although se-
posure and may have further obscured differences vere marital problems are often seen in conjunction
among variants of exposure. From a clinical stand- with this disorder, Marks (1981) has noted that the
point, the therapist may begin treatment by conducting presence of marital problems does not make exposure
some exposure in office and then assign exposure be- treatment inadvisable. In fact, Cobb, McDonald,
tween sessions. Only if the patient has serious diffi- Marks, and Stem (1980) found that exposure treatment
culty should he or she insist on being present through- improved both obsessive-compulsive symptoms and
out treatment. Gradual exposure is likely to be marital problems, whereas marital treatment alone im-
preferred by patients, unless circumstances require proved only the couple relationship. Assertiveness
more rapid confrontation. Modeling may be used training produced favorable results with patients who
wherever patients feel it would be helpful. had obsessions about harming others and was found at
least as effective as thought stopping (Emmelkamp &
Response Prevention Variants. Although differ- van der Heyden, 1980). However, since thought stop-
ential effects of several variants of exposure have been ping did not yield impressive results, the com-
studied, relatively little attention has been directed to parability of assertiveness training does not recom-
mend it as an effective strategy. When used in has it yielded inferior results with ruminators? One
conjunction with exposure procedures, assertiveness possibility is that "pure" ruminators, who do not have
training and marital therapy may provide useful ad- behavioral compulsions, have cognitive compulsions
juncts (e.g., Queiroz, Motta, Madi, Sossai, & Boren, that remain undetected and therefore untreated with
1981). response prevention. That is, anxiety-evoking ob-
sessive thoughts are interspersed with cognitions that
briefly ameliorate anxiety. Prolonged exposure to the
Differential Effects of Exposure and Response
entire chain in such cases might fail on two counts: (1)
Prevention
it might serve to strengthen rather than extinguish the
Exposure and response prevention have typically rituals through their repeated evocation and the conse-
been employed in tandem, and thus, the separate effect quent negative reinforcement; and (2) the frequent in-
of each procedure could not be ascertained. Because terruption of the obsessions by cognitive rituals may
this treatment program is stressful, it is important to prevent prolonged exposure and thus interfere with
ascertain whether both procedures must be applied. anxiety reduction. Blocking strategies would be
Theoretically, exposure should be needed to reduce needed specifically for the cognitive compulsions. In-
anxiety associated with obsessions. Because ritualistic deed, in two cases where obsessions and cognitive
behavior terminates confrontation with the anxiety- compulsions were treated differentially with exposure
evoking stimuli, it should be simultaneously blocked for the former and blocking for the latter, successful
to permit extinction of anxiety reactions. outcomes were observed (Rachman, 1976a).
In case studies, response prevention reduced com-
pulsions, whereas exposure alone did not (Mills et at.,
Processes during Exposure
1973), nor did the addition of exposure further reduce
them (Turner, Hersen, Bellack, Andrasik, & Cap- Data collected in various clinical studies reveal a set
parell, 1980). As to anxiety, some reduction was evi- of responses occurring in patients who improve during
dent during response prevention, with further im- exposure treatment that may indicate processes under-
provement resulting from flooding. To investigate this lying treatment efficacy. Foa and Kozak (1986) have
question in a between subjects design, Foa, Steketee, argued that evidence from both clinical outcome stud-
and Milby (1980) assigned 8 OCD washers to either ies and laboratory experiments point to the validity of
exposure alone followed by exposure plus response the following indicators. First, the physiological and
prevention (Group A), or to response prevention alone verbal responses of successful patients evidence ac-
followed by the combined treatment (Group B). After tivation of anxiety during exposure. Second, their re-
the first phase, Group B washed significantly less than actions decrease gradually (habituate) within exposure
Group A, and this difference disappeared after re- sessions. Third, initial reactions to feared situations
sponse prevention was implemented for the latter decrease across exposure sessions.
group. With regard to subjective anxiety, Group A
(exposure only) reported significantly less discomfort Reactivity. In regard to the first indicator, activa-
to contaminants than did Group B. Again, after the tion, Lader and Wing (1966) found that complex pho-
addition of prolonged exposure, the groups did not bics (agoraphobics, social phobics, persons with anx-
differ; both showed significant reduction in subjective iety states, etc.) were more aroused (as evidenced by
anxiety. In a second study conducted to assess the dif- more spontaneous fluctuations, higher skin conduc-
ferential effects of treatment components at follow-up, tance level, and higher pulse rate) and habituated more
32 washers were assigned to exposure in vivo alone, to slowly than did simple phobics; the latter, in turn, were
response prevention alone, or to the combination(Foa, more aroused and habituated more slowly than nor-
Steketee, Grayson, Turner, & Latimer, 1984). As in mals. Phobic subjects who profited most from system-
the previous study, anxiety to contaminants was re- atic desensitization showed increased heart rate during
duced mainly by exposure, whereas ritualistic behav- the initial feared images; weak reactors benefited less
ior was affected more by response prevention. Com- from such treatment (Borkovec & Sides, 1979; Lang,
bined treatment led to the best results. Thus, separate Melamed, & Hart, 1970). Similarly, physiological re-
mechanisms appear to operate in the two treatment sponsiveness during prolonged exposure to feared sit-
modalities. uations or images was positively related to the out-
If exposure reduces obsessions in ritualizers, why come of treatment for specific phobics and
agoraphobics (Watson and Marks, 1971). In exploring Shahar and Marks (1980) observed marked reduction
process variables during exposure treatment, Foa, of heart rate and subjective anxiety across sessions,
Grayson, Steketee, Doppelt, Thrner, and Latimer when both the beginnings and ends of the two exposure
(1983) observed that the degree of habituation within periods were compared in two OCD patients. Such
and between sessions was mediated by the intensity of decrement of subjective anxiety and physiological re-
the anxiety response (reactivity) to the most feared sponses across sessions has been observed in several
item; the greater the initial subjective fear, the less studies, even though increasingly difficult situations
patients habituated. Further, heart-rate response at first were added in the course of treatment (Chaplin &
presentation of the most feared situation was moder- Levine, 1980; Foa & Chambless, 1978; Foa et aI.,
ately positively correlated with outcome on nearly all 1982; Hafner & Marks, 1972; Shahar& Marks, 1980).
measures of obsessive-compulsive symptoms accord- Foa, Grayson, et at. (1983) found across-session sub-
ing to a study by Kozak, Foa, and Steketee (1985). By jective anxiety to be positively related to treatment
contrast, subjective anxiety ratings taken at the same benefit: greater habituation was associated with more
time were not significantly associated with outcome, change. Similar results were obtained by Kozak, Foa,
perhaps because nearly all patients reported very high and Steketee (1988) for cardiac responses. Reduction
anxiety levels, thus reducing the range of scores on this in heart-rate response from the beginning of session 6
variable. These findings suggest that the degree of to the beginning of session 14 (the last session), was
arousal plays a role in the outcome of exposure positively related to reductions in all target OeD
treatments. symptoms. Habituation of subjective anxiety ratings
across sessions was also positively related to reduced
Habituation. Evidence for the second indicator, fear and avoidance but not to reductions in ritualistic
habituation within sessions, is derived from several behavior. The above discussed reports argue for the
sources. When exposure was delivered imaginally, importance of subjective and physiological habitua-
similar patterns of response decrement were observed tion processes in determining the outcome of exposure
for heart rate in phobics (Borkovec, 1972; Mathews & treatment.
Shaw, 1973) and for subjective anxiety in both ob-
sessive-compulsives and agoraphobics (Foa & Cham- Associated Factors. Variables that affect habitua-
bless, 1978). With regard to in vivo exposure, tion, and therefore outcome, have been examined in
Grayson, Foa, and Steketee (1982) reported heart-rate several studies. Grayson and colleagues observed that
reduction for 16 obsessive-compulsive washers ex- habituation of heart rate was greater when attention
posed for 90 min to contaminants under distraction and was focused on the feared object rather than distracted
attention conditions. Within-session habituation was from it (Grayson et at., 1982; Grayson, Steketee, &
also reported by Shahar and Marks (1980) for both Foa, 1986). Their findings suggest that greater benefit
heart rate and subjective anxiety and by Foa, Grayson, from exposure is likely to accrue from focusing on
and Steketee (1982) for subjective anxiety. Similarly, feared situations or thoughts than from avoiding them.
Likierman and Rachman (1980) observed decrement Foa (1979) noted that although most obsessive com-
of subjective discomfort and urges to wash during six pulsives evidenced habituation both within and across
consecutive exposure sessions, with faster reduction sessions, some did not manifest either type, and for
evident in later sessions. Discomfort decreased more some, anxiety decreased within but not across ses-
rapidly than urges to wash in the first few sessions, sions. The reverse was not observed: no patient habitu-
suggesting a desynchrony between these two subjec- ated across but not within sessions. These observations
tive phenomena. It appeared that higher initial levels suggest that the two types of habituation are interde-
may require a longer period to decline. pendent, and that each may be governed by separate
A decrease in anxiety has been observed not only mechanisms. In commenting on short- and long-term
within, but also across sessions. Habituation across (or habituation, Groves and Lynch (1972) noted that the
between) sessions has been defined in several ways: two may involve different brain functions. It may be
(1) the difference between the initial level of one ses- that the reduction of fear within sessions involves the
sion and the initial level of the next; (2) the difference autonomic nervous system, whereas long-term habitu-
between the final level of one session and the initial ation is influenced more by cognitive processes.
level of the next; or (3) the difference between the final Foa, Grayson, et al. (1983) found that depressed
level of one session and the final level of the next. patients habituated less within and across sessions and
gained less from treatment. Perhaps depression affects sized the erroneous beliefs of obsessive-compulsives,
outcome by its impact on autonomic processes that including ideas that one must be perfectly competent in
increase arousal and inhibit its reduction. Depressive all endeavors, that failure to live up to perfectionistic
cognitions may impede long-term learning required ideas should be punished, and that certain actions can
for habituation across exposure sessions. prevent catastrophes. Such mistaken beliefs, they sug-
Little information is available regarding generaliza- gested, lead to erroneous perceptions of threat, which,
tion of habituation effects. In a single case study con- in tum, provoke anxiety. Coupled with tendencies to
ducted by Moergen, Maier, Brown, and Pollard devalue their ability to deal adequately with such
(1987), habituation to the visual form of the number 13 threats, these ideas result in feelings of pervasive un-
generalized to auditory, behavioral, and cognitive certainty, discomfort, and helplessness. Rituals are
forms of the number. More information on factors af- viewed by the patient as the only available method for
fecting generalization of exposure benefits to other less coping with the perceived threat, since other more ap-
closely related obsessional fears is needed. For exam- propriate coping resources are lacking. In line with this
ple, some patients show a chronic symptom course in conceptualization, Beech and Liddell (1974) proposed
which the content of obsessive fears has periodically that ritualistic behaviors are maintained not only to
changed. Will exposure to current fear cues generalize reduce immediate discomfort, but also to address the
to other potential fear stimuli, or must the patient be obsessive-compulsive's need for certainty before ter-
exposed to more general "risk-taking" situations to minating an activity. Likewise, Guidano and Liotti
achieve lasting gains? (1983) have suggested that strong perfectionistic be-
The preceding discussion suggests that in planning liefs in the potential for a correct solution to all situa-
exposure treatments, attempts should be made to in- tions characterize these patients.
crease the reactivity of avoiders and decrease the Experimental findings lend some support to the
arousal level of overreactors. The techniques used to above assertions. Obsessive-compulsives were ob-
regulate arousal levels will undoubtedly vary from one served to catalogue events discretely without being
patient to the next. For example, excessive reactors able to link concepts integratively, thus creating "is-
might receive exposure with distraction, whereas low lands of certainty" amid confusion, in an effort to con-
reactors might be treated with attention-focusing pro- trol and predict events (Makhlouf-Norris, Jones, &
cedures. Such techniques as relaxation prior to ex- Norris, 1970; Makhlouf-Norris & Norris, 1972). Reed
posure might be employed to increase attention found that the thinking of obsessive-compulsives was
(Rachman, 1980). Clomipramine has been found help- characterized by underinclusion or overspecification
ful in enhancing the effects of behavior treatment with of concepts (Reed, 1969), and attributed their doubt
depressed obsessive-compulsives (Marks et al., and indecision to a distrust of their own conclusions
1980). Whether some drug treatments confer addi- (Reed, 1968). Consistent with these findings, Persons
tional benefits by decreasing initial reactivity to dis- and Foa (1984) observed that ritualizers utilized over-
comforting stimuli and thereby promoting habituation specific concepts in their thought patterns with respect
is unknown. to both obsessional and neutral cues. A greater tenden-
cy of obsessive-compulsives than other psychiatric pa-
tients to request a repetition of information before ren-
Cognitive Theory and Treatment dering a decision has also been observed (Milner,
Beech, & Walker, 1971; Volans, 1976). Findings from
Cognitive Features of OCD
an analogue study of checkers indicated that memory
It is apparent from the phenomenology and descrip- deficits may motivate repetitious checking behavior
tion of OCD that patients with this disorder exhibit (Sher, Frost, & Otto, 1983).
significant disturbances in cognitive functioning. In an The above findings suggest that obsessive-com-
attempt to explain obsessional symptoms, Carr (1974) pulsives are more rigid, perfectionistic, and doubting,
proposed that such individuals overestimate the risk of requiring excessive amounts of information to make a
negative consequences for a variety of actions. Obses- decision, only to distrust their choice. These observa-
sional content typically includes exaggerations of nor- tions must be interpreted with some caution, however,
mal concerns regarding health, death, other's welfare, since several of the studies by Reed included indi-
sex, religious matters, performance at work, and so viduals who seemed to have a compulsive personality
forth. McFall and Wollersheim (1979) also empha- style rather than OCD, and the study by Sher and col-
leagues was not conducted with patients seeking treat- 10 obsessional volunteers. Cognitive therapy (disput-
ment for their checking symptoms. ing irrational beliefs and making rational analyses of
Foa and Kozak (1986) have conceptualized anxiety obsessional situations) did not improve OCD symp-
disorders as specific impairments in affective memory toms or alter cognitions, according to Emmelkamp. In
networks. Neurotic fears, they proposed, are charac- another study by Emmelkamp and his colleagues, 18
terized by the presence of erroneous estimates of patients were assigned to either rational emotive thera-
threat, unusually high negative valence for the threat- py (RET) or self-controlled exposure in vivo (Em-
ening event, and excessive response elements (e.g., melkamp, Visser, & Hoekstra, 1988). Both treatments
physiological, avoidance, etc.). The persistence of improved OC symptoms, and RET also decreased de-
such fears may result from failure to access the fear pression and irrational beliefs. No differences were
network, either because of active avoidance or because found between conditions and results were maintained
the content of the fear network precludes spontaneous at a 6-month follow-up. This study is the first to show
encounters with situations that evoke anxiety in every- that a cognitive treatment alone was clinically bene-
day life. Additionally, anxiety may persist because of ficial for OCD. It utilized a treatment that was perhaps
some impairment in the mechanism of change. Cog- more appropriate for the cognitive dysfunctions found
nitive defenses, high arousal, faulty premises, and er- in OCD, such as perfectionism, errors in beliefs about
roneous rules of inference might hinder the processing danger, and the like.
of information necessary for changing the fear struc- It seems unlikely that a cognitive treatment could
ture. produce gains which exceed those already achieved by
These authors suggest that no single type of fear exposure treatment, particularly for ritualistic behav-
structure is common to all obsessive-compulsives. ior. A treatment tailored specifically for correcting
Most, however, base their beliefs about danger on the cognitive distortions typical of OCD may, however,
absence of evidence that guarantees safety; further, slightly enhance immediate outcome or reduce relapse
they fail to assume general safety from specific experi- in the obsessional aspect of this disorder. Longer trials
ences of exposure to feared situations in which no harm with larger sample sizes, comparing exposure with ex-
occurred. Consequently, although rituals are per- posure plus specialized cognitive correction, are
formed to reduce the likelihood of harm, they can nev- needed at this point. However, Reed (1985) has pro-
er really provide safety, and therefore must be repeat- posed that cognitive procedures, such as those outlined
ed. Evidence supporting these suggestions has not yet by Ellis (1962) and Beck, Rush, Shaw, and Emery
been presented. (1979), may be inappropriate for treating obsessive-
compulsives who, by definition, recognize their ob-
sessions as irrational and are characteristically over-
Cognitive Treatment
controlled. Treatment, he suggests, should include the
Only a few studies have applied cognitive theories "de-emphasis of the thought and the reduction of at-
regarding dysfunctional thought processes to treat- tention paid to it" (p. 213).
ment strategies for OCD. The cognitive interventions
employed represented attempts to modify thoughts,
belief systems, and irrational ideas and have been de- Combined Behavioral and
livered in conversational form. Studying 15 patients, Pharmacological Treatment
Emmelkamp et al. (1980) compared graded exposure
in vivo with exposure preceded by self-instructional The present chapter is focused on the phe-
training. Both treatments produced significant im- nomenology and behavioral treatments for OCD.
provement in both groups, and no differences between However, because mental health care providers are
conditions were found at posttreatment or at follow-up. increasingly focusing on the effects of biological treat-
The cognitive technique did not appear to enhance the ments on OCD, a brief discussion of recent develop-
efficacy of exposure. This treatment, however, cannot ments in drug plus behavior therapy is presented here.
be said to be specific to the types of cognitive deficits All but one of these studies have utilized antidepres-
posited for oeD. sant drugs that block the receptakes of serotonin, in-
Emmelkamp (1982) reported results of a study by cluding clomipramine, fluvoyamine, and fluoxetine.
Bleijenberg (1981), in which exposure therapy and ra- In an uncontrolled study, Neziroglu (1979) treated
tional therapy were compared in a crossover design for 10 patients with clomipramine followed by behavioral
treatment. Clomipramine decreased symptoms over amine and behavior therapy that contrasted three
baseline by 60%, with a further improvement of 19.7% groups: (1) drug and exposure, (2) drug and instruc-
observed following behavioral treatment. Since de- tions to avoid, and (3) placebo and exposure. There
pression was not measured, its role in the drug ac- was some evidence for a stronger effect of the drug
tion could not be assessed. Sookman and Solyom over exposure on depressed mood, but little difference
(1977) compared clomipramine with behavioral treat- among groups was apparent on OCD symptoms. Com-
ment, concluding that the drug was as effective as be- bined treatment showed a significant advantage over
havior therapy in reducing ruminations but not in ame- the exposure only group on measures of depression but
liorating rituals. However, no statistical tests were on only two of nine measures of OCD symptoms.
conducted on the data, and again, measures of depres- Overall percentage reductions were slightly higher in
sion were not collected. Amin, Ban, Pecknold, and the combined group. These findings contrast with
Klinger (1977) also examined the separate and com- those of Marks et at. (1988), who found that clo-
bined effects of clomipramine and behavior therapy. mipramine conferred no advantage over exposure
However, the number of subjects per cell (three, two, alone. As noted earlier, the antidepressant action of
and three, respectively) was too small to provide reli- fluvoxamine appeared to be independent of its antiob-
able information, and the behavioral procedure se- sessive effects. A comparison of fluoxetine and ex-
lected by the authors, desensitization, has not proven posure was conducted by Stanley, Turner, Beidel, and
effective with obsessive-compulsives. Jacob (1987) with five OCD patients who received the
Two large controlled studies in which the effects of drug followed by behavioral treatment. Group means
clomipramine and behavioral treatment (exposure in indicated a clear antidepressant effect by fluoxetine but
vivo and response prevention) were compared have little benefit on OCD symptoms, particularly obses-
been conducted by Marks and his colleagues. In the sions. Exposure led to some further decreases in de-
first, 40 obsessive compulsive patients were assigned pression and a consistent and substantial antiobsessive
to the following groups: (1) clomipramine followed by effect.
behavioral treatment; (2) clomipramine followed by To examine the impact of depression level, anti-
placebo psychotherapy (relaxation) and then by behav- depressant drug treatment, and behavior therapy on
ioral treatment; (3) placebo drug followed by behav- mood and on OCD symptoms, Foa, Steketee, Kozak,
ioral treatment; and (4) placebo drug followed by and McCarthy (1989) compared imipramine (a non-
placebo psychotherapy and then by behavioral treat- serotonergic antidepressant) versus placebo in de-
ment (Marks et at., 1980). Patients with primary depressed and nondepressed OCD patients, followed by
pression were excluded from the study. Clomipramine exposure and response prevention and by supportive
alone improved both mood and OCD symptoms; the therapy. Although imipramine improved depressed
application of behavioral treatment was followed by mood, it had little effect on OCD symptoms and did
additional significant improvement on most behavioral not enhance the effects of behavioral treatment. Ex-
measures but not on mood scales. A comparison of posure with or without drug was highly effective at
means of clomipramine and behavior therapy versus posttreatment and at follow-up.
placebo and behavior therapy after 10 weeks suggested It appears, then, that in most studies serotonergic
slight differences between groups favoring drug drugs, including clomipramine, fluoxetine, and
treatment. fluvoxamine, have both antidepressant and antiob-
In the second study, clomipramine was compared sessive effects, whereas other antidepressants, such as
with self- and with therapist-aided exposure and re- imipramine, exhibit only the former action. Behavior
sponse prevention (Marks et at., 1988). Consistent therapy also improves both depressive and OCD
with previous findings, superior improvement was ef- symptoms, the latter to a greater degree and more last-
fected in rituals and depression by CMI (clomipra- ingly than clomipramine or fluoxetine. A comparison
mine) compared to placebo. The advantage shown by of effect sizes across trials using tricyclics compared
self-exposure after 7 weeks was lost at the IS-week with exposure and response prevention also supports
comparison. Clomipramine, then, had an initial ad- the superiority of the behavioral treatments (Chris-
ditive effect that disappeared with continued exposure tensen, Hadzi-Pavlovic, Andrews, & Mattick, 1987).
and was not evident at follow-up. The combination of drugs and behavior therapy has
Cottraux, Nury, Mollard, Bouvard, and Sluys thus far shown little advantage over behavior therapy
(1988) conducted a controlled comparison of fluvox- alone. In general, it should be noted that most studies
indicate that both clomipramine and exposure therapy

Demographics, Personality, and Severity of
have a greater impact on ritualistic behavior than they
Symptoms
do on obsessions, which respond more slowly and less
completely. It seems probable that residual obsessional In general, researchers have been more successful in
fears may be at least partly responsible for eventual identifying factors associated with immediate rather
relapses in some behaviorally treated patients. Re- than long-term outcome. Demographic variables were
lapses on drug withdrawal are likely to derive from rarely predictive (Basoglu, Lax, Kasvikis, & Marks,
other sources, including physiological and attribu- 1986; Foa, Steketee, Grayson, & Doppelt, 1983b;
tional factors. Clearly, more trials will be needed to Mawson, Marks, & Ramm, 1982). Age of onset was
adequately examine the separate and combined effects found negatively associated with long-term gains in
of these serotonergic drugs and exposure treatment. As two studies (Foa, Steketee, et al., 1983; Steketee,
Towbin, Leckman, and Cohen (1987) urge, such stud- 1987). Higher socioeconomic status predicted better
ies should attempt to utilize similar measures that sepa- immediate outcome, whereas more religiously devout
rate OCD symptoms from depressive ones and do not patients fared more poorly (Steketee, Kozak, & Foa,
rely exclusively on self-report scales. The need for 1985). Premorbid compulsive personality style was
comparability across studies and confidence in the va- associated with better outcome immediately after
lidity of the findings should be paramount at this point. treatment in one study (Rabavilas et al., 1979). How-
ever, the presence of a personality disorder in general
has usually been related to a poor prognosis (Ingram,
Predictors of Outcome of Behavioral
1961; Kringlen, 1970; Lo, 1967), particularly for
Treatment schizotypal personality (Jenike, Baer, Minicello,
Schwartz, & Carey, 1986) and borderline patients
Treatment by exposure and response prevention
(Hermesh, Shahar, & Munitz, 1987). The association
benefits about two thirds to three quarters of the ob-
of poor outcome and personality disturbance in other
sessive-compulsives who undergo it, leaving a signifi-
anxious patients (e.g., Mavissakalian & Hamann,
cant number who are unaffected or who relapse over
1986) suggests that personality disorders of most types
time. Several researchers have attempted to identify
may herald failure for OCD patients.
specific variables that have played a role in short- and
Surprisingly, several authors have failed to find a
long-term outcome.
relationship between severity of symptoms and out-
come (Boulougouris, 1977; Foa, Steketee, et al.,
Compliance
1983; Meyer et al., 1974; Rachman et ai., 1973). In
In discussing their failures, Rachman and Hodgson most of these studies, patients had had their symptoms
(1980) noted that failure to comply with instructions to for more than 3 years, and thus, those with mild symp-
stop ritualizing led to poor response. It is clear from the toms were not included. In a sample with a wider range
findings regarding behavioral treatment components of severity and duration, these two factors might well
that partial treatment by a single procedure yields re- be associated with outcome.
sults inferior to those of combined treatment (Foa et
al., 1984). Uncooperative patients would, in effect, be
Mood State
receiving only partial treatment and would therefore be
unlikely to benefit. Further, noncompliant patients With regard to mood state variables, initial anxiety
may have had low expectations of gain from the outset was found related to short-term treatment outcome
which may impede their willingness to proceed. In a (Foa, Grayson, et al., 1983), but not to gains at follow-
single-case study, Silverman (1986) examined cooper- up (Mawson et al., 1982; Steketee, Foa, & Kozak,
ation between therapist and client and the effective 1985). Similarly, in some studies, pretreatment de-
components of behavioral intervention, using active pression has been found associated with less benefit
modeling, response discrimination, and delay. The au- immediately after treatment (Boulougoris, 1977; Foa,
thor concluded that OCD patients may respond more to 1979; Foa, Grayson, et al., 1983; Marks et al., 1980),
techniques that emphasize self-control, self-definition although not at follow-up (Foa, Grayson, et al., 1983;
of appropriateness, and client participation in treat- Mawson et al., 1982). These findings, however, have
ment planning. not been replicated in other studies (Basoglu et al.,
1986; Foa & Kozak, 1986; Mavissakalian etat., 1985; group. The higher (worse) initial scores of the partner-
Mawson et at., 1982, Steketee 1987; Steketee et at., assisted group on target symptoms, mood state, and
1985), which found no association with initial mood marital and social adjustment may have accounted for
state and benefits on OeD symptoms. Steketee (1987) the failure of this group to improve further after treat-
observed that posttreatment anxiety and depression did ment. It is also possible that inclusion of the spouse as
predict relapse: greater disturbance was related to cotherapist may prove detrimental when marital in-
poorer maintenance of gains. These results suggest teraction is marked by conflict or strong dependence
that the relationship between depression and ob- (Emmelkamp, 1982; Mathews, Gelder, & Johnston,
sessive-compulsive symptoms is more complex than 1981). Such conflicts may be temporarily suppressed
initially thought: high levels of depression in ob- when the therapist is directing the treatment but may
sessive-compulsive patients are not necessarily predic- manifest themselves during the follow-up phase, im-
tive of failure. peding further progress.
Another variable thought to affect outcome is over- Although some clinicians have suggested that fami-
valued ideation, which was observed by Foa (1979) to ly member's reactions to obsessive-compulsive pa-
impede across-session habituation to feared stimuli. tients' symptoms during and after treatment are impor-
McKenna (1984) noted that overvalued ideas also oc- tant in recovery, little data on this issue are available.
cur in other disorders, several of which are closely Steketee and Foa (1985) have noted that many family
related to OeD, such as morbid jealousy, hypo- members are impatient, expecting treatment to result
chondriasis, and anorexia nervosa, all of which are in rapid and complete symptom remission, whereas
conditions considered difficult to treat. It is not surpris- others continue to "protect" the patient from formerly
ing that the more firmly the patient holds a mistaken upsetting situations, thus reinforcing avoidance behav-
belief, the more difficult it will be to dislodge it with iors. Years of accommodation to the patient's peculiar
mere exposure. Unfortunately, successful efforts to requests have established patterns that are difficult to
rectify such beliefs have not been reported. break and may foster relapse. Steketee (1987) found
that general social support was not associated with
outcome, but patients were more likely to relapse if
Social Functioning
their close family members were critical, reacted an-
With respect to the prognostic value of social func- grily to symptoms, or held a firm belief that patients
tioning factors, obsessive-compulsives with more co- could in fact control their obsessional symptoms if
hesive marital relationships fared better after treatment they wished. Interventions directed at these difficulties
(Hafner, 1982). Steketee et al. (1985) observed that may be required in such cases. Indeed, the better post-
mQre satisfaction in employment was related to poorer treatment outcome and reduced relapse rate achieved
outcome. This finding may be due to a stronger moti- by treatments that included the participation of family
vation to improve on the part of those who were least members for other patient groups support this sug-
content with their level of functioning. These authors gestion (e.g., Barlow, O'Brien, & Last, 1984; Falloon
also found that improvement in social and home func- et aI., 1982; Mermelstein, Lichtenstein, & McIntyre,
tioning at posttreatment was related to better long-term 1983). Further investigation of the association of fa-
outcome. In a subsequent study on a larger sample, milial responses and patient outcome seems war-
Steketee (1988a) reported that pretreatment levels of ranted.
social adjustment were not related to relapse, but post- In the literature discussed above, no single variable
treatment scores were, particularly for family and accounts for a large proportion of the variance in the
work adjustment. outcome of behavioral treatment for OeD. Benefits
In the only prospective study of social factors, Em- are undoubtedly affected by a complex set of interac-
melkamp and De Lange (1983) investigated the contri- tive factors associated with the client, the treatment
bution of spouse involvement to otherwise self-con- process, and the environment. Factors that are not ma-
trolled exposure treatment of obsessive-compulsives. nipulable within the treatment context are less impor-
Although the spouse-assisted treatment produced tant to the clinician and researcher who seeks to im-
greater response immediately after treatment, at a 1- prove treatment procedures. Of those factors that may
month follow-up it had lost its statistical advantage respond to therapeutic intervention, environmental
because of the continued improvement of the unaided variables including social and familial supports and
related client attributes, such as social anxiety and so- Little is known about the cognitive changes that take
cial skills, have frequently been implicated as relevant place during or following exposure treatment. Meyer's
to the outcome of not only anxiety disordered but also (1966) first paper posited that patient's expectations of
other diagnostic groups. With some notable excep- consequent disasters are disconfmned when he or she
tions (e.g., Foa, Grayson, et aI., 1983; Kozak et ai., confronts feared stimuli without ritualizing, and this
1988; Lang et ai., 1970), it should be pointed out that disconfirmation leads to altered behavior. Clinical ob-
most studies of predictors of behavioral treatment out- servations of patients who improve suggest that they
come have focused largely on pretreatment factors to become more confident of their ability to withstand
the exclusion of process variables occurring during anxiety and are thus able to avoid ritualizing. To inves-
treatment. Attention to relational and other processes tigate the cognitive changes that take place during and
during treatment may shed light on important factors after effective treatment, we must first delineate the
that affect outcome. variables that we hypothesize to be salient. Such cog-
nitions may include attitudes toward discomfort, judg-
ments of risk, beliefs regarding outcome, and percep-
Further Considerations tions of coping abilities. Although assessment
procedures for some of these variables are available,
It is apparent from the foregoing review that in vivo others need to be developed. Cognitive treatment stud-
exposure to feared situations, coupled with prevention ies may be premature at this point: we must first know
of ritualistic responses, has substantially improved the what to change before attempting to change it.
prognosis for obsessive-compulsive ritualizers. So far, Among the potentially important factors associated
antidepressants have not enhanced the outcome of be- with treatment outcome are familial responses to OCD
havioral treatment, although there are not yet sufficient patients during and following behavior therapy. Recent
data to settle this question. Findings emerging from findings point to a possible association of significant
studies on pure obsessionals and those with cognitive others' critical, angry reactions and mistaken beliefs
compulsions are less encouraging, possibly because regarding controllability of symptoms. These observa-
exposure and blocking procedures have not been ap- tions require confirmation using measures already de-
plied appropriately for the latter group. As evident for veloped to identify Expressed Emotion (EE) among
ritualizers, it appears that exposure procedures should family members of schizophrenia and depression
be directed at obsessional material, whereas blocking (Hooley, 1985). Although implementation of family
procedures should be applied to compulsions, whether psychoeducational treatment to correct such patterns is
overt or covert. The omission of either procedure premature at this time, it may well prove helpful in the
greatly reduces treatment efficacy. Both behavioral future for the subset of patients who come from high
and pharmacological treatment have their greatest ef- EE homes. Similarly, assertiveness training may well
fect on compulsive behavior; obsessions are less re- be appropriate as an adjunctive treatment to exposure
sponsive to any treatment. Whether newer cognitive therapy with the subgroup of OCD patients who evi-
treatments will have an impact on such symptoms re- dence serious deficits in essential social skills.
mains to be seen; further research in this area is badly It is evident that we can successfully treat the large
needed. majority of OCD patients. What we must pursue fur-
With regard to processes during treatment, predic- ther is a clearer understanding of factors that affect
tors of short- and long-term behavioral treatment gains individual patient's responses to the exposure/re-
include moderate initial subjective and physiologic response prevention regimen and the degree of gener-
actions to fear cues, habituation of these responses alization of treatment effects to cognitive and social
across sessions, and low levels of anxiety and depres- functioning. An understanding of what patients actu-
sion after treatment. Findings regarding the experience ally iearn during therapy, rather than what we think we
ofanxiety early in treatment may be used to ideritify teach them, may help identify processes critical to suc-
potential failures who may need additional strategies cessful and lasting outcomes.
to improve their immediate prognosis. Searching for
correlates of these responses (e. g., specific beliefs,
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CHAPTER 16
Cognitive Therapy of Depression

Arthur Freeman and Denise D. Davis
Introduction behaviors. In addition, the individual may have a defi-

ciency in the instrumental skills needed to obtain and
There are many psychological explanations for the de- sustain reinforcement (Lewinsohn, 1974)
velopment of depressive patterns of response. Gener- The S-R motivational model is based on Mowrer's
ally, psychoanalytic formulations regarding intro- theory of avoidance learning (1947, 1960) and Miller's
jected anger have not stood the test of time or research conflict theory (1959). Stampfl and Levis (1960)
(Beck, Rush, Shaw, & Emery, 1979). Behavioral for- posited two models for understanding the etiology of
mulations, by contrast, have focused on well-estab- depression. The first model involves the loss of
lished principles ofleaming in trying to understand the positive affect plus the arousal of anxiety. In this
establishment, maintenance, and treatment of the de- model, specific internal and external cues that pre-
pressive process. Boyd and Levis (1980) have identi- viously elicited positive affect (e.g., feeling good) be-
fied four conceptual approaches for understanding de- come associated with some aversive event (e.g., rejec-
pression from a behavioral perspective: S-R nonmoti- tion), and this leads to a negative emotional state (e.g.,
vational, S-R motivational, S-S nonmotivational, and depression). The negative emotional state may then
S-S motivational. become part of a downward spiral wherein additional
In the S-R nonmotivational model, exemplified by cues (cognitions, images, memories) elicit further
Ferster (1973, 1974) and Lewinsohn (1974), the de- negative affect. The reversal of this trend through ex-
pressed individual fails to develop or maintain adap- tinction will then lead to greater activity including
tive or "adjustive" behaviors. The depression is greater interaction with others, which is then rein-
viewed as a consequence of a lack of reinforcement or forced. The depression is based on the individual's
a loss of reinforcer effectiveness. Adaptive behaviors violating perceived expectations of self or others,
are not reinforced and are thereby extinguished. The thereby eliciting previously conditioned self-imposed
generally retarded behavior pattern of the depressive punishment (Boyd & Levis, 1980).
individual is seen to be a result of a prolonged extinc- The second explanatory model posits fear of rejec-
tion schedule. The lack of response-contingent position, loss of love, or an inhibition of unacceptable
tive reinforcement has the potential to elicit dysphoric aggressive responses as the major factors in the etiolo-
gy and maintenance of depression. Depressive behav-
Arthur Freeman • Department of Psychiatry, University of iors function to prevent exposure to aversive experi-
Medicine and Dentistry of New Jersey, School of Osteopathic
ences. The aversion develops from previous condition-
Medicine, Cherry Hill, New Jersey 08002. Denise D.
Davis • Affective Disorders Unit, Department of Psychiatry, ing in which instrumental behaviors were punished.
Vanderbilt University, Nashville. Tennessee 37240 The S-S nonmotivational model of depression is
333
based on Seligman's (1974, 1975) model of learned proaches that include a variety of cognitive and
helplessness. The theory developed by Maier and Selig- behavioral strategies and techniques; self-manage-
man (1976) stated that when an outcome was indepen- ment or self-control approaches; attribution retaining
dent of the organism's ability to assert voluntary control for learned helplessness; and physical exercise.
over that outcome, helplessness occurred. The orga- . The focus of the present chapter will be to explicate
nism would then gradually cease responding and be- the cognitive-behavioral approach developed by Beck,
come passive and nonresponsive to further stimulation. which incorporates many of the above-mentioned
In the reformulated model of helplessness (Abramson, strategies and techniques. This approach has more em-
Seligman, & Teasdale, 1978), helplessness was hy- pirical support than any other psychosocial strategy.
pothesized to be dependent on both the specific content From Hippocrates' humoral view of the develop-
of the attributions and the more general attributional ment of melancholia, through Freud's views on de-
style. The reformulated theory offered three pression, to contemporary understandings of the syn-
dimensions of attribution: internal-external, global- drome, depression has been a part of the human
specific, and stable-unstable. The internal-global- condition through all of recorded history. Because of
specific pattern would lead to depression as the indi- its prevalence, depression has been called "the com-
vidual perceived the lack of control to be his own fault mon cold of emotional disorders." It is, by itself and in
(internal), pervasive (global), and unchangeable combination with other disorders, the most common
(stable). problem seen in clinical practice. The terms depres-
The final model is the S-S motivational model ex- sion and depressive warrant 26 references in the Psy-
emplified by the cognitive approach of Beck et al. chiatric Dictionary (Campbell, 1981). In some cases,
(1979). This approach, which is the focus of the pre- it can be chronic or recurrent; in other cases, a more
sent chapter, is based on the individual's distorted ongoing and general pattern of response is seen. It may
negative perceptions of self, world or experience, and appear in varying degrees of severity and is often reac-
the future. These negative distortions result in a with- tive to external stressors.
drawal from previously enjoyable and reinforcing ex- In his earliest studies of depression, Beck (1967)
periences and a consequent increase in depression. focused on the paradoxical nature of depression.
Walen, Hauserman, and Lavin (1977, p. 196) identi- "There is (often) . . . an astonishing contrast between
fy five broad behavioral treatment strategies for the depressed person's image of himself and the objec-
depression: tive facts" (p. 3). Depression is the clinical problem
that has been most studied in terms of the treatment
1. Discovering or renewing possible sources of efficacy of cognitive therapy (Blackburn, Bishop,
reinforcement Glen, Walley, & Cristie, 1981; Kovacs, Rush, Beck, &
2. Heightening the effectiveness of reinforcers Hollon, 1978; Murphy, Simons, Wetzel, & Lustman,
3. Analyzing and correcting faulty interpersonal 1984; Rush, Beck, Kovacs, & Hollon, 1977). The
patterns that have resulted in lost opportunities focus of this chapter is to offer the reader an overview
for reinforcement of the cognitive model of depression and to discuss the
4. Restructuring cognitive sets to refute assumed various strategies and techniques of cognitive therapy
helplessness for the treatment of depression.
5. Prompting emotional freedom and building as- Cognitive therapy (CT) is a short-term, active,
sertiveness skills structured, directive, collaborative, psychoeduca-
tional, and dynamic model of psychotherapy that uti-
In a review of extant behavioral approaches to the lizes a broad range of cognitive and behavioral tech-
treatment of depression, Rehm and Kaslow (1984) niques to effect changes in mood, thought, and action.
have identified the following models: counter-condi- Cognitive therapy, as developed, researched, and
tioning, including imagery techniques, such as flood- practiced by Aaron T. Beck (1967, 1976; Beck et al.,
ing, systematic desensitization, systematic resen- 1979) and his colleagues, is one of several cognitive-
sitization, hypnosis, and relaxation; contingency behavioral models of therapy. Included in this group
management and activity increase strategies utilized are the works of Ellis (1962, 1973, 1985), Lazarus
both in session and in vivo; social skills training, in- (1976, 1981), and Meichenbaum (1977), and a number
cluding problem-solving training, marital skills train- of off-shoots of each of these major theoreticians. The
ing, and parenting skills training; "cognitive" ap- major therapeutic focus in the cognitive-behavioral
CHAPTER 16 • COGNITIVE THERAPY OF DEPRESSION 335
models is to help the patient examine the manner in correspond with the negative content of these views.
which he or she construes and understands the world For example, if a patient views himself as physically
(cognitions) and to experiment with new ways of re- unattractive, he may feel sad, disappointed in his
sponding (behaviors). By learning to understand the looks, and may then avoid situations in which physical
idiosyncratic way in which he or she perceives self, attractiveness might be seen as a prerequisite for suc-
world, and experience, and the prospects for the fu- cess (e.g., dating).
ture, the patient can be helped to alter negative affect The therapist can start to focus and structure the
and to behave more adaptively. The therapist works therapy from the onset of treatment by paying special
through a Socratic questioning to develop greater attention to the depressive triad. Personal issues relat-
awareness in the patient. Further, the therapist can of- ing to self, world, and future differ for each patient.
fer hypotheses for consideration, act as a resource per- Each constituent of the triad does not necessarily con-
son, or directly point out areas of difficulty. By devel- tribute equally to the depression. By assessing the de-
oping an understanding of the patient's problems, the gree of contribution of each of the three factors, the
therapist can begin to develop hypotheses about the therapist can begin to develop a visual conceptualiza-
patient's life issues, and thereby begin to develop a tion of the patient's problems. This visualization can
conceptualization of the problems within the cog- be used to help the patient have a better understanding
nitive-behavioral framework. Although best known of the problem focus of the therapy, which will be basic
for the outpatient treatment of depression, cognitive to the development of collaborative treatment strat-
therapy may be the psychotherapeutic treatment of egies. The triad can be pictured as an equilateral tri-
choice, along with appropriate pharmacotherapy, with angle (see Figure I). One can draw a perpendicular line
depressed patients needing inpatient or day hospital from each of the three sides, and the degree of impor-
treatment (Bowers, 1989; Coche, 1987; Freeman & tance of a particular factor is represented by the dis-
Greenwood, 1987; Greenwood, 1983; Grossman & tance from the side of origin.
Freet, 1987; Perris et al., 1987; Wright, 1989; Schrodt The shorter the line (closer to the side), the greater
& Wright, 1987). the degree of importance of that factor for the indi-
vidual. The longer the line, the less important that
particular factor appears to be. For example, for pa-
The Basic Cognitive Therapy Model tient A, the concerns are predominantly self and world
and would be voiced by statements reflecting low self-
The CT model posits three issues in the formation esteem and negative views of world and experience.
and maintenance of the common psychological disor- When questioned about hopelessness and suicidal po-
ders: the cognitive triad, cognitive distortions, and tential, this patient might say, "Kill myself? Oh No!
schema (Beck et al., 1979). The triad represents an I'll just continue to live my poor, miserable life be-
accumulation of thought content. The distortions de- cause I deserve to."
scribe the way in which thoughts are structured. Final-
ly, the schema characterize conceptual processes of
thinking. These cognitive phenomena are assumed to
correspond with biological processes, both represent-
ing different perspectives on a unified, synergistic pro-
cess (Beck & Emery, 1985).
The Cognitive Triad

The cognitive triad for depression (Beck et al.,
1979) describes the patient's negative views of self,
world or experience, and of the future. Virtually all
patient problems can be subsumed under one, or a
combination, of these areas. The accumulated content
in each of these three areas is evident in the patient's
overt and covert cognitions, including verbal and visu-
al representations. Affect and behavior will typically Figure 1
If the patient's concerns focus on self and future world with a positive bias that can create chaos for the
(patient B), the verbalizations would include those re- patient and for others associated with them.
flecting low self-esteem and suicidal thoughts: "What Distortions become the initial focus of the therapy.
good am I? I deserve to die. The world seems to get The therapist works with the patient to make the distor-
along pretty well. It's me that is at variance with the tions manifest by tracking" automatic thoughts" or the
rest of the world." spontaneous thoughts associated with certain moods or
Finally, if the patient's concerns involve a negative situations. These spontaneously generated thoughts
view of the world and the future (patient C), the pa- are then evaluated for the content, degree of patient
tient's verbalizations might include a diatribe against belief, style, and the impact on the patient's life. The
the ills and evils of the world and a multitude of rea- distortions become the thematic directional signs that
SOilS as to why the best course of action in dealing with point to the underlying schema. The main purpose of
the awful world is their death. Suicidal impulses are labeling the style or content of the distortion is to pro-
often based on a desire for retribution or as a means of vide a conceptual tool to help patients understand their
"getting even" with others. When asked about self- thoughts and to begin to alter those thoughts that are
esteem or personal contributions to their difficulty, dysfunctional. Correct classification of the distortions
these patients will often go on in great detail about how are always secondary to the process of collaborative
they have tried and not succeeded but are victimized exploration. It is oflittle value for the therapist to insist
because of the world's problems. They see themselves on the "correct" label. Reinforcing the patient for
as the innocent victims. (This perceptual/response questioning the possibility of a distortion and testing
style is common among Axis II patients: Beck & Free- alternatives is far more important than the rightness of
man, in press; Freeman & Leaf, 1989.) By including the label. The distortions that follow are in no way a
the patient in the assessment and understanding of each comprehensive list of all of the possible distortions the
of the triadic factors, the therapeutic collaboration can therapist might encounter. The distortions occur in
begin early in the therapy and can be directed at specif- many combinations and permutations. They are pre-
ic areas of concern rather than on vague, global, and sented here in isolation for the sake of discussion. Typ-
amorphous treatment issues. ical distortions include (Freeman & Zaken-Greenburg,
1988):
Cognitive Distortions
1. All or nothing thinking: "I'm either a success or
Distortions are basically idiosyncratic views that are a failure." "The world is either black or
not consensually validated. An individual can distort white."
in a variety of ways. These distortions can be positive 2. Mind reading: "They probably think that I'm
or negative. The patient who distorts in a positive di- incompetent." "I just know that he/she disap-
rection may be the "fool that rushes in where angels proves."
fear to tread." The positive distorter may view life in 3. Emotional reasoning: "Because I feel inade-
an unrealistically positive way. He or she may take quate, I am inadequate." "I believe that I must
chances that most people would avoid; for example, be funny to be liked, so it is fact."
starting a new business, investing in a risky stock. If 4. Personalization: "That comment wasn't just
successful, the positive distorter is vindicated. If un- random, it must have been directed toward
successful, the positive distorter may see the failure as me." "Problems always emerge when I'm in a
a consequence of taking a low-yield chance. However, hurry."
the positive distorter can take chances that may eventu- 5. Overgeneralization: "Everything I do turns out
ate in being in situations of great danger; for example, wrong." "It doesn't matter what my choices
experiencing massive chest pains and not consulting a are, they always fall flat."
physician. The positive distortion in this case might 6. Catastrophizing: "lfI go to the party, there will
be, "I'm too young and healthy for a heart attack." be terrible consequences." "I better not try be-
Excessive positive distortion is typically termed denial cause I might fail, and that would be awful."
because of the potential neglect of realistic negative 7. Should statements: "I should visit my family
factors. At the extreme, the patient in a manic episode every time they want me to." "They should be
exhibits great neglect of consequences and sees the nicer to me."
8. Control fallacies: "If I'm not in complete con- Although all of the above distortions are stated in the
trol all the time, I will go out of control." "I first person, they can also apply to expectations of
must be able to contol all of the contingencies in others, including family, social, religious, or gender
my life." groups. The novice cognitive therapist might be in-
9. Comparing: "I am not as competent as my co- clined to practice what we call the "Pac-man" model
workers or supervisors." "Compared to others, ofCT. In this model, the therapist, like the video-game
there is clearly something flawed about me." hero, charges about munching up the ghosts (distorted
10. Disqualifying the positive: "This success expe- thoughts). Unfortunately, like the video game, the
rience was only a fluke." "The compliment ghosts have the ability to return again and again. Our
was unwarranted." goal is to not just displace the distortions but to do
11. Perfectionism: "I must do everything perfectly away with them. The goal is to understand the schema
or I will be criticized and be a failure." "Doing that generates the distortions.
a merely adequate job is akin to being a
failure."
12. Selective Abstraction: "The rest of the informa-
Schema
tion doesn't matter. This is the salient point."
"I must focus on the negative details while I Schemata are hypothesized structures that guide and
ignore and filter out all the positive aspects of a organize the processing of information and the under-
situation. " standing of life experience. An essential element of
13. Externalization ofself-worth: "My worth is de- cognitive therapy is on understanding and making
pendent upon what others think of me." "They manifest the underlying rules, beliefs, or schemata.
think, therefore I am." Beck (1966, 1976, 1977) and Freeman (1986) have
suggested that schemata are the cognitive substrate
that generate the various cognitive distortions seen in
patients. These schemata serve to increase or decrease
The Fallacies the individual's vulnerability to various situations
These schemata or basic rules of life begin to be estab-
1. Control: "If I'm not in complete control all of lished as a force in cognition and behavior from the
the time, I will be totally out of control." "I must earliest points in life, and are well fixed by the middle
be able to control all of the events in my life, and childhood years. They are the accumulation of the in-
sensations in my body." dividual's learning and experience within the family
2. Change: "If my situation were different, all of group, religious group, ethnic, gender, or regional sub-
my problems would be reduced." groups, and the broader society. The particular extent
3. Worrying: "If! worry about it enough, it will be or effect that a schema has on an individual's life de-
resolved." "One cannot be too concerned." pends on (1) how strongly that schema is held, (2) how
4. Ignoring: "If! ignore it maybe it will go away." essential the individual sees that schema to his or her
"If I don't pay attention I will not be held safety, well-being, or existence, (3) the individual's
responsible. " previous learning vis-a-vis the importance and essen-
5. Fairness: "Life should be fair." "People should tial nature of a particular schema, (4) how early a par-
all be fair." ticular schema was internalized, and (5) how power-
6. Being right: "I must prove that I am right as fully, and by whom, the schema was reinforced.
being wrong is unthinkable." "To be wrong is to The schema is very rarely isolated and separate but,
be a bad person." like the distortions, occurs in complex combinations
7. Attachment: "I can't live without a man." "If I and permutations. The schema becomes, in effect,
was in a relationship, all of my problems would how one defines oneself, both individually and as part
be solved." of the group. Schemata can be active or dormant, with
8. Heaven's reward: "If I do everything perfectly the more active schemata being the rules that govern
here, I will be rewarded later." "I have to mud- day-to-day behavior. The dormant schemata are called
dle through this life, maybe things will be better into play to control behavior in times of stress. A sche-
later." ma may be either compelling or noncompelling. The
more compelling a schema, the more likely that the particular schema is consensually validated. Signifi-
individual or family will respond to it. cant others not only help to form the schema, but help
The particular extent of effect that a schema has on to maintain the particular schema, be it negative or
an individual's life depends on several factors: (1) how positive. McGoldrick, Pearce, and Giordono (1982)
strongly held is the schema; (2) how essential the indi- stressed that families view the world through their own
vidual sees that schema to his or her safety, well-being, cultural filters so that the particular belief systems may
or existence; (3) the lack of disputation that the indi- be familial or more broadly cultural. An example of a
vidual engages in when a particular schema is acti- family schema based on the culture in which the family
vated; (4) previous learning vis-a-vis the importance is immersed might be basic rules regarding sexual be-
and essential nature of a particular schema; and (5) havior, reaction to other racial, ethnic, or religious
how early a particular schema was internalized. groups, or particular religious beliefs.
Schemata are in a constant state of change and evo- What differentiates the individual who develops a
lution. From the child's earliest years, there is a need to schema that is held with moderate strength and amena-
alter old schemata and develop new ones to meet the ble to change later on and the individual who develops
different and increasingly complex demands of the a core belief that is powerful and apparently immuta-
world. One way of conceptualizing the change process ble? We may posit several possibilities. (1) In addition
is to utilize the Piagetian concept of adaptation, with to the core belief, the individual maintains a powerful
its two interrelated processes-assimilation and ac- associated belieftha! he or she cannot change. (2) The
commodation (Rosen, 1985, 1989). Environmental belief system is powerfully reinforced by parents or
data and experience are only taken in by individuals significant others. (3) While the dysfunctional belief
when they can utilize these data in terms of their own system may not be especially reinforced, any attempt
subjective experience. The self-schemata then become to believe the contrary may not be reinforced or may
selective because individuals may ignore environmen- even be punished; that is, a child may be told, "You're
tal stimuli. The assimilative and accommodative pro- no good." A second possibility would be that the child
cesses are interactive and stand in opposition, one with is not told he or she lacks worth but any attempt to
the other. There is an active and evolutionary process assert worth would be ignored. (4) The parents or sig-
in which all perceptions and cognitive structures are nificant others may offer direct instruction contrary to
applied to new functions (assimilation), whereas new developing a positive image; for example, "It's not
cognitive structures are developed to serve old func- nice to brag" or "It's not nice to toot your own hom
tions in new situations (accommodation). Some indi- because people will think less of you."
viduals may persist in utilizing old structures without
fitting them to the new circumstances in which they are
involved, but using them in toto without measuring fit General Treatment Approach
or appropriateness. They may further fail to accommo-
date or build new structures. The distinguishing features of CT include the con-
The schemata are cognitive structures that can, with ceptual model upon which the general treatment strat-
the proper training, be described in great detail. We egies are based, as well as the specific techniques used
can also deduce them from behavior or automatic to carry out the treatment strategies. A common mis-
thoughts. The behavioral component involves the way conception about CT is that it is carried out in a rigid,
the belief system governs the individual's responses to mechanistic "cookbook" approach. Although ses-
a particular stimulus or set of stimuli. In seeking to sion-by-session protocols have been designed for re-
alter a particular schema that has endured for a long search purposes in the treatment of unipolar depression
period of time, it would be necessary to help the indi- (e.g., Beck et at., 1979), clinicians will probably find
vidual to deal with the belief from as many different that the course of treatment is, more generally, charac-
perspectives as possible. A pure cognitive strategy terized by focusing on the patient's unique needs and
would leave the behavioral and affective element un- problems. Treatment includes a beginning or assess-
touched. The pure affective strategy is similarly lim- ment phase, a middle or skill-building phase, and a
ited, and, of course, the strict behavioral approach is termination, skill consolidation, and relapse preven-
limited by its disregard for cognitive-affective ele- tion phase. Each of these phases will be considered
ments. In many cases, we find that an individual's separately in order to highlight the strategy and tech-
niques most characteristic of that phase. In addition, 4. The problem focus, for example, specific areas
certain clinical strategies and techniques are utilized of discussion
throughout the treatment. 5. A wrap-up, review of the session, and feedback
to the therapist
General Therapy Characteristics
1. The therapist reviews the BDI, BAI, and other
Cognitive therapy requires all of the general charac- scales filled out by the patient prior to the session.
teristics of any effective therapy, including rapport Specific issues or questions can be put on the agenda.
building and strengthening of the therapeutic rela- 2. During the overview of the week, the patient can
tionship, the development of mutual trust, inspiration be asked to report to the therapist any events of impor-
for the availability of help, provision of new learning tance that happened in the week, including the pa-
experiences, empathy and active listening, enhancing tient's response to the last therapy session.
the patient's sense of mastery and self-efficacy, afford- 3. The review of homework reveals any problems in
ing opportunities for rehearsal and practice, and the doing the homework and the results of the homework.
maintenance of the therapeutic alliance (Frank, 1985). 4. Particular problems are put on the agenda for
work within the session. This might involve teaching a
particular skill (social or assertiveness skills), or the
Structure of the Therapy
questioning of particular dysfunctional thoughts.
The establishment of a discrete problem list helps 5. The work can be ended 3 to 5 min prior to the
both patient and therapist to have an idea of where the closing of the session, and the patient ~an be asked to
therapy is going, and how it is progressing. The con- review and outline what he or she has gotten from the
tent and the direction of the therapy are established session. This gives the therapist an opportunity to help
early in the collaboration. Having established and the patient to clarify the goals and accomplishments of
agreed upon a problem list and focus for therapy, the the session. The homework for the next session can
individual sessions are then structured through agenda also be emphasized. Finally, the patient can be asked
setting and homework. for his or her response to the session, which helps to
Agenda setting is used in meetings by many groups solidify progress made in the session and to give the
to help the participants have a direction for the meet- session closure.
ing, to add to the agenda, to become more active in the Accomplishing the items on the agenda requires that
meeting process, and, generally, to allow for max- the therapist be skilled at setting priorities and pacing
imum success in the minimal time often alloted to the the session, taking into account the needs of the pa-
meeting. Rather than having the therapy session mean- tient. This is a skill that is refined through practice and
der, the therapist can work with the patient to set an experience. However, even seasoned therapists may
agenda for the session in order to help to focus the feel tense, anxious, and exhibit a loss of effectiveness
therapy work and make better use of time, energy, and when they are first learning how to pace a session that
available skills. Agenda setting at the beginning of the is built around a collaborative agenda.
session allows both patient and therapist to put issues
of concern on the agenda for the day. We would make
Short-Term Nature of the Therapy
the point that the reason that individuals often become
patients is that they have lost their ability to organize The research protocols for testing the efficacy of CT
and problem solve. By setting an agenda, a problem- generally involve 12 to 20 sessions over a period of no
solving focus is modeled by the therapist. A typical more than 20 weeks. The course of treatment is not,
agenda might include: however, limited to 20 weeks. For certain patients, the
length of therapy may be 6 sessions; for other patients,
1. A review of the Beck Depression Inventory 50 sessions. The length of the therapy, the frequency of
(BDI), Beck Anxiety Inventory (BAI), and other the sessions, and the session length are all negotiable.
scales The problems being worked on, the skills of the patient
2. A brief overview of the week's interac- and of the therapist, the time available for therapy, and
tions/ problems the financial resources all have the potential to dictate
3. A review of homework the parameters of treatment. As noted earlier, the ad-
herence to a treatment protocol has a positive effect for Strategies for the Initial Sessions
both patient and therapist in that it helps to maintain a
focus in the therapy. During the initial sessions, the presenting problems
are investigated to get an overview of the problem(s).
A full developmental, family, social, occupational,
Therapist Activity in the Therapy educational, medical, and psychiatric history is taken.
The therapist takes an active, and possibly directive, These data are collected through interviews, reports of
role in the therapy. Rather than simply restating the previous therapists, standard scales and tests, and, in
patient's words, or reflecting the patient's mood, the some cases, interviews with significant others. These
CT therapist will share hypotheses, utilize guided dis- data are essential in helping to develop the problem list
covery, encourage the patient, serve as a resource per- and the treatment conceptualization. The therapist
son, be a case manager, and, in certain limited cases, gathers information on the triadic view of the patient,
be an advocate for the patient. the characteristic distortions, and the compelling
schemata.
Collaboration
Assessment Methods
Cognitive therapy is a collaborative therapy. The
In addition to clinical diagnostic interviews, either
therapist and patient work together as a team. The
structured or unstructured, the basic mental status
collaboration is not always 50-50, but may be 30-70,
exam and several paper-and-pencil measures have
or 90-1 0, with the therapist providing most of the ener-
proven very useful. The Beck Depression Inventory
gy or work within the session or, more generally, in the
(BDI) is among the most useful tools available to the
therapy. The more severely depressed the patient, the
therapist. The BDI (Ward, Mendelson, Mock, & Er-
less energy the patient may have available to use in
baugh, 1961) is a self-report measure that consists of
the therapy. The therapeutic focus should be to help
21 items designed to reflect the overall level of depres-
patients make maximum use of their energy and to
sion. Depressed individuals tend to negatively distort,
build greater energy.
thereby incorporating negative events and attributing
them to lack of qualities in self, and ignoring positive
Dynamic Model of Therapy events and outcomes (Simon & Fleming, 1985). De-
pressed individuals may be hopeless about positive
The dynamic cognitive approach to therapy pro- changes, may attribute life problems to their perceived
motes self-disclosure of individual cognitions in order shortcomings, and frequently compares themselves
to increase understanding through enhanced knowl- negatively to others. Weekly administration ofthe BDI
edge and an understanding of thoughts, beliefs, and prior to each session can serve to provide objective
attitudes. Early schemata develop and are modified data regarding therapeutic progress, and to serve as an
within the family group. Cognitive therapy with fami- aid in helping validate (or invalidate) assumptions
lies can provide a context for observing these schemata about self, world, and the future.
in operation (Freeman & Zakon-Greenburg, 1989; In addition to its quantitative use, the BDI has great
Teichman, 1986). utility as a qualitative measure. By doing a weekly
content analysis, the specific content of the depression
can be elicited and then utilized in the agenda. For
Psychoeducational Nature of CT
example, if a patient who is a chronic "1" on Item 9
Cognitive therapy is a skill building or coping model (suicide) endorses either a "0" or a "3," it would be
of therapy as opposed to a cure model. Patients in CT incumbent upon the therapist to elicit information
ideally gain skills to cope more effectively with their about the reason(s) for the change.
own thoughts and behaviors that may be dysfunc- Among the most difficult depressed patients to work
tional. Rather than cure depression and anxiety, the with is the individual that presents with dysthymia.
cognitive therapist helps patients to acquire a range of This disorder may equate to a BOI score of 12 or 13.
coping strategies for present and future exigencies of By definition, the dysthymic disorder is "charac-
life. terized by a chronic mild depressive syndrome that has
been present for many years. When dysthymia is of periences greater self-efficacy, and perceives change,
many years' duration, the mood disturbance cannot be the level of hopelessness decreases.
distinguished from the person's 'usual' functioning" The BOI, BAI, and HS are basically measures of dys-
(DSM-III-R, 1987, p. 231). This patient often comes functional thoughts and symptomatology that are gen-
to therapy at the behest or demand of a significant erated by underlying assumptions and core beliefs. The
other. The patient may have a depression that meets Dysfunctional Attitude Scale (DAS) is a quantitive
criteria for major depression recurrent, however, the measure of the maladaptive underlying assumptions
therapist discovers that even when the depression re- (Weissman, 1979). This scale provides measuresofvul-
mits, there is still an underlying dysthymic personality nerability, attraction/rejection, perfectionism, im-
style. Even though this might appear quite low, com- peratives, approval, dependence, autonomous atti-
pared to most depressed patients, the chronic nature of tudes, and cognitive philosophy, allowing the therapist to
the depression makes it difficult to treat. The dys- determine what are the individual maladaptive assump-
thymic patient seems to gain little pleasure from life, tions, how they overlap or discriminate, and what are
without being severely depressively debilitated. One the shared maladaptive family assumptions. These as-
of us recently saw a 34-year-old attorney who was sumptions can then be challenged, upsetting the home-
referred for therapy by his wife. She threatened to ostasis of the system and personal belief and opening up
leave him if he did not change his negative attitude. He the system for interventions leading to change.
was successful in his practice, married, and had two An additional scale, based on the cognitive model,
children. If he and his wife were to have dinner in the that may be used is the Sociotropy-Autonomy Scale
best restaurant in their city, he described the meal as (SAS) (Beck et aI., 1983), which was originally devel-
"tasty." Sex was "OK." An evening at the ballet to see oped as a measure of relatively stable individual dif-
Mikhail Barishnikov dance elicited the comment that ferences in motivational patterns in two major areas.
Barishnikov was "a fine dancer." This patient de- These two areas refer to affiliation (sociotropy) and
scribed his entire life (work, family, and leisure) as achievement (autonomy). It is hypothesized that these
"an underwhelming experience." two personality styles may mediate a vulnerability to
The patient who is more severely depressed may be depression (Beck et al., 1983). An individual high in
far more powerfully motivated to change his or her sociotropy is one who is invested in maintaining warm
depressive thoughts and behaviors. Further, when the interpersonal relationships in order to satisfy strivings
more typical depressed patient changes from a BOI for "intimacy, sharing, empathy, understanding, ap-
score of32 to a score of21, there is great change. The proval, affection, protection, guidance and help"
patient feels better, does more, and thinks differently. (Beck, Epstein, & Harrison 1983, pp. 1-2). Such an
When the dysthymic goes from a BOI score of 13 to an individual may be particularly vulnerable to interper-
11, the change is hardly noticeable. Given the small sonallosses, separation, or rejection. Conversely, in-
changes, the initial low motivation for treatment is dividuals high in autonomy may be more invested in
lowered even further. themselves, in acquisition of power, and in control
When anxiety is a target symptom, the Beck Anx- over their environment. A high autonomous individual
iety Inventory (BAI) is useful. The BAI is a 21-item tends to be particularly vulnerable to failure in achiev-
self-report symptom checklist designed to measure the ing desired outcomes, and to situations in which free-
severity of anxiety-related symptoms (Beck, Epstein, dom of action is thwarted or constrained.
Brown, & Steer, 1985). As with the BOI, the BAI is a
useful, weekly, objective measure of the overall level
Diagnosis and Treatment Plan
of anxiety and is diagnostic both quantitatively and
qualitatively. There are several steps in establishing a treatment
The Hopelessness Scale (HS) was developed as a plan for the patient. The initial step requires that the
measure of the negative view of the future and of the therapist develop a conceptualization of the prob-
intensity of that view (Beck, Weissman, Lester, & Trex- lem(s). This conceptualization will, of necessity, be
1er' 1974). The HS is frequently used in conjunction based on family and developmental histories, test data,
with the (BOI) as a measure of potential suicidal behav- interview material, and reports of previous therapists
ior. This measure may also be used as an index of or other professionals. This conceptualization must
change. As the patient learns new ways of coping, ex- meet several criteria. It must be (1) useful, (2) simple,
(3) coherent, (4) able to explain past behavior, and (5) tions and the schemata that underly them. These tech-
be able to predict future behavior. Part of the concep- niques can be taught to the patients to help them re-
tualization process is the compilation of a problem list, spond in more functional ways. A rule of thumb in
which can be prioritized in terms of identifying a se- treating severely depressed patients would be that the
quence of problems to be dealt with in therapy. The greater the severity of the depression, the greater the
reasons for choosing one problem as opposed to an- proportion of behavioral to cognitive interventions
other as the primary, secondary, or tertiary focus of the the therapist will use.
treatment depends on many factors. A particular prob- The precise mix of cognitive and behavioral tech-
lem may be the primary focus of therapy because of its niques will depend on the patient's skills, the level of
debilitating effect on the individual. In another case, depression, the skills of the therapist, the duration of
there may be no debilitating problems. The focus may the therapy and the treatment goals. Further, the use
be on the simplest problem, thereby giving the family of pharmacotherapy may be essential with the patient
practice in problem solving and some measure of suc- who is in a vegetative state. For the severely depressed
cess. In a third case, the choice of a primary focus patient, the initial goals of treatment would be focused
might be on a "keystone" problem; that is, a problem on having the patient do self-help tasks. Graded task
whose solution will cause a ripple effect in solving assignments can be used with great success. Starting at
other problems. Having set out the treatment goals the bottom of a hierarchy of difficulty and moving
with the family, the therapist can begin to develop through successively more difficult tasks can help the
broad strategies and the specific interventions that will patient achieve a greater sense of personal efficacy.
help to effect the treatment strategies. This personal efficacy can then be used as evidence for
A crucial question for the therapist is what rein- the cognitive work in therapy.
forces and maintains the dysfunctional thinking and The therapist should be prepared to counter the pa-
behavior. The major factor would appear to be the self- tient's ideas or expectations for total, automatic, and
consonance of the belief system. If a particular belief is immediate relief from the depression. Multiple, con-
only partially believed, it is much easier to give up. current strategies are usually needed to solve difficult
This is because the individual is giving up a small piece problems. Partial gains and gradual improvements
of a belief system as opposed to challenging what is need to be documented with the BDI or other measures
regarded as the "self." The more chronic patient, in- and used in highlighting therapeutic change. Thera-
cluding the chronic "neurotic" and the patient with peutic interventions will need repetition before the pa-
character disorders who seek treatment, often sees tient learns to use them effectively and spontaneously.
symptoms as "me." He or she will readily verbalize The old therapy adage, "The problems must get worse
"This is how I am and this is the way I have always before they get better," should not typically apply.
been." By asking a female patient to challenge or di- Changes in one area may temporarily exacerbate or
rectly dispute her dysfunctional beliefs, we are then emphasize problems in another area. If a patient in
asking her to directly challenge hervery being. When a treatment gets worse, the therapist should immediately
challenge to "self' is perceived, this individual usu- and energetically explore the reasons for the deepening
ally responds with anxiety. She is then placed in a of the depression and not disregard it as an artifact of
conflict situation as to whether she would prefer to treatment.
maintain dysfunctional symptoms or to experience
anxiety. As she sees herself defined by the problem,
Challenging Dysfunctional Thinking
she would hesitate to give up the problem because it
would, in her view, leave her an empty shell. We can One of the most powerful techniques in CT involves
see that any challenge to the self needs to be the result using the various cognitive techniques to question or
of a careful, guided discovery based on collaboration challenge dysfunctional thinking. The CT model
as opposed to a direct, confrontational, and dis- posits an interaction between the individual's thoughts
putatious stance. and emotions. The model does not posit a direct linear
relationship of thoughts causing feelings. In fact, for
some patients the emotional response may precede the
Strategies for Middle Sessions
thought. For example, Patient A awakes in the morn-
Several cognitive and behavioral techniques can be ing and lies in bed thinking, "Another lousy day. I've
used by the therapist to help to question both the distor- got nothing to do. It wouldn't make a difference any-
way, since I'm such a hopeless case." Patient A will presents with a thought, for example, "I'm a loser,"
begin to feel more and more depressed as a conse- the therapist needs to ascertain the feelings and the
quence of the dysfunctional thinking. Patient B situation. Finally, the patient may present a situation,
awakes and is quickly overcome by feelings of depres- for example, "My husband left me." The therapist
sion. As a result of the depressed feeling he thinks, needs to determine the range of thoughts and emo-
"Another lousy day, I've just gotten up and I'm al- tions. Such statements as "I feel like a loser" need to
ready depressed. There is nothing I can do to ease my be reframed as thoughts, and the emotions that are a
depression. I'm a hopeless case." Whether the thera- concomitant of the thought need to be elicited.
pist focuses on the preceding cognition or the subse- Often, patients phrase thoughts as questions: "Why
quent.attribution, the major focus will be a cognitive does this always happen to me?" "Why can't I main-
focus. tain a relationship?" or "Why doesn't my life turn out
The Daily Record of Dysfunctional Thoughts better?" A heuristic view is that questions are gener-
(DTR) is an ideal form for this purpose. The goal is not ally functional. It is important to ask questions and
to have the patient become expert at filling out forms, then to answer them: "Does this always happen to
but to have them develop a format for problem solving. me?" "Why do I have difficulty in maintaining rela-
Whether the patient's problems are directly expressed tionships?" "or "What has caused my life to be less
as depression, or as a more vague set of thoughts and than I had hoped for?" The dysfunctional and de-
feelings wherein the depression may be subtly pressogenic thoughts are more generally declarative
masked, the therapeutic approach would be substan- than interogatory: "This always happens to me." "I
tially the same. The clinician, attuned to the subtleties can't maintain a relationship." and "My life is less
of the depressive syndrome, can easily identify the than I had hoped for." The cognitive and behavioral
depressive synonyms, "blue," "down," "out of techniques offer a menu of interventions. This menu is
sorts," "sad," "hopeless," or "guilty," or "blahs." mastered by the therapist, and then the techniques can
Less easily identified are the many masks that depres- be used to question the patient's conclusions. For ex-
sion can wear. These might include sleeping difficulty, ample: Dysfunctional thought: "I can't maintain a re-
eating problems, loss of appetite, loss of libido, or a lationship." Sample adaptive responses: "What do
loss of social drive, all with the feelings of sadness you mean by 'maintain a relationship' "? (idiosyncrat-
directly attributed to the "problems." ic meaning). "What evidence are you using that you
Kramlinger, Swanson, and Maryta (1983), Lesse cannot maintain a relationship?" (evidence). "Has it
(1974), and Ward and Bloom (1979) found that hyper- always been you who has caused the relationship to
sensitivity to pain or the development of a chronic pain end?" (reattribution). "Have you never maintained a
syndrome can be a concomitant of depression. Noll, relationship for any length of time?" (exaggeration).
Davis, and Deleon-Jones (1985) suggested that a "On a scale from 1-10, where would you place the
broad range of medical conditions may be related to quality of the relationship?" (scaling).
the depressive syndrome, for example, anxiety, pho- As can be seen, the utilization of the techniques is
bias, panic attacks, school phobia, bulimia, and child- limited only by the creativity ofthe therapist. The tech-
hood enuresis. Another term that may be more appro- niques need to be well learned so that the therapist can
priate is secondary depression, which may be used to move quickly and easily among the appropriate varia-
describe patients who have a primary medical or psy- tions. If one technique offers little movement, another
chiatric diagnosis but who also manifest the symptoms technique can be used.
of depression (Shaw, Vallis, & McCabe, 1985) sec-
ondary to the medical problems. Whether the depres-
Cognitive Techniques
sion is primary or secondary, cognitive therapy tech-
niques can be used for the depression. In many cases, 1. Define idiosyncratic meaning. The therapist can-
when the depression lifts, the associated problems are not assume that a term or statement used by a patient is
also lessened or ameliorated. completely understood until the patient is asked for
The process can begin with the thought, the emo- meaning and clarification. It is essential to question
tion, or the situation. If the patient presents an emo- patients directly on the meanings of their verbaliza-
tion, for example, "I'm very sad," the therapist would tions. While this may appear to be intrusive, it can be
inquire as to the situations that might engender the structured by the therapist as a way of making sure that
emotion, and the attendant thoughts. If the patient the therapist is not merely in the right ballpark in un-
derstanding but is right on target. This also models for evaluate if they are overestimating the catastrophic
patients the need for active listening skills, increased nature of a situation. Questions that might be asked
communication, and a means for checking out as- include, "What is the worst thing that can happen?" or
sumptions. "And if it does occur, what would be so terrible?" This
2. Question the evidence. Individuals use certain technique has the therapist working against a "Chick-
evidence to maintain ideas and beliefs. It is essential to en Little" styIe of thinking. If the patient sees an expe-
teach individuals to question the evidence that they are rience (or life itself) as a series of catastrophies and
using to maintain and strengthen an idea or belief. problems, the therapist can work toward reality test-
Questioning the evidence also requires examining the ing. The patient can be helped to see the consequences
source of data. Patients who are depressed often give of life's actions are generally not "all or nothing" and
equal weight to all sources; for example, a spouse ap- are thereby less catastrophic. It is important that this
pears to frown when a patient passes. This reaction technique be used with great gentleness and care so
may be used by patients as evidence that they are un- that the patient does not feel ridiculed or made fun of
loved and thus may as well kill themselves. Many by the therapist.
patients have the ability to ignore major pieces of data 6. Fantasize consequences. In this technique, indi-
and focus on the few pieces of data that support their viduals are asked to fantasize a situation and to de-
dysfunctional view. By having patients question the scribe their images and the attendant concerns. In the
evidence with family members or significant others, a direct verbalization of their concerns, patients often
fuller accounting can be had. If the evidence is strong, see the irrationality of their ideas. If the fantasized
the therapist can help to structure alternative ways of consequences are realistic, the therapist can work with
either perceiving the data, or changing behaviors so patients to realistically assess the danger and to devel-
that the evidence is either modified or no longer exists. op coping strategies. This technique allows the pa-
3. Check attributions. A common statement made tients to bring imaged events, situations, or interac-
by patients is, "It's all my fault." This is often heard in tions that have happened previously into the consulting
situations of relationship difficulty, separation, or di- room. By having the patients move the fantasy to the
vorce. Although one cannot dismiss this statement out "reality" of being spoken, the images can become
of hand, it is unlikely that a single person is totally grist for the therapeutic mill. The fantasy, being
responsible for everything going wrong within a rela- colored by the same dysfunctional thinking that alters
tionship. Depressed patients often take responsibility many patients' perceptions, may be overly negative.
for events and situations that are only minimally at- Often the fantasy will be based on biased or incomplete
tributable to them. The therapist can help patients dis- information. For example, a severely depressed physi-
tribute responsibility among all relevant parties. If the cian was reluctant to try an antidepressant medication
therapist takes a position of total support, "It wasn't because of his fantasy of having a seizure caused by the
your fault," "She isn't worth it," "You're better off medication. This image was made all the more vivid
without her," or "There are other fish in the ocean," by the number of grand mal seizures he had seen in the
the therapist ends up sounding like friends and family course of his medical practice. Another vivid fantasy
that the patient has already dismissed as being a cheer- involved being ridiculed and rejected by his colleagues
ing squad, and not understanding of his or her position. were he to try and socialize with them. The explication
By taking a middle ground, the therapist can help the and investigation of the style, format, and content of
patient to reattribute responsibility and not take all of the fantasy can yield very good material for the therapy
the blame, nor unrealistically shift all blame to others. work, especially involving feedback from the others.
4. Examining options/alternatives of thought or ac- 7. Advantages and disadvantages. The weighing of
tion. Many individuals see themselves as having lost the advantages and disadvantages of maintaining a par-
all options. Perhaps the prime example of this lack of ticular belief or behavior can help patients to gain a
options appears in suicidal patients. They see their balance and perspective. The depressed patients who
options and alternatives as so limited that among their have dichotomized life events may see only one side.
few choices, death might be the easiest or simplest By asking that they examine both the advantages and
choice. This cognitive strategy involves working with the disadvantages of both sides of an issue, a broader
them to generate additional options. perspective can be achieved. This technique can be
5. Decatasrophize. This technique, also called the used to examine the advantages and disadvantages of
"What if" technique, involves helping patients to acting a certain way (e. g., dressing a certain way),
thinking a certain way (e.g., thinking of what others or embarrass the patient. Given a hypersensitivity to
will think of you), and feeling a particular way (e.g., criticism and ridicule, some patients may view the
sad). Although individuals will often claim that they therapist who uses paradoxical strategies as making
cannot control their feelings, actions, and thoughts, it light of their problems. There seems to be room at the
is precisely the development of this control that is the extreme for only one person. Patients may see things in
strength of cognitive therapy. their most extreme form. When the therapist takes a
8. Turning adversity to advantage. There are times more extreme stance, such as focusing on the absolutes
that a seeming disaster can be used to advantage. Los- "never," "always," "no one," "everyone," patients
ing one's job can be a disaster but may, in some cases, will often be forced to move from their extreme view to
be the entry point to a new job or even a new career. a position closer to center. There is the risk, however,
Having a deadline imposed may be seen as oppressive that patients may take the therapist's statement as rein-
and unfair, but may be used as a motivator. This CT forcement of their position of abject hopelessness. The
technique appears to ask the patient to look for the therapist who chooses to use the paradoxical or exag-
silver lining in the cloud. Given that the depressed geration techniques must have (1) a strong working
individual has taken a view that often eventuates in relationship with the patient, (2) good timing, and (3)
finding the darkened lining to every silver cloud, look- the good sense to know when to back away from the
ing for the positive kernel in a situation can be very technique.
difficult for many patients. They may simply not see 11. Scaling. For those patients who see things as
the positive. Individuals will sometimes respond to the "all or nothing," the technique of scaling or seeing
therapist by pointing out any positive aspects with things as existing on a continuum can be very helpful.
greater negativity. They may accuse the therapist of The scaling of a feeling can force patients to utilize the
being unrealistic, of being a Pollyanna or a Mary Pop- strategy of gaining distance and perspective. Patients
pins. The therapist can point out that the view that is can scale feelings or beliefs using a 1-10 or 1-100
offered is no less real than the patient's unrealistically metric. Patients can be guided toward scaling a specif-
negative view. However, many patients believe the ic event within the broader context of all events in their
negative view is the real view because of the strength life. The scaling technique has as its purpose helping
and weight of the negative feelings. patients to place their current concerns and feelings
9. Guided association discovery. Through simple within a life-referenced context. Since patients may be
questions, such as "Then what?" "What would that at a point of extreme thoughts and behaviors, any
mean?" "What would happen then?" the therapist can movement toward a midpoint is therapeutic.
help the family explore the significance attached to 12. ExternaLization of voices. By having the thera-
events. The collaborative therapist can help the family pist take the part of the dysfunctional voice, patients
explore the significance they see in events. The idea can get practice in adaptive responding. The therapist
behind the free-association strategy is that the "free" can first model an adaptive response to the patients'
wandering mind will eventually meander to the imme- verbalization of their dysfunctional thoughts. After
diate areas of conflict and concern. The use of what we modeling the functional voice, the therapist can, via a
call the "chained" or "guided association technique" graded manner, become an increasingly more difficult
requires that the therapist work with the patient to con- dysfunctional voice for the patients to respond to. Pa-
nect ideas, thoughts, and images. The therapist pro- tients "hear" the dysfunctional voices in their head.
vides the conjunctions to the patient's verbalizations When they externalize the voices, both patients and
and helps the patient stay on track in exploring uncom- therapist are in a better position to deal with the
fortable areas that he or she might prefer to avoid. The voices/messages in a variety of ways. The patients can
use of such statements as "And then what?" "What then recognize the dysfunctional nature of the voice.
evidence do we have that that is true?" allows the The therapist can hear the tone, content, and general
therapist to guide the patients along various therapeu- context of the suicidal thoughts and generate strategies
tic paths, depending on the conceptualization and ther- for intervention.
apeutic goals. 13. Self-instruction. We all talk to ourselves. We
10. Use of exaggeration or paradox. By taking an give ourselves orders, directions, instructions or infor-
idea to its extreme, the therapist can often help to move mation necessary to solve problems. Meichenbaum
the family to a more central position vis-a-vis a partic- (1977) has developed an extensive model for under-
ular belief. Care must be taken not to insult, ridicule, standing self-instruction. According to his model, the
child moves from overt verbalization of instructions to (Beck et al., 1979; Burns, 1980; Ellis & Harper, 1961;
subvocalization to nonverbalization. This same pro- McMullin, 1987). Even though this technique is a short-
cess can be developed in the adult. The patient can start term technique, it is very useful to allow patients the
with direct verbalization which, with practice, will time to establish some degree of control over their
become part of the behavioral repertoire. Patients can thinking. This time can then be used to utilize other
be taught to offer direct self-instructions or, in some cognitive techniques.
cases, counterinstructions. In this technique, the thera- 16. Direct disputation. Although we do not advo-
pist is not introducing anything new. Rather, the pa- cate arguing with a patient, there are times when direct
tient is being helped to systematically utilize and disputation is necessary. A major guideline for neces-
strengthen a technique already used at various times. sity is the imminence of a suicide attempt. When it
14. Thought stopping. Dysfunctional thoughts often seems clear to the clinician that a patient is going to
have a snowball effect for individuals. What may start make an attempt, the therapist must directly and quick-
as a small and insignificant problem can, if left to roll 1y work to challenge the hopelessness. While it might
along, gather weight, speed, and momentum. Once on appear to be the treatment technique of choice, the
the roll, the thoughts have a force of their own, and are therapist risks becoming embroiled in a power struggle
very hard to stop. Thought stopping is best used when or argument with the patient. Disputation coming from
the thoughts start, but not in the middle of the process. outside the patient may, in fact, engender passive re-
The patient can picture a stop sign, "hear" a bell, or sistance and a passive-aggressive response that might
picture a wall. Any of these interventions can be include suicide. Disputation, argument, or debate are
helped to stop the progression and growth of the potentially dangerous tools. They must be used care-
thoughts. A therapist's hitting the desk sharply or ring- fully, judiciously, and with skill. If the therapist be-
ing a small bell can serve to help the patient to stop the comes one more harping contact, the patient may turn
thoughts. The memory of that intervention can be used the therapist off completely.
by the patient to assist his or her thought stopping. 17. Labeling ofdistortions. The fear of the unknown
There is both a distractive and aversive quality to the is a frequent issue for anxiety patients. The more that
technique. the therapist can do to identify the nature and content
15. Distraction. This technique is especially helpful of the dysfunctional thinking, and to help label the
for patients with anxiety problems. Since it is almost types of distortions that patients utilize, the less fright-
impossible to maintain two thoughts at the same ening the entire process becomes. The labeling helps
strength simultaneously, anxiogenic thoughts generally to make the components of the depression more con-
preclude more adaptive thinking. Conversely, a crete, specific, and changeable.
focused thought distracts from the anxiogenic thoughts. 18. Developing replacement imagery. Imagery or
By having patients focus on complex counting, addition visual representations sometimes constitute the cogni-
or subtraction, they are rather easily distracted from tions that generate and maintain dysphoric affect. Pa-
other thoughts . (One should take care that a person is not tients can be helped to develop coping images; for
math ornumberphobic, in which case the counting may example, rather than imaging failure, or recalling de-
work to increase the anxiety.) Having patients count to feat or embarrassment, the therapist can practice with
200 by 13s is very effective. When out of doors, count- the patient new, effective, coping images. Once well-
ing cars, people wearing the color red, or any cog- practiced, patients can do image substitution. When
nitively engaging task will also work. Distraction or anxiety is a component of the overall problem, it
refocusing of attention may be achieved by focusing on should be noted that rather than a patient's having a
some aspect of the environment, engaging in mental quantum or reservoir of anxiety, the anxiety is con-
exercise or imagery, or initiating physical activity. It is stantly being generated by the anxiogenic imagery.
helpful if the distraction activity can also serve to chal-
lenge the patient's catastrophizing. For example, pa-
Behavioral Techniques
tients who are concerned about a loss of control can
engage in physical activity that demonstrates they can There are two major goals in using behavioral tech-
take control. A female patient who fears "losing her niques within the context of cognitive therapy. The
mind" can distract herself with a mental distraction that first goal is to utilize direct behavioral strategies and
provides evidence that she has control of her mind techniques to test dysfunctional thoughts and behav-
iors. By having the patient try, as an experiment, sues involved in the actions. GTA is especially useful
feared or avoided behaviors, old ideas can be directly in overcoming the all-or-nothing approach to problem
challenged. A second use of behavioral techniques is solving, where the patient fails to make an attempt
to practice new behaviors as homework. Certain be- because the first step is so large and threatening.
haviors can be practiced in the office and then practiced 7. Behavioral rehearsal/role-playing. The therapy
at home. The following are behavioral interventions session is the ideal place to practice many behaviors.
that are commonly incorporated in cognitive therapy The therapist can serve as teacher and guide and can
and in no way constitute an extensive list of available offer direct feedback on performance. The therapist
behavioral techniques. can monitor the patient's performance, offer sug-
1. Activity scheduling. The activity schedule is, per- gestions for improvement, and model new behaviors.
haps, the most ubiquitous form in the therapist's arma- In addition, anticipated and actual road blocks can be
mentarium. rorpatients who are feeling overwhelmed, identified and worked on in the session. There can be
the activity schedule can be used to plan more effective extensive rehearsal before the patient attempts the be-
time use. havior in vivo.
2. Masiery and pleasure ratings. The activity sched- 8. In vivo exposure. There are times that the practice
ule can also be used to assess and plan activities that in the consulting room needs to be expanded. The ther-
offer patients both a sense of personal efficacy (mas- apist can go with patients into feared situations. The
tery, 1-10) and pleasure (1-10). The greater the mas- therapist can drive with a patient across a feared
tery and pleasure, the lower the rates of anxiety and bridge, go to a feared shopping mall, or travel on a
depression. By discovering the low- or high-anxiety feared bus. The in vivo exposure can be an important
activities, plans can be made to increase the former and adjunct to the office-based work. Combined with the
decrease the latter. patient-generated homework, the effect of the therapy
3. Social skills training. Ifpatients' views are accu- is markedly increased.
rate and if they actually lack specific skills, it is incum- 9. Relaxation training. The depressed and agitated
bent upon the therapist to either help them to gain the patient can profit from relaxation training inasmuch as
skills or to make a referral for skills training. The skill the anxiety response and the quieting relaxation re-
acquisition may involve anything from teaching pa- sponse are mutually exclusive. Relaxation training can
tients how to properly shake hands to practicing con- be taught in the office and then practiced by the patient
versational skills. for homework. Ready-made relaxation tapes can be
4. Assertiveness training. As with the social skills purchased, or the therapist can easily tailor a tape for a
training, assertiveness training may be an essential patient. The therapist-made tape can include the pa-
part of the therapy. Patients who are socially anxious tient's name and can focus on particular symptoms and
can be helped to develop responsible asertive skills can be modified as needed (Lehrer & Woolfolk, 1985).
(Jakubowski & Lange, 1978).
5. Bibliotherapy. Several excellent books can be as-
Homework
signed as readings for homework. These books can be
used to socialize or educate patients to the basic CT Therapy is inevitably influenced by what happens
model, emphasize specific points made in the session, beyond the confines of the consulting room. It is
or to introduce new ideas for discussion at future important for the patient to understand that the system-
sessions. atic extension of the therapy work to the nontherapy
6. Graded tasks assignments (GTA). GTAs involve a hours will result in faster, more comprehensive im-
shaping procedure of small sequential steps that lead to provement. The homework can be either cognitive or
the desired goal. By setting out a task and then arrang- behavioral. Homework can range from acting differ-
ing the necessary steps in a hierarchy, patients can be ently, practicing active listening, being verbally or
helped to make reasonable progress with a minimum physically affectionate, or doing things in an new way.
of stress or difficulty. As patients attempt each step, the It might involve having the patient complete an activity
therapist can be available for support and guidance. schedule (an excellent homework for the first session),
The therapist can have the patient rate the liklihood of complete several DTRs, or try new behaviors. The
success in attempting a new behavior. The patient can homework needs to flow from the session material,
be helped to identify the emotional and cognitive is- rather than being tacked onto the end of the session
simply because CT should include homework. The When the depression inventory, patient report, thera-
more meaningful and collaborative the homework, pist observation, and the feedback from significant
the greater the likelihood of patient compliance with others confirm decreased depression, greater activity,
the therapeutic regimen. It is helpful to encourage an and higher level of adaptive abilities, the therapy can
experimental attitude toward the homework, where move toward termination. The termination is accom-
effort and new information are more important than plished gradually to allow time for ongoing modifica-
specific results. The results of the homework should tions and corrections. Sessions are tapered off from
always be part of the agenda and reviewed at the next once weekly to biweekly. From that point, sessions can
session. If the homework is not part of the session be set on a monthly basis, with follow-up sessions at 3
agenda, the patient will quickly stop doing the home- and 6 months until therapy is ended. Patients can, of
work. The homework should not be assigned so much course, still call and set an appointment in the event of
as arrived at collaboratively. Important questions for an emergency. Sometimes, patients will call simply to
the therapist to ask include: Does the patient under- get some information, a reinforcement of a particular
stand the reason for the homework? Does the patient behavior, or to report a success. With the cognitive
agree with the rationale and purpose of the homework? therapist in the role of a consultant/collaborator, this
Is the homework within the patient's capability to com- continued contact is appropriate and important.
plete? Are there any factors that would preclude the Relapse prevention is an essential part of the thera-
patient from doing the homework? Is the homework py. Patients are made aware of the need for monitoring
reasonable for the timeframe before the next session? their mood. If they begin to feel more depressed, they
If the answer to any of these questions is no, then the can institute their previous learned skills. If they have
therapist must revise the homework to avoid having it any difficulty in doing this, an additional appointment
be a failure experience for the patient. can be scheduled for a "booster" session.
For example, a 42-year-old male patient was re-
cently separated from his wife of 18 years. Prior to
Use of Medication in Conjunction with
ma.rrying, he had dated infrequently. When the ques-
Psychotherapy
tion of dating arose in the therapy, he believed that he
could not date at his "advanced age." He was, he said, For a number of patients, medication is an important
"too old, too unattractive, too dumb, and too boring." part of the overall psychotherapy regimen. Although
The world was, he said, "populated by couples. many studies have investigated cognitive therapy ver-
Everyone has someone but me." He could not, he said, sus medication for the treatment of depression (e.g.,
eat at a restaurant by himself: "Everyone would look at Rush et al., 1977), the cognitive therapist is in no way
me." A homework experiment was to visit a local res- against the appropriate use of medication. For severely
taurant that had a bar attached to it. He agreed to go depressed patients with vegetative symptoms, medica-
into the bar for a drink and to observe how many single tion may be essential in helping them reach a level
men or women were in the bar. He would also look into where they can utilize the therapy. For bipolar or
the dining section and count any diners who were eat- schizophrenic patients, medication is essential. In
ing alone. He was surprised to see that there were working with severely anxious patients, anxiolytic
several single people dining. Future experiments in- medication may be an important part of the therapeutic
volved eating out. After each experiment, he recorded regimen. However, in the treatment ofthe more typical
his expectations before the attempt, and his thoughts unipolar depressive patients, medication may not be
during and afterward. These items were then discussed indicated. In these cases, patients on medication may
at the next session. be withdrawn from medication over several weeks,
with the consultation and agreement of a psychiatrist.
Termination
Indications for Cognitive Therapy
Termination in CT begins in the first session. Since
the goal of CT is not cure but more effective coping, Cognitive therapy is an effective treatment model
the cognitive therapist does not plan for therapy ad for a broad range of patients and clinical problems.
infinitum. As a skill-building model of psychotherapy, With the appropriate modifications, the basic model
the therapist's goal is to assist patients in acquiring the has been applied to families (Epstein, Schlesinger, &
skills to deal with the internal and external stressors. Dryden, 1988; Freeman, Epstein, & Simon, 1987;
Freeman & Zaken-Greenburg, 1989; Teichman, working conceptualization of the patient's problems,
1986), children (DiGiuseppe, 1987, 1989), groups (4) the socialization of the patient to the therapy
(Sank & Schaffer, 1984; Wessler & Hanken-Wessler, model, explaining the interrelationship of thoughts,
1989), chronic psychiatric patients (Bowers, 1989; feelings, and behavior, (5) identifying the dysfunc-
Freeman & Greenwood, 1987; Greenwood, 1983), tional thoughts and the schemata, (6) using cognitive
substance abuse (Beck & Emery, 1980; Wright, 1989), and behavioral techniques to test thoughts and assump-
eating disorders (Edgette & Prout, 1989; Fairburn, tions, (7) practicing adaptive cognitive and behavioral
1985; Garner & Bemis, 1985), anxiety (Beck & responses outside the therapy session (homework),
Emery, 1985; Freeman & Simon, 1989; Michelson & and (8) relapse prevention.
Ascher, 1987) and personality disorders (Beck & free- Ongoing use of the Beck Depression Inventory,
man, 1990; Freeman & Leaf, 1989). Scale of Suicidal Ideation and of the Hopelessness
Scale serve as important data collection tools. The
therapy utilizes a broad range of cognitive and behav-
Summary ioral techniques for testing. The proportion of cog-
nitive to behavioral techniques may be estimated by
Often called the common cold of emotional disor- the degree of the dysfunction: the greater the dysfunc-
ders, depression is one of the most common disorders tion, the more behavioral techniques will be utilized.
encountered in clinical practice, either by itself or in Cognitive therapy is active, directive, structured,
combination with other problems. The symptoms of problem focused, and collaborative. The emphasis on
depression may be experienced as affective, behav- skill building serves to facilitate generalization and
ioral, physiological, or cognitive, and, depending on maintenance of gain. If necessary, pharmacotherapy
the strength of the symptoms, are often disabling in will be utilized conjointly with the therapy. The em-
personal, social, or occupational functioning. phasis on skill building serves to facilitate generaliza-
The cognitive model of depression stresses the role tion and maintenance of gain. Cognitive therapy pro-
played by the individual's perceptions, thoughts, im- vides the patient with tools to cope effectively with the
ages, beliefs, and other cognitive phenomena in the present and with future problems, thus alleviating
origins and maintenance of depression. Specifically, emotional distress and offering hope for coping in the
the central theme in the cognitions of depressed per- future.
sons are a negative view of self, the world and experi-
ence, and of the future. The negative view of the fu-
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CHAPTER 17
Schizophrenia
Alan S. Bellack and Kim T. Mueser
Introduction been assumed that this pattern of impairment was not

remediable. However, beginning in the early 1970s, a
The treatment of schizophrenia has played a central series of single-case and group-comparison studies
role in the history of behavior therapy. Beginning in the demonstrated that (1) the social dysfunction could be
1950s, Lindsley and Skinner, Goldiamond, Ayllon, operationalized as a series of discrete behaviors or
and others conducted a seminal series of case studies skills, and (2) that even severely impaired patients
which demonstrated that conditioning procedures could be taught these skills with a new behavioral tech-
could have a significant impact on psychotic behavior nique called "social skills training." As will be dis-
(Kazdin, 1978). These were among the first illustra- cussed further below, subsequent research has demon-
tions that therapeutic techniques based on laboratory strated that social skills training can produce durable
principles could playa role in the treatment of signifi- changes that have a significant impact on overall func-
cant human problems. These studies also illustrated tioning and the risk of relapse (Morrison & Wixted,
the possibility that such behaviors could be produced 1989). More recently, behavioral family therapy has
and! or maintained by environmental factors. This proven to be highly effective in reducing relapse rates
work led to the development of the token economy, and in improving the emotional climate within the
and culminated in the publication of Ayllon and family (Mueser, 1989). Social skills training and be-
Azrin's manual in 1968. The classic study by Paul and havioral family therapy today represent the most effec-
Lentz (1977) provided empirical evidence of the tive psychosocial procedures available for the outpa-
efficacy of token programs. Token systems remain the tient treatment of schizophrenia. They are widely
most effective approach for structuring the inpatient regarded as essential components of any comprehen-
milieu of severely impaired patients and stand as a sive treatment program (Bellack, 1989).
monument to the power of behavioral techniques. Despite the success achieved by behavior therapy,
Social disability is one of the cardinal symptoms of schizophrenia has received scant attention from behav-
schizophrenia (Bellack, 1989; Morrison & Bellack, ior therapists in the last decade. With the exception of a
1987). Even when core psychotic symptoms are in handful of research groups in the United States, Great
remission, a majority of schizophrenics are left with Britain, and Switzerland, schizophrenia has been vir-
residual social impairment. Through the 1960s, it had tually abandoned in favor of less severe disorders. This
phenomenon is both surprising and disappointing.
Elsewhere, we have hypothesized that there are four
Alan S. Bellack and Kim T. Mueser • Department of Psy-
chiatry, Medical College of Pennsylvania at EPPI, Philadelphia, erroneous beliefs which have contributed to this situa-
Pennsylvania 19129. tion (Bellack, 1986): (1) the belief that schizophrenia
353
is an overgeneralized label which does not represent a nosed or that the label has no practical utility are no
coherent entity; (2) the belief that schizophrenia is a longer viable.
biological disease which is not amenable to behavioral
interventions; (3) the belief that schizophrenia is ade-
The Nature of Schizophrenia
quately treated by medication; and (4) the belief that
schizophrenia is too severe and unmodifiable to be of When Ayllon and Azrin and Paul and Lentz were
interest. The reader is referred to Bellack (1986) for a developing their token programs, state psychiatric
discussion of each of these assumptions. We will ad- hospitals provided nearly 50% of all psychiatric care in
dress two points here that are particularly germane: the the country (Sharfstein, 1984). These institutions were
recent developments in diagnostic precision and the almost all overcrowded, underfunded, and under-
current understanding of the nature of the illness. staffed. As a result, they placed greater emphasis on
control and management of patients than on "treat-
ment." The result was often mistreatment and the so-
Diagnosis
called institutionalization syndrome of withdrawal,
There has been substantial progress in categorizing apathy, and infantile behavior (Paul & Lentz, 1977).
and differentiating psychotic disorders in the last 10 The role of the state hospital in the overall mental
years. Prior to the publication of the Research Diag- health service delivery system has changed substan-
nostic Criteria (RDC) (Spitzer, Endicott, & Robins, tially in the interim. In line with the generic policy of
1978) and the third edition of the Diagnostic and Sta- "deinstitutionalization," there has been a dramatic
tistical Manual ofMentalD isorders (DSM -III) (Amer- shift from primary reliance on long-term hospitaliza-
ican Psychiatric Association, 1980), schizophrenia tion in state facilities to short stays and community-
was an ill-defined and vastly overused label; it was based treatment. The number of state hospital beds
something of a "wastebasket" category for difficult, decreased from a high of 559,000 in 1955 to 138,000
psychotic patients. As a result, the label had little relia- in the late 1970s. The average length of stay dropped
bility, validity, or utility. Both the RDC and DSM have from 6 months to 3 weeks during that period. By the
altered this situation dramatically. There now are ob- late 1970s, state hospitals provided only 9% of all
jective definitions of key symptoms and operational mental health care in the country (Sharfstein, 1984).
criteria for making the diagnosis. Recent studies em- Unfortunatel y, these dramatic changes do not reflect
ploying these new criteria have documented that there changes in the prevalence or effects of chronic mental
are substantial differences in treatment needs, course illness. To the contrary, they result from differences in
of illness, outcome, and psychopathology between how and where treatment is provided. In fact, the
schizophrenia and other psychotic disorders, such as change in service delivery patterns is better charac-
bipolar disorder and schizoaffective disorder (Levitt & terized by the term transinstitutiona/ization than de-
Tsuang, 1988). Although current criteria are far from institutionalization. The reduction in state hospital
perfect, they are sufficiently well-defined to assure at beds has been paralleled by an equally dramatic in-
least a moderate degree of homogeneity within studies crease in psychiatric beds in local facilities, including
and consistency across studies. general hospitals, Veteran's Administration hospitals,
Diagnostic precision has been substantially in- community mental health centers, and private psychi-
creased by the use of standardized, structured inter- atric hospitals (Goldman, Adams, & Taube, 1983).
views, including the Schedule for Affective Disorders Since 1955, there has been a 38% increase in inpatient
and Schizophrenia (SADS) (Endicott & Spitzer, episodes, which is primarily a result of a tremendous
1978), the Structured Clinical Interview for DSM-III increase in readmissions. Currently, almost 70% of all
(SCID) (Spitzer & Williams, 1985), and the Present admissions involve patients with a previous history of
State Examination (PSE) (Wing, Cooper, & Sartorius, hospitalization (Sharfstein, 1984). Patients entering a
1974). Interrater agreement for schizophrenia diag- psychiatric hospital in the 1950s could expect a multi-
noses derived from these instruments by trained inter- year stay. Today, they enter through a "revolving
viewers range upward of r = .80 (Spitzer, Forman, & door," and can expect to have multiple admissions of
Nee, 1979), which is comparable to agreement figures several days to several weeks. Schizophrenics alone
for behavioral coding systems. Consequently, argu- may account for as many as 500,000 hospital admis-
ments that schizophrenia cannot be adequately diag- sions per year (Goldman, 1984). These figures would
CHAPTER 17 • SCHIZOPHRENIA 355
be even higher if current commitment laws were more physical health and have shortened life expectancies.
lenient. They also fail to take advantage of social and recrea-
A major component of deinstitutionalization was tional opportunities available in the community be-
the development of the Community Mental Health cause they lack the money, skills, and motivation to
(CMH) system. The goal ofCMH was to provide treat- participate in such activities. Recreation for most pa-
ment in the community, rather than in large, geograph- tients is limited to watching television or listening to
ically isolated institutions. It was assumed that living the radio. They are socially isolated, and can be found
in the community would allow patients to be reinte- spending endless hours sleeping, walking the streets,
grated into family and peer groups and to find em- or sitting in community mental health center
ployment, as well as restoring civil liberties and allow- dayrooms.
ing patients to enjoy the many privileges and benefits The practice of long-term hospitalization employed
society has to offer. Although these expectations were through the early 1960s created the institutionalization
fulfilled for some patients, the majority have traded the syndrome. Deinstitutionalization has inadvertently
distressing conditions in state hospitals for marginal created a new syndrome: the After Care Client. Pa-
lives in the community (Klerman, 1977; Lehman, tients with this syndrome are characterized by revolv-
1983). ing door rehospitalization, poor physical health, social
Only a small proportion of ex-patients have been isolation, inadequate housing, dependence on others,
effectively reintegrated into the community. Many ex- chronic unemployment, and poverty. To a great extent,
patients are ostracized by other people because of their this new syndrome is as pernicious and has an equally
odd appearance or behavior, whereas others actively poor prognosis.
avoid social contacts. The vast majority are chron- A number of factors have led to this current state of
ically unemployed, with little hope or desire to find affairs, but two are particularly relevant to this discus-
work. They remain dependent on the social service sion. First, initial expectations about the effectiveness
system for money, food, and shelter, and often suffer of antipsychotic medication were overly optimistic. It
from poor nutrition and health. Only a small propor- was assumed that medication could not only control
tion of ex-patients are capable ofliving independently; psychotic symptoms but also enable patients to take
most require some form of supervised living arrange- advantage of community programs and develop con-
ments (Goldstrom & Manderscheid, 1981). Of those structive lives. Recent data demonstrate that this as-
who do live on their own, a great many live in run- sumption is far from accurate. As many as 50% of
down apartments or rooming houses in decaying areas schizophrenics may not receive appreciable benefit
of cities. A large number have no residence what- from neuroleptics (Gardos & Cole, 1976). A signifi-
soever; as many as one half of the 2 million homeless cant minority do not have a notable clinical response,
people in our country are chronically mentally ill whereas others do not take it as prescribed. Of those
(Cordes, 1984). A significant number of mentally ill who do respond, 25%-30% can be expected to relapse
individuals also find shelter in prisons, having been within 1 year, and as many as 50% within 2 years
arrested rather than brought to psychiatric facilities by (Hogarty, Schooler, Ulrich, et al .• 1979).
police. The overall impact of medication is also more cir-
The most comprehensive data to date on the com- cumscribed than had been thought. Neuroleptics have
munity adjustment of chronic mental patients are pro- their most demonstrable effect on positive symptoms,
vided by the NIMH sponsored Community Support such as thought disorder, hallucinations, and delu-
Program (Goldstrom & Manderscheid, 1981). The sions. However, they often do not appreciably reduce
data document that most chronic patients have a poor negative symptoms, such as apathy, anergia, and so-
quality of life, even aside from housing. They are fre- cial withdrawal (Carpenter, Heinrichs, & Alphs,
quent crime victims because they are easy prey for 1985). Similarly, they do not directly enhance skills of
street criminals. A majority of patients are unable to daily living or improve quality of life (Diamond,
perform requisite tasks of daily living: fewer than 60% 1985). Moreover, between 15% and 50% of patients
are able to independently perform household chores, experience significant side effects, including akinesia,
prepare meals, or maintain an adequate diet; less than akathisia, and tardive dyskinesia (Johnson, 1985).
50% can manage their own money or take medication These side effects can be as disruptive and distressing
as prescribed. Chronic patients often suffer from poor as core psychotic symptoms (Drake & Ehrlich, 1985;
Van Putten & May, 1978). The antiparkinsonian medi- each of which serves an essential role in the overall
cation used to control these side effects have disruptive care of the patient (Bellack, 1989; Test, 1984). The
side effects of their own (McEvoy, 1983). It is now range and types of services required are illustrated in
apparent that antipsychotic medication is crucial in the Table 1. It is readily apparent that behavioral strategies
treatment of a majority of patients, but that it is far playa critical role in the treatment component. But,
from a panacea. behavioral techniques can also make significant contri-
A second factor contributing to the current situation butions to the implementation of pharmacotherapy
was an unrealistic model of illness. The mental health (Bellack, 1986; Wallace, Boone, Donahue, & Foy,
community, including behavior therapists, has long 1985), as well as to the rehabilitation component (An-
subscribed to an infectious disease model of illness, in thony & Nemec, 1984). Behavior therapy may not
which treatment is viewed as a short-term process for produce the demonstrable changes associated with
dealing with a circumscribed, temporary disturbance. treatment of anxiety disorders or depression, but it is
This model is inappropriate for a disorder such as no less valuable for the treatment of schizophrenia. In
schizophrenia, which is characteristically multiply fact, given the dearth of other effective treatments, it
handicapping and a life-long disorder. Only a small seems almost unethical for behavior therapists to with-
proportion of patients will have a substantial recovery hold their expertise from this very needy population.
with a return to premorbid levels of functioning We previously indicated that many behavior thera-
(Strauss & Carpenter, 1981). The majority will have pists assume that schizophrenia is a "biological" dis-
residual handicaps even when the primary symptoms order which is not responsive to psychosocial interven-
are well controlled. As many as one third of schizo- tions. Schizophrenia does have a substantial biological
phrenics will have a minimal recovery. They will have basis. But the environment plays a critical role in both
residual symptoms and remain substantially dysfunc- the etiology and course of the disorder, and there is
tional for their entire lives. They will be dependent on ample room for behavioral input. The best current con-
the social service system and mental health establish- ceptualization of the illness is provided by Zubin and
ment for some services throughout their lives. Even Spring's (1977) stress-vulnerability model. They pos-
patients who have a "good" outcome can be expected tulate that schizophrenic symptoms emerge as a result
to have notable handicaps and periodic exacerbations.
Relapse is a natural part of the illness for most patients,
and cannot be viewed as a sign of treatment failure. Table 1. A Comprehensive
In many respects, the mental health system has been Program of Care
frustrated by the fact that schizophrenics do not get
Treatment
better and "go away." Furthermore, the "up and out"
Medication
philosophy of treatment resulting from such expecta- Family therapy
tions is not only ineffective for schizophrenics, but Social skills training
may actually increase stress and precipitate relapse Medical care
(Schooler & Spohn, 1982). Schizophrenia is best rep- Crisis intervention
resented by a chronic illness model, akin to that em- Rehabilitation
ployed for individuals suffering from renal disease, Housekeeping
juvenile diabetes, and Down syndrome. These disor- Nutrition and hygiene
ders require long-term, multidimensional treatment. Job training
The goal of treatment is management of symptoms, Transportation
teaching living and coping skills, and enhancing quali- Social Services
ty oflife, not "curing" the illness. A similar approach Income support
is required for the treatment of schizophrenia. Housing
Social support
The chronic illness model provides a dramatically
Recreation
different perspective of the needs of the schizophrenic
patient. It is no longer viable to think of "treatment" in Continuity of care
Active coordination of above services
the traditional sense of the patient's coming to the
clinic for a brief visit to receive a single intervention Note. From A Clinical Guide for the Treatment of
Schizophrenia (p. 7), edited by A. S. Bellack, 1989,
for a limited period of time. Treatment per se is only New York: Plenum Press. Copyright 1989 by Plenum
one element of a multicomponent system of services, Press. Reprinted by permission.
of the combined influence of psychobiological vul- training (Bellack, Morrison, & Mueser, 1989). But, it
nerability and environmental stress. The term vul- by no means precludes a significant role for behavior
nerability refers to a sensitivity or predisposition to therapy in the overall treatment process.
decompensate under stress and experience a range of
psychotic symptoms. Vulnerability is determined
largely by genetic and developmental factors, and var- Assessment
ies in degree across affected individuals. Vulnerability
may be mediated by structural anomalies in the brain, As indicated above, schizophrenia is characterized
such as enlarged cerebral ventricles (Weinberger, by multiple handicaps. Thus, outcome must be as-
Wagner, & Wyatt, 1983), or biochemical dysfunc- sessed across a variety of domains, including symp-
tions, such as excessive dopaminergic activity and/or tomatology, role functioning, exacerbations and re-
hypersensitivity of dopamine receptors (Haracz, lapses, medication dose and side effects, impact on the
1982). The degree of vulnerability is reflected by such family, quality of life, and so forth. Assessment of
factors as genetic loading (Gottesman, 1968), reduced these diverse domains is a sufficiently complex topic to
information-processing capacity (Nuechterlein & warrant its own chapter. The following section is
Dawson, 1984), heightened autonomic reactivity intended to provide a brief overview of the predomi-
(Dawson & Nuechterlein, 1984), and schizotypal nant approaches to assessment.
personality.
Stressors are environmental events that impact
Behavioral Observation
negatively upon an individual, including life events
(Rabkin, 1980), negative ambient family emotion Behavioral observation remains the hallmark of be-
(Koenigsberg & Handley, 1986), or an unstructured, havioral assessment. One of the most comprehensive
impoverished environment (Wing & Brown, 1970; and sophisticated of all behavioral observation systems
Wong et al., 1985). Internal "events," such as phys- has been developed for work with chronic psychiatric
ical illness and the effects of psychostimulants or hal- inpatients, including those with schizophrenia: the
lucinogens can also serve as significant stressors. The Time-Sample Behavioral Checklist (TSBC) (Paul &
greater the degree of vulnerability, the less stress is Licht, 1988). The TSBC is designed for observing
required for schizophrenic symptoms to appear. Con- ongoing behavior on an inpatient ward or other con-
versely, even low or moderate stress can precipitate trolled environment. It contains 69 codes, covering
illness in a highly vulnerable person. almost every aspect of a subject's behavior, including
The impact of stress on vulnerability is modulated his location, body position, whether he is awake or
by a person's coping skills. Coping skills are diverse asleep, facial expression, social orientation, appropri-
abilities and resources that enable an individual to re- ate concurrent activities, and crazy behavior. Each of
solve problems, reduce arousal, and achieve instru- the codes is scored in discrete 2-sec observation peri-
mental or socioemotional goals that maximize adapta- ods. Paul and Licht (1988) reported that a skilled ob-
tion. They include social skills, problem-solving server can code an entire ward of patients in 20 to 30
skills, skills needed for daily living (such as using sec. They have developed a system that permits the
public transportation and money management), and mass of resultant data to be stored and analyzed on
basic self-care skills (such as personal hygiene and line. The TSBC has excellent reliability and has
grooming). Coping skills can help to minimize the proven to have considerable validity for evaluating the
negative effect of a stressor on the individual by cir- outcome of treatment programs, including predictions
cumventing potential stressors entirely, as well as by of postdischarge effects.
decreasing the severity and duration of their impact. It Despite these positive features, we are not aware of
seems apparent that behavioral techniques could be any major outcome study that has employed the instru-
useful in modifying the environment, reducing stress- ment other than those conducted by Paul and his col-
producing behaviors (e.g., substance abuse), and de- leagues. Like most other extensive observational sys-
veloping effective coping skills. The biologicallimita- tems, the TSBC appears to have two "fatal flaws":
tions imposed by the disorder (e.g., restricted attention high cost and low relevance. The TSBC would be
and information processing) may limit the effective- highly appropriate for a behavioral study in which
ness of some behavioral procedures that are useful with focal behaviors are the primary subject of interest; but
less impaired populations, such as problem-solving that is not the case in most broad-based clinical out-
come studies. Schizophrenia, in particular, is marked cussed above, in regard to other observational sys-
by mUltiple handicaps, and outcome must be evaluated tems, the use of these procedures as generic outcome
across a variety of domains. Outcome studies are, measures is somewhat limited because of the high cost
thus, difficult and expensive to conduct. Staff time , the of rating the interactions.
assessment burden on patients, and costs must be care-
fully limited or the project quickly becomes un-
Self-Report Inventories
manageable. Observational systems like the TSBC are
extremely expensive and time-consuming to imple- Self-report is an uncertain source of information in
ment. Conversely, they account for only a small pro- the assessment of schizophrenia patients. Although
portion of unique variance in overall outcome. They patients are the only source of information about their
provide high-fidelity information on patient behavior, inner world (e.g., delusional beliefs), they are notori-
which is not otherwise available. But clinically and ously poor reporters. In addition to the customary lim-
socially significant domains of outcome, such as re- itations of self-report, such as inaccurate recollection
lapse and role functioning in the community, can be and response bias (Bellack & Hersen, 1977), schizo-
assessed more cheaply and conveniently (e.g., by in- phrenics suffer from a number of cognitive problems
terviewer ratings). Moreover, detailed behavioral that further restrict their ability to provide accurate
codes have low face validity in comparison to more information. They frequently are disorganized and
typical clinical ratings. That does not indicate low cri- have some residual thought disorder even between
terion validity, but it does limit the acceptability of the acute episodes (Harrow & Quinlan, 1985). They also
procedure to the broader scientific and clinical com- have marked impairments in information processing
munity. It seems unlikely that behavioral observation and attention span (Neuchterlein & Dawson, 1984),
will ever achieve widespread acceptance unless and which can interfere with responding on self-report
until it is shown to be a cost-efficient system and to be inventories.
clinically useful.
One area in which observational strategies are fre-
Interviewer Rating Scales
quently used is in studies evaluating social skills train-
ing and family interactions. Despite well-known lim- The primary role of self-report in assessment of
itations, role-play tests and structured conversations schizophrenia patients is as a source of data for clini-
remain the standard for assessing interpersonal behav- cian judgments. Interviewer rating scales comprise the
ior (Bellack, 1979, 1983). These strategies reliably most important assessment strategy in research on
document differences between populations, and are schizophrenia. Such scales are used for assessing
related to other measures of social functioning (Bel- symptomatology (e.g., Brief Psychiatric Rating Scale
lack, Morrison, Wixted, & Mueser, in press; Bellack, [BPRS], Scale for the Assessment of Negative Symp-
Morrison, Mueser, & Wade, 1989). toms [SANS]), ability to fulfill social roles (e.g., So-
Structured conversations, in particular, have proven cial Adjustment Scale-II [SAS]), overall adjustment
to be increasingly useful for assessment of family in- (e.g., Global Adjustment Scale [GAS]), and medica-
teraction patterns. The prototypical strategy involves tion side effects (e.g., Abnormal Involuntary Move-
two lO-min problem-solving discussiofls between the ment Scale [AIMS]). The BPRS and GAS are particu-
patient and a significant other. A staff person first larly useful measures of symptomatology and overall
meets individually with each participant to identify a functioning, respectively. As with the structured diag-
set of problems that are a source of conflict between the nostic interviews, carefully constructed interview
participants (Goldstein & Doane, 1982). The dyad or scales have been shown to be highly reliable and have
triad is then directed to try to resolve the issue. After 10 good criterion and predictive validity (Morrison,
minutes, the staff person interrupts and presents a sec- 1988). They characteristically serve as the centerpiece
ond problem. The interaction is videotaped for subse- of a comprehensive assessment battery.
quent rating on a standardized coding system. This
strategy has proven useful as a measure of behaviors
Significant-Other Reports
that are related to expressed emotion (Miklowitz,
Goldstein, Falloon, & Doane, 1984), and for evalua- Given the limitations of patient self-report, signifi-
tion of the effects of behavioral family therapy (Doane, cant others are often the only source of information
Falloon, Goldstein, & Mintz, 1985). However, as dis- about the patient's functioning outside of the hospital.
CHAPTER 17 • SCmZOPHRENIA 359
Family members have access to vital information about general strategies: bolstering the patient's coping skills
the patient's role functioning in the community, social and reducing ambient stress impinging on the patient.
competence, compliance with medication, symp- Coping skills can be enhanced by training social skills
tomatology, medication side effects, illicit drug use, relevant to patients' interpersonal needs, or by teach-
and the like. Recently, families have also been enlisted ing behavior management techniques, such as relaxa-
to report on prodromal changes which forewarn of im- tion or self-control strategies, in order to reduce the
pending relapse (Herz & Melville, 1980). These di- negative effects of stressors. Behavioral family thera-
verse data can be assessed by paper-and-pencil in- py can reduce stress emanating from tense and hostile
ventories, such as the Katz Adjustment Scales (Katz & interactions with family members as well as improve
Lyerly, 1963), or by interview. For example, a sightly the coping skills of patients and relatives alike. Pa-
modified version of the SAS is often administered to tients residing in structured and supervised environ-
significant others to assess patient role functioning. ments, such as board-and-care homes, halfway
Another target of assessment is the family (or signif- houses, or institutions, may benefit from the applica-
icant other) itself. Family attitudes about the patient tion of operant methods (e. g. , token economy) to shape
and associated behaviors can play a critical role in more adaptive coping behaviors.
relapse. Expressed emotion (EE) has proven to be Paul and Lentz's (1977) classic study on chronic
among the most potent factors affecting outcome patients in a state psychiatric hospital demonstrated
(Hooley, 1985). EE is formally assessed by the Cam- that an intensive social learning program based on the
berwell Family Interview (CFI) (Vaughn & Leff, token economy was more effective than equally inten-
1976), a semistructured interview designed to facili- sive milieu treatment or standard hospital care in de-
tate the expression (and assessment) of feelings and creasing symptomatic behaviors, discharge and tenure
attitudes about the patient. EE is subsequently coded in the community, and total cost. However, these re-
on three dimensions: Critical Comments, Hostility, sults have not yet been replicated, perhaps because the
and Emotional Overinvolvement. Trained raters regu- sheer complexity of the token economy approach re-
larly achieve reliabilities above .80. The CFl requires quires changes at a variety of administrative levels as
upward of 1 112 hours to administer. Consequently, well as in on-line staff behavior. Issues concerning the
several alternative procedures have been developed, design and efficacy of social-learning token economy
including the Five Minute Speech Sample (Magana et programs have recently been reviewed and are not con-
al., 1986), and the Patient Rejection Scale (Kreisman, sidered further here (Glynn & Mueser, 1989). Over the
Simmens, & Jay, 1979). Family members' perceptions past 10 years, the emphasis in controlled outcome
of the "burden" imposed on the family by the patient is studies on behavioral interventions for schizophrenia
another related concept that can be assessed more easi- (i.e., research utilizing random assignment of patients
ly (Platt, 1985). Preliminary research with these in- to treatment groups) as well as clinical applications of
struments (especially the speech sample) has yielded behavioral techniques have been published on social
promising results. skills training and behavioral family therapy. Conse-
quently, we will now focus on the growing importance
of the treatment of schizophrenia.
Behavioral Interventions for
Schizophrenia Social Skills Training
As previously described, the accumulation of evi- Deficits in social functioning are a necessary criteri-
dence documenting the influence of genetic-biological on for the diagnosis of schizophrenia according to the
factors and stress on the episodic course of schizo- latest revision of the Diagnostic and Statistical Man-
phrenia led to the development of the stress-vul- ual of Mental Disorders (DSM-III-R) (American Psy-
nerability-coping skills model of psychiatric outcome. chiatric Association, 1987). A large body of evidence
This conceptual model has served as a valuable has demonstrated that impairments in the social func-
heuristic in treating multiple handicaps in social and tioning of schizophrenic patients date back to poorer
vocational functioning and in minimizing symp- childhood social competence (Lewine, Watt, & Fryer,
tomatology characteristic of the disorder. Based on 1978) and adult premorbid adjustment (Zigler &
this model, behavioral interventions can improve the Glick, 1986) in the majority of patients. An important
course of the illness and reduce relapses through two consequence of inadequate social competence of
schizophrenic patients is an impoverished quality of for improvement regarding his or her performance; (7)
life (e.g., Lehman, 1983; Sylph, Ross, & Kedward, repeated behavioral rehearsal and feedback; and (8)
1978). One fruitful approach to the assessment and homework assignments to practice the skill and en-
modification of behaviors necessary to achieve social hance generalization. The clinical procedures for con-
competence has been the development of the concept ducting social skills training with psychiatric patients
of social skills. Social skills are defined as the interper- are described in other chapters of this volume and in
sonal skills necessary to achieve instrumental and affil- several books (Kelly, 1982; Liberman, DeRisi, &
iative goals relevant to independent living and a satis- Mueser, 1989).
factory quality of life (Liberman, Mueser, Wallace,
Jacobs, et al .• 1986). Social skills refer to the specific, Efficacy. Extensive research has been conducted
discrete verbal, nonverbal (e.g., eye contact, ges- over the past two decades on the feasibility of social
tures), and paralinguistic (e.g., voice tone, loudness, skills training for schizophrenics and other chronic
affect) interpersonal behaviors, which in combination mental patients (Donahoe & Driesenga, 1988). Many
result in effective social behavior. Recently, social per- of these studies were limited by the failure to employ
ception skills (e.g., the ability to accurately perceive standardized instruments to establish psychiatric diag-
relevant social parameters, such as emotional ex- nosis (e.g., the Structured Clinical Interview for
pression in others: Morrison & Bellack, 1987; Mor- DSM-III; Spitzer & Williams, 1985), lack of attention
rison, Bellack, & Mueser, 1988) and information-pro- to possible confounds because of concomitant use of
cessing skills (e. g., the ability to generate possible psychotropic medications, and not using widely ac-
response options and anticipate possible conse- cepted measures of treatment outcome (i.e., symp-
quences; Wallace et al.. 1980) have also been included tomatology, relapse rate, social and vocational func-
as important social skills in need of remediation in tioning, hospitalization; Strauss & Carpenter, 1977).
many patients. Extensive research has repeatedly doc- However, there has been a convergence of results
umented that most schizophrenics have pronounced across this research, indicating that schizophrenic pa-
deficits in their social skills compared to other psychi- tients can be trained to improve a wide range of social
atric patients and nonpatients (for a review, see Mor- skills in specific situations, including conversational
rison & Bellack, 1987), and recent evidence suggests skills (Holmes, Hansen, & St. Lawrence, 1984; Urey,
that within the population of schizophrenics poor pre- Laughlin, & Kelly, 1979); assertive responses (Eisler,
morbid social functioning antedates skill deficits Blanchard, Fitts, & Williams, 1978; Hersen, Bellack,
prominent after the onset of the illness (Mueser, Bell- & Thrner, 1978), nonverbal behaviors, such as smiles
ack, Morrison, & Wixted, 1989). and eye contact (Edelstein & Eisler, 1976; Kolko, Dor-
Social skills training has developed over the past 30 sett, & Milan, 1981), paralinguistic behaviors, such as
years as an important strategy for improving the social voice loudness and tone (Eisler, Hersen, & Miller,
competence of psychiatric patients and enhancing their 1973; Finch & Wallace, 1977); job interview skills
coping skills, thereby improving their ability to man- (Furman, Geller, Simon, & Kelly, 1979; Kelly, Laugh-
age stress effectively. The origins of social skills train- lin, Claiborne, & Patterson, 1979); and independent
ing date back to conditioned reflex therapy (Salter, living skills (Brown & Munford, 1983). Furthermore,
1949) and assertion training (Wolpe, 1958), and there is moderate generalization of acquired skills to
evolved to incorporate principles of social learning similar situations following social skills training, with
(e.g., modeling; Bandura, 1969). Although a variety more complex skills showing less generalization (Bell-
of different models have been developed for social ack et al .• 1976; Frederiksen, Jenkins, Foy, & Eisler,
skills training with psychiatric patients, they all adhere 1976).
to the following strategies for producing changes in The success of social skills training techniques in
social behavior: (1) assessment of patient's behavioral demonstrating that specific skills can be taught to
strengths, deficits, and excesses in interpersonal situa- symptomatic patients paved the way for controlled
tions; (2) provision of a rationale and motivation for treatment studies with schizophrenic patients. Several
learning a specific skill; (3) modeling the skill in a role- recent studies employing random assignment of pa-
play by the therapist; (4) provision of focused instruc- tients to treatment groups have provided modest sup-
tions to the patient to practice the skill; (5) behavioral port for the efficacy of social skills training and suggest
rehearsal of the skill by the patient in a role-play; (6) that this method may have promise in the rehabilitation
giving the patient positive feedback and suggestions of schizophrenic patients.
Bellack, Turner, Hersen, and Luber (1984) com- lower for the social skills group compared to holistic
pared the efficacy of group social skills training as an health treatment, but the difference was not statis-
adjunctive treatment for schizophrenic patients par- tically significant (50% and 78%, respectively). Two
ticipating in an outpatient day treatment program. Pa- aspects of the experimental design of this study limit
tients were randomly assigned to either day treatment the conclusions that can be drawn from it. Social skills
only or day treatment plus social skills training for a 3 training versus holistic health treatment were con-
month period. At a 6-month follow-up, patients who founded with family treatment, because relatives of
had receive social skills training had maintained im- patients in the former treatment received behavioral
provements in symptomatology and social functioning family therapy (Falloon, Boyd, & McGill, 1984),
achieved during the first 3 months of treatment, com- whereas relatives of patients in the latter treatment
pared to patients who received day treatment only. received holistic health-oriented family treatment.
However, I-year posttreatment relapse rates did not Thus, differences in outcome could reflect the different
differ between the two groups. These results are en- methods of family therapy, rather than the impact of
couraging, but the lack of differences in relapse rates social skills training. A second limitation is the ab-
of schizophrenic symptoms, an important outcome sence of a no-treatment group, obscuring the relative
measure, suggest that the skills training intervention efficacy of either treatment compared to none. Never-
may have been too brief or may not have addressed a theless, this study provides additional support for the
sufficiently broad range of problem areas (e.g., inde- potential importance of social skills training in the
pendent living skills). treatment of schizophrenia.
Hogarty et al. (1986) compared the efficacy of indi-
vidual social skills training and psychoeducational Future Directions. Controlled research on the
family therapy in the prevention of relapse in schizo- efficacy of social skills training for schizophrenia is at
phrenic patients who had recently been treated for a an early stage, and much work remains to be done. The
symptom exacerbation. All patients were living with question of the optimal intensity and duration of social
parents who were high in EE, and were thus at in- skills training is crucial to assessing its clinical
creased risk for relapse because of exposure to nega- efficacy. Schizophrenia is a chronic illness requiring
tive family affect. All patients were maintained on long-term interventions. Two of the controlled studies
neuroleptic medications throughout the study. Patients provided skills training for a relatively brief duration
were randomly assigned to one of four psychosocial (Le., less than 6 months; Bellack et al., 1984; Liber-
treatment groups: social skills training, family therapy, man, Mueser, & Wallace, 1986), which is probably
social skills training plus family therapy, or no psycho- inadequate to remediate the wide range of interper-
social treatment. Patients who participated in social sonal and instrumental skill deficits common to
skills training received weekly sessions for 1 year and schizophrenics. Hogarty et al. (1986) provided weekly
biweekly sessions for a second year. One-year relapse sessions for 1 year and biweekly sessions for another
rates supported the efficacy of social skills training and year. Even though the duration of this treatment was
family therapy (20% and 19% relapse rates, respec- long, the frequency of sessions was less than many
tively), as well as the combination of these two treat- earlier single-case studies that provided multiple
ments (0%), compared to no treatment (41 %). Two- weekly sessions. Future controlled research will need
year relapse rates continued to support the family ther- to examine the importance of frequency and length of
apy, but not the social skills intervention (Hogarty, treatment sessions on clinical outcome.
1988, personal communication). A related issue concerns the relationship between
Liberman, Mueser, and Wallace (1986) compared improvements in social skill and changes in symp-
two intensive 9-week treatments for schizophrenic in- toms, social functioning, and risk of relapse. Accord-
patients awaiting discharge in a state hospital: group ing to the stress-vulnerability-coping skills model, im-
social skills training and holistic health treatment. Pa- proved social skills mediate the noxious effects of
tients were randomly assigned to either treatment, stress on vulnerability, and, hence, symptomatology.
which included multiple daily treatment sessions and If this assumption is correct, improvements in social
weekly family sessions. Results based on a 2-year skill would be expected to be correlated with improve-
posttreatment follow-up favored the social skills train- ments in symptoms and social functioning. On the
ing group on a variety of symptom and social adjust- other hand, if clinical improvement during social skills
ment measures. Two-year relapse rates were also training is independent of skills acquisition, it might
suggest that nonspecific features of the intervention differentiate treatment responders from nonrespon-
(e.g., structure, support) were responsible for im- ders. This integrated program should provide a good
provement, rather than the training of specific skills. test of the generalizability of the skills training
This question has not been addressed in controlled out- process.
come studies and deserves further attention. If changes
in specific skills were correlated with improvements in
Behavioral Family Therapy
particular areas of functioning, it would be important
to target these skills in a treatment program. The discovery of the antipsychotic properties of
Another area in need of further exploration is the neuroleptic medications over 30 years ago enabled the
generalization of skills acquired during social skills majority of schizophrenic patients to be treated in the
training to patients' natural environment, and the in community, with periodic inpatient hospitalizations to
vivo social reinforcement of these skills. Social skills treat the symptoms of acute exacerbations. A conse-
training is assumed to improve patient social function- quence of the movement toward deinstitutionalization
ing by enhancing skill competencies, which are subse- has been a dramatic increase in the number of schizo-
quently reinforced and maintained by persons in the phrenic patients living in the homes of relatives. Esti-
patient's immediate social environment. If changes in mates of the percentage of noninstitutionalized psychi-
social skill are not sufficiently reinforced in the pa- atric patients living with relatives are high, ranging
tient's natural setting, they will cease to be used, and from 58% to 73% (Goldman, 1982; Minkoff, 1978).
social functioning will remain impaired. Thus, effec- As families have assumed an increased responsibil-
tive programs that seek to train social skills must also ity for caring for their schizophrenic relative, they have
ensure that patients' social environments are suffi- also experienced economic and psychological hard-
ciently supportive of these improvements. One strat- ships in coping with the stressful behavior of a chron-
egy to improve the generalization of social skills train- ically ill patient at home (Dearth, Labenski, Mott, &
ing and to maximize reinforcement of newly acquired Pellegrini, 1986). Negative symptoms, such as social
skills has been to provide training sessions outside of isolation and lack of motivation, are particularly trou-
the usual clinic setting in environments where patients blesome to family members, who are more prone to
spend more time, such as day treatment programs and criticize patients for these behaviors than for positive
board-and-care homes. In a recent survey of board- symptoms, such as delusions and hallucinations (Leff
and-care homes, the vast majority of operators re- & Vaughn, 1985). The burden of the illness on the
ported that social skills training was provided to resi- family acts as a potent stressor on relatives, and can
dents (Taylor & Dowell, 1986). However, closer ex- lead to excessive criticism or emotional overinvolve-
amination of the training methods used by operators to ment directed toward the patient. These communica-
improve social skills revealed that few were familiar tions, described earlier in this chapter as "expressed
with the principles of social skills training, many util- emotion," have been found to increase patients' risk
ized ineffective techniques, such as "encouragement" for symptomatic relapses (Koenigsberg & Handley,
or "nurturance" to train social skills, and relatively 1986).
little time was devoted to the training of skills. Behavioral family therapy has emerged over the past
To improve the generalization of skills training and 10 years as an important treatment approach for modi-
to ensure that trained skills are socially reinforced in fying negative affect in the family directed toward the
vivo, we have recently initiated a social skills training patient and for reducing the burden of the illness on the
program with the schizophrenic residents of a board- family. Two different behavioral interventions with
and-care home. Multiple skills training sessions are families have been developed that have received em-
conducted weekly at the day treatment program that pirical support, one by Falloon and his colleagues
the residents attend, in addition to training in self-care (Falloon et al., 1984, 1988; Mueser, 1989), and one by
and independent living skills at the board-and-care Barrowclough and Tarrier (1987; Tarrier et al., 1989).
home. Furthermore, weekly excursions into the com- Both approaches provide education to family members
munity are planned to provide additional opportunities about the nature of schizophrenia, strive to minimize
to practice targeted social and independent living stress on all family members, and aim to enhance pa-
skills. Patients are routinely assessed for symp- tient functioning. The two methods differ in the strat-
tomatology, social adjustment, and social skills in egies they employ to change the behavior of family
order to evaluate treatment needs and gains and to members. Falloon's approach focuses on changing be-
havior primarily through teaching specific interper- requisite to training in problem solving, to ensure that
sonal skills using social skills training methods. Bar- family members can discuss problems with a mini-
rowclough and Tarrier's method, on the other hand, mum of stress and negative affect. Four skills are
provides stress management training and goal setting taught during this phase of treatment, including (1)
to improve patients' social and vocational functioning active listening, (2) expressing positive feelings, (3)
and does not target specific interpersonal skills for making positive requests, and (4) expressing negative
modification. Falloon's model will be briefly de- feelings. Training of additional skills is done on an "as
scribed next, followed by Barrowclough and Tarriers' needed" basis, such as compromise and negotiation or
approach. requesting a "time-out." The component behaviors of
the skills taught during communication skills training
Falloon's Model. The primary goal of this ap- are listed in Table 2. Social skills training is used to
proach is to teach family members the interpersonal teach these skills, with all family members participat-
skills necessary to solve their own problems and to ing in role-plays and completion of homework assign-
achieve personal goals without the aid of the therapist. ments. Four to ten sessions are usually required to
The focus of treatment is on improving the coping teach these skills, although booster sessions to retrain
skills of the entire family, rather than only the patient. communication skills later in treatment are often nec-
Treatment is usually initiated following recovery from essary. Most of the remaining sessions are spent teach-
an acute symptom exacerbation, although it may be ing a structured, step-by-step approach to solving
given at other stages of the illness as well. Therapy is problems. Families are taught to have weekly problem-
divided into five phases, including (1) assessment, (2) solving meetings, which are led by a family-elected
education about the illness, (3) communication skills chairperson and follow the steps of (1) defining the
training, (4) problem-solving training, and (5) special problem or goal to everyone's satisfaction; (2) brain-
problems. Treatment sessions are usually conducted at storming possible solutions; (3) evaluating the advan-
the home with individual families in order to minimize tages and disadvantages of each solution; (4) selecting
dropouts, and are provided over an extended period of the best solution or combination of solutions; (5) plan-
time on a declining contact basis. Patients and family ning how to implement the solution(s); and (6) review-
members participate in all sessions. ing implementation of the plan and determining strat-
Individual assessments are conducted with each egies for overcoming obstacles encountered. A written
member of the family at the beginning of treatment and record of problem solving is maintained during all
are repeated at 3-month intervals throughout the family meetings. The therapist's role in problem-solv-
course of therapy. The purpose of these assessments is ing training is limited to assuring that the family learns
to assess family members' knowledge about schizo- the problem-solving sequence, rather than focusing on
phrenia and its treatment, the subjective burden of the the specific content of the problem. Special problems
illness, and to establish short- and long-term personal that are unresponsive to problem solving, can be ad-
goals to work toward during therapy. Assessment in- dressed through the use of additional behavioral tech-
formation is also obtained regarding family commu- niques, such as contingency contracting to increase
nication skills and deficits via naturalistic observation socially desirable behaviors, relaxation training for
throughout treatment, and with structured family prob- anxiety, and social skills training for interpersonal
lem-solving tasks. Two to four educational sessions deficits.
are conducted, in which information regarding the ill- One controlled study has provided strong support
ness is presented didactically, organized around three for the efficacy of Falloon's model (Falloon, 1985;
topic areas: What is Schizophrenia? (myths, diagnosis, Falloon et al., 1985; Falloon, McGill, Boyd, & Peder-
symptoms, course, genetics, prognosis), Medication son, 1987). In this study, 36 schizophrenic patients
for Schizophrenia (neuroleptic drug types, side effects recently discharged from a psychiatric hospital for
and coping strategies, effects of neuroleptics, and drug treatment of a symptom exacerbation were assigned to
abuse), and Role of the Family (recognition of early 2 years of behavioral family therapy or equally inten-
warning signs of relapse, reduction of stress, support- sive individual therapy. All patients lived with or were
ing patient improvements). Handouts summarizing the in high contact with at least one relative who was high
material presented are given, and active discussion is in expressed emotion. Sessions in both treatment
solicited from all participants. groups were provided on a declining contact basis:
Communication skills training is a necessary pre- weekly sessions for 3 months, biweekly for 6 months,
Table 2. Component Behaviors Taught during with the family model, compared to 83% for patients
Communication Skills Training in Behavioral receiving individual treatment. Patients in the family
Family Therapy treatment compared to individually treated patients
also had fewer hospitalizations, made greater gains in
Communication skill Component behaviors
social and vocational adjustment, required fewer crisis
Active listening Look at person sessions, and were prescribed lower doses of neurolep-
Nod head, say "uh-huh" tic medications by psychiatrists who were blind to
Ask clarifying questions
treatment assignment. In addition, the family treat-
Check out what you heard
ment was more effective in alleviating stress on rela-
Expressing positive Look at person with a pleasant tives. Relatives who participated in family treatment
feelings facial expression
reported less disruption in activities, fewer physical
Say exactly what he or she did
that pleased you
and mental health problems, and less burden of illness
Tell the person how it made you than relatives of individually treated patients. Finally,
feel relatives who received family treatment communi-
cated fewer critical and intrusive statements to patients
Making positive re- Look at the person with a pleasant
quests facial expression during family problem-solving tasks, suggesting fami-
Say exactly what you would like ly treatment reduced expressed emotion more than the
that person to do individual treatment. These strong results are currently
Tell how it would make you feel being replicated in several studies, including the Na-
Expressing negative Look at person with a pleasant tional Institute of Mental Health Collaborative Study
feelings seriously facial expression: speak firmly on the Treatment of Schizophrenia.
Say exactly what the person did
that upset you Barrowclough and Tarrier's Model. Bar-
Tell how it made you feel
rowclough and Tarrier (1987; Tarrier et at., 1989) have
Suggest how person might prevent
this from happening again in the
developed an intervention for families that strives to
future reduce relapse rates through teaching stress manage-
ment strategies, and helping families progress toward
Compromise and nego- Look at the person
goals relevant to improving patient functioning. In
tiation Explain your viewpoint
Listen to the other person's contrast to the Falloon approach, sessions are con-
viewpoint ducted at the clinic, on a less intensive basis (13 ses-
Repeat back what you heard sions over a 9-month period). Two weekly sessions are
Requesting a time-out Indicate that the situation is spent teaching information about schizophrenia, fol-
stressful lowed by three biweekly sessions devoted to teaching
Tell the person that it is interfer- families how to cope effectively with stress. Home-
ing with constructive work assignments are given to family members to
communication monitor stressful situations at home, which are then
Say that you must leave used in the session to formulate a functional analysis of
temporarily
the antecedants and consequences of family problems.
State when you will return and be
willing to problem-solve then Based on this analysis, strategies are developed and
implemented to modify the stressor, a process that con-
tinues throughout the therapy.
Following the sessions on stress management, seven
and monthly for the remaining duration of the 2-year sessions are conducted that are aimed at setting goals
intervention. The individual treatment utilized a goal- for improving patient functioning. Families are taught
oriented approach aimed at improving the ability of how to set and progress toward goals using a construc-
patients to anticipate and cope with a range of environ- tional approach (Goldiamond, 1974). Family members
mental stressors. are taught to construct a list of patient strengths and
Assessments conducted at 9 months and 2 years then the behaviorally specific needs that are rank-or-
after the initiation of treatment supported the efficacy dered in terms of importance and short-term at-
of the family approach. Two-year relapse rates of tainability. The goal is then broken down into small
schizophrenic symptoms were 17% for patients treated steps, the role ofthe relatives in implementing the goal
is established, and progress toward the goal is questions: (l) the importance and need for behavioral
monitored at subsequent sessions. After the second versus educational family interventions, and (2) the
biweekly goal-setting session, one session is spent durability of treatment following the end of therapy.
helping the family formulate a plan in the event that the In the Falloon and in the Tarrier studies, behavioral
patient begins to relapse. This entails reviewing pro- family treatment was more effective than comparison
dromal signs of relapse and developing effective cop- interventions involving less or no family involvement.
ing strategies. Following this session, monthly goal- Whether a purely educational intervention of equal in-
setting sessions are continued to the end of the 9-month tensity and duration would be as effective as a behav-
treatment period. ioral treatment is currently unknown. Two different
A controlled clinical trial of this method has recently family educational interventions have been reported to
been reported (Tarrier et al., 1989). Sixty-four schizo- reduce relapse rates of schizophrenic patients when
phrenic patients recently hospitalized for an acute compared to no intervention (Hogarty et al., 1986;
symptom exacerbation and discharged to the homes of Leff, Kuipers, Berkowitz, & Sturgeon, 1985), sug-
high EE relatives were assigned to one of four treat- gesting that education alone could be a critical factor.
ment groups: (1) routine outpatient treatment, (2) edu- The importance of behavior modification in addition to
cational treatment, (3) behavioral family intervention, education about the illness can be determined only by
enactive, or (4) behavioral family intervention, sym- studies comparing treatments providing education-
bolic. Relatives of patients in the routine treatment alone with education plus behavior modification,
group received no services. Relatives of patients in the while controlling for total amount of therapist contact.
educational treatment participated in two educational This research has important theoretical and practical
sessions (Barrowclough et al., 1987). Families in the implications. Since clinicians can probably be trained
two behavioral interventions also participated in these more easily to perform an educational intervention
educational sessions, in addition to the 9-month inter- than a behavioral one, the additional effort required to
vention. The two behavioral groups differed in the teach a behavioral approach can only be justified in the
strategies used to teach the stress management and long run if superior clinical outcomes can be demon-
goal-setting skills. The group receiving the enactive strated as a result of this method.
treatment participated experientially in learning the The durability of either behavioral or educational
skills, such as through role-playing, guided practice, family interventions for schizophrenia also remains to
and record keeping. The group receiving the symbolic be established. This is a crucial question, because it
method was taught the skills through instruction and has been argued that psychosocial interventions can
discussion. All patients received standard outpatient forestall, but not prevent symptom relapses (Hogarty
treatment coordinated by an interdisciplinary treat- et al., 1986). Falloon's intervention provided family
ment team, and were maintained on neuroleptic treatment to the end of the follow-up period, as did the
medications. two controlled educational treatments (Hogarty et al.,
Preliminary results have been encouraging. An as- 1986; Leff et al., 1985). The Falloon and the Tarrier
sessment conducted 9 months after treatment initiation models both postulate that relapses can be prevented if
supported the efficacy of both behavioral interventions families are taught the skills necessary to decrease am-
over the comparison treatments. Relapse rates for the bient stress and progress toward goals. After family
behavioral-symbolic and behavioral-enactive groups treatment has been terminated, follow-up data are nec-
were 8% and 17%, respectively, compared to 43% for essary in order to determine whether relapses of symp-
the educational treatment and 53% for routine toms can actually be prevented, rather than only
treatment. forestalled.
Future Directions. The two controlled studies by

Falloon and Tarrier provide the strongest evidence yet Summary and Conclusions
available that psychosocial interventions may improve
the outcome of schizophrenia. These approaches ap- The focus of this chapter has been behavioral assess-
pear to hold much promise in improving patient func- ment and treatment for schizophrenia. Rather than
tioning and reducing the burden of schizophrenia on simply provide a comprehensive review of this large
relatives of the patient. Future research on behavioral literature, we opted to provide a picture of the most
family interventions will need to address two critical promising behavioral strategies in light of the current
socioenvironmental milieu in which schizophrenics American Psychiatric Association. (1987). Diagnostic and sta-
can be found. There have been a number of significant tistical manual of mental disorders (3rd ed., rev.). Wash-
ington, DC: Author.
conceptual and pragmatic changes since the period Anthony, W. A., & Nemec, P. B. (1984). Psychiatric rehabilita-
when behaviorists first reported success in working tion. In A. S. Bellack (Ed.), Schizophrenia: Treatment, man-
with schizophrenics. The genetic/biological basis of agement, and rehabilitation. Orlando, FL: Grune & Stratton.
the disorder is now well-established. Social learning Bandura, A. (1969). Principles of behavior modification. New
York: Holt, Rinehart and Winston.
models are no longer viable, and conditioning tech- Barrowclough, C., & Tarrier, N. (1987). A behavioural family
niques for controlling psychotic symptoms cannot be intervention with a schizophrenic patient: A case study. Be-
considered appropriate except in the most unusual havioural Psychotherapy, 15, 252-271.
Barrowclough, c., Tl!Irier, N., Watts, S., Vaughn, c., Bamrah,
cases. In general, treatment demands a comprehensive
1. S., & Freeman, H. (1987). Assessing the functional value of
mix of pharmacological and psychosocial interven- relatives' knowledge about schizophrenia: A preliminary re-
tions, administered over an extended period of time. port. British Journal of Psychiatry, 151, 1-8.
Symptom control is best established pharmacolog- Bellack, A. S. (1979). A critical appraisal of strategies for as-
sessing social skills. Behavioral Assessment, 1, 157-176.
ically, whereas behavioral strategies can play a vital Bellack, A. S. (1983). Current problems in the behavioral assess-
role in rehabilitation and stress management. ment of social skills. Behaviour Research Therapy, 21, 29-
Another major change pertains to where patients 42.
Bellack, A S. (1986). Schizophrenia: Behavior therapy's forgot-
live and the nature of their most pressing needs. In
ten child. Behavior Therapy, 17, 199-214.
contrast to the period between 1950 and 1975, most Bellack, A. S. (1989). A comprehensive model for treatment of
patients are now found living in the community and schizophrenia. In A. S. Bellack (Ed.), A clinical guide for the
receiving some form of medication. Even though the treatment of schizophrenia (pp. 1-22). New York: Plenum
Press.
core symptoms of the disorder remain the same, the Bellack, A. S., & Hersen, M. (1977). The use of self-report
needs of patients and the environment in which treat- inventories in behavioral assessment. In 1. D. Cone & R. P.
ment must be implemented have changed dramat- Hawkins (Eds.), Behavioral assessment: New directjons in
ically. Token programs were uniquely suited for trans- clinical psychology (pp. 52-76). New York: Brunner/Maze!.
Bellack, A. S., Hersen, M., & 'furner, S. M. (1976). Generaliza-
formation of pernicious state hospital milieus, but are tion effects of social skills training in chronic schizophrenics:
not easily translated to the unstructured community An experimental analysis. Behaviour Research and Therapy,
settings in which most patients now reside. Conse- 14, 391-398.
Bellack, A. S., Turner, S. M., Hersen, M., & Luber, R. F.
quently, the current emphasis is on teaching patients
(1984). An examination of the efficacy of social skills training
and their families coping skills to deal with the inter- for chronic schizophrenic patients. Hospital and Community
personal stresses of daily life. Social skills training and Psychiatry, 35, 1023-1028.
behavioral family therapy have proven to be promising Bellack, A. S., Morrison, R. L., & Mueser, K. T. (1989). Social
problem solving in schizophrenia. Schizophrenia Bulletin, 15,
interventions, and are widely considered to be essen- 101-116.
tial parts of a comprehensive program for the disorder. Bellack, A. S., Morrison, R. L., Wixted, J. T., & Mueser, K. T.
We have previously indicated that behavior thera- (in press). An analysis of social competence in schizophrenia.
pists have seemingly abandoned schizophrenia in favor Journal of Consulting and Clinical Psychology.
Bellack, A. S., Morrison, R. L., Mueser, K. T., & Wade, 1. H.
of more mild disorders. Both the need for services and (1989, April). Social competence in schizoaffective disorder,
the promise of providing concrete help make that a schizophrenia, and bipolar disorder. Paper presented at the
serious mistake. We strongly urge behavioral clini- International Congress on Schizophrenia Research. San
Diego.
cians and scientists to rediscover the disorder and to Brown, M. A., & Munford, A. M. (1983). Life skills training for
help rectify not only one of society'S most serious pub- chronic schizophrenics. Journal of Nervous and Mental Dis-
lic health problems but a major human tragedy. ease, 171, 466-470.
Carpenter, W. T., Jr., Heinrichs, D. w.,
& Alphs, L. D. (1985).
Treatment of negative symptoms. Schizophrenia Bulletin, 11,
ACKNOWLEDGMENT. This research was supported 440-452.
by grants MH 38636 and MH 41577 from the National Cordes, C. (1984). The plight of the homeless mentally ill. APA
Institute of Mental Health to the senior author. Monitor, 15, 1-13.
Dawson, M. E., & Nuechterlein, K. H. (1984). Psychological
dysfunctions in the developmental course of schizophrenic
disorders. Schizophrenia Bulletin, 10, 204-232.
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CHAPTER 18
Adult Medical Disorders

c. Barr Taylor, Gail Ironson, and Kent Burnett
Introduction cine, borrowing heavily from the knowledge of

physiology, biochemistry, pathophysiology, pharma-
Identification of Problem or Topic cology, epidemiology and prevention to determine
both the focus and outcome of interventions. For in-
The behavioral treatment of adult medical disorders
stance, behavior therapy techniques designed to re-
falls into the discipline of behavioral medicine. In the
duce dietary cholesterol intake were developed in re-
broadest sense, behavioral medicine refers to the ap-
sponse to epidemiological data showing a correlation
plication of behavioral science knowledge and tech-
between serum cholesterol and increased risk for heart
niques to the understanding of physical health and ill-
disease; biofeedback instruments were derived from
ness and to prevention, diagnosis, treatment, and
instruments originally developed by physiologists.
rehabilitation; so defined, it is closely linked to health
psychology. Behavioral medicine and health psychol-
ogy have undergone astonishing growth in the past 10
years, as noted below. Overview of this Chapter
Most of the behavior therapy techniques used in
behavioral medicine are the same as those used to treat In this chapter, we review the application of various
other problems; for example, progressive muscle relearning theory-based techniques to treat illnesses, to
laxation and related techniques and positive reinforce- enhance health care, and to reduce disability. We have
ment and feedback have all been used extensively to emphasized areas where enough research has been
treat medical problems. The methodologies for eval- conducted to allow for conclusions to be drawn. Since
uating such techniques are also similar in behavioral the previous edition of this book, all areas of behav-
medicine to those in behavior therapy, although the ioral medicine have undergone growth. We have exten-
preponderance of studies use group outcome designs. sively revised the cardiovascular section to include
Behavioral medicine differs from other areas of behav- new findings related to Type A behavior, hypertension,
ior therapy because of its close connection with medi- coronary artery disease, and rehabilitation. We have
shortened other areas, particularly gastroenterology
and respiratory disease, where the previous version
c. Barr Taylor and Gail Ironson • Department of Psychia- remains relevant. We have added four sections to re-
try, Stanford University School of Medicine Stanford Califor-
flect important new areas: cancer, psychoneuroim-
nia 94305. Kent Burnett • Depart~ent of C~unseling
Psychology, University of Wisconsin, Madison Wisconsin munology, AIDS, and biobehavioral applications of
53706. ' computers.
371
Historical Perspective attempt to care for the whole patient, who has been lost
in an increasingly mechanistic and technological med-
Because behavioral medicine is an interface disci- ical system. As Lipowski noted (1977), developments
pline relating behavioral science to medicine, its histo- in psychosomatic medicine since its beginning in the
ry embodies many trends. Three disciplines are 1920s have followed two major directions: first, at-
particularly important: the history of patient care, psy- tempts to identify specific psychological variables
chosomatic medicine, and behavioral approaches to postulated to underlie specific somatic disorders; and
medical problems. second, attempts by experiment or epidemiological
study to discover correlations between social stimulus
situations, a subject's psychological and physiological
Patient Care
responses, and changes in health status. The first ap-
Patient care involves two important aspects: how proach was largely directed by Franz Alexander, a psy-
patients are cared for and who cares for them. As Ben- choanalyst who studied asthma, hypertension, peptic
jamin Rush, one of the fathers of American medicine, ulcer disease, ulcerative colitis, rheumatoid arthritis,
noted, patients can be "cured" through four processes: hyperthyroidism, and headaches in particular (Alex-
first, from their own natural recuperative properties; ander, French, & Pollock, 1968). Such disorders were
second, from medicines and allied procedures; third, viewed as symptoms of underlying intrapsychic con-
through surgery; and fourth, through nonspecific fac- flicts and as being connected with certain personality
tors (Binger, 1966). The history of medical "cures" in types. But no personality type has been shown to cor-
this century is largely that of the second and third relate with the seven disease states studied by Alex-
types. The advancement of technology in medicine ander (Weiner, 1977) (with the possible exception of
and surgery has been nothing less than spectacular; Type A and coronary heart disease [CHD]). Further-
many diseases previously fatal are now curable. But more, no psychodynamic therapy has been demon-
how well patients recover because of their own "natu- strated as having a specific effect on preventing or
ral properties" may, if anything, have taken a setback improving the outcome of any particular disease in
(Illich, 1976), and nonspecific factors continue to be carefully controlled outcome studies. For instance,
viewed by physicians as a nuisance rather than a bene- while some patients may exhibit reduced blood pres-
fit (Goodwin, Goodwin, & Vogel, 1979). sure in the course of psychotherapy, it has not been
Historically, technological developments have demonstrated that the psychotherapy per se brings
placed the care of sick individuals firmly in the hands about the reduction in blood pressure. Because of this
of physicians. As a result, preventive care for adults lack of success and probably because psychosomatic
has not achieved great importance in the health care theory has tended to be too abstruse for most general
system, and preventive practices for adults, except as practitioners, it has not had a widespread impact in
they are prescribed by physicians, have not achieved changing medical care or in influencing the practice of
widespread use. Yet the nature of medical practice is medicine. Nevertheless, behavioral medicine re-
rapidly changing. Health maintenance organizations, searchers continue to focus on many of the same dis-
for-profit hospitals and other practice plans have begun eases identified by early psychosomatic practitioners.
to replace the solo practitioner. As the competition for The second trend in psychosomatic medicine
customers has increased, practice plans have em- focused on the scientific study of the relationships
ployed a variety of marketing plans, many of which among sociological, social, and biological factors in
feature the preventive and educational aspects of the determining health and disease. Wolff and Goodell
practice plan, presumably because the marketing (1968) undertook many classic studies relating biolog-
groups have decided that this is what consumers want. ical and interpersonal factors, and many of the studies
Consumer demands, marketing, and economics will are close in design to those now undertaken by behav-
play an increasingly important role in shaping the ioral medicine researchers.
nature of practice.
Behavioral Medicine
Psychosomatic Medicine
Behavioral medicine as a discipline has a short his-
The second field directly related to behavioral medi- tory. A few early studies relevant to behavioral medi-
cine is psychosomatic medicine. In part, psychoso- cine can be found scattered throughout the medical
matic medicine has arisen in the last 50 years as an literature. For example, Ferster, Nurnberger, and Lev-
CHAPTER 18 • ADULT MEDICAL DISORDERS 373
itt (1962) outlined many of the eating behaviors that (1987) estimated that about 3,000 psychologists are
would subsequently become the focus of the behav- now employed in medical settings. In 1985, 12.5% of
ioral interventions aimed at changing eating patterns; memberships in the American Psychological Associa-
Yates (1958) used massed practice to treat tics; Ray- tion (APA) were members of medical school faculties
mond (1964) used aversive conditioning to change compared to 6% in 1976.
smoking behavior in a young boy; Jacobson (1938), in With its success and visibility has also come some
the 1920s, used relaxation to effect change, and the concern that behavioral medicine practice may be
1960s provided EMG feedback for polio victims to oversold. Concerning health promotion, Evans (1988)
restore muscle strength. The first collection of articles wonders, "Is there a danger that more might be prom-
(focusing mostly on biofeedback) appeared only in ised by health psychologists than can be truly delivered
1973 (Birk, 1973). In 1975, when Katz and Zlutnick in effectively preventing disease?" He notes that the
prepared a collection of behavioral medicine articles, Multiple Risk Factor Intervention Trial (MRFIT, 1978)
they noted that, although examples could be found in achieved significant reductions in cigarette smoking
behavior therapy of interventions applicable to many but less impressive changes in other risk factors. As
medical disorders, the literature was neither broad nor another example, he notes that techniques to improve
deep. Since Katz and Zlutnick's (1975) publication, adherence were described as promising but have
the field has exploded. A recent handbook now 5 years proved less successful in practice.
old contained 92 chapters written by over 150 authors Although many examples of specific and powerful
citing over 2,000 references (Matarazzo, Weiss, Herd, interventions will be given below, behavioral medi-
Miller, & Weiss, 1984). The Abstracts of Behavioral cine researchers and practitioners need to be con-
Medicine includes over 1,200 articles each year cerned about such criticism. Often treatments shown
deemed important for behavioral medicine practice to be effective in short-term, carefully controlled stud-
and research. ies undertaken in academic environments are advo-
Behavioral medicine has played an important role in cated for practice without consideration of generaliza-
several very large trials aimed at determining the ef- tion, maintenance, and dissemination. Agras, Kazdin,
fects of reduction in one or more cardiovascular risks and Wilson (1979) described a course of clinical re-
and subsequent decline in actual morbidity and mor- search that seems relevant for behavioral medicine. In
tality. For instance, the Lipid Research Center (LRC) this model, clinical observations and/or basic re-
trial, which required 3,550 hypercholesteric men, in search/theoretical models are tested in uncontrolled
12 centers, to be followed for 7 years or longer, relied popUlations or the basic laboratory and generate inter-
on behavioral scientists for recruitment and adherence vention procedures. Promising procedures are then
(Marshall, 1982; Lipid Research Clinics Program, tested in single-case studies, shorter term controlled
1979). The Multiple Risk Factor Intervention Trial studies, and then larger studies. Procedures shown to
(MRFIT) (Multiple Risk Factor Intervention Trial, be effective in such controlled studies may undergo
1978) involving 12,000 high-risk men randomized to further study of generalization, maintenance, and
an intensive cardiovascular risk reduction or standard analysis of treatment components and parameters.
care, used behavior modification techniques to alter Each ofthese studies may generate new hypotheses, or
risk factors. The Stanford Heart Disease Prevention a failure to achieve anticipated results, or may start the
Trial (Farquhar et at., 1989), the Minnesota Heart process over again. Eventually, interventions shown to
Health Project (Blackburn, Luepker, & Kline, 1984) be effective in longer term trials may undergo com-
and the Pawtuckett Heart Health Program (Lefebvre, parative outcome studies. Of course, the development
Lasater, Carleton, & Peterson, 1987) have all incorpo- and implementation of techniques are rarely so struc-
rated behavioral science principles and practice into tured and systematic, but examples can be found in
their interventions. The LRC and MRFIT trials alone some areas, including the treatment of headaches
cost over $250 million dollars! (Blanchard, 1987), where various strategies have been
Behavioral medicine and health psychology seem to compared, refined, and evaluated over long periods,
be the fastest growing areas in psychology. The and in obesity, where the failure to achieve significant
number of new Ph.D.s per year in psychology in- long-term results has led to a reexamination of as-
creased from about 1,000 in 1965 to about 3,500 in sumptions about the cause of obesity.
1985. Most of the growth occurred in health service This chapter was revised to reflect the growth and
providers, and many ofthese providers practice behav- development of behavioral medicine. In areas where
ioral medicine and health psychology. Thompson numerous studies have been done, for example, the
treatment of headaches or the use of relaxation to de- Table 1. Possible Mechanisms of Behavioral
crease blood pressure, we present conclusions and re- Intervention Aimed at Blood Pressure Reduction
fer readers to reviews. We present new findings that
Blood pressure
have led to questions about old assumptions. We have pathophysiology Behavioral intervention
also included new sections on cancer, psychoneuroim-
munology, AIDS, and computers-areas of rapid Increased cardiac output Reduced salt intake, pulse-
growth in the last decade. With regret, we have deem- transit time biofeedback,
relaxation and related
phasized areas where relatively little change or growth procedures, medication
has occurred and even omitted a few, like diabetes, compliance, weight
which has undergone great growth with children but reduction, exercise
not with adults. Increased fluid volume Reduced salt intake, medica-
tion compliance
Increased vascular reactivity Relaxation and related tech-
niques, exercise
Cardiovascular Disorders Increased catecholamine Caffeine reduction, relaxa-
excretion and/or elevated tion and related tech-
Behavioral medicine researchers have made signifi- renin niques, exercise
cant advances in understanding and treating car-
diovascular disorders. Most of the work has focused
on hypertension, lYpe A behavior, and cardiovascular
risk reduction. to pursue a more Western life-style. Women who as-
pired to such a life-style but who were unsuccessful in
so doing (usually because of a lack of proficiency in
Hypertension
French) had higher blood pressures (Beiser, Collumb,
Hypertension is a major national health problem, Ravel, & Nafzigers, 1976). Other studies suggest that
affecting as many as 24 million Americans and leading living or working in environments that require mobili-
to increased cardiovascular morbidity and mortality zation of coping resources to ward off physical or psy-
unless controlled (Smith, 1977a). There are many chological harm (Syme, 1979), as is demanding work
etiologies of hypertension, and some forms can be with few opportunities for control (Karasek, Theorell,
completely cured by surgery. However, the mainstay Schwartz, Pieper, & Alfredson, 1982; Krantz, De
of treatment is pharmacological. Unfortunately, as Quattro, Blackburn, 1987) are associated with higher
many as 10% of patients refuse to take medication blood pressures. The "hypertensive personality" has
because of drug intolerance, and many more adhere not received consistent support; however, traits, such
poorly to medication for other reasons (Smith, 1977b). as submissiveness and problems with anger ex-
In theory, behavioral techniques would be of value in pression, are correlated with hypertension in patients.
patients: (I) who have essential hypertension but are There is also evidence that genetic and environmental
intolerant to medications or are poorly controlled on factors interact to produce hypertension in animals and
medication, or (2) who have blood pressure levels not probably in humans. For instance, Falkner, Onesti,
customarily treated by physicians but who might bene- Angelakos, Fernandes, and Langman (1979) found
fit from reduced blood pressure levels. Behavioral that children of hypertensive parents had higher blood
techniques might also be useful in all patients as an pressures both before and during stress when ingesting
adjunct to other blood pressure therapies. Potential additional salt. This response was not seen in offspring
mechanisms of behavioral intervention can be seen in of normotensive parents.
Table 1. In recent years, there has been considerable discus-
The psychosocial factors contributing to blood pression as to what constitutes the most desirable blood
sure remain elusive. A few issues have been clarified pressure level. There is consensus that diastolic blood
or at least focused: the old observation that "moderni- pressure should be below 90 mmHg and that systolic
zation" may lead to hypertension seems true at least as blood pressure should be below 140 mmHg. Blood
far as the active pursuit of a Western life-style occurs pressures above these levels need to be reduced, usu-
under conditions that are not conducive to success ally using medications. There is less agreement as to
(James, 1987). For instance, in recent years many Se- the need to treat diastolic blood pressures between 80
rer tribespeople migrated to the Senegal city of Dakar to 90 mmHg or systolics between 120 to 140. Non-
pharmacological interventions should be tried first in 1985). Dietary calcium, alcohol, and fat intake have
patients with such mild hypertension. Nonphar- also been related to blood pressure levels (Celentano,
macological interventions have focused on weight re- Martinez, & McQueen, 1981; McCarron, Morris,
duction, alterations in diet, blood pressure biofeed- Henry, & Stanton, 1984; Puska, Nissinen, & Var-
back, or the practice of relaxation and exercise. tiainen, 1983).
Exercise
Weight Reduction
Active individuals have significantly lower systolic
There is a direct relationship between excess body
and diastolic blood pressures at rest than their less
weight and elevated blood pressure. Furthermore, a
active counterparts. Cross-sectional studies have sug-
decrease in body weight is associated with a corre-
gested that the incidence of hypertension is lower for
sponding fall in blood pressure (Reisen, Abel, Mo-
fit than unfit individuals. In support of these epi-
dan, et at., 1978): a weight loss of 1 kg results in a
demiologic studies, physical training is associated
decrease of about 2.5 mmHg (Ramsay, Ramsay,
with modest blood pressure reductions independent of
Hehiarachichi, Davies, & Winchester, 1978). Obesity,
weight loss. In fact, physical training may help reduce
hypertension, hypertriglyceridemia, and glucose in-
blood pressure through changes in plasma insulin. It is
tolerance are common and often coexist. Among the
theorized that the change in plasma insulin, which may
obese, hypertension is three times more common than
be associated with decreases in sodium reabsorption,
among the non-obese, and hyperglyceridemia and di-
reflects changes in sympathetic activity which, in tum,
abetes are at least two times more common than among
might be associated with blood pressure reduction
the non-obese. Conversely, obesity and diabetes are
(Krotkiewsky et at., 1983). Animal research suggests
both more common among hypertensive than among
that physical training delays the development of hyper-
normotensive people. Weight loss to a normal body
tension in animals genetically predisposed to hyper-
weight for height, sex, and age (based on the 1959
tension.
Metropolitan Life Insurance tables) and maintenance
of normal body weight are important methods to con-
Relaxation and Related Techniques
trol blood pressure and this "deadly quadrangle," par-
ticularly when achieved in combination with increased In a classic paper, Benson, Beary, and Carl (1974)
exercise. observed that progressive muscle relaxation, hypnosis,
many forms of meditation, and autogenic training
shared several properties: the subject assumes a passive
Diet
frame of mind in a relaxed position, repeats a simple
Across populations, the amount of sodium con- phrase, and breathes in a deep, regular manner. They
sumed is correlated with blood pressure. Such epidem- argued that this technique elicits the so-called relaxa-
iologic studies and other more rigorously controlled tion response, which tends to reduce central nervous
studies have suggested that reduction of sodium intake system sympathetic activity, which, in tum, reduces
could reduce blood pressure. Indeed, extreme sodium peripheral sympathetic activity. Practice of these pro-
depletion can result in blood pressure reductions in as cedures has been associated with short-term phys-
many as 60% of hypertensives, although compliance iologic changes, including decreased oxygen consump-
to such a regimen is low. More realistic, smaller scale tion, heart-rate, and blood pressure. These procedures
reductions in sodium may also reduce blood pressure may even have a long-term effect of decreasing respon-
and may assist in maintaining blood pressure control in sivity to plasma norepinephrine (Hoffman, Benson,
withdrawal from drug therapy (Jacob, Fortmann, Ams, et at., 1982).
Kraemer, Farquhar, & Agras, 1985; Langford, Many studies have demonstrated the usefulness of
Blaufox, Oberman, et at., 1985; Laragh & Pecker, relaxation training to lower blood pressure. The mag-
1983). Newer evidence suggests that other nutrients nitude of blood pressure decreases ranges from 5 to 20
may play an important role in blood pressure and the mmHg systolic and 3 to 15 mmHg diastolic. The
effects of blood pressure. Potassium supplementation amount of decrease is related to the initial blood pres-
may lower blood pressure and also prevent some of the sure level, with larger decreases occurring with higher
vascular and renal damage caused by hypertension initial levels. Unsurprisingly, the procedures seem
(Kaplan, Carnegie, Raskin, Heller, & Simmons, most useful in patients who are poorly controlled with
medication. In one of the largest and longest trials to to hypertension. The committee also recommended
date, Agras, Taylor, Kraemer, Southam, and that:
Schneider (1987) compared relaxation therapy to
blood pressure monitoring at two worksites with 137 1. For newly identified hypertensive patients with
medicated hypertensives randomized to one of the two blood pressures in the mild range, repeated mea-
conditions. The mean reduction for the relaxation surement of blood pressure should occur before
group at the 30-month follow-up was -9.2/-10.1, any therapy is instituted (many newly identified
butthe control group had dropped by - 8.41 - 9.8. On hypertensives tum out to be normotensive on re-
the other hand, significantly more subjects in the relax- peat measurement).
ation group were in control compared to the monitor- 2. Nonpharmacologic approaches should be con-
ing-only group up to 24 months (63.9% vs. 47.7%), sidered before initiation of antihypertensive
although the differences were not significant at 30 medication (except with patients with malignant
months. The largest initial difference between the two hypertension who need immediate blood pres-
groups was for individuals whose entry diastolic blood sure reduction).
pressures were almost out of control (> 106 mmHg). A 3. Nonpharmacologic approaches should be moni-
companion study found that in the newly diagnosed tored as closely as pharmacologic inter-
hypertensive, blood pressure monitoring may be the ventions.
most cost-effective approach to nonpharmacologic 4. Patients who remain hypertensive should be
management (Chesney, Black, Swan, & Ward, 1987). given pharmacologic therapy according to the
recommendations of the 1984 Joint National
Blood Pressure Feedback Committee. Behavioral interventions can help
with adherence.
Normal and hypertensive subjects can be taught to 5. Nonpharmacologic interventions should con-
raise andlor lower systolic or diastolic blood pressure tinue even when pharmacologic therapy is
in the short term. In one study, direct measures of introduced.
cardiac output and intra-arterial pressure showed that 6. Periodic stepdown or decrease in medication
patients taught to lower diastolic blood pressure had should be considered in controlled hyperten-
lower levels of total peripheral resistance after 2 weeks sives while nonpharmacologic interventions are
of practice. Hypertensive subjects can be trained to practiced.
lower blood pressure and to maintain this effect for up
to 6 months, even using a simple home sphyg- Clinical trials are now underway to evaluate the ef-
momanometer (Glasgow, Gaarder, & Engel, 1982). fectiveness of such approaches.
Some patients trained to lower their blood pressure
were able to maintain a lower blood pressure for up to 9
months (Engel, Glasgow, & Gaarder, 1983). Coronary Artery Disease
Combined Interventions Prevention

Presumably, although not yet demonstrated in Perhaps the major area where behavioral ap-
clinical trials, combined behavioral interventions proaches have contributed to the treatment of car-
aimed at reducing weight, salt, and alcohol intake (and diovascular problems is the provision of techniques to
perhaps increasing potassium-although excessive reduce cardiovascular risk factors. Large prospective
potassium intake can be dangerous), and increasing studies have shown that cigarette smoking, obesity,
exercise, the practice of blood pressure feedback blood pressure, and serum cholesterol levels are relat-
andlor relaxation would be of benefit for reducing ed to cardiovascular disease and mortality, and that
blood pressure. In fact, the 1984 Joint National Com- reducing or eliminating these risks is associated with
mittee on Detection, Evaluation and Treatment of decreased morbidity and mortality (Blackburn, 1978).
High Blood Pressure (Joint National Committee, Other data suggest that exercise and perhaps stress (see
1984) recommended that nonpharmacologic ap- lYpe A below) are also related to cardiovascular risk.
proaches should be part of a comprehensive approach Thus, interventions directed at altering these risk fac-
tors reduce the risk of cardiovascular illness. Weight tionship between Type A and subsequent events. Re-
reduction and smoking interventions are addressed in analysis of WCGS data even found that Type As had a
other sections of this book. better survival rate than Type Bs post-myocardial in-
In addition to trials that have focused on altering farction (MI) (Raglan & Brand, 1988). It is possible
single risk factors or all risk factors in high-risk popu- that Type A is only a risk factor in younger populations
lations, the NHLBI (National Heart, Lung, and Blood «50) or in those not yet suffering from irreversible
Institute) has sponsored three large, long-term com- atherosclerotic changes. We have found, for instance,
munity-based interventions for cardiovascular risk re- that Type A emerged as a risk factor only in uncompli-
duction: the Stanford Five Cities Project (FCP), the cated post-MI patients-that is, in those patients who
Minnesota Heart Health Project, and the Pawtucket had less serious CHD.
Heart Health Program. Each of these projects uses a As the global role of Type A in CHD pathogenesis
somewhat different mixture of mass media, communi- has been questioned, evidence is emerging that some
ty-based interventions, and face-to-face intervention Type A components might be more "toxic" than oth-
to achieve change in the target communities. The re- ers. In particular, a variety of studies suggest that some
sults of the first 5 113 years of education intervention factor related to hostility/ cynicism/ anger is associated
have recently been reported for the FCP, the earliest of with increased CHD risk. For instance, Barefoot,
the three interventions (Farquhar et aI., 1989). The Dahlstrom, and Williams (1983) obtained follow-up
study design used an independent sample of men and on 255 physicians who had completed the MMPI 25
women, 12-74 years old, who were surveyed in each years ago. Three percent of the physicians with Ho
city at baseline and after 16, 42, and 64 months of scores less than 14 had died compared to 18% of those
education; a cohort was resurveyed after 8, 30, and 51 with Ho greater than or equal to 14. Extensive work is
months of education. In the cohort at 51 months, the now under way to specify the domain of relevant be-
treatment produced a significant increase in knowl- haviors and determine mechanisms.
edge, reduction in total risk of death, resting pulse, Can Type A behavior be modified and, if so, does it
smoking rate, and systolic and diastolic blood pressure make much difference? One large, important study
relative to mean changes from baseline in the control. says yes to both questions. In the Recurrent Coronary
In the independent sample at 64 months, the treatment Trial (RCT) Friedman, Thoresen, Gill, et al., (1984)
produced a significant change in knowledge, choles- randomized 1,000 post-MI patients to a comprehen-
terol, 12-year CHD risk, total risk, resting pulse, sive group counseling program directed at altering
adiposity, and systolic and diastolic blood pressure rel- Type A behavior. The 3-year rate of nonfatal infarc-
ative to the mean changes from baseline in the control tions in the behavior modification program was 7.2%
sample. The study suggests that community-based ed- compared with 13.2% for a control. The intervention
ucation can be effective in achieving significant de- produced a significant reduction in Type A behavior as
creases in CHD risk. measured by a videotaped structured interview scored
for various components. There is an obvious contra-
diction between the epidemiologic studies and the
The Coronary Prone Behavior Pattern
RCT, but the impressive and important results of the
In 1981 an NHLBI committee concluded that Type latter cannot be ignored.
A behavior produced the same order of magnitude of Replication of the RCT will be expensive and diffi-
risk as that imposed by systolic blood pressure, serum cult. CHD medical and surgical interventions are pro-
cholesterol, or smoking. This conclusion was based gressively more aggressive. Medications are pre-
primarily on the long-term prospective Western Col- scribed to most post-MI patients. Invasive techniques
laborative Group Study (WCGS) which showed a are used earlier and in more patients. These interven-
positive relationship between Type A behavior and tions and medications have changed the nature of post-
subsequent CHD and several studies showing a MI care and confound the impact of psychological
positive association between Type A behavior and interventions. It has been argued, for instance, that
CHD in patients undergoing diagnostic coronary an- beta-blockers achieve the same results as psychologi-
giography. In the last 10 years, this conclusion has cal interventions. Leaving aside the question as to
been seriously questioned. Eight of ten studies in pop- whether or not beta-blockers should therefore be pre-
ulations at high risk for CHD have found no rela- scribed (they have many side effects and may be no less
expensive than psychological interventions) in uncom- of fitness and less smoking and with improved psycho-
plicated patients who are at low risk of subsequent logical functioning (Oldenburg, Perkins, & Andrews,
morbidity, one study found that behavioral stress man- 1985; Taylor, Houston-Miller, Ahn, Haskell, & De-
agement reduced psychophysiological reactivity to Busk, 1986). Another controlled trial has shown that a
public speaking to the same level seen with pro- clear message as to when a patient can return to work
pranolol, the most commonly used beta-blocker reduces return time in uncomplicated patients (Dennis
(Gatchel, Gaffney, & Smith, 1986). et al., 1988). As previously discussed, a very impor-
tant study has suggested that alteration of Type A be-
havior in post-MI patients is associated with reduced
Reactivity
morbidity and mortality.
Many investigators have attempted to identify sub-
components of Type A or other psychological factors
that might contribute to CHD. Of various putative
mechanisms, the relationship of psychophysiologic re-
Gastrointestinal System
sponse to psychological stressors has achieved the
One of the most important contributions of behav-
most study. Investigators suggest that heightened car-
ioral medicine to adult medical disorders has occurred
diovascular reactivity during behavioral stress may be
in the demonstration that biofeedback is both clinically
a risk factor for CHD (Mathews, 1986). Heart-rate
effective and specific in treating fecal incontinence.
reactivity to standardized laboratory stressors, among
Behavioral approaches also have been useful in reduc-
a number of psychosocial factors, have been shown to
ing nausea and symptoms associated with diarrhea and
contribute to coronary artery atherosclerosis in male
irritable bowel.
cynomolgus monkeys (Manuck, Kaplan, Adams, &
Clarkson, 1988). Early studies found that reactivity
was related to Type A Behavior (at least in men) (Con-
Fecal Incontinence
trada & Krantz, 1988), but many recent studies have
found no association between Type A and reactivity. The use of biofeedback to treat patients with fecal
Furthermore, reactivity is not clearly related to car- incontinence was first described by Engel, Nikooma-
diovascular risk factors. Reactivity studies have relied nesh, and Schuster (1974). The basic procedure in-
on laboratory measurements that do not necessarily volves the use of three balloons inserted rectally. The
correlate with natural stressors or natural stressor ef- uppermost is lodged in the rectosigmoid space. The
fects. Perhaps ambulatory studies will clarify some of next balloon is positioned in the internal sphincter, and
these issues. With a few notable exceptions (e. g. , the third balloon is in the external sphincter. During
Gatchel et al., 1986), psychological interventions have conditioning, patients are taught to contract the exter-
had limited success in reducing reactivity (Jacob & nal sphincter in synchrony with internal sphincter re-
Chesney, 1986). laxation when they sense rectal distension. They can
monitor these contractions by observing pressure read-
ings obtained by balloons inserted into the rectum. In
Rehabilitation
the largest series reported, 36 of 50 patients reported a
Many of the issues relevant to prevention of car- decreased frequency of incontinence of 90% or greater
diovascular disease also apply to rehabilitation, since following therapy (Cerulli, Nikoomanesh, &
the problems that caused the CHD persist after the Schuster, 1979). After observing that diabetic patients
patient has exhibited overt disease. Rehabilitation also with fecal incontinence frequently exhibit impaired
focuses on resumption of many premorbid activities, rectal sensation, Wald and Tunuguntla (1984) postu-
like return to work, sexual activity and prevention of lated that sensory discrimination techniques could be
psychological dysfunction and even increase in phys- used to reduce the sensory threshold and therefore in-
ical activity (Taylor, 1986). Epidemiologic studies crease cues for defecation. Such training normalized
have shown that patients with so-called uncomplicated abnormal rectal sensory thresholds in six of seven in-
myocardial infarctions can resume normal activities continent diabetic patients. In contrast, biofeedback
soon after the MI. In such patients, participation in an has not been successful in children with neurologic
exercise program is associated with more rapid return denervation.
Diarrhea and Irritable Bowel Stress Reduction
Although diarrhea and the irritable bowel syndrome Many studies using systematic desensitization and
are often caused by different problems, both relate to relaxation suggest that such procedures produce an im-
increased gastric motility and are discussed together mediate effect on improving airway functioning (Alex-
here. Diarrhea is often a symptom of irritable bowel ander, Cropp, & Chai, 1979). Unfortunately, the ex-
syndrome, although abdominal pain with alternating tent of these changes has been less than 15% relative to
diarrhea and constipation may be the presenting com- baseline. Changes not exceeding a 30% increase in
plaint. Stress has been demonstrated to increase gastric airflow over baseline are required before a therapy
motility (Almy & Tulin, 1947). Of the two general appears to produce relief in most patients.
behavioral approaches to the irritable bowel syn- Anxiety or fears that may alter lung function directly
drome, one is to provide biofeedback to decrease colo- are very different from the anxiety or stress that results
nic motility; the second is to desensitize or to use relax- from asthma. On the assumption that stimuli associ-
ation procedures, presumably to reduce the amount of ated with asthma (e.g., tightness and wheezing) are
the patient's stress or anxiety. For instance, Cohen and classically conditioned to trigger fear and anxiety re-
Reed (1968) used systematic desensitization to treat sponses, Eckert, McHugh, Philander, an~ Blumenthal
two patients with diarrhea, which was exacerbated (1979) used desensitization to reduce anxiety and thus
when the patients were required to travel. The patients reduce expiratory resistance in nine patients.
described modest gains, which remained at 6- to 12-
month follow-up.
Biofeedback has been used in several ways. Furman Biofeedback
(1973) had patients listen to their bowel sounds Biofeedback of respiratory rate and airflow has been
monitored with an electronic stethoscope. The patients used to increase these variables in asthmatics. Khan
were taught to increase or decrease their peristaltic and Olson (1977) provided verbal praise contingent on
activity. The author reported that within five training increases in airflow to children with asthma. The tech-
sessions, all patients showed some degree of control nique was effective in reducing the number of asthma
over intestinal motility and apparently experienced attacks, the amount of medication used, and the
symptomatic improvement. Another approach has number of emergency room visits. However, another
been to provide direct feedback of rectosigmoid dis- investigation did not confirm Khan's findings (Dan-
tension to patients with irritable bowel syndrome by ker, Miklich, Prott, & Creer, 1975).
using the same biofeedback treatment system de-
scribed above for fecal incontinence (Bueno-Miranda,
Cerulli, & Schuster, 1976). Illness and Management
The third area where behavioral techniques have
been demonstrated to be useful with respiratory prob-
Respiratory Disorders lems is in reducing the problems that result from hav-
ing asthma and the constant struggle to cope with and
adapt to it (Creer, 1978). Disease-related problems in-
Asthma
clude poor medication compliance, maladaptive be-
Behavioral treatment approaches to respiratory dis- haviors, untoward specific emotional reactions, and
orders have focused primarily on treating bronchial the development of symptoms (like a cough) that begin
asthma. Asthma would seem to be a condition amena- to occur autonomously from the asthma itself. There
ble to behavioral interventions, because (1) asthma have been many case reports indicating the usefulness
attacks seem to occur during times of emotional stress of behavioral procedures in reducing these problems.
or are made worse by such stress; (2) bronchial spasms The studies have focused on children, but the tech-
may, in some cases, represent a classically conditioned niques could be used equally for adults. For example,
response; and (3) the management of the illness re- Rene and Creer (1976) used operant conditioning tech-
quires considerable effort on the part of the patient and niques to teach four asthmatic children to correctly use
the family. Studies have been directed at developing an intermittent-positive-pressure breathing device.
interventions appropriate for each of these areas. The authors documented that the training procedure
significantly reduced the amount of drug required dur- much speculation as to how an acute pain can develop
ing the subsequent treatments and, furthermore, that into a chronic pain. Fordyce (1976), a pioneer in the
the procedure could be used by nurses. development of treatment approaches to chronic pain,
Ironically, mortality from asthma has actually in- assumed that some patients develop chronic pain as a
creased in the United States, despite the availability of result of being reinforced for pain behavior in their
many agents that can alleviate many symptoms. It has environments. He differentiated between respondent
been suggested that the very effectiveness of the agents pain, which represents a classically conditioned re-
may be part of the problem. Patients achieve relief of sponse to a particular stimulus, and operant pain,
some symptoms but other aspects of the disease-the which results from reinforced pain behavior. Fordyce's
bronchial swelling, which can be resolved by the use program is significant in providing a comprehensive
of steroids-continue and lead to the fatal event. Be- treatment approach that has now been applied to thou-
havioral techniques might be used to help patients be- sands of patients in many different settings.
come aware of interoceptive cues indicating that this Fordyce begins his treatment approach with a com-
phenomenon is occurring. plete evaluation of the patient. The evaluation is de-
signed to identify the relationship between the pa-
tient's behavior and the environmental events or
Chronic Obstructive Lung Disease
consequences resulting from this behavior. Fordyce
Issues of management of asthma also apply to pa- analyzes the time pattern of the pain, the environmen-
tients with chronic obstructive lung disease (COLD), a tal events that increase or diminish the pain, the effect
very common and disabling condition, particularly in of tension and relaxation on the pain, and the changes
older Americans. Yet little work has been done in this in activity level as a result of the pain. Patients who
area. One study points the way to the possible benefit seem amenable to a behavioral program are then ac-
of exercise in patients with COLD. Atkins, Kaplan, cepted into an inpatient program. The goals of the
Timms, Reinsch, and Lofback (1984) randomized pa- program are to reduce pain behavior, to increase ac-
tients to a behavior modification group which included tivity, to retrain the family to provide appropriate en-
goal setting, functional analysis of reinforcers, behav- vironmental contingencies, to reduce excessive health
ioral contracts and contingency management, a cog- care utilization, and to establish and maintain well be-
nitive therapy group, a combination of cognitive and havior. Patients addicted or habituated to medication
behavioral therapy, and an attention control group. All are slowly withdrawn by means of a pain cocktail con-
three treatment groups complied more than those in the taining the patient's baseline medications mixed with a
two control groups. However, there were no signifi- color- and taste-masking vehicle. The cocktail is first
cant changes in spirometric parameters. administered as needed. Then the active ingredients
are slowly faded, and the cocktail is finally terminated
when the active ingredients reach zero. To increase
Pain Syndromes activity, subjects are given a selection of easily
monitored exercises relevant to posttreatment ac-
Pain is one ofthe most common human experiences: tivities. Patients work to quotas determined by pre-
at anyone time 10% of the population may, for in- viously achieved levels of exercise and monitor the
stance, suffer from headache. In this section, we re- symptoms that may occur from excessive exercise.
view the behavioral approaches to three important pain Quotas and the level of success in achieving these
problems: chronic pain, migraine headaches, and ten- quotas are graphed, and verbal praise is given com-
sion headaches. mensurate with goal attainment level. Patients may
also be given vocation and career counseling as appro-
priate to increase general levels of activity.
Chronic Pain
Several studies have reported the effects of inpatient
A few patients with acute pain eventually develop programs modeled after Fordyce's (Cairns, Thomas,
chronic pain, defined as pain ()f at least 6 months' Mooney, & Pace, 1976; Fordyce, Fowler, Lehmann,
continuous duration with no organic base to explain its DeLateur, Sand, & Trieschmann, 1973; Newman,
origin. Often these patients suffer from polysurgery, Seres, Yospe, & Garlington, 1978; Sternbach, 1974;
polymedication, and poly addiction. There has been Swanson, Floreen, & Swenson, 1976). Unfortunately,
the outcome measures have varied so widely between tingent group at postdetoxification. Bemtzen and
these programs (the methodology has been fairly inad- Gotestam (1987) also found that a fixed analgesic
equate, and no controls were employed in any study) schedule was more effective than an on-demand sched-
that it is hard to determine the effects of these various ule for relieving pain symptoms.
programs. In general, inpatient programs have led to
significant pre- and posttreatment reductions in chron-
Headache
ic pain complaint and medication use, as well as signif-
icant increases in activity. Follow-up results of 6 The two most common headache complaints are mi-
months and longer have indicated that the increases in graine and tension headaches. Both headaches share
activity are maintained, that the disability claims have common features, and the distinctions between mi-
decreased, that employment has increased, and that graine and tension headaches are often difficult to
the pain has usually decreased or increased slightly but make. Such headaches are common and for many
has not returned to preadmission levels. Medication people disabling. In the past 10 years there have been
reduction is also maintained at follow-up. Philips many studies evaluating treatments for these head-
(1987) compared the effects of an outpatient cognitive- aches. In a recent review of 10 long-term follow-up
behavioral treatment with a waiting list control. Pa- studies, Blanchard (1987) concluded that the available
tients in the control exhibited a significant reduction in data support two tentative conclusion& for tension
pain avoidance behavior and affective reaction to pain, headache: (1) headache relief from cognitive therapy
and an increase in perceived control over pain. These or relaxation training is maintained for 2 years or long-
studies are tantalizing but inconclusive. It is not clear, er, whereas (2) the initial headache reduction obtained
for instance, which components of the multicompo- from frontal EMG biofeedback alone deteriorates by
nent programs that have evolved are necessary for this time. For migraine headache, there is good main-
treating patients, or even if these programs could be tenance of headache reduction at 12 months using ei-
successfully carried out in an outpatient setting. ther treatment regimen. Finally, specific maintenance
As medical economics have dictated shorter hospital strategies have generally failed to show any advantage
stays, it will be necessary for more chronic pain pa- over naturalistic follow-up.
tients to be treated as outpatients. YMCAs have been
evaluating the effectiveness of a 6-week outpatient ex-
ercise program for people with low back pain. In an Cancer
uncontrolled evaluation, over 80% of patients reported
a decrease in back pain (Kraus, Naglei, & Mellely, Nearly one in three Americans will be diagnosed
1983). Return to work has become a program goal. In with some form of cancer in his or her lifetime (Ameri-
one program, 59% of patients returned to work com- can Cancer Society, 1985). Although the majority of
pared to 25% in the same population before the pro- cancer patients live past the 5-year survival time, can-
gram began (Catchlove & Cohen, 1982). Overall, out- cer remains the second leading cause of death in this
patient treatment programs appear to be effective in country (Peterson, 1986).
resolving nonheadache chronic pain symptoms (Lin- Having cancer is often associated with emotional
ton, 1986). distress and, in a significant proportion of cases, psy-
There have also been a few studies that have ad- chiatric disorders. Assessing 215 patients at three can-
dressed the issue of schedules of medication. If pain cer centers, the prevalence of patients with at least
complaints are reinforced by patients receiving pain one DSM-III diagnosis was 47% (Derogatis et al.,
medication, then medication dispensed on a time-con- 1983). Most of these (85%) had a disorder with a cen-
tingent basis should produce less pain than medication tral feature of anxiety or depression, both considered
delivered contingent on pain complaints. Several stud- highly treatable. Prospective studies of women with
ies have lent support to this observation. White and early nonmetastatic breast cancer revealed that at 2-
Sanders (1985) placed four patients on a time-con- year follow-up 22% to 25% were depressed. In addi-
tingent pain delivery schedule and another four on a tion, psychological morbidity because of cancer and
pain-contingent medication system. The time-con- its treatment include such problems as the manage-
tingent group exhibited significantly lower pain and, ment of pain and nausea and vomiting secondary to
to a lesser extent, improved mood than the pain-con- chemotherapy.
Psychological/Psychiatric Interventions sight of the nurse (CS) alone produces its own re-
sponse, nausea and vomiting, a conditioned response
As the figures indicate, there are many potential
(CR) before the chemotherapy is administered; hence
applications for interventions. Psychological/psy-
the term anticipatory nausea and vomiting.
chiatric interventions for cancer patients have included
A variety of behavioral techniques have successful-
psychotherapy, pharmacotherapy, behavioral tech-
ly been applied to reduce the frequency and severity of
niques, and group therapy. Since the focus in this vol-
ANV. These include progressive muscle relaxation
ume is on behavioral-cognitive techniques, those inter-
treatment (PMRT) with guided imagery (Burish &
ventions will be emphasized in the remainder of this
Lyles, 1981; Burish, Carey, Krozely, & Greco, 1987;
section. Separate sections are devoted to behavioral
Carey & Burish, 1987; Lyles, Burish, Krozely, &
treatment of anticipatory nausea and vomiting, behav-
Oldham, 1982), hypnosis with imagery (Redd, An-
ioral and cognitive techniques used in group therapy,
dresen, & Minagwa, 1982), systematic desensitization
and psychological coping strategies and the progres-
(Morrow & Morrell, 1982), biofeedback (Burish,
sion of disease. The interested reader will find reviews
Shartner, & Lyles, 1981), and distraction in pediatric
of topics not covered as follows: psychotherapeutic
patients (Redd et al., 1987).
techniques (Greer, 1987); psychopharmacologic tech-
Although behavioral interventions seem to amelio-
niques (Goldberg & Cullen, 1987); the psychological
rate the anticipatory nausea and vomiting due to che-
management of pain (Jay, Elliott, & Varni, 1987). Also
motherapy, these procedures are labor intensive. One
not covered in this section, but quite important, is the
question that naturally arises from this concern is
prevention of behaviors that increase risk of cancer
whether relaxation tapes may work as well as thera-
(smoking, alcohol, dietary factors, sexual practices,
pists' intervention. Studies favor live therapy over
etc.).
tapes (Carey & Burish, 1987; Lehrer, 1982), and in
one study the tape became a conditioned stimulus asso-
Behavioral Treatment of Anticipatory Nausea
ciated with nausea (Morrow, 1984).
and Vomiting
Many cancer patients treated with chemotherapy
Psychological Factors and Cancer
have an emetic response that cannot be controlled with
antiemetic medication. For some agents, the preva- Investigators have long explored the relationship be-
lence of associated nausea and vomiting are quite high tween cancer and the psychological make-up of pa-
(e.g., over 90% for those taking cisplatin), whereas tients with the illness. Although it is beyond the scope
other agents are associated with a low rate (S-FU, vin- of this chapter to review this voluminous literature,
cristine, tomoxifen) (Morrow & Dobkin, 1987). After Derogatis (1986) provides a summary in which several
several chemotherapy treatments, some patients de- factors are identified: a high prevalence of loss, re-
velop nausea and vomiting before the subsequent treat- pressed emotional conflicts, depression, hopeless-
ments. This phenomenon is called "anticipatory nau- ness, and an inability to express frustration and anger.
sea and vomiting" (ANV). In a study of 736 cancer Even though much of this literature is fraught with
patients, Morrow and Dobkin (1987) found that 26% methodologic problems (such as problems discerning
experienced anticipatory nausea and 8% experienced antecedent from consequent conditions, lack of con-
anticipatory vomiting by their fourth chemotherapy trols, reliance on anecdotal reports), at least one pro-
treatment; furthermore, they noted that this prevalence spective study (Shekelle et al., 1981) of 2,020 men
is underestimated by clinical oncologists. from the Western Electric Health Study corroborated
One frequently noted explanation of the develop- depression as associated with a two-fold increased risk
ment of ANV involves the learning paradigm of clas- of cancer in a 17-year follow-up. Another prospective
sical conditioning. According to this paradigm, an un- study (Shekelle, Gale, Ostfeld, & Paul, 1983) identi-
conditioned stimulus (the chemotherapy drugs) elicits fied hostility as positively associated with 20-year
an unconditioned response (nausea and vomiting). A mortality from malignant neoplasms.
conditioned stimulus (CS) (sight of the nurse, smell of
alcohol used to clean skin before chemotherapy be-
Behavioral Factors and Cancer Progression
gins) initially elicits no response. As the chemotherapy
sessions proceed, the nurse (CS) is associated (or A number of studies have examined the relationship
paired) with the drugs (UCS) and subsequently the between psychological adjustment to cancer and dis-
ease progression. Greer, Morris, and Pettigale (1979) having a poorer prognosis, the evidence is not as con-
classified patients' responses to breast cancer into one sistent as it could be. Furthermore, an obvious ques-
of four categories: (1) fighting spirit, (2) denial, (3) tion is whether interventions aimed at arousing a fight-
stoic acceptance, or (4) helplessness/hopelessness. At ing spirit will have any effect on disease progression or
both the 5-year (Greer et al., 1979) and lO-year (Pet- quality of life. Some intervention studies are currently
tingale, Morris, Greer, & Haybittle, 1985) follow-ups, under way specifically addressing this, but it is too
those with a fighting spirit were most likely to be alive. early to reach any conclusion as to their effectiveness.
Those with denial did better than either the stoic accep-
tance group or those with a helpless/hopeless attitude.
Group Interventions
Further support for an unfavorable cancer disease
course in patients with helplessness/hopelessness or Supportive group therapy is one of the most widely
stoic acceptance was found in DiClemente and Tem- used psychological interventions for cancer (Telch &
oshok's (1985) study of melanoma patients. Telch, 1985). Because several reviews are available,
Several other studies suggest that a passive, help- only representative interventions will be discussed
less, or nonexpressive response style is associated with here. A review of the effects of psychosocial interven-
poorer outcomes. Rogentine et al. (1979) found in a tions in cancer patients may be found in Watson
sample of melanoma patients those with lower (1983). A more general review ofthe beneficial effects
melanoma adjustment scores (Le., "using denial or of social support for people who are already ill is also
repression of impact of the disease") were more likely available (Wallston, Alagna, DeVellis, & DeVellis,
to relapse. Derogatis, Abeloff, and Melisaratos (1979) 1983).
reported longer survival in breast cancer patients who Spiegel, Bloom, and Yalom (1981) compared sup-
expressed distress. Studies at the National Cancer In- portive group therapy to a no-treatment control in 58
stitute and at the University of Pittsburgh (cited in patients (34 in treatment group, 24 in control) with
Levy, 1985, p. 165) also found passivity and helpless metastatic breast cancer. The intervention group
response style associated with worse breast cancer out- showed less tension, less depression, less fatigue, and
comes and distress associated with better outcomes. fewer phobias at 12-month follow-up. There were no
Apathetic response style was also associated with differences on self-esteem, denial, or health locus of
lower Natural Killer cell number-a type of cell that control measures. Other studies (Ferlic, Goldman,
fights tumor cells. Kennedy, 1979; Vachon, Lyall, Rogers, Cochrane, &
Temoshok and Heller (1981) summarized some of Freeman, 1981) have also found supportive group ther-
the literature by defining a "lYpe C" individual as one apy to be of benefit but not all studies have obtained
who is cooperative and unassertive, who suppresses positive results (Bloom, Ross, & Burnell, 1978; Jac-
negative emotions (particularly anger), and who ac- obs, Ross, Walker, & Stockdale, 1983).
cepts/complies with external authorities. They found An intervention comparing coping skills training
support for association between Type C and cancer in (cognitive and behavioral) to supportive group ther-
their study (Temoshok et al., 1985) of melanoma pa- apy to a no-treatment control was done by Telch
tients, however, the psychosocial factors were more and Telch (1986) in 41 cancer patients. The coping
significant for younger subjects. The notion that being skills modules focused on teaching and rehearsal of
nice and not expressing dysphoric emotion may be cognitive, behavioral, and affective coping strategies
related to cancer progression has received support and included (1) relaxation and stress management, (2)
from other earlier studies as well (Bahnson & communication and assertion training, (3) cognitive
Bahnson, 1966; Blumberg, West, & Ellis, 1954; restructuring and problem solving, (4) feelings man-
Schmale & Iker, 1966). agement, and (5) pleasant activity planning. Behav-
However, not all studies support the above notions. ioral strategies included homework assignments,
Most notably, Cassileth, Lusk, Miller, Brown, and goal-setting, self-monitoring, behavioral rehearsal,
Miller (1985) found no association between psycho- role-playing and feedback, and coaching. Results indi-
social variables and length of survival or time to re- cated a general superiority of the coping skills group
lapse. However, their study included only patients over the supportive group therapy (discussing feel-
with advanced malignant disease. ings, concerns, and problems) and no-treatment con-
In summary, although there seems to be some sup- trol, with greater improvement in patients' self-
port for the helpless/passive nonexpressive patient's efficacy, mood ("Profile of Mood States" showing de-
creased tension, depression, anger, fatigue, and confu-

Acute Stressors
sion; increased vigor), independent observer ratings of
distress, and decreased severity and intensity of cancer A wide variety of acute stressors have been associ-
problems. ated with decrements in immune function, particularly
A more recent intervention, including a cognitive cellular immune function. Bereavement following
component and relaxation techniques in addition to death of a spouse has been studied by a number of
group support, lends further support to the helpful- investigators. Bartrop, Luckhurst, Lazarus, Kiloh,
ness of these added components in an intervention and Penny (1977) found a 10-fold decrease in T cell
(Stolbach et at., 1988). In their study, the relaxation response to mitogen stimulation 8 weeks after death of
component included meditation, breathing tech- a spouse. Studies of husbands of women with breast
niques, and imagery; the cognitive component in- cancer similarly found decreased lymphocyte response
cluded both a focus on coping skills as well as promo- to mitogen stimulation 1 to 2 months after their wife's
tion of "stress hardiness" or Kobasa's commitment, death (Stein, Keller, & Schliefer, 1985). Linn, Linn,
challenge, and control. The intervention group and Jensen (1982) studied 60 men who had experi-
showed improvements in overall functioning, anxiety enced family deaths or serious illness during the past 6
measures, depression, hopelessness, and a fighting months and found reduced responsiveness to mitogen
spirit, which continued through a 6-month follow-up. in the more depressed group. Disruption in rela-
Overall, group interventions may be of some benefit tionship through divorce has been studied by Kiecolt-
in reducing cancer patients' emotional distress, partic- Glaser, Fisher, et al. (1987). Divorced women had
ularly if they involve coping skills training in addition decreased mitogen (PHA) response, lower percentage
to social support and group counseling. of Natural Killer cells and higher Epstein-Barr virus
antibody titers (indicating poorer immune functioning)
compared to married controls. In addition, shorter sep-
Psychoneuroimmunology aration periods and greater attachment to (ex)husband
were associated with poorer immune function. Poorer
It has long been thought that psychological distress marital quality and separation/divorce have also been
plays a role in physical disease. However, it has not associated with poorer values on various immunologi-
been until recently, with advances in immunological cal measures (Kiecolt-Glaser, Kennedy et aI., 1988) in
methods and the emergence of the field of psycho- men. Other acute stressors associated with decreased
neuroimmunology, that the direct evidence linking dis- lymphocyte proliferation with mitogen stimulation in-
tress to alterations in the immune system became ac- clude exposure to 48 or 77 hours of sleep deprivation,
cessible for study. noise, and stressful environmental tasks (Palmblad,
In this section, a brief overview of the effects of 1981) and the splashdown phase that astronauts expe-
acute and chronic stress on the immune system (focus- rience (Kimzey, Johnson, Ritzman, & Mengel, 1976).
ing on humans), and psychological interventions, will A series of studies done by Kiecolt-Glaser, Glaser, and
be presented. There are several excellent reviews (Dor- their associates (reviewed in Kiecolt-Glaser & Glaser,
ian & Garfinkel, 1987; Jemmott & Locke, 1984; 1987b) have found a variety of impairments in immune
Kiecolt-Glaser & Glaser, 1987a,b) for the reader who function for medical students during exam periods.
wishes more in-depth overviews. These include decreased lymphocyte response to
A detailed description of the immune system is be- mitogens, decreased Natural Killer cell percentage and
yond the scope of this section. However, mention of a activity, decreased percentage of T lymphocytes, de-
few of the key elements may help orient the reader. creased interferon production, elevated antibody titers
Some of the major "players" are macrophages, T cells to Epstein-Barr virus, herpes simplex virus, and
(T helper, T suppressor, and cytotoxic T cells), B cells cytomegalovirus, and increased incidence of infec-
(produce immunoglobulins or antibodies, such as tious disease. Several other studies support the rela-
IgA), Natural Killer cells (especially useful for fight- tionship between stress and Epstein-Barr virus infec-
ing off tumor cells), and lymphokines (biochemical tion (e.g., Kasl, Evans, & Niederman, 1979). Taken
mediators that activate various components of the im- together, these studies suggest that psychological
mune system, e.g., interleukin I and 2, interferon). stressors have an impact on the immune system, al-
(An introduction to the immune system may be found though the importance of this impact in terms of in-
in Borysenko, 1987.) creasing vulnerability to disease is less clear.
normal weaning is associated with decreased lympho-
Chronic Stress
cyte response to mitogens, that handling from infancy
Studies of chronic stress indicate the response may leads to improved antibody response to immunization,
be different from that found in acute stress. For the and that social isolation is tumor enhancing in mice
most part, human studies suggest chronic stress is as- reared communally (Dorian & Garfinkel, 1987).
sociated with immune decrement. For example, poorer
marital quality (Kiecolt-Glaser, Fisher, et al., 1987),
Interventions
taking care of chronically ill Alzheimer's victims
(Kiecolt-Glaser, Glaser, et al., 1987), and unemploy- Given the above findings linking distress and im-
ment for 9 months (Arnetz et al., 1987) have all been mune function, it would seem logical to determine
associated with poorer immune function. Psychologi- whether interventions designed to reduce distress had a
cal factors, such as depression and loneliness, may be beneficial effect on immune functioning. Interventions
viewed as chronic stress: both have been associated reviewed here are of direct behavioral relevance and
with immune decrements (e. g., KiecoIt-Glaser et al. , include relaxation, hypnosis, psychosocial programs,
1984; Stein et al., 1985). therapy, classical conditioning, and positive emo-
In contrast, the animal literature suggests either ad- tion/cognition enhancement. Other interventions (not
aptation to chronic stress or heightened immunologic reviewed here) have included meditation, exercise,
responses with chronic stress. For example, rats ex- and nutrition.
posed to noise over 45 days showed immunosuppres-
sion in the first 10 days but increased responsiveness
Relaxation
on days 10-20 (Monjan & Collector, 1977). Chronic
exposure to uncontrollable footshock in mice injected Kiecolt-Glaser et al. (1985) systematically studied
with tumor cells resulted in a slight retardation of tu- the effects of relaxation (vs. social contact vs. no-con-
mor growth (Sklar & Anisman, 1979). Although pre- tact control) in a group of 45 geriatric residents. Resi-
liminary, one study in the human literature shows evi- dents in the relaxation group were seen for 45-min
dence of immune enhancement during a 5-week sessions three times a week for a month. The pro-
"chronically" stressful period of anticipating one's re- cedure was presented as an active coping skill and
sults of AIDS antibody testing (Ironson et al., 1988). consisted of progressive relaxation with guided imag-
Although the focus of this chapter is on human stud- ery. Those in the relaxation group showed a significant
ies, it is important to note that animal studies have not decrease in antibody titers to herpes simplex virus and
only highlighted a possible difference in immune re- self-rated distress. In another study using a very differ-
sponse dependent upon acute versus chronic stress, but ent population, Kiecolt-Glaser et al. (1986) randomly
have suggested the importance of other factors as well. assigned 34 medical students to a relaxation procedure
Factors that have been identified include control- or a control group. The relaxation procedure included
lability and ability to develop an adaptive coping re- self-hypnosis, progressive relaxation, autogenic train-
sponse (escapable vs. inescapable stressors), intensity ing, and imagery exercises. Although group mem-
of the stressor, timing of the stressor (stress prior to or bership was not significantly related to the immune
concurrent with introduction of an antigen is associ- parameters, within the relaxation group the frequency
ated with a reduction in antibody response), social cir- of relaxation practice was significantly related to the
cumstances, and early experience of the animals (with percentage of T helper cells, but not to Natural Killer
respect to weaning, handling, and communal rearing). (NK) cell activity. In yet another study examining re-
For example, Laudenslager, Ryan, Drugan, Hyson, laxation techniques (Jasnoski & Kugler, 1987),30 un-
and Maier (1983) found that acute escapable stress did dergraduates were randomly assigned to a progressive
not influence tumor growth, but uncontrollable stress muscle relaxation (PMR) and focused breathing (FB)
exacerbated tumor growth. Inescapable shock has group or a PMR, FB, and Imagery group (imagery
been associated with decrements in both lymphocyte included powerful, positive, immune functioning) or a
response to mitogen stimulation and Natural Killer cell vigilance task (VT) control. Although the intervention
cytotoxicity. Furthermore, as noted, if inescapable lasted only one hour, salivary IgA was significantly
stress was chronic, tumor activity was inhibited (for higher in both relaxation groups as compared with the
sound, footshock, and chronic restraint). Studies on VT condition. Thus, relaxation procedures have been
early experience suggest that early weaning versus associated with improved immune function.
Hypnosis social interventions are likely to provide an area of

continued interest. In a direct study involving specific
Studies from several different laboratories suggest
immune function testing, Pennebaker, Kiecolt-Glaser,
that in subjects who are responsive to hypnosis, hyp-
and Glaser (1988) found that confronting negative ex-
nosis may positively affect immune function (Good,
periences through writing about them on 4 consecutive
1981), particularly delayed hypersensitivity reactions.
days resulted in enhancement of two measures of cel-
In a typical paradigm, subjects are injected in both
lular immune function and a decrease in health center
arms with the same amount of allergen and given a
visits.
hypnotic suggestion to suppress a response in one arm.
Although much of the literature has focused on es-
Skin test responses (wheals) to allergens in asthmatic
tablishing a relationship between distress and poor im-
patients have also been responsive to hypnosis. How-
mune function, some studies suggest a link between
ever, some studies have failed to find a positive effect
"positive" emotions and cognitions, immune func-
of hypnosis on delayed hypersensitivity reactions
tion, and health. For example, Rodin (1988) found a
(Locke et aI., 1987) or other immune parameters.
pessimistic exploratory style to be associated with a
lower T4/T8 ratio, and Temoshok et al. (1988) found
Classical Conditioning "upness" to be positively related to the number of
virocidal cells. Positive film stimuli, including a
Using an animal model, Ader and Cohen (1975) Mother Theresa film (McClelland & Kirschnit, 1987)
were able to classically condition immune suppression and humor (Dillion, Minchoff, & Baker, 1985), have
by pairing an inert substance (saccharide) with an im- also been associated with enhanced immunologic
mune suppressive drug (cyclophosphoramide). The function.
conditioning effect has been replicated by several in- The relationship between an increased sense of con-
vestigators (e.g., Wayner, Flannery, & Singer, 1978) trol and self-efficacy and immune function is an area of
and has been found to generalize to cell-mediated and recent interest. Weidenfeld (1988) found that about
antibody-mediated immunity, NK cell response, and two-thirds of snake phobic subjects showed increases
delayed hypersensitivity reactions in rats. Of particu- in immune function during exposure to the snake; how-
lar interest, Ader and Cohen (1982) were able to apply ever, inefficacious subjects experiencing a high level
conditioning techniques to delay the development of of stress displayed a decrease in immQne function.
disease and mortality in mice treated for systemic In summary, some psychosocial interventions (e.g.,
lupus erythematosus, an autoimmune disease. Using relaxation) have been shown to enhance at least some
similar principles, subjects conditioned to having no aspects of immunity. Although this research is well
response to injections of saline were less reactive to a accepted in behavioral circles, the basic science com-
tuberculin skin test since they were conditioned to have munity is less convinced. Future intervention research
no response (Smith & Daniels, 1983). may do well to incorporate knowledge gained from
animal studies as well as human studies in related
areas. Variables, such as control and predictability,
Psychosocial and Other Interventions
self-efficacy, coping styles, expression of affect, tim-
Very few studies have investigated whether socially ing of stressors (including stress innoculation), adapta-
geared interventions may affect immune function. Ar- tion to chronic stress, loneliness, and depression, have
netz et al. (1987) found that a psychosocial interven- all been implicated in disease models; many are poten-
tion, including social support, information gathering, tially modifiable. In addition, more studies are needed
and activity options, was ineffective in countering the that are prospective in nature, that include multiple
decrease in lymphocyte response to mitogen PHA and time points, and that address the question of gener-
the decrease in response to tuberculin skin testing in alizability of immune function measures.
unemployed women 9 months after losing their jobs.
Negative results (no consistent significant change in
immune function) were also obtained for a social-con- Acquired Immune Deficiency
tact intervention with elderly patients (Kiecolt-Glaser Syndrome
et aI., 1985). Although results have been disappoint-
ing, there is enough good evidence in the literature that Perhaps no medical illness in recent times has
social relationships are significantly related to well- caused more fear or is more important than the ac-
being (Cohen, 1988; Wallston et at., 1983) and that quired immune deficiency syndrome (AIDS). AIDS
occurs in previously healthy, relatively young indi- the disease is associated with dysphoria; feeling you
viduals (50% are between 30 and 39; Hulley, 1988), are responsible for your own improvement is associ-
there is no vaccine and no cure, and it is usually fatal ated with improved mood and safer sex practices
within 2 to 3 years of diagnosis. The course of the (Moulton, Sweet, Temoshok, & Mandel, 1987; Tem-
illness before death can be quite devastating-includ- oshok, Sweet, Moulton, & Zich, 1987).
ing opportunistic infections, malignancies, and disor-
ders of the central nervous system. The only good
Interventions
news is that AIDS is preventable-avoidance of high-
risk sex and sharing of contaminated needles would Behavioral interventions of relevance to the AIDS
prevent most new cases. In fact, there is evidence that epidemic include but are not limited to (1) AIDS anti-
the AIDS epidemic has led to a remarkable alteration body test results counseling, (2) individual and group
in sexual habits in the gay community. Although only a therapy, (3) community prevention programs to modi-
few "behavioral medicine" studies have been com- fy high-risk behaviors, and (4) stress management and
pleted in this area, and treatment of the disease is exercise programs. In addition, depression, organic
rapidly changing, AIDS is of such importance that we brain syndromes, anxiety and denial are common in
decided to include a brief update on the application of AIDS/HIV patients and often require treatment (Perry
behavioral medicine techniques to the prevention of & Markowitz, 1986). For instance, depression may be
AIDS and highlight possible areas for future interven- present in as many as 80% of patients, but the majority
tion. of these have adjustment disorder rather than major
depression (Goodkin, 1988). However, it is striking to
note that there is an increased suicide rate in men with
Epidemiology
AIDS of 66 times that of the general population (Mar-
As of June 1988, there were about 66,000 cases of zuk et al., 1988).
AIDS diagnosed in the United States (Hulley, 1988). The major pred.ictor of risk for HIV infection within
The major risk groups are homosexual males and intra- the gay male popUlation is sexual behavior and, as such,
venous drugs users. The Centers for Disease Control this has been the main target for behavior change. Dra-
(CDC) projects that there will be 39,000 new cases of matic behavior changes have already occurred in the
AIDS in 1988 and a total of 365,000 by 1992, if cur- gay popUlation: for example, the percentage of gay and
rent trends continue. An estimated 2.5 million Ameri- bisexual men in a San Francisco study engaging in
cans are infected with the human immunosuppressive passive anal intercourse decreased from 33.2% in 1985
virus (HIV) (the virus that causes AIDS) but have not to 18.5% in 1986, and to 3.5% in 1987 (Ekstrand &
developed the clinical manifestations of AIDS. The Coates, 1988). Highest risk behaviors include receptive
factors that may cause patients with HIV to develop unprotected anal intercourse and multiple sexual part-
AIDS are not known. There is some speCUlation that ners (Moss et al., 1987). Use of drugs, alcohol, nitrite,
psychosocial factors may contribute to the progression and cannabis are also associated with unsafe sex (Stall,
of AIDS. Preliminary analyses of some studies now McKusick, Wiley, Coates, & Ostrow, 1986; van
underway (Solomon & Temoshok, 1987) suggest that Griensven et at., 1987) and the development of AIDS.
the following are related to more positive outcomes of Other predictors of high risk for HIV infection, some of
immune function, symptoms, or disease outcome: which are potentially modifiable, include perception of
positive mood states, "upness," not doing unwanted health threat, response efficacy, social skills, peer sup-
favors, active coping, hardiness, perhaps anger (indi- port, self-esteem (Charles, 1985), belief in health
cating fighting spirit?), less defensiveness, more open- guidelines, and personal efficacy (a belief that one is
ness about being gay, and possibly exercise. Both lone- capable of taking recommended actions that would
liness and negative affect states are associated with lessen the risk of exposure to AIDS) (Morin, Charles,
negative outcomes. The evidence for social support is Coates, & McKusick, 1987). In a 3-year longitudinal
mixed: while some studies have suggested certain as- analysis of 824 gay men, McKusick, Coates, Stall, and
pects of social support and problem-solving to be asso- Morin (1988) found that persistence of high-risk behav-
ciated with positive outcomes, others have failed to iorwas related to being alone, knowledge ofHIV status,
find a relationship. However, supportive social norms and alcohol use. In a review of studies, Coates, Stall,
have been related to attempts to reduce the number of Catania, Dolcini, and Hoff (1989) and Coates, Stall,
one's sexual partners (Emmons et al., 1986). Finally, and Hoff (1988) suggested thatHIV testing is associated
in AIDS patients, feeling that you are responsible for with reductions in levels of high-risk behavior.
There has been an increasing emphasis on the use of suggest that 10 weeks of regular exercise may enhance
education to reduce high-risk behavior. The mailing of certain immune parameters, for example, T helper
an AIDS information brochure by the Surgeon General cells particularly in those subjects who are HIV nega-
to every household in America is probably the greatest tive (Laperriere et al., 1988). A number of other inter-
effort of its kind ever. The effect of fear-inducing mes- ventions are currently under study, including stress
sages is controversial. One study found that persuasive management (Antoni et al., 1988).
messages achieve their effects by increasing self- Changes in gay male sexual behavior may help re-
efficacy rather than increasing fear (Meyerowitz & duce the number of new AIDS cases in that population.
Chaiken, 1987). Gay men who were knowledgeable Unfortunately, there has been relatively less change in
about safe sex practices may be unable to act on this behavior in the other high-risk group-IV drug users,
knowledge if they have a low sense of self-efficacy. who spread the disease through shared needle use.
Individuals with high-risk sexual behavior are more
likely to change if presented with alternative accept-
able behaviors rather than a prescription to avoid sex Computers in Behavioral Medicine
altogether (Kelly & Lawrence, 1986).
Computers presently play an important role in medi-
Face-to-Face Programs cine and have begun to play an important role in behav-
ioral medicine. Microcomputers are currently being
In an effort to modify high-risk behavior, Kelly,
used in behavioral medicine for administering, scor-
Lawrence, Hood, and Bransfield (1987) implemented
ing, and interpreting psychological tests and diag-
a 12-week group intervention consisting of informa-
nostic interviews (Erdman, Klein, & Griest, 1985;
tion on AIDS risk, cognitive-behavioral self-manage-
Fowler, 1985; Matarazzo, 1986), conducting behav-
ment training to turn down requests involving high-
ioral assessments (Burnett, Taylor, Thoresen, Rose-
risk behavior, and the development of social supports.
kind, & DeBusk, 1985; Burnett & Taylor, in press),
One hundred and four homosexual men with a history
making treatment decisions (e.g., Goldman, Cook,
of high-risk behavior were randomized into the experi-
Brand et al., 1988), and providing direct treatment.
mental treatment group or a waiting list control. Re-
The most significant developments with respect to di-
sults indicated a decrease in the experimental group
rect treatment can be divided into two broad catego-
from 1.2 episodes per month of unprotected anal inter-
ries: (1) computer-assisted health promotion and (2)
course at baseline to 0.2 episodes per month at 4-
computer-assisted interventions aimed at specific
month follow-up. There was no change in the control
health problems.
group. There was also a significant increase in the use
of condoms in the experimental group.
Coates, McKusick, Kuno, and Stites (1989) studied Computer-Assisted Health Promotion
the effect of a positive health habit change and stress
Computer-assisted health promotion programs are
management intervention on the sexual behavior and
multifocused interventions designed to foster health
immune function of a group of 64 HIV positive men.
behavior change across a broad spectrum (Gustafson,
Results indicated fewer sexual partners for experimen-
Bosworth, Chewning, & Hawkins, 1987). As such,
tal subjects (1.37 per month at baseline to 0.5 at post-
these programs should be differentiated from comput-
treatment) versus more sexual partners in the control.
er-assisted health education programs that are de-
There was no change in immune function or in percent-
signed primarily to provide information about specific
age reporting unsafe sex.
health topics or to assess specific health risks. In this
Fawzy, Namir, and Wolcott (1989) showed that
section, we examine several computer-assisted health
group interventions with AIDS patients, focusing on
promotion programs that illustrate the important role
problem solving and coping or relaxation, led to less
that such programs can play in promoting health be-
depression and anxiety and to more active behavioral
havior, particularly in large-group settings.
coping and less avoidant coping as compared to an The Body Awareness Resource Network (BARN)
emotional support group. program, developed at the University of Wisconsin-
Madison (BARN Research Group, 1985), was one of
Other Interventions
the earliest computer-assisted health promotion pro-
Preliminary results of an aerobic exercise program grams. The BARN program combines computer-as-
for asymptomatic HIV positive and negative males sisted problem-solving techniques with computer-as-
sisted instruction to teach teenagers and their families CHAP program reported greater reductions in fat in-
to make wise decisions about alcohol and other drugs, take and greater increases in fiber intake than partici-
nutrition/exercise, sexuality, smoking, stress manage- pants in the control conditions. CHAP also identified
ment, and local health resources. To use the program, overweight participants and advised them regarding
an individual uses a desktop microcomputer to explore weight loss. Overweight participants in the CHAP
interactive game modules, simulations, and problem- condition lost a mean of 2.92 kg in 12 weeks compared
solving exercises. Based on pre- and posttests of health to minimal or no change in the control groups.
knowledge, observations, and interviews involving Finally, the Pepsico Lifeline program was revised to
approximately 2,400 teenagers, the program has re- provide dietary feedback to patients screened for hy-
ceived highly positive evaluations. percholesteremia in a physician's waiting room. Pa-
The Pepsico Lifeline program was developed col- tients randomized to the intervention exhibited a sig-
laboratively by researchers at Stanford University nificant reduction in serum cholesterol compared to
Medical School and the University of Wisconsin- patients given feedback of their cholesterol only.
Madison. In contrast to the BARN program, the Pep-
sico Lifeline program does not require the participant
Computer-Assisted Interventions Aimed at
to interact directly with the computer. Rather, the par-
Specific Problems
ticipant uses paper and pencil to complete a health
behavior questionnaire each month over the course of a Behavior therapists have a long history of interest in
year. After each administration of the questionnaire, automating various aspects of the therapeutic process.
each participant's responses are entered into the com- This interest was considerably heightened shortly after
puter by the program staff. The Pepsico Lifeline pro- Lang, Melamed, and Hart (1970) demonstrated the
gram then produces a confidential, personalized report clinical efficacy of an automated systematic desensi-
for each participant. Because of the time-oriented tization procedure that used a computer-controlled
nature of the program, participants' reports contain feedback system to allow phobic patients to manipu-
recommendations not only about current health behav- late the rate of presentation of audiotaped fear hier-
ior, but about changes in health behavior compared to archy items. Although Lang's work pushed the limits
previous reports. The reports also recommend that the of the computer technology of that era, Lang's com-
participant read the most relevant of a series of printed puter-assisted therapy did not involve direct comput-
health "tip sheets" that are linked to the program con- er-patient interaction. As computer technology has
tent areas. become more sophisticated, so have the behavioral ap-
This intervention was combined with a risk assess- plications of this technology. In this section, we focus
ment and an on-site health education program in two on some recent interactive computer-assisted therapy
food processing plants and evaluated in comparison to applications that have relevance for behavioral
two control plants. The combined population of the medicine.
plants was 450 and 442, respectively, mostly young, Sorrel, Griest, Klein, Johnson, and Harris (1982)
blue-collar workers. The proportion of smokers in the described the development of a computer program de-
control and intervention sites was 38% and 34% at signed to enhance patient adherence to tricyclic anti-
baseline, of whom 3% and 23% quit-a significant depressants. In addition to being used to monitor ad-
difference. The intervention was also associated with a herence, the program employed techniques to enhance
9.6 mg/dl reduction in plasma cholesterol (compared patients' understanding of the proper use of the medi-
to a reduction of2.8 mg/dl in the control group). Blood cation and to help patients alter negative cognitions
pressure and body weight were also favorably affected. about possible side effects. Sorrell (1983) conducted a
The study did not parcel out the specific effects of the preliminary evaluation of this system and found that
computer intervention. use of the system was associated with high adherence,
The Computer-Assisted Health Awareness and Pro- although adherence was not significantly higher for
motion (CHAP) program is an enhanced version of the those in the computer-monitoring group than for those
previously described Pepsico Lifeline program. The in a control group that received "normal" physician
CHAP program was evaluated recently with 77 senior- supervision. Adherence was extremely high in both
year high school students who either used the CHAP groups, however, suggesting that the computer-
program or participated in one of two active control monitoring program may be of value as an adjunct to
groups (Burnett, Magel, Harrington, & Taylor, 1989). physician supervision, especially with poor adherers.
Compared to baseline levels, the students who used the Selmi, Klein, Griest, Johnson, and Harris (1982)
developed a six-session, computer-assisted cognitive- a liquid crystal display for presenting messages to the
behavioral intervention for mild-to-moderate depres- patient. In addition, the system contained a real-time
sion. The computer program, MORTON, was used in- clock, an auditory prompting system, and an eight
teractively to conduct weekly assessments of depres- channel analog-to-digital conversion chip capable of
sion, to educate patients regarding the principles of sampling physiological indices.
cognitive-behavioral therapy, and to make weekly Burnett, Taylor, and Agras (1985) first used this
homework assignments. Selmi (1983) evaluated this system to implement and evaluate the CADET I weight
program and found that patients treated by MORTON loss program (CADET is an acronym for "computer-
evidenced significantly less depression on several assisted diet and exercise training"). Throughout the
measures at posttreatment. Furthermore, there were no program, clients used the computer to set daily calorie
significant differences at posttreatment between those limits and exercise goals, to record daily food intake and
treated by MORTON and those treated by a human thera- exercise, and to receive intensive quantitative and
pist who followed the same treatment protocol. None qualitative progress evaluations. The computer also
of the patients were on antidepressants at the time of provided auditory prompting throughout the day and
treatment. early evening to remind patients to make self-reports
A computer-assisted instructional approach was and to reflect on their program goals. Patients using the
also employed by Ghosh, Marks, and Carr (1984) in CADET program lost a mean of 3.7 kg in 8 weeks,
the treatment of phobia. The patients (primarily agora- significantly more than the 1.5 kg lost by matched
phobics) were instructed by an interactive computer controls. More important, however, was the fact that at
program on how to conduct self-administered, in vivo a 40-week follow-up, the patients in the computer-
exposure therapy. Patients instructed by computer im- therapy condition had continued to lose weight (a mean
proved significantly and to a similar extent as did those reduction of 17. 71bs for the computer group compared
instructed by a therapist or through bibliotherapy; to a mean reduction of only 2.3 lbs for the control
however, the type of computer-assisted instruction em- group). An enhanced version of the CADET program is
ployed in this study required as much therapeutic time currently being evaluated in a large-scale clinical trial
and involvement as was required for those instructed and other applications are being explored (Burnett,
by a therapist. Ghosh and Marks (1987) replicated this Taylor, & Agras, 1987). The use of ambulatory micro-
study using a computer program that required much computers to provide immediate, goal-related feedback
less therapist time and involvement and obtained simi- inreal-life settings represents a major advance in behav-
larly positive results. ior therapy and behavioral medicine methodology.
Foree-Gavert and Gavert (1980) used computers as
an important aid to treatment planning for obese
female patients participating in an intensive 16-week Future Perspectives
behavioral weight reduction program conducted at a
private clinic in Stockholm. Computer programs were Behavioral medicine has grown at such a fast pace
used to plan weekly personalized diets, analyze week- and in so many directions that its future, other than to
ly food intake, and to provide feedback on patient pro- say that it is promising, is difficult to predict.
gress. Participants in the computer-assisted program On a basic science level, we can anticipate that be-
lost a mean of 14 kg compared to 6 kg for participants havioral medicine researchers will continue to make
in an active-control condition. Although this program important contributions to medical science. There has
did not involve direct computer-patient interaction, it been a recent trend to turn away from intervention
illustrates the powerful role that computers can play in studies and to examine mechanisms; it is hoped that
the areas of behavioral planning and feedback. studies will point to new directions for intervention.
Researchers at the Laboratory for the Study of Be- On the other hand, there has been relatively less em-
havioral Medicine at Stanford developed the first com- phasis on the study of overt behaviors and it is hoped
pletely portable, interactive computer system designed that this trend will reverse in the future.
for ambulatory computer-assisted behavior therapy in On a treatment level, more techniques will be devel-
real-life settings (ambulatory meaning "usable while oped and practiced. The success of the application of
walking about"). The computer was small enough for these techniques will be determined as much by politi-
patients to carry with them throughout their normal cal and social factors-such as how adequately behav-
daily routine and had a built-in keyboard for input and ioral medicine practitioners are reimbursed and how
easily they become incorporated into the medical sys- niques have shown promise in reducing the complaint
tem-as by scientific ones. Current trends suggest that of nausea and symptoms of the irritable bowel syn-
behavioral medicine will become a major aspect of drome. Psychosocial factors have been shown to be of
psychological treatment in the ever-expanding group great importance for the treatment of cancer and to
and HMO practice plans. affect the immune system. Interventions that may po-
We can expect that behavioral medicine techniques tentially improve immune function, or reduce the im-
will play an even more important part in prevention pact of stress on the immune system, are being devel-
and rehabilitation of diseases. The impetus for adopt- oped and studied.
ing such changes and the philosophy for incorporating Finally, behavioral medicine may achieve its great-
these changes may have to come from social and politi- est contribution to society in helping to prevent the
cal forces, since commitment to prevention has been spread of AIDS.
minimal on the part of traditional medical practi-
tioners. The United States has established a set of ACKNOWLEDGMENT. Preparation of manuscript was
Health Objectives for the year 2000 most of which partially supported by a National Institute of Mental
involve change in life-style. Behavioral medicine Health research training grant MH 16744; principal
practitioners and researchers have already made a sub- investigator R. Moos.
stantial contribution in helping to achieve these goals
and, it is hoped, they will continue to play an important
role.
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CHAPTER 19
Pain
Dennis C. Turk and Thomas E. Rudy
Introduction had to be expanded from the rather simple notion of

pain as an alarm signal indicating pathology, to models
Pain is perhaps the most common physical symptom that view pain as a complex perceptual event resulting
and the primary reason for seeking medical attention. from the interaction among biological, psychological,
Pain of relatively brief duration (acute pain) can be and behavioral parameters. Development of expanded
successfully controlled by analgesic medication and perspectives on pain have been greatly enhanced by
other short-term strategies, such as bed rest and heat. psychologists and by psychological thinking, most no-
For a substantial number of individuals, however, pain tably by work initiated in the 1960s on the conscious
will persist beyond the expected period of healing, control of motor units through biofeedback (e.g.,
recur intermittently, or develop in association with pro- Basmajian, 1963), the maintenance of overt commu-
gressive conditions, such as arthritis. Despite the ad- nications of pain through operant conditioning (For-
vances in knowledge of anatomy and physiology, exot- dyce, Fowler, & DeLateur, 1968), and the modulating
ic diagnostic imaging procedures, as well as innova- role of descending central nervous system processes
tive medical and surgical treatments, the problem of (Melzack & Wall, 1965).
persistent pain is unresolved and remains a major Although in the following pages we will discuss
health care problem. models of pain based on behavioral research as if they
Historically, the health care system has attempted to are independent, we also will attempt to demonstrate
meet the challenge posed by pain with surgical and that they are not mutually exclusive but rather comple-
pharmacological modalities designed to eliminate or mentary. Respondent learning, operant conditioning,
inhibit the transmission of nociceptive stimulation, and cognitive-social learning factors are, in fact, inter-
that is, sensory stimulation capable of being perceived related and each must be considered in addition to
as pain. Unfortunately, reliance on these somatic physical pathology in order to understand and success-
modalities has not produced results that are con- fully treat chronic pain patients.
sistently and uniformly successful (Melzack & Wall, It is our intent in this chapter to describe current
1982). Consequently, conceptualizations of pain have psychological (behavioral) perspectives on pain and to
show how these perspectives influence assessment.
Dennis C. Turk • Department of Psychiatry, and Pain Eval- Furthermore, one's conceptualization of the cause of
uation and Treatment Institute, University of Pittsburgh School nociception and pain, somatic or psychological, will
of Medicine, Pittsburgh, Pennsylvania 15213. Thomas E. influence one's choice of treatment modalities. Table 1
Rudy • Department of Anesthesiology, and Pain Evaluation
and Treatment Institute, University of Pittsburgh School of Med- illustrates the way in which perceived cause may guide
icine, Pittsburgh, Pennsylvania 15213. treatment decisions. Note in Table 1, however, that
399
Table 1. Association between Perceived Cause of cause of physical damage leading to a pain-tension
Pain and Treatment Modalities Prescribed cycle. This model views pain as. a response to specific
Treatment approach
antecedent nociceptive stimulation. It may be a signal
Presumed cause of disease or biological malfunction but also may oc-
of pain Somatic Psychological cur in response to a variety of stimuli once initial con-
Physical/ sensory Surgery Biofeedback ditioning has occurred. This conceptualization sug-
Nerve blocks Relaxation gests that during the acute phase of the injury,
Physical therapy Hypnosis avoidance behavior, such as limping and decreased
TENS Coping skills activity, are adaptive in that they promote tissue heal-
Analgesic medications ing and attenuate the experience of pain (Bolles &
Psychological/ Psychotropic medica- Psychotherapy Franslow, 1980; Wall, 1979).
motivational tions Operant condi- Caldwell and Chase (1977) and Lenthem, Slade,
tioning Troup, and Bentley (1983) have suggested that once an
Denial of com- acute pain problem exists, conditioned fear of move-
pensation
ment may lead to avoidance of activity. For example,
individuals who suffer from acute back pain, re-
gardless of the cause, may adopt specific protective or
both psychologically based and somatically based in- preventive behaviors, such as limping, in order to
terventions have been used with somatic and psycho- avoid exacerbation of pain. From the respondent per-
logical etiological views. spective, avoidance is viewed as being motivated by
We will argue that both somatic and psychological the expectation of pain increase following activity
perspectives are inadequate and that to understand and (Linton, 1986; Philips & Jahanshahi, 1985).
successfully treat pain of long duration requires a more Attempts to avoid nociceptive stimulation prevent
integrated perspective on pain. We will describe an the patient from receiving "corrective feedback" be-
approach that we have labeled "multiaxial" in order to cause they fail to perform more natural movements.
integrate medical-physical, psychosocial, and behav- Moreover, avoiding stimulation is likely to play an
ioral-functional parameters (Thrk & Rudy, 1987). Fur- active role in reducing the patient's sense of control
thermore, we also will suggest that treatment should be over pain and increasing his or her expectation that
individualized to meet the specific characteristics of activity will increase pain. These appraisals may lead
patients derived from the multiaxial perspective. We to further withdrawal from normal activities and in-
suggest this approach as an alternative to relying solely creased intolerance of stimulation (Philips, 1987a).
on medical diagnosis, which tends to be based on loca- When someone has had pain for any length oftime, he
tion, the physiological system involved, and the pre- or she usually begins to identify activities or situations
sumed etiology (see International Association for the that increase pain. If the pain exacerbation is severe
Study of Pain, 1987). The medical diagnostic ap- enough, the individual may develop a strong fear and
proach may be more appropriate for acute conditions avoidance to that situation. Significant reduction in
and syndromes with an identifiable physical cause but physical activity may subsequently result in muscle
does not appear adequate for patients with chronic atrophy, increased impairment, and greater disability.
nonmalignant (low back), chronic recurrent (head- In this manner, the physical abnormalities may be sec-
ache, temporomandibular pain dysfunction), and chro- ondary to changes in behavior.
nic malignant (e.g., associated with cancer) pain for As pain symptoms persist, more and more situations
which no cure is available and conventional medical may elicit anxiety. Preparatory muscle tension may
and surgical interventions have proven to be actually exacerbate pain and further reinforce the fear
inadequate. of activity. Depression and dependence on medication
may follow, intensifying the pain-tension cycle. Psy-
chological expectations may lead to modified behavior
Respondent Conditioning Model of that, in tum, may produce physical changes leading to
Chronic Pain still greater physical deconditioning. With chronic
pain, the anticipation of pain or prevention of suffering
The respondent model, as described by Gentry and may be sufficient for the long-term maintenance of a
Bernal (1977), suggests that classical conditioning of wide range of avoidance behaviors.
pain and tension may occur in an acute pain state be- Specifically, from a respondent conditioning per-
CHAPTER 19 • PAIN 401
spective, the patient may have learned to associate muscle tension and, consequently, reduction in muscle
increases in anxiety and muscle tension with many tension should lead to reduction of pain. Following
types of stimuli originally associated with nociceptive from this perspective, authors suggest that patients
stimulation. Thus, sitting, walking, bending, or even with muscularskeletal pain will display (1) higher lev-
thoughts about these movements may elicit anticipato- els of general arousal and generalized muscle tension,
ry anxiety and increases in muscle tension. Subse- (2) aberrant muscular reactivity as an idiosyncratic re-
quently, patients may display maladaptive responses to sponse to psychological stress, and (3) aberrant mus-
many stimuli and reduce their frequency of performing cular activity during specific movement. Treatment
many activities. The anticipated pain may lead to anx- interventions (e.g., muscle relaxation, biofeedback,
iety about movement that may act as a conditioned graded exposure physical therapy) have been pre-
stimulus (CS) for muscle tension, and a conditioned scribed in order to modify the hypothesized maladap-
response (CR) that may be maintained after the origi- tive responses. Note that the maladaptive responses
nal unconditioned stimulus (VCS, e.g., injury) and are both cognitive (fear) as well as behavioral (muscle
unconditioned response (VCR, pain and muscle ten- tension, avoidance of activity).
sion) have subsided. Thus, although the original asso- Despite the attractiveness of the pain-muscle ten-
ciation between injury and pain results in anxiety re- sion view and the firm hold that it has taken in the
garding movement, with time the anxiety may lead to literature (e.g., Stroebel & Glueck, 1976), the em-
increased muscle tension and pain. Nonoccurrence of pirical evidence to support this model is not very con-
pain is a powerful reinforcer for reduction of move- vincing (FIor & Turk, 1988a). Several studies have
ment and, thus, the original respondent conditioning reported no differences or significantly lower resting
may lead to an operant conditioning process whereby paraspinal EMG levels between patients with and
the nociceptive stimuli need not be present for the without back pain (e.g., Collins, Cohen, Naliboff, &
avoidance behavior to occur. Schandler, 1982; Stuckey, Jacobs, & Goldfarb, 1986).
What has been described illustrates our contention Some preliminary support for the pain-muscle tension
that behavioral models may not be contradictory but view is provided by results from a study reported by
rather complementary. That is, our description of the Flor, Turk, and Birbaumer (1985). These authors
role of respondent processes in chronic pain can read- found that back pain patients, compared to healthy
ily incorporate operant conditioning and cognitive controls, displayed elevated EMG patterns only in
learning factors (e.g., anticipation, knowledge of their paravertebral musculature and only when discuss-
contingencies). ing their pain or a personally relevant stressful
Despite the fact that the role of avoidance has been situation.
hypothesized in the maintenance of pain behaviors In a set of studies, Schmidt (1985a,b) demonstrated
(overt communications of pain and suffering, such as that low back pain patients displayed poor behavioral
limping, bracing), few systematic investigations of persistence on various exercise tasks that was indepen-
this mechanism have been reported. Fordyce, Shelton, dent of any physical parameters or actual self-reports
and Dundore (1982) investigated avoidance of aver- of pain. These patients appeared to have a negative
sive consequences as a mechanism for maintaining view of their abilities and expected increased pain if
pain behaviors. In this case study, guarding (protective they performed physical exercises. Thus, the rationale
movements) pain behaviors appeared to be maintained for their avoidance of exercise was not the presence of
by anticipated nociceptive stimuli and consequent pain but their anticipations of heightened pain.
pain. The authors hypothesized that avoidance behav- Schmidt postulated that these negative perceptions of
ior does not necessarily require intermittent nocicep- their capabilities for physical performance form a
tion from the site of bodily damage, environmental vicious circle with the failure to perform activities
reinforcement, or successful avoidance of aversive so- feeding back to augment the perception of helplessness
cial activity to account for the maintenance of protec- and incapacity.
tive guarding. From the respondent view, the protec- These data provide preliminary support for some of
tive behaviors can be maintained by anticipation of the postulates contained within a respondent view of
aversive consequences based on prior learning and not chronic pain and argue that clinicians need to pay
necessarily the actual experience of increased closer attention to these factors in the assessment of
nociception. pain patients, especially the fear and avoidance of
The respondent model also proposes that pain, or at physical activity. It is important to recognize that re-
least the perception of nociception, is associated with search related to the respondent model appears to ex-
tend beyond respondent conditioning per se and has physical and/or psychological stressors. The goal of
implications relevant for operant models and cog- treatment, therefore, should be to interrupt this vicious
nitive-behavioral views described below. circle and to replace maladaptive muscular activity by
an incompatible competing response, such as relaxa-
tion.
Assessment Based on the Respondent Two related strategies have received the greatest
Conditioning Model amount of attention, generalized relaxation and bio-
feedback, both of which are intended to reduce mal-
The emphasis of the respondent model on excessive
adaptive physiological responses. Note that these psy-
muscular arousal has resulted in studies to determine
chologically based interventions are being employed
whether patients with specific muscularskeletal pain
to modify somatic activity presumed to cause pain (see
syndromes demonstrate generally higher levels of
Table 1). Although we will not directly consider the
muscle tension than healthy controls. The research ev-
research on the use of physical therapy for chronic pain
idence tends to contradict this hypothesis (see Flor &
patients, it is worth noting that one of the contributors
Turk, 1989a). It would be expected that clinicians who
to the success of physical exercise is that the graded
ascribe to the general arousal hypothesis would, prior
increases in activity may contribute to a reduction in
to attempting to modify this putative maladaptive
the fear of movement that is fostered by the perfor-
arousal, assess patients' muscular hyperactivity.
mance of previously avoided activities (desensitization
Somewhat surprisingly, this is rarely the case. Clinical
and exposure). Performance of activity has also been
reports of the efficacy of biofeedback and muscle re-
suggested as a powerful mechanism to enhance the
laxation, provided in order to reduce the maladaptive
patient's sense of self-efficacy (Bandura, 1977).
levels of muscular arousal, rarely report on patients'
pretreatment levels of muscle arousal.
Biofeedback and Relaxation. Biofeedback and
The assessment of patients' avoidance of activity
relaxation training are based on the stress-hyper-
because of fear of pain exacerbation or reinjury has
arousal model whereby it is assumed that stress-related
only recently received systematic attention. Philips
elevated muscle tension levels exacerbate and main-
and her colleagues (Philips & Hunter, 1981; Philips &
tain pain, which originally may have had an organic
lahanshahi, 1985) have examined the avoidance of ac-
cause. Thus, muscular hyperarousal does not have to
tivity reported by headache patients. Unlike back pain
be linked to the original cause of the nociception. In
patients, who tend to avoid physical activity, headache
these treatment approaches, the patient typically is
patients appear more likely to avoid or withdraw from
provided with a model of the relationship between
social activity.
muscle tension or maladaptive vascular reactivity and
Thus, the assessment of the factors assumed from
pain, and biofeedback and/ or relaxation training under
the respondent model to be of importance have not
static conditions is provided by means of auditory or
received adequate empirical investigation. Although
visual signals. Additionally, attention may be given to
the respondent model is appealing, much more re-
proprioceptive cues either from the frontalis muscle or
search is needed on the psychophysiological basis and
other specific muscles believed to be associated with
the importance of avoidance of activity. Research
the individual's experience of pain, or, in the case of
should also focus on the interrelationship between this
migraine headaches, thermal or cephalic blood flow.
model and research on the assessment of operant fac-
Since there have been numerous reviews of the rela-
tors and cognitive appraisals in the maintenance of
tive efficacy of biofeedback, we will not examine this
maladaptive responses by chronic pain patients.
topic. The typical conclusion reached is that the evi-
dence is mixed (e.g., Keefe & Hoelscher, 1987; Turner
& Chapman, 1982a). Recently, there appears to be
Treatments Based on the Respondent
more emphasis on combining biofeedback with other
Conditioning Model
modalities rather than relying exclusively on biofeed-
The theoretical basis for treatments based on re- back in the treatment of chronic nonmalignant pain.
spondent conditioning is the assumption of a nocicep- Greater attention also has been focused on what char-
tion ~ pain ~ tension ~ pain ~ avoidance circle, and acterizes patients who benefit from biofeedback,
that pain is associated with muscle tension either as rather than the question of whether or not biofeedback
demonstrated by general arousal or in response to is effective in alleviating pain.
Operant Conditioning Model of creased, or that well behaviors (i.e., activity) can be
Chronic Pain increased, by verbal reinforcement and the setting of
exercise quotas. Block, Kremer, and Gaylor (1980)
Another alternative to the purely somatic model of demonstrated that pain patients reported differential
chronic pain is a model based on operant conditioning levels of pain in an experimental situation depending
originally proposed by Fordyce (1976). The operant on whether they were observed by their spouses versus
model distinguishes nociception, pain, suffering, and their ward clerks. Pain patients with nonsolicitous
pain behavior. The first three are related to the private spouses reported more pain when a neutral observer
experience of pain, whereas the latter is directly ob- was present other than the spouse. When solicitous
servable and quantifiable. The operant model assumes spouses were present, patients reported more pain than
that only suffering and, to a greater extent, pain behav- in the neutral observer condition.
iors are amenable to behavioral assessment and treat- In a study to examine directly the impact of social
ment in contrast to treatment of nociception in acute reinforcement on pain behaviors, Cairns and Pasino
pain. Specifically, this model proposes that acute pain (1977) assigned pain patients to one of three experi-
behaviors that may originally have served some pro- mental conditions: (1) a control group that received
tective or pain-alleviating function may come under occupational and physical therapies; (2) a group that
the control of environmental and social contingencies received verbal reinforcement from physical therapists
of reinforcement and thus, in some cases, lead to the for increased activity and exercise performance; and
development of a chronic pain problem. Pain behav- (3) a group that initially received graphed feedback
iors may be directly reinforced, for example, byatten- about the day's activity performance posted over their
tion from a spouse or medical personnel, rest, reduc- beds and, subsequently, verbal reinforcement from the
tion in pain level by analgesic medication, financial staff for activity. The results indicated that only the
compensation, and so forth. Pain behaviors may also verbal reinforcement increased activity levels. Unfor-
be maintained by avoidance of undesirable activities tunately, this study did not provide any evidence that
(e.g., work). Moreover, well behaviors (e.g., up-time) the activity increases induced by the verbal reinforce-
may not be sufficiently reinforcing, and the more re- ment were maintained outside the hospital environ-
warding pain behaviors may therefore be maintained. ment. In fact, the demonstration of a return to baseline
Unlike respondent pain, where pain behaviors are activity levels following the removal of social rein-
directly related to the presence of antecedent nocicep- forcement in this and the Doleys et al. (1982) study
tive stimuli, operant pain (i.e., pain behavior) can mitigates against any expectancy of maintenance un-
occur in the absence (i.e., can be independent) of noci- less the patient's environment is modified so that rein-
ception and organic factors. Specifically, the operant forcement for activity is provided on an ongoing basis.
conditioning model suggests that the maintenance of
pain behaviors may occur through a process of rein-
Assessment Based on the Operant
forcement and, consequently, instrumental learning.
Conditioning Model
The model does not directly concern itself with the
internal subjective state of pain but rather with the Assessment from the operant model focuses most
overt manifestations of pain and suffering. Because of heavily on the presence of pain behaviors-overt ex-
the consequences of specific behavioral responses, it is pressions of pain, suffering, and distress. These behav-
proposed thut pain behaviors may persist after the ini- iors consist of specific physical expressions presumed
tial cause of the pain is resolved or greatly reduced. In to indicate pain, such as distorted ambulation or pos-
a classical conditioning or respondent model, anticipa- ture, facial grimacing, moaning, avoidance of ac-
tion of nociception or fear of reinjury may be factors tivities, "downtime" (e.g., time reclining or sitting),
that maintain maladaptive behaviors; whereas in the use of medication, and use of the health care system. A
operant model, the receipt of positive reinforcement number of procedures have been used to assess these
serves to maintain the maladaptive behaviors. pain behaviors, ranging from patient reports of ac-
Several studies provide evidence that supports the tivities to the use of observations and electrome-
underlying assumptions of the operant conditioning chanical devices. The various assessment approaches
model. Cairns and Pasino (1977), Doleys, Crocker, have been recently reviewed (Turk & Flor, 1987).
and Patton (1982), and Sanders (1983) showed that The most systematic approach to the quantification
pain behaviors (specifically, inactivity) can be de- of pain behaviors is reflected in the work of Keefe and
his colleagues (e.g., Keefe & Block, 1982; Keefe, Historically, operant treatment programs were usu-
Wilkins, & Cook, 1984). Keefe and Block developed a ally conducted on an inpatient basis because this per-
coding system for the observation of five pain behav- mits better control of reinforcement contingencies.
iors in back pain patients (Le., grimacing, rubbing, Recently, outpatient studies of operant treatments have
bracing, guarded movement, and sighing) that occur appeared in the literature (e.g., Kerns, Turk, Holzman,
under standardized static and dynamic movement con- & Rudy, 1986; Thrner & Clancy, 1988). Spouse par-
ditions. Patients are videotaped while they perform ticipation is often included because the spouse is prob-
each of several tasks in both positions. The frequency ably the most important reinforcer and only he or she
of pain behaviors during this structured task is aggre- can secure transfer of new behavioral patterns within
gated, and a total score is computed. Keefe has shown the home environment. Interestingly, no attention has
that these behaviors can be reliably observed and that been given to reinforcement contingencies in the
they are significantly correlated with patients' and ob- working environment and the role of employers, su-
servers' pain ratings and physical pathology, that they pervisors, and co-workers.
change in the course of treatment, and they are specific In the initial report on the efficacy of the operant
for chronic back pain patients as compared to de- approach, Fordyce et al. (1968) presented the results
pressed nonpain patients and normal controls. of three patients with low back pain who underwent 3
The extent to which pain behaviors themselves are to 9 weeks of inpatient and several weeks of outpatient
dependent on certain cognitions is unclear (Philips, treatment. At posttreatment and several months fol-
1987a). That is, as noted earlier, patients may engage low-up, significant increases in patients' activity levels
in certain protective movements or avoid specific ac- and significant medication reductions were reported.
tivities because they fear exacerbation of pain, greater Pain levels (not specific targets of treatment) were not
physical damage, or because they are physically un- reported.
able to engage in activities. Thus, respondent factors Several subsequent uncontrolled group outcome
and cognitive appraisal may be associated with what studies, which were based on the operant approach,
has been labelled as pain behaviors, in addition to the have reported significant decreases in medication
traditional view of external reinforcement of these be- usage, increases in hours of up-time and activity levels
haviors as the maintaining factors. Although there are in general, with follow-up times ranging from 5
a number of limitations to the assumptions made re- months to 7 years (Anderson, Cole, Gullickson,
garding these pain behaviors and conclusions that can Hudgens, & Roberts, 1977; Fordyce et al., 1973;
be drawn (Turk & Flor, 1987), there is little doubt that Roberts & Rinehardt, 1982).
consideration of these behaviors is an important com- Two recent studies have examined the efficacy of
ponent of the comprehensive assessment of chronic operant interventions offered on an outpatient basis.
pain patients. The effectiveness of the treatment is somewhat equiv-
ocal. Kerns et al. (1986) reported significant reduc-
tions in health care utilization following 10 weekly
Treatments Based on the Operant
sessions that focused on increased activity and reduc-
Conditioning Model
tion of pain behaviors; however, these authors did not
The pioneer in the field of operant treatment for find significant improvements in activity levels or self-
chronic pain is Wilbert Fordyce (1976; Fordyce et al., reports of pain. By way of contrast, Turner and Clancy
1968). The goals of operant treatment are: (1) extinc- (1988) reported significant improvements in self-re-
tion of pain behaviors (e. g., use of analgesic medica- ported ratings of pain, pain-related physical and psy-
tion, complaining); and (2) promotion of well behav- chosocial dysfunction, and pain behaviors following 8
iors, namely, behaviors that are incompatible with pain weekly group sessions. A number of factors might
behaviors (e.g., exercise, work). These goals are ac- account for these differences. For example, in the
complished by changing the analgesic medication reg- Turner and Clancy study, spouses were included in one
imen from an as needed (pm) to a regular time-interval half of the therapy sessions, whereas in the Kerns et al.
schedule and then graded reduction in analgesic medi- study, spouses were less systematically included in
cation; graded physical activity to increase strength, treatment. Another important factor that differentiates
endurance, and flexibility; work to quota versus work the Kerns et al. and the Thrner and Clancy studies
to pain levels; positive reinforcement for activity; and concerns the patient samples. In the Turner and Clancy
inattention to pain behaviors. study, only 10% of the patients were unemployed due
to pain and 6% were receiving pain-related disability tions of low self-efficacy and helplessness interfere
compensation, whereas in the Kerns et at. study, 85% with patients' motivation, efforts, and appraisals and
were unemployed and 52% were receiving disability exacerbate their general experience of distress and suf-
compensation. Thus, the Kerns et at. sample appears fering (Dolce, 1987; Turk, Meichenbaum, & Genest,
to be significantly more disabled by their pain. 1983). Moreover, chronic pain patients tend to believe
that they have limited ability to exert any control over
their pain. Such negative, maladaptive appraisals
Cognitive-Behavioral Perspective on about the situation and personal efficacy may reinforce
Chronic Pain the experience of demoralization, inactivity, and over-
reaction to nociceptive stimulation (e. g. , Biedermann,
The generic rubric "cognitive-behavioral" has been McGhie, Monga, & Shanks, 1987).
used to incorporate a range of techniques. However, A number of studies have been conducted to exam-
there appears to be a set of common factors that under- ine the importance of cognitive components of the pain
lie most of the interventions that label themselves as experience in laboratory and acute contexts as well as
cognitive-behavioral. It is important to differentiate with chronic pain patients (see Turk & Rudy, 1986a).
between the cognitive-behavioral perspective and the For example, several authors have demonstrated that
cognitive and behavioral modalities. Specifically, perceived self-efficacy ratings correlated significantly
there are five general assumptions that characterize the with tolerance for laboratory-induced pain (e.g., Dol-
cognitive-behavioral perspective (Thrk & Meichen- ce, Doleys, et at., 1986; Litt, 1988). Bandura and his
baum, 1989; Turk & Rudy, 1987a): colleagues (e.g., Bandura, O'Leary, Taylor, Gauthier,
& Gossard, 1987) demonstrated that perceived self-
1. Individuals are active processors of information efficacy not only was correlated with tolerance for
and are not simply passive reactors to social and noxious stimulation, but that there appeared to be a
environmental perturbations. direct neurochemical effect of self-efficacy and cog-
2. Thoughts (e.g., beliefs, appraisals, expecta- nitive coping skills training in that increased cate-
tions) based on prior learning history can elicit or cholamine secretions and endorphin reactivity were
modulate mood and physiological processes, as related to levels of self-efficacy.
well as serve as impetuses for behavior. Research on chronic pain has also supported the
3. Conversely, mood, physiological activity, and important role played by cognitive factors. For exam-
social and environmental factors can influence ple, Thrk and Rudy (1986c) demonstrated the impor-
the nature of thought processes. tant relationship between perceptions of control and
4. Individuals can learn more adaptive ways of affective distress in a heterogeneous sample of chronic
thinking, feeling, behaving, and influencing pain patients. Lefebvre (1981), basing his work on
their circumstances. Aaron Beck's (1976) conceptualization of logical er-
5. Individuals are capable and should be involved rors in the thinking of depressed patients, showed that
as active agents in the change of maladaptive depressed low back pain patients commit general as
thoughts, feeling, behaviors, and both social and well as pain-specific cognitive errors. Recently, Flor
environmental circumstances. and Turk (1988b) examined the relationship between
general and situation-specific pain-related thoughts,
This perspective can be superimposed on any treat- convictions of personal control, pain severity, and dis-
ment modality employed with chronic pain patients ability in back pain patients and rheumatoid arthritis
and, in many cases, the cognitive-behavioral perspec- patients. The general and situation-specific cognitive
tive is as important as the specific content of the re- variables were more highly related to reports of pain
habilitation modalities used. and disability than disease-related variables.
From the cognitive-behavioral perspective, people Philips (1987b) treated a heterogeneous group of
with problems related to the experience of chronic pain chronic pain patients in a 9-week group outpatient pro-
are viewed as having negative expectations about their gram that included relaxation, a graded exercise pro-
own ability to control certain motor skills, such as gram, cognitive and behavioral coping strategies train-
performing specific physical activities that are ating, activity pacing, anxiety management, and mood
tributed to the overwhelming factor, namely, physical control. Treatment resulted in a clinician-rated im-
or pain-based limitations (Schmidt, 1985b). Percep- provement for 83% of the patients; however, only 17%
were pain free. A significant number of the patients to provide an exhaustive review (see Turk & Rudy,
also rated themselves as significantly improved fol- 1986b). In general, instruments developed to measure
lowing treatment. These improvements were sustained the cognitive processes involved in chronic pain fall
at a 12-month follow-up. Patients reported significant into three major categories: (1) instruments designed
increases in perceived self-efficacy following treat- to measure the cognitive component of pain as a con-
ment, with a substantial negative correlation (r = tributor to the perception of pain per se, (2) instru-
- .81) between the patients' ratings of self-efficacy ments designed to assess the cognitive consequences
and the magnitude or impact of their pain problem. of pain, and (3) global instruments to assess patients'
Holroyd et al. (1984) have examined self-efficacy appraisal of the impact of pain on their lives.
expectations as predictive of headache patients' re- The first category of cognitive assessment is related
sponses to biofeedback. Holroyd et al. provided sub- to the gate control theory of pain (Melzack & Wall,
jects with bogus verbal feedback suggesting that they 1965). The gate control theory postulates that the per-
were either successful or unsuccessful in reducing ception of pain is comprised of cognitive-evaluative
frontalis electromyographic (EMG) activity. In addi- and motivational-affective factors, as well as sensory-
tion, one half of the subjects were given feedback that discriminative factors. It is suggested further that cog-
was designed to lower frontalis EMG, whereas the nitive and affective inputs descending from the brain
other half were given biofeedback designed to increase can modulate nociception. From this perspective,
frontalis EMG levels. Despite the nature of the bio- evaluation of pain at a given point in time should ad-
feedback provided, patients who were told they were dress these three components. In order to perform such
very successful in affecting EMG levels reported sig- a multidimensional assessment, Melzack (1975) de-
nificant increases in self-efficacy ratings and reduc- veloped the McGill Pain Questionnaire. This instru-
tions in headache activity. Actual changes in EMG ment attempts to separate the cognitive, affective, and
levels were not associated with headache activity. sensory components of pain through the use of verbal
In considering the efficacy of biofeedback for back descriptors endorsed by patients. Other attempts to
pain patients, Nouwen and Solinger (1979) concluded separately measure components of pain, for example,
that "simultaneous accomplishment of muscle tension sensory and unpleasantness, using verbal descriptors
reduction and lowering reported pain convinced pa- have been developed (e.g., Gracely, McGrath, & Du-
tients that muscle tension, and subsequently pain, bner, 1978), as have numerical rating and visual ana-
could be controlled .... As self-control could not be logue scales (e.g., Jensen, Karoly, & Braver, 1986).
demonstrated in most patients, it seems plausible that a Several investigators have attempted to assess cog-
feeling of self-control, rather than actual control of nitive processes (e.g., distortions, Lefebvre, 1981; at-
physiological functions or events is crucial for further titudes; Jensen, Karoly, & Huger, 1987) that are likely
pain reductions" (p. 110). In other words, it appears LO emerge only as a result of experiencing prolonged
that the extent to which voluntary control over muscles pain and that may influence the perception of pain over
has been perceived dictates the outcome, independent time. Thus, although the cognitive-evaluative compo-
of lasting reduction in muscular activity. nent is involved in pain perception regardless of pain
The studies cited above suggest that cognitions, duration, it is hypothesized that certain cognitive rep-
such as expectations of pain increase following ac- resentations that incorporate prior experiences, affec-
tivity and beliefs about one's capacity to control pain, tive responses, beliefs, and expectations may emerge
can significantly influence how patients respond to as a result of chronicity.
nociceptive stimulation and their circumstances. If one adheres to the perspective that chronic pain is
a complex, subjective phenomenon that is uniquely
experienced by each individual, then knowledge about
Cognitive-Behavioral Assessment
idiosyncratic appraisals and coping repertoires be-
Cognitive-behavioral assessment includes assess- come critical for optimal treatment planning and for
ment based on the operant and respondent approaches accurately evaluating treatment outcome. For exam-
described above as well as procedures that focus on ple, patients' subjective evaluations of the impact of
cognitive factors believed to contribute to the pain ex- pain on their lives are likely to be important factors in
perience. We will only briefly review some of the cog- determining motivation for treatment and treatment
nitive assessment approaches that have been devel- adherence (Meichenbaum & Turk, 1987). Addi-
oped and used in clinical settings and will not attempt tionally, patients' perceptions of their life circum-
stances are likely to influence their communications feedback trials that provide an opportunity for the pa-
with significant others and with health care tient to question, reappraise, and acquire self-control
professionals. over maladaptive thoughts, feelings, behaviors, and
A number of instruments have been developed to physiological responses.
examine the perceived impact of pain (e.g., West Proponents of the cognitive-behavioral approach
Haven-Yale Multidimensional Pain Inventory; Kerns, may rely on any of a range of techniques, including
Turk, & Rudy, 1985) and coping strategies (e.g., biofeedback, physical therapy, problem-solving train-
Rosensteil & Keefe, 1983). Many of these instruments ing, contingency management, and so forth. More
are quite broad and attempt to assess the perception of important than the techniques, however, is the general
how pain affects mUltiple areas of the patient's life, as perspective on human functioning described above.
well as examining coping resources, perceptions of Detailed description of cognitive-behavioral treatment
pain, and how others respond toward them. A strength is beyond the scope of this chapter, and the interested
of these instruments is the careful attention to psycho- reader is encouraged to see recent publications that
metric properties and the formative development on describe this approach in depth (e.g., Holzman, Thrk
pain patients, rather than relying on more traditional & Kerns, 1986; Turk etal., 1983; Turk & Rudy, 1989).
psychiatric and personality measures that were never A number of studies have demonstrated the efficacy
normed on populations of chronic pain patients. of various cognitive-behavioral treatment for chronic
pain (e.g., Corey, Etlin, & Miller, 1987; Kerns etal.,
1986; Mayer et aI., 1987; Moore & Chaney, 1985;
Treatment Based on the Cognitive-Behavioral
Turner & Clancy, 1988). A few studies have provided
Perspective
some contradictory results (e.g., Sturgis, Schaefer, &
Perhaps most important in cognitive-behavioral ap- Sikora, 1984). Space limitations do not permit a de-
proaches to the treatment of pain is their adherence to a tailed review of each of these studies, and thus, we will
multidimensional model of pain. The basic assump- only highlight a few for illustrative purposes.
tion underlying cognitive-behavioral treatments is that In a treatment comparison study, Kerns et al. (1986)
pain has physical-sensory, affective, cognitive, psy- investigated the clinical efficacy of behavioral (i.e.,
chosocial, and behavioral (respondent and operant) operant conditioning and relaxation) and cognitive-
components, all of which should be addressed during behavioral treatment for chronic pain. Twenty-eight
treatment. A central goal of cognitive-behavioral treat- patients with a diversity of long-standing chronic pain
ments is to reduce feelings of helplessness and hope- syndromes refractory to medical and surgical treat-
lessness through the use of diverse cognitive, behav- ment were assigned to one of the two active treatments
ioral, and physical training to produce changes of or a waiting list control condition. Following a 10-
maladaptive cognitive and behavioral patterns. week (one session per week) treatment phase provided
Cognitive-behavioral treatment approaches to pain on an individual basis, patients in the two conditions
management evolved from research on a number of significantly reduced their use of the health care sys-
psychologically based problems (e.g., anxiety, de- tem and reported making significant progress on indi-
pression). The common denominators across different vidually tailored behavioral goals (e.g., return to
cognitive-behavioral interventions include (1) interest work). However, only patients receiving the cognitive-
in the nature and direct modification of patient's mal- behavioral treatment demonstrated significant dif-
adaptive thoughts and feelings, as well as behaviors; ferences on measures of pain severity, affective dis-
(2) concerns regarding the impact of social and en- tress, increased instrumental activities, and depen-
vironmental factors on the maintenance of maladap- dence. These results were maintained at the 6-month
tive thoughts, feelings, and behaviors; and (3) commit- follow-up. Patients in the waiting list condition did not
ment to behavior therapy procedures for promoting . display significant changes on any of the dependent
change. In general, cognitive-behavioral approaches measures. These results are consistent with a study
are concerned with using environmental manipUla- reported by Turner (1982) in her comparison of cog-
tions, as are adherents of the operant approach. They nitive-behavioral treatment to relaxation training and a
also give attention to the potential of stress-induced waiting list control group.
and site-specific muscular reactivity, as do proponents Interestingly, the results of the Kerns et at. study
of the respondent model. However, in cognitive-be- (1986) are somewhat at variance with a recent study
havioral approaches, such manipulations represent reported by Turner and Clancy (1988). Turner and
Clancy contrasted an operant treatment as described all components of the treatment were designed to enlist
above with a cognitive treatment in which patients the patients' active participation, to increase their level
were provided with imagery and relaxation training of functioning, and to return them to gainful em-
and were taught to identify negative emotions related ployment. At posttreatment, patients demonstrated
to pain and stressful events and to identify associated significant reductions in self-reports of pain and signif-
maladaptive thoughts. Following treatment, the group icant increases in coping ability and functioning level.
receiving operant behavioral treatment demonstrated These results were maintained at a mean of 18.5
significantly greater gains on pain behaviors as rated months following treatment. Prior to treatment, none
by patients, spouses, and staff, and on disability, cog- of the patients were working; at follow-up, over 33%
nitive distortions, and self-reports of pain. In- were working fulltime, 17% were working part-time,
terestingly, by the 12-month follow-up, both of the and 11 % were in job-retraining programs or seeking
treated groups made significant improvements on all employment (an overall success rate of 69%).
of the dependent measures, and there were no signifi- We selected the studies above because of some of the
cant differences between the groups. The com- differences encountered when one examines such a
parability of the groups at the follow-up reflected a heterogeneous group of factors that are included under
gradual improvement for the group receiving the cog- an ill-defined treatment orientation, such as "cog-
nitive treatment rather than relapse for the operant be- nitive-behavioral." The studies considered above dif-
havioral treatment group. fered not only in what content was included within the
Moore and Chaney (1985) examined the efficacy of "cognitive-behavioral" regimen but also in the mode of
outpatient group cognitive-behavioral therapy with a presentation (e.g., individual versus group, outpatient
heterogeneous sample of chronic pain patients. The versus inpatient, hospital-based versus home-based,
treatment consisted of 8 twice weekly sessions that professional versus paraprofessional), and extent of
focused on identification of pain-related life changes, spouse involvement. The general efficacy reported in
rational thinking techniques, goal-setting exercises, these studies may be attributed to the robustness of the
problem-solving training, relaxation and controlled approach. That is, it is our belief that the cognitive-
breathing techniques, coping skills training, assert- behavioral perspective generally adopted by these in-
iveness training, active listening exercises, and home vestigators is more important than specific charac-
practice of each of these components of the interven- teristics of the treatment.
tion. Moreover, operant components of chronic pain
were discussed in the groups. At 3-month and 7-month
follow-ups, patients reported significant reductions in Issues
pain and physical and psychosocial dysfunction. In
Assessment
addition, patients significantly reduced spouse-ob-
served pain behaviors, spouse-rated dysfunction, and Despite the frequent acknowledgment that pain is a
improved their marital satisfaction. Interestingly, complex phenomenon, many of the treatment outcome
these results were independent of the active involve- studies in the literature rely on a very limited perspec-
ment of the spouse in the treatment. Finally, patients in tive of pain. For example, conventional somatic views
this study significantly reduced their utilization of of pain focus on eliminating the cause of pain or block-
health care resources. ing the pain pathways by pharmacological or surgical
Quite a different approach to the delivery of cog- interventions. Treatments based on respondent mod-
nitive-behavioral treatment was adopted by Corey et els, such as biofeedback and muscle relaxation, rely
at. (1987). In this study, Corey et al. described a pro- predominantly on reduction of muscle hyperactivity.
gram that was provided in the patients' homes. The Operant conditioning programs tend to focus only on
bulk of the therapy was provided by "field" therapists reduction of pain behaviors and augmentation of well
(nurses, social workers, and a paraprofessional with an behaviors. Yet most investigators readily acknowledge
undergraduate degree in psychology). These therapists that pain is a complex phenomenon. Simple assess-
were trained and supervised extensively by a doctoral ment measures and subsequent treatment that is
level clinical psychologist. Patients were initially seen focused solely on physiological activity, physical pa-
by the field therapists twice a week then tapered to thology, behavioral responses, or emotional distress
once a week in their home. The treatment included a are likely to be inadequate.
wide variety of cognitive-behavioral techniques, and Although there have been calls for comprehensive
assessment strategies for pain (e. g., Brena, 1984), For the chronic pain sufferer who is "dysfunc-
there have been few attempts to develop assessment tional," the self-defeating cycle of avoidance, low mo-
batteries that integrate medical-physical data with psy- tivation, and maladaptive cognitions may playa sig-
chosocial and behavioral data. Psychometrically sound nificant role in maintaining the avoidance pattern.
procedures to assess psychosocial and behavioral vari- These maladaptive thoughts may actually accentuate
ables have been described above, and there is some the distress experienced by these patients. Reesor and
preliminary evidence on the ability of physicians to Craig (1988) demonstrated that the primary difference
reliably quantify medical-physical findings (Rudy, between chronic low back pain patients who were re-
Thrk, & Brena, 1988). However, treatment outcome ferred because of the presence of many "medically
studies have not directly examined the integration of incongruent" signs and those who did not display these
physical, behavioral-functional, and psychosocial in- signs was maladaptive thoughts. Interestingly, there
formation to identify groups of patients for whom were no significant differences between these groups
treatments are successful (see Turner & Chapman, on the number of surgeries, compensation, litigation
1982a,b). status, or employment status. These maladaptive cog-
With increasing recognition that chronic pain can nitive processes may amplify or distort patients' expe-
impact on the patient in many ways (e.g., emotional, rience of pain and suffering.
social), investigators and clinicians frequently assess
chronic pain patients with a multitude of measures.
Treatment
The difficult task is to integrate such large quantities of
data in meaningful ways. Recently, we (Turk & Rudy, Comparison of the Kerns et al. (1986) and the Turn-
1988) examined the utility of cluster analytic and mul- er and Clancy (1988) studies discussed earlier can be
tivariate classification procedures to discover more used to illustrate some relevant points related to treat-
about the similarities and differences among hetero- ment outcome. Neither operant nor cognitive-behav-
geneous groups of chronic pain patients on psycho- ioral treatments have standard protocols; thus, one
social and behavioral measures. must be careful in comparing results from different
Our program of research has identified three distinct studies. For example, Kerns et al. included relaxation
patient groups that we have labelled as follows: (1) training as part of the treatment regimen that they la-
"Dysfunctional," patients who perceive the severity beled as operant, whereas Turner and Clancy included
of their pain to be very high, report that pain interferes relaxation training in the treatment protocol labeled as
with much of their lives, report a high degree of psy- cognitive-behavioral. Moreover, Turner and Clancy
chological distress because of pain, and report low included aerobic exercises and active spouse involve-
levels of physical activity; (2) "Interpersonally Dis- ment within the protocol labeled as operant. In con-
tressed," patients with a common perception that sig- trast, Kerns et al. included unspecified physical thera-
nificant others are not very understanding or suppor- py and spouse involvement for patients in both operant
tive of their pain problems; and (3) "Adaptive and cognitive-behavioral treatment regimens. These
Copers," patients who report higher levels of social differences illustrate the importance of examining the
support, lower levels of pain and perceived inter- specific content of the treatment protocols used rather
ference, and greater levels of physical activity. Addi- than relying on the labels given to treatments by
tional research has established the external validity of authors.
these three distinct patient profiles and recently we The question of the active ingredients of compre-
(Thrk, Rudy, Curtin, & Zaki, 1988) replicated these hensive pain intervention programs is an issue that has
pain profiles on a sample of temporomandibular pain not received sufficient attention. Typically, authors
dysfunction (TMD) patients. It is important to note choose to emphasize either the overall program or the
that TMD patients are quite different from the hetero- component that they are most disposed toward. Exam-
geneous groups of patients who are treated in pain ination of a recent influential study published by May-
clinics and who were included in the study described er et al. (1987) in the Journal of the American Medical
above. Even though patients with TMD pain were less Association supports our emphasis on the content of
impaired than chronic back pain patients on all the treatment and the authors' emphasis on the "active
measures used in our empirically derived taxonomy, treatment ingredient." Mayer et al. emphasized the
nonetheless, the same three profile types were importance of "functional restoration" (Le., specific
identified. physical therapy exercises, training in functional
tasks, body mechanics education, and work simula- low-up. Thus, of the original 200 patients treated, only
tion/work hardening) in their highly successful inter- 42 (21 %) were successful 1 year following treatment.
vention for low back pain. Careful examination of Similar relapse rates were reported by Dolce, Crocker,
their treatment regimen, however, reveals that in- Moletteire, and Doleys (1986) for medication and ex-
cluded in the treatment program was "(1) behavioral ercise levels following originally successful treatment.
stress management, (2) cognitive-behavioral skills The efficacy of intensive outpatient versus inpatient
training, (3) individual and group counselling empha- treatment was directly examined in a study reported by
sizing a crisis-intervention model, and (4) family Cairns, Mooney, and Crane (1982). These authors re-
counselling" (p. 1764). The differential contribution ported that the outpatient treatment demonstrated
of these different treatment components are not exam- greater maintenance of activity levels, medication
ined, yet the efficacy of the intervention was attributed usage, and reductions in self-report of pain levels at 1-
to the physical component of the multicomponent year follow-up than the inpatient treatment. Moreover,
intervention. at the follow-up, 52% of those receiving outpatient
Conversely, many programs that include multiple treatment were working compared to 15% of those
components frequently attribute success to the overall treated on an inpatient basis.
treatment and do not directly test the additive contribu- Patient demographics also can contribute to the
tion of any single factor. Thus, for example, large differences in results in some studies compared to
McArthur, Cohen, Gottlieb, Naliboff, and Schandler others. Thus, when Mayer et al. (1987) report 87% of
(1987) described the relative efficacy of a 6- to 8-week patients treated with active functional restoration and
inpatient program based on a cognitive-behavioral per- cognitive-behavioral treatment were working 2 years
spective consisting of biofeedback, attribution based following treatment, it is important to note that the
psychotherapy, patient-controlled medication reduc- average duration of pain was 25 months and the time
tion, physical reconditioning, vocational counseling, since last working was 12 months before treatment.
didactic educational lectures, recreational therapy, and This is a very different pain sample than, for example,
assertion training. Corey et al. (1987) and Moore and the study reported by Kerns et al. (1986), where the
Chaney (1985) listed a large number of components, average pain duration was over 7 years.
but the contribution of any of these was not directly
tested. Although it is initially important to demonstrate
that a comprehensive program can have the desired Summary and Conclusions
impact, given the cost of treatment it is also important
to dismantle the program to establish the necessary and Psychological conceptualizations and treatment ap-
sufficient components. proaches for chronic pain have mushroomed (or should
Turk and Holzman (1986) reviewed the most com- we say metastasized) over the last 20 years. Reviews of
mon psychological interventions employed with the various treatment literatures often conclude with
chronic pain patients and concluded that there was a set statements that "preliminary results are encouraging
of features that appeared to underlie each of them. but more and better controlled studies are needed be-
These included (1) fostering optimism and combating fore any definitive conclusions can be drawn." When
patient demoralization, (2) individualizing of treat- the better controlled and designed studies are consid-
ment, (3) active patient participation and responsibil- ered, we believe that we are justified in concluding that
ity, (4) skills acquisition, (5) fostering self-efficacy, psychological interventions for chronic pain have
and (6) self-attribution of improvement. These six fac- proven their worth. Psychological interventions ap-
tors appear to be highly important and deserve addi- pear to .demonstrate significant decreases in pain
tional attention regardless of the specific treatment and/or muscle tension, and/or psychological distress,
modalities employed. and/or use of the health care system, and/or medica-
Relapse is a major problem for any treatment ap- tion, as well as increased activity levels, em-
proach and has been reported to be high for treatment ployability, and return to gainful employment. How-
of addictive disorders and weight loss, as well as pain ever, comparisons among the various psychological
treatment. For example, Swanson, Maruta, and Swen- methods used in the treatment of pain do not appear to
son (1979) observed that 60% of their patients dis- produce a "clear-cut winner," nor would we expect
played marked improvement following treatment with there to be one. The preliminary taxometric strategy
35% of these "successes" relapsing by the I-year fol- described above may serve as a useful point of depar-
ture to examine the relative efficacy of various treat- treatment outcome. Is this conclusion justified? How
ments delivered to patients from each of the identified mlght the results have looked if intensive spouse in-
cluster types. volvement had been provided specifically to those pa-
A major difficulty in comparing and evaluating the tients who were classified in the taxonomy described
various treatments in a systematic way is that treat- above (Turk & Rudy, 1988) as "interpersonally
ments based on different orientations or perspectives distressed?"
each rely on their own idiosyncratic outcome mea- Our presentation on the broad topic of pain could
sures. If, following treatment, patients are signifi- obviously not be exhaustive. We attempted to provide
cantly less depressed but are no more active, is this a breadth rather than depth and to illustrate some recent
successful outcome? If patients are significantly more conceptualizations and issues. However, we were un-
active but they rate their pain as no better, is this a able to do justice or even to mention a number of
successful outcome? If patients are significantly more important topics; for example, pain in children and the
active, demonstrate significantly less pain behaviors importance of familial factors, medical-legal issues,
but have not significantly reduced the quantity of their acute pain, and pain related to cancer. Readers in-
analgesic medication, is this a success? How we an- terested in these topics are encouraged to see some
swer these questions will depend on our conceptualiza- recent review papers and texts (e.g., Brena & Chap-
tion of pain and the appropriate target of treatment. In man, 1984; Cleeland & Tearnan, 1986; Flor, Thrk, &
other words, although we have described a number of Rudy, 1987; McGrath & Unruh, 1987; Turk, Flor, &
studies that report "success" following treatment, the Rudy, 1987, Varni, Jay, Masek, & Thompson, 1986).
criteria of success and how they were measured varied
widely across studies. There is no agreement among ACKNOWLEOOMENTS. Preparation of this article was
investigators as to what outcome should be used to supported by Grant ARNS38698 from the National
establish successful outcome. Institute of Arthritis and Musculoskeletal and Skin
Comprehensive assessment of pain patients, in our Diseases and Grant DE07514 from the National In-
opinion, should be multiaxial and should use standard- stitute of Dental Research.
ized and psychometrically sound instruments if we ex-
pect to develop individualized interventions custom-
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277-295.
CHAPTER 20
Alcohol and Drug Problems

Mark B. Sobell, D. Adrian Wilkinson, and
Linda C. Sobell
Introduction legally sanctioned (Callahan & Pecsok, 1988); today,

the same use could incur serious legal consequences.
Psychoactive Substances Likewise, in the United States, cocaine was exten-
sively used in the nineteenth century but by the early
Alcohol and many other drugs are "psychoactive sub- 1900s was considered so serious a problem that "the
stances" that pharmacologically affect various func- term 'dope fiend' was first coined to describe cocaine
tions (e.g., mood, cognitions, judgment). In this addicts" (Kleber, 1988, p.4). From the 1920s through
chapter, the use of psychoactive drugs, including alco- the 1960s cocaine waned as a problem, only to re-
hol, which results in adverse consequences for the user emerge as perhaps the paramount contemporary North
or for society, will be referred to as drug problems. American illicit drug problem (see Kleber, 1988, for a
Although alcohol and drug problems have plagued review). Finally, the reduced social acceptability of
mankind since the dawn of recorded history, not all cigarette smoking illustrates the fluidity of social
drug use causes problems or is harmful. Also, ap- mores.
praisal of the social value of drug use is highly depen-
dent on the circumstances of use. For example, certain
drugs can be used with approval when medically pre- The Scope of This Chapter
scribed (e.g., to alleviate pain or to control mood A review of the literature reveals that annotated and
states), whereas the same use would be considered comprehensive bibliographies of the clinical behav-
abusive if the drug were obtained from a pusher. In- ioralliterature on drug problems are in abundant sup-
terestingly, over time, the use of some drugs has been ply (e.g., Callahan & Pecsok, 1988; Callahan, Long,
condemned and condoned. For example, a century Pecsok, & Simone, 1987; Miller & Hester, 1986a;
ago, opium was readily available, widely used and O'Farrell & Cutter, 1984; O'Farrell & Langenbucher,
1987; Riley, Sobell, Leo, Sobell, & Klajner, 1987; L.
Mark B. Sobell and Linda C. Sobell • Addiction Research
C. Sobell, M. B. Sobell, & Nirenberg, 1988; Stitzer,
Foundation, and Departments of Psychology and Behavioral Sci-
ence, University of Toronto, Toronto, Ontario, Canada M5S Bigelow, & McCaul, 1983). Conceptual reviews,
2S I. D. Adrian Wilkinson • Addiction Research Foun- however, are in short supply. This chapter is a concep-
dation, and Department of Psychology, York University, Toron- tual, rather than a methodological, review of behav-
to, Ontario, Canada M3J IP3. The views expressed in this
chapter are those of the authors and do not necessarily reflect
ioral research on treatment of drug problems. Our in-
those of the Addiction Research Foundation. tent is to provide an overview of how the research has
415
evolved and to delineate major research issues and fu- tion's DSM-III-R (1987), is purported to resolve many
ture directions. inconsistencies of its predecessor, the DSM-III (Amer-
The behavioral literature on alcohol and drug prob- ican Psychiatric Association [APA) , 1980). Among
lems is considerably varied. For example, several the changes, the diagnosis of substance "abuse" has
studies have used behavioral treatments to investigate been downplayed in favor of a broadened "depen-
other issues (e.g., a comparison of individuals par- dence" criterion. The diagnostic importance of toler-
ticipating in the same behavioral treatment program on ance has also been lessened. The problem with the
a day-treatment basis versus an inpatient basis; Fink et DSM-III's reliance on indications of tolerance as a
aI., 1985). Although studies of this sort illustrate the criterion of dependence is that tolerance can develop
applicability of behavioral methods to clinical prob- during a single dose (Kalant, LeBlanc, & Gibbins,
lems, they do not evaluate theoretically based ele- 1971). The new DSM-III-R criteria require the devel-
ments of the treatments. Consequently, such studies opment of exceptional levels of tolerance; indicated,
will receive little attention in this chapter. for example, by having to "take greatly increased
Finally, though it would be helpful to be able to amounts of the substance in order to achieve intoxica-
compare the effects of behavioral treatments to no tion or the desired effect" (APA, 1987, p. 167).
treatment, the reality is that "no-treatment" control The DSM-III-R focuses on compulsive use, stating
groups are extremely rare and difficult to implement in "the essential feature of this disorder is a cluster of
studies of serious clinical disorders (Elkin, Pilkonis, cognitive, behavioral, and physiologic symptoms that
Docherty, & Sotsky, 1988); studies of drug problems indicate that the person has impaired control of psy-
are no exception. Thus, although conclusions usually choactive substance use and continues use of the sub-
can be drawn with respect to how much individuals stance despite adverse consequences" (APA, 1987,
change from pretreatment to posttreatment, unequivo- p.166). A dependence diagnosis requires the occur-
cal assertions about the absolute value of treatment are rence of at least three of the following symptoms: (1)
not possible. taking more substance than intended; (2) unsuccessful
attempts to reduce or control use; (3) preoccupation
with acquiring the substance; (4) having intoxication
Psychoactive Substance Use Disorders
or withdrawal symptoms when expected to fulfill ma-
Drugs can be classified in many ways (e.g., chem- jor role obligations; (5) arranging daily activities to be
ical structure, pharmacological actions, legal stand- conducive to substance use; (6) social, psychological,
ing). The Diagnostic and Statistical Manual ofMental or physical problems related to heavy and prolonged
Disorders, Third Edition, Revised (DSM-III-R) of the substance use; (7) significant tolerance; (8) withdrawal
American Psychiatric Association (1987) identifies 10 symptoms; and (9) substance use to relieve or avoid
drug classes associated with abuse or dependence: al- withdrawal symptoms (see Rounsaville, Spitzer, &
cohol; amphetamine or similarly acting sympathomi- Williams, 1986; Rounsaville, Kosten, Williams, &
metics; cannabis; cocaine; hallucinogens; inhalants; Spitzer, 1987).
opioids; phencyclidine (PCP) or similarly acting In Europe, another diagnostic schema predomi-
arylcyclohexylamines; sedatives, hypnotics or anx- nates. This is the ICD-9, promulgated mainly by the
iolytics; and tobacco. For this chapter, only nine of the World Health Organization (Edwards, Arif, & Hodg-
drug classes will be considered. The one exception, son, 1981; Rounsaville et aI., 1986). The ICD-9 uses a
tobacco (in which nicotine is the main psychoactive multidimensional approach and postulates a depen-
ingredient), is the topic of a separate chapter in this dence syndrome (the core drug effect on the indi-
volume. In some ways this may be unfortunate, be- vidual) and a set of drug-related disabilities (i.e., phys-
cause tobacco use is strongly related to other psycho- ical complications, psychological complications, and
active drug use (Kandel & Faust, 1975), and it has been areas of living complications) that mayor may not
suggested as an excellent model for studying psycho- accompany any individual case. Vulnerability to the
active substance use disorders (e.g., Baker, Morse, & disabilities is viewed as determined by the person's
Sherman, 1987). constitution, other health conditions, and life circum-
The complexity of describing drug problems is read- stances. Some of the changes in the DSM-III-R reflect
ily evident from the continually changing diagnostic the concept of a core dependence syndrome, as formu-
literature. There are two major diagnostic formula- lated by Edwards and his colleagues (Edwards, 1986;
tions. The first, the American Psychiatric Associa- Edwards, Gross, Keller, Moser, & Room, 1977). Both
CHAPTER 20 • ALCOHOL AND DRUG PROBLEMS 417
diagnostic systems emphasize the compulsiveness of spectrum" approaches incorporating several interven-
drug taking, the user's preoccupation with the drug, tions directed at the multifaceted dimensions of alco-
and the manifestation of withdrawal symptoms upon hol problems. Skills training, used in most of these
cessation or reduction of use. Both systems derive as studies (e.g., Lovibond & Caddy, 1970; M. B. Sobell
much from consensus among experts as from demon- & L. C. Sobell, 1973), was based on the following
strated validity. theoretical premise: If alcohol use serves certain func-
tions for a person, then for the person to forego or
reduce drinking, those functions need to be served by
The Evolution of Behavioral alternative less problematic behaviors. It was usually
Treatments for Alcohol and Drug assumed that such behaviors did not occur naturally
Problems either because the individual was unskilled in accept-
able alternatives, or because their expression was
being suppressed (e.g., by fear). Unfortunately, not
Development of Behavior Therapies
only was little research undertaken to test this assump-
"' The development of clinical behavioral approaches tion, but one study (Twentyman et al., 1982) failed to
to drug problems has been simultaneously influenced find evidence that alcoholics were deficient in social
by two different sources: (a) developments in behavior skills. Sometimes the skills training involved the in-
therapy, and (b) developments in knowledge about culcation of new skills thought to be useful in control-
substance abuse (M. B. Sobell, 1987). These influ- ling alcohol consumption (e.g., learning to estimate
ences are most identifiable where alcohol is the sub- one's own blood alcohol level, Lovibond & Caddy,
stance of concern, but similar patterns can be traced for 1970). Further, early treatment studies often involved
other drugs. anxiety-reduction methods, such as relaxation training
Learning-theory-based approaches to treatment or systematic desensitization, either to replace a sim-
were in use prior to the establishment of behavior ther- ilar function served by alcohol or to allow the ex-
apy as a major clinical orientation. An aversive-condi- pression of behaviors suppressed by fear.
tioning treatment for alcohol problems, based on The operant approach was used to a lesser extent
Pavlovian principles, was reported in 1929 by Kan- with abusers of other drugs (e.g., Boudin, 1980;
torovich and in 1931 a similar treatment for morphine Rawson, Glazer, Callahan, & Liberman, 1979). The
addiction was reported by Rubenstein. Some private relative lack of behavioral treatment research with
treatment programs also attempted to develop an asso- drugs other than alcohol may derive in part from the
ciation between drug-related stimuli and aversive popUlarity of methadone maintenance (Dole &
events (Voegtlin & Lemere, 1942). Also, Wikler Nyswander, 1965), a specific pharmacotherapy for
(1948) proposed a learning theory account of the drug heroin users, the popUlation that was the major focus
relapse process that inspired much of current condi- of drug programs in the 1960s. The major reason for
tioning and relapse prevention research. the dearth of behavioral research on treatment of drug
In the 1960s, behavior therapies based on operant problems, however, is more likely the fact that less
principles (e.g., token economies, contingency man- research has been conducted on treatment of drug
agement) became popular. Central to this approach in problems in general as compared to alcohol problems,
the drug field was the functional analysis of reinforce- regardless of the approach (Goldstein, Surber, &
ment contingencies related to drug use, with drug tak- Wilmer, 1984).
ing considered to be a discriminated operant behavior In behavior therapy as in psychology, the 1970s wit-
that occurred only in the presence of stimuli associated nessed the rise of the "cognitive sciences" (see Ma-
with particular reinforcement contingencies. For alco- honey & Lyddon, 1988). In behavior therapy, cog-
hol specifically, analyses of this sort (e.g., Bandura, nitive-behavioral approaches came to dominate the
1969; Lazarus, 1965), coupled with laboratory re- literature. Two prominent examples are Bandura's
search demonstrating that alcohol consumption could (1977) self-efficacy theory and Beck's (1976) cog-
be treated as an operant behavior (e.g., Mendelson, nitive therapy for emotional disorders. A cognitive-
1964; Reviewed in L. C. Sobell & M. B. Sobell, behavioral emphasis is apparent in recent drug and
1983), led to tests of treatments based on operant alcohol treatment research (e.g., Marlatt & Gordon,
conditioning. 1985; O'Brien et al., 1988; Sanchez-Craig, Annis,
Early operant-based studies were often "broad- Bornet, & MacDonald, 1984). These approaches all
involve a consideration of cognitions (e.g., expecta- individual counseling to confront "denial" of the
tions of drug effects, appraisals of oneself as a drug seriousness of the problem and to help persons become
user, attributional processes) as related to drug use. comfortable with an abstinent lifestyle, and, typically,
Most recently, in line with general notions advanced a month-long inpatient treatment program followed by
by Wikler many years ago (Wikler, 1948, 1965, a year or two of frequent aftercare meetings. Although
1971), several conditioning-based models of addiction this basic program style dominates the alcohol field in
have been introduced, supported by considerable basic the United States, in Great Britain and several other
research (Niaura et al., 1988). The development of countries this model has never strongly taken hold.
these models was spurred by research showing that Outpatient treatments are more favored, although they
Pavlovian processes play an important role in the de- often have an ideological foundation similar to the
velopment of tolerance, previously considered a pure- American programs (Zimmerman, 1988). The main
ly physiological adaptation. This led to associative difference between countries may well have its seeds in
models of drug use and relapse (Poulos, Hinson, & different methods of financing health care; govern-
Siegel, 1981). mentally funded health insurance places a greater pre-
Since cognitive-behavioral treatments and condi- mium on cost-effectiveness, whereas private programs
tioning models are two of the most important recent and private insurance company financing can more
developments in the behavioral approach to alcohol easily confuse care with profits (Gordis, 1987;
and drug problems, they will be discussed at length in Weisner & Room, 1984-1985; Yahr, 1988).
this chapter. In treatment for other drug dependence, the history
has been somewhat different, though common ele-
ments occur. As the number of young, urban heroin
Development of the Substance Abuse Field
addicts increased in the United States during the
Besides the development of behavior therapy in gen- 1950s, "drug addiction" became a subject of concern
eral, the second main influence on the development of (Jaffe, 1979). The most prominent clinical response
behavioral treatments for alcohol and drug problems was Synanon, established by an AA member. This was
has been the explosion of research in the substance- a residential therapeutic community (TC) staffed by
abuse field, particularly the alcohol field. ex-addicts and employing strong confrontation and
Major research efforts involving the treatment of peer pressure to produce personality change. Since its
substance abuse began in the 1960s, when substantial founder regarded Synanon as a way of life and not a
governmental funding first became available (Gordis, treatment program, evaluation of its merits was
1987). In the alcohol field before the 1960s, an ideo- deemed unnecessary (Bale, 1979). Other res have
logically based approach to treatment, which derived been evaluated (DeLeon & Ziegenfuss, 1986). In the
substantially from the principles of Alcoholics Anony- late 1960s, methadone was introduced and rapidly em-
mous and involved intensive inpatient programs braced as a relatively inexpensive and apparently ef-
(Cook, 1988), had established a firm hold and a strong fective treatment of heroin users, particularly young
constituency in the United States. These early (i.e., urban males from minority groups. However, a simul-
1930s-1950s) approaches were based on beliefs rather taneous phenomenon was the rise of non-opioid multi-
than research (Callahan et al., 1987; Pattison, Sobell, ple-drug use among white youths, who tended to be
& Sobell, 1977). Consequently, for decades a conflict treated in "drug free outpatient" programs, if not re-
has existed between scientific and ideological ap- ferred to a TC. The treatment objective of such pro-
proaches to explaining alcohol problems (M. B. Sobell grams was typically abstinence, achieved without
& L. C. Sobell, 1984). Historically, behavioral ap- pharmacotherapy, but their specific procedures have
proaches to clinical problems have been empirically been very little described.
grounded, and thus they have come to be associated
with the scientific side of this conflict.
Findings from the Earlier Edition of This
Hallmarks of the traditional approach to treatment
Chapter
include: residential treatment, heavy reliance on para-
professional staff who themselves are "recovering" Before considering issues that have guided behav-
alcoholics, education in the disease concept of alco- ioral alcohol and drug treatment research over the past
holism, an insistence on abstinence as the only accept- few years, our previous conclusions (M. B. Sobell, L.
able criterion for a successful outcome, group and C. Sobell, Ersner-Hershfield, & Nirenberg, 1982)
about the research published through early 1980 are pecially when nonabstinent goals were used.
here summarized: With drug abusers, while case studies had pro-
duced positive outcomes, a well-controlled
1. Aversive conditioning methods were evaluated evaluation was discouraging.
as possibly having short-term utility in prevent-
ing drinking by alcohol abusers while other treat- The review concluded that though behavioral stud-
ment is conducted. Aversive conditioning ap- ies of alcohol and drug problems had produced impor-
plied to drug abusers involved few well- tant contributions, they had not achieved their full po-
controlled studies and yielded mixed outcomes. tential, particularly in the drug field. The two major
2. Anxiety management methods with alcohol problems were the general lack of controlled investiga-
abusers, including relaxation training, systemat- tions and the rarity of long-term outcome evaluations.
ic desensitization, and biofeedback, were evalu- It should also be noted, however, that behavioral treat-
ated as promising. Most studies, however, had ments have done better than nonbehavioral in avoiding
not evaluated the long-term efficacy of these pro- such problems (Riley et al., 1987).
cedures. With drug abusers, the methods were
basically unevaluated.
3. A variety of skills-training procedures had been Major Areas of Progress or
used with alcohol abusers. Although this was Investigation since 1980
evaluated as a promising research area, few stud-
ies were found to have adequate designs. Also,
Conditioning Explanations of Drug Taking
there was little research demonstrating that alco-
hol abusers had deficient skills. There was also a Historical Precedents. Relapse is the most likely
serious lack of outcome-evaluated skills-training outcome of treatment for psychoactive substance use
research with drug abusers. (Hunt, Barnett, & Branch, 1971; see also Marlatt &
4. Much research had been conducted with both Gordon, 1985). Several decades ago, Wikler (1948,
alcohol and drug abusers using contingency 1965) had noted that periods of isolation from a psy-
management techniques. These procedures had choactive substance (e.g., in hospital or jail) are not
mainly shown immediate positive effects, but sufficient to prevent relapse shortly after returning to
there were few evaluations oflong-term efficacy. the environment where drug taking had previously oc-
Contingency management procedures had clear curred. He hypothesized that stimuli associated with
value for managing the behavior of clients during experience of the drug withdrawal syndrome come to
treatment, thus structuring a favorable environ- elicit a conditioned withdrawal reaction. Individuals
ment for therapeutic change. cope with the conditioned reaction the same way that
5. Self-management procedures, wherein clients they cope with withdrawal symptoms, by seeking
are encouraged to serve as mediators of their drugs to alleviate the symptoms. Thus, the abstinent
own treatment, were evaluated as having great addict was hypothesized to manifest conditioned with-
promise for use with alcohol abusers, but lacking drawal symptoms that, consequently, led to relapse.
controlled evaluations. No similar studies with Except for Wikler and his colleagues' work (e.g.,
drug abusers had been reported. Ludwig, Wikler, & Stark, 1974), the role of condition-
6. Behavioral marital therapy studies were only re- ing factors in drug taking received little research atten-
ported with alcohol abusers, and few outcome tion until recently, possibly because the postulated
data were available. conditioned withdrawal symptoms were linked to the
7. The potential conceptual contribution of the re- concept of drug "craving" (Ludwig & Stark, 1974).
lapse prevention model to the alcohol field was Craving has been dismissed as involving circular rea-
acknowledged, though no evaluations of the re- soning (Mello, 1972; reviewed in Pattison et al.,
lapse prevention model had been undertaken. 1977). Recently, though, Kozlowski and Wilkinson
No studies involving drug abusers had been re- (1987) have asserted that craving can be concep-
ported. tualized in several ways, some of which are testable.
8. Multimodal, or broad-spectrum, treatment The idea that conditioned stimuli could trigger drug
studies were found to be a major source of taking was given impetus in the late 1970s with dem-
promising results with alcohol abusers, es- onstrations that associative (i.e., learned) factors play
an important role in the development and manifesta- All of the above models predict that persons with an
tion of drug tolerance (Poulos et aI., 1981). extensive history of drug use should show stronger
conditioned responses to drug-related stimuli than in-
Recent Research. The explanation of drug taking, dividuals with a less extensive history. A strength of
based on Pavlovian and operant conditioning pro- the appetitive motivational models is their hypothesis
cesses, has been the focus of much recent research. that conditioned responses to drug stimuli can be either
Most of this research has involved studying the role of similar or opposite to drug effects, depending on the
conditioning in precipitating relapse to drug taking type of effect for which conditioning occurs. For
(Niaura et al., 1988). Conditioning approaches sug- clinical purposes, the critical distinction between these
gest the treatment value of extinction, such as the cue models and the conditioned withdrawal and condi-
exposure-response prevention approach found to be tioned compensatory response models is that the appe-
efficacious with obsessive-compulsive disorders titive motivational models predict that positive as well
(Rachman & Hodgson, 1980). Niaura et al. classified as negative affective states are likely to trigger drug
the studies into four lines of learning-based research seeking (and thus also relapse).
intended to account for the problem of drug relapse: Finally, whereas the conditioning based models rely
the conditioned withdrawal model, the conditioned heavily on conditioned responses to drug-related stim-
compensatory responding model, the appetitive moti- uli to explain drug-seeking behavior, the social learn-
vational model, and the social learning model. ing approach also incorporates cognitive factors that
determine whether or not conditioned responses result
Models " Relapse. The conditioned withdrawal in drug taking. By including cognitive processes as
model of Wikler (1948, 1965) postulated that con- mediators of behavior, the social learning approach is
sumption of drugs by a severely dependent person was able to account for the actions of individuals who do
repeatedly associated with alleviation of withdrawal not have extensive drug-taking histories. This ap-
symptoms. Later, exposure to drug cues would elicit proach is exemplified by the relapse prevention model
conditioned withdrawal, and the individual would re- developed by Marlatt and his colleagues (Marlatt &
lapse to relieve these symptoms. Gordon, 1985), discussed later in this chapter.
According to the conditioned compensatory re-
sponding model (Siegel, Krank, & Hinson, 1987), the Treatment-Related Research. A group of researchers at
body reacts homeostatically to ingestion of drugs by the University of Pennsylvania have developed and
responses opposite in direction to the drug effects evaluated procedures for measuring and extinguishing
(Poulos et al., 1981). With repeated trials, these com- conditioned responses to drug cues. In one of their
pensatory responses become conditioned to environ- early studies, they examined the effectiveness of ex-
mental correlates of the drug effect, and in the presence tinction procedures with methadone-treated opiate ad-
of such stimuli the conditioned compensatory re- dicts (McLellan, Childress, Ehrman, O'Brien, &
sponses occur. The important implications are that the Pashko, 1986). Patients were randomly assigned to
conditioned compensatory responses can be triggered one of three conditions: drug counseling, cognitive-
by stimuli previously associated with drug use, that behavior therapy with relaxation training, or cog-
they may be experienced as similar to withdrawal nitive-behavior therapy with relaxation training plus
symptoms, and that they can be escaped by drug ad- graduated extinction trials. After 6 months in treat-
ministration, thus accounting for relapse. ment, it was found that both therapy groups did gener-
Appetitive motivational models have been proposed ally better than the counseling group, but the therapy
by Stewart, DeWit, and Eikelboom (1984) and by T. groups did not differ in outcome. Thus, the extinction
B. Baker, Morse, and Sherman (1987). These models procedures did not appear to have contributed to the
have in common that they propose drug use to be asso- outcomes. However, McLellan et al. speculated that
ciated with positive affective motivational states. the use of more individualized cues with longer extinc-
Urges to take drugs are considered to be conditioned tion trials might be a more effective procedure. With
affects associated with approach behavior. Drug inges- respect to methadone maintenance patients, they noted
tion is hypothesized to have a rewarding effect in the that "the only direct effect of this procedure (extinc-
central nervous system, and stimuli associated with tion) that can reasonably be expected is the continua-
drug use come to acquire an incentive function (i.e., tion and extension of drug-free status in a drugjree
they motivate drug seeking). patient" (p.37, italics in original). Based on their ex-
perience, they also noted that cognitive set and emo- exposures over 20 sessions, and the exposure pro-
tional state may be influential determinants of whether cedures were found to be highly effective in eliminat-
a conditioned response is expressed, consistent with ing craving and withdrawal symptoms. No outcome
the appetitive-motivational (T. B. Baker et al., 1987) data were reported. The potential importance of their
and compensatory conditioning (Poulos et al., 1981) approach is underscored by the fact that, despite hav-
models. ing just completed one month of residential treatment,
Bradley and Moorey (1988) reported the use of ex- the subjects were still vulnerable to stimulus-elicited
tinction procedures with three drug abusers. In ana- craving and withdrawal. This finding underscores the
lyzing the failure of Mclellan et al. (1986) to demon- concept and underpinnings of the conditioning
strate extinction, they noted that the literature for model-the 30-day treatment program in which the
other disorders suggests that "short duration exposure subjects had participated had failed to eliminate their
can produce sensitization to anxiety-relevant mate- conditioned reactions to drug stimuli; if craving and
rial" (p.46). Bradley and Moorey, therefore, used withdrawal are related to relapse, as frequently sup-
continued exposure in a session until craving ratings posed, extinction of such responses should form an
had dropped to a low level (usually 40 to 60 min). important aspect of relapse prevention efforts.
They noted evidence of spontaneous recovery at the O'Brien et al. (1988) studied conditioned responses
start of sessions, and that dysphoric mood states in opiate and cocaine users. Like Mclellan et al.
seemed to lead to a dishabituation of craving. They (1986) and Bradley and Moorey (1988), they noted a
also found that a distraction procedure (repeatedly re- relationship between dysphoric mood state and ex-
citing a nursery rhyme) while in the presence of drug- pression of a conditioned response to drug-related
related cues seemed to facilitate habituation, but that stimuli. Describing one subject, they stated: "While in
recovery occurred when the distraction procedure was the angry mood, he was exposed to the same stimuli
discontinued. This led them to speculate that distrac- that had previously lost their ability to evoke a re-
tion might be a helpful coping aid for drug abusers in sponse. This time, he developed tremendous craving
the presence of craving-eliciting cues. Drug-related and withdrawal-like responses" (p.19). These obser-
thoughts and images were related to high levels of vations are highly consistent with the associative pro-
craving, suggesting that cognitive cues should be cess models. They suggest a possible associative ex-
considered part of the complex of drug-related planation for the common observation that relapse is
stimuli. most frequently associated with negative effect (Mar-
Consistent with motivational models, Bradley and latt & Gordon, 1985). In discussing the study by
Moorey suggested that the processes related to self- O'Brien et al. (1988), Bradley and Moorey asserted
reported cravings are similar to those related to self- that "cocaine may be particularly potent in producing
reported anxiety, and that these states may be mediated conditioned responses" (p.18), and they noted that ex-
by a common mechanism. They stated "the phe- tinction procedures were most effective if the eliciting
nomenon of habituation both within and between ses- stimuli were directly related to the typical route of
sions, the role of imagery in accentuating the response cocaine administration.
and dishabituation of responding all suggest important Although there has been considerable research on
common features with anxiety" (p.54). Hence, they cue reactivity with alcohol abusers (see L. H. Baker,
suggested that extinction sessions should be conducted Cooney, & Pomerleau, 1987; Hodgson, Rankin, &
in the presence of induced moods, a procedure recently Stockwell,1979; Niaura et at. , 1988); there have been
reported by Litt and Cooney (1987). few evaluations of treatment procedures based on
Childress, Mclellan, and O'Brien (1986) measured those findings and no well-controlled clinical trials.
physiological and subjective responses to drug-related Blakey and Baker (1980) reported an uncontrolled
and neutral stimuli in opiate addicts who had just com- study of the use of in vivo cue exposure with response
pleted a 30-day rehabilitation program. Using an elab- prevention in six subjects. Most of the subjects re-
orate set of stimuli, they found clear evidence of stim- ported decreased cravings over the sessions, and five
ulus-elicited craving and some cases of conditioned of the six reported abstinent outcomes ranging from 2
withdrawal. Drug-related stimuli increased arousal to 9 months. Because of the lack of any controls, how-
(galvanic skin resistance), peripheral skin tempera- ever, these findings must be considered promising at
ture, and craving. Six of the ten subjects were assigned best.
to extinction procedures involving 180 total stimuli In a case study by Hodgson and Rankin (1982), the
strongest cue for eliciting craving in the subject was a In summary, though treatment procedures based on
single alcoholic drink. Over repeated sessions involv- conditioning models of addiction have considerable
ing consumption of one drink and then stopping, the promise, they await conclusive evaluation.
craving dissipated, and the subject showed improve-
ment over 5 years following treatment. Again, the lack
of any comparative evaluation prohibits meaningful
Cognitive-Behavioral Treatments
interpretation of these findings. It is worth noting that
Greeley, Le, Poulos, and Cappell (1984) demonstrated Relapse Prevention Treatments. The develop-
,that conditioned compensatory responses to high doses ment of the relapse prevention model (Marlatt & Gor-
of alcohol can be elicited in rats by low doses of the don, 1985) represents a sustained line of excellent
drug. Hence, it may be that in severely dependent hu- behavioral research. As early as the 1940s, Wikler
mans the "craving" elicited by low-alcohol doses is (1948) had pointed out that there was an extremely
the result of conditioned compensatory responding. high frequency of relapse among substance abusers
The only controlled investigation of extinction pro- after treatment. He suggested that the key to explaining
cedures with alcohol abusers was a study reported by relapse lay in environmental triggers for drug use that
Rankin, Hodgson, and Stockwell (1983). Five se- were not present during treatment. In contrast to
verely dependent alcoholics received six sessions of Wikler, Marlatt's approach to understanding relapse
cue exposure and response prevention, while another involved a social learning perspective (Bandura, 1986)
five received a control treatment of covert rehearsal. that included operant conditioning and cognitively me-
The procedures decreased the exposure subjects' de- diated learning explanations of behavior in addition to
sire to drink, increased their confidence in their ability classical conditioning. Relapse was conceptualized as
to resist drinking, and decreased their speed of drink- failure to maintain a behavior change after treatment.
ing in a posttest, but no outcome data were reported. Marlatt's early work on relapse involved studying its
Rankin (1986) has pointed out that it is not clear circumstances in treated alcoholics (Marlatt, 1978).
whether the changes observed in these subjects were He found that most of the reported situations could be
mediated by extinction of conditioned responses, or by classified into a limited number of categories. The
a different "cognitive effect." In terms of clinical ap- most common relapse situations for alcoholics in-
plications, therefore, the use of extinction procedures volved negative affect, interpersonal conflict, or social
with alcohol abusers has not been tested in any major pressure to drink. Identification of these "high-risk"
way. This is surprising, given that a large literature situations provided a rationale for social skills training
demonstrates alcohol abusers' reactivity to alcohol- in treatment (Chaney, O'Leary, & Marlatt, 1978).
related cues. Similar explorations of situations antecedent to relapse
The only recent, well-designed treatment outcome with other substance abusers revealed the same basic
study of conditioning procedures involves emetic aver- categories of high risk as for alcohol abusers, although
sive conditioning methods (Cannon, Baker, Gino, & the rank ordering of categories differed slightly (e.g.,
Nathan, 1986). This treatment was not based on ex- for narcotic addicts, social pressure was the most com-
tinguishing urges to drink, but rather was intended to mon situation preceding relapse).
establish conditioned aversive responses to alcohol- The social learning model of abusive drinking im-
related stimuli. The study demonstrated the effective- plies that relapse might be a response to specific stim-
ness of the procedures in producing a conditioned aver- uli, and that treatment should focus on effective coping
sive response. After conditioning, subjects showed an in such situations. The relapse prevention model
increased mean cardiac interbeat interval and a longer enlarged the social learning approach to include
duration electromyograph (EMG) response to alcohol procedures for dealing with relapse, an emphasis on
stimuli. Several predictions made by the authors for cognitive aspects of relapse, and procedures for main-
behavioral tasks (e.g., subjects' ratings of the taste of taining a commitment to behavior change in spite of a
beverages in a taste test) were also supported. At 1- relapse.
year outcome, a significant association was found be- Although relapse prevention is extremely popular,
tween within-session heart response corrected for pre- there have been few evaluations of its efficacy, and no
test levels and latency to drink for those subjects who published study has attempted to evaluate the unique
did drink during the follow-up year. contribution of the cognitive aspects of relapse preven-
tion procedures. Also, all investigations have involved restricted, for example, to clients who tend to cata-
social skills training as the primary relapse prevention strophize the occurrence of a lapse.
procedure. In Norway, Eriksen, Bjornstad, and
Gotestam (1986) randomly assigned groups of 12 alco- Self-Management Approaches. In this section,
hol-dependent clients to receive either eight sessions we consider various studies that have in common the
of social skills training in addition to a standard alco- attempt to help clients analyze their own behavior and
holism group counseling treatment or only the stan- manage their own behavior change. This approach is
dard treatment. The skills subjects had their first drink most often a procedure for outpatients whose problems
a mean of 51.6 days following treatment, compared to are not severe. Factors associated with the develop-
8.3 days for control subjects. They drank only about ment of self-management approaches include: (1) the
two thirds as much alcohol per week as the control need for outpatient treatments for persons whose sub-
subjects, and when they drank, the level of consump- stance use problems are not severe; (2) demonstrations
tion was comparable to Norwegian norms and was that for many individuals brief treatments are as bene-
judged by their significant others as socially accept- ficial as more intensive interventions (suggesting that
able. much of the change process was self-effected); and (3)
Ito, Donovan, and Hall (1988) compared the effects an emphasis on self-control processes in the evolution
of two aftercare conditions (a cognitive-behavioral re- of cognitive-behavior therapy (e.g., Mahoney & Lyd-
lapse prevention or an interpersonal process orienta- don, 1988; Thoresen & Mahoney, 1974).
tion) for recently hospitalized male alcoholic veterans. The large majority of well-designed studies have
At 6-month follow-up, both groups showed compara- been conducted with alcohol abusers. Many of these
ble outcomes on several variables. compare variants of the same general treatment. Such
Roffman, Stephens, Simpson, and Whitaker (1988) a design can identify the contribution of various treat-
reported preliminary findings for a relapse prevention ment components, but it precludes conclusions about
treatment of marijuana dependence. The subjects were the absolute efficacy of the treatment or its relative
generally well-educated, employed, in their 30s, and efficacy as compared to widely used alternatives. A
mainly used marijuana rather than other drugs. The recent study (Alden, 1988), however, suggests that for
relapse prevention treatment (n = 54) was compared problem drinkers treatments of this sort are superior to
with a social support treatment (n = 56) that empha- no treatment. In this study, a 12-session behavioral
sized developing and using a support network. Treat- self-management program (n = 40) was compared to a
ments involved 10 group sessions and booster sessions 12-session developmental counseling alternative (n =
at 3- and 6-month follow-up. Only I-month outcome 33), an established approach in counseling psychol-
data were reported, and abstinence rates did not differ ogy. An additional 54 subjects were randomly as-
significantly between the groups. signed to a waiting list control group, and after waiting
Finally, Hawkins, Catalano, and Wells (1986) ran- 12 weeks were then randomly assigned to the two
domly assigned 70 drug abusers in a therapeutic com- treatments. The subjects, recruited through the media,
munity to a skills training intervention, and another 60 were problem drinkers who were not severely depen-
to a control condition. Experimental effects were noted dent on alcohol.
for the skill training group on within-treatment mea- Two-year follow-up results found that both treat-
sures of social skill, but no outcome data were ments resulted in a significant reduction of drinking
presented. based on several parameters, but that the two groups
The studies to date, therefore, provide limited sup- did not differ. However, during the 3-month waiting
port for the effectiveness of social skills training for period, the waiting list subjects' drinking remained
alcohol abusers, but the unique contributions of the unchanged. Based on these findings, it can be con-
key cognitive features of the relapse prevention ap- cluded that improvement in drinking was related to
proach have not been evaluated. This is unfortunate, treatment. However, although the cognitive-behav-
because it is the emphasis on cognitive aspects of re- ioral treatment was superior to no treatment, it was no
lapse (i.e., how relapses are construed) that mainly more effective than developmental counseling. Alden
differentiates the model from previous behavioral interpreted the study as providing support for the use of
treatments. There is also a need to evaluate whether moderation-oriented treatment for problem drinkers.
relapse prevention should be generally applicable or She also suggested that the lack of differences between
the two methods may have related to commonalities otherapy treatment-4 hours of instruction in use of a
between the treatments: establishing goals, self- self-help manual, n = 11; (2) therapist-directed treat-
monitoring of drinking, and discussing problems with ment-12 hours plus the manual, n = 10; (3) training
empathic counselors. In other contexts, self-set goals in coping skills-12 hours, n = 11; or (4) a combina-
and performance feedback have been shown to be tion of the behavioral self-control training and training
important determinants of goal attainment (Bandura, in coping skills-16 hours, n = 11. One-year follow-
1986). up found significant reductions in drinking for all
Sanchez-Craig et al. (1984), using a cognitive-reap- groups, but no differences between groups. In-
praisal approach, randomly assigned 70 socially stable terestingly, "the majority of clients reduced their alco-
problem drinkers to abstinence and moderation goals. hol consumption during the assessment period, before
The treatments differed only in that subjects in the treatment started" (Skutle & Berg, 1987, p. 493), sug-
moderation group received counseling regarding how gesting that though treatment may have contributed to
to control their drinking. Both groups significantly re- the maintenance of behavior change, it was not respon-
duced their consumption over 2 years of follow-up, but sible for the initiation of change.
the two groups did not differ significantly in outcome. Heather and his colleagues (Heather, Whitton, &
In each group, few subjects became abstinent. Sub- Robertson, 1986; Heather, Robertson, MacPherson,
jects in the abstinence condition drank significantly Allsop, & Fulton, 1987) evaluated the effectiveness of
more during treatment and requested significantly a controlled drinking self-help manual for Scottish
more elective aftercare sessions, causing the authors to problem drinkers recruited by newspaper advertise-
conclude that though specific training for moderation ments. Subjects were randomly assigned to receive by
is not essential for achieving that outcome, it is to be mail either the self-help manual or a general advice and
preferred for problem drinkers, the large majority of information booklet. At I-year follow-up, subjects in
whom reject lifelong abstinence as a goal. both groups were found to have reduced their con-
Graber and Miller (1988) conducted a study similar sumption by about one third. However, when subjects
to that of Sanchez-Craig et at. (1984), but with sub- who had received other help for their problem were
jects (N = 24) who had more severe alcohol problems excluded from the analysis, it was found that subjects
and who had no clearly stated preference for either in the manual group had significantly lower alcohol
abstinence or moderation goals. Randomly assigned consumption than the control group, having reduced
moderation goal subjects were taught goal setting and their consumption by about one half, while control
given a self-help manual on controlling their drinking, subjects had barely changed their consumption. High
while abstinence subjects received the same manual consumers at assessment showed more marked reduc-
with the drinking control sections deleted. Also, they tions in consumption than low consumers at assess-
were introduced to the disease model of alcoholism as ment, contradicting the expectation that those with less
a rationale for abstinence, and they were told about severe problems would respond better to controlled
defense mechanisms for denial. drinking treatment. The authors cautioned that a find-
Outcomes for the two groups did not differ signifi- ing of differential attrition from follow-up between the
cantly at 42-month follow-up or at several shorter fol- groups may have accounted for the observed difference
low-up intervals. At 42 months, 4 subjects had been between groups.
abstinent for at least 12 months and, using very strin- Robertson, Heather, Dzialdowski, Crawford, and
gent classification criteria, 3 had been moderate and Winton (1986) randomly assigned 37 problem drink-
asymptomatic drinkers. Graber and Miller suggested ers to either brief treatment (3-4 sessions of advice; n
that because their sample had more severe symp- = 21), or an intensive treatment (about 9 sessions of
tomatology and a longer problem history, the results cognitive-behavior therapy; n = 16). The brief treat-
differed from those of Sanchez-Craig et at. (1984). ment involved functional analysis of drinking, the for-
The very strict criteria for asymptomatic moderate mulation of drinking guidelines, and provision of a
drinking may also account for the relatively low (30%) controlled drinking advice sheet. The intensive treat-
success rate in this study. ment involved problem-solving skill training, marital
In Norway, Skutle and Berg (1987) used a treatment contracting, relaxation training, cognitive restructur-
similar to that used extensively in Miller's earlier re- ing, self-management training, and sexual counseling,
search. Problem drinkers recruited by newspaper ad- as needed. All subjects received controlled drinking
vertisements were randomly assigned to (1) bibli- counseling.
Follow-up was reported for a mean interval of 15.5 earn credits that could be exchanged for goods or privi-
months, and drinking data reflected the heaviest drink- leges. The two conditions differed in that for one group
ing month in the prior 6 months. Controlled drinking the reinforcement was individual-contingent (given to
successes were classified based only on consumption. a subject contingent only upon his or her behavior),
Intensive treatment subjects showed a significantly while for the other it was group-contingent (all mem-
greater reduction in mean monthly consumption; how- bers of the group either received or did not receive the
ever, 7 of the 14 intensive treatment subjects were reinforcement, contingent upon the collective behav-
classified as controlled drinkers at follow-up, and 1 ior of the members).
was abstinent, while 8 of the 19 minimal treatment Follow-up was conducted, independent of the treat-
subjects were classified as controlled drinkers. Be- ment staff, at 1 and 2 years after assessment. At I-year,
cause females were overrepresented in the intensive drug consumption was greatly reduced relative to as-
treatment group, it is possible that gender differences sessment, and was further reduced at 2 years. Clients
provide an alternative explanation ofthe observed dif- in the group-contingent reinforcement condition had a
ference between groups. superior outcome to the individual-contingent rein-
Self-management studies involving alcohol abusers forcement and outpatient conditions, which did not
have been important in indicating the feasibility of differ from one another. In terms of cost effectiveness,
moderation goals for selected clients. The self-man- the authors suggested that the outpatient treatment
agement studies are on less firm ground, however, might have an advantage because the same amount of
when it comes to drawing conclusions about their ab- resources would be able to support the treatment of
solute or relative effectiveness. Assessing absolute ef- many more clients. The authors indicated that the op-
fectiveness is nearly impossible because of ethical pro- timum treatment strategy would be to identify those
scriptions of the use of no treatment or placebo clients most likely to benefit from the brief interven-
treatments, especially when subjects are recruited by tion. Further analyses, restricted to the outpatient
advertisement. Even if subjects could be assigned to group, found that unimproved subjects tended to have
no treatment, it is impossible to prevent them from a greater number of drug and other life problems, were
using other treatments. With respect to relative more likely to have raised their drug use goals by their
efficacy, studies addressing this question have either second session, and were more likely to drop out of
failed to find cognitive-behavioral self-management treatment. These results indicate early predictors of
treatment superior to an alternative (Alden, 1988) or treatment outcome that can be employed as possible
have produced findings of superiority for the self-man- indicators of the need for more intensive or different
agement treatment that are open to alternate interpreta- treatments.
tion (Heather et aI., 1986, 1987).
Although outpatient treatments are a common ap- Other Cognitive-Behavioral Approaches.
proach to substance use disorders besides alcohol, few Cognitive-behavioral methods have been used in three
well-controlled trials exist. An exception is a study studies as treatments for benzodiazepine dependence
(Wilkinson & LeBreton, 1986; Wilkinson & Martin, for subjects who had been prescribed the drug and
1983) that randomly assigned young (16-30 years of were later unable to discontinue its use (Dean, Walker,
age) multiple drug abusers to either a short-term cog- Bone, Cooke, & Baird, 1985; Higgitt, Golombok,
nitive-behavioral treatment consisting of three training Fonagy, & Lader, 1987; Sanchez-Craig, Cappell, Bus-
sessions, and six follow-up sessions conducted over 70 to, & Kay, 1987). One study (Dean et al., 1985) de-
weeks, or to one of two 6-week broad-spectrum cog- scribed three cases, while the other two studies used
nitive-behavioral residential treatments. The outpa- controlled designs. In both controlled studies, all sub-
tient condition involved self-monitoring, goal setting, jects received the same cognitive-behavioral treat-
identification of high-risk situations, devising cog- ment. In one case, the experimental manipulation in-
nitive and behavioral strategies for dealing with high- volved group versus individual counseling (Higgitt et
risk situations, and identification of other life prob- al., 1987), while in the other it involved whether ben-
lems. The residential conditions involved the same zodiazepines were discontinued abruptly with placebo
treatment components as used in the outpatient condi- or gradually tapered (Sanchez-Craig et al., 1987).
tion, plus social skills training, vocational counseling, Thus, neither study relates to the relative efficacy of
leisure counseling, stress management, and relaxation cognitive-behavioral treatment for benzodiazepine de-
training. In the residential programs, subjects could pendence. Both controlled studies suggested that there
may be some therapeutic gain to patients experiencing ateness for severely dependent individuals (M. B. So-
some level of withdrawal symptoms. This finding can bell & L. C. Sobell, 1986/1987). In that regard, the
be interpreted, however, as resulting either from in- results of several early studies (see M. B. Sobell,
creased self-efficacy or from the aversive properties of 1978, for a review) had suggested what Orford and
the withdrawal experience. Keddie (1986) termed the "severity of dependence hy-
Finally, Woody, McLellan, Luborsky, and O'Brien pothesis." By this account, the likelihood of a suc-
(1987) randomly assigned opiate addicts in a meth- cessful moderation outcome is posited to be inversely
adone maintenance program to paraprofessional drug related to the severity of an individual's alcohol depen-
counseling, paraprofessional counseling plus suppor- dence. Yet, though the severity of dependence hypoth-
tive-expressive psychotherapy, or paraprofessional esis has intuitive appeal, several recent studies, not all
counseling plus cognitive-behavioral therapy. One of which are behavioral, have drawn it into question.
year follow-up showed that the two therapy groups Orford and Keddie (1986) pitted the severity of de-
differed significantly from the counseling group on pendence hypothesis against what they called the "per-
several measures (e.g., employment, legal status, psy- suasion hypothesis," which assumes that clients are
chiatric symptoms). However, the three groups did not most likely to have successful outcomes if the treat-
differ on drug or alcohol use factor scales of the Addic- ment modes and objectives are consistent with their
tion Severity Index. Findings such as these and those own preferences. Using a vaguely described behav-
of Alden (1988) raise serious questions about the ioral treatment, they assigned subjects who expressed
unique value of behavioral treatments over other struc- a goal preference to the goal of their choice, but clients
tured treatments. with no clear preference were randomly assigned ei-
ther to an abstinence or to a moderation-oriented treat-
ment. One year follow-up results supported the persua-
Moderation Goals and Outcomes in
sion hypothesis, whereas severity of dependence was
Treatment
not predictive of the nature of successful outcomes.
A basic difference between alcohol and drug abuse Sanchez-Craig and Lei (1986) also reported results
treatment outcome research is that in the drug field, a inconsistent with the severity of dependence hypoth-
reduction in drug use is usually the major variable of esis. They examined how subjects' pretreatment drink-
interest, and totally drug-free outcomes are recognized ing behavior was related to outcome. The lighter drink-
as rare. Although abstinence is the stated goal of most ers at intake were likely to have a moderation outcome,
treatment, treatment effectiveness is typically evalu- regardless of the treatment goal to which they had been
ated by reduction in drug use without adverse conse- randomly assigned. The heavier drinkers at intake,
quences, or use of less hazardous substances (e.g., however, were more successful in treatment and at
discontinuing heroin but persisting with alcohol and outcome if they had been assigned to a moderation
marijuana), rather than by proportion of totally drug- goal than an abstinence goal, although the difference at
free outcomes (Hubbard, Rachal, Craddock, & Cav- outcome was not statistically significant. The over-
anaugh, 1984; Sells & Simpson, 1980). whelming majority of all successes were moderation
In the alcohol field, moderation has been a central outcomes in both goal conditions. It should be noted
issue in a conflict between traditional notions, which that the range of severity of dependence was truncated
lacked a scientific foundation, and modern empirically in this study, because severely dependent subjects
based notions (M. B. Sobell & L. C. Sobell, 1984). were excluded. Nevertheless, within the range of se-
For years, moderation outcomes have been reported in verity sampled, the findings were contrary to the sever-
the alcohol treatment outcome evaluation literature ity of dependence hypothesis: subjects with more se-
(Pattison et at., 1977; Riley et at., 1987) for both rious problems appeared to benefit more from a
behavioral and nOllbehavioral studies. Also, as evident moderation than from an abstinence orientation.
from the earlier review of self-management ap- During this review period, only one experimental
proaches, the use of moderation as a treatment goal for study focused on "chronic alcoholics" and directly
abusers who are not severely dependent has come to be compared abstinence and moderation treatment goals
accepted as a reasonable treatment approach (Sanchez- (Foy, Nunn, & Rychtarik, 1984; Foy, Scott, Lokey, &
Craig & Wilkinson, 1986/1987; Wallace, Cutler, & Prue, 1987). The subjects were male veterans, nearly
Haines, 1988). Controversy about moderation goals all of whom had exhibited some withdrawal symptoms
and outcomes has revolved around their appropri- (frequently major symptoms). The subjects all re-
ceived an inpatient broad-spectrum behavioral treat- fective states elicit drinking urges). Dependence sever-
ment involving alcohol education, behavioral group ity is also associated with problems, such as home-
therapy, problem-solving skills training, drink refusal lessness and damaged family relationships, which may
training, relaxation training, social skills training, and also increase the difficulty of maintaining a modera-
vocational assistance. Subjects were randomly as- tion outcome. Usually health and other risk factors
signed in sequential groups to either abstinence or would weigh against advising a severely dependent
moderation treatment goals. The moderation group re- person to seek a moderate drinking outcome, although
ceived 15 additional hours of training in controlled we concur with Hore (1988) that "if they refuse this
drinking skills, including blood alcohol level discrimi- (ilbstinence), do not send them away, but try to assist
nation training. them in their alternative goal" (p.449). Over the last
Follow-up was reported for a 5- to 6-year period. For few years, there has been a definite trend to construe
the first 6 months of follow-up, the moderation sub- treatments as not only giving direction to behavior
jects had significantly fewer abstinent days and more change, but also as effecting the motivation to change
abusive drinking days than the abstinence goal sub- (Miller, 198611987; Miller & Heather, 1986).
jects. However, pretreatment differences in drinking Allowing clients to make their own informed deci-
behavior were not taken into account in the analyses. sions about treatment goals probably increases their
When one considers pretreatment to postreatment commitment to achieving the goals (Bandura, 1986;
change, the difference between groups vanishes. In Miller, 1986/1987), a proposition which has been test-
fact, at I-year follow-up, the moderation subjects had a ed in some studies. Orford and Keddie (1986) con-
mean of 118.4 fewer abusive drinking days than precluded that treatment was most effective when it was
treatment, whereas the abstinence group had a mean compatible with the client's personal beliefs. Elal-
reduction of 116.2 days. The difference in abusive Lawrence, Slade, and Dewey (1986) allowed clients
drinking days was not significant at the I-year or the 5- free of liver and brain damage to select their own goals
to 6-year follow-up. Long-term outcomes were nearly and reached conclusions similar to those of Orford and
indistinguishable between the goal groups, and con- Keddie, though they also reported that goal choice at
siderable individual instability in outcomes was evi- assessment was not predictive of outcome. Final!y,
dent over the course of follow-up. No significant rela- Booth, Dale, and Ansari (1984), in a study similar to
tionship was found between number of major Elal-Lawrence et al. (1986), found that subjects were
withdrawal symptoms experienced prior to treatment most likely to achieve the goal they had chosen for
and drinking level at outcome-a finding apparently themselves. None of the above studies assigned clients
inconsistent with the severity of dependence hypo- to a goal that was not at least somewhat acceptable to
thesis. them. In this regard, it should be recalled that most
Several other recent studies, including ones with problem drinkers in the Sanchez-Craig et al. (1984)
nonbehavioral orientations, have also reported results study who were assigned to the abstinence goal quick-
inconsistent with the severity of dependence hypoth- ly rejected that goal, and that the overwhelming major-
esis (reviewed in M. B. Sobell & L. C. Sobel!, 1986/ ity of successful outcomes for clients assigned to the
1987). One possible explanation of the inconsistencies abstinence goal were of moderation. The relationship
is that the main determinants of type of successful betwcen the goal selection process and motivation for
outcome are other disabilities that are weak correlates behavior change would seem a particularly fruitful
of the syndrome (M. B. Sobel! & L. C. Sobel!, area for future research.
1986/1987). For example, Schaefer, Sobieraj, and
Hollyfield (1987) reported a positive relationship be-
Contingency Management Approaches
tween severity of alcohol dependence and psychiatric
symptomatology in male alcoholics. For substance Contingency management has been used for several
abusers, global psychiatric symptomatology has been years with drug abusers, usually with one of two objec-
found to be negatively related to treatment outcome tives: (1) to produce a change in drug use or drug-
(McLellan, 1986). For alcohol abusers, one could related target behaviors, or (2) to structure an environ-
speculate that psychiatric symptoms, especially those ment favorable for the acquisition of new behaviors
involving mood changes (see the section on "Condi- (e.g., contingency management to structure the milieu
tioning Explanations of Drug Taking" above), impede of residential treatment). Positive contingencies, or
the maintenance of moderation outcomes (e.g., if af- contingent withdrawal of privileges, or a mixture of
both types of contingency have been used. For exam- adone. Once their methadone had been discontinued,
ple, Dolan, Black, Penk, Robinowitz, and DeFord patients returned to the use of street drugs regardless of
(1985, 1986) used contingency contracting in an at- incentives. This finding indicates that methadone, not
tempt to reduce illicit drug use among methadone the payment, was the effective reinforcer.
maintenance patients. The subjects were "failures" in As part of a controlled study of treatment for multi-
other treatments for whom detoxification from meth- ple substance abuse, Wilkinson and Martin (1983)
adone was contingent on urinalyses positive for illicit compared two systems to structure the social milieu of
drugs. The aim of the study was to explore predictors residential treatment, in the context of an identical
of compliance. Compliant patients (11 of 21) were broad-spectrum behavioral treatment program. In one
older, had longer opiate addiction and methadone condition (GCR), access to reinforcers was contingent
maintenance histories, and lower rates of drug use, upon the mean performance of the group of clients in
especially cocaine, during a pre study baseline period. participating in treatment activities, completing as-
McCarthy and Borders (1985) randomly assigned signments, achieving short-term goals, and complying
methadone maintenance patients to contingent detox- with ward rules. In the alternate condition, reinforce-
ification from methadone if they had "dirty urines" ment was contingent upon individual (lCR), not mean
during 4 consecutive months, or to an information con- group, performance. The GCR condition yielded supe-
trol condition (feedback but no contingency). After 1 rior outcomes (defined in terms of annual use of psy-
year, 75% of the contingent group were drug free, as choactive substances) to ICR, at both 1- and 2-year
compared to 25% of the control group. However, there follow-ups. The outcome of the ICR group was no
was high attrition, and data were only reported for the better than that of a control group receiving three ses-
time when subjects were participating in the meth- sions of out-patient behavioral self-control training
adone maintenance program. (Wilkinson & LeBreton, 1986).
Other studies have arranged mixed contingencies. A limitation of contingency management is that
Stitzer, Bickel, Bigelow, and Liebson (1986) com- sometimes behavior change does not generalize to the
pared the effects of increasing patients' methadone extratreatment environment. Crowley (1984) present-
dose contingent upon "clean urines," with the effects ed a one group study suggesting that in some cases it is
of contingent decreases in dose (for "dirty urines"). feasible to arrange supportive contingencies in the
The positive contingency was as effective as the nega- community. The subjects were drug abusing physi-
tive contingency procedure and with less attrition. In cians, nurses, and dentists. The contingency involved
another positive contingency study, Magura, Casriel, withdrawal of their licenses if they were not found to
Goldsmith, Strug, and Lipton (1988) made take home be drug-free by urinalysis. The author acclaimed the
doses of methadone contingent upon clean urines. The program as a success because 70% of the 17 subjects
subjects generally did not meet the contingency re- used the confirmation of drug-free urines to reacquire
quirements, leading Magura et al. to the odd conclu- their licenses.
sion that the contingency procedure may have been of Only one recent study has investigated the efficacy
value in demonstrating to subjects "that their drug use of contingency management for dealing with alcohol
had indeed gotten out of control" (p.117). An alter- problems (Sisson & Azrin, 1986). The subjects were
native interpretation is that "take home privileges" are 12 women, each of whom had a family member who
not a potent reinforcer. had a severe alcohol problem but who was not in treat-
Finally, McCaul, Stitzer, Bigelow, and Liebson ment. Seven of the women were assigned to an experi-
(1984) studied the effects of contingent reinforcement mental treatment and five to a control condition. The
on opiate addicts being withdrawn from methadone. control treatment was a traditional program for "sig-
Control subjects were simply paid for providing urine nificant others" of alcoholics, which included educa-
specimens, whereas experimental subjects were paid tion in the disease concept of alcoholism, discussion
and received a take home methadone dose for each groups, and referral to AI-Anon. The experimental in-
"clean" urine, and also forfeited those incentives and tervention was described as follows:
received more intensive counseling for "dirty" sam-
ples. Early in the study, the experimental subjects had To reduce physical abuse. she was taught how to react at the
earliest sign of impending violence, as well as to the violence
significantly more opiate-free urines, but the dif- itself. To encourage sobriety, she learned how to reinforce the
ference was no longer significant by the third month, alcoholic for periods of sobriety, and how to arrange negative
when subjects had been fully withdrawn from meth- consequences of drinking through requiring the drinker to take
responsibility for correcting or overcorrecting . . . the disrup- their treatment from among alternatives are more com-
tion caused by his drinking. To encourage him to seek treatment, pliant with the treatment and more likely to be suc-
the other family members learned to identify moments when the
drinker was most motivated to do so. To assist in the treatment,
cessful than clients not offered a choice.
the farnily members attended the professional sessions and Several studies relevant to the matching hypothesis
helped the alcoholic to engage in the prescribed activities there- have been discussed previously (e.g., less dependent
after. (p.16) clients seem to benefit as much from brief, self-man-
agement oriented treatments as from more intensive
None of the drinkers who were relatives of the con- ones, and prefer moderation to abstinence as a goal).
trol subjects came in for counseling, whereas six of the However, much of the existing matching research is
seven drinkers related to experimental subjects sought limited to post hoc correlational analyses exploring
counseling. Before entering treatment, the drinkers re- client characteristics predictive of outcome. Few stud-
lated to experimental family member subjects reduced ies have used an a priori design to test a matching
their drinking by approximately 50%, and over the hypothesis. Of the studies reviewed thus far, only the
course of 5 months, they showed significantly less study by Orford and Keddie (1986) has done so. An-
drinking than the drinkers related to the control family other recent a priori test of matching classified one
member subjects. Although the sample was small and group of alcoholic patients into anxiety, depression, or
the intervention labor-intensive, the very positive find- psychopathic personality subgroups and then provided
ings suggest that contingency management can be used different forms of behavioral treatment to each sub-
effectively as a generalizable treatment with substance group (McMillan & Lynn, 1986). A second patient
abusers and their families. group received self-control training focusing on their
The study by Sisson and Azrin (1986) represents drinking behavior, and a third group received suppor-
unusually creative use of contingency management. tive counseling and discussion groups. Treatment in-
Although contingency procedures can be used to pro- volved eight sessions, delivered in addition to an inpa-
mote an environment conducive to behavior change, in tient treatment program in which all of the patients
many studies the relationship between the contingency participated, thus somewhat compromising the match-
and treatment outcome is unclear or untested. ing design. At 9-month follow-up, no differential ef-
fects of treatment were found.
Although very few behavioral studies have involved
Patient-Treatment Matching
tests of the matching hypothesis, the value of this ap-
A final contemporary issue concerns the so-called proach seems clear, at least at a rudimentary level. For
matching hypothesis. This notion has a long history, example, it is unrealistic to expect alcoholics with se-
especially in the alcohol field (see reviews by Glaser, rious brain damage to respond well to cognitively com-
1980; Miller & Hester, 1986b). Readers may find it plex treatments (Wilkinson & Sanchez-Craig, 1981),
curious that the question of whether treatments should or to refer an adolescent who occasionally consumes
be tailored to individuals is even an issue. However, alcohol to extended inpatient treatment. At some level,
clinical practice in the alcohol field has long been dom- therefore, the need for an individualized approach is
inated in the United States by a relatively standardized incontestable. Beyond such obvious considerations,
treatment approach viewed as suitable for all cases, the however, the issue of matching becomes much more
so-called "Minnesota Model" (Cook, 1988; Zimmer- complex (see Finney & Moos, 1986).
man, 1988). Against this background, the concept of A major issue is whether matching research is war-
individualized treatment is innovative. ranted when clearly effective treatments for substance
With respect to patient-treatment matching, Miller abuse problems have not yet been demonstrated. On
and Hester (1986b) offered the following conclusions the one hand, it can be argued that it is imprudent to
based on a review of the alcohol literature: (1) Degree attempt to maximize effectiveness in the absence of an
of benefit from a broad-spectrum intervention depends effective treatment. On the other hand, it is possible
on the extent to which the various components address that failure to take account of patient-treatment in-
problems that the client manifests; (2) clients benefit teractions might obscure evidence of treatment effec-
most from a treatment approach congruent with their tiveness. By mixing the results of patients who re-
cognitive style; (3) clients with more severe problems spond well to a treatment with those of patients who
benefit more from more intensive treatment, and vice- respond poorly, the grouped outcome would be unim-
versa; and (4) clients actively involved in choosing pressive and misleading. Finney and Moos (1986) take
the latter position, largely because the diversity of the (e.g., nonlinear, higher-order interactions, multilevel
affected population is so extensive that some level of effects; Finney & Moos, 1986), and the complexity
matching seems imperative. deepens even more. What is the appropriate strategy
The practical difficulties of matching research are for selecting matching variables? Finney and Moos
also considerable. Finney and Moos noted that there suggest that a conceptual approach will be more pro-
are several domains of patient and treatment variables ductive than a purely empirical approach. Where will
that might be used for matching, and that within each the resources be found to support adequately designed
domain, many specific variables can be identified. matching research? Well-controlled clinical trials that
For example, in a set of studies with substance would be necessary to soundly test matching predic-
abusers that did not use behavioral treatments, tions would ideally involve multiple treatment pro-
Mclellan (1986) first conducted an exploratory analy- grams, elaborate controls, and large numbers of sub-
sis relating a variety of patient factors to treatment jects (Elkin et al., 1988). Few studies of that sort have
outcome. He found that "a global estimate of a pa- even been attempted in the entire substance abuse
tient's psychiatric symptomatology . . . is the single field, and current levels of funding suggest that such
best overall predictor of outcome across patient types, studies will remain a rarity. Nevertheless, as the recent
treatment methods, and outcome measures" (p.98). research has demonstrated, much can be learned from
Greater psychiatric symptomatology was associated the present piecemeal approach. The difficulty of un-
with poorer outcomes irrespective of the treatment. dertaking large scale matching research, however, un-
Mclellan suggested that previous studies had not derscores the importance of having a conceptual basis
found many meaningful predictors of outcome be- for the selection of matching variables.
cause global psychiatric severity had not been as-
sessed. The analyses also suggested that patients could
pursue nonabstinent goals and benefit from outpatient Conclusions and Future Directions
treatment unless they had significant family or em-
ployment problems (extratreatment variables), in In general, behavioral treatment research on psy-
which case they would benefit more from inpatient choactive substance use disorders has shown modest
treatment. In a subsequent study, patients were either treatment effects. Although it would be comforting to
matched as well as possible to one of six treatments or make stronger assertions regarding the efficacy of be-
were mismatched. At 6-month follow-up, matched al- havioral treatments, the findings of modest effective-
cohol dependent patients had a somewhat better out- ness place us in good company with those attempting
come than the mismatched group. A curious finding to tackle other difficult and complex health and social
occurred for the drug dependent patients in that the problems (Gordis, 1987).
mismatched patients showed more improvement than Even with modest effects, however, the overall re-
the matched during treatment, but the matched had search strategy that emerges from the literature needs
better outcomes. In a further extension of this work, to be examined. Much of the research compares varia-
which represents a fine example of research on tions in behavioral treatments (e. g., method of goal
"matching," it was shown that clients high on the mea- selection, number of sessions), when it is not clear that
sure of "psychiatric severity" had poorer outcomes this treatment is of significant benefit. This problem is
directly related to the duration of treatment in a thera- not easily remedied, because the conduct of tests of
peutic community. In contrast, similar patients receiv- comparative treatment effectiveness (i.e., using a
ing methadone treatment and psychotherapy had more baseline of competently delivered conventional treat-
positive outcomes as a function of treatment length. ment, large samples, and multiple facilities to control
This result indicates a contraindication to the referral for facility-specific variables) would require resources
of a specified subset of problems to a particular type of and a research network not presently available. In the
treatment. absence of multicentered, well-controlled clinical
The preceding example illustrates the conceptual treatment trials, workers in the field will likely have to
and practical complexity of patient-treatment match- settle for incremental progress toward answering core
ing research. Further complicating the matter are ques- research questions, such as the extent to which treat-
tions about multistage matching (i.e., using different ment is better than no treatment, and whether one ge-
matching procedures as treatment progresses) and neric type of treatment is superior to another. Further,
about the nature of matching effects that might occur there is a serious lack of studies comparing behavioral
with nonbehavioral treatments, though the conduct of Sobell et ai., 1988; Wilkinson, Leigh, Cordingley,
such studies is feasible and has been informative (e.g., Martin, & Lei, 1987).
Alden, 1988; Pomerleau, Pertschuk, Adkins, & In our view, the field must strive for an integrative
Brady, 1978; Sisson & Azrin, 1986; Woody et ai., conceptualization that explains both the general phe-
1987). nomenon of the compUlsiveness of some drug taking
For substance abuse problems, as with most serious and the relationships between specific users and spe-
disorders, no-treatment control groups are extremely cific substances. Certain theoretical approaches, such
rare and difficult to implement (Elkin et aI., 1988). as conditioning models, would seem amenable to
Thus, conclusions about how individuals would have using common processes to explain difficulties in
fared without treatment are usually based on conjec- abandoning the use of cocaine and opiates, for exam-
ture or on survey findings that may not directly gener- ple, while other theories (e.g., stress reduction) seem
alize to a population that seeks treatment. Although less prepared to explain the use of stimulant drugs.
conclusions are drawn about the change that behav- General formulations (e.g., the motivational approach
iorally treated individuals show from pretreatment to presented by T. B. Baker et aI., 1987) that attempt to
posttreatment, seldom have unequivocal assertions explain substance use in terms of an interaction be-
been possible in regard to whether the change is greater tween situational, pharmacological, and biological de-
than that which would have occurred without treat- terminants show promise in accounting for the broad
ment. Because subjects are usually volunteers, waiting and changing range of psychoactive substance use
list controls are usually a "temporarily denied treat- over time, though the testability of such formulations
ment" group. remains to be demonstrated.
In preparing this conceptual review of progress in The evolution of behavioral approaches has now
the behavioral treatment of psychoactive substance use progressed to the point where they playa major role in
disorders, it was clear that it is only recently (except in generating theory-based explanations for compulsive
isolated cases, such as Wikler's conditioning ap- psychoactive substance use and treatments. This, we
proach) that theory-driven approaches (e.g., condi- hope, will be the major contribution of behavioral
tioning theory, cognitive-behavioral model of relapse) treatment research to the addictions field over the next
have begun to strongly influence treatment research. several years.
Related to this, it seems especially important that the
theoretical premises on which such research is based
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CHAPTER 21
Cigarette Dependence
Sharon M. Hall, Robert G. Hall, and
Dorothy Ginsberg
Tolerance and Dependence As Jarvik and Henningfield (1988) have noted, even
within a single day, tolerance is lost and gained. Toler-
Nicotine, the putative active component of cigarettes, ance decreases during sleep, so that the first cigarette
has many beneficial actions. It aids memory, con- of the day provides the strongest effect. Smokers often
centration, alertness, and relaxation. It also suppresses report little effect of evening and afternoon cigarettes.
weight gain (e.g., Comstock & Stone, 1972; Gordon, Over time, they may increase nicotine dose by switch-
Kannel, Dawber, & McGee, 1975). In tolerant users, ing to brands with greater nicotine content, increasing
nicotine produces relaxation, pleasure, and even eu- the number of cigarettes smoked, or changing smoking
phoria. Unfortunately, nicotine is smoked in tobacco, behavior so that more nicotine is ingested.
which is not benign. Tobacco also includes tars and The evidence for dependence also exists. In a series
other carcinogenic substances that increase the risk of of studies, Hatsukami, Hughes, and their colleagues
cancer. The carbon monoxide in the smoke has (Hatsukami, Hughes, & Pickens, 1985) demonstrated
harmful effects on the heart. Lastly, nicotine itself is that an uncomfortable syndrome exists when smokers
cardiotoxic (Gilman, Goodman, Rall, & Murad, quit. The most consistent symptoms are decreased
1985). heart rate, increased eating, sleep disturbance, confu-
Nicotine is an addicting drug. Classically, addiction sion, and craving for cigarettes. Other difficulties re-
has two components: tolerance (the need to use in- ported include increased irritability, anxiety, poor con-
creasing amounts of the drug to obtain the same ef- centration, restlessness, and somatic complaints.
fects) and dependence (the experience of withdrawal Evidence for the physical basis of these symptoms is
symptoms and craving when drug use is ended). Nic- found in the data that show that craving, confusion,
otine meets both of these criteria (Gilman et at. 1985). and sleep disturbances are correlated with blood nic-
Tolerance does occur. For example, the daily doses otine, with cotinine-a nicotine metabolite-and with
most smokers tolerate are much greater than the doses other measures of smoke exposure. However, the net-
they would have tolerated when they began to smoke. work of relationships is not simple. Some withdrawal
symptoms are not reduced by administration of nic-
otine gum as they should be if nicotine were the active
Sharon M. Hall and Dorothy Ginsburg • Department of agent in producing dependence. For example, Hat-
Psychiatry, University of California at San Francisco, San Fran- sukami's group has found that difficulty in concentra-
cisco, California 94143. Robert G. Hall • Palo Alto
Veterans Administration Medical Center, Palo Alto, California tion, irritability, impatience, anxiety, and somatic
94304. complaints are alleviated by nicotine gum. Hunger,
437
craving, insomnia, overeating, and supine heart rate the accuracy of a self-report can be good (S. M. Hall,
decreases are not. However, others have found that Rugg, Thnstall, & Jones, 1984).
nicotine gum reduced weight gain (Fagerstrom, 1987). There are five methods to validate self-reported ab-
It is unclear how many smokers show evidence of stinence. The simplest is verification by significant
physical dependence when they quit smoking. others. Most researchers have found practically no dis-
Hughes, Gust, and Pehacek (1987) used two sets of crepancies between a self-report and the report of sig-
criteria for withdrawal. The first were those listed in nificant others. However, informants are not always
the Diagnostic and Statistical Manual of Mental Dis- present, or may be deceived by the smoker. For exam-
orders (DSM-III). These include use of more than 10 ple, co-workers may not be aware of smoking that
cigarettes per day that contain at least 0.5 mg of nic- occurs at home. The smoker may conceal his or her
otine, and the occurrence of at least four of the follow- smoking from his informant and from the researcher.
ing reactions within 24 hours of stopping smoking: Carbon monoxide, a byproduct of combustion, is
craving for tobacco, irritability, anxiety, difficulty con- inhaled in cigarette smoke and moves into the lungs. It
centrating, restlessness, headache, drowsiness, and can be measured in blood or expired air. The level of
gastrointestinal disturbances. The second set of crite- carbon monoxide can be measured by blood carbox-
ria were those derived empirically by the investigators. yhemoglobin, or noninvasively with expired air sam-
These included the presence of at least four of the ples. Measurement by expired air samples can serve as
following reactions in a smoker who had stopped for biofeedback for quitting smoking. Smokers can be
24 hours: the fIrst five DSM-III withdrawal symptoms, shown changes in level and can be instructed in their
plus increased appetite, impatience, somatic com- interpretation. Carbon monoxide has a short half-life
plaints, and insomnia. Twenty-one percent of their of (about 2-5 hours), so it can be used to detect smok-
sample of 875 abstainers met the DSM-III criteria. ing only up to 10 hours before. Also, contamination
Forty-six percent met the criteria of Hughes et al. from exposure to heavy automobile traffic and to
Agreement between the two diagnostic systems was smoke from nontobacco products, such as marijuana,
poor. As these data indicate, there is still work to be is not uncommon (Benowitz, 1987).
done to describe physical dependence accurately. Thiocyanate measures hydrogen cyanide, which is
For many years, smoking was considered a simple also a combustion byproduct. Thiocyanate has a half-
habit. In recent years, the role of physical dependence life of 10 days. This long half-life makes it an appeal-
has overshadowed the role of psychological and behaving measure of continuous abstinence. Thiocyanate
ioral factors. Although the role of physical dependence can be measured in blood or urine. However, thiocya-
and withdrawal are important in tobacco addiction, nate does not distinguish light smokers from non-
they do not explain all the variance in quitting smoking smokers very well. It also can be influenced by large
and in relapse. Behavioral and psychological variables amounts of cruciferous vegetables in the diet
must be considered. There is a large literature on the (Benowitz, 1987). Because of these problems it is less
relationships between these variables and cigarette frequently used in research now than in earlier studies.
smOking (e.g., Tunstall, Ginsberg, & Hall, 1984). Cotinine is a metabolite of nicotine. Its half-life
However, these studies have not been based on a model ranges from 20 to 40 hours, so it can detect smoking
so compelling or consistent as the nicotine dependence for 2 to 3 days before the assessment. Cotinine can be
model. Nor are they overwhelmingly consistent. measured in blood, in saliva, and in urine (Jarvis,
Hence, they have not had the impact of recent studies Tunstall-Pedoe, Feyerabend, Vesey, & Salloojee,
of nicotine dependence. 1984). The primary drawback to its use is that any
nicotine product will produce a measurable blood
cotinine level, including nicotine gum. Also, the as-
Measurement of Smoking Behavior says are expensive.
The ideal verification measure for self-report of
At first glance, measurement of cigarette smoking smoking depends upon the purpose of the verification.
would appear to be straightforward; but it is not. If the purpose is to determine carefully the incidence
Smoking is not socially desirable. Self-reports of ab- and prevalence of smokers in a population, then self-
stinence are often inflated. However, when subjects report of smoking, use of other nicotine products, and
believe that their report will be verified biochemically, presence of both carbon monoxide and cotinine are
CHAPTER 21 • CIGARETTE DEPENDENCE 439
useful. On the other hand, if the primary purpose of the tion's material. A total of I ,237 subjects were enrolled
research is an initial comparison of abstinence rates, and randomly assigned to one of four conditions: (1)
then a decision to use carbon monoxide only might be leaflet only, (2) leaflet plus the 64-page ALA manual,
justified. The slightly lower precision would be offset "Freedom from Smoking in 20 Days," (3) leaflet plus
by the considerably lower cost. the 28-page ALA maintenance manual, "A Lifetime
of Freedom from Smoking," (4) leaflet and both man-
uals. Subjects were followed by telephone at 1,3,6,9
The Range of Treatments and Their and 12 months. For all groups combined, the quit rate
Effectiveness was 25% at I-month follow-up. At 1 year, 16% of the
combined sample reported abstinence. The two groups
The range of smoking treatments is extensive. Cur- receiving the maintenance manual represented the
rently, there is no widely accepted method to suggest highest point prevalence abstinence rate at 12 months
how smokers should be assigned to treatments. In the (18%). When continuous abstinence was measured,
section that follows, we review the common follow-up rates for the combined sample dropped to
interventions. 3% at 12 months. Again, the two groups receiving the
maintenance manual had the highest continuous non-
smoking rates (4% and 5%).
Minimal Interventions
Most smokers quit with little or no intensive profes- Computerized Self-Help. Recent self-help vari-
sional help, although some large numbers do use mini- ants use computers. Schneider, Benya, and Singer
mal interventions. Minimal interventions include (1984) studied interactive computerized letters. Sub-
pamphlets, mail and computerized programs, and phy- jects were assigned to one of three conditions: (1) an
sicians' advice. individualized series of letters that integrated personal
Minimal interventions are important because (1) information by a computerized technique in a
many smokers do not want the burden of appointments "lesson" format, (2) a noninteractive weekly mailing,
and prefer materials they can use at their leisure (Jeff- and (3) a pamphlet on quitting. The abstinence rates of
ery, Danaher, Killen, Farquhar, & Kinnier, 1982); (2) the computerized direct-mail program were compara-
the costs of minimal interventions are lower than ble in point prevalence abstinences to a group of self-
clinical interventions; (3) minimal interventions reach selected group participants. However, at 6 months the
more people (Russell, Wilson, Taylor, & Baker, group participants reported 14.3% continuous absti-
1979); and (4) most smokers quit several times to nence. The computerized mail condition reported
achieve sustained abstinence. A definitive study of the 7.4% abstinence. The pamphlet and noninteraction
natural history of smoking cessation has not been com- condition had abstinence rates of less than 2%.
pleted. However, some proportion of smokers may use Schneider (1987) has been studying an on-line be-
both minimal treatment and formal interventions to havioral program that is accessed on an electronic bul-
achieve sustained abstinence. letin board. In a preliminary report, he reported that 28
subjects had tried the program. Ten (35%) quit smok-
Self Help. Self-help is the most limited method of ing for 3 months.
treatment. The smoker receives a pamphlet from a
physician or public health outreach, reads it, and Physician Advice. There have been several physi-
adopts some or all of the suggestions. The materials cian advice studies (e.g., Cullen, 1983; Ewart, Li, &
focus on specific behavioral tasks. These pamphlets, Coates, 1983; Mausner, Mausner, & Rial, 1968; Rose
manuals, and guides are produced by the American & Hamilton, 1978). The "classic" study is that of
Cancer Society, the National Cancer Institute, the Russell et al. (1979), who evaluated 2,138 cigarette
American Heart Association, and the American Lung smokers who were attending the "surgeries" of 28
Association (ALA). There are not many studies of English general practitioners. Subjects were assigned
their efficacy. However, a study by Davis, Faust, and to one offour groups: (1) follow-up only, (2) question-
Ordentlick (1984) provided a good estimate of the im- naires and follow-up, (3) physician advice plus ques-
pact of self-help interventions. These investigators tionnaire and follow-up, and (4) leaflet plus advice,
tested the effectiveness of the American Lung Associa- questionnaire, and follow-up. Subjects were assessed
at 1 and 12 mo,.ti;s. ')utcomes were validated with continue to be low. Clinic-based treatments are needed
nicotine assays. At both 1 month and 1 year, the physi- for many smokers.
cian advice conditio•. s reported the highest abstinence
rates. For example, at 1 year the rate for the condition Aversive Smoking. "Aversion" encompasses a
with all the intervention elements was about 5% con- variety of techniques, including rapid smoking (e.g.,
tinuous abstinence. For the follow-up only group, it Danaher, 1977a; R. G. Hall, Sachs, & Hall, 1979; R.
was < 1%. G. Hall, Sachs, Hall, & Benowitz, 1984), blown
As with other self-help treatments, abstinence rates smoky air (e.g., Lichtenstein, Harris, Birchler, Wahl,
are low. Physician's advice may motivate smokers. & Schmahl, 1973), stimulus satiation or saturation
However, many physicians do not have the time or (e.g., Best, Owen, & Trentadue, 1978), smoke hold-
skill to provide treatment to smokers who need more ing or taste satiation (e.g., Tori, 1978,), covert sen-
than advice. Referral by the physician to a therapist sitization (e.g., Barbarin, 1978), and shock therapy
skilled in behavioral methods is in the best interest of (e.g., Berecz, 1979).
the many patients who cannot quit with advice alone. The most effective aversion procedures are those
One example of how this might be accomplished that use cigarette smoke as the aversive stimulus
comes from the Palo Alto Veterans Administration (Schwartz, 1987). Of these, rapid smoking has gener-
Medical Center. According to hospital policy, the ated the most research. In the standard procedure,
pharmacy will dispense nicotine gum to outpatients smokers are instructed to inhale from a cigarette every
only if the prescription is cosigned by the director of 6 seconds to the point of physical discomfort (nausea
the Smoking Program, who is a psychologist. This or dizziness) or until a time limit is reached, whichever
signature indicates that the patient is also engaged in a occurs first.
behavioral treatment program. The policy was adapted In early studies, abstinence rates of 100% at treat-
after a presentation to the Pharmacy and Therapeutics ment termination (e.g., Harris & Lichtenstein, 1971;
Committee that included data that indicated gum Schmahl, Lichtenstein, & Harris, 1972) and 60% at 6-
efficacy was increased when psychological support month follow-up were reported (Lichtenstein, et al.,
was added. 1973; Schmahl et al., 1972). Later research produced
variable results. In Danaher's (1977b) review of 22
Summary: Minimal Interventions rapid smoking studies, abstinence rates ranged from
0% to 81 % at 3-month follow-up and 6.7% to 55% at
Minimal treatment interventions do not produce
6-month follow-up. In 10 of 14 studies permitting
high abstinence rates. Yet, as has been pointed out with
comparison with placebo control or alternative treat-
much enthusiasm (e.g., Russell et al. 1979), they are
ments, rapid smoking produced higher abstinence
inexpensive and may appeal to many smokers who
rates at 3- to 6-month follow-up (Danaher, 1977b).
would refuse formal treatment programs. How they
However, these differences were not statistically sig-
are woven into the natural history of quitting is not
nificant. In most of these studies, abstinence rates
clear, because studies of this history of quitting smok-
were based on unverified self-reports or incomplete
ing are few. It may be that limited success with a mini-
samples (subjects who completed treatment or re-
mal intervention encourages the relapsed smoker to
sponded to follow-up).
seek more intensive treatments. A self-efficacy model
Since Danaher's review, there have been at least 10
would suggest this is so. Smokers who failed intensive
rapid smoking studies that used biochemical verifica-
treatments, but who leamed from them, may need only
tion of abstinence and included dropouts in outcome
a booster in the form of minimal treatment. On the
analyses (Danaher, 1977a,b; Danaher, Jeffery, Zim-
other hand, it is possible that minimal interventions are
merman, & Nelson, 1980; Glasgow, 1978; R. G. Hall
a nonproductive detour for some smokers, especially
etal., 1979;R. G. Halletal., 1984;S. M. Halletal.,
those who are physically dependent on nicotine. At
1984; S. M. Hall, Tunstall, Ginsberg, Benowitz, &
present, we do not know.
Jones, 1987; Lando, 1975; Norton & Barske, 1977;
Raw & Russell, 1980). Some studies compared rapid
Clinic-Based Treatments
smoking to control conditions or other aversive smok-
Despite the recent increase of interest in minimal ing procedures. Others compared rapid smoking alone
interventions, the abstinence rates produced by them to rapid smoking in multicomponent programs. These
studies produced mixed results about the relative effec- al., 1984; S. M. Hall&R. G. Hall, 1987). Compared
tiveness of rapid smoking compared to the nonspecific to normally paced smoking, rapid smoking produces
components of the treatment or other aversive smoking increases in heart rate, blood nicotine levels, carbox-
procedures. Most programs produced lower absti- yhemoglobin, and other blood gases (R. G. Hall et al.,
nence rates than the original Lichtenstein studies. De- 1979; Miller, Schilling, Logan, & Johnson, 1977;
viations from the original method may be the cause Russell, Raw, Taylor, Feyerabend, & Saloojee, 1978;
(Danaher, 1977a,b; R. G. Hall et al., 1984). These Sachs et al., 1978). Concerns that rapid smoking
studies have restricted or controlled the number of ses- might lead to nicotine poisoning have not been sub-
sions (Lando, 1975; Raw & Russell, 1980), conducted stantiated (Russell et al., 1978). Guidelines are avail-
treatment in groups (R. G. Hall et al., 1984; S. M. Hall able concerning screening procedures and the safe use
et aI., 1987; Lando, 1975; Norton & Barske, 1977) of rapid smoking (S. M. Hall & R. G. Hall, 1987;
added other components or booster sessions (Danaher, Lichtenstein & Glasgow, 1977).
1977a,b; Hall etal., 1984; S. M. Hall etal., 1987); or
had clients rapid smoke at home (Danaher et aI., Nicotine Gum. Nicotine gum or nicotine polar-
1980). In studies that replicated the procedure used by crilex was approved by the Food and Drug Administra-
Lichtenstein's group (R. G. Hall et al., 1979; R. G. tion (FDA) in 1984 as a prescription treatment for to-
Hall et al., 1984), results are similar to those found by bacco dependence. Trademarked as Nicorette, the
him. These conditions include individual sessions, a product is distributed by Lakeside Pharmaceutical.
warm client-therapist relationship, positive expecta- Nicotine gum was designed to provide an alternative
tions of success, individualized treatment scheduling, source of nicotine to smokers during the quitting peri-
office-based treatment, and the admonition that the od. According to the Dow Chemical Co. (1980), "the
client was not to smoke between sessions. Detailed gum allows the patient to attack the smoking habit in a
clinical descriptions of the most successful rapid staged approach rather than the often used cold turkey
smoking procedures are available in Danaher method" (p. 3). Theoretically, the gum prevents
(1977 a, b), Danaher and Lichtenstein (1978) and S. M. abrupt withdrawal from nicotine and provides an oral
Hall and R. G. Hall (1987). substitute for cigarettes. Once the smoker has learned
Rapid smoking has continued to be a popular smok- to cope with the learned aspects of smoking, nicotine
ing intervention. In recent years it has usually been withdrawal presumably is easier. After 3 to 6 months,
used in conjunction with other smoking cessation pro- the smoker gradually tapers off the gum. Nicotine gum
cedures. Schwartz (1987) reviewed 49 rapid smoking is contraindicated for smokers who are pregnant or
trials and found only 4 trials after the year 1977 that have life-threatening arrhythmias, stomach ulcers, and
employed rapid smoking without additional pro- temporomandibular joint disease.
cedures. Modifications of rapid smoking that are of Researchers, practitioners, and Merrill-Dow all
only moderate effectiveness alone may be more suc- agree that the gum should be administered in conjunc-
cessful when combined with other procedures. tion with therapeutic support. Across studies, the high-
Schwartz (1987) reported that 17% of the studies using est quit rates are found when the gum is combined with
rapid smoking alone produced abstinence rates of at behavioral treatment. In studies with at least I-year
least 33% at I-year follow-up. Fifty percent of those follow-up, nicotine gum with behavior therapy re-
using combined treatments did so. Although many of sulted in abstinence rates of 12% to 49%. The median
these studies had weak methodology, rapid smoking was 29% (Schwartz, 1987). When nicotine gum was
and other aversive smoking procedures used in multi- the major treatment, abstinence rates were lower. They
component programs produced quit rates that are ranged from 8% to 38%. The median was 11%
among the highest in the literature. (Schwartz, 1987).
Before selecting rapid smoking, the health of the Differences in quit rates may reflect differences in
patient should be carefully assessed. Evidence sug- populations. Behavioral treatment is usually provided
gests that rapid smoking among healthy smokers does in smoking cessation clinics rather than in general
not present a health risk greater than that of normally medical practices. Smoking clinics see patients who
paced smoking (Sachs, Hall, & Hall, 1978). However, are specifically seeking assistance for cessation and
caution should be used in selecting rapid smoking for who are receiving treatment from experienced smok-
patients with cardiopulmonary disease (R. G. Hall et ing cessation therapists. In contrast, low-contact treat-
ments are often conducted by physicians. Also, pa- rates. Some investigators have recommended that the
tients coming to physicians' offices are there for gum be used for up to 1 year following cessation (Rus-
reasons other than to get help for quitting smoking. sell, Raw, & Jarvis, 1980). In contrast, themanufactur-
Therefore, they may be less motivated. er advises patients not to use the gum for more than 6
Even though nicotine gum is recommended as an months. Extended use has raised concern about addic-
adjunct to behavioral treatment, the optimal type and tion to the gum. However, difficulty giving up the gum
amount of therapeutic support for use with the gum is infrequent. Among smokers who used the gum to
remains unclear. We found four randomized trials that help them quit, gum use 1 to 2 years later generally has
compared nicotine gum plus behavioral treatment to not exceeded 5% (Hjalmarson, 1984; Raw, Jarvis,
low-contact nicotine gum control groups (Ginsberg, Feyerabend, & Russell, 1980). Although there are dis-
Hall, & Rosinski, 1988; S. M. Hall, Tunstall, Rugg, advantages to use of the gum, the health risks are less
Jones, & Benowitz, 1985; S. M. Hall et ai., 1987; than those of smoking cigarettes.
Killen, Maccoby, & Taylor, 1984). These studies were Evidence also indicates that the gum is more helpful
conducted in smoking clinics and produced mixed re- to smokers who are highly dependent on nicotine
sults. Some indicated nicotine gum plus behavioral (e.g., Fagerstrom, 1982; S. M. Hall et ai., 1985; Jar-
treatment was superior to low-contact nicotine gum vik & Schneider, 1984). One method for evaluating a
controls(S. M. Halletai., 1985; Killenetai., 1984). smoker's level of nicotine dependence is the
Others showed combined treatments to have lower ab- Fagerstrom Tolerance Scale (Fagerstrom, 1978). Al-
stinence rates than low-contact nicotine gum control though the scale has some methodological weaknesses
groups, although in no study were the differences sig- (Lichtenstein & Mermelstein, 1986), it has predicted
nificant (Ginsberg et ai., 1988; S. M. Hall et ai., which smokers will benefit most from nicotine gum
1987). (Fagerstrom, 1982; S. M. Hall et ai., 1985). Blood
Randomized trials in general medical practices have cotinine may also be useful (S. M. Hall et ai., 1985).
also produced mixed results. Lando, Kalb, and Nicotine gum is a useful adjunct to treatment, es-
McGovern (in press) compared nicotine gum com- pecially for smokers who are highly dependent on nic-
bined with behavioral self-help materials to nicotine otine. Some researchers have suggested that data de-
gum combined with a pamphlet. Contrary to predic- rived from published studies inflate the abstinence
tion, smokers who received self-help booklets did not rates obtained when the gum is dispensed by most
do better than smokers receiving the comparison pam- physicians, who have little experience with the gum,
phlets. Fagerstrom (1984) studied nicotine gum versus who may not be skilled in instructing patients in its
no gum and short versus long follow-up. Smokers pro- use, or who may not have the time to do so. We found
vided nicotine gum plus long follow-up had the highest no study of the efficacy of nicotine gum as usually
abstinence rates throughout the I-year follow-up peri- dispensed by physicians with populations comparable
od, but main effects of follow-up treatment were not to those in the controlled trials reviewed here. The
consistently significant. British Thoracic society (reviewed below) studied the
Randomized trials have not identified the nature of efficacy of the gum with physicians who had minimal
the support or guidance necessary for optimal use of (and probably typical) training in gum use, but sub-
nicotine gum. Explanations for these negative results jects were patients with chronic disease. Therefore,
may include minimal differences between comparison abstinence rates were not directly comparable.
groups (Fagerstrom, 1984; Lando et ai., 1988), and
small sample sizes. Most of the low-contact treatments Nicotine Fading. Nicotine-fading treatment is
in the clinic studies included at least four group ses- based on the assumption that a gradual reduction of the
sions that may have provided enough support (S. M. amount of nicotine ingested will facilitate abstinence
Hall et ai., 1985, 1987; Killen et ai., 1984). The op- (Foxx & Brown, 1979; Foxx, Brown, & Katz, 1981).
timallevel of support to supplement nicotine gum may Smokers decrease the number of cigarettes smoked
vary by sex and level of psychological dependence. and change to lower nicotine cigarettes, so that Federal
Evidence suggests that women may benefit from clinic Trade commission (FTC) yields of nicotine are de-
support more than do men (Ginsberg et ai., 1988). creased according to a predetermined schedule. Early
Another unresolved issue is length of administra- results were promising. Foxx and Brown reported 50%
tion. Many quitters return to smoking when the gum is abstinence at 6 months. At 2V2 years later, 50% of the
discontinued. Longer use of the gum improves quit subjects were still abstinent. Nicki, Remington, and
McDonald (1984) reported a comparable abstinence tingency management and relaxation. Contingency
rate. At 1 year, 46% of the subjects in the nicotine- management involves the use of a contract to specify
fading condition were abstinent. However, abstinence treatment goals and to enhance motivation for quitting
rates in later studies were not so high, ranging from 9% (e.g., Lando & McCullough, 1978; Paxton, 1980;
to 46% at 6-month to I-year follow-up (Bowers, Win- Stitzer & Bigelow, 1982). Contracts typically include
ett, & Frederiksen, 1987; Brown, Lichtenstein, McIn- monetary deposits or social contracts with peers. Re-
tyre, & Harrington-Kostur, 1984; Foxx & Axelroth, laxation techniques may be taught to smokers under
1983, Lando & McGovern, 1985; Prue, Davis, Mar- tape-recorded or therapist direction. Relaxation tech-
tin, & Moss, 1983). niques may be used to reduce the stress generated by
Thus, nicotine fading has not produced consistently quitting, or as a substitute for smoking in anxiety-pro-
high abstinence rates. The basic assumption of the ducing situations.
treatment may be flawed. FTC tar and nicotine yields The most effective use of self-management ap-
may be poor indicators of the actual amount of these proaches is in multicomponent programs, especially in
substances ingested (Benowitz, Hall, Heming, Jacob, combination with aversive smoking. Self-manage-
& Osmon, 1983), because smokers can titrate their ment procedures alone have not produced results better
intake by inhaling more deeply, more rapidly, or by than the generally expected rates of 20% to 30% absti-
smoking different numbers of cigarettes. This is less nence at follow-up (Pechacek & McAlister, 1980).
the case at very low tar and nicotine levels, or when
few cigarettes are smoked (Benowitz, Jacob, Yu, Tal-
Summary: Clinic-Based Interventions
cott, Hall, & Jones, 1986). Nevertheless, these data
suggest that nicotine fading differs little from any grad- Clinic-based interventions can result in high absti-
ual reduction strategy so far as the amount of nicotine nence rates. Aversive smoking and nicotine gum are
ingested is concerned. Hence, one would not expect the most promising approaches. They are currently the
markedly different abstinence rates. treatments of choice. Both are expensive, however,
and require highly trained professionals for effective
Self-Management Procedures. Self-manage- administration.
ment procedures include many behavioral procedures Nicotine fading and self-management interventions
implemented under professional supervision. Self- have a role in programs for smokers for whom aversive
management programs include (1) the recording of smoking is contraindicated, or who cannot tolerate
one's own smoking behavior, (2) changes in the ante- nicotine gum. Both can be used in settings where pro-
cedent consequences of one's smoking response, and fessionals are too expensive or not available.
(3) developing awareness of and changing cue-elicited
smoking patterns (Schwartz, 1987).
Because awareness of stimuli that control smoking Relapse Prevention
behavior is central to this approach, self-monitoring is
a basic element in all self-management procedures. Almost all interventions for tobacco dependence
Smokers may monitor behaviors, such as the number have relapse prevention as a goal. However, a few
of cigarettes smoked, nicotine intake, and the time, interventions evaluated specific components that are
place, activity, and mood when smoking each cigarette designed to decrease relapse. Those aimed at relapse
(e.g., Abrams & Wilson, 1979; Foxx & Axelroth, can be partitioned by whether they are based on a the-
1983; McFall & Hammen, 1971; Moss, Prue, Lomax, oretical model or whether they are atheoretical. Sever-
& Martin, 1982). al studies have examined the effects of nonspecific
Self-management procedures combined with self- continued support from a theoretical perspective.
monitoring include gradual reduction and stimulus However, there are theoretically derived interventions
control techniques. Gradual reduction entails the set- that are based on either the cognitive-behavioral model
ting of goals to reduce gradually the number of ciga- emphasizing coping skills (S. M. Hall, 1980; Marlatt
rettes smoked. This technique is frequently used in & Gordon, 1979) or the pharmacologic model.
combination with a stimulus control procedure, in A straightforward method to prevent relapse is to
which the number of situations in which smoking oc- provide some kind of social support after treatment.
curs is gradually reduced. Usually, this takes the form of continued group meet-
Other self-management procedures include con- ings. Several studies have evaluated such support. Evi-
dence for continued nonspecific support is mixed. gum was available. Some relapse occurred when gum
Some studies find an effect (e.g., Tiffany, Martin, & use was stopped.
Baker, 1986), but most do not, or find an effect only In summary, specific, targeted interventions appear
while groups continue to meet (e.g., Brandon, promising. Most have solid theoretical underpinnings,
Zelman, & Baker, 1987). derived from specific relapse models (S. M. Hall,
More theoretically interesting and promising are in- 1980, Marlatt & Gordon, 1979). None has yet shown
terventions that are provided either during treatment or robust, replicable effects on smoking. The evidence
immediately afterward to teach skills and ways of for nicotine gum is stronger, although the theoretical
thinking that are specifically designed to prevent re- bases for using the gum as a relapse prevention strat-
lapse. Several such programs have been evaluated. egy are weaker. Pharmacologically, an ex-smoker
The first of these was a "self-control" program devel- should be nicotine free within 24 hours after quitting.
oped by Danaher (1977a), that included self-manage- Most clinicians agree that acute withdrawal symptoms
ment skills before providing aversive smoking for ces- are over within 7 to 10 days. Nicotine gum purports to
sation. The training was found to produce lower alleviate withdrawal symptoms. Use beyond this time
abstinence rates than a nonstructured discussion con- period can only be justified if a conditioned abstinence
trol. However, both the timing and the content of the syndrome model is used, where the gum is seen as a
self-management intervention may have operated conditioned response to stimuli that elicit the urge to
against success. Before quitting, most smokers have smoke.
difficulties in thinking about anything other than quit-
ting. Relapse prevention seems of secondary impor-
tance. In addition, the program itself was complex and Thoughts for the Future
multifaceted. An overly complex program may be too
difficult to learn. Clinical reports and informal observation suggest
1. R. Davis and Glaros (1986) compared a multi- that smoking rates are dropping as smoking becomes
component smoking relapse prevention program, less convenient, because of legislation about smoke-
which was based on Marlatt and Gordon's model of free environments, and more socially disapproved.
relapse, with controls that received only Pomerleau Given these trends, we predict that the rate of smoking
and Pomerleau's (1977) smoking program, or that re- will drop among many segments of the population but
ceived the Pomerleau and Pomerleau program and a not among others. We anticipate a steady smoking rate
discussion of high-risk situations. There were no dif- among patients who have chronic smoking-related dis-
ferences in abstinence rates. However, subjects in the eases, among patients with other psychiatric and psy-
relapse prevention condition took longer to relapse and chological disorders, and possibly among other disad-
smoked fewer cigarettes when they did relapse. vantaged segments of the population. We suggest that
A targeted, skill-training-based, relapse prevention ill and mentally impaired smokers will continue to
intervention that was based on a cost benefit model (S. smoke at higher rates than the rest of the population
M. Hall, 1980) was reported by Hall and her col- because they are among the most physically or psycho-
leagues (S. M. Hall etal. , 1984,1985,1987). Subjects logically dependent, or because smoking is perceived
were taught relapse prevention skills through role play- to meet needs in their lives that cannot be otherwise
ing and cognitive rehearsal. Substantial abstinence filled. Members of disadvantaged groups may con-
rates have been obtained. However, abstinence rates tinue to smoke because they have less access to public
have fluctuated considerably from study to study. health information, and perhaps because they are less
These fluctuations could not be attributed to dif- likely to believe that to which they do have access. We
ferences in the sample, in therapists, or in the treat- know of no studies specifically addressing the needs of
ment. It is possible they may reflect the large confi- either the disadvantaged or the psychiatrically im-
dence intervals that occur when moderate sample sizes paired smokers. However, studies of smoking inter-
are used with dichotomous variables, such as absti- ventions in smokers with chronic disease exist. Both
nence. Sirota, Curran, and Habif (1985) and R. G. Hall et al.
Both S. M. Hall etal. (1985, 1987) and Killen etal. (1984) reported good results with chronically ill
(1984) used nicotine gum as a relapse prevention strat- smokers. Sirota et al. (1985) used nicotine fading,
egy. Both found excellent abstinence rates when the stimulus control, and relapse prevention skill training.
R. G. Hall et al. used rapid smoking in a medical Benowitz, N., Jacob, P., Yu, L., Talcott, R., Hall, S., & Jones,
context. Both groups of investigators reported absti- R. T. (1986). Reduced tar, nicotine, and carbon monoxide
exposure while smoking ultralow- but not low-yield ciga-
nence rates of 50% at about 1 to 2 years. Both trials rettes. Journal of the American Medical Association, 256,
lacked randomly assigned control groups. However, 241-246.
R. G. Hall et al. did report a zero continuous absti- Benowitz, N. L. (1987). The use of biological fluid samples in
nence rate for waiting list control subjects. assessing tobacco smoke consumption. In 1. Grabowski & C.
S. Bell (Ed.), Measurement in the analysis and treatment of
Two controlled trials have reported less optimistic smoking behavior (pp. 6-25). Rockville, MD: National In-
outcomes. S. M. Hall, Bachman, Henderson, Bar- stitute on Dmg Abuse.
stow, and Jones (1983) randomly assigned smokers Berecz, J. M. (1979). The reduction of cigarette smoking
through self-administered wrist band aversion therapy. Behav-
with chronic disease to either a health motivation treat- ior Therapy, 10, 669-675.
ment or an aversive smoking treatment group. The Best, J. A., Owen, L. E., & Trentadue , L. (1978). Comparison
health motivation treatment emphasized the benefits of of satiation and rapid smoking in self-managed smoking ces-
quitting, encouraged self-management, and provided sation. Addictive Behaviors, 3, 71-78.
Bowers, T. G., Winett, R. A., & Frederiksen, L. W. (1987).
a film about quitting. The aversive smoking group re- Nicotine fading, behavioral contracting, and extended treat-
ceived eight slow-paced aversive smoking sessions, ment: Effects on smoking cessation. Addictive Behaviors, 12,
relaxation training, and relapse prevention training. At 181-184.
Brandon, T. H., Zelman, D. C., & Baker, T. B. (1987). Effects
the 6-month follow-up, the health motivation group
of maintenance sessions on smoking relapse: Delaying the
had 26% abstinence (verified by CO) versus only 6% inevitable? Journal of Consulting and Clinical Psychology,
for the aversive smoking group. However, these dif- 55, 780-782.
ferences were not statistically significant. British Thoracic Society (1983). Comparing four methods of
smoking withdrawal in patients with smoking related disease.
The British Thoracic Society (1983) randomly as- British Medical Journal, 286, 595-597.
signed chronically ill smokers to either (1) physician Brown, R. A., Lichtenstein, E., McIntyre, K. 0., & Harrington-
advice, (2) advice plus a booklet, (3) advice and Kostur, 1. (1984). Effects of nicotine fading and relapse pre-
placebo gum, and (4) advice plus nicotine gum. Con- vention on smoking cessation. Journal of Consulting and
Clinical Psychology, 52, 307-308.
tinuous abstinence rates at 1 year ranged from 10% to Comstock, G. w., & Stone, R. W. (1972). Changes in body
14%. Differences were not significant, despite a large weight and subcutaneous fatness related to smoking habits.
sample size (N = 1,550). Archives of Environmental Health, 24, 271-276.
Cullen, I. W. (1983, November). Opportunities for physician
The conflicting results suggest the study of treat- intervention in smoking cessation. Paper presented at the Con-
ment for chronically ill smokers is in its infancy. Fur- ference on Problems and Cessation of Smoking. Dusseldorf,
ther direction for research includes more work in the Germany.
intriguing area plus studies of other special popula- Danaher, B. G. (1977a). Rapid smoking and self-control in the
modification of smoking behavior. Journal of Consulting and
tions. Clinical Psychology, 45, 1068-1075.
Danaher, B. G. (1977b). Research on rapid smoking: Interim
ACKNOWLEDGMENTS. Preparation of this chapter was summary and recommendations. Addictive Behaviors, 2,
151-166.
aided by funding from grants ROI-DA02538, ROl- Danaher, B. G., & Lichtenstein, E. (1978). Become an ex-
DA03082, K02-00065 from the National Institute on smoker. Englewood Cliffs, NI: Prentice-Hall.
Drug Abuse, HL39201 from the National Heart, Lung, Danaher, B. G., Jeffery, R. W., Zimmerman, R., & Nelson, E.
and Blood Institute, and PB- 5 from the American (1980). Aversive smoking using printed instructions and au-
diotape adjuncts. Addictive Behaviors, 5, 353-358.
Cancer Society. Davis, A. L., Faust, R., & Ordentlich, M. (1984). Self-help
smoking cessation and maintenance programs: A comparative
study with 12-month follow-up by the American Lung Asso-
ciation. American Journal of Public Health, 74, 1212-1217.
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372-382. Lichtenstein, E., Harris, D. E., Birchler, G. R., Wahl, J. M., &
Hall, S. M., Bachman, 1., Henderson, 1. B., Barstow, R., & Schmahl, D. P. (1973). Comparison of rapid smoking, wann,
Jones, R. T. (1983). Smoking cessation in patients with car- smoky air, and attention placebo in the modification of smok-
diopulmonary disease: An initial study. Addictive Behaviors, ing behavior. Journal of Consulting and Clinical Psychology,
8,33-42. 40,92-98.
Hall, S. M., Tunstall, C. D., Ginsberg, D., Benowitz, N. L., & Marlatt, G. A., & Gordon, 1. R. (1979). Determinants of relapse:
Jones, R. T. (1987). Nicotine gum and behavioral treatment: A Implications for the maintenance of behavior change. In P.
placebo controlled trial. Journal of Consulting and Clinical Davidson (Ed.), Behavioral medicine: Changing lifestyles
Psychology, 55, 603-605. (pp. 410-452). New York, Brunner/Mazel.
Mausner,1. S., Mausner, B., & Rial, W. Y. (1968). The influ- trial of the effect on middle-aged men of the advice to stop
ence of a physician on the smoking of his patients. American smoking. Journal of Epidemiology and Community Health,
Journal of Public Health, 58, 46-53. 32, 275-281.
McFall, R. M., & Hammen, C. L. (1971). Motivation, structure, Russell, M. A. H., Raw, M., Taylor, C., Feyerabend, C., &
and self-monitoring: Role of non-specific factors in smoking Saloojee, Y. (1978). Blood nicotine and carboxyhemoglobin
reduction. Journal ofConsulting and Clinical Psychology, 37, levels after rapid-smoking aversion therapy. Journal of Con-
80-86. sulting and Clinical Psychology, 46, 1423-1431.
Miller, L. C., Schilling, A. F., Logan, D. L., & Johnson, R. L. Russell, M. A. H., Wilson, C., Taylor, C., & Baker, C. D.
(1977). Potential hazards of rapid smoking as a technique for (1979). Effect of general practitioners' advice against smok-
the modification of smoking behavior. New England Journal ing. British Medical Journal, 2, 231-235.
of Medicine, 297, 590-592. Russell, M. A. H., Raw, M., & Jarvis, M. J. (1980). Clinical use
Moss, R. A., Prue, D. M., Lomax, D., & Martin, 1. E. (1982). of nicotine chewing gum. British Medical Journal, 280,
Implications of self-monitoring for smoking treatment: Effects 1599-1602.
on adherence and session attendance. Addictive Behaviors, 7, Sachs, D. P. L., Hall, R. G., & Hall, S. M. (1978). Effects of
381-386. rapid smoking. Physiologic evaluation of a smoking cessation
National Cancer Institute: The smoking digest. (1977, October). therapy. Annals of Internal Medicine, 88, 639-641.
Progress report on a nation kicking the habit. Bethesda, MD: Schmahl, D. P., Lichtenstein, E., & Harris, D. E. (1972). Suc-
U.S. Department of Health, Education and Welfare; Public cessful treatment of habitual smokers with warm, smoky air
Health Service; National Institutes of Health; and National and rapid smoking. Journal of Consulting and Clinical Psy-
Cancer Institute. chalogy, 38, 105-IlI.
Nicki, R. M., Remington, R. E., & MacDonald, G. A. (1984). Schneider, S. 1. (1987). Trial of an on-line behavioral smoking
Self-efficacy, nicotine-fading/self-monitoring and cigarette- cessation program. Computers in Human Behavior, 2, 277-
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rapid-smoking treatment procedure. Addictive Behaviors, 2, and Biomedical Research, 17, 409-415.
21-25. Schwartz, 1. L. (1987). Review and evaluation of smoking con-
Paxton, R. (1980). The effects ofa deposit contract as a compo- trol methads: The United States and Canada, 1978-1985.
nent in a behavioral program for stopping smoking. Behaviour Division of Cancer Prevention and Control, National Cancer
Research and Therapy, 18, 45-50. Institute, U.S. Department of Health and Human Services,
Pechacek, T. F., & McAlister, A. L. (1980). Strategies for the Public Health Service. (NIH Publication No. 87-2940). Wash-
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257-298. tion in chronically ill medical patients. Journal of Consulting
Pomerleau, O. F., & Pomerleau, C. S. (1977). Break the smok- and Clinical Psychology, 41, 575-579.
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Champaign, II: Research Press. ment for reduced carbon monoxide levels in cigarette smok-
Prue, D. M., Davis, C. J., Martin, 1. E., & Moss, R. A. (1983). ers. Addictive Behaviors, 7, 403-412.
An investigation of a minimal contact brand fading program Tiffany, S. T., Martin, E. M., & Baker, T. B. (1986). Treatment
for smoking treatment. Addictive Behaviors, 8, 307-310. for cigarette smoking: An evaluation of the contributions of
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Raw, M., Jarvis, M. 1., Feyerabend, c., & Russell, M. A. H. medical risk. Journal of Clinical Psychology, 34, 574-577.
(1980). Comparison of nicotine chewing gum and psychologi- Tunstall, C. D., Ginsberg, D., & Hall, S. M. (1984). Quitting
cal treatments for dependent smokers. British Medical Jour- smoking. International Journal of the Addictions, 20, 1089-
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Rose, G., & Hamilton, P. 1. S. (1978). A randomized controlled
CHAPTER 22
Obesity
Thomas A. Wadden and Susan T. Bell
Obesity is a puzzling disorder. It is easily defined and multiple causes. We will then discuss the assessment
diagnosed, and its treatment could not seem more and treatment of this disorder and conclude with rec-
straightforward-eat less and exercise more. And yet ommendations for future research.
more than 25% of Americans are significantly over-
weight (Van Itallie, 1985).
Research on obesity has increased exponentially Definition and Epidemiology
during the past decade and has yielded a number of
important findings. Foremost among these is that Obesity is characterized by an excessive accumula-
obesity is a highly heritable disorder-a fact that was tion of body fat and is defined as a fat content greater
long suspected but only recently verified (Stunkard, than 35% in women and 30% in men (Van Itallie &
Foch, & Hrubec, 1986; Stunkard, Sorenson, et aI., Margie, 1981). Body fat may be determined by hydro-
1986). Moreover, obesity in some persons may be at- static weighing, skin fold thicknesses, or a number of
tributable to their inheritance of a low metabolic rate other methods, but is usually estimated on the basis of
(Bouchard et al., in press). body weight. A body weight 20% greater than that
The treatment of obesity has improved markedly in recommended by height-weight tables is indicative of
the past decade. There are now therapies for persons obesity (except in cases of large boned or very mus-
needing to lose2.0kgto 50.0kg (Stunkard, 1984), and cular persons). By this criterion, 23% of American
researchers have begun to develop more effective strat- men, 27% of women, and 10% of children are obese
egies for maintenance of weight loss (Perri et al., (Van Itallie, 1985).
1988). Results of treatment should continue to im- The prevalence of obesity varies greatly according
prove with the realization that obesity is, in many to age, race, and socioeconomic status. There is a
cases, a chronic disorder requiring long-term care. steady increase in prevalence from childhood to age
In this chapter, we will define obesity, review its 50, with a two- to three-fold increase from ages 20 to
epidemiology and complications, and examine its 64 (Stunkard, 1983a). Black women and men 35 to 54
years of age are consistently more obese than are their
white counterparts, with the prevalence in older black
Thomas A. Wadden • Department of Psychiatry, University women reaching a striking 61 % (Van Itallie, 1985).
of Pennsylvania School of Medicine, Philadelphia, Pennsylva-
Obesity is six times more common in women of low
nia 19104. Susan T. Bell • Graduate School of Educa-
tion, University of Pennsylvania, Philadelphia, Pennsylvania socioeconomic status than in those of higher status
19104. (Goldblatt, Moore, & Stunkard, 1965).
449
Complications and is likely to make the overweight person feel as if he

or she "does not fit in." There may also be racial
The health complications of obesity are a topic of differences in preferred body type that affect psycho-
lively debate. Persons 30% or more overweight are . logical responses to obesity. Blacks and other minor-
clearly at increased risk of hypertension, diabetes, ities do not appear to value thinness to the same extent
gallbladder disease, coronary artery disease, and sud- as whites (Wadden, Stunkard, Rich et al., in press).
den death (Bray, 1976, 1986). The health risks of mild This fact may help to explain the very low prevalence
obesity (up to 30% overweight) are disputed. Re- of eating disorders (i.e., bulimia and anorexia) in
searchers from the Framingham study (Garrison & blacks as compared with whites.
Castelli, 1985) believe that persons as little as 10%
overweight are at increased risk of complications, but
Andres and his colleagues contend that health risks are The Multiple Causes of Obesity:
age dependent (Andres, Elahi, Tobin, Muller, & Biological Factors
Brant, 1985). In their opinion, weights recommended
by the 1983 Metropolitan Life Insurance tables for Risk factors for obesity can be divided into three
optimal life expectancy are generally too heavy for broad categories: (1) biological, (2) behavioral, and
persons 25 and younger and too light for persons 45 (3) the interaction of the two. This division is clearly
and older. artificial since all behavior ultimately has a biological
Recent evidence has shown that the distribution of basis. However, the division allows us to look at events
body fat affects health (Bjomtorp, 1985; Lapidus et over which obese persons have greater (i.e., behav-
ai., 1984). Persons whose fat is confined primarily to ioral) and lesser (i.e., biological) degrees of control.
the upper body (android type) are at greater risk of
diabetes and cardiovascular disease than are those
Genetics
whose weight is confined to the lower body (gynecoid
type) (Lapidus et al., 1984). Although their risks are Lay persons and researchers have long known that
reduced, persons with lower body obesity are, never- obesity "runs in families." However, the question has
theless, more vulnerable to health complications than remained whether this familial similarity was at-
are nonobese persons. tributable to shared genes or shared eating and exercise
habits.
Stunkard and his colleagues have now demonstrated
Psychological Complications
in a series of studies of twins and adoptees that human
Obese individuals are subjected to prejudice and fatness is under substantial genetic control (Stunkard,
discrimination in school, work, and social settings Foch, & Hrubec, 1986; Stunkard, Sorenson, et al ..
(Wadden & Stunkard, 1985). Such discrimination 1986). Figure 1 shows the weights of 540 Danish adop-
could easily lead to feelings oflow self-esteem, inade- tees compared with the weights of both their biological
quacy, and self-contempt. Thus, it is surprising (and a and adoptive parents. The adoptees were divided into
tribute to the overweight) that most population studies the four classes of thin, median, overweight and
have found no differences between obese and average obese, whereas parental degree of obesity was as-
weight persons on measures of depression or anxiety sessed by the body mass index (BMI) (weight in kilo-
(Kaplan & Wadden, 1986; Wadden, Foster, Brownell, grams/height in meters squared; higher scores indicate
& Finley, 1984; Wadden, Foster, Stunkard, & greater obesity). The reader will note the increase in
Linowitz, 1989; Wadden & Stunkard, 1985). the BMI of biological parents with the increase in the
The psychological complications of obesity are like- weight class of the adoptees. No such increase was
ly to be context dependent, however (Wadden, Foster, found with the adoptive parents.
et al., 1989). Thus, obese persons from lower social Heritability estimates of obesity were not obtained
classes are not as likely to experience weight-related in this study. Estimates from twin studies, however,
distress as are overweight persons from the upper indicate that genetic factors account for approximately
class. The reason is that obesity is quite common in the 64 to 88% of the variance in weight (and/or fat)
lower social classes and, thus, perhaps is not a source (Stunkard, Foch, & Hrubec, 1986).
of shame (Moore, Stunkard, & Srole, 1962). By con- Overweight persons are understandably chagrined
trast, obesity is much less common in the upper class by findings of a major genetic component to obesity.
CHAPTER 22 • OBESITY 451
27 Biologicol Po rents Adoptive Po rents
en 26
C
I!!
c
a.. 25
-8'"c 24
:ll
~ 23
>-
"C
o
m 22
21~--.----r---.----'--
n m n m
Thin Median Overweighl Obese Thin Median Overweighl Obese
Adoptee Weight Closs Adoptee Weight Class
Figure 1. Mean body-mass index of parents of four weight classes of adoptees. Note the increase in mean body-
mass index of biologic parents with the increase in weight class of adoptees. No such increase was found with
adoptive parents. Bars represent 1 SEM. BF = biologic fathers; BM = biologic mothers; AF = adoptive fathers;
AM = adoptive mothers. From A. J. Stunkard, T. I. A. Sorensen, C. Hanis, T. W. Teasdale, R. Chakraborty, W. J.
Schull, and F. Schulsinger, 1986, "An Adoption Study of Human Obesity" by New England Journal ofMedicine,
314, p. 195. Copyright 1986 by Massachusetts Medical Society. Reprinted by permission.
The practitioner must be careful to explain that these those with normal or elevated metabolic rates (Rav-
findings do not mean that weight control is impossible, ussin et at., 1988; Roberts, Savage, Coward, Chew, &
though it will be more difficult. The patient's dietary Lucas, 1988). We have observed obese women in our
and exercise habits can still play a significant role in clinic of roughly equivalent age, height, and weight
minimizing the tendency toward obesity, as suggested whose metabolic rates differed by as much as 1,000
by studies of laboratory animals predisposed toward calories a day (Foster et at., 1988).
obesity (Sclafani, 1980). The practitioner should also Metabolic rate can be measured easily and inexpen-
use this information about genetic causes to help self- sively by indirect calorimetry (Feurer & Mullen,
critical patients stop blaming themselves for perceived 1986). This service is often provided by pulmonary
deficiencies of will power. departments in hospitals and by sports medicine clinics
and should be used to evaluate patients who report
gaining weight on low-caloric intakes.
Basal Metabolic Rate
Researchers are far from identifying the specific
Fat Cell Number
genes that produce obesity in humans. Low basal met-
abolic rate and increased fat cell number are two fac- Persons of average weight have approximately 25 to
tors, however, which may be inherited and are likely to 35 billion fat cells (Leibel, Berry, & Hirsch, 1983).
play a significant role in causing obesity. Persons with hypertrophic obesity have essentially
Basal metabolic rate accounts for roughly 60%- normal fat cell number but fat cell size and weight are
75% of daily energy expenditure (Danforth & Land- increased (i.e., hypertrophied). Persons with hyper-
sberg, 1983), as seen in Figure 2, and is the single best plastic obesity may have as many as 100 to 150 billion
determinant of weight loss on a fixed-calorie diet (Gar- fat cells; cell size and weight are also usually increased
row, 1981). Studies of twins by Bouchard et at. (in (Hirsch & Knittle, 1970; Leibel et at., 1983; Sjostrom,
press) have shown that basal metabolic rate is highly 1980). Persons with hyperplastic obesity tend to be
heritable. Additional longitudinal studies of infants markedly overweight and are unlikely to achieve
and adults have shown that individuals with low meta- "ideal" weight even with extremely rigorous dieting.
bolic rates are more likely to become obese than are The reason is that fat cell number is apparently irre-
:p------------------.
AT : Since fat cell number cannot apparently be decreased, weight
-------------------
TEF
gain results in a biological trap: each time weight is gained over
previous levels, new fat cells are formed but weight losses do not
result in any decrease in fat cell number. (p. 96)
TEE
Set-Point Theory
------------ ------
The set-point theory of weight regulation holds that
body weight (or body fat) is regulated at a relatively
constant level in much the same manner as body tem-
perature, blood pressure, or blood glucose levels
RMR (Keesey, 1980, 1986). The most important corollary of
"BMR" set-point theory is that an organism will defend its
weight against pressures to change; deviations from
the set point are met by compensatory responses de-
signed to return the organism to its original weight.
Keesey (1986) has shown in rats that underfeeding and
weight loss are met by a reduction in the animal's basal
metabolic rate, designed to preserve body weight (or
fat free mass), whereas overfeeding and weight gain
are met by increases in metabolic rate, designed to
Figure 2. Schematic presentation of 24-hour energy expendi-
ture in a sedentary subject. BMR = the basal metabolic rate or prevent greater obesity.
the nadir of energy expenditure during the early morning. RMR Set-point theory holds that weight is regulated in
= the resting metabolic rate throughout the day, which is not part humans, as in laboratory animals, and there is evi-
of the increased energy expenditure that follows meals and exer-
cise. TEE = the thermic effect of exercise. TEF = the thermic dence for the relative stability of human body weight
effect of food. AT = adaptive thermogenesis, which is also (W. Bennett & Gurin, 1982; Stunkard 1982a). Obesity
referred to in humans and animals as nonshivering ther- represents a special case in which weight is regulated
mogenesis, and in animals as facultative or regulatory ther- but at an elevated level; some women 165 cm tall are
mogenesis; this compartment is still controversial in humans.
From "Thermogenesis, Obesity, and Thyroid Hormone" by E. programmed to maintain a weight of 90 kg, while oth-
Danforth, 1981, Thyroid Today, 4, p. 3. Copyright 1981 by First ers maintain weights of 60 kg or 55 kg. The obese
Laboratories. Reprinted by permission. individual's attempts to achieve a lower body weight
through dieting are likely to be thwarted by the unre-
lenting set point (w. Bennett & Gurin, 1982).
versible; once created, adipocytes remain for life Set-point theory is essentially untestable in humans.
(Sjostrom, 1980). Investigators have no methods of identifying a priori
Cross-sectional studies have suggested that there are an individual's set point, and ethical considerations
two critical periods of fat cell proliferation: the second prevent definitive experiments from being conducted.
year of life and, in females, early adolescence. Obese It is apparent, however, that metabolic rate and fat cell
children and adolescents have been shown to have up number are two mechanisms that may serve in some
to twice the number of adipocytes as their normal persons to maintain an elevated body weight, or, in
weight peers (Knittle, Timmens, Ginsberg-Fellner, other terms, an elevated set point (Keesey, 1986). Per-
Brown, & Katz, 1979). Sjostrom (1980) believes that sons with low metabolic rates will become overweight
fat cell number increases continuously throughout life when consuming the same diet on which others of the
rather than being limited to critical periods. New cells same height, sex, and age maintain a normal weight
appear to be synthesized when existing cells exceed (Ravussin et al., 1988). And persons with severely
their capacity for triglyceride storage and can be syn- increased fat cell number are unlikely to attain ideal
thesized in adulthood in response to marked weight weight no matter how rigorously they diet; the excess
gain. Sjostrom (1980) has noted the regrettable conse- cell number dictates that they will have excess body fat
quences of this continued cell proliferation in response (Sjostrom, 1980).
to weight gain: Dieters react to news about set-point theory with the
same gloom elicited by that concerning the genetics of has been shown to be an oversimplification of a far
obesity. Practitioners must again explain that although more complex problem (Stunkard, 1982b). Although
weight does appear to be regulated, most people prob- it is true that obesity results from a caloric imbalance,
ably have a broad range in which their body weight can principles of learning may not be involved in this ac-
be regulated. This possibility has been suggested by cumulation of excess calories. Instead, the genetic and
studies of rats, some strains of which will double their metabolic processes discussed above may play a far
weights when fed a high-fat "supermarket diet," more important role, in some persons, than do eating
which includes generous portions of junk food and exercise behaviors. Learning principles may prove
(Sclafani, 1980; Sclafani & Springer, 1976). Their de- important in teaching patients to adapt to a biological
gree of weight gain can be limited by allowing them to condition, rather than in correcting purportedly inap-
exercise, and their weight falls toward baseline levels propriate eating habits. We will briefly review several
when they are returned to a standard chow diet of the other behavioral assumptions.
(Sclafani, 1980). These findings indicate that the set
point is not completely "set" and that the point at
Eating Behavior
which weight is regulated is significantly affected by
diet and exercise. Caloric Intake. The behavioral model suggests
that overweight individuals consume more calories
than do their average weight peers. However, studies
The Multiple Causes of Obesity: of mild to moderately obese persons have failed to
Behavioral Factors support this premise. Garrow (1974) found that in 12
of 13 studies, obese persons reported consuming no
Future research will improve our understanding of more calories than did their nonobese counterparts,
the role of genetic, metabolic, and related factors in and Wooley, Wooley, and Dyrenforth (1979) have
causing obesity. For the time being, we know that noted seven additional studies that question the as-
obesity results from an energy imbalance in which sumption of increased caloric intake. In the best study
energy intake exceeds energy output (Garrow, 1974, to date, which was conducted on a metabolic ward,
1978, 1981). Simply put, overweight individuals con- Leibel and Hirsch (1984) found that a group of reduced
sume more calories than their bodies need; their bodies obese persons, who remained 60% overweight, re-
respond to this imbalance by increasing fat storage. quired 100 calories less per day to maintain their
Traditional conceptions of obesity have focussed on weight than did the average weight controls. A small
the energy intake side ofthe equation and, specifically, study by Waxman and Stunkard (1980) revealed that
on the eating and exercise habits of obese persons obese boys did consume significantly more calories
(Stunkard, 1982b). than did their nonobese peers, but other studies of chil-
dren have failed to observe overconsumption among
the obese (Brownell & Stunkard, 1980a).
Behavioral Model of Obesity
In the behavioral model, obesity is seen as a learned Eating Habits. The behavioral model further as-
disorder in which overeating and underexercising are sumes that obese and nonobese persons differ in their
created by and amenable to principles of conditioning. eating styles. This premise was originally proposed by
This model also suggests that obese individuals are Ferster, Nurnberger, and Levitt (1962), who portrayed
distinguishable by their excess caloric intake, their the obese eating style as the quick ingestion of food,
oversensitivity to food cues, and their unique eating involving large bites at frequent intervals. Subsequent
style. Finally, the model assumes that obese indi- studies, however, did not support these claims
viduals need only modify eating and exercise habits to (Adams, Ferguson, Stunkard, & Agras, 1978;
lose weight (Stunkard, 1982b). Kisseleff, Jordan, & Levitz, 1978; Rosenthal & Marx,
Surprising to researchers and lay persons alike, the 1978; Stunkard, ColI, Lundquist, & Meyers, 1980;
behavioral model has not held up to empirical exam- Stunkard & Kaplan, 1977). In reviewing this liter-
ination; experimental studies have generally failed to ature, Stunkard (1982b) concluded that, "the eating
support its principal assumptions. The cardinal as- style of obese individuals seems to be indistinguisha-
sumption, that obesity results from a learning disorder, ble from nonobese people."
Externality. Support for the view of the obese indi- stairs (Brownell & Stunkard, 1980b). Thus, the pre-
vidual as an overeater was provided by Schacter's scription provided in most behavioral programs for
(1968) theory of externality. He and Rodin proposed patients to increase their physical activity is highly
that appropriate. Physical activity accounts for a relatively
small degree of total daily energy expenditure, but
the eating behavior of the obese, under conditions of high cue or patients have greater control over this compartment of
cognitive salience is stimulus bound. A food-relevant cue, above
a given level of prominence, appears more likely to trigger an
energy expenditure than they do over the other com-
eating response in an overweight than in a normal weight person. partments shown in Figure 2.
(Rodin, 1980, p. 228) Findings of decreased physical activity in obese
adults, however, do not necessarily mean that inac-
The externality theory, which led to the adoption of tivity causes obesity; inactivity may instead result
stimulus control measures in behavioral treatment, from obesity (Brownell & Stunkard, 1980b). This pos-
was generally not supported by subsequent empirical sibility has been suggested by studies of children,
investigations. It appears that most people are sen- which are divided evenly between those showing less
sitive to external cues, regardless of their weight activity in obese children and those showing no dif-
(Leon, Roth, & Hewitt, 1977; Mahoney, 1974; ferences (Brownell, 1982). Waxman and Stunkard
Meyers, Stunkard, & ColI, 1980; Milich, 1975; Mil- (1980) converted measures of activity to caloric ex-
ich, Anderson, & Mills, 1976). penditure and found that obese boys, by virtue of their
greater weights, actually expended more calories
Behavior Change and Weight Loss. Data on through activity than did their average weight peers.
behavior change and weight loss have also generally
failed to support assumptions of the behavioral model.
Evaluation of the Behavioral Model
It is still unclear whether weight loss in behavioral
programs is attributable to patient adherence to pre- With the exception of findings for physical activity,
scribed eating and exercise behaviors or to other causal research has generally not supported assumptions of
factors (Brownell & Stunkard, 1978). Initial studies the behavioral model of obesity. Nevertheless, patient
using self-reports of daily eating behaviors showed reports and observations from our clinical work at the
significant relationships between habit change and University of Pennsylvania indicate that some obese
weight loss (Hagen, 1974; Wollersheim, 1970). individuals clearly do overeat. Many report that they
Subsequent studies, however, which used global usually overeat in private to avoid shame and disap-
ratings and direct observations of habit change, rather proval and explain that their public eating (i.e., restau-
than questionnaires, produced contradictory findings; rants, bars, etc.) bears little resemblance to their pri-
several studies failed to show a relationship between vate eating. They report that they are least likely to
behavior change and weight change (Brownell, keep accurate records of food and calorie intake when
Heckerman, Westlake, Hayes, & Monti, 1978; Jeffery, they have been overeating.
Wing, & Stunkard, 1978; Pearce, leBow, & Orchard, Given these clinical impressions, as well as the suc-
1981; Stalonas, Johnson, & Christ, 1978). In a recent cess of behavioral treatment (to be discussed shortly),
study by Stalonas and Kirschenbaum (1985), eating it would appear premature to dismiss entirely the as-
habits were found to account for only 21.1 % of the sumptions of the behavioral model. Practitioners must
variance in weight loss, and a comparison of the differ- recognize, however, that not all overweight patients
ent assessment strategies suggested that methodology overeat or underexercise. To treat them as if they do
may be responsible for the equivocal results in this can only damage the patient-practitioner relationship
area. and lead patients to blame themselves for their in-
ability to control their weight more satisfactorily.
Exercise
Obese adults are less physically active than are their Interaction of Biology and Behavior
average weight peers, as determined by self-reports,
pedometers, a device that discriminates standing from Some persons appear to be born with a predisposi-
sitting, and the spontaneous use of escalators in lieu of tion toward obesity, which may be exacerbated by diet-
ing and other efforts to control weight. The problems his food efficiency. These events purportedly increase
of restrained eating and weight cycling are two cases in the likelihood of weight regain and make subsequent
point. efforts to lose weight more difficult.
Weight cycling theory has not been adequately test-
ed at present. Animal data pertaining to the theory are
Restrained Eating
contradictory (Cleary, 1986; Gray, Fisler, & Bray,
Herman and Polivy (1980) have identified a popula- 1988), as are human data concerning changes in meta-
tion of individuals who chronically restrain their eating bolic efficiency following weight loss (Albu, Heshka,
in order to maintain a desirable body weight. These & Heymsfield, 1988; Barrows & Snook, 1987; Yang,
individuals use will power and cognitive control to Heshka, & Pi-Sunyer, 1988). In addition, studies ex-
stop themselves from eating as much as they would amining the relationship between dieting history (i.e.,
like. Restrained eaters thus differ markedly from unre- number of diets and pounds lost) and subsequent
strained eaters who are generally free of the preoc- weight loss have yielded contradictory findings. Two
cupying thoughts and behaviors associated with studies reported a positive relationship between these
weight control. Some restrained eaters may well have a events-the greater the number of previous diets (or
biological predisposition toward obesity (i.e., low pounds lost), the greater the subsequent weight loss
metabolic rate, increased fat cells, etc.) which they (Bonato & Boland, 1987; Gormally, Rardin, & Black,
fight through chronic dieting; unrestrained eaters are 1980). Three others reported a negative relationship
more likely to be free of this predisposition or, at least, (Foster & Jeffery, 1986; Jeffery, Snell, & Foster, 1985;
of social pressures to be thin. Jeffery et al., 1984), whereas a fourth found no rela-
Herman and Mack (1975) showed that restrained tionship (Carroll, Yates, & Gray, 1980). Despite the
eaters are extremely vulnerable to disinhibition of con- contradictory findings, weight cycling theory has in-
trol of their eating. When they initially overeat or con- troduced a needed note of caution that may deter some
sume "prohibited" foods, restrained eaters are likely persons from going on crash diets which are likely to
to continue overeating as a result of the perception that produce little more than rapid weight loss followed by
they have "blown their diet." Thus, restrained eaters equally rapid weight regain (Wadden & Stunkard,
consume more ice cream following consumption of 1986).
two milkshakes than following no preload. Unre-
strained eaters compensate for the milkshake preload
by eating less ice cream. Classification and Assessment
Dietary restraint, followed by binge eating, is uni-
formly observed in bulimics and in many obese per- The classification presented in Table 1, which was
sons (Fairburn, Cooper, & Cooper, 1986; Gormally, proposed by Stunkard (1984), enables clinicians to
Black, Daston, & Rardin, 1982). Bingeing is likely to classify the severity of the patient's obesity, make in-
lead to weight gain in obese patients, because most ferences concerning etiology, and recommend appro-
overweight individuals do not compensate for binge- priate treatment. The classification is a simple three-
ing by vomiting or using laxatives, as do bulimic pa- fold one of mild, moderate, and severe obesity,
tients. Behavioral treatment encourages obese patients characterized by body weights that are, respectively,
to avoid strict dietary restraint. 5% to 40%,40% to 100%, and 100% or more over-
weight. The percentages of obese women falling into
each category are also presented; these are percentages
Weight Cycling
of the obese female popUlation, not the entire female
Brownell and colleagues have recently proposed population (National Center for Health Statistics,
that the principal treatment for obesity-dieting- 1981).
may, in fact, only exacerbate weight control efforts Persons 5% to 40% overweight usually have hyper-
(Brownell, Greenwood, Stellar, & Shrager, 1986; trophic obesity with approximately normal fat cell
Steen, Opplinger, & Brownell, 1988). The weight cy- number. These persons generally have a good prog-
cling theory, which was derived from animal research, nosis for treatment and for reaching close to "ideal"
holds that each time an individual diets, he reduces his weight because cell hypertrophy is reversible
basal metabolic rate and lean body mass and increases (Sjostrom, 1980). As weight increases beyond 140%
Table 1. A Classfication of Obesity

Classification of obesity
Type Mild Moderate Severe

Percentage overweight 20%-40% 41%-100% >100%
Prevalence (among 90.5% 9.0% 0.5%
obese women)
Pathology Hypertrophic Hypertrophic, hyperplastic Hypertrophic, hyperplastic
Complications Uncertain Conditional Severe
Treatment Behavior therapy Low-calorie diet and Surgery
behavior therapy
Note. From "The Current Status of Treatment for Obesity in Adults" by A. J. Stunkard in Eating and Its Disorders (p. 158)
edited by A. J. Stunkard and E. Stellar, 1984, New York: Raven Press. Copyright 1984 by Raven Press. Adapted by
pennission.
of ideal, the probability increases that the patient's physical activity, (3) current psychosocial function-
adipose tissue is characterized not only by increased ing, and (4) reasons for seeking weight loss. The two
fat cell size but also increased cell number (hyper- latter issues are particularly important. Patients should
plasia) (Leibel et al., 1983; Sjostrom, 1980). As pre- be relatively free of significant life stressors (i.e., ma-
viously indicated, severely obese persons may have jor affective disorder, marital or vocational difficulties,
100 to 150 billion fat cells, which bodes poorly for the etc.) which might disrupt efforts to diet. Those experi-
patient's attainment of goal weights specified in encing such difficulties should consider waiting for a
height-weight tables. Even with weight reduction, the more propitious time to diet. In addition, the practi-
hyperplastically obese patient will still have increased tioner must help patients articulate their reasons for
fat cell number and an increased fat mass. Thus, suc- seeking weight loss. Many persons wish to lose weight
cessfully treated patients may remain 50% or more as a means to achieving another goal (Wadden, 1985).
overweight (Mason, 1987). If these goals, such as finding a new relationship or
Determination of fat cell size and number is time job, can be articulated at the onset of treatment, patient
consuming, costly, uncomfortable to patients (because and practitioner can evaluate whether the goals are
a needle biopsy is required), and beyond the abilities of realistic and, if necessary, plan additional steps to
most practitioners (Wadden, 1985). Practitioners can achieve them.
estimate fat cell number, however, by carefully assess-
ing the patient's weight and dieting histories and fami- Medical Evaluation. Space limitations prevent
ly history of obesity. They can expect to find approx- adequate description of the initial assessment but sev-
imately normal fat cell number in mildly overweight eral practitioners have discussed the topic in detail
persons who have become obese in adulthood. Persons (Brownell, 1981; Grommet, 1988; Wadden, 1985) and
previously of normal weight who have become moder- provided useful questionnaires (Agras et al., 1976).
ately or severely obese as adults are likely to display Psychologists and other nonmedical practitioners
increased fat cell number but probably not to the same should bear in mind that moderately and severely over-
degree as persons of similar weight with childhood weight persons should receive a thorough medical
onset and a family history of obesity. Further research evaluation before attempting weight reduction, and
is needed to confirm these hypotheses (Sjostrom, their physicians should be fully informed of the details
1980). of the weight reduction program (Wadden, 1985).
These patients frequently take medications or have a
history of illness which would contraindicate the use of
some approaches. It is similarly advisable for mildly
Assessment
overweight persons to consult with their physicians
In addition to reviewing the patient's history of before dieting, even though there are fewer risks of
obesity, the initial evaluation should explore the pa- complications, particularly if a balanced diet of 1,000
tient's (1) eating and dietary habits, (2) degree of to 1,200 kilocalories (kcal) is used.
Treatment of Mild Obesity behavioral package. These include self-monitoring,

problem solving, nutrition education, stimulus con-
Of those persons who are overweight, approx- trol, slowing eating, exercise, and cognitive restruc-
imately 90% are mildly overweight, as shown in Table turing.
1. Thus, we will devote most of our attention to mild
obesity, for which the treatment of choice is a compre- Self-Monitoring. Self-monitoring, the observa-
hensive program of nutrition education, physical action and recording of one's own behavior, is the main-
tivity, and behavior therapy (Stunkard, 1984). We will stay of behavioral treatment. It is not only a useful
also examine the treatment of moderate obesity by assessment tool, but numerous studies suggest that pa-
very-low-calorie diet and behavior therapy. Persons tients spontaneously reduce their calorie intake simply
desiring information about the surgical treatment of as a result of becoming more aware of their eating
severe obesity are referred to papers by Mason (1982, habits (Bellack, Rozensky, & Schwartz, 1974; Ro-
1987), Halmi (1980), and Stunkard, Stinnett, and manczyk, Tracey, Wilson, & Thorpe, 1973).
Smoller (1986). Patients record daily the types and amounts offoods
that they eat and their caloric value. Records are ex-
panded over the course of treatment to include infor-
Components of Behavioral Treatment
mation concerning times, places, and feelings associ-
The behavioral approach is anchored upon Stuart's ated with eating. This information provides practition-
(1967) belief that "only two common characteristics er and patient a detailed view of the patient's eating
have been observed in obese persons: a tendency to patterns and enables them to plan and implement spe-
overeat and a tendency to underexercise." We have cific interventions.
previously noted that research has only partially sup- As treatment progresses, patients monitor addi-
ported Stuart's assumptions. Nevertheless, over 150 tional events, including exercise, rate of eating, and
studies have demonstrated the effectiveness of behav- upsetting thoughts or emotions. Patients report in
ior therapy for obesity and shown it to be more effec- weekly group meetings on their success in completing
tive than other conservative approaches, including homework assignments and receive feedback from the
drug therapy, nutrition education, supportive psycho- practitioner and fellow group members. Completion of
therapy, and self-help approaches (Brownell & Wad- homework is critical to long-term behavior change.
den, 1986; Wilson & Brownell, 1980; Wing & Jeffery, Group meetings usually last only 60 to 90 min and,
1979). These results suggest that even if patients do not thus, most learning must occur outside of the group
have inappropriate eating and exercise habits, they can (Wadden, 1985).
be taught a set of new behaviors with which to control
their weight. Problem Solving. Instruction in problem-solving
Behavioral treatment relies extensively on the func- skills goes hand-in-hand with self-monitoring. In its
tional analysis of behavior (Brownell, 1982; Brownell application to obesity, patients are taught to (1) identi-
& Wadden, 1986). Eating and exercise behaviors are fy the weight-related problem, (2) generate alter-
analyzed to determine their covariation with other natives for handling the difficulty, (3) evaluate the al-
stimuli, including times, places, thoughts, emotions, ternatives and select one, (4) plan and implement the
and other persons (Stunkard, 1982b). Problem behav- behavior, (5) evaluate the outcome, and (6) if the plan
iors are identified and efforts are then made to modify is unsuccessful, reevaluate the problem and select an-
the events associated with them or to find alternative other alternative (Black, 1987; Black & Scherba,
behaviors. 1983).
There is a tendency for behavioral treatment to be Patients are taught to view overeating, weight gain,
delivered as a package (Brownell & Wadden, 1986; or nonadherence to the behavioral program as cues to
Stunkard, 1982b). This approach has been adopted engage in problem solving. For example, a female pa-
because therapy is usually delivered in groups of 10 to tient who had not exercised for several weeks identi-
12 persons, and it is difficult to provide the attention fied her primary problem as lack of time and desire for
needed to help each patient complete a rigorous func- physical activity. She generated a list of alternatives
tional analysis of behavior. Consistent with practice, for exercising (e.g., joining a health club, playing ten-
we will describe the primary components of the current nis, jogging with a friend, walking during her lunch
hour), evaluated the pros and cons of each and chose style-the only possible way for long-term change to
the one with the highest likelihood of yielding positive occur (Wadden, 1985).
results (e.g., walking during lunch hour). She devised
a specific plan for exercising (e. g. , brisk walking in the Stimulus Control. Stimulus control procedures
downtown area for 30 min on Mondays, Tuesdays, and are designed to limit the overweight individual's ex-
Thursdays), as well as for evaluating the success of her posure and responsiveness to food (Stunkard, 1982b).
routine (e. g., she would consider her plan successful if Although the efficacy of these techniques and their
she exercised five or more times in 2 weeks). If she contribution to behavioral treatment remain unclear,
walked less than five times, she would review each they continue to be included in treatment because of
problem-solving step, make revisions, write a new their intuitive appeal. The procedures can be classified
plan of action, and try again. into five broad categories: (1) shopping prudently to
keep problem foods out of the house; (2) storing foods
properly to reduce incidental eating; (3) leaving food
Nutrition Education. Early behavioral programs on the plate; (4) limiting times, places, and activities
did not include formal nutrition education (Wadden, associated with eating; and (5) planning for social sit-
1985). However, it is now clear that a low-fat, high- uations involving food.
carbohydrate diet promotes not only good car-
diovascular health but also a lower body weight. Re- Slowing Eating. A host of techniques has been
search by Sclafani (1980), for example, has shown that developed to help patients slow their eating rate in an
the laboratory rat maintains a very stable and nonobese effort to improve satiety (Stunkard, 1982b). These in-
body weight when allowed to feed ad libitum on a clude putting utensils down between bites, pausing
standard chow diet containing grain and a small during meals, counting bites, and chewing food thor-
amount of fat. However, this same animal becomes oughly before swallowing. Although benefits of these
very obese when allowed ad libitum consumption of a strategies have not been determined empirically, they
high-fat diet (Sclafani, 1980). These data suggest that seem to serve many functions, in addition to possibly
the high-fat content of the American diet (which de- enhancing satiety (Wadden, 1985). First, patients learn
rives about 40% of calories from fat) may contribute to appreciate the texture and taste of food; this is partic-
significantly to the striking prevalence of obesity in ularly important when calories are limited to 1,200-
this country (Wadden & Brownell, 1984). Therefore, 1,500 daily. Increased enjoyment of food may help
most nutritionists currently recommend a diet deriving patients overcome feelings of deprivation. Second,
no more than 30% of calories from fat, 12% from slower eating gives overweight persons time to think
protein, and the remainder from carbohydrate (Select about the appropriateness of their eating and to plan
Committee on Nutrition and Human Needs, 1977). subsequent behavior. Finally, many patients report that
The four food groups, or some alternative system of a relaxed eating style increases their feelings of self-
sensible eating, serve as the cornerstone of our nutri- control and well-being.
tion intervention (Wadden, 1985). Additional informa-
tion is provided concerning the salt, cholesterol, and Exercise. Thus far, we have focussed primarily on
fat content of common table foods, since many pa- methods of reducing food intake. This focus is con-
tients have diet-related illnesses which are ameliorated sistent with the age-old bias that obesity results from
by the reduction of these elements (Bray, 1986). We do excessive eating, even though energy expenditure is a
not prescribe a specific diet, except when patients re- key component in the energy balance equation. Phys-
quest one. Prescribing a diet in which certain foods ical activity is the second largest component of energy
must be eaten and others avoided sets the stage for expenditure, as shown in Figure 2, and the component
abandoning weight control efforts when the inevitable over which patients have the greatest voluntary
dietary transgressions occur. control.
Women usually limit their calories to 1,200 daily Exercise can be divided into two broad categories-
and men to 1,500. Caloric intake is adjusted depending programmed and life-style activity (Brownell &
upon the individual's energy balance (or measured Stunkard, 1980b). Programmed activity consists of
metabolic rate), but the makeup of the diet, within the regularly scheduled bouts of physical exertion, which
boundaries of good nutrition, is left to the patient. This include running, calisthenics, swimming, cycling, and
way, dietary changes are woven into the patient's life- today's popular areobic workouts. These activities are
clearly beneficial but are associated with 6-week attri- identify and correct these pejorative self-statements
tion rates of 50% or more even in highly motivated that are frequently associated with emotional upset and
persons (Brownell & Stunkard, 1980b). further overeating. Using the methods of Beck (1976)
Life-style activity can be incorporated into day-to- and Meichenbaum (1977), patients are taught to coun-
day patterns of living. It might include walking rather ter arguments to their frequently held negativistic be-
than riding, standing rather than sitting, and any other liefs. One useful technique is to have patients record on
behaviors that increase activity throughout the day the left-hand side of a sheet of paper the negative self-
(Brownell & Stunkard, 1980b). Epstein and col- statements that they experience during and after an
leagues have shown in a series of studies that life-style overeating episode. Whether at home or in group ses-
activity is associated with better maintenance of sions, patients then examine the rationality and appro-
weight loss in children than is programmed activity priateness of their self-statements. Irrational thoughts,
(Epstein, 1986; Epstein, Wing, Koeske, Os sip, & such as "I'm a disgusting failure; I have absolutely no
Beck, 1982). The reason is that the children continue self-control," are challenged, and more appropriate,
to engage in life-style activity past the point of the rational responses are developed and recorded on the
program's ending. right-hand side of the paper. A rational response to the
Walking is an ideal form of physical activity for above statement might be, "I'm disappointed that I
overweight persons. It requires little special equip- overate. I need to plan better to prevent this from hap-
ment or skill, is noncompetitive, and can be accom- pening again when I go to parties."
plished in a variety of settings. The initial distance Modification of self-defeating statements is difficult
walked depends on the patient's physical condition; and requires persistence by both practitioner and pa-
thus, some start with one block every other day, while tient. Interested persons may wish to read Beck's
others begin with 2 miles daily. As a rule, patients who (1976) work, which describes several types of cog-
have been very sedentary should see their physician nitive distortions exhibited by depressed persons and
before beginning a walking program. They might be- by many overweight individuals.
gin by walking for only 6 to 8 min, twice a week, at
40% to 60% of maximum heart rate. The ultimate goal
Delivery of Treatment
is to have patients walk approximately 120 min per
week at 60% to 80% of maximum heart rate (Perri, Behavioral treatment of obesity is usually delivered
Lauer, McAdoo, McAllister, & Yancey, 1986; Perri et in groups, ranging in size from 8 to 12 persons. Group
al., 1988). Further information about walking pro- treatment is not only more cost-effective than indi-
grams can be obtained from the American College of vidual therapy but may be more clinically effective
Sports Medicine (Indianapolis, IN). (Wilson, 1980). Group treatment reduces the sense of
Exercise is likely to play its most significant role in isolation that patients frequently experience concern-
the maintenance of weight loss and in the improvement ing their weight, and group cohesiveness and support
of physical and psychological health (Brownell & appear to facilitate continuation in treatment. In addi-
Wadden, 1986; Jeffery, 1987). We will examine these tion, group members are often able to help each other
topics in a later section on weight loss maintenance and in important ways that practitioners cannot (Wadden,
relapse prevention. 1985).
Behavioral programs are generally highly struc-
Cognitive Restructuring. Cognitive therapy is tured, problem-focused, and time-limited (15 to 25
now routinely included in the behavioral treatment of weeks), which helps patients set appropriate goals and
obesity and is based upon Mahoney and Mahoney's pace their efforts. Typically, there is an agenda for each
(1976) description of the irrational and maladaptive weekly session, and skills for weight-control are cov-
cognitions that dieters often experience. These include ered in a prescribed order. Most of the group's time is
thoughts about (1) the impossibility of weight loss devoted to review of homework assignments and pa-
(e.g., "I've never done it before. I can't do it now."); tients' efforts to modify eating, exercise, and thinking
(2) unrealistic goals (e.g., "I'll never eat chocolate habits. Manuals are frequently used to standardize pro-
again. "); and (3) self-disparaging statements (e.g., "I gram delivery and enhance learning outside of treat-
should not have eaten cake. I'm a disgusting failure, ment sessions (Brownell, 1985; Ferguson, 1975).
and I'll always be fat!"). Despite the structured nature of these programs,
Cognitive restructuring techniques help patients to they should not be impersonal or inflexible (Wadden,
1985). Practitioners must individualize treatment to Table 2. Summary of Data from Controlled
the needs of patients, encourage patient interaction and Trials of Behavior Therapy
participation wherever possible, and avoid lecturing
1974 1978 1984 1985-1987
the group. Attention should be focussed on the "pro-
cess" of behavior change, since virtually all patients Number of studies 15 17 15 13
know "what they should do" (i.e., content) but need included
Sample size 53.1 54.0 71.3 71.6
help discovering "how to do it." The practitioner
Initial weight (kg) 73.4 87.3 88.7 87.2
should maintain continuity from session to session by Initial percentage 49.4 48.6 48.1 56.2
summarizing at the outset of each meeting the impor- overweight
tant points from the previous session. In addition, the Length of treatment 8.4 10.5 13.2 15.6
practitioner must be conversant with the particular (weeks)
changes on which each patient is working at any given Weight loss (kg) 3.8 4.2 6.9 8.4
week. Loss per week (kg) 0.5 0.4 0.5 0.5
Attrition (%) 11.4 12.9 10.6 13.8
Length of follow-up 15.5 30.3 58.4 48.3
Practitioners' Skills. Insufficient attention has (weeks)
Loss at follow-up 4.0 4.1 4.4 5.3
been paid to the skills and training required to lead
(kg)
such groups. Several studies have indicated that pro-
fessional therapists produce greater weight losses (in Note. The data, adapted and updated, are taken from "Behavior Therapy
for Obesity: Modern Approaches and Better Results" by K. D. Brownell
participants) than do nonprofessional peer counselors and T. A. Wadden in The Physiology, Psychology, and Treatment of
using the same treatment manual (Jeffrey et al., 1978; Eating Disorders (p. 182) edited by K. D. Brownell and J. P. Foreyt,
1986, New York: Basic Books. Copyright 1986 by Basic Books. Adapt-
Levitz & Stunkard, 1974; Wilson, 1980). However, in ed by permission.
actuality, most behavioral weight-loss programs are
probably conducted by relatively inexperienced
therapists.
Short-Term Results. Table 2 shows that current
We strongly believe that training in psycho-
behavioral programs (1985-1987) clearly are effec-
pathology and group psychotherapy helps practi-
tive, producing an average weight loss of 8 .37 kg. This
tioners lead more effective groups through enhanced
is a clinically significant weight loss that is associated
sensitivity to nonbehavioral events (Wadden, 1985).
with improvements in physical and psychological
When behavioral treatment is ineffective, it is fre-
health.
quently because of a failure to establish a supportive
Weight losses produced by behavioral treatment ap-
and cohesive group in which to deliver treatment. Un-
pear to be improving with time. The average loss re-
toward group dynamics, which can be introduced by
ported in 1974 was only 3.83 kg, less than half of the
patients who are overly aggressive or emotionally dis-
current loss. Caution must be exercised in interpreting
tressed, must be addressed with the group in order to
these findings, however. Although we might assume
establish a secure and trusting atmosphere in which
that current behavioral treatment is significantly more
patients can attempt change (Yalom, 1975).
effective than its predecessor as a result of the inclu-
sion of cognitive restructuring and exercise, other fac-
tors may explain the improved results. Larger weight
Results of Behavioral Treatment
losses may, for instance, merely be a function oflonger
How effective is behavior therapy for obesity? Is it treatment. The average length of treatment was ap-
more effective today than it was a decade ago? How proximately 8.4 weeks in 1974, compared with 15.6 in
well are weight losses maintained following treat- recent studies. Even though current programs may be
ment? The data presented in Table 2 provide answers to more comprehensive, it is possible that earlier behav-
these questions. The table, which was adapted from ioral programs might have yielded similar weight
Brownell and Wadden (1986), summarizes the results losses simply if extended (Brownell & Wadden, 1986).
for all studies published in the following journals from Support for this view is provided by examination of
1974 to 1987: Behavior Therapy, Journal ofConsult- average weekly weight losses in earlier and later stud-
ing and Clinical Psychology, Behaviour Research and ies. Patients treated in 1974 lost O. 54 kg a week, which
Therapy, and Addictive Behaviors. is virtually identical to the weekly losses of 0.54 and
0.50 kg reported for patients in the 1984 and 1985- weight losses, as previously noted. Larger losses are
1987 studies, respectively. likely to elicit compensatory biological responses that
The substantial increase in overall weight loss may contribute to weight regain (w. Bennett & Gurin,
also be attributable to the increased initial weight of 1982).
patients in recent studies. Table 2 shows that subjects Rather than viewing current long-term data as a tes-
in the 1974 studies averaged 73.35 kg and 49.4% over- timonial to the inadequacies of behavioral treatment,
weight, as compared with 87.17 kg and 56.2% over- they may merely emphasize the fact that until recently
weight for patients in the most recent studies. Studies practitioners have paid little attention to the special
have shown that heavier persons tend to lose more problems of weight-loss maintenance and relapse pre-
weight than do less obese individuals (Jeffery et al., vention. We will return to this issue after briefly re-
1978). viewing the treatment of moderately obese persons.
In summary, the current behavioral program pro-
duces short-term weight losses more than double the
size of earlier programs. Current losses consistently Treatment of Moderate Obesity
approach 8.0 kg and confer significant physical and
psychological benefits. Reasons for the improved A comprehensive behavioral program is clearly ef-
losses are unclear, however. fective with mildly obese persons. A loss of 8.0 kg is
hardly sufficient, however, for moderately obese per-
sons needing to lose a minimum of 15 to 25 kg (Foreyt
Long-Term Follow-Up
et al., 1982). This fact has led to efforts to increase
The true measure of obesity treatment is mainte- weight losses by increasing the length of treatment and
nance of weight loss following therapy (Foreyt, 1987; by combining behavior therapy with other modalities,
Jeffrey, 1987). Researchers have acknowledged the including social support, pharmacotherapy, and very-
importance of weight loss maintenance by following low-calorie diets. We will review briefly the first three
patients for longer periods of time. Table 2 shows that developments before discussing in detail what we con-
the mean length of follow-up has increased from 15.5 sider the most promising approach-very-low-calorie
weeks in the 1974 studies to 48.3 weeks in the 1985- diet combined with behavior therapy.
1987 studies.
Long-term results of the most recent studies (1985-
Improving Weight Losses
1987) reveal some important trends. Of the 10 studies
which included long-term follow-up data, only two Longer Treatment. Our previous review sug-
reported continued weight loss after treatment (Bur- gested that the increased weight losses of subjects in
nett, Taylor, & Agras, 1985; Pekarik, 1987). Subjects recent behavioral studies may have been attributable to
in the eight remaining studies regained between 25% increased length of treatment. Perhaps even larger
and 55% of their posttreatment weight loss. Overall, losses could be produced by extending treatment to 25
subjects in these 10 studies regained an average of38% or more weeks (G. A. Bennett, 1986).
of their end-of-treatment weight loss in the 48 weeks Support· for this view was provided by studies by
following therapy. Subjects in the 1984 studies re- Craighead, Stunkard, and O'Brien (1981) and Wadden
gained approximately the same amount of weight dur- and Stunkard (1986), in which patients were treated by
ing this time, which suggests that maintenance of two traditional behavioral methods for 26 weeks and lost
thirds of the end-of-treatment weight loss at I-year 10.8 and 13.95 kg respectively. Perrietal. (1988) have
follow-up is the current status quo. similarly reported a mean loss of 13.5 kg at the end of
Patients in the 1974 and 1978 studies maintained 20 weekly meetings, which increased to 15.75 kg after
almost all of their weight loss, suggesting that current 26 additional weeks of bimonthly meetings. Weight
behavioral therapy is less effective on a long-term basis losses declined to 12.6 kg, however, after an addi-
than was its predecessor. This impression is not war- tional 26 weeks of bimonthly treatment.
ranted, however. Follow-up in earlier studies was lim- We recently treated patients in a controlled trial for
ited to less than 30 weeks, which allowed less time for 52 consecutive weeks (Wadden, Foster, & Letizia,
the observation of weight regain. In addition, the ear- 1989). Weight losses averaged 11.9 kg after 6 months,
lier studies were associated with significantly smaller as expected. However, they increased to only 14.4 kg
after 52 weeks of treatment. Perri, Nezu, Patti, and respectively, in the year following treatment, as com-
McCann (1989) have reported similar findings for per- pared with only a 1.8 kg gain for the behavior therapy
sons treated for 40 consecutive weeks; patients lost 9.9 patients.
kg in the first 20 weeks, but only an additional 3.6 kg Weight regain following termination of drug treat-
in the second 20 weeks of treatment. Thus, it appears ment remains a major problem that has not been im-
that there is an upper limit to the average weight loss proved to date by administering pharmacotherapy and
produced by behavior therapy. This limit appears to be behavior therapy in different sequences (Craighead,
13.5 to 15.8 kg, and the great majority of this loss is 1984). One possibility is to use pharmacotherapy on a
achieved in the first 25 weeks of treatment. Losses chronic basis because weight generally remains at a
beyond this point are likely to average 0.15 kg per lower level as long as the drug is continued (Stunkard,
week or less. 1982a). Weight loss frequently controls disorders,
We should note, however, that some patients in our such as hypertension and diabetes, and the effects of
study lost as much as 31.5 kg in the year of treatment, some anorectic agents may be more benign than those
and there was a trend toward a bimodal distribution, in of antihypertensive or antidiabetic agents. Further
which many individuals continued to lose after the studies are needed to assess the safety and efficacy of
initial 26 weeks of treatment whereas others began to long-term pharmacological treatment, particularly by
regain small amounts of weight. We have not been able the serotonin re-uptake inhibitors (Blundell & Hill,
to differentiate continued losers from "stallers" on the 1987).
basis of pretreatment characteristics.
Very-Low-Calorie Diets
Social Support. Brownell et al. (1978) reported
average weight losses of approximately 13.5 kg in an Very-low-calorie diets providing protein of high bio-
initial study in which family members assisted the logical quality produce average weight losses of 1.5 to
obese individual's efforts to lose weight. Subsequent 2.0 kg weekly and are safe when limited to periods of
investigations did not produce such robust weight 16 weeks or less under proper medical supervision
losses, however, and some failed to find an effect for (Wadden, Stunkard, & Brownell, 1983). The diets,
social support (Brownell & Wadden, 1986). Clinical which provide approximately 400 to 800 calories
experience suggests that involving family members in daily, are an outgrowth of experimentation with total
treatment is likely to have numerous therapeutic bene- fasting (i.e., starvation) conducted in this country in
fits, including resolving spouses' negative feelings the 1950s and 196Os. Fasted patients were reported to
about obesity; but increased weight loss does not con- lose up to 22 kg in 50 days with little apparent discom-
sistently result from family participation (Wadden, fort (Drenick & Johnson, 1978). Fasting was aban-
1985). doned, however, when several fasting-related deaths
were reported; deaths appeared attributable to the loss
Pharmacotherapy. Pharmacotherapy has been of vital lean body tissue from tI'1e heart (Garnett, Ber-
used for years in the treatment of obesity and was nard, Ford, Goodbody, & Woodhouse, 1969). It is well
perhaps the principal treatment in the 1950s and 1960s known that bodily protein is lost during fasting, as
when a whole generation of dieters was introduced to protein is converted into glucose (needed by the brain)
amphetamines. Pharmacotherapy is still used today, in the process of gluconeogenesis (Wadden et al.,
although amphetamines have been largely abandoned 1983).
in favor of drugs with fewer side effects and less abuse Very-low-calorie diets produce the same large
potential (Brownell & Wadden, 1986). weight losses as fasting, while preserving lean body
Pharmacotherapy produces large weight losses, as tissue by the provision of 70 to 100 g daily of dietary
demonstrated in a controlled trial by Craighead et al. protein (Wadden et al., 1983). Protein may be obtained
(1981). Patients who received fenfluramine for 6 from lean meat, fish, or fowl, served in food form, or
months lost 14.4 kg and those who received from milk- or egg-based protein formulas served as
fenfluramine plus behavior therapy lost 15.3 kg. This liquid diets (Blackburn, Bistrian, & Flatt, 1975; Ver-
contrasted with a 10.8 kg loss for patients receiving tes, Genuth, & Hazelton, 1977). Both diets must be
behavior therapy alone. However, patients in the phar- supplemented with vitamins and minerals, but all other
macotherapy alone and the pharmacotherapy plus be- foods are prohibited (Bistrian, 1978). The diets pro-
havior therapy conditions regained 8.1 and 10.8 kg, duce comparable weight losses and both are generally
free of disturbing side effects, including hunger (Wad- conditions showed losses from pretreatment of 4.63,
den, Stunkard, Brownell, & Day, 1985; Wadden, 9.40, and 12.78 kg, respectively. Two principal find-
Stunkard, Day, Gould, & Rubin, 1987). These diets ings emerged from the study, the first of which was that
should not be confused with the liquid-protein diets of use of very-low-calorie diet alone resulted in rapid re-
1976-1977, which were associated with multiple fa- gaining of weight. Subjects, on average, regained two
talities (Van Itallie, 1978). The safety of the current thirds of their weight loss in the year following treat-
diets appears attributable to improved medical ment. The second finding was that behavior therapy
monitoring, provision of higher quality protein, and helped to limit regaining of weight following treatment
limitation of the diets to 16 weeks or less (Wadden et by very-low-calorie diet. Subjects in the combined
aI., 1983). treatment condition regained only one third of their
weight loss, which was comparable to that regained by
Weight Losses. Very-low-calorie diets produce subjects in the behavior therapy alone condition. This
large weight losses that average 15.75 to 20.25 kg for percentage regain is comparable to that observed in the
12 weeks of treatment, with greater losses for longer treatment of mild obesity by behavior therapy and a
treatment (Andersen, Backer, Stokholm, & Quaade, 1,200 kcal diet.
1984; Hartman, Stroud, Sweet, & Saxton, 1988;
Hovell et aI., 1988; Kirschner, Schneider, Ertel, & Changes in Metabolic Rate. Investigators have
Gonnan, 1988; Palgi et al., 1985; Sikand, Kondo, been impressed by the size of the weight losses pro-
Foreyt, Jones, & Gotto, 1988; Vertes et al., 1977; duced by very-low-calorie diets but alarmed by the
Wadden et al., 1983). Recent attention has focussed possibility that these diets may pennanently lower
upon the maintenance of these losses. In our current metabolic rate, making weight maintenance and future
treatment, very-low-calorie diet is used for approx- weight loss more difficult (Brownell, Greenwood,
imately 12 weeks to induce a large rapid weight loss, Stellar, & Shrager, 1986; Steen et aI., 1988). These
then behavior therapy (with a 1,200-calorie diet) is concerns are well taken since investigators have long
used for an additional 12 or more weeks to instruct known that resting energy expenditure (REE) declines
patients in maintenance of the loss. Two pilot investi- as much as 20% in persons consuming a very-Iow-
gations (Lindner & Blackburn, 1976; Wadden, calorie diet (Bray, 1969).
Stunkard, Brownell, & Day, 1984) produced encour- However, a recent study showed that the precipitous
aging results that led to a controlled clinical trial which drop in REE is limited to the time that dieters are
assessed the efficacy of (1) very-low-calorie diet used consuming the low-calorie diet (Wadden, Foster,
alone, (2) behavior therapy used with a 1,200 kcal Letizia, Stunkard, & Mullen, 1988). REE rises appro-
diet, or (3) very-low-calorie diet plus behavior therapy priately as soon as subjects tenninate the very-low-
(combined treatment) (Wadden & Stunkard, 1986). calorie diet and return to a balanced diet. This fact is
Subjects in the first condition were treated weekly for 4 illustrated in Figure 3, which compares changes in
months and subjects in the other two conditions for 6 REE in subjects randomly assigned to a 1,200 kcal
months. Subjects in the first and third condition re- balanced diet or a 420 kcal high-protein diet (OP-
ceived very-low-calorie diet for 2 months and a 1,200 TIFAST 70; Sandoz Nutrition Company). REE in-
calorie diet for the remainder of treatment. Only sub- creased in the low-calorie diet subjects at week 18 as
jects in the second and third conditions received in- they began realimentation after a 16-week consump-
struction in behavioral methods of weight control. tion of the low-calorie diet and a 24% decline in their
Mean weight losses at the end of treatment for the REE. Differences in REE between the two conditions
diet alone, behavior therapy alone, and combined were not significantly different at the end of 24 weeks,
treatment conditions were 13.95,14.13, and 19.13 kg, when the very-low-calorie diet subjects had completed
respectively. Losses for the combined treatment sub- 8 weeks of realimentation with a 1,200 kcal diet. There
jects were significantly greater than those for subjects were no differences between conditions in REE despite
in the other two conditions. Thus, the addition of a the fact that the very-low-calorie diet subjects had lost
short-tenn/very-Iow-calorie diet to a traditional pro- more than twice as much weight as the 1,200 kcal diet
gram of behavior therapy improved weight losses by subjects (23.4 kg versus 10.8 kg).
more than 5.0 kg.
The I-year follow-up losses were the true focus of Clinical Use of Very-Low-Calorie Diets. The
the study, however. At this time subjects in the three effective use of a very-low-calorie diet requires a mul-
~r BDD~
w
w -5
0::
~
i---f~!---l-+;t~
w -10
<.:>
z
«
I
u
-15
r 1 1 0 VLCD
I-b_~ [/
I-
z -20
w
u
0::
w
0..
-25 1 j -------- 0
-30
1
0 4 8 12 16 20 24
WEEKS
Figure 3. Percentage reduction in resting energy expenditure (REE) for subjects receiving a 1,200 kcal balanced
deficit diet (BOD) (N = 9) or a very-low-calorie diet (VLCD; OPTIFAST 70) (N = 9). VLCD subjects were
realirnentated with a balanced deficit diet at the end of Week 18, at which time their REE returned toward baseline.
tidisciplinary team that should include a physician, long-term results are favorable when placed in per-
psychologist, and nutritionist (Blackburn & Green- spective. They must be examined in relationship to
berg, 1978). Inclusion of an exercise physiologist is (1) the effects of no treatment, and (2) the limited du-
also desirable to meet the special activity needs of ration and scope of previous treatments for obesity.
markedly obese individuals. Practitioners seeking
treatment for their markedly obese patients are encour- Comparison with No-Treatment. It is impossi-
aged to refer them to comprehensive programs that ble to evaluate the long-term results of obesity
specialize in the use of very-low-calorie diets. Infor- therapies in the absence of data for untreated persons.
mation concerning the most widely used hospital- For example, is a 90 kg woman who loses 12 kg in 6
based very-low-calorie diet program may be obtained months, but regains 4 kg (i.e., one third) a year later, a
from the Sandoz Nutrition Company (Minneapolis, success or failure? The answer depends upon whether
MN). she still has positive medical benefits of treatment
(i.e., her blood pressure is still under control) and con-
tinues to feel positive .about her appearance and in-
Improving Maintenance of Weight Loss
creased mobility (Blackburn & Kanders, 1987). The
answer also depends upon what would have happened
The challenge now confronting researchers is to find
if she had not sought treatment. Epidemiological data
effective methods of maintaining the weight losses
suggest that, without treatment, she would have gained
produced by behavior therapy, very-low-calorie diet,
0.9 to 1.4 kg during this 18-month period (Hartz &
and surgery (Foreyt, 1987; Jeffery, 1987). This need is
Rimm, 1980; National Center for Health Statistics,
apparent from many sources. Patients tell us that they
1981). Thus, instead of weighing 82 kg one year after
need more help, and this review has shown that pa-
treatment, she probably would have weighed 91.4 kg
tients regain an average of one third of their lost weight
without treatment.
in the year following therapy, whether they are treated
Brownell and Jeffery (1987) have called for evalua-
by a 1,200 kcal diet or a very-low-calorie diet. Weight
tion of obese persons who do not enter weight reduc-
regain increases over time so that, on average, 50% or
tion programs so that long-term changes in their
more of lost weight is regained 3 years after treatment
weight, physical health, and psychological well-being
(Brownell & Jeffery, 1987; Kramer, Jeffery, Forster, &
can be compared with those of persons receiving treat-
Snell, 1989; Wadden, Stunkard, & Liebschutz, 1988).
ment. Current long-term data cannot be evaluated fair-
ly without such information.
Evaluation of Long-Term Results
Data on the long-term outcome of treatments for Limited Duration and Scope of Treatment.
obesity should not be cause for pessimism. In fact, Perhaps the best reason for optimism about improving
long-term results of obesity treatment is that so little Table 3. Comparison of Behaviors
professional attention has actually been devoted to this and Reinforcement Associated with Losing
problem. We cannot expect 15 weekly group therapy Weight versus Maintaining a Weight Loss
sessions to not only induce weight loss but also to
Weight loss Maintenance of weight loss
facilitate maintenance of this loss. This is analogous to
thinking that 15 weeks of jogging is sufficient to confer The goal of treatment is to The goal of treatment is to
physical fitness for life. In both cases, continued effort lose a large amount of lose small amounts of
weight, after a prolonged weight, as small increases
is required to maintain the initial improvements in
period of weight gain. in weight occur.
health and fitness.
Moreover, researchers now realize that the skills The dieter's principal strat- The dieter's principal task is
egy is to avoid eating all to learn to eat troublesome
and contingencies associated with maintaining a
of the foods that have foods in a controlled fash-
weight loss differ markedly from those associated with ion (mastery) and to eat
caused the weight prob-
losing weight (Wadden, 1985). We had previously as- lem. new foods, low in fat and
sumed that maintenance would follow naturally from calories.
successful weight reduction, without stopping to ex-
Treatment is time-limited, Treatment is on-going and
amine differences between these events. usually 15 to 25 weeks. life-long.
The dieter receives support The dieter receives little or

Losing Weight versus Maintaining from the diet program and no support from profes-
a Weight Loss from family and friends. sionals or family mem-
bers.
Table 3 outlines several key differences between los-
Weight loss is highly rein- Maintenance of weight loss
ing weight and maintaining a weight loss. These in-
forcing; it is very notice- is not reinforcing; dieters
clude the markedly different goals of treatment, the able and pleasing to forget about their accom-
behavioral strategies required, and the differential re- dieters and their families. plishments, as do their
inforcement associated with the two behaviors. A key family members.
difference involves that between avoiding problem Dieters do not have to ex- Exercise appears to be crit-
foods, when losing weight, and learning to consume ercise to lose weight. ical to maintenance of
such foods in a controlled manner to facilitate mainte- weight loss.
nance of weight loss. Avoiding problem foods (by diet-
ing) is a highly effective means of losing weight but
does not teach the dieter how to consume these foods in In the second case, patients drop out of treatment
a controlled manner. Inappropriate behavior is merely feeling that they have failed, when they instead have
suppressed during weight loss and is likely to reappear the most to benefit from therapy when they are having
when "the diet is over." difficulties. Gaining weight during treatment provides
Reversing small weight gains, immediately as they an opportunity for the practitioner and the patient to
occur, is the single most important skill that patients gain firsthand knowledge of the patient's problems.
fail to learn in conventional weight loss programs The patient's impulse to avoid treatment when having
(Wadden, 1985). Patients fail to acquire this skill for difficulties with food is analogous to a patient's belief
one of two reasons: (1) either they continue to lose that when sick with the flu, he or she should avoid the
weight for the entire time that they are in treatment, or family doctor. Practitioners must help patients realize
(2) they drop out of therapy when they gain weight, that they have only to benefit by asking for help when
feeling that they have failed the program. they are having difficulties.
In the first case, patients face their first bout of
weight regain on their own, having completed the pro-
Two-Step Approach to Maintenance
gram. Without the benefit of continued professional
support, patients are likely to think, even when regain- Effective maintenance of weight loss requires two
ing small amounts of weight, that they have "re- sets of skills: basic upkeep and crisis intervention
lapsed" and that further weight-control efforts are (e.g., relapse prevention). Upkeep is performed on a
futile. Paradoxically, such patients are able to lose 15 daily, weekly, or monthly basis and consists of such
kg during treatment but are unable to lose the 1.5 kg behaviors as keeping a diet diary, exercising regularly,
regained in the first month after therapy. and recording and charting weight. These ongoing be-
haviors are prerequisite to maintaining a weight loss, Twentyman, & McAdoo, 1984; Perri et al., 1986,
just as regular inspections and tune-ups are prerequi- 1988). These studies have yielded a number of interest-
site to maintaining a car in good running condition. ing findings, the most important of which is that pa-
Upkeep skills are largely preventive. tient-therapist contact following treatment is associ-
ated with excellent maintenance of weight loss. Thus,
Crisis Intervention. Dieters must respond imme- Perri et al. (1988) found that subjects who received 1
diately to eating- and weight-related crises. Such year of biweekly maintenance meetings following 20
crises might include overeating by 1,000 kcal at a par- initial weeks of behavioral treatment maintained their
ty, bingeing at home on gourmet ice cream or gaining full end-of-treatment weight loss at the end of the fol-
several pounds during the winter holidays. Dieters are low-up year. Subjects who received the same 20-week
extremely vulnerable in such situations to experienc- program without maintenance meetings regained one
ing what Marlatt (1986) has termed the "abstinence half of their weight loss in the year following treat-
violation effect;" they feel guilt and despair for having ment. The study further indicated that the content of
engaged in a behavior that they believe is inappropriate the maintenance sessions appeared to be less important
(Marlatt, 1985; Marlatt & Gordon, 1980, 1985). They than the contact (or structure) that they provided. Perri
are also likely to experience a loss of self-efficacy and colleagues have also shown that social support, as
(Marlatt, 1985), believing that their dietary indiscre- provided by peer-group meetings held outside of the
tion shows that they are unable to control their weight treatment setting, can significantly enhance weight-
and eating. Marlatt (1985) has discussed how an ini- loss maintenance (Perri, McAdoo et al., 1984; Perri,
tial, insignificant lapse is frequently perceived as a ~hapiro, et al., 1984).
relapse and how this perception can lead to the indi-
vidual's abnegation of self-control and increased vul- Exercise. Most studies have shown that exercise
nerability to relapse. has little effect upon the induction of weight loss. Exer-
Crisis intervention involves teaching dieters behav- cise's greater strength appears to be in the maintenance
ioral and cognitive methods by which to cope with of weight loss (Brownell & Jeffery, 1987). Several
dietary lapses and small weight gains. These occur- studies have suggested that individuals who establish a
rences must be responded to immediately and effec- regular program of physical activity are more likely to
tively before they lead to significant relapse, just as an maintain their weight loss than are sedentary indi-
overheated car engine or water line break in a home viduals. This finding holds true whether weight is lost
must be repaired immediately before they do greater with a 1,200 kcal balanced diet (Dahlkoetter, Call-
damage. ahan, & Linton, 1979; Hill et al., in press; Stunkard,
Marlatt has developed a systematic program for 1983b) or a very-low-calorie diet (Hartman et ai.,
identifying situations that precipitate relapse (Le., 1988; Sikand et ai., 1988).
high-risk situations), practicing responses to these sit- The mechanisms by which exercise facilitates main-
uations, and rehearsing self-statements to overcome tenance of weight loss are poorly understood. Physical
the negative thoughts that usually accompany a relapse activity burns calories, which should contribute to
episode (Marlatt, 1985; Marlatt & Gordon, 1980, weight maintenance, but it may also improve mood
1985). These behaviors must be learned and practiced and self-confidence (Sime, 1984) and, thus, adherence
prior to entering the high-risk situation so that they can to a weight-control regimen. At mild to modest levels,
be performed automatically. It is difficult to acquire exercise also appears to (1) suppress appetite,
such behaviors during a high-risk situation because the (2) counteract the ill effects of obesity, and (3) pre-
dieter is likely to feel overwhelmed by food, anxiety, serve lean body mass (Brownell & Stunkard, 1980b).
and guilt. Anaerobic activity (i.e., weight training) has been
shown to increase lean body mass which should, in
turn, produce a higher metabolic rate, since there is a
Studies of Weight-Loss Maintenance
strong positive association between these two vari-
Perri and his colleagues have completed a series of ables (Foster et al., 1988).
studies evaluating the effectiveness of different Perhaps the most controversial benefit of exercise
weight-loss maintenance strategies (Perri, McAdoo, concerns its effect on metabolic rate during dieting.
Spevak, & Newlin, 1984; Perri, Shapiro, Ludwig, Two initial studies reported that vigorous exercise par-
tially reversed the drop in metabolic rate caused by therapies, such as that developed by Roth (1984), a
dieting (Donahoe, Lin, Kirschenbaum, & Keesey, recovered compUlsive eater. Preliminary findings indi-
1984; Stem, Schultz, & Mole, 1980). A third study cate that Overeaters Anonymous may be helpful with
showed no effect for exercise (Pi-Sunyer & Woo, some patients (Malenbaum, Herzog, Eisenthal, & Wy-
1985), whereas a fourth reported that vigorous exercise shak, 1988).
in patients consuming a very-low-calorie diet was as- 3. Treatment of body-image disparagement. Body-
sociated with a greater reduction in metabolic rate than image disparagement and weight dissatisfaction are
was dieting alone (Phinney, LaGrange, O'Connell, & common among persons with anorexia nervosa and
Danforth, 1988). In light of this last report, we recom- bulimia nervosa (Fairburn et al., 1986). And in a soci-
mend that persons limit the intensity and duration of ety that worships thinness, they are observed in less
their physical activity while consuming a very-Iow- pathological forms among women of all weights and
calorie diet. Brisk walking is probably the most appro- ages, particularly adolescent girls from middle- and
priate activity. Patients should increase the upper-middle-class families (Wadden, Foster, et al.,
rigorousness of their activity once they begin a weight- 1989).
maintenance program. Body-image disparagement is likely to be particu-
larly severe in the overweight because their negative
evaluations of their weight are echoed by a society that
disdains obesity. The disorder is most commonly ob-
Future Directions served in persons with childhood and adolescent onset
of their obesity who felt scorned for their weight by
In this last section, we will briefly discuss recom- parents and peers (Stunkard & Burt, 1967).
mendations for practice and research. Recommenda- Research is needed to examine changes in body-
tions for research are limited to treatment. image disparagement accompanying weight reduc-
1. Individualizing treatment. Obese patients fre- tion. In some cases, weight regain may be attributable
quently have markedly different treatment needs, to a failure to perceive positive changes in weight and
many of which go unmet. Greater attention must be shape accompanying treatment. Or it may occur in
paid to the initial evaluation of patients with the goal of patients who remain dissatisfied with their weight, de-
meeting their specific needs. Thus, patients with spite substantial reduction, because they are unable to
marked body-image dissatisfaction or affect-induced achieve "ideal" weight. Investigators should explore
eating, for example, should receive individual help the process by which some persons are able to accept
with these problems, in addition to group treatment. their weight, despite remaining obese. Techniques for
Some patients may require adjunct dietary counseling, mitigating body-image disparagement in the obese
psychotherapy, or marital therapy. Individualized care must be developed, as they have been for anoretic and
should be provided in addition to group treatment, not bulimic patients (Wooley & Kearney-Cooke, 1986).
in place of it. 4. Cognitive style. Despite the fact that cognitive
2. Treatment ofcompulsive / binge eaters. Many pa- therapy is increasingly used in the "behavioral pack-
tients report that the traditional behavioral approach age," there is little empirical evidence to demonstrate
does not address the "underlying causes" of their eat- its effectiveness (Collins, Rothblum, & Wilson,
ing. These "causes" are reported to include feelings of 1986). (This is true of several of the components of the
worthlessness, emotional emptiness, and isolation, as package.) Moreover, present cognitive interventions
well as fears of sexual or emotional intimacy (Roth, generally assume that obese individuals are cata-
1982). For some persons, eating apparently provides a strophizers who become emotionally distressed when
pseudosolution to these conflicts. they overeat (i.e., "I've blown my diet again. I'm such
Research is needed to explore the phenomenology a failure. It's no use. I might as well keep eating.").
and history of persons with compulsive eating, and it We have found that a significant minority of our
has recently begun (Gormally, Black, Daston, & Rar- patients display a minimizing rather than catastrophiz-
din, 1982; Marcus & Wing, 1987; Marcus, Wing, & ing style. They effectively use denial, avoidance, and
Hopkins, 1988). Once we have a better understanding rationalization to mitigate possible emotional reac-
of the etiology and nature of this disorder, we will be tions to their overeating. The goal of cognitive restruc-
able to design and assess the efficacy of different turing with these individuals is to help them identify
their habitual methods of minimizing (rather than ex- experience in working with unsuccessful patients, for
aggerating) their dietary indiscretions. Research is they are usually the same ones experienced by the pa-
needed to determine how patients' cognitive and de- tient-frustration, anger, sadness, and impotence. In
fensive styles affect treatment outcome. many cases, the greatest service that the practitioner
5. Natural history of obesity. Surprisingly little is can provide is to allow patients to verbalize their feel-
known about the natural history of obesity or life ings of disappointment and to respond emphatically to
events associated with the amelioration of this disorder them. Particularly with persons who appear unable to
(Brownell, Marlatt, Lichtenstein, & Wilson, 1986). lose weight, the goal of treatment is to help patients
Encouraging findings were obtained by Schacter recover their diminished self-esteem and to realize that
(1982) in an uncontrolled study in which 62% of per- they can live fulfilling lives, regardless of what they
sons surveyed reported that they had lost at least 10% weigh.
of their initial weight and had maintained the weight
loss for several years. Thus, obesity in the general
population may be more controllable than suggested References
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Matarazzo, N. Miller, S. M. Weiss, A. Herd, & S. Weiss ment of bulimia and body image disturbance. In K. D.
Brownell & 1. P. Foreyt (Eds.), Handbook of eating disorders: Yalom, I. (1975). The theory and practice of group psycho-
Physiology, psychology, and treatment of obesity, anorexia, therapy (2nd ed.). New York: Basic Books.
and bulimia (pp. 476-502). New York: Basic Books. Yang, M., Heksha, S., & Pi-Sunyer, X. (1988). Resting meta-
Wooley, S. C., Wooley, O. W., & Dyrenforth, S. R. (1979). bolic rate after weight loss in obese patients (abstract). Ameri-
Theoretical, practical and social issues in behavioral treatment can Journal of Clinical Nutrition, 44. 776.
of obesity. Journal of Applied Behavior Analysis, 12, 3-25.
CHAPTER 23
Marital Distress
Robert L. Weiss and Richard E. Heyman
Introduction and Overview (e.g., Baucom & Epstein, 1989; Jacobson & Holtz-
worth-Munroe, 1986; Margolin, 1987a; O'Leary,
The first version of this chapter (Weiss & Wieder, 1988).
1982) was structured around the four intervention The present chapter covers developments in four
modules of the Oregon Marital Studies Program large subareas of BMT: affect, cognition, spouse be-
(OMSP) model; the literature relevant to each of the haviors, and therapeutic effectiveness. The inclusion
modules was reviewed for possible applications to be- of affect mirrors the heightened interest this topic en-
havioral marital therapy (BMT). The organization of joys within BMT. Similarly, cognitive factors have be-
the present chapter is different, reflecting not only the come quite commonplace in the BMT literature.
contributions of a new coauthor but the considerable Spouse behaviors have been the mainstay of traditional
amount of clinically relevant research activity in BMT BMT and, therefore, hardly need justification. Finally,
since 1982. The empirical basis of BMT has now ex- the measurement of therapeutic effectiveness has be-
panded to include international contributions. Al- come a more refined area unto itself.
though it would have been easier to revise the earlier
chapter, the current organization reflects our ease with
being critical of the area of behavioral marital distress. Conceptual Developments
This is not so much an indication of our disaffection
with BMT, as it is recognition of the area's increased Affect and cognition had already become topics of
maturity. So much has been written in this field-as considerable interest in the earlier chapter on marital
single papers and literature reviews-that it is impos- distress. Not surprisingly, that interest has continued
sible to do justice to the topic in a single chapter; in- apace, and it is now commonplace to find conceptions
deed, we may soon see metareviews, reviews of the of BMT that aggressively champion the inclusion of
reviews. Therefore, our focus will be on fewer, but in cognitive variables (e.g., Baucom & Epstein, 1989;
our minds the more salient, issues facing BMT. The Fincham & O'Leary, 1983; Floyd & Markman, 1983;
decision to provide a more critical appraisal than a Weiss, 1980, 1981) and affective variables (e.g.,
review of issues in clinical practice is justified by the Bradbury & Fincham, 1987a; Gottman & Levenson,
sheer number of clinically useful books, chapters, and 1988; Jacobson, 1983; Margolin, 1983). However,
papers that now comprise the current BMT literature there have been only minor conceptual developments
since the earlier chapter. Emphases on subjectivity are
Robert L. Weiss and Richard E. Heyman • Department of noteworthy, with a notable exception (Gottman &
Psychology, University of Oregon, Eugene, Oregon 97403. Levenson, 1988) that speculates about basic physio-
475
logical gender differences in husbands' and wives' re- other's behaviors by means of each other's informa-
actions to stressful stimuli. Indeed, Gottman is cur- tional presets. It is the interplay between cognitions,
rently concerned with endocrine and immune system the behavioral environment, or context, which spouses
functions in marital interactions (personal commu- provide for each other, and each spouse's reactions that
nication, November 14, 1988). shape these presets. As Baucom and Epstein noted, the
By their very nature, cognitive concepts tend to consequences of holding a particular standard (wife
focus inward; the increased usage of self-report assess- ought to do X) implies that subsequent wife behavior
ment among BMT therapists also fosters subjectivity. will be encoded negatively if the standard is not met,
But even behavioral observation techniques them- thereby causing husband distress. The possibility for
selves-truly the hallmark of the BMT tradition!- mismatch between cognitive set and the (actual) val-
increasingly have implications for how we concep- ence of spouse behavior prompted Weiss (1980) to coin
tualize BMT. We refer here to the growing interest in the term "sentiment override." Many studies pertain-
macrocoding approaches (reviewed below). As we ing to marital distress have focused on this mismatch.
move farther out from the security of direct observa- We introduce some of them here by way of illustration.
tion of interactions, relying more heavily on inferences Floyd (1988) and Notarius, Benson, Sloane, Van-
(often the basis of the macrosystems), the techniques zetti, and Hornyak (1989) have reported separate stud-
themselves change thresholds for acceptable levels of ies germane to the sentiment-override hypothesis
subjectivity (Weiss, 1989). What is most notable about (SOH). In both studies, each partner rated the impact
these macrosystems is their definition of much larger on him-or herself of the other's communications in a
units of interaction, for example, "withdrawal," "es- turn-taking (communication-box or talk-table) situa~
calation," "commitment." These terms become part tion; in both studies, outside observers independently
of our "understanding" of marital interaction. Al- rated the positiveness (or constructiveness) of the each
though not necessarily a practical disadvantage, we partner's communication.
need to recognize the extent to which our conceptions Floyd (1988) reasoned that the SOH predicts two
have become technique driven. forms of cognitive/ affective noncontingency with re-
With their emphasis on "information-processing gard to partner behavior: (1) partner A's impact ratings
systems," researchers now rely more heavily on the- of partner B's messages should be independent of the
oretical constructs implicating central mechanisms. outside observers' ratings ofB's messages, and that (2)
As Fincham and Bradbury (in press) correctly ob- A's impact ratings (ofB's messages) would be related
served, we may now be in the third of three identifiable to outside observers' ratings of A's messages. Thus, no
phases of marriage research: the first, the sociological matter how the observers rated the quality of B 's mes-
phase, was followed by the behavioral phase; now we sages, A would have his or her own positivity (nega-
see an ascendance of the third or "mediational" phase. tivity) set point. However, A's rated impact of B's
The mediational phase does not so much represent messages would agree with the outsider's positivity
dissatisfaction with the behavioral phase, but rather an (negativity) ratings of A's subsequent messages; A
interest in augmenting the behavioral knowledge base. should be consistent in sending messages that agreed
Whatever the reasons, social learning approaches gen- with A's (subjective) impact ratings of B.
erally (e.g., Bandura, 1977), and social learning- Floyd claimed partial support for the SOH (true for
based BMT specifically (Jacobson & Holtzworth- males but not females) with a sample of premarried
Munroe, 1986; Stuart, 1980; Weiss, 1980, 1984), have couples. He tested the first part of the SOH by correlat-
embraced mediational concepts. Bandura's principle ing the mean of each person's impact ratings of their
of "reciprocal determinism" is seen restated within the partner's messages with the corresponding mean of the
many models proposed by the cognitive behavioral outside observers' ratings of each partner's behavior.
marital writers (cf. Epstein, Schlesinger, & Dryden, There was no statistical association between how
1988). Baucom and Epstein (1989) defined five types males rated the impact of their female partner's mes-
of cognitive "phenomena" (basic to information pro- sages and the overall observer ratings of these female
cessing) as the center piece of their cognitive behav- messages. If males rated a message positively, for ex-
ioral marital therapy (CBMT) model: perceptions,. at- ample, observers may have rated it as positive, neutral,
tributions, expectancies, assumptions, and beliefs or or negative. The situation for females was reversed:
standards. At the heart of this and other similar con- female impact ratings were significantly correlated
ceptions is the manner in which spouses process each with observer ratings of the male partners (r = .47,
CHAPTER 23 • MARITAL DISTRESS 477
p < .01), It might seem that observers had a more Agreement on positive ratings was 52.5%. When cou-
difficult time reading the male's behavior than they did ples and outsiders were compared on a standard (not
reading the female's behavior; or taking the outsider their own) taped interaction, the agreements were
ratings as veridical, the males are not effective de- much higher; 65.6% agreement on positive and 47.7%
coders of females. (Whereas outside ratings between agreement on negative. Because the findings were
males and females were statistically unrelated, the cor- similar for different levels of marital adjustment, these
relation between partner impact ratings was highly sig- figures represent performances of all couples com-
nificant, r = .72, p < .01.) bined. As the authors noted, either their couples distort
The second part of the SOH states that a partner's in a positive direction, or they do not perceive (recall)
response to the other would be dependent upon the their interactions as negatively as do outsiders. The
(prior) rated impact of that other. Once again the cor- mismatch between couples' and outsiders' ratings of
relations for males and females were reversed: where- what constitutes negative interactions is rather striking
as males gave what they believed they got, females and deserves further attention. We are inclined to con-
gave what outsiders said they had gotten! "The cur with Gottman (1979) that couples have a private
females' cognitive/affective reactions were relatively communication system; however, the Margolin et al.
congruent with the communication quality of their (1985) study does not allow us to assess this system.
partners' behaviors" (Floyd, 1988, p. 528). We view current research on noncontingencies be-
The Notarius et al. (1989) study, although based on tween partner and outsider cognitive/ affective evalua-
a very small number, demonstrates a methodologically tions as promising leads for furthering conceptual de-
sophisticated approach, using hierarchical log linear velopments in understanding marital distress. BMT
models, for analyzing important cognitive/affective research continues to demonstrate empirically how
contingency sequences. For example, given the rated couples coerce benefits from one another and subjec-
quality of husband communications (positive, neutral, tivity figures largely in these studies.
or negative), we ask what is the wife's rating of impact We tum next to the separate sections that deal with
as well as the outsider rating of the wife's subsequent affect research, cognitive factors, spouse behaviors,
response? Marital distress status was added as a classi- and therapeutic effectiveness, and in each of these we
fication variable. This approach allows for sequential will highlight further conceptual developments.
tracking of antecedent, affective evaluation of the
antecedent, and the subsequent response to both. "The
interaction of distressed couples was shown to be Affect Research
shaped by both negative sentiment override and by
diminished editing" (p. 60). Negative sentiment-over- BMT, and socialleaming theory from which it de-
ride was shown by the greater likelihood that dis- rives, has received considerable criticism on human-
tressed husbands' neutral behaviors were more often istic grounds since its inception. Critics saw BMT's
evaluated as negative by their wives. Additionally, focus on negotiation, problem solving, and objec-
when these husbands' neutral behaviors were received tification as treating highly emotional human inti-
by wives as negative, distressed wives showed a strong macies in a cold, mechanistic manner. Although BMT
tendency to reply negatively. Nondistressed wives, on in the 1980s included many activities aimed at increas-
the other hand, edited their reactions to the negative ing intimacy and positive affect, its main thrust-
antecedents they evaluated negatively by responding changing affect and cognition through behavior modi-
positively. That is, they did not reciprocate negative fication-remained unaltered.
antecedents with their own negative responses. As this decade draws to a close, it seems clear that
Finally, a finding by Margolin, Hattem, John, and BMT is at a crossroads. Research findings, clinical
Yost (1985), on insider versus outsider ratings of cou- limitations, and clinical outcome studies have caused
ples' interactions, is germane to the broader issue of both 8MT proponents (Bradbury & Fincham,
noncontingency between couples' and outsiders' rat- 1987a,b; Jacobson, 1989; Margolin, 1983, 1987a) and
ings of affective impact. Whenever outsiders rated a critics (Greenberg & Johnson 1986a,b,c; Johnson,
unit of negative interaction (affectively) negative, cou- 1986; Johnson & Greenberg, 1985) to champion the
ples, who were rating the same interaction, only need for emotionally based treatment components in
agreed with outsiders 22.7% of the time. Couples rated marital therapy.
45% of these negatively rated interactions as positive. In this section, we will review some of the most
important findings in the affect literature as it applies to Table 1. Factors Associated with Concurrent
marriage therapy (for a more complete review of re- Distress
cent literature on affect in marriage see Bradbury &
Events of day-Low conflict
Fincham, 1987a,b; Noller, 1984), highlight the dif- 1. More negative affect for wives.
ferences between emotionally focused therapy (EFf)
and BMT, and make recommendations for including Problem discussion-High conflict
1. Less positive affect for wives.
an affective focus in BMT.
2. More reciprocity of negative affect during same to-
second period.
Levenson and Gottman: Psychophysiology of 3. More of wife's reciprocating husband's negative affect
to-seconds later.
Marriage
4. Less of husband's reciprocating wife's positive affect to-
Robert Levenson and John Gottman's (Gottman & seconds later.
Levenson, 1985, 1986; Levenson & Gottman, 1983, 5. More of wife's reciprocating husband's positive affect
during same and next to-second period.
1985) research added physiological measurement to
the traditional observational research paradigm (cf.
Gottman, 1979). These papers firmly established the
concurrent and long-term link between marital conflict
and marital distress. Levenson and Gottman (1983) found that physio-
These papers are most important for three reasons. logical linkage (how closely spouses' physiological
First, Levenson and Gottman (1983, 1985) found a responses matched during the interactions) accounted
strong association between self-report of affect and for an extraordinary 59% of the variance in marital
marital distress/deterioration 3 years later. Second, satisfaction. When we consider that behavioral mea-
there is substantial but as yet unrealized clinical poten- sures using trained observers are able to account for no
tial for this work. This paradigm can identify specific more than 30% of the variance in marital satisfaction
patterns of affect/behavior exchange that not only con- (Gottman & Levenson, 1986), this finding is indeed
tribute to marital distress and deterioration, but also impressive. In addition, the couples' self-reports of
create reinforced but maladaptive conflict resolution affect explained a significant percentage of variance in
patterns (Le., Gottman & Levenson's 1986 "escape satisfaction (16%), over and above that of physiologi-
conditioning hypothesis" based on coercion theory cal linkage (Levenson & Gottman, 1983). Thus, cog-
Patterson, 1982). Third, the finding that individuals, nitive appraisals of affect add nonredundant informa-
while watching a videotape, substantially relive the tion to the measurements of emotional/physiological
physiological (and, theoretically, the emotional) pat- response to conflict.
terns they experienced during the actual discussion The results correlating self-report of affect and cur-
validates the watching of taped samples of behavior for rent marital distress are summarized in Table 1.
both research and clinical uses. Three years later, 19 of the 30 couples were located
Levenson and Gottman recruited 30 couples and agreed to complete a set of questionnaires, includ-
through newspaper advertisements in Bloomington, ing the marital satisfaction measures (Levenson &
Indiana, newspapers. Couples participated in two dis- Gottman, 1985). The patterns of interactions that pre-
cussions: one low-conflict exchange on the events of dict decreases in marital satisfaction 3 years hence are
their days and one high-conflict talk on an area of summarized in Table 2.
conflict. Measures of heart rate (interbeat interval), These patterns seem to reflect a male with-
circulation (pulse transmission time to the finger), drawal/female approach pattern. This pattern is the
sweating (skin conductance), and general somatic ac- subject of much recent research (e.g., Christensen,
tivity were collected. Three to five days later, partners 1988; Gottman & Krokoff, 1989; Heyman & Weiss,
returned separately to the lab to watch videotape of the 1988; Margolin, John, & Gleberman, 1988) and the-
interactions. Again, their physiological responses orizing (Gottman & Levenson, 1988; Jacobson, 1989).
were recorded. While seeing the videos, subjects ma- In addition, the more physiological arousal subjects
nipulated a dial to provide a continuous rating of the felt during either discussion, the more their marital
affect (on a scale of I = very negat!ve, to 9 = very satisfaction deteriorated. If these discussions were in-
positive) they believed they had experienced during deed typical samples of the couples' interactions-and
the original session. as Gottman and Levenson (1986) point out, laboratory
Table 2. Aspects of Interaction Associated with research needs to be conducted to test this hypothesis,
Decrease in Satisfaction Three Years Later but clinicians should pay particular attention to behav-
iors that seem to precipitously reduce conflict (Got-
Events of day
tman & Levenson, 1986, hypothesized that anger on
I. Less positive affect by the husband.
2. More positive affect by the wife. the part of the wife is frequently the escape valve).
3. Less reciprocity of the wife's negative affect by the Once we can empirically identify these stereotyped
husband during the same lO-second period. (Decrease in microbehavioral patterns, we can sharpen our thera-
satisfaction for wives only) peutic interventions and test if therapy reduces the ster-
4. Less reciprocity of the wife's negative affect by the eotypy and if the reduction leads to satisfaction gains.
husband during the following IO-second period. (Wives
only)
Problem discussion
Recent Affect Research Relating to Marital
I. Less negative affect by the husband. Distress
2. Greater reciprocity of the husband's negative affect by
As Smith and O'leary (1987) pointed out, marital
the wife in the same (IO-second) rating period. (Wives
only, r = -.78) researchers need not rediscover affect, because they
3. Greater reciprocity of the husband's negative affect by have been studying affective appraisals of relationship
the wife in the following (lO-second) rating period. satisfaction all along. Levenson and Gottman's work
(Wives only, r = -.96) (1983, 1985) is important not only because of their
findings, but also because of the valid paradigm they
created for combining observational research with
continuous ratings of affect.
settings tend to elicit less conflictual discussions than Despite the exceptional promise of this paradigm,
occur at home-then it strongly implies that conflict is its effect has yet to be felt in the published marital
indeed deleterious to relationships, and that increasing research literature. Experimental research programs
levels of conflict are increasingly harmful. on communication of emotion in marriage, however,
There are several problems and promises regarding have generated several important findings. These stud-
these studies that should be noted. First, we must bear ies had spouses send several standard messages in
in mind that these findings are based on 30 volunteer positive, neutral, and negative fashions. The other
couples from Indiana. Replication is necessary to see spouse and outside observers attempted to discern
how well these findings generalize to other couples in which of the three affect possibilities matched with
other locations. Unfortunately, the costs involved which of the messages.
make this type of study almost prohibitively expen- Noller (1980) and Gaelick, Bodenhausen, and Wyer
sive. Second, until we can link affective findings with (1985) found that men have a negativity bias (they
specific behavioral-affective observations, the clinical interpret a lack of positive affect as hostility), whereas
utility of this research is limited. Although Gottman wives have a positivity bias (they interpret a lack of
and Levenson have developed a system for "specific negative affect as positivity). Furthermore, both stud-
affect," they have yet to publish findings that pinpoint ies found that messages intended to be negative were
what is going on (observationally) when spouses are more accurately perceived than messages intended to
experiencing and reciprocating affect. Combining af- be positive.
fect ratings with observational coding systems has Adjustment was also found to influence emotional
great promise in uncovering which interactional ex- communication accuracy. Noller (1980) found higher
changes are the most crucial. agreement on communication intent for satisfied than
Third, Gottman and Levenson (1986) used the affect for dissatisfied couples. Gottman and Porterfield
findings and the specific affect coding results from one (1981) reported a high correlation between the wife's
couple to propose the "escape conditioning hypoth- Marital Adjustment Test (MAT) score (Locke & Wal-
esis" (based in part on Patterson's [1982] coercion the- lace, 1959) and the husband's accuracy in perceiving
ory) that certain aversive behaviors are associated with the emotional content of her messages. There was no
a joint reduction in arousal and are thus reinforced. association between the wife's accuracy and the hus-
This hypothesis is extremely important, as it may ex- band's MAT score. In addition, there was no signifi-
plain the stereotyped, self-defeating patterns of con- cant link between the wife's MAT score and the in-
flict that many distressed couples experience. Further terpretive accuracy of men in the study who did not
know her. Gottman and Porterfield (1981) concluded Moreover, they hypothesized that arousal will lead
that it was the husband's inaccurate decoding of the couples to ignore external factors contributing to the
message, rather than the wife's encoding of the mes- conflict.
sage, that was associated with the wife's marital quali- Second, Bradbury and Fincham (1987b) proposed
ty rating. that mood state-dependent learning occurs in mar-
In a less experimentally controlled study using the riage, causing those in distressed marriages to learn
talk-table paradigm (where couples engage in a con- behaviors that are then more easily recalled in a nega-
flictual discussion and rate the intent and impact of tive state. Also, the partner's negative features and
each statement made), Schachter and O'Leary (1985) adverse behavior will be focused on, remembered bet-
found that distressed couples rated both the intent and ter, and recalled easier in negative emotional states.
impact of their statements as negative and super-nega- However, as Coyne (1986) pointed out, state-de-
tive significantly more often than the nondistressed pendent learning studies have been difficult to repli-
group did. In both groups, listeners rated their part- cate. It seems inadvisable at this time to encourage
ners' statements more negatively than the speakers BMT to evoke more negative affect as the only way to
intended. For distressed couples, this usually meant get at cognitions associated with negative mood states.
rating a neutral statement as negative, whereas for Moreover, Coyne (1986) cited research which sup-
nondistressed couples, this meant rating a positive ports the claim that calm reframes can provide affec-
statement as neutral. This study replicated the talk- tive and physiological changes when individuals later
table findings of Markman (1979) that base rates of encounter stressful situations. He concluded that emo-
positivity and negativity, not intent-impact mismatch, tion in therapy sessions may be a useful, but not a
discriminate between distressed and nondistressed necessary, tool of change.
groups.
Recently, Margolin et al. (1988) and Smith and
Affective Disorders and Marital Distress
O'leary (1987) have used affective coding systems in
studying the problem discussions of physically One of the most promising recent research develop-
abusive couples. Margolin et al. found that physically ments in clinical psychology is the firm establishment
abusive husbands displayed more negative behaviors of the link between marital distress and depression.
and negative voice tone than husbands in other types of Clinical research from both the marital and depression
conflictual marriages. On a postinteraction question- fields has noted for some time that distress and depres-
naire, abusive men reported more sadness, fear, anger, sion covary (e.g., Beach, Jouriles, & O'Leary, 1985;
physiological arousal, and feeling attacked than the Ilfeld, 1977; Weiss & Aved, 1978; Weissman et al.,
other husbands. Similarly, Smith and O'Leary (1987) 1979). Further, evidence from longitudinal studies
found that the expression of negative affect during an supports the hypothesis that marital distress strongly
audiotaped premarital problem discussion was a strong contributes to the development of depression, rather
longitudinal predictor of spousal aggression, though than the other way around (Beach, Arias, & O'Leary,
observer-rated arousal was not. 1988; Lin, Dean, & Ensel, 1986; Monroe, Bromet,
Bradbury and Fincham (1987a,b) integrated basic Cornell, & Steiner, 1986).
emotion research, research on social situations outside Beach et al. (1988) measured marital satisfaction,
of marriage, and behavioral marital research in their depression, and life events 6 and 18 months after mar-
reviews of affect and cognition in marriage. Two of riage. They adopted a conservative strategy in testing
their propositions are particularly worthy of attention, the marital distress and the depression relationship;
as they bring up important issues potentially affecting they removed the effects of initial levels of depression
the effectiveness of BMT interventions. and intervening life events before testing if marital
First, Clark and Isen (1982) found that high levels of satisfaction 6 months after marriage predicted wives'
arousal make conscious behavioral strategies less ac- level of depression 1 year later. Thus, any effects of
cessible. Because Levenson and Gottman (1983) preassessment distress or life-event-mediated distress
found that couples in conflict exhibit high levels of on depression were eliminated, leaving only effects
arousal, Bradbury and Fincham (1987b) proposed that from "pure" marital distress that arose during the in-
communication skills (especially those newly learned tervening year.
in therapy) may be extremely difficult to employ ifthe Beach and his colleagues found that both wives' and
problem discussion reaches the level of conflict. husbands' initial level of marital satisfaction predicted
wives' level of depression 1 year later. Interestingly, group (a group not included in the Biglan etal., 1985,
husbands' , but not wives' , level of marital satisfaction and Hops et al., 1987 studies) were significantly less
buffered the depressive effects of negative life events likely to respond to depressed behaviors with ag-
on wives. Although the level of variance accounted for gressive behaviors than were husbands in de-
by marital satisfaction was small (6.6%), Beach et al. pressed/distressed or nondepressed/distressed mar-
emphasized that this should be considered to be a mini- riages. Nelson hypothesized that the differences
mum estimate of the relationship. These results concur between his study and those of the Biglan group may
with those of Monroe and his colleagues (1986), who be due to husbands of depressed wives habituating to
found that wives' report of marital conflict and marital the depressed behavior of their wives, making them
support-which were entered into the regression less coerced by the depressed behavior. He found that
equation in a similar fashion as the one detailed wives in the depressed/distressed group emitted sig-
above-accounted for a small but significant propor- nificantly more depressed behaviors than wives in the
tion of the variance in their depression measured 1 year other groups, most likely because these behaviors no
later. longer provided the suppression they once did. He pro-
Because well-conducted prospective studies have posed that the results from his study and the Biglan et
concurred that initial levels of marital distress predict al. study would be compatible if the husbands in the
future levels of depression, it seems prudent to con- Biglan et al. study had been exposed to the coercive
clude that, at least for some couples, marital distress behaviors for less time than the husbands in his study.
leads to depression. The treatment implications of this Research in understanding the manner in which
finding are obvious, and later in this chapter we will marital distress may increase the risk of depression is
review recent outcome studies using BMT to treat both in its infancy. Longitudinal studies that observe cou-
marital distress and depression. Even more obvious is ples across time and that isolate interactive patterns
the need to examine how distress facilitates depres- that are predictive of future depression and distress are
sion. crucial to our understanding of this phenomenon. By
On the theoretical level, Beach and Nelson (1989) empirically isolating these predictive patterns, marital
proposed six intermediate factors in the effects of mar- researchers will be able to create better etiological
ital distress on depression-low levels of marital sup- models and establish more firmly the legitimacy of
port (cohesion, affective expression, concrete as- marital therapy for the treatment of depression.
sistance, self-esteem support, perceived spousal
dependability, and intimacy) and high levels of marital
Emotionally Focused Therapy versus
stress (arguments, fear of separation, severe spousal
Behavioral Marital Therapy
denigration, severe disruption of scripted marital be-
havior, and idiosyncratic major marital stressors)- Not only has the debate over affect increasingly
which when combined with nonmarital factors influ- caught the attention of marital researchers, but also it
ence the level of depression. has set the stage for a modern-day sequel to the Wizard
On the empirical level, sequential analyses have of Oz. In this edition, Oz (played masterfully by
been used to examine interactional patterns of de- Greenberg and Johnson) continues to be "a very good
pressed or distressed, depressed or nondistressed, and man but a very bad wizard" -using a facade of flash
nondepressed or nondistressed couples. Biglan and his and smoke when a gentler approach would accomplish
colleagues (Biglan et aI., 1985; Hops et al., 1987) his point much better. The Tin Man (BMT) has be-
used coercion theory (Patterson, 1982) to predict that come king through his use of rugged empiricism. This
depressed behavior by wives would be aversive and causes Oz to attempt to overthrow the Tin Man by
would thus reduce the probability that their husbands exposing to the kingdom that he has no heart!
or children would respond aggressively. They indeed Johnson and Greenberg (Greenberg & Johnson
found that depressed behavior, in the depressed 1986a,b,c; Johnson, 1986; Johnson & Greenberg,
/ distressed group only, caused a reduction-relative to 1985), have caricatured BMT as cold and fixated with
the base rate-in the husband's (Biglan et al., 1985) businesslike negotiations. For example, Greenberg
and the children's (Hops et al. 1987) aggressive and Johnson (1986a) informed us that "the behavioral
behavior. view . . . sees emotion as a learned maladaptive re-
Nelson (1988), however, found a seemingly diver- sponse" (p. 3).
gent pattern. Husbands in the nondepressed/distressed These distortions are unfortunate not only because
they are patently false, inflammatory, and misleading, for '''some ofthe couples, some ofthe time,' " and we
but also because their "straw-man" strategy extended heartily agree. Intense emotional expression and ex-
to their outcome study (Johnson & Greenberg, 1985), posure should not be a required part of marital therapy.
where they contrasted the full emotionally focused But, we hope that a strategic affective-behavioral-cog-
therapy (EFf) package with a portion of the BMT nitive therapy, as advocated by Margolin (1987a), will
program and declared EFf the victor. give more of the couples what they seek more of the
Despite the rhetoric and the widely divergent the- time.
oretical backgrounds of the two camps, BMT and EFf,
in practice, do share some elements. Each group can
learn something from the other, and some cross-pol-
Cognitive Factors
lination of treatment ideas is not only possible but po-
tentially fruitful.
Attribution
EFf emerged from the experiential and structural
orientations. From the experiential tradition of Rogers Attributional process, derived largely from social
and PerIs, EFf theorists have adopted the view that psychology and from the reformulated learned-help-
people seek growth in their relationships and are ac- lessness model of Abramson, Seligman, and Teasdale
tive, holistic perceivers and organizers of information (1978), figures prominently in most considerations of
in their environments (Greenberg & Johnson, 1986c). cognitive factors in BMT. In its most general sense,
From the structuralist perspective, EFf borrowed a attribution refers to the search for causes to explain
focus on communication and interactional cycles that some event. In the context of intimate relationships,
are self-defeating. attribution refers to attempts that partners make to ex-
According to this theory, emotion serves not only as plain their relationship to themselves, or, as Weiss
a basic source of human communication but also as an (1980) has noted, to erect a theory of their relationship
organizer of cognitive and perceptual experience. By (see also Baucom & Epstein, 1989). Research teams
intervening in the emotional process itself, EFf theo- under the direction of Bradbury and Fincham have
rists believe EFf can modify cognitive-emotional sub- contributed the lion's share of the research in this area,
structures, such as schemas and concepts, thereby giv- conveniently summarized in Fincham and Bradbury
ing new meaning to the partner's behavior. (in press).
Both EFf and BMT are heavily therapist directed; As with all mediating variables, caution is advised.
utilize homework assignments; strive to improve sup- We offer a partial listing of cautions to be exercised
port and understanding; attempt to create a positive, before enthusiastically accepting the contribution of
safe environment during sessions to facilitate self-ex- attribution variables.
pression and change; aim to eliminate negative, self- First, current methods for determining whether at-
defeating interactional cycles; and employ outcome tributions are operating in a given instance are them-
studies to test the effectiveness of their treatments. The selves often highly reactive. Holtzworth-Munroe and
basic difference between the two therapies is that EFf Jacobson (1985) have attempted to reduce this reac-
tries to change behaviors by focusing on affect and tivity by use of an open-ended reporting technique that
cognition, whereas BMT tries to change emotion by becomes increasingly focused and directed with re-
focusing on behaviors and cognition. Both have their peated inquiries. Second, attributions are not limited
strengths and weaknesses. Whereas EFf may indeed to attribution of causality. Fincham, Beach, and
succeed in facilitating the renewal of affective bonds, Nelson (1987) have found it necessary to distinguish
affective change without concomitant behavioral im- between causality and responsibility attributions, not-
provements would not be long-lasting. Conversely, ing that, in marriage, the assignment of responsibility
BMT that succeeds in modifying behaviors but that may be more important than causality. Weiss (1980)
fosters no improvement in emotional ties can hardly be stressed that intent and skillfulness need to be included
deemed a success. in the attributional process, because a person's judged
The core concept of EFf-getting couples to un- intent to do good or bad is modulated by the perceived
cover, identify with, and accept the role of primary skillfulness of the actor. Having knowledge that one's
emotions in their conflicts-warrants attention from partner lacks the necessary skills makes it more diffi-
the entire field of marital therapy. Coyne (1986, p. 13) cult to attribute malevolence. Third, the distinction
warns that emotionally based interventions should be between attributions as state or trait variables is not
often made. Does a spouse invoke an attribution de counted for by a measure of depression (Beck Depres-
novo on a given occasion, or do attributions function as sion Inventory: BDI). In a subsequent study (cited in
dispositional constructs? Attributions coded as global Fincham & Bradbury, in press), three groups of wives
and stable have traitlike status. Fourth, as with the role were constituted by combining clinical depression
of attributions in cognitive theories of depression, we (using the DSM-III ratings) with marital distress status
ask whether specific attributions actually follow, (distressed/nondistressed). There were no difference
rather than precede, the behavior of interest. Are at- on attribution measures between the Depressed-Dis-
tributions a posteriori explanation of our current nega- tressed and the Nondepressed-Distressed groups (indi-
tive state, rather than being the cause of it? The ties cating that the attribution measures were not reflecting
between the presence of an attribution and subsequent depression), but there were significant differences be-
behavior are often difficult to discern unequivocally tween the Nondepressed-Distressed and the Non-
(Kelley & Michela, 1980; Weiss, 1984). Finally, in our depressed-Nondistressed wives (indicating the signifi-
view, researchers have often failed to recognize a sim- cance of marital adjustment status). When BDI scores
ple truism: measures of "blame" and marital dissatis- were used as measures of depression, as before, 20%
faction are necessarily correlated because both are me- of satisfaction variance was accounted for indepen-
diated by the same affect. The methods for dently of depression.
determining dissatisfaction with a spouse (negative The attribution-marital-satisfaction relationship
self-report), and those that provide opportunities to has also been demonstrated with a longitudinal design
cast blame on that spouse (also negative self-report), (Fincham & Bradbury, 1987a). Spouses completed
are highly similar expressions of negative sentiment. measures of marital satisfaction, and causal and re-
This confound is now being recognized within the at- sponsibility attributions for marital difficulties and for
tribution literature. Fincham and Bradbury (1988) negative partner behavior approximately 12 months
mentioned the overlap between measures of marital apart. Both attribution indices were associated with
satisfaction and attributions. They endorsed, as do we, marital satisfaction at each testing period; wives'
Norton's (1983) recommendation that a single eval- causal and responsibility attributions predicted their
uative rating of marital quality must replace the con- later marital satisfaction independent of their earlier
tent of specific items used in popular measures of mar- satisfaction. The greatest decline in marital satisfac-
ital adjustment, such as the Dyadic Adjustment Scale tion occurred 1 year later for those wives who located
(Spanier, 1976). A rose by any other name is still senti- negative partner behaviors and marital difficulties (1)
ment. This is a point we stress below as well. Armed within the husband and (2) as global and stable charac-
with these concerns, our truth shield, we will now teristics. These findings held only for wives and not
consider empirical studies of the role of attributions in husbands. Marital satisfaction at Time 1 did not pre-
marital distress. dict attribution scores at Time 2. There was further
A number of studies have shown that, in comparison evidence for the discriminant validity of the attribut.ion
to nondistressed partners, those in distressed mar- measures: none of the findings replicated when a sec-
riages are more likely to attribute negative partner be- ond cognitive factor, unrealistic relationship beliefs,
haviors to stable and global causes within their part- was substituted as the cognitive variable.
ners, that is, traits (Baucom, Bell, & Duhe, 1982; The evidence, at least for wives, strongly suggests
Fincham & O'leary, 1983; Holtzworth-Munroe & that the causal and responsibility attributions (as well
Jacobson, 1985). Because attributions have been asso- negative explanations of husband's intent), which are
ciated with depression, and depression has been impli- held at Time 1, predict relationship satisfaction 12
cated in marital satisfaction, Fincham, Beach, and months later. These findings are certainly the cognitive
Bradbury (1989) sought to establish the discriminant homologue of Markman's affective impact ratings. It
validity of the concept by showing that attributions will be recalled that affect impact ratings predicted
account for amounts of marital satisfaction variance marital satisfaction some 5 years later (Markman,
beyond that accounted for by other relevant variables, 1981). The specificity to relationship problems and not
for example, depressive mood. In their sample of vol- generalized unrealistic relationship beliefs is worth
unteer wives, Fincham and colleagues were able to noting.
show that indices of "responsibility attribution" (both Positive and negative responsibility attributions are
positive and negative) together accounted for 44% of important factors in accounting for unique variance in
the variance of marital satisfaction beyond that ac- marital satisfaction. Perhaps even more important for
clinicians is the relationship between attributions and studies at this point is somewhat arbitrary because they
behaviors (attributional processes). Fincham and are also pertinent to communication of affect. (We ac-
Bradbury (1988) reported an experimental manipula- knowledge that a substantial communications liter-
tion with distressed and nondistressed community cou- ature exists outside of psychology, but reviewing such
pies, designed to provide either (I) a plausible external studies is beyond the scope of this chapter; see
reason for a spouse's having written a "negative eval- Fitzpatrick, 1988.)
uation" of the other, or (2) a condition that provided no Noller (1984) has reported on a program of research
"explanation" for the negative evaluation. One spouse dealing with husband-wife differences in communica-
was randomly enlisted as a confederate of the experi- tion "skillfulness"; differences in ability to send and
menter. After reading the "evaluation" and the written receive nonverbal messages between spouses and
instructions presumed to have been the stimulus for the strangers. (The basic format is to have partners send
evaluation, the spouses interacted for 5 minutes, dur- charadelike messages communicating a specifIc af-
ing which time the confederate spouse remained neu- fect. Judges may also rate the difficulty of understand-
tral. As expected, for distressed spouses, when there ing the messages that spouses send to one another,
had been no external explanation given.for a negative thereby establishing whether a message is clear.)
evaluation, the subject spouses behaved more nega- In studies by Noller and also by others (e.g.,
tively toward their (confederate) spouse. There was Sabatelli, Buck, & Dreyer, 1982), it is the wives' abil-
also an unexpected increase in positive behavior under ity to encode and decode husband messages that seems
this condition. Behavior of nondistressed spouses did to be a critical factor in marital happiness. Wives who
not vary across the conditions. Fincham and Bradbury were good encoders and good decoders of poorly sent
speculated that the distressed spouses became more husband messages were generally in happier marriages
aroused in the unexplained negative evaluation condi- and were happier themselves. Gottman and PorterfIeld
tion; the arousal served to activate negative behaviors (1981) found, to the contrary, that it was the husbands'
because the offended spouse had confIrmation that he ability to read their wives' communications that was
or she had been belittled in public .. associated with increased marital satisfaction. Noller
In a recent paper, Bradbury and Fincham (1988) (1984) has shown that husbands and wives in dis-
demonstrated a link between type of attribution (e. g. , tressed marriages do less well with each other's mes-
globality, intent, selfIsh motivation) and sequentially sages, but quite well with those of strangers sent in this
dependent behaviors as coded from couple interac- same paradigm. This fInding is reminiscent of the orig-
tions. Using z scores derived from a lag sequential inal Birchler, Weiss, and Vincent (1975) study, which
analysis, they found that husbands and wives, who also showed that distressed partners evidenced a per-
also held essentially negative attributions about the formance deficit; they had the wherewithal to engage
other's behavior, were less likely to reciprocate in positive behaviors, but did so much less with their
positive behavior from the other. These findings go partners.
beyond the general fInding in the literature that nega- Clinically, there is ample evidence that spouses
tive sentiment toward one's partner is associated with want clearer emotional expression from one another,
negatively coded interactions because the relationship but that wives request this more (Margolin, Talovic, &
remained significant even after partialling out the ef- Weinstein, 1983). Guthrie and Snyder (1988) exam-
fects of marital satisfaction. Bradbury and Fincham ined cognitive appraisals in male-female emotional
have taken the necessary steps to show that attributions expressiveness, with appraisals or cognitive construals
relate to subsequent behaviors. functioning as schemata for interpreting emotional
events. Spouses evaluated a set of emotionally relevant
communicative acts (e. g., "Saying sorry to your part-
Communication Effectiveness and
ner'" "Telling your partner what's making you mad,"
Understanding
"Telling your partner how good you feel") against a
We have already considered a number of studies that set of self-evaluation constructs (e.g., "worthwhile"
deal with the process of communication effectiveness "inhibited" "powerless") in a repertory grid; scale
within marital relationships. In this section, we will ratings ranged from "1 = I would never feel" to "6 = I
briefly review studies that provide some insight into would always feel." Using multidimensional scaling,
gender differences in marital communication effec- Guthrie and Snyder showed that "husbands and wives
tiveness and understanding. The inclusion of these differ mainly in their appraisals of admitting ner-
vousness, telling personal problems, saying sorry and partners, they were also less accurate. From another
showing anger, all of which involve images of study (Noller & Venardos, 1986), distressed partners
powerlessness for husbands but of powerlessness and were more confident of their (inaccurate) judgments.
also acceptance for wives. Wives tend to regard anger There were no distress status differences in how part-
displays as indicative of independence" (p.1SO). Hus- ners expressed anger; both groups express anger equal-
bands self-report less expressiveness of emotions they ly strongly. Finally, the behavior of distressed (relative
regard as showing powerlessness. Both husbands and to nondistressed) receivers was rated more negatively
wives in distressed marriages self-report less ex- across all three emotion communications. As Guthrie
pressiveness (with the exception of anger) than their and colleagues point out, it may be as important to
nondistressed counterparts. Spouses with low marital focus on how a spouse responds to the emotional ex-
adjustment regard increases in positive affiliative be- pression of the other as it is to focus on the emotion
haviors to be important to happiness. The conclusion itself.
that we draw from this research is that it is not so much
gender differences in emotional capability, as very dif-
Cognitive Therapy
ferent appraisals of the costs of expressing emotion. In
her dissertation, Guthrie (1988) made an important As one rereads the earlier BMT literature, it almost
observation from these same data: females and males appears that BMT began as a cognitively based marital
differ in the instrumental utility associated with differ- therapy in spite of its avowed emphasis on perfor-
ent modes of expressing emotion. Although females mance. Aspects of subjectivity (attributions, cognitive
may see problem discussion and complaining as a restructuring, expectancies) seem to have been a com-
means of drawing closer, males read these behaviors as mon feature from early on (e.g., Jacobson, 1984;
expressions of disaffiliation and powerlessness. Ep- Stuart, 1969; Weiss, 1980, 1984; Weiss, Hops, & Pat-
stein, Pretzer, and Fleming (1987) also reported gen- terson, 1973). It has been well established that ratings
der differences in self-report measures of communica- of behavioral events account for approximately 25% of
tion as these are related to marital distress and the variance in marital satisfaction ratings (Broderick
inventories of dysfunctional beliefs. Three factors & O'Leary, 1986; Jacobson, Waldron, & Moore,
were derived from a marital communication measure: 1980; Weiss & Isaac, 1976; Wills, Weiss, & Patterson,
for females these were Critical/Defensive, Withdrawn 1974). The figure is somewhat higher if one correlates
and Submissive, and for males, Critical/Defensive, "sentiment" measures (e.g., positive feelings) with
Withdrawn/Submissive, and Dominant/Controlling. satisfaction measures, in part because of "item" sim-
The role of intention is a prime cognitive candidate ilarity. The issue, therefore, is whether one can in-
(e.g., Fincham & Emery 1989; Weiss, 1980). In a crease the "take" of BMT interventions by adding
complex study, Guthrie and Noller (1988) had spouses cognitive components. Put differently "the emphasis
interact when in three emotional states; that is, interac- on behavior change is a means to an end [increasing
tions during which each, in tum, was to either express satisfaction] as much as it is an end in itself" (Jacobson
(or receive) expressions of anger, affection, and de- & Holtzworth-Munroe, 1986, p. 33).
pression. The emotional states were resurrected from An earlier suggestion (Weiss, 1980) held that BMT
each partner's recall of a personal interaction involving had two components that followed Bandura's notions
the specific emotion. Spouses rated how well the in- of efficacy and outcome expectancies, respectively; a
tention of the sender (e.g., sender is angry) matched cognitive component that dealt with the "theory" or
that rated by the receiver (receiver rates emotion as "meaning" of a couple's relationship and a perfor-
anger). Outside raters also rated the agreement be- mance or skills-oriented component that reflected
tween spouses' intention ratings. knowing what to do. The cognitive component, like
Guthrie and Noller (1988) found that level of marital efficacy expectations, included the attitudes, beliefs,
adjustment was related to the intentions spouses at- and expectations associated with the "meaning" of the
tributed to each other during their emotional interac- relationship. As such these cognitions address the pos-
tions: high marital adjustment partners attributed more sibilities or the "We believe we can do it" aspects of a
positive intentions to their partners and were also more relationship. The performance or skill-based compo-
accurate than were low marital adjustment partners in nent, like outcome expectancies, addresses the "We
ascribing intentions to their partner. Dissatisfied part- know how to do it" aspects. This distinction helps
ners not only ascribed more negative intentions to their locate cognitive behavioral marital therapy (CBMT) in
the context of more traditional BMT. For example, a are isolated suggestions in the literature for applying
number of authors (Baucom & Epstein, 1989; this or that specific technique to couples. Halford and
Birchler, 1988; Jacobson & Holtzworth-Munroe, Sanders (1988), for example, demonstrated how well a
1986; Weiss, 1979, 1980, 1984) have suggested that "thought-listing" technique, which assesses the self-
CBMT elements are needed to overcome resistance to statements spouses (presumably) made during a prob-
the changes BMT seeks to effect. Merely focusing on lem-solving interaction, discriminated between dis-
skill enhancements is not sufficient, if couples still tressed and nondistressed couples. The distressed,
hold cognitions that interfere with the maintenance of compared to nondistressed couples, retrospectively
their newly found skills (e.g., Jacobson & Holtzworth- and unaided listed more partner-negative cognitions
Munroe, 1986). Efficacy expectations may prevent they "held" during their interactions with their spouse.
sustained functioning of important marital skills. Di- Over 50% of all cognitions reported by the distressed
rected interventions on efficacy expectations are, in a couples were negative references to their partners (p.
general sense, what is meant by cognitive restructur- 525). (These authors correctly note that there was no
ing. Many writers have suggested that CBMT is most independent verification that these negative self-state-
useful in the initial stages of therapy to facilitate ac- ments about spouse were actually made during the in-
quisition of performance skills. Baucom and Epstein teractions and therefore could possibly direct behav-
(1989) suggested that often it is necessary to "so- ior.)
cialize" couples in the ways of CBMT, specifically We have already discussed attribution at length and
with regard to the potential awkwardness they experi- have noted the attempts at model building by Bradbury
ence when asked to examine the foundations of their and Fincham. Baucom and Epstein (1989) and Epstein
relationship cognitions. et al. (1988) have offered a systematic cognitive ap-
A similarity between CBMT and many of the sys- proach to marital therapy. Epstein et al. listed the ma-
tems (especially strategic) theory approaches to cou- jor tenets and objectives of CBMT as follows: prob-
ples and families has also been suggested (see lems arise from distorted perceptions and dysfunc-
Birchler, 1988; Weiss, 1980). When the therapist functional behaviors, and perceptions and interactions have
tions like a director of a stage play, manipulating the reciprocal impact; perceptions are distorted by faulty
context of relationship exchanges, he or she is engag- processing of information inputs. Insight and reality
ing in large-scale cognitive restructuring. For exam- testing are necessary to therapeutic change. "The syn-
ple, we might suggest to a competitive couple, who are ergistic relationship between cognitions and behaviors
battling over who is "right," that "There can be no requires that both be targets of treatment" (p. 12).
winner in a marital fight, because if one is successful in With regard to cognitive processing, many authors
beating the other down, one is left living with a loser!" have pointed out how couples display automatic
This dyadically focused "reframe" changes the mean- thoughts (Beck et al., 1979), a kind of mindless reflex-
ing of winning by denigrating the spoils and making ive meaning system. Similar to George Kelly's (1955)
winning losing. constructs, schemata represent organized experiences
Thus, it appears that there is widespread recognition that provide immediate connotative information.
of the importance of assessing and targeting cogni- These schemata trigger thought "responses"; self-talk
tions, up front, which are the likely impediments to is a conscious representation of this process as in the
change. Additionally, there is general agreement that self-instruction "She does this to annoy me!" Attribu-
cognitions may activate emotion, and, consequently, tions, as content, represent such schemata. Cognitive
therapists must deal with the trinity of affect, behavior, restructuring seems to encompass changes in both con-
and cognition. tent and process. The use of reframes, for example,
Much of the work in CBMT seems to have been may impact some specific content ("His behavior re-
adapted from various cognitive based therapies em- flects his being over-concerned rather than his mal-
ployed with individuals and is already familiar from ice"), but they may also teach a method for cuing
the cognitive therapy literature; for example, attribu- alternative explanations. Insight, mentioned by Ep-
tional dynamics from the revised learned helplessness stein et al. (1988), refers to helping couples make as-
model (Abramson et al., 1978), Ellis's RET model sumptions explicit, allowing them to test dysfunc-
(Epstein, 1982), and Beck's cognitive model of de- tional beliefs about each other (e.g., negative global,
pression (Beck, Rush, Shaw, & Emery, 1979). There stable attributions).
Spouse Behaviors with one another's coding or descriptive language sys-
tems and borrow from one another, the overlap in
In view of the heavy emphasis on cognitive factors methods imposes shared "meaning" on what we ob-
in current formulations of BMT, it is not surprising to serve. What is currently "theoretically interesting" is
find that the old standbys of behavior contracting and ever more so method dependent.
arranging reinforcing contingencies are hardly men- Markman and Notarius (1987), in their most recent
tioned in the current literature. Consequently, our review of marital and family interaction, "identified
focus will be somewhat more methodological, looking six primary theoretical dimensions around which most
at developments in observational and quasi-observa- family-interaction coding systems have been con-
tional methods, because itis there that we can expectto structed" (p. 339). They note, correctly in our view,
find instances of spouse behaviors. That is to say, these that coding systems are likely to reflect their origina-
very methodologies define spouse behaviors. There tors' theoretical hypotheses as well as hunches about
has been a literal outpouring of books, chapters, and important interactional behaviors yet to be observed.
papers dealing with all aspects of behavioral observa- However, there are major differences among re-
tion of spouse and family interactions (e.g., Gottman, searchers in how they operationalize the "same" di-
1987; Grotevant & Carlson, 1987; Jacob & Krahn, mension, creating the potential for a mini Tower of
1987; Jacob, Tennenbaum, & Krahn, 1987; Margolin, Babel.
1987b; Markman & Notarius, 1987; Revenstorf, Hahl- The six global bipolar dimensions discerned by
weg, Schindler, & Vogel, 1984; Schaap, 1984; Weiss, Markman and Notarius (1987) are: dominance, affect,
1989; Weiss & Summers, 1983). In addition, a special communication clarity (skills), information exchange,
issue of Behavioral Assessment (Notarius & Mark- conflict, and support validation. The dimensions are
man, 1989) was devoted to behavioral observation of bipolar in the sense that extreme scores indicate malad-
marital interactions. Under the heading of quasi-obser- justment. Coding methods may focus on either micro-
vational methods, we might include self-reports of in- or macrolevel observational systems. That is to say,
teraction patterns (e.g., Christensen, 1988; Margolin, behavioral units can be defined as events or in terms of
1987b; Peterson & Rapinchuk, 1989). In any event, temporal intervals, usually-but not always-with
behavioral observation is alive and well! We begin one code per unit, which are then combined in some
with an overview of conceptual issues relating to be- fashion to provide an index of one or more of the six
havioral coding systems. dimensions. Alternatively, one can start with a mac-
rosystem that defines broader categories similar to the
six dimensions; here "coding" is a matter of rating
Conceptual Issues in Observational Coding
very substantial chunks of an interaction, presumably
Systems
in some configural manner (e.g., Floyd & Markman,
The maturity of an area of scientific inquiry can be 1984; Floyd, O'Farrell, & Goldberg, 1987; Julien,
judged by the degree of remoteness of concepts from Markman, & Lindhal, 1989; Krokoff, Gottman, &
methods of observation. This may appear as an anti- Hass, 1989; Margolin, Burman, & John, 1989). Some
positivism (indeed, antibehavioral!) point of view, but examples of "codes" representing current macrosys-
a moment's reflection will show otherwise. A non- tems are:
theoretical area, like BMT, relies heavily on em-
piricism; but empiricism means testability as well as
Margolin et al. (1989):
operationalism. To a large degree, we depend on our
Overt Hostility-attribution of problem to
methods of assessment as the means for defining in-
spouse, emotional investment
teresting phenomena. Often, our observational meth-
Patronizing-competitiveness, morality lesson
ods define the "what" in what it is couples do with
condescending/ patronizing, insensitivity
each other (Weiss & Margolin, 1986). In part, the
Despair-sulk, hurt, helpless
problem is the lack of a language of interactions (Gott-
Warmth-happy/content, playfulness, positive
man, 1982); we have some 18,00{) natural language
descriptors for individuals but very few interactional Julien et al. (1989):
terms. We must recognize the possibility that as (Individual) Dominance, denial, withdrawal,
clinical researchers in the marital area become familiar support/ validation
(Dyadic) Positive and negative escalation, com- Krahn study provides useful information about MICS
mitment, future stability code categories as well as an object lesson in assigning
"meaning" to these categories.
Krokoff et al. (1989):
A method's utility, of course, resides primarily in its
(Negative) Escalate negative, negative rela-
validity, which, in turn, is defined by its intended pur-
tionship issue problem, talk,
pose. Observational coding systems do quite well in
(Positive) Humor/laugh, task-oriented rela-
discriminating marital distress as defined by self-re-
tionship information, backchannels present
ports. However, the cost of obtaining this bit of infor-
mation (distress status) is quite high relative to self-
The Krokoff et al. (1989) method codes each spouse report methods. Currently, we depend upon couples to
as speaker and listener using some 22 codes, which are tell us whether they are maritally distressed. Jacobson
then used to form a single speaker and listener score for (1985) has cautioned against possible overreliance on
husband and wife. That is, the overall quality (positiv- a behavioral observation, favoring instead self-report
ity) is indexed as the difference between the respective of marital satisfaction. Opposing views, focusing on
sums of positive and negative scores. the utility of coding approaches, were expressed by
Although perhaps not immediately obvious, the Gottman (1985) and Weiss and Frohman (1985).
various coding system categories (codes combined
into categories) map well onto the six dimensions. For
Some Recent Studies of Marital Interactions
example, the Marital Interaction Coding System
(MICS-III) (Weiss & Summers, 1983) lists seven ma- Behavioral observational coding is the methodology
jor categories (for behavior codes), such as Validation, of choice for describing interaction process. Here, the
Blame, Invalidation, and Facilitation. Here, too, the consequences of what couples do to each other in their
categories comprise individual codes, representing interactions can be discerned, and the contingency pat-
more or less discrete microbehaviors. terns (quantified as scores) can be correlated with other
Jacob and Krahn (1987) reported on three multivari- information about the couple. For example, does dis-
ate methods for establishing categories for grouping tress status predict differences in response to positive
individual MICS codes. Using multidimensional scal- or negative behavioral antecedents? A number of stud-
ing (MDS), principle components factor analysis, and ies have shown such relationships.
transitional probability analysis (a lag sequential meth- Hahlweg, Revenstorf, and Schnidler (1984) devel-
odology), they were able to show that despite sim- oped an observational coding system (Kategorien-
ilarities in categories across methods, there were meth- system fur Partnerschaftliche Interaktion) (KPI) to
od-dependent differences. The choice of categoriza- measure specific aspects of communication skill-
tion method is dependent upon one's objective. It is fulness; for example, the speaker's use of "I state-
important to note, however, that any data-reduction ments" in the here and now and use of active listening
procedure is constrained by the vocabulary of the basic skills, such as open questions, paraphrasing, and so
items. The more homogeneous the code vocabulary forth. The KPI defines 12 code categories based on
(e.g., a focus on codes relevant to problem solving vs. codes initially defined in the Marital Interaction Cod-
codes for specific affects), the greater the commonality ing System (MICS) (Hops, Wills, Patterson, & Weiss,
one will observe among methods. Thus, for the MI CS, 1972) and the Couples' Interaction Scoring System
the three methods disclosed a common problem-solv- (CISS) (Gottman, 1979; Notarius & Markman, 1981);
ing dimension. MDS methodology merely establishes for example, Positive Solution, Agreement, Criticism,
congruence with the intent of the originators of the and the affect coding rules from the CISS. Using a K-
codes, because judges are asked to rate the similarity Gramm (information-theory based) conditional proba-
(to them) of all code pairs. If judges "read" behaviors bility analysis, they showed how unique patterns of
as the authors have done, there will be a match. Only behavior were associated with distress status and the
the transitional probability method establishes func- effects of their BMT-based intervention on these pat-
tional similarities among codes, that is, whether sim- terns. In these types of (sequential) analyses, the idea
ilar behaviors are controlled by different antecedents. is to describe how spouses react to each other's ante-
Factor analyses establish concomitance of frequencies cedent communication behavior at points in time suc-
but not necessarily functional similarity, a point to be cessively more remote from the partner stimulus be-
noted in the studies reviewed below. The Jacob and havior. Thus, Hahlweg et at. demonstrated that,
although negative escalation is characteristic of both example, patterns of feeling expression, mind-read-
distressed and nondistressed couples, the latter "cool ing, information exchange, and so forth. They do not,
down" or cycle out of negative reciprocity sooner. however, spell out just how their model helps define
Similar evidence for escalation of negative affect has researchable issues beyond the observation that levels
been reported by Gottman (1979, 1980), who showed 2 through 4 are reflected already in the literature, for
that nondistressed couples essentially break the tit-for- example, the increased negativity of distressed cou-
tat exchange of negatives much sooner than their dis- ples and their greater negative reciprocity.
tressed counterparts. Comparing German and English More focused attempts to define important patterns
couples, Hooley and Hahlweg (1989) demonstrated of conflictual interactions are reported in studies by
once again the negative escalation "signature" of dis- Margolin and her colleagues (Margolin et al., 1988,
tressed couples. 1989). In order to enhance the intensity of conflictual
Julien et al. (1989) and Notarius et al., (1989) have interactions (relative to those typically sampled in lab-
provided further examples of how behavioral observa- oratory settings) Margolin et al. had couples reenact
tions can be used to predict, respectively, distal marital (coached) interaction conflicts in their own home set-
satisfaction (up to 4 years later) and proximal re- tings. The authors defined four marital conflict styles
sponses (within the same interaction setting). Negative (according to hierarchical inclusion rules) based on
and positive escalation codes were associated with re- Straus's (1979) Conflict Tactics Scale: occasional ex-
lationship satisfaction: r = - .29 and r = .38 (p < change of Physical Aggression (PA), predominant use
.05), respectively (Julien et aI., 1989). Similarly, gen- of Verbal Aggression (VA), predominant use of With-
der differences have been noted: maritally distressed drawal (WI), and low levels of conflict characteristic
females maintain high levels of negative reciprocity of Nondistressed (ND) couples. Videotaped interac-
(Margolin et al. 1989), and unlike their nondistressed tions were divided into thirds in order to detect changes
counterparts, they do not edit negative husband ante- in conflict resolution tactics over time.
cedent behaviors (Notarius et aI., 1989). Others (Got- As noted above, the specific code items were as-
tman & Krokoff, 1989) have shown that husbands' signed to one of the seven categories (that resulted
lack of response to wives' affective behavior is predic- from a factor analysis). In addition, as a preliminary
tive of marital distress some 3 years later. validation, the new code categories were used in dis-
Filsinger and Thoma (1988) examined interaction criminate function analyses to predict the rated out-
behaviors as predictors of long-term relationship sta- come of the conflict interactions, whether the latter
bility and adjustment (up to 5 years) using a behavioral had been resolved or unresolved. The percentages of
system based on the MICS and CISS (Dyadic Interac- discussions correctly classified, that is, using all seven
tion System), with a small sample (N = 21 premar- code categories in discriminant function analyses that
rieds). Instability (whether still married) was predicted agreed with the consensus ratings of outcomes, ranged
by (1) negative and positive reciprocity and (2) level of from 68% to 86%.
female interruptions. The latter also (negatively) pre- Margolin et al. (1989) found that PA couples (rela-
dicted males' subsequent adjustment. Positive reci- tive to the others) exhibited more overt hostility and
procity is noteworthy because it suggests a tit-for-tat became more uninvolved and defensive toward the end
exchange rule that implies "I will be nice only if you of the discussion. ND couples, when compared to the
are nice" (p. 793), which is quite different from three groups of conflictual couples, expressed less de-
positive sentiment override. spair, more warmth, and positive problem-solving
Schaap, Buunk, and Kerkstra (1988) provided a strategies. Surprisingly, the ND couples were not dif-
wide-ranging review of their own work (with observa- ferent from the others in terms of hostility, patronizing,
tional coding) and the work of others on conflict styles or defensiveness. It would seem that the increased
and resolution. They proposed a four-level hierarchal positiveness of the ND group, relative to the others,
model of marital interaction (modifying Gottman's, overcomes the lasting effects of their negative dis-
1979, model): (1) an abstract, general metaconcept plays.
level, which embodies generalized patterning or pre- The Margolin et al. (1989) study illustrates a syn-
dictability irrespective of specific behaviors of a rela- thetic approach to defining conflict styles displayed by
tionship; (2) two specific structural concepts, domi- spouses: first, specific code items were gleaned from
nance and reciprocity; (3) a general content level, other coding systems, the marital interaction literature
positivity; and (4) content of interaction patterns, for and the authors' clinical experiences. Next, these were
assigned to scales, using factor analytic techniques, ported aggressiveness. The usual patterns of negative
and became a rninilanguage of molar facets of marital escalation were somewhat more clear in these ag-
interaction, for example, Overt Hostility, Patronizing, gressive couples. In the Margolin et al. (1988) study,
Warmth, and the like. What is apparent from this se- the PA group was the most maritally distressed, which
lected review of behavioral observation studies is the may account for their findings of higher rates of nega-
trend toward enriching the meaning of the behaviors tive affect in the aggressive group.
themselves. Although empirically based on factor Other studies from the O'leary group have focused
analysis of individual ratings, the scale category on a longitudinal data base, consisting of engaged cou-
names will be remembered, and these inevitably carry ples who were assessed 1 month prior to marriage and
excess meaning (Weiss, 1989). then after 6-, 18- and 30-month intervals into mar-
There has been considerable interest among BMT riage. Murphy and O'Leary (1987) addressed an in-
researchers in the topic of aggression between intimate teresting question about the relationship between ver-
partners, reflecting still another facet of how couples bal aggression and subsequent physical aggression,
behave toward each other. In addition to Margolin and that is, does verbal aggression lead to increased like-
her associates, O'Leary and associates have an active lihood of physical aggression (as the Social Learning
program of research on abusive patterns in engaged Model would hold) or is there a "catharsis" effect,
and married couples (O'leary, 1988; O'Leary, Arias, such that verbal aggression drains off the impetus to
Barling, Rosenbaum, Malone, & Tyree, 1989). physical aggression? Using the CTS and a Spouse Spe-
Vivian, Smith, Sandeen, and O'Leary (1987) com- cific Aggression Scale (SSAS) (O'Leary & Curly,
pared aggressive and nonaggressive couple groups, 1986), they showed that nonphysically aggressive cou-
equally maritally discordant, for anger and negative ples who subsequently showed physical aggression
verbal behaviors. Both spouses in the aggressive group ("new cases") were significantly higher on verbal ag-
(self-reported pushing, shoving, slapping, and throw- gression at earlier testing points. Relationship satisfac-
ing things at partner) admitted to aggressive acts dur- tion scores did not predict subsequent aggression. Al-
ing the year preceding their self-referred clinic con- though not a direct test of the SL or catharsis
tact, at frequencies of 3 to 5 times per year. Transcripts hypotheses, the data are more consistent with the SL
of audiotaped IO-minute interactions were coded using model, and add to Straus's (1974) similar finding
the KPI. In addition, ratings of specific emotions were based on cross-sectional retrospective data. Also,
made by different coders who used 41 different emo- these data are consistent with the role of negative non-
tion adjectives. verbal affect in behavioral observational studies; that
Generally, there were few differences between is, BMT must alter these patterns early on in therapy.
groups on base rate scores; overall categories of
positive and negative verbal communication did not Quasi-Observational Studies. It has been ar-
differentiate the groups. Nonaggressive spouses gued that couples can serve as observers of their own
agreed more. Aggressive wives were more critical of interactions and provide data of interest at much less
their husbands. However, there were interesting se- cost using quasi-observational reports (Christensen,
quence effects. Nonaggressive compared to aggressive 1988; Heyman & Weiss, 1988; Peterson & Rapinchuk,
husbands reciprocated their wives' positive commu- 1988). This was the intent of the original Spouse Ob-
nication with more predictability. Aggressive as dis- servation Checklist (SOC) (Weiss & Perry, 1983). Ac-
tinct from nonaggressive wives were more likely to cording to the advocates of this point of view the SOC
immediately reciprocate their husbands' negative has repeatedly been shown to lack even remotely ac-
statements after correcting for their higher negative ceptable levels of (spouse) observer agreement; for a
code base rates. There were strong indications of nega- current review, see Christensen (1987a). Although this
tive affect reciprocity, lasting over especially long lags lack of agreement is not always a major problem (El-
for the aggressive husbands' responses to their wives. wood & Jacobson, 1982), it is comforting nonetheless
There were no major differences in the ratings of spe- to note that with self-training, 15 days of structured
cific emotions. comparisons of their daily records, spouses doubled
The results of the Vivian et al. (1987) study indi- their kappa agreement coefficients (Elwood & Jacob-
cated that when comparisons were made between son, 1988). Control couples (including an awareness
equally maritally distressed groups, there were only a group) did not show systematic changes.
few major differences, possibly associated with re- More to the point of the present discussion are the
quasi-observational approaches that focus explicitly of satisfied and average couples. Although the cycle
on interaction patterns. Clearly, we have seen that data were based on very small frequencies, a major
behavioral coding systems are useful in this regard, but reversal was noted: aggression/retaliation cycles were
equally clear is their high cost and relative inac- not coded for the distressed couples but were present
cessibility. Can couples provide meaningful infonna- for the nondistressed groups. One wonders whether
tion from which to derive relationship interaction pat- once again we have an insider-outsider difference in
terns? In contrast to the usual behavioral observation assigning negative affect, as was discussed above in
approaches considered thus far, a few researchers have the section on Cognitive Factors.
attempted to define functional relationships as pro- Peterson and Rapinchuk (1989) analyzed four affec-
vided by the actors and not by the a priori language of tive states associated with either constructive or de-
the coding manual. (This is the heart of the Jacobson, structive conflicts; data from highly educated married
1985, critique of behavioral observation, viz., over- couples, previously studied by Knudson, Sommers,
reliance on the manual and not on demonstrated func- and Golding (1980), were coded using the complex IR
tional relationships.) method. The affective states were "affection,"
Peterson (1979; Peterson & Rapinchuk, 1989) de- "calm," "anger," and "distress." Conflicts were des-
veloped the Interaction Record (IR), which asks ignated as "constructive" or "destructive" according
spouses to tell what happened from the viewpoint of to their outcomes, which, in turn, involved the judged
each individual, that is, antecedents, action, and out- affect of the participants, for example, outcomes were
come, emphasizing thoughts, feelings and behaviors. constructive if the participants were "satisfied" with
Each spouse recounts important, self-selected, daily the outcome and were content with one another. (Be-
interaction episodes similar to the "critical incident cause the affects and the criteria for categorizing out·
technique." The coding rules for the IR are compli- comes were similar in each case, the conclusions to be
cated and require high levels of inference and, unfortu- drawn from this otherwise innovative approach are
nately, time. quite limited.)
Each interaction is first broken down into moves, The authors analyzed transitional frequencies in
and coders infer three categories: affect, construals, order to establish patterns of reciprocity within and
and expectations about how the other would respond between affect states. For example, are moves rated as
from the moves. For each of the three categories, four "affection" reciprocated by affection moves from the
exemplars were defined. For affect, the exemplars partner? For all four affective states there was greater
were affection-affiliation, calm-neutrality, aggression- congruence of reciprocity within the appropriate out-
disapproval, distress-dysphoria. For construal, they come, constructive or destructive, than across out-
were positive relationship, sense of control, negative comes. Thus, for constructive outcomes, affection was
relationship, and loss of control. Expectation included reciprocated 63% of the time, but only 27% ofthe time
compliance, positive affect, withdrawal, and negative in destructive outcomes. Results were similar for tran-
affect. Peterson was able to demonstrate coderreliabil- sitions between different affective states and the out-
ity even though the judgments were quite SUbjective: comes. Thus, the transition from anger to calm oc-
kappas for general and specific categories, respec- curred 29% of the time in constructive outcomes, but
tively, were .77 and .65 (Peterson, 1979). only 12% of the time in destructive outcomes. The
The aim of this work was to define interaction cy- sequences Peterson and Rapinchuk established are
cles or statement and reply sequences inferred from the similar to those noted with observational coding sys-
content of critical interactions. Peterson identified tem, for example, escalation and negative reciprocity,
eight such interaction cycles (mutual enjoyment, sup- particularly for anger. However, when a partner in-
port, aggression/injury, aggression/retaliation, mutu- volved in a destructive outcome expresses calm, the
al affection, cooperation, etc.). He used these to differ- partner reacts with anger over two thirds of the time.
entiate, among marital therapy (self-identified) satis- The authors argue that a qualitative analysis of such
fied and "average" couples; the latter two groups had data as these can yield subtle manners in which part-
responded to different advertisements. The major find- ners control their interactions.
ings indicated that the patterns were quite different for Christensen and associates (reported in Christensen,
the three groups, with the negative cycles generally 1987b) simplified IR scoring by having raters classify
more characteristic of the marital therapy couples and the context within which interactions occurred and the
positive cycles (e.g., mutual enjoyment) characteristic general patterns that the interactions illustrated. These
classifications were done from a listing provided to the ods of discerning patterns of interactions capture these
coders that contained contexts (e.g., household tasks) uniformities, but in a still costly manner. Christensen's
and interaction patterns (e.g., mutual enjoyment). approach seems particularly promising (but not as
Household tasks and recreational events were the main clinically rich as Peterson's) especially if he can cap-
contexts for negative and positive interactions, respec- ture clinically relevant uniformities. The ecumenical
tively; aggression/retaliation and nonsupportiveness acceptance of still more constructs may seem, once
were the two most common negative interactions, and again, contrary to the canons of behavioral orthodoxy;
mutual enjoyment and collaboration-cooperation were but "the times they are-a-changing."
the two most common positive interaction patterns
(Christensen, 1987b).
Recognizing the relative high cost of such an elabo- Measuring Therapeutic Effectiveness
rate coding approach, Christensen and his associates
evolved a self-report methodology that retained the Clinical effectiveness outcome research is difficult.
notion of interaction cycles, but asked couples to Methodological obstacles are numerous - even the best
choose from various alternatives provided for three studies often suffer from one or more of the following:
stages (leading up to, during, and after) a single con- low n per treatment group, inexperienced therapists,
text (discussion) involving "conflict and disagree- inflexible (but consistently applied) treatment plans,
ment" (Christensen, 1988). The various patterns in- or researchers testing their own brand of therapy
cluded avoidance, demanding, withdrawing, blaming, against other forms (and, according to Baucom and
negotiating, withholding, reconciliation, and so forth. Hoffman [1986], the pet persuasion of the researchers
Partners independently rated the likelihood of the pat- always wins).
terns fitting their own situation. Despite its difficulties and ethical dilemmas, out-
The patterns were categorized into three major sub- come research is the only way we can evaluate the
scales having good interpartner agreement. The scales effectiveness of, compare among, and improve upon
and their respective intraclass correlation coefficients the treatments of marital distress. In this last section,
are as follows: Demand/Withdraw Communications we will review recent suggestions for ways to measure
(.74), Demand/Withdraw Roles (providing a measure therapeutic effectiveness, recap findings on the effec-
of whether husband or wife demands/withdraws) tiveness of BMT, discuss the previously mentioned
(.74), and Mutual Constructive Communication (.80). skirmish between EFf and BMT, and examine the use
Using the DAS as the criterion, Mutual Constructive of BMT as a treatment for depression.
Communication correlated .79 (p <.001), De-
mand/Withdraw Communication -.55 (p <.(01),
How Should Change Be Measured?
and Demand/Withdraw Roles - .12 (ns). "Thus, in
terms of relationship satisfaction, it doesn't matter Jacobson, Follette, and Revenstorf (1984) argued
who plays what roles in a demand/withdraw interac- that an overreliance on statistical significance obfus-
tion; it is the existence of the interaction pattern itself cates important clinical considerations. Clinically sig-
that is associated with relationship satisfaction" nificant change-when clients move from the dys-
(Christensen, 1988; p. 49). Other data are presented functional to the functional range-is a more
that indicate a female-demand male-withdraw se- important yardstick of change to clinicians than statis-
quence, arising out of differences in desired intimacy. tically significant change. Likewise, reports of the per-
Although there are problems with item overlap when centage of couples who improve or deteriorate based
using the DAS because of the preponderance of spouse on specified clinical criteria is of more interest than
"agree" items, the Christensen approach (based as it is statistical comparisons of group differences.
on the original IR methods) is useful in defining what Jacobson et at. (1984) also recommended the use of
couples do with each other. a "reliable change index," which tests if change from
The potential of the Peterson and Christensen ap- pretest to posttest significantly exceeds that which
proaches appears to be the use of ecologically valid would be expected by measurement error. Their sug-
scenarios and response choices. One is struck with the gestions have fueled the debate on how to measure
considerable similarity of experiences in married life change, culminating in an entire issue of Behavioral
(Weiss, 1978) across situations. These IR-based meth- Assessment being devoted to the topic. This issue in-
cluded a fine tuning of formulas for and rationale of the as the dependent variable of choice since the late
reliable change index (Jacobson & Revenstorf, 1988), 1950s. Although various critics have written on the
plus a debate on what constitutes clinical change. gross inadequacies of these measures (e. g., Donohue
Jacobson and his colleagues (Jacobson et at., 1984; & Ryder, 1982; Fincham & Bradbury, 1987b; Lively,
Jacobson & Revenstorf, 1988) viewed dysfunctional 1969; Norton, 1983; Sabatelli, 1984, 1988; Trost,
people as coming from a different population than 1985), they are still used in almost every study in the
functional people. They recommended that separate marriage research and therapy outcome domains.
norms and standard deviations be calculated for the Although content overlap between the DAS and in-
two populations. Wampold and Jenson (1984) rejected dependent variables is typically not as troublesome in
this bifurcation on the grounds that symptomatology is outcome studies as it is in descriptive marital research,
distributed along a continuum in the population. This the use of the complete DAS as an outcome measure is
argument has been expanded upon elegantly by Hollon most ill-advised because of its disproportionate
and Flick (1988), who maintained that separating weighting. There are 15 agreement items, 10 satisfac-
people into functional and dysfunctional populations is tion items, 5 cohesiveness items, and 4 affection
unnecessary and adds formidable methodological items. (Spanier could not possibly have believed that
problems. Baer (1988) added the additional complaint agreement was nearly four times more important than
that the definition by Jacobson et al. of clinical signifi- affection!) Norton (1983) believed that the agreement
cance is more a definition of what change clinicians, items were included because they passed the skewness
not clients, view as significant. test; they were normally distributed. Whatever the rea-
This debate has been extremely productive. Baer's son, the number of items in each of the four factors
point is one that eats away at many humanistic-ori- weights them in a way with which few people would
ented clinicians-if the client is happy with the agree.
change, why should some researcher claim that the This weighting makes the DAS inappropriate for all
change is not good enough? How do you handle "non- but the crudest clinical uses. Affection and satisfaction
dysfunctional" clients who seek therapy to actualize should be highly prized as therapy outcome measures,
themselves? Still, researchers have to draw the line and their underweighting in the DAS may make mar-
somewhere, and it seems logical to declare that ital therapy appear less (or more) effective than it truly
clinically significant change results in nondistressed is.
marriages. Because global ratings correlate extremely highly
How to accomplish that goal is still unresolved. Al- with the DAS anyway, researchers should abandon the
though the efforts of Jacobson and his colleagues use of the DAS as an outcome measure for the time
should be lauded for advancing the standardization of being. Valid and reliable global rating scales like the
outcome research, we agree with the critics that argue Quality Marriage Index (QMI) (Norton, 1983) would
that his method of calculating change using the notion be preferable as a stopgap measure, but our field is in
of two populations is flawed. The outcome research desperate need of an outcome measure with real
field urgently needs a definitive model based on the clinical relevance. The Marital Satisfaction Inventory
one population theory, but until then, Jacobson et al.'s (MSI) (Snyder, 1979), with its 14 scales, is a poten-
model (1984; Jacobson and Revenstorf, 1988) is the tially useful clinical tool, but its lack of an overall
only explicit standard we have. score makes it inappropriate for widespread research
use.
Patterson (1988) noted that "the first step in moving
Outcome Measures
a therapeutic field forward is to solve the problem of
As noted by Heyman (1988), it is oddly appropriate [biased self-report outcome measures]. This means de-
that marital researchers-social scientists who probe, veloping a relatively nonreactive outcome measure
examine, and describe the intimacies of couples- that is also reliable and valid" (p. ix). This is clearly
have yet to discover that their emperor has no clothes. one of the most difficult but crucial challenges facing
The emperor in this case is "marital quality" -as the marital therapy field in the 1990s. The outcome
measured by the Marital Adjustment Test (MAT) measure of choice would be one that could combine
(Locke & Wallace, 1959) and the Dyadic Adjustment global satisfaction ratings with research-supported ob-
Scale (DAS) (Spanier, 1976)-which have held court servational criteria (Bradbury & Fincham, 1989).
BMT has been so successful in establishing itself pre- also pointed out by Baucom and Lester (1986) in their
cisely because it insists on verifiable efficacy of treat- comparison of BMT, BMT with a cognitive-behav-
ment. It would be wickedly ironic if researchers who ioral therapy (CBT) module focussing on attributions
base their scientific and clinical work on observable and expectations (CBMT), and a wait-list control
phenomenon were to continue to ignore the fact that group. Both BMT and CBMT groups improved signif-
their emperor has no clothes. icantly compared to the wait-list group, but the two
treatments were equally effective. Because couples
were randomly assigned to one of the three groups,
BMT Effectiveness
some couples who did not need the CBT module re-
Despite the presence of many comprehensive nar- ceived it, whereas some couples who did need it never
rative reviews of BMT effectiveness (e. g., Baucom & received it. Furthermore, the invariant sequence of the
Hoffman, 1986; Beach & O'Leary, 1985), a recent CBMT intervention (CBT followed by BMT) may
meta-analysis of BMT outcome research (Hahlweg & have reduced the effectiveness of CBMT. Baucom and
Markman, 1988) provides the best consolidation of the Lester concluded that only a clinically flexible applica-
literature. This study used 17 BMT and 7 prevention- tion of CBMT could test if the additional CBT module
oriented studies, for a total of 613 couples from five was worthwhile.
countries. They found that BMT was significantly
more effective than either wait-list or nonspecific ther-
Emotionally Focused Therapy versus
apy controls. Specifically, 72% ofBMT couples made
Behavioral Marital Therapy
significant improvement versus 28% for the control
couples. This finding held for European as well as As mentioned earlier, Johnson and Greenberg
American couples. The BMT intervention maintained (1985) found that EFT was (statistically) significantly
its effectiveness at follow ups of up to 1 year. Preven- more effective than the problem-solving module of
tion programs were also successful: at posttest, 67% of BMT (Jacobson & Margolin, 1979) in improving mar-
the treated couples had improved, versus 33% of the ital satisfaction and intimacy levels and in reducing
control couples. pretherapy complaints. EFT couples were signifi-
However, BMT did not fare so well using clinical, cantly happier with their marriages than BMT couples
as opposed to statistical, significance tests. Hahlweg at a 2-month follow-up.
and Markman (1988) concluded that a considerable Johnson and Greenberg's (1985) study is hindered
number of couples were still distressed following by their use of the problem-solving module only rather
BMT. The reanalysis by Jacobson, Follette, Re- than the entire BMT model (e.g., Perry & Weiss,
venstorf, Baucom, et al. (1984) of four BMT studies 1986) and by what could be called the "fox guarding
found that only one third of couples treated with BMT the henhouse" effect. (As noted above, Baucom and
crossed over from the distressed to the nondistressed Hoffman, 1986, found that marital researchers con-
ranks, with clinically significant success rates ranging sistently find their own treatment orientation to be
from 21 % to 58%. superior.)
Jacobson et al. (1989) compared the effects of re- Although Johnson and Greenberg (1985) appear to
search-structured (invariant version of BMT used in have made some efforts to assure that both treatment
outcome studies) and clinically flexible (more typical modalities were conducted at equal levels of expertise,
of BMT as it is actually practiced) BMT approaches. the assumption that therapist effects were equal is
They found that, although there were no differences in doubtful. Training in the problem-solving module con-
improvement between the two approaches at the end of sisted of a I-day workshop given by a University of
therapy, couples treated with the flexible approach Washington graduate student (Jacobson, personal
maintained their treatment gains at 6-month follow-up communication, December 13, 1988). One might ex-
much better than those treated with the invariant ap- pect that the "home team" in this case was a bit better
proach. Because nearly all outcome studies prior to the equipped clinically.
Jacobson et al. (1989) study used the research-struc- Furthermore, BMT, as it is typically practiced, be-
tured model, effectiveness of BMT as it is usually gins with a careful assessment phase that is designed to
practiced in clinical settings has most likely been give a complete idiographic picture of the couple's
underestimated. needs. A treatment plan is then developed, flexibly
The need for flexible outcome study research was modifying the BMT module format to the specific
needs of the couple. The focus on support improve their relationships, BMT may be the most
lunderstanding, affectionate behaviors, and commu- appropriate treatment.
nication skills typically overshadows the problem- Jacobson et al. (1988) also compared the effects of
solving portion of the treatment package. To inflexibly BMT and CBT for depression and marital distress, and
treat clients with the problem-solving module borders concluded that O'Leary and Beach were working with
on the unethical, even for an outcome study. a subpopulation, which was perfectly suited for their
However, this study is critical because, for the first intervention. Jacobson et at., using more stringent cri-
time, researchers found another therapy to be superior teria for classification of depression, worked with 60
to BMT. Granted, the game was fixed, but the results married, depressed women. Half of the sample was
certainly caught the attention of BMT researchers. maritally distressed and half was not. They were treat-
It is interesting to note that since the publication of ed with either BMT, CBT, or a combination of the two
Johnson and Greenberg's (1985) study, both authors of (see Dobson, Jacobson, & Victor, 1989).
the primary BMT treatment manual (Jacobson & Mar- For depression, BMT only was the best treatment
golin, 1979) have published explicit accounts of affec- for the distressed group, although CBT also worked
tive treatments in their practices (Margolin, 1987a; reasonably well. For the nondistressed group, BMT
Jacobson, 1989). It is clear from the papers themselves had no effect on depression, whereas CBT did. For
and from their timing that Margolin and Jacobson were marital problems, none of the treatments were over-
incorporating affect into their approaches because of whelmingly effective. BMT only did the best, produc-
their own frustrations with traditional BMT's lack of ing statistically and clinically significant changes in
success with some couples, and not as a direct result of satisfaction. BMT was not as effective for this de-
the EFf study. Margolin's (1987a) paper described a pressed/distressed sample when compared with typ-
highly integrative approach-a synthesis of BMT, ical outcome results. Jacobson et at. (1988) concluded
systems, strategic, cognitive, and emotional ap- that it is harder to work with couples in marital therapy
proaches. Jacobson's (1989) article described his at- when one of the partners is depressed.
tempts to incorporate EFf procedures (Greenberg & Jacobson (personal communication, December 13,
Johnson, 1986c) into a module that complements his 1988) noted that this sample was different from the
BMT package. O'Leary and Beach sample because many of the cou-
Regardless of future replications of the Johnson and ples in his study defined the presenting problem as
Greenberg study (1985), it appears clear that affective strictly one of depression, not of marital distress. The
procedures are destined to become a standard feature Jacobson et at. findings are probably more representa-
of BMT packages. As noted previously, BMT with tive of the expected effectiveness of applying BMT to
the discretionary use of an affect module will likely the general treatment of depression, because only a
give more of the couples what they seek more of the subpopulation defines their problems as concomitant
time. depression and marital distress.
BMT as a Treatment for Depression

Summary and Conclusions
As mentioned earlier, because marital distress ap-
pears to be etiologically related to some depressions, Our review of the literature pertaining to marital
excitement about the clinical implications of em- distress from a behavioral perspective, although cer-
ploying marital therapy in the treatment of depression tainly not exhaustive, has covered a wide range of
seemed warranted. O'Leary and Beach (1988), work- books, chapters, and papers. The fact that our cover-
ing with a sample of depressed women with concur- age could have been broader still is testimony to the
rently distressed marriages, found that both BMT and degree of activity in this area. The first conclusion to
cognitive-behavioral therapy (CBT) produced clini- be drawn is that BMT, and now CBMT, together with
cally significant reductions in depression. Clients their associated knowledge bases, are comfortably
treated with BMT also showed significant gains in grounded in empirical work. Our review of the liter-
marital satisfaction, whereas those treated with indi- ature reinforces what has characterized behavioral ap-
vidual CBT did not. O'Leary and Beach (1988) cau- proaches to marital distress and its therapy, namely, a
tiously concluded that for those clients presenting with commitment to empiricism. On just about every
both depression and marital distress, and desiring to front-affect, cognition, and behavior-one finds
considerable research activity. This continues as one of therapy. This is certainly a reflection of the inherent
the well-established positive facets of BMT. subjectivity of marriage itself. Marital symptoms are
There is no question that affect is very much a part of not public, and although there may be subjective dis-
behavioral approaches to marital distress and therapy. tress, troubled marriages do not annoy the public the
Representations that this is not so are simply incorrect. way other clinical problems do. But we need to know
How successful we will continue to be in tying emo- more about successful accommodation in intimate re-
tional activation cycles to specific aspects of marital lationships. The area is ripe for an assessment break-
satisfaction is, of course, uncertain; but the search con- through. Again we suggest that behaviorally oriented
tinues in exciting ways and we look forward to new thinkers address the tasks required for having a satisfy-
clinical applications. For example, it would be most ing-and we would add, productive-relationship.
encouraging to see the escape-conditioning specula- Tell us, please, how well partners specifically accom-
tions of Gottman and Levenson supported by data from plish those tasks and to what extent the behavioral acts
other laboratories. Certainly, there is ample evidence are necessary to support positive cognitions.
in this literature that establishes patterns of negative
escalation as being characteristic of distressed
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Perry, B. A., & Weiss, R. L (1986). Interactive couples thera- Weiss, R. L (1978). The conceptualization of marriage from a
py: A couple's guide. (Available from Dr. Robert L Weiss, behavioral perspective. In T. 1. Paolino & B. S. McCrady
Department of Psychology, Straub Hall, University of (Eds.), Marriage and marital therapy: Psychoanalytic, behav-
Oregon, Eugene, OR 97403). ioral, and systems theory perspectives (pp. 165-239). New
Peterson, D. R. (1979). Assessing intrapersonal relationships by York: Brunner/Maze!.
means of interaction records. Behavioral Assessment, I, 221- Weiss, R. L (1979). Resistance in behavioral marriage therapy.
236. American Journal of Family Therapy, 7, 3-6.
Peterson, D. R., & Rapinchuck, J. G. (1989). Patterns of affect Weiss, R. L (1980). Strategic behavioral marital therapy: To-
in destructive and constructive marital conflicts. Unpublished ward a model for assessment and intervention. In 1. P. Vincent
manuscript, Rutgers University. (Ed.), Advances infamity intervention, assessment and theory
Revenstorf, D., Hahlweg, K., Schindler, L, & Vogel, B. (Vo!. I, pp. 229-271). Greenwich, CT: JAI Press.
(1984). Interaction analysis of marital conflict. In K. Hahlweg Weiss, R. L (1981). The new kid on the block: Behavioral
& N. S. Jacobson (Eds.), Marital interaction: Analysis and systems approach. In E. E. Filsinger & R. A. Lewis (Eds.),
modification (pp. 159-181). New York: Guilford Press. Assessing marriage: New behavioral approaches (pp. 22-
Sabatelli, R. M. (1984). The Marital Comparison Level Index: A 37). Beverly Hills: Sage Publications.
measure for assessing outcomes relative to expectations. Jour- Weiss, R. L (1984). Cognitive and strategic interventions in
nal of Marriage and the Family, 46, 651-662. behavioral marital therapy. In K. Hahlweg & N. S. Jacobson
Sabatelli, R. M. (1988). Measurement issues in marital research: (Eds.), Marital interaction: Analysis and modification. (pp.
A review and critique of contemporary survey instruments. 337-355). New York: Guilford Press.
Journal of Marriage and the Family, 50, 891-915. Weiss, R. L (1989). The circle of voyeurs: Observing the ob-
Sabatelli, R. M., Buck, R., & Dreyer, A. (1982). Nonverbal servers of marital and family interactions. Behavioral Assess-
communication accuracy in married couples: Relationships ment, 11, 135-148.
with marital complaints. Journal of Personality and Social Weiss, R. L, & Aved, B. M. (1978). Marital satisfaction and
Psychology, 43, 1088-1097. depression as predictors of physical health status. Journal of
Schaap, C. (1984). A comparison of the interaction of distressed Consulting and Clinical Psychology, 46, 1379-1384.
and nondistressed married couples in a laboratory situation: Weiss, R. L, & Frohman, P. (1985). Behavioral observations:
Literature survey, methodological issues, and an empirical Not through a glass darkly. Behavioral Assessment, 7, 309-
investigation. In K. Hahlweg & N. S. Jacobson (Eds.), Mar- 316.
ital interaction: Analysis and modification (pp. 133-158). Weiss, R. L, & Isaac, J. (1976, April). Behavioral versus cog-
New York: Guilford Press. nitive measures as predictors of marital satisfaction. Paper
Schaap, C., Buunk, B., & Kerkstra, A. (1988). Marital conflict presented at the meeting of the Western Psychological Asso-
resolution. In P. Noller & M. A. Fitzpatrick (Eds.), Perspec- ciation, Los Angeles.
tives on marital interaction (pp. 203-244). Philadelphia: Weiss, R. L, & Margolin, G. (1986). Assessment of marital
Multilingual Matters, Ltd. conflict and accord. In A. R. Ciminero, K. Calhoun, & H. E.
Schachter, 1., & O'Leary, K. D. (1985). Affective intent and Adams (Eds. ), Handbook of behavioral assessment (pp. 561-
impact in marital communication. American Journal of Fami- 600). New York: Wiley.
ly Therapy, 13, 17-23. Weiss, R.L, & Perry, B. A. (1983). The Spouse Observation
Smith, D. A., & O'Leary, K. D. (1987, July). Affective compo- Checklist: Developments and clinical applications. In E. E.
nents of problem-solving communication and their rela- Filsinger (Ed.), Marriage and family assessment: A source-
tionships with interspousal aggression. Paper presented at the book for family therapy (pp. 65-84). Beverly Hills: Sage
Third National Family Violence Research Conference, Du- Publications.
rham, NH. Weiss, R. L, & Summers, K. 1. (1983). Marital interaction
Snyder, D. K. (1979). Marital Satisfaction Inventory (MSI): coding system-III. In E. E. Filsinger (Ed.), A source book of
Manual. Los Angeles: Western Psychological Services. marriage andfamily assessment, (pp. 85-115) Beverly Hills:
Spanier, G. B. (1976). Measuring dyadic adjustment: New Sage Publications.
scales for assessing the quality of marriage and similar dyads. Weiss, R. L, & Wieder, G. B. (1982). Marital distress. InA. S.
Journal of Marriage and the Family, 38, 15-28. Bellack, M. Hersen, & A. Kazdin (Eds.), International hand-
book of behavior modification (pp. 767-809). New York: Weissman, M. M., Prusoff, B. A., DiMascio, A., Neu, C.
Plenum Press. Goklney, M., & Klerman, G. L. (1979). The efficacy of drugs
Weiss, R. L., Hops, H., & Patterson, G. R. (1973). A frame- and psychotherapy in the treatment of acute depression. Amer-
work for conceptualizing marital conflict: A technology for ican Journal of Psychiatry, 136, 555-558.
altering it, some data for evaluating it. In L. D. Handy & E. L. Wills, T. A., Weiss, R. L., & Patterson, G. R. (1974). A behav-
Mash (Eds.), Behavior change: Methodology concepts and ioral analysis of the determinants of marital satisfaction. Jour-
practice (pp. 309-342). Champaign, IL: Research Press. nal of Consulting and Clinical Psychology, 47, 802-811.
CHAPTER 24
Interpersonal Dysfunction
Randall 1. Morrison
The assessment and treatment of social dysfunction Also, although much of the work on social skills has
has been a mainstay of behavior therapy throughout the involved psychiatric patients, there has been little con-
last decade and a half. Social skills training, including sideration of the relationship of social skills deficits to
all of its many variants (e.g., assertiveness training), is other aspects of psychiatric symptomatology. Indeed,
one of the most widely practiced behavioral interven- early investigations of social competence deficits were
tions, and has been a prominent topic in scientific jour- conducted with mixed groups of psychiatric patients,
nals and applied clinical textbooks. Despite a long his- which virtually precluded consideration of such rela-
tory of interest and activity in the area of social tionships (e.g., Curran et al., 1980). Recent studies
dysfunction, there have been several very recent ad- have begun to address differences in the social perfor-
vances that stand out as significant developments. mance of patients from different diagnostic categories.
Most behavioral investigations of social skills have The impact of specific psychiatric symptoms on social
been concerned with overt response components of competence and other aspects of the interrelationships
social skills, such as eye contact, speech content, and between social and psychiatric symptoms have been
voice tone (e.g., Curran, Miller, Zwick, Monti, & more closely evaluated.
Stout, 1980; Kelly, Urey, & Patterson, 1980). Al- This chapter will discuss conceptualizations of so-
though definitions of social skill have always referred cial skill and will review recent empirical develop-
to a broader range of abilities, including social percep- ments, with an emphasis on findings regarding the
tion skills (e.g., Curran, 1979; Hersen & Bellack, broader range of abilities which are requisite for effec-
1976), for the most part these were ignored in practical tive social functioning. Given the volume and diversity
applications and empirical investigations. Recent find- of material on social skills, it would be impossible to
ings have emphasized the importance of these addi- cover all recent developments in the literature in detail.
tional skills in poor social functioning and offer con- Rather an overview, highlighting the major develop-
siderable promise for the development of improved ments, will be presented. Indeed, given the increasing
treatment techniques. specificity of findings regarding social skill to particu-
lar diagnostic categories, detailed consideration of is-
sues in a chapter dealing generally with interpersonal
Randall L. Morrison • Department of Psychiatry, Medical
College of Pennsylvania at EPPI, Philadelphia, Pennsylvania dysfunction would in effect be contrary to prevailing
19129. research trends.
503
Social Skills: Conceptual/Theoretical for the identification of responses that define/delimit

Issues individuals' interpersonal capabilities, and, indeed,
much research within the general area of social
Despite the voluminous literature on interpersonal skills/social competence has attempted to identify
dysfunction, there is no single, universally accepted overt behavioral components of social skill. By im-
definition of social skills. Even though numerous defi- plication of the tenet that response capabilities are
nitions have been proposed, most are lacking in opera- learned, some individuals have deficient learning his-
tional specificity, and offer little in the way of guidance tories, resulting in limited or faulty repertoires. They
in terms of specific selection of behaviors to be consid- are defined as having social skills deficits. In keeping
ered in assessment or treatment. A common charac- with a pragmatic behavioral orientation, these deficits
teristic of the most widely accepted and enduring defi- are presumed to be defineable, measurable, and sub-
nitions (e.g., Hersen & Bellack, 1976; Libet & ject to remediation via education, practice, and rein-
Lewinsohn, 1973) is the ability to relate to others and forcement. Also, other factors can affect the extent to
express feelings in such a way as to maximize the which an individual utilizes skills in his or her reper-
social reinforcement received from others. Thus, these toire, and, therefore, the extent to which an individual
definitions emphasize a functional perspective-so- responds in a socially competent manner. For exam-
cial skills are defined as whatever behaviors serve the ple, an individual who is experiencing a significant
function of increasing reinforcement. (Furthermore, depressive episode may respond in an extremely dys-
reinforcement is, by definition, a functional concept, functional manner in interpersonal situations, despite
associated with its effect on the probability of a re- the presence of adequate social skills in his or her
sponse.) Trower, Bryant, and Argyle (1978) converse- repertoire. This dysfunction could result from im-
ly defined social inadequacy: paired motivation, and/or impaired cognitive and/or
information-processing abilities that would limit his or
A person can be regarded as socially inadequate if he is unable to her capability in social situations. Whether poor social
affect the behavior and feelings of others in the way that he performance is associated with a social skills deficit
intends and society accepts. Such a person will appear annoying,
unforthcoming, uninteresting, cold, destructive, bad-tempered, per se, or other mediating factor, can often be difficult
isolated or inept, and will generally be unrewarding to to sort out and will be considered in greater detail
others.(p.2) below. Finally, a further mediating factor that here-
tofore had received only minimal attention is the pres-
Newer definitions have retained this functional orien- ence of organic impairments. Organic factors can af-
tation. For example, in considering social skill from a fect the individual's ability to learn, and thereby affect
developmental perspective, Waters and Sroufe (1983) the acquisition of new skills. Also, organic impair-
described a skilled individual as one who "is able to ments can affect the ability to utilize skills that were in
make use of environmental and personal resources to the repertoire prior to the occurrence of the impair-
achieve a good developmental outcome" (p.81). ment. Although the limiting role of organic impair-
Thus, each of these definitions, while emphasizing ments had been recognized for some time in relation to
the effect of socially skilled responding, fails to spec- gross organic impairment (e.g., mental retardation), it
ify behaviors that are requisite for achieving the de- is only recently that the limiting impact of organic
sired effect. Fortunately, although specific definitions factors on social functioning has been considered
in this area may be lacking, a pragmatic behavioral across a broad spectrum of disorders. This has oc-
model of social skills has developed that is broad based curred as the role of various physiologic mediators of
and inclusive, and that has been more than sufficient as interpersonal processes has been better identified.
a groundwork for significant research. Thus, there has been much recent consideration of the
One of the primary tenets of the behavioral model of interrelation of antecedent learning and neuroin-
the assessment and treatment of interpersonal func- tegrative functions in the mediation of interpersonal
tioning regards interpersonal behavior as consisting of competence.
a set of learned performance abilities. Based on this There are no definitive data on precisely how
viewpoint, (1) response capability must be acquired, and when social skills are learned, but childhood is
and (2) it consists of a set of specific abilities, such as undoubtedly a critical period. For example, in an
voice intonation and the use of social reinforcers (see early investigation, Kagan and Moss (1962) reported
below). Thus, pragmatically, there has been a concem that
CHAPTER 24 • INTERPERSONAL DYSFUNCTION 505
passive withdrawal from stressful situations, dependence on the The appropriateness of specific responses even var-
family, ease of anger arousal, involvement in intellectual mas- ies at different stages of the same interaction:
tery, social interaction anxiety, sex-role identification, and pat-
tern of sexual behavior in adulthood were each related to reasona-
The socially skilled individual must know when, where, and in
bly analogous behavior dispositions during the early school
what form different behaviors are sanctioned. Thus, social skill
years. ( p. 266)
involves the ability to perceive and analyze subtle cues that de-
fine the situation, as well as the presence of a repertoire of
More recently, Kagan (1988 cited in Hosterles, 1988) appropriate responses. (Bellack & Hersen, 1978, p. 172)
reported data that suggest that young children at the
extreme ends of the spectrum in terms of inhibition or Thus, social perceptuallcognitive factors are intri-
spontaneity may be born with a temperamental bias, cately involved in the situational specificity of inter-
and that this behavioral dimension is related to an in- personal behavior.
herited physiological bias which may mediate such Particular situations or areas of social functioning
responding. Kagan concluded that "a combination of have attracted the attention of clinicians and re-
extremely shy, fearful and affectively subdued behav- searchers alike. Perhaps the most consideration has
ior, combined with signs of limbic arousal, especially been directed toward assertive behavior. Other areas
a high and stable heart rate, are diagnostic of a tem- that are frequently addressed include conversational
peramental predisposition to those behaviors that are skills, heterosociallheterosexual skills, and job-relat-
popularly called shyness or social phobia" (Hosterles, ed interpersonal skills (e.g., interviewing, getting
1988, p.6). Thus, early learning experiences may in- along with peers). For the most part, interest in these
teract with biological predispositions in determining areas initially developed on a face valid basis, as these
certain relatively consistent patterns of social function- are areas in which many patients "seem" to have diffi-
ing in at least certain youngsters, and at least through- CUlty. These categories of interpersonal functioning
out a significant portion of their childhoods. Further are sometimes referred to as "compound skill reper-
developmental data document that rudimentary affect- toires," and investigators have searched for the critical
recognition skills are present in children as young as 3 response parameters that comprise effective function-
years old, and that by age 10 the performance of chil- ing in these areas (again, with most emphasis having
dren is comparable to that of adults (Ekman & Oster, been placed on overt responding). A second issue has
1979). been the identification of deficits in each of these areas
An important implication of a view of interpersonal in certain groups of patients. It is important to note that
behavior, which emphasizes the role of learning, is that findings have emphasized situational specificity with-
social skill and, conversely, social skill deficits will be in compound skill repertoires. For example, indi-
situation-specific. That is, different sorts of social sit- viduals may be differentially effective across different
uations call for different interpersonal responses; what types of assertive situations. Variability in an indi-
is socially appropriate behavior in one context may not vidual's ability to deal effectively with different inter-
be appropriate in another. For example, "Direct ex- personal situations that require assertion may be more
pression of anger is more acceptable within families relevant than dichotomous classifications of persons as
and when directed toward an employee than with either "assertive" or "unassertive." In an early study,
strangers or toward an employer" (Bellack & Hersen, Eisler, Hersen, Miller, and Blanchard (1975) reported
1978, p.I72). The acceptable form of eye contact, in- differential assertiveness among psychiatric inpatients
terpersonal (spatial) distance, voice intonation, pos- in the presence of male versus female interpersonal
ture, and the like vary according to sex, age, status, partners. A more recent example involves a study by
degree of familiarity, and the cultural background of Rist and Watzl (1973), who reported that female alco-
the interpersonal partner, as well as the context of the holics experienced differential discomfort in response
interaction. An individual may have learned how to to general assertive situations and situations requiring
interact skillfully in some situations, but not in others. refusal of temptations to drink. As shall be repeatedly
A common example would be heterosocial or dating emphasized throughout this chapter, it is important to
experiences that represent novel experiences for ado- consider a broad range of skills and associated factors
lescents and require certain (previously unpracticed) when dealing with interpersonal behavior, and obser-
responses. (Again, a number of other factors affect vations of situational specificity within compound
performance in dating situations, including the indi- skill classes clearly indicate the importance of factors
vidual's anxiety/comfort level.) in addition to overt behavioral response skills.
Components of Social Skill Table 1. Components of Social Skills

Much of the research on interpersonal dysfunction A. Expressive elements
has attempted to identify specific behavioral compo- 1. Speech content
nents of social skills, and/or to document the absence 2. Paralinguistic elements
a. Voice volume
of certain behavioral components of social skill among b. Pace
socially dysfunctional individuals. Dow (1985) re- c. Pitch
cently reviewed the results of 18 studies in this area and d. Tone
concluded that there is moderate evidence for the rele- 3. Nonverbal behavior
vance of nine conversational behaviors as components a. Proxemics
of socially skillful behavior. (Again, given an empha- b. Kinesics
c. Gaze (eye control)
sis on the situational specificity of compound skill rep-
d. Facial expression
ertoires, it is important to specify the relevance of B. Receptive elements (social perception)
these behaviors as conversational skills.) Behaviors 1. Attention
that have been found to relate to increased levels of 2. Decoding
social skills include: more eye contact, more smiles, 3. "Social Intelligence"
more expression of personal attention (e.g., talking C. Interactive balance
about the other person and asking questions), limited 1. Response timing
2. Turn taking
overt or verbal indicators of anxiety, such as trem-
bling, stammers, or fidgets, more talking time, more Note. From "Interpersonal Dysfunction" by A. S. Bellack and R. L.
Morrison in International Handbook of Behavior Modification and
hand gestures, fewer pauses or long latencies, more Therapy (p. 720) edited by A. S. Bellack, M. Hersen, and A. E. Kazdin,
compliments, and more positive statements about third 1982, New York: Plenum Press. Copyright 1982 by Plenum Press. Re-
printed by permission.
persons or things. Conger and Farrell (1981) found talk
time and gaze to be strongly related to judgments of
heterosocial skill. Burleson et at. (1986) examined ing depending upon whether it was spoken with a flat
communicative correlates of peer acceptance in first- or animated tone, loud or soft voice volume, or in a
and third-grade children. Rejected subjects were found slow or rapid manner.
to have less developed communication skills than chil- Nonverbal behavior refers to an individual's bodily
dren who were accepted by their peers, with signifi- positions and movements during social interaction. As
cantly poorer referential, persuasive, and comforting with paralinguistic elements, these responses play an
communication skills. In a study by S. Beck, Collins, important role in that they can either strengthen or
Overholzer, and Terry (1985), the interpersonal class- detract from a verbal message. Thus, as an example,
room behaviors of first-grade subjects nominated as an assertive refusal of an unreasonable request is more
friends or liked sixth-grade subjects. Hence, compo- likely to be effective when accompanied by direct eye
nent skills may differ across compound skill reper- contact and serious facial expression than when ac-
toires, and even within compound skill repertoires companied by downcast eyes and shuffling feet.
across different contexts. Receptive elements refer to an individual's social
At the most elementary level, social skill, or any perceptual abilities. Effective social interaction is de-
particular compound skill repertoire, can be divided pendent upon the ability to detect, interpret, and re-
into various verbal, nonverbal, and social perceptual spond appropriately to what are often subtle interper-
abilities. Table 1 lists the range of behaviors that are sonal cues. A wide range of cues are involved, ranging
usually evaluated as components of social skill. For from nonverbal affect states to more complex indica-
example, expressive elements consist of the verbal and tors of intent. For example, in order to accurately in-
nonverbal response parameters involved in commu- terpret the affective state of others, an individual must
nicating a message to another individual. The most be able to "read" specific nonverbal cues, including
important of these is speech content. The words one both facial representations of affect and auditory affect
chooses to use are of obvious importance in determin- cues. It is in relation to affect recognition abilities that
ing the received meaning of a spoken message. research on interpersonal dysfunction has progressed
Paralinguistic elements refer to the voice param- most markedly in the past several years. Recent ad-
eters that serve to qualify a verbal message. The same vances in the assessment of affect recognition will be
verbal statement can assume different shades of mean- discussed in a subsequent section of this chapter.
An important prerequisite of affect recognition abil- Table 2. Nonskill Factors Associated

ities, one that can easily be taken for granted, is with Interpersonal Performance
focused attention. A diminished ability to attend to
Motivational cognitive factors
critical interpersonal cues may characterize indi- Reinforcement history
viduals who experience an episode of a major psychi- Values, goals, expectancies
atric disturbance (e.g., schizophrenia, major affective Self-evaluation
disorder) or persons who experience high levels of Nonclinical affect states
anxiety. Therefore, patients may require extensive Anxiety, anger, sadness
Psychopathology
training to attend to relevant cues and training in how
Anxiety, affective disorders
to respond appropriately to them (e.g., Wallace, Schizophrenia
1982). Alcohollsubstance abuse
Once relevant social cues are perceived, the indi- Other organic/physical factors
vidual must decide upon an appropriate response. Al- Physical attractiveness
though in many instances this process may not involve Motor skill, physical fitness
a calculated decision, there are some situations in
which social problem-solving skills may be relevant
(Bellack, Morrison, Mueser, & Wixted, 1989). The
either not been reinforced or have been punished, and
individual must consider various response possibilities
that such a choice may represent the most adaptive
and decide on the most effective alternative.
response style under certain circumstances (O'Leary,
A final category of social skill is interactive bal-
Curley, Rosenbaum, & Clarke, 1985). Social situa-
ance. Included in this category are response timing,
tions are likely to be avoided and behaviors are likely to
turn taking, and social reinforcement. Psychiatric pa-
be inhibited if they are thought to be socially inap-
tients may, for example, exhibit inappropriately long
propriate, immoral, unfair, or to lead to unpleasant
response latencies when they are asked a question,
consequences (Eisler, Frederiksen, & Peterson, 1978).
causing others to feel uncomfortable. They may also
Shyness in college males is often more a function of
be ignorant of the give-and-take of conversational in-
inaccurate self-evaluation and expectations of rejec-
teraction and try to inject statements at inopportune
tion than of heterosocial skills deficits (Arkowitz,
moments. Social reinforcement refers to the cues one
1977; Galassi & Galassi, 1979). Newton, Kindness,
individual provides to another to indicate attention and
and McFadyen (1983) compared 28 psychiatric outpa-
interest (e.g., head nodding, "um-hm," occasional
tients with social interaction difficulties on social per-
smiles).
formance, social anxiety, and self-esteem measures to
a nonclinical comparison group. The predominant dif-
ferences between groups were found on the anxiety
Associated Factors
and esteem measures. High social anxiety among the
As noted, the quality of interpersonal performance patient group was more often related to low self-es-
is affected by numerous factors in addition to the indi- teem than adequacy of social performance.
vidual's skill repertoire. Table 2 presents some of the Another factor that can have an impact on interper-
primary influences. sonal functioning is affect. Both nonclinical fluctua-
Motivational and/or cognitive factors, including a tions in affect, and more significant disturbances, can
person's history of reinforcement (or punishment) for disrupt social performance. Anxiety and anger can dis-
various social behavior, self-evaluation of competen- rupt the smooth performance of well-learned routines,
cy, motivation and goals, values, and expectancies re- causing stuttering, trembling, rapid speech, poverty of
garding interpersonal outcomes (all of which may be speech content, and the like. (Bellack, 1980). High
secondary to, or at least affected by, reinforcement levels of emotional arousal can interfere with the re-
history) can influence the types of situations the indi- ceptive and cognitive processes required for effective
vidual will enter and the specific behaviors that he or performance. Of course, social anxiety can also lead to
she will perform. For example, data from research on the avoidance of social situations. Public-speaking
marital conflict and marital assault suggest that some anxiety is a relatively common manifestation of social
women might elect not to respond assertively toward anxiety (e.g., Hayes & Marshall, 1984; Matias &
their husbands if previous attempts at assertion have Turner, 1986), and persons who are fearful of speaking
in public will often go to great lengths to avoid having rin (1984) observed that left-handedness was associ-
to do so. The symptoms of social phobia, by defini- ated with inferior social competence in newly hospi-
tion, result in avoidance of certain feared social talized chronic schizophrenic males. Given findings
situations. indicating a crossover between preferred eye and hand
Depression is associated with reduced behavioral associated with inferior left hemisphere performance
output, loss of desire and energy to pursue rela- in a visual half-field presentation task (Kerschner,
tionships, and a variety of responses that elicit aversive 1974) and organic brain disease (Swiercinsky, 1977),
reactions from others (e.g., Altmann & Gotlib, 1988; the possibility of sinistrality in schizophrenics being
Puig-Antich et ai., 1985a,b; Zeiss & Lewinsohn, the result of a neurodevelopmental deficit cannot be
1988). In a study by Fisher-Beckfield and McFall ruled out. Dvirskii (1976) earlier reported that an in-
(1982), undergraduate males who reported the pres- crease in left-handedness in an extremely large sample
ence of a nonclinical state of depression as measured of schizophrenics was characteristic of patients with a
by the Beck Depression Inventory (A. T. Beck, 1972) "continuous form of the illness." It has been hypoth-
earned significantly lower interpersonal competence esized that altered patterns of lateralization may be
scores on a behavioral role-playing measure than non- especially likely to be related to affect recognition defi-
depressed subjects. Although the authors conclude cits among paranoid schizophrenics (Morrison, Bell-
that incompetence is a concomitant of depression, if ack, & Mueser, 1988). Similarly, altered lateralization
not a precursor, an alternative consideration is that the has been implicated in the cognitive functioning of at
presence of the depressive state could have impacted least some depressed patients (Silberman, Weingart-
on the efficacy of these subjects' role-play perfor- ner, Stillman, Chen, & Post, 1983), and a right hemi-
mance. shere deficit syndrome associated with a range of cog-
In addition to anxiety and depressive conditions, nitive impairments and impaired social functioning
other psychiatric symptoms can have a dramatic, ad- has been identified in several child learning-disordered
verse impact on social performance. Recently, consid- samples (e.g., D. Tninel, Hall, Olson, &N. N. Tranel,
erable attention has been directed to social dysfunction 1987; Voeller, 1986).
associated with the negative symptoms of schizo- Attention deficits associated with other psychiatric
phrenia (e.g., Andreasen, 1982; Crow, 1980; Strauss, and neurological disorders can also impair social per-
Carpenter, & Bartko, 1974). Negative symptoms have formance. Problems in attention and memory can also
commanded a great deal of attention in recent years occur as the result of a wide range of pharmacological
because they have been hypothesized to be inflexible, regimens, including medications that are commonly
indicative of intellectual impairment, associated with prescribed for psychiatric as well as medical condi-
structural brain abnormalities, prognostic of poor out- tions (Morrison & Katz, in press).
come, and resistant to neuroleptic therapy (Andreasen, Finally, other physical factors can affect social per-
1985; Crow, 1980, 1985; Owens & Johnstone, 1980). formance, or the extent to which an individual comes
It is apparent that patients who exhibit negative symp- to be regarded by others as socially competent. Two
toms are more socially impaired than other schizo- factors that have been demonstrated to relate to social
phrenics (Andreasen & Olsen, 1982; Pogue-Geile & competence are physical attractiveness and physical
Harrow, 1984, 1985). Other symptoms or disabilities motor skills or fitness. In a study by Guise, Pollans,
associated with schizophrenia can similarly impact on and Turkat (1982), 45 male undergraduates completed
social functioning. Attentional deficits are common the Rathus Assertiveness Schedule (Rathus, 1973)
(whether or not the patient exhibits a preponderance of about a female depicted in either an attractive, neutral,
negative symptoms), and can impair affect recognition or unattractive presentation. (The photographic condi-
and other aspects of information processing that are tions had been previously validated in ratings by an
necessary for effective social interaction. Seidman, independent undergraduate sample.) Groups shown
Sokolove, McElroy, Knapp, and Sabin (1987) corre- the attractive photograph differed from those shown
lated lateral cerebral ventricular size with social net- the neutral and unattractive photographs (the latter two
work differentiation and measures of social outcome in groups did not differ). There was a significant positive
a sample of young schizophrenic and schizo- correlation between attractiveness and perceived as-
phreniform patients. Patients with fewer social con- sertiveness. Similarly, Nelson, Hayes, Felton, and Jar-
texts, fewer types of interpersonal relationships, and rett (1985) reported that socially unskilled undergradu-
less independent residence had larger ventricles. Mer- ates tended to be less attractive than their skilled
counterparts. Farina, Burns, Austad, Bugglin, and mance, including longitudinal fluctuation in major
Fischer (1986) reported that among a sample of male psychiatric symptoms.
and female psychiatric inpatients who were rated for It is beyond the range of this chapter to discuss the
physical attractiveness just prior to discharge, physical multitudinous measures that can be employed in the
attractiveness was significantly related to the number assessment of associated factors. The range of pos-
of days the patient remained out of the hospital and to sibilities would include interviewing and self-re-
social competence at a 6-month follow-up. port/self-monitoring, psychological and/or neuropsy-
Gross, Johnson, Wojnilower, and Drabman (1985) chological testing, evaluation of psychotropic blood
reported a significant correlation between physical fit- plasma levels, and so forth. Certain assessment tech-
ness measures and peer sociometric status ratings niques have become established as the hallmark of
among 1507- to 13-year-old children at the start of an social skills assessment (i.e., role-play procedures). In
8-week summer camp program. Children who exhib- addition, new techniques pertaining to affect recogni-
ited a significant improvement in physical fitness dur- tion have been developed, and there has been consider-
ing the camp session (a sports fitness program was able progress in terms of empirical evaluation of these
conducted throughout the 8-week session) evidenced a new measures.
significant rise in social status.
The interface of these associated factors with defi-
Role-Play Measures of Overt Behavioral
cits in social skill in determining an individual's quali-
Social Skills
ty of interpersonal performance is complex. Similar
impairments in performance may be seen across indi- The optimal manner in which to determine whether
viduals, but can result from different deficits. Skill a patient exhibits deficits in any of the behavioral com-
deficits may be a primary problem in certain instances, ponents of social skill would be through extended ob-
whereas cognitive, physical/organic factors may play servation of his or her social behavior. However, natu-
a primary role in other cases. Finally, some cases of ralistic observation is time consuming and expensive,
impaired interpersonal performance are multiply· and presents numerous ethical and pragmatic difficul-
determined . ties. Several more cost-effective methods have been
developed in recent years. The most widely used pro-
cedure in this regard is the "role-play" test.
Assessment of Social Skill A role-play test involves the brief enactment of a
social interaction as if the situation were really happen-
Given the diversity of factors involved in interper- ing. In a typical test, a situation is described to the
sonal behavior, one of the roles of assessment is to patient, and the therapist, playing the role of another
identify the specific factors that are affecting impaired individual in the situation, issues a verbal prompt. The
social performance. Thus, as models of interpersonal patient is instructed to respond to the prompt as real-
functioning become more complex, assessment prac- istically as possible, and the therapist extends the in-
tices need to be more encompassing. For example, in teraction for one or two more interchanges. Role-play
considering the interpersonal dysfunction of a newly procedures have proved useful at reflecting differences
diagnosed, young schizophrenic, a comprehensive as- between treatment and control groups in investigations
sessment should, at the very least, consider attentional of social competence in known groups, and in skills
and information-processing abilities and motivational training studies (McNamara & Blumer, 1982). How-
factors as well as social skills per se. Problems in any ever, the validity of role-playing with regard to repre-
of these general areas would, of course, need to be sentation of more naturalistically occurring social be-
better specified in order to develop an adequate inter- havior is less well-established (Bellack, 1983). Also,
vention. For example, if the patient's cognitive abili- the validity of role-play performance in comparison to
ties were found to be markedly impaired, options other measures of social skills/ social competence is
would include increasing or decreasing the patient's uncertain. Several recent studies have examined the
neuroleptic dose (as cognitive impairment could result validity of role-playing for the assessment of chil-
from poorly controlled psychotic symptoms or medi- dren's social skill. Matson, Esveldt-Dawson, and Kaz-
cation side effects). Basically, the social skills of the din (1983) found that role-play test performance was
patient need to be evaluated within the context of the not consistently correlated with other measures of so-
range of associated factors that can affect perfor- cial skills, including peer and teacher ratings of popu-
larity and interpersonal competence among a sample personally relevant scene content. Kern (1982) com-
of third to fifth graders. In a similar study, Kazdin, pared the external and concurrent validity of brief,
Matson, and Esveldt-Dawson (1984) again reported extended, and "clinical, replication-type" role-plays
that role-play performance was not correlated with nat- with undergraduate subjects. Low-, moderate-, and
uralistic observations of social performance or ratings high-frequency male undergraduate daters were unob-
by hospital staff, teachers, or parents among a sample trusively assessed in a waiting room condition, and
of 7- to 14-year-old psychiatric inpatients. subjects were assessed (individually) in randomly or-
Nelson et al. (1985) had male and female under- dered blocks within each role-play condition. Analy-
graduates participate in four behavioral assessment ses focusing on the relationship between role-play and
techniques (role-playing, interviews, questionnaires, unobtrusive performance, differentiations between re-
and self-ratings) in each of three heterosocial situa- liably high- and low-frequency daters, and changes in
tions (relationship initiation, maintenance, and termi- absolute levels of performance indicated that the rep-
nation). Assessment techniques in which subjects lication role-play was clearly superior to the brief role-
evaluated themselves produced significantly poorer play test and somewhat superior to the extended role-
ratings of social skills than techniques in which experi- play test, particularly on ratings of heterosocial skill
menters evaluated subjects (interviews and role- (as opposed to anxiety ratings). Chiauzzi, Heimberg,
playing). Becker, and Gansler (1985) compared personalized
Using an adult sample of day-hospitalized psychi- role-play scenes, which were drawn from critical sit-
atric patients, Monti, Corriveau, and Curran (1982) uations in subjects' lives, to standard role-plays in the
compared the results of day hospital staff ratings of assessment of depressed patients' social skill. The per-
social skills to the results of role-play and structured sonalized role-play situations were perceived as more
interview assessments. Although each assessment relevant by patients and resulted in more discomfort
modality had adequate reliability, there was generally and less skillful interpersonal behavior than standard
poor agreement among the various rating sources. scenes. Behavioral ratings of the personalized scenes
One factor in the evaluation of the validity of role- were also found to relate more strongly to measures of
play results may be that some participants may role- depression than the same ratings for the standard
play more "naturally" than others. De-Armas and scenes.
Brigham (1986) divided undergraduates into groups In addition to scene content and number of prompts,
based on self-report ratings of their ability to produce the manner in which the prompts are delivered can
naturalistic responses. Subjects indicating high and affect role-play performance. Moisan-Thomas, Con-
low levels of typical behavior during a role-play test ger, Zeilinger, and Firth (1985) examined the impact
and an unobtrusive (waiting room) observation were of confederate responsivity on judges' ratings of the
contrasted on correspondence of ratings of social skill. skill, anxiety, and attractiveness of unmarried males
Substantially higher correlations between the role-play during heterosocial role-play interactions. Subjects
and unobtrusive ratings were found for the group indi- were rated as more skillful when interacting with a
cating naturalistic responses. moderately responsive confederate than with a mini-
A further consideration in the validity of role-play mally responsive confederate. In a study designed to
assessments is variation in the role-play procedure it- examine the effects of variations in a role-play confed-
self. Although an attractive feature of role-play tests is erate's response latency on ratings of the role-play per-
that they can be modified to pertain to a wide variety of formance of low- and high-frequency male under-
social scenarios and interpersonal dysfunction, this graduate daters, Mahaney and Kern (1983) reported
flexibility has also served as somewhat of a disadvan- that variations in latency altered the difficulty level of
tage. There have been widespread inconsistencies in the role-play procedure. Also, the level at which the
role-play format and content across empirical investi- confederates' response latency was standardized af-
gations, making comparisons difficult. Until quite re- fected the ability of the role-play test to discriminate
cently, it was typical for tests to have been constructed between criterion groups. Finally, the ability of the
on the basis of face validity, with uncertain psycho- role-play test to discriminate between groups also var-
metric adequacy. Moreover, the careful evaluation of ied across confederates, which may have been due to
procedural variations has also progressed slowly. differences in attractiveness.
Variations that have received considerable attention In a study by Jarernko, Myers, Daner, Moore, and
include the use of brief versus extended role-play Allin (1982), in which pairs of male and female under-
scenes, and, recently, the use of general versus more graduates of high- and low-dating frequency interacted
with one another in a role-play format, the dating fre- The previous discussion pertains to procedural vari-
quency of the partner was found to affect self-report ations in the conduct of the role-play test itself. A
and behavioral ratings of skill and anxiety. These au- further issue regarding the validity of role-play test
thors did not assess the role that physical attractiveness data is the question of how to evaluate role-play behav-
may have played in these findings. ior. The most common use of role-plays involves vid-
A further source of variability in role-play perfor- eotaping subjects' performance, and then retro-
mance, which has been subject to recent empirical spectively rating the performance of the participant on
evaluation, is the pre-role-play experience and/or in- measures of social skill. Two general strategies have
structional set provided to the subject. Kazdin, been utilized for ratings, either singly or in combina-
Esveldt-Dawson, and Matson (1982) evaluated the ef- tion: molecular and molar.
fect of a positive affect induction experience on role- The molecular approach is closely tied to the behav-
play performance of 6- to 12-year-old psychiatric inpa- ioral model of social skill. Interpersonal behavior is
tients. Subjects who were provided with a success broken down into specific component elements, such
experience in a laboratory task unrelated to social as the expressive features described above (e.g., eye
skills prior to role-playing exhibited significantly contact and speech rate). These elements are then mea-
higher levels of social skills, as reflected in concrete sured in a highly objective fashion (e.g., number of
responses (e.g., number of words spoken), molar be- smiles and number of seconds of eye contact). Such
haviors (e.g., making requests), and self-reported con- measures are highly reliable and have good face valid-
fidence in their social behavior. In a subsequent report, ity. However, there are a number of serious problems
Kazdin, Esveldt-Dawson, and Matson (1983) found with this approach. The most serious concern pertains
that role-play performance of psychiatric inpatient to just how meaningful it is to measure such specific,
children, aged 7-13 years, who were under instruc- static response characteristics. Social impact is deter-
tions to either fake-good (e. g., highly appropriate) so- mined not by the number of seconds of eye contact or
cial behavior or fake-poor (e.g., highly inappropriate) speech duration, but by a complex pattern of responses
social behavior was consistently better or worse, re- that occur in conjunction with the partner's behavior.
spectively, than pretest performance under standard Earlier research had suggested that the specific ele-
instructions. ments most commonly assessed did not account for
Frisch and Higgins (1986) varied the amount of in- much of the variance in response quality, either indi-
formation about role-play scene content and desired vidually or when combined mathematically (cf. Ro-
response to the role-play which was given to subjects, mano & Bellack, 1980). However, more recently, in-
and found that female undergraduate students were vestigators have begun to analyze systematically
rated as more socially skilled when given more ad- precisely which response elements are critical. As an
vance information about the role-play. Subjects par- example, Millbrook and Farrell (1986) examined the
ticipating in a role-play condition, regardless of relationship between a variety of molecular behaviors
amount of information provided, responded more as- and global ratings of social skills and anxiety. Vid-
sertively than subjects who participated in an in vivo eotapes of psychiatric inpatient and nonpatient males
interaction involving the same assertive scenario. who participated in 2-min interactions with a confeder-
Finally, Perri, Kerzner, and Taylor (1981) evaluated ate were rated by untrained raters for global social skill
the effects of live versus taped role-play prompt ad- and anxiety. Subjects were also rated by trained raters
ministration on the performance of high- and low-so- from six research laboratories on component ratings.
ciallyexperienced 18- to 28-year-old males. Although Molecular behaviors that held up consistently across
the mode of stimulus presentation significantly af- analyses for ratings of skill were talk time, silence, and
fected ratings of anxiety, there were no effects on ade- gaze behaviors. Silence, leg movements, and gaze be-
quacy of content. haviors were consistently found to relate to global anx-
These findings regarding the validity of role-play iety ratings.
tests and, in particular, the variability in role-play per- The molar approach to assessment eschews specif-
formance, which can result from variations in the role- ic, objective ratings in favor of overall, subjective rat-
play procedure itself, indicate the importance of spec- ings. Judges use Likert scales to rate overall skill, anx-
ifying the role-play procedure and context used in iety, assertiveness, and so forth. Their subjective
investigations. Further work is needed in order to con- impressions presumably integrate the component re-
tinue to refine role-play tests so as to maximize exter- sponse elements and provide a measure of how the
nal validity. subject impacts on others. These ratings tend to corre-
spond better with meaningful external criteria, but they complex abilities involved in attending to the cues pro-
may be difficult to derive reliably. A further disadvan- vided by the interpersonal partner and in decoding and
tage is that they fail to indicate what specifically the interpreting these cues in order to develop an appropri-
subject is doing well or poorly; hence, they do not ate interpersonal response has been referred to as so-
provide information about which skills should be dealt cial perception ( Morrison & Bellack, 1981). Although
with in training, or which skills were improved in the importance of these factors has been discussed, it is
training. Indeed, as this chapter has repeatedly empha- only recently that empirical data regarding the rela-
sized, an individual could fare poorly in terms of tionship of social perception abilities to other measures
global ratings of skill or anxiety during a role-play of interpersonal skill and/or overall adjustment have
procedure for a wide variety of reasons. Given that the accumulated. Findings have indicated that social per-
purpose of assessment and training is ultimately tied to ception abilities relate to measures of overall social
how the subject affects others, qualitative ratings are adjustment in studies involving undergraduate student
vital. But it is important to break down such ratings in samples (e.g., Firth, Conger, Kuhlenschmidt, & Dor-
order to determine the cues that the judges use in mak- sey, 1986; Fischetti et ai., 1983). Other studies have
ing their judgments, and/or the specific types of defi- described deficits in social perception associated with
cits which result in subjects' impaired social perfor- various clinical conditions in child (e.g., Gerber &
mance. Zinkgraf, 1982; Russell, Stokes, & Snyder, 1987;
Somewhat of a compromise approach to ratings has Stone & LaGreca, 1984) and in adult (e.g., Monti &
recently been considered by a number of investigators, Fingeret, 1987) populations. However, these investi-
who have attempted to derive "intermediate" ratings gations have been confounded by a number of meth-
of social skill, combining elements of both the molar odological issues. Measures that have been used to
and molecular approaches. For example, Monti and assess social perception skills have most typically been
his colleagues have begun to evaluate "midi-level" some type of photographic or pictorial stimuli. These
ratings of skill and anxiety (e.g., Monti et al., 1984). analogue tasks may lack sufficient validity to provide
The use of these sorts of intermediate scoring systems meaningful information about real-world social func-
has not yet become widespread, and their ultimate util- tioning. There has been little consideration of com-
ity remains to be more carefully evaluated. parability and/or standardization across studies, as nu-
A final issue pertaining to the assessment of re- merous different measures have been used. Also, the
sponse components of social skill requires brief com- role of attentional factors in social perception has sel-
ment-the role of social validation in the assessment dom been assessed or controlled.
process. Often, the primary criterion used to identify However, recently there has been considerable pro-
targets for assessment and training of overt social skills gress toward the development and standardization of
has been the researcher's or clinician's own judgment affect recognition assessment measures. This pro-
about what behaviors are appropriate. It is now becom- gress has been based on research concerned with fa-
ing apparent that much more consideration must be cial and vocal affect recognition as specific, right-
directed toward how the subject's environment evalu- hemisphere-mediated, information-processing tasks.
ates his or her behavior. Failure to conduct social val- The predominant hypothesis with regard to hemi-
idation of particular social skills that have been tar- spheric lateralization of affect recognition is that the
geted in social skills training may relate to the limited nondominant hemisphere is primary for recognizing
generalization and maintenance of social skills train- emotional aspects of stimuli. Findings from investi-
ing effects. Recent work by Janet St. Lawrence and her gations of the functional asymmetry of the hemi-
colleagues (Hansen, St. Lawrence, & Christoff, 1985; spheres have indicated that (at least in right-handed
Holmes, Hansen, & St. Lawrence, 1984) represents adults) the right hemisphere is more involved in fa-
some of the most significant progress in this area. cial-identity recognition, facial-affect recognition,
These studies will be considered in some detail below. and affective-voice-tone recognition than is the left
hemisphere. Two primary experimental meth-
odologies have been used in investigations of later-
Affect Recognition
alization of facial-affect recognition. Both have in-
It has long been recognized that social behavior, like volved tachistoscopic presentation of affective stimuli
any other form of human response, draws upon a vari- (either photographs or drawings of faces) to indi-
ety of perceptual, motor, and intellectual skills. The vidual hemifields. One series of investigations has
focused on hemispheric differences in perceptions of tween schizophrenic patients and the affective patients
facial emotions in neurologically normal adults. A on the emotion-discrimination task. Finally, Feinberg,
second series has considered the performance of adult Rifkin, Schaffer, and Walker, (1986) compared the
patients with unilateral damage to either the left or facial-affect-recognition abilities of hospitalized
right hemisphere. A unique aspect of these investiga- schizophrenic patients to those of hospitalized patients
tions has been that neuropsychological tasks have with major depressive disorder and nonpatients. Four
been utilized to evaluate attentional abilities (e.g., fa- tasks were constructed from the facial-affect pho-
cial identity recognition tasks). The results of studies tographs of Ekman, Friesen, and Ellsworth, (1972).
with nonpatients have typically shown a significant Two tasks were designed to investigate facial-identity
left-visual-field (right hemisphere) advantage for the matching, independent of emotion expressed (one task
recognition of facial stimuli (e.g., Landis, AssaI, & presented inverted faces, while the other task faces were
Perret, 1979; Ley & Bryden, 1979; Strauss & presented right side up). The other two tasks were de-
Moscovitch, 1981). Similarly, studies involving neu- signed to assess emotion recognition (matching) and
rological patients have revealed that patients with emotion labeling, respectively. Although depressed pa-
right-hemispheric lesions are typically more impaired tients differed from controls only on the emotion-label-
than patients with left-hemispheric damage or con- ing task, schizophrenic patients showed deficits on all
trols on tasks involving identification and/or recogni- four tasks when compared with controls. Also, schizo-
tion of emotion (e.g., Benowitz et al., 1983; De- phrenics performed more poorly than depressed pa-
Kosky, Heilman, Bowers, & Valenstein 1980; Etcoff, tients on the emotion tasks. The authors conclude that
1984ab). even though schizophrenics are impaired on a broader
The use of sophisticated cognitive assessments to range of facial-perception skills than depressed pa-
investigate affect recognition as a lateralized phe- tients, it is in the area of emotion discrimination and
nomenon is becoming widespread in clinical studies recognition that they show the greatest deficit.
with other populations. Studies with schizophrenic pa- These recent studies offer significant methodologi-
tients have been conducted using aspects of the newer cal advances over earlier investigations of "social per-
methodology. To evaluate the issue of a differential ception" with schizophrenics. However, studies on af-
deficit in affect recognition (versus generalized cog- fect recognition with schizophrenics (as well as
nitive impairment) in schizophrenic patients, long-stay research in this area with other subject populations)
chronic patients were compared to a matched group of still require increased experimental rigor. As noted,
nonpatient controls by Novic, Luchins, and Perline the stimuli used have varied across investigations. No
(1984) on a test of facial-affect recognition using the investigations have yet considered lateralization pat-
Izard photographs (1971) and a facial-recognition task terns in affect recognition studies with schizophrenics.
(Benton & Van Allen, 1973). Schizophrenics tended to Virtually no attention has been given to the possible
perform more poorly than controls on the affect-recog- impact of medication on affect recognition. Finally,
nition measure. However, this difference was elimi- the relationship of affect recognition performance to
nated when facial-identify recognition was included in other measures of social skill has not been adequately
the analysis as a covariate. In a similar study, Walker, considered. Much further research is needed to under-
McGuire, and Bettes, (1984) compared hospitalized stand better the relationship of affect recognition defi-
schizophrenic patients with schizoaffective disorder cits to impaired social competence.
patients and nonpatient controls. Subjects completed a
facial-identity discrimination task based on the Benton,
Other "Cognitive" Factors
an emotion-discrimination task (in which subjects de-
termine whether the emotions depicted in pairs of pho- A number of investigations have examined the rela-
tographs are the same or different), an emotion-labeling tionship of other cognitive phenomena that relate to
task, and a multiple-choice emotion task. Stimuli for social skills, including social problem-solving compe-
the emotion-recognition tasks were taken from the Izard tencies and self-statements regarding interpersonal
photos. There were significant group differences on all competence. Deficiencies in problem-solving skill
three emotion-recognition tasks, but not on the facial- have been observed to be associated with social dys-
discrimination task. On the emotion-recognition tasks, function in both child and adult samples. Asamow and
schizophrenic patients consistently differed from non- Callan (1985) examined the social problem-solving
patients. There was also a significant difference be- skill and self-statements of fourth- and sixth-grade
males with positive or negative peer status. Assess- Chiauzzi & Heimberg, 1986; Robinson & Calhoun,
ments were conducted using an interview format in 1984). Cognitive parameters of interpersonal compe-
which subjects were presented with hypothetical social tence among depressed subjects have recently been
situations and asked about problem-solving strategies evaluated. In comparison to nondepressed students,
and attributional style. Results indicated that males depressed undergraduates tend to rate themselves as
with negative peer status generated fewer alternative less socially competent, although no differences were
solutions, generated more intense aggressive solu- noted between groups on ratings of social competence
tions, showed less adaptive planning, and evaluated by objective observers (Gotlib & Meltzer, 1987). In a
physically aggressive responses more positively and study involving depressed and nondepressed inpa-
prosocial responses more negatively than did males tients, both patient groups were rated as less competent
with positive peer status. Gouze (1987) examined the than nonpatient controls (Haley, 1985). Depressed
relationship between two cognitive processing vari- subjects rated their own recent interpersonal behavior
ables: attention and social problem solving, and ag- and optimal social skills significantly lower than non-
gression in preschool-age boys. Subjects were admin- depressed patients and nonpatient subjects.
istered two selective attention tasks that assessed Other clinical populations have also been observed
children's tendency to focus on aggressive versus co- to exhibit distorted self-evaluations of interpersonal
operative social situations, and a preschool interper- competence. Segal and Marshall (1986) compared
sonal problem-solving measure. Aggressive behavior self-efficacy predictions of sex offenders (rapists and
was measured by teacher ratings and observational child molesters) to their actual performance during a
data. Results indicated that aggressive subjects conversation with a female confederate. The behavior
focused their attention on aggressive social interac- of non-sex-offender inmates and non-inmate controls
tions in their environment and provided aggressive so- was also assessed. Child molesters had the highest
lutions to hypothetical interpersonal conflict situations discrepancy between predicted and actual perfor-
more often than their less aggressive peers. Rubin, mance and showed particular difficulty in gauging
Daniels-Beimess, and Bream (1984) investigated the their ability to answer the confederate's questions.
social problem-solving abilities of kindergarten and
first-grade children who were observed to interact in-
frequently with their peers. Both quantitative and Social Skills Training
qualitative indices of social problem-solving compe-
tence correlated (concurrently and predictively) in a As has been emphasized in this chapter, the most
negative direction with the observed frequency of iso- notable of the recent advancements in the literature
late play and in a positive direction with social play. In regarding the assessment of social skills has dealt pri-
a second study, the relationships between frequency of marily with factors in interpersonal competence other
isolate and social play and naturalistic social problem- than the overt behavioral response components of so-
solving skills were examined. The findings indicated cial skills. Despite increasing recognition of these fac-
that nonassertive, compliant social problem-solving tors, research on social skills training has continued to
strategies correlated concurrently with isolate play in be based on the skills deficit model (e.g., Rice, 1983)
kindergarten and predictively with isolate play in and has emphasized consideration of specific motor
Grade 1. responses relating to socially competent behavior. The
Stefanek, Ollendick, Baldock, Francis, and Yeager most common protocol based on the skills deficit
(1987) observed that popular fourth graders reported model is the response acquisition approach. In this
making significantly more facilitating self-statements protocol, treatment proceeds by training on each defi-
(i.e., self-statements that make it easier to deliver an cient response element (one at a time, in order of in-
effective social response) than inhibiting responses. creasing difficulty). Specific responses should be at-
Withdrawn and aggressive fourth graders reported sig- tacked in an order that maximizes the patient's success
nificantly fewer facilitating self-statements than popu- throughout training (i.e., based on what the patient can
lar students, but did not differ from one another. most easily learn at each point). The strategy of focus-
Similar findings have resulted from studies using ing on the response elements one at a time and of
adult samples. Several recent investigations have ensuring continuing success throughout the treatment
shown that unassertive (based on self-reports) under- is especially important for patients with attentional dif-
graduates anticipated poorer outcomes from assertive ficulties (e.g., schizophrenics). Training can be tele-
response alternatives than did assertive students (e.g., scoped when the patient is less disturbed or when it has
proceeded to a point where many responses are gener- should be specific and focus initially on the positive
alized across situations. aspects of the response under training. This principle
The training consists of five techniques: (1) instruc- is adhered to even when the patient's performance is
tion, (2) modeling, (3) role-playing, (4) feedback and grossly deficient. Only after the patient's attempt is
social reinforcement, and (5) homework. appropriately praised are suggestions for change pro-
vided. For example, the therapist might say, "You did
a very good job of looking at my eyes when you first
Instruction
started to speak. This time, try to do even more of
When presenting a new skill to be learned, the first that." A patient who experiences frequent feelings of
step is to instruct the patient in its use and to provide a success and who receives prodigious praise and en-
rationale for learning to use it. For example, when ad- couragement from the therapist is far more likely to
dressing the common problem of poor eye contract, retain the motivation required to practice social skills
the therapist might say, "If people are going to know to proficiency than one who receives only suggestions
that you are serious, you should look at them when you for improvement.
speak. Try to look me in my eyes when you answer
me."
Homework
Role-play interaction provides an opportunity for
Modeling
the patient to learn and practice new skills, but addi-
Although verbal instructions are helpful, one of the tional practice between sessions is required in order for
best ways to communicate essential information about those skills to generalize to other settings. In this re-
a skill is to simply demonstrate or model its use. Imme- gard, patients are routinely given specific homework
diately prior to demonstrating the skill, the therapist assignments to use the skills acquired in a particular
should draw attention to the most important response session with other individuals prior to the next session.
component (e.g., "Watch how I nod sometimes while Specific assignments, such as "Ask your roommate to
I am listening"). The enactment should be brief and to help you play cards tonight" are more likely to meet
the point. Extended demonstrations are likely to ex- with compliance than vague assignments, such as
ceed the patient's attentional abilities or draw his or her "Try requesting things from people." The assignment
attention to extraneous behavior. The skill may have to should be one that is likely to meet with success. Thus,
be demonstrated repeatedly for some patients. the therapist should be reasonably certain that the pa-
tient is capable of carrying out the assignment and that
it stands a good chance of receiving a favorable re-
Role-Playing
sponse. At the beginning of each session, the home-
After the skill has been demonstrated, the patient is work assignments from the preceding session are re-
asked to try to mimic the therapist's behavior in a brief viewed and any problems that have arisen are resolved
role-play interaction. This is a most important compo- before proceeding to a new skill.
nent of social skills training as simply talking about Perhaps the most significant recent developments
and/or viewing skillful behavior is unlikely to impart pertaining to social skills training have been concerned
those skills to the patient. Using the same scenario that with the social validation of target behaviors, and the
was used to model the skill, the patient attempts to evaluation of the efficacy of combined treatment pack-
implement the skill in role-play with the therapist. ages which have included social skills training as a
Once the patient masters the minimal components of significant component. These developments have been
the skill, the therapist can generate more complex role- spurred, in part, by ongoing concerns regarding the
plays. Although the learning abilities of individual pa- generalization and maintenance of social skills train-
tients will vary, in most cases extended practice and ing effects. The extent to which the effects of social
repetition will be necessary. skills training generalize to nontraining environments
and persist following training has been raised as a con-
cern for some time. Although some recent studies have
Feedback and Social Reinforcement
obtained adequate generalization and/or maintenance
In an effort to shape appropriate social skills, the (e.g., Michelson et al .• 1983), other investigators have
therapist should provide feedback and positive rein- continued to report problems in generalization and
forcement following every role-play. The feedback maintenance of "standard" applications of social
skills training, especially in studies with more severely Social validation in relation to social skills training
and/or chronically impaired patients (e.g., Rice, involves selecting component behaviors for training,
1983). As early as 1978, Bellack and Hersen described as well as performance criterion levels for the behav-
the findings regarding generalization and maintenance iors, based on an assessment of the interpersonal skills
with chronic psychiatric patients as "mixed." In a sub- of "normal" nonpsychiatric persons in the communi-
sequent paper, Morrison and Bellack (1984) con- ty. The rationale for this approach is that training be-
cluded that relatively little progress had been made in haviors to criterion levels will permit the behaviors to
this area. In fact, it has only been relatively recently more easily come under the control of environmental
that investigators have considered generalization and contingencies, thus facilitating both generalization
maintenance in a methodologically sophisticated fash- and maintenance. Holmes et al. (1984) provided group
ion. Early investigations evaluated outcome using the social skills training that focused on specific conversa-
same laboratory role-play scenes that were used to tional components and speech content to 10 chronic
assess pretreatment competence. Later, responses to psychiatric patients enrolled in a partial hospitalization
novel role-play scenes were employed as a generaliza- program. All of the patients had conversational diffi-
tion measure (e.g., Bellack, Hersen, & Turner, 1976; CUlty. Results were evaluated using a multiple-baseline
Monti et al., 1979). Finally, investigators began to design, and demonstrated the effectiveness of the
evaluate in vivo performance. Current findings indi- training procedures. Following training, the frequency
cate that generalization can be obtained if the skills of targeted component behaviors increased to socially
training program includes procedures to specifically validated criterion levels. Training effects generalized
facilitate transfer to the natural environment (Baer, to unfamiliar, nonpsychiatric conversational partners,
Wolf, & Risley, 1968). The procedure which has been and were maintained throughout a 7-month follow-up.
used most widely has been in vivo practice. Liberman However, even investigations ofthis sort fail to fully
et al. (1984) have reported a series of controlled case address the overall clinical impact of social skills train-
reports in which the effects of intensive (20 hours per ing. Even though these training techniques are effec-
week) social skills training with three schizophrenic tive in terms of patients' acquiring and maintaining
patients were augmented with in vivo homework as- new skills in their repertoires, and of their using these
signments. Also, Finch and Wallace (1977) assigned new skills during social interactions, the issue of
homework to pairs of schizophrenic patients, to be whether these new skills provide a clinically mean-
completed together. This procedure was successful in ingful difference has not been addressed. The purpose
increasing homework completion, and patients who of any psychosocial intervention for chronically im-
received skills training and homework performed paired patients is to facilitate better adjustment in the
more skillfully than a matched nontreatment control community and, ultimately, to prevent or postpone re-
group in spontaneously enacted situations occurring in lapse. Unfortunately, Holmes et al. did not address
the natural environment. relapse. A frequent critique of social skills training
Similarly, investigators have become more sophisti- with chronic patients has been that changes in social
cated with regard to the evaluation and facilitation of skills repertoires "do not often result in substantial
maintenance of the effects of social skills training with differences in patients' quality oflife" (Wallace, 1982,
chronic psychiatric patients. The results of earlier p.60).
studies with follow-up assessments ranging from 8 Bellack, Turner, Hersen, and Luber (1984) used a
weeks to 10 months posttreatment suggest that social 12-week day hospital program supplemented by com-
skills training can produce durable improvements in prehensive social skills training to treat a group of 44
social functioning (e.g., Bellack et aI., 1976; Hersen chronic schizophrenic patients. The performance of
& Bellack, 1976; Monti et al., 1979; Monti, Curran, these patients was assessed, using a battery of self-
Corriveau, Delancey, & Hagerman, 1980). However, report and behavioral measures, and compared to the
most follow-up procedures have relied on either self- performance of 20 chronic schizophrenic patients who
report or behavioral laboratory assessment procedures. received only day hospital treatment. Results indicated
Performance on these measures is an important indica- that both patient groups had improved at posttreat-
tor of whether the targeted responses remain in the ment. However, during the 6-month posttreatment pe-
patient's behavioral repertoire. However, it does not riod, patients who had received social skills training
reflect the clinical significance of social skills training either continued to improve or maintained their gains
in terms of the patient's ongoing use of "new" skills in on most measures, whereas the patients receiving day
his or her interpersonal environment. hospital treatment alone either maintained gains or lost
them. Finally, almost half of the patients in both of community functioning and therapist ratings than
groups were hospitalized at least once during the year did subjects who received the graduated exposure
following treatment. Thus, the findings suggest that alone. Stravynski, Marks, and Yule (1982) evaluated
social skills training did little to forestall relapse with the effects of social skills training with and without
these patients. cognitive modification in the treatment of socially dys-
Subsequent findings reported by Liberman, functional adult outpatients. Social skills training re-
Mueser, and Wallace (1986) indicate that schizo- sulted in self-reported clinically significant improve-
phrenics who received intensive (12 hours per week) ment that persisted at a 6-month follow-up. The effects
social skills training as inpatients evidenced better of social skills training were not enhanced by the addi-
functioning, spent less time hospitalized, and had tion of cognitive modification.
fewer symptomatic relapses 2 years after treatment Clearly, part of the variability of the findings regard-
than a comparable patient group which had received ing the efficacy of social skills training used indepen-
holistic health treatment during the index inpatient dently versus in combination with other interventions
hospitalization. That the findings reported by Bellack may relate to the severity of the symptoms and/ or so-
et al. (1984) and Liberman et al. (1986) are so discor- cial impairment exhibited by the patients. While social
dant with regard to the prevention of relapse may be skills training alone may be an adequate intervention
attributable to differences in the skills training pro- with less impaired individuals, more intensive psycho-
tocols and/ or to characteristics of the patients them- social interventions may be indicated for severely ill
selves. With regard to treatment, the skills training patients.
procedures utilized by Liberman et al. were much Finally, a particularly promising development is the
more intensive. This factor should receive further con- use of interactive videotape instruction in social skills
sideration in relationship to treatment outcome. training. Interactive video has already been favorably
Data reported by Hogarty et al. (1986) attest to the evaluated in empirical studies concerned with the
importance of possible interactions between social training of overt behavioral social skills (e.g., Malouf,
skills training and specific patient characteristics. McArthur, & Radin, 1986), and holds particular prom-
These investigators examined the effects of social ise for training of social perceptual skills.
skills training, family psychoeducation, and mainte-
nance medication in the aftercare treatment of schizo-
Social Perception Training
phrenic and schizoaffective patients. Both social skills
training and family treatment, administered in con- The mastery of individual response skills does not
junction with medication, resulted in a significant re- guarantee their effective use in social situations. In
duction in first-year relapse rates relative to control addition to training overt response skills, patients usu-
subjects (maintenance neuroleptic treatment). Further- ally must be taught when and where to use them. These
more, combined treatment (social skills training and abilities require that the patient attend to and correctly
family psychoeducation) reduced first-year relapse to interpret both interpersonal and contextual cues. For
0% (among 17 subjects receiving combined treat- example, a patient who has just mastered the ability to
ment). Finally, the effects of social skills training were initiate a conversation may also need to learn that it can
apparently somewhat mitigated among patients dis- be unwise to implement that skill with someone dis-
charged in a psychotic state. Three patients in the so- playing an extremely unreceptive facial expression.
cial skills training condition experienced a 1Ype II Training in social perceptual abilities does not fol-
relapse, defined by the authors as a "severe clinical Iowa separate structured sequence of activities, but
exacerbation of persistent psychotic symptoms" has instead typically been integrated into the response
(p. 636). training procedures described above. The objective is
Social skills training has also been utilized as part of to train the patient to attend to and interpret interper-
combined treatment programs with other patient popu- sonal cues that signify the feelings and motives of
lations. Cappe and Alden (1986) compared graduated other individuals and to contextual variables that deter-
exposure to fear-provoking situations and graduated mine the appropriateness of various responses. This
exposure plus social skills training in the treatment of can be accomplished during role-play interaction by
adults who reported impairments in their social, oc- introducing subtle variations in the therapist's behavior
cupational, and heterosocial functioning because of and inquiring into the possible meanings of those vari-
extreme shyness. Subjects who received the combined ations. For example, during role-plays involving casu-
intervention improved significantly more on measures al conversation, the therapist can increasingly exhibit
nonverbal cues indicating a lack of interest and a desire This is consistent with the majority of research in psy-
to leave (e.g., fidget, glance at watch, look at door). chiatry and clinical psychology. The relatively recent
After each role-play, patients can be questioned about development and acceptance/implementation of ob-
possible interpretations of and acceptable responses to jective and operational diagnostic criteria, with ade-
such behavior. With respect to contextual cues, train- quate reliability and validity, was a necessary precur-
ing is mainly achieved through didactic means. Thus, sor to diagnostic specific investigations (e.g., DSM-
a portion of each session can be devoted to discussing TIl, DSM-TIl-R, RDC) across a range of diagnostic
the social rules that govern the acceptable use of the entities.
skills under consideration. Increasing attention has been directed to parameters
Wallace (1982) has developed a program specifical- of responding in addition to overt response compo-
ly intended to improve the information-processing nents. These include social perception and, in particu-
skills of schizophrenic patients. In this program, pa- lar, affect recognition, as well as "associated" factors
tients are taught to accurately receive and process in- that can affect social performance, such as variations
coming stimuli and to subsequently send effective ver- in affect and cognitive status. Notably, the mediative
bal and nonverbal responses. The distinctive compo- role of certain neurointegrative functions in social
nent of this approach is its emphasis on interpersonal functioning and the possibility of disruptions in neu-
stimulus processing, or problem-solving, during rointegration producing social dysfunction have been
which patients are taught to generate various response subject to increasing investigation. Parameters of this
options, weigh the value of those options, and devise sort have received the most consideration in relation to
an appropriate response implementation strategy. This the social functioning of patients with major psychi-
approach has proven to be effective with many schizo- atric disturbance.
phrenic patients, and it appears to offer a practical All the while, there continues to be a great deal of
means of addressing the information-processing defi- attention directed toward behavioral response compo-
cits of negative schizophrenics. nents, especially in terms of attempts to derive the
With the increasing emphasis on facial-affect recog- optimal set or sets of components to be addressed in
nition, it is likely that a particular training technology clinical and research efforts. Role-play measures of
for the (re)training of facial-affect cue recognition will interpersonal skill remain the primary measure for the
be developed. A number of possible strategies for this assessment of behavioral response components. It is
sort of training exist. Training can be modeled after clear that role-play performance is affected by a diver-
procedures that have been used for the retraining of a sity of factors, and that greater investigation and con-
variety of cognitive skills in the rehabilitation of brain- trol of factors which affect role-play performance are
injured patients (c.f. Goldstein & Ruthven, 1983). necessary in order to further enhance the validity of
role-play assessments of social skill.
Few studies have considered interpersonal function-
Summary and Conclusions ing from a longitudinal perspective. This is crucial, as
the course of interpersonal dysfunction associated with
Interpersonal dysfunction continues to be at the cen- particular psychiatric disorders will potentially vary in
ter of a great deal of clinical and research activity. relationship with other parameters or symptoms of ill-
Indeed, this chapter provided merely an overview of ness. It is important to emphasize that consideration of
current issues regarding the assessment and treatment the social dysfunction which is associated with partic-
of social skills, and only a limited representation of ular diagnostic categories does not imply that interper-
recent empirical findings was discussed. Based simply sonal problems are invariably secondary to other
on the immensity of the literature, it is difficult to symptoms of psychiatric impairment. Indeed, there is
derive overall conclusions regarding the general topic evidence that social dysfunction can precede the onset
of interpersonal dysfunction. Perhaps the most mean- of diagnosable episodes of at least certain categories of
ingful summations can be drawn from a descrip- psychiatric illness (e.g., schizophrenia). Future re-
tion/reiteration of trends in the literature, as well as search should consider more carefully the relationship
speculation regarding probable future directions. of interpersonal, neuorintegrative, and other psychi-
Foremost among these trends is the tendency for atric symptoms in longitudinal designs with carefully
findings regarding interpersonal dysfunction to be in- diagnosed, homogeneous groups of patients.
creasingly specific to particular psychiatric diagnoses. Modifications of social skills training will be forth-
coming. Developments are likely in relation to affect An experimental analysis. Behaviour Research and Therapy,
recognition training approaches and to increasingly so- 14, 391-398.
Bellack, A. S., Thrner, S. M., Hersen, M., & Luber, R. F.
phisticated combinations of social skills training with (1984). An examination of the efficacy of social skills training
other psychosocial and/or somatic interventions. for chronic schizophrenic patients. Hospital and Community
Also, more diagnostically sophisticated social valida- Psychiatry, 35, 1023-1028.
tional investigations are needed, with greater consid- Bellack, A. S., Morrison, R. L., Mueser, K., & Wixted, J.
(1989). Social problem solving in schizophrenia. Schizo-
eration of the longitudinal clinical impact of social phrenia Bulletin, 15, 101-116.
skills training based on the social validational model. Benowitz, L.I., Bear, D. M., Mesulam, M. M., Rosenthal, R.,
Zaidel, E., & Sperry, R. W. (1983). Non-verbal sensitivity
following lateralized cerebral injury. Cortex, 19, 5-12.
ACKNOWLEDGMENT. Preparation of this chapter was Benton, A. L., & Van Allen, M. W. (1973). Test of Facial
supported in part by grant MH 38636 from the National Recognition: Manual. Iowa City: University of Iowa.
Institute of Mental Health. Burleson, B. R., Applegate, J. L., Burke, J. A., Clark, R. A.,
Delia, J. G., & Kline, S. L. (1986). Communicative correlates
of peer acceptance in childhood. Communication Education,
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CHAPTER 25
Crime and Aggression/

Child and Spouse Abuse
Michael T. Nietzel and David T. Susman
Authors often begin their handbook summaries of a strained unlawful conduct, and environmental pres-
literature by charting the paths of early explorers who sures toward wrongdoing (what he called the "atmo-
first traveled the terrain and paved the way for modern sphere of criminality").
investigators. Claims about who was first to name a Throughout the twentieth century several crimi-
phenomenon, who introduced a concept, or who initi- nologists proposed that crime was learned through so-
ated a theoretical perspective on a problem often domi- cial interaction. These accounts, which have been
nate these introductions, as authors attempt to place called social process or sociopsychological theories
their topic in a proper historical, or at least accurate (Nettler, 1974; Reid, 1976), attempt to bridge a gap
chronological, context. We admit to the same tempta- between the broad-brush environmentalism of so-
tions, but we are skeptical that claims to have identi- ciological approaches to criminology and the narrow
fied the "first" behavioral account of crime/delin- individualism of biological or psychological theories.
quency can be defended. Social process theories can be further divided into two
On whom one bestows the honor of "Originator" subclassifications: control theories and direct learning
depends on the criteria used in judging whether a for- theories.
mulation was sufficiently systematic to be considered a Control theorists assume that people will behave
theory and whether the language used conveys a be- antisocially unless they learn not to. Lawful behavior
havioral or learning-derived explanation of crime. Was depends on successful socialization and the develop-
Francis Bacon, who implicated stimulus control with ment of a conscience that restrains illegal conduct. All
his claim that "opportunity makes a thief," the first control theories focus on faults in moral development
behavioral criminologist? How about Gabriel Tarde whereby the conscience fails to control crimes to
and his belief that "criminality... is to be accounted for which a person is tempted. The most prominent con-
better than in any other way by the general laws of trol theorists have been Hans Eysenck (1964), who
imitation"? (Tarde, 1912). A vote could be cast for believed that persons high in extroversion and neurot-
Hugo Munsterberg who argued in On the Witness icism would be slow to develop the classically condi-
Stand (1908) that criminality derived from imitation of tioned inhibitions that were the elements of con-
society's bad actors, reductions in forces that re- science, and Walter Reckless (1961), who argued that
criminality resulted from defects in either external
Michael T. Nietzel and David T. Susman • Department of
Psychology, University of Kentucky, Lexington, Kentucky containments (social, institutional pressures for con-
40506. formity to rules) or internal containments (self-con-
523
cepts and cognitive strategies that allow persons to Wilson and Hermstein begin with the operant princi-
resist temptations and to increase their sense of person- ple that behavior is determined by its consequences.
al responsibility). Of course, any theory of moral de- Both criminal and noncriminal behavior have gains
velopment is at least an implicit control theory of crime and losses. Gains associated with not committing
even though most of them try to explain general abili- crime include avoiding punishment and having a clear
ties for self-control rather than specific restraints on conscience; gains associated with committing crime
illegal behaviors. Therefore, Kohlberg (1969), Piaget include revenge and peer approval. Whether a crime
(1932), and Hogan (1973) could all be placed in the is committed depends, in part, on the net ratio of
control theory camp, although their use of learning- these gains and losses for both criminal and non-
based concepts is obviously limited. Social learning criminal behavior. Wilson and Hermstein contend
accounts of moral development (e.g., Bandura & that individual differences, affecting both operant and
McDonald, 1963; Prentice, 1972), emphasizing the respondent learning processes, influence the percep-
accumulation of observed, modeled, reinforced, and tion of these ratios and help determine whether a per-
instructed socialization, also seek to explain behav- son will engage in criminal behavior (a perspective
ioral controls, albeit with less emphasis on internalized with some similarity to rational choice theory; Corn-
structures. ish & Clarke, 1986). For example, individuals differ
The second type of social process theory, direct in the ease with which they develop a conscience
learning theory, concentrates on the learning mecha- through respondent conditioning; a weak conscience
nisms by which criminal behavior is directly acquired increases the gains associated with criminal behavior
and maintained. Control theories emphasize socializa- and decreases the gains associated with legal con-
tion processes that fail; direct learning theories focus duct. Another individual difference is impUlsivity.
on criminalization experiences that succeed. Included Because the gains of crime tend to be immediate,
in this category are (1) Edwin Sutherland's (1939) whereas the losses associated with it usually occur
enormously influential theory of differential associa- much later in time, impulsive persons will be less
tion, (2) traditional operant conditioning extended to deterred by more remote consequences. A final dif-
the domain of criminal behaviors, often in the form of a ference concerns how people respond to what they
behavioral translation of Sutherland's concepts (Bur- perceive as inequitable relationships; judgments of
gess & Akers, 1966; Jeffery, 1965; Krohn, Massey, & equity can change the reinforcing value of crime. If
Skinner, 1987), and (3) social learning theory with its one perceives oneself as being unfairly deprived by
"triple threat" explanations involving stimulus in- society, this sense of inequity can increase the gains
stigators, vicarious learning and cognitive mediation, associated with criminal behavior because such be-
and differential reinforcement (Bandura, 1973, 1976; havior can help restore one's sense of equity. Wilson
Platt & Prout, 1987). Social labeling theory, with its and Hermstein believe that constitutional factors in-
study of deviance constructed through processes of fluence variations in intelligence, arousal, and im-
social typing (Becker, 1963; Lemert, 1967; Schur, pulsivity, which, in tum, translate into the individual
1971), is also a learning theory of sorts, although it differences that contribute to crime. They also sug-
does not explain the primary deviance of criminal be- gest that, of several social factors thought to increase
havior so much as the secondary deviance produced by criminal behavior, families' methods of discipline and
society's official reactions to offenses. early experiences in school are the most important
Several theorists have tried to integrate multiple- because of the effects they have on developing behav-
learning processes into a comprehensive, coherent, ioral repertoires.
behaviorally based formulation of criminality. An ear- Can we extract a core set of principles from these
ly example of this approach was Feldman's (1977) in- theories that provides us with a behavioral concep-
tegrated learning theory, which assimilated the per- tualization of criminality? We believe so as long as one
spectives of individual differences in conditionability, remembers that there are several causal paths a person
problematic learning histories involving both operant may travel to behaving criminally. There is no single
and respondent processes, and social labeling as an criminogenic influence. However, there are at least
exacerbator of deviant conduct. four behaviorally based etiologic factors with impor-
Another influential, but more controversial, multi- tant implications for how best to intervene into prob-
ple-component theory is defined in Wilson and lems of crime and delinquency.
Hermstein's (1985) Crime and Human Nature. I. Much crime is the product of interactions be-
CHAPTER 25 • CRIME AND AGGRESSION 525
tween antecedent situations, rich in their opportunities fines, counts, and records such conduct is not a settled
and temptations for illegal behavior and victimization, matter, however, and leads to considerable disagree-
and persons, deficient in prosocial skills and/or well- ment.
stocked in attitudes, cognitions, and motivations for The range of criminal behavior is enormous; its to-
antisocial behavior. pography so varied as to defy any simple description.
2. Contingencies for criminal behavior are often fa- Crime includes conduct that is predatory, violent, and
vorable either because short-term positive reinforce- dangerous, dishonest, manipulative, and fraudulent,
ment for crime is so much more probable than long- obnoxious, unhealthy, and embarrassing. As a result,
term punishment or because some individuals are it is necessary to limit one's comments and recommen-
uniquely immune (through constitutional factors or dations about crime to certain categories of behavior or
learning history) to negative consequences that are re- else run the danger of reaching only the most general
mote in time. and usually trivial conclusions. In this chapter, we lim-
3. Two early, family-based precursors of delinquen- it ourselves to serious, predatory crimes, or what
cy are (1) violence and physical abuse within a family Wilson and Herrnstein (1985) termed criminality-
directed either toward a child or a spouse, and (2) the crimes, condemned and punished in all societies, in-
failure of parents to practice effective child-manage- volving predatory, aggressive, or larcenous conduct.
ment and discipline resulting in their inability to con- There are four methods for measuring crime: (1) the
trol a child's initial episodes of impulsive behavior and Federal Bureau of Investigation's Uniform Crime Re-
acting-out. ports (UCR), (2) victimization surveys, (3) self-re-
4. Modeling and peer pressure can exert a substan- ports in the form of interviews and questionnaires
tial influence toward delinquency and increased crimi- about criminal behavior, and (4) unobtrusive mea-
nality. More specifically, crime and/or the severity of sures.
crime increases when peer contingencies support it and The UCR is the oldest and best recognized compila-
when the criminal justice system itself, by virtue of its tion of crime statistics, the metric against which all
official processing and labeling of offenders, increases other measures are evaluated. Begun in 1930, the UCR
the association of "beginning" criminals with more measures the raw frequency and the rate per 100,000
serious, seasoned felons. inhabitants of criminal violations known to the police.
Although it contains figures on several categories of
crime, the UCR concentrates on eight of the most se-
Assessment of Crime and Delinquency rious crimes against persons and property: murder (and
nonnegligent manslaughter), forcible rape, robbery,
Behaviorists will appreciate the main criterion for aggravated assault, burglary, larceny-theft, motor ve-
defining a crime: it requires an overt act. Regardless of hicle theft, and arson. These crimes, which account for
one's preferred criminological theory, the assessment about a fifth of all arrests in the United States, are
of crime and delinquency is consistent with behav- combined into a Crime Index that is then published as a
iorists' emphasis on observable conduct. How one de- summary of crime trends in the country (Table 1).
Table 1. FBI Index of Crime: 1980-1986

Murder and Motor
Crime nonnegligent Forcible Aggravated Larceny- vehicle
Year index total manslaughter rape Robbery assault Burglary theft theft Arson a
1980 13,408,300 23,040 82,990 565,840 672,650 3,795,200 7,136,900 1,131,700

1981 13,423,800 22,520 82,500 592,910 663,900 3,779,700 7,194,400 1,087,800
1982 12,974,400 21,010 78,770 553,130 669,480 3,447,100 7,142,500 1,062,400
1983 12,108,600 19,310 78,920 506,570 653,290 3,129,900 6,712,800 1,007,900
1984 11,881,800 18,690 84,230 485,010 685,350 2,984,400 6,591,900 1,032,200
1985 12,430,400 18,980 87,670 497,870 723,250 3,073,300 6,926,400 1,102,900
1986 13,210,800 20,610 90,430 542,780 834,320 3,241,400 7,257,200 1,224,100
Note. From Uniform Crime Report by FBI, 1987, Washington, DC: U.S. Government Printing Office. Reprinted by permission.
aSufficient data not available to estimate totals for this offense.
Despite its status as the country's official crime sta- changes in behavior associated with changes in rein-
tistic, the UCR has been criticized on several grounds. forcement contingencies. Furthermore, studies of in-
Because it counts only incidents known to the police, it mates' receptivity toward such interventions sug-
underestimates the actual incidence of crimes, and al- gested they found them generally favorable (Ayllon,
most as surely underestimates certain offenses (rape, Milan, Roberts, & McKee, 1979; Wilkinson & Rep-
family assaults) more than others (murder, auto theft). pucci, 1973). Finally, a survey of 203 psychologists
Other difficulties include inconsistencies in the way whose primary employment was in correctional in-
different police departments define certain criminal stitutions found that 75.8% were in favor of behav-
events, political motivations to underreport or over- ioral procedures (Clingempeel, Mulvey, & Reppucci,
report crimes, and changes in police methods that re- 1980).
flect increased or decreased detection of crimes rather However, a wealth of problems began to disturb this
than real fluctuations in criminal activity. Victim sur- climate and ultimately led to the reduction or elimina-
veys, self-reports of crime, and unobtrusive measures tion of many institutional behavior modification pro-
of crime are intended to overcome one or more of the grams. Reppucci and Sanders (1974) identified eight
UCR problems, but they each have their own deficien- problems they encountered while implementing a be-
cies that are serious enough to prevent any of them havioral program for juveniles that are representative
from replacing the UCR, in the near future, as the of the difficulties encountered in the field, including
major system of crime quantification. institutional constraints, external political and eco-
nomic pressures, limited supplies and personnel, and
the often deleterious methodological compromises
Institutional Programs
caused by these influences. Additionally, Reppucci
Milan and Long (1980) referred to behavioral ap- and Sanders cited staff resistance in adhering to behav-
proaches to crime and delinquency as behavioral psy- ioral principles, inadequate understanding of or op-
chology's "last frontier." If so, behavior modification position to behavioral terminology, staff concep-
programs in closed institutions for adult and juvenile tualizations of program activities by their label rather
offenders are at the far reaches of this final frontier, for than by their behavioral function, and staff perceptions
despite advances that have been made, a sense offrus- that experimenters were inflexible and dictatorial.
tration and unfulfilled promise now prevails in this Although many of these factors were instrumental in
area. In this section we trace the history of behavioral disrupting or eliminating institutional programs, the
institutional programs and provide an overview of the most problematic attacks have taken the form of legal
procedures utilized. challenges. For example, the infamous Special Treat-
ment and Rehabilitative Training (START) program, a
History and Developme~t. Riding the crest of behavioral rehabilitation program for aggressive
the applied behavioral research wave of the mid- federal inmates (Levinson, 1974), was sued by the
1960s, ambitious investigators began behavioral American Civil Liberties Union (ACLU) on several
programs with institutionalized offenders, based on grounds, including the use of coercive strategies for
their confidence that the basic tenets of behaviorism achieving inmate compliance. Despite the fact that the
would generalize to these new populations. If criminal program was ultimately shut down by the Federal Bu-
behavior was a learned phenomenon, then it could be reau of Prisons during litigation, questions remain as
unlearned, especially in a closed environment where to whether the standard correctional program that re-
the antecedents and consequences of such behavior placed it might not be even more coercive. Several
could be controlled with precision. other programs have met similar fates in response to
As a consequence of this optimism, institutional media and professional criticisms, judicial inquiries,
programs flourished, and many studies in the late or inmate rebellion (Geller, Johnson, Hemlin, & Ken-
1960s and early 1970s showed statistically, and in nedy, 1977; Kennedy, 1976; Trotter, 1975).
many cases clinically significant, short-term im- Perhaps as a consequence of these concerns, re-
provement in reducing undesirable inmate behaviors search interest in institutional behavioral programs has
and increasing desirable behaviors (Milan, 1987b). also diminished. Very few studies have been published
For example, despite many methodological limita- in the 1980s, which led Milan (1987b) to conclude
tions, all of the 20 institutional programs reviewed by "this area will soon be in the unique position of having
Davidson and Seidman (1974) indicated substantial generated more reviews of programs than programs for
review" (po 215). In light of the available reviews of ders. For adults, six token economies were described
this literature (Braukmann & Fixsen, 1975; Brauk- in detail: (l) the Walter Reed project for soldiers with
mann, Fixsen, Phillips, & Wolf, 1975; Burchard & "character or behavior disorders" (Boren & Colman,
Harig, 1976; Burchard & Lane, 1982; Davidson & 1970), (2) the previously mentioned START project at
Seidman, 1974; Geller et aI., 1977; V. S. Johnson, the Medical Center for Federal Prisoners in Spring-
1977; Kennedy, 1976; Milan, 1987a,b;Milan&Long, field, Missouri (Levinson, 1974), (3) Virginia's Con-
1980; Milan & McKee, 1974; Musante, 1975; Nietzel, tingency Management Program (Geller et al., 1977),
1979; Sandford & Bateup, 1973; Stumphauzer, 1981), (4) the Patuxent program (Trotter, 1975) (5) Ohio's
we cite only representative examples of the behavioral Junction City Treatment Center (McNamara & An-
techniques that have been applied to offenders. drasik, 1977), and (6) the Cellblock Token Economy in
Alabama, which was the most carefully evaluated pris-
Techniques and Methodological Issues. In- on token economy to date (Milan, 1987b; Milan &
stitutional programs for offenders have employed a McKee, 1974).
variety of behavioral techniques, ranging from Among several shortcomings, lack of specificity in
positive reinforcement (Burchard, 1967; Tyler, 1967) or objections to the choice of target behaviors was a
and negative reinforcement (Smith, Hart, & Milan, significant problem in many institutional token econo-
1972; Smith, Milan, Wood, & McKee, 1976) to so- mies. Targets often were vaguely defined or reflected
phisticated token economies (D. F. Johnson & Geller, only superficial examples of the three general classes
1973; McNamara & Andrasik, 1977; Milan & McKee, of target behaviors summarized by Burchard and Lane
1974) and differential reinforcement of other behavior (1982): educational behavior, compliance with institu-
(DRO) (Allison, Kendall, & Sloane, 1979; Ayllon et tional rules of conduct, and delinquent or disruptive
al., 1979). In addition, time-out (G. D. Brown & behavior.
Tyler, 1968), response cost (Bassett & Blanchard, Another major concern with prison token econo-
1977), and social skills training (D. H. Kolko, Dorsett, mies was the lack of meaningful outcome data. The
& Milan, 1981) have been used with adult and juvenile majority of reports provided no follow-up results, and
populations. Although each of these behavioral pro- those few who did found mixed results. For example,
cedures has been used as an isolated intervention, they two sets of investigators reported decreased recidivism
have often been combined with each other to form a rates for inmates who completed an institutional be-
presumably more powerful intervention package. havior modification program (H. L. Cohen & Fil-
Four types of institutional programs deserve special ipczak, 1971; Jenkins et al., 1974). Conversely, two
mention. First, several early programs concentrated on additional studies noted the reverse-higher rates of
developing academic skills and promoting educational recidivism at follow-up for experimental subjects (Fer-
attainments in inmates by using programmed instruc- dun, Webb, Lockard, & Mahan, 1972; R. R. Ross &
tion and contingency management. McKee (1964) and McKay, 1976).
his associates (Clements & McKee, 1968) pioneered These conflicting outcomes were confounded fur-
the use of programmed instruction at the Draper Cor- ther by the fact that random assignment of inmates to
rectional Center in Alabama with considerable success conditions was rarely feasible. Two studies, however,
(Milan et al., 1974). Partial replications and exten- were able to use random assignments: the Walter Reed
sions of this work (Bassett, Blanchard, Harrison, & program (Colman & Baker, 1969) and the Karl Holton
Wood, 1973; Bassett, Blanchard, & Koshland, 1975) school for juveniles in California (Jesness & DeRisi,
also proved effective in increasing target behaviors but 1973). Whereas 69.5% of the soldiers in the token
lacked data that demonstrated generalization to non- economy at Walter Reed had successful outcomes,
institutional environments. there were only 28.3% successes in the control group
A second type of institutional program is the prison at follow-up. In contrast, no difference was noted be-
token economy, some form of which was used by more tween juveniles who completed the Karl Holton school
than 20 states in the mid-1970s (Opton, 1974). Now and a control group who underwent transactional anal-
largely a relic of that not-too-distant past because of ysis. Both samples had 12- and 24-month recidivism
legal challenges, prison token economies were oper- rates of 32% and 48%, respectively.
atedforbothjuvenile{H. L. Cohen & Filipczak, 1971; A third category of institutional programs involves
Ingram, Gerard, Quay, & Levinson, 1970; Jesness & training offenders in a variety of social skills presumed
DeRisi, 1973; lYler & Brown, 1968) and adult offen- or demonstrated to be deficient among delinquents and
criminals (Freedman, Rosenthal, Donahoe, Schlundt, effects fade quickly when the interventions are termi-
& McFall, 1978; Marshall & Barbaree, 1984; Over- nated. Fifth, with all aversive control procedures,
holser & Beck, 1986). Examples of social skill training harmful side effects must be monitored carefully and
interventions include anger control (Kaufman & minimized at all costs. Finally, despite their mixed
Wagner, 1972; D. H. Kolko et at., 1981), assertion success rates, prison token economies have brought
training (Shoemaker, 1979), heterosocial skills (Quin- about significant positive effects with both adult and
sey, Chaplin, Maguire, & Upfold, 1987) and positive juvenile offenders, and could hold promise for the fu-
interpersonal skills (Ollendick & Hersen, 1979). Al- ture if their frequently complicated legal status could
though this approach appears promising, we do not be remedied.
know what effect such programs have on recidivistic A problem in all behavioral institutional programs is
conduct or even on social skills outside of the institu- the lack of generalization of positive effects following
tions in which training was conducted. release of offenders to the community. Of course, gen-
Although these more traditional behavioral tech- eralization is better when treatments are delivered in an
niques have not been free from criticism or controver- environment similar to that in which the desired behav-
sy, they have . ,ot engendered as much opposition as iors are expected. The logical extension of this argu-
aversive procedures, the fourth category of institu- ment is that offenders should be treated in community
tional programs. Aversion therapies have been most settings whenever possible, and we discuss this prefer-
often used to control sexually deviant, unmanageably ence for community settings in the next section. How-
aggressive, or pervasively uncooperative behaviors. ever, not all offenders are suitable for community
Although not widely reported, aversive procedures are placement. A "next best" step would be to ensure that
undoubtedly used at a greater rate than the existing treatments in institutions introduce contingencies that
literature would suggest. Those studies reporting aver- are applicable to the "real world." This could be facili-
sion therapies have employed such procedures as in- tated by decreasing the use of aversive and externally
jections of a neuromuscular blocking agent (suc- controlling procedures as much as possible and by in-
cinylcholine) followed by verbal warnings to decrease creasing strategies that build offenders' internal con-
unacceptable behavior (Reimringer, Morgan, & trols. Such interventions could include instruction in
Bramwell, 1970; Spece, 1972), electric shock paired decision making, problem solving, social skills, and
with slides of sexually deviant stimuli (Quinsey & cognitive restructuring (Platt & Prout, 1987).
Marshall, 1983), and covert sensitization accom- Before initiating further behavioral research with
panied by exposure to a noxious-smelling chemical institutionalized adults and juveniles, investigators
(Levin, Barry, Gambaro, Wolfinsohn, & Smith, should weigh carefully several factors we have dis-
1977). Many of these techniques are hard to justify cussed. Institutional, political, and methodological
from a theoretical perspective because of the high obstacles will remain formidable deterrents to working
probability of unwanted side effects and failures of with this population. Yet we must not overlook the
desired effects to generalize. In addition, vociferous great need for renewed interest in applied institutional
criticisms on moral, legal, and ethical grounds have research. Despite our best efforts to divert offenders to
reduced the use of extreme aversive therapies in alternative settings, there will still be a large institu-
prisons. tional criminal and delinquent population in the fore-
Although it is difficult to isolate the relative effec- seeable future. Although the literature to date does not
tiveness of individual techniques in institutions, some allow us to conclude institutional behavioral ap-
general conclusions have been drawn by Milan proaches are consistently effective, there is evidence
(l987a,b). First, positive reinforcement strategies they are beneficial under certain conditions. If we are
have consistently shown potential for rehabilitation ultimately successful in isolating the conditions for
and management of unwanted behaviors. Second, reliably effective institutional treatment, behavioral in-
negative reinforcement, if perceived favorably by interventions will have an important role to play.
mates, is beneficial, but has shown negative side ef-
fects if applied in a coercive manner. Third, punish-
Community Programs
ment has not been systematically applied in behavioral
institutional programs, but holds promise as a supple- The community is championed by almost all re-
ment to other procedures if presented humanely. viewers of behavioral corrections as the preferred set-
Fourth, time-out and response cost strategies have ting of intervention. Within the "community," there
proven effective for control of aggression, but their are three types of behavioral interventions that have
been employed and evaluated. First, there is nonresi- (Epstein & Peterson, 1973), and aversion therapy (Kel-
dential behavior therapy, which refers to an assort- lam, 1969) have been reported in case-history studies
ment of treatment techniques applied to diverse types of offenders charged with theft. There have also been
of offenders, who, often in lieu of being imprisoned, reports describing nonresidential behavioral pro-
undergo psychological treatment for their misbehavior grams, typically in the form of social skills training
or for a disorder that contributes to the misbehavior. and anger control, for assaultive offenders (Foy, Eisler,
Second, there are group homes, which are community- & Pinkston, 1975; Frederiksen, Jenkins, Foy, & Eisler,
based residences housing a small group of delinquents 1976).
whose lives in the home are structured around a set of Any conceptualization of crime and delinquency
carefully specified contingencies. Finally, there are must consider the relationship of alcohol and drug
probation and parole, the main systems for communi- abuse to criminal behavior. This relationship manifests
ty corrections in this country, accounting for more than itself in at least two ways. First, there are several alco-
75% of the offenders in our correctional systems (U. S. hol and drug-related crimes in and of themselves (e.g.,
Department of Justice, 1982). drunken driving, possession of illegal substances) that
command enormous resources from the criminal jus-
Nonresidential Behavior Therapy. Nonresi- tice system. For example, in 1986, about one third of
dential behavior therapy has been used infrequently the 12.5 million arrests in the United States were for
with offenders, especially adult criminals. There are drug- or alcohol-related crimes (FBI, 1987). Second,
several reasons why it is not an intervention of choice, alcohol and drug abuse are associated with increased
including demands that the public be protected from rates of serious crimes. There is a strong relationship
dangerous persons, difficulties in forming therapeutic between illegal drug use and property crimes (Ball,
relationships with offenders, and the ethical and Shaffer, & Nurco, 1983), and it has been estimated that
clinical difficulties involved in coercive therapy one-third to one-half of all felons were under the influ-
(Nietzel, 1979). At the same time, when noninstitu- ence of alcohol when they committed their crimes
tional therapy is considered, behavioral techniques (Kittrie, 1971). Because of these factors, prevention,
have often been employed because their focus on time- control, and/or treatment of drug and alcohol abuse
limited treatment and overt target behaviors is more must be included in any comprehensive social policy
compatible with criminal rehabilitation than most al- on crime and delinquency in this country. Behavioral
ternative approaches. For the most part, the quality of interventions for drug and alcohol abuse have been
research on these interventions lags behind other areas employed frequently in community as well as residen-
of behavior therapy. Case histories predominate; com- tial settings, and their use will have continued rele-
parisons to other treatments are infrequent; when com- vance for all aspects of the criminal justice system. A
parisons are attempted, random assignment is seldom review of this area cannot be accomplished in this
possible; multichannel assessments are not attempted chapter; however, useful surveys can be found in Mil-
or are beyond the scope of most investigations. ler and Hester (1986), Nathan and Skinstad (1987),
Most examples of "outpatient" behavioral treat- Sobell, Sobell, and Nirenberg (1988), and Stitzer and
ment of offenders have been with sex offenders. Ini- McCaul (1987).
tially, these treatments relied on aversive methods, but
more recent programs have become increasingly diver- Group Homes. Of all the behavioral approaches
sified and include heterosocial skills training, sex edu- employed with juvenile offenders, none has been as
cation, cognitive therapy, and techniques to increase widely used and researched as group homes. Group
nondeviant sources of arousal (Abel, Becker, & Skin- homes are community-based residential structures typ-
ner, 1985). The specific targets of these interventions ically housing 4 to 12 delinquent teenagers. Although
have ranged from such nuisance offenses as fetishes the residents engage in a structured slate of activities
(Marks, Gelder, & Bancroft, 1970) and exhibitionism with staff and live in the facility, they participate in
(Abel, Levis, & Clancy, 1976; Wickramasekera, activities outside the group home as well. Such pro-
1972) to acts of pedophilia (Marshall, 1973; Quinsey, grams may include enrollment in public schools, part-
Chaplin, & Carrigan, 1980), rape, and sexual aggres- time employment, and home visits or outings with par-
sion (Abel, Blanchard, & Becker, 1978). ents or other relatives.
Nonsexual offenses have also been the targets of The most systematically developed and most often
behavior therapy on a nonresidential basis. Desensi- replicated model for juvenile group homes is the
tization (Marzagao, 1972), self-control techniques Teaching-Family model, initially developed by re-
searchers at the University of Kansas in the 1960s functioning productively and lawfully in the future
(Wolf, Phillips, & Fixsen, 1972). James et at. (1983) (Braukmann, Kirigin, & Wolf, 1980).
reported there were approximately 200 Teaching-Fam- Beginning with the first Teaching-Family group
ily group homes in operation in the United States, and home (Achievement Place in Lawrence, Kansas) and
the model has been attempted in other countries as well continuing in subsequent replications, one of the core
(Yule & Brown, 1987). In this section, we focus pri- treatment elements has been a token economy in which
marily on the Teaching-Family model, outlining the residents earn points for appropriate behavior or lose
basic elements of the program and common treatment points if they behave inappropriately. Earned points
strategies. Finally, after addressing outcome studies on are exchanged for a variety of reinforcers, including
Teaching-Family treatment efficacy, we broaden our money, television privileges, or special activities.
perspective and include a review of a recent meta- Various reports have shown these contingency man-
analytic study that examined the effectiveness of var- agement programs to increase the rate of desired target
ied behavioral approaches with juvenile offenders. behaviors, such as academic proficiency, following di-
A Teaching-Family group home houses an average rections, group home maintenance, and good behavior
of six youths, and is staffed by a married couple re- outside the home, and to decrease aggressiveness
ferred to as "teaching parents," who have received (Bailey, Wolf, & Phillips, 1970; Kirigin, Phillips, Fix-
extensive training and supervision in Teaching-Family sen, & Wolf, 1972; Liberman, Ferris, Salgado, & Sal-
treatment strategies, plus general instruction in social gado, 1975; Phillips, 1968; Phillips, Phillips, Fixsen,
skills, juvenile case management, and other topics. & Wolf, 1971).
Teaching parents participate in a wealth of liaison ac- Associated with the token economies, Teaching-
tivities with courts, schools, families, and social ser- Family group homes have employed two basic govern-
vice agencies in addition to their role as primary treat- mental systems, as outlined by Braukmann and Wolf
ment coordinators in the group home. Group home (1987). First, a "peer manager" system involves elec-
residents, who are typically between 12 and 17 years tion of one resident as a manager by a vote of group
old, are referred to the group home by the courts after home members. This manager has the authority to give
repeated involvement with the juvenile justice system. and take points from the other residents; however, the
The average length of treatment is between 6 months manager also participates in the token economy pro-
and 1 year. gram and is subject to its guidelines. The second gov-
Group homes are located in residential neigh- ernmental system employs a "family conference"
borhoods and in "campus" settings, contiguous to sev- model in which teaching parents and residents meet
eral other group homes. All Teaching-Family homes daily to discuss problem-solving skills, set rules, and
are supervised by trainers from a regional training cen- plan treatment programs and behavioral contingen-
ter approved by the National Teaching-Family Asso- cies. These systems, which allow group home mem-
ciation. Homes receive funding from both public and bers to share in the responsibility for treatment and
private sources; accordingly, they may have local program issues, are effective in increasing the youths'
boards of directors staffed by community members or satisfaction with their milieu (Fixsen, Phillips, &
agency advisors from sponsoring private organizations Wolf, 1973; Phillips, Phillips, Fixsen, & Wolf, 1973).
(Braukmann & Wolf, 1987). Another hallmark of the Teaching-Family program
The Teaching-Family group home draws on classic is its explicit set ofteaching criteria. In brief, the for-
behavioral conceptualizations that behavior is a prod- mal educative components of the program include spe-
uct of learning history, current reinforcement patterns, cific descriptions and demonstrations of appropriate
and genetic characteristics. Therefore, interventions and inappropriate behaviors, rationales for behaving
with delinquents attempt to change well-learned mal- appropriately that stress natural consequences, and su-
adaptive patterns of behavior by teaching and reinforc- pervised behavioral rehearsal with feedback and rein-
ing prosocial behaviors. Emphasis is placed on main- forcement (Braukmann, Ramp, Tigner, & Wolf,
taining educational programs and treatment environ- 1984). Additional components of Teaching-Family
ments that have a large, varied number of positive group home treatment programs include extensive
reinforcers. Practical skills training in interpersonal staff training through a year-long series of workshops,
relations, family living, and community living is also in-service progmms, and staff performance ratings by
stressed, with the intent of giving group home" gradu- trainers and consumers (Braukmann, Fixsen, Phillips,
ates" a foundation in the basic skills necessary for & Wolf, 1975), and emphasis on developing positive,
CHAPTER 2S • CRIME AND AGGRESSION 531
mutually supportive relationships between youths and al. (1987) discovered that, in all but two studies, the
staff (Solnick, Braukmann, Bedlington, Kirigin, & intervals included zero and ranged into negative values
Wolf, 1981). for all measures except pre-post comparisons of social
Early outcome studies showed significant improve- behaviors and experimental versus control com-
ment during treatment for Treatment-Family youth on parisons of program behavior. As was the case with
academic performance and rate of alleged offenses, group homes in general, recidivism was not positively
but these effects were not maintained at follow-up (R. related to behavioral treatments. Gottshalk et al.
J. Jones & Timbers, 1982; Kirigin, Braukmann, At- (1987) concluded that their meta-analysis suggests
water, & Wolf, 1982). Results from a more compre- "no substantial outcome evidence exists for the
hensive evaluation, comparing 354 juveniles in 26 efficacy of behavioral techniques in affecting violence
Teaching-Family homes and 363 youths in 25 com- and antisocial behavior as represented by juvenile of-
parison group homes in 10 states were reported by R. fenders" (p. 418).
R. Jones, Weinrott, and Howard (1981), who found
that experimental homes had significantly higher con-
sumer satisfaction ratings, were more cost-effective, Probation and Parole. Although they are both
and elicited better academic performance than the con- examples of community corrections, probation and pa-
trol facilities. No difference between groups was noted role differ in several respects. Probation, which is
on measures of self-esteem or delinquency, both dur- about six times more frequent a disposition than pa-
ing and after treatment. Additional studies have con- role, is administered by judges when they suspend a
firmed this same trend: Teaching-Family youths im- prison sentence and place the defendant on probation
prove significantly during treatment on behavioral and for a specified period or when they postpone imposing
academic measures in comparison to control samples, the sentence contingent on the offender's meeting cer-
but improvement is not maintained after the youths tain conditions of probation. Probation is a frequent
leave the program (Braukmann, Bedlington, et al., sentence for juveniles, misdemeanants, and some non-
1985; Braukmann, Wolf, & Kirigin Ramp, 1985); at dangerous first-time felons (Carney, 1977).
posttreatment, group home youths are offending sub- Parole has been defined as "a form of conditional
stantially above normative levels. release of the prisoner from the correctional institution
In an attempt to measure the long-term effectiveness prior to the expiration of his sentence" (Tappan, 1960,
of all types of behavioral interventions with juvenile p. 709). Parole is an executive rather than a judicial
offenders, Gottshalk, Davidson, Mayer, and Gen- responsibility and is usually administered by special
sheimer (1987) performed a meta-analysis of 25 stud- parole boards, commissions, or agencies affiliated
ies conducted with delinquents between 1967 and with correctional departments. The average state pris-
1983. To be included in the analysis, studies had to (1) oner has about a 70% chance of being paroled (N. P.
include follow-up assessment outside the treatment Cohen & Gobert, 1983).
setting; (2) include only "official" delinquents; and (3) Probation and parole are being criticized from sever-
provide specific descriptions of the behavioral pro- al directions as part of a more general attack on the
cedures used. A summary of the 25 studies indicated criminal justice system. Several jurisdictions have
that on the average, 78% of the subjects were males, passed statutes that either deny probation to offenders
with an average age of 15.7 years. Interventions were who once could receive it or that reduce court discre-
primarily community-based (57%) as opposed to in- tion in assigning offenders to probation. Objections to
stitutional (43%). Eighty percent of the studies used parole have been even more vigorous, and some states
positive reinforcement, 57% used token economies, have eliminated it completely while others have cur-
and 50% employed behavioral contracting and model- tailed it considerably (Nietzel & Himelein, 1987a).
ing/role-playing. Behavioral group homes were repre- Both systems suffer from numerous deficiencies and
sented in this sample (e.g., Kirgin et ai, 1982; excesses, but both are likely to stay part of the correc-
Weinrott, Jones, & Howard, 1982). tional scene because a large reduction in either disposi-
Results of the meta-analysis indicated that effect tion would increase the need for new prison construc-
sizes were positive for recidivism, program behavior, tion, a politically very unpopular proposal. Behavioral
academic performance, social behavior, and overall technology is well-suited to the needs of both systems
effectiveness. However, by examining the confidence and has shown promise in the hands of trained and
intervals surrounding these effect sizes, Gottshalk et motivated staff, as we discuss below.
Probation. The initial behavioral probation project by Polakow and Doctor (1974) of 26 adult proba-
was Tharp and Wetzel's (1969) Behavior Modification tioners, most of whom had been convicted of drug-
in the Natural Environment, in which the authors ap- related crimes. The project consisted of three gradu-
plied a "triadic" model of intervention to 77 "pre- ated contingency phases.
delinquent" children, ages 6 - 16. Target behaviors In the first phase, probationers earned credits for
ranged in severity from noncompliance to truancy and weekly meetings with their probation officers. Ac-
stealing. Each participant was assigned to a behavioral cumulation of a required number of points allowed
consultant, who, in conjunction with a supervisory participants to move to Phase 2, where points were
psychologist, was responsible for developing a treat- earned for attendance at group meetings devoted to
ment plan. Interventions were then implemented mutual support and self-correction of problem behav-
through "mediators," who were persons of impor- iors. Phase 3 required probationers to execute a written
tance in the youth's school, family, social, or occupa- contract with their supervisor that specified indi-
tional milieu. vidualized target behaviors that needed improvement.
Single-subject designs were used to evaluate each Successful completion of contracted behaviors earned
participant's treatment. Averaged across all youths, predetermined reductions in the remaining probation
nearly 90% of target behaviors were reduced to one time.
half or less of baseline levels. About 15 % of the prob- Participants' performance during a previous period
lem behaviors were eliminated completely. Mainte- of traditional probation was compared to the con-
nance of these effects was not adequately tested, but tingency contracting period. The contingency program
there was evidence of generalization of effects to non- was associated with significantly superior outcomes in
treated problems. On the less positive side, police re- all four areas assessed: number of new arrests, number
cords indicated that 26 of the 77 subjects committed of probation violations, proportion of time employed,
one or more offenses after treatment began, the major- and attendance at scheduled probation meetings. The
ity of these occurring prior to termination. Only five rearrest data were particularly impressive because sys-
subjects committed offenses during the 6-month fol- tematic contingencies had not been applied to that tar-
low-up period. Thorne, Tharp, and Wetzel (1967) get. Although there was not a control group or a rever-
demonstrated that the triadic model could be imple- sal phase in the design, contingency contracting was
mented by trained probation officers, whereas Fo and contrasted with an intensive supervision caseload and
O'Donnell (1974) showed that nonprofessional "bud- was once again found superior on three of the four
dies" could be trained to be effective mediators. dependent measures: fewer probation violations,
Following this seminal demonstration by Tharp and fewer arrests, and more time employed.
Wetzel (1969), five categories of behavioral tech- 2. Social skills training. Spence (1982) has sug-
niques have been applied to probation and parole. We gested that youths who are unable to obtain social,
briefly review each of these categories next. academic, and financial success because of poorly de-
1. Contingency contracting. The most common be- veloped interpersonal skills are at risk for seeking
havionH technique with probationers has been con- these goals through illegal means. Training delin-
tingency contracting. This approach is popular be- quents in social skills should therefore be an effective
cause it requires specification of goals and spells out component in probation (Stumphauzer, 1986). Based
consequences for success and failure, two aspects of on Alexander's (1973) finding that families of juvenile
probation case management that have always frus- offenders communicate in maladaptive ways, Alex-
trated probation officers. Even though it is clear that ander and Parsons (1973) investigated, in a classic
probation officers can be taught behavior modification study, the effects of family-oriented interpersonal
principles effectively (Burkhart, Behles, & Stump- skills training on juvenile delinquents, several of
hauzer, 1976), high-quality implementation of these whom were on probation. Training was aimed at fami-
principles in the field is less likely (Jesness, 1975). ly patterns of communication; families were instructed
Contracting has been used most extensively with drug to divide communication more equally among family
abusers, although there is at least one published eval- members, to seek clarification more often, to improve
uation of it with a probated child abuser (Polakow & their negotiation skills, and to deliver more positive
Peabody, 1975) and one with a mixed group of juvenile feedback. Families receiving this training interacted in
first offenders (Fitzgerald, 1974). One of the best ex- a more positive manner following this intervention,
amples of this technique was a well-controlled study becoming more similar to normal families in commu-
nication styles. Benefits of this treatment were com- attendance and academic grades associated with the
pared to those gained in three comparison groups. Re- use of the paradoxical injunctions. Contingency con-
cidivism for participants at an l8-month follow-up was tracts were then used to maintain these gains.
26% in the communication skills group, 47% in a cli- R. A. Brown (1980) contrasted a IS-hour conven-
ent-centered group, 73% in an analytically oriented tional educational course with a IS-hour course in con-
group, and 50% in a no-treatment control group. How- trolled drinking for a group of New Zealand drunken
ever, behavioral family therapy has tended to be less drivers placed on that country's version of probation.
effective with families of delinquents who were "hard- Twenty participants in the controlled-drinking course
er core" than the Alexander and Parsons subjects learned how to monitor their blood-alcohol levels and
(e.g., Weathers & Liberman, 1975). practiced controlled drinking in a simulated lab. Twen-
In contrast to Alexander and Parson's emphasis on ty subjects in the conventional course listened to lec-
the family, Hazel, Schumaker, Sherman, and Sheldon- tures, watched films, and then discussed topics on the
Wildgen (1982) aimed their skills training directly at effects of alcohol and drinking and driving. Twenty
juvenile offenders. Their program, delivered in a control subjects reported to the Periodic Detention
group format, consisted of instruction in eight interper- Center but received no special education. Drivers in
sonal skills, including giving and accepting feedback, both treatments showed significant decreases in the
resisting peer pressure, negotiation, and problem solv- incidence of drinking-and-driving episodes at a 12-
ing. An evaluation with a multiple-baseline design month follow-up. Only those drivers who received the
suggested substantial improvements in all criteria. Re- controlled-drinking course decreased uncontrolled
cidivism data were not collected, but self-ratings of drinking.
satisfaction with the program and of social competence 5. System-level interventions. One interesting sys-
were very favorable. tem-level approach to probation was California's pro-
3. Covert sensitization. Maletzky (1980) compared bation subsidy program begun in 1966 where prin-
the effectiveness of 24 weeks of covert sensitization ciples of contingency management were applied on a
("assisted" by exposure to foul odors) in the treatment large scale. Subsidy is a system in which the state pays
of 55 pedophiles and exhibitionists, 62% of whom counties for each offender placed on probation rather
were undergoing treatment as a condition of probation. than incarcerated in a prison. Initially, the amount of
A wide variety of adjunctive techniques (masturbatory payment was based on the cost of confinement times
reconditioning, cognitive therapy) were employed in the amount by which a county reduced its commit-
addition to the covert sensitization, and aversion ments from a pre-1966 baseline. Although the pro-
"booster" sessions were employed every 3 months for gram was originally viewed as a success and several
3 years. Outcome data, consisting of self-reports, peer other states introduced their own versions of subsidy,
reports, legal records, and physiological measures of the increased political conservatism of the late 1970s,
arousal, collected up to 30 months posttreatment, indi- along with uncertainity about whether subsidy resulted
cated that treatment had been successful, even with in more effective rehabilitation, resulted in repeal of
nonvoluntary clients. the original legislation and passage of a more limited
4. Reframing and behaviorally based education. D. program that curtailed offender eligibility and recalcu-
1. Kolko and Milan (1983) used reframing and para- lated the basis for payments.
doxical instruction to treat three delinquents who had
not benefited from more traditional behavioral inter-
ventions. Refrarning consisted of "prescribing the Parole. Behavioral techniques have been used less
symptom" with such comments as the following: "We frequently in parole than in probation. Reasons for this
don't want you to try things you might be too young disparity probably include the reduced enthusiasm for
and immature to handle ... we don't want you to fight rehabilitation on the part of offenders who are complet-
the urge to misbehave since you apparently aren't ma- ing their sentence rather than beginning it, and the fact
ture enough to handle it" (D. 1. Kolko & Milan, 1983, that parolees tend to be older and have a longer, more
p. 657). Although none of these youths was on official serious criminal record than probationers. Two behav-
probation, each had been referred by juvenile court for ioral techniques have received the most attention in the
treatment of antisocial and school problems. Using a parole literature: contingency contracting and training
multiple-baseline design across subjects, D. 1. Kolko in job-finding skills.
and Milan (1983) demonstrated improvements in class 1. Contingency contracting. Contingency contract-
ing for parolees uses similar methods to those pre- terviews; Mills and Walter (1979) demonstrated signif-
viously described for probationers. For example, icantly greater employment and lower recidivism for
Boudin et at. (1974) described a contracting program delinquents nonrandomly assigned to a "behavioral-
for drug offenders, 91 % of whom had been arrested employment" program versus a control group.
and 76% of whom had been convicted of a criminal
offense. Forty-two percent of the subjects were re- Summary. The need for an effective behavior
quired to take part in the program as a condition of their change technology in probation and parole can be an-
parole, probation, or work release from an institution. swered to a large degree with existing behavioral tech-
A sequence of four types of contracts was used that niques. However, whether these techniques are ap-
attempted to individualize treatment goals and con- plied more systematically to probation and parole
tracted consequences as much as possible. For partici- caseloads than they have been in the past depends on
pants to be judged as having positive outcomes, they whether mental health and correctional personnel can
had to demonstrate satisfactory performance in three work together in the following crucial areas (see also
of four criteria: work and school performance, person- Stumphauzer, 1986): (1) bringing caseloads down to
al and social adjustment, drug use, and arrest record. realistic levels, thereby permitting individualized con-
Data were reported on 19 participants who had been in tingency management; (2) clarifying the ethical and
the program for at least 15 days and who had termi- legal issues involved in coercive interventions; (3) re-
nated treatment. Of these persons, six were program storing the public's commitment to rehabilitation as a
graduates and were showing positive outcomes. Elev- goal balanced along side the other correctional goals of
en persons had terminated against staff advice; seven protection, punishment, and deterrence; (4) conduct-
of these terminators were meeting criteria for a ing methodologically adequate evaluation research on
positive outcome, two were classified as negative out- innovative programs; and (5) implementing con-
comes, and the status of the other two was not known. tingencies that encourage professionals to train para-
Two other terminators for "other reasons" were classi- professionals in behavior management skills and that
fied as "negative outcomes." encourage probation and parole workers to use these
2. Job-finding skills. Following the pioneering work skills regularly.
of R. 1. Jones and Azrin (1973), behavior therapists
have attempted job-interviewing skills programs with
Crime Prevention
offenders. Most noteworthy of these projects is the
work of Sharon Hall and her colleagues in San Francis- We focus in this section on primary prevention of
co. Hall, Loeb, Coyne, and Cooper (1981) randomly crime and delinquency, which we define as (1) inter-
assigned 55 probated or paroled heroin abusers to ei- ventions intended to prevent crime by modifying fac-
ther an II-hour behaviorally based workshop on job- tors known to contribute to criminality; and (2) pro-
finding or to a 3-hour information-only workshop. Be- grams designed to promote law-abiding behavior as a
havioral training emphasized role-playing, coaching protection against the development of antinormative
appropriate behaviors, simulated interviews, and vid- conduct. In addition to an emphasis on primary pre-
eotaped feedback. After training, subjects were as- vention, we concentrate on psychological variables
sessed at a simulated interview conducted by em- because those are the variables that psychologists
ployees of a vocational rehabilitation service. know the most about. Concentrating on these variables
Experimental participants were superior to the controls does not mean that biological, sociological, economic,
on specific interview behaviors. At a 12-week follow- environmental, or political influences are unimportant
up, 85.7% of the experimental participants versus 54% in understanding or preventing crime. It simply means
of the controls had ajob. These results were replicated that in terms of psychologists' expertise, there is suffi-
with a sample of methadone-maintenance clients, cient knowledge about etiological factors for crime to
more than 40% of whom were on probation or parole justify the selection of certain goals for preventive in-
(Hall, Loeb, LeYois, & Cooper, 1981). In addition, terventions. Five areas seem promising because, as we
Twentyman, Jensen, and Kloss (1978) reported that a have elaborated elsewhere (Nietzel & Himelein,
mixed group of adult offenders receiving a behavioral 1986), they possess the two components that Cowen
training program were more effective on a mock job (1983) argues are essential to sound primary preven-
interview and tended to obtain employment more tion: a generative base that provides the conceptual
quickly than offenders given money for attending in- rationale for interventions, and an executive base that
implements and evaluates preventive programs. The evidence that children reared in violent homes are at
five areas that we believe hold the greatest potential for risk to become aggressive, abusive, or criminal adults.
preventing crime and delinquency are: The reduction of family violence is therefore a worthy
target for crime prevention.
1. Reductions of spouse and child abuse that have Studies of abusive parents reveal a tendency for per-
been associated with a spectrum of later anti- petuation of an "abused-abusing" cycle of family vio-
social and violent behavior by adults who were lence. In their clinical examinations of 60 child-abus-
abused or who observed domestic abuse as ing families, Steele and Pollock (1968) reported that
children all the abusing parents had histories of having been
2. Development of better parental discipline tech- raised abusively, a relationship that has been fre-
niques in order to improve controls in children quently replicated (e.g., Gelles, 1980; Hunter, Kils-
with faulty impulse control trom, Kraybill, & Loda, 1978). Violence between
3. Development of cognitive, behavioral, academ- spouses also follows a pattern of social inheritance.
ic, and occupational competencies as buffers in Straus et al.(1980) reported that men raised by parents
youth's struggle to cope with various stressors who assaulted each other were three times more likely
and temptations for illegal conduct to hit their own wives than were men raised by non-
4. Modification of environmental opportunities violent parents (see also Rosenbaum & O'leary,
and victim vulnerabilities suspected to be dis- 1981).
criminative stimuli for criminal conduct Children exposed to abusive parents exhibit signifi-
5. Diversion of predelinquents and delinquents cantly more behavior problems, more aggressive con-
from the criminal justice system in order to re- duct and fantasies, and lower social competence than
duce the negative effects of official labeling and nonabused controls (Garbarino, Guttman, & Seeley,
the association with more serious criminals that 1986; George & Main, 1979; Harter, Alexander, &
official processing produces Neimeyer, 1988; Wolfe, Jaffe, Wilson, & Zak, 1985).
Feshbach (1980) maintained that "the best predictor of
juvenile violence is socialization in a family where
Child and Spouse Abuse. The American family violence ... is a characteristic behavior pattern" (p.56).
is a violent institution. Based on a nationwide survey, Anecdotal reports (Baer & Wathey, 1977; Keller &
Straus, Gelles, and Steinmetz (1980) estimated that Erne, 1983) as well as large scale surveys (Alfaro,
14% of American children are abused within their fam- 1977, cited in Newberger, 1982) have suggested high
ilies each year. About one million cases of child abuse rates of delinquency, drug abuse, and violent crime
and neglect are reported to child protection agencies among formerly abused children. Bolton, Reich, and
every year in the United States (Wolfe, Edwards, Man- Gutierres (1977) found that the siblings of abused chil-
ion, & Koverola, 1988). Of course, these figures are dren were also at increased risk for antisocial behavior.
subject to diverse interpretations depending on one's Behavioral interventions have shown promise for
definition of abuse and variations in reporting prac- the treatment of abusive families who usually suffer
tices, but there is a consensus that child abuse is on the from serious, chronic patterns of maladaptive interac-
increase (Wolfe, 1987). Family violence is obviously tions (Herrenkohl, Herrenkohl, & Egolf, 1983). Abus-
not limited to parental abuse of children. Violent being parents tend to (1) have unrealistic expectations of
havior between husbands and wives has been esti- their children, (2) attribute malevolent intentions to
mated to occur in 1.5% of American couples each year their children, (3) become more annoyed when
(Straus et al .• 1980), and estimates ofthe lifetime inci- stressed, and (4) choose violence as a means of resolu-
dence of spouse abuse (where females are the victims tion when they feel unable to control their children's
98% of the time) range as high as 50% of married behavior (Bauer & Twentyman, 1985; Friedman,
couples. Sandler, Hernandez, & Wolfe, 1981; Morton &
Reducing family violence is an important goal for Ewald, 1987). Abuse is then maintained in a violent
two reasons. First, physical assaults against family family because it is reinforced by its short-term conse-
members are serious crimes in themselves that require quences-control of a child's behavior or cessation of
effective intervention from law enforcement and/ or an aversive childhood behavior like crying or fighting.
the mental health system. Second, and of greater im- A basic premise of this model is that abusive parents
portance for our present purposes, there is substantial lack appropriate child management and stress manage-
ment skills. Treatment is aimed at replacing parents' the prevention of child abuse. They suggest crisis inter-
dysfunctional interactions with effective, nonabusive vention services, parent education programs for both
techniques and at improving parents' capacity to cope neophyte and expectant parents, expanded referrals,
with stress. Sandler, Van Dercar, and Milhoan (1978) and they emphasize the need for special social service
explored the efficacy of child management skills train- programs for families at high-risk of violence. In this
ing using a single-subject multiple-baseline design and regard, Wolfe et al. (1988) compared a special behav-
found an increase in healthy management and a de- ioral parent training program to a standard child pro-
crease in maladaptive interactions on the part of moth- tection agency information program for 30 parents
ers. Many of the positive changes were maintained at a identified by a screening instrument to be at risk for
5-month follow-up. Denicola and Sandler (1980) add- child abuse and neglect. Although both groups showed
ed a stress management component to their initial pro- improvements in their child-rearing environments and
gram and reported similar improvements in the use of in their childrens' adaptive behaviors, caseworker rat-
constructive child-rearing practices. Maintenance of ings of parents' abilities to manage their families and
these improvements was demonstrated at a I-year fol- their risks for maltreatment significantly favored the
low-up (Wolfe & Sandler, 1981). Wolfe, Sandler, and families receiving the behavioral training.
Kaufman (1981) included instruction in human devel- Effective prevention of family violence, particularly
opment, child management, and self control for their child abuse, will require that society commit itself to
treatment of abusing parents referred by a child-wel- many system-level changes that extend beyond treat-
fare agency. Sessions were conducted for 2 hours each ment programs for already violent or at-risk families.
week for 8 weeks, and families were given assistance These changes and policies, many of which can be
in the use of new child-rearing techniques. Positive delivered from or enhanced by a behavioral perspec-
changes in parent effectiveness in all areas of training tive, include adequate day-care services (Hunter &
were maintained through a lO-week follow-up, and a Kilstrom, 1979), community development, especially
review of agency records after 1 year revealed no sus- in poverty neighborhoods (Garbarino, 1980), limits on
pected or reported abuse in any family completing the the use of corporal punishment in schools, and suppor-
program. Anger-control techniques, reattribution ther- tive services aimed at parents at risk for abusive behav-
'apy, and direct modification of aversive behavior by ior because they are undergoing a period of special
children are also frequent components in treatments of stress.
child-abusing families (see Morton & Ewald, 1987,
for a review). Effective Discipline Techniques. Family influ-
There are few published studies concerning the ences have long been implicated in the development of
treatment of spouse abuse although experimental study delinquency. For example, Glueck and Glueck (1950)
of violent couples is beginning to yield data with ob- concluded that parents of delinquents tended to be in-
vious relevance for treatment (Margolin, John, & different or hostile toward their sons and described the
Gleberman, 1988). In addition, behavioral marital disciplinary practices of these parents as lax, inconsis-
therapy, to the extent that it concentrates on reducing tent, and punitive (see also McCord, McCord, & Zola,
reciprocally escalating violence that often accom- 1959). Of all the predictors surveyed in Loeber and
panies marital discord, holds promise as an interven- Dishion's (1983) review of delinquency prediction
tion for abusive couples. Lindquist, TeIch, and Taylor studies, composite measures of child-management
(1983) treated abusing couples conjointly in a behav- techniques were found to yield the greatest improve-
iorally oriented program. Assessment of the treatment, ment in the prediction of delinquency. Some investiga-
which included instruction in communication, stress tors have compared the interactions of families with
management, anger control, and problem solving, conduct-disordered children to control families in an
demonstrated that couples were more satisfied with effort to identify differentiating features. This research
their marriages, less angry, aggressive and jealous, suggests that the parents of the conduct-disordered
and more assertive after therapy. No incidents of phys- children express more commands, disapproval, and
ical violence were reported at the end of treatment, but generally negative behavior toward their children than
this improvement was not maintained for all couples at do the controls (Forehand, King, Peed, & Yoder, 1975;
a 6-week follow-up. Lobitz & Johnson, 1975). Alexander (1973) compared
C. 1. Ross and Zigler (1980) and Rosenberg and communication patterns of families of juvenile offen-
Reppucci (1985) have outlined several strategies for ders to families of nonoffenders and found that the
offender families used defensive styles of communica- dered children showed reductions in antisocial behav-
tion more often; they were more silent, exhibited fewer ior of 30% or more. Improvement continued through-
positive interactions, and relied more on judgmental out the 12-month follow-up. A more recent
dogmatism and superiority to change opinions. The evaluation compared improvements gained in the
families of the nonoffenders engaged in more suppor- Oregon program with those gained in an eclectically
tive interactions, characterized by information seek- oriented control group (Patterson, Chamberlain, &
ing, empathic understanding, and equitable divisions Reid, 1982). Children in the Patterson program evi-
of time. denced a significantly greater reduction in antisocial
Patterson (1980) has observed that a majority of behaviors than did children in the comparison group.
parents of antisocial children treated at the Oregon We have already reviewed, in the probation section
Social Learning Center "did not identify with the role of this chapter, the Alexander and Parsons (1973) in-
of parent and were not attached to their children" (p. fluential study of brief behavioral family-systems ther-
81). Patterson's resulting coercion theory is similar to apy. An interesting implication of this approach for
Hirschi's (1969) control theory in that both assume delinquency prevention is that if faulty family interac-
delinquency results from a failure to internalize neces- tion patterns are modified, delinquency in the younger
sary social controls. In Hirschi's framework, attach- siblings of the initially referred youths should be
ment is the central factor in the control system. In lowered because the family system would have be-
coercion theory, the critical variable is parental man- come a more efficient problem-solving unit. Klein,
agement of children. Patterson believes that the so- Alexander, and Parsons (1977) examined the juvenile
cialization of children will be arrested without con- records of the younger siblings in the families that
sistent discipline and management by parents. A were participating in the original study in order to de-
similar theory is proposed by the noted criminologist, termine the incidence of delinquency among these sib-
James Wilson, who believes that, as parents have grad- lings. The results indicated significantly lower sibling
ually lost the assistance of social institutions in con- recidivism rates for the families treated by behavioral
trolling the impulses of their children, they have be- family-systems therapy in comparison to those fami-
come less interested in being parents, therefore the lies receiving client-centered therapy, dynamic treat-
children are presented with more opportunities to ment, or no treatment.
avoid parental control (Wilson, 1983).
The most promising interventions for improving Competence Building. The relationship of vari-
parents' child-management skills have been con- ous cognitive, behavioral, and social competencies to
ducted by Patterson and his colleagues at Oregon and successful adjustment is an important focus through-
Forehand and his group at the University of Georgia out preventive psychology. Special emphasis is given
(Forehand & McMahon, 1981). The Patterson group to the development of crucial coping skills that can
has concentrated on the treatment of the predelin- buffer the negative effects of stress or transition peri-
quent boy, with treatment aimed at the family as a ods and prevent these effects from becoming more per-
unit. The original intervention, developed about 20 manent dysfunctions. In the area of crime and delin-
years ago, consisted of five phases: (1) observation of quency, competence-building programs should be
families in their homes in order to establish base rates most effective as preventive interventions when they
of deviant behaviors, prosocial behaviors, and parent are aimed at the specific problems which at different
techniques, (2) instruction in social learning strat- ages of high-risk populations are most strongly related
egies of child management, (3) instruction in the rec- to delinquency. Among primary school children, the
ognition, tracking, and recording of target behaviors, target should be helping children to develop the cog-
(4) development of contingency contracts and other nitive and behavioral controls necessary for impulse
behavioral techniques to be used in the home, and (5) control and well-regulated interpersonal behaviors.
use of follow-ups after the intervention in order to Among adolescents, the aim should shift to improving
determine the stability of treatment effects (Patterson academic performance that would make it more likely
& Reid, 1973). The overall goal of the program is to that at-risk juveniles stay committed to the conven-
reduce the reciprocal coercion between parents and tional norms of educational achievement. Programs
children that is typical of these families. Patterson intended to enhance occupational and employment
(1974) reported that for an average cost of 31.5 hours skills should have their greatest impact when delivered
of professional time, two thirds of conduct-disor- to young adults.
Cognitive and Behavioral Controls. Spivack and and meeting social expectations. Findings such as
Cianci (1983) reported a cluster of behavioral factors these can help pinpoint the specific skills that indi-
emerging as early as kindergarten that identify chil- vidual at-risk children most require.
dren most vulnerable to delinquency. Children show-
ing this high-risk pattern were rated as significantly Academic Achievement. In their review of delin-
elevated on classroom disturbance, impatience, dis- quency predictors, Loeber and Dishion (1983) listed
respect/defiance, external blame, and irrelevant re- poor academic performance as one of the five variables
sponsiveness. These problems suggest a pervasive dif- with the best predictive validity for official delinquen-
ficulty in such youngsters' ability to conform to cy. Although the literature is consistent on the point
external controls and to modulate their behavior to the that academic difficulties during primary years are not
needs of others around them. Impulse controls are de- powerful predictors of later delinquency, grade point
ficient, as is responsiveness to social and task de- average does become predictive of delinquency around
mands. Impulsive behavior is likely to elicit aversive the age of 15, and dropping out of school is related to
peer responses and critical adult reprisals that, in turn, delinquency and adult criminality (Lane & Murakami,
lead to repudiation of authority. The sequence acceler- 1987). An example of a preventive intervention aimed
ates in a negative direction, resulting in more inten- at academic achievement among adolescents is Bry
sified adult demands for compliance which, in turn, and George's (1980) behaviorally based program. for-
provoke more hostile reactions from the youngsters. ty urban adolescents were randomly assigned to either
Unless broken, this chain of behavior culminates in a control group or a program that (1) provided feed-
increasingly generalized defiance of authority and the back to students and their parents about the students'
type of antisocial behavior that typifies later delin- school performance, (2) rewarded students for appro-
quency. priate academic behavior, and (3) instructed students
A number of investigators have attempted to im- how to earn more points for classroom performance.
prove primary schoolers' problem-solving, social The program lasted 2 years and resulted in improved
skills, and cognitive abilities. Kendall and Braswell attendance and grades for the participants. Follow-up
(1985) described an extensively researched program evaluations confirmed that reduced delinquency was
(see also Kazdin, Esveldt-Dawson, French, & Unis, associated with the intervention up to 5 years after
1987) that combines cognitive retraining and con- termination, although substance abuse was not af-
tigency management to improve the self-control of fected (Bry, 1982).
impulsive elementary 'school children. Spivack and Despite these favorable results, school-based pro-
colleagues (Shure & Spivack, 1982; Spivack, Platt, grams have not generally produced impressive long-
& Shure, 1976) have developed an interpersonal cog- term gains in academic achievement or demonstrable
nitive problem-solving (ICPS) intervention designed prevention of official delinquency. Their effects have
to prevent the dyscontrol pattern found to precede de- been moderate whether they have relied on rather sim-
linquency. In ICPS training, children are taught to ple contracting procedures (e.g., Stuart, Jayratne, &
improve their alternative solution thinking, means- Tripodi, 1976) or have used multifaceted programs
end cognition, and social role-taking ability. How- involving academic training, social skills interven-
ever, the linkage between ICPS and behavioral ad- tions, family therapy, and contracting (Filipczak,
justment has not been as strong as assumed because Friedman, & Reese, 1979).
(1) many research studies have not measured such a
linkage, and (2) the relationship between ICPS and Employment. Glaser (1964) reported that postre-
adjustment is moderated by such factors as demo- lease employment was the best predictor of non-
graphics, age, and IQ. recidivism for offenders. In addition, the relationship
An important accomplishment in social competence between economic indicators and crime has been as-
building is fine-grained analyses ofthe specific social- sumed to be an inverse one, with offense rates highest
cognitive deficits and attributional biases that ag- among the lowest socioeconomic status (SES) classes.
gressive, peer-rejected children show (Asarnow & Tittle, Villence, and Smith (1978) indicated that this
Callan, 1985). For example, Dodge, McClaskey, and inverse relationship is confined to pre-1950 studies
Feldman (1985) discovered that rejected, aggressive with no relationship revealed by data collected in the
children were significantly less competent than adap- 1970s. Seidman and Rapkin (1983) concluded that for
tive children in responding to provocations from peers young adolescents, increases in prosperity are associ-
ated with higher arrest rates, whereas for men in their justice system as possible and to reduce juveniles' con-
20s and 30s the relationship between unemployment tacts with delinquent peers (O'Donnell, Manos, &
and arrests is strongly positive, as traditionally as- Chesney-Lind, 1987). An example of secondary pre-
sumed. Psychologists' attempts to influence em- vention, diversion derives from the belief that official
ployability among underemployed samples have been processing of misbehaving youths produces insidious
confined for the most part to behaviorally oriented effects including the exacerbation of crime. The the-
training programs designed to improve job-seeking oretical underpinnings for diversion are found in label-
and job-interviewing skills. Such programs were pre- . ing theory and socialleaming theory. Deviance is con-
viously described in the earlier section on probation sidered to be a role first enforced on youths by official,
and parole. pernicious labels that is then strengthened by the rein-
forcement patterns established by other delinquents
Situational Crime Prevention. Some crime pre- and the more seasoned offenders to whom youths are
vention can be based on interventions that change the exposed within the criminal justice system.
relationship between the offender, the victim, and the Proponents of diversion praise its flexibility, econo-
crime environment in such a way that opportunities for my, minimization of stigma, and maintenance of par-
crime are reduced. Prevention of this type can be con- ticipants in the community. Critics attack the potential
ceptualized in a behavior-analytic framework. Social coerciveness of the programs and possible jeopardiza-
and physical environments provide numerous anteced- tion of due-process protections. They also claim that
ent cues that set the occasions for criminal behavior diversion programs include a large number of status
and the consequences that follow that behavior. If we offenders who would not "graduate" to more serious
could design environments that make criminal behav- crimes without any intervention, thereby inflating the
ior more difficult and/or increase the costs of commit- appearance of prevention by involving these "false
ting crimes, some criminal behavior could be pre- positives" in the intervention.
vented. Evaluative data on diversion are quite mixed. Meth-
The rationale for situational prevention of crime vic- odological inadequacies have plagued most evalua-
timization has been summarized by Clarke (1983) and tions. Other than for a few exemplary projects, the
by Lewis and Salem (1981) as follows: (1) crime is the effectiveness of diversion is disappointing; it has not
result of opportunities for victimization provided by been shown to lower recidivism significantly
certain physical environments or by certain generally (Lundman, 1976), although the method by which re-
or specifically vulnerable people, all of which can be cidivism is assessed is an important moderator.
conceptualized as discriminative stimuli; (2) crime can Among those characteristics associated with positive
be prevented by decreasing these opportunities; and results are vocationally oriented crisis intervention
(3) the opportunities themselves can be decreased (Shore & Massimo, 1979), use of paraprofessionals
through increasing the probability of surveillance in coupled with an attitude of advocacy on behalf of cli-
the environment or "hardening" specific targets of ents (Davidson, Redner, Blakely, Mitchell, &
crime, training victims with general or specific vul- Emshoff, 1987), disruption of delinquent social net-
nerabilities to become less susceptible to victimiza- works (O'Donnell et aI., 1987), and behavioral inter-
tion, organizing communities and neighborhoods to ventions including contingency contracting (Davidson
strengthen their means of social control, and eliminat- et al., 1987) and family treatment (Klein et al., 1977).
ing any widespread portrayals of groups of people that
might increase their risk of victimization. Environ-
mental target hardening and training of victim protec- Summary
tion skills are two strategies especially well-suited to
behavioral interventions, and there are preliminary re- Rehabilitation for delinquents and adult criminals
sults in both areas that show promise (see Nietzel & ranges across a continuum that spans institutionaliza-
Himelein, 1987b for a review). tion, community-based corrections such as probation
and parole, and strategies aimed at preventing crimi-
Diversion. Diversion is intended to find non- nality. In each of these contexts, behavioral techniques
judicial, community-based, short-term alternatives for have been moderately successful although not reliably
handling predelinquent and delinquent youths. The superior to other approaches. Within institutions, be-
goals are to bypass as much formal processing by the havioral programs have produced significant improve-
ments in specific targets, but their failure to achieve Bandura, A. (1973). Aggression: A social learning analysis.
generalized, long-term effects and a host of legal ob- Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. (1976). Social learning analysis of aggression. In E.
jections, some well-conceived, some not, have re- Ribes-Inesta & A. Bandura (Eds.), Analysis of delinquency
duced their implementation. Behavioral community and aggression (pp. 203-232). Hillsdale, NJ: Lawrence
corrections have often shown promise as initial dem- Erlbaum.
onstrations, but they have seldom been incorporated Bandura, A., & McDonald, F. 1. (1963). The influence of social
reinforcement and the behavior of models in shaping chil-
on a regular, consistent basis in community programs. dren's moral judgments. Journal ofAbnormal and Social Psy-
Finally, behavioral formulations have much to offer in chology, 67, 274-281.
the way of crime prevention, but preventive strategies Bassett, 1. E., & Blanchard, E. B. (1977). The effect of the
absence of close supervision on the use of response cost in a
are hard to evaluate, and it is notoriously difficult for
prison token economy. Journal ofApplied Behavior Analysis,
them to achieve significant improvements over exist- 10, 375-379.
ing alternatives. The distinct challenges in each of the Bassett, J. E., Blanchard, E. B., Harrison, H., & Wood, R.
above settings will have to be confronted if behavior (1973). Applied behavior analysis on a county penal farm: A
method of increasing attendance at a remedial education cen-
modification is ever to realize its full measure as an ter. Proceedings of the 81 st annual convention ofthe American
intervention for crime and delinquency. Psychological Association. Washington, DC: American Psy-
chological Association.
Bassett, J. E., Blanchard, E. B., & Koshland, E. (1975). Ap-
plied behavior analysis in a penal setting: Targeting "free
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CHAPTER 26
Sexual Dysfunction
Joseph LoPiccolo
Treatment of Sexual Dysfunction Notzing (1895), used direct sex education and instruc-
tion in sexual techniques to treat successfully sexual
This chapter will review the history and current status dysfunction.
of behavioral treatment focused on problems of sexual A major breakthrough in our conceptualization of
functioning in heterosexual couples. This type oftreat- sexual dysfunction occurred with the application of
ment, once a secondary component of marital therapy, systematic desensitization to sexual problems. Salter
individual psychotherapy, and sex education, has (1949) and Wolpe (1958) conceptualized sexual dys-
come to be a more-or-less independent type of behav- functions as conditioned anxiety responses to the sexu-
iorally oriented treatment, popularly referred to as al situation. Engaging in a graduated hierarchy of sex-
"sex therapy." ual behaviors while forbidding the goal of orgasm or
erection, sometimes coupled with muscle relaxation,
proved quite effective in many cases. Another behav-
History of Behavioral Approaches to Sexual
ioral technique used in this period was assertion train-
Dysfunction
ing (Lazarus, 1965; Salter, 1949; Wolpe, 1958). In this
"Behavioral approaches" refer to a type of therapy approach, socially and sexually inhibited patients were
in which the therapist actively and directly educates given modeling and behavior rehearsal training to in-
the patient about sexual physiology and sexual tech- crease their communication skills.
niques, restructures maladaptive behaviorpattems and Before the rise of direct "sex therapy" with the pub-
cognitions regarding sexuality, and uses anxiety-re- lication of Masters and Johnson's Human Sexual In-
duction and skill-training techniques to improve the adequacy in 1970, there were two therapists who had
patient's functioning. The history of the application of described very effective quasi-behavioral treatment
behavioral techniques to sexual dysfunction is a long techniques for sexual dysfunction. For treatment of
one that considerably predates the rise of formal behav- premature ejaculation, Semans (1956) described his
ior therapy. In the late eighteenth century, a British technique of repeated pauses during penile stimulation
physician, Sir John Hunter (cited in Comfort, 1965) as being nearly 100% effective. Hastings (1963) de-
described a treatment program for erectile failure that scribed simple retraining programs designed to in-
is very similar to the program described by Wolpe struct couples in effective sexual techniques, such as
(1958) and by Masters and Johnson (1970). At the turn concurrent clitoral manipulations for coitally in-
of the century, hypnotherapists, such as Schrenck- orgasmic women.
Joseph LoPiccolo • Department of Psychology, University Following the publication of Human Sexual Inade-
of Missouri, Columbia, Missouri 65211. quacy, a number of other accounts of behavioral or
547
quasi-behavioral approaches to treatment of sexual begun to apply their ideas to sexual dysfunction. In the
dysfunction have appeared (e.g., Hartman & Fithian, earlier years of family systems work, sexual dysfunc-
1972; Kaplan, 1974; Lobitz & LoPiccolo, 1972; 1. tions were seen merely as symptoms of underlying
LoPiccolo & Lobitz, 1972). These accounts all differ family dynamics and were not focused upon per se.
greatly in the degree to which behavioral terminology There was an underlying assumption that sexual dys-
is used and in the theoretical framework that is present- functions would disappear when the family issues
ed. However, if differences in language are ignored, were resolved. In more recent years, systems theorists
all of these reports seem to describe fairly similar treat- have begun to look more closely at sexual dysfunc-
ment procedures (1. LoPiccolo, 1977b). Although tions. The focus now is upon assessing the role the
there are unique elements in various programs, (1) sexual dysfunction plays in the maintenance of home-
reduction of performance anxiety (often through im- ostasis in the emotional relationship between husband
plicit counterconditioning and cognitive behavioral and wife (Heiman et at., 1981).
strategies), (2) sex education, (3) skill training in com- The major contribution of the systems theory ap-
munication and sexual technique, and (4) attitude proach to the treatment of marital and sexual dysfunc-
change procedures remain elements common to both tion has been to offer an alternative to the notion of
"behavior therapy" and "sex therapy" approaches to linear causality (1. LoPiccolo & Friedman, 1985). That
sexual dysfunction. is, rather than asking the question of whether marital
In the late 1970s, there was a renewal of interest in dysfunctions cause sexual dysfunctions or, alter-
cognition as well as in overt behavior. For example, in natively, sexual dysfunctions cause marital dysfunc-
conceptualizations of depression, the purely behav- tions, systems theory proposes reciprocal and mutual
ioral focus on lack of environmental reinforcers causation. This notion is not only of theoretical in-
(Lewinsohn, 1974) was broadened to include focus on terest. Without such a view, assessment necessarily
the patient's self-image, self-esteem, and depressive must focus on the issue of whether a particular couple
cognitions (Beck, Rush, Shaw, & Emery, 1979). With- is best treated by focusing on their marital problems or
in the field of sex therapy, this cognitive-behavioral their sexual problems. With the systemic reciprocal
emphasis led to a focus on the patient's thinking about causality notion, this issue can be bypassed. Instead,
sex. Therapy came to include modification of the pa- treatment can focus on elucidating the role that sex
tient's cognitions regarding sexual issues. Unrealistic plays in the maintenance of equilibrium in the marital
expectations, negative self-images, distorted views of relationship. This approach is not incompatible with a
the opposite sex's needs and requirements, and tenden- behaviorally oriented approach. In a sense, systemic
cies to catastrophic thinking became a major focus of homeostatic issues are only another class of reinforcers
therapy (Lazarus, 1978). Interestingly enough, much to be considered in a behavioral functional analysis of
of this cognitive-behavioral approach to sex therapy the causes of a sexual dysfunction.
that began to develop in the 1970s and 1980s had been
anticipated in somewhat different theoretical terms by
Functional Analysis Assessment of Sexual
the work of Albert Ellis some 20 years earlier (Ellis,
Dysfunction
1958, 1962). Although Ellis's theoretical label for his
procedure is Rational Emotive Therapy, the pro- Attempts to assess sexual dysfunction generally fall
cedures described by him for sexual dysfunctions are into three categories that differ in the method of data
extremely similar to those "new" procedures advo- collection.
cated by the cognitive-behavior therapists some 20
years later. Direct Observation, Videotaping, and "Sex-
The final development in our conceptualization of ological" Exams. Historically, one approach to as-
sexual dysfunctions has been the development of sys- sessment of sexual dysfunction has been to simply ob-
tems theory approaches (Heiman, L. LoPiccolo, & 1. serve the patient couple during their sexual relation-
LoPiccolo, 1981). Although systems theory ap- ship, either by having the therapist present (Hartman &
proaches were developed initially in schizophrenia, Fithian, 1972) or by videotaping the patient couple
they relatively quickly became a mainstay of the fami- (Serber, 1974), with the tape later viewed by the thera-
ly therapist and, to a somewhat lesser degree, the mar- pist. Another variety of direct observation technique is
ital therapist (Gurman & Kniskern, 1981). However, it the "sexological exam" (Hartman & Fithian, 1972). In
is only in the last few years that systems theorists have this procedure, the therapist stimulates the breast and
CHAPTER 26 • SEXUAL DYSFUNCTION 549
genitals of the opposite sex patient, for the purpose of best, as research indicates that such events are of high
assessing and demonstrating physiological respon- base-rate occurrence in our society and appear fre-
siveness. quently in life histories taken from functional adults
Although such procedures may seem to offer the (Heiman, Gladue, Roberts, & LoPiccolo, 1986).
advantage of direct, nondistorted recording of actual
sexual behavior, there are a number of issues that Psychometric Approaches to Assessment. Al-
rather convincingly argue against their use. First, of though many sex therapists view standardized assess-
course, is the issue of stimulus control and reactivity of ment procedures as holding little utility, behavioral
sexual behavior to the stimulus situation. It seems un- assessment in sex therapy can be of great value to the
likely that most couples with a sexual dysfunction will practicing clinician (Nowinski & J. LoPiccolo, 1979).
be unaffected by being observed, videotaped, or stim- If the assessment is to be useful, it must be specifically
ulated by their therapist. Thus, the behavior elicited in relevant and the connection between the test content,
these situations may have little generalizability to the diagnostic schemes, and treatment strategy must be
target stimulus situation-the couple interacting direct and easily seen. Three widely used instruments
alone, in the privacy of their own bedroom. Similarly, that meet these criteria are the Derogatis Sexual Func-
such assessment procedures are simply unacceptable tioning Inventory (Derogatis, 1980), the Sexual
to the majority of dysfunctional couples seeking treat- Arousability Index, (Hoon, Hoon, & Wincze, 1976),
ment. Finally, the ethical problems in patient-thera- and the Sexual Interaction Inventory (J. LoPiccolo &
pist sexual contact and the possibility for exploitation Steger, 1974).
of the patient are obvious (J. LoPiccolo, 1977b). Even The Derogatis Sexual Functioning Inventory (DSFI)
though such direct observation procedures were once (Derogatis, 1980) is a self-report inventory designed
fairly widely used, they have virtually ceased to exist for use with normal and sexually dysfunctional indi-
in contemporary clinical practice. viduals. The DSFI assesses frequency and quality of
sexual activities, as well as attitudes toward sexual
Sex History Interviews. A major element in behavior. The original version was comprised of 245
many sexual treatment programs is the sex history in- items assessing 8 different content areas. The revised
terview (Kaplan, 1974; Masters & Johnson, 1970; version included 258 items and 2 additional subtests.
Hartman & Fithian, 1972). Theformat of such an inter- A total of 10 subtests are available that reflect sexual
view is usually that of an extended face-to-face semi- functioning. The Global Sexual Satisfaction Index
structured interview, conducted separately with each (GSSI) gives additional information, in that it reflects
patient by a therapist of the same sex. The content of the individual's subjective feeling of the quality of his
such an interview varies considerably from program to or her sexual relationship.
program, with some history interviews routinely tak- In contrast to the DSFI, which is useful with a wide
ing as much as 7 hours to complete. variety of individuals, Hoon et al. (1976) developed a
The utility of such extensive history taking has not specific inventory to measure sexual arousal in wom-
been empirically demonstrated, and is open to ques- en. The Sexual Arousability Index (SAl) assesses sex-
tion in terms of the most efficient use of therapeutic ual arousal dysfunction in women, regardless of the
time. Certainly, many of the questions asked in the presence or absence of relationships with men or wom-
more extensive interviews have minimal clinical utility en. Hoon et al. (1976) defined sexual arousability as
in that treatment procedures remain the same re- the sum of the woman's ratings of how she believes she
gardless of the varying nature of the patient's answer. would think or feel in 28 erotic situations.
Such extensive history interviews may, however, serve The Sexual Interaction Inventory, or SII (J. LoPic-
a useful rapport-building function in that the therapist colo & Steger, 1974), consists of a listof17 heterosex-
demonstrates great interest in the patient. Extensive ual behaviors adopted from Bentler's (1968a,b) Gutt-
histories may also allay the therapist's and, to a lesser man scaling of sexual behaviors. Husband and wife
degree, the patient's anxiety by providing a seemingly separately answer six questions for each behavior us-
coherent explanation for the cause of the sexual probing a response format of a 6-point rating scale. The
lem. It should be noted that causal explanations of responses from each member of the couple are
etiology based on occurrence of supposedly patho- summed across all 17 behaviors. The totals are used to
genic life history events must be viewed with caution. derive an II-scale profile. The 11 scales were chosen
Such explanations are likely to be oversimplified at on the basis of clinical experience in treating dysfunc-
tional couples. Factors found to be crucial in detennin- uation of functioning via interviewing, paper-and-pen-
ing sexual satisfaction included dissatisfaction with cil questionnaires, and physiological assessment.
frequency and range of sexual behaviors engaged in,
self-acceptance, pleasure obtained from sexual ac-
Diagnostic Systems: DSM-III
tivity, accurate knowledge of partner's preferred sexu-
al activities, and acceptance of partner. The SII has Several diagnostic systems for sexual dysfunctions
considerable diagnostic utility as well as serving as a have emerged, but in the past none have stood out as
measure of treatment outcome for the couple. Because the standard in the field. The various systems used
the patterns of scale elevations indicate which aspects before the existence of the Diagnostic and Statistical
ofthe couple's sexual relationship are most distressed, Manual of Mental Disorders (American Psychiatric
it is very useful as an aid in planning treatment strat- Association, 1980) (DSM-III) suffered from a com-
egies. There are many other assessment instruments mon problem of many classification systems-dif-
available to the clinician. A critical review of such ferences in tenninologies. These discrepancies cause
instruments is available (Conte, 1983). difficulty in comparing research from different settings
or in sharing clinical techniques. The DSM-III does
Physiological Assessment. Despite the fact that include a section on psychosexual disorders, which is
the large majority of sexually dysfunctional patients based largely on Kaplan's (1974) work. Although the
are organically intact, it is becoming clear that there DSM-III specifies in great detail the behavioral criteria
are a large number of biological processes that can be for most of the psychopathologies (e.g., schizo-
implicated in sexual dysfunction. The differentiation phrenia, affective, anxiety disorders, etc.), it leaves
between biogenic and psychogenic etiology is es- much to be desired in regard to the psychosexual
pecially crucial in cases of male erectile failure and in dysfunctions.
cases of female dyspareunia. At the present stage of A good diagnostic system not only places different
our knowledge, organic factors do not seem as clearly behavioral patterns into distinct categories, but also
implicated in premature ejaculation or female allows for assessment of multiple dysfunctions, direct-
orgasmic dysfunction. _ ing attention to all important problem areas. A major
A complete evaluation of the patient's biological problem with the DSM-III system is the inclusion of
status requires consideration of a number of param- various dysfunctions into broad categories. Cases with
eters that are not included in routine physical examina- important clinical distinctions can easily fit into the
tions. Obviously, complete and thorough pelvic exam- same category. For example, two women are diag-
inations by a consultant urologist or gynecologist are nosed as cases of inhibited sexual excitement. One
indicated. Current medications should be carefully as- woman exhibits no physiological changes during sexu-
sessed, because many common prescribed agents dra- al activity with her husband but functions nonnally
matically interfere with sexual dysfunction (1. LoPic- with an outside lover. In contrast, the other woman is
colo & Daiss, 1988). Beyond this, tests for thyroid unable to become sexually aroused with any partner, or
function, endocrine status (especially testosterone), while attempting masturbation. The women's identical
and glucose tolerance should probably be routine, es- DSM-III diagnoses do not provide infonnation suffi-
pecially in cases of low sex drive and of erectile cient to predict their behavior across situations, or their
failure. An examination for neuropathy and peripheral prognosis in therapy.
vascular function is also indicated, with penile pulse In order to offer a more specific and useful classifi-
and blood pressure especially important in erectile cation instrument, a multiaxial problem-oriented diag-
failure cases. In differentiating organic from psycho- nostic system has been designed that is useful for both
genic erectile failure, measurement by penile plethys- clinicians and researchers who work with sexually dys-
mograph of nocturnal erection during rapid eye move- functional individuals (Schover, Friedman, Weiler,
ment (REM) sleep has been found to be a valid and Heiman, & 1. LoPiccolo, 1982). The Schover et al.
highly useful measure (Schiavi & Fisher, 1982). Vagi- (1982) system, illustrated in Table 1, comprises six
nal plethysmography is of some use in the diagnosis of axes: Desire disorder, arousal deficits; orgasm prob-
female arousal deficits (Heiman, 1978). lems; coital pain; frequency dissatisfaction; and
To summarize, behavioral assessment of sexual dys- qualifying infonnation. Diagnostic categories within
function includes problem focused, multimethod eval- the first five axes are mutually exclusive and ex-
Table 1. Multiaxial Problem-Oriented System for Sexual Dysfunction

Desire phase (list I) Coital pain (list I)
10. Low sexual desire 50. Vaginismus
11. Aversion to sex 51. Dyspareunia
(L vs. N) (G vs. S) (p)a 52. Pain on ejaculation
53. Pain after ejaculation
Arousal phase (list 1)
54. Other pain exacerbated by sexual
20. Decreased subjective arousal
activity (L vs. N) (G vs. S) (P)
21. Difficulty achieving erections
22. Difficulty maintaining erections Frequency dissatisfaction (list 1)
23. Difficulty achieving and maintain- 60. Desired frequency much lower
ing erections than current activity level
24. Decreased subjective arousal and 61. Desired frequency much higher
difficulty achieving erections than current activity level
25. Decreased subjective arousal and (L vs. N) (G vs. S) (P)
difficulty maintaining erections
Qualifying information (list up to 6)
26. Decreased SUbjective arousal and
70. Prefers gender other than that of
difficulty achieving and maintain-
partner
ing erections
71. Transvestism
27. Decreased physiological arousal,
72. Fetishism
female
73. Voyeurism
28. Decreased physiological arousal,
74. Exhibitionism (male)
male
75. Sexual pleasure from inflicting
(L vs. N) (G vs. S) (P)
pain
Orgasm phase (list 1) 76. Sexual pleasure from experiencing
30. Premature ejaculation, before en- pain
try (G vs. S) 77. Sexual pleasure from humiliating
31. Premature ejaculation less than 1 partner
min (G vs. S) 78. Sexual pleasure from being humi-
32. Premature ejaCUlation, 1-3 min liated
(G vs. S) 84. History of severe psychopatho-
33. Premature ejaculation, 4-7 min logy
(G vs. S) 85. Current severe psychopathology
34. Inhibited ejaculation (G vs. S) 86. Severe marital distress
35. Anhedonic orgasmic (G vs. S) 87. History of substance abuse
36. Orgasm with flaccid penis (G vs. S) 88. Current active substance abuse
37. Anhedonic orgasm with flaccid 89. History of physically abusing spouse
penis (G vs. S) 90. Currently physically abusing spouse
38. Rapid ejaculation with flaccid 91. Active extramarital affair
penis (G vs. S) 92. Medical condition possibly affect-
39. Anhedonic orgasm with rapid ing sex
ejaCUlation (G vs. S) 93. Medication possibly affecting sex
40. Inorgasmic (G vs. S) 98. No dysfunction
41. Inorgasmic except for masturba- 99. No diagnosis (P)
tion (S)
42. Inorgasrnic except for partner ma-
nipulation (S)
43. Inorgasrnic except for masturbation
44. Infrequent coital orgasms (S)
45. Inorgasmic except for vibrator or
mechanical stimulation
(S) (L vs. NI) (P)
aL vs. N = lifelong vs. not lifelong; G vs. S = global vs. situational; P = presenting complaint.
haustive. Thus, only one diagnostic category may be developed in the past decade. Thorough reviews of the
used per axis. The last axis is reserved for qualifying basic behavioral sex therapy procedures are available
information: these are descriptors that include infor- in Masters and Johnson (1970), Kaplan (1974), LoPic-
mation on unusual sexual preferences, which may af- colo and LoPiccolo (1978), Heiman, L. LoPiccolo,
fect the individuals' compatibility with partners. Other and J. LoPiccolo (1981), J. LoPiccolo (1984), and J.
descriptors, such as severe marital problems, traumat- LoPiccolo and Stock (1986).
ic sexual experiences, substance abuse, or interfering
problems that may affect prognosis of sex therapy, are
Male Dysfunctions
also listed on this axis. Axis six ensures that clinically
relevant information is not ignored because it does not Premature Ejaculation. The treatment of pre-
fit into a specific category. This system does not have a mature ejaCUlation, using the pause-and-squeeze pro-
special category for medical conditions that may affect cedures developed by Semans (1956) and by Masters
sexual functioning, but these conditions can be listed and Johnson (1970), has been found to be highly effec-
on axis six. tive. Research has demonstrated that such procedures
Within each of the first five axes, there are two work well in group as well as in individual treatment,
additional dimensions used to refine the diagnosis. in self-help programs, and can be done in individual
The first dimension labels the problem as "lifelong" masturbation with relatively good generalization to sex
(indicating no period of normal sexual functioning), or with a partner. Success rates of 90% to 98% are re-
"not lifelong" (signifying there has been some period ported (Kilmann & Auerbach, 1979).
of normal behavior). The second dimension describes We do not have any definitive data on the causes of
the dysfunction in terms of "global" (occurring across premature ejaculation. Recently, sociobiologists have
all activities: partner, manual or oral stimulation, inter- theorized that premature ejaculation offers an evolu-
course, and masturbation), or "situational" (occurring tionary advantage and thus is built into the human or-
only in some contexts, or with some current partners). ganism (Hong, 1984). Such theorizing does not effec-
All axes also receive another modifier, "presenting tively deal with the extremely large variability in
complaint," if the problem is brought forth by the pa- duration of intercourse observed across free-living
tients as the reason for seeking treatment. This label is mammalian species.
clinically useful for tagging patient areas of distress Kaplan (1974) theorized that men with premature
and formulating goals for therapy. ejaculation are unable to perceive accurately their own
In summary, the Multiaxial Problem-Oriented Sys- level of sexual arousal and thus do not engage in self-
tem attempts to fulfill the four goals of psychiatric control to avoid rapid ejaculation. However, one re-
classification. It helps to facilitate professional com- cently laboratory analogue study found that premature
munication by dividing sexual problems into discrete ejaculation patients, compared with controls, had bet-
behavioral categories. Because it does not infer etiolo- ter awareness of their physiological arousal level
gy, the system allows clinicians and researchers to (Spiess, Geer, & O'Donohue, 1984). Prematureejacu-
think more broadly about sexual dysfunction without lation patients, because of their concern about rapid
regarding it as purely psychogenic or organic. The ejaculation, may constantly self-observe their arousal
system also has more predictive power than such cate- and thus may have more training and experience in
gories as the DSM-III, and the categories more closely self-observation than do controls.
correspond to actual sexual behavior. The Multi-axial Kinsey, Pomeroy, and Martin (1948) proposed that
Problem-Oriented System can aid in assessment and premature ejaculation was primarily related to a low
treatment planning by giving the therapist a thorough frequency of sexual activity. Some research has indi-
picture of the patient's sexual functioning (Schover et cated that sensory thresholds in the penis are lowered
aI., 1982). by infrequent sexual activity (Kedia, 1983) and that
premature ejaculation patients have a low rate of sexu-
al activity (Spiess et ai., 1984). However, it may well
Treatment Techniques be that premature ejaculation makes sex an unpleasant
failure experience, which is therefore avoided, rather
Behavioral treatment techniques for each major di- than that low frequency of sexual activity causes pre-
agnostic category will be briefly described. The em- mature ejaculation.
phasis will be on newer treatment interventions We also have no real understanding of why the
pause-and-squeeze procedures described by Semans tion present. '{hat is, if one is unable to maintain erec-
(1956) and Masters and Johnson (1970) work. The tion or if one has no interest in sex, it is not highly
usual procedure involves stimulation of the penis until surprising that one does not ejaculate. This diagnosis
high arousal, but not threshold for ejaculation, is would perhaps be best restricted to men who do not
reached. Following a pause for arousal to subside, have other sexual dysfunctions, but who have diffi-
stimulation is repeated until high arousal is again culty in ejaculating despite an intact erection and de-
reached. This procedure fits the paradigm for spite intact interest in sex.
Guthrie's (1952) counter-conditioning extinction pro- There has been virtually no research on the etiology
cedure of crowding the threshold. Alternatively, the of inhibited ejaculation. Clinical case studies suggest a
stimulate and pause procedure may train a man in variety of anxiety or other psychological factors, but
monitoring more accurately his arousal level. The there is virtually no empirical research to support this
stimulation and pause procedure involves the man re- clinical material (Dow, 1981; Schull & Sprenkle,
peating the procedure several times per week, thus 1980).
raising the frequency of sex and raising the sensory Inhibited ejaculation has recently been recognized,
threshold of the penis. Any or all of these mechanisms however, as a symptom of a number of physiologic
may underlie the effectiveness of treatment. conditions. For example, inhibited ejaculation may be
Some variations on the pause-and-squeeze pro- the first symptom of multiple sclerosis, or of a number
cedure have been reported, typically as clinical case of other neurological conditions (Kedia, 1983). Simi-
reports. One variation involves reversing one of the larly, a number of medications will have the side effect
physiological changes that occur during high arousal of preventing ejaculation (Ban & Freyhan, 1980).
(J. LoPiccolo, 1977a,b). Atthistime, the scrotum con- Such medications include many of the antihyperten-
tracts and elevates the testes close to the body. As well sives (which are usually thought of in terms of inhibit-
as having the patient cease stimulation and/or squeeze ing erection), and most of the psychotropic, anti-
on the penis, the patient is also instructed to stretch out psychotic medications. Phenothiazines seem es-
the scrotum and reverse this testicular elevation. How- pecially prone to produce this effect. Similarly, it has
ever, during high arousal, any additional stimulation of recently been noted that one effect of the "postconcus-
the scrotum and perineum may trigger an ejaculation sion syndrome" may be the inability to ejaculate. This
and thus may make the pause-and-squeeze procedure syndrome is postulated to involve damage to hypothal-
ineffectual. Empirical data on the effectiveness of this amic structures involved in the regulation of sex hor-
technique are lacking. mones, so it is not clear why ejaculation should be
Another procedure that has been proposed is to have interfered with, as opposed to sex drive, or even erec-
the patient perform a Valsalva maneuver while pausing tion (Kosteljanetz et al., 1981).
or squeezing (J. LoPiccolo, 1977a). The Val salva ma- Relatively little has appeared in the literature re-
neuver involves forced exhalation with the airways garding treatment of inhibited ejaCUlation. The stan-
closed and is purported to reduce sympathetic nervous dard treatment strategies, involving elimination of per-
system anxiety. Because ejaculation is posited to be formance anxiety and ensuring adequate stimulation,
mediated sympathetically, the Valsalva should delay remain the state-of-the-art treatment approaches. In
ejaculation. However, more recent neurological evi- this approach, the couple is instructed to caress the
dence indicates that there are also major parasympa- penis manually (and, if acceptable to the couple, or-
thetic elements in ejaCUlation (Kedia, 1983). Further- ally) until erection is attained, but to cease stimulation
more, performing a Valsalva maneuver may simply whenever arousal is increasing or approaching the
lower arousal by distracting the patient. Empirical re- point of impending orgasm. This paradoxical instruc-
search is lacking in clinical reports on this procedure. tion reduces goal-focused anxiety about performance
and allows the male to enjoy the sexual pleasure pro-
Inhibited Ejaculation. Inhibited ejaculation has vided by this caressing. Elements from the treatment
received very little attention in the therapeutic liter- program for inorgasmic women, including encourag-
ature. As initially reported by Masters and Johnson ing the use of electric vibrators, behavioral maneuvers
(1970), this remains a relatively rare dysfunction. which are orgasm triggers, and having the patient role-
When seen, it is often secondary to erectile failure or to play an exaggerated orgasm, do seem to have some
low sexual desire. In such cases, it is questionable success with this disorder (J. LoPiccolo, 1977a).
whether there is a true dysfunction of inhibited ejacula- For cases with neurological diseases, medication
side effects, or the postconcussion syndrome, more pacity may be sufficient to produce full erection. This
physiological interventions are indicated. There is is an important issue, because the usual alternative is
some success reported with the use of sympathom- a penile prosthesis.
imetic agents, such as ephedrine sulfate (Murphy & The implantation of the penile prosthesis has some
Lipshultz, 1988). At a behavioral level, increased fairly serious difficulties and problems. First, recent
stimulation of scrotal, perineal, and anal areas tends to reports indicate that the percentage of surgical and me-
trigger orgasm. Most effective is the use of an anal chanical complications from such prosthetic implant is
insertion probe, which can be either vibratory or much higher than might be considered acceptable
providing a mild electric current, and indeed this type (Fallon, Rosenberg, & Culp, 1984; Sotile, 1979). Sec-
of anal stimulation is the only effective treatment for ond, whatever degree of naturally occurring erection a
severely neurologically impaired patients (Murphy & man is capable of will be disrupted, and perhaps elimi-
Lipshultz, 1988). nated, by the surgical procedures and scarring that is
involved in prosthetic implants. Finally, although pa-
Erectile Dysfunction. The major focus of recent tients are typically rather eager to have a prosthesis
work on erectile failure has been on differential diag- implanted and report being very happy with it at short-
nosis. In 1970, Masters and Johnson stated that 95% of term surgical follow-up, longer term behavioral assess-
all erectile failure was purely psychogenic in origin ment indicates poor sexual adjustment in some cases.
and did not involve any physiological pathology. More It seems reasonable that if a man has a number of
recent studies have indicated that neurological, vas- psychological, marital relationship, or sexual tech-
cular, and hormonal abnormalities are involved in a nique problems that lead him to have erectile failure,
considerable percentage of cases of erectile failure the implantation of the prosthetic device will result in
(Tanagho, Lue, & McClure, 1988). his now having these same difficulties but with an ar-
Although a complete evaluation of organic factors tificially rigid penis. One would not expect the fre-
is necessary before undertaking behavioral treatment quency or quality of sexual activity to be high in such
of erectile failure, the presence of some degree of cases (Tiefer, Pedersen, & Melman, 1988).
organic impairment does not always argue against be- The use of the penile prosthesis is part of a trend in
havioral treatment. The argument that organic impair- the physical treatments of erectile failure, which in-
ment precludes behavioral treatment suffers from the clude hormonal treatment and vascular surgery. Al-
flaw of attempting to categorize the patients into dis- though hormonal treatment is indicated for men with
crete, nonoverlapping categories of organic or psy- endogenous deficiencies, if a man is hormonally
chogenic erectile failure. Yet many cases, perhaps the within the normal range, administering exogenous
majority of cases, involve both organic and psycho- hormones has no impact beyond a placebo effect
genic factors in the genesis of erectile failure. Some (Bancroft, 1984; Krane, Siroky, & Goldstein, 1983).
researchers do categorize patients on a bipolar scale, Unfortunately, it is common medical practice to ad-
from primarily organic to primarily psychogenic, in minister testosterone to normal men, but the risks of
an attempt to avoid a simple two-part typology. How- liver damage, activating an occult prostatic tumor,
ever, this bipolar reasoning also presents a problem. and other negative side effects of testosterone raise
The dimensions of organic and psychogenic logically questions about this procedure.
are not the opposite ends of a bipolar, unidimensional After an initial flurry of highly positive reports
scale, but rather represent two orthogonal dimen- (Metz & Mathiesen, 1979; Michal, Kramar, Pospi-
sions. That is, a man may be high in both organic and chal, & Hejhal, 1977), vascular surgery, as a means
psychogenic causation of erectile failure, low in both of correcting insufficient penile blood flow, currently
factors, or any combination of high on one and low seems less promising. Vascular surgery is quite effec-
on the other. There are many cases in which a man tive in the rare cases of blockage of a specific, large
has a mild organic impairment, which then makes his artery or a penile structural defect. Unfortunately, dif-
erection more vulnerable to being disrupted by psy- fuse, small-vessel atherosclerotic disease is much
chological, behavioral, and sexual technique factors. more common, and vascular surgery is ineffective in
Many such cases with some partial organic impair- these cases (Melman & Leiter, 1982). There has been
ment can be treated successfully by sex therapy. If a similar history on the use of direct intracavernous
psychological and behavioral difficulties are elimi- injection of vasoactive agents, such as papaverine.
nated, the patient's mildly impaired physiologic ca- Although these agents will produce erection, they do
not seem viable as long-tenn aids, as the develop- into the vagina is allowed, but only with the female
ment of fibrous plaques in the penis become common physically pushing the male's flaccid penis into her
over time (Althof et al., 1987). vagina while she sits astride his supine body. Again,
The behavioral treatment program for erectile the couple is told, "This procedure works best with a
failure consists of two basic components: (1) ensuring flaccid penis. If you can't avoid an erection, it's all
that the patient is receiving a high level of physical right, although not as good, to go ahead and insert
and psychological sexual stimulation from his wife, anyway. But please try not to have an erection." Once
and (2) eliminating anxiety and perfonnance de- the male has been unable to avoid an erection during
mands that interfere with erection despite such ade- vaginal containment, slow pelvic thrusting, vigorous
quate stimulation. intercourse, and, finally, coital ejaCUlation can be
Some cases of erectile failure are at least partially allowed.
the result of the wife's poor sexual technique and her Even though this procedure works well with most
placing strong demands on the male to have erections. cases, it has not been found successful in cases where
In such cases, perfonnance demands on the husband the male has a homosexual orientation (Masters &
and the wife's frustration can be reduced through in- Johnson, 1970, p. 273). In such cases, lack of psycho-
structing the couple to assure orgasm for the female by logical stimulation (rather than the male's anxiety and
means of manual, oral, or electric vibrator stimulation the wife's poor technique) may be a factor. If a male is
of her genitals, none of which require the male to have more aroused by men than by women, removing his
an erect penis. Explicit films and books can be used to perfonnance anxiety may still leave him unaroused in
train the wife in effective stimulation techniques. response to his wife's lovemaking, regardless of how
An equally powerful source of anxiety, independent nondemanding and skilled she may be. For such cases,
of the spouse's reaction, stems from the male's own addition of a classical conditioning procedure to in-
attitude toward sex once erectile failure has begun to crease heterosexual arousal seems to increase effec-
occur. A male with erectile failure tends to enter his tiveness of the basic treatment strategy (1. LoPiccolo,
sexual encounters as an anxious observer rather than as Stewart, & Watkins, 1972). In this procedure, the male
an aroused participant. That is, he watches closely for masturbates with his currently arou5ing homosexual
signs of erection, is upset by any lag in gaining erec- fantasies and explicit stimuli, such as pictures of nude
tion or any signs of partial loss of erection. Since this males. Just prior to orgasm, the male is instructed to
anxiety about erection obviously prevents erection switch his focus to fantasies of heterosexual activities
from occurring, one therapeutic approach is to pre- with his spouse. This procedure ensures that the plea-
scribe a course of homework activities for the couples sure of orgasm occurs in a heterosexual context. On
that preclude perfonnance anxiety and ensure ade- subsequent occasions, this switch can be made earlier
quate stimulation for the male. For example, the first in masturbation, until fantasies and actively involving
set of activities might require the couple only to mas- the wife become effective sexual stimuli in their own
sage each other's nude bodies, not including any stim- right. This stimulus-switching procedure can also be
ulation of the male's genitals. The male is paradox- used by the couple in their series of prescribed sexual
ically instructed that, "The purpose of this exercise is activities.
for you to learn to enjoy sensual pleasures, without The author has recently been experimenting with the
focusing on sexual goals. Therefore, you should try to therapeutic use of nocturnal penile tumescence in
not get an erection. Erection would mean you are being cases of global, lifelong erectile failure. This diag-
sexual rather than sensual." Obviously, a nude mas- nostic label refers to the patient who has never been
sage is a sexually stimulating experience. The para- able to achieve an erection, in any way, in his entire
doxical demand not to get an erection in this setting life. Treatment is generally unsuccessful in such cases,
effectively frees the man from anxiety about getting an using the procedures previously described. What we
erection. have added to the treatment of such cases is the thera-
Over successive occasions, the couple's repertoire peutic use of naturally occurring nocturnal penile tum-
of sexual activities can now be rebuilt. The next as- escence. In this procedure, the couple is instructed that
signment might be for the wife to stimulate the male's the man is to go to bed and go to sleep. The wife
penis, but to stop such stimulation immediately should remains in another room. After an hour or two has
an erection occur. Only when the penis is flaccid passed, she begins to check on him every 15 min or so.
should stimulation be resumed. Next, penile insertion At some point, she will observe that he has an erection
while he sleeps. The couple is instructed that at this focused sensate exercises and addressing historical is-
point, she is to begin caressing his penis very gently. sues that result in a sex-negative orientation. However,
The result is that he gradually awakens to a unique a number ofstudies (e.g., Kohlenberg, 1974; Riley &
experience for him-an erection during sexual activity Riley, 1978) have shown that a program of directed
with his wife. This milestone experience has led to masturbation training is a more effective method for
remarkable treatment progress in three otherwise the woman who has never had an orgasm. The directed
deadlocked and unsuccessful cases. In one case, the masturbation program developed by J. LoPiccolo
wife was even able to accomplish vaginal intromission forms the basis for a popular self-help book and film
while her husband was awakening, thus achieving in- entitled Becoming Orgasmic (Heiman et aI., 1976,
tercourse for the first time in an unconsummated mar- first edition; Heiman & J. LoPiccolo, 1988, second
riage of 7 years duration. Although we have used this edition).
technique with only three cases to date, the success In a recently completed study (Morokoff & J. loPic-
seen so far seems to warrant further clinical trials. colo, 1986), we compared the effectiveness of the self-
treatment book and film, Becoming Orgasmic, when
used in a full sex therapy format with a self-help for-
Female Dysfunctions
mat. Full sex therapy meant weekly hour-long meet-
Arousal and Orgasmic Dysfunction. Orgasmic ings with the therapists for 15 consecutive weeks. Self-
dysfunctions in women have traditionally been divided help involved only three sessions with the therapists,
into two major categories. Primary orgasmic dysfunc- spaced 5 weeks apart, with the woman using the book
tion applies to women who have never experienced alone between sessions. In treating a group of women
orgasm through any means. Secondary inorgasmia has with global, lifelong lack of orgasm, it was found that
generally been applied to women who are not orgasmic the self-help program was fully as effective as full sex
during sexual intercourse, but, in the more recent therapy in helping the women obtain orgasm and in
clinical literature, also described women who only producing gains in overall marital and sexual satisfac-
have orgasm in masturbation, and not through any type tion. This suggests that the treatment model is robust
of partner stimulation, or who define their limited rep- and does not depend upon therapist effects for its suc-
ertoire of stimulation techniques leading to orgasm as cess. The directed masturbation/behavior therapy pro-
problematic. The adoption of a fine-grained descrip- gram described in Becoming Orgasmic (Heiman & J.
tive system of sexual functioning (Schover et at., loPiccolo, 1988) involves nine steps:
1982) has made these overly broad categorizations ob- In Step 1, the woman is supplied with the Becoming
solete. Primary orgasmic dysfunction is now described Orgasmic book, which contains diagrams and draw-
as "lifelong, global orgasmic dysfunction." The vari- ings of the female genitals. She learns to identify the
ous behavioral patterns previously listed as "second- various parts of her genitals and is encouraged to do
ary orgasmic dysfunction" are now described vari- some attitudinal work on acceptance of female sexu-
ously in combinations of "situational," "global," ality as a legitimate expression for a decent woman and
"lifelong," and "not lifelong" as modifiers of the to examine her own sexual history in terms of patho-
basic diagnosis of orgasmic dysfunction. genic influences.
The most effective treatment to date for lifelong In Step 2, the woman is encouraged to repeat this
global lack of orgasm in women is a program of di- visual exploration, but this time adding exploration of
rected masturbation developed by J. LoPiccolo and his her body and genitals by touching. Again, consider-
students (Heiman et at., 1976, Heiman & J. LoPic- able attitude change work is done in this stage of the
colo, 1988; J. LoPiccolo & Lobitz, 1972; J. loPic- program as well.
colo, 1977a). The program is based on a sexual skills In Step 3, the woman attempts to locate areas of her
learning model and is an adjunct to a behavioral, time- body and genitals that produce pleasure when touched.
limited treatment program involving both the male and Not surprisingly, most women identify the obvious
the female partners. The basic components ofthis pro- erogenous zones, including the clitoris, as the focus
gram include education, self-exploration and body for their sexual pleasure.
awareness, and directed masturbation. The use of di- In Step 4, the woman is directly instructed in tech-
rected masturbation has been questioned by some and niques of masturbation. She is encouraged to explore
is not a component of all treatment programs for varieties of 'pressures and speeds in stimulating her
global, lifelong lack of orgasm. Masters and Johnson own genitals.
(1970), for example, stressed performing couple- In Step 5, an attempt is made to make this procedure
more erotic and sexual. That is, the woman is encour- during penile-vaginal intercourse following this pro-
aged to develop sexual fantasies and imagery; to read gram. Data from recent sociological surveys indicate
sexual books, including one of the many popular an- that this figure of 40% orgasmic during coitus is sim-
thologies of women's sexual fantasies (e.g., Friday, ilar to general population incidence for coital orgasm
1973); and to use this visual, written, and fantasy ma- (Hunt, 1974).
terial as an aid to facilitate her arousal. For the woman who complains of becoming highly
In Step 6, if the woman has not yet reached orgasm, aroused but unable to have an orgasm, or who com-
the use of the electric vibrator is introduced. When plains that she is able to reach the orgasm in her own
introducing the vibrator at this late stage in treatment, masturbation but not with her male partner, several
it is very unlikely that the woman will remain orgasmic other sex therapy techniques can be used.
only with the vibrator at the end of treatment. Indeed, One technique concerns the use of "orgasm trig-
well over half of our patients have their first orgasm gers" (Heiman & J. loPiccolo, 1988). Orgasm trig-
without ever using the vibrator. Those women who do gers are behaviors that occur more or less spon-
have their first orgasm with the vibrator routinely go on taneously and involuntarily during orgasm and, if
to have orgasms in other forms of sexual stimulation, performed voluntarily during high arousal, may initi-
but the vibrator is a useful means of obtaining the first ate or trigger the orgasm. These behaviors include
orgasm. holding of the breath and displacing the diaphragm
While the woman has been progressing through the downward, "bearing down" with the pelvic muscles,
first six steps in the sex therapy program, she and her contracting the vaginal muscles, pointing the toes and
male partner have been typically assigned to do the tensing the leg and thigh muscles, throwing the head
standard Masters and Johnson (1970) "sensate focus," back and displacing the glottis, and pelvic thrusting.
or body awareness, exercises, involving mutual ca- Although there is nothing magical about these pro-
ressing and touching and communication. At this cedures (in that they will not initiate an orgasm in a
point, the woman's masturbation program and the cou- person who is not highly aroused), they are of some use
ple exercises that she and her partner have been doing in triggering orgasm for women who complain of an
converge in Step 7. ability to get highly aroused but who cannot quite
In Step 7, the woman demonstrates for the male reach the threshold for orgasm.
partner the technique she has learned that produces Another technique is especially valuable for women
arousal and orgasm for her. In sex therapy, we rou- who can have orgasm alone in masturbation but cannot
tinely encourage the male to also demonstrate his mas- do so with their male partner. Many such cases seem to
turbation techniques for the woman, so this is a truly involve an inhibition, modesty, or fear of displaying
coequal and reciprocal learning process. the relatively uncontrolled, "unladylike aspect" of
In Step 8, the woman instructs her male partner in orgasm to a male. An effective procedure for dealing
his caressing and touching of her genitals to produce with this problem is to instruct the couple that the
orgasm through his direct stimulation. woman should role-play or act out a grossly exagge-
In Step 9, the couple resumes penile-vaginal inter- rated orgasm during sexual activity with her partner. If
course with the woman and/or the man continuing di- she is inhibited by the fear of appearing somewhat
rect manual stimulation of the clitoris to facilitate unrestrained and uncontrolled during an orgasm, hav-
orgasm during penetration. Positions that facilitate this ing her role-play and act out a grossly exaggerated
continued clitoral stimulation include coitus with the orgasm will effectively disinhibit her. We have had the
man supine and the woman kneeling above him, the experience on many occasions of having a woman who
Masters and Johnson (1970) lateral-coital position, was to "role-play" a grossly exaggerated orgasm actu-
and rear entry intercourse during which the man can ally experience her first real orgasm during this role-
reach around the woman's body and have easy access play. Again, however, it should be noted that this is not
to her clitoris. a magical procedure and will not be effective in cases
Results on approximately 150 women treated in the of low arousal. The technique works only for women
author's clinic with this program have achieved about with high arousal but with a specific inhibition about
95% success in terms of the woman's being able to having an orgasm.
reach orgasm in her own masturbation. About 85% of
these women are also able to have orgasm during direct Situational Lack of Orgasm. In dealing with sit-
genital stimulation by their male partner. About 40% uationallack of orgasm, one must raise the issue of just
of our women patients have been able to obtain orgasm what is an appropriate focus for treatment. Sex thera-
pists do not consider lack of orgasm during coitus to be bate to orgasm using digital manipUlation of her clito-
an indication for treatment, provided that the woman ris, but does not experience arousal during coitus, and
can have orgasm in some way with her partner, and that finds continued clitoral manipUlation during coitus to
she enjoys coitus. However, for couples who would be painful.
like to experience coital orgasm, not out of a feeling In analyzing the differences between this client's
that it is pathologic not to do so, but simply as an own masturbation of the clitoris and coitus, one can
experience they would like to have, there are some note several qualitative differences. During masturba-
techniques that can be tried. tion, the women is stimulating herself, without male
First, the therapist can simply advise the woman to involvement. There is nothing contained in the vagina,
continue doing during coitus whatever it is that does and there is no thrusting of an object in and out of the
produce orgasm for her. That is, if she can manipulate vagina. Attempting to directly switch from orgasm
her own genitals to orgasm, she should be advised to during self-stimulation of the clitoris, with nothing
continue to do this during coitus. Similarly, if her hus- contained in the vagina and no thrusting, to coital
band can produce orgasm by caressing her genitals, the orgasm involves changing several things at once, and
couple should use coital positions (discussed pre- such an approach is likely to be unsuccessful. A more
viously) that enable him to continue manual stimula- successful approach has been described by Zeiss,
tion of the clitoris during penile-vaginal thrusting. Rosen, and Zeiss (1977). In this stimulus generaliza-
This simple set of techniques will enable some couples tion approach, a more sequential series of changes is
to experience coital orgasm. made in effective stimulation. As a first step, the wom-
There are, however, two other situations in which an might be instructed to masturbate as she always has,
this strategy will not work. The first situation is one in but simply with a finger passively inserted in the vagi-
which the activity that produces orgasm for the woman na, right from the beginning of the masturbation se-
is incompatible with having coitus. For example, the quence. This procedure will enable her to learn to ex-
woman may only be able to have an orgasm during oral perience orgasm with something contained in the
stimulation by her husband, or during masturbation by vagina. Once this has been accomplished, she can be
lying face down with her ankles crossed and pressing instructed to masturbate while thrusting the finger in
her thighs together while rhythmically rocking. In the vagina. Once success is achieved in this procedure,
such cases, a good technique is to attempt to capitalize a change can be made by having the male partner ma-
on the arousal produced by the activity that will pro- nipulate her clitoris, again with nothing in the vagina.
duce orgasm in order to enhance arousal during coitus. Once he is able to produce orgasm for her in this way,
That is, if the woman is able to become highly aroused this can be repeated, but with her finger, and then his
and have an orgasm during oral sex, she can be advised finger, inserted in the vagina. If this step is successful,
that the couple should engage in oral sex until she is the progression can be made to having his penis pas-
just on the verge of orgasm. At that point, the couple sively contained in the vagina while she masturbates to
can shift activities and engage in intercourse. If she orgasm. The next step would involve passive penile
should lose her arousal during intercourse, she can containment while he stimulates her to orgasm man-
shift back to oral sex until high arousal is re- ually. As the final step, thrusting of the penis in the
established, and then switch back to coitus. vagina with direct manual stimulation may now suc-
A second type of situational orgasmic dysfunction ceed in producing orgasm. Thus, by breaking down
that does not respond to simply pairing coitus with the differences between masturbation and coitus into a
concurrent direct genital stimulation involves women series of very small and discrete changes, there is a
who find coitus unarousing, or who find that once they much greater success in broadening the woman's range
have begun coitus, they seem to lose erotic sensitivity of orgasmic responsivity.
in the clitoris. Some of these women report that while
direct clitoral stimulation prior to intercourse is highly Treatment of Vaginismus. Vaginismus refers to
arousing and will produce orgasm, continuing to ma- spasm of the muscles surrounding the vagina so that
nipulate the clitoris during intercourse is neutral or insertion of the penis is impossible. Such cases are
even painful and irritating. often associated with traumatic histories of childhood
In treating these sorts of cases, a "stimulus gener- sexual abuse, incest, or adult rape. The emotional af-
alization" procedure is used. As an example, let us termath of such experiences must first be dealt with in
consider the case in which the woman is able to mastur- a more supportive and cognitively based therapy, be-
fore the behavioral procedures described below can be gressively insert more and more of the penis until full
tolerated by the client. containment is accomplished. She can then begin
The effective treatment element in resolution of vag- some pelvic thrusting, and finally the husband can be
inismus is a combination of relaxation training and allowed to initiate pelvic movements.
progression dilation of the vagina (Fuchs, Hoch, & There is now a professional film and treatment guide
Palki, 1978; Sarrel & Sarrel, 1979). Thefemale patient available that shows a couple with unconsummated
can be given relaxation instructions or urged to buy marriage due to. vaginismus going through the treat-
one of the many commercially available books, au- ment program (J. loPiccolo, 1984). In treating many
diotapes, or videotapes that demonstrate deep muscle women with the program shown in the film, it has
relaxation techniques. Similar to what is prescribed as become clear that the program is extremely effective, if
the first treatment steps for orgasmic dysfunction, the the couple can be convinced to follow it. Virtually all
woman should be instructed in genital anatomy and treatment failures result not from a failure of the thera-
physiology and encouraged to explore her own exter- py program, but from a failure of the therapist to struc-
nal genitals. As the next step, she begins on a program ture matters in such a way that the couple remains on
of progressive dilation of the vagina. the program. That is, many patients with vaginismus,
Dilation can be done by a gynecologist in the office especially those with unconsummated marriages, are
or by the therapist sending the woman home with a set very frustrated and inpatient. They will tend to rush
of progressively larger dilators. Available research ahead too rapidly, continue attempts to insert the penis
does not indicate'that one procedure is more effective in the vagina, use large dilators too quickly, and so
than the other. The important element is that the dila- forth. These failure experiences tend to be very shatter-
tion be under the woman's control, and done at her ing, and the couple will then discontinue treatment.
own pace so that she does not experience pain or fear We routinely advise our patients that, because they
during dilation. have struggled with this problem for months, and often
If the dilation is done in the office by the for years, a few more weeks will not be harmful. Grad-
gynecologist, the woman should also be instructed to ual and slow progress leads to a sure success in these
practice with the dilators at home. She can be in- cases of vaginismus.
structed to take a warm bath to relax, lie on the bed, do
her muscle relaxation exercises, and then insert the
Low Sexual Desire in Men and Women
smallest dilator. We routinely instruct our patients to
leave the dilator inserted from one-half hour to 1 hour Low sexual desire is a disorder that is seen with
while engaging in some other activity, such as reading increasing frequency in clinical practice. Desire disor-
or watching TV. This procedure accustoms the vagina ders now constitute the largest group of complaints
to the sensation of containing on object. voiced by patients seeking therapy (J. loPiccolo &
Over a few weeks, the woman gradually begins Friedman, 1988). Furthermore, although low desire
using progressively larger dilators, until she is using a disorders were more frequently seen in women in years
dilator that is larger than an erect penis. At this point, past, the current cases are male and female in equal
she can be encouraged to insert her own fingers in the numbers (J. LoPiccolo & Friedman, 1988).
vagina. As a next step, we routinely have our couples In dealing with low desire concerns on the part of
experiment with the husbands using the dilators with patients, the first issue is defining what is truly low
the wife under her direction and control. The therapist desire. That is, if the woman, for example, com-
must stress to the couple that this insertion by the hus- plains that she never feels any desire for sex and does
band must be done gradually and slowly, under the not seem to have a spontaneously occurring sex drive,
woman's control, withno forcing. there is no question that there is a genuine problem.
Once the couple can accomplish insertion of the What of the case, however, in which the woman states
largest dilator by the husband, a switch can be made to that she feels her level of sexual interest is normal but
progressive insertion of the penis. In this procedure, her husband considers her to have low sexual drive and
the couple should be instructed that the man is to lie on to be insufficiently interested in sex? In these cases,
his back and not to move or thrust. The woman is to what the woman is actually asking the therapist for is
kneel above him, grasp his penis, and very gradually guidance of the issue of what is a "normal" frequency
and slowly insert just the glans into the vagina. If all of sex. Even though extreme cases are clear, most
goes well, on successive occasions, she can pro- clinical cases fall into areas in which questions of defi-
nition become paramount. That is, if the woman re- partner, poor sexual skills in the partner, marital con-
ports that she likes sex three to four times a week but flict, fear of closeness, concerns over "personal
her husband wants sex twice a day, presumably most space" in the relationship, a passive aggressive style in
professionals will feel comfortable in reassuring the resolving other marital issues, and loss of erotic attrac-
woman that her level of sexual interest is normal. The tion to the partner following marriage or childbirth.
clinician may go on to explain that although her hus- Obviously, with such diverse etiology, treatment of
band's level of sexual interest is a good deal higher low sexual desire needs to be complex and multi-
than average, it may not necessarily be abnormal in the faceted. Low sexual desire cases do not respond well
sense of being pathologic. In cases in which husband to standard sex therapy procedures which are focused
and wife differ somewhat on desired frequency of sex on reduction of performance anxiety and on skill
but both of them seem to be within the broad limits of training.
what might be considered normal, simple reassurance 1. LoPiccolo and Friedman (1988) described a com-
is perhaps the best office management procedure. That plex, four element sequential treatment program for
is, the couple should be told that they both are in the low sexual desire that has been found to have good
normal range for desired frequency of sex, and that effectiveness (Schover & 1. LoPiccolo, 1982). The
they must happen to be slightly mismatched. The ques- first component of treatment is called affectual
tion remains, of course, just what is the normal range. awareness. In this phase of therapy, the focus is on
Various sociological studies from the work of getting the client in touch with any negative attitudes,
Kinsey et al. (1948; Kinsey, Pomeroy, Martin, & Geb- beliefs, and cognitions regarding sex. For example,
bard, 1953) to more recent studies (Hunt, 1974) have the client may feel that sex is basically not something
shown that there is a very broad range of what might be which a decent woman, a wife, and a mother engages
considered a normal frequency of sex. Average fre- in. Often clients will report that although because of
quency seems to be related to age, number of years their parents or their religion they were brought up to
married, socioeconomic status, religious beliefs, and a have such negative attitudes, they have overcome these
host of other sociological variables. Survey studies attitudes as a result of their education and their grow-
show an "average" frequency of sex of around three ing up into an independent person. Close examination,
to four times a week for younger couples, declining to however, reveals that although this change has oc-
twice a week for· couples in their 40s, and down to curred at an intellectual or a cognitive level, it is not a
frequencies of once every 2 weeks or once a month for true "gut-level" feeling change. Making the person
couples in their 60s, 70s, and 80s. These "average" aware of these lingering negative residues of earlier
values should not be taken too seriously, however, as indoctrination constitutes the affectual awareness
there is a very broad range of reported frequencies in stage of therapy.
all sociological survey studies. The second phase of sex therapy for low sexual de-
The causes of low sexual desire are highly diverse sire involves insight-oriented therapy. In this phase of
and vary from case to case. 1. LoPiccolo and Friedman therapy, clients are helped to gain an understanding of
(1988) list the following as common individual why they have the negative emotions that were identi-
courses of low sexual desire: religious orthodoxy, fied in the affectual awareness phase. Influence of ear-
anhedonic or obsessive-compulsive personality struc- lier experiences, attitudinal indoctrination, reserva-
ture, gender identity or object choice issues (homosex- tions about what the spouse might think if the patient
ual orientation), specific sexual phobias (such as to behaves in a truly unrestrained way sexually, for exam-
activities that occurred during a sexual assault), a hid- ple, might be insights into the causes of the negative
den sexual deviation, fear ofloss of control over sexual feelings the client has toward sex. Steps 1 and 2 are, in
urges, fear of pregnancy, depression, hormonal abnor- some sense, only preparatory for the more active inter-
malities, medication side effects, concerns about ventions of Steps 3 and 4.
aging, and the "widower's syndrome," in which an The third phase oftreatment involves cognitive ther-
elderly widowed male rushes into a second marriage apy. The cognitive phase of therapy is designed to alter
before resolving the grief and mourning over the death irrational thoughts that inhibit sexual desire. Patients
of his first wife. are helped to identify self-statements that interfere
Relationship causes oflow desire listed by 1. LoPic- with sexual desire. They are taught that unrealistic or
colo and Friedman (1988) include lack of attraction to irrational beliefs may be the main cause of their emo-
tional reactions, and that they can change these unre- training in negotiation are examples of such behavioral
alistic self-statements. With change, patients can re- interventions. Third, behavioral assignments are used
evaluate specific situations more realistically and for skill training. If patients are successful in therapy,
reduce negative emotional reactions that cause low they may find themselves in sexual (and other) situa-
desire. tions that they have been avoiding in the past, and that
With the help of the therapist, individualized coping thus they are ill-prepared for. They often need to devel-
statements are generated to help the patient cope with, op new behavioral repertoires to function effectively
rather than avoid, emotional reactions to particular and comfortably in these situations.
sexual situations. Typical coping statements might in- For those with a particularly strong reaction to sexu-
clude, "Just because I engage in sex doesn't mean I'm al activity, hand or body massage is sometimes a less
a bad person," or "I know that when I was younger I threatening first step in sensate focus. Behavior re-
learned to feel guilty about engaging in sex and I don't hearsal, role-playing other characters (e.g., very sexy
want to, nor do I have to, feel that way anymore," or women), and role reversal are useful interventions that
"If I allow myself to enjoy sex, it does not mean that I often elicit affective responses. Depending upon a
will lose all control." Another useful cognitive inter- case's particular etiological factors, contact with sym-
vention is to help patients identify and reevaluate their pathetic clergy, stress reduction interventions, and
worst fears. For example, they are asked to imagine the problem-solving skills all may be used as part of the
worst thing that could happen if they became sexually behavioral intervention. Bibliotherapy, education on
aroused. They are taught that their behavior, for the human sexuality and sexual techniques, and training in
most part, is under their own control, that they can take sexual initiation and refusal are just some of the inter-
responsibility for what they currently do, and that it is ventions that may help patients function more effec-
within their own power to change their own behavior. tively, once initial therapeutic gains allow for this skill
For patients whose low drive is related to family of training.
origin issues, coping statements differentiating the A particularly useful behavioral intervention for low
sexual partner from the opposite sex parent are useful. sexual desire is drive induction or "priming the
For example, for a woman with a low sexual drive who pump." This intervention makes sex more salient to
was raised in a family with an alcoholic father, a useful the low drive patient, who typically avoids all sexual
coping statement is, "My husband is not like my fa- stimuli. This can be done with the help of a desire
ther. I deliberately picked a man I can trust, who is checklist or a desire diary, in which the patient records
dependable, and who is not an alcoholic." We often all sexual stimuli, thoughts, and emotions. Another
have our patients write 15 to 20 such coping statements such intervention is the assignment of fantasy
on cards and ask them to spend some time every day "breaks" during the day, in which the patient is asked
reading and elaborating on the coping statements. to spend several minutes consciously having a sexual
The fourth element of this treatment program con- fantasy. Patients are also assigned to go to films with
sists of behavioral interventions. Behavioral assign- sexual content, read books with sexual content, rent
ments are used throughout the therapy process and erotic videos, look at erotic magazines, read collec-
include basic sex therapy, in vivo desensitization pro- tions of sexual fantasies, and so forth.
cedures (Masters & Johnson, 1970), as well as other As part of drive induction, patients are also assigned
sexual and nonsexual behavioral procedures. Specific to engage in casual, low intensity physical affection. In·
behavioral assignments are chosen to complement and most low drive cases, there is very little kissing, hug-
potentiate the other three components. First, behav- ging, and petting. This affection deficit develops be-
ioral assignments are used early in therapy to help cause of the low drive, as the low drive partner learns
evoke feelings in patients during the experien- not to be affectionate for fear that the spouse will mis-
tial/sensory awareness exercises. Thus, patients who interpret casual affection as sexual initiation.
have actively been avoiding sexual contact can focus In summary, this program first gets patients to attend
on and label feelings that occur during sensate focus to their bodies for cues to the feelings that result in·
exercises. Second, behavioral interventions are used to disinterest or avoidance of sex. Second, insight-ori-
help patients change nonsexual behaviors that may be ented therapy gets patients to understand the cause of
helping to cause or maintain the sexual difficulty. As- these negative feelings. Cognitive coping statements
sertion training, communication training, and skill are then generated to lead to alternative responses.
Finally, behavioral interventions give practice in alter- References

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CHAPTER 27
Sexual Deviation
Nathaniel McConaghy
Conditions previously considered sexual deviations could make covert sensitization unsuitable for the
were separated in the latest revision of the American many paraphiliacs whose behaviors are currently be-
Psychiatric Association's Diagnostic and Statistical lieved not to be sexually motivated.
Manual of Mental Disorders (DSM-III-R) (1987). Assessment techniques capable of measuring sub-
Paraphilias remained with Sexual Dysfunctions as jects' sexual arousal to paraphilic stimuli would allow
Sexual Disorders. Gender Identity Disorders were determination of the relative contributions of sexual
classified as Disorders Usually First Evident in Infan- arousal and of nonsexual motivating mechanisms to
cy, Childhood, or Adolescence. A residual class of the strength of paraphilic urges. It is widely accepted
Other Sexual Disorders included nonparaphilic sexual that such assessment techniques exist for male sub-
addiction and persistent and marked distress about jects, and they are in common use both in diagnosis
one's sexual orientation. and in assessment of treatment outcome of para-
The reference to nonparaphilic sexual addiction philiacs. Establishment of their validity is therefore
possibly reflected a recent paradigm shift in constructs not merely of theoretical but of practical and, indeed,
concerning the motivation and treatment of para- of ethical significance (McConaghy, 1989).
philias. The hypothesis (McConaghy, 1980) that sexu-
al urges, which are experienced by the subject as com-
pulsive are, in part, motivated by behavior completion Assessment of Paraphilias
mechanisms, which are similar to those operating in
the nonsexual disorders of impulse control, led to use Determination of subjects' penile-circumference re-
of a low-dose short-duration form of medrox- sponses to paraphilic urges has become the major form
yprogesterone therapy and to the development of a of assessment advocated by North American research-
behavioral procedure-imaginal desensitization. This ers. The method is derived from measurement of sub-
procedure was shown (McConaghy, Armstrong, & jects' penile-volume responses to erotic stimuli of brief
Blaszczynski, 1985) to be more effective than covert duration introduced by Freund (1963). He used it to
sensitization, the most commonly used treatment for assess subjects' sexual orientation and pedophilic in-
paraphilias in North America. Covert sensitization terest. The transducer Freund developed was very
aims to weaken the sexual motivation of paraphilic complex. McConaghy (1967) introduced a simpler
urges by aversive conditioning. Adherence to that aim one, also used to assess penile-volume changes, and a
brief standardized film procedure to present 10-sec
Nathaniel McConaghy • School of Psychiatry, University movie segments: 10 of nude women and 10 of nude
of New South Wales, Sydney, Australia. men. The validity of volume measurement of the onset
565
of penile tumescence to correctly identify the sexual heterosexual men; but no attempt was made in either
orientation of most or all subjects who were being study to use it to identify the orientation of the indi-
investigated was established in a number of studies vidual men (Bancroft, 1971; Mavissakalian,
(Buhrich & McConaghy, 1977, 1978; Freund, 1963; Blanchard, Abel, & Barlow, 1975). The authors of
McConaghy, 1967, 1976). both studies showed no awareness that this degree of
Evidence that such penile-volume assessment accu- validity was limited in comparison to that of penile-
rately discriminated most subjects with from those volume assessment. The two measures continued to be
without pedophilic interest was less convincing. treated as equivalent (Abel, Blanchard, & Barlow,
Freund's analysis of his results in the 1963 study was 1981; Blader & Marshall, 1984; Hinton, O'Neill, &
difficult to follow and possibly took advantage of Webster, 1980), despite attempts by Freund, Lan-
chance differences by post hoc analysis. A later study gevin, and Barlow (1974) and McConaghy (1974) to
(Freund, Chan, & Coulthard, 1979) reported that a stress their difference.
standard procedure misdiagnosed only 4 of 88 sex of- The misplaced faith in the validity of penile-strain-
fenders, who admitted being attracted to pubescent or gauge assessment of sexual arousal in relation to sexu-
prepubescent children, in that they were assessed as al orientation was transferred to its use in assessment to
erotically preferring physically mature persons. How- paraphilias. Even when it failed to discriminate para-
ever, one third of 18 nonadmitters were misdiagnosed philiacs from controls, its validity remained unques-
in this way. Error concerning the preferred sex or age tioned. It was concluded that the paraphiliacs were not
range of the child occurred in 21 of the 88 admitters sexually motivated.
and a further one third of the nonadmitters. Modifica- Abel, Barlow, Blanchard, and Guild (1977) and
tions were reported that could improve the assessment. Barbaree, Marshall, and Lanthier (1979) reported that
Fisher, Gross, and Zuch (1965) introduced a mercu- convicted rapists showed mean penile-circumference
ry-in-rubber tubing strain gauge that measured penile responses to a 2-min audio-taped individualized de-
circumference changes to detect nocturnal erections. scription of sexual interactions carried out by threat or
Bancroft, Gwynne Jones, and Pullan (1966) reported force, equivalent to their penile-circumference re-
the use of a similar strain gauge in treatment of a ped- sponses to descriptions of mutually consenting inter-
ophile. They concluded that for the device to register course. Nonrapists showed significantly lower mean
responses to erotic photographs, usually some mental penile-circumference responses to descriptions of
imagery was required, and most responses occurred forced rather than of consenting intercourse. Abel,
within 5 min of stimulus exposure. Penile-volume re- Becker, Blanchard, and Djenderedjian (1978) found
sponses occurred within 10 to 13 sec of stimulus ex- that a "rape index," the ratio of penile-circumference
posure and without instructions to the subject to induce responses to rape cues versus consent cues, correctly
imagery. The difference should have suggested that classified 78% of rapists and 75% of nonrapists, using
penile-circumference and penile-volume measures of a cutting point of 0.9. Quinsey, Chaplin, and Varney,
sexual arousal differed significantly. Penile-circum- using the rape index with a cutting point of 0.8, were
ference responses were introduced to measure full or able to correctly classify 80% of rapists and 74% of
near full erection. Penile-volume responses measured normal controls (Murphy, Krisak, Stalgaitis, & Ander-
the changes associated with onset of penile tumes- son, 1984). Baxter, Marshall, Barbaree, Davidson,
cence. Unfortunately, the identification of penile cir- and Malcolm (1984) calculated rape indices of 60 rap-
cumference with penile volume responses made by ists and 18 hebephiles and reported the indices did not
Bancroft et at. was accepted and promulgated by correlate with number of rapists' sex offenses or degree
Zuckerman (1971) in a widely quoted review. He rec- of violence used in the offenses, in contrast to the
ommended that the strain gauge be used to measure findings of Abel et al. (1978). In their study of rapist
sexual arousal, because it was simpler to apply and did and nonrapist incarcerated offenders, Murphy et al.
not stimulate as large an area of the penis. His recom- found that the mean rape index of the rapists did not
mendation was almost universally followed. differ significantly from that of the nonrapists. Using
Because of the identification of strain gauge and cutting points of 0.8, 0.9, or 1, rape indices did not
volume responses, there was no expressed need to vali- discriminate the two groups. Baxter, Barbaree, and
date separately the strain gauge. In two studies, it was Marshall (1986), commenting that previous studies
shown to have sufficient validity as a measure of sexual had used relatively small samples, investigated 60 rap-
orientation to discriminate groups of homosexual from ists and 41 male students. The rapists, like the con-
CHAPTER 27 • SEXUAL DEVIATION 567
troIs, responded less to rape cues than consenting cues, min of audio presentation. They decided that child
and the pattern of sexual arousal of the two groups was abusers required longer stimulus presentation. With a
not grossly different. In seeking reasons for the con- caution unique in penile-circumference assessment lit-
trast between their findings and those of previous stud- erature, they pointed out that there existed no long-
ies of rapists, the authors did not consider the pos- term predictive validity or reliability data for the pro-
sibility that the validity of penile-circumference cedure, and it should be regarded strictly as holding
assessment of sexual arousal was low. They consid- potential for being an objective method for classifying
ered its validity to have been established by the studies sexual child abusers.
of penile-volume assessment of sexual orientation. Without reviewing the numerous studies demon-
In relation to assessment of pedophiles, Quinsey, strating the validity of penile-volume as compared to
Steinman, Bergersen, and Holmes (1975) reported penile-circumference assessment of sexual arousal,
that molesters of female children showed maximal Wheeler and Rubin (1987) recently concluded that the
penile-circumference responses to pictures of nude volumetric device was not more sensitive than the cir-
female children compared to pictures of nude males cumference measure. The methodology of their study
and females of other ages, but failed to replicate the made this conclusion inevitable. It reflected failure to
finding (Quinsey, Chaplin & Carrigan, 1979) as did appreciate that valid penile-volume responses do not
Baxter et al. (1984). Quinsey and Bergersen (1976) assess degree-Oferection but the phase of i:: rapid
reported that normal subjects could influence their initiation (McConaghy, 1989). The valid volume re-
penile-circumference responses to such pictures so as sponses so far reported occurred within a few seconds
to appear pedophilic, suggesting that pedophiles could of stimulus presentation, so that a series of stimuli of
reverse this procedure. immediate erotic impact, such as pictures of nudes,
Abel, Becker, Murphy, and Flanagan (1981) devel- were required. Wheeler and Rubin used a lO-min film
oped a pedophile aggressive index that was based on of unstated erotic content as stimulus, a procedure
the penile-circumference response of six nonag- which was totally inappropriate to determine the rela-
gressive and four sadistic child abusers to 2-min au- tive validities of penile-volume and penile-circum-
diotapes of interactions with children. The interactions ference responses as measures of sexual arousal. The
included nonsexual physical assault, and sexual con- factors determining the dynamics of penile tumes-
senting, nonconsenting, nonforceful, and nonconsent- cence of rapid onset may well be different from those
ing forceful assault. The less dangerous offenders which operate to produce or maintain greater degrees
showed a mean index of .67 and the sadistic offenders, of erection. Certainly, with brief exposures, subjects
2.16. In investigating this finding, Avery-Clark and have less time to alter their penile responses by fantasy.
Laws (1984) altered the method of assessing the ped- Evidence of the effectiveness of using fantasy to modi-
ophile aggressive index and the duration of stimulus fy penile-circumference responses to stimuli of longer
presentation. They rated 50 men convicted of child duration has been reported (Alford, Wedding, &
assault as more or less dangerous. Eight were rejected Jones, 1983).
as unable to be rated with sufficient confidence, and a Despite their finding of no differences between pen-
further 11 subjects because they did not produce penile-circumference responses of rapists and normals,
ile-circumference responses to the stimuli equivalent which conflicted with findings of earlier studies,
to 20% of erection. Ten audiotapes of approximately 5- Marshall, Earls, Segal, and Darke (1983) recom-
min duration, varying on dimensions of degree of sex- mended that responses of individual sex offenders be
uality and aggression, were used as stimuli. The less used to assess their deviant tendencies both in diag-
dangerous offenders produced an average, dangerous nosis and in evaluation of treatment outcome. They
child abuser index of .54, and the more dangerous of concluded that absence of the expected penile-circum-
1.04. The difference between the mean maximum ference responses in rapists did not demonstrate lack of
erection scores of the two groups at the end of 2 min validity of the assessment. Rather, they questioned the
was not great, and it would appear the study did not role of sexual motivation in rape and hypothesized that
replicate that of Abel et al. (1981), which used 2-min the manner in which the stimuli were presented in their
stimulus presentations. Avery-Clark and Laws re- study may have been insufficiently prolonged, despite
ferred to an earlier finding of Abel et al. (1977) that the fact it matched that used in the earlier studies. The
offenders against adults produce the greatest and statis- lack of consistent evidence for the validity of penile-
tically significant penile-circl' 'llference responses at 2 circumference assessment of rapists provided the bio-
logical foundation for the widely accepted belief that outcome, including pre- and posttreatment assessment
rape is not motivated by sex but by aggression. of subjects' sexual and social behavior by outside
Marshall et al. (1983) concluded that sources as well as self-report, physiological measures
including galvanic skin re~ponse (GSR), heart rate,
some rapists are sexually deviant and some child molesters are blood pressure, and penile plethysmography, semantic
not. Since we cannot know this in advance in any particular case,
we must routinely assess the erectile preferences of all these differential ratings, and objective psychological tests.
men. (p. 156) They did not discuss the validity of these measures,
except to comment that the use of penile-response
If there is any possibility that penile-circumference measures to assess outcome was of questionable
assessment could affect a subject's legal disposition, it validity.
would be considered by many to be ethically question- Moore, Zusman, and Root (1985) pointed out the
able, even if substantial evidence for its validity with lack of relevance of the findings of intensive treatment
individual subjects existed. In the absence of such evi- programs for the majority of settings treating sex of-
dence, its use in this situation or in reaching decisions fenders. Many offenders are only able to attend weekly
concerning patients' assessment and treatment seems because of their need to hold jobs and otherwise exist
unacceptable. in the world. Studies using outcome measures, such as
Assessment of paraphilic urges and behaviors cur- those required by Kilmann et al., are not practical for
rently must rely on subjects' self-report and, if avail- the majority of such offenders. Noncompliance in-
able and relevant, the behavioral observations of ac- creases with the complexity, duration, and cost of ther-
quaintances and victims. Fortunately, the marked apy (Appel, Saab, & Holroyd, 1985).
distrust of self-report, which paralleled the over-enthu- A more pertinent criticism made by Kilmann et at.
siastic acceptance of the validity of behavioral meth- (1982) of the studies they reviewed was that very few
ods of assessment in the 1970s, now appears unwar- included a control condition and that most were single-
ranted (Bellack & Hersen, 1988; McConaghy, 1988a). case studies. It was not possible to determine whether
The impossibility of using behavioral observation for one type of treatment was clearly superior for one or all
assessment of most paraphilic behaviors has become paraphilias. Most studies reported the use of behav-
less important. The significant correlations of sex of- ioral treatments, especially aversive therapies. The lat-
fenders' reported reduction of paraphilic urges and be- ter procedures differed considerably in the sexual,
haviors with general tension (McConaghy et al., 1985) aversive, and relief stimuli used. The data did not al-
and with state anxiety (McConaghy, Blaszczynski & low meaningful comparison of the relative efficacies
Kidson, 1988) provided evidence of the reliability of of these differences. Kilmann et at. concluded that for
their self-reports. The significant correlations between many subjects, regardless of their specific sexual para-
self-reported reduction in paraphilic urges and behav- philias, a comprehensive, multimodal behavioral
iors and the reduction in testosterone levels (unknown treatment program seemed to be essential in prevent-
to both assessor and patients) in sex offenders treated ing or reducing recidivism. Given their earlier com-
with medroxyprogesterone provided evidence of the ment concerning the impossibility of drawing conclu-
validity of the self-reports (McConaghy et at., 1988). sions from the studies, the fact that no studies
compared multimodal programs with less comprehen-
sive ones, and that Kilmann et al. provided no analysis
Treatment of Paraphilias of treatment outcomes to support their conclusion, it
would seem they reached it primarily on the basis of its
Studies evaluating treatment of paraphilias prior to plausibility.
1980 were reviewed by Kilmann, Sabalis, Gearing, The conclusion that multimodal behavioral pro-
Bukstel, and Scovern (1982). About 50 studies re- grams should be used routinely in treating paraphilias
ported treatment of individual paraphilias, mainlyex- has continued to be advocated (Bancroft, 1983) with-
hibitionism. In a further 30 studies or so, groups with out recognition that it requires empirical support.
heterogenous paraphilias were treated. Kilmann et at. When such support has been sought in the treatment of
were critical of the strong reliance upon subjects' ver- cigarette dependence (Lichtenstein & Brown, 1982),
bally obtained self-reports to assess outcome. Though alcohol abuse (Lawson, 1983), and migraine (Sorbi &
pointing out that the privacy of much sexual behavior Tellegen, 1984), it has not been obtained. Indeed,
made outcome measurement difficult, they concluded some studies found multimodal therapy to be less ef-
that future research should utilize multiple measures of fective than a simple therapy.
Perhaps because it was not possible to derive valid comparison studies with paraphilic subjects appear to
conclusions concerning the specific effectiveness of have been carried out in the present decade. A more
the therapies investigated in the numerous studies of likely explanation for the currrent situation is that, as
paraphilias in previous decades, or because it was ac- the techniques now in use are employed in a multi-
cepted that their effectiveness was established, few modal fashion, their relative efficacy is not of immedi-
studies evaluating therapies for paraphilias and addic- ate consequence. If the patient does not respond to
tive sexuality have been reported in the present decade. one, another can be added until, for whatever reason,
When, in a few studies, single-case research design the majority of patients show the appropriate penile-
was employed, the essential reversal stage was in- circumference responses or report an acceptable
cluded but the absence of a reversal effect was not outcome.
addressed (Hayes, Brownell, & Barlow, 1983; La-
montagne & Lesage, 1986). Reversal is employed in
single-case design to establish that a treatment out- Aversive Therapy
come is produced specifically by a particular con-
tingency. If the outcome appears when the contingency Aversive therapies are used to reduce the frequency
is introduced and disappears (or reverses) when the of particular behaviors or feelings. Stimuli that
contingency is withdrawn, this is accepted as evidence provoke the behaviors or feelings are presented to the
of specificity. With animal subjects, which have no subject and followed by unpleasant stimuli-a clas-
expectancy of improvement, this acceptance is justi- sical conditioning procedure. The use of aversive ther-
fied. With humans it is possible that expectancy pro- apy to modify sexual behavior was reintroduced by
duces the appearance and the reversal of the response Freund (1960), using an emetic as an aversive stim-
to the introduction and the withdrawal of the con- ulus. His aim was to reorient homosexuals to hetero-
tingency. Use of a placebo contingency does not solve sexuality. However, it was not clear that he believed
the problem. As Kazdin and Wilcoxin (1976) pointed the technique acted by conditioning to produce an aver-
out, failure of the placebo to produce an effect could be sion. Nevertheless, this concept was widely accepted
due to the placebo's producing less expectancy. The (Eysenck, 1960; Feldman & MacCulloch, 1964). This
patient may consciously or unconsciously regard the acceptance had the advantage that most workers fol-
placebo therapy as less credible. lowed Eysenck's advice and used much less unpleas-
A further problem with reversal effects is that they ant, but equally effective (McConaghy, 1969, 1970;
can be used only to evaluate a therapy whose effect McConaghy, Proctor, & Barr, 1972), brief, unpleasant
disappears once the therapy is withdrawn. Few thera- electric shocks rather than emetic drugs as the aversive
pists would find such therapy useful. In theory, the stimulus. Eysenck considered such shocks preferable
effect will not disappear on cessation of the therapy if it on the theoretical ground that being more accurately
is withdrawn in a very gradual fashion, until the fre- timed, they would be more effective in conditioning.
quency of its administration is equivalent to that oper- Though a number of workers reported reduction in
ating in the environment to which the patient will re- the behaviors or feelings of subjects treated with aver-
turn. To my knowledge, such gradual withdrawal has sive procedures throughout the 1960s, they rarely re-
never been attempted in the single-case design evalua- ported the presence of the expected aversive re-
tions of therapy carried out in previous decades. In sponses. Nevertheless, the belief that the procedure
these studies, the patient was discharged after a final acted by conditioning remained unquestioned (Mac-
reintroduction of treatment with the hope that his or her Culloch & Feldman, 1967). It was not until the end of
normal environment would maintain the treatment ef- the decade that the absence of the expected condi-
fect without reversal. Criticisms of this methodology tioned responses following aversive therapy was em-
(McConaghy, 1977, 1982) and, more significantly, phasized (Bancroft, 1969; McConaghy, 1969).
Hersen's (1982) suggestion that single-case design be Subsequently, an equally unquestioned assumption
used to generate and refine treatment hypotheses, has been advanced: that aversive therapies produce not
which could then be pitted against each other in larger- aversion, but indifference to the conditioned (Em-
scale group-comparison studies, may have led workers melkamp, 1982) or formerly attractive stimuli
to conclude enough treatment hypotheses are available (Hawton, 1983). Wolpe (1986) recently argued that
for the group-comparison studies to be initiated. How- this indifference is due to classical conditioning, even
ever, apart from two studies by the author and col- though no conditioned response is observed. He sug-
leagues (McConaghy et aI., 1985, 1988), no group- gested that during the procedure the response to the
conditioned stimulus is inhibited by the averSive was more understandable. Without careful question-
arousal to the unconditioned aversive stimulus, leading, it is easy to conclude from successfully treated
ing to the development of conditioned inhibition. This subjects' self-reports that they experience indifference
conditioned inhibition is hypothesized to be responsi- to those stimuli that caused them to carry out behaviors
ble for the subsequent indifference to the conditioned or to experience feelings beyond their control prior to
stimulus. Wolpe concluded that conditioned inhibition treatment. Careful questioning of such subjects elicits
is easier to produce than a conditioned fear response. the information that, when confronted with such stim-
Hence, no overt conditioned response is apparent in uli, they still experience attraction to them. However,
addition to the indifference. In fact, substantial evi- the urge to respond behaviorally, or to become preoc-
dence exists indicating (1) that it is an oversimplifica- cupied with fantasies concerning the stimuli, is much
tion to conclude that aversive therapies produce indif- reduced or absent. This complex response has been
ference, (2) that aversive therapies do not produce their noted by other workers who follow aversive therapy.
effects by conditioning. The strength and the re- MacCulioch and Feldman (1967) reported that six pa-
sistance to extinction of conditioned responses, tients who responded well to aversive therapy for com-
whether excitatory or inhibitory, are determined by pulsive homosexuality "were still displaying an occa-
many variables, including the strength of the condi- sional and very slight degree of homosexual interest in
tioned and unconditioned stimuli, the sensory directly observing males without, however, any subse-
modalities in which they are administered, the number quent fantasy" (p. 596).
of administrations, and the time interval between ad- In view of the lack of evidence that penile
ministrations (Pavlov, 1927). If aversive therapies plethysmography validly assesses paraphilic im-
were administered according to conditioning pro- pulses, it cannot be used to establish the physiological
cedures, which varied markedly on these variables, the sexual responses of paraphiliacs following aversive
resulting conditioned responses should vary markedly therapy. The validity of penile-volume plethysmogra-
in strength and resistance to extinction. If the therapeu- phy in assessing subjects' reported sexual orientation
tic response were dependent on conditioning, it should enabled it to be used to assess response to aversive
vary similarly. therapy for nonparaphilic sexual addiction. A series of
A number of studies (Feldman & MacCulioch, studies investigating the response of homosexual sub-
1971; McConaghy, 1969, 1970; McConaghy et al., jects who reported this disorder enabled chance or
1972) compared treated subjects' responses to a vari- Type 1 errors to be detected and valid findings to be
ety of aversive therapies, which differed in the nature replicated. In the initial studies (McConaghy, 1969,
of the conditioned and unconditioned stimuli, the 1970; McConaghy et al., 1972; McConaghy & Barr,
number of trials, and the pattern of reinforcement. 1973), small reductions in subjects' penile-volume re-
There were no significant differences in response to sponses to pictures of nude men followed aversive
these differing therapies. To provide additional evi- therapy, but did not correlate consistently with the sub-
dence that aversive therapies did not act by condition- jects' reported reduction in urge to engage in addictive
ing, a further comparison study was carried out which sexual activity or fantasy. In a fourth study, aversive
included an aversive procedure administered in a back- therapy was compared with a positive conditioning
ward conditioning paradigm (McConaghy & Barr, procedure that was aimed at increasing heterosexual
1973). Backward conditioning is relatively ineffective arousability (McConaghy, 1975). The latter procedure
in producing conditioned responses (Pavlov, 1927). If proved ineffective and so acted as a placebo procedure.
aversive therapies acted by conditioning, the backward Significantly greater reduction in addictive sexual be-
procedure should be considerably less effective than havior was reported at 1 year following aversive thera-
one administering the same conditioned and uncondi- pyas compared to positive conditioning. Equivalent
tioned stimuli, in the same number of trials, but in a small reductions in subjects' penile-volume responses
forward conditioning paradigm. Again, there was no to pictures of nude men followed both procedures. The
difference in responses of the subjects randomly allo- reductions did not correlate with reported reduction in
cated to one or the other of the two procedures. addictive homosexual fantasy or behavior. It was con-
In addition to this evidence establishing that aver- cluded that these small reductions in penile-volume
sive therapies do not produce their effect by condition- responses were a placebo effect unrelated to the specif-
ing, further evidence demonstrated that they do not ic effect of aversive therapy in reducing the strength of
produce indifference. Acceptance of this latter belief addictive sexuality. The penile-volume assessments of
the treated homosexuals remained significantly different showed a penile-circumference response to the picture
from those of heterosexual paraphiliacs who had received of a child one third or more of his largest response to all
aversive therapy, with the majority of the homosexual such pictures, a red light was presented. On 40% of
subjects continuing to show a predominant homosexual such occasions an electric shock was also adminis-
orientation. Hence, following treatment the subjects' tered. In subsequent sessions, the light and shock were
penjle-volume responses were still providing a valid as- presented when penile-circumference responses less
s~sment of their sexual orientation, demonstrating they than one third occurred. Using penile-circumference
were not indifferent to homosexual stimuli. responses to pictures of children to assess outcome, the
It was concluded from penile-volume assessments authors reported better response to the red light bio-
that aversive therapy did not alter sexual orientation, feedback with, as compared to that without, signalled
and from the consistent self-reports of patients, that it punishment. This procedure has one potential limita-
did reduce the secondary reinforcing properties of sit- tion. In some subjects, the increase in penile blood
uations in which the subjects had carried out homosex- flow occurring at the onset of tumescence is insuffi-
ual activity in the past. When in these situations fol- cient to maintain both length and circumference in-
lowing treatment, they could, if they wished, resist crease (McConaghy, 1977). As penile length and vol-
carrying out the activity which prior to treatment they ume increase, the circumference temporarily dimin-
had experienced as compUlsive. However, those sub- ishes. In subjects showing these paradoxical penile
jects who wished to continue acceptable homosexual circumference responses, the procedure would punish
behaviors had no difficulty in doing so. Their ability to penile detumescence to pictures of children. This may
enjoy those behaviors was unchanged. Aversive thera- not affect treatment outcome if the procedure does not
py produced control, not indifference. act by conditioning.
Because of the lack of placebo-controlled studies of
aversive therapy with paraphilias, the assumption that
it has specific effects, reflected in its widespread use to Covert Sensitization
treat these conditions, can be justified only by extrapo-
lation from the placebo-controlled trials of its use in Covert sensitization was the form of aversive thera-
addictive homosexuality (Birk, Huddleston, Miller, & py used in about one tenth of the studies employing
Cohler, 1971; McConaghy, 1975). These studies pro- aversive therapy to treat paraphilias until 1974, and in
vide no reason to believe that aversive therapy in para- one half of those published from 1975 to 1980 (Kil-
philias would alter the sexual motivation of para- mann et al., 1982). Currently, it is considered the pre-
philias. This belief had produced the expectation that ferred form of aversive therapy in the United States
aversive therapy would modify subjects' penile re- (Marshall et al., 1983). Termed "covert sensitization"
sponses as valid measures of such motivation. It has by Cautela (1967), the treatment was introduced by
important therapeutic implications if interpreted to Gold and Neufeld (1965). They combined a desensi-
mean that aversive therapy would not be useful in para- tization procedure with imagined aversive stimuli. The
philiacs who do not show penile-circumference re- patient was trained to relax and then was instructed to
sponse evidence of their paraphilia. Whatever its mode visualize carrying out the behavior he wished to con-
of action, almost all studies of aversive therapy in para- trol. He then visualized prohibitions, such as the image
philias reported some positive effects (Kilmann et al., of a policeman standing nearby. As developed by Cau-
1982). This clinical evidence of its efficacy presum- tela, the aversive stimuli included visualizing an at-
ably explains why it remains the most commonly used tractive but prohibited person being covered in scabs
treatment in North America to give subjects control of and giving off a terrible stench so that the patient was
deviant sexual behaviors which they experience as nauseated. Maletzky (1973) attempted to enhance the
compUlsive. effect of covert sensitization by augmenting the aver-
sive image with a noxious smell. Lichstein and Hung
(1980), in reviewing studies employing covert sen-
Aversion-Assisted Biofeedback sitization, concluded its widespread acceptance
stemmed in part from its not needing equipment, its
Quinsey, Chaplin, and Carrigan (1980) investigated safe and convenient form of administration, and its
aversive-assisted biofeedback in imprisoned child mo- ability to be self-administered by the patient. Evidence
lesters. When in the first treatment session the subject reviewed by Lichstein and Hung, including that from
studies using a backward conditioning paradigm, indi- treatment of sexual aggressors, they used satiation
cated that, like electric shock aversive therapy, covert therapy. The patient was instructed to masturbate con-
sensitization does not act by conditioning. Also, there tinuously for I hour (whether or not he ejaculated)
was considerable variation in the number and duration while verbalizing aloud every variation he could think
of treatment sessions and the number of pairings of the of on his deviant fantasies. Marshall et al. also re-
imagined target behavior with the undesirable conse- ported a self-managed version of the therapy which
quence, as in studies employing aversive therapy with they said had been described by Abel and Annon in an
unpleasant physical stimuli. Lichstein and Hung point- unpublished conference paper. The patient carried out
ed out the paucity of adequately controlled studies of the procedure at home, recording his verbalized fan-
covert sensitization. Of those using single-subject de- tasies on a tape recorder, so that the therapist could be
signs, they considered only that by Barlow, Agras, sure he was following instructions. Reduction of de-
Leitenberg, Callahan, and Moore (1972) to have con- viant arousal was also reported to follow a form of
trolled for the effect of patients' expectancy of im- satiation therapy in which sadistic or aggressive fan-
provement. The method of control for the two forms of tasies were extensively rehearsed in a nonaroused state
treatment compared, was to tell subjects that visualiz- (Quinsey, 1984). No comparison studies of these
ing deviant images repeatedly without nauseating im- forms of satiation therapy have been carried out.
ages was therapeutic, but visualizing them with nau-
seating images would increases their deviant behavior.
This information appears so opposed to common sense Systematic Desensitization
expectations that it would seem doubtful that the sub-
jects believed it. In fact, the authors reported that one Bond and Hutchison (1960) initiated treatment with
subject did not and continued to visualize nauseating systematic desensitization in a subject with severe ex-
images against instructions. A further problem with hibitionism. His deviant behavior was preceded by
the study was that it discounted patients' self-reports of feelings of sexual excitement and tension, activated by
improvement and relied totally on their penile-circum- the sight of attractive young women. The authors con-
ference responses as the measure of outcome. The low sidered the subject's exhibitionism to be an instrumen-
validity of this measure has been previously discussed. tal act which reduced the anxiety response cued off by
Barlow et al. concluded that the addition of the nau- the specific stimuli. They reportedly based their desen-
seating aversive images increased the therapeutic ef- sitization procedure on that described by Wolpe. As
fect of desensitization to the deviant images. they presented images conducive to exposure in the
N() group design studies evaluating covert sensitiza- first session, the relaxation training must have been
tion in treating addictive sexual behaviors had been much curtailed. Wolpe (1958) trained subjects with
carried out when Lichstein and Hung reviewed the progressive muscular relaxation for several sessions
literature. Subsequently, McConaghy, Armstrong, and before presenting images. Though the patient treated
Blaszczynski (1981) found covert sensitization equiv- by Bond and Hutchinson relapsed on a few occasions,
alent to electric shock aversive therapy for addictive the frequency and intensity of his exhibitionism was
homosexuality. Possible differences in expectancy of markedly reduced. The authors briefly referred to a
improvement with the two treatments were not investi- second case treated similarly who did not relapse in the
gated in that study. They were examined in a subse- following 22 months. Rachman (1961) pointed out
quent comparison of covert sensitization and imaginal that their account conformed to a case treated by Wolpe
desensitization for addictive homosexuality and para- (1958). That patient's exhibitionism occurred follow-
philias (McConaghy et al., 1985). This study did not ing frustration or anxiety induced by submission to
support the conclusion of the Barlow et al. study, authority. He was treated by instigating assertive be-
finding covert sensitization inferior to imaginal havior and desensitization to social situations which
desensitization. provoked anxiety. Some tendency to exhibit persisted.
The case studies reporting effectiveness of desensi-
tization techniques in increasing subjects' control over
Satiation paraphilic urges experienced as compulsive were sup-
ported by studies reporting good response to desensi-
Marshall et al. (1983) reported that when they found tization in subjects who were seeking control of homo-
electric or covert forms of aversion therapy to fail in sexual impulses (Huff, 1970; Kraft, 1967). In later
comparison studies, desensitization proved at least as without completing the behavior, while remaining re-
effective as electric shock aversive therapy (Bancroft, laxed. The aim is that treated subjects, when in such
1970; James, 1978; James, Orwin, & Turner, 1977). situations in the future, will not experience the increase
Nevertheless, aversive therapy has continued to be in arousal which drove them to complete the behavior.
preferred by North American workers despite the natu- The behavior-completion model is considered also
ral repugnance to its use, possibly because of the lack to apply to nonsexual compulsive behaviors; that is,
of a clearly stated rationale for desensitization in treat- impulse control disorders. It was initially tested with
ing compulsive sexuality. compulsive gamblers, because it was considered that,
unlike paraphiliacs, they would have social contacts
who would be likely to be aware of the deviant behav-
Imaginal Desensitization ior and, hence, would be able to give an independent
report of the response. Gamblers randomly allocated
A behavior completion model of compulsive sexu- to receive imaginal desensitization reported signifi-
ality (McConaghy, 1980, 1983) led to the development cantly more cessation or control of gambling at I-year
of a modification of desensitization-imaginal desen- follow-up than those allocated to electric shock aver-
sitization. The model was advanced to account for the sive therapy, the previous standard behavioral treat-
paradoxical finding, previously discussed, that follow- ment (McConaghy, Armstrong, Blaszczynski, & All-
ing aversive therapy for homosexual feelings experi- cock, 1983). On the basis of this finding it was
enced as compulsive, male subjects were able to con- considered justified to evaluate imaginal desensitiza-
trol these findings while remaining aware and showing tion in the treatment of subjects with compulsive sexu-
penile-volume responses indicative of attraction to ality, including sex offenders.
men. This finding suggested that a nonsexually moti- Fifteen sex offenders and five subjects with non-
vated mechanism had been responsible for the com- paraphilic sexual addiction were randomly allocated to
pulsivity of their sexual feelings. It is hypothesized receive imaginal desensitization or covert sensitiza-
that when a behavior is carried out regularly, a neu- tion. At I-year follow-up, subjects reported signifi-
rophysiological behavior-completion mechanism for cantly greaterreduction in strength of compulsive sex-
that behavior is established in the nervous system. This ual urge following imaginal desensitization. Five
mechanism assumes responsibility for motivating the reported cessation and two marked reduction of com-
continuance of the behavior to an independent extent pulsive behavior, as compared with three and one, re-
from the primary drive which originally motivated the spectively, following covert sensitization (Mc-
behavior. If the behavior is interrupted prior to comple- Conaghy et al .. 1985). Patients assessed the degree to
tion, the mechanism activates the arousal system. The which they expected the treatment to reduce their para-
resulting increase in arousal is experienced by the sub- philic urge after the initial, the eighth and the four-
ject as tension or anxiety and is sufficiently aversive to teenth sessions of treatment, and at I-month and 1-
encourage him to complete the behavior, even if he year follow-up. Correlations between expectancy and
does not wish to do so. The model accounts for the response were of moderate strength for expectancy as-
otherwise somewhat paradoxical experiences of many sessments following the first session of treatment, but
normal individuals, as when they find it difficult to much stronger for expectancy assessments following
cease an unimportant activity when called to a meal. the last session of imaginal desensitization. It was con-
They often seem to prefer to let the meal grow cold and cluded that patients experienced a specific response
risk the annoyance of the caller. Sexual activities being during sessions of imaginal desensitization which led
intrinsically more exciting would produce higher lev- them to better predict a positive response.
els of aversive arousal if not completed, when once In a subsequent study of 30 sex offenders, 10 subjects
activated. were randomly assigned to receive medroxyprogester-
In imaginal desensitization, subjects are briefly one, 10 imaginal desensitization, and 10 both treat-
trained to relax and then instructed to visualize being in ments (McConaghy et al .. 1988). Medroxyprogester-
situations where they had previously carried out the one lowers subjects' testosterone levels, but is also
compulsive behavior. The situations are not arranged considered to reduce tension (Kelly & Cavanaugh,
in hierarchical order. Instead of visualizing aversive 1982). There were no significant differences in re-
consequences at the end of the situation as with covert sponse to the three treatments. At I-year follow-up, 24
sensitization, patients visualize leaving the situations had ceased paraphilic behavior in response to the initial
therapy and a further four in response to the addition of in many treatment programs in North America, al-
the alternative therapy, or aversive therapy. In the 20 though they indicated that much more empirical re-
who received medroxyprogesterone alone or in com- search was required before they could accept its rou-
bination, self-reported reduction in strength of para- tine application.
philic urge correlated significantly with reduction in Other procedures used to increase heterosexual
testosterone level, to which subjects and assessor were arousability in male subjects were repeated exposure
blind, as it took several days to be assessed. This cor- to a lO-min movie of a nude, seductive woman (Her-
relation provided evidence of the validity of subjects' man, Barlow, & Agras, 1974a) and presentation of
self-report and the specificity of medroxyprogesterone heterosexual and homosexual stimuli in temporal asso-
in reducing paraphilic urge. Further support for imag- ciation in a variety of paradigms. In one study, a slide
inal desensitization as the most effective initial behav- of a nude male was faded into a slide of a nude female
ioral procedure for giving patients control of com- (Barlow & Agras, 1973). In a second, the reverse pro-
pulsive urges was recently provided by a 2- to 9-year cedure was employed (McGrady, 1973). In a third,
follow-up of compulsive gamblers (McConaghy, following a classical conditioning paradigm, slides of
1988b). Imaginal desensitization proved significantly a woman were followed by slides of a man or a film
superior to such other procedures as aversive therapy, with homosexual content (Herman, Barlow, & Agras,
imaginal relaxation, and exposure. 1974b). Most of these studies employed single-case
research designs and exploited the freedom the designs
allow to prolong or alter the treatment contingency
Treatment Aimed at Increasing until the expected response occurred. They also relied
Appropriate Sexual Arousability upon penile-circumference assessment. In a study dis-
cussed earlier, McConaghy (1975) found a similar
A percentage of paraphiliacs have reported insuffi- classical conditioning technique to produce no evi-
cient sexual arousal to perform sexual activities which dence of conditioning as assessed by penile volume,
they or society find appropriate; consequently, a He concluded the procedure acted as a placebo. Evi-
number of treatments have been employed to increase dence that regular heterosexual intercourse does not
such arousal. Usually, they were directed at increasing alter the penile volume responses of married, predomi-
subjects' ability to be aroused heterosexually, and were nantly homosexual men to pictures of male and female
evaluated mainly in male subjects' reporting non- nudes also indicates that the technique would be inef-
paraphilic addiction to homosexual cues or persistent fective (McConaghy, 1978).
and marked distress about homosexual orientation.
The procedure most commonly employed was intro-
duced by Thorpe, Schmidt, and Castell (1963) and, Treatment Programs for Sex Offenders
later, was termed orgasmic reconditioning. It aimed to
increase heterosexual arousability by instructing the Treatment is offered to all subjects who seek help for
subject to masturbate and to report when orgasm was sexual urges or behaviors they feel unable to control.
being reached. He was then shown a picture of an No women have sought help for sex offenses, though a
attractive, scantily dressed woman until he reported he few have for masturbation they experienced as com-
had ejaculated. Over 10 years later, Conrad and pulsive. In a study discussed previously (McConaghy
Wincze (1976) pointed out that evidence that the pro- et al., 1988), it was reported that 28 of 30 male offen-
cedure was effective had not gone beyond the case ders had ceased deviant behavior 1 year following an
study level. They were critical of the exclusive reliance initial course of either imaginal desensitization,
in these studies on self-report and the frequent use of medroxyprogesterone, or the two combined. Two of
other treatments so that the effect of orgasmic recondi- the 28 had required aversive therapy. Three relapsed in
tioning could not be isolated. Unfortunately, in their the following 2 to 5 years, but responded to reinstitu-
own study, these authors relied upon penile-circum- tion of medroxyprogesterone.
ference assessment to assess individual subjects' het- The author and his colleagues have developed a pro-
erosexual arousal. Marshall et at. (1983) reported that gram, at the Prince of Wales Hospital in Sydney, that is
orgasmic reconditioning, also called masturbatory re- based on this study. The standard procedure in this
training, was the most popular procedure for increas- program is to offer subjects the choice of either imag-
ing appropriate sexual arousal and was in common use inal desensitization or medroxyprogesterone. If in 1
month following institution of the selected treatment bitionists, of whom 45 were self-referred and 55 court-
subjects are still aware of significant deviant urges or referred. All were treated with assisted covert sen-
have failed to control them, those treated with imaginal sitization administered in weekly sessions over 24
desensitization are offered medroxyprogesterone in weeks, followed by three monthly booster sessions for
addition. Those reporting an inadequate response fol- 3 years. Adjunctive homework assignments included
lowing medroxyprogesterone are offered imaginal de- thought changing, masturbatory fantasy change, and
sensitization in addition if their testosterone level was covert sensitization. The number of subjects who
reduced to below 30% of the pretreatment level. If it is ceased paraphilic behavior was not reported. Eight
above this, the dose of medroxyprogesterone is in- were charged for II offenses over the 3-year period.
creased. If following a further month they still report Marshall et al. (1983) described a behavioral pro-
difficulty or lack of control, they are offered aversive gram for assessing and treating sexual aggressors. It is
therapy. Imaginal desensitization is administered in 14 not clear that the aggressors were prisoners; but if they
sessions of about 20-min duration spaced over 5 days, were, this could explain why the authors appeared to
during which the patient is hospitalized. Medroxypro- use modification of subjects' penile-circumference re-
gesterone is administered as eight injections (1M) of sponses to deviant stimuli as the aim of treatment,
150 mg, the first four at intervals of 2 weeks and the rather than modification of their feelings or behaviors.
remainder at intervals of 1 month. Aversive therapy is Alternatively, it could be due to the belief of Marshall
administered in 14 sessions, as in previous studies et al. in the greater validity of penile-circumference
(McConaghy et al., 1981). The model of paraphilic assessment than of subjects' reports of their feelings or
behavior used to explain the mode of action of the behaviors. Marshall et al. used electric shock to audio
procedures is that of behavioral completion, discussed depictions of the subjects' deviant sexual acts to nor-
previously. It is hypothesized that during the 6-month malize subjects' penile responses but stated their inten-
period in which subjects' sexual interest is reduced by tion to routinely adopt the aversion-assisted biofeed-
medroxyprogesterone, the behavior-completion mech- back therapy (Quinsey et al., 1980), because they
anisms for the paraphilic behaviors are weakened by considered the data established it to be a very powerful
extinction as the subjects continue to be exposed to the procedure. When this procedure was discussed earlier,
cues for the behaviors without their being reinforced. it was pointed out that the data concerning its efficacy
When the subjects' sexual interest returns to normal relied entirely on subjects' penile-circumference re-
levels following cessation of treatment, the urge to sponses. Further, those subjects who showed paradox-
carry out the paraphilic behavior is no longer suffi- ical penile-circumference responses at onset of tumes-
ciently strong to be experienced as compulsive. On the cence would be punished if they responded with penile
basis of this model, the treatments used in this program detumescence to the deviant stimuli. When aversion
are not considered suitable for administration while therapy failed to produce the desired penile-circum-
subjects are imprisoned and, hence, not exposed to the ference responses, Marshall et at. used satiation thera-
environmental cues for their paraphilias. Treatment for py to reduce subjects' inappropriate arousal. It is not
these subjects can be instituted immediately prior to or clear if they used aversive therapy or satiation in sub-
following release. jects who did not show penile-circumference evidence
The minority of treated sex offenders who were nev- of sexually aggressive feelings. To increase subjects'
er involved in acceptable sexual relationships are of- appropriate arousal they used orgasmic reconditioning
fered social skills and assertiveness training or referral or masturbatory retraining.
to a surrogate therapist, where these procedures seem Marshall et at. also gave sex offenders both indi-
indicated. These offers have rarely been taken up, usu- vidual and group social skills training, assessing their
ally because of subjects' deciding they could not afford conversational skills, negative evaluations, and assert-
the time involved. However, these interventions when iveness before and after the training. The procedure
taken up have usually been terminated prematurely or, was justified by a claimed general agreement that defi-
when completed, have rarely resulted in the subjects cits in social functioning characterized individuals
subsequently becoming involved in acceptable sexual with behavioral and emotional problems, particularly
relationships; their rejections of these offers are not rapists and child molesters. However, Marshall et al.
reacted to negatively. quoted unpublished research of Marshall and Reed
Maletzky (1980) reported the response of 100 male showing that difficulties with social perception shown
sex offenders, 38 homosexual pedophiles, and 62 exhi- by rapists in comparison with middle-class males was
shared by other prisoners and males with similar so- significant findings would require multivariate statis-
cioeconomic background. Quinsey (1984) reported tics and, hence, large subject numbers. This require-
that 20 sexual assaulters did not differ from 20 non- ment has no doubt contributed to the paucity of re-
sexual offenders in hetero- and homosocial skills. search in this area.
Quinsey (1986) reported preliminary data from a
cognitive-behavioral program using covert sensitiza-
tion and masturbatory satiation with cognitive restruc-
turing, social and assertiveness skills, and sex educa- Treatment of Other Sexual Disorders
tion established at the New York Psychiatric Institute
by Abel and Becker (Travin, Bluestone, Coleman, In the DSM-III-R classification, the most common
Cullen, & Melella, 1986). Of a mixed group of self- Sexual Disorders Not Otherwise Specified for which
referred sex offenders, 89% of 44 contacted at 6 subjects seek help are nonparaphilic sexual addiction
months and 79% of 19 contacted at 12 months re- to activity with a number of partners, or distress about
ported, under confidential conditions, no further de- sexual orientation. Almost all subjects who report ei-
viant activity. Travin, Bluestone, Coleman, Cullen, ther condition are male and predominantly homosex-
and Melella (1985) found less recidivism over a short- ual. Fear of infection with the AIDS virus currently
er follow-up period with similar therapy in more highly appears to be a major contributing factor, particularly
selected sex offenders. to the desire to control sexual activity which is experi-
enced as compUlsive. Such control is attained by the
treatments used to treat compulsive paraphilic behav-
ior, most of which were developed in relation to homo-
Prognostic Aspects of Individual sexuality. The author employs imaginal desensitiza-
Paraphilias tion as the initial treatment of choice (McConaghy et
aI., 1985). Studies reviewed earlier to establish that
Clinical experience indicates that some paraphilias, aversive therapy did not produce indifference but con-
particularly uncomplicated exhibitionism and voy- trol demonstrated that subjects' sexual orientation re-
eurism, respond much better to treatment than others, mains unchanged by such treatment (McConaghy,
in that most subjects are able to cease ·them without 1976). Though it has been claimed that treatment can
relapsing in response to brief interventions. Fetishism produce change in orientation (Masters & Johnson,
appears more resistant to treatment, possibly being due 1979; Pattison & Pattison, 1980), no evidence of this
more to biological than environmental factors, con- has been advanced using the highly valid penile-vol-
sistent with its frequent initial expression in early ume assessment of orientation.
childhood. Little research has been carried out to in- It is the author's practice to inform subjects who are
vestigate these prognostic relationships. Evidence was seeking to make a more heterosexual adjustment that
advanced that adolescents with paraphilias responded there is no treatment that alters their basic sexual orien-
more poorly than adults, though most of the adults' tation. There are treatments to enable them to control
paraphilias commenced in adolescence (McConaghy, homosexual feelings or behaviors they experience as
Blaszczynski, Armstrong, & Kidson, 1989). compulsive and to reduce anxiety concerning hetero-
The relationships between individual paraphilias sexual activity. Then the concept that heterosexual and
and outcome are complicated not only by the factor of homosexual feelings are on a continuum is discussed.
subjects' age at presentation, but also their personality It is pointed out that possibly 40% of adolescents and
as well as social variables. Though most exhibitionists young adults are aware of a degree of homosexual
and voyeurs have stable personalities and are in satis- feelings (McConaghy, 1987); that 64% to 84% of sub-
factory sexual relationships, those with marked psy- jects who identified as homosexual had experienced
chopathic features whose relationships are less satis- heterosexual intercourse (Bell & Weinberg, 1978); that
factory, and who can be ambivalent about wishing to some homosexual men, with minimal evidence of het-
cease the paraphi1ic behavior, are likely to respond erosexual arousability on penile-volume assessment,
poorly. Most homosexual pedophiles and hebephiles wish and are able to maintain a satisfactory heterosex-
have personality features that make it difficult for them ual relationship for many years (McConaghy, 1982),
to sustain close, nonsexual, as well as sexual rela- and that marital relationships of women who subse-
tionships with adults, making relapse more likely. quently identified as lesbian were reported to be no
Given the number of variables involved, establishing more conflicted than heterosexual marriages and had
endured for the same length of time (Kirkpatrick, Summary

1988). The subjects are encouraged to accept the idea
that though their basic orientation cannot be changed, The major method currently used in North America
they can determine how they express that orientation for assessment and determining response to treatment
and how they identify to themselves and to others, as of paraphiliacs is measurement of penile-circum-
homosexual, heterosexual, or bisexual. ference responses to stimuli that describe paraphilic
behaviors. This assessment was suggested by the dem-
onstration that measuring subjects' penile-volume re-
Treatment of Gender Identity sponses to 10 to 13-sec exposures of pictures of male
Disorders and female nudes validly assessed most subject's sexu-
al orientation. Penile-volume responses were derived
Several studies report successful response to behav- from the initial stage of penile tumescence. Penile-
ioral treatments of small numbers of subjects with gen- circumference assessment measured the degree of
der identity of childhood and transsexualism. Single- erection to stimuli of some minutes' duration. It has
case design was employed to demonstrate the specific never been shown to validly assess the sexual orienta-
effect of positive reinforcement of appropriate sex-role tion of the majority of individuals investigated. Never-
play in an effeminate boy (Rekers & Lovaas, 1974). theless, its validity was .assumed to be equivalent to
The long-term improvement noted may have occurred that of penile-volume assessment.
without the intervention. Zuger (1966) commented Penile-circumference assessment was generally
that for the subjects he followed-up, the "telltale found not to differentiate groups of subjects with from
symptoms of effeminacy were suppressed as a con- those without paraphilias, but it has been concluded
firmed orientation toward homosexuality was taking that the paraphilias not identified by the assessment
place" (p. 1101). Kosky (1987) reported that cross- were not sexually motivated. On the basis of this be-
dressing and many other cross-gender behaviors pre- lief, use of aversive therapy to normalize penile-cir-
sent for years in seven male and one female gender- cumference responses to paraphilic stimuli remains the
disordered children vanished within weeks of their recommended treatment for those paraphiliacs who
admission to a child psychiatric unit, without attempts show deviant responses. It is not clear what should be
to encourage same-sex behaviors. The role of behav- the recommended treatment aim and method of assess-
ioral interventions is also unclear in those unusual ing outcome for those paraphiliacs who do not show
transsexuals who are prepared to accept treatment to deviant penile-circumference responses to paraphilic
remain members of their assigned sex. Edelmann stimuli.
(1986) contrasted previous reports of successful re- An alternative theory concerning motivation of
sponse of individual transsexuals to intensive thera- paraphilic behaviors is advanced. It explains the find-
peutic packages, with rapid response of a male subject ing of earlier research with addictive homosexual be-
to nine weekly sessions of modification of sitting, haviors: that aversive therapy did not make treated sub-
standing, and walking by modeling and video feed- jects indifferent to homosexual stimuli. It gave them
back. The reversal of gender identity, which occurred control of the addictive behavior but did not alter pen-
in a male transsexual over 2 hours of exorcism (Bar- ile-volume assessments of their sexual orientation, or
low, Abel, & Blanchard, 1977), suggests that, with their ability to enjoy accepted homosexual behaviors.
appropriate motivation, even brief training may be It is suggested that addictive behaviors, both non-
unnecessary. paraphilic and paraphilic, are driven by behavior-com-
Subjects seek treatment for gender identity disorder pletion mechanisms. Treatment produces no change in
of adolescence or adulthood, nontranssexual type, be- subjects' valid penile-response assessments but gives
cause of their distress concerning it or its effect on them control over behaviors previously experienced as
others: their parents, in the case of adolescents, and compulsive. The theory led to use of imaginal desensi-
their spouses, in adults. If it is not possible for the tization for addictive behaviors. A comparison study in
behavior to be accepted or there is a significant risk of subjects with nonparaphilic sexual addictions and sex
their stealing clothes, their urges to cross-dress or to offenders found imaginal desensitization superior to
steal clothes can be treated like compulsive paraphilic covert sensitization, the form of aversive therapy most
behaviors. Like fetishism, which it closely resembles commonly used in the United States to treat sex
in adolescence, the condition appears somewhat re- offenders.
sistant to treatment. Lastly, treatments to develop arousability to accept-
ed sexual behaviors are discussed. Evidence is re- P. R., & Malcolm, P. B. (1984). Deviant sexual behavior:
viewed suggesting that they could be ineffective. Cur- Differentiating sex offenders by criminal and personal history,
psychometric measures, and sexual response. Criminal Jus-
rent treatment programs for sex offenders are tice and Behavior, 11, 477-501.
described, and the behavioral procedures used in gen- Baxter, D. J. , Barbaree, H. E., & Marshall, W. L. (1986). Sexu-
der identity disorders are evaluated. al responses to consenting and forced sex in a large sample of
rapists and non-rapists. Behaviour Research and Therapy, 24,
513-520.
Bell, A. P., & Weinberg, M. S. (1978). Homosexualities: A
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CHAPTER 28
Geriatric Populations
Roger 1. Patterson
Behavioral approaches to the elderly is a field that This chapter deliberately seeks to consult and to
since 1970 has largely come into being and reached an refer to books and major reviews wherever these are
early stage of maturity. In the late 1970s, when Patter- available. The organization of the chapter is divided
son and Jackson (1980) reviewed the field, it consisted into major problem areas, and, it is hoped, this will
largely of a number of original case studies along with assist the user. However, the reader should be aware
some theoretical writings arguing for the plasticity of that the classification is arbitrary, and many items
behavior of the elderly. The decade of the 1980s has could and possibly should be discussed under several
produced a number of different books on the subject. headings.
For example, there are edited books with chapters on
behavioral management (e.g., Carstensen & Edels-
tein, 1987); a book by Hussian (1981), giving a behav- Social Behavior
iorist's perspective on known causes of behavioral dys-
function in the elderly along with behavioral interven- The literature pertaining to modifying the social be-
tions; another book (Patterson et al., 1982) reports on a havior ofthe elderly is relatively large (see Carstensen,
very large-scale program that used behavioral tech- 1987, and Gambrill, 1985, for recent reviews). This
niques to prepare one group of psychiatric residents for may be largely due to the frequently expressed percep-
return to community living and to train another group tion of the dysfunctional elderly person as being iso-
of community residents to remain successfully in the lated and withdrawn. The interventions employed
community rather than to be institutionalized by means have generally been aimed at one or both of two tar-
of behavioral day treatment. Still another approach is gets: (1) increasing social participation, and (2) in-
that of family management described in a book by creasing the effectiveness of social communication or
Pinkston and Linsk (1984). There are also many re- social skills training (e. g., assertiveness). Different
views that consider not only the whole field (e.g., methods have often been employed for these two tar-
Hussian, 1984; Wisocki, 1984), but also the applica- gets. Social effectiveness training has often employed
tion of behavioral approaches to circumscribed prob- one or more of these techniques: modeling, role-play-
lem areas (e.g., social skills, Gambrill, 1985; wandering, discussions of effective behavior, and relatively
ing and disorientation, Hussian, 1987; anxiety, detailed feedback regarding the trainee's own behav-
Patterson, 1988a). ior, often accompanied by social or other reinforce-
ment for correct behavior. In contrast, increasing the
Roger L. Patterson • Veterans Administration Outpatient frequency of interaction has employed relatively sim-
Clinic, Daytona Beach, Florida 32117. ple interventions.
581
Perhaps the simplest way of increasing social par- participation in these activities continued, but that ac-
ticipating has been to alter the stimulus field. Rear- tivities outside the experimental setting had not
ranging the furniture in an institutional ward so as to increased.
form conversational groupings was shown to be effec- Patterson et at. (1982) reported two experiments
tive by Sommer and Ross (1958) and Peterson, Knapp, and a quasi-experimental evaluation (Campbell &
Rosen, and Pither (1977). In a series of studies in a Stanley, 1963) study that employed operant techniques
nursing home environment, McClannahan, Risley, to promote increased verbal interaction in a psychiatric
and their associates showed that the participation of residential group and in a group of community resi-
residents with each other and in recreational activities dents who were receiving day treatment. Both groups
could be greatly increased for ambulatory and for non- were instructed to sit in a dayroom and converse. The
ambulatory residents. For this purpose, McClannahan day treatment group was given social reinforcement
and Risley (1973) opened a store in a nursing home. In only. The residential group was given social and token
1974, these authors reported that both written and spo- reinforcement. In both cases, reinforcement was given
ken prompts were effective for increasing participa- at specified intervals during the training of the groups.
tion. In 1975, these authors showed that the provision A reversal design produced evidence that the interven-
of recreational supplies and equipment alone was not tion with the two groups was highly effective in in-
nearly as effective as was the inclusion of appropriate creasing conversation. For the quasi-experimental
verbal prompts along with the material objects. Risley, evaluation, the group-training sessions for both groups
Gottula, and Edwards (1978) were able to increase of subjects were continued as during the experiments;
social interactions at mealtime by serving meals family but the evaluation data consisted of interval recordings
style in large bowls as opposed to individual servings. made by ward staff in the same dayrooms but at times
In a similar vein, Blackman, Howe, and Pinkston other than during the training sessions. The evaluation
(1976) offered coffee and juice to nursing home resi- data showed that conversational frequency did in-
dents while they were waiting for breakfast, which crease over time during periods of the day other than
served to promote interactions. just during the training sessions.
The introduction of operant conditioning techniques In addition to data obtained from interval frequency
is another more complex level of intervention that has observations, the quasi-experimental evaluation also
been shown to be effective. Some early studies that included further data that provided evidence as to the
used prompting and contingent reinforcement to prosocial validity of the training. Two behavioral rating
duce conversation among withdrawn elderly institu- scales were introduced that measured social participa-
tional residents were by Mueller and Atlas (1972), tion and appropriateness in the general treatment en-
Hoyer, Kafer, Simpson, and Hoyer (1974), and Mac- vironment outside the training room and the training
Donald (1978). sessions. Positive changes were obtained on these
The earlier studies were largely demonstrations to scales, and the evaluation indicted that these changes
show it was possible to increase interactions. Later were probably due to treatment. Furthermore, statis-
studies addressed additional issues, such as gener- tically significant correlations between changes over
alization and maintenance. Also addressed was the time in performance on the generalized conversation
issue of whether the treatment remained effective for frequency measure and changes during the same time
an extended time in an applied program as contrasted on three relevant behavior rating scores were found
with a relatively brief, time-limited experiment con- (see also Patterson 1988b). Therefore, support was
ducted by staff not normally present in the treatment thus provided for the hypothesis that the training did
setting (e.g., college professors, students, etc.). have some desirable effects and that these effects gen-
More recently, Konarski, Johnson, and Whitman eralized to the general ward environment.
(1980) employed verbal prompts in the form of a gen- In the most recently available study of this type,
eral announcement of availability of activities and in- Carstensen and Erickson (1986) provided refresh-
dividual prompting along with reinforcers in the form ments to nursing home residents while they were seat-
of refreshments to increase social participation in an ed in groups. An ABAB design showed once again that
institutional population. The treatment components this simple procedure increased verbal interactions on
were introduced sequentially. Each was effective, but the part of the residents. However, this study also in-
the combination of all was most effective. A lO-week cluded measures of the content of the verbal behavior
follow-up after discontinuation of treatment found that which showed that most of the increase was due to
CHAPTER 28 • GERIATRIC POPULATIONS 583
"ineffective vocal behavior" rather than desirable assessing speech content directly is always desirable.
verbalizations. Furthermore, if content is not appropriate, it may be
Both major recent reviews of this area (Carstensen, possible to alter it by behavioral techniques. In addi-
1987; Gambrill, 1985) have concluded that intervention to the above studies, there have been others in-
tions, such as those described above, have been shown volving means of communication other than the di-
to be useful for increasing social interactions among rectly spoken word.
the elderly. However, the researchers have expressed Goldstein and Baer (1976) selected a group of nurs-
reservations regarding the ultimate usefulness of these ing home residents who wanted to receive more mail.
operations because of insufficient demonstrations of These people were taught to write letters in ways that
generalization and maintenance, and also because of a prompted others to reply; for example, they asked
sparsity of data showing that this type of treatment has questions, included stamped, self-addressed enve-
increased the quality of life of the elderly. An addi- lopes, and responded promptly to all replies. The inter-
tional problem is presented by Carstensen and vention was successful in that the subjects did receive
Erickson, who found that the quality of the increased more mail and thus communicated much more widely.
interactions in their study was undesirable. In contrast, Wisocki and Mosher (1980) were able to provide
the evaluation studies of Patterson et al. (1982) pro- elderly, aphasic, brain-damaged patients with a way to
vide for some optimism regarding generalization and communicate by teaching them sign language. They
the appropriateness of the verbal behavior presented by also used other residents in the training program to
the behavior-rating scale data. promote generalization. A 4-month follow-up found
Based on their finding of increased inappropriate that the behavior and its general usage had persisted.
content of verbal behavior produced by environmental
manipulations, Carstensen and Erickson (1986) rec-
Social Effectiveness
ommended that it may be desirable to shape the nature
of the communications as well as the frequency. For- Beginning with Corby (1975), many clinicians and
tunately, there are studies available that indicate that researchers have commented that improving the social
this can be done, at least on an individual basis. Liber- skills of the elderly (i.e., assertiveness) should have
man, Teigen, Patterson, and Baker (1973) showed that benefits. A study by Baffa and Zarit (1977) confirmed
the proportions of unrealistic speech could be de- this hypothesis by showing that elderly people who
creased, whereas the proportion of realistic speech was performed assertively were perceived much more
increased during conversations of two elderly, institu- positively than those who did not.
tional patients with staff members, using contingent A number of researchers have successfully demon-
social interactions. Furthermore, there was evidence strated that elderly people in communities and in in-
of limited generalization in that similar results were stitutions can learn to be more socially effective, at
found during conversations with staff members at least in the training setting (Gambrill, 1985).
times other than training sessions. However, attempts Patterson, Smith, Goodale, and Miller (1978)
to show generalization during casual interactions on showed that elderly psychiatric patients could be
the ward other than sit-down conversations failed. taught to increase their level of affective expression of
Patterson and Teigen (1973) were able to use token both positive and negative feelings. In a classroom
reinforcement with one of the above subjects (a 64- setting, patients were first taught to express positive
year-old female) to alter her responses to specific ver- feelings to each other. There was evidence that the
bal prompts that reliably produced delusional re- improved expressiveness did generalize to the ex-
sponses. There was evidence of limited generalization pression of negative feelings in the classroom before
to a noninstitutional postdischarge setting. the latter was taught. A randomly assigned control
Much more recently, Green, Linsk, and Pinkston group received prompting and reinforcement for in-
(1986) demonstrated that they could teach the wives of creased amount of communication without specific
two brain-damaged elderly men to modify the undesir- training for increased expression of affect. The control
able content of their speech. The training was con- groups increased in frequency of talk, but showed no
ducted in the home and maintained by the trainers, so improvements in the specific social skills.
generalization and maintenance beyond treatment and Patterson et al. (1982) produced evidence for gener-
the treatment setting were less significant issues. alization of the social skills training done in the same
From this group of studies, one can conclude that way by showing that changes produced in the class-
room measures of social skills were significantly cor- All groups learned the structured task; however, the
related with changes in social functioning as measured monetary reward decreased transfer.
by several psychiatric rating scales completed by di- In an interesting twist on social skills training, Pra-
rect care personnel (see also Patterson, 1988b). deras and MacDonald (1986) taught isolated nursing
Berger and Rose (1977) found that social skills were home residents to be more effective users of the tele-
effective in teaching nursing home residents solutions phone for social conversations. Multiple-baseline eval-
to 8 of 16 identified common social problems in the uations of the teaching of four skills (common courte-
home. Solutions to the other eight situations were not sies, positive self-disclosure, conversational ques-
taught, but rather subjects were tested for solutions to tions, interjections and acknowledgments) showed that
these as a measure of generalization from the training. training was effective for four subjects as measured by
No evidence of such generalization was found. Main- collected data. Improvements in conversational skills
tenance of the learned responses was found at a 2- for two subjects were also sufficient to be noticed by
month follow-up. Furthermore, the results were rep- untrained observers. Two- and four-week follow-ups
licable with different groups of patients and different using the same role-play situations as used in training
staff members. found that two subjects maintained all four skills and
Toseland and Rose (1978) studied group social skills two more maintained only one type of skill.
training with elderly community residents. Three Foxx, Martin, McMorrow, Bittle, and Ness (1986)
groups procedures were used: (1) behavior rehearsal, have contributed further to the methodology of social
(2) cognitive techniques, and (3) group verbal prob- skills training and to knowledge of factors relating to
lem-solving (social group work). Both self-report and the generalizations of such training. In this study, a
ratings of role-playing were used to assess perfor- game format was used to provide training to three el-
mance. Both the behavior rehearsal and the cognitive derly mentally retarded residents of a facility. Results
techniques produced positive results on immediate were compared (by inspection only) with those of a
posttraining results as measured by the role-plays. contrast group, who played a game with no training
Three months after the training, all three groups had components. As expected, the game format was effec-
improved significantly and equally as measured by the tive. Observations made in the general institutional
role-plays. No significant results were obtained from environment revealed that training effects were largely
the self-report measure. Notably, all three groups were delayed until after training, and that the trained behav-
reported to be satisfied with their treatment, and the ior was more likely to occur among those who had
results were said to generalize to untrained situations. received the training as contrasted with nontrained res-
The authors attributed these latter results to the fact idents. Foxx et al. pointed out that social behavior
that they worked with real situations which occurred in considered normal may not always be effective and
everyday life. thus maintained and generalized among institutional
Lopez and her associates (Lopez, 1980; Lopez, subjects unless all those involved have been similarly
Hoyer, Goldstein, Gershaw, & Sprafkin, 1980) de- trained.
vised procedures for the specific purpose of increasing The most evident conclusion from these studies is
generalization of a form of social skills training (struc- that a variety of elderly subjects, including institu-
tured learning therapy, Goldstein, Sprafkin, & tional and noninstitutional, psychiatric, retarded, and
Gershaw, 1976). Three levels of overlearning and pre- normals, can be taught social skills. The effectiveness
training counseling were the techniques used to proof generalization of this training with the elderly as
mote generalization. The only training task was that of with all social skills training is somewhat more contro-
expressing appreciation. All experimental groups ac- versial. As noted by Patterson (1988b), "generaliza-
quired the skill. The medium overlearning condition tion" is a rather vague term. Workers in the social
enhanced both skill acquisition and transfer, but the skills area rarely distinguish between stimulus and re-
high overlearning decreased both. The precounseli~g sponse generalization. If the training situation seeks to
was ineffective. include highly specific situations that the trainee ex-
Lopez et al. (1980) used the same training to teach pects to encounter with identified individuals in known
elders to initiate conversations. The same three over- environments, then transfer would require primarily
learning situations and the use of a monetary incentive minimal stimulus generalization to the actual setting
were the independent variables. The results for the where the problem occurs. The work of Toseland and
overlearning were similar to those of Lopez (1980). Rose (1978) with community residents with real-life
problems encountered on a day-to-day basis appar- derly women residents of a long-term care facility.
ently approximates these conditions. The merit of this These women were afraid of riding the elevator. They
type of training may be called into question because it were taught how an elevator works and were trained in
would be useful only in highly specific situations. the use of relaxation combined with coping statements
However, there are many clinically relevant situations to enable them to enter and finally ride the elevator.
of this type (e.g., various types of highly disturbing Haley (1983) used combinations of positive rein-
interpersonal crises). forcement, extinction, stimulus control, and relaxa-
tion to assist three elderly women living in the commu-
nity. One demented woman would cry out as if in fear
Anxiety when she was left alone in her room even for brief
intervals. Relaxation training, putting a clock and re-
In the elderly, anxiety has a peculiar status as a prob- assuring messages in her view, and reinforcement with
lem area. As noted by several reviewers and clinicians, ice cream were used to get her to increase the time she
anxiety is widely reported to be a frequent and impor- would remain without disturbance with no one in her
tant problem among the elderly, but very little research room.
and empirically based treatment using behavior thera- Another woman caused problems by calling her
py has been reported (Patterson, 1988a; Patterson, niece 10 times daily. Behavior rehearsal of extinction
O'Sullivan, & Spielberger, 1980; Sallis & Lichstein, of more than 3 calls per day, followed by actual extinc-
1982). An additional complication is injected by many tion, proved successful.
knowledgeable clinicians who have asserted that anx- A third woman refused to leave her room to eat and
iety presents differently in the elderly than in the socialize with her family. Incorporating her into meal
young. However, these same authorities have not planning was used as a reinforcer to produce the de-
agreed as to the nature of these differences (see Patter- sired behavior.
son, 1988a). Obsessive-compulsive checking by an elderly
Fortunately, this situation may be changing as some female was the primary target of a rather complex case
case-study demonstrations of the uses of behavior ther- study by Juninger and Ditto (1984). Behavioral pro-
apy to alleviate anxiety-related problems of the elderly cedures included deliberate practice of some behavior
have been published quite recently. Also, Hussian and followed by response prevention, and verbal exposure
Davis (1985) have described the application of several to some fear situations that could not be elicited in
fear-reducing techniques to the elderly, including vivo. Behavioral treatment was preceded by 3 weeks of
(among others) shaping approach behavior, behavior pharmacotherapy with imiprimine. Large improve-
rehearsal, and the learning of coping statements. Sum- ments resulted in the target behavior problems as well
maries of some recent case studies will be presented as in other areas. Unfortunately, the complexity of this
next. study makes results hard to interpret.
Garrison (1978) successfully employed stress man- In addition to his research on overcoming fears and
agement training (Suinn & Richardson, 1971) to al- avoidance behavior, Yeasavage and his associates have
leviate fears of an elderly resident of the "crazy also published several experiments the results of which
people" in a long-term care facility. Stress manage- indicate that the reduction of anxiety in the elderly may
ment training included relaxation training followed by help to improve cognitive functioning (see Yeasavage,
sessions of learning to control fears using imagery and 1985, for a review). Thus far, no clinical data have
relaxation. been presented, but the nonclinical results are such as
Desensitization was used successfully but with con- to invite clinical experimentation.
siderable difficulty by Garfinkel (1979) with an elderly
female community resident. This woman experienced
anxiety attacks related to fears of going out alone and Behavioral Medicine
doing tasks in the presence of strangers. The clinician
was able to improve treatment compliance by allowing Several authors have written of the results that they
her to talk freely about any of her concerns as a form of obtained using behavioral approaches as therapy for
social reinforcement. problems which have more commonly been treated
Hussian (1981) applied stress inoculation as devel- medically. Such problems have included insomnia,
oped by Meichenbaum (1977) to a group of four el- headaches, mobility losses, pain, obesity, constipa-
tion, and tooth-plaque formation. This diversity is real. examined the records of 11 of 250 total patients
markable and very encouraging to those practitioners they had treated who were aged 60 years and older.
looking for new and safe answers to old problems. Treatment consisted of largely biofeedback, extinction
Some publications relating to these topics will now be of pain-related behaviors, and self-monitoring. Only
reviewed. 18.2% of these subjects were clinically improved after
treatment. None of the five tension headache patients
treated had improved. Although these figures are not
Sleep
impressive, some individuals were dramatically im-
Bootzin, Engle-Friedman, and Hazelwood (1983) proved: for example, three of the cases with 48-year
as well as Bootzin and Engle-Friedman (1987) have histories of headaches were significantly improved. In
discussed the behavioral assessment and treatment of a separate study, King and Arena (1984) reported suc-
sleep disorders in the elderly, along with case illustra- cess, using procedures similar to those of.Blanchard
tions and research results. They recommend the use of and colleagues, with a 67-year-old man who had a 37-
three basic categories of treatment: (I) information and year history of cluster headaches. Blanchard et al. sug-
support, (2) relaxation training, and (3) stimulus-con- gested that changes in treatment procedures, including
trol instruction. The goal of information and support is longer treatments and possible different techniques,
to provide accurate information about the sleep pro- might improve treatment effectiveness with this
cess and to alter the insomniac's cognitive appraisal of population.
the problem. For example, people are informed about
the stages of sleep, the developmental changes affect-
Mobility
ing sleep, and the effects of various substances on
sleep. They are then taught that it is not a calamity to do Behavioral treatments for the loss of mobility as
without sleep in order to lessen anxiety which interrelated to pain and fear associated with movements as
feres with sleep. Relaxation procedures follow those of well as environmentally induced dependence have
Bernstein and Borkovec (1973), modified so as to omit been studied by several investigators. More than 10
some muscle tensing in cases where pain limits move- years ago, Libb and Clements (1969) attached token
ment. Stimulus control teaches people to eliminate as- dispensers with signal lights (discriminative stimuli) to
sociations they have with the bed except for sleep. exercise bicycles in a Veterans Administration (VA)
They are taught to go to bed and to remain in bed only physical therapy program. This procedure increased
when sleepy (an exception is made for sexual activity) greatly the amount of exercise obtained by four elderly
rather than eating in bed, watching TV, and so forth. multiple-handicapped residents.
Bootzin and Engle-Friedman (1987) have summa- Using a different approach, Discipio and Feldman
rized the results of the efforts toward evaluating the (1971) were able to use behavior therapy to get a 52-
effectiveness of these therapies with elderly subjects, year-old Parkinson's disease victim to leave her wheel-
including a large study of 53 insomniacs. In brief, all chair and walk. These authors assumed that the woman
three forms of therapy were found to be effective when was afraid to walk and were able to use desensitization
measured immediately after the therapy and 2 years so that she would overcome this fear.
latet, although the magnitude of these positive effects As reported by Miller and LeLieuvre (1982), the
was not as great with older subjects as was found for mobility of nursing home residents with osteoarthritis
younger ones. Where differential effects were found was improved by behavioral procedures. The residen-
for the methods of therapy, stimulus control was the tial care staff and an occupational therapist were taught
most effective. to prompt and socially reinforce nonpain behaviors as
well as to extinguish pain behavior. These residents
were able to increase their activities, to decrease the
Headaches
amount of pain medications used, and to improve their
Failure and success in the application of behavior scores on a pain inventory.
therapy to headaches of elderly people is the subject of People subjected to hip surgery had their postsurgi-
a paper by Blanchard, Andrasik, Ev~s, and Hillhouse cal pain reduced by relaxation training, according to
(1985). Noting that previous research had found a pro- Ceccio (1984). In this study, a group of patients were
nounced negative correlation between success in be- provided with relaxation training prior to surgery and
havioral treatment of headaches and age, Blanchard et then were instructed to use relaxation postsurgery
while being turned in the bed. This trained group re- visiting nurse inspected the log regularly and gave so-
quired less pain medication and experienced less sub- cial reinforcement for appropriate accomplishments.
jective pain than did a control group.
Stroke victims have had their mobility improved by
Dental Care
basic behavioral shaping and biofeedback. Burnside,
Tobias, and Bursill (1982) conducted a controlled Loss of teeth because of gum disease largely caused
study of the effectiveness of biofeedback for improv- by dental plaque is a widely reported problem among
ing the walking of elderly stroke victims, all of whom older people. Price and Kiyak ( 1981 ) showed that they
had foot drop. A group that received biofeedback and could teach elderly Japanese and Caucasian communi-
gait training improved more and retained these gains ty residents to reduce dental placque using behavioral
much better than a control group that received the same procedures. Groups that received instructions accom-
treatment with the exception of biofeedback. In an- panied by checklists and praise for accomplishment
other study (Davies, 1983), a 78-year-old stroke victim fared better in measurements of plaque build-up than
with mild left-side hemiparesis was taught to walk did controls that received assessments and lessons
again by using behavioral shaping. only.
Most recently, L. D. Burgio, K. L. Burgio, Engel,
and Tice (1986) have used prompting and praise to get
Urinary and Fecal Incontinence
nonwalking nursing home residents, who were phys-
ically able to walk, to meals. Generalization of train- Incontinence in the elderly is one of those peculiar
ing from one meal to another was obtained. Also, the problems in that it has been commonly recognized as
behaviors were well maintained. being of significant concern but about which very little
was being done until quite recently. Earlier research
almost always involved mentally retarded or psychi-
Obesity atric cases, some of whom were elderly. Thanks
largely to the funding and efforts of the Gerontology
Behavioral treatment of obesity in elderly women
Research Center of the National Institute on Aging
was the subject of a study of Baanders-van Halewijn,
(NIA) , the applicability of previously developed ap-
Choy, Van Uitert and de Waard (1983). However, it
proaches to the elderly as a group has been examined,
was shown that a group of these women who met for 10
and some newer methods have been developed and
training sessions and received structured training in
evaluated.
self-control and in the modification of nutritional hab-
According to Engel (1978), urinary incontinence is
its with follow-up group meetings, were able to lose
a very complex area requiring highly skilled medical
clinically significant amounts of weight and to main-
as well as psychological and environmental assess-
tain significant losses 17 months after treatment. A
ments. For example, it may be secondary to sensory
comparison group that received 10 mailed lessons with
deficiencies, cognitive losses, or mobility difficulties.
pre- and postcourse interviews had a much higher
It may also be primarily related to improper action of
drop-out rate, lost less weight, and maintained the loss
the nerves and muscles controlling the bladder, the
to a lesser extent.
sphincter, and other muscles of the abdominal/pelvic
area. K. L. Burgio and Engel (1987; see also Burgio &
Constipation Burgio, 1986) described these processes and the as-
sessment of them as well as provided a review of the
Laxative dependence was reported by Bradford and research in treatment techniques.
Dunbar (1987) to be a highly prevalent problem among Biofeedback and several methods not requiring spe-
the elderly. They published a case study in which they cial apparatus have shown promise for urinary and for
were able to teach a 67-year-old woman to increase fecal incontinence. These include habit training, blad-
walking along with fluid and bran intake in order to der training, contingency management, as well as
obtain healthy bowel movements without the use of combinations of two or more techniques (Burgio &
laxatives. The essence of the treatment was that the Burgio, 1986, K. L. Burgio and Engel, 1987, K. L.
woman was instructed in self-treatment, was delivered Burgio, Whitehead, & Engel, 1985). Probably one of
packets of bran, and was taught to keep a log on her the techniques most widely used in institutions has
exercise and on her water and bran consumption. A been scheduled voiding, also called habit training. For
example, Risley, Spangler, and Edwards (1978) found form of cleaning up and practicing going to the com-
that they could reduce incidence of both types of in- mode several times.
continence in a nursing home by about two thirds sim- Biofeedback approaches, combined with more ade-
ply by prompting residents to void every two hours. quate assessments of all the factors contributing to in-
Equally significant results have been obtained with continence, have recently provided new and greatly
similar techniques by others (Clay, 1978; Schnelle, improved treatments. Engel (1978) used biofeedback
Traughber, Morgan, Embry, Binion and Coleman, to teach 40 subjects (including elderly individuals) to
1983; Sogbein & Awad, 1982). Habit training is often relax and contract the rectum as well as the internal and
regarded as a prosthetic rather than a therapeutic ap- external sphincters at appropriate times in order to con-
proach since continued prompting is used. However, trol defecation. He reported that 70% of the subjects
Whitehead, Burgio, and Engel (1985) did achieve were able to decrease fecal incontinence by at least
some lasting therapeutic effects of habit training on 90%. Results were maintained for long periods follow-
fecal incontinence with 4 of 18 elderly subjects (10 ing treatment. Whitehead et al. (1985) studied the ef-
others benefited from biofeedback). fectiveness of these techniques with 13 elderly fecally
Frewen (1979, 1980) proposed that the procedure incontinent patients and concluded that biofeedback
known as bladder training could be used to actually had specific value in 77% of this group.
correct urinary incontinence. With this procedure, K. L. Burgio et al. (1985) used feedback of bladder
subjects are asked to increase the intervals between pressure, sphincter activity, and intra-abdominal pres-
urination on a gradual basis by using preset schedules. sure to teach appropriate contraction and relaxation of
This procedure was done in a hospital and was accom- relevant muscles in these areas to control micturition.
panied by anticholinergic medication, sedatives, and With these techniques, elderly men and women were
social/verbal support. Frewen reported these pro- able to achieve 39% to 100% reductions in
cedures to be successful in more than 80% of a group incontinence.
of women aged 15-77 years. Other researchers have
also reported successful results with groups of women
(e.g., Jarvis, 1981; Jarvis & Miller, 1980). Behavior Associated with Dementia
Several researchers have found that relatively sim-
ple reinforcers, including cigarettes, candy, preferred There is a whole group of behaviors often found to
clothing, tokens, social approval, as well as other coexist in the same individuals that, when continuing
awards given contingent upon successful toiletting chronically and being not attributable to infection or
and/or good clothing checks, have improved conti- toxins, are often considered to be evidence of dementia
nence in many institutional patients (Azrin & Foxx, or organic brain disease. Global labels for behavior of
1971; Grosicki, 1968; Prehn, 1982). Wagner and Paul this type include memory loss, confusion, disorienta-
(1970) also withheld up to two meals for incontinence. tion, and wandering. Although this whole field was
Pollock and Liberman (1974) failed to achieve success largely neglected by behavior therapists for many
using positive reinforcement with any of six demented years, in the 1980s there have been several relevant
elderly patients. These experimenters attributed their publications. For example, Hussian (1987) provided a
lack of success to the severity of the subjects' memory good review and summary of his own work as well as
deficits, including the inability of some of them find- that of others regarding intervention with more severe
ing the bathroom, low frequency of reinforcement, behavior in this category. Citing a number of studies as
and an inability to determine more precisely the fre- support, he claimed that disorientation and wandering
quency of reinforcement. are special cases of inappropriate stimulus control. An
Sanavio (1981) reported success with two elderly, appropriate intervention strategy, therefore, is to try to
nonretarded people using procedures developed by establish control over the individual behavior by se-
Azrin and Foxx (1971) for use with mentally retarded lecting discriminative stimuli to which the subject will
adults. Azrin and Foxx approached successful toilet- respond, or can be trained to respond. For example,
ting as a chain of discrete behaviors, each of which had Hussian (1981) reduced the dangerous wandering be-
to be taught (e.g., going to the commode, removing havior of three nursing home residents who were diag-
clothing, urinating and/or defecating). Procedures in- nosed as having senile dementia by placing two differ-
cluded positive reinforcement for successful behavior ent colored symbols in the home. One of the colors had
and contingent response-costs for incontinence in the been associated with positive consequences, whereas
the other had been paired with noxious noise. The demented elders by using associated images and group
positive cue was placed to indicate safe areas, while problem-solving techniques with the elders and their
the other cue was positioned in dangerous areas. In this caretakers. Both techniques resulted in improved or
way, the number of attempted entries into dangerous stabilized recall of words, but no improvements were
areas was greatly reduced. Hussian (1981, Chapter 7) found on measures of general functioning.
also provided guidelines and case studies concerning An effort to retrain demented residents of a short-
institutional treatment of the demented. term behavioral treatment program in five different
Disorientation and confusion are more general skill areas was reported by McEvoy and Patterson
terms than wandering and usually refer to behaviors (1987). The subjects were 30 residents of the modular
interpreted as being due to memory loss. People with behavioral treatment program described by Patterson
these problems give incorrect replies when asked et al. (1982). Fifteen of these subjects were diagnosed
about who they are, where they are, and what is the as having dementia, whereas the other 15 had other
time. They also may act overtly as if they were some- diagnoses but were matched to the demented subjects
where else and/or at some other time period. As sum- on five variables (age, sex, length and number of hos-
marized by Russian (1987) and Patterson (1985), there pitalizations, length of stay). All 30 received highly
has existed since the early 1960s an approach to teach structured group and individual training in personal
"disoriented" people correct information by class- information (PI: name, place of residence, etc.), spa-
room training accompanied by frequent prompting in tial orientation (how to find one's bedroom, the nurs-
the residential setting. These procedures originally de- ing station, the dining room, etc.), and two levels of
veloped independently of learning-theory-based be- activities of daily living (ADL). ADL-I concerned per-
havioral approaches. According to these two re- sonal hygiene and ADL-II included laundry, meal se-
viewers, there is some evidence that these approaches lection, money management, and similar skills needed
do teach verbal information, although the research is for minimally supervised community living. Social
difficult to interpret on account of variations in tech- skills of expressing gratitude and dislike to others were
nique, populations, and outcome measures. also taught in a communication module. Presentation
An early attempt to combine classroom verbal ori- of prompts, prompt fading, social and token reinforce-
entation training with behavioral shaping, using token ment as well as other behavioral techniques were used
and social reinforcement, was by Johnson, Frallicciar- in the training.
di, and Patterson (1977; also described by Patterson et Although the demented subjects showed lower lev-
al., 1982, pp. 215-218). The results were that four els of performance at baseline than did the others, they
elderly victims of dementia did learn specific catego- showed significant gains after training. These gains
ries of orientation information as each category was were to the level of the nondemented subjects, except
taught. Although there was some retention at follow- in ADL-II, after 1 month of training and at the time of
up periods of 6 and 12 weeks, the overall results discharge. However, the demented subjects took much
showed that much of the relearned material was forgot- longer to learn the experimenters' criteria of success.
ten within a few days of training. Token and other In earlier related studies, Mishara (1978, 1979)
means of reinforcement given contingent upon earning compared the effectiveness of a residential token econ-
verbal information has also been demonstrated to be omy with milieu therapy and a nontreatment control
effective by several other researchers. group. All subjects were diagnosed as having organic
Langer, Rodin, Beck, Weinman, and Spitzer (1979) brain syndrome. Reinforcement in the token economy
successfully used tokens and also another technique was contingent upon prosocial activities and self-care
not as familiar to behavior therapists to promote verbal work on the ward. The milieu therapy program pro-
memory in nursing home residents. The other tech- vided similar activities, and consumables were used
nique (called "personal incentive") was for the inter- for back-up reinforcers in the token economy, but these
viewer to reveal information about themselves to the were provided noncontingently.
residents. Both techniques resulted in generalized re- In the 1978 study, only the token economy and mi-
call and in improved behavior, indicating alertness and lieu groups were included, and both groups were found
social adjustment. to improve similarly. Further statistical analyses of the
An additional technique that was employed is the characteristics of the individuals who improved in
teaching of the use of mnemonics. For example, Zarit, each program (as determined by rating scales) showed
Zarit, and Reever (1982) sought to improve memory in that those who responded best to the token economy
were actively psychotic, needed more staff care, had of the environment that serve to naturally prompt and
been admitted more recently, had worse dressing hab- reinforce acceptable behaviors. As an example,a sup-
its, were more actively discontented, and were in bet- portive relationship with a family member would be
ter health. Those improving most in milieu therapy one in which the member made or accepted contacts
were less socially responsive. that promote desirable social behavior and a positive
A very unusual finding was that scores on a neuro- self-evaluation of the elder as opposed to promoting
psychological test improved for the milieu and the dependence. Two cases (one depressed and another
token economy treatments as compared with the con- suffering from memory loss) were presented to illus-
trol. These results would indicate that appropriate trate support-oriented family interventions. (Other
treatment environments can actually improve global case studies of family management published by
brain functioning, though more research is required to Haley, 1983, were discussed above.) Hussian and
demonstrate this phenomenon conclusively. Davis (1985) provided a different aspect of family
management in that they described a series of modules
which they give to families of elderly state hospital
Home Management patients who are being discharged. These modules
structure postdischarge interventions that are to be
The studies discussed above regarding dementia made in the home.
were mostly concerned with the elderly in institutions.
Most recently, a new body of literature has come into
existence concerning behavioral procedures as applied Depression
by family members in the home for the demented and
for others. (See Patterson, 1987, for a review and some Empirically based work on therapy for the de-
case presentations.) pressed elderly has only begun quite recently. Much of
Pinkston and Linsk (1984) have provided us with this work has been done by Gallagher and her col-
perhaps the most detailed information in this area. leagues and associates (see Gallagher & Thompson,
These authors, along with their students and col- 1983a,b, and Gallagher & Czirr, 1984, for an over-
leagues, have operated in Chicago a project devoted to view of this work).
this purpose for several years. In their book, they point These clinical researchers have developed versions
out the necessity for evaluation of the care-givers on of both behavior therapy and cognitive therapy specifi-
several dimensions before instituting training. They cally for elderly individuals. The individual behavioral
provide guidelines and forms that are useful for assess- therapy (IBT) approach, which was used by them, was
ing various aspects of the care-giver, the targeted el- adapted from the work of the University of Oregon
derly, and the treatment process. For example, before Depression Research Unit (Lewinsohn, Biglan, &
trying to institute treatment, it is very important to Zeiss, 1976), which worked with young and middle-
assess the ability of the care-giver to manage behav- aged persons. The cognitive therapy methods were
ioral programs, not only in the measurement of person- modeled after those of Beck (1976) and his associates
al strengths and weaknesses of the care-taker, but also (Beck, Rush, Shaw, & Emery, 1979), incorporating
the nature of the living arrangement of both parties and changes for the elderly, that were suggested by Emery
the relationship between them. In order to initiate (1981).
treatment, the behavioral practitioner must provide Based upon this work, Gallagher and Czirr (1984)
training and structure to the care-giver. have described some general modifications in therapy
Pinkston and Linsk provided examples of the suc- for elderly people that apply to behavior therapy and to
cessful management of six cases to illustrate their cognitive therapy. Problems more common to the el-
methods and successes. Among the problem behaviors derly include sensory deficits along with the slowing
that were modified are included verbal behavior, self- of reaction time and thinking. Therefore, it is neces-
care behavior, social isolation, elimination, and oth- sary to speak, interact, and pace information according
ers. Most of the targeted elders were diagnosed as to the determined need of the individual. Furthermore,
demented. it is necessary to check frequently to see that material is
Patterson (1987) discussed the need for and assess- being properly understood. More time may be required
ment of environmental supports as aspects of family with older people. Young therapists should explicitly
management. Environmental supports are components acknowledge age differences and explore ways of
dealing with any problems presented. But undue fa- no difference between the outcomes for the two groups
miliarity should be avoided. Young therapists should except that the cognitive group improved more on the
allow the elders to spend time telling them about being Beck Depression Inventory. The reasons for this result
old. are unclear and have been disputed (see Mintz, Mintz,
With both cognitive and behavior therapy, it is rec- & Jarvik, 1985); Riskind, Beck, & Steer, 1985).
ommended that individual therapeutic approaches be This ongoing work in depression in the elderly is an
presented as experiments for the person to try to see if impressive body of research and development to be so
the approach is right for that person. This procedure is new. Although research issues remain, it would seem
useful to overcome rigidity and a lack of self-perspec- that psychotherapy and behavior therapy for depressed
tive, which may be characteristics of some elderly. elders could be quite useful.
IBT seeks to teach clients how to identify events in
their lives that influence their mood. Once these events
are identified, clients are helped to learn the rela- Dependency and Self Care
tionships between these events and their feelings and
to influence the occurrence of these events and/ or their Previously, dependency and self-care deficits, often
reactions to them. For example, relaxation training can called deficits in activities of daily living (ADL), oc-
be used to help clients control their reaction to unavoid- curring in old age have been viewed as medical prob-
able events. Assertiveness training, interpersonal lems. However, in recent years, behavior therapists
skills building, and training in personal resource man- have shown that the loss of independent self-care skills
agement can be used to decrease negative events. may be codetermined by physical disabilities and en-
Cognitive therapy teaches clients that it is their in- vironmental conditions (Baltes & Werner-Wahl,
terpretation of events and not the events themselves 1987). Furthermore, it may be possible to improve
that leads to depression. Therefore, the treatment con- independent functioning by behavioral techniques
sists of teaching people to identify their disturbing (Patterson et at., 1982).
thoughts, to question thought validity, and to modify Baltes, along with her associates and students, have
nonvalid thoughts. conducted several highly sophisticated natural obser-
Gallagher (1981) evaluated the effectiveness of a vational studies in nursing homes in the United States
version of IBT that was further developed for use with and in West Germany. The purpose of these studies
groups. Elders were randomly assigned to either be- was to study the nature of dependency in nursing
havior therapy or supportive therapy groups for 10 homes and the way that dependency was functionally
sessions. Both groups improved significantly, and im- related to events in the environment. Although the re-
provements were maintained at a follow-up evaluation searchers were interested in nursing homes per se, they
5 weeks after treatment. In a follow-up study, Gal- also considered this setting to be an extreme case of
lagher and Thompson (1982) compared individual events that might serve to produce dependency in other
treatment using behavior therapy, cognitive therapy, settings.
and an insight-oriented relational control condition. Fortunately, for present purposes, Baltes and
Comparable levels of improvement were found for all Werner-Wahl (1987) have provided a summary of this
three conditions. Significantly, a I-year follow-up re- research along with a discussion of its theoretical basis
vealed important differences in longer term therapeutic and its results. Two classes of dependent behavior,
effects: the relapse rate (56%) for the insight group was each with different social consequences, were re-
far higher than for either behavioral or cognitive thera- ported. Dependent self-care behaviors, which ap-
py (11 %). Gallagher and Thompson (1982, 1983a,b) peared to others present that the resident needed help in
have reported that skills-building therapies (both cog- performing such activities as eating or bathing, got an
nitive and behavioral) have been found to be superior immediate social response with a great deal of atten-
to insight-relationship therapies in several small tion. On the other hand, passive, nonengaged depen-
studies. dent behaviors were largely ignored. Interestingly,
A study that specifically compared cognitive-behav- constructive, independent, self-care behaviors were
ioral (Beck et aI., 1979) and psychodynamic group ignored also.
therapies with depressed elders was by Steuer et al. Baltes and Werner-Wahl (1987) concluded that de-
(1984). Both groups improved significantly on two pendent self-care behaviors actually served the pur-
observer-rated and two self-rating scales. There was pose of giving the resident a form of passive control
over the environment. Independent behaviors were companied by social and token reinforcement. The
met with rather sparsely scheduled intermittent rein- complete training package (called modules) for each of
forcement and were maintained rather well by many three levels of ADL included instructions for staff to
residents who were physically able to perfonn them. use in applying the behavioral techniques as well as an
The latter result was attributed to a partial reinforce- assessment used to detennine particular deficits of
ment effect and the very long history the residents had each targeted individual. Assessments were repeated
had of performing these tasks without immediate and to determine progress. ADI..rI taught basic self-care,
direct reinforcement. including grooming and eating. ADL-II included care
These authors also concluded that dependent behav- and mending of clothing, handling small sums of mon-
iors may sometimes serve a useful purpose; therefore, ey, using a telephone, meal selection, and maintaining
behavior therapists should examine the nature of the one's room and bathroom. ADL-III concerned com-
behavior before planning interventions. One case in munity living skills, such as meal planning and prepa-
which intervention might be destructive is when, be- ration, obtaining community resources, bUdgeting,
cause of declining abilities, the elder has chosen to and housekeeping. Not all clients were able or had the
limit activities in one area in order to maintain optimal need to be trained at all levels, based on assessments
functioning in another. A second case for abstaining and other clinical considerations.
from intervening is when the loss of behavior is di- Quasi-experimental designs provided evidence that
rectly due to a physical disability. Interventions are most who entered each training level were able to pro-
warranted when "dependent behaviors are the result of gress satisfactorily. Evidence for generalization of
confonnity with social stereotypes and prejudices, or these skills came from the fact that changes in ADL-I
of an underestimation of one's resources and of the and ADL-III, based on assessments measuring training
environmental responsiveness" (Baltes & Werner- progress, were significantly correlated with change
Wahl, 1987, p. 218). scores on appropriate behavior rating scales. Progress
Two studies have been undertaken to demonstrate on ADL-II was not similarly correlated, but the rating
that training nursing home staffs to reverse the process scales did not really address the same types of behavior
of reinforcing dependent behavior and largely ignoring that this particular classroom training taught.
independent behavior can improve independent func- In conclusion, the literature indicates that most el-
tioning. Baltes and Werner-Wahl (1987) cites a disser- ders for whom no physical impainnent prevents the
tation by Neumann (1986) which confinned the de- behavior can improve their level of independent self-
sired effect. Similarly, Sperbeck and Whitboume care. Training should not be provided in cases in which
(1981) were able to retrain an institutional staff in the elder has chosen to limit activities in one area in
knowledge of functional disabilities and operant tech- order to maximize functioning in another. Changes in
nology with the result that dependent behavior of spe- the social and physical environment to eliminate
cific residents were improved. prompting and reinforcement for dependence as well
as to include prompting and reinforcement for inde-
pendence will promote independence. Structured
ADL training may also be of benefit especially in areas
ADL Training
teaching community rather than institutional living
skills.
Using a different approach to the problem of self-
care deficits, Patterson et ai. (1982; see also Patterson
& Eberly, 1983) demonstrated that elders in need of
mental health treatment who were functionally rather
Future Applications
than physically impaired could be trained or retrained
in a wide variety of basic and more complex self-care It would seem that the applicability of behavior
skills (ADL), enabling them to live more independent- modification/therapy to elderly populations has been
ly. Some of these people received residential care well established. It has also become evident that it is
while others lived in the community but came in for now time to give more thought to the proper uses of
day treatment. The approach was to provide structured such technology. Both Baltes and Werner-Wahl (1987)
classroom training that incorporated the use of instruc- and Carstensen (1987) have provided reasons for cau-
tions, prompt fading, and modeling-the latter being tion in selecting behavioral targets. As noted above,
followed by opportunities for supervised practice ac- Baltes has described the situation where dependence in
limited areas of self-care is desirable in order to max- book of clinical gerontology (pp. 204-221). New York: Per-
imize functioning in others. Carstensen has suggested gamon Press.
Beck, A. T. (1976). Cognitive therapy and the emotional disor-
that similar situations may exist with regard to social ders. New York: International Universities Press.
functioning. That is, elders may choose to limit the Beck, A. T., & Rush, A. J., Shaw, B. F., & Emory, G. (1979).
number of their social interactions in order to conserve Cognitive therapy of depression. New York: Guilford Press.
Berger, R. M., & Rose, S. D. (1977). Interpersonal skill training
energy to be used for those interactions that are consid-
with institutionalized elderly patients. Journal ofGerontology,
ered of the most importance. 32, 346-353.
In the area of "family management" of the elderly, Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxa-
Patterson (1987) has cautioned against the very mean- tion training. Champaign, IL: Research Press.
Blackman, D. K., Howe, M., & Pinkston, E. M. (1976). In-
ing implied by these terms. That is, one must consider creasing participation in social interaction of the institu-
the elder as a client who has specific wishes and who is tionalized elderly. Gerontologist, 16, 69-76.
part of a family system rather than someone who is to Blanchard, E. 1., Andrasik, F., Evans, D. D., & Hillhouse, 1.
be controlled. A practical implication of these points is (1985). Biofeedback and relaxation treatments for headache in
the elderly. Biofeedback and Self-Regulation, 10, 69-73.
that the behavior therapist must be very careful in se- Bootzin, R. R., & Engle-Friedman, M. (1987). Sleep distur-
lecting behaviors that are targets of change. If the be- bances. In L. L. Carstensen & B. A. Edelstein (Eds.), Hand-
haviors are to be modified, the therapist must make book of clinical gerontology (pp. 238-251). New York: Per-
gamon Press.
sure that such changes will be likely to increase the
Bootzin, R. R., Engle-Friedman, M., & Hazelwood, L. (1983).
level of satisfaction of the targeted elder, as well as Insomnia. In P. M. Lewinsohn & P. M. Teri (Eds.), Clinical
others affected by those behaviors. geropsychology: New directions in assessment and treatment
Another area in which new and increased applica- (pp. 81-115). New York: Pergamon Press.
Bradford, L., & Dunbar, J. (1987). Behavioral home manage-
tion of behavior applications is desirable is to change ment of cathartic withdrawal in a laxative-dependent elderly
the functioning of social institutions affecting a large woman. Archives of Psychiatric Nursing, 1, 359-365.
number of the elderly. The work of Baltes and her Burgio, L. D., & Burgio, K. L. (1986). Behavioral gerontology:
Application of behavioral methods to the problems of older
students is a recent step in this direction for nursing
adults. Journal of Applied Behavior Analysis, 19, 321-328.
homes. According to Garland (1985), the work of Pat- Burgio, K. L., & Engel, B. T. (1987). Urinary incontinence:
terson et al. (1982) was quite rare in that its purpose Behavioral assessment and treatment. In L. L. Carstensen &
was to prepare eiders for life in the broader community B. A. Edelstein (Eds.), Handbook of clinical gerontology (pp.
252-266). New York: Pergamon Press.
rather than to improve life within an institution or with- Burgio, L. D., Burgio, K. L., Engel, B. T., & Tice, L. M.
in a given household situation. Patterson (1986) has (1986). Increasing distance and independence of ambulation
recently called for a revision of the behavior modifier's in elderly nursing home residents. Journal of Applied Behav-
usual single-case and small-group approaches to ad- ior Analysis, 19, 357-366.
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PART V
Intervention and Behavior

Change
Children and Adolescents
CHAPTER 29
Stuttering
Roger J. Ingham
Introduction Approximately 40% to 80% of children with the disor-

der are reported to recover, for various reasons, by
Stuttering is probably the best known and most re- adolescence or adulthood. The ratio of males to
searched speech disorder; but it also ranks among the females who stutter ranges from 2 to 3 : 1 in childhood
most difficult to define, plausibly explain, or, es- to 4 to 5: 1 by adulthood. There is also convincing
pecially in adults, treat effectively. In the recent edition evidence that the prevalence of the disorder is much
of the Diagnostic and Statistical Manual of Mental higher among family members than in the general pop-
Disorders (DSM-III-R) (American Psychiatric Asso- ulation (Bloodstein, 1987).
ciation, 1987), the "essential features" of the disorder Theories of stuttering are bountiful. At different
are described as "frequent repetitions or prolongations times, psychoanalytic, traditional learning, ser-
of sound or syllables. Various other types of speech vosystem, or biogenic ally based theories have held
dysfluencies may also be involved, including blocking sway over research and/or therapy for this disorder.
of sounds or interjection of words or sounds" (Ameri- Most current research on stuttering, however, ema-
can Psychiatric Association, 1987, p. 86). However, nates from a perspective that considers the disorder to
this description neither defines the frequency of these be a byproduct of neuromotor dysfunction with strong
behaviors nor distinguishes then from normal disfluen- genetic underpinnings. This is also reflected in a shift
cies. Nevertheless, few observers have difficulty in away from an environmental perspective, which, in
recognizing the features of chronic stuttering. The be- tum, may be one reason why stuttering therapy re-
haviors that listeners judge as stutterings appear to vary search has markedly declined in recent years.!
in their frequency across speaking situations and are In the first edition of the International Handbook of
dramatically reduced during certain speaking condi- Behavior Modification and Therapy, Lanyon and
tions or with the use of certain speech patterns. Chron- Goldsworthy (1982) provided an excellent overview
ic stuttering usually begins in early childhood, al- of research on stuttering and the use of behavior thera-
though adult onset of the disorder occasionally occurs, py in treatment for this disorder. In the years since that
usually in conjunction with brain damage. Stuttering review, there has been an enormous increase in re-
appears to occur in all nationalities with an incidence
'Over the past 5 years, there has been quite a dramatic decline in
of approximately 1% and a prevalence of 4% to 5%. the number of data-based investigations or reports on or con-
cerning stuttering therapy for adults or adolescents. After re-
viewing all English language journal publications that fit this
Roger J. Ingham • Department of Speech and Hearing Sci- category, this writer found that in 1973-1977 there were 57
ences, University of California at Santa Barbara, Santa Barbara, reports, in 1978-1982 there were 50 reports, but in 1983-1987
California 93106. (and including half of 1988) there were only 25 reports.
599
600 PART V • INTERVENTION AND BEHAVIOR CHANGE: CHILDREN AND ADOLESCENTS
search on this disorder, though not in therapy research, investigating stuttering, but it is yet to be shown that a
or even therapy reports. However, in order to appreci- stutterer's judgment of loss of control is a reliable and
ate the reason for this dichotomous development, it is valid indicator of stuttering. Clearly, it will be difficult
necessary to review some of the significant trends in to establish reliability unless this private experience is
stuttering research. Consequently, this chapter begins reflected in some observable form, and will have dis-
with a review of studies concerned with (1) the defini- puted validity if it is also found to accompany other
tive features of the disorder, (2) its development, (3) speech disorders. Already Martin and Haroldson
the search for its proximal and distal causes, and (4) (1986) have shown that counts of "loss of speech con-
variables that modify stuttering. An overview of recent trol" by stutterers resemble counts of their stutterings
developments in therapy for this disorder will then be made by a listener during repeated oral readings.
offered. These findings suggest that measures made from either
source might be equally valid.2
Meanwhile, the search for reliable listener-judged
Describing Stuttering markers of stuttering has produced an array of findings
that illustrate the definition problem. An earlier inves-
As suggested above, the problem of precisely iden- tigation by MacDonald and Martin (1973) appeared to
tifying and defining stuttering is largely due to im- show that listeners are able to label, unambiguously,
precision in the descriptors for stuttering events and certain events as stutterings and others as disfluencies
the unreliability with which those events are identi- from videotaped oral reading samples. Curlee (1981),
fied. Both aspects of the problem have sparked an however, failed to replicate this finding when using
interesting recent debate and some equally interesting videotaped samples of stutterers' oral readings and
research. spontaneous speech. Curlee also demonstrated (yet
The current debate largely stemmed from a review again) the relatively low level of interjudge and intra-
of stuttering research and theories (Andrews et al., judge agreement on instances of stuttering (and dis-
1983), which concluded that stuttering is most likely to fluencies) and showed that this occurred regardless of
be identified through "the occurrence of audible pro- whether judges were simply asked to identify "stutter-
longations and double unit repetitions and on the outings" or were assisted by Wingate's standard defini-
right frequency of repetition or prolongation" (p. tion of stuttering. A rather contrary finding emerged
227). These are the so-called kernel characteristics of when Martin and Haroldson (1981) had one group of
the disorder specified in Wingate's (1964) much-refer- listeners use Wingate's kernel characteristics of stut-
enced standard definition of stuttering; but like Win- tering ("repetition of a sound, syllable, or one-syllable
gate's definition, it, too, fails to distinguish the disor- word; 0r a silent or audible prolongation; or both") to
der from normally dis fluent speech. Perkins (1983a) judge stutterings and another group was simply in-
recently revived this objection but gave it added poten- structed to judge "stutterings" in IS-sec audio record-
cy by asserting that any definition based on listener ings of stutterers. The latter group achieved signifi-
judgments will never be entirely valid whenever it fails cantly higher interjudge and intrajudge levels of
to incorporate the speaker's experience of an involun- agreement, although their respective mean scores
tary disruption to fluency. In a cogent response, Wing- (57.10% and 63.35%) were unimpressive.
ate (1984a) argued that normal disfluencies are also The difference between Curlee's (1981) and Martin
involuntary and that there is ample evidence that lis- and Haroldson's (1981) findings might be due to the
tener-judged features of stutterers' speech adequately supplemental and, possibly, complicating role of visu-
distinguishes their speech from normal speech. Perk- al cues that were available only in Curlee's study. This
ins (1984b) then sharpened the argument by noting that variable was highlighted by Seymour, Ruggiero, and
stutterers may manufacture disfluent events, which lis-
teners (including the stutterer who manufactured the
2Actually, the descriptions of events that stutterers and the lis-
event) cannot distinguish from genuine stutterings. tener did not agree on in Martin and Haroldsons' (1986) study
The latter, he argued, occur only when there is "tem- show the immense problems that confront a definition that by-
porary overt or covert loss of control of the ability to passes a listener's judgments of stuttering. For example, "On
nine occasions, SS held his breath for at least 4s prior to 'ex-
move forward fluently in the execution of lin- ploding' a word or syllable but did not depress his hand switch"
guistically formulated speech" (p. 431). The virtue in (p. 188) to indicate a loss of control. It is difficult to believe that
Perkins's position is that it may open new avenues for these behaviors would constitute normal nonfluencies.
CHAPTER 29 • STUTTERING 601
McEneaney (1983), who found that observers accu- viously incorporates disfluencies. There is, however,
rately identified significantly more 20-sec speech sam- reasonable agreement (Bloodstein, 1987) that "dis-
ples of stutterers (intermingled with similar samples fluency" and "dysfluency" should not be synonyms
from nonstutterers) from visual-only samples when for the term stuttering.
compared with their judgments on audio-only and au-
diovisual samples.
The latest search for physiologic correlates of stut- Onset and Development of Stuttering
tering events is recounted below, but it also has im-
plications for endeavors to isolate definitive markers of Numerous surveys (see Bloodstein, 1987; Van
stuttering. The notion that laryngeal activity plays a Riper, 1982) claim to show that stuttering occurs in
critical role in stuttering has been severely challenged about 1% of preadolescent populations (almost re-
by evidence that stuttering may continue after a gardless of nationality), is slightly less prevalent in
laryngectomy (Rosenfield & Freeman, 1983). Free- adolescent populations, usually begins before 5 years
man andRosenfield (1982) noted, however, that when of age, and ceases spontaneously by late adolescence
a nonstuttering laryngectomized patient learns to for about 80% of stutterers. This depiction of the disor-
speak with a surgically constructed neoglottis, this der has provided a fertile base for some prominent
produced stuttering-like disfluencies with audible theories of stuttering, but it may also obscure some
struggle and tension. Such behaviors could confound significant features of the disorder. For instance, it is
investigations on whether laryngectomized stutterers far from certain that most stutterers recover spon-
continue to stutter. On the other hand, if the larynx taneously. Also, because most surveys have not in-
does produce distinctive actions during stuttering, then cluded adults, it is not clear whether the onset of the
these may constitute the "loss of control" experience disorder in adulthood relates to "typical" stuttering or
that Perkins contends distinguishes genuine stuttering. some other disorder.
Shapiro and De Cicco (1982) provided support for this Recent reviews (Ingham, 1983a; 1984a; Martin &
by assessing supraglottal and laryngeal events during Lindamood, 1986) of studies on recovery from stutter-
the "dysfluencies" of a normal speaker and a stutterer. ing have highlighted the great variability in reported
They documented similarities between both speakers' recovery rates; they now seem to be more like 40%
supraglottal muscular actions, but only the stutterers rather than 80%. Furthermore, these rates are often
produced laryngeal muscle contractions when re- confounded by therapy factors. The retort (Andrews,
ciprocal motions were expected. Similar events were 1984) that these factors can be ignored because in these
documented in a fiberoptic investigation (Conture, studies both recovered and nonrecovered stutterers
Schwartz, & Brewer, 1985) on these muscle actions. may have received therapy does not remove the con-
As the search for physiologic correlates of stuttering found; the so-called spontaneous recovery rates may
continues (see below), other potentially invariant simply reflect the benefits of more effective "thera-
markers of stuttering are likely to be investigated. pies," be they formal or informal. Recovery without
Among the more interesting possibilities could be the treatment (formal or informal) is now considered to be
coordinated movements of the articulators (Zimmer- a much less probable event. When this knowledge is
man, 198Oc) and electroencephalogram (EEG) ac- coupled with evidence that stuttering may be treated
tivity (Moore, 1984a). successfully in young children (Ingham, 1984a), there
The indiscriminate use of "disfluency," "dysfluen- is an urgent need to counter a widely held belief that
cy," "stuttering," and "fluency" in stuttering treat- children will recover from stuttering if their problem is
ment and research has produced some unnecessary merely ignored (Prins & Ingham, 1983).
complications (Bloodstein, 1987; Quesal, 1988; The nature of stuttering onset in children is still
Wingate, 1984b). The search for agreed definitions of poorly understood. Yairi and Lewis (1984) managed to
these different disruptors to fluency, as Adams (1982) secure speech samples that are probably the most prox-
has argued, is still likely to be problematic because of imate yet recorded to its onset in children. They were
the uncertain definition of normal fluency. Neverthe- from five boys and five girls (25-39 months) who,
less, Wingate (1984b) has urged clinicians and re- according to their parents estimations, began stuttering
searchers to recognize that the four terms have dis- 2 to 8 weeks earlier. Comparisons with matched nor-
tinctive referents. Such clarity may not be all that mally fluent controls showed that the stutterers had
simple to achieve because normally fluent speech ob- significantly more disfluencies, mainly "dysrhythmic
phonation" and "part-word repetitions." With respect instance, in two recent reviews of adult onset of stutter-
to the latter, the stutterers had a larger range of repeating (Lebrun, Leleux, et al., 1983; Rosenbek, 1984)
ed units (1-11) when compared with their controls (1- following nervous system damage, it was concluded
2), although there was much variability within and that the stuttering behavior among such cases was not
between the groups' disfluencies. Such variability may typical stuttering. One explanation for that could be
account for the dissimilar proportions of disfluencies because reports on "acquired" stuttering often de-
that Bloodstein and Grossman (1981) identified in the scribe the disorder with labels that embrace the dis-
spontaneous speech of five slightly older stutterers fluencies associated with dysarthria, apraxia, and aph-
(46-67 months; sex not stated). They found the most asia. On the other hand, the resemblance between late
prominent category of behaviors, which were labeled and early onset stuttering has been accentuated by re-
instances of stuttering, were whole-word repetitions. ports (Deal, 1982; Fleet & Heilman, 1985; Marshall &
Both studies verified the prominence of repetition-type Neuburger, 1987; Rosenbek, Messert, Collins, &
behaviors in early stutterings. The latter study also Wertz, 1978) that acquired stuttering is modified by
suggested that early stuttering mainly occurs on func- procedures known to reduce developmental stuttering,
tion rather than content words; the reverse of the pat- for example, chorus reading, rhythmic stimulation,
tern found in older children and adults (Bloodstein, and delayed auditory feedback (DAF).
1987). Any consistency in the proportions and fre- A principal difficulty in evaluating reports of "ac-
quencies of these types of behaviors from so few cases quired" stuttering is that most omit corroborative or
would be surprising, however, considering the wide systematically gathered data that justify a late onset
variability in types of disfluencies among non stutter- stuttering description. For instance, Mazzucchi, Mor-
ing children (De Joy & Gregory, 1985; Wexler & My- etti, Carpeggiani, Parma, and Paini (1981) described
sak, 1982; Yairi & Lewis, 1984). 16 cases of "acquired" stuttering following left hemi-
The growing acceptance that genetic factors playa sphere damage, but only 4 stuttered when they were
prominent role in explaining the onset of this disorder assessed - and 2 of these stuttered prior to their injury!
appears to have diminished interest in the search for It is also possible that some recent reports of acquired
environmental causes of stuttering. That interest might stuttering (Homer & Massey, 1983; Lebrun & Leleux,
be revived by careful reporting along the lines of Rud- 1985) are actually reports on palilalia-a condition in
min's (1984) account of events surrounding the onset which the patient repeats words and phrases (Kent &
of his daughter's stuttering and which may have a func- La Pointe, 1982; La Pointe & Homer, 1981). Quite
tional role in the development of stuttering. Rudmin's obviously, the resemblance between these different ex-
daughter was reported to have unusual "articulation amples of stuttering cannot be satisfactorily resolved
oscillations" at 16 months, but otherwise normal without controlled perceptual investigations.
speech. Then, at 33 months, numerous domestic Meanwhile, some recent reports suggest that late
changes (mother took a full-time job, father moved onset stuttering might be a product of categorically
jobs, mother became pregnant) coincided with the first different causal agents, including motor-neuron dis-
appearance of stuttering. It diminished with minimal ease (Koller, 1983; Lebrun, Retif, & Kaiser, 1983),
parent-managed therapy, only to reemerge with the drug therapy for psychotic conditions (Nurnberg &
arrival of a second child and then diminish once again. Greenwald, 1981; Rentschler, Driver, & Callaway,
In view of the known influence of environmental fac- 1984), and unspecified severe stress (Deal, 1982;
tors on stuttering frequency (see below), it seems like- Weiner, 1981). A medication for asthma (the-
ly that some environmental conditions might influence ophylline) may also induce stuttering in children (Mc-
its onset. Carthy, 1981). Unfortunately, these reports also omit
The current dominance of neuromotor perspectives crucial and corroborative speech data.
on stuttering probably explains the growing interest in There have been some interesting effects of nervous
physiological or neurophysiological changes that may system damage on persons with a history of stuttering
precipitate stuttering, and especially the "atypical" or a family background of stuttering. Cooper (1983)
stutterer (see St. Louis, 1986). Most, but not all, re- reported on a young adult female stutterer who suf-
ports on this topic refer to adults and presume that they fered a brain-stem contusion and then became fluent
must, therefore, have an "acquired" rather than a "de- for about 6 months (verified by family, friends, and a
velopmental" stuttering (Andrews et al., 1983; telephone call to the author), but she gradually reac-
Lebrun, Leleux, Rousseau, & Devreux, 1983). The quired her previous level of stuttering. By contrast,
point of the distinction is not completely clear. For Riggs, Nelson, and Lanham (1983) described a 60-
CHAPTER29 • STUTTERING 603
year-old right-handed male who had stuttered as a cipitating (or proximal) factors that may activate
child but only began again briefly when he suffered a stuttering events. The review will consider studies on
left-parietal hematoma. Rosenfield, Jones, and Lil- genetic influence, physiologic factors, language-relat-
jestrand (1981) reported on a 47 -year-old right-handed ed factors, and personality-related variables.
lifelong stutterer who incurred massive right temporal
lobe destruction, which failed to alter his stuttering,
Genetic Factors
suggesting that stuttering is not always associated with
bilateral cerebral location of the speech centers. This The evidence that stuttering occurs in about the
might not be as true for female stutterers. Fleet and same proportions within different nationalities, runs in
Heilman (1985) outlined a case of a 42-year-old wom- families, and is characterized by a sex ratio (Blood-
an whose father and brother stuttered, but she began to stein, 1987; Van Riper, 1982), is often interpreted to
stutter only after a right hemisphere infarct. The "dis- mean that its etiology is genetically influenced. Until
appearance" of stuttering after a head injury and its recently, however, this conclusion was based on rela-
"reappearance" after a stroke was reported by Helm- tively unsophisticated genetic investigations of stutter-
Estabrooks, Yeo, Geschwind, Freedman, and Wein- ing. That justifies interest in the findings of a recent,
stein (1986); although the validity of these observa- carefully controlled twin study and, especially, the
tions have been questioned (Ingham, 1987). Finally, conclusions from a lengthy investigation on the fami-
Miller (1985) described how the advancing effects of lies of stutterers.
multiple sclerosis led to the reduction of stuttering in Howie (1981) was the first to study carefully identi-
two chronic stutterers; reductions that seem to be relat- fied same-sex monozygotic and dizygotic twins with at
ed to changes in their speech patterns. least one member a stutterer. She studied 30 twin pairs
In summary, there are few reports of the develop- (21 male pairs and 9 female pairs), of which 17 were
ment of stuttering in adults where the onset is not ac- assessed as monozygotic and 13 as dizygotic. If genet-
companied by neurological damage. But without care- ic influences occur, then both monozygotic members
fully conducted surveys of stuttering among adults, it should be more commonly affected than both dizygotic
is difficult to know whether this explains its onset in members. This projection appeared to be the case as
adulthood. At the same time, it is not at all clear what both members of a pair were stutterers in 58% to 63%
will be gained by learning that adult onset stuttering (depending on the criterion used to assess stuttering) of
differs, qualitatively, from stuttering originating in the monozygotic twins, but that was the case in only
childhood. If controlled studies show they are similar, 13% to 19% of the dizygotic pairs. This finding clearly
then that would merely confirm that any distinction is implied that stuttering is influenced by a combination
unrelated to behavior; if they differ, then the reasons of genetic and nongenetic factors.
would be clouded by the subjects' speech history. Far The Yale family study of stuttering, initiated in 1973
more interesting would be the prognostic or treatment by Kenneth Kidd, reported findings on more than 600
response characteristics of both groups. If they re- stutterers and several thousand of their first -degree rel-
sponded differently to treatment (and there is no evi- atives. Details on parts of this study have appeared
dence that they do), then that may also relate to their over the past decade, but the entire project's principal
different histories, but certainly it would be clinically findings have finally emerged in some recent reports
useful information. In the final analysis, the impor- from Kidd and his colleagues (N. 1. Cox, Seider, &
tance of adult onset cases might be that they show Kidd, 1984; Gladstien, Seider, & Kidd, 1981; Kidd,
stuttering to be a disorder emerging from a variety of 1983, 1984; Kidd, Heimbuch, & Records, 1981;
sources, some more prominent than others. There may Seider, Gladstien, & Kidd, 1982). To reduce sources of
also be an interesting pattern among these cases that variability, the study was based, perforce, on a rela-
relates to recent neuromotor perspectives on stuttering tively select group of stutterers; they were of European
(see below). descent with English as a first language; they were free
of questionable diagnoses (e.g., cluttering or spastic
dysphonia); excluded were those "with mental retar-
The Search for Distal and Proximal dation, epilepsy, cerebral palsy, or indications of any
Causes of Stuttering neurological disfunction" (Kidd et at., 1981, p. 606);
and they were either referred by clinicians or were
This section will consider the attempt to find poten- engaged in intensive stuttering therapy programs.
tiating (or distal) causes of stuttering, and the pre- They were also selected with no prior knowledge of
family size or stuttering in other family members. (Cox et al., 1984) via structured case-history inter-
About 50% of the identified stutterers (the probands) views and self-report inventories. No differences were
were assessed directly by a speech-language patholo- found between the family groups on prenatal, develop-
gist, whereas the rest (stutterers and recovered stut- mental, or medical factors, self-rated anxiety levels,
terers) were identified via a self-report questionnaire. familial attitudes toward speech, or ratings of parental
Only individuals who had stuttered for at least six con- behavior and children's traits. Somewhat less reliable
secutive months were selected as probands. findings emerged from an analysis (Seider et al.,
The Yale study is already considered a landmark 1982) of the onset of speech and language problems in
study on stuttering; but it is difficult to fully evaluate its the stutterers and nonstutterers. The probands or their
foundations. This is because published reports on the relatives were asked to indicate whether the proband
study give little more detail on its methodology than began to talk at an "early, normal, or late" stage, and
the preceding summary. There are few details on the to describe the occurrence of "any speech problem
reliability of the subjects' diagnoses (only partially other than stuttering" (Seider et al., 1982, p. 483). No
in Kidd, Heimbuch, Records, Oehlert, & Webster, substantial differences were reported between the ages
1980), and none for the reliability of questionnaire at which two groups began to speak, or any accom-
responses. Indeed, the questionnaire used in the study panying language problems. Two other interesting
has never been reproduced, although some of its ques- findings were (1) that 46.7 % of the stutterers in the
tions appear in reports on parts of the study (e.g. Seider study had recovered from the problem (Kidd, 1984),
et al., 1982). Kidd (1984) has mentioned that about 5 and (2) that 99% of all the identified stutterers had
years after beginning the study, follow-up question- begun to stutter by 12 years, and only 3 out of 437
naires were received from 145 families with a stutterer stutterers incurred the disorder after 19 years (20, 21,
under 14 years at the initial interview, but no other and 43 years) (Kidd, 1983).
details were provided. More importantly, though, In general, the Yale study largely confirmed find-
there is no evidence that all subjects in the study were ings obtained by many earlier and less systematic in-
directly assessed. vestigations on stutterers' family histories. However,
The findings of the Yale study are many, but the the size of the popUlation and the careful documenta-
most significant general conclusion was that a genetic tion of the proband's relatives mean that it is far and
influence was evident though not in the form of a sim- away the most convincing demonstration that genetic
ple pattern of inheritance. The data were interpreted to factors can contribute to stuttering'S etiology. It is still
indicate genetic transmission of susceptibility to stut- unclear what level of contribution derives from these
tering with sex-modified expression" (Kidd et al., factors, or their nature. But, in all probability, these
1981, p. 608). That is most evident in the finding that factors are not evenly distributed between the sexes,
female stutterers produced a much higher percentage which means that the disorder in males and females
of stutterers than their male counterparts (27.5% vs. may differ in degree or kind. Notwithstanding some
16.3%) and that 35.8% of their male offspring were methodological concerns, there can be little doubt that
stutterers. By contrast, only 9% of the female offspring these recent studies have strengthened the argument
of male stutterers showed the disorder. Such percent- that stuttering has physiological rather than environ-
ages greatly exceed those expected within the general mental origins.
population (Bloodstein, 1987).
The Yale study also yielded other data that run coun-
ter to nongenetic explanations for the etiology of stut- Physiological Factors
tering. For instance, onereport(Gladstienetal., 1981)
showed that stutterers are randomly distributed for The recent upsurge in physiological investigations
birth order, age of separation between siblings in their of stuttering has been spurred by improved technology
families, and frequency of stutterers among birth ranks and some suggestive findings from research on stut-
before or after the proband's birth rank. Also, more terers' cerebral processing, speech motor, and auditory
than half of the fathers of pro bands , who were also systems. The following review of this research will
stutterers, had recovered from their disorder before the show these findings remain suggestive because they
proband was born. Another interesting finding derived emerge mainly from comparisons between stutterers
from a comparison between 14 families all containing and nonstutterers, rather than attempts to find func-
at least 5 stutterers, and 14 families with no stutterers tional associations between these differentiating vari-
abIes and stuttering (Perkins, 1981, 1985), although mechanism for control of temporal structure" (p. 292)
there are interesting signs that this may change. while speaking.
Meanwhile efforts to clarify the nature of cerebral
Cerebral Processing Research. Virtually any in- processing among stutterers are continuing. Dichotic
teresting finding about stuttering is sure to fit one of the listening studies (G. W. Blood, 1985; G. W. Blood, I.
multitude of theories it has generated over the years. M. Blood, & Hood, 1987; Cimorell-Strong, Gilbert,
That appears to be the case with the findings of investi- & Frick, 1983) with children have indicated that many
gations on cerebral hemisphere language processing young dextral male stutterers may have mixed or right
by stutterers. In the 1920s, Orton and Travis theorized hemisphere processing of such stimuli and that this
that stutterers may lack lateral dominance for speech may change in the 7 to 12-year age period. Among
production and the resulting interhemispheric com- adults, Moore, Craven, and Faber (1982) showed that
petition somehow manifests stuttering. Lately, more dextral stutterers have excessive EEG alpha-wave sup-
sophisticated techniques for tracking cerebral process- pression in the right hemisphere (relative to dextral
ing of language and speech have yielded evidence that male and female normal speakers) when observing or
seems to be at least consistent with this rather broad recalling words with positive, negative, or neutral val-
theory (Moore, 1984a). encies. Another technique for determining hemi-
Invasive, noninvasive, and inferential investiga- spheric language lateralization is a dual-task strategy
tions have virtually established that normal right-hand- (Kinsbourne & Cook, 1971) through which Sussman
ed (dextral) subjects process linguistic tasks predomi- (1982) found symmetrical patterns of hemispheric in-
nantly in the left hemisphere, whereas the right terference in sinistral normal speakers and dextral stut-
hemisphere is prominent in processing nonlinguistic terers, but not dextral normal speakers. A partial rep-
operations (Segalowitz & Gruber, 1977). This func- lication of this study (Brutten & Trotter, 1985) did
tionallateralization appears to be more decisive in dex- suggest that this finding may not be due to lateraliza-
tral males than in dextral females. But, at best, asym- tion alone.
metrical processing appears only to characterize these The possibility that unusual hemispheric processing
populations; its clarity and function are conditioned by in (what appear to be) developmental stutterers might
variables ranging from measurement methodology be due to significant cortical or subcortical abnormali-
(Blumstein, Goodglass, & Tartter, 1975) through to ty does not seem likely in view of findings from neu-
the use of specialized skills (Gates & Bradshaw, 1977) rological test battery investigations (M. D. Cox, 1982;
or psychological states (Gruber & Segalowitz, 1977). Fitzgerald, Cooke, & Greiner, 1984), and equally am-
Nevertheless, prompted by some intriguing (though biguous findings from central auditory system assess-
mixed) findings from comparisons between stutterers ments (G. W. Blood & I. M. Blood, 1984). Two cen-
and normal speakers on dichotic listening tasks (G. W. tral auditory system investigations, one on stutterers
Blood, I. M. Blood, & Newton, 1986; Brady & Ber- (Hall & Jerger, 1978) and the other on normally dis-
son, 1975; Cross, 1987; Curry & Gregory, 1969; Dor- fluent speakers (Wynne & Boehmler, 1982), have indi-
man & Porter, 1975; Quinn, 1972; Sommers, Brady, & cated that some aberrant elements in this system may
Moore, 1975), visual field tasks (Hand & Haynes, impair fluency. This is fortified by some suggestive
1983; Moore, 1976; Rastatter & Dell, 1987), and vari- findings from two recent brainstem-evoked response
ous electrophysiological methods (Moore & Haynes, studies (I. M. Blood & G. W. Blood, 1984; Newell
1980a,b; Zimmermann & Knott, 1974), it is becoming Decker, Healey, & Howe, 1982).
increasingly evident that dextral stutterers display un- The search for hemispheric processing's contr;bu-
expected amounts of right hemisphere processing of tion to stuttering has recently achieved added interest
meaningful linguistic stimuli. through studies that imply that stuttering treatment
If the right hemisphere is less suited to processing may modify hemispheric asymmetry. Boberg,
the fine-grained temporal programs necessary to regu- Yeudall, Schopflocher, and Bo-Lassen (1983) found
late the motor, auditory, and language operations, then prominent right hemisphere EEG alpha-wave suppres-
this may mean that stutterers have an impeded capacity sion in the midst of verbal tasks which 11 adult stut-
to coordinate the actions that constitute fluent speech terers carried out prior to therapy. But after their thera-
production. It may be the case, as Kent (1984) has py, there was more evidence of left hemisphere
argued from the preceding evidence, that stutterers processing during the same tasks. Similar effects were
"almost continually contend with a faulty or unreliable described by Moore (l984b) in the course of an elec-
tromyograph (EMG) treatment of one adult stutterer. searchers: that aberrant sensory feedback factors might
Neither study reported decisive effects, however; both cause stuttering (Garber & Siegel, 1982; Yates, 1970).
relied on averaged data that bypassed the variable ef- The modified vocalization hypothesis and its pro-
fects from different alpha measurement sites or from geny (Adams, 1974; Adams, Sears, & Ramig, 1982;
within different experimental conditions. A cerebral Perkins, Bell, Johnson, & Stocks, 1979) released a
laterality study by Wilkens, Webster, and Morgan torrent of perceptual, acoustic, and physiological in-
(1984) did show that the visual reaction time of 12 vestigations into the speech production performance of
stutterers to a letter stimulus (but not a figure stimulus) stutterers, especially their control of phonation and
was improved after therapy. A non stuttering control articulation timing. Aided by sophisticated tech-
group showed no such change on either task over sim- nology, the findings confirmed and refined earlier sug-
ilar assessments. gestions of speech motor control problems among stut-
Should it emerge that hemispheric processing corre- terers (Ingham, 1984a; Perkins, 1981). In general
lates with changes in stuttering, then it is still unclear terms, the physiologic investigations have shown that
what significance should be attached to this phe- stutterers may have unusual kinematics and abnormal
nomenon. For instance, it is possible that different laryngeal muscle activity. Also, perceptual and acous-
ways of speaking will alter the dominant mode of cere- tic investigations have revealed abnormal qualities in
bral processing. Either the variability of stuttering or the fluent speech of stutterers, whereas reaction time
the peculiar fluency that derives from a modified studies suggest that stutterers are relatively slow in
speech pattern (a common variable among therapy initiating and terminating phonation (Adams, 1981;
strategies in the three studies mentioned above) are Adams, Freeman, & Conture, 1984; Zimmermann,
rival explanations for these effects. 1984). The last few years have witnessed little more
A number of recent reviews of the hemispheric pro- than refinements to these general findings.
cessing investigations (Andrews et al., 1983; Kent, One of the most conceptually innovative develop-
1983, 1984; MacKay & MacDonald, 1984; Moore, ments among speech motor control approaches to stut-
1984a) on stutterers see much promise in these find- tering has been Zimmermann's (l980a,b,c, 1984) at-
ings, but they only allude to the dysfunctionalities that tempt to apply kinematic principles to the study of
might be responsible for stuttering. The principal diffi- stutterers' articulatory movements. In the course of
culties with these investigations is that, as yet, it is these studies, Zimmermann used high-speed cin-
impossible to measure hemispheric processing during efluorographic techniques to record the coordination
speech in order to relate aberrant activity directly to of articulatory movements of the jaw, lip, and tongue
stuttering. When this difficulty is resolved, it will be of stutterers and nonstutterers. The results from a few
possible to determine whether unusual processing is an stutterers did suggest that their movements may have
epiphenomenon or a functional agent in this disorder. "lower velocities and longer durations ... [that] ...
are associated with processes that keep activation of
Speech Motor Research. The reliability with brainstem pathways below 'threshold' level during
which stuttering decreases during certain well-docu- perceptually fluent speech" (1984, p. 139). The effect
mented conditions (Bloodstein, 1987) has pointed to of this might be a critical alteration in the excitability
other physiological variables with distal and proximal of certain pools of motor-neurons that fine tune artic-
causal potentialities. In a series of immensely influen- ulatory muscles. It might also align with Kent's (1984)
tial papers, Wingate (1969, 1970, 1976) suggested suggestion that stutterers always experience impeded
that virtually all these conditions are linked because temporal management. This association will surely be
they involve changes in vocalization. This modified interesting to some researchers.
vocalization hypothesis provided a seemingly simple To date, Zimmermann's proposals have activated
unifying and potentially testable explanation for stut- much interest but little relevant research. A study by
tering variability. It also helped to excite interest in the A. Smith and Luschei (1983) and another by McClean,
possibility that stutterers' speech motor control sys- Goldsmith, and Cerf (1984) have tangential relevance
tems, especially the coordination and control of pho- to Zimmermann's proposed model. The former study
nation and articulation (Bloodstein, 1987; Van Riper, found that the force output and EMG activity of areas
1982), contained the proximal causes of stuttering. So of the jaw-closing muscle (in response to reflex stim-
strong is this interest that it has virtually pushed aside a uli) were not significantly different in stutterers and
prevailing zeitgeist among many physiological re- nonstutterers, although the most disfluent stutterer did
have the largest reflex amplitude. In the McClean et al. 1987) stutterers, but not in the speech of childhood
study, EMG activity in the lower lip movements during stutterers (Colcord & Gregory, 1987; Krikorian &
stuttered bilabials was not associated with either Runyan, 1983). Further evidence of a "learning fac-
heightened muscle activity or co-contractions-actor" occurs in recent studies on the voice-timing skill
tions that might have impeded coordinative move- of stutterers. For example, it has been found that voice
ments in these parts of the articulators. It is too early to onset-offset actions in oral reading may partially in-
judge whether these findings help or harm the move- fluence stuttering (Adams & Reis, 1971; 1974), but
ment coordination model. this finding was not replicated when young stutterers
There has also been much interest in the notion that performed similar oral readings (McGee, Hutchinson,
stutterers have a deficient ability to coordinate respi- & Deputy, 1981). Also, the findings of slow voice
ratory, articulatory, and phonatory actions (Adams, initiation and termination among stutterers (Adams &
1981; Perkins, Rudas, Johnson, & Bell, 1976) which, Hayden, 1976; Starkweather, Hirschman, & Tannen-
in turn, produces stuttering. Conversely, it is argued baum, 1976) appear to be conditioned by subject age
that when coordination or timing demands are either and severity of stuttering factors (see below). Never-
simplified or reduced then stuttering is also reduced. theless, a careful analysis of the speech of young stut-
This incoordination may also be responsible for the terers (Wall, Starkweather, & Harris, 1981) has shown
unusual perturbations that are reported in the percep- that the majority of their stutterings occur when voice
tibly fluent speech of (mainly) adult stutterers onset is required after a pause, regardless of its loca-
(Adams & Runyan, 1981). Acoustic analyses of this tion in a sentence. The simplest interpretation of these
activity have raised the possibility that stutterers have findings is that voice-timing problems may initially
only tenuous intervals of fluency as evidenced by ex- surround stuttering events, but, with time, they spread
cessive short pausing, unusual voicing features on to the rest of a stutterer's speech.
certain phonemes, and minute difficulties in starting Save for the adaptation effect (Bloodstein, 1987), no
and sustaining phonation. It has also been suggested stuttering phenomenon appears to have attracted more
that this tenuous fluency may be even more evident research than the finding that stutterers (as a group) are
immediately adjacent to stuttering events (Adams & relatively slow to initiate and terminate phonation.
Runyan, 1981). With continuing investigation, the size and consisten-
Recent acoustic studies have continued to identify cy of this effect appear to be mainly related to voice
unusual vocal behavior characteristics among stut- initiation (Horii, 1984) and the severity of stuttering
terers. One interesting pattern of findings concerns the (Borden, 1983; Cullinan & Springer, 1980; Ven-
fundamental frequency of their speech. Two studies katagiri, 1981; 1982; B. C. Watson & Alfonso, 1982;
(Adams et al., 1982; Rarnig & Adams, 1981) showed 1983). Comparisons of the reaction times of stutterers
that restricting fundamental frequency range by either and nonstutterers on manual tasks, nonspeech vocal
monotone, or high- and low-pitched oral reading may tasks, and unvoiced tasks have yielded mixed findings
reduce stuttering. Interestingly, both child and adult (Cross & Luper, 1983; Long & Pindzola, 1985; Reich,
stutterers produced significantly less stuttering in the Till, & Goldsmith, 1981; Starkweather, Franklin, &
low-pitched condition. But even without such manip- Smigo, 1984; Till, Reich, Dickey, & Seiber, 1983;
ulations, there is evidence that adult stutterers proba- Venkatagiri, 1981). But the most common effects still
bly use a relatively restricted fundamental frequency seem to be confined to voice initiation, which, of
range (Healey, 1982) that is not dissimilar (as it is for course, might be part of stuttering rather than its cause.
normally fluent speakers) in oral reading and spon- However, there is increasing evidence that slow voice
taneous speech (Schaferskupper & Simon, 1983). This reaction time is less evident in young stutterers (Cross
restriction in prosody might well be the peripheral ef- & Luper, 1983; Cullinan & Springer, 1980; McKnight
fect of a temporal management problem (see above). & Cullinan, 1987; Murphy & Baumgartner, 1981; Till
Most evidence of timing and coordination difficul- et al., 1983; Zebrowski, Conture, & Cudahy, 1985), a
ties in stutterers' perceptually fluent speech derives factor that may be entangled with the relatively late
from studies with adult stutterers. It is possible, there- development of voice onset timing skills (Kent, 1976).
fore, that they are learned responses to a history of Among adults, there is suggestive evidence that stut-
stuttering. There is evidence, for example, that lis- terers have comparatively low lung volume for the mo-
teners discern a tenuous fluency in the speech of adult bilization of their vocal folds during prephonation in-
(Young, 1984) and adolescent (Brown & Colcord, tervals (Baken, McManus, & Cavallo, 1983), which
may also explain why Watson and Alfonso found that that most have investigated the "fluent" spe~ch of stut-
forewarning stimuli mediate the reaction time effect in terers without specifying the normalcy of this speech
mild but not severe stutterers (B. C. Watson & Alfon- or even the reliability with which fluent samples were
so, 1983; 1987). As they astutely observed, this find- identified (Finn & Ingham, 1989). It seems, therefore,
ing could mean that "mild stutterers' major difficulty that the search for critical speech motor variables con-
may be in posturing the speech mechanism, while the tinues to be hindered by, what Johnston and Pen-
more severe stutterers may have both posturing and nypacker (1980) have aptly termed, methodological
vibration initiation deficits" (B. C. Watson & Alfonso, "vaganotics. "
1983, p. 197). Yet another important variable may be
hemispheric processing, which Hand and Haynes Auditory System Research. Past attempts to find
(1983) implicated through finding differential effects physiologic influences on stuttering have been largely
on stutterers' vocal reaction times to left and right visu- directed by two general orientations: that stuttering is a
al field stimuli. product of impaired speech motor control, or that it
The search for more proximal causes of aberrant derives from incongruous sensory feedback (Garber &
phonatory activity among stutterers has led, almost Siegel, 1982; Yates, 1970). As previously mentioned,
inexorably, to the investigation of laryngeal behavior. recent studies have been dominated by the former ori-
Fiberoptic and implanted EMG investigations (see entation. But evidence that stuttering is altered by
Adams et al.• 1984) have shown that unusual vocal modified audition ,(Bloodstein, 1987), that stutterers
fold movements and muscle activity frequently ac- and normals respond differently to some auditory stim-
company intervals of stuttering (Conture et af.• 1985; uli (Curry & Gregory, 1969; McFarlane & Prins, 1978;
Moore, Flowers, & Cunko, 1981) and may produce Rastatter & Dell, 1987), and inconsistent suggestions
less obvious "laryngeal stuttering" (Starkweather, that stutterers have abnormal central auditory function
1982). But doubts about the necessary role oflaryngeal (Gregory & Mangan, 1982) have managed to keep
actions to stuttering (Perkins, 1981; Rosenfield & alive interest in the feedback model. That interest must
Freeman, 1983; Tuck, 1979) and evidence showing now contend with some extensive reviews of years of
that laryngeal activity coincides with, but does not research in these areas which shows little support for
precede, stuttering (McLean & Cooper, 1978) have the claim that stuttering is caused by an impaired au-
tended to dampen interest in laryngeal-based explana- ditory feedback system (Garber & Siegel, 1982; In-
tions of the disorder.. Some evidence of EEG-detected gham, 1984a), or that stutterers have an abnormal cen-
laryngeal disruption during the perceptually fluent ut- tral auditory function (Hannley & Dorman, 1982;
terances of very young stutterers (Conture, Rothen- Rosenfield & Jerger, 1984).
berg, & Molitor, 1986) does align with a related and The most promising lines of research into auditory
earlier finding (Stromsta, 1965), and may promote a factors seem related to hemispheric processing which,
profitable extension in this research area. in some presently unclear fashion, may interact with
It becomes very clear when surveying speech motor speech motor control. In tum, this interaction could
control studies of stuttering that most have been con- explain some findings that suggest that stutterers may
cerned with identifying comparative differences behave an impaired sensory feedback system-a system
tween stutterers and nonstutterers. Relatively few at- still considered critical to normal speech motor control
tempts have been made to manipulate presumed (Netsell, 1981). Consequently, the evidence that stut-
relevant variables to determine whether they directly terers have an interaural phase disparity in processing
control stuttering frequency or severity, despite fre- bone-conducted tones (Stromsta, 1972) and have rela-
quent calls for these types of investigations (Ingham, tively poor oral shape discrimination (Martin, Law-
1984a; Perkins, 1981; A. Smith & Luschei, 1983; rence, Haroldson, & Gunderson, 1981) may tum out
Zimmermann, 1983). One such study by Ingham, to be interesting manifestations of this impaired
Montgomery, and Ulliana 1983) found the frequency system.
of certain phonation durations in the speech of two The picture of stuttering that begins to emerge from
adult stutterers directly influenced their stuttering fre- current physiological studies is a disorder charac-
quency. When such direct control over stuttering can terized by unusual hemispheric processing and a
be established across many stutterers, then this may speech motor control system that has an impaired tim-
help to identify the aspects of phonation that influence ing and/or coordinative function. It will be interesting
stuttering. Another concern with studies in this area is to observe how researchers will determine which fac-
tors offset or exacerbate the aberrant aspects of that feature shift (Wells, 1983). These findings might be
system. That process alone may require viewing the predicted results of a "grammatical factor" effect on
disorder as a byproduct of an impairment in a vastly stuttering (see Bloodstein, 1987). Wingate (1976,
more sophisticated servosystem than the system that 1984c) considers that this might be due to a more fun-
has orientated past research on stuttering. damental factor-a prosodic or linguistic stress factor.
In other words, stuttering may occur at points where
linguistic stress is a prominent part of speech. This
Language-Related Factors
explanation would seem to fit some recent findings
There is still a strongly held conviction that stutter- that show that "critical" meaning words (Kaasin &
ing may be some form of language disability, or that it Bjerkan, 1982) and low-frequency words (Palen & Pe-
is a disorder influenced by language-related variables terson, 1982) attract disproportionate stuttering (es-
(Hamre, 1984; Homzie & Lindsay, 1984; Wall & pecially for severe stutterers) regardless of their loca-
Myers, 1982). Much of this position stems from the tion in a sentence. Such linguistically meaningful or
fact that most stuttering begins when language is de- important words, as Wingate (1984c,d) argued in re-
veloping and because children who stutter often have appraising early language investigations of stuttering,
delayed language development (Bloodstein, 1987). may require prosodic variation-a variable that may
There is also much evidence that stuttering is con- have as much involvement in stuttering as utterance
strained by linguistic variables (Bloodstein, 1987). initiation.
The explanatory conundrum facing this notion, how- Wingate's (1984c) interesting conceptualization of
ever, is that language problems among these stutterers the linguistic-motoric factors that may be involved in
may be the result rather than the cause of their prob- the disorder is consistent with his claim (Wingate,
lem. That difficulty has not been solved in any recent 1982) that "stuttering is not limited to problems of
language-related investigations, although there may incoordination of the peripheral level but involves
be prospects of a solution in the notion that linguistic more central functions integral to the complex opera-
stress could produce stuttering. tions which generate speech production" (p. 256).
The explanatory ambiguities in this area are well Thus far, however, there have been few attempts to
illustrated in recent attempts to test for a relationship carefully assess the role of involvement of linguistic
between syntactic structure and stuttering. Two such stress in stuttering. Weiner (1984) had stutterers orally
studies on young stutterers (Bernstein, 1981; Wall, read bisyllables (from a list used by Wingate, 1967),
Starkweather, & Cairns, 1981) found that their stutter- with stress placed on either the first or second syllable.
ing was most prominent at clause boundaries, which She reported no differences in stuttering on either syl-
seems to imply that sentence formulation difficulties lable but, in the absence of independent assessments of
might produce stuttering. A study of adult stuttering in stress or reliability data, this finding has limited value.
two languages (Jayaram, 1984) also found that a clause Wingate (1984d) provided rather more positive evi-
located at the beginning of a sentence attracted more dence in a study in which 35 stutterers orally read a
stuttering than when it was located at the middle or end sentence that had been independently appraised for
of a sentence. It is equally likely, however, that this intervals of linguistic stress. He reported that stuttering
effect is due to poor motor coordination when initiating frequency varied positively with acoustic measures of
new utterances after a pause between clause bound- stress as determint!d by a vocal intensity measure.
aries (Costello, 1984). This motor, rather than lan- Wingate (l984d) claimed the graphed trends (see p.
guage, factor is partly supported in a finding (Janssen, 298) "show a clear correspondence between stutter
Kraaimaat, & van der Meulen, 1983) that young stut- events and stress peaks" (p. 299).3 These findings
terers do not display poor reading abilities-a condi- were also supported in a related study by Bergmann
tion which might have signified relatively poor lan- (1986). However, there is some reason to doubt the
guage formulation abilities. reality of a strong correspondence between linguistic
The entanglement of linguistic and motoric con- stress and stuttering. Rhythmic (even arrhthymic)
cepts is also obvious in some recent linguistic studies stimulation (Ingham, 1984a), which produces regular-
on stuttering. In the main, these studies have re-
affirmed, albeit in different populations, that stuttering
3When this writer quantified these graphs, there was only a
is more probable on voiceless consonants (Jayaram, modest (albeit significant) .45 correlation (Spearman's Rho)
1983), and when there is a (- voice) to (+ voice) between both sets of data.
ly (and irregularly) stressed syllables, is known to re- ing may reside in the general beliefs and attitudes that
duce rather than increase stuttering. It is possible that others have toward stutterers. Investigations on the
this type of stressed speech pattern is a special excep- attitudes of teachers (Crowe & Walton, 1981), em-
tion to Wingate's notion, but it does use linguistic ployers (M. I. Hurst & Cooper, 1983), vocational re-
stress and decreases rather than increases stuttering. habilitation counselors (M. A. Hurst & Cooper, 1983),
In general, therefore, language analysis has not and students (St. Louis & Lass, 1981; Turnbaugh,
proven to be a profitable avenue for explaining stutter- Guitar, & Hoffman, 1981) toward amorphous stut-
ing. The notable absence of carefully controlled inves- terers show that even in apparently enlightened times
tigations in which language-related variables are sys- these various groups harbor surprisingly negative be-
tematically manipulated to assess their effect on the liefs about those who have this disorder. Indeed, even
disorder may account for this state of affairs. However, clinicians and students seem to believe that stutterers
there may be some merit in Wingate's suggestion that a have mildly (and not so mildly) disabling personality
closer examination of prosody will help to refine characteristics. This has emerged from investigations
speech motor analyses of stuttering. using semantic differential type scales (Ragsdale &
Ashby, 1982; Turnbaugh et at., 1981; White & Col-
lins, 1984). The value of this and other such findings is
Personality Factors also questionable in view of the Turnbaugh et at (1981)
finding that such negative judgments may dissolve
After countless unproductive studies of the person- when listeners assessed particular stutterers.
ality of stutterers, there is reasonable agreement that Some of the findings of these studies should give
the disorder is not a byproduct of personality distur- pause to health care professionals and those responsi-
bance or that stutterers have unusual personalities ble for educating clinicians and the public about stut-
(Bloch & Goodstein, 1971; Bloodstein, 1987; Good- tering. For this reason alone, this area of research may
stein, 1958). Predictably, therefore, some recent not be as futile as previous attempts to understand the
small-scale attempts to find distinctive personality fea- influence of social and personality factors on stutter-
tures or features relevant to changes in stuttering (De- ing.
vore, Nandur, & Manning, 1984; Sermas & Cox,
1982) have provided few reasons to alter that agree-
ment. The unprofitable search for a stuttering person-
ality may also have led to a shift in the focus of this type
Stuttering Variability Research
of research. It may explain the upsurge of interest in
listeners' judgments or beliefs about stutterers and, to a Recent endeavors to find factors that cause stutter-
lesser extent, stutterers' reactions to their disorder. ing frequency and severity to vary have been mainly
Any suggestion that stuttering has benign effects on concerned with the study of conditions that reliably
its sufferers should be dispelled by noting the prolifera- reduce stuttering, especially the so-called fluen::y-in-
tion of self-help groups for stutterers and distress-filled ducing conditions. Most recent research on stuttering
accounts of their lives in places, such as the newsletter variability stems largely from Wingate's (1969, 1970,
of the National Stuttering Project. Too few systematic 1976) speculations about the common variables that
attempts have been made to document the impact of the link these fluency-inducing conditions. The essence of
disorder, although Manning, Dailey, and Wallace's these speculations was that altered vocalization may be
(1984) recent survey on 29 older aged stutterers in a the common functional variable when stuttering di-
self-help group is an interesting exception. They found minishes with use of a distinct speech pattern (i.e.,
that most of the group judged their disorder to have through slow speaking, rhythmic speaking, prolonged
been a social, vocational, or educational handicap speech, whispering, and singing) or under certain
whose severity had only diminished (behaviorally and stimulus conditions (i.e., rhythmic stimulation, cho-
socially) in their later years. Other evidence may exist rus reading, shadowing, masking, and delayed audito-
in Greiner, Fitzgerald, Cooke, and Djurdjic's (1985) ry feedback (DAF). The investigative approach to
finding that adult stutterers scored higher than matched what was ultimately labeled "the modified vocaliza-
normals on a general anxiety scale, though not at a tion hypothesis" has been mainly focussed on the
level recorded for psychoneurotics. motoric variables that control vocalization. The inten-
Some reasons for the handicapping effects of stutter- sity of this development has been such that it has al-
most stalled interest in environmental influences on during many fluency-inducing conditions. 4 This in-
variability-especially the control exerted by re- consistency alone probably means that any common
sponse contingent stimuli (although there is even some causal variable (if it exists) may reside at an entirely
interest in relating this effect to motoric factors). In- different level of analysis. Meanwhile, there is vir-
deed, so great is the interest in variables that cause tually no recent study that has advanced the search for
reduced stuttering that researchers have almost over- a common variable among the fluency-inducing condi-
looked the importance of finding factors that also in- tions. Actually there has been far too little interest in
crease stuttering (Young, 1985). It is of interest, there- careful analyses of each of these conditions, especially
fore, that some recent studies have shown that when the critical parameters of conditions such as
increases in the use of short phonation intervals (Ing- masking, rhythm, prolongation and chorus reading are
ham et al., 1983) and changing from monologue to still not well defined (Ingham, 1984a). There are at
conversational speech (Martin & Haroldson, 1988) least some recent studies on masking and rhythm that
will reliably increase stuttering. may help to identify these parameters.
The intense search for a common and sufficient ex- In two recent masking studies, Martin and col-
planation for the changes produced by fluency-induc- leagues (Martin, Johnson, Siegel, & Haroldson, 1985;
ing conditions has not been altogether successful. Martin, Siegel, Johnson, & Haroldson, 1984) evalu-
Efforts to test the modified vocalization hypothesis ated the effects of amplified sidetone (up to 20dB
have led to investigations on the effects of variation in SPL); a condition that usually reduces vocal intensity.
speech rate, pause duration, phonation duration, fun- They found that this procedure only reduced stuttering
damental frequency, and vocal intensity; all have been when it was preceded by auditory masking (100 dB
inconsistently implicated in changes wrought by SPL white noise); a condition that usually reduces stut-
rhythm, masking, DAF, and the various speech pat- tering and increases vocal intensity. Amplified side-
terns. At present, the net result of all these efforts tone was not effective in reducing stuttering when it
appears to have been little more than the creation of was preceded by rhythmic stimulation conditions
even more hypotheses. These include the "facilita- (which also produced the most substantial reductions
tion-simplification hypothesis" (Adams et al., 1982), in stuttering during these studies). This complex in-
the "effective planning time hypothesis" (Perkins et teraction does not seem to fit with any current explana-
ai., 1979), and the "modified prosody hypothesis" tion for the effects of these procedures.
(attributed to Wingate, 1979). These "neohypotheses" The dramatic reduction in stuttering that occurs
have yet to be seriously tested, but their explanatory when stutterers speak to the accompaniment of an au-
strength is also likely to be quite limited because some dible metronome beat were replicated in a study by
fluency-inducing conditions (most notably chorus Howell and EI-Yaniv (1987). At the same time, they
reading and shadowing) do not seem to produce the showed that if the audible beat was always activated by
acoustic changes these hypotheses predict (Ingham, the stutterer's initial syllable (following a pause inter-
1984a). val) then this produced similar reductions in stuttering,
At best, recent studies on these hypotheses have and with more natural sounding speech. In other
shown that any or all of the above mentioned acoustic words, the critical variable in the effect of rhythm on
variables may functionally control stuttering in differ- stuttering may be a self-directed rather than an im-
ent subjects. When some of these variables have been posed speech pattern.
manipulated (e.g., fundamental frequency [Ramig & A noteworthy change in stuttering research has been
Adams, 1981], speech rate [Healey & Adams, 1981; a decline in the number of response contingent stim-
Ingham, Martin, & Kuhl, 1974], and phonation dura- ulation (ReS) studies of stuttering. That might be be-
tion [Ingham et al., 1983; Perkins et al., 1979]), there cause there is now sufficient evidence that stuttering is
is evidence that stuttering is reduced. However, be- reduced for many adults and children under punish-
cause of the potential interaction among numerous ment conditions, particularly response contingent
acoustic or motoric variables (only a few are con-
sistently recorded in these studies), it is difficult to 4It is noteworthy that the interjudge reliability scores on some of
identify their causal properties. The point is shown by these variables was occasionally large enough (up to 41 % dif-
ference in the two judges' scores for mean phonation duration,
the inconsistent association that Andrews, Howie,
and up to 51 % difference in pause proportion scores) to absorb
Dozsa, and Guitar (1982) found between rate, pause any variability that could be attributed to a fluency inducing
intervals, phonation duration, and stuttering frequency condition.
time-out from speaking (Costello & Ingham, 1984a; finding is obvious and aligns with some interesting
Ingham, 1984a; Martin & Haroldson, 1979). Another findings from therapy studies (see below). Equally in-
reason might relate to the perceived clinical value of teresting, especially for clinical purposes, is the role of
the findings; the stuttering reductions produced by accuracy in the self-delivery of contingencies. Some
RCS procedures generally appear to be neither as size- earlier studies (see Ingham, 1984a, Chapter 9) seemed
able nor as immediate as some of the above-mentioned to show that the effectiveness of self-managed RCS
fluency-inducing conditions (Ingham, 1984a). procedures do not depend on observer-judged ac-
The most recent RCS studies have added little to the curacy of stimulus delivery. James ( 1981 b) took this a
well-known effects of these procedures. James step further in a study that found that the modifying
(1981a), however, did demonstrate that across a effects of self-delivered time-out on stuttering were
number of subjects time-out is not effective when the significantly larger among subjects who were rela-
stimulus is arranged noncontingently, or when a speak- tively less accurate in delivering time-out. The im-
ing pause does not accompany the time-out stimulus. plications of this finding are less clear, but they may
Also, two studies (Christensen & Lingwall, 1982, relate to Perkins's (1986) suggestion that stutterers are
1983) showed that the experimental environment and more likely to be valid identifiers of their own stutter-
the duration of RCS conditions may mediate the effects ing. It could mean, for instance, that the effects in
of a verbal contingency ("no") on stuttering. But, like James's study mainly occurred with subjects who
James's study, the amount of reduction in stuttering chose to deliver time-out in accordance with their own
(averaged across the groups of subjects in these stud- judgments, rather than with what observers would per-
ies) was little more than 50%. Such findings need to be ceive to be stutterings.
related to evidence from a series of single-subject stud- There are still many interesting aspects of RCS
ies (Costello & Hurst, 1981) that show that time-out is studies that await investigation. These include the
not a reliable modifier of stuttering for all subjects, and role of attention, associated changes in motoric vari-
(most importantly) that different contingent stimuli ables, and the unclear effects of reinforcement (see
may be suitable for different subjects. One might be Ingham, 1984a, Chapter 9). Less promising have
loss of tokens contingent on stuttering (response cost), been recent attempts to "explain away" the findings
which Salend and Andress (1984) investigated in a from RCS studies by relating their effects to other
time-series experiment with a 12-year-old male stut- hypothetical constructs. The most recent claimants
terer. There were relative reductions in stuttered words suggest that the benefits from RCS occur because
per minute during experimental phases, although these stutterers utilize increased "functional capacity"
reductions were not demonstrated to be independent of (Andrews et al., 1982), or because "the stutterer
changes in speaking rate. knew what the signal meant and what to do about it"
Despite the paucity ofRCS research, it does include (Wingate, 1983, p. 26). Both hypotheses appear to
one important new development: self-managed con- spring from some dissatisfaction with the notion that
tingent stimulation by stutterers. A study by Martin stuttering may be brought under stimulus control and
and Haroldson (1982), which compared self- and ex- that this is adequately explained by reference to prin-
perimenter-controlled delivery of time-out (5-sec) ciples operating at this level of analysis. That does
with a control condition, revealed that the self-man- not mean that stimulus control is independent of cer-
aged time-out condition produced significantly less ev- tain necessary conditions, but that the temporal ar-
idence of extinction during a posttreatment telephone rangement of certain environmental stimuli might be
conversation task. 5 The clinical implication of this sufficient to control stuttering frequency. This factor
might even extend to control over response patterns
5This is another interesting finding in this study related to the that operate at more molecular levels, including the
widely held belief that stuttering always increases during tele- intricacies of speech motor control. Vague explanato-
phone conversations. A recent survey of 260 stutterers by Leith ry concepts, such as increased functional capacity or
and Timmons (1983), for instance, reported that 72% judged
this to be among their top three most difficult speaking situa- awareness of instructions, not only trivializes these
tions. But that difficulty may not be transmitted to differences in operations but may even be quite misleading. For in-
stuttering frequency. Martin and Haroldson (1982), for instance, both of the above explanations could be in-
stance, found no evidence among 30 stutterers that their fre- terpreted to mean that stuttering will decrease if a
quency of stuttering in spontaneous speech differed signifi-
cantly during a telephone task and a monologue task in subject is simply instructed to try hard not to stutter.
laboratory conditions. Experimental attempts to compare the performance of
stutterers under such instructions and under con- to be the most appropriate place to locate lawful con-
tingency arrangements (James & Ingham, 1974; Mar- trols over the variability of this disorder.
tin & Haroldson, 1979; Martin & Siegel, 1966) have
adequately refuted this notion.
One of the most prominent behaviorally based theo- Stuttering Therapy
ries of stuttering has been the Brutten and Shoemaker
(1967; 1971) two-factor theory. It claims that stutter- In the past two decades, there have been dramatic
ing is composed of respondent and operant behaviors improvements in the variety and quality of procedures
that are differentially controlled by conditioned stim- for treating stuttering. There are many reasons for
uli. It is fair to say that this theory has generally failed these improvements, but one of the least recognized
to weather experimental analysis (Ingham, 1984a). factors was a virtual demand for accountability that
Nevertheless, this thesis stilI has some appeal for re- permeated speech pathology-and especially stutter-
searchers, especially in their search for antecedent ing therapy-during the 1970s. In all likelihood, this
stimuli that might produce respondent stuttering. For was caused by the inroads that behavior therapy and its
example, Brutten, Bakker, Janssen, and van der principles made on therapy practices that, until that
Meulen (1984) found measured eye movements in time, were neither reliable nor effective (Bloodstein,
stutterers were more pronounced than in non stutterers 1987; Ingham, 1984a). These inroads were achieved
during silent oral reading. Their finding implied that by a combination of some new and some revamped
stutterers might engage in more "searching and sort- techniques, the specification and systemization of
ing" among stimuli to find those that are conditioned therapy activities, and, most importantly, an emphasis
to elicit stuttering. In this instance, however, the mea- on quantification in therapy evaluation (Ingham,
sured differences might also be due to the slower read- 1984a). The extent to which this research-oriented ap-
ing rate used by the stutterers. Even less positive find- proach to therapy has improved the chances that stut-
ings emerged from Baumgartner and Brutten's (1983) terers are able to be relieved of their disorder is still
attempt to relate heart-rate activity to words that sub- debatable; perhaps because this is the first era of stut-
jects expect to stutter; only one of their three stutterers tering therapy in which reasonably objective informa-
showed any sign of this relationship-and then very tion has been used to estimate therapy benefits.
imperfectly. This is underscored by Peters and Hulsti- It is fair to say that clinicians now have access to a
jn's (1984) analysis of various physiological indicators variety of reasonably well-described strategies that re-
of arousal before and during speech tasks performed flect the behavioral orientation to stuttering therapy.
by stutterers (n = 24) and nonstutterers (n = 24). They They have been described in some important recent
found no differences between the measures from both publications (peins, 1984; Perkins, 1984a; Prins &
groups, although the stutterers did make higher verbal Ingham, 1983; Ryan, 1974), and in some therapy
ratings of anxiety. Finally, the predicted differences in "packages" (Shames & Florance, 1980; Shine, 1981;
the frequency of presumed respondent and operant Cooper & Cooper, 1976). This is not to gainsay the
stutterings to RCS and instructional conditions failed presence of other therapy orientations; but with the
to occur in Costello and Hurst's (1981) investigation of possible exception of drug therapies, most non-
response class patterns among these events. After behavioral programs (almost by definition) do not pro-
some years of research on Brutten and Shoemaker's vide clinicians with specifiable or replicable opera-
(1967) two-factor theory, it would now seem that it has tions. Nevertheless, there may well exist an interesting
little explanatory strength and should be either dras- dichotomy between the dominant practices clinicians
tically revised or discarded. use to treat stuttering and the dominant orientation of
The search for lawful relationships between the stuttering therapy researchers: most American and
variability of stuttering and environmental conditions British clinicians surveyed recently (Cooper &
has largely revolved around principles derived from Cooper, 1985; Cooper & Rustin, 1985; Curlee, 1985)
speech motor control and operant conditioning. This appear to employ a mixture of behavioral and non-
has yielded little new information; a situation that may behavioral practices. In turn, this raises interesting
continue in the light of recent trends in this research. questions about the contribution that current stuttering
Actually, many of the issues that relate to stuttering therapy research has made to routine clinical practice.
variability are now being pursued in different arenas. In the past few years, there have been numerous
One of these is stuttering therapy, which may turn out reviews of stuttering treatments (Adams, 1984; Blood-
stein, 1987; Costello, 1983; Curlee & Perkins, 1984, that appear to embrace many of the known require-
Section 3; Dalton, 1983; Hegde, 1985; Guitar, 1984; ments for adequate evaluation. These amounted to ap-
Guitar & Peters, 1980; Luper, 1982; Martin, 1981; propriate experimental controls, objective and repeat-
Peins, 1984; Perkins, 1984a; St. Louis & Westbrook, ed measures of stuttering frequency, speech rate, and
1987; Wall & Myers, 1984). The present writer also severity across speaking situations and over time, as-
published an extensive review of behavior therapy sessments of speech quality, and evaluation of the ex-
practices in stuttering therapy (Ingham, 1984a). The tent to which the subject is free of the need constantly
results of those reviews highlighted some interesting to self-monitor speech. In addition to those criteria,
commonalties and features among those practices. The Bloodstein suggested that the subject should also be
most favored therapy practices for adults and children free of the sense of handicap caused by the disorder.
involve three general features: a method that estab- There may be some debate about the essentialness of
lishes reduced or stutter-free speech under relatively all of Bloodstein's criteria (Ingham, 1984a), but few
controlled conditions; a method for transferring that would question the need for controlled studies which
improvement beyond the treatment setting; and strat- use most of them. On balance, the problem facing
egies for maintaining that improvement. The most stuttering treatment research seems to be the absence
favored techniques for establishing control over stut- of practical and valid methods for assessing speech
tering appear to fall into three categories: response quality, performance, durability, and (for want of a
contingent schedules, prolonged speech (or one of its better telrn) the "automaticity" of stutter-free speech.
variants), and mechanical aids for modifying stutter- Arguably, the unavailability of these measures vir-
ing. These techniques are also often used in conjunc- tually calls into question the clinical value of most
tion with speech rate control. No simple categorization stuttering therapy reports, including those that will be
can be made for transfer methods, but most depend on reviewed in this section.
systematically introducing the subject to increasingly A number of clinical researchers have begun to tum
demanding speaking situations. Maintenance tech- their attention to the task of finding measures that will
niques are even less developed (see Boberg, 1981; help close the credibility gap facing stuttering treat-
Ingham, 1984b), but are typified by intermittent ment research (Ingham, 1985). And, as will be dis-
schedules of contact with the subject over periods last- cussed, there is some evidence that this is beginning to
ing up to 2 or 3 years. Another feature is the impor- yield results. One unhelpful approach to this problem,
tance of using suitable measures to evaluate the pro- however, has been to rely on a meta-analysis (L. M.
cess and outcome of therapy. There is also clear Smith & Glass, 1977), such as that conducted by An-
recognition of the value that may be gained from rela- drews, Guitar, and Howie (1980), to identify effective
tively direct treatment of stuttering in children-prob- treatments for stuttering. The Andrews et al (1980)
ably one of the most dramatic changes in the last dec- meta-analysis attempted to cut across some obvious
ade (Prins & Ingham, 1983). However, there are some imperfections among stuttering treatment studies
less positiv~ features. One is continuing disquiet over while still claiming to satisfy Bloodstein's criteria. On
the long-term effects of treatment, especially for adult the basis of this analysis, they concluded that only
and adolescent stutterers, which is linked to concern treatments that use "prolonged speech" and precision
over therapy evaluation techniques and the effective- fluency shaping strategies (presumably in the estab-
ness of maintenance procedures. lishment phase of therapy) satisfy the majority of
The concern over therapy evaluation amounts to a Bloodstein's requirements. Putting aside the legion of
concern about the absence of a measurement tech- objections to meta-analyses that, perforce, virtually
nology that will validly assess stuttering therapy ignore the quality of treatment research, there is little
speech performance. The dissatisfaction with therapy value in a comparison that actually excluded a substan-
reports that simply describe changes in stuttering fre- tial and important group of treatments (those using
quency in a clinical setting were based on ample evi- either contingency management or masking). More-
dence that such changes do not always transfer to other over, the simple fact is that none of the treatment pro-
settings, and do not necessarily mean that the subject cedures included in the Andrews et al. meta-analysis
has acquired more normal sounding speech. Such con- evaluated speech quality (Ingham, 1984a; Wingate,
cerns have stepped up the search for criteria that should 1983), and most were confounded by a host of other
be obligatory in any evaluation of stuttering therapy variables, including, in some instances, additional
outcome. Bloodstein (1987) offered one set of criteria treatment (see Ingham, 1984a, Chapter 10). On the
other hand, if usage is an indicator of a successful precisely where most research is needed-especially
technique, it is also fair to note that the prolonged on maintenance strategies and their effects (Ingham,
speech treatments (those using this technique in the 1981, 1984b).
establishment phase of therapy) constitute the majority
of recent therapy reports.
The problems facing clinical researchers are also A Review of Recent Therapy Reports
shared by clinicians faced with the need to determine
the quality and durability of therapy gains. A satisfac- The recent reports on stuttering therapy largely re-
tory compromise between the exigencies of clinical flect the type of procedures that continue to attract the
practice and the demands for adequate therapy evalua- interest of clinical researchers. Therapy studies that
tion (by clinicians and clients) is difficult to achieve. were published up until 1982 were reviewed in the
However, a strategy outlined by this writer and Cos- previous edition of this Handbook. This section will
tello in various places (Ingham, 1984a,b, 1985; Ing- mainly update that review and will be confined to re-
ham & Costello, 1984, 1985) is one attempt at a com- ports that use some form of data base in order to evalu-
promise. This strategy (which is based on single- ate therapy effects. The reports are categorized accord-
subject research principles, plus measures suitable for ing to the principal treatment procedure used to
clinical use) requires repeated assessments of recorded establish reduced stuttering.
speech samples within and beyond the clinic over a Among the nonbehavioral approaches to therapy,
period preceding, throughout, and following therapy. there is much interest in the possibility that childhood
It also includes occasional covert assessment and fol- stutterers may be assisted by procedures that are di-
low-up sampling over a period of 6 months to 2 years, rected at language-related factors. Unfortunately, none
and supplementary data where appropriate. In addi- ofthe advocates ofthis approach (Wall, 1982; Wall &
tion, it incorporates decision-making principles that Meyers, 1984; Yovetich, 1984) has outlined therapy
help to determine the effectiveness of the therapy methods in a form that would encourage serious inves-
process. tigation. However, one therapy based on these prin-
Clinicians also need a rational basis for deciding ciples, the Stocker Probe Technique (Stocker, 1976),
which therapy procedure they should choose for a par- has incorporated some procedural outlines that may
ticular client. The most recent literature continues to help to assess its treatment value. The central feature
provide them with numerous suggestions, but none is of this treatment is client-clinician interaction using
backed by the force of serious research (Blaesing, specified levels of communication demand. The only
1982; Cooper, 1982; Costello, 1984; Costello & Ing- recent attempt to evaluate the effects of this therapy
h'am, 1984b; Ingham, 1984a; Prins, 1984; Riley & was a report by Stocker and Gerstman (1983) on the
Riley, 1983). At best, there seems to be some merit in treatment of 39 "young stutterers": 15 were treated by
the proposal that therapy for children should begin "conventional methods" and 24 by the "probe tech-
with procedures that involve less complex speaking nique." Seventeen treated by the probe technique and
demands before other more demanding activities are one treated by conventional methods were reported
required (Costello, 1983). The same principle may be "fluent at discharge," a claim totally unsupported by
just as relevant to adult therapy, with perhaps the added any other data. Another less frequently advocated non-
suggestion that intensive (even residential) treatment behavioral procedure is play therapy, which Wakaba
should be available for clients with a history of therapy (1983) used to treat three preschool stutterers. They
failure. received 21 I-hour per week sessions of therapy that
As previously mentioned, there is now some recog- appeared to produce no change in any child's stuttering
nition of the stringencies that must be met by any study frequency. Five years later, however, these children
that seeks to investigate a stuttering treatment. This had markedly improved according to their parents.
may explain an evident decline in therapy research The design of this study militates against Wakaba's
studies, although this might be due to the time frame claim that the treatment was responsible for the re-
required for this type of investigation. The time con- ported (and undocumented) improvement in these
straints facing graduate research (the setting for much children.
treatment research) virtually precludes the long-term The recent reports on behaviorally oriented stutter-
study of treatment effects. There is an obvious need for ing treatments can be categorized into six principal
some creative solutions to this problem, because this is stuttering modification strategies: rhythm, masking,
operant methodology, prolonged speech (or one of its ofthis is Ryan and Van Kirk Ryan's (1983) evaluation
variants), biofeedback, and reciprocal inhibition. of various forms of the Monterey treatment program
The first two categories are represented by two re- that they used to treat 16 young stutterers (7-18 years)
ports that do little to encourage the use of either tech- in four groups. This report was based on a study de-
nique. In what was claimed to be an "experimental scribed elsewhere (Ryan, 1974), which assessed the
study," Coppola and Yairi (1982) individually treated program's establishment, transfer, and maintenance
three preschool stutterers over 5 weeks, using three 45- schedules in the treatment of various age stutterers.
min sessions per week, and a follow-up evaluation 6 Like its predecessor, this report evaluated the use of
weeks later. They were treated through the use of met- "traditional" (those of Charles Van Riper) strategies, a
ronome-controlled speaking tasks that became in- DAF schedule, and two contingency management
creasingly longer over the course of the program (sim- methods (time-out and the GILCU procedure) during
ilar to Ryan's, 1974, Gradual Increase in Length and the programmed establishment phase of this treatment.
Complexity of Utterance [GILCUj procedure). As- Only four subjects were treated in each group (the
sessments of speech with a clinician and the child's groups were relatively well matched on average age
mother before and after treatment, plus at follow-up, and stuttering frequency), which makes it difficult to
showed a variable and unimpressive outcome: all the compare the general effects of each procedure. That
children reduced their percentages of syllables stut- task is made even more difficult because three subjects
tered at follow-up (two by over 80%, and the other by dropped out ofthe first treatment phase, and only four
more than 60%), but no child was stutter-free. The of the original 16 were assessed at a 9-month follow-
study also failed to include beyond clinic and speech up. The positive aspect of the study is that it incorpo-
rate data. The masking treatment report was a some- rated systematic assessments within and beyond the
what more controlled, but less therapy-oriented study, clinic, plus interviews with parents. It is also evident
by Block and Ingham (1984). They evaluated use of a that the treatment schedules could be managed by vari-
voice-actuated portable masking unit, known as the ous clinicians and that most subjects improved with
Edinburgh Masker (Dewer, Dewer, & Barnes, 1976), treatment. Possibly the most interesting finding was
on a variety of speaking tasks in a clinic and home that the four children who completed all phases of
setting. All 14 adult stutterers (18-58 years) in this treatment (they were the only subjects who passed a
study reduced their percentage of syllables stuttered criterion test permitting entry to transfer and mainte-
while using the Masker (for IO-min periods) in all nance phases) were those who had been treated by the
speaking tasks (clinic and the home), but only during time-out (one child) and GILCU (three children)
an oral reading task did their speech rate increase. The schedule. Assessments in the subjects' homes or
clinically interesting aspects of this study were that the schools at follow-up revealed that all had reduced their
mean reductions in stuttering were approximately stuttered words per minute scores by approximately
50%, no subject was stutter-free during any masking 80% and had increased their speech rates-but none
condition, and there was no evidence that improve- was stutter-free. In generalterms, this result resembled
ments during masking carried over to unmasked condi- earlierfindings from this program (Ryan, 1974). The
tions. More importantly, all subjects found the mask- differences between the amount of speaking time used
ing procedure "very disturbing." This is a rather more in each of the establishment phases and the uncertain
positive fi!lding on the Masker than a previous report functional features of this program still make it diffi-
(Ingham, Southwood, & Horsburgh, 1981), though cult to identify the significant treatment agents in the
not sufficient to encourage its use unless clients fail to Monterey program. But this result shows, yet again,
respond to other techniques. that children may respond positively to this type of
The use of contingency management principles in treatment.
stuttering therapy is now so widespread that it is almost It is even more difficult to determine the necessary
impossible to assess its contribution to therapy for this features, let alone the therapeutic benefits, among
disorder. For instance, treatment schedules that make therapy studies that employ prolonged speech (or vari-
the client's progress contingent on meeting perfor- ants of this speech pattern) as part of their treatment
mance targets and the use of putative reinforcers and schedules. The original use of prolonged speech
punishers are usually embedded in treatments em- among behaviorally oriented stuttering treatments de-
ploying other procedures to control stuttering (see Ing- rived from Goldiamond's (1965) use ofDAF in a nega-
ham, 1984a, Chapters 9,10, & 11). A perfect example tive reinforcement schedule. That method of instating
a controlled stutter-free pattern (characterized by ex- the subject's improved performance was maintained.
tended vowels, reduced articulatory contrasts, and But, like many similar reports, there were no beyond
gentle initiation of phonation) under a reduced speak- clinic or reliability data that would justify the claim
ing rate has been largely bypassed by the use of speech that this proved to be a successful treatment. More-
models. Nevertheless, DAF is still occasionally em- over, there was no independent evidence that this sub-
ployed in the context of some therapy programs, most ject had only recently acquired his disorder, or even an
notably the Monterey treatment program. One attempt attempt to verify the medical staff's impression that his
to demonstrate the comparative value ofDAF-instated stuttering was being used "to obtain monetary benefits
prolonged speech did occur in Ryan and Van Kirk under false pretenses" (Marshall & Starch, 1984, p.
Ryan's (1983) study. The contribution of DAF to their 88). Marshall and Neuberger (1987) used the same
findings is difficult to determine, but it was evident treatment schedule with three other adults (51, 39, 39
that the four subjects treated with this technique fared years old) who allegedly began stuttering following a
poorly relative to those treated by GILCU or time-out. head injury. The data trends show that two patients
The reasons for this might be due to the relatively responded to the DAF schedule, but only one main-
shorter time that the DAF-treated subjects took to com- tained therapy gains 3 months after treatment ceased.
plete the establishment phase, or perhaps the "prob- Some prolonged speech treatment programs have
lems for clinicians in teaching the pattern of slow, pro- also used a combination of DAF and recorded target
longed fluent speech" (Ryan & Van Kirk Ryan, 1983, speech models to help establish this speech pattern.
p. 304). This is the case in Ingham and Andrews' (1973) token
The uncertain replicability of prolonged speech economy program that Evesham and Huddleston
treatment procedures has plagued any investigation on (1983) adapted to treat 47 stutterers (age range 18-65
this type of therapy (Ingham, 1984a, Chapter 10), and years) in small groups. Spontaneous speech assess-
will probably continue to do so until the functional ments were obtained (only within a clinic) prior to
aspects of prolonged speech are identified and used treatment, immediately after treatment, and at follow-
reliably by clinicians. Furthermore, since DAF has no up sessions 9 and 18 (for 24 subjects only) months after
more reliability in establishing this speech pattern than the subjects completed the program's transfer phase (it
clinician instructions, this may also explain the lack of is not clear whether a maintenance phase overlapped
interest in the development of DAF technology. That the treatment phase). These results show that before
extends to interest in portable DAF units that, seem- treatment most subjects spoke with more than 5% of
ingly, might assist use of this speech pattern in beyond syllables stuttered, but at the 9- and 18-month follow-
clinic conditions. However, such units have been de- up sessions, 83% and 75% (respectively) of the sub-
v';!loped (Muellerleile, 1981) and, in a study by Craven jects had 2% (or fewer) syllables stuttered, and a much
and Ryan (1984), one was used with an adult stutterer improved speech rate. Unfortunately, this study also
to assist in the transfer phase of the Monterey program. failed to report beyond clinic or reliability data in sup-
Unfortunately, although the clinicians judged the sub- port of its findings. However, Evesham and Fransella
ject's performance in the transfer phase to be relatively (1985) provided some measurement reliability data in
"superior," the subject had "negative feeling about their reanalysis of Evesham and Huddleston's study.
the need to consistently use a fluent speech pattern" This later report reveals that 24 of the original 47 sub-
(Craven & Ryan, 1984, p. 241), and virtually dropped jects also received Personal Construct (Kelly, 1955)
out of therapy. training to help improve long-term maintenance.
The essential features of Ryan's (1974) DAF estab- Those who received this training showed less evidence
lishment schedule were used by Marshall and Starch of relapse, although their pretreatment frequency of
(1984) to modify a 32-year-old VA patient's "ac- stuttering was about half of the group who did not
quired" stuttering. A multiple baseline evaluation receive this training.
showed that this subject's stuttering decreased sub- The Ingham and Andrews (1973) token economy
stantially when the DAF schedule was introduced se- program has also been investigated for the contribution
quentially to oral reading, picture description, and that token reinforcers make to a subject's rate of pro-
monologues (although the subject's speech rate regress through part of that treatment. Howie and Woods
mained very slow in the latter two conditions). On the (1982) reported a series of comparisons between sub-
basis of within-clinic "follow-up" sessions, con- jects treated under a contingent, noncontingent, and
ducted at intervals over 101 days, it was claimed that "no token reinforcement" schedule during the pro-
gram's establishment phase. Essentially, they found no interest because of the two assessment findings. First,
difference between the effects obtained under any of the importance of covert assessments were shown
these schedules, which suggested that token reinforce- through covert recordings of the subject's telephone
ment was a redundant procedure. But an examination conversations 20 and 30 weeks after a second period of
of this study (Ingham, 1983b) showed that Howie and treatment; they contained much more stuttering when
Woods' token schedule had little in common with that compared with other overt assessments. Second, the
used by Ingham and Andrews, and was not demon- study used a perceptual analysis of video-recorded
strated independently to control speech behavior. The speech samples (mixed with those from normal speak-
entire study is also without measurement reliability ers and other treated stutterers) to establish the sub-
data. Nevertheless, it is noteworthy that most later ject's posttreatment speech quality. This analysis re-
applications of this program have relied upon a perfor- vealed that at follow-up the subject's speech (within
mance-contingent speech task schedule (see Ingham, the clinic) resembled the speech of normal speakers.
1981, 1982; Ingham & Onslow, 1985), rather than a The most problematic aspect of this report is that there
supplementary token economy, to control speech were no beyond clinic data which, when related to the
performance. covert assessment findings, does not augur well for the
A variation on Ingham and Andrews' (1973) treat- reliability of the perceptual analysis result.
ment program was described and evaluated in a report A major concern surrounding the continuing failure
by Howie, Tanner, and Andrews (1981). The results of to specify clearly the functional variables within pro-
treatment for 43 adult stutterers were based on a 3- longed speech treatments is that it has promoted
minute telephone conversation made by each subject vaguely described practices that are virtually impossi-
immediately before and after the intensive instatement ble to replicate-practices that have little relevance to
and transfer phases of the program, and then 12 to 18 the principles of behavior therapy (Ingham, 1984a,
months later. Their data show that there was a mean Chapter 10). Thus Runyan and Runyan (1986) re-
70% reduction in stuttering frequency (accompanied ported on a "fluency rules" therapy program that
by substantial increases in speaking rate) between the structures some of the speech production features of
initial and final assessments. These were encouraging prolonged speech for treating young stutterers. These
findings save for the fact that these subjects continued operating rules, which were not criteria-referenced,
to receive regular assistance with their speech through- were somehow combined with self-monitoring and
out the postintensive phase of this program via a self- transfer exercises in a school-based therapy program
help organization. The same evaluation problem arises for 9 children (3.8-7.1 years). Evaluations at school,
in a replication of this study by Andrews and Feyer made 1 and 2 years after treatment ceased, showed that
(1985). They reported on 37 adult stutterers who were most children had increased their speaking rate and
finally assessed 13 months after the intensive phase of decreased their stuttering by more than 90% (none
the program and showed a 92.1 % reduction in stutter- were stutter-free), but it is difficult to relate this result
ing frequency; again based on a 3-minute telephone to the therapy program.
conversation in a clinic setting. The combination of A more striking example of the development of
continuing treatment activities in the follow-up phase vaguely described therapy practices is the regulated
of this program and a reactive-prone method of out- breathing treatment developed by Azrin and Nunn
come assessment makes it difficult to judge the clinical (1974, 1977). The initial reports of this multi treatment
value of these findings. package were accompanied by almost astonishing
The Shames and Florance (1980) treatment program claims for success-claims that bear little resem-
also uses a combination of DAF and models to estab- blance to the findings from other reports on the use of
lish "stutter-free speech." Goldsmith and Anderson this procedure (Ingham, 1984a, Chapter 10). The
(1984), however, only employed models of the pro- poorly described procedures used in this treatment,
longed speech pattern in using this program to treat a which includes an obvious variant of prolonged
19-year-old mild stutterer. Their report does not ex- speech, were investigated in a series of studies by
plain how much of Shames and Florance's program Ladouceur and colleagues. It is, of course, almost im-
was employed, which may relate to why there was possible to know whether these studies faithfully repli-
some relapse 10 weeks after the subject achieved a cated Azrin and Nunn's procedures. Nevertheless, this
100% reduction in stuttering (albeit at a slightly slower program of research has used reasonably objective
than basal speech rate). This report has some added obtrusive and unobtrusive assessments to measure the
treatment's effects on adults (Ladouceur, Cote, sessment 6 months after treatment, one subject had
Leblond, & Bouchard, 1982; Ladouceur & Saint-Lau- relatively little stuttering (with improved speech rate),
rent, 1986) and children (Ladouceur & Martineau, while the other had partially relapsed. There was no
1982). Various additives (for example, awareness evidence, however, that these were representative as-
training and parent training) have been used in the sessments of their speech performance.
course of this research program in order to improve An even more questionable therapy program, also
outcome-all without success. There was no evidence based on a variant of prolonged speech, has been advo-
in these studies that clinically significant benefits were cated by Schwartz (1976). Despite many criticisms of
sustained when subjects were followed-up 1 or 2 this program (see Ingham, 1984a) it would appear that
months after treatment ceased. One exception to this Lee (see Andrews & Tanner, 1982) has prepared a
trend is Ladouceur and Saint-Laurent's (1986) study structured (though unpublished), two-phase version of
which reported that six of eight adult stutterers treated Schwartz's program which might aid its evaluation:
in a version of this program maintained treatment gains the initial phase involves teaching clients a "passive
at a 6-month follow-up. In this case, however, their airflow" technique, while the second is a series of
gains were related to levels of disfluency found in nor- weekly group meetings of treated clients who received
mal speakers; but this type of comparison ignores the speech assignments. Andrews and Tanner (1982) re-
distinction between stuttering and normal disfluences. ported an evaluation of this first phase with six adult
One drawback to the procedure that Ladouceur and his stutterers. Their treatment regime, which was also
colleagues used is that it consistently omits the exten- vaguely described, was conducted on five occasions
sive follow-up telephone contact procedure in Azrin spread over 30 days. Assessments of conversational
and Nunn's program. That omission may have ex- telephone tasks showed that 12 months later the sub-
cluded a powerful control over "posttreatment" jects' stuttering had returned almost to pretreatment
performance. levels. But it is difficult to imagine what can be learned
Three other reports on the use of Azrin and Nunn's from an evaluation of only part of an ill-specified treat-
program do not alter the growing impression that this ment. At best, it highlights the rather sorry state of
therapy produces rather dubious benefits. Greenberg research on the prolonged speech treatments-a state
and Marks (1982) reported using Azriil and Nunn's that appears unchanged since an earlier review (Ing-
program to treat 15 adult stutterers for an average of 12 ham, 1984a).
hours. Ten of these subjects were followed for 6 Biofeedback treatments of stuttering have been
months and eight rated their problem as "much im- largely confined to the use of EMG feedback from oral
proved." The total absence of any other relevant infor- facial sites that are presumed (but rarely shown) to be
mation in this report does little more than highlight the relevant sources of control over stuttering. Earlier ap-
unreliability of its findings. Waterloo and Gotestam plications of this procedure assumed that when mus-
(1988) compared 16 adult stutterers treated by a ver- cles at these sites were relaxed, this would modify
sion of Azrin and Nunn's program with a control group stuttering. More recently it has become clear (Ingham,
of 15 adult stutterers over a period of 1 month prior to 1984a; Moore, 1978) that part of the effect of these
treatment and 6 months after treatment. Assessments procedures may be due to other factors. These may
across various speaking tasks, including an unob- include the control exerted by contingency arrange-
trusive telephone call, showed that the treatment group ments in biofeedback schedules, and the possible in-
dramatically reduced stuttering immediately after trusion of "prolonged speech" variables (Moore,
treatament; but it systematically increased over the fol- 1978). These are important issues in considering the
low-up period (though notto the control group's level). findings of two recent EMG studies.
Rustin and Kuhr (1983) found that a combination of Craig and Cleary (1982) used EMG feedback from
relaxation and Azrin and Nunn's program was not ef- two preselected sites (the levator and superior or-
fective in treating two adult stutterers. A subsequent, bicularis oris muscles) to help treat three young stut-
almost bizarre, application of self-managed time-out terers (10, 13, and 14 years) in decreasingly frequent
("every time he stammered he would be required to sessions over approximately 18 weeks. The interesting
turn away from the person to whom he was speaking feature of this treatment was that oral reading and con-
for one minute" [Rustin & Kuhr, 1983, p. 93]), fol- versational samples were gathered in the clinic and
lowed by a transfer hierarchy, appeared to decrease home over the course of the program and again at
stuttering in both subjects. During an unspecified as- follow-up 9 months later. There is some evidence that
the feedback procedure may have modified stuttering to evaluate (obtrusively and unobtrusively) each sub-
during oral reading tasks, but this was not so during ject's performance with confederates. Schloss et al.
conversational speech. Indeed, the rather significant claimed that two of the subjects benefitted from this
improvement by all subjects during maintenance and procedure when assessed during follow-up, but the
follow-up assessments appears to have been due to data trends displayed in their results are not clear
self-managed procedures introduced after EMG treat- enough to justify this conclusion.
ment ceased: these procedures included regular speech There is one other treatment program that deserves
practice, self-recording, and a loosely described re- mention because it appears to embrace almost all of the
ward system based on days "free of serious dysfluen- treatment methods mentioned thus far. This is Riley
cy." This study is one of few that shows that treatment and Riley's component model for treating, mainly,
benefits were maintained in clinic and nonclinic condi- young stutterers. A most recent description of this
tions. The conversational speech of all three subjects at model (Riley & Riley, 1983) outlines a diagnostic
follow-up, however, still contained between 1% and strategy that will classify the subject's stuttering prob-
3% syllables stuttered (from between 11 % and 25% lem into "neurologic" (attending disorders, auditory
syllables stuttered before treatment). processing disorders, sentence formulation disorders,
In the course of an experimental study, which did not oral motor disorders), "intrapersonal" (high self-ex-
include beyond-clinic or follow-up assessments, pectations, manipUlative stuttering) and "interper-
Moore (1984b) employed EMG biofeedback (based on sonal" (disruptive communicative environment, unre-
a previously described treatment schedule [Moore, alistic parental expectations, abnormal parental needs
1978]) to treat an adult stutterer. Laryngeal area feed- for the child to stutter) components. Three levels of
back, which was used during a sequence of oral read- intervention may follow this diagnosis, each organized
ing tasks, appeared to reduce the subject's "percentage in a performance-contingent arrangement so that all
of dysfluencies." The accompanying changes in vocal problematic components are treated. The treatment of-
intensity and speech rate did suggest, however, that the ferings for each component may ultimately embrace a
EMG feedback procedures largely caused the subject combination of behavioral and nonbehavioral strat-
to adopt "different vocal production strategies to com- egies. But the evaluation of the structure of this treat-
ply with EMG criteria demands" (Moore, 1984b, p. ment and its outcome are open to question. It was
159). reported that 54 stutterers (3-12 years) were treated by
In view of the findings from these recent biofeed- this program and then assessed 12 to 23 months (n =
back studies, there is still little reason to believe that 44) and 24 to 48 (n = 37) months after completing
EMG feedback of oral facial muscle action (particu- treatment. Only ratings on a 1 to 5 scale by the parents
larly when it has not been established as a site of con- and clinicians were used to support the claim that at
trol over stuttering) is either an effective or valid meth- each of these follow-up assessments 84% and 81 %
od of treating stuttering. Moreover, if the effects rely (respectively) of the children had a successful out-
on changes in vocal production strategies, then there come.
are many less complicated ways of producing those In general terms, it is quite obvious that stuttering
changes. There would also seem to be far more profit treatment continues to be haunted by the problem of
for biofeedback treatments to utilize procedures that inadequate (even inappropriate) process and outcome
transduce variables that more directly influence stut- evaluation. Most of the problematic aspects among
tering (for example, airflow, phonation intervals, therapy studies previously reviewed by the writer (Ing-
etc.). ham, 1984a) remain and make it difficult to judge the
It is interesting to note that there are virtually no value of recent treatment reports, especially for clini-
recent reports on the use of relaxation and systematic cians who want reliable information on how to treat
desensitization in stuttering therapy. However, the re- this disorder. The following section reviews some re-
ciprocal inhibition principles were the basis of cent research on certain aspects of stuttering therapy
Schloss, Freeman, Smith, and Espins' (1987) use of that may resolve some of these problems.
assertiveness training to treat three adult stutterers.
The treatment involved systematic training (instructors
Stuttering Treatment Methodology Research
modeling, feedback, and homework assignments) in
dealing with "disagreeable," "impatient," and "pa- The problem of stuttering treatment evaluation and
tronizing" conversants. A multiple baseline was used the need to find factors and procedures that may help to
maintain therapy benefits have been welcome con- ment occurring in other stutterers, their stuttering was
cerns in the treatment literature. These problems, also reduced. Another study (Stephenson-Opsal &
which are echoed in most recent reviews of stuttering Bernstein-Ratner, 1988) showed the beneficial effects
treatment (Hegde, 1985; Howie & Andrews, 1984; on two stuttering children of their mothers' reducing
Ingham, 1984a, 1985; Kamhi, 1982; Perkins, 1983b; their speech rates and speaking with "elongated sylla-
St. Louis & Westbrook, 1987), are probably responsi- bles and increased pause time between words." The
ble for a general reduction in the number of stuttering reductions in the childrens' "mean percent time dis-
therapy studies. fluent" did not appear to be due to their reduced speak-
Central to the problem of evaluating the positive ing rate. There is also one recurring theme among
results of most current therapies is the difficulty of many recent treatment reviews that have sought vari-
establishing the status of treatment outcome from re- ables that may assist outcome: that is, self-managed
ported data. For example, it is often the case that out- activities appear to be at the heart of the most effective
come depends on the speaker's retaining certain treatments of stuttering (Ingham, 1984a,b; Kamhi,
speech production controls (especially altered rate, 1982; Perkins, 1983b). The need for further research
prolongation, or other vocal changes), or supplemen- on these activities is obvious.
tary managed programs (self-, parent-, or other-per- The search for nonspeech variables that might im-
son-managed programs), during intervals preceding prove therapy outcome has produced one contentious
outcome evaluations. Both of these "additives" are development-the revival of interest in the contribu-
either uncontrolled or undocumented factors in many tion that stutterers' attitudes may make to mainte-
therapy reports, which make it almost impossible to nance. The issue has been approached from two direc-
learn the true status of therapy outcome (Ingham, tions: stutterers' attitudes toward cOmIDunication, and
1984a). Covert assessment of outcome performance is the stutterers' perceptions of sources of influence on
at least one way in which the fragility of motoric con- their own problem. The suggestion that there is a
trol strategies or measurement reactivity can be recog- "communication attitude" that may directly affect
nized. Also, as a number of studies have shown (Gold- therapy outcome emerged from studies by Guitar
smith & Anderson, 1984; Howie, Woods, & Andrews, (1976) and Guitar and Bass (1978). The latter study
1982; Ingham, 1982), some telling and clinically appeared to show that immediate posttreatment scores
important differences often appear between covert and on the S24 (Andrews & Cutler, 1974), a self-rating
overt outcome assessments. On the other hand, evi- scale designed to measure these attitudes, partially
dence that stutter-free speech occurs in covert and predicted long-term outcome. In challenging this find-
overt assessments may simply mean that motoric con- ing, this writer (Ingham, 1979) observed that the
trols or posttreatment management programs are act- wording of the scale's items might be sufficient to at-
ing effectively. They do not, as Wingate (1983) has tract responses that reflect current speech performance
pointed out, mean that the subject is "speaking unas- rather than a communication attitude. Moreover, when
sisted." Simply stated, it is often hard to know when the Guitar and Bass findings were reanalyzed, it was
treatment has ended! shown that their subjects' outcome performance was
A closer study of the methods that are used to select not significantly related to immediate posttreatment
and manage treatment is one area that has been consid- S24 scores (Guitar, 1981; Ingham, 1979). An even
ered important for improving therapy outcome. Most clearer depiction of the influence of speech perfor-
recent approaches to this issue (as mentioned above) mance on S24 scores emerged from an investigation by
largely amount to suggestions for choosing a therapy Ulliana and Ingham (1984), which showed· that sub-
program. Some, however, refer to a variety of almost jects based the majority of their responses to the S24 on
"placebo-like" factors, such as the manner in which their current stuttering and speech behavior, rather
the clinician presents therapy (Lay, 1982; Prins, 1984), than nonbehavioral variables. Even more significant
or the choice of speech tasks (Gerstman, 1983) that was evidence from three stutterers that showed that
may be necessary for effective therapy. One rather their frequency of stuttering in situations mentioned on
overlooked factor is the role of modeling (Prins, the scale could directly modify the scale's scores.
1984), which has received little attention in therapy Surprisingly, quite similar issues have surfaced in
management. Its importance is evident in at least two recent attempts to evaluate the contribution of a
studies. The first, by Martin and Haroldson (1977), learned or "conditioned helplessness" which, some
found that when stutterers merely observed improve- argue (Adams, 1983; Williams, 1982), contributes to
poor maintenance. It is claimed that some stutterers procedures, its widespread use is probably testimony
perceive that they are not always responsible for con- to the strength of certain motoric changes in control-
trol over changes in their disorder; the responsible fac- ling stuttering. It is puzzling, therefore, that so little
tors are beyond their locus of control. Craig and Howie interest has been directed at finding their critical com-
(1982) attempted to investigate the role of this con- ponent(s) in order to improve the efficiency of treat-
struct in the outcome performance of 30 stutterers who ment. In six before-and-after therapy evaluations of
had received stuttering therapy by a variation of Ing- the speech of stutterers, treated by either Van Riper
.ham and Andrews' (1973) program. Scores on the Rot- type therapy (Metz, Samar, & Sacco, 1983; Ramig,
ter Generalized Scale (Rotter, 1966), which purports to 1984; Samar, Metz, & Sacco, 1986) or prolonged
measure a general locus of control, were found to cor- speech programs (Mallard & Westbrook, 1985; Robb,
relate .58 with the amount of change in stuttering Lybolt, & Price, 1985; Shenker & Finn, 1985), it ap-
scores from pretreatment to 18 months after treatment. peared that durational components in certain acoustic
Despite this moderate correlation, Craig and Howie and aerodynamic variables were changed by therapy.
concluded that clients "whose perceptions of control But the importance of these changes to the production
were enhanced after therapy" are more likely to main- of normal sounding speech was not identified; nor are
tain their therapy gains. The fragility of this conclusion they likely to be without controlled manipulations of
is even more pronounced by the absence of measure- these variables independent of therapy. One attempt to
ment reliability data for either the scale or stuttering do this occurred in the previously reported study by
scores. Craig, Franklin, and Andrews (1984) at- Ingham et al., (1983), which manipulated the frequen-
tempted to improve the predictive strength of locus of cy of relatively short phonation intervals and showed
control scaling by using 17 items which, it was re- that these changes were not only sufficient to control
ported, predicted relapse among stutterers 10 months stuttering, but could do so without producing nonnor-
after treatment by a similar prolonged speech program. mal sounding spontaneous speech. There may be ad-
Similar results were obtained by Craig and Andrews vantages to therapy if such a limited manipulation of
(1985). But the items on this scale, like the S24 com- speech behavior serves to produce normal sounding
munication attitude scale, may provide scores that re- stutter-free speech. There is also some evidence that
flect the presence or absence of stuttering as much as a speech rate manipulation may help to produce normal
locus of control. For example, it is entirely possible sounding posttreatment speech. Prosek and Runyan
that the continuing presence of stuttering would be (1982; 1983) reanalyzed recordings of stutter-free
sufficient to produce a score on items, such as "my speech from treated stutterers and found that listeners
problem(s) will dominate me all my life," or "to con- were less adept at identifying their speech among sam-
tinuously manage my problems I need professional ples from nonstutterers when the speaking rates of both
help." In other words, scale responses that are alleged groups were matched.
to depict an inappropriate locus of control might sim- The task of evaluating and producing natural sound-
ply show that the subject still stutters in nonassessed ing speech during stuttering therapy may have been
circumstances, thereby confounding a locus of control aided greatly through Martin, Haroldson, and Triden's
score. The need for research that will establish whether (1984) important discovery that listeners can reliably
a locus of control construct is indeed independent of quantify the naturalness of I-minute speech samples
measures of speech performance is obvious. Some at- from stutterers and nonstutterers by using a 9-point
tempts in this direction are reported by 1. B. Watson, scale. A study by Ingham, Gow, and Costello (1985)
Gregory and Kistler (1987) in the development of a showed that listeners could also use this scale to dis-
stutterers' Communication Attitudes Inventory. tinguish between posttreatment speech samples from
Given the evidence that certain treatment pro- stutterers, who had completed the establishment and
cedures reliably control stuttering, it is understandable transfer phases of a prolonged speech therapy program
that some clinical researchers have sought to improve (Ingham, 1980b), and matched samples from nonstut-
therapy outcome by refining these procedures. This terers. An even more significant feature of this scale
has occurred in three main areas: identifying acoustic was revealed by the finding that the scale's ratings
and, ultimately, motoric variables that might be associ- could be fed back to stutterers, and that this modified
ated with therapy outcome, finding methods of im- their speech naturalness independently of changes in
proving speech quality, and investigating maintenance stuttering frequency and speech rate (Ingham, Martin,
strategies. Haroldson, Onslow, & Leney 1985). Ingham and
Despite the imperfections in the prolonged speech Onslow (1985) then used essentially the same pro-
cedure with three adolescent stutterers during the es- nated by a growing belief that stuttering is a neu-
tablishment phase of a prolonged speech therapy pro- romotor disorder with genetic underpinnings. There is
gram. Fifteen-second interval feedback of naturalness also some continuing commitment to the notion that
ratings by a clinician were able to be used reliably and, stuttering can only be modified by certain motoric
more importantly, were found to improve the speech changes. The evidence in support of these premises
naturalness of the three stutterers; however, only two appears to be sufficient to maintain interest in neu-
managed to achieve levels consistent with completely romotor and genetic hypotheses. To a large extent, the
natural sounding speech. Relatively similar findings strength of this trend appears to have diminished in-
have also been obtained when stutterers' self-manage terest in the search for environmental variables that
their naturalness ratings (Ingham, Ingham, Onslow, & may control or even activate this disorder. This over-
Finn, 1989). It is reasonable to claim, even at this early sight may be costly, especially because of the rather
stage, that this technique may have immense promise significant role that these variables have in the findings
in helping to overcome one possible source of therapy of many studies conducted within the neuromotor
relapse-the unwillingness of stutterers to use speech framework.
which, for them, may sound as unpleasant as The strength of the neuromotor orientation may also
stuttering. help to explain why there has been a general decline in
Sad to report, there is very little evidence that the stuttering therapy research. At the same time, reports
constant cry for stuttering therapy maintenance re- on stuttering therapy continue to be dominated by pro-
search (Boberg, 1981; Ingham, 1984a,b) has been cedures that derive from the prolonged speech tech-
heard by researchers. Some even believe that the prob- nique developed by Goldiamond (1965) more than two
lem will not be solved by refining behavioral manage- decades ago. There are numerous variations on this
ment strategies-mainly because of neuromotor lim- procedure, but their applications in a behavior therapy
itations (Kamhi, 1982), or learned reactions to context remain questionable in view of the failure to
stuttering (Perkins, 1983b). It is ironic, therefore, that identify the functional and replicable components of
this perception should emerge at a time when promis- prolonged speech or its variants. Contingency man-
ing findings have appeared among some relatively de- agement procedures are now fundamental to much of
tailed treatment evaluation studies. These investiga- stuttering therapy and are probably most influential in
tions (Ingham, 1980a, 1982; James, 1981c) have therapies for children. There are enormous problems
shown that self-managed time-out and self-evaluation associated with adequately evaluating the outcome of
of performance may produce sustained reductions in stuttering therapy, and many of these proj:>lems are
stuttering in young adult stutterers-arguably the most now occupying the attention of clinical researchers
relapse-prone type of patient. That irony is com- concerned with this disorder. In general, there is a need
pounded by evidence that very young stutterers are for refinements to management and measurement
also likely to obtain sustained therapy gains (Ingham, strategies, plus increased attention to factors that may
1984a). The s'imple fact is that there are numerous improve the maintenance of therapy gains.
behavioral or cognitive-behavioral maintenance strat-
egies that still await investigation (Ingham, 1984b;
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CHAPTER 30
Anxiety Disorders
Greta Francis
The purpose of this chapter is to provide an overview withdrawal as part of the "internalizing" or "over-
of assessment strategies and treatment approaches for controlled" dimension (e.g., Achenbach & Edel-
anxiety disorders in children and adolescents. Al- brock, 1978; Ross, 1980). However, according to
though the clinical and research literature on mild to Achenbach (1980), there is some support for an em-
moderate fears is large, there are relatively few studies pirically derived, narrow-band syndrome labeled
of clinic-referred youngsters with anxiety disorders. "anxious."
The scope of this chapter is limited to a discussion of Those classification schemes based on nosological
anxiety disorders in clinic-referred children and ado- methods emphasize the essential features and the dura-
lescents. The reader is referred to Graziano, De- tion of each disorder as a way of determining differen-
Giovanni, and Garcia (1979) and Hatzenbuehler and tial diagnoses. The essential features of each disorder
Schroeder (1978) for reviews of the assessment and typically are derived from clinical observation of the
treatment of subclinical fears in youngsters. disorder. The best example of a nosological approach
to classification is the Diagnostic and Statistical Man-
ual of Mental Disorders and its revisions (e.g., DSM-
Classification III-R; American Psychiatric Association, 1987). The
DSM-III-R delineated three anxiety disorders specific
Classification of anxiety disorders in children has to children and adolescents: separation anxiety disor-
been proposed on both empirical and nosological der, overanxious disorder, and avoidant disorder. In
bases. Empirically based classification schemes rely addition, children and adolescents may receive anxiety
on statistical techniques, such as factor analysis, to diagnoses that are not specific to children, including
determine features common to particular dimensions. generalized anxiety disorder, simple phobia, social
Childhood psychopathology generally is assessed by phobia, panic disorder with or without agoraphobia,
parent and teacher behavior checklists and rating obsessive-compulsive disorder, and posttraumatic
scales. The most stable and consistently reported syn- stress disorder.
dromes have been broadband "internalizing" and "ex- Separation anxiety disorder is characterized by
ternalizing" dimensions. Anxiety in children typically marked distress related to the separation of the child
has been classified along with depression and social from major attachments figures, usually parents, or the
home. Children with separation anxiety disorder may
worry about their own or their parents' safety, be reluc-
Greta Francis • Department of Psychiatry and Human Be-
havior, Bradley Hospital, Brown University, East Providence, tant to attend school or other activities away from par-
Rhode Island 02915. ents, be reluctant to sleep alone or away from home,
633
complain of aches and pains at separation times, be bics are said to avoid situations because of a fear of
very clingy with parents, become very upset in antici- having a panic attack or being incapacitated.
pation of separation, and show signs of distress while Obsessive-compulsive disorder in children and ado-
separated from parents. According to the DSM-III-R, lescents is virtually identical to that seen in adults. The
in order to receive a diagnosis of separation anxiety hallmark of obsessive-compulsive disorder is re-
disorder, the child must evidence at least three of the petitive disturbing thoughts and/or behavioral rituals.
above-mentioned nine symptoms. The interruption of these thoughts or rituals typically
The hallmark of overanxious disorder is excessive causes the person to become distressed. Common ob-
or unrealistic worry. In contrast to the relatively cir- sessions are thoughts of doubt, dying, or contamina-
cumscribed worries indicative of separation anxiety tion. Common compUlsions include washing, check-
disorder, the worries of overanxious disorder children ing, touching, and counting rituals.
tend to be rather pervasive and involve many social, Occasionally children and adolescents present with
athletic, and academic situations. The child with over- symptoms indicative of posttraumatic stress disorder
anxious disorder may worry about both past and future (PTSD). The essential feature of PTSD is continued
events, be overly concerned with his or her perfor- distress following an unusual, markedly distressing
mance in academic, athletic, or social situations, ex- event. The continued distress is exhibited by reex-
press a variety of vague somatic complaints, evidence periencing the traumatic event, avoidance of situations
extreme self-consciousness, require excessive reas- associated with the event, and persistent symptoms of
surance, and complain of tenseness or an inability to increased arousal.
relax. According to the DSM-III-R, in order for a child
to receive a diagnosis of overanxious disorder, he or
she must evidence at least four of the above-mentioned Assessment Issues
seven symptoms.
Children with avoidant disorder are said to show Diagnostic Reliability
excessive shyness around unfamiliar people so much
so as to interfere with social functioning in peer rela- There are three published studies that address the
tionships. The child with avoidant disorder will avoid question of the diagnostic reliability of childhood anx-
social situations in which he or she is exposed to un- iety disorders (Last, Hersen, Kazdin, Finkelstein, &
familiar peers. In order to receive a diagnosis of avoid- Strauss, 1987; Strober, Green, & Carlson, 1981;
ant disorder, the child must value interpersonal in- Williams & Spitzer, 1980). Both Strober et at. (1981)
volvement as evidenced by appropriate relationships and Williams and Spitzer (1980) found very poor diag-
with familiar people, such as family members. nostic reliability for anxiety disorders in children and
The diagnosis of phobia in children is identical to adolescents. Strober et at. (1981) reported a kappa
that in adults and is subtyped according to the nature of coefficient of .47 for anxiety disorders in their inpa-
the phobic object (social or simple). The phobic child tient adolescent sample using a structured diagnostic
must show persistent fear of a situation or object, avoid interview. Similarly, Williams and Spitzer (1980) re-
the feared object or endure contact with intense anx- ported kappa coefficients ranging from .25 to .44 for
iety, recognize that the fear is excessive or unreason- anxiety disorders in their child and adolescent sample
able, and evidence impairment in day-to-day function- using an unstructured diagnostic interview. It is impor-
ing or be bothered by having the fear. Common tant to note that both of the above-mentioned studies
phobias in children include fears of animals, public contained very small numbers of anxiety-disordered
speaking, school, and medical procedures. subjects (n = 6 and n = 15, respectively).
Panic disorder with or without agoraphobia also In contrast, Last et at. (1987) examined the diag-
may be diagnosed in children and adolescents using nostic reliability of separation anxiety disorder (n =28
the adult criteria specified in DSM-III-R. Panic disor- and overanxious disorder (n = 32) in a sample of anx-
der without agoraphobia is characterized by spon- iety-disordered outpatient children and adolescents
taneous anxiety attacks, consisting of multiple physio- using a semistructured diagnostic interview. Their di-
logical symptoms, in the absence of significant agnostic agreement was quite good, as evidenced by
avoidance behavior. In contrast, the diagnosis of panic kappa coefficients of .81 for separation anxiety disor-
disorder with agoraphobia requires both spontaneous der and .82 for overanxious disorder. Possible reasons
anxiety attacks and significant avoidance. Agorapho- for the dramatic differences in diagnostic reliability
CHAPTER 30 • ANXIETY DISORDERS 635
between this study and previous studies include the dren: 75% presented with more than three symptoms.
larger sample size, use of the same two interviewers In addition, there was some evidence that young chil-
for all subjects, and potential interviewer bias stem- dren demonstrated different symptoms than did older
ming from the recruitment of subjects with anxiety children or adolescents. Young children were more
disorders (Last, 1987). likely to report nightmares involving separation and
excessive distress upon separation.
Similarly, Strauss et at. (1989) studied age dif-
Normative and Developmental
ferences in a clinic sample of 55 children diagnosed
Considerations
with overanxious disorder. The authors compared chil-
In order to assess anxiety in youngsters, it is impor- dren (ages 5 to 11 years) and adolescents (ages 12 to 19
tant to consider a number of normative and develop- years) on symptom ratings and self-report inventories.
mental factors. There is empirical evidence to suggest They reported that although adolescents were more
that normal children show a relatively large number of likely to describe unrealistic concern about the appro-
fears (e.g., Agras, Sylvester, & Oliveau, 1969; Jersild priateness of their past behavior than were younger
& Holmes, 1935; Lapouse & Monk, 1958; Mac- children, there were no differences in the rates at which
Farlane, Allen, & Honzik, 1954). For example, in their they described other overanxious symptoms. How-
classic epidemiological study, Lapouse and Monk ever, adolescents presented with a greater number of
(1958) discovered that 43% of children in the sample symptoms than did children. This finding is opposite
had seven or more fears, as reported by their mothers. to what has been described in separation anxiety disor-
No epidemiological information is available regarding der (Francis et al., 1987). Finally, overanxious adoles-
the prevalence of other anxiety symptoms in normal cents reported significantly more anxiety and depres-
children. Although the prevalence of common fears is sion using self-report questionnaires.
high, severe fears and phobias account for only a small Generally, it has been found that girls tend to report
percentage of child psychiatric referrals (Graziano et more fear and anxiety than do boys (e. g., Abe & Mas-
al., 1979). ui, 1981; Anderson, Williams, McGee, & Silva, 1987;
Studies of subclinical fears indicate a change in the Lapouse & Monk, 1958; Richman, Stevenson, &
type and number of fears over the course of childhood Graham, 1975). However, as Graziano et at. (1979)
and adolescence (e.g., Graziano et at., 1979; Mac- aptly point out, it is unclear whether the higher rate of
Farlane et at., 1954). For example, young children fears reported for girls reflects a greater prevalence of
tend to evince more and different fears than do older fearfulness in girls or a greater willingness by girls and
children and adolescents. Although there appears to be their parents/teachers to report fears. Recently, data
an age-related decrease in reported fears of imaginary have become available regarding gender differences in
creatures, the dark, and animals, there is an age-relat- clinic-referred youngsters. Strauss and Francis (1989)
ed increase in social fears (e.g., Agras, Chapin, & reported that females in their clinic sample of 171 out-
Oliveau, 1972; Bauer, 1976; Maurer, 1965). Such inpatient youngsters more commonly received diag-
formation is not available regarding the relationship noses of simple and social phobias than did males. In
between age and anxiety symptoms other than fears. comparing youngsters with anxiety-based school re-
1\\'0 recent studies examined the relationship be- fusal, Last, Hersen, Kazdin, Finkelstein, and Strauss
tween age and anxiety symptom expression (Francis, (1987) found that males in their outpatient clinic sam-
Last, & Strauss, 1987; Strauss, Lease, Last, & Fran- ple were more frequently found to have school phobia,
cis, 1989). Francis et al. (1987) investigated the ex- whereas females were more frequently found to have
pression of separation anxiety disorder in a sample of separation anxiety disorder. No gender differences
45 outpatient youngsters diagnosed with separation were reported by Strauss et at. (1989) in their study of
anxiety disorder. They found that young children (ages overanxious disorder. Furthermore, Francis, Last, and
5 to 8 years) evidenced more total symptoms than did Strauss (1989) found equal numbers of boys and girls
older children (ages 9 to 12 years). Although 100% of to present at their outpatient clinic with avoidant
young children received a diagnosis of separation anx- disorder.
iety disorder based on having met more than the mini- Children of varying socioeconomic status (SES)
mum three diagnostic criteria, this was true for only levels have been found to differ in the number and type
69% of older children. Adolescents (ages 13 years and of fear reported. Angelino, Dollins, and Mech (1956)
above) did not differ from either young or older chil- and Lapouse and Monk (1959) found that children
from lower SES levels reported more fears and worries comorbid affective disorder), children with mixed anx-
than did children from higher SES levels. Moreover, iety and depressive disorders evidenced more addi-
low SES children were more likely to report fears of tional concurrent anxiety disorders and reported higher
rats and drunks, whereas higher SES children were levels of anxiety and depression as assessed by self-
more likely to report fears of car accidents. Last and report instruments.
colleagues (Last, Strauss, & Francis, 1987) reported
demographic differences in their sample of anxiety-
disordered children and adolescents as a function of Assessment Instruments
diagnosis. They found that the majority of families of
children with separation anxiety disorder received low As with any psychological disorder, there is a vari-
socioeconomic status ratings, whereas the majority of ety of assessment methods appropriate to the study of
families of children with a phobic disorder of school or anxiety disorders in children and adolescents. The ma-
overanxious disorder received middle-upper so- jor weaknesses of assessment studies of childhood
cioeconomic status ratings. anxiety have been the lack of inclusion of clinical pop-
In sum, little is known about the demographics and ulations and the overreliance of single-assessment
natural history of anxiety disorders in clinical and non- methods. The inclusion of multimethod assessment
clinical samples. As such, there is a tremendous need techniques is necessary, and would include interviews,
for longitudinal research in order to understand the behavioral and cognitive self-report measures, signifi-
developmental course of anxiety in children and ado- cant-other report measures, observational measures,
lescents (Campbell, 1986). and physiological measures. The bulk of the research
in the assessment of childhood anxiety has focused on
self-report measures offear and anxiety. Considerably
Comorbidity
less research attention has been paid to alternate as-
Available evidence suggests that comorbidity sessment methods.
among anxiety disorders in children often occurs.
Last, Strauss, and Francis (1987) discovered that the
Behavioral/Diagnostic Interviews
majority of children and adolescents with primary di-
agnoses of separation anxiety disorder, overanxious There are a number of semistructured interview
disorder, or phobic disorder of school presented with schedules appropriate for use with anxiety-disordered
concurrent psychiatric disorders (79%, 73%, and populations. In particular, a child version of the Anx-
64%, respectively). Moreover, there was a high degree iety Disorders Interview Schedule (Kiddie-ADIS)
of overlap among anxiety disorders. One third of sepa- (Silverman, 1987a), Interview Schedule for Children
ration-anxious youngsters presented with concurrent (ISC) (Kovacs, 1978), Children's Anxiety Evaluation
overanxious disorder. Of overanxious disorder chil- Form (CAEF) (Hoehn-Saric, Maisami, & Wiegand,
dren, one third presented with concurrent social pho- 1987), Children's Assessment Scale (CAS) (Hodges,
bia, and one fourth presented with avoidant disorder. 1978) and a recent revision of the Schedule of Affec-
Anxiety disorders in children also have been found tive Disorders and Schizophrenia for School-Age
to be related to other types of psychopathology. A Children (KSADS) (Puig-Antich & Chambers, 1982)
number of researchers have commented upon the asso- appear to be promising inst1'!Iments. With most of the
ciation between anxiety disorders and affective disor- semistructured, symptom-oriented interviews, both
ders in clinic-referred youngsters (e.g., Gittelman, the child and a parent are interviewed. The interviewer
1986; Puig-Antich & Rabinovich, 1986). In particular, then is required to make a summary clinical judgment
school avoidant, separation-anxious, and overanxious about each symptom and, subsequently, each disorder.
children have been found to evidence relatively high The ISC is administered to the child and the parent,
rates of concurrent affective disorders, particularly and is appropriate for use with children aged 8-13
major depression (Strauss, Last, Hersen, & Kazdin, years of age. The majority of questions on the ISC tap
1986). Strauss, Last, Hersen, and Kazdin (1988) re- components of depression, although various content
ported that 28% of their sample of anxiety disordered areas are included. Kovacs (1983) reported excellent
outpatient children and adolescents presented with interrater reliability for anxiety symptoms using the
concurrent major depressive disorder. In addition, as ISC. Similarly, Last (1989) reported excellent inter-
compared to children with "pure" anxiety (i.e., no rater reliability for childhood anxiety disorders (i.e.,
separation anxiety disorder, overanxious disorder, Part III, the interviewer rates the extent to which the
avoidant disorder) using the ISC. child exhibited behavioral indicants of anxiety (e.g.,
Recently, Last (1987) modified the KSADS (Puig- nail biting, stuttering) during the interview. Unlike the
Antich & Chambers, 1982) for use with anxiety-disor- above-mentioned semistructured interviews, the
dered populations. This modification entailed expand- CAEF assesses anxiety symptoms rather than anxiety
ing the anxiety sections of the instruments so as to disorders. The authors administered the CAEF to 63
include diagnostic criteria for all child and adult anx- inpatient children with diagnoses including anxiety
iety disorders. Thus, the modified KSADS allows for disorder, dysthymia, oppositional disorder, and con-
the assessment of depression, dysthymia, mania, all duct disorder. They reported that scores on the CAEF
anxiety disorders, attention-deficit disorder, opposi- distinguished the anxiety disorder group from each of
tional disorder, conduct disorder, and psychosis. Last the other diagnostic groups.
and colleagues have found excellent interrater reliabil-
ity for anxiety disorders using the revised KSADS (c.
Self-Report Measures
G. Last, personal communication, August, 1987).
The Kiddie ADIS (Silverman, 1987a) is a revision A number of self-report measures of anxiety exist
of the adult anxiety disorders interview schedule. The for children and adolescents. The most widely used
Kiddie ADIS includes the following content areas: include the Children's Manifest Anxiety Scale-Re-
anxiety disorders, affective disorders, disruptive be- vised (CMASR) (Reynolds & Richmond, 1978),
haviordisorders, and psychotic disorders. For many of State-Trait Anxiety Inventory for Children (STAIC)
the diagnostic criteria, the Kiddie ADIS assesses the (Spielberger, 1973), Test Anxiety Scale for Children
presence or absence of the symptom without regard to (TASC) (Sarason, Davidson, Lighthall, Waite, &
the severity of that symptom. However, if a child re- Ruebush, 1960), and the Fear Survey Schedule for
ceives enough symptoms to qualify for a diagnosis, Children-Revised (FSSCR) (Ollendick, 1983).
severity of the overall symptom picture and functional Other, more recently developed self-report measures
impairment are then rated. that have been used with anxious children include the
The Child Assessment Schedule (Hodges, 1978) Social Anxiety Scale for Children (SASC) (LaGreca,
also provides information so as to allow for differential Dandes, Wick, Shaw, & Stone, 1988), Children's
diagnoses. The CAS is organized according to content Cognitive Assessment Questionnaire (CCAQ) (Zatz &
areas (e.g., fears, worries, moods, family). Unlike the Chassin, 1983), and the Children's Negative Cognitive
KSADS, the CAS does not attempt to determine the Error Questionnaire (CNCEQ) (Leitenberg, Yost, &
severity of symptoms. Rather, the CAS is designed to Carroll-Wilson, 1986).
assess the presence or absence of symptoms. Ques-
tions tap the DSM-III diagnostic criteria for anxiety, Children's Manifest Anxiety Scale-Revised.
conduct, attention deficit, and pervasive developmen- The revised Children's Manifest Anxiety Scale
tal and depressive disorders. The CAS has been used (CMASR) (Reynolds & Richmond, 1978) is a 37-item
for the assessment of anxiety disorders in children questionnaire consisting of a lie scale and three anxiety
(Beidel & Turner, 1989). subscales: physiological anxiety, worry-oversen-
The CAEF was developed by Hoehn-Saric and col- sitivity, and concentration anxiety. The CMASR has
leagues (Hoehn-Saric et al., 1987) in order to assess been studied widely. Normative data are available, as
the presence of anxiety symptoms in hospitalized chil- well as data suggesting acceptable internal consistency
dren. The CAEF consists of three parts: history of and test-retest reliability (e.g., Reynolds, 1981; Rey-
present illness, anxiety symptom assessment, and ob- nolds & Paget, 1982; Reynolds & Richmond, 1978).
servations of anxiety during the interview. In Part I, the According to Finch and Rogers (1984), less is known
interviewer reviews the history of the child and indi- about the validity of the CMASR. However, CMASR
cates the presence or absence of symptoms thought to scores have been found to correlate positively with
be indicative of anxiety, such as fears/worries and TAlC scores (Reynolds, 1981).
somatic complaints. In Part n, the interviewer uses a
semistructured format to assess a variety of anxiety State-Trait Anxiety Inventory for Children.
symptoms (e. g. , autonomic symptoms, gastroin- The State-Trait Anxiety Inventory for Children
testinal complaints) and the situations in which such (STAIC) (Spielberger, 1973) contains two 20-item
symptoms occur (e.g., social, separation). Finally, in scales that are said to tap trait and state anxiety in
school-aged children. On the trait scale, the child is Schedule (Hodges, 1978) to identify test-anxious and
asked to rate how he or she "usually feels," while on nontest-anxious elementary school children. They
the state scale the child is asked to rate how he or she found that test-anxious children differed from nontest-
feels "right now, at this very moment." The distinction anxious children in a variety of ways. Test-anxious
between state and trait anxiety, as measured by the children reported higher anxiety and fear scores than
STAIC, has been questioned, however. Contrary to did nontest-anxious children. In addition, test-anxious
expectations, the trait anxiety score has not been found children reported more negative cognitions and higher
to correlate more highly than the state anxiety score state anxiety ratings during vocabulary and read aloud
with other measures of trait anxiety, such as the tasks than did nontest-anxious children. A striking
CMASR(e.g., Finch & Nelson, 1974; Montgomery & finding was the extent to which test-anxious children
Finch, 1974). However, as with the CMASR, the received DSM-III anxiety disorder diagnoses. Beidel
STAIC has been used widely and found to possess and Turner reported that 60% of their test-anxious chil-
adequate psychometric properties (Ollendick, 1983). dren met DSM-III criteria for anxiety disorders, in-
cluding social phobia, simple phobia, separation anx-
Fear Survey Schedule for Children-Revised. iety disorder, and overanxious disorder. This is in
The revised Fear Survey Schedule for Children contrast to the nontest-anxious group which received
(FSSCR) (Ollendick, 1983) is an 80-item question- no psychiatric diagnoses. As the authors concluded,
naire that instructs children to rate their level of fear on these results suggest that test anxiety is not necessarily
a 3-point scale ranging from "none" to "a lot." The a benign fear, and may be an indicator of clinically
FSSCR contains a meaningful 5-factor structure, insignificant anxiety states in children.
cluding fear of the unknown, fear of failure and crit-
icism, fear of danger and death, fear of minor injury Children's Cognitive Assessment Question-
and animals, and medical fears. In a recent study, naire. Zatz and Chassin (1983) developed a cognitive
Ollendick, King, and Frary (1989) explored develop- self-report questionnaire for assessing test anxiety in
mental and cultural differences in self-reported fear in children-the Children's Cognitive Assessment Ques-
a large group of children and adolescents from the tionnaire (CCAQ). The measure consists of 40 items
United States and Australia. Consistent with earlier that are rated as "yes" or "no." Four subscales are
findings (Ollendick, 1983; Ollendick, Matson, & included that tap on-task thoughts, off-task thoughts,
Helsel, 1985), girls tended to have higher total fear and positive evaluation, and negative evaluation. The au-
factor scores than did boys. Moreover, younger chil- thors established acceptable internal consistency and
dren tended to have higher total fear and factor scores test-retest reliability for the CCAQ. Zatz and Chassin
than did older children and adolescents. The authors administered the CCAQ to elementary school-aged
reported no significant cultural differences between children who were identified as high anxious (HA),
their American and Australian samples. Furthermore, moderate anxious (MA), or low anxious (LA) on the
there is empirical evidence that the FSSCR has clinical basis of the TASe. Subsequently, these children were
utility. Ollendick and Mayer (1984) reported that the administered two academic tests and then completed
total fear score on the FSSCR discriminate between the CCAQ. Results indicated that HA children en-
normal and school avoidant youngsters. Moreover, the dorsed more negative evaluation and off-task thoughts
FSSCR has been found to differentiate reliably the than did other children. Moreover, HA children en-
fears of blind and normally sighted children (Ollendick dorsed fewer positive evaluation thoughts than did LA
et al., 1985). children. Contrary to predictions, there was a high
prevalence of on-task thoughts endorsed by both HA
Test Anxiety Scale for Children. Although the and MA children.
TASC (Sarason et aI., 1960) has been used widely in
the educational arena, it is less well known in the Social Anxiety Scale for Children. LaGreca et
clinical arena. The TASC is a 30-item self-report inal. (1988) recently developed a social anxiety scale for
strument that measures evaluation anxiety in school- children (SASC). Their 10-item scale consists of items
aged children. Recently Beidel and Turner (1989) tapping fear of negative evaluation (e. g., "I worry
completed a study of the relationship between test anx- about doing something new." "I worry about kids
iety and DSM-III anxiety disorders in children. The making fun of me") and social avoidance and distress
authors used the TASC and the Child Assessment (e.g., "I am quiet when with a group." "I get nervous
when I talk to new kids"). LaGreca and colleagues each content area (social, athletic, academic) com-
administered the SASC to 287 children in grades two pared to low test-anxious children. The scores ob-
through six. In addition, they asked these children to tained by the high test-anxious children were similar to
complete sociometric ratings and nominations as well those seen in depressed and low self-esteem children.
as the CMASR (Reynolds & Richmond, 1978). The
authors reported the following 2-week test-retest reli-
Physiological Assessment
ability coefficients for the SASe: .70 for fear of nega-
tive evaluation items, .39 for social avoidance and dis- Physiological assessment of children, although fre-
tress items, and .67 for the total scale. Results quently recommended as an important source of as-
indicated that children with high SASC scores also sessment information, rarely has been conducted.
reported high anxiety on the CMASR. In addition, Fortunately, a few investigators have completed physi-
sociometric ally neglected children reported higher ological assessments of anxious children. For exam-
total SASC scores and higher FNE (fear of negative ple, Melamed and Siegel (1975) reported electroder-
evaluation) scores than did children in other so- mal responding (palmer sweat print) to be correlated
ciometric groups. Clearly, more research is needed with both self-report and observation of dental fear in
before statements can be made regarding the reliabili- children.
ty, validity, and clinical utility of the SASe. However, Beidel (1988) conducted a multimethod assess-
LaGreca and colleagues have made a promising start. ment, including physiological measures, of test-anx-
ious and nontest-anxious children. The sample con-
Children's Negative Cognitive Error Ques- sisted of 50 boys and girls between the ages of 8 and 12
tionnaire. Leitenberg et al. (1986) developed a self- years. Blood pressure and heart rate were monitored
report questionnaire designed to assess cognitive er- during baseline, and while children participated in a
rors in children-the Children's Negative Cognitive vocabulary test and an oral reading task. Beidel re-
Error Questionnaire (CNCEQ). The CNCEQ consists ported that high test-anxious children exhibited signif-
of 24 items tapping cognitive errors in social, athletic, icantly larger heart rate changes than did nontest-anx-
and academic situations. Example items include: (1) ious children, from baseline to the vocabulary task and
Catastrophizing in a social situation-You invite one from baseline to the oral reading task. Although not
of your friends to stay overnight at your house. An- statistically significant, high anxious children main-
other one of your friends finds out about it. You think, tained a relatively constant elevation in heart rate
"He or she will be real mad at me for not asking him or throughout the tasks as compared to nonanxious chil-
her and never want to be friends again." (2) Person- dren, who exhibited a steady decrease in heart rate
alizing in an athletic situation-Your class is having 4- over the course of each task. No differences in blood
person relay races in gym class. Your team loses. You pressure were observed between the two groups.
think, "If I had just been faster, we would not have
lost." (3) Selective abstraction in an academic situa-
tion-You were having a good day in school up until Treatment
the last period when you had a math quiz. You did
poorly on the quiz. You think, "School is a drag, what The purpose of this section is to highlight innovative
a waste of time." (4) Overgeneralizing in an athletic behavioral treatment approaches to anxiety problems
situation-Some of your friends have asked you if in children and adolescents. Although the treatment of
you're going to try out for the school soccer team. You childhood fears has been studied extensively, the treat-
tried out last year but did not make it. You think, ment of other anxiety disorders in children has re-
"What's the use of trying out, I couldn't make it last ceived virtually no attention in the literature. The bulk
year." These authors administered the CNCEQ to a of current knowledge regarding treatment approaches
group of elementary school children who were identi- for anxiety-disordered children is based on case report
fied, using the TASC (Sarason et al., 1960), as report- and single-case methodologies. As such, definitive
ing high or low test-anxiety. Results indicated that the statements regarding treatment effectiveness cannot be
high test-anxious children evidenced significantly made. Generally, the behavioral treatment strategies
higher total distortion scores as well as higher scores used with anxious children parallel those used with
on each cognitive error (i.e., catastrophizing, person- anxiety-disordered adults. These include gradual ex-
alizing, selective abstraction, overgeneralizing) and posure, flooding, relaxation, and cognitive strategies.
640 PART V • INTERVENTION AND BEHAVIOR CHANGE: CIDLDREN AND ADOLESCENTS
According to Ollendick (1979), the element common began to imagine a pleasant scene, the image became
to most package treatments for anxious children is negative (e.g., while imagining a warm and sunny day
gradual exposure. she began to picture stormy clouds). As such, the child
was instructed to distract herself by engaging in an
anxiety-incompatible behavior, such as reading. Over
Separation Anxiety Disorder
the course of treatment, the child was able to spend
Mansdorf and Lukens (1987) described the use of a gradually increasing periods of time alone at home
cognitive-behavioral approach to the treatment of two while using the above-mentioned techniques. By the
separation-anxious children with school refusal. Both end of treatment, the child was able to tolerate time
children previously had failed to respond to treatment alone at home without distress. Her self-reported anx-
with imipramine. The authors initially completed an iety while alone at home decreased while her perceived
assessment aimed at delineating the self-statements of ability to remain alone at home increased. At the time
the children and of their parents and at determining of a I-year follow-up, the child was able to stay at
already existing consequences for nonattendance at home alone for greater than an hour at a time. This case
school. Treatment consisted of self-instruction train- is of particular interest because of the careful monitor-
ing for the child, cognitive restructuring for the parent, ing of the child's ability to use treatment techniques in
and environmental restructuring in which parental re- a successful manner.
inforcement was made contingent upon school atten-
dance. In addition, children were gradually returned to
Phobias: School
school. The goal of treatment was to promote the use
of coping cognitions by the children and by their par- There have been many articles published on the be-
ents. For example, one child reported the worry that havioral treatment of school refusal. Behavioral ap-
"the kids in school make fun of me." This inhibiting proaches, such as contingency contracting (e.g, Welch
cognition was replaced with the following coping cog- & Carpenter, 1970), in vivo exposure (e.g., Garvey &
nition: "That's their problem, not mine." Similarly, Hegrenes, 1966), imaginal exposure (e.g., Galloway
the parents of this child acknowledged the concern that & Miller, 1978), and various combinations of the
"my child is sick so I shouldn't push." This inhibiting above (e.g., Ayllon, Smith, & Rogers, 1970; Lazarus,
cognition was replaced by the following coping cogni- Davison, & Polefka, 1965; P. Miller, 1972), reported-
tion: "This is the way to help." ly have been effective in the treatment of school
Mansdorf and Lukens reported that within 4 weeks refusal.
both children were able to remain alone in school all Unfortunately, this literature is plagued by a number
day. Moreover, at 3-month follow-up, treatment gains of serious methodological problems that preclude de-
were maintained. Although this study needs to be rep- finitive statements about treatment effectiveness.
licated with a larger sample and longer follow-up, it These methodological problems include inadequately
stands as a promising, time-efficient approach to the defined samples, lack of controlled treatment outcome
treatment of separation anxiety including both the studies, and failure to use objective, standard assess-
child and parent. ment procedures. Somewhat surprisingly, there have
Peterson (1987) presented a multifaceted treatment been few advances in the school refusal treatment liter-
program consisting of relaxation, cognitive coping ature of late. Notable exceptions are two controlled
strategies, imagery, a reward system, and graduated group studies (Blagg & Yule, 1984; L. C. Miller, Bar-
exposure for the treatment of separation anxiety in an rett, Hampe, & Noble, 1972).
8-year-old girl. At the start of treatment, the child was The first controlled group study of childhood pho-
afraid to be alone at home for even a few seconds and bias was conducted by L. C. Miller and colleagues (L.
exhibited intense anticipatory anxiety about separa- C. Miller et al., 1972. Although their sample consisted
tion. The child and her mother participated in eight of children with various types of phobias, the majority
treatment sessions in which the child was taught deep (69%) presented with school phobia. Children were
muscle relaxation, positive imagery, and coping state- randomly assigned to one of three treatment condi-
ments (e.g., "I can do it"). In addition, the mother tions: waiting list control, systematic desensitization,
instituted a reward system for time spent alone at or psychotherapy. Outcome measures included parent
home. The author noted that the child had difficulty and clinician ratings of improvement, as well as parent
using the positive imagery skills, in that each time she checklists that measured the child's fear.
When considering parental reports of improvement, contrast to the success rates for inpatient hospitaliza-
results indicated that both active treatment conditions tion (37.5%) and home tutoring (10%). In addition,
were more effective than the waiting list control, with children in the behavioral treatment condition evi-
no significant difference between the two treatment denced improvement on measures of self-esteem and
conditions. In contrast, clinician ratings of improve- extraversion. Behavioral treatment was found to be
ment were no different among the three conditions. much less time-consuming than the other treatment
Several problems are inherent in the L. C. Miller et conditions. Children in the behavioral treatment condi-
al. study. First, there were a number of similarities tion received an average of 2.53 weeks of treatment as
between the two treatment conditions. Both the psy- compared with 45.3 weeks for inpatient hospitaliza-
chotherapy condition and the systematic desensitization and 72.1 weeks for home tutoring. The results of
tion condition included the use of operant techniques Blagg and Yule yield compelling support for the
in which the parents were instructed to modify their efficacy of in vivo flooding plus operant procedures in
contingencies for "fearful" behavior. For example, in the treatment of school phobia.
both conditions, parents were instructed to remove
daytime television watching if their child refused to
Phobias: Social
attend school. Second, 110 clear indication was given
of the severity of the children's phobias. There was Very little information is available about the treat-
little information available about the presence of pho- ment of social phobias in children. This is in contrast to
bic avoidance. Third, the outcome measures used were the large literature on the treatment of social with-
problematic. The authors reported that they were un- drawal and simple phobias in children. Francis and
able to keep blind the nontreating clinician who made Ollendick (in press) conducted a case study of the
improvement ratings. In addition, there was no direct treatment of an adolescent with social phobia using
measure of treatment effectiveness. The parent check- graduated exposures. The subject was a 16-year-old
lists provided information regarding general fear- female (Rebecca) with a lengthy history of school
fulness; however, no direct measures of fear or avoid- avoidance coupled with avoidance of many other social
ance were given. Although Miller et at. advanced the situations (e.g., parties, stores). Her extensive avoid-
literature by presenting a controlled group study of the ance was not due to a fear of panicking; rather, she
treatment of childhood fears, methodological prob- feared embarrassment. For example, Rebecca became
lems make interpretation of the results difficult. very anxious about having to take the trash out to the
The second controlled group study of the treatment dumpster because she felt as though she might do or
of school refusal was conducted by Blagg and Yule say something embarrassing. She was diagnosed with
(1984). The authors compared behavioral treatment, social phobia: generalized type. Self-report assess-
inpatient hospitalization, and home tutoring plus psy- ment questionnaires revealed that the youngster re-
chotherapy for a group of school phobic children. The ported significant depressive and anxiety symptoms as
majority of the children in the sample were between 11 well as intense social-evaluative fears. There was no
and 14 years of age. The behavioral treatment consist- evidence of a social skills deficit as measured by a
ed of frequent contact with school personnel, operant behavioral role-play test.
strategies (e. g. , parents praised school attendance Using a graduated in vivo exposure approach, a hier-
while ignoring physical complaints in the morning be- archy was developed. Each week the adolescent com-
fore school), and in vivo flooding. The inpatient hospi- pleted homework assignments drawn from the hier-
talization condition consisted of the physical separa- archy. The least anxiety-provoking hierarchy items
tion of the parent and child, therapeutic milieu, were "going to a shopping mall with someone,"
possible pharmacotherapy, and discharge school "going to a small department store with someone,"
placement planning. Finally, in the home-tutoring con- and "standing in line at a fast-food place with some-
dition, the child was permitted to remain at home while one." The most anxiety-provoking items were "taking
receiving educational tutoring and psychotherapy. out the trash without getting ready first" and "going to
Blagg and Yule collected a number of measures of school all day." Over the course of 3 months, Rebecca
overall emotional adjustment as well as a record of was exposed gradually to a number of social situa-
school attendance. Following treatment, 93.3% of the tions. She practiced such tasks as taking the trash to the
children in the behavioral treatment condition attended dumpster after getting ready for no more than 30 min-
school without significant problems. This is in marked utes, riding the bus with someone, going early to a
movie and waiting, and going to a shopping mall dren's behavior and reward immediately. The children
alone. The gradual exposure program appeared to be were given "bravery" tokens by their parents each
effective in treating her social-evaluative anxiety. By morning and evening. The tokens were to be used to-
the end of treatment, she completed her GED, enrolled ward a party at a popular fast-food restaurant.
in a community college, confronted the majority of The authors had children and their parents monitor
social situations with minimal anxiety, and reported "fearless nighttime behavior." Fearless nighttime be-
significantly fewer symptoms of depression, anxiety, havior consisted of the child going to bed within 20
and fear. minutes of an instruction to do so, sleeping in their
own room with the lights and radio off, and not com-
plaining at bedtime or throughout the night.
Phobias: Simple
Results indicated that the experimental group evi-
Most of the available treatment literature on simple denced significant improvement in nighttime fears as
phobias consists of case reports of the treatment of compared to the control group. Treated children were
simple fears in children. Graziano and colleagues fearful on fewer nights, fell asleep faster, went to bed
(Graziano & Mooney, 1980, 1982; Graziano, Mooney, faster, were more willing to go to bed, and evidenced
Huber, & Ignasiak, 1979) provided the most compre- fewer "delay" tactics, like crying, getting out of bed,
hensive evaluation of a self-control procedure for re- and asking for water, than did control children.
duction of severe nighttime fears in children. In their Graziano and Mooney (1982) were able to follow-
controlled group study, Graziano and Mooney (1980) up many of the children in their 1980 study between
treated 17 children with severe, frequent, and disrup- 2.S and 3.0 years posttreatment. They used self-report
tive nighttime fears. They included a control group measures that asked parents whether their child was
that consisted of 16 children who participated in the still afraid at bedtime, and whether their child had
assessments but did not receive treatment. Subjects developed any new problems. Results indicated that 23
were assigned randomly to experimental or control of 34 children were reported to have maintained their
conditions. Children in the experimental group ranged improvement, 8 of 34 were reported stili to be afraid
in age from 6.2 to 12.3 years, with an average age of but much less so than pretreatment, and 3 of 34 were
4.9 years. Children in the control group ranged in age reported to evidence significant nighttime fears. In ad-
from 6 years to 13.S years, with an average age ofS.2 dition, the majority of children were reported not to
years. As can be seen, the majority of children in this have developed any additional problems.
study were quite young. In addition, the entire sample
evidenced nighttime fears for an average of greater
Overanxious Disorder
than 2 years.
Children and their parents were seen for a total of There are no reports in the research literature about
five sessions. The first and fifth sessions were devoted the treatment of overanxious disorder. However,
to assessment, whereas the remaining three sessions Strauss (1989) presented a case study of the treatment
were used for treatment. Both groups participated in a of overanxious disorder in an ll-year-old girl (Ash-
7 -day baseline phase in which nighttime behaviors ley). Ashley worried excessively about most future and
were monitored. The experimental group then partici- past events. She was perfectionistic and often sought
pated in 3 weeks of family self-control training. Post- reassurance as to the correctness of her academic and
treatment assessment was conducted for both groups, social behavior. She was extremely self-conscious and
and consisted of 7 days of monitoring. had difficulty relaxing. A multimethod assessment
Treatment consisted of parent groups and child was conducted, including self-report inventories and
groups. During the child-focused group treatment, teacher-rating scales. Ashley described herself on self-
children were taught to relax, imagine a pleasant report questionnaires as anxious, fearful, sad, and
scene, and say, "I am brave, I can take care of myself lonely. Her teachers characterized her as exhibiting
when I am alone. I can take care of myself when I am in anxious and withdrawn behavior as well as being so-
the dark." They were instructed to practice each night cially neglected among her classmates.
and self-monitor their behavior. During the parent- Treatment consisted of a package based on interven-
focused group treatment, parents were instructed to tions used successfully with generalized anxiety disor-
initiate the children's practice sessions each evening. der in adults. The treatment package included relaxa-
In addition, the parents were to monitor their chil- tion techniques, cognitive restructuring, and assert-
iveness training. Ashley was seen for a total of 25 & Seidner, 1983; Kolko, 1984). Barlow and Seidner
individual treatment sessions over a 6-month period. (1983) described a multicomponent group treatment
The initial phase of treatment consisted of deep muscle approach that involved the adolescent and the parent
relaxation training. A reward system was added to en- and included panic management strategies, cognitive
courage Ashley to practice relaxation exercises at restructuring, and graduated exposure. They studied
home. The child reported no reduction in anxiety or three adolescent subjects: a 15-year-old male, a 16-
worrying following completion of the relaxation train- year-old female, and a 17-year-old female. Each sub-
ing. During this initial phase of treatment, Ashley also ject evidenced significant impairment in school atten-
self-monitored her cognitions and subjective anxiety. dance related to the agoraphobia. Assessments in-
Cognitive rehearsal and cognitive restructuring were cluded weekly hierarchy ratings by the parent and the
used to modify her maladaptive thoughts. She was adolescent, as well as questionnaires designed to tap
taught to replace maladaptive thoughts with coping the extent of effective parent-adolescent communica-
thoughts, such as "I know that I am as good as the tion. Pretreatment, midtreatment, posttreatment, and
other kids." In addition, Ashley was taught to modify follow-up assessments were conducted.
her faulty thinking by identifying and challenging cog- Results indicated that two of the three adolescents
nitive errors, such as catastrophizing thoughts. Ac- evidenced significant improvement over the course of
cording to the author, progress in cognitive therapy treatment and at the 6-month follow-up assessment. In
was slow. However, once Ashley grasped the concept these two cases, there were marked decreases in hier-
that her thinking was interfering with her behavior, her archy anxiety ratings as well as evidence of improving
progress quickened. The final phase of treatment con- parent-adolescent relationships. The third subject ex-
sisted of assertiveness training. Role-play practice ses- hibited no change in her agoraphobic behavior over the
sions were used to increase assertive responding and course of treatment.
initiations of social interactions. For example, Ashley Barlow and Seidner concluded that the inclusion of
practiced refusing unreasonable requests and calling the parent, like the inclusion of the spouse when treat-
peers on the telephone. Strauss reported that this multi- ing adult agoraphobics, appeared to be helpful. In ad-
component treatment package was effective in modify- dition, they noted that the adolescents would not toler-
ing Ashley's overanxious symptomatology. At the end ate any anxiety during practice sessions despite the
of treatment, Ashley no longer met DSM-III criteria presentation of a detailed treatment rationale. That is,
for overanxious disorder. Her self-reported anxiety, the adolescents remained convinced that their fears
fear, sadness, and loneliness also decreased. At 3- were rational. This is unlike adults, who generally ac-
months posttreatment, both Ashley and her parents cept that their fears of dying essentially are irrational.
reported that treatment gains had been maintained. In this way, the adolescents were said to resemble the
This case study highlights the wide range of distur- adult agoraphobics with overvalued ideation who typ-
bance that can be observed in children with overanx- ically do not respond to treatment (Foa, 1979). As
ious disorder. Ashley evidenced motor tenseness, cog- Barlow and Seidner point out, this argues for the inclu-
nitive distortions, and unassertive behavior. The sion of a parent in the treatment of adolescent agora-
treatment package that was used directly targeted each phobia as the adolescent may be unlikely to make the
of these problem areas. Naturally, future research necessary changes without active support.
efforts need to be directed toward demonstrating the Kolko (1984) detailed the treatment of an adolescent
effectiveness of such behavioral treatment strategies agoraphobic using paradoxical instruction. The 16-
by the use of controlled single-case experimental de- year-old female subject reported panic attacks and re-
signs and group designs. quired physical accompaniment to go outside the
home. Treatment was evaluated using an AB design
with follow-up. During the 3-week baseline, assess-
Agoraphobia
ment was conducted and a lO-item hierarchy was de-
There have been very few reports of the treatment of veloped. Assessment consisted of self-reported anx-
agoraphobia in youngsters. This is somewhat surpris- iety ratings during exposure treatment and anxiety and
ing given that the typical age of onset for agoraphobia fear questionnaires. Anxiety ratings were completed
is late adolescence or early adulthood (e. g. , 0' Brien & every 10 minutes during exposure to the 10 situations
Barlow, 1984). Two published treatment studies that delineated on the hierarchy. At pretest, the adolescent
involve adolescent subjects shall be discussed (Barlow was able to complete only 1 of 10 hierarchy tasks.
Treatment consisted of paradoxical instruction and in from exhibiting any bedtime or wake-up rituals during
vivo exposure. Essentially, the adolescent was in- this time. According to the authors, treatment gains
structed to approach each situation on the hierarchy were maintained for approximately 8 weeks following
while focusing her attention on the associated fear, discharge. However, then the adolescent began to en-
thoughts, and physiological symptoms. gage in a new series of bathing rituals. Further outpa-
Results revealed that the adolescent reported less tient treatment, which consisted of response preven-
fear and avoidance to all items on the hierarchy follow- tion implemented by both parents, was successful in
ing completion of treatment. At posttest and at follow- reducing the bathing rituals.
up, she was able to complete all 10 hierarchy tasks and Extinction procedures also have been used in the
reported decreased anxiety levels in all situations. In treatment of childhood obsessive-compulsive disor-
addition, reductions of emotional sensitivity, state and der. Hallam (1974) noted that compUlsive reassurance
trait anxiety, and fear were observed using self-report seeking often is a problem in children with obsessive-
questionnaires. Kolko concluded that paradoxical in- compulsive disorder. He des~ribed the use of extinc-
struction to embellish subjective anxiety and anticipate tion to treat a 15-year-old hospitalized female with a 3-
negative consequences was associated with a decrease year history of repetitive questions about whether
in avoidance behavior as measured by an in vivo ap- people were saying nasty things about her. The initial
proach task. phase of treatment consisted of instructing staff to re-
spond to her questions by saying" I can't answer that. "
The author reported that this strategy made no impact
Obsessive-Compulsive Disorder on the frequency of her compUlsive reassurance seek-
ing. As such, an extinction procedure was started in
Childhood obsessive-compulsive disorder is a rare which staff were instructed to ignore her questions by
and debilitating psychiatric problem. Estimates of the turning/looking away and redirecting conversation. At
prevalence of obsessive compulsive disorder in chil- first, the adolescent was described as highly agitated
dren have been placed at less than 2% of childhood and anxious; however, within 4 weeks the reassurance
disorders (Hollingsworth, Tanguay, Grossman, & seeking behavior had been eliminated. Halfway
Pabst, 1980; Judd, 1965). As such, there have been through the extinction phase, a response cost pro-
few accounts of the behavioral treatment of childhood cedure was added in which the adolescent lost 1 minute
obsessive-compulsive disorder in the literature. The of recreation time for each reassurance-seeking ques-
majority of available studies have employed flooding tion asked. Although this study presented a promising
and response prevention for the treatment of childhood approach to the treatment of compulsive reassurance
obsessive compulsive disorder (e.g., Bolton, Collins, seeking in an obsessive-compulsive adolescent, the
& Steinberg, 1983; Mills, Agras, Barlow, & Mills, case-study design and lack of pretreatment baseline
1973; Stanley, 1980). The combination of flooding and data collection make it difficult to evaluate the results
response prevention has been studied extensively with empirically.
obsessive compulsive adults and has been found to be In an attempt to expand on Hallam's (1974) work,
the treatment of choice (e.g., Steketee & Foa, 1985). Francis (1988) conducted a within-subject single-case
Mills and colleagues (1973) described the use of study of the use of extinction to treat an obsessive-
response prevention to treat a 15-year-old hospitalized compulsive l1-year-old boy. The child was seen on an
boy who evidenced elaborate bedtime and wake-up outpatient basis, and treatment was implemented by
rituals. Following a 12-day baseline, response preven- the parents. The child presented with an acute exacer-
tion was applied to the bedtime rituals. The adolescent bation of obsessive worries about death and dying as
was told that he would no longer be allowed to engage well as compUlsive reassurance seeking. He frequently
in the bedtime rituals. During the response prevention voiced fears of dying from various diseases and per-
phase, a staff member remained in the bedroom with sistentlyasked, "Am I going blind?" "Do you think I
the adolescent during the night. Within 10 days, bed- will throw up?" and "Am I going to die?" The parents
time rituals stopped. In addition, the authors noted a were instructed to monitor his reassurance-seeking
concomitant decrease in wake-up rituals, even though questions four times per day. During the 8-day baseline
wake-up rituals had not been a target of treatment. phase, the parents were instructed to respond in their
During the return to baseline phase, the staff member usual way to the child's reassurance seeking. During
no longer remained in the room with the adolescent the 8-day extinction phase, the parents were instructed
during the night. The adolescent continued to refrain to ignore all reassurance-seeking questions by look-
ing/turning away and redirecting the conversation. which required him to return to the shopping center
The therapist maintained frequent phone contact with where the explosion had occurred. By the time of his 6-
the family during this phase. The return to baseline month, posttreatment, follow-up assessment, the child
phase lasted for 5 days and consisted of a return to was able to complete 95% of the BAT criteria in com-
attending to the reassurance-seeking behavior. This parison to completing only 45% of the criteria prior to
phase occurred naturally when the parents began at- treatment.
tending to the reassurance-seeking behavior at a time
when a number of family members were ill. Of note,
the family illness persisted for another 5 days follow-
Summary
ing the end of this phase. The return to extinction phase
lasted for 20 days and consisted of the reimplementa-
tion of the extinction procedure. A I-month follow-up Over the past several years, more research attention
assessment was conducted in which the parents has been paid to the study of anxiety disorders in chil-
monitored that child's behavior for 3 days. dren and adolescents. Attempts have been made to
Results indicated that the extinction procedure was examine the diagnostic reliability and validity of child-
successful in decreasing the frequency of reassurance hood anxiety disorders. Anxiety assessment instru-
seeking behavior to zero within 6 days. During the ments have been developed and researched. Finally,
withdrawal of extinction, the child's behavior wors- preliminary efforts have been made to identify and
ened dramatically, at which time reassurance seeking evaluate the effectiveness of various treatment strat-
was occurring at rates higher than those seen during egies for the alleviation of anxiety in children.
baseline. Once extinction was reimplemented, the fre- It is beyond the scope of this chapter to discuss the
quency of reassurance seeking behavior fell to zero vast array of remaining clinical and research ques-
within 12 days, and remained at zero for 9 consecutive tions. Like the tremendous advances that have been
days and at the I-month follow-up. made in the study of adult anxiety, it is hoped that
It is important to emphasize that the available sin- similar rapid progress will be made in the study of
gle-case treatment studies of childhood obsessive- childhood anxiety.
compulsive disorder have shown short-term treatment
successes. Given the chronic and disabling nature of
obsessive-compulsive disorder, future researchers
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CHAPTER 31
Childhood Depression
CURRENT STATUS AND FUTURE DIRECTIONS
Nadine J. Kaslow and Gary R. Racusin
Introduction Institute of Mental Health (NIMH) report (Teuting,

Koslow, & Hirschfield, 1982) estimated that the preva-
Childhood depression is receiving increased recogni- lence of moderate to severe depression in children in
tion in the professional literature. Although some ear- the general population ranges up to 33%. The best
lier writers questioned the existence of a childhood available epidemiological data suggest that depression
depressive syndrome (e.g., Rie, 1966), more recent affects 2% of the general child population and up to
authors have suggested that children do manifest 30% to 60% of children referred to mental health pro-
clinically significant depression (Cytryn, McKnew, & fessionals (Kashani et al., 1981), with prevalence ap-
Bunney, 1980). Despite these more recent contribu- parently increasing with age (Kashani, 1982). Preva-
tions, however, there remains a lack of clear consensus lence data regarding sex differences in depression in
in the field that depression represents a childhood prepubertal children are not clear cut, although there
clinical syndrome. A prime example of this lack of are some indications that the sex ratio approximates
clarity is evident in the recent edition of the Diagnostic 1: 1 (Angold, 1988). As children enter adolescence,
and Statistical Manual ofMental Disorders (DSM-III- however, there is an increase in depression among girls
R) (American Psychiatric Association (APA), 1987). but not in boys, and gender is the most significant
Although depression is not listed under disorders usu- sociodemographic risk factor for depression in this age
ally first evident in infancy, childhood, or adoles- group (Gurian, 1987). Although there are no data re-
cence, childhood mood disorders are purported to be garding the relationship between the prevalence of
similar to those seen in adults. childhood depressive disorders and family so-
The reported prevalence of childhood depression cioeconomic status, there are some empirical data sup-
varies widely, according to the population sampled and porting an inverse relationship between so-
the diagnostic criteria and assessment devices em- cioeconomic status and depressive severity (Angold,
ployed (Kashani, 1982). A comprehensive National 1988; Mullins, Siegel, & Hodges, 1985). Finally,
childhood depression is found across ethnic groups,
and there is no research to date addressing differential
Nadine J. Kaslow • Departments of Psychiatry, Psychology, prevalence for this variable (Kashani, 1982).
and Child Study Center, Yale University, Yale Psychiatric In- Depressive symptoms in middle childhood have
stitute, New Haven, Connecticut 06520. Gary R.
Racusin • Department of Psychiatry and Child Study Cen- been found to be relatively stable over brief time peri-
ter, Yale University, New Haven, Connecticut 06519. ods (Seligman et al., 1984; Tesiny & Lefkowitz,
649
1982). Similarly, studies adopting a longitudinal de- which the child lives, including the family, the peer
velopmental perspective (Kovacs, Feinberg, Crouse- group, and the school.
Novak, Paulauskas, & Finkelstein, 1984; McGee &
Williams, 1988) reveal that though the depressive epi-
sodes of most children may eventually remit, they tend Assessment
to be of longer duration than previously thought and
they tend to recur. These findings argue against a pre- Diagnostic Criteria
viously mounted hypothesis that depression in chil-
dren is a transitory developmental phenomenon dis- The clearest and most commonly utilized criteria for
sipating with time (Lefkowitz & Burton, 1978). diagnosing depression in children are provided by the
Depression may disrupt children's cognitive style DSM-III-R (APA, 1987) and are almost identical to
and their interpersonal, affective, and intellectual those utilized to diagnose depression in adults. Al-
functioning (e.g., Blechman, McEnroe, Carella, & though there are data to support the utility of adult
Audette, 1986; Blumberg & Izard, 1985; Kaslow & diagnostic criteria in children and adolescents
Rehm, 1985; Kaslow, Tanenbaum, Abramson, Peter- (Mitchell, McCauley, Burke, & Moss, 1988), many
son, & Seligman, 1983; Puig-Antich et aI., 1985a; developmental psychopathologists hold significant re-
Tesiny, Lefkowitz, & Gordon, 1980). Depressions in servations about adopting such a stance (Carlson &
children may also result in suicidal and self-destructive Garber, 1986).
behaviors (e.g., Kazdin, French, Unis, Esveldt- In order to be eligible for a diagnosis of major de-
Dawson, & Sherick, 1983b). pression, a child must exhibit a change from previous
Finally, current writing increasingly emphasizes the functioning encompassing five of the following nine
necessity of adopting a developmental approach in symptoms over a single 2-week period: depressed or
studying the etiology, diagnosis, course, and treatment irritable mood, anhedonia, significant change in
of childhood depression. A variety of etiological mod- weight or appetite, sleep disturbance, psychomotor
els have been proposed, initially borrowing from those agitation or retardation, anergia, feelings of worth-
posited to explain adult depression (e.g., lessness or excessive guilt, impaired concentration or
Schulterbrandt & Raskin, 1977). More recently, in re- indecisiveness, and recurrent thoughts of death or pas-
sponse to calls for adopting a developmental approach sive or active suicidal ideation, with or without plan.
(Bemporad & Wilson, 1978; Digdon & Gotlib, 1985), Of the five required symptoms, the depressed child
a number of authors have proposed developmentally must exhibit at least one of the following: depressed
informed models emphasizing cognitive (Cicchetti & mood, irritable mood, or anhedonia. The DSM-III-R
Schneider-Rosen, 1986; P. M. Cole & Kaslow, 1988), (1987) notes age-specific features associated with de-
affective (Izard & Schwartz, 1986), and interpersonal pression in children and adolescents, a stance that has
(Emde, Harmon, & Good, 1986) variables associated been supported by empirical research (Kashani,
with the presentation of depression at different ages. Holcomb & Orvaschel, 1986; Ryan et af., 1987). De-
Likewise, there has been an upsurge in writings re- pressed preschool children are more angry and apa-
flecting a developmental orientation tc diagnosing, thetic, and less interested and cooperative than their
classifying, and assessing depressive disorders in chil- nondepressed peers. Prepubertal children, relative to
dren (Carlson & Garber, 1986; Kovacs, 1986). Cic- their nondepressed age-mates, frequently exhibit
chetti and Schneider-Rosen (1984) have emphasized greater depressed appearance, somatic complaints,
that the course of a depressive episode is related to the psychomotor agitation, separation anxiety, phobias,
age of onset, which, in turn, has ramifications for a and mood congruent auditory hallucinations. Adoles-
developing child's vulnerabilities to subsequent de- cents evidence greater classic depressive symptoms,
pressions and for treatment and prevention. Thus, in- including anhedonia, hopelessness, hypersomnia,
formed treatment of depressed children must integrate weight change, lethality of suicide attempt, rest-
understanding of normal child development, develop- lessness, grouchiness, sulkiness, withdrawal, inatten-
mental psychopathology, and treatments found tion to personal appearance, affective lability, and re-
efficacious for other childhood emotional and behavior jection sensitivity. In addition, adolescents may
disorders and for adult depression. In addition, such display a range of acting-out symptoms, including
treatment must take into account the social context in negativistic, aggressive, and antisocial behavior, use
CHAPTER 31 • CHILDHOOD DEPRESSION 651
of alcohol and illicit drugs, desires to run away, and The field has witnessed considerable progress since
school difficulties. the early 1980s when reviewers (Kazdin, 1981; Ka-
Children who evidence depressive symptoms may zdin & Petti, 1982) noted that the technology for as-
qualify for a diagnosis of dysthymic disorder rather sessing childhood depression was in its infancy and
than major depression. In fact, dysthymic disorder in called for obtaining information regarding convergent
children and adolescents may be diagnosed less fre- and discriminant validity, differentiation among popu-
quently than is warranted according to DSM criteria lations of children, an expanded range of assessment
(Fine, Moretti, Haley, & Marriage, 1984). As defined modalities, and assumption of a more developmental
in DSM-III-R, a child or adolescent may be assigned a stance. Additional work needs to be undertaken in each
diagnosis of dysthymia if, for a period of 1 year, the ofthese areas, however, especially in the utilization of
individual is never without depressive symptoms for a developmental perspective to inform the design and
more than 2 months and if there is no clear evidence of administration of assessment devices, because this is-
major depression during that time. The essential defin- sue has received the least recent attention.
ing feature is chronic depressed or irritable mood for
most of the day, more days than not, as indicated either
Informant Agreement
by self-report or observation by others. In addition, the
child or adolescent must exhibit at least two of the In the past 10 years, increasing emphasis has been
following six symptoms while depressed: appetite displaced on the issue of intra- and interinformant agree-
turbance, sleep disturbance, anergia, impaired self- ment in assessing childhood depressive symptoms. In-
esteem, difficulties in concentration or decision-mak- trainformant agreement across various types of mea-
ing, and feelings of hopelessness. The diagnosis is sures (e.g., self-report, interview) is reportedly
subclassified as early onset if the symptoms emerge acceptable (Weissman, Orvaschel, & Padian, 1980).
prior to age 21. The literature examining interinformant agreement,
The majority of children who carry a depression however, remains inconclusive. Some authors have
diagnosis not only have a variety of other psychologi- found little or no correspondence between parent (both
cal symptoms but also meet criteria for other diagnoses mother and father) and child reports of the children's
(Kaslow, Rehm, Pollack, & Siegel, 1988). Specifical- depression (Kazdin, French, Unis, & Esveldt-
ly, depression in children has been reported to coexist Dawson, 1983a; Weissman et al., 1980), whereas
with anxiety and phobic disorders (e.g., Bernstein & other researchers describe acceptable rates of agree-
Garfinkel, 1986; Norvell, Brophy, & Finch, 1985; ment (Orvaschel, Puig-Antich, Chambers, Tabrizi, &
Strauss, Last, Hersen, & Kazdin, 1988; Wolfe et al., Johnson, 1982). Additionally, although one study of
1987), conduct disorders (Marriage, Fine, Moretti, & psychiatrically disturbed hospitalized children indi-
Haley, 1986; Puig-Antich, 1982), attention-deficit hy- cated that parents described their children as more de-
peractivity disorder (Brumback & Weinberg, 1977), pressed than these children described themselves (Ka-
anorexia nervosa and bulimia (for review see Swift, zdin, French, Unis, & Esveldt-Dawson, 1983a), the
Andrews, & Barklage, 1986), and learning disabilities bulk of relevant research has reported the opposite ten-
(Brumback & Staton, 1983). dency (Angold et at., 1987; Leon, Kendall, & Garber,
1980; Lobovitz & Handal, 1985; Moretti, Fine, Haley,
& Marriage, 1985; Orvaschel, Weissman, Padian, &
Assessment Techniques
Lowe, 1981; Weissman et al., 1980; Weissman et at..
Concurrent with this increasing clarity in the diag- 1987). Correlations of mothers' and fathers' ratings of
nosis of childhood depression, the past 10 years have children's depressive symptoms fall in the moderate to
witnessed a proliferation of assessment techniques for high range and are stronger than those comparing par-
use in clinical and research settings. These techniques ent and child reports (Kazdin, French, Unis, &
encompass a variety of types, including self-report, Esveldt-Dawson, 1983a). There appear to be a number
structured interviews, parent and clinician or staff rat- offactors contributing to the discrepancy in parent and
ings, peer nominations, and projective techniques (for child reports including the child's age (Stavrakaki,
reviews see Kazdin, 1981; Kazdin & Petti, 1982; Vargo, Roberts, & Boodoosingh, 1987) and gender
Kovacs, 1981). Table I summarizes scales utilized for (Angold et al., 1987; Stavrakaki et al., 1987), the
assessing depression in children. varying item content of scales administered to different
Table 1. Depression Assessment Scales

Samples and psychometrics
Scale Author Descriptions reported
Children's Depression Kovacs & Beck 27-item self-report. Modi- Psychiatric, medical, and
Inventory (COl) (1977) fied version of Beck De- normal children, ages 6-
pression Inventory for 17. Item-total correla-
adults. Measures severity tions, internal consisten-
of depression. cy, test-retest reliability,
and discriminant validity
are acceptable. Correlates
with clinician rating and
DSM-III diagnosis.
Children's Depression Tisher & Lang (1983) 66-item self-report. Alter- Psychiatric and normal sam-
Scale (CDS) nate forms for parents, ples, ages 9-16. Internal
teachers, and siblings. consistency and discrimi-
Subscales for affect, so- nant validity are ade-
cial problems, self- quate.
esteem, thoughts of death
and illness, guilt, and
pleasures.
Depression Self-Rating Birleson (1981) 18-items-original scale and Psychiatric inpatients and
Scale (DSRS) 21-items-modified scale. children, ages 7-13. Ad-
Self-report scale patterned equate criterion validity,
after the Zung. concurrent validity, and
internal consistency.
Depression Adjective Sokoloff & Lubin Both forms of the C-DACL Emotionally disturbed
Checklist (C-DACL) (1983) self-report scale contain youth. High internal con-
34 adjectives pertaining sistency, alternate form
to presence or absence of and split-half reliabilities.
depressed mood. Good concurrent validity.
Center for Epi- Weissman, Orvaschel, 20-item self-report scale Normal sample and inpa-
demiologic Depres- & Padian (1980) which is derivative of the tients. 6-17 year olds.
sion Studies- adult CES-D. Adequate test-retest re-
Depression Scale liability, internal con-
Modified for Chil- sistency, and concurrent
dren (CES-DC) validity.
Children's Depression Reynolds, Anderson, 30-item self-report scale Normal children, ages 8-
Scale-Revised & Bartell (1985) with 29 items measuring 13. Demonstrated high
(CDS-R) depressive symptoms and internal consistency, high
1 item being a global rat- correlation with COl, and
ing of depression. with teacher's global rat-
ings.
Modified Zung (M- Lefkowitz & Tesiny II-item self-rating scale. Normal children, ages lO-
Zung) (1980) Modified version of Zung ll. Adequate internal
for adults. Measures pres- consistency.
ence/absence of depres-
sive symptoms.
Kiddie-SADS- Ovaschel & Puig- Structured interview to as- Psychiatric and normal sam-
Epidemiologic Ver- Antich (1987) sess past and current epi- ples, ages 6-17. Ade-
sion (K-SADS-E) sodes of depression and quate psychometrics.
other forms of psycho-
pathology. Based on the
Table 1. (Continued)
SADS interview and is

DSM-III-R compatible.
Kiddie-SADS-Present Revised by Puig- Structured interview for de- Psychiatric and normal sam-
Episode (K-SADS-P) Antich & Ryan pression, other diagnoses, pies, ages 6-17. Interra-
(1986) and psychiatric history ter reliability high, good
focuses on present epi- convergent validity, but
sode. Modified version of low to moderate interin-
Schedule for Affective formant reliability.
Disorders and Schizo-
phrenia. DSM-II1-R com-
patible revised version.
Interview administered to
parent and child.
Bellevue Index of De- Petti (1978) Structured 40-item interview Inpatient and outpatient
pression (BID) under 19 headings. As- samples, ages 6-12.
sesses severity and dura- Good interrater reliability
tion of symptoms on and adequate convergent
basis of Weinberg crite- validity.
ria. Parent and child re-
port used.
Interview Schedule for Kovacs (1981) Structured interview cover- Psychiatric and normal sam-
Children (ISC) ing mental status, behav- pies, ages 8-13. Ade-
ioral observations, and quate interrater reliability
DSM-III diagnoses. Child for most items. Correlates
and parent are admin- with CDI.
istered the interview.
Children's Affective McKnew, Cytryn, Clinical interview assessing Psychiatric inpatients, medi-
Rating Scale Efron, Gershon, & mood, behavior, verbal cal patients, normals, and
(CARS) Bunney (1979) expression, and fantasy children of depressed par-
on lO-point scales. ents, ages 5-15. Ade-
quate interrater reliability
and concurrent validity.
Children's Depression Poznanski, Grossman, Clinician-rated instrument Psychiatric and pediatric
Rating Scale- Buchsbaum, Bane- for the severity of depres- samples of children, ages
Revised (CDRS-R) gas, Freeman, & sion scale has 17 -items, 6-12. Scale has good
Gibbons (1984) 14 scored on verbal ob- test-retest reliability, in-
servation, and 3 on non- terrater reliability, and
verbal observation. Revi- concurrent validity.
sion of Hamilton Depres-
sion Rating Scale.
School Aged Depres- Petti & Law (1982) 28-item interview to mea- Psychiatric inpatients, ages
sion Listed Inter- sure change in severity of 6-13. Psychometric prop-
view (SADLI) depressive symptomatol- erties not explored, al-
ogy. though high interrater
reliability on videotaped
interviews.
Dysthymic Check List Fine, Moretti, Haley, Clinician rating scale to as- Outpatient, inpatient, and
(DCL) & Marriage (1984) sess each criteria of dys- medical populations, ages
thymia on a 3-point 8-17. Good interrater re-
severity scale. liability.
( continued)
Diagnostic Interview Costello, Edelbrock, Clinical interview. Children, ages 6-17. Ade-
Schedule for Chil- Dulcan, Kales, & quate test-retest and in-
dren (DISC) Klavic (1984) terrater reliability.
Diagnostic Interview Herjanic, Herjanic, Interview with parent and Adequate psychometrics.
for Children and Brown, & Wheatt child forms to assess
Adolescents (DICA) (1975) school progress, social
behavior, somatic, and
psychiatric symptoms.
Parent form also assesses
early development, fam-
ily history, and SES.
Personality Inventory Wirt, Lachar, 600-item parent report in- Designed for ages 3-16.
for Children- Klinedinst, & Seat ventory, 46-item depres- Good test-retest re-
Depression Scale (1977) sion scale; symptoms liability. Factor analysis
(PIC) identified by clinicians. yields clusters directly
comparable to DSM-III-
associated symptoms of
depression.
Child Assessment Hodges, McKnew, Scale includes a clinical in- Outpatients, inpatients, and
Schedule (CAS) Cytryn, Stem, & terview and clinician rat- normal latency age chil-
Kline (1982) ing of depression and dren and offspring of af-
other forms of psycho- fectively disturbed and
pathology. Administered normal mothers. Satisfac-
to the child. tory interrater reliability
and concurrent validity.
Peer Nomination In- Lefkowitz & Tesiny Peer nomination ratings for Given to fourth and fifth
ventory for Depres- (1980) 13 depression, 4 happi- graders. Good internal
sion ness, and 2 popularity consistency, test-retest,
roles. and interrater reliability,
and content and concur-
rent validity.
Staff Nomination In- Saylor, Finch, Bas- 20-item scale by which staff Staff members on inpatient
ventory of Depres- kin, Furey, & Kel- members nominate chil- unit rating 7-11-year-
sion ley (1984) dren on the unit who best olds. No psychometrics
fit each description. reported.
reporters ("infonnation variance") (Stavrakaki et al., with those of both parents and depressed children. Peer
1987), the degree and type ofthe child's disorder (Mor- ratings tended to correlate reasonably well with chil-
etti et al., 1985), and the degree and type of parental dren's reports of their own depression and with others'
psychopathology (Kashani, Orvaschel, Burk, & Reid, (e.g., hospital staff) ratings of a child's depression.
1985; Moretti et al., 1985). The authors suggested that these variable rates of
Hoier and Kerr (1988) reviewed the empirical work agreement may be attributable to inadequate reporting
examining extrafamilial infommtion sources in the instruments.
study of childhood depression. Teachers' ratings corre- In conclusion, this literature has defined some
lated highly with students' ratings of their peers' de- trends in interinfonnant reporting of depressed chil-
pression. Variable and typically low agreements, how- drens' symptoms. A critical review of this work re-
ever, were found when comparing reports of teachers veals, however, that unitary descriptions of a child's
depression are misleading as children may present dif- becomes depressed, exhibits lowered self-esteem, and
ferently across settings and to various informants. In has cognitive and motivational deficits that impair
order to paint a comprehensive picture of a child's problem solving and instrumental responding. In their
depression, it is essential to utilize a multitrait, multi- reformulated model of learned helplessness, Abram-
method, multi-informant approach to assessment son and colleagues (1978) postulate that compared to
(Reynolds, Anderson, & Bartell, 1985; Saylor, Finch, nondepressives, depressives attribute failure to more
Baskin, Furey, & Kelly, 1984; Wolfe et al., 1987). internal, stable, and global causes and attribute suc-
cesses to more external, unstable, and specific causes.
Finally, Rehm's (1977) self-control model of de-
Deficits in Functional Domains pression incorporates aspects of the models of Beck,
Lewinsohn, Seligman, and Abramson and colleagues.
Consistent with current knowledge, we now turn to Self-control, a three-stage feedback loop process, in-
specific functional domains in which depressed chil- cludes self-monitoring, self-evaluation, and self-rein-
dren may evidence deficits. Cognitive style, interper- forcement. Depressed individuals are hypothesized to
sonal functioning, affective functioning, family func- have deficits in one or more of these areas. Rehm
tioning, and psychobiological functioning will be characterizes the self-control deficits evidenced by de-
discussed in turn. pressed individuals as follows: (1) selective monitor-
ing of negative events to the exclusion of positive
events; (2) selective monitoring of immediate versus
Cognitive Style
delayed consequences of one's behavior; (3) setting
Cognitive models of adult depression dominate in overly stringent self-evaluative criteria; (4) failing to
clinical and social psychology (Abramson, Seligman, make accurate attributions of responsibility for one's
& Teasdale, 1978; A. T. Beck 1967; Lewinsohn, 1974; behavior; (5) insufficient contingent self-reinforce-
Rehm, 1977; Seligman, 1975). Lewinsohn (1974), for ment; and (6) excessive self-punishment.
example, views the etiology of depression as a loss or Research indicates that the cognitive patterns of de-
lack of response-contingent positive reinforcement. pressed children are similar to those of depressed
His model assumes that a low rate of such reinforce- adults. Consistent with the original learned help-
ment acts as an eliciting stimulus for some depressive lessness model (Seligman, 1975), children reporting
behaviors. Further, the low rate of response-contingent more depression display deficits in instrumental re-
positive reinforcement received by a person depends sponding as evidenced by poorer performance on a
upon the number of potentially reinforcing events in block design task, an anagram task, and on the Match-
the environment, the social skills of the individual to ing Familiar Figures task (Kaslow et aI., 1983;
elicit such reinforcement, and the person's ability to Schwartz, Friedman, Lindsay, & Narrol, 1982). In line
experience pleasurable reinforcement without inhib- with Beck's cognitive model of depression (1967), de-
itory anxiety. Low activity level, inadequate social pressed children have lower self-esteem and perceived
skills, and anxiety are held to be the central symptoms competence, evidence cognitive distortions, and feel
of depression. more hopeless about their futures (Asarnow, Carlson,
Beck's model, on the other hand, postulates that at & Guthrie, 1987; Blechman et aI., 1986; Haley, Fine,
an early age, depressives develop a negative view of Marriage, Moretti, & Freeman, 1985; Hammen &
themselves, the world, and the future ("negative cog- Zupan, 1984; Kaslow, Rehm, & Siegel, 1984; Kazdin
nitive triad"). Experiences are filtered through this set et al.. 1983b; Kazdin, Rodgers, & Colbus, 1986;
of cognitive schema, which distort reality negatively. Layne & Berry, 1983; Leitenberg, Yost, & Carroll-
The negative cognitive triad is a determinant of the Wilson, 1986; McGee, Anderson, Williams, & Silva,
associated affective, motivational, behavioral, and 1986; Windle et al .• 1986). As predicted by the refor-
somatic symptoms of depression. mulated model of learned helplessness (Abramson et
A third model, Seligman's (1975) concept of al .• 1978), higher levels of depression in children are
learned helplessness, asserts that depressed indi- associated with an external locus of control, "con-
viduals expect bad events to occur and believe that no tingency uncertainty," and a depressive attributional
response in their repertoire will permit effective avoid- style (Blumberg & Izard, 1985; Kaslow et al .• 1984,
ance (response-outcome independence). Upon learn- 1988; Lefkowitz, Tesiny, & Gordon, 1980; Leon et
ing that outcomes are uncontrollable, an individual al .. 1980; Mullins et al.. 1985; Nolen-Hoeksema,
Girgus, & Seligman, 1986; Saylor et al., 1984; Selig- ting fewer positive behaviors, and as being in greater
man et al., 1984; Tesiny & Lefkowitz, 1982; Tesiny et need for therapy (Peterson, Mullins, & Ridley-John-
al., 1980; Weisz, Weiss, Wasserman, & Rintoul, son, 1985). These perceptions are mitigated if the de-
1987). Further, in accord with Rehm's self-control pressed child is perceived by peers as subject to greater
model (1977), depressed children evidence deficits in life stress. Sacco and Graves (1984) reported that de-
self-monitoring, evaluation, and reinforcement (D. A. pressed children are less satisfied with their interper-
Cole & Rehm, 1986; Kaslow et al., 1984, 1988). In sonal problem-solving performance and exhibit defi-
addition to the aforementioned cognitive deficits, de- cits in this domain. Regardless of the severity of
pressed children exhibit impaired actual or perceived depression, prepubertal children display deficits in so-
academic performance (Blechman et al., 1986; cial functioning with their peers, parents, and siblings
Lefkowitz & Tesiny, 1980; McGee et al., 1986; Nolen- (Altmann & Gotlib, 1988; Kazdin, Esveldt-Dawson,
Hoeksema et al., 1986; Puig-Antich et al., 1985a,b; Sherick, & Colbus, 1985; Puig-Antich et al., 1985a).
Tesiny et al., 1980). Further, some deficits in childrens' intra- and extra-
The fact that research findings from studies of de- familial relationships remain after recovery from an
pressed children are consistent with predictions rooted affective episode (Puig-Antich et al., 1985b).
in cognitive theories of adult depression does not nec-
essarily imply that the cognitive functioning of de-
Affective Functioning
pressed children is identical to that of depressed adults.
Further, it does not necessarily follow that theoretical "Depressed affect is the sine qua non of the clinical
models of adult depression can simply be extended diagnosis of depression" (Poznanski, 1982; p. 297). A
downward to explain depression in children. Rather, developmental perspective on the study of dysphoric
numerous authors (e.g., P. M. Cole & Kaslow, 1988; affect requires that changes associated with age be
Cicchetti & Schneider-Rosen, 1986) have argued that taken into account when investigating the means by
although adult models may inform our understanding which children express such affect (Glasberg &
of the cognitive components of childhood depression, Aboud, 1981). Depressed mood in children may be
these models need to be modified to take into account expressed either verbally, nonverbally, or both. Sim-
normal cognitive development in children. A develop- ilar to the verbal expression of affect characteristic of
mentally informed approach to depression may not depressed adults, depressed children report a pattern of
only enhance understanding of the associated cog- emotional experiences, including sadness, anger, self-
nitive deficits in children but may provide an enriched directed hostility, and shame (Blumberg & Izard,
understanding of the development and maintenance of 1985; Izard & Schwartz, 1986). In the nonverbal
such deficits in adults. Thus, cognitive deficits in adult sphere, Kazdin and colleagues (Kazdin, Esveldt-
depressives may represent developmental sequellae of Dawson, Sherick, & Colbus, 1985; Kazdin, Moser,
failure to negotiate in an age-appropriate manner cog- Colbus, & Bell, 1985) reported that depressed inpa-
nitive tasks initially encountered earlier in life. tients exhibited less affective expression (e.g., smil-
ing, frowning) than did their nondepressed peers. This
research reveals a less robust relationship between de-
Interpersonal Functioning
pression and nonverbal behavior for children than for
Recent work investigating depressed adults' social adults.
functioning and the developmental literature regarding
children's interpersonal relationships both underscore
Family Functioning
the need to investigate the social behavior of depressed
children (Altmann & Gotlib, 1988). Unpopular and A review of the substantial body of research demon-
socially withdrawn children are more depressed than strating a correlation between family patterns and de-
their popular and more sociable cohorts (Lefkowitz & pression reveals four major streams of relevant
Tesiny, 1980; Jacobsen, Lahey, & Strauss, 1983; literature (e.g., Orvaschel, Weissman, & Kidd, 1980).
Strauss, Forehand, Smith, & Frame, 1986; Vosk, fore- First, some studies have considered depressed children
hand, Parker, & Rickard, 1982) and are seen by teach- as the probands and have examined their families.
ers as less socially skilled (Lefkowitz & Tesiny, 1980). These studies suggest that a significant number (40%-
In addition, as compared to their nondepressed coun- 70%) of these children have depressed mothers and a
terparts, depressed elementary school children are high incidence of psychopathology in their extended
rated by peers as less likeable and attractive, as emit- family (for a review, see Orvaschel et al., 1980). In
CHAPTER 31 • CmLDHOOD DEPRESSION 657
some of these families, serious family dysfunction and cluded family history, response to antidepressants,
negative family life events have also been reported, neuroendocrine correlates, and sleep polysom-
including parent-child conflict, parental death, di- nographic findings (for reviews, see Puig-Antich,
vorce or separation, child maltreatment or physical 1982; Weller & Weller, 1984). Family history data re-
abuse, marital discord, and a problematic parenting veal that prepubertal major depressives carry a high
style characterized by hostility and alternating rejec- genetic loading for affective disorder, alcoholism, and
tion and overinvolvement (S. Beck & Rosenberg, antisocial personality disorder. Although a number of
1986; Bemporad & Won Lee, 1984; Forehand et al., studies examining the efficacy of antidepressants
1988; Handford, Mattison, Humphrey, & McLaugh- (most notably imipramine) for depressed prepubertal
lin, 1986; Kazdin, Moser, et al., 1985; Lefkowitz & children revealed a high response rate with elevated
Tesiny, 1984; Poznanski & Zrull, 1970; Puig-Antich, plasma levels (for review, see Puig-Antich, 1982),
Blau, Marx, Greenhill, & Chambers, 1978; Trad, more recent research utilizing double-blind studies
1987). There also appears to be a "poorness of fit" with adequate sample size failed to demonstrate the
between the demands and expectations of the environ- superiority of antidepressants over placebo (Campbell
ment and the child's capacities, motivation, and behav- & Spencer, 1988). Neuroendocrine studies regarding
ioral style (Chess & Thomas, 1984). It is important to growth hormone, cortisol secretion, dexamethasone
note that the relationship between these family vari- suppression, and melatonin provide tentative indica-
ables and depression in a child is currently understood tions that the neuroendocrine correlates of depression
to be correlational, and that causality has not been in the young are similar to those of depressed adults.
demonstrated. From a family systems perspective, Polysomnographic studies attempting to differentiate
however, attempts to demonstrate causality are mis- sleep patterns of depressed prepubertal children from
directed given that perspective's emphasis is on re- those of controls generate equivocal findings. More-
ciprocal directions of effect. Second, retrospective over, the findings regarding the similarities in sleep
studies indicate that compared to nondepressed sub- architecture between depressed prepubertal children
jects, adult depressives remember their parents as and depressed adults are inconsistent. Overall, the
more overprotective, rejecting, intrusive, and control- findings suggest an interaction between age, sleep, and
ling, as lacking in nurturance, support, and affection, depression.
and as inadequate as caretakers (e.g., Blatt, Wein,
Chevron, & Quinlan, 1979; Holmes & Robins, 1987;
Parker, 1979). Third, as parents, depressed women are Treatment
less emotionally involved or affectionate, and exhibit
greater communication difficulties and higher levels of The existing literature on the treatment of depres-
hostility (e.g., Weissman & Paykel, 1974). Compared sion in children is composed primarily of psycho-
to nondepressed mothers, depressed mothers of clinic- dynamic and behavioral case studies, descriptions of a
referred children have a more negative perception of variety of recommended treatment interventions, and
their child's adjustment, especially when the child is pharmacotherapy outcome research. The only psycho-
less compliant (Brody & Forehand, 1986; Rogers & social treatment outcome studies reported in the liter-
Forehand, 1983). Fourth, high-risk research indicates ature to date are two cognitive-behavioral group treat-
that children of depressed mothers have difficulties in ment studies with depressed children. Following a
concentration and attention, academic performance, brief review of case and outcome studies, this section
and competent social functioning. These children also calls for large-scale intervention studies into the rela-
evidence a higher rate of behavior and psychiatric tive efficacies of psychosocial intervention paradigms
problems, including depression, than the general pop- incorporating current directions in the field. A possible
ulation (for reviews , see Beardslee, Bemporad, Keller, design for such a study is presented.
& Klerman, 1983; Morrison, 1983; Trad, 1987).
Psychodynamic Case Studies
Psychobiological Functioning
A number of case studies in the literature describe
During the past 20 years, several psychobiological individual psychodynamically oriented psychotherapy
correlates have been reported to accompany major de- with depressed children (e.g., Bemporad, 1978;
pression in adults and more recently in children and Boverman & French, 1979; Cohen, 1980; Gilpin,
adolescents. The major variables examined have in- 1976). This approach assumes that depression involves
a self-perpetuating pathological mode of interaction els of above 140 to 150 ng/ mi. In view of this lack of
fostered by unconscious distortions that are a function clarity in the research literature regarding efficacy of
of problematic parent-child interactions. These in- pharmacotherapy with depressed children in conjunc-
teractions produce impaired self-esteem, a perceived tion with the presence of frequent behavioral and car-
lack of environmental instrumentality, dependence on diotoxic side effects, it is recommended that anti-
significant others for gratification, and a pervasive depressants be prescribed only if other types of
sense of sadness. The goals of treatment are to increase treatments have failed after a reasonable length of
the child's sense of happiness, self-esteem, and capac- time, when the family is compliant with the treatment
ity to cope with the inevitable frustrations encountered protocol, and when appropriate medical monitoring is
in interactions with the environment. In order to ac- conducted (Campbell & Spencer, 1988). Some com-
complish these goals, a developmental approach ne- ment regarding bipolar disorder and lithium treatment
cessitates different therapeutic foci with children of in children is warranted. There is considerable uncer-
different ages (Bemporad, 1978; Boverman & French, tainty about the prevalence and diagnosis of childhood
1979). With younger children who are more dependent bipolar disorder. Even though there are scattered re-
on caregivers for comfort and a sense of self-esteem, ports of the effective use of lithium in alleviating the
therapy may entail greater environmental manipula- symptoms of this disorder in children, the dearth of
tions and family involvement. As children mature, methodologically sound empirical research precludes
however, and internalize their difficulties and are more any definitive recommendation for this treatment strat-
vulnerable to the development of a stable and negative egy (Campbell & Spencer, 1988).
self-concept, the aim of psychodynamically informed
individual psychotherapy should shift to enhancing the
Behavioral Case Studies
child's awareness of these negative internalizations
and their effect on behavior and the child's increasing The behavioral case studies of depressed children
responsibility for effecting change. reported to date have emphasized social skills training
(e.g., Frame, Matson, Sonis, Fialkov, & Kazdin,
1982; Matson et aI., 1980; Petti, Bomstein, De-
Pharmacotherapy Outcome Research
lamater, & Conners, 1980). Social skills training has
The efficacy of antidepressant medication in the focused on teaching verbal and nonverbal behaviors
treatment of major depression in adults has been well important in the expression and acceptance of feelings,
established, and previous reviews of the use of such and on developing socially appropriate interactions
medication with depressed children (Petti, 1983; Puig- with others by improving verbal behavior, body pos-
Antich, 1980) suggested that antidepressants were ef- ture, eye contact, speech patterns, and affect ex-
fective in 75% of cases. Building on this initial evi- pression. Training has included an evaluation of the
dence of success, these reviews called for employing child's social skills pre- and postintervention. In addi-
specific research criteria in selecting a large sample of tion to this evaluation, the training programs consisted
depressed children to participate in a double-blind, of instruction, modeling, role-playing, information
placebo-controlled study of the efficacy of antidepres- feedback, and social reinforcement. Data from the
sants. case studies support the efficacy of these interventions
A recent review of the literature found that such in reducing social skills deficits and depressive symp-
studies have been initiated (Campbell & Spencer, tomatology in depressed inpatient and outpatient
1988), but to date have failed to demonstrate the supe- children.
riority of antidepressants over placebo in prepubertal
children (Puig-Antich et al., 1987) or in adolescents
Cognitive-Behavioral Outcome Studies
(Kramer & Feiguine, 1981). Several hypotheses have
been put forth to account for this failure, including Buttressing this work conducted from a behavioral
such diagnostic and methodological issues as treat- orientation, two control-group intervention outcome
ment duration, inpatient versus outpatient status, and studies utilizing cognitive and behavioral interventions
lack of pretreatment placebo periods. Further, there is have been described (Butler, Miezitis, Friedman, &
some indication that imipramine dosages employed in Cole, 1980; Stark, Kaslow, & Reynolds, 1987). Butler
these studies of prepubertal children were too low, and and her colleagues (1980) compared the relative
that future studies should insure serum imipramine lev- efficacy of role play, cognitive restructuring, attention
placebo, and waiting list conditions. Although both based on research findings regarding the functioning
active interventions were effective, the role-play con- of depressed children and the treatment outcome liter-
dition appeared more efficacious. This intervention ature regarding depressed adults. Reflecting streams in
consisted of training in a general problem-solving the relevant literature, the three experimental condi-
strategy and behavioral rehearsal of social skills. Stark tions could include a cognitive-behavioral psycho-
and colleagues (1987) weighed the relative efficacy of educational intervention, interpersonal family therapy,
self-control therapy, behavior problem-solving thera- and brief dynamic group therapy. Although there may
py, and a waiting list control. The self-control inter- be some overlap across experimental conditions in tar-
vention focused on teaching children such self-man- get deficits to be addressed and the intervention tech-
agement skills as adaptive self-monitoring, self- niques to be utilized, each condition would be struc-
evaluating, self-consequating, and appropriate causal tured to alleviate focal deficits identified by branches
attributions. The behavioral problem-solving therapy of the literature as contributory to the development and
consisted of education, self-monitoring of pleasant maintenance of childhood depression. The control
events, and group problem solving directed toward condition is included to conform with methodological
improving social behavior. Postintervention and fol- precedents from the psychotherapy outcome research
low-up assessments found participants in both active literature, and provides a way to investigate Lefkowitz
interventions significantly improved on self-report and and Burton's (1978) hypothesis that childhood depres-
interview measures of depression, whereas members sion is a transient developmental phenomenon that dis-
of the waiting list condition reported minimal change. sipates with time. To examine cost-effective psycho-
Although comparison of the two active intervention social interventions with clinical community relevance
outcomes was equivocal, the pattern suggested that the that develop coping skills and minimize potentially
self-control intervention was the most effective. deleterious effects, the proposed design does not incor-
porate either individual psychotherapy or phar-
macotherapy conditions. Further, because child devel-
Current Directions for Treatment opment and childhood depression are understood to be
Outcome Research embedded within the context of the family, the three
active interventions would each include some family
The foregoing literature provides preliminary indi- involvement.
cation that planned interventions with depressed chil- The first experimental condition, the cognitive-be-
dren can be efficacious in reducing depressive havioral psychoeducational group intervention, is
symptomatology. To advance the field, research based on clinical research with depressed adults (Abra-
should now focus on developing cost-effective psy- mson et ai., 1978; Lewinsohn, 1974; Rehm, 1977;
chosocial interventions and comparing their relative Seligman, 1975) and depressed children (Butler et al.,
efficacies in reducing depressive symptomatology and 1980; Stark et al., 1987), as well as recommendations
in enhancing cognitive, interpersonal, affective, fami- for cognitive-behavioral treatments with depressed
ly, and adaptive behavior functioning. The following children and adolescents (Clarizio, 1985; DiGiuseppe,
methodology presents a design for a large-scale inter- 1986; Emery, Bedrosian, & Garber, 1983; Kaslow &
vention study for the accomplishment of these tasks. Rehm, 1983, 1985; Wilkes & Rush, 1988).
First, a thorough assessment of depressed prepuber- Cognitive-behavioral interventions with children
tal children and their families conducted pretreatment, need to take into account childrens' cognitive develop-
posttreatment and at follow-up would provide a syn- mental capacities and require therapists to have a more
thetic and developmentally informed description of active role in effecting the desired change by utilizing
childhood depression encompassing the domains list- more action-oriented techniques and concrete task as-
ed above. A battery to accomplish such an assessment signments. Accordingly, children in this program
might take several forms (e.g., Kaslow & Rehm, would meet in a small, six-member group led by a
1983, 1985). Table 2 presents possible child, parent, clinician experienced with this intervention approach
and family batteries designed to meet the requirements utilizing a manual spelling out the intervention pro-
of this experimental design. cedures. These procedures entail activity scheduling
Second, the intervention phase of the study might (including scheduling of pleasurable activities), con-
compare three time-limited experimental conditions tingent reinforcement (food, toys, and praise) for ac-
and a control condition, each of 4-months duration and quisition of targeted behaviors, cognitive restructur-
Table 2. Child, Parent, and Family Batteries

Domain Instrument Reference
Child measures
Symptomatology
Depressive symptomatology Children's Depression Inventory Kovacs & Beck (1977)
(CDI)
Psychiatric symptomatology Schedule for Affective Disorders Orvaschel & Puig-Antich

and Schizophrenia (K-SADS); (1987); Puig-Antich & Ryan
Epidemiologic Version and (1986)
Present Episode Version
Cognition
Intellectual functioning Peabody Picture Vocabulary Dunn & Dunn (1981)
Test-Revised (PPVT-R)
Self-esteem Self-Perception Profile for Chil- Harter (1985)

dren
Hopelessness Hopelessness Scale for Children Kazdin, Rodgers, & Colbus

(HSC) (1986)
Attributional style KASTAN-R Children's Attri- Seligman, Peterson, Kaslow,

butional Style Questionnaire Tanenbaum, Alloy, &
(KASTAN-CASQ) Abramson (1984)
Self-control Children's Perceived Self-Control Humphrey (1982)

Scale-Usually That's Me
(UTM)
Interpersonal behavior
Social adjustment Social Adjustment Inventory for John, Gammon, Prusoff, &
Children and Adolescents Warner (1987)
(SAICA)
Affective expression
Emotional characteristics Differential Emotion Scale IV Izard, Dougherty, Bloxom, &
(DES-IV) Kotsch (1974)
Adaptive behavior
Adaptive behavior Vineland Adaptive Behavior Sparrow, Balla, & Cicchetti
Scales (1984)
Parent measures
Symptomatology
Self-report of depression Beck Depression Inventory (BDI) Beck, Ward, Mendelson,
Mock, & Erbaugh (1961)
Psychiatric symptomatology Structured Clinical Interview for Spitzer & Williams (1985)
DSM-III-R-Patient Version
(SCID-P)
Cognition
Intellectual functioning PPVT-R Dunn & Dunn (1981)
Self-esteem Tennessee Self-Concept Scale Fitts & Roid (1988)
Hopelessness Hopelessness Scale (HS) Beck, Weissman, Lester, &

Trexler (1974)
Domain Instrument Reference
Attributional style Attributional Style Questionnaire Seligman, Abramson, Sem-

(ASQ) mel, & von Baeyer (1979)
Self-control Self-Control-Schedule-Self- Rehm (1977)

Control Questionnaire (SCS-
SCQ)
Interpersonal Behavior
Social adjustment Social Adjustment Scale-Se1f- Weissman & Bothwell (1976)
Report (SAS-SR)
Affective Expression
Emotional characteristics DES-IV Izard, Dougherty, Bloxom, &
Kotsch (1974)
Adaptive Behavior
Adaptive behavior Vineland Adaptive Behavior Sparrow, Balla, & Cicchetti
Scales (1984)
Family measures
Symptomatology
Family functioning Family Adaptability and Cohesion Olson, Portner, & Lavee
Evaluation Scale (1985)
Marital functioning Dyadic Adjustment Scale- Locke & Wallace (1959);

Locke-Wallace (DAS-LW) Spanier (1976)
Family interaction Living and Familial Environments Arthur, Hops, & Biglan
Coding System (LIFE) (1982)
ing, and graded task assignments. This program is work in the sessions and would be helped to develop
designed to help children recognize the relationship more effective communication skills. Additionally,
between cognition, affect, and behavior, address cog- since parents of depressed children evidence prob-
nitive distortions, and learn more appropriate modes of lematic monitoring, evaluation, and reinforcement of
information processing, problem solving, and social their children's behavior (D. A. Cole & Rehm, 1986),
interaction. Through the use of homework assign- parents would receive assistance in more effective par-
ments, children would be taught to monitor and evalu- enting strategies.
ate recurrent patterns of thinking and to modify dys- The second experimental intervention condition,
functional attitudes. In general, the children would brief dynamic group therapy, would address the inter-
acquire more adaptive means of self-monitoring, self- personal and affective difficulties characteristic of de-
evaluating, and self-consequating, and of making at- pressed children. This model borrows from three lines
tributions about negative and positive events. Given of related work: short-term dynamic therapy with
that the family is the primary system within which adults (e.g., Mann, 1973) and children (Sloves & Pe-
children develop and that family patterns are instru- terlin, 1986), individual psychodynamic psycho-
mental in the development and maintenance of the therapy with depressed children (e.g., Bemporad,
child's depressive behavior, family involvement is cru- 1978; Boverman & French, 1979; Cohen, 1980), and
cial. Borrowing from the work of Lewinsohn and Clar- dynamic group therapy with children (Grunebaum &
ke (1984) and McCoy (1982), a companion parent Solomon, 1980, 1982; Schamess, 1976). This closed-
course might also be offered, the basic premise of ended, theme-directed treatment, which includes an
which is that parents can facilitate their child's pro- opening, a working-through, and a termination phase,
gress by supporting participation in the intervention is conducted in a six-member group led by an experi-
program. Parents would be informed of their child's enced group therapist with the aid of a treatment man-
ual. The group structure includes a "talking time" ad- fundamental assumption of IPT is that depressive
dressing conflicts in the group members' lives, an symptomatology and interpersonal problems are inter-
activity time utilizing projective play and dealing with related. It is further assumed that addressing the de-
the childrens' interpersonal skills deficits, and a con- pressed person's interpersonal difficulties is essential
cluding talking time focusing on the events occurring for alleviating the depression and possibly for prevent-
specifically in that group session. Group treatment ing future episodes. Short-term IPT has two primary
provides an arena within which children can receive goals: (1) alleviating the affective, cognitive, moti-
needed emotional nurturance, model more age-appro- vational, and neurovegetative symptoms of depres-
priate conflict resolution, and assert more immediate sion; and (2) helping the individual devise more effec-
environmental control. Group discussions challenge tive strategies for dealing with social and interpersonal
members' assumptions of personal responsibility for problems. Similar to IPT's focus on current function-
family dysfunction. Short-term dynamic therapy ing and behavior change, Minuchin and colleagues'
focuses on the resolution of separation-individuation (1978) structural family therapy focuses on the present
conflicts that have impeded the normal developmental family context and views the therapeutic task as one of
process and contributed to the development of depres- directed behavior change. To enhance the application
sion in the child. Children develop strong transferen- of IPT concepts to work with families, IPT could be
tial attachments to the therapist, the examination of blended with basic principles of structural family ther-
which enables working through of feelings for primary apy including joining with the family, deriving a fami-
objects. Resolution of these feelings permits develop- ly map or diagnosis, and restructuring the family ac-
ment of a more stable sense of self and more adaptive cording to the goals implied in the diagnosis. Such
interpersonal relationships. Based on the work of such work would occur in weekly family sessions with a
writers as Poey (1985) and Bion (1959), this interven- skilled therapist employing a treatment manual and
tion focuses on interpretation of immediate intragroup would include as many members of the nuclear family
relationships and transferential representations of fam- as possible. Given the problematic interactional pat-
ily interactions. Parent group meetings would be held terns in families of depressed children, such a blending
monthly to inform parents of the general progress of would potentially supply a very effective intervention.
the group and to discuss alternative ways of coping
with their children's difficulties. Parental alliance is
essential because it reduces the possibilities for both Concluding Comments
the child and the parents to undermine the treatment
process. Additionally, parental involvement prepares This review of the literature on the diagnosis, etiolo-
the parents to facilitate more age-appropriate develop- gy, and treatment of childhood depression reveals a
ment in the child as the treatment ends and parents clear convergence of interest in assessment of depres-
once again assume full responsibility for their child. sion in children and its impact on functional domains.
Because there is no extant family intervention for Despite this interest, there remains a need for work
depression, the family intervention experimental con- synthesizing depressed childrens' functioning across a
dition might incorporate the theoretical notions and number of domains, including psychological symp-
techniques of interpersonal psychotherapy (lPT) toms and cognitive, affective, interpersonal, family,
(Klerman, Weissman, Rounsaville, & Chevron, 1984) and adaptive behavior functioning. Further, the liter-
with structural family system approaches (Minuchin, ature leads us to believe that the field is ripe for com-
Rosman, & Baker, 1978). IPT for depression was parative intervention outcome studies.
chosen as one of the two psychologically based treat-
ments utilized in the NIMH-sponsored depression col-
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CHAPTER 32
Conduct Disorders
Alan E. Kazdin
Introduction contact for youths whose behaviors are identified as

severe. Within the educational system, special ser-
Conduct disorder encompasses a broad range of anti- vices, teachers, and classes are often provided to man-
social behaviors, such as aggressive acts, theft, van- age such children on a daily basis.
dalism, firesetting, lying, truancy, and running away. Conduct disorder raises special challenges in rela-
Although these behaviors are diverse, their common tion to treatment. The purpose of the present chapter is
characteristic is that they tend to violate major social to examine current progress in the behavioral treatment
rules and expectations. Many of the behaviors often of conduct disorder. The focus, effectiveness, and lim-
reflect actions against the environment, including both itations of alternative techniques are reviewed. In ad-
persons and property. Many antisocial behaviors dition, special issues raised by conduct disorder and
emerge in some form over the course of normal devel- the directions for future treatment research are present-
opment. Fighting, lying, stealing, destruction of prop- ed. Prior to discussing current interventions, it is crit-
erty, and noncompliance are relatively high at different ical to convey characteristics of conduct disorder and
points in childhood (Achenbach & Edelbrock, 1981; their associated features. Indeed, evaluation of the ef-
MacFarlane, Allen & Honzik, 1954). For the most fectiveness and limitations of alternative treatments
part, these behaviors diminish over time, do not inter- depends on clarifying the full range of characteristics.
fere with everyday functioning, and do not predict un-
toward consequences in adulthood.
The term conduct disorder is usually reserved for a Characteristics of Conduct Disorder
pattern of antisocial behavior that is associated with
significant impairment in everyday functioning at Central Features
home or school and the concerns of significant others
There are several features of conduct disorder that
that the child or adolescent is unmanageable. Clinical-
make the behaviors discrepant from what is seen as
ly severe antisocial behavior is likely to bring the youth
part of "normal development." First, many of the be-
into contact with various social agencies. Mental
haviors, such as fighting, temper tantrums, stealing,
health services (clinics, hospitals) and the criminal jus-
and others, are relatively frequent. In some cases, the
tice system (police, courts) are the major sources of
behaviors may be of a low frequency (e.g., firesetting)
in which case intensity or severity, rather than frequen-
Alan E. Kazdin • Department of Psychology, Yale Univer- cy, is the central characteristic. Second, repetitiveness
sity, New Haven, Connecticut 06520. and chronicity of the behaviors are critical features.
669
The behaviors are not likely to be isolated events or to Another effort to identify subtypes has been to focus
occur within a brief period where some other influ- on salient symptoms. The approach is illustrated in the
ences or stressors (e.g., change in residence, divorce) work of Patterson (1982), who has distinguished anti-
are operative. Third, the breadth of the behaviors is social children whose primary symptom is aggression
central as well. Rather than an individual symptom or (aggressors) from those whose primary symptom is
target behavior, there are usually several behaviors that stealing (stealers). Aggressors have a history of fight-
occur together and form a syndrome or constellation of ing and engaging in assaultive behavior; stealers have a
symptoms. Conduct disorder, as a syndrome, includes history of repeated theft and contact with the courts.
several core features, such as fighting, engaging in Although these characteristics often go together, sub-
temper tantrums, theft, truancy, destroying property, populations of "pure" aggressors or stealers can be
defying or threatening others, and running away, readily identified.
among others. The syndrome is recognized in Several studies have suggested the utility of dis-
clinically derived diagnostic systems, such as the Di- tinguishing aggressors and stealers. For example, ag-
agnostic and Statistical Manual of Mental Disorders gressive children have been found to engage in signifi-
(American Psychiatric Association [APA], 1987). In cantly more aversive and coercive behaviors in their
addition, empirically derived diagnostic systems interactions in the home and are less compliant with
based on multivariate analyses have consistently iden- parents' requests than are children who steal (Patter-
tified conduct disorder as a distinct syndrome (see son, 1982; Reid & Hendriks, 1973). Also, parents of
Quay, 1986a). It is important to underscore the fact that stealers show greater emotional distance in relation to
the ~onduct disorder includes a constellation of behav- their children (e.g., lack of responding, less disap-
iors because evaluation of one ofthe behaviors (e.g., proval, fewer commands) than do parents of ag-
aggressive acts) may well be quite limited. gressors (Patterson, 1982). The prognosis of antisocial
children may vary as a function of whether they have
been identified as aggressors or stealers. For example,
Variations and Types
subsequent contact with the courts several years later is
Conduct disorder is meaningful as a summary label significantly more likely for children previously iden-
for a particular set of behaviors and other charac- tified as stealers than as aggressors (Moore, Cham-
teristics that covary. However, there is remarkable het- berlain, & Mukai, 1979).
erogeneity in the patterns that children may show. Interestingly, the salient symptom approach has not
Efforts have continued to identify specific subtypes neglected the fact that many children are likely to be
using alternative approaches. In current psychiatric di- both aggressors and stealers. Indeed, the combination
agnosis (e.g., DSM-III-R), two major subtypes of of salient symptoms may be significant in its own
Conduct Disorder are recognized, referred to as Group right. "Mixed" symptom children show charac-
lYpe and Solitary Aggressive Type. In the Group teristics of both types and are especially at risk for
Type, the conduct problems occur primarily as a child abuse (Patterson, 1982). Thus, the approach pro-
group activity in the company of friends who have vides preliminary evidence regarding different salient
similar problems and to whom the individual is loyal. symptom patterns.
Physical aggression may be present. Children are in- Expansion of the aggressor-stealer dimension has
cluded in the Solitary Aggressive Type if they show suggested a broader focus to delineate SUbtypes. Anti-
physically or verbally aggressive behavior. The behav- social behavior can be examined according to a bipolar
ior usually is initiated by the individual, rather than as dimension of overt and covert behavior (Loeber,
part of group activity, and no attempt is made to con- 1985). Overt behaviors consist of those antisocial acts
ceal the behavior. The subtype notes that social isola- that are confrontive, such as fighting, arguing, and
tion often may be evident. Delineation of the two sub- temper tantrums. Covert behaviors, on the other hand,
types have been influenced by research findings on consist of concealed acts, such as stealing, truancy,
patterns of antisocial behavior. Multivariate ap- lying, and firesetting.
proaches to diagnosis have often identified patterns of Loeber and Schmaling (1985a) analyzed a large
conduct that correspond to aggressive and delinquent number of studies that evaluated antisocial behavior of
types (Lessing, Williams, & Gil, 1982; Quay, 1986b). school-aged children. Statistical analyses of the group-
By no means are the precise criteria for these types ing of antisocial behaviors across studies supported the
clearly developed and validated. dimension of overt and covert behavior. The data indi-
CHAPTER 32 • CONDUCT DISORDERS 671
cated that overt behaviors tend to cluster together. This & Stewart, 1982; Carlson, Lahey, & Neeper, 1984).
means that the presence of one overt behavior was Such youths have been found to be socially ineffective
likely to be associated with other overt behaviors. Sim- in their interactions with an array of adults (e.g., par-
ilarly, the presence of a particular covert behavior is ents, teachers, community members). Specifically,
likely to be associated with other covert behaviors. antisocial youths are less likely to defer to adult author-
Some behaviors, such as disobedience and sassiness, ity, to show politeness, and to respond in ways that
tend to be present with both types of antisocial behav- promote further positive interactions (Freedman,
ior. Children with both overt and covert behaviors are Rosenthal, Donahoe, Schlundt, & McFall, 1978;
distinguished from "purer" types by more severe fam- Gaffney & McFall, 1981).
ily dysfunction and poorer long-term prognoses, as The correlates of antisocial behavior not only in-
reflected in subsequent contact with police and careers volve overt behaviors but also a variety of cognitive
of antisocial behavior (Loeber & Schmaling, 1985b; and attributional processes. Antisocial youths have
McCord, 1980). been found to be deficient in cognitive problem-solv-
ing skills that underlie social interaction (Dodge,
1985; Kendall & Braswell, 1985). For example, such
Associated Features
youths are more likely than their peers to interpret
The central features of conduct disorder refer to the gestures of others as hostile and are less able to identify
antisocial, aggressive, and defiant behaviors. There solutions to interpersonal problem situations and to
are several correlates or associated features as well. take the perspective of others. In addition, conduct-
Among alternative symptoms that have been found disordered youth are higher than nonconduct-disor-
among antisocial children, those related to hyperac- dered peers on cognitive perceptual characteristics,
tivity have been the most frequently identified. These such as resentment, suspiciousness, and irritability
symptoms include excessive motor activity, rest- (becoming upset) in response to others (Kazdin,
lessness, impulsiveness, and inattentiveness. In fact, Rodgers, Colbus, & Siegel, 1987).
the co-occurrence of hyperactivity and conduct disor-
der has made their diagnostic delineation and assess-
Family Characteristics
ment a topic of considerable research (e.g., Hinshaw,
1987). Several other behaviors have been identified as The correlates or associated features of conduct dis-
problematic among antisocial youths, such as bois- order extend beyond the characteristics of the child. A
terousness, showing off, and blaming others (Quay, variety of parent and family characteristics are associ-
1986a). Many of these appear to be relatively mild ated with the dysfunction, and these may have impor-
forms of obstreperous behavior in comparison to ag- tant implications for identifying and implementing ef-
gression, theft, vandalism, or other acts that invoke fective treatments. Parents of antisocial youths are
damage to persons or property. more likely to suffer from various psychiatric disorders
Children with conduct disorder are also likely to than parents of children in the general population (Rut-
suffer from academic deficiencies, as reflected in ter, Tizard, & Whitmore, 1970). Criminal behavior
achievement level, grades, and specific skill areas, and alcoholism, particularly of the father, are two of
especially reading (e.g., Ledingham & Schwartzman, the stronger and more consistently demonstrated pa-
1984; Sturge, 1982). Such children are often seen by rental characteristics of conduct-disordered youths
their teachers as uninterested in school, unenthusiastic (Robins, 1966; Rutter & Giller, 1983; West, 1982).
toward academic pursuits, and careless in their work Several features related to the interaction of parents
(Glueck & Glueck, 1950). They are more likely to be with their children characterize families of conduct-
left behind in grades, to show lower achievement lev- disordered youths. Parent disciplinary practices and
els, and to end their schooling sooner than their peers attitudes have been especially well studied. Parents of
matched in age, socioeconomic status, and other de- conduct-disordered youths tend to be harsh in their
mographic variables (Bachman, Johnston, & O'Mal- attitudes and disciplinary practices with their children
ley, 1978; Glueck & Glueck, 1968). (e.g., Farrington, 1978; Glueck & Glueck, 1968; Mc-
Poor interpersonal relations are likely to correlate Cord, McCord, & Howard, 1961; Nye, 1958). Con-
with antisocial behavior. Children high in ag- duct-disordered youths are more likely than normals
gressiveness or other antisocial behaviors are rejected and clinical referrals without antisocial behavior to be
by their peers and show poor social skills (e.g., Behar victims of child abuse and to be in homes where spouse
abuse is evident (Behar & Stewart, 1982; Lewis, The present discussion does not exhaust the range of
Shanok, Pincus, & Blaser, 1979). Lax, erratic, and characteristics of parents and families of conduct-dis-
inconsistent discipline practices for a given parent and ordered youths. Other characteristics, such as mental
between the parents also characterize families of chil- retardation of the parent, early marriage of the parents,
dren with conduct disorder. For example, severity of lack of parent interest in the child's school perfor-
punishment on the part of the father and lax discipline mance, and lack of participation of the family in re-
on the part of the mother have been implicated in delin- ligious or recreational activities, have been found as
quent behavior (Glueck & Glueck, 1950; McCord, well (Glueck & Glueck, 1968; Wadsworth, 1979).
McCord & Zola, 1959). When parents are consistent in Many of the factors come in "packages." For exam-
their discipline practices, even if they are punitive, ple, family size, overcrowding, poor housing, poor
children are less likely to be at risk for antisocial behav- parental supervision, parent criminality, and marital
ior (McCord et al., 1959). discord are likely to be related. Thus, although re-
Parents of antisocial children are more likely to give search can identify the influence of individual compo-
commands to their children, to reward deviant behav- nents, in practice they are invariably intertwined.
ior directly through attention and compliance, and to
ignore or provide aversive consequences for prosocial
Course and Prognosis
behavior (see Patterson, 1982). Fine-grained analyses
of parent-child interaction suggest that antisocial be- For the children who are diagnosed with conduct
havior, particularly aggression, is systematically, al- disorder and who are seen clinically for their antisocial
beit unwittingly, trained in the homes of antisocial behavior, the course and prognosis are relatively clear.
children. Longitudinal studies have consistently shown that anti-
Supervision of the child, as another aspect of par- social behavior identified in childhood or adolescence
ent-child contact, has been frequently implicated in predicts a continued course of social dysfunction,
conduct disorder (Glueck & Glueck, 1968; Goldstein, problematic behavior, and poor school adjustment (see
1984; Robins, 1966). Parents of antisocial or delin- Kazdin, 1987a). One of the most dramatic illustrations
quent children are less likely to monitor their chil- of the long-term prognosis of clinically referred chil-
dren's whereabouts, to make arrangements for their dren was the classic study by Robins (1966), who eval-
care when they are temporarily away from the home, uated their status 30 years later. The results demon-
or to provide rules in the home stating where the chil- strated that antisocial child behavior predicted multiple
dren can go and when they must return home (Wilson, problems in adulthood. Youths who had been referred
1980). for their antisocial behavior, compared to youths with
Dysfunctional family relations are manifest in sev- other clinical problems or matched normal controls, as
eral ways. Parents of antisocial youths, compared with adults suffered dysfunction in psychiatric symptoms,
parents of normal youths, show less acceptance of criminal behavior, physical health, and social adjust-
their children, less warmth, affection, and emotional ment.
support, and report less attachment (Loeber & Dish- Even though conduct disorder in childhood portends
ion, 1983; McCord et aI., 1959; West & Farrington, a number of significant problems in adulthood, not all
1973). At the level offamily relations, less supportive antisocial children suffer impairment as adults. Never-
and more defensive communications among family theless, data suggest that a high percentage of children
members, less participation in activities as a family, are likely to suffer as adults. Across several different
and more clear dominance of one family member are samples, Robins (1978) noted that among the most
also evident (Alexander, 1973; Hanson, Henggeler, severely antisocial children, less than 50% become
Haefele, & Rodick, 1984; West & Farrington, 1973). antisocial adults. Even though less than half of the
In addition, unhappy marital relations, interpersonal children continue antisocial behavior into adulthood,
conflict, and aggression characterize the parental rela- the percentage is still quite high.
tions of delinquent and antisocial children (see Major factors that influence whether antisocial
Hetherington & Martin, 1979; Rutter & Giller, 1983). youths are likely to continue their behavior into
Whether or not the parents are separated or divorced, it adulthood include parent antisocial behavior, alco-
is the extent of discord that is associated with antisocial holism, poor parental supervision of the child, harsh or
behavior and childhood dysfunction. inconsistent discipline practices, marital discord in the
family, large family size, older siblings who are anti- boys (Graham, 1979). Sex differences also are appar-
social, and so on. The most significant predictors of ent in the age of onset of dysfunction. Robins (1966)
long-term outcome are characteristics of the child's found that the median age of onset of dysfunction for
antisocial behavior. Early onset of antisocial behav- children referred for antisocial behavior was in the 8-
iors, antisocial acts evident across multiple settings to 1O-year age range. Most (57%) boys had an onset
(e.g., home and school), and many and diverse anti- before age 10 (median = 7 years old). For girls, onset
social behaviors (e.g., several vs. few, covert and of antisocial behavior was concentrated in the 14- to
overt acts) are the primary factors that predict un- 16-year age range (median = 13 years old). Charac-
toward long-term consequences (Loeber & Dishion, teristic symptom patterns were different as well. Theft
1983; Rutter & Giller, 1983). was more frequent as a basis of referral among anti-
social boys than among antisocial girls. For boys, ag-
gression was also likely to be a presenting problem.
Prevalence
For girls, antisocial behavior was much more likely to
The prevalence of conduct disorder is difficult to include sexual misbehavior.
estimate, given very different definitions that have
been used and variations in rates for children of differ-
Implications for Intervention
ent ages, sex, socioeconomic class, and geographical
locale. Estimates of the rate of conduct disorder among The purpose in describing conduct disorder and its
children have ranged from approximately 4% to 10% many characteristics was not to paint a bleak picture,
(Rutter, Cox, Tupling, Berger, & Yule, 1975; Rutter, but rather to highlight what is known about the dys-
Tizard, & Whitmore, 1970). function. Many aspects of conduct disorder have major
When rates are evaluated for specific behaviors that implications for the implementation and evaluation of
comprise conduct disorder and youths themselves re- alternative treatments. Key characteristics to bear in
port on their activities, the prevalence rates are extraor- mind for effective intervention are the pervasiveness
dinarily high. For example, among youths (ages 13- and stability of conduct disorder. Youths with conduct
18) more than 50% admit to theft; 35% admit to as- disorder are likely to show dysfunction in diverse areas
sault; 45% admit to property destruction; and 60% ad- of their lives. They are likely to be functioning poorly
mit to engaging in more than one type of antisocial at home and at school; and within a given setting multi-
behavior (such as aggressiveness, drug abuse, arson, ple problems are likely to be evident. For example, at
vandalism) (see Feldman, Caplinger, & Wodarski, school, antisocial youths are likely to be performing
1983; Williams & Gold, 1972). Even though it is diffi- poorly in their academic tasks and to have few pro-
cult to pinpoint how many children might be defined as social relationships with their peers. The core symp-
evincing conduct disorder at a particular age, data con- toms of the dysfunction appear to begin a sequence of
sistently reveal that the problem is great by most events that support continued dysfunction. Thus,
definitions. failure to complete homework and possible truancy or
The extent of the problem is attested further by the lying are likely to portend further deterioration. Apart
utilization of clinical services by youths with antisocial from the characteristics in a particular setting, the as-
behavior and their families. The rates of referrals of sociated features conveyed the breadth of dysfunction
conduct disorder to clinical services are relatively in academic, cognitive, and interpersonal domains.
high. Estimates have indicated that referrals to outpa- Apart from pervasive dysfunction, parents and fam-
tient clinics for aggressiveness, conduct problems, and ily correlates raise critical issues as well. Parents and
antisocial behaviors encompass from one third to one the family may suffer significant dysfunction that is
half of all child and adolescent cases (Gilbert, 1957; related to the child's problems. Parent psycho-
Robins, 1981). pathology and harsh child-rearing practices, for exam-
Conduct disorder in children and adolescents varies ple, may contribute directly to interactions with the
as a function of sex (Gilbert, 1957; Robins, 1966). The child in ways that promote antisocial behavior (Patter-
precise sex ratio is difficult to specify because of vary- son, 1986). In general, the challenge of antisocial be-
ing criteria and measures of conduct disorder among havior derives in part from the range of characteristics
the available studies. Nevertheless, antisocial behavior with which it is associated and the implications regard-
appears to be at least three times more common among ing where to intervene.
Current Treatments include operant conditioning based interventions, so-

cial skills training, parent- and family-based treat-
ments, and cognitively based treatments.
Overview
Several treatments have been implemented for anti-
social behavior, including diverse forms of individual Operant Conditioning Techniques
and group therapy, behavior therapy, residential treat-
ment, pharmacotherapy, psychosurgery, and a variety The principles of operant conditioning have gener-
of innovative community-based treatments (Kazdin, ated a large number of intervention techniques applied
1985; McCord, 1982; D. 1. O'Donnell, 1985). At pre- to antisocial behavior. The techniques can be dis-
sent no treatment has been demonstrated to ameliorate tinguished on the basis of whether they attempt to in-
conduct disorder and to controvert its poor prognosis. crease the frequency of appropriate (e.g., nonag-
The absence of effective treatments has not resulted gressive) behavior or to decrease the frequency of
from a paucity of creative efforts or available tech- inappropriate behavior. In fact, the procedures are
niques. Indeed, many different classes of treatment often combined. However, the specific techniques can
can be identified. Table I highlights major classes of be better illustrated separately.
treatment and their therapeutic focus.
The majority of treatments focus on the individual
Reinforcement Techniques
by altering a particular facet of functioning or pro-
cesses within the child. Diverse approaches that focus Characteristics. Many applications of operant
on changing the individual child include individual conditioning are based on the administration of
and group therapy, behavioral and cognitive therapies, positive reinforcement to increase appropriate (pro-
and pharmacotherapies. A number of other treatments social) behavior. Positive reinforcers usually include
focus on the family. Treatment is aimed at altering the delivery of praise, attention from others, privi-
interaction patterns or other family processes in the leges, and tangible rewards, such as prizes. Many pro-
home; techniques, such as family therapy and parent grams incorporate a large number of rewards in the
management training, are examples. Other treatments form of a token economy (Kazdin, 1977), in which the
are worth delineating on the basis of their use or incor- child earns tokens (e.g., stars, tickets, points, money)
poration of therapeutic influences in the context of the for specific behaviors. The tokens are exchangeable
community. The influence of direct contact and infor a variety of rewards, privileges, and activities
volvement of youth with prosocial peers and commu- (back-up reinforcers). Token economies may be indi-
nity services is accorded major weight. Community- vidually designed for only one child or may be applied
based techniques often rely on other treatments, such to an entire classroom, hospital ward, family, or group
as psychotherapy and behavior therapy. Yet these are of children.
integrated within a larger social, organizational, and
peer-group context. Within a given class of treatment, Illustrations. As an example of token reinforce-
several variations can be identified. For example, indi- ment applied to an individual child, Bristol (1976) re-
vidual psychotherapy consists of psychodynamic, ported a program for an 8-year-old boy in a second-
nondirective, play therapies, and others. Similarly, be- grade classroom who constantly engaged in fighting.
havior therapy can include a range of techniques, such The program involved the cooperation of the parents,
as social skills training, contingency managements, the teacher, and the child, who agreed to the con-
and token economies. At the level of specific tech- tingencies and signed a "contract" to that effect. Each
niques, rather than the more generic classes of treat- morning the child received a card with a smiling face
ment, the number of available procedures is great. on it. In the morning, at lunch, and at the end of the
The plethora of available treatments might be day, the teacher signed the card if the boy had not
viewed as a healthy sign that the field has not become engaged in fighting. The teacher's signatures served as
rigidly set on one or two techniques. On the other points that could be accumulated toward back-up re-
hand, the diversity of procedures suggests that no par- wards, such as being a student helper in class, going to
ticular approach has ameliorated clinically severe anti- the library for free reading, or staying up 15 min later
social behavior. Four classes of treatment have been at bedtime. Experimental evaluation demonstrated
utilized and evaluated and are detailed here. These that fighting decreased whenever the program was in
Table 1. Therapeutic Focus and Processes of Major Classes of Treatment for Antisocial Behavior
Types of treatment Focus Key processes
Childjocused treatments
Individual psychotherapy Focus on intrapsychic bases of antisocial Relationship with the therapist is the pri-
behavior especially conflicts and psy- mary medium through which change is
chological processes that were adversely achieved. Treatment provides a correc-
affected over the course of development. tive emotional experience by providing
insight and exploring new ways of be-
having.
Group psychotherapy Processes of individual therapy, as noted Relationship with the therapist and peers
above. Additional processes are reas- as part of the group. Group processes
surance, feedback, and vicarious gains emerge to provide children with experi-
by peers. Group processes, such as ences and feelings of others and oppor-
cohesion and leadership, also serve as tunities to test their own views and
the focus. behaviors.
Behavior therapy Problematic behaviors presented as target Learning of new behaviors through direct
symptoms. Pro social behaviors are training, via modeling, reinforcement,
trained directly. practice and role-playing. Training in
the situations (e.g., at home, in the
community) where the problematic be-
haviors occur.
Problem-solving skills training Cognitive processes and interpersonal cog- Teach problem-solving skills to children
nitive problem-solving skills that under- by engaging in a step-by-step approach
lie social behavior. to interpersonal situations. Use of mod-
eling, practice, rehearsal, and role-play
to develop problem-solving skills. De-
velopment of an internal dialogue or pri-
vate speech that utilizes the processes of
identifying prosocial solutions to prob-
lems.
Pharmacotherapy Designed to affect the biological substrates Administration of psychotropic agents to
of behavior, especially in light of control antisocial behavior. Lithium car-
laboratory-based findings on neuro- bonate and haloperidol have been used
humors, biological cycles, and other because of their antiaggressive effects.
physicological correlates of aggressive
and emotional behavior.
Residential treatments Means of administering other techniques in Processes of other techniques apply. Also,
day treatment or residential setting. Foci separation of the child from parents or
of other techniques apply. removal from the home situation may
help reduce untoward processes or crises
that contribute to the clinical problem.
Familyjocused treatments
Family therapy Family as a functioning system serves as Communication, relationships, and struc-
focus rather than the identified patient. ture within the family and such pro-
Interpersonal relationships, organization, cesses as autonomy, problem solving,
roles, and dynamics of the family. and negotiation.
Community-based treatments
Community-wide interventions Focus on activities and community pro- Develop prosocial behavior and connec-
grams to foster competence and proso- tions with peers. Activities are seen to
cial peer relations. promote prosocial behavior and to be in-
compatible with antisocial behavior.
effect. By the end of the project, fighting was elimi- For example, Murphy, Hutchison, and Bailey (1983)
nated over a 3-week period. A report obtained 7 reorganized play activities as well as altered conse-
months after the program was terminated indicated quences to decrease aggressive behavior of elementary
that the boy was doing well without any special school children. The children included 344 first and
program. second graders who played outside prior to the begin-
A novel application of token reinforcement was re- ning of school. During this time, high rates of ag-
ported by Blue, Madsen, and Heimberg (1981), who gressive behavior (e.g., striking, slapping, tripping,
increased the coping behaviors of elementary school kicking, pushing, or punching others) were observed.
children identified as aggressi ve by teachers and peers. After collecting baseline information, an intervention
Children received token reinforcement exchangeable began which included several components. The major
for back-up reinforcers in 10 treatment sessions in component was structured play (organized) game ac-
which they participated in a "taunting game." The tivities, including rope jumping and foot races, super-
game was designed to provoke aggressive behavior. vised by playground aides. During the activities, aides
Peer assistants (not in need of treatment) were trained praised appropriate behavior (reinforcement) and in-
to provoke anger in the target children by teasing or voked time-out (punishment) by placing disruptive
yelling as part of the game. The children earned re- children on a bench for 2 min for particularly unruly
wards for coping, that is, not engaging in verbal or behavior. The program was alternately implemented
physical aggression, and providing verbal statements and withdrawn over time to evaluate its effects. The
(e.g., "leave me alone") that did not respond to the results, presented in Figure 1, illustrate that aggressive
provocation. Token reinforcement led to significantly behavior decreased when the intervention was in
greater changes in coping behavior during the game in effect.
these children relative to waiting list and attention-
placebo (discussion of aggressive behavior) control Comments. Several basic steps are involved when
groups. However, groups did not differ in coping re- instituting a positive reinforcement program. The tar-
sponses assessed on the playground. get behaviors must be carefully defined and measured
In most applications of reinforcement, specific ap- prior to the intervention. There will be at least two
propriate behaviors are identified and rewarded. Yet target behaviors to assess: the aggressive behavior (to
there are many other effective ways of administering be eliminated) and a more socially appropriate behav-
reinforcement. One procedure, referred to as differen- ior (to be increased). Following the assessment of
tial reinforcement ofother behavior (DRO), consists of baseline (pretreatment) rates of these behaviors,
providing reinforcement for nonoccurrences ofthe un- positive reinforcement can begin. The choice of an
desired behaviors. As an example, Frankel, Moss, effective positive reinforcer is often an empirical ques-
Schofield, and Simmons (1976) used DRO to modify tion with each child. Possibilities may be obtained by
the aggressive behaviors of a 6-year-old mentally re- asking the child about things he or she would like to
tarded girl. The child engaged in a high level of pinch- earn or by observing the types of free-time activities in
ing, biting, and hair pulling directed toward others, as which the child engages. If observable changes in tar-
well as head banging. The child was praised and given get behaviors are not obtained within several days of
candy every 5 sec for quiet, appropriate behavior in reinforcement, substitution of another reinforcer
class, and every 60 sec during free time. Intervals were should be considered. With some children, social rein-
timed with a stopwatch by an observer behind a one- forcement (verbal praise) alone may be effective for
way mirror and were communicated to the teacher changing behavior. If praise is used, designating the
through a "bug in the ear." The teacher administered specific act for which the child is being commended
the reinforcers. After 4 days, the rates of aggression results in greater behavior change than making general
began to decrease. The intervals between reinforcer comments, such as "Good, Susie" (Drabman &
delivery were gradually lengthened until the entire Tucker, 1974; Forehand & Peed, 1979). Because social
procedure was eliminated 16 days later, without reap- reinforcers may have little value with aggressive chil-
pearance of the aggression. dren (Agee, 1979), it is desirable to pair praise with
The application of operant techniques may involve material reinforcers. Praise may eventually acquire re-
more than the administration of consequences. Often inforcing properties through association.
the stimulus conditions are altered as well to help pro- To maximize the effects of positive reinforcement,
mote the desired behaviors so they can be reinforced. the desired response should be reinforced frequently.
CHAPTER32 • CONDUCT DISORDERS 677
BASELINE ORGANIZED BASELINE ORGANIZED
GAMES GAMES
300
I
250 I I
VI
I~II
~
z
S I
~200
~ I I
;
VI
I I I
:'v: :'V
I
0
150
~ 100
I
II:
I I
50 i I I
I I
0
5 10 15 20 25
DAVS
Figure 1. Number of incidents of aggressive behavior recorded on the playground before school started. Baseline-no intervention.
Intervention-organized activities, praise, and time-out. Reversal-return to baseline conditions. Intervention-return to the
activities, praise, and time-out procedures.
After the response is strengthened, the schedule of iors. The punishment procedures differ from the usual
reinforcement should then be "thinned" gradually consequences applied to behavior in everyday life, and
(called "partial reinforcement") to maintain behavior. they are implemented somewhat differently. Punish-
The type of reinforcer should also be adjusted gradu- ment procedures in the context of treatment typically
ally until it resembles those more typically available to consist of the withdrawal of reinforcers.
the child in the natural environment (Kazdin, 1989).
In addition to these basic points, there are other Illustrations. One procedure is referred to as time-
considerations specific to the individual techniques. out from reinforcement and consists of the removal of
The token economy involves the choice of token to be positive reinforcers for a brief period of time. During
used. Although physical tokens (e.g., tickets, cards, time-out, the child does not have access to positive
coins) are useful because individuals may enjoy their reinforcers that are normally available in the setting.
accumulation, they also may be lost, destroyed, The crucial feature of time-out is delineating a time
stolen, or traded. As a result, point systems involving period in which reinforcers are unavailable. Typically,
checkmarks or records of earnings are usually pre- time-out consists of social isolation where the child is
ferred. Also, before beginning a token economy, it is removed from the situation for a brief period (e.g., 5
necessary to specify the desired and undesired behav- min). Extended periods are not necessary for time-out
iors and the rules for obtaining rewards. Children are to be effective.
frequently offered a choice of backup reinforcers de- As an example, Drabman and Spitalnik (1973) ap-
scribed with their costs on a "reward menu." Several plied a social isolation program to a class of 9- to 11-
program options are available that vary the specific year-old aggressive boys in a residential psychiatric
way in which the contingencies can be implemented setting. When a target behavior, such as hitting another
(see Kazdin, 1989). child, occurred, a classroom observer unobtrusively
signaled the teacher. The teacher immediately identi-
fied the child and said, "You have misbehaved. You
Punishment Techniques
must leave the class." The child was then escorted
Characteristics. Punishment techniques also have without further comment to a small, dimly lit isolation
been used to suppress or eliminate antisocial behav- room (a music practice room). A teacher assistant
stayed nearby to ensure the child's safety. After 10 to its correct position and straighten the spread and
min, the child was returned to the class, where obser- pillows). In addition, she was required to rehearse the
vations began again. There was no limit to the number correct behavior by straightening all of the other beds
of times a child could be sent out of the room. This on the ward (positive practice). After 11 weeks of
procedure resulted in a marked decrease in aggressive training, the patient no longer threw objects.
acts after 16 days of the program. Similarly, in other For many behaviors, it is not possible to have per-
studies, social isolation has been effective in reducing sons "correct" the environmental consequences be-
such problem behaviors as aggressiveness and non- cause their behaviors have not altered the environment
compliance (e.g., Patterson, Cobb, & Ray, 1973; in a tangible fashion. In such cases, positive practice is
Roberts, Hatzenbuehler, & Bean, 1981; Wahler, often used alone with the person required to perform
1972). Other variations of time-out include withdrawal the appropriate behavior. For example, Azrin and
of attention and suspension of the opportunity to earn Powers (1975) used positive practice to control the
reinforcers (see Kazdin, 1989). In each case, relatively classroom behavior of six disruptive boys. Talking out
brief time-out durations have effectively suppressed and leaving one's seat were decreased by having the
behaviors. children practice appropriate classroom behavior by
Response cost is another type of punishment used to sitting in their seats, raising their hands, being recog-
decrease inappropriate behavior. Response cost usu- nized by the teacher, and asking permission to get up.
ally involves the loss of a positive reinforcer. Unlike Overcorrection and positive practice include a number
time-out, there is no necessary time period involved in of variations that have been applied effectively to a
the punishment. The most common use of response wide range of disruptive behaviors (see Kazdin, 1989).
cost is taking away tokens or points for inappropriate
behavior as a part of a token economy. A child may Comments. As with positive reinforcement meth-
earn tokens for appropriate behavior but lose them for ods, punishment procedures require clear definition
inappropriate behavior. For example, Burchard and and measurement of target behaviors before imple-
Barrera (1972) used a response-cost token program menting treatment. In addition, it is important that
with ·11 mildly retarded adolescents who had a history punishment programs be written in an explicit manner
of antisocial behavior. Swearing, disobedience, and and be closely followed. Those involved in administer-
aggression were identified as behaviors to be elimi- ing such a program should be carefully monitored for
nated. When a child engaged in one of the target behav- adherence to the written conditions. Perhaps the most
iors, he was required to give up either 5 or 30 of his important single practice when punishment is used is
tokens, or take 5 or 30 min of time-out. Each child to ensure that alternative (prosocial) behaviors are re-
experienced each type of penalty over the course of the inforced directly. When punishment for undesired be-
program. Both response cost and time-out were effec- haviors is embedded in a larger behavioral program
tive in reducing aggressive behaviors, with the more that includes positive reinforcement, behavior change
severe penalties resulting in greater behavior change. is likely to be more rapid and not include many of the
Overcorrection is also designed to reduce inap- untoward side effects evident when punishment is used
propriate behavior. The technique includes two com- alone.
ponents. The first component, restitution, consists of Research with time-out has revealed several impor-
having the child correct the environmental effects of tant parameters. To begin with, longer time-out inter-
the inappropriate behavior. The second component, vals are not necessarily more effective than shorter
positive practice, consists of repeatedly practicing the ones. Intervals of social isolation as brief as one or a
appropriate behaviors in the situation. Both compo- few minutes have been shown to be effective (S. A.
nents are combined to suppress deviant behavior. Hobbs, Forehand, & Murray, 1978; White, Nielsen, &
For example, Foxx and Azrin (1972) used overcor- Johnson, 1972). Periods exceeding 30 min do not ap-
rection with a hospitalized 50-year-old profoundly re- pear to possess much additional punishment value.
tarded female, who had engaged in severely disruptive Time-out should be administered at each occurrence of
and aggressive behavior, especially throwing things. the undesirable behavior until the behavior has been
After baseline observations were made, overcorrec- reduced, at which time an intermittent schedule can
tion was implemented. When the patient performed a maintain suppression (Calhoun & Lima, 1977; Jack-
disruptive behavior (e.g., overturning a bed), she was son & Calhoun, 1977). Release from time-out may be
required to "correct" (restitution) the physical effects contingent on a IS-sec period of appropriate behavior
of her behavior on the environment (i.e., turn the bed at the end of the interval. This method has been found
to decrease noncompliance in preschoolers. In gener- with delinquent youths and the literature is quite exten-
al, time-out is effective when the situation from which sive (e.g., see Stumphauzer, 1979). Selected programs
the child has been removed is reinforcing (Solnick, are illustrated here to convey the application of more
Rincover, & Peterson, 1977). Thus, if a child detests complex interventions than isolated reinforcement or
being in the classroom, removal from the class for punishment contingencies.
aggressive acts conceivably could increase the un-
wanted behaviors. Illustrations. Multifaceted behavioral programs
If response cost is used, the program needs to pro- have been conducted in several different settings, in-
vide the child with the opportunity to receive positive cluding special home-style facilities, psychiatric hos-
reinforcement for appropriate behavior. Once earned, pitals, prisons, schools, and the community at large.
the tokens or points can be withdrawn for inappropri- Perhaps the most well-known of behavioral interven-
ate behaviors. Often small costs are very effective. tions is the program at Achievement Place (in Kansas),
Here, too, the effectiveness can be augmented by a which is conducted for youths (ages 10 to 16) who have
program that provides continuous reinforcement for been adjudicated for a variety of offenses, primarily
pro social behaviors that compete with the undesired felonies. Diverse diagnoses have been applied to the
target behavior. population, including personality disorder, adjustment
As for overcorrection, brief periods of restitution reaction, and conduct disorder. Because the program is
and practice (only a few minutes) have been effective community-based and youths are not confined to the
in suppressing behavior (see Foxx & Bechtel, 1983). facility, children who commit violent offenses
Other research suggests that requiring positive practice (murder, rape, armed robbery) and who might require
of behaviors that are topographically similar to the restriction are excluded (Kirigin, Wolf, Braukmann,
target behavior results in larger initial behavior change Fixsen, & Phillips, 1979).
and longer maintenance (Ollendick, Matson, & Mar- The program is conducted in a home-style situation
tin, 1978). Persons employing overcorrection should in which a small number of boys or girls (usually six to
carefully observe for side effects, such as the develop- eight) live with a specially trained married couple re-
ment of other undesirable behaviors, and terminate ferred to as "teaching parents." In the setting, the
treatment if necessary. Because physical guidance is children participate in a token economy in which a
often necessary, overcorrection should be attempted variety of self-care (e.g., room cleaning), social (e.g.,
only with those children who are not physically more communicating with peers, participating in group ac-
powerful than the supervising adults. tivity), and academic behaviors (e.g., reading, com-
In general, aversive consequences often can sup- pleting homework) are reinforced. The reinforcers are
p~ess antisocial behavior. However, such conse- provided in a point system with several rewards and
quences should be embedded in a larger program that privileges that can be earned, including an allowance,
emphasizes positive reinforcement for prosocial be- access to TV, games and tools, and permission to go
havior. It is not likely that programs which emphasize downtown or to stay up late. Points can be lost for
aversive consequences would be very effective in the failure to meet particular responsibilities (e.g., to
long-run in altering conduct disorder behaviors. In- maintain passing grades in school) or violation of rules
deed, many of the side effects of punishment (e.g., (e.g., being late in returning home, lying, stealing).
emotional reactions, escape from adults, aggression) The program is managed by the teaching parents who
are already well established in the repertoires of such complete special training in the general principles and
youth and could be exacerbated by a punishment practical skills needed for administering the program
program. effectively. In addition to reinforcement and punish-
ment techniques, several other procedures are in-
cluded, such as training children in specific skill areas
Multifaceted Operant Conditioning
(e.g., vocational training), self-government in which
Programs
children decide many of the consequences for their
The previous discussion conveys relatively circum- behavior, a close interpersonal relationship with the
scribed interventions in the sense that one or two con- teaching parents, and a structured family situation
tingencies were invoked to alter one or two behaviors. (e.g., Wolf et at., 1976).
Many programs are multifaceted and combine several Several studies have demonstrated the effects of re-
reinforcement and punishment contingencies to inforcement and punishment contingencies on such
change multiple behaviors. Most programs have dealt behaviors as aggressive statements, completion of
homework and chores, keeping up on current events, (kindergarten through third grade). The target behav-
and communication skills (e.g, Phillips, 1968; Phil- iors were identified through initial work on charac-
lips, Phillips, Wolf, & Fixsen, 1973; Werner et ai., teristics that distinguish aggressive children from their
1975). In addition, while the youths were in the pro- normal peers. A number of behaviors were selected
gram, the gains were reflected in a reduction in crimi- (e. g. , teasing, provoking fights, arguing, making
nal offenses in the community. The youths engaged in threats, speaking in an irritable fashion). The program
fewer criminal offenses than did others in community- was conducted on the playground and in the classroom
based or more traditional institutional programs and included several procedures to alter negative and
(Kirigin, Braukmann, Atwater, & Wolf, 1982). aggressive behavior. Social skills training was pro-
The teaching-family model has been extended to vided by a trainer who taught children to discriminate
over 150 group homes throughout the United States appropriate and inappropriate behaviors. Reinforce-
and in a few foreign countries (Jones, Weinrott, & ment and punishment contingencies on the playground
Howard, 1981). Evaluations of these extensions across consisted of praise for appropriate interactions and re-
multiple settings have not supported the efficacy of the sponse cost (loss of points given at the beginning of
procedures on community measures. Measures of of- recess) for aggressive social interactions or violations
fenses and reinstitutionalization from one to three of rules of the playground. Time-out was also used
years after participation in the program are no different (sitting out of the recess period) if all points were lost.
for youths who complete the program than for those A similar program was used in the classroom if the
who participate in more traditional programs (Jones et child's behavior was a problem there. Group and indi-
aI., 1981; Kirigin et aI., 1979, 1982). Thus, the evi- vidual contingencies were often combined to obtain
dence has been relatively consistent in showing gains peer support and reinforcement of the child's appropri-
during treatment but not thereafter. ate behavior.
Multifaceted behavioral programs for delinquent The program involved several persons, including a
youths have been conducted in institutional settings special consultant to help design and implement the
where youths are confined. For example, T. R. Hobbs procedures, the teacher, the parents, and peers. All
and Holt (1976) utilized a token economy for 125 ad- were involved in some way to promote change across
judicated males (ages 12 to 15) in a correctional indifferent settings and to maximize generalization.
stitution. The majority of the adolescents had six or Evaluation of the special program showed that rein-
more charges ranging from truancy and unmanageabil- forcement and punishment contingencies were effec-
ity to arson and homicide. The program was imple- tive in reducing negative and aggressive behavior to
mented in separate cottages in the facility. Target be- within the range of that of normal peers. Although
haviors included engaging in appropriate peer some of the gains were lost when the program was
interaction, following rules of the cottage, following discontinued and children were returned to regular
instructions from staff, and not engaging in verbal and classes, improvements were still evident. Moreover,
physical aggression. Tokens, delivered for these ap- the gains generalized to classroom and playground pe-
propriate behaviors, were backed by candy, toys, riods where the intervention was not in effect.
games, the opportunity to go home on a pass or to A final illustration conveys the use of reinforcement
attend athletic events, and other rewards. The effects procedures on an outpatient basis. Fo and O'Donnell
of the program were evaluated in a multiple-baseline (1974, 1975) developed a large-scale program for
design across separate cottages over a 14-month peri- youths (ages 11 to 17) with various behavioral and
od. As evident in Figure 2, when treatment was intro- academic problems. The youths were referred from
duced to each cottage, appropriate behavior increased. public schools, the police, the courts, and social wel-
For one of the cottages (D), which served as a control fare agencies. Adults were recruited from the commu-
condition, the program was not introduced and no nity to work as therapists and to conduct behavior mod-
changes were evident. The pattern or results across the ification programs individually with the youths. They
cottages reflects the impact of the program. However, met with the youths, engaged in a variety of activities
no data were provided on the impact of treatment after (e.g., arts and crafts, fishing, camping) and imple-
the youths left the setting. mented and evaluated behavior modification pro-
Walker, Hops, and Greenwood (1981) have re- grams. Individualized reward programs focused on
ported a multifaceted program for remediation of ag- such behaviors as truancy, fighting, completing chores
gressive behavior among elementary school children at home, and homework. Social and token reinforce-
Baseline Treatment
100
80
Cottag- A I--y\ ~
I
..'"
0
60
40
20
V-/I I
.~ 100
III
-= 80
-
Qj
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Qj
III 60
·cr=.
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0 40
20
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III
0
100 l ..
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-=.. '-I~
Qj
De
III
80
Qj
u
eo
Qj I
r=.
=
III
40 •I
Qj 20 I
:; 100
80
eo
40
20
S-day Intervals
Figure 2. Mean percentage of appropriate behavior as treatment was introduced across each cottage in a multiple-baseline design.
The final cottage served as a no-treatment control condition.
ments (money) were used to alter these behaviors. The due to the contact that these children had over the
results indicated changes in truancy, fighting, staying course of the project with others who had committed
out late, and other problem behaviors in relation to more serious offenses. In any case, the results were
behavior of control youths who did not receive treat- mixed, showing clearly beneficial and deleterious ef-
ment (Fo & O'Donnell, 1975). Also, over a 2-year fects as a function of different histories of deviant be-
follow-up period, arrest records reflected treatment havior among the youths.
gains relative to no-treatment controls (C. R. O'Don- The multifaceted behavioral programs highlight the
nell, Lydgate, &Fo, 1979). However, the effects of the use of relatively complex procedures beyond isolated
program varied as a function of whether the children reinforcement or punishment contingencies. Gains
had a prior record of offenses. Youths who completed during or after treatment cannot be attributed to any
the program and who had no prior arrest record became particular component of the program. Indeed, factors
worse with treatment, as reflected by an increase in regarded as particularly significant in traditional treat-
their rates of major offenses. This finding was possibly ment procedures, such as the therapeutic relationship,
may playa major role in outcome. For example, in the example, many programs are based upon the use of
Achievement Place program, the number of delin- reinforcing activities, privileges, and various consum-
quent and behavioral-problem acts the youths per- able and social reinforcers to alter aggressive behavior
formed during their stay at the home was inversely in children (e.g., Doke, Wolery, & Sumberg, 1983).
correlated with variables that reflect the relationships Also, in some programs, contingencies are imple-
the youths had with the teaching parents. In separate mented in quite novel settings, such as at summer
reports encompassing over 10 homes, self-reported or camps (e.g., Hughes, 1979). In addition, a variety of
recorded acts of delinquency were inversely correlated different types of reinforcement schedules are avail-
with the amount of time the youths spent talking with able to decrease or eliminate undesirable behaviors
or in close proximity to their teaching parents, and to (Kazdin, 1989). The examples also fail to convey the
the youths' ratings of the fairness, concern, pleas- obvious, namely, that incentive systems do not always
antness, and similar characteristics of these parents alter antisocial behavior (Weathers & Liberman, 1975;
(Kirigin et at., 1982; Solnick, Braukmann, Bed- Wodarski & Pedi, 1978).
ington, Kirigin, & Wolf, 1981). In most applications, reinforcement and punishment
techniques are combined, so that consequences for ap-
Comments. Multifaceted programs are based on propriate and inappropriate behavior are provided.
combinations of reinforcement and punishment con- Punishment alone may decrease specific behaviors,
tingencies noted previously. Consequently, specific but it does not develop acceptable behaviors. Conse-
recommendations for their constituent techniques quently, reinforcement techniques are usually empha-
readily apply. Multifaceted programs often include ad- sized. In some applications with children with conduct
ditional complexities, such as special settings and con- problems, reinforcement alone, such as social ap-
tingencies that are implemented to alter behavior in proval for appropriate behavior, shows little or no ef-
less structured situations. For example, a program im- fect without the simultaneous use of mild punishment,
plemented in a family-style setting that addresses such as time-out (Herbert et at., 1973; Wahler & Fox,
chores, interpersonal interaction, mealtime behavior, 1980). In general, the combined use of reinforcement
and self-care is more than a minor extension of a cir- and punishment appears to maximize the behavior
cumscribed reinforcement program, such as one im- change in operant conditioning programs and is more
plemented in a classroom to control on-task behavior. effective than either procedure alone (e.g., Pfiffner &
As a result ofthis difference, often more staff and more O'Leary, 1987; Walker et aI., 1981).
highly trained staff are required in multifaceted inter- In light of the above, there is little question that
vention programs. Implementation of the desired con- operant-conditioning-based interventions can reduce
tingencies and, perhaps as important, administration aggressive behavior and conduct disorder and increase
of consequences for the many desired behaviors that pro social behavior. An advantage of the techniques is
might fall outside of these contingencies are critical. that they provide relatively clear guidelines for inter-
Thus, in everyday interaction in an institutional setting vention strategies. There are limitations in what the
or on the playground at a school, praise for appropriate studies have shown in relation to aggressive behavior
behavior is critical and extends beyond the contingen- and conduct disorder. These include the tendency to
cies that might be administered in a highly circum- focus on one or a few target behaviors, rather than the
scribed program. Training of staff and ensuring that the larger constellation of antisocial behaviors in which
contingencies are implemented are always critical. that behavior may be embedded. Thus, the often dra-
However, as the program becomes more complex, matic effects achieved with a particular behavior are
there are increased opportunities for decay. tempered by the absence of information on related be-
haviors that may not have been addressed.
The infrequent evaluation oflong-term effects raises
Overall Evaluation
another issue. Because of the recalcitrance of anti-
Reinforcement, punishment, and combined prosocial behaviors to change, there is a strong likelihood
grams discussed previously only sample the vast liter- that conduct problems will return and continue. Con-
ature on various disruptive behaviors and conduct sequently, demonstrations of long-term impact on the
problems with children and adolescents. The examples constellation of antisocial behavior are also greatly
fail to represent the range of effective consequences needed. At this point, the literature is impressive in
and the settings in which they have been applied. For demonstrating the range of techniques that can be used
to alter aggressive behavior in diverse settings. Further the therapist, practice by the child, corrective feed-
demonstrations are needed that apply the approach to back, and social reinforcement (praise) for appropriate
address the problem more broadly, that is, with multi- performance. The sequence of these procedures is en-
ple behaviors and domains of functioning. acted with several interpersonal situations, such as in
interactions with parents, siblings, and peers. In each
situation, the child and therapist role-play the appro-
Social Skills Training
priate behaviors. Instructions convey what the child is
Characteristics. Social skills training (SST) refers to do, what the overall purpose is (e.g., "It is impor-
to a behavioral treatment approach that has been wide- tant to be positive when interacting with others. Look
ly applied to children, adolescents, and adults. Train- at the other person when talking") and what features of
ing focuses on the verbal and nonverbal behaviors that the behavior actually are to be emphasized. Modeling
affect social interactions. Specific behaviors are devel- by the therapist shows exactly how the behavior should
oped in order to enhance the child's ability to influence be performed. Feedback from the therapist conveys
his or her environment, to obtain appropriate out- how the child's responses might be improved. The
comes, and to respond appropriately to demands of therapist may model what the child has done and show
others. the child how the action may be done differently. The
The underlying rationale for SST is drawn from the child again enacts the desired behaviors. If they are
notion that conduct problems in children are basically appropriate, the therapist provides social reinforce-
interpersonal problems. Children are often identified ment. The general sequence is continued until the
as in need of treatment because their behaviors have child's responses are appropriate in particular situa-
deleterious impact on others, as is evident in ag- tions and across a large number of different situations.
gressive acts, property destruction, noncompliant be-
havior, negativism, and tantrums. Several maladaptive Illustrations. As an example, Elder, Edelstein,
patterns of social interaction among children have been and Narick (1979) used SST with four adolescents who
implicated in clinical dysfunction. For example, had been hospitalized (from 2 months to 5 years). Each
asocial behavior, social isolation, and unpopUlarity in had a history of verbal and physical aggressiveness.
childhood are risk factors for childhood psycho- Based on the behavior checklist ratings and interviews
pathology, delinquency and conduct problems, drop- with the youths, the following behaviors were selected
ping out of school, and antisocial behavior in adult- for treatment: interrupting others, responding to nega-
hood (e.g., Cowen, Pederson, Babigan, Izzo, & Trost, tive provocation, and making requests of others. Role-
1973; Hartup, 1970; Roff, Sells, & Golden, 1972). play situations were devised in which training was
SST has been applied to withdrawn, isolated, and conducted. Training was carried out in a group in
aggressive children (see Michelson, Sugai, Wood, & which each person had an opportunity to role-play and
Kazdin, 1983). In each case, the assumption is made to observe others enact the situation. Treatment was
that children suffer from social skills deficits, that is, a evaluated in a multiple-baseline design in which the
lack of responses in their repertoires that will enable behaviors were trained in sequence using instructions,
them to act appropriately in their environment. Differ- modeling, practice, and feedback, as highlighted ear-
ent lines of evidence suggest that children with con- lier. The effects of training on those situations in which
duct problems suffer deficiencies in their responses in behaviors were developed (training scenes) and in
social situations. For example, children who are dis- novel situations in which there was no specific skills
ruptive at school and are delinquent are less likely than training (generalization scenes) can be seen in Figure
their normal peers to identify appropriate solutions to 3. The results indicated improvements when the train-
interpersonal problems (e.g., Deluty, 1981; Freedman ing regimen was introduced for each particular behav-
et al., 1978; Richard & Dodge, 1982; Spivack, Platt, ior. The improvements were associated with increases
& Shure, 1976). Moreover, the solutions to interper- in social behaviors on the ward and with decreases in
sonal problems that are suggested often rely on phys- the frequency of seclusion for inappropriate behavior.
ical force, such as aggressive responses to others. Three of the four subjects were discharged and were
SST develops a variety of interpersonal skills, usu- reported to have maintained their gains up to 9 months
ally in the context of individual treatment sessions. later.
IYpically, training includes several procedures to de- As another example, Spence and Marzillier (1981)
velop the skills, including instructions, modeling by applied SST to male offenders (ages 10 to 16) who
Baseline Treatment
..
CI
5 I
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.2
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4 I
. I
I
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3
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~
I .--.. Generalization scenes
0
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5 I
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Session days
Figure 3. Ratings of target behaviors during baseline (pretreatment) and treatment phases for scenes used in treatment and novel
scenes used to measure generalization. Higher ratings reflect more socially appropriate behaviors.
resided in a special school. SST consisted of 12 one- Evaluation. Several studies have demonstrated
hour sessions that utilized instructions, modeling, that social skills can be developed in aggressive and
role-play, feedback, reinforcement, and other compo- conduct problem children and adolescents (Bomstein,
nents. Attention-placebo subjects met for an equal Bellack, & Hersen, 1980; Matson, Kazdin, & Esveldt-
amount of time, viewed films, and enacted and taped Dawson, 1980). In such investigations, the focus is
their own social play situations. No-treatment control usually on specific behaviors in simulated social situa-
subjects had no contact with therapists but were in the tions. These behaviors include hostile tone of voice,
same residential program as the other youths. The re- eye contact, content of verbal statements, making ap-
sults indicated that SST improved behaviors on role- propriate requests of others, and responding appropri-
play measures (e.g., eye contact) in comparison to the ately to unreasonable requests. The evidence on the
other groups. On broader measures of social skills, effectiveness of training for aggressive children comes
including staff ratings of social behavior, social work- mainly from studies with small samples of only one or
ers' ratings of work, school, and family relationships, a few children. Group studies on the effectiveness of
and self-report and police records of offenses (up to six SST have been conducted primarily with socially with-
months after treatment), there were no consistent dif- drawn children (Michelson et al .• 1983). The effects of
ferences favoring SST. Thus, training had an impact on SST on adjustment in the community and over the
highly specific measures of social skills included in course of follow-up have been infrequently evaluated
training but the effects were not evident on broader (e.g., Gross, Brigham, Hopper, & Bologna, 1980).
measures of social behavior. Thus, the therapeutic impact, apart from changes in
highly specific behaviors within the treatment setting, ents, teachers, and peers, might be incorporated into
is difficult to evaluate. training to help the child develop skills in everyday
interactions. Practice assignments for the child and
Comments. The techniques designed to develop reinforcement contingencies administered by parents
social skills are relatively straightforward in the sense and teachers are examples of procedures that might be
that they reflect application of instructions, modeling, useful to incorporate into training. As part of the treat-
practice, feedback, and reinforcement. These are used ment' it is essential to show that the changes have
repeatedly until the individual acquires the target be- impact on measures of conduct. The assumption that
haviors and performance reaches a criterion level. A overcoming deficits in social skills will reduce anti-
number of manuals are available that describe and il- social behaviors and increase prosocial behaviors has
lustrate the manner in which training is conducted been rarely tested.
(e.g., Kelly, 1982; Michelson et al., 1983). Critical
issues need to be addressed before training begins. An
initial issue is to identify the specific behaviors that are
Parent- and Family-Based Treatment
to be developed. In many social skills studies, such
behaviors as initiating conversation, making requests
Parent Management Training
assertively rather than aggressively, refusing unrea-
sonable requests of others, making eye contact with Characteristics. Parent management trammg
the other person, and responding to friendly overtures (PMT) refers to procedures in which a parent or par-
of others have served as the focus. It is likely that ents are trained to interact differently with their child.
antisocial youth have deficits in these areas. However, Training is based on the general view that conduct
that alone does not serve as a strong warrant for their problem behavior is inadvertently developed and sus-
focus in treatment. Selecting behaviors for training tained in the home by maladaptive parent-child in-
requires a stronger conceptual or empirical connection teractions. In fact, research has shown that parents of
that establishes how developing these social skills will antisocial youths engage in several practices that pro-
alter the constellation of conduct disorder. It is not mote aggressive behavior and suppress prosocial be-
clear that teaching social skills will address the anti- havior (Patterson, 1982). These practices include the
social behaviors that serve as the primary basis of con- inadvertent and direct reinforcement of aggressive be-
cern. In any case, for the application of treatment, havior, frequent use of commands, nonreinforcement
selection of the target behaviors should be as closely of pro social behaviors, and others. PMT alters the pat-
related as possible to the areas that relate to antisocial tern of interchanges between parent and child so that
behavior. prosocial, rather than aggressive, behavior is directly
A related issue is selection of the stimulus condi- fostered within the family.
tions in which the behaviors are developed. Typically, Although many variations of PMT exist, several
a number of situations are selected in which the social common characteristics can be identified. First, treat-
skills are practiced. These often address generic social ment is conducted primarily with the parents who di-
situations. It might be advisable to sample a wide rectly implement several procedures in the home. Usu-
range of situations emphasizing those related to the ally, there is no direct intervention of the therapist with
performance of antisocial behavior. Training and gen- the child. Second, parents are trained to identify, de-
eralization situations are often included in studies of fine, and observe problem behavior in new ways. The
social skills training. Generalization in this context careful specification of the problem is essential for the
usually refers to novel situations that were not included delivery of reinforcing or punishing consequences and
in training. It is important to consider in training an- for evaluating if the program is working.
other use of generalization in the sense of training so- Third, the treatment sessions cover socialleaming
cial behaviors broadly across a variety of situations principles and the procedures that follow from them,
involving interactions with parents, teachers, peers, including positive reinforcement (e.g., the use of so-
siblings, and under a variety of circumstances (e. g. , cial praise and tokens or points for prosocial behavior),
shopping with parents, being tempted by peers). mild punishment (e. g., use of time-out from reinforce-
Finally, treatment may be enhanced if practice and ment, loss of privileges), and negotiation and con-
reinforcement of the skills extend to situations other tingency contracting. Fourth, the sessions provide op-
than specific training sessions. Others, such as par- portunities for parents to see how the techniques are
implemented, to practice using the techniques, and to poorly the child was doing, the trainer directed the
review the behavior change programs in the home. conversation toward the behaviors that the parents per-
The immediate goal of the program is to develop formed in relation to the child. The trainer and parents
specific skills in the parents. This is usually achieved role-played situations at home where the parents might
by having parents apply their skills to relatively simple have responded more effectively. Parents practiced de-
behaviors that can be easily observed and that are not livering the consequences and received feedback and
enmeshed with more provoking interactions (e.g, reinforcement for this behavior from the trainer. Any
punishment, battles of the will, coercive inter- problems in the programs, ambiguity of the observa-
changes). As the parents become more proficient, the tion procedures, or other facets were discussed. Thus,
program can address the child's most severely prob- the initial portion of the session was used to review
lematic behaviors and can encompass other problem practical issues and applications for the previous
areas (e.g., school behavior). week. After the program was reviewed, new material
was taught, as outlined in Table 3.
Illustration. The application of PMT can be illus- Each session with Shawn's mother lasted about 2
trated by a case of a 7-year-old boy, named Shawn, hours. Between the weekly sessions, the trainer called
referred for treatment because of his aggressive out- the parent on two occasions to find out how the pro-
bursts toward his two younger sisters at home as well grams were working and to handle problems that
as toward his peers at school. He argued and had se- arose. The calls between sessions were designed to
vere tantrums at home, stayed out late at night, and correct problems immediately instead of waiting until
occasionally stole from his mother's boyfriend who one week elapsed. Shawn's mother and the therapist
lived in the home. At school, his behavior in class was developed a program to increase Shawn's compliance
difficult to control. He fought with peers, argued with with requests. Simple chores were requested (e.g.,
the teacher, and disrupted the class. PMT was pro- cleaning his room, setting the table) in the first few
vided to the mother. The stepfather could not attend the weeks of the program to help the parents apply what
meetings on a regular basis because of his work as a they had learned. Time-out from reinforcement was
trucker and his extended periods away from the home. introduced to provide mild punishment for fighting.
Training began by discussing Shawn's behavior and Any fights in the home resulted in Shawn's going to an
discussing child-rearing practices that might be useful isolated place in the hall near the kitchen of his home
in developing prosocial behavior as well as reducing or for a period of 5 min. If he went to time-out immediate-
eliminating the problems for which he was referred. ly upon instructions from his mother or stepfather, the
A master's degree-level clinician trained in PMT for duration of time-out was automatically reduced to 2
over 2 years administered treatment. She agreed to min.
meet with the parents once each week for approx- Over time, several behaviors were incorporated into
imately 16 sessions. The overall goal of treatment was a program where Shawn earned points that could pur-
to train the parents to behave differently in relation to chase special privileges (e.g., staying up 15 min be-
Shawn and their other children. Specifically, they were yond bedtime, having a friend sleep over, small prizes,
to be trained to identify concrete behaviors to address time to play his video game). About halfway through
their concerns, to observe these behaviors systemat- treatment, a home-based reinforcement program was
ically, to implement positive reinforcement programs, developed to alter behaviors at school. Two teachers at
to provide mild punishment as needed, and to negoti- the school were contacted and asked to identify target
ate such programs directly with the child. behaviors. The program was explained, and the teach-
The contents of the 16 sessions provided to the par- ers were asked to initial cards that Shawn carried to
ents are highlighted in Table 2. In each session, the indicate how well he behaved in class and whether he
trainer reviewed the previous week's data collection completed his homework. Based on daily teacher eval-
and implementation of the program. The purpose was uations, Shawn earned additional points at home.
to identify the parents' behavior in relation to their After approximately 5 months, Shawn improved
children. Queries were made to review precisely what greatly in his behavior at home. He argued very little
the parents did (e.g., praise, administer points or with his mother and sisters. His parents felt they were
tokens, send the child to time-out) in response to the much better able to manage him. At school, Shawn's
child's behavior. Although the parents would invari- teachers reported that he could remain in class like
ably focus on the behavior of the child and how well or other children. Occasionally, he would not listen to the
Table 2. Parent Management Training Sessions for the Case of Shawn
Session, topic, and brief description
I. Introduction and overview-This session provides the parents with an overview of the program and outlines the demands
placed upon them and the focus of the intervention.
2. Defining and observing-This session trains parents to pinpoint, define, and observe behavior. The parents and trainer
define specific problems that can be observed and develop a specific plan to begin observations.
3. Positive reinforcement-This session focuses on learning the concept of positive reinforcement, factors that contribute to
the effective application, and rehearsal of applications in relation to the target child. Specific programs are outlined where
praise and points are to be provided for the behaviors observed during the week.
4. Review of the program and data-Observations of the previous week as well as application of the reinforcement program
are reviewed. Details about the administration of praise, points, and back-up reinforcers are discussed and enacted as needed
so the trainer can identify how to improve parent performance. Changes are made in the program as needed.
5. Time-out from reinforcement-Parents learn about time-out and the factors related to its effective application. The use of
time-out is planned for the next week for specific behaviors.
6. Shaping-Parents are trained to develop behaviors by reinforcement of successive approximations and to use prompts
and fading of prompts to develop terminal behaviors.
7. Review and problem solving-In this session, the concepts discussed in all prior sessions are thoroughly reviewed. The
parent is asked to apply these concepts to hypothetical situations presented within the session. Areas of weakness in
understanding the concepts or their execution in practice serve as the focus.
8. Attending and ignoring-In this session, parents learn about attending and ignoring and choose an undesirable behavior
that they will ignore and a positive opposite behavior to which they will attend. These procedures are practiced within the
session.
9. School intervention-In this session, plans are made to implement a home-based reinforcement program to develop
school-related behaviors. Prior to this session, discussions with the teachers and parents have identified specific behaviors to
focus on in class (e.g., deportment) and at home (e.g., homework completion). These behaviors are incorporated into the
reinforcement system.
10. Reprimands-Parents are trained in effective use of reprimands.
II. Family meeting-At this meeting, the child and parent(s) are brought into the session. The programs are discussed
along with any problems. Revisions are made as needed to correct misunderstandings or to alter facets that may not be
implemented in a way that is likely to be effective.
12. Review of skills-Here the programs are reviewed along with all concepts about the principles. Parents are asked to
develop programs for a variety of hypothetical everyday problems at home and at school. Feedback is provided regarding
program options and applications.
13. Negotiating and contracting-The child and parent meet together to negotiate new behavioral programs and to place
these in contractual form.
14. Low rate behaviors-Parents are trained to deal with low rate behaviors, such as firesetting, stealing, or truancy.
Specific punishment programs are planned and presented to the child as needed for behaviors characteristic of the case.
15, 16, & 17. Review, problem solving, and practice-Material from other sessions is reviewed in theory and practice.
Special emphasis is given to role-playing application of individual principles as they are enacted with the trainer. Parents
practice designing new programs, revising ailing programs, and responding to a complex array of situations in which
principles and practices discussed in prior sessions are reviewed.
teacher or get into heated arguments with peers on the problem children varying in age and degree of severity
playground. However, he was less physically ag- of dysfunction (see Kazdin, 1985). The work of Patter-
gressive than he had been prior to treatment. son and his colleagues, spanning more than two dec-
ades, exemplifies the ongoing development of a con-
Evaluation. The effectiveness of PMT has been ceptual model and outcome research on parent training
evaluated in scores of outcome studies with behavior with antisocial youths (see Patterson, 1986). Over
200 families have been seen that include primarily ag- achieved in treatment, they are unlikely to be main-
gressive children (ages 3 to 12 years) referred for tained in families with socioeconomic disadvantage.
outpatient treatment (see Patterson, 1982). Several The social support system of the mother outside of the
controlled studies have demonstrated marked im- home also contributes to the efficacy of PMT (Dumas
provements at home and at school in child behavior & Wahler, 1983). Mothers who are insulated from so-
over the course of treatment. Moreover, these changes cial supports outside the home (i.e., who have few
surpass those achieved with variations of family-based positive social contacts with relatives and friends) are
psychotherapy, attention-placebo (discussion) and no- less likely to profit from treatment. Thus, variables
treatment conditions (Patterson, Chamberlain, & beyond the specific parent-child interactions need to
Reid, 1982; Walter & Gilmore, 1973; Wiltz & Patter- be considered in treatment.
son, 1974). PMT has brought the problematic behav- Many issues regarding the effects of PMT remain.
iors of treated children within normative levels of their Perhaps most significant is the need for long-term fol-
peers who are functioning adequately (Eyberg & John- low-up with clinically dysfunctional samples. With
son, 1974; Patterson, 1974; Wells, Forehand, & antisocial youths referred for aggressive behavior, fol-
Griest, 1980). Improvements often remain evident 1- low-up typically has been completed up to 1 year.
year after treatment (e.g., Fleischman & Szykula, Given the recalcitrance of severe antisocial behavior,
1981); the continued benefits of treatment have been evidence is needed to assess the long-term impact.
evident with noncompliant children up to 4.5 years
later (Baum & Forehand, 1981). The impact of PMT is Comments. PMT is one of the more well-re-
relatively broad. The effects of treatment are evident searched techniques to alter antisocial behavior among
for child behaviors not focused on directly as part of children (Kazdin, 1978b). There are many critical
training. Also, siblings improve, even though they steps upon which effective application is likely to de-
are not directly focused on during treatment. In addi- pend. The first has to do with the training of the per-
tion, maternal psychopathology, particularly depres- sons who administer the interventions. Such persons
sion, decreases systematically following PMT. These require clear mastery of reinforcement and punishment
changes suggest that PMT alters multiple aspects of procedures discussed previously. It is critical for train-
dysfunctional families (see Kazdin, 1985). ers to understand the principles and to be able to trans-
Several characteristics of the treatment and of the late these into a wide array of feasible practices that
families who participate contribute to treatment out- can be implemented in the home.
come. First, duration of treatment appears to influence The actual lesson content can vary across a variety
outcome. Brief and time-limited treatments (e.g., < of programs. Central to virtually all programs are ses-
10 hours) are less likely to show benefits with clinical sions on the administration of reinforcement tech-
populations. More dramatic and durable effects are niques and mild forms of punishment. A number of
evident with protracted or time-unlimited programs different treatment manuals are available to guide
extending up to 50 or 60 hours of treatment (see Kaz- trainers regarding specific content (see Ollendkk &
din, 1985). Second, specific training components, Cerny, 1981, for a list). In addition, a number of books
such as providing parents with in-depth knowledge of have been made available that are designed for parents
social-learning principles and utilizing time-out from to read as a supplement to training sessions (e.g.,
reinforcement in the home, enhance treatment effects Clark, 1985; Patterson, 1975).
(e.g., McMahon, Forehand, & Griest, 1981; Wahler & Although therapist training and treatment content
Fox, 1980). Third, therapist training and skill appear to are obviously important, selection of the family may
be associated with the magnitude and durability of be critical as well. PMT is a rather demanding form of
therapeutic changes (Fleischman, 1982; Patterson, treatment. Parents are required to master educational
1974), although these have yet to be carefully tested. materials that convey major principles underlying the
Parent and family characteristics also relate to treat- program, to observe deviant child behavior, to imple-
ment outcome. As might be expected, families charac- ment multiple procedures at home, and to respond to
terized by many risk factors associated with childhood frequent telephone contacts made by the therapist.
dysfunction (e. g., marital discord and parent psycho- Many parents firmly believe that the child has the
pathology) tend to show fewer gains in treatment than problem and has to be treated by a therapist. Seeing the
families without these characteristics (e.g., Strain, parents in treatment sessions, even when couched in a
Young, & Horowitz, 1981). Moreover, when gains are detailed rationale, occasionally is met with reluctance.
In addition, families of conduct-disordered youth spective focuses on the attributions, attitudes, assump-
often are characterized by a variety of stressors as iden- tions, expectations, and emotions of the family. Fami-
tified in the discussion of risk factors. These factors ly members may begin treatment with attribution that
often militate against parents' coming to sessions. In focus on blaming others or themselves. New perspec-
general, parents under severe stress or social disadvan- tives may be needed to help serve as the basis for
tage, not at all rare in clinical samples, may profit little developing new ways of behaving.
from PMT. FFT requires that the family see the clinical problem
Notwithstanding the potential limitations, PMT is from the relational functions it serves within the fami-
one of the more well-developed and researched tech- ly. The therapist points out interdependencies and con-
niques for conduct disorder. Among the strengths of tingencies between family members in their day-to-
the approach is the fact that it permits integration of day functioning and with specific reference to the
several domains of maladaptive functioning of the problem that has served as the basis for seeking treat-
child. Specifically, the child's interactions and behav- ment. Once the family sees alternative ways of view-
ior at home are central to the development of antisocial ing the problem, the incentive for interacting more
behavior. In addition, school behavior can be inte- constructively is increased.
grated into treatment. This is usually accomplished by The main goals of treatment are to increase reciproc-
the use of contingencies to address school-related be- ity and positive reinforcement among family mem-
haviors at home (e.g., completion of homework) or bers, to establish clear communication, to help specify
home-based reinforcement in which teachers evaluate behaviors that family members desire from each other,
child deportment (e.g., in-class behavior) and parents to negotiate constructively, and to help identify solu-
provide back-up reinforcers at home based on the tions to interpersonal problems. The family members
teacher's evaluations. read a manual that describes social learning principles
to develop familiarity with the concepts used in treat-
Functional Family Therapy ment. In therapy, family members identify behaviors
they would like others to perform. Responses are in-
Characteristics. Functional family therapy (FFT) corporated into a reinforcement system in the home to
reflects an integrative approach to treatment that has promote adaptive behavior in exchange for privileges.
relied on two perspectives of human behavior and ther- However, the primary focus is within the treatment
apeutic change. The first perspective is a systems ap- sessions where family communication patterns are al-
proach in which clinical problems are conceptualized tered directly. During the sessions, the therapist pro-
from the standpoint of the functions they serve in the vides social reinforcement (verbal and nonverbal
family as a system, as well as for individual family praise) for communications that suggest solutions to
members. The assumption is made that problem be- problems, clarify problems, or offer feedback to other
havior evident in the child is the only way some inter- family members.
personal functions (e.g., intimacy, distancing, sup-
port) can be met among family members. Maladaptive Illustration. An illustration of the entire process of
processes within the family are considered to preclude FFT is difficult to convey because of the complex set of
a more direct means of fulfilling these functions. The techniques, their relation to the nature of family func-
goal of treatment is to alter interaction and commu- tioning, and their dependence on individual features of
nication patterns in such a way as to foster more adap- the family. The technique is well illustrated elsewhere
tive functioning. The second perspective is an opera- where guidelines are provided for therapists (Alex-
tional behavioral perspective that is based on learning ander & Parsons, 1982). SeIected features of the tech-
theory and focuses on specific stimuli and responses niques can be described and illustrated to convey the
which can be used to produce change. The perspective manner in which the technique operates.
includes behavioral procedures identifying specific be- The technique requires understanding of several
haviors for change, reinforcement of new appropriate types of functions that behaviors can serve within the
adaptive ways of responding, and evaluation and as- family. These functions include behaviors that family
sessment of change. members perform to sustain contact and closeness
More recent formulations of FFT have included a (merging), to decrease psychological intensity and de-
third perspective that emphasizes cognitive processes pendence (separating), and to provide a mixture of
(Morris, Alexander, & Waldron, in press). This per- merging and separating (midpointing). These pro-
cesses are intricate because they usually involve the A number of other strategies are employed during
relations of all family members with each other. Also, the course of treatment. These include not blaming
the behaviors of a given family member may serve individuals, relabeling thoughts, feelings, and behav-
multiple and opposing functions in relation to different iors to take into account relational components, dis-
individuals within the family. Thus, a behavior that cussing the implications of symptom removal, chang-
may draw one family member close may distance an- ing the context of the symptom to help alter the
other member. Finally, several different behaviors functions it may have served, and shifting the focus
(e.g., the fighting of a child with a sibling, getting into from one problem or person to another. FFT is not
trouble at school, running away from home overnight) designed merely to identify functional relations but
may serve quite similar functions (e.g., bring the also to build new and more adaptive ways offunction-
mother and father together). ing. Communication patterns are altered and efforts
During the course of treatment, all family members are made to provide families with concrete ways of
meet. The focus of treatment is to identify consistent behaving differently both in the sessions and at home
patterns of behavior and the range of functions they (see Alexander & Parsons, 1982).
serve and messages they send. A number of specific
techniques that can be used to focus on relations in Evaluation. The few available outcome studies of
therapy are used. The specific techniques, goals, and FFT have produced relatively clear effects. The initial
illustrations are presented in Table 3. study included male and female delinquent adoles-
Table 3. Selected Therapy Techniques in Functional Family Therapy

Technique Goal
Asking questions T.o help focus on the relationships raised by the issue or problem. Example: After a de-
scription of an event involving the child (named Ginger) and the mother, the thera-
pist may ask the father, "How do you fit into all of this 7"
Making comments To help identify and clarify relationships. Example: The therapist may say to the fa-
ther, "So you are drawn into this argument when your wife gets upset."
Offering interpretations To go beyond the obvious observations by inferring possible motivational states, effects
on others, and antecedents. Example: The therapist may say, "So when you have an
argument, you believe that this is a message that you are needed. But at the same
time, you feel pushed away."
Identifying sequences To point to the relations among sequences or patterns of behavior to see more complex
effects of interactions, that is, several functional relations over time. Example: The
therapist says, "It seems to me that the argument between Ginger and you (to mom)
makes both you and your husband upset. This leads to everyone arguing for a while
about who did what and what has to be done and no one agrees. But after the dust
settles, you both (to mother and father) have something to talk about and to work
on. This brings you both together, at least for a little while. And this may help you
a lot, too, Ginger, because you don't get to see your mother and father talking to-
gether like this very often.
Using the therapist as a direct tool To have the therapist refer to his or her relation to the family within the session and
what functions this could serve. Example: The therapist says, "I feel as if 1 am still
being asked to choose sides here because it may serve a function similar to the one
that Ginger serves. That is, to help bring you two together. That's not good or bad.
But we need to see how we can get you two together when there is no argument or
battle with a third party.
Stopping and starting interaction To intervene to alter interactions between or among family members. The purpose may
be to induce new lines of communication, to develop relations between members not
initiating contact, or to point out functions evident at that moment. Example: The
therapist says to Ginger and father, "What do you two have to say about the effect
that this has on each of you 7" (without the mother being asked to comment here).
cents referred to juvenile court for such behaviors as pathology, social disadvantage, large family size) have
running away, truancy, theft, and unmanageability impact on the priority of treatment for the parents or
(Parsons & Alexander, 1973). Cases were assigned to the feasibility of attending sessions.
FFT, an attention-placebo condition (group discussion Second, and related, for many families a functional
and expression of feeling), or a no-treatment control approach is likely to be problematic. Many parents
group. Posttreatment evaluation, following 8 treat- clearly believe the problem is "in the child" and that a
ment sessions, revealed that FFT led to greater discus- no-nonsense approach (e.g., teach the child to act dif-
sion among family members, more equitable speak- ferently, punish the child) is needed. In such cases,
ing, and more spontaneous speech than did the entering into the dynamics of family life is often not
attention-placebo and no-treatment conditions. welcome or understood. The therapist's task, of
In an extension of the above program, Alexander course, is to reframe the "child's problem" into a
and Parsons (1973) compared FFT, client-centered larger family and interactional context. For many
family groups, psychodynamically oriented family clinically dysfunctional families, the difficulty of the
therapy, and no treatment. The FFT group showed task may be insurmountable.
greater improvement on family interaction measures The extent to which the reservations noted here re-
and lower recidivism rates from juvenile court records strict the application of FFT is not known. Hence, in
up to 18 months after treatment. Follow-up data ob- advance, they should not be used to preclude the ap-
tained 2Y2 years later indicated that the siblings of plication of the intervention. Currently available mate-
those who received FFT showed significantly lower rials (e. g. Alexander & Parsons, 1982) convey that the
rates of referral to juvenile courts (Klein, Alexander, approach does not engage in a high level of inference
& Parsons, 1977). Thus, the results suggest significant away from the direct observations of family interaction
changes on both index children as well as their and discussion. The relatively straightforward ap-
siblings. proach in addressing interactions concretely and in
FFT shows obvious promise, notwithstanding the providing directives regarding new ways to change
paucity of studies and independent replication at- these interactions are advantages that may counteract
tempts. From the few available studies, several state- the points noted previously.
ments can be supported. First, the effectiveness of
treatment is influenced by the relationship (e.g.,
warmth, integration of affect and behavior) and struc- Cognitively Based Treatment
turing (e.g., directiveness) skills of the therapist (Al-
exander, Barton, Schiavo, & Parsons, 1976). Second, Alternative interventions have focused on the
process measures of family interactions at posttreat- child's cognitive processes (perceptions, self-state-
ment are related to subsequent recidivism (Alexander ments, attributions, and problem-solving skills) that
& Parsons, 1973). This finding lends credence (0 the are presumed to underlie maladaptive behavior. Cog-
model from which treatment was derived. Finally, in nitive processes are frequently accorded a major role in
the outcome studies, client-centered and psycho- aggressive behavior (Berkowitz, 1977; Novaco,
dynamically oriented forms of family-based therapies 1978). Aggression is not merely triggered by environ-
have not achieved the positive effects of FFT. Thus, mental events, but rather through the way in which
treatment of the clinical problem at the level of the these events are perceived and processed. The process-
family per se does not appear to be sufficient to alter ing refers to the child's appraisals of the situation,
antisocial behavior. anticipated reactions of others, and self-statements in
response to particular events. Clinic and nonreferred
Comments. FFT represents a promising treatment children identified as aggressive have shown a pre-
for families with antisocial children. As with parent disposition to attribute hostile intent to others, es-
training, there are some obvious minimal conditions pecially in social situations where the cues of actual
that need to be invoked to carry out therapy. To begin, intent are ambiguous (Dodge, 1985). Understandably,
the family obviously needs to agree to come to treat- when situations are initially perceived as hostile, chil-
ment. In clinically referred families, this requirement dren are more likely to react aggressively. The ability
excludes a large percentage of cases. It is often difficult to take the perspective of, or to empathize with, other
to obtain one parent because some of the conditions persons is also related to aggressive behavior. For ex-
surrounding antisocial behavior (e. g., parent psycho- ample, among delinquents, those who are aggressive
(i.e., committed acts against other persons or proper- steps to obtain them, to see fewer consequences asso-
ty) are less empathic than nonaggressive delinquents ciated with their behavior, to fail to recognize the
(see Ellis, 1982). Perspective taking appears to in- causes of other people's behavior, and to be less sen-
crease with age among normal children and adoles- sitive to interpersonal conflict.
cents and to be inversely related to the expression of
aggression (Feshbach, 1975). Characteristics. Problem-solving skills training
(PSST) consists of developing interpersonal problem-
solving skills in which conduct problem children are
Problem-Solving Skills Training
considered to be deficient. Many variations of PSST
The relationship between cognitive processes and have emerged for conduct problem children (Camp &
behavioral adjustment has been evaluated extensively Bash, 1985; Kendall & Braswell, 1985; Spivack etal. ,
by Spivack and Shure (1982; Shure & Spivack, 1978; 1976). The variations share many characteristics.
Spivack et al., 1976). These investigators have identi- First, the emphasis is on how children approach situa-
fied different cognitive processes or interpersonal cog- tions. Although it is obviously important that children
nitive problem-solving skills that underlie social be- ultimately select appropriate means of behaving in
havior (see Table 4). The ability to engage in these everyday life, the primary focus is on the thought pro-
processes is related to behavioral adjustment, as mea- cesses rather than the outcome or specific behavioral
sured in teacher ratings of disruptive behavior and so- acts that result. Second, children are taught to engage
cial withdrawal. Disturbed children tend to generate in a step-by-step approach to solve interpersonal prob-
fewer alternative solutions to interpersonal problems, lems. They make statements to themselves that direct
to focus on ends or goals rather than the intermediate attention to certain aspects of the problem or tasks that
Table 4. Selected Characteristics of tbe Outcome Study Conducted by

Kolvin, Garside, Nicol, MacMillan, Wolstenholme, and Leitch (1981)
Domain Major characteristics
Sample Ages 7-8 (juniors) or 11-12 (seniors)

Sample size 60-90 youths per group (N = 574)
Screening Multistage screening to identify dysfunctional youths
Setting Regular public schools
Treatments (juniors) Parent-counseling/teacher consultation, group (play)
therapy, no treatment
Treatments (seniors) Parent-counseling/teacher consultation, group (nondirective,
discussion) therapy, behavior modification, no treatment
Treatment sessions Number and duration varied for each treatment
Sources of data Parent, teacher, peer, self, and clinician ratings
Assessment domain Adjustment, psychopathology, cognitive, and social func-
tioning
Major outcome measures Rutter Teacher and Parent Scales; Parent Interview to assess
neurotic, antisocial, and psychosomatic behavior; Junior
Eysenck Personality Inventory; Devereaux Elementary
School Behavior Rating Scale; measures of vocabulary,
intelligence, and reading ability; sociometric data
Assessment periods Pretreatment, posttreatment, follow-up (18 months after
treatment ended)
Training of therapists Special programs for trainers involving formal and informal
instruction and supervision, varying as needed by condi-
tion
PROBLEM IDENTIFICATION
lead to effective solutions. Third, treatment utilizes
structured tasks involving games, academic activities, 1001 ..... ~... ............ •
and stories. Over the course of treatment, the cognitive 90~ ~"""" '"
80L-: / \ , -~ , \ / ' "
problem-solving skills are increasingly applied to real- 70;' : r"<>" '.
,r'" "
life situations. Fourth, the therapist usually plays an 60~
:h,,--·: '.,'
: '- ,
active role in treatment: he or she models the cognitive
processes by making verbal self-statements, applies 3' I
the sequence of statements to particular problems, pro- 2 , :
vides cues to prompt use of the skills, and delivers l~ I
04 !
feedback and praise to develop correct use of the skills.
Finally, treatment usually combines several different
procedures, including modeling and practice, role-
playing, and reinforcement and mild punishment (loss I•
of points or tokens). I
I
I
Illustration. An illustration of PSST was provided ......... ~_.

I
I
I
in a recent report of eight adolescents (ages 13-19) I
I
who had been diagnosed as conduct disordered and
GENERATIO:'I"O~F-A~LT~E~RN~A~TI:':!:V=ES~"-'''-'-''''''-'''''''''''--
who resided in a state hospital (Tisdelle & St. Law-
rence, 1988). Problem-solving skills were taught l~ ----I ~.
across different components of problem-solving skills. !) 80 1/--- -
Training was conducted in a group format with 45-min a 70 :
sessions twice per week for a total of 13 sessions. In o

()
each session, training consisted of (1) providing the ""()Z 3

fol
rationale and instructions for the skill component, (2)
','
,
modeling of the component by the trainer, (3) practice ~ ~R

by the youths, and (4) feedback and verbal reinforce-
ment for use of the skill. Assessment consisted of pre- COMPARISON ~---------------,~,-,--,
or
ALTERNATIVES I
'-----I
-,-
senting the situations used in training and evaluating
: ;'\
I "
how well individual skill components were evident.
Additional novel situations were presented in this fash-
ion to evaluate transfer of the skills to new areas. In I/.1! "
I
I .'
addition, in the hospital, in vivo situations were de-
vised to present these youths with situations to see if
they applied the problem-solving skills.
The effects of training can be seen in Figure 4, I 2 S 4 5 • 1 • II Iii (I 12 (S I~ i, I" i,
which shows that each problem-solving skill compo- SESSION
nent changed as it was addressed in training in a multi-
ple-baseline design. The figure also shows that the Figure 4. Mean percentage of occurrence for each problem-
solving component by session. The solid horizontal line repre-
skills generalized to nontraining scenes as well. Not sents the mean for normal (nonreferred) adolescents, The solid
included in the figure are the data on performance on and dashed lines represent trained and generalization problem
the hospital ward itself where in vivo assessment of situations that show the same pattern of improvements.
skill use was conducted. The results indicated that the
youths had not improved in their effectiveness in prob- mixed, showing clear and robust changes on measures
lem solving and had not applied the skills they learned. on the hypothetical problems during assessment but
One month after treatment was completed, improve- little or no change on measures of adjustment or func-
ments in the in vivo situations were evident for three of tioning in everyday situations.
the original eight youths who were still inpatients.
Staff ratings of adjustment of the patients from pre- to Evaluation. A number of researchers have con-
posttreatment had indicated no significant improve- ducted programmatic series of studies showing the
ments in adjustment. Thus, the results are somewhat efficacy of PSST (see Kendall & Braswell. 1985;
Spivack & Shure, 1982). Research has established the red samples matched on various demographic vari-
efficacy of alternative variations on treatment. The ables. Finer distinctions need to be explored to
majority of studies, however, have evaluated the im- delineate the cognitive correlates or underpinnings of
pact of training on cognitive processes and laboratory- specific clinical problems (cf. Dodge, 1985). In turn,
task performance, rather than deviant child behavior at these distinctions may lead to more highly focused
home or at school (see Gresham, 1985; Kazdin, interventions that have greater impact on antisocial
1987b). In some studies with impulsive or aggressive behavior than current treatments suggest.
children and adolescents, cognitively based treatment
has led to significant changes in behavior at home, at
Other Variations of Treatment
school, and in the community, and these gains are evi-
dent up to 1 year later (Arbuthnot & Gordon, 1986; Most outcome studies have evaluated variations of
Kazdin, Esveldt-Dawson, French, & Unis, 1987; Ken- problem-solving strategies described earlier. Other
dall & Braswell, 1982; Lochman, Burch, Curry, & variations are worth noting in passing to convey the
Lampron, 1984). However, the magnitude of the range of interventions included in cognitively based
changes needs to be greater than those currently training even though outcome evidence for their
achieved to return children to normative or adaptive efficacy is sparse.
levels of functioning at home and at school. A major variation has focused on training children
PSST at this point in time has not been shown to be to take the perspective of other persons. Training in
an effective treatment for antisocial behavior. PSST perspective- or role-taking ability is often part of a
can often lead to improvements in children with mild comprehensive approach for developing problem-
adjustment problems. That change is achieved at all, solving skills. Applications have focused on this skill
and that these changes cannot be attributed to such by itself with some success. The most promising work
influence as exposure to specific tasks or stimulus ma- was completed by Chandler (1973), who developed
terials and discussion of interpersonal situations, role-taking skills in delinquent boys ages 11 to 13. The
should not be treated lightly. Few studies have evalu- boys had mUltiple contacts with the police and had
ated factors that contribute to treatment outcome. committed felonies. The treatment programs, con-
Some evidence has suggested that the greater the level ducted one-half day per week for 10 weeks, utilized
of child aggression, the less effective treatment is drama and films as a means of helping the subjects to
(Kendall & Braswell, 1985). Duration of treatment in- see themselves from the perspective of others and to
fluenced outcome in one study, with longer treatment take the roles of other people. During the sessions, the
(> 18 sessions) leading to greater change than shorter children were encouraged to develop, portray, and ac-
treatment (Lochman, 1985). However, further tests of tually film brief skits dealing with other people their
the effects of duration are needed among different own age. Skits were repeated and filmed until each
treatments. person (working in a small group) had the opportunity
Age and cognitive development may influence out- to participate in each role in the plot. The films of these
come as well, although these have yet to be explored in skits were reviewed and discussed to identify ways
the context of clinical treatment trials (Cole & Kazdin, behavior could be improved. Trained youths improved
1980). Cognitive processes highly significant at one in their role-taking skills on a standard laboratory-
age (e.g., means-ends thinking in adolescents) may based measure (involving characters in cartoon se-
be less critical at other ages (early childhood) (Spivack quences) relative to a no-treatment group and a
et al., 1976). Consequently, further work is needed to placebo-control group that met to make films but did
evaluate whether treatment efficacy is influenced by not focus on role taking. More importantly, at a follow-
child and other characteristics. up assessment 1Y2 years later, police and court records
Research to date has generally adopted the view that revealed that treated subjects had fewer documented
children with problems of adjustment, broadly con- delinquent acts than control subjects.
ceived, have cognitive deficits. For example, Spivack In a subsequent study, Chandler, Greenspan, and
et al. (1976) have found similar cognitive deficits of Barenboim (1974) developed role-taking skills in in-
children who are socially withdrawn or who act out. stitutionalized psychiatric patients (ages 9 to 14)
Their work with adolescents and adults has also shown whose diagnoses included primarily antisocial behav-
that drug addicts, delinquents, and schizophrenic pa- ior. Two treatments, role taking and communication
tients evince cognitive deficits compared to nonrefer- training, were compared to no treatment. Communica-
tion training consisted of encouraging the children to Stolberg, 1983; Schlichter & Horan, 1981). These
identify and correct miscommunications, using a studies have shown treatment effects on measures of
gamelike format, and focused on improving peer com- problem-solving and coping skills, and on role-play
munication. Both treatments led to increases on a test measures, with mixed effects on measures of problem
of role-taking skills. A I-year follow-up showed that behavior outside of treatment.
improvement in either role-taking or communication A final variation of cognitively based therapy, men-
skills was moderately correlated with ratings of behav- tioned only in passing, pertains to programs conducted
ioral improvement in the institution. Although ratings in the schools. Much of the work of Spivack and
of behavioral improvement favored role-taking and Shure, already discussed, has been conducted by train-
communication-training groups, they were not statis- ing teachers to introduce specific lessons in class to
tically different from those of no-treatment controls. In develop problem-solving skills (Spivack et al., 1976).
several other studies, children were trained in role- Several programs have emerged from this work and are
taking skills by enacting the roles of others, discussing intended to develop large-scale classroom applications
thoughts, feelings, or motives of others, and switching of problem-solving training for children at risk for so-
roles (e.g., Iannotti, 1978; Little & Kendall, 1979; cial maladjustment. For example, Weissberg and Ges-
O'Connor, 1977). Yet these studies have not provided ten (1982) devised and evaluated a problem-solving
firm evidence that behavior changes occur outside of curriculum for elementary school children (grades 2
the context of the treatment setting after training. through 4). In one variation of the program, children
In some variations of cognitive therapy, parents oc- receive 34 lessons of 20 to 30 min each in addition to
casionally are involved in training. Utilization of par- opportunities to review skills and practice resolving
ents is a reasonable extension given that many behav- interpersonal conflicts. The major units of the curricu-
ior problems of children emerge and are evident in the lum include recognizing feelings in oneself and others,
home and in relation to the parents (e.g., non- identifying problems, generating alternative solutions,
compliance). Moreover, the problem-solving skills considering consequences, and integrating diverse
that parents use to resolve problems with their children problem-solving behaviors. Use of the skills covered
and their manner of interacting with their children in the lessons is integrated with classroom activities
more generally are related to the child's problem-solv- (e.g., solving problems between children). The results
ing skills and classroom behavior (Shure & Spivack, of several evaluations of the program have shown that
1978). Thus, training the parent to interact in ways that cognitive skills improve significantly relative to those
promote problem-solving skills may have broad effects of untreated children. However, the impact of training
on the parent and on the child. on teacher ratings of classroom adjustment has been
As part of the Shure and Spivack (1978) program for equivocal; some studies have shown gains but other
preschool children, mothers have been trained to studies have not (Gesten et al., 1982; Weissberg et al.,
develop problem-solving skills in their children. Treat- 1981).
ment led to improvements in the children's problem- The school applications of problem-solving training
solving skills and in teacher ratings of classroom are important to mention even though they are not
behavior, as well as to changes in the mothers' prob- necessarily applied for purposes of "treatment" of
lem-solving skills and approach toward child rearing. children whose behaviors have been identified as prob-
This study suggests that training mothers may not only lems. Problem-solving skills can be taught as part of
have direct impact on the child but may also change ordinary classroom curricula and perhaps improve the
several aspects of the child's interpersonal environ- behaviors of may children. Integrating problem-solv-
ment that may contribute to deviant or pro social ing training in the early elementary grades as part of
behavior. the routine curricula also raises intriguing possibilities
In other studies, youths who have engaged in ag- for the prevention of deviant behaviors.
gressive behavior or who represent serious behavioral
problems at school, as well as institutionalized delin- Comments. In conveying the techniques, 1t 1S
quents, have been exposed to variations of cognitively important to note that many distinctions might be made
based interventions. The treatments have combined among alternative approaches. These differences can
self-instruction and problem-solving skills training, be seen in the treatment manuals that are available
relaxation, and the use of imagery to cope with anger (e.g., Camp & Bash, 1985; Kendall & Braswell,
(e.g., Feindler, Marriott, & Iwata, 1984; Garrison & 1985). The techniques were included under a single
rubric because of their common focus on cognitive different types of child dysfunction were investigated;
processes that are considered to underlie disruptive namely, neurotic and conduct disorder. Neurotic disor-
behavior and because of distinctions among alternative der was defined broadly to include internalizing types
techniques that, in practice, are often difficult to of dysfunction (e.g., neuroses, depression, anxiety);
invoke. conduct disorder was defined to include externalizing
The techniques usually focus on developing a prob- types of dysfunction (e.g., disruptive behavior, bully-
lem-solving approach to a variety of different situa- ing, delinquency). Because of the potential signifi-
tions. As such, many of the recommendations dis- cance of developmental stage on the nature of child
cussed in relation to social skills training may be dysfunction and response to treatment, two different
relevant here as well. Special importance may be age levels were selected. Children of ages 7 to 8 and 11
placed on identifying the specific situations in which to 12 years old were included and referred to, respec-
the problem-solving approach is to be applied and tively, as juniors and seniors. Screening of 4,300 chil-
sampling these broadly to incorporate many different dren was undertaken to identify the final group
types of interactions (home, school, community) with (slightly less than 600) of children included in the
many different participants (parents, teachers, peers, study. Screening criteria were invoked to identify chil-
siblings, and others). In addition, it would probably be dren who showed maladjustment problems at school
useful to extend the approach outside of the session and who were at risk for psychiatric impairment
and to involve others to support, foster, or reinforce Guniors), or who already evinced psychiatric distur-
such applications directly. Because generality of treat- bance (seniors). Multiple measures involving parent,
ment effects beyond laboratory tasks and treatment teacher, peer, and clinician evaluations were used to
sessions has been somewhat problematic in the out- conduct screening and to evaluate treatment outcome.
come studies with problem-solving-based approaches, Major characteristics of the study are highlighted in
these latter points may be especially important. Table 5.
Once identified, children were assigned randomly
to one of four conditions. The conditions varied
Approaches to Treatment: Exemplary slightly for younger and older children (see Table 6);
Studies but for each group there was a no-treatment control
group that provided the basis for comparison over the
The previous discussion illustrates alternative treat- course of treatment and follow-up. Parent counseling
ment techniques. Although it is critical to convey spe- plus teacher consultation consisted of social work con-
cific techniques, it is also important to go beyond the sultation with parents and teachers in an effort to coor-
focus on techniques alone. Techniques are likely to dinate school and home activities, casework with the
vary in their efficacy as a function of many factors family, and support for the teacher. Nurture work con-
related to the nature of the dysfunction, children, fami- sisted of providing enrichment activities for the chil-
lies, therapists, and others. In the area of child psycho- dren, close interaction with the child, and behavioral
therapy in general, relatively few studies examine al- shaping for individual child goals. Group therapy was
ternative techniques and conditions that influence their based on client-centered principles and practices and
effectiveness (see Kazdin, 1988). Two exemplary consisted of play group therapy (for younger children)
studies are detailed below to convey alternative ap- or discussion (more traditional) group therapy for
proaches to conduct disorder and, as well, the more older children. In each case, the focus was on the ex-
complex questions that need to be considered when pression of feelings, acceptance of the child, warmth,
selecting intervention techniques. and the therapeutic relationship. The behavior modifi-
cation program (for seniors only) consisted of class-
room reinforcement systems relying on social and
School-Based Treatments of Neurotic and token reinforcement to improve deportment and class-
Antisocial Behavior
room performance.
Kolvin et al. (1981) conducted an ambitious out- The treatments involved different models of care
come study in England between 1972 and 1979 to ex- delivery and different personnel (e.g., social workers,
amine the impact of different treatments, on dif- teachers, teacher aides). The treatments were carefully
ferent types of clinical problems, with children at dif- developed, structured, and implemented. Training of
ferent stages of development and dysfunction. Two staff provided formal and informal supervision and
Table 5. Selected Characteristics of the Outcome Study Conducted by
Feldman, Caplinger, and Wodarski (1983)
Domain Major characteristics
Sample Referred for antisocial behavior (ages 8-17; M = 11.2)
Sample size N = 452 participants; N = 54 at follow-up
Screening Severity of antisocial behavior on checklists completed by

referral agent and parent
Setting Jewish Community Center
Treatments Traditional group social work, behavior modification, mini-

mal treatment (no explicit or structured plan)
Treatment sessions Range from 8-29 sessions (m = 22.2 sessions) 2-3 hours
each
Sources of data Referral agency, parents, children, therapists
Assessment domain Antisocial, prosocial, nonsocial behavior
Major outcome measures Checklist questions designed to measure prosocial, antiso-

cial, and nonsocial behavior completed by professionals
at referral agencies, parents, therapists, and youths; direct
observations of youths in the groups designed to measure
prosocial, antisocial, and nonsocial behavior; therapist
and observer completed measures of group norms, child
and peer relations; aggression scale completed by youths
Therapists Experienced (social work graduate students) versus inexperi-

enced (undergraduates)
Training of therapists In-service training; prior course work and practical training
for "experienced" therapists.
discussion, and reading and background information whereas conduct problems appeared to be more ame-
on the principles and practices underlying treatment. nable to change in girls than in boys.
The effects of treatment are not easily summarized The treatments sampled different dimensions of in-
given the large number of outcome measures and dif- terest in contemporary work. One dimension is the
ferent sources of information. In general, for the extent to which treatment is direct versus indirect. Di-
younger children, play group therapy and nurture work rect treatment consists of face-to-face interaction with
led to significantly greater changes than no-treatment the child (e.g., group therapy), whereas indirect treat-
controls and the parent-teacher condition. These ef- ment consists of working with significant others (e.g.,
fects were evident primarily for neurotic rather than parents and teachers) who treat the child (e.g., parent-
conduct problem behavior. For the older children, teacher consultation). Another dimension is whether
group therapy and behavior modification led to greater treatment focuses on intrapsychic process versus overt
changes than controls and the parent-teacher condi- behavior (e.g., group therapy vs. behavior modifica-
tion. tion, respectively). Finally, treatments varied marked-
Among the different treatments, children with neu- ly in duration and intensity with a brief versus more
rotic disorders, as defined earlier, responded better extended treatment (e.g., 10 sessions of group therapy
than children with conduct disorders. Also, girls re- versus 20 weeks of daily behavioral treatment).
sponded better to treatments than did boys. There were In the present project, each of these dimensions was
no consistent interactions between the type of treat- not fully represented or extensively sampled. Never-
ment and type of child disorder nor between treatment theless, at the end ofthe project, tentative conclusions
and child sex. However, neurotic behavior appeared to could be drawn. Indirect treatment (parent-teacher
be more amenable to change in boys than in girls, consultation) did not appear to produce major changes;
more direct treatments, including group therapy and in St. Louis, Missouri. The St. Louis Experiment, as it
behavioral approaches, produced the most significant was called, included youths (ages 8-17) who were
changes. Treatment focus, whether intrapsychic or be- referred for antisocial behavior (referred youths) or
havioral, did not seem to be the crucial determinant who normally attended the regular activities programs
given the impact of both group therapy and behavioral and were not identified as showing problem behavior
approaches. Duration of treatment did not seem to be (nonreferred youths). The project began with approx-
an issue, because relatively shorter and longer treat- imately 700 youths; this number declined to approx-
ments (e.g., group therapy and behavior modification) imately 450 by the end of treatment.
led to greater change. Again, each of the dimensions of The design of the study was complex because of the
possible interest was not carefully sampled, so the con- interest in evaluating the separate and combined ef-
clusions of the study can be applied only to the specific fects of different influences on outcome (see Table 6).
condition. The study evaluated the effects of three types of treat-
There are a number of excellent features of this ment, two levels of therapist experience, and three
study. The use of multiple measures for screening, a different ways to compose the groups. The three treat-
comparison of separate treatments with a randomly ments were traditional group social work (focus on
comprised no-treatment control group, assessment of group processes, social organization and norms within
mUltiple domains of functioning (maladjustment, cog- the group), behavior modification (use of reinforce-
nitive functioning, social relations with peers), and the ment contingencies, focus on prosocial behavior), and
evaluation of follow-up make this study truly outstand- minimal treatment (no explicit application of a struc-
ing. Kolvin et al. (1981) addressed treatment at the tured treatment plan, spontaneous interactions of
level of complexity that avoids highly diluted and dif- group members). Activity groups within the center
fuse conclusions. The focus on different treatments were formed and assigned to one of these three inter-
and clinical problems, and on children of different ages ventions. The groups were led by trainers, some of
within a single study serves as an excellent basis for whom were experienced (graduate students of social
drawing conclusions about treatment. work with previous experience) and others who were
inexperienced (undergraduate students). Finally, the
groups were comprised in three ways: all members
Community-Based Treatment for Antisocial
were youths referred for antisocial behavior, all mem-
Youths
bers were nonreferred ("normal") youths, and a mix-
Feldman et al. (1983) conducted a community- ture of referred and nonreferred.
based treatment project for antisocial youths. Commu- The main objective was to evaluate changes in anti-
nity-based treatment attempts to take advantage of the social behavior of referred youths over the course of
resources in the everyday environment that can support
prosocial behavior. Integration of treatment in existing
Table 6. Interpersonal Cognitive Problem-
community programs reduces the problem of ensuring
Solving Skills
carry over of prosocial behavior from treatment to the
community settings. This problem is likely to arise if I. Alternative solution thinking-the ability to generate
the youths are removed from the community (e.g., different options (solutions) that can solve problems in
psychiatric hospital, juvenile correctional facility) for interpersonal situations
2. Means-end thinking-awareness of the intermediate steps
their treatment.
required to achieve a particular goal
Another characteristic of community-based treat- 3. Consequential thinking-the ability to identify what might
ment is the effort to include problem youths as well as happen as a direct result of acting in a particular way or
their prosocial peers. If positive peer group influences choosing a particular solution
are to be fostered in treatment, it is critical that the 4. Causal thinking-the ability to relate one event to another
peers not be restricted to other deviant youths. Segre- over time and to understand why one event led to a
gation of deviant youths in residential settings in par- particular action of other persons
5. Sensitivity to interpersonal problems-the ability to
ticular provides them with models for further deviant
perceive a problem when it exists and to identify the
behavior. interpersonal aspects of the confrontation that may emerge
Feldman et al. (1983) conducted a large-scale com-
Note. From The Problem·Solving Approach to Adjustment by G.
munity-based program that was integrated with ac- Spivack, J. J. Platt, and M. B. Shure, 1976, San Francisco, CA: Jossey-
tivities of the Jewish Community Centers Association Bass. Copyright 1976 by Jossey-Bass. Adapted by permission.
the intervention. Measures were obtained from par- relative impact of alternative treatments. Yet it is rare
ents, referral agents, the youths, and group leaders as for child treatment studies to even assess treatment
well as direct observations of the groups. The interven- integrity. Consequently, attention should be directed to
tion was conducted over a period of a year in which the this superb methodological feature rather than faulted
youths attended sessions and engaged in a broad range on the departures from the intended interventions.
of activities (e .. g, sports, arts and crafts, fund raising, Nevertheless, it is still possible that there would be
discussions). The specific treatments were superim- greater differences in outcome when the treatments are
posed on the usual activity structure of the community conducted as intended and even substantially different
facility. Treatment sessions ranged from 8 to 29 ses- conclusions about individual treatment conditions.
sions (mean = 22.2 sessions), each lasting about 2 to 3 The absence of stronger follow-up data raises other
hours. problems. Follow-up was restricted to ratings on non-
The results indicated that treatment, trainer experi- standardized measures of antisocial behavior and was
ence, and group composition exerted impact on at least available for only 12% (511450) of the sample. From
some of the measures. Youths showed greater reduc- these data, it is not possible to tell how the vast major-
tions in antisocial behavior with experienced rather ity of youths fared. Follow-up data are critical given
than inexperienced leaders. Referred (antisocial) the possibility that the results might differ from, and
youths in mixed groups (that included nonreferred even be diametrically opposed to, the pattern evident
children) showed greater improvements than similar immediately after treatment. Nevertheless, the St.
youths in groups comprised of only antisocial youths. Louis Experiment represents a major contribution to
Treatments also differed; behavior modification led to the treatment literature. The project shows that inter-
greater reductions in antisocial behavior than did tradi- ventions can be delivered on a relatively large scale
tional group treatment. Traditional treatment led to and can provide benefits for referred (and nonreferred)
some decrements in antisocial behavior relative to the youths.
minimal contact group. However, treatment accounted
for only a small amount of variance in predicting
outcome. General Comments
Overall, antisocial youths benefitted from the pro- The two previously noted studies illustrate very spe-
gram, especially those who received the most favor- cial efforts to evaluate alternative treatments for con-
able intervention condition (i.e., behavior modifica- duct disorder. The studies share several charac-
tion with an experienced leader and in a mixed group teristics, such as the evaluation of multiple treatments,
of referred and nonreferred peers). For a small subsam- the reliance upon multiple measures and perspectives
pIe (n = 54), follow-up data were available 1 year later. to examine outcome, and the sampling of different
The follow-up data revealed slight (nonsignificant) in- "types" of youths to examine the differential respon-
creases in antisocial behavior based on data from par- siveness of clients to treatment. More than the specific
ent and referral agent reports. Yet the size of the fol- commonalities, both studies focus on questions involv-
low-up sample precluded evaluation of the effects of ing the interaction of treatment outcome with other
treatment, trainer experience, and group composition. variables (e.g., clinical problem, child age, referral
status). This level of specificity is what is needed in
Overall Evaluation. There remain some ambigu- outcome research, a fact widely recognized but rarely
ities regarding the impact of alternative treatments. translated into action in the child therapy literature.
Checks on how treatment was carried out revealed a
breakdown in treatment integrity. For example, obser-
vations of treatment sessions revealed that approx-
imately 35% of the leaders did not implement the be-
Current Issues
havior modification procedures appropriately for two
Severity of Dysfunction
of the three sessions observed; approximately 44% of
the minimal-treatment leaders carried out systematic There remain several issues that cloud the evalua-
interventions even though none was supposed to; final- tion of current treatments (see Kazdin, 1988). Perhaps
ly, only 25% of the leaders in the traditional group the most critical issue is the need to specify the clinical
treatment condition carried out the intervention appro- dysfunction in a way that permits comparisons among
priately. It is difficult to draw conclusions about the studies. Within the treatment literature, children who
have been referred to as having a conduct disorder or a progress at school). The measure permits evaluation of
conduct problem vary widely in terms of the severity these characteristics in relation to same-age peers who
and breadth of their dysfunction. Noncompliance and function adequately in everyday life. The normative
oppositional behavior as well as repeated fighting and basis of this and other measures also would be helpful
stealing have been grouped under a single rubric. The for better specifying the popUlation that has been
point here is not to say that some of these cases are treated.
conduct disorder and that others are not. Presumably Subscales especially relevant to conduct disorder
the continuum of dysfunctions is worth treating. How- (e.g., aggression, delinquency, hyperactivity) can be
ever, it is quite likely that the effectiveness of treatment compared across investigations to evaluate severity of
will vary as a function of the severity and breadth of the dysfunction in relation to normative and clinic sam-
antisocial behaviors of the children. Youths who en- ples. Other measures more specific to antisocial behav-
gage in more severe and diverse forms of antisocial ior are available (see Kazdin, 1987a). For example, the
behavior, who exhibit these across more situations, Eyberg Child Behavior Inventory (Eyberg & Robin-
and for a longer period of time, are more likely to son, 1983) is specifically designed to examine fre-
continue these behaviors over time. In evaluating any quency and severity of conduct problems. Use of this
intervention, it is important to know how the children or other measures in a more consistent fashion across
fare on these dimensions. studies would greatly improve the evaluation of the
It would be quite useful if researchers would adopt a effectiveness of alternative treatments.
standardized descriptive system in reference to con- The point made here regarding the need to specify
duct disordered youth so that the results of different the severity, breadth, and chronicity of dysfunction
studies could be compared. There are standard ways of might be extended to evaluation of the family. Clearly,
classifying dysfunction, such as the use of a diagnos the effectiveness of treatment varies as a function of
tic system like the DSM-lli-R (APA, 1987). The ad- family characteristics (e.g., social disadvantage,
vantage of such a system is that it provides a widely mother isolation from positive social contacts) (Dumas
used, even if not maximally explicit, means of delin- & Wahler, 1983; Wahler, Leske, & Rogers, 1979).
eating severity, breadth, and chronicity of dysfunc- Thus, it would be useful to convey further details about
tion. Knowing that children in an investigation met the parents and families of children included in a treat-
criteria for conduct disorder does not resolve all of the ment trial. Although such assessment is a laudable
ambiguities. However, the information conveys that at goal, there are obstacles, such as the absence of widely
least a minimum level of dysfunction was met. Use of agreed upon assessment tools or diagnostic systems,
other facets of current diagnosis (severity ratings, sub- that are designed to focus on characteristics of families
type of conduct disorder, multiple axes) help to further of antisocial youth. At this point, a basic priority is the
elaborate potentially important descriptive charac- need to specify operationally and in more detail the
teristics of the sample. nature of the child's dysfunction. Better specification
Psychiatric diagnosis is only one means to better will help identify the children for whom some treat-
convey the level, type, and severity of clinical dys-. ments may be effective.
function. Diagnosis does not resolve many issues in
the search for consistencies in delineating dysfunction
Focusing on the Constellation of Behaviors
because the diagnostic criteria have undergone peri-
odic revisions. In addition, individuals with a diag- An important issue for many interventions is the
nosis of conduct disorder can be extremely hetero- focus of treatment. Often one or two salient behaviors
geneous in the specific symptoms they evince and the serve as the target focus. For example, reinforcement
severity and chronicity of each. Thus, diagnosis can and punishment techniques frequently focus on indi-
help to describe some features but also obscures vidual target behaviors. A demonstration that such be-
others. havior as fighting in the classroom or obeying parents
An alternative is to use standardized measures, such at home is altered dramatically is noteworthy. Yet the
as parent and teacher checklists. For example, the short- and long-term impact of a restricted focus is of
Child Behavior Checklist (Achenbach & Edelbrock, unclear, if not limited, clinical value. It is very likely
1983) assessed mUltiple-symptom domains, broad that a pattern of dysfunction and package of symptoms
scales (internalizing, externalizing), and prosocial be- will need to be altered.
havior (participation in activities, social interaction, It is not clear that all domains of a child's dysfunc-
tion need to be treated for the child to function well in glecting the development of positive competencies in
everyday life. However, it is critical to evaluate child this area may detract from effective interventions de-
functioning across a wide range of problematic do- signed to reduce maladaptive behaviors.
mains. Thus, decreases in classroom fighting are Many treatments emphasize reduction of symptoms
important. Additional assessment is needed to evaluate or development of prosocial behavior. The implicit
functioning in class (e.g., deportment or other mea- assumption has been that the focus on one of these will
sures, academic functioning), at home (e.g., com- invariably help the other. However, it is quite likely
pliance with parents, interactions with others), and in that the reduction of symptoms and the increase of
the community (e.g., staying out overnight, stealing prosocial behavior require separate attention. This
with peers). The importance of assessment across does not necessarily mean that entirely separate inter-
many domains of functioning is usually argued as a ventions are needed, but rather that the program focus
generally advisable strategy. In the case of conduct probably should include and assess the impact on be-
disorder, the strategy would appear to be essential behaviors within these two broad domains.
cause of the pervasive nature of the dysfunction. Also,
effectively altering one or a few behaviors, while im-
pressive, may have no clear impact on the overall func- Conclusions
tioning of the child across other relevant behaviors and
situations. The treatment of conduct disorder represents a sig-
nificant priority because of the prevalence of the prob-
lem and the poor prognosis. Because of the impact of
Developing Prosocial Behaviors
the problem on others (e.g., victims) and society at
Treatments for conduct disordered youths probably large and the transmission across generations, the
need to include specific efforts to develop prosocial problem is clinically and socially significant. Current
behavior as well as to decrease deviant behavior. Pro- treatments have shown that antisocial behaviors can be
social functioning refers to the presence of positive altered. The challenges are primarily in the areas of
adaptive behaviors and experiences, such as participa- establishing impact on multiple behaviors of the con-
tion in social activities, social interaction, and making stellation, obtaining effects that are sustained, and ef-
friends. There are separate reasons to advocate the dual fecting large enough changes to be clinically signifi-
approach of decreasing symptoms and increasing pro- cant.
social behaviors. To begin with, reducing deviant be- The difficulties in effecting change in these areas
havior does not by itself ensure an increase in positive might suggest a variety of different directions. In
prosocial behaviors. For example, decreasing fighting clinical work, the direction is likely to be to combine
with the teacher and peers is very unlikely to develop multiple approaches to achieve change. The goal
positive interactions with either. Evidence in the study would be to address as many domains of dysfunction
of childhood dysfunction more generally has sug- (family life, school, peer interactions) that are in-
gested that the overlap of symptom reduction and volved. Even with broad foci of clinical work, it is
positive prosocial functioning may not be great. In- often difficult to consider critical domains. For exam-
deed, correlations between measures of symptoms and ple, academic dysfunction is quite problematic for
prosocial behavior, whether completed by parents or many antisocial youths. Academic dysfunction pre-
children, are in the low to moderate range (e.g., -.3 to dicts long-term antisocial behavior and perhaps is haz-
-.5) (Kazdin, 1986). The small amount of shared ardous to neglect. Yet persons who are most likely to
variance between the scales indicates that the low lev- be responsible for clinical intervention in treatment
els of deviant behaviors are not tantamount to the pres- settings (i.e., mental health professionals) may not be
ence of positive prosocial behaviors and vice versa. familiar with or trained in procedures to develop the
Another reason for focussing on prosocial behaviors child academic competencies. In short, even broad-
is their possible relevance to long-term adjustment. based approaches may omit critical domains.
For example, it is likely that developing academic Because of the demonstrated but often insufficiently
competence would be an important prosocial focus strong changes with many current treatments, alter-
apart from reduction of antisocial behaviors. Poor aca- native models of intervention have been suggested.
demic functioning is frequently associated with con- One approach includes the use of more protracted
duct disorder and predicts a long-term prognosis. Ne- treatments perhaps spanning years and/or continued
on an as needed basis for several antisocial youths Delinquent behavior linked to educational attainment and
(e.g., Kazdin, 1987a; Wolf, Braukmann, & Ramp, post-high school experiences. In L. Otten (Ed.), Colloquium
on the correlates of crime and the determinants of criminal
1987). Ii is reasonable to assume at this time that a core behavior (pp. 1-42). Arlington, VA; The MITRE Corp.
group of conduct disordered youths are likely to con- Baum, C. G., & Forehand, R. (1981). Long-term follow-up
tinue their dysfunction after the most potent treatment assessment of parent training by use of multiple outcome mea-
.approaches of those typically invoked have been ap- sures. Behavior Therapy, 12, 643-652 .
Behar, D., & Stewart, M. A. (1982). Aggressive conduct disor-
plied. At the same time, it is clear that studies referring der of children. Acta Psychiatrica Scandinavica, 65, 210-
to conduct disordered youths include many persons 220.
who are oppositional, noncompliant, and mildly ag- Berkowitz, L. (1977). Situational and personal conditions gov-
gressive but not of the ilk that might require such treat- erning reactions to aggressive cues. In D. Magnusson & N. S.
Endler (Eds.), Personality at the crossroads: Current issues in
ment. Improved efforts are needed to help identify interactional psychology (pp. 165-171). Hillsdale, NJ: Law-
different levels or types of conduct disorder and to rence Erlbaum.
monitor persons after intervention to see if further Blue, S. W., Madsen, C. H., Jr., & Heimberg, R. G. (1981).
Increasing coping behavior in children with aggressive behav-
treatment is needed. ior: Evaluation of the relative efficacy of the components of a
treatment package. Child Behavior Therapy, 3, 51-60.
Bomstein, M,. Bellack, S., & Hersen, M. (1980). Social skills
ACKNOWLEDGMENTS. Completion of this chapter was training for highly aggressive children: Treatment in an inpa-
facilitated by a Research Scientist Development tient setting. Behavior Modification, 4, 173-186.
Award (MH 00353) and a grant (MH 35408) from the Bristol, M. M. (1976). Control of physical aggression through
National Institute of Mental Health. school- and horne-based reinforcement. In J. D. Krumboltz &
C. E. Thoresen (Eds.), Counseling methods (pp. 180--186).
New York: Holt, Rinehart & Winston.
Burchard, J. D., & Barrera, F. (1972). An analysis of time out
and response cost in a programmed environment. Journal of
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Weissberg, R. P., Gesten, E. L., Carnike, C. L., Toro, P. A., Quarterly, 5, 92-103.
CHAPTER 33
Sexual Abuse of Children

Vicky Veitch Wolfe
Childhood sexual abuse has been defined as any sexual Surveys of adults who were abused as children re-
experience between a child (usually defined as under veal that only 3%-6% ever reported their abuse to an
age 16) and an adult or person at least 5 years older official agency. However, because of changes in legis-
than the child (Finkelhor, 1979). The definition in- lation and public awareness campaigns, reports of sex-
cludes a wide range of acts, including exhibitionism, ual abuse have increased dramatically. Between 1977
fondling, intercourse, and pornography. Recent epi- and 1980, a 566% increase in reports of sexual abuse
demiological findings from adults' retrospective re- occurred in the United States (Russell & Trainor,
ports indicate that as many as 19% to 28% of women 1984) and a 500% increase occurred in Canada (Com-
and 8.6% to 16% of men report at least one sexual mittee on Sexual Offenses against Children and Youth,
victimization experience during childhood (Finkelhor, 1984). As a result of the increased rate of disclosures,
1979; Russell, 1983; Timnick, 1985). The majority of communities have found themselves ill-prepared to
sexually abusive experiences involve "serious" to cope with the unique and complex demands that these
"very serious" forms of abuse that have the potential cases bring. Many cases require the coordinated efforts
for psychological trauma and short- and long-term se- of child protective services, prosecutors and judges,
quelae. Finkelhor's (1979) survey of college students educators, and mental health professionals. Demands
revealed that 20% of his sexually abused sample had for interventions occur at three levels: prevention and
experienced exhibitionism, 40% reported genital fon- early disclosure, crisis intervention following dis-
dling, and 40% reported either oral-genital contact or closure, and treatment for psychological sequelae.
vaginal or anal intercourse. Similar statistics were re- This chapter describes and reviews various interven-
ported by Russell (1983) for a sample of women who tions at each level.
were sexually abused as children. Twenty-three per-
cent reported "very serious" sexual contact (penile
penetration of the vagina or anus, fellatio, cun- Primary Prevention and Early
nilingus, analingus) and 41 % reported "serious" sexu- Disclosure
al contact (digital vaginal penetration, unclothed fon-
dling of breasts or genitals, and simulated or attempted As the public has become more aware of childhood
intercourse). sexual abuse, many communities have launched pri-
mary prevention programs. Plummer and Crisci
(1986) surveyed 27 communities that had on-going
Vicky Veitch Wolfe • Department of Psychology, Children's
Hospital of Western Ontario, London, Ontario, Canada N6A prevention programs of at least 2-years' duration.
405. Most of the communities had a task force that planned,
707
coordinated, or oversaw sexual abuse prevention ac- review of the research of the effectiveness of some of
tivities (85.2%). Public schools had the primary re- the school-based prevention programs.
sponsibility for prevention by teaching children how to Programs vary in length from 1 session to 12 or
protect themselves against potential perpetrators. All more sessions, which obviously relates to the amount
the community programs targeted elementary school of information that can be conveyed and the extent to
students, and 51.9% had programs targeting pre- which children are able to grasp the message con-
schools, elementary schools, adolescents, parents, veyed. Although televised programs as short as 30 sec
teachers, and professionals. Interestingly, only 2% of have been found to promote disclosures of sexual
the communities addressed a wider audience by using abuse, longer duration programs are thought to have
public service announcements on television or radio. more far-reaching effects by teaching children what
Several strengths and weaknesses characterized the sexual abuse is, how to disclose the abuse, the impor-
programs (Plummer & Crisci, 1986). On the positive tance of disclosing, and what will happen as a result of
side, most communities paid professionals to develop dis,closing (Conte et al., 1986). Some evidence sug-
and implement programs and had multidisciplinary ad- gests that once the initial program is complete, follow-
visory boards. However, funding problems and public up and booster interventions are essential to ensure that
acceptance of the programs often impeded service. children remember what was taught (Plummer, 1984).
Unfortunately, few communities had treatment re- Teachers, police officers, rape crisis counselors,
sources adequate to deal with the increased rates of mental health professionals, and community volun-
sexual abuse disclosures following prevention pro- teers often serve as trainers for school-based sexual
grams. abuse prevention programs (Conte et aI., 1986).
In the next three sections, prevention programs tar- Teachers are most often called upon to provide the
geting school children, parents, and physicians are retraining because children may feel most comfortable
viewed, followed by a discussion of the problem of discussing the topic with someone who is well known
adolescent offenders. Outcome goals of prevention to them. Nevertheless, teachers are often unaware of
programs include reducing frequency and severity of the issues involved in childhood sexual abuse and re-
sexual abuse; the process goals include public knowl- quire training themselves before they can conduct sex-
edge and awareness of sexual abuse, knowledge of ual abuse prevention programs (McGrath, Cappelli,
what to do when sexual abuse occurs, and treatment of Wiseman, Knalil, & Allen, 1987). Mcintyre (1987)
individuals at risk to abuse children seXUally. Although found that teacher awareness of the signs of abuse
we hope that prevention efforts will reduce the proba- related to college training and in-service training.
bility that abuse will occur in the first place, the greater However, 81 % of teachers had no training in college
impact may well be that children learn how to report and 60% received no in-service training. Many teach-
their abuse. Interestingly, as a result of prevention pro- ers are unaware of the laws mandating reports of sus-
grams, we may see an actual increase in the amount of pected child abuse. Twenty-two percent indicated they
reported abuse, but the abuse being reported is of a less would not report abuse if the parents denied it and if
serious or less long-term nature (Garbarino, 1986). their principal was not supportive.
Regardless of who conducts the program, the curric-
ulum of the training should be thoughtfully developed.
School-Based Programs
Without a well-developed program, trainers are likely
Today there are in-school prevention programs in to emphasize those aspects of abuse for which they feel
every state in the United States and plans or discussion most knowledgeable and comfortable. For example,
in virtually every community regarding strategies to discussing abuse by strangers may involve less sen-
prevent child victimization (Plummer & Crisci, 1986). sitive topics than abuse by family members. There-
In fact, California now has legislation mandating that fore, although abuse by strangers is relatively uncom-
schools provide sexual abuse prevention programs for mon, such abuse may be highlighted and the more
all children. School-based sexual abuse programs have common forms of abuse may be deemphasized (Conte
varied along several dimensions: content, length of et al., 1986).
training, occupation of trainer, prevention materials, Program content often includes the concepts of body
and types of abuse covered (Conte, Rosen, & Saper- ownership, touch continuum, secrets, acting on one's
stein, 1986). In the next section, these different dimen- own intuition, saying "No," and locating helpful
sions of programs will be discussed, followed by a people to tell about one's own sexual abuse. Some
CHAPTER 33 • SEXUAL ABUSE OF CHILDREN 709
programs teach assertiveness and self-defense skills, Sexual abuse prevention programs must present ma-
and one program goes so far as teaching children how terial in an entertaining yet informative manner that is
to kick if someone tries to grab them (Conte et aI., appropriate to the children's developmental needs.
1986). The contention is that sexual abuse can be pre- There are many teaching materials available to en-
vented if children are taught to recognize inappropriate hance program effectiveness. Anatomically correct
adult behavior, resist the inducements, react quickly to dolls are often used to teach names for sexually related
leave the situation, and then tell someone of the body parts. Touch Cards (Illusion Theater Company &
incident. Media Ventures, Inc., 1984) are used to depict differ-
Reppucci (1987) criticized school-based programs ent types of touching. Films are used to discuss various
in that children are taught skills that have never been scenarios that include sexual abuse, and other films
proven to prevent sexual abuse or that help children model ways that children can react to potentially
effectively ward off a sexual abuse encounter. He sug- abusive situations. Some programs include work-
gested that program developers utilize what is known books, plays, and role-playing (Conte et aI., 1986).
about sexual abuse to determine what children must Byers (1986) suggested that of all the mediums for
learn in order to protect themselves. Furthermore, it is conveying information about sexual abuse, films have
not clear, even if the skills taught could be effective, the greatest potential, reaching and influencing both
that children will use the skills once encountered with children and adults in many different settings. Overall,
sexual abuse. Along these lines, several authors have however, Byers (1986) criticized the films for children
recognized patterns of sexual abuse and called for along these dimensions: (1) many are entertaining, but
teaching children more sophisticated self-protection lack educational value; (2) many are too long to hold
skills. Drawing from studies of the way child mo- the attention of young viewers; and (3) many employ
lesters gain children's compliance, Conte et al. (1986) too many gimmicks to gain children's attention.
suggested that children need to know about the lies, Nevertheless, some exemplary films were reviewed,
manipulations, and forms of coercion that adults may including a series offour Feeling Yes, Feeling No films:
use, and to be taught methods for coping with such an introductory film for adults, a film about self-
deceit. Berliner (1984), reflecting on the fact that at worth, self-confidence, and good judgment, a film
least 90% of perpetrators are well known to the child, about sexual assault by strangers, and a film about
suggested that it be stressed that no one, including sexual assault by family members or other trusted
family members, has the right to touch private body adults. Other films recommended by Byers (1986) in-
parts in a sexual way. cluded What Tadoo, Kids Can Say No, Touch, and Yes,
In an effort to avoid concerns that children are ex- You Can Say No, You Can Say No. Unfortunately, as
posed to premature sexual information, many pro- pointed out, the effectiveness of these films has not
grams focus prevention programs on self-protection been evaluated, but Byers (1986) suggests some
efforts and personal self-esteem, rather than on infor- important aspects for evaluating films: overall appeal
mation specifically detailing what sexual abuse is and for particular age levels, ability to catch the attention
what to do about it. Finkelhor (1986b) criticized such of the viewer, educational content, and children's re-
school-based programs and warned that by excluding tention of the information taught.
sexual material, children may believe that adults do not
want to talk about the serious forms of sexual activity Program Evaluations. Evaluating the effective-
they find themselves exposed to. ness of child abuse prevention programs involves a
Probably one of the strongest rationales for school- number of issues. As already mentioned, prevention
based programs is that they encourage children to re- programs should result in a lower incidence and preva-
port past or ongoing sexual abuse. Berliner (1984) lence of sexual abuse, as well as less serious (less
noted that children usually decide to tell about sexual severe and less frequent) abuse by encouraging early
abuse only after they believe that the disclosure will disclosure. Leventhal and Conte (1987) outlined sever-
not bring about any negative consequence to them- al additional outcome measures pertinent to programs
selves or that the disclosure would not cause family designed to teach children how to protect themselves
disruption. Therefore, the content of prevention pro- against abuse. They point out that although the ulti-
grams should address these issues and carefully teach mate goal of school-based prevention programs is to
children how to disclose abuse and inform them of the teach behaviors that a child can use if an adult makes a
resources available to them after they tell. sexual advance, few programs actually assess im-
provements in children's abilities to display these be- petrators were closer in age to themselves, and older
haviors in vivo. Such assessment obviously involves children more accurately believed perpetrators to be
many ethical and logistical constraints, which has led either teenagers or adults. Younger children tended to
to the majority of programs assessing changes in chil- believe perpetrators were strangers, whereas older
dren's knowledge about sexual abuse as an intermedi- children correctly recognized that most perpetrators
ate measure. However, as is well known from previous were people known to their victims. Older children
prevention work, knowledge about what to do and ac- tended to see perpetrators as deviant or "crazy," and
tually behaving as instructed do not necessarily coin- many believed that sexual abuse involves serious phys-
cide, and this may be particularly true in the case of ical aggression. Girls and older boys tended to view
sexual abuse where the child may be quite intimidated victims as female, although younger males tended to
by an adult (Fryer, Kraizer, & Miyoshi, 1987). As the see victims as either male or female. Approximately
exception, Fryer et al. (1987), in a study to be dis- 20% of the children, regardless of age, could not offer
cussed later, actually simulated a situation that could suggestions about how children can protect themselves
lead to an abduction (asking a child to go to a stranger's against sexual abuse. When children did offer sug-
car to help carry material into the school). Such an gestions, saying "No," getting away, and telling
assessment, however, is not possible for situations someone were most common.
more directly related to sexual abuse, and Leventhal The outcome of abuse prevention evaluations may
and Conte (1987) suggested an alternate measure: sur- relate to the measures used. When paper-and-pencil
veying parents, teachers, and other adults to see measures are used to assess gains in knowledge about
whether sexual abuse prevention programs result in an sexual abuse, the greatest effects appear to be in teach-
increase in the number of disclosures pre- to postinter- ing the subtleties, since most children already know
vention. Furthermore, rates of reporting to child pro- the general principles. Following a program of skits
tective services agencies could also be recorded pre- and classroom discussions about physical and sexual
and postintervention. abuse, the greatest improvements on a pre- and post-,
Before evaluating the effectiveness of programs, true-false test were on questions related to self-blame,
children's pretraining knowledge and skills should be identification of potential perpetrators, probability of
considered. Pre- and posttraining evaluations reveal being believed, and recognition of less obvious forms
that most children already have some basic informa- of abuse, such as exposure of genitals. Saslawsky and
tion about sexual abuse before training. It appears that Wurtele (1986) showed the film Touch (Illusion The-
most elementary school-aged children know the im- atre Company & Media Ventures, Inc., 1984) to chil-
portance of seeking help if approached sexually (D. A. dren in kindergarten, first, fifth, and sixth grades. Al-
Wolfe, MacPherson, Blount, & V. V. Wolfe, 1986) though children answered correctly to most of the
and know that it is unsafe to get into a car with a questions whether or not they viewed the film, children
stranger, that it is wrong for an adult to put his or her who watched the film were more likely to appreciate
hands on one's body, and that it is wrong for anyone to the importance of telling someone about the abuse
tell a child not to tell his or her parents about something even if the perpetrator said he would not do it again.
they did with the child (Sigurdson, Strang, & Doig, They were also more likely to say they would tell
1987). Fryer et at. (1987) pointed out, however, that someone else if the first person they told did not help
pretreatment self-protection concepts and knowledge them.
of techniques do not necessarily relate to children's The advantages of abuse prevention programs are
ability to behave in a self-protective manner in real-life probably best tapped by vignettes and behavioral skill
situations. tests. In the Saslawsky and Wurtele (1986) study, chil-
Pretraining knowledge (and misinformation) may dren who watched the Touch film outperformed those
vary with age, however. Wurtele and Miller (1987) who did not watch the film on a measure called the
found that younger children (M = 6.1 years) were not "What If" Situations Test (WIST). The WIST in-
able to define sexual abuse, whereas older children (M volved four vignettes describing potential encounters
= 11.3 years) were able to provide a relatively accu- with adults who made sexual advances toward chil-
rate description by implying sexual contact. Most of dren. Questions were then asked to determine if the
the children tended to believe perpetrators were male; child (1) recognized the inappropriateness of the situa-
however, younger children tended to believe per- tion, (2) indicated that he or she would verbally refuse
the advance, (3) described a response where he or she BST program for enhancing personal safety skills as
would leave the situation, and (4) listed the names of assessed by the WIST. The treatments were not differ-
those whom he or she would tell about what happened. entially effective across gender or age, but older chil-
Fryer et al. (1987) found that traditional measures of dren performed significantly better than did younger
knowledge and understanding of prevention concepts children. The knowledge and skill gains made directly
were relatively poor predictors of children's actual be- after treatment were maintained for the 3 months be-
havior in situations where they are at risk prior to train- tween posttest and follow-up assessments.
ing. In this study, children first completed a measure of In addition to variations in program content and
self-esteem, the Harter Perceived Competence Scale evaluation strategies, effectiveness of programs may
for Children (Harter, 1982), and a measure of chil- relate to characteristics of children. As already noted,
dren's knowledge of concepts and techniques for pre- Fryer et al. (1987) found that children who had a more
vention of abuse, the Children Need to Know Knowl- positive self-concept prior to training showed the
edge-Attitude Test (Kraizer, 1981). They were then greatest improvements after training. Also, previous
exposed to a simulated potential abduction situation in research has highlighted differences in children's
which they were asked by a stranger to go to his car to knowledge and attitudes about sexual abuse as a func-
help him carry materials to the school. The training tion of age. All the studies reviewed thus far have
consisted of eight 20-min presentations of information focused primarily on elementary school-aged chil-
about sexual abuse and other forms of maltreatment, dren. Borkin and Frank (1986) reported a program
along with behavioral role-plays of techniques for designed specifically for preschoolers between the
avoiding abuse. Children who received the training ages of 3 and 5. The program involved a puppet show,
improved considerably over those who did not receive which was followed by a coloring activity, and empha-
the training, both on the knowledge-attitude measure sized the following rules: Say "No" if you feel uncom-
and the simulated abduction situation. Interestingly, at fortable with someone's touches; run away if neces-
pretest, neither the self-esteem nor the knowledge- sary; and tell someone about what happened. Interest-
attitude test predicted performance on the simulation. ingly, although 76% of the teachers and parents who
However, both measures were predictive of behavior observed the program thought the program did "very
on the simulation after training. Thus, it appears that well" in teaching the rules, and 72% felt the program
those children who had a positive self-esteem prior to was well suited to preschoolers, few ofthe 3-year-olds
training showed the greatest gains on the knowledge- were able to remember any of the rules taught by the
attitude test after training, and also showed the greatest program, and only 43% of the 4- and 5-year-olds were
likelihood of refusing the man's request in the simula- able to remember at least one rule.
tion test. Some programs may be more effective with either
In addition to the importance of assessing behavioral boys or girls, and boys and girls may respond differen-
responses in evaluating prevention programs, it ap- tially to programs. Garbarino (1987) described a study
pears that the most effective programs are those that evaluating the effectiveness of a comic book presenta-
include a component in which children actually prac- tion of sexual abuse information. Two Spiderman
tice behavioral responses to abuse-related situations. comic books deal with sexual abuse and over two mil-
Wurtele, Saslawsky, Miller, Marrs, and Britcher lion have been distributed. In the first comic, Spider-
(1986) compared the effectiveness of various educa- man discovers a boy who has been sexually molested
tional approaches for teaching personal safety skills to by his teenage babysitter. Spiderman subsequently
children. These approaches included (I) a filmed pro- tells the boy his own sexual abuse by an adult male
gram, Touch, (2) a Behavorial Skills Training (BST) who had befriended him. With Spiderman's help, the
program in which modeling, behavioral rehearsal, and boy was able to disclose the abuse to his parents. In the
social reinforcement were used, (3) a combination of second comic, a girl runs away from home because she
the two, and (4) a no-treatment control presentation. In is being sexually abused by her father and because her
comparison with the control presentation, the BST mother refuses to believe her when she tells her.
program, alone or in combination with the film, was Eventually, she meets the Power Pack Kids who en-
more effective than the film alone in enhancing knowl- courage her to tell their own parents, who believe her
edge about sexual abuse. In addition, posttreatment and promise to help her and the girl's family. In order
group comparisons suggested the superiority of the to evaluate the effectiveness of the Spiderman comics,
73 children were given copies and later interviewed. seven percent of the children responded that they had
The following infonnation was obtained. First, the discussed with their parents what to do if someone
girls were less interested in reading a Spidennan comic wanted to look at or touch their private parts, and 80%
book and were less familiar with Spidennan than were of the parents indicated discussing this topic after the
boys. Second, based upon 10 multiple-choice ques- program's implementation.
tions about the comic, it was clear that the majority of
the children understood the story line and remembered Parent Education. It is clear that prevention pro-
key infonnation about sexual abuse. Third, girls re- grams are primarily oriented toward elementary
ported more fear and worry after reading the comic school-aged children. Finkelhor (1986b) suggested
book when compared to boys. Fourth, among fourth that parents also be instructed about how to help pre-
graders, those who read the comic with their parents vent sexual abuse. From a survey of parents, Finkelhor
reported feeling more scared and worried than those found that only 29% said they had discussed the topic
who did not. Although Garbarino interpreted this find- of sexual abuse with their child. When they talked
ing as related to the parents' discomfort, an alternate about sexual abuse, most parents left out important
interpretation is that while sharing the experience with infonnation. Despite the fact that most sexual abuse is
their parents, the parents had the opportunity to ob- perpetrated by someone well-known to the child, only
serve and label the child's discomfort (Conte et al .• 53% of parents mentioned the possibility of abuse by
1986). an adult acquaintance, and only 22% mentioned that
As illustrated by the Garbarino (1987) study, pre- abuse might even involve a family member. Further-
vention programs can result in some signs of anxiety more, most parents were vague about the exact nature
and worry among participants. Although many have of sexual abuse, with only 63% mentioning that sexual
voiced these concerns, evaluations of programs have abuse might involve someone who was trying to take a
generally found the negative side effects to be mini- child's clothes off. Most parents did not talk to their
mal. Wurtele and Miller-Perrin (1987) evaluated chil- children until the child was around age 9, despite the
dren's reactions to the school-based program that used fact that at least 33% of sexual abuse begins when the
the film Touch by assessing children's abuse-related child is younger than 9.
fears, and parent's perceptions of their child's abuse- Many parents had several misconceptions about
related fears and some problematic behaviors thought sexual abuse (Finkelhor, 1986b). Most believed that
to relate to trauma (e.g., cries easily, seeks attention, sexual abuse was less common than it is, that their
nightmares, school refusal, wets bed, and anorexia). child was well supervised, and that their neighborhood
In addition, parents were asked to rate the global effect was safer than most. Most parents were concerned
of the program on their child (good vs. bad effect) and about unnecessarily frightening their children. Never-
were asked whether the child had commented about theless, as Finkelhor points out, most parents warn
the program or had asked questions of them on the children about other possible dangers, such as small
topic of sexual abuse. Results of the evaluation re- animals and cars, even kidnapping, without similar
vealed that the children showed no changes in how concern over making the children fearful. He suggests
fearful they were of abuse-related people or situations, that parents are simply uncomfortable with the topic of
and their parents reported no changes in abuse-related sex.
fears or problematic behaviors as a result of program Finkelhor suggests that prevention programs target
participation. Parents did not report any negative be- particular subpopulations of parents whose children
havioral changes in their children that were due to are statistically more vulnerable to childhood sexual
program participation, and 75% felt that the program abuse, such as custodial mothers who are marrying or
had a positive effect. No parent reported that the pro- remarrying because common law partners and step-
gram had an overall negative effect. Forty-six percent fathers are often perpetrators. Also, he suggests target-
of the parents indicated that their children commented ing mothers who were themselves victimized as chil-
to them about the program. It was hoped that par- dren, since some research suggests that the children of
ticipating in the program would serve as a vehicle for these women may be particularly vulnerable. Perhaps
further discussion at home so that the children could these mothers find discussing sex with their children
obtain additional infonnation and so that the secrecy particularly difficult because such discussions trigger
surrounding the topic could be further diffused. Fifty- strong emotional responses in themselves.
Physician Education. Aside from teachers and many were uninformed of their duty to report abuse,
parents, physicians are likely to have ongoing contact and those who were informed were reluctant to report
with children and are in an ideal position for monitor- abuse to child protective service agencies (Attias &
ing children's health and detecting sexual abuse, par- Goodwin, 1985). Surveys conducted prior to 1985 in-
ticularly for those children who are symptomatic, yet dicated that only one third to one half of cases detected
still unidentified. In a recent study by Hunter, Kil- by physicians were ever reported (J. P. Anderson,
strom, and Loda (1985), 50% of sexual abuse cases Fraser, & Bums, 1973; Anglin, 1983; Chang,
followed by a sexual abuse treatment program in a Oglesby, Wallace, Goldstein, & Hexler, 1976;
hospital setting were first identified in hospital. Key Finke1hor, Gomes-Schwartz, & Horowitz, 1984;
factors identifying children as possible sexual abuse James, Womack, & Straus, 1978). A more recent sur-
victims were the presence of genital symptoms, psy- vey conducted by Attias and Goodwin (1985) revealed
chosomatic complaints and behavioral disorders, and a more optimistic picture, in which 98% of profes-
drug overdoses and suicidal gestures. Their study sug- sionals surveyed (physicians, psychologists, and fam-
gested that "masked" cases of sexual abuse may be ily counselors) were knowledgeable about their man-
distinct from other cases of sexual abuse that were date to report suspected abuse. Nevertheless, when
referred after disclosure. The masked cases were more cases were complicated by a retraction of an alle-
likely to involve infants and toddlers, and there was a gation, one half of the psychiatrists and one third of
higher percentage of males among the masked popula- other professionals indicated they would not report the
tion than the previously identified sample of sexually abuse. Interestingly, 40% of psychiatrists estimated
abused children. Furthermore, masked cases were that 25% or more children fantasized their stories of
more likely to involve incestuous, long-term abuse and abuse. Female professionals were more likely than
the children were more likely to have been identified male professionals to believe incest to be serious and
previously as having school or psychosomatic prevalent, were more likely to report abuse even after a
problems. retraction, and more likely to suggest a physical exam-
Cantwell (1983), convinced that many cases of sex- ination. Male professionals were more likely to over-
ual abuse go undetected even among children identi- estimate the probability of children's reports as fantasy
fied as maltreated in other ways, suggested that phys- and tended to underestimate the frequency of father-
ical examinations of all young girls under thirteen daughter incest.
should include inspection of the vaginal opening to
determine whether sexual abuse should be suspected. Juvenile Offenders. Thus far, most prevention
From routine examinations of girls treated at a program programs have placed the onus on potential victims to
for maltreated children, she found that three of four act to protect themselves against perpetrators. How-
girls not previously identified as sexual abuse victims, ever, Cohen (1986) argued that "the major responsi-
who presented with vaginal openings greater than 4 bility for prevention should not, indeed cannot, be
mm, were later identified as having been sexually placed on the victims and potential victims, particu-
abused. Cantwell (1983) suggested that these exam- larly because they are children" (p. 559). Rather, she
inations can be done without digital penetration and suggests that our major focus of prevention should be
without the use of instruments by simply measuring placed on potential perpetrators and on cultural and
the horizontal plane of the vaginal opening. societal values that allow the problem to persist. Based
Other circumstances that should alert physicians to upon the outcomes of a working conference from the
the possibility of sexual abuse include the presence of National Committee for Prevention of Child Abuse,
vaginal infection, such as gonorrhea (Ingram, White, Cohen outlined several rationales for focusing preven-
Durfee, & Pearson, 1982; Sgroi, 1977), condylomata tive strategies on potential offenders. She argues that
acuminatum (Herskowitz, 1983; McCoy, Applebaum, sexual abuse is an outgrowth of sexual ideas, beliefs,
& Besser, 1982), and genital mycoplasmas with ex- misconceptions, and preferences that are formulated
udative vaginitis (Waites et al., 1983), as well as any during childhood and adolescence. Therefore, chil-
ano-rectal trauma (Black, Pokorny, McGill, & Har- dren should not only be taught how to protect them-
berg, 1982). selves against abuse, but prevention programs should
Although physicians are often in a position of dis- promote an ideology antithetical to exploitive sex.
covering and documenting sexual abuse, historically Thus, sexual abuse prevention efforts should target
those who are most likely to become abusers. One but not abusive, sexual experiences or no inappropriate
group that seems particularly prone to becoming sexu- or abusive experiences, the sexually abused males re-
al abusers are boys who were sexually abused them- ported more dreams of negative sexual experiences
selves. and more dreams of intercourse with nonspousal fami-
Swift (1979) has criticized sexual abuse programs ly members. Sexually abused males reported more
that target potential victims, saying the programs do negative emotional reactions during intercourse, less
not prevent abuse but displace abuse onto younger, frequent sexual arousal during intercourse, more sexu-
weaker, more vulnerable, and less-informed children. al fantasies involving children, and a greater desire to
To support her position that prevention efforts be di- fondle or engage children in sexual activities. Further-
rected toward potential perpetrators, she cites the more, sexually abused boys showed more signs of de-
cyclical pattern of sexual abuse for males. Studies of pression, sleep disturbance, and posttraumatic stress
sex offenders reveal that a disproportionate number disorder than any other group.
were sexually abused as children or adolescents. Ser- Ryan, Lane, Davis, and Isaac (1987) described a
rill (1974) found that 75% of 150 male sex offenders at dysfunctional cycle of how abused boys develop a pat-
Rahway State Prison in New Jersey were sexually tern of abusing younger children. The cycle begins
abused as children. Groth (1979) found that at least with a poor self-image and expectations of rejection.
one third of males convicted of sexual assaults spon- Isolation and withdrawal ensue, followed by feelings
taneously reported childhood sexual abuse. Gebhard, of anger and blame of others. Fantasies and plans of
Gagnon, Pomeroy, and Christenson (1965) reported retaliation and self-aggrandizement occur, which give
that most homosexual pedophiles had their first sexual way to sexual acting out against weaker targets. As a
experience before age 14. Furthermore, Chapman and result the offender feels afraid and vows never to do it
Lloyd (1982), working within a hospital setting, found again, which leads to further reduction in his self-
that one third of the identified perpetrators were ado- esteem.
lescents. Thomas (1982) found 46.8 % of identified Ryan et al. (1987) described a treatment process that
perpetrators to be juveniles. To magnify the extent of begins with confronting the offender's denial. The of-
the problem of adolescent offenders, the majority of fender is then made aware of the sexual assault cycle
identified adult perpetrators revealed histories of vic- described above and taught alternative modes of think-
timizing younger children when they were teenagers ing and behaving when the cycle is recognized. Jour-
(Groth, Longo, & McFadin, 1982). Therefore, adoles- nals can be used for recording components of the cy-
cent offenses cannot be viewed as a phase-of-life prob- cle. Self-esteem can be addressed via individual and
lem; many times their offenses set the stage for a long family sessions, and sex education and heterosexual
history of serial offenses. Altogether, these sobering dating skills can be taught to enhance the probability of
statistics mandate an additional focus for prevention appropriate sexual behaviors. Activities, such as read-
efforts that (1) encourage boys to report their sexual ing victim-impact statements, viewing films about the
abuse, (2) provide sex education and treatment for impact of sexual abuse (e.g., Silent Scream), or engag-
abused boys, and (3) identify and treat adolescent ing in face-to-face confrontations with the victim, can
offenders. help to sensitize the offender to the impact of his behav-
Recent evidence suggests that primary prevention ior on the victim. Other treatment approaches include
can be accomplished by treating sexually abused boys. covert sensitization and aversive conditioning to re-
However, sexual abuse of boys is even less likely to be duce sexual arousal to children.
reported than abuse of girls, and boys may only come Smets and Cebula (1987) described a group ap-
to the attention of official agencies after they are re- proach to treat adolescent sex offenders using a five-
ported for having sexually abused other children. Ur- level program. Participants are told the group will not
quiza (1988) described a survey of young college end until all group members reach Level 5. The pro-
males that reveals the process by which abused boys gressive steps are: (1) acknowledgment of adjudica-
may become abusers themselves. The survey revealed tion, (2) details of offenses, (3) details of sexual devel-
that 17% of college males reported some form of sexu- opment, (4) enhancement of insights into their
al abuse as a child. One half reported oral-genital con- behavior and sexuality, and (5) established plans to
tact and one third reported anal or vaginal penetration. avoid subsequent offenses. Smets and Sebula indicate
One quarter reported a female perpetrator. As com- that most groups require 12 sessions of 1Y2 hours
pared to males who reported a history of inappropriate, each.
Investigative Interviewing. Proper investiga- can terminate the interview or change topics whenever
tive interviewing is important for several reasons. they show signs of feeling uncomfortable. Paradox-
First, the basis for any further action on behalf of the ically, she found children were actually more likely to
child is contingent upon the quality of the information provide information when she gave them many oppor-
gleaned from the interview. Second, if the investiga- tunities to avoid the topics.
tion is not conducted properly, charges may not be To maximize the accuracy of the information, the
pursued because the interviewer may be accused of interviewer should be aware of his or her potential to
planting seeds for the child's story through leading bias the child's report (Underwager, Wakefield,
questions. Third, the investigative interview serves as Legrand, Bartz, & Erickson, 1986). White (1986)
the child's introduction to the "helping system," and goes so far as to recommend that the person interview-
may facilitate the child's involvement with therapeutic ing the child should remain relatively uninformed
services, as well as with the child's ability to serve as a about the specifics of the case until after the interview
witness in courtroom procedures. with the child. Underwager et al. (1986) suggested
Investigative interviews can be conducted by a that the interview be videotaped not only to avoid mul-
number of professionals, including police, social tiple interviews by other professionals, but also to be
workers, and psychologists. Although not true in used as a reliability check when reviewing the inter-
many cases and communities, investigative interview- view. Questions should be open-ended and should
ing should only be conducted by those who are exten- avoid leading the child as to potential responses. Stud-
sively trained in interviewing young children and in ies of children's recall indicate that open-ended ques-
child development, and who have knowledge of and tions produce the most accurate, although incomplete,
experience working with sexually abused children. accounts of events (Dent & Stephenson, 1979). In-
Investigative interviews are often conducted over terestingly, asking children to recall the event soon
several sessions, with the first session focused on after it occurred facilitates recall several months later.
building rapport, general development, and adjust- However, even when questioned after several months
ment to school, peers, and family (Gilgun, 1984). Fun- for the first time, recall is generally accurate, although
neling from the broad to the specific, information less complete. In most cases, interviewing should be
about the sexual abuse should include the name of the conducted without the presence of parents. Once the
perpetrator, the child's relationship to the perpetrator, investigative interview is complete, however, some
the duration and frequency of the abuse, and details of professionals suggest interviewing the child in the
the sexual behavior, including places and circum- presence of both parents, particularly when there is a
stances surrounding the abuse, date and time of the last custody and access dispute. However, interviewing
occurrence to assess the likelihood of physical evi- the child in the presence of the accused perpetrator
dence, whether anyone else was involved or observed magnifies the potential for retraction of the story or
the abuse, whether the child told his or her mother and alteration of the story such that the parent may no
the mother's response to the abuse, other people who longer be implicated in the abuse.
know about the abuse, the methods employed to gain Many children lack the vocabulary to communicate
compliance, why the child disclosed the abuse, and the clearly about what happened to them. Drawings, pic-
child's assessment of the situation and what he or she tures, and anatomically correct dolls are often used to
believes will happen next (Wells, 1984). facilitate communication. Anatomically correct dolls
Considering the investigative interview as the initial have received a lot of attention as interview aids and, in
step in therapy, children can also be asked about what some cases, as a projective medium. Generally, at least
they felt before, during, and after the abuse, and per- four dolls are involved in the interview: a male and
ceptions of their role in the abuse. The child's under- female adult and a male and female child. When used
standing of the perpetrator's deviance and their under- as part of the investigative interview, the child is given
standing of human sexual interaction can also be the opportunity to play with the dolls and is encour-
explored (Gilgun, 1984). Gilgun (1984) recommends aged to undress them. White, Strom, Santille, and
that a child's right to self-determination in the inter- Halpin (1986) used a five-part standard protocol for
view be placed at par with the goal to obtain complete interviewing children with the anatomically correct
and accurate information. Although interviews should dolls: (1) naming the doll and labeling it male or
not continue over excessive time periods, Gilgun ad- female; (2) naming body parts and function; (3) knowl-
vises that children be reminded frequently that they edge of private parts; (4) abuse evaluation, including
questioning the child if she or he has ever been touched sexual behaviors, stress or trauma-related symptoms,
or hurt in the private areas, or has ever been threatened such as bedwetting, fearing darkness, refusing to be
to keep a secret; and (5) abuse elaboration. To evaluate left alone, nightmares, increased dependency, and un-
the validity of the interview process, interviewers used cornfortableness with men or boys.
an anchored rating scale of suspicion of sexual abuse As noted previously, professionals are most cau-
following the interview. Sexually abused children tious about children's reports of sexual abuse when
scored significantly higher than children in a non- custody and access disputes are involved. Although
abused group. Older sexually abused children were fictitious reports of sexual abuse are often related to
more likely to report abuse that was consistent with custody and access disputes, sexual abuse of young
other sources of information. children occurs more frequently in the context of mar-
Jampole and Weber (1987) compared sexually ital dissolution, with fathers the primary perpetrator
abused children to nonsexually abused children in soli- (Mian, Wehrspann, Klajner-Diamond, leBaron, &
tary free play with anatomically correct dolls. Ninety Winder, 1986). Therefore, no allegation of sexual
percent of the sexually abused children demonstrated abuse in a custody and access dispute can be dis-
sexual behavior with the dolls, as compared with 20% regarded. Even if fabricated or coached by a vindictive
of the nonabused group. Interestingly, the sexual be- parent, a thorough evaluation is necessary to ensure
havior depicted by the nonabused group included vagi- that the marital conflict does not cause further damage
nal and oral intercourse. Therefore, sexual play with to the child. Complications arise in the investigation of
anatomically correct dolls should not by itself be used sexual abuse with noncustodial fathers because access
as evidence of sexual abuse. must be denied for a period of time sufficient to allow
Until recently, a paradox existed as to children's for a proper investigation. Unfortunately, child protec-
allegations of sexual abuse. Although it was often as- tive service workers may feel that their power to re-
sumed that children never lie about sexual abuse, their strict visitation during the investigation is limited, and
testimony in court was suspect and they were thought visitation may be restored. Once visitation is restored,
to make poor witnesses. These dogmas have given way and if a child's story alters, it is unclear whether the
to more thoughtful consideration of both positions. child has been pressured to recant or whether the origi-
Although approximately 47% of cases of reported sex- nal story was a fabrication.
ual abuse go unfounded (Jones & McGraw, 1987), Methods of assessing custody and access cases
only 8% can truly be considered fictitious. Of those where there are allegations of sexual abuse, and in-
fictitious reports, three fourths were generated by terpretation of the resulting information, are not clear-
adults, often in custody disputes. Of the unfounded ly established, and are hotly debated, as evidenced by
cases, 24% of the cases did not produce enough infor- two recent articles (Corwin, Berliner, Goodman,
mation to categorize, and 17% of the cases followed a Goodwin, & White, 1987; Green, 1986). Green
legitimate suspicion that was not substantiated during (1986) advocates longer evaluation periods with fre-
the investigation. quent contacts between the professional and the child.
Given even a small percentage of cases in which One of the Green's recommended assessment pro-
abuse may be fabricated, it is important to examine a cedures is to interview the child in the presence of the
child's report for credibility. Faller (1984) suggested alleged abusing parent. He suggests that true alle-
that a child's ability to provide details about the abuse gations of sexual abuse are accompanied by fear-
and emotional responses consistent with topics dis- fulness and inhibitions on the part of the child when in
cussed enhance the credibility of the child's report. the presence of the father. He also advocates that false
Sgroi (1982) suggested that as children's descriptions allegations are characterized by the child's facility in
mirror what is generally known about the process of providing abuse details and "checking" with the
sexual abuse, credibility is enhanced (i.e., multiple mother before proceeding with their stories.
incidents over time, progression in the severity of sex- Corwin et at. (1987) criticize Green's methods of
ual activities, secrecy, pressure and coercion, and abil- investigation and his interpretation of the information,
ity to provide specific information about the sexual and cautions professionals against an oversimplified
behaviors that occurred). Other sources of evidence approach to the complex problem of alleged sexual
may corroborate a child's story (Faller, 1984): the abuse in custody disputes. They warn that misdiag-
child's report to significant-other adults, sexualized nosis can lead to failure to protect children that were
doll play or drawings, age-inappropriate knowledge of indeed sexually abused and caught in a custody battle.
They criticize Green's formulation as based upon "an child's recovery? (2) In intrafamilial abuse cases, who
inadequate data base, a biased sample, and unsup- should leave home-the perpetrator or the child? (3)
ported conclusions." In particular, they caution that Should the perpetrator be prosecuted? and (4) What
interviewing the child in the presence of the alleged therapeutic services should be rendered for the child
perpetrator can be potentially damaging to the child, and the family?
with an unpredictable outcome in terms of the child's Interestingly, relatively few cases of sexual abuse of
response. In addition, interpreting lack of fear with the children are ever reported to official agencies, much
perpetrator as a false allegation, runs against the obser- less result in criminal prosecution. Tirnnick (1985),
vation of many professionals working with incestuous reporting the results of the Los Angeles Times poll of
families who note rather positive interactions between adults who were sexually abused as children, found
some abused children and their abusing parent. As that only 3% of those who ever disclosed their abuse to
well, as Corwin et al. note, Loftus (1979) has demon- anyone told the police or other appropriate agency.
strated that ease in reporting the details of a stressful Seven out of 10 of those who did report the abuse to an
event is actually related to greater accuracy in report- official agency stated that no effective action was ever
ing. Finally, "checking" with mothers during inter- taken. Alarmingly, Groth et at. (1982) reported that by
views can also be interpreted as the well known phe- the time they are prosecuted, child molesters have vic-
nomenon of "social referencing," a common pattern timized an average of 4.7 additional children.
for individuals in ambiguous or novel situations.
Bressee, Steams, Bess, and Packer (1986) recom-
Crisis Family Counseling
mend that two interviewers become involved in these
cases, one for the child and one for the parents. Fathers Parents often feel in a quandary as to how to deal
who sexually abuse their children may exhibit some with the sexual abuse with their child and may fear that
corroborating personality characteristics, such as poor their responses may either cause psychological harm to
impulse control, self-centeredness, strong dependency their child or that discussion with their child about the
needs, poor judgment, and difficulty monitoring and abuse may jeopardize prosecution of the offender. The
directing emotions. Vindictive mothers may display result may be that the parent totally deemphasizes the
several characteristics as part of the interview. The abuse, which may communicate to the child that he or
mother may not be able to describe what made her she should cope by forgetting it. The following recom-
suspicious of the sexual abuse, may resist allowing the mendations can be made to parents after the disclosure
child to be interviewed alone, may resist alternate ex- of their child's sexual abuse (Berliner, 1977; Funk,
planations for the abuse, may be eager to have the child 1980; Weeks, 1976):
testify in court, and may pursue the matter despite neg-
ative results and its detrimental impact on the child. In 1. Convey your belief in the child's story.
contrast, mothers who have not coached their child tend 2. Avoid judgmental remarks about the child, the
to express remorse at not protecting the child, express perpetrator, or the way the case is being han-
concern about the impact of courtroom testimony on the dled by community professionals.
child, allow the child to be interviewed alone, and are 3. Ensure the child's safety by restricting aecess
willing to consider alternate explanations. Again, these by the perpetrator.
guidelines should be interpreted very cautiously, as 4. Instruct the child as to what to do if the per-
empirical investigation of their validity have not been petrator should attempt to make contact.
conducted. 5. Reassure the child of safety and that the child is
physically OK.
6. Consult with family physician about the neces-
Disclosure Crisis sity of a physical exam.
7. Encourage discussion of the abuse, but respect
Once sexual abuse has been disclosed or discovered the child's privacy and avoid interrogation or
and verified through the investigative interview, sever- overemphasis on the abuse.
al questions and decisions face those who are responsi- 8. Remain calm and discuss issues in a matter-of-
ble for the child: (I) How should caretakers respond to fact manner.
the child's allegations and how can they themselves 9. Keep routines as stable as possible.
cope with the new information while fostering the 10. Inform those who are involved with the child
(siblings, teachers, grandparents) about what to the child's family, lack of cooperation from the child
has happened, but do not provide unnecessary or the child's family, concerns that such matters are
details that the child may consider private. better managed through mental health services, and
lack of evidence or concern that the child will not be
One important factor to consider when talking with able to provide credible testimony. In general, several
parents after the disclosure of child sexual abuse is that factors differentiate those cases where prosecution is
the parents themselves will be undergoing a crisis. pursued: the perpetrator was not a family member; the
Allowing the parents a forum for discussing their own child was between the ages of 7 and 12 years of age;
reactions and concerns can be important (Funk, 1980). and the accused had a prior record with the police or
Parents can be told what kinds of behavioral reactions had a history of drug, alcohol, or spouse abuse. As
they may expect from themselves and their child, well, cases first reported to police are more likely to be
and be praised for those aspects of the situation that prosecuted than those reported to the child protective
were well handled. Some of the problems parents can service agencies.
be forewarned of include: sleep disturbance, loss of Despite the many concerns about children's par-
appetite, bedwetting, irritability, need for assurance, ticipation in the criminal justice system process, pros-
fears, clinginess, developmental regression, and other ecution of offenders has several societal and social
changes in behavior. Nevertheless, parents can be as- functions as well as potential psychological benefits
sured the abuse need not impose lifelong adjustment for victims (V. V. Wolfe, Sas, & Wilson, 1987). First,
problems. prosecution provides a clear motivation for the of-
In cases of intrafamilial abuse, particularly when the fender to stop the abuse and ensures protection for the
perpetrator was the mother's spouse (either the child's child. Second, rates of prosecution reflect the commu-
father or stepfather or the mother's common law part- nity's norm that such behavior is considered morally
ner), immediate protection of the child will require that and legally wrong, and that violation of sexual abuse
either the perpetrator leave the home or the child leave laws will not be tolerated (Bulkley, 1982; Finkelhor et
and be placed with a relative, family friend, or in foster at., 1984). Third, even treatment programs that offer
care. In most cases, the resolution is for the child to therapy for offenders whenever possible, as opposed to
remain in the home and the perpetrator either opts to incarceration or other forms of punishment, have rec-
leave or the mother makes that decision for him. ognized the importance of working closely with the
Nevertheless, in some cases, mothers do decide to criminal justice system in order to improve the proba-
continue living with her spouse, and foster-care ar- bility that the perpetrator will become engaged in ther-
rangements must be made. Based upon evidence from apy. Some communities have instituted "prosecution
a national reporting system for child abuse and ne- diversion" programs, in which charges are not im-
glect, approximately 17% of children who disclose posed on the condition that the perpetrator admits guilt
sexual abuse are placed outside the home (Finkelhor, and responsibility for the abuse and becomes engaged
1983b). In general, older children who report their in therapy (e.g., see Giarretto, 1982). Prosecution di-
abuse to an official agency are most likely to be moved version programs have been criticized in some com-
to foster care, and are generally in agreement to leave munities because treatment recommendations are
the home. Other factors that contribute to foster place- often not followed, and criminal proceedings are often
ment include: abuse by a parent, collusion of the moth- difficult to reinstitute. Other communities have opted
er or the mother's failure to act to protect the child, to prosecute first and have therapeutic involvement as
multiproblem families, especially those characterized a part of probationary terms. Unfortunately, prosecu-
by alcoholism, and a history of other forms of mal- tion can take up to 2 or more years, and thus treatment
treatment within the family. may not occur in a timely fashion. Fourth, if courtroom
procedures are handled appropriately and if the child is
adequately prepared, involvement with the criminal
Decisions about Prosecution
justice system can be therapeutic for the child, because
According to a recent analysis of a United States it can help him or her gain a sense of mastery over the
data base (Finkelhor, 1983b), approximately 24% of victimization experience.
officially reported sexual abuse cases result in criminal Unfortunately, participation in criminal litigation
prosecution. Reasons for not prosecuting include con- can present a succession of stressful events for which
cerns that such action will be detrimental to the child or the child is unprepared (V. V. Wolfe et at., 1987). Prior
CHAPTER 33 • SEXUAL ABUSE OF CIDLDREN 719
to court, children are often required to relate repeat- the circumstances surrounding the abuse, and thus the
edly the details of their abuse to police officers, pros- children who went to court may have experienced
ecutors, child protection workers, and mental health more serious abuse, or the circumstances of the abuse
professionals. Such repeated interrogations may have were more traumatizing.
the emotional effect of repeatedly stirring the thoughts Two more recent studies have addressed this issue.
and feelings associated with the abuse in fear-produc- Runyan, Everson, Edelsohn, Hunter, and Coulter
ing environments. As court dates approach, children (1988) conducted a prospective study of 100 sexually
often show heightened emotionality, sometimes fo- abused children, ages 6 to 17. All children tended to
cused specifically around the trial, but also of a diffuse show a high degree of distress at the initial assessment
nature, with symptoms of increased distractibility at after disclosure of the abuse. Of those not involved in
school, noncompliance, irritability, and somatic sys- court, a 30% improvement in symptoms was noted
tems. The child may seem more fearful, dependent, over a 5-month period. For those awaiting court, an
and show excessive need for assurance and protection. improvement of 17% was observed over the 5-month
One major problem for children who serve as witness- follow-up period. However, for those children who
es is that they often must go to court many times, often had already participated in juvenile court proceedings,
waiting to testify only to discover that the trial date was a 42% improvement on an anxiety measure was noted
postponed or the defense was granted a continuance. at follow-up, as compared with a 17% improvement on
During courtroom testimony itself, the child must other measures. The authors concluded that testimony
face several stressful situations. First, because the in juvenile court may be beneficial in reducing anxiety,
mother or other close family members may be called as whereas protracted proceedings within the criminal
witnesses, the child must often be in the courtroom justice system may have an adverse effect on the
without a close ally. Second, because the defendant child's overall mental health.
has the constitutional right to confront the accusor, the Tedesco and Schnell (1987) assessed children's
child generally must testify in the presence of the per- global perceptions of the court procedures as helpful or
petrator. Many children anticipate that this will be the hannful. Of the 48 participants, 48% felt the experi-
most frightening aspect of courtroom testimony and ence was helpful, 19% felt the experience was
fear either the perpetrator will make negative gestures hannful, 19% felt the experience was both helpful and
or comments to them or that the anxiety and/or anger hannful, and 5% felt the experience neither helped nor
evoked upon seeing the defendant will interfere with hanned them. Males tended to see the process as more
their ability to tell their story. Third, as a witness, the helpful than females, and incest victims seemed more
child must disclose in a public forum the precise details conflicted as to whether the process was helpful or
of the sexual acts that occurred. Fourth, once ques- hannful. As well, the greaternumber of interviews and
tioned by the prosecutor, the child must undergo a testifying in court correlated negatively with the
second round of questioning by the defense attorney child's perception of the process as helpful.
(Y. Y. Wolfe et al., 1987). Innovative communities have developed a number
In general, the research investigating the impact of of ways to counteract the problems of mUltiple inter-
courtroom testimony indicates that these children take views prior to trial (V. V. Wolfe et al., 1987). Some
longer to overcome the negative sequelae to the abuse communities have designated one individual or group
than do children who are not required to testify. Gib- of individuals as solely responsible for interviewing
bens and Prince (1963) compared a sample of child abuse victims; and, in addition, videotaping now ne-
victims who were involved in criminal proceedings gates the need for a succession of subsequent inter-
with a random sample of child victims who were not views. Various community systems have been devel-
involved in court proceedings. They found that 73% of oped to help coordinate the services to sexually abused
the court sample had significant behavior problems children and their families. The most noteworthy, the
compared with 57% of the random sample. In addi- Children's Advocacy Center in Huntsville, Alabama
tion, recovery rates were substantially faster for the (Cramer, 1985), provides a central place through
sample of children who did not participate in court. which agents of the district attorney's office, child pro-
Although 57% of the random sample of sexually tective services, mental health, and police work to-
abused children recovered quickly, only 18% of the gether through the investigation and then coordinate
court sample managed to recover over the same period plans for treatment, protection, and prosecution. De-
of time. Unfortunately, the study failed to control for spite the success of the Children's Advocacy Center,
other communities have reported serious difficulties (4) reinforcing themselves and appraising their perfor-
coordinating their services (Byles, 1984; Dale, Wa- mance after coping with the stressor. Guided imagery
ters, Davies, Roberts, & Morrison, 1986; Thomas, can be helpful, during which children can imagine
Rogers, Lloyd, & Sihlanger, 1985). Interagency con- themselves in the courtroom confronting stressful
flict was related to differences in roles and in the per- events successfully and using the coping self-state-
spective as to what was best for the child, variations in ments throughout. These procedures can be especially
effectiveness of interventions and in expertise among helpful in reducing panic associated with thoughts
professionals, and lack of clear leadership. about the court appearance. Rather than feeling help-
To reduce the stress children experience in court, less and overwhelmed, children can mentally rehearse
several reforms have been considered: broadening ex- coping successfully in the courtroom setting.
ceptions to the use of hearsay evidence, use of vid-
eotaped testimony, closed courtroom trials, and use of
closed circuit television (the child presents information Treatment
in a "mini-courtroom," which is televised directly into
the larger courtroom such that the defendant can ob- Following the disclosure of sexual abuse, children
serve the child's testimony). Other courtroom reforms often present with a wide variety of symptoms. Many
include assigning special district attorneys to follow of the symptoms reflect a pattern of behavior associ-
cases from start to finish and restricting the conditions ated with posttraumatic stress disorder (Burgess,
under which trial continuances and postponements can Hartman, McCausland, & Powers, 1984; V. V. Wolfe,
be granted. Gentile, & Wolfe, 1989): intrusive thoughts, recurrent
In addition to modifying courtroom protocol, Whit- nightmares, avoidance of abuse-related stimuli, fears,
comb (1985) suggested that simply "demystifying" diminished interests in previously enjoyed activities,
the courtroom may prove sufficiently beneficial in re- estrangement from others, heightened arousal, sleep
ducing children's court-related stress. Victim/witness disturbance, and concentration difficulties. Associated
assistance programs are available in many commu- features include depression, anxiety, impulsivity,
nities to acquaint children with the court facilities and guilt, and suicidal ideation and gestures. Other symp-
the various courtroom personnel. These individuals toms associated with the abuse include feelings of stig-
are often available to attend the trial with the child, and matization, helplessness, hopelessness, and negativity
can teach the child such courtroom etiquette skills as about sexuality (Browne & Finkelhor, 1986). As well,
the correct way to address the judge, what to do if the some children display aberrant sexual behavior, in-
child does not understand questions, the importance of cluding inappropriate sex play with other children, se-
speaking loudly and clearly, and the appropriate dress ductive behavior with adults, and excessive masturba-
for court. Meeting the district attorney to review prob- tion (Adams-Tucker, 1984; Friedrich, Urquiza, &
able direct- and cross-examination questioning can Beilke, 1986; Yates, 1982).
also help prepare the child for the courtroom appear- Studies have demonstrated elevations on both the
ance. Internalizing and Externalizing scales of the Child Be-
In addition to familiarizing children with the havior Checklist (Friedrich et ai., 1986; V. V. Wolfe et
courtroom process, children can also benefit from anx- al., 1989). On the externalizing dimension, problems
iety management techniques for pretrial and intrial with aggression, cruelty, delinquency, destruction,
stressors and cognitive behavior therapy to help them and running away have been highlighted. However,
view their courtroom experience as one to be mastered Gruber and Jones (1981) point out that the externaliz-
rather than as one to be dreaded and avoided (V. V. ing behaviors of sexually abused children may be less
Wolfe et al., 1987). Anxiety management techniques related to the sexual abuse than to the disorganized,
include systematic relaxation and systematic desensi- chaotic features of their families. They found that the
tization to a hierarchy of court-related stimuli. Based families of sexual assault victims are often charac-
on a model developed by Veronen and Kilpatrick terized by marital discord, abusive relationships, alco-
(1983), children can be taught a "guided self-di- holism, and criminal behavior. Furthermore, V. V.
alogue" of self-statements to use in (1) preparing for Wolfe et af. (1989) found that 60% of their sample of
the stressor, (2) confronting and handling a stressor, sexually abused children had suffered either other
(3) coping with feelings of being overwhelmed, and forms of maltreatment, such as physical abuse or ne-
glect within their family, or had witnessed spousal vio- learning about the abuse and its impact on the child is
lence. For a complete description of assessment issues neglected.
and methods, see V. Wolfe and D. Wolfe (1988). Childhood sexual abuse, particularly intrafamilial
To date, there is little systematic research regarding abuse, is a complex problem that cannot usually be
treatment for sexually abused children. In fact, most of treated by one method exclusively. Comprehensive
the literature reflects a tendency to treat the sexually treatment programs generally include individual,
abused child within the context of the family, particu- group, dyadic counseling, and family therapy compo-
larly when the abuse was incestuous. Several authors nents, with family members participating in differing
have criticized this approach as failing to address the therapies depending upon their needs and their pro-
needs of the child and placing the needs of other family gression toward resolution of their problems. Probably
members above that of the victim (Adams-Tucker, the most widely known and comprehensive program is
1984; Hoier, 1987). Regardless of focus, many of the the Child Sexual Abuse Treatment Program (CSATP)
treatments described in the literature either do not ad- of Santa Clara County, California (Giarretto, 1982).
dress sexual abuse specifically and attempt to treat the This program consists of three components: profes-
problem as a symptom of underlying causes, or fail to sional staff, volunteers, and self-help groups. The pro-
provide enough detail about treatment to facilitate rep- fessional staff includes all members of the county who
lication and also lack the rigorous methodology to sup- are officially responsible for the protection and treat-
port claims of success (Conte, 1984). ment of sexually abused children. The major thrust of
Several authors have discussed problems in provid- the program appears to be a variety of self-help groups,
ing therapy for sexually abused children and their fam- which are broadly defined as Parents United, including
ilies. In general, families tend to have numerous prob- groups for perpetrators, nonoffending mothers, and
lems and are in a state of flux after the disclosure couples, as well as groups for social skills, orientation,
(Krener, 1985). Often such families have difficulty and the training of group leaders, and Daughters and
focusing their attention on specific problems and also Sons United. Each group runs 8 sessions each. The
have problems complying with treatment. Children Santa Clara Parents United program boasted over 200
who are seen in individual sessions may have problems members in 1982, with weekly participation of over
with transference because the situation itself may re- 125 members, and 120 members for the Daughters and
mind them of their abuse (e.g., private sessions with Sons United group.
one individual, sometimes of the same sex as the per- The Parents United creed contains the following ob-
petrator, in an air of secrecy and confidentiality) jectives: friendship not judgment; better understanding
(Jones, 1986). The therapist may feel outrage at the of self and the child; appropriate expression of anger;
treatment received by the child by the perpetrator and acceptance of self as human; acceptance of help; ac-
by other agencies, such as police or protective ser- ceptance of no quick cure for their problems; facilita-
vices. tion of patience; optimism about each day; acceptance
Solin (1986) discussed the potential for displace- of occasional backsliding; acceptance that there is al-
ment of affect in families following incest disclosure. ways someone to listen and help; and becoming lov-
In many incestuous families, part of the problem has ing, constructive, and giving parents. The creed for
been the inability to openly discuss problems. When Daughters and Sons United includes: alleviation of
faced with the problem of incest, anger toward various trauma via emotional support; promotion of personal
members of the family may be too difficult to express growth and communication skills; alleviation of guilt;
directly, and thus is displaced onto "safe" targets- prevention of self-destructive behavior; prevention of
often helping agencies. Solin suggested this frequently reabuse via assertiveness, independence, and self-es-
happens when intervening agencies fail to respond teem; prevention of dysfunctional emotional and sexu-
with concern for all family members' welfare, includ- al relationships; and breaking multigenerational pat-
ing the perpetrator. Negative attitudes and comments terns of abuse.
toward a family member may well generate enough Giarretto (1982) described the program as human-
family loyalty to create a desire to protect each other istic and reported the focus was to rebuild the family
and to see the intervening agencies as callous and dis- around the mother-daughter core. In order to facilitate
ruptive. Unfortunately, when families focus their an- this, treatment was ordered as follows: individual
ger at the helping agencies, the important business of counseling for child, mother, father; mother-daughter
counseling, marital counseling, father-daughter Jones (1986) emphasized several additional issues
counseling, family counseling, and group counseling. that are important for therapy with sexually abused
Several comprehensive treatment programs have de- children: their sense of vulnerability, their feelings of
veloped with the Santa Clara County CSATP as the being neglected and emotionally abused, their feelings
model, including programs in Alberta, Canada (C. of being exploited, and their adaptation to the abuse
Anderson & Mayes, 1982), Hartford, Connecticut through such processes as dissociation, sexualization,
(Bander, Fein, & Bishop, 1982), and Virginia Beach, mutuality, and gUilt. Dawson (1984) recommended
Virginia (Deaton & Sandlin, 1980). that treatment address the following goals: the child's
Statistics from the Santa Clara County program in- guilt, fears, and ambivalence about the perpetrator and
dicate that 90% of the children return to their homes, the abuse, and the child's self-esteem, assertiveness,
and the recidivism rate of families who complete the and knowledge about sexuality.
program is less than 1%, with 85% of the offenders Two avenues toward treating sexually abused chil-
returning to live with the family. Also, the program dren are individual and group therapy. From the
reported a 40% increase per year in the number of CSATP model, all family members, including the
families referred to the program, with the majority of child, receive individual therapy. One of the stated
offenders opting for participation in the program over objectives of the individual therapy is to prepare the
potential prosecution. Unfortunately, evaluation of the victims for other forms of therapy, such as group and
program has been based solely upon gross outcome family work. Unfortunately, the model does not out-
measures, such as reuniting family members and re- line the specific components or objectives of the pre-
ports of subsequent abuse. Additional research is scribed individual therapy.
needed into child adjustment following treatment and Jones (1986) suggested that individual therapy is a
observation of family interaction patterns. model of intervention most important for young chil-
dren under 6 years, children who are withdrawn or
depressed, and children with a damaged self-esteem.
Therapy for the Child
Jones described three stages of the therapy. For the first
Several authors have discussed the issues and goals stage, play is used to build rapport and allow ex-
of therapy with sexually abused children. Concep- pression of the traumatic aspects of the experience.
tualizing sexual abuse sequelae as PTSD, Johnson During this phase, the individual therapist can facili-
(1987) suggested these patient treatment goals: (1) tate the child's awareness of emotions by identifying
gaining access in a safe, controlled way to traumatic them as they occur and by discussing the meaning of
memories and overcoming tendencies of denial; (2) the play at later points. During the middle phase of
working through the trauma by acknowledging, exam- treatment, discussion with the child may focus on
ining, and conceptualizing it; and (3) rejoining the themes of guilt, threats and use of violence, neglect,
world by interacting with other trauma victims, find- loss, depression, and dissociation, as well as issues
ing forgiveness for oneself, and going on with one's with regard to attending court. During the closing
life. phase, issues of attachment to the therapist and feel-
McCarthy (1986) suggested that cognitive-behav- ings of abandonment and rejection must be explored
ioral therapy with sexual assault victims can address because the end of therapy for some children may be
the manner in which the child conceptualizes the trau- likened to the ending of other significant relationships
ma and can examine the child's coping strategies. from their past.
Common self-defeating coping mechanisms include To facilitate emotional expression, art therapists can
avoidance and denial, anxiety and guilt, and taking the be engaged for either individual or group work with
role of the perpetrator. He felt that the critical issue is sexually abused children. Naitove (1982) defined the
preventing the sexual abuse from negatively control- goals of art therapy as (1) involvement in a gratifying
ling sexual self-esteem. Goals for the cognitive inter- art experience to enhance self-esteem; (2) expression
ventions are to (1) view sex in a positive light, (2) to of conflict and a mode through which the child can
see sexuality as a vital component of personality, and work toward resolution; (3) development of an alliance
(3) to understand that sexual expression can enhance with the therapist and facilitation of independence; and
the quality of life. The restoration of a sense of sexual (4) acceleration of delayed cognitive and functional
comfort and the feeling of being in control of future behavior. For examples of various forms of art therapy,
sexual encounters are seen as two overriding goals. see Mazza, Magaz, and Scaturro (1987) for poetry;
Goodill (1987) for dance; MacKay, Gold, and Gold damaged. Specific knowledge and skill deficits can be
(1987) for drama; and Wheeler (1987) for paraverbal addressed as well, such as information about court, sex
therapy. education, self-protection skills, and social and het-
Two clinical case examples have been published that erosexual skill development (Riva, 1989; Sturkie,
describe behavior therapy techniques used as part of 1983). Children may wish to discuss their ambivalence
therapy for sexually abused children. Becker, Skinner, about the abuse and their feelings toward the per-
and Abel (1982) described treatment of a 4-year-old petrator. Children may need to know that sexual re-
victim of incest who displayed the symptoms of sponses are automatic physical responses to sexual
anorexia, phobias, and self-injurious behavior. A be- stimulation, just as laughing and wiggling are auto-
havior management program was successful in facili- matic responses to tickling (Sturkie, 1983).
tating eating via a sticker chart program and in reduc- To facilitate group expression, several activities
ing fears and self-injurious behavior via contingent have been reported: discussion of sexual words and
withdrawal of attention. reactions to them; Kinetic Family Drawings and dis-
Kolko (1986) treated an ll-year-old sexually abused cussions of content; and role-plays and dramas with
male who had sexually abused another child. Targeting themes of regression, court, counseling, marriage, and
interpersonal skill deficits, instruction, modeling, and social workers (Delson & Clark, 1981). Inhibitions
role-playing with feedback were used to improve voice about body contact can be addressed with the use of
quality, eye contact, and physical gesturing. Coaching "soccer boppers," circles of held hands, round-robin
and didactic instructions were used to enhance the backrubs, and wrestling.
quality and content of his social conversations. With adolescents, these additional themes can be
Group treatment for sexually abused children can addressed (Gottlieb & Dean, 1981): the views of soci-
have several advantages over individual therapy (Riva, ety or religion about sex, birth control, masturbation,
1989). Because other group members have had similar sexual deviancy, incestuous feelings and acts, sexual
experiences, children can learn that they are not alone vocabulary, and feelings and fantasies about the thera-
in their victimization and can gain an understanding of pists and their private lives.
their own reactions as stress responses typical of The structures of the groups vary with the goals of
abused children. Groups encourage open expression of the therapists and the logistical constraints of therapy.
issues that were held secret, often for long periods. Many authors recommend male and female cothera-
Children can experience emotional support from group pists. Cotherapy allows the children to observe open,
members and can feel believed and understood. Be- respectful communication between a man and a wom-
cause the post-disclosure crisis often involves many an. Also, the children have the opportunity to interact
life changes and upsets in personal relationships, with an adult male in a nonsexual yet caring and emo-
group therapy can serve as an anchor of stability in an tionally receptive manner (Gottlieb & Dean, 1981).
otherwise changing and unpredictable world. As such, Groups for young children under 6 years are less
children can go through the processes of reestablishing common, but some recent reports describe play groups
trust with group members and group leaders. (Pescosolido & Petrella, 1986; Steward, Farquhar, Di-
Groups have been described for all ages, including charry, Glick, & Martin, 1986). The goals of these
preschoolers, latency-aged children, and adolescents. groups are to facilitate expression of feelings and
Whatever the age, group homogeneity facilitates cohe- thoughts, with translation into words by the therapists
sion and mutual support. Furthermore, groups tend to when appropriate. Steward et al. (1986) recommended
be better attended, less conflictual, and lead to quicker structured time periods, such as juice time, free play
relief of symptoms. Although the sexual abuse experi- time, and snack time. The focus on foods provides a
ences need not be the same across all group members, sense of nurturance and provides a quiet time during
groups are usually unisex. Because males are less like- which children can talk about issues important to
ly to report sexual abuse, most groups include only them. Play materials that promote the use of sym-
females (Riva, 1989). bolism and representation of themes relevant to the
Groups for latency-aged girls are the most typical. sexual abuse and family relations are recommended,
Common themes include believability, isolation, guilt such as dolls, baby bottles, telephones, playdough,
and responsibility, body integrity and protection, se- and art materials.
crecy and sharing, anger, powerlessness, distrust of Few outcome studies are available to establish the
adults and authority, low self-esteem, and feeling utility of group treatment with sexually abused chil-
dren. Some studies have revealed improvements in denies the abuse, she must serve as "judge" as to
broad pre- and postmeasures of self-esteem and per- whom she should believe. She must decide whether to
sonal growth, but no studies have been able to tie to- have her spouse leave the home or whether the child
gether the goals of treatment with specific outcomes should go to foster care. She must relate what has
associated with the sequelae to sexual abuse. In an happened to those who are close to the child, such as
attempt to establish the curative effects of these siblings, grandparents, and teachers. With the separa-
groups, Bonney, Randall, and Cleveland (1986) used a tion from the spouse, she may experience financial
Q-sort measurement strategy. They found that the difficulties and may need to move to more affordable
group members placed their highest value on the housing. If she decides to separate from her spouse,
group's capacity to facilitate self-understanding. she may experience pressures from him to reconcile,
Group members also valued reenactments of family threats against her for supporting the child's alle-
dynamics within the group. gations, and alienation from friends and relatives who
are aligned with the perpetrator.
Often mothers are counseled by the same therapist
Treatment for the Nonoffending Parents
who sees the child. However, in such situations, the
Mothers of sexually abused children often experi- mother's concerns will generally be secondary to those
ence many problems following the disclosure of the of the child. Landis and Wyre (1984) described a 10-
sexual abuse; which are not unlike those of their session group for mothers in incestuous families,
daughters and sons who were abused, with post- which was integrated into a CSATP-type program. The
traumatic stress reactions being quite common. Moth- sessions focused on the following themes: sharing sim-
ers often report intrusive thoughts, nightmares, sleep ilar experiences; understanding the dynamics of in-
disturbance, guilt, anxiety, hypervigilance, and irri- cestuous families; personal strengths; responsibility as
tability. Parenting may be affected because the parents a silent partner; confrontation of role in the incestuous
may feel less tolerant of minor behavior problems yet family; families of origin and trans generational as-
may experience guilt when disciplining the abused pects of incest; adult and family relationships; rela-
child. Vacillation between overindulgence and irri- tionship with the daughter; and personal values. The
tability can occur. final session was reserved as a confrontation with the
As childhood sexual abuse occurs with a relatively father's/perpetrator's group.
large percentage of the female population, many of the
mothers of sexually abused children were sexually
Family Therapy
abused themselves as children, or were raped as an
adolescent or young adult. Many have never disclosed The incestuous family has been characterized as in-
their own abuse, much less come to a sense of resolu- cluding several "threads of dysfunction" (Jones & Al-
tion about what occurred. In such cases, the sexual exander, 1987): emotional unavailability; indiscrimi-
abuse of their child brings to the fore the mother's own nant sexuality; lack of privacy; vague family
victimization as well as her child's. Some research has boundaries and role confusion; maladaptive family
suggested that women who were sexually abused as a viewpoints or myths; poor attachment; lack of empa-
child are more likely to have children who are vic- thy for the child; suppression of emotional expression;
timized, not by themselves but by others. Perhaps and emmeshment whereby individual integrity is not
childhood victimization experiences relate to coping recognized or respected. Lack of information ex-
styles that leave their children vulnerable, and part of change within the family and insularity within the
their therapy should focus on recognizing such pat- community contribute to a "closed" system that is
terns and learning new ways of protecting their stagnant and unable to cope with the developing de-
children. mands of family members (Alexander, 1985).
When the perpetrator is a family member, particu- Jones and Alexander (1987) described three stages
larly a spouse, further issues arise for the mother. The of family treatment: acknowledgment of the abuse,
mother may experience several stressful, stigmatizing increasing parental sensitivity and emotional availabil-
events, in addition to the realization that her child has ity to the child, and resolution. Acknowledgment
been sexually abused by her spouse. Police and social should include admission that the abuse occurred by
workers may have come to the home unexpectedly and the perpetrator and by the nonoffending parent, an un-
her spouse may have been arrested. If the perpetrator derstanding of the impact of the abuse on the child, the
family's inability to protect the child, and the degree 6. Overnight visits, with the following rules: per-
and extent of parental unavailability to the child. Reso- petrator always fully dressed outside of the bed-
lution can be one of three options: completion of treat- room; perpetrator not outside bedroom when
ment and reuniting the family under supervision, di- spouse is asleep; when perpetrator leaves the
vorce from the perpetrator without visitation, or the bedroom in the night, he wakes and informs his
nonoffending parent's opting to remain with the per- spouse.
petrator despite the perpetrator's failure at therapy. In
that case, Jones and Alexander recommended con-
tinued foster placement, and, potentially, termination Summary
of parental rights. In total, Jones and Alexander esti-
mated that treatment takes about 2 years, which they Childhood sexual abuse is a complex problem that
felt was necessary to overcome the long-standing se- has only recently gained the attention of mental health
rious family pathology. researchers. Issues of severity of abuse, parental and
Alexander (1985) highlighted the need to reduce familial adjustment, community resources, and such
family insularity and enmeshment by encouraging the child-coping factors as attributional style interplay to
family'S acceptance of input from outside sources and affect the severity of a vast array of symptoms, includ-
individualization and role definitions among family ing those associated with PTSD, depression, exter-
members. She suggested that individual sessions may nalizing problems, and negative psychosexual adjust-
be necessary to meet these family-oriented goals be- ment (Y. Wolfe & D. Wolfe, 1988). Thus far, the field
cause of the need for individualization. has progressed by providing an epidemiological basis
Once the family has reached the point where the for understanding the phenomenon of sexual abuse,
offender can be reunited with the nonoffending parent including severity, child characteristics, circum-
and child, O'Connell (1986) recommended a series of stances, and risk factors. Furthermore, recent studies
steps to ensure that the process is not traumatic to the have documented aspects of the impact of sexual abuse
child and that clear boundaries are established between that are helpful in guiding the development and evalua-
the child and the perpetrator. These steps are as fol- tion of treatment programs (e.g., Wolfe et al., 1989).
lows: In terms of interventions and treatment, the greatest
strides have been made in the area of prevention, par-
1. The perpetrator writes a letter to the victim ex- ticularly in teaching elementary school-aged children
plaining his responsibility for the abuse. about sexual abuse. Various program dimensions and
2. First visit should include perpetrator, victim, training methods have been defined, and assessment
nonoffending parent, child's therapist, and per- methodology has been developed for evaluating pro-
petrator's therapist. The visit should occur at the gram effectiveness. Given the extensive implementa-
office of the victim's therapist, and issues of tion of in-school sexual abuse prevention programs,
abuse should be addressed upfront and without broader scale evaluations should be forthcoming with
hesitation. assessment of process goals (e. g., acquisition of
3. Visits with the perpetrator in public places knowledge of sexual abuse and self-protection skills)
should take place under circumstances where the and of outcome goals (e. g. , reduced frequency of over-
perpetrator cannot be alone with the child or act all abuse and less severe abuse because of early dis-
as a disciplinarian. Other rules include no phys- closures). Evaluations should include potential nega-
ical contact or affection outside of greetings or tive side effects of abuse prevention programs. Also,
departures, no tickling, lap sitting, or horseplay, continuing epidemiological analyses of child sexual
no secrets, no discussions of sexuality or boy- abuse will reveal whether prevention programs change
friends, and no discussions of the sexual abuse. the pattern of abuse. Swift (1979) warned that without
4. Family outings outside the home can occur next, prevention efforts to reduce the pool of potential per-
with the same constraints as in Step 3. petrators, sexual abuse will continue, but with younger
5. Visits to the home, with the following rules: and weaker victims.
planned activity, such as a meal; perpetrator nev- Treatment programs have progressed in several
er in bedroom or bathroom with the victim; ways. Goals of treatment are more clearly delineated
everyone locks bathroom doors; and perpetrator and treatment processes are beginning to be defined. It
always fully dressed. is clear that no one mode of treatment is sufficient to
meet the needs of all sexually abused children. It is Berliner, L. (1977). Child sexual abuse: What happens next?
also clear that careful evaluation of child and family Victimology: An International Journal, 2, 327-331.
Berliner, L. (1984). Some issues for prevention of child sexual
adjustment is needed to delineate the modes of treat- assault. Journal of Preventive Psychiatry, 2, 427-431.
ment necessary (Y. Wolfe & D. Wolfe, 1988). Indi- Black, T., Pokorny, W. 1., McGill, C. W., & Harberg, F. 1.
vidual, group, family, and all other permutations of (1982). Ano-rectal trauma in children. Journal of Pediatric
treatment have been described to address the sequelae Surgery, 17, 501-504.
Bonney, W. C., Randall, D. A., & Cleveland, I. D. (1986). An
of sexual abuse. analysis of client-perceived curative factors in a therapy group
Unfortunately, no research, to date, has thoroughly of form incest victims. Small Group Behavior, 17, 303-321.
evaluated any treatment program. This is very much a Borkin, 1., & Frank, L. (1986). Sexual abuse prevention for
preschoolers: A pilot program. Child Welfare, 65, 75-82.
function of a lack of evaluation tools, and the initial Bressee, P., Stearns, G. B., Bess, B. H., & Packer, L. S. (1986).
stages of establishing treatment goals. Evaluation of Allegation of child sexual abuse in child custody disputes: A
programs for treating sexually abused children will therapeutic assessment model. American Journal of Ortho-
require (1) matching the treatment needs of victims to psychiatry, 56, 560-569.
Browne, A., & Finkelhor, D. (1986). Impact of child sexual
the treatment program, (2) pre- and postassessment of abuse: A review of the literature. Psychological Bulletin, 99,
global adjustment and adjustment specific to the sexu- 66-77.
al abuse, and (3) long-term follow-up regarding subse- Bulkley,1. (1982). Recommendationsfor improving legal inter-
quent developmental and emotional adjustment. Com- vention in intrafamilial child sexual abuse cases. Washington,
DC: American Bar Association, Young Lawyers Division.
parison groups of treated and untreated children will be Burgess, A. W., Hartman, C. R., McCausland, M. P., &
necessary, especially since research with other victim Powers, P. (1984). Response patterns in children and adoles-
populations, such as rape victims, reveals a changing cents exploited through sex rings and pornography. American
Journal of Psychiatry, 141, 656-662.
pattern of adjustment across time (Kilpatrick, Yer- Byers, I. (1986). Films for child sexual abuse prevention and
onen, & Resnick, 1979). treatment: A review. Child Abuse and Neglect, 10, 541-546.
Byles, 1. A. (1984). Problems in interagency collaboration:
Lessons from a project that failed. Child Abuse and Neglect,
ACKNOWLEDGMENTS. Preparation of this chapter was 9,549-554.
supported in part by grants from the Social Sciences Cantwell, H. B. (1983). Vaginal inspection as it relates to child
and Humanities Research Council of Canada and sexual abuse in girls under thirteen. Child Abuse and Neglect,
7, 171-176.
Health and Welfare Canada. Chang, A., Oglesby, A., Wallace, H., Goldstein, H., & Hexler,
A. (1976). Child abuse and neglect: Physicians' knowledge,
attitudes and experiences. American Journal ofPublic Health,
66, 1199-1201.
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CHAPTER 34
Mental Retardation
Ronald A. Madle and John T. N eisworth
Introduction Definition and Concepts

The most commonly accepted definition is that of
"Mental retardation" is a diagnostic label that sub-
the American Association on Mental Retardation I
sumes an array of behaviors. From a behavioral stand-
,,:hich specifies that mental retardation "refers to sig~
point, whatever is retarded is not "mentality." In order
ru~c~ntly subaverage general intellectual functioning
to emphasize that behaviors rather than individuals or
~xlstlOg concurrently with deficits in adaptive behav-
"mentalities" are retarded, some researchers have ad-
Ior, and manifested during the developmental period"
vocated supplanting the term mental with either devel-
(Grossman, 1983, p. 11). This definition also refers to
opmental or behavioral (e.g., Bijou, 1963). Since nei-
delayed levels of behavioral performance without ref-
ther of these alternatives has received broad
erence to actual or presumed causes and contains three
acceptance, we will use the term retardation alone to
discrete criteria. Significantly subaverage intellectual
refer to a generalized delay in a wide range of behav-
functioning is operationally defined as an IQ that is two
ioral domains (Madle, 1983). Although this allows
or more standard deviations below the mean. Adaptive
other diagnoses, such as autism, it is consistent with
behavior refers to the extensive set of behaviors indi-
other contemporary definitions of mental retardation
vidu~s must have to "make it in society," including
as well as the label developmental disabilities, which
behavIOrs clustered under domains, such as self-care
has ~radually ~ncompassed the many traditional diag-
motor, communication, socialization, and self-man~
nostlc categones for pervasive disorders which man-
agement skills. Although intellectual performance has
ifest themselves during the early part of the life span
?een the most conspicuous criterion used in identify-
(Neisworth & Smith, 1974). The emphasis has turned
109 retarded individuals, adaptive behavior has be-
to delays or limits across varied behavioral domains
come increasingly important as measures of the con-
rather than alleged causes.
struct have improved beyond simple checklists to
norm-referenced devices with prescriptive outcomes,
such as the Vineland Adaptive Behavior Scale (Spar-
row, Balla, & Cicchatti, 1984) or Scales of Indepen-
dent Behavior (Bruinicks, Woodcock, Weatherman, &
Ro~a1d A. Madle • Laurelton Center, Laurelton, Pennsyl- Hill, 1984). These measures have significantly altered
vania I ~835; and Department of Human Development and Fami-
ly Studies,. Pennsylvania State University, University Park, intervention practices by sharpening the focus on
Pennsy~vanla 168~2. John T. Neisworth • Department
of Special EducatIOn, Pennsylvania State University University
Park, Pennsylvania 16802. ' IFormerly the American Association on Mental Deficiency.
731
changing observable behaviors rather than "mental number. Whatever the criteria, however, retardation is
functions." Therefore, most current approaches to in- a universal and significant social problem.
tervention more closely resemble behavioral ones than Throughout history there have been four major ap-
they did 20 years ago. The last criterion is that the proaches to the retarded. During primitive times, when
delays in both intellectual and adaptive functioning are survival was difficult, handicapped individuals simply
observed during the developmental period, which were allowed to die. Later, with more plentiful re-
rules out individuals who "regress" during adulthood sources, they survived but were often ridiculed, used
and aging, perhaps due to trauma, psychiatric disor- as slaves, or maimed to serve as beggars. By the Mid-
der, or senility. dle Ages, religious movements stressed human-
The broad syndrome is officially divided into four itarianism and the retarded were often cared for in
levels: mild, moderate, severe, and profound (Gross- monasteries or in asylums. The last major era, that of
man, 1983). Mild retardation (Wechsler IQ 55-69) treatment and training, traces to the philosophy of
involves the least degree of delay. These individuals John Locke, who espoused the notion that human func-
differ relatively little from others of their chronological tioning was vastly influenced by the environment
age. The primary areas of delay are usually in academ- rather than merely unfolding as a result of biological
ic, interpersonal, and self-management skills. Often predestination. This brought a new optimism for treat-
mildly retarded individuals are not even identified un- ment and training of the handicapped, although there
til they enter school and begin having academic diffi- was a brief throwback to earlier views during the eu-
culties. After leaving school, they may lose the label genics movement when retardation again was consid-
when they "blend into" a less academically oriented ered to be solely biologically determined. This re-
society. At more impaired levels, retarded individuals sulted in massive institutionalization, sterilization,
usually require at least some level of services through- and even destruction (Scheerenberger, 1983). Moving
out the lifespan. Moderately retarded individuals (IQ into the mid-1900s, a treatment and training philoso-
40-54) evidence increased difficulty in learning and phy once again emerged.
performing tasks taken for granted by most people. In
addition to markedly more severe deficits in academic,
Behavioral Approaches
interpersonal, and self-management skills, deficits are
seen in learning simple tasks, such as dressing, domes- Behavioral approaches to the retarded are generally
tic skills, money use, and managing leisure time. De- traced to the work of Jean Itard, a French physician and
lays at the severely (IQ 25-39) and profoundly re- educator of the eighteenth century, who attempted to
tarded (under IQ 25) levels become pronounced in "civilize" a feral child found in the woods of France.
virtually all areas of functioning. Skills, such as self- Although Itard emphasized the sensory aspects of his
toileting, relating to people, and following simple in- work, it has become clear from his records that the
structions, are learned only through systematic, inten- techniques also were remarkably behavioral. It was not
sive instruction. until the mid-twentieth century, however, that behav-
Although 10% to 15% ofthe retarded have a discrete ioral techniques fully emerged. An isolated report
medical syndrome linked to their retardation, most re- (Fuller, 1949) demonstrated that arm movements in a
tarded individuals have no identifiable biological profoundly retarded adult could be brought under rein-
causes or "brain damage." Using the normal distribu- forcement control. Basic laboratory research appeared
tion to predict, 2.27% of the population would be rein the 1950s demonstrating the applicability of operant
tarded; however, actual prevalence may be higher principles to the learning and behavior of the retarded.
(e.g., Dingman & Tarjan, 1960). Empirical estimates In 1963, Ellis produced a theoretical account of how
range from less than 1% to as high as 12%. The best toilet training could be accomplished with operant
estimate is considered to be about 3% during the techniques. The mid-1960s marked the beginning of
school years and approximately 1% during the re- vigorous work in the application of behavioral pro-
mainder of the lifespan (Scheerenberger, 1987). Prev- cedures in training and treatment. Prominent behav-
alence also is related to factors, such as geographic ioral researchers, such as Sidney Bijou, Norman Ellis,
region, sex, and age. For example, countries more Beatrice Barrett, Ogden Lindsley, Joseph Spradlin,
tolerant of minor deviations from the cultural norm and Edward Zigler, began to set the foundation for
(e. g. , Scandinavian countries) generally report a lower applied behavior analysis in retardation.
CHAPTER 34 • MENTAL RETARDATION 733
Even though various behavioral frameworks of re- velopmental opportumtIes may be physical ap-
tardation have been posed (e.g., Bijou, 1963, 1966; pearance, which may restrict or distort learning oppor-
Lindsley, 1964; Neisworth & Smith, 1973), most tunities by affecting the quality and quantity of social
contemporary models derive from Bijou's (1966) interactions. An ugly or merely homely individual is
framework, which is an extension of Skinner's (1953) often deprived of the usual positive social interactions
criticisms about inferring "traits" from observed be- provided to the physically normative one (see
haviors and consequently using the trait to explain be- Neisworth, Jones, & Smith, 1978, for expansion of
havior. Bijou concentrated on retardation as a behav- this topic).
ioral deficiency generated by adverse reinforcement
histories or failures of stimulus and response func- Inadequate Reinforcement and Discrimina-
tions, rather than as a result of theoretical constructs, tion Histories. Bijou (1966) also discussed the im-
such as mentality or presumed impairment of brain pact of reinforcement and discrimination histories on
function. The behavioral view of the retarded indi- behavioral development, speculating on three condi-
vidual is as "one who has a limited repertory ofbehav- tions where this may occur. In the first, children may
ior shaped by events that constitute his history" (Bi- be in situations where infrequent or minimal reinforce-
jou, 1966, p. 2). The great advantage to such an ment (especially social) occurs. Dull, routine, and un-
approach is that causative factors are subject to objec- derstaffed environments, such as in some child care
tive definition and measurement and are potentially institutions, restrict interactions and would likely limit
manipulable. This is not only obviously desirable but repertoires in self-care, emotional-social reactions,
imperative for scientific research and intervention. In- and preacademic and academic skills. Such conditions
dependent and dependent variables must be em- might also arise in home settings where parents are
pirically verifiable. Clearly, constructs such as "intel- overly preoccupied with factors other than child rear-
lect," "mentality," and "cognitive structure" do not ing, such as excessive outside activity or health and
expedite empirical inquiry. Bijou's framework re- family adjustment problems or, as mentioned earlier,
quires only the extension of general operant· principles where the child's appearance encourages avoidance.
to explain and to modify retarded behavior rather than Reinforcement may also be withheld or provided on a
a special theory of retardation. Bijou (1966) outlined noncontingent basis. Parents may reinforce dependent
four primary factors leading to the development and behavior and systematically extinguish, or even
maintenance of retarded behavior. punish, independent child behaviors, thus extending
and ensuring the need for continued parenting. Non-
Abnormal Biological Structure and Func- contingent reinforcement is common when children
tion. Biological aberrations may alter development in are viewed as chronically sick, disabled, or incapaci-
several ways. First, basic response structures may be tated; parents often react by providing nearly continu-
impaired. An individual unable to speak because of ous supervision and attention, which is ineffective
vocal apparatus· impairment experiences further devel- since contingent reinforcement, not the reinforcement
opmental delays in multiple areas. Although compen- per se, promotes behavioral development. The third
satory skills that serve the same functions (e.g., sign factor is reduced opportunities to display developmen-
language or communication boards) may be learned, tally appropriate behaviors, perhaps because of eco-
no amount of training will produce speech. Behavioral nomic or social shortcomings of parents or other care-
repertoires also may be limited through the restriction givers. Limited reinforcement and discrimination
of ordinarily available stimuli. The individual who can histories may be expected because retarded children
see, hear, smell, and feel by moving about can have are frequently raised under conditions that are less than
countless more experiences than one whose sen- optimal, including being raised in isolated commu-
sorimotor mechanisms are impaired. Lindsley (1964) nities, in group-care institutions, and in families with
focused on these conditions suggesting that prostheses disturbed or deficient parenting.
were available: devices that could be carried about by
an individual, training that could overcome behavioral Contingent Aversive Stimulation. Parental use
handicaps, and special environments where the child's of strong punishment to eliminate undesirable behav-
performance would be more normal than in the average iors, or even the presence of an extremely aversive
environment. The third biological factor restricting de- event, such as an accident or a medical treatment, also
may alter desirable responses. For example, a child oping an overall paradigm of retardation or into sys-
who is punished for saying derogatory things about his tematically developing a comprehensive and coherent
younger brother may eventually garble words so that system of behavioral technology with the retarded that
they do not provoke punishment. Although such encompasses assessment, prescription, intervention,
changes may avoid punishment, they surely do not lead and evaluation.
to adequate language development. Punishment also
stops ongoing behavior and, if severe enough, may
have long-lasting suppressive effects which are ex- Current Empirical Status and
ceedingly resistive to change (Hutchinson, 1977). Developments
These effects become particularly disruptive when
generalization occurs. Not only are punished behav- The literature on behavioral applications with the
iors suppressed, but so are related behaviors in similar retarded is vast; hundreds of articles were published
settings. Previously neutral stimuli, such as the situa- during the 1980s alone. This section provides selective
tion in which the punishment occurred, may become coverage of this literature organized by various target
aversive. The prepotent response becomes one of behaviors. Certain areas, such as academic skills,
avoiding the punishing situation, in which many skills obesity, and physical dysfunctions, will not be cov-
are normally learned; this constitutes negative rein- ered. Instead, we concentrate on the areas of greatest
forcement for avoiding potential learning situations. relevance to the behavioral clinician working with the
retarded. More depth, as well as many earlier refer-
Reinforcement of Aversive Behaviors. The last ences, can be obtained from books on behavior modifi-
factor occurs when reinforcement is unintentionally cation with the retarded (e.g., Matson & Andrasik,
contingent upon undesirable behaviors. Parents often 1983; Matson & McCartney, 1981).
will "give in" to stop ongoing undesirable behaviors,
such as temper tantrums. As the rate of undesirable
Self-Care Skills
behaviors increases, the time available to learn, dis-
play, and receive reinforcement for adaptive behaviors Early behavioral work emphasized the development
decreases. Second, parents and others are also not im- of self-care skills with the institutionalized severely
mune to the effects of aversive stimuli. As with the and profoundly retarded. Operant techniques were par-
unattractive child, they may begin to avoid contacts ticularly well-suited to this group because "talk thera-
with the child, which further decreases positive learn- py" or instruction based on verbal interaction is not
ing opportunities. usually feasible. Many reviews have been published in
this area (e.g., Langone & Burton, 1987; Watson &
Also, Lindsley (1964) emphasized the fallacy ofthe Uzell, 1981). Konarski and Diorio (1985) quan-
similia similibus curantur ("like-cures-like") doctrine titatively summarized 87 self-care training studies
and that treatment need not be dictated by the alleged dealing with the severely and profoundly retarded. A
cause of dysfunction. Even practitioners who do not third of the studies used the profoundly retarded and
accept a behavioral model of retardation profitably the majority occurred in institutions with residential
may employ behavioral procedures in modifying re- workers as trainers. There was a steady interest from
tarded development. Subsequent applied research on 1964 to 1982, with 63% of the studies focusing on
behavior modification with the retarded and a rapidly toileting and feeding. Multicomponent packages con-
expanding literature clearly support either the ade- sisting of primarily accelerative methods most fre-
quacy of a behavioral model, or at least the relevance quently were used. Although the experimental rigor of
of Lindsley's formulations. the studies improved substantially, few studies re-
Although Bijou's (1966) analysis is over two dec- ported evaluations of generalization, maintenance, or
ades old, it remains current. Unfortunately, minimal social validity.
systematic effort has been put into comprehensive be-
havioral assessment methods based on such models. Toileting. Toileting training was among the ear-
Although increased efforts have been noted recently, liest areas receiving substantial behavioral attention.
especially in the functional analysis of maladaptive Applications of Ellis's (1963) analysis emerged quick-
behaviors (e.g., Iwata, Dorsey, Slifer, Bauman, & ly (e.g., Giles & Wolf, 1966; Minge & Ball, 1967).
Richman, 1982), little effort has been devoted to devel- Overall, the development of toilet-training programs
serves as a prototype for the progressive refinement of however, when therapist involvement was removed
behavioral technologies. Initially, positive reinforce- and behavioral contracting added, there was an imme-
ment and punishment were used almost exclusively, diate reduction to no wet nights. A 6-month follow-up
with little attention to other techniques. For example, revealed only occasional wetting. It seems that this
Dayan (1964) had severely retarded children toileted method may also benefit from supplementary compo-
every 2 hours, and reinforcement was delivered for nents. Another method consists of prompting the child
elimination during any of these times. The primary to report urination "urges" during the day and to wait,
advantage of these methods over traditional toilet- briefly at first, and then for longer periods (Kimmel &
scheduling methods was the introduction of appropri- Kimmel, 1970). Successful results were reported with
ate consequences for correct responses. all three individuals, including maintenance after 12
Program effectiveness improved when Azrin and months. In a controlled replication, however, less than
Foxx (1971) used multiple, intensive procedures, in- half of the children become dry (Paschalis, Kimmel, &
cluding an apparatus used to signal toileting incidents, Kimmel, 1972). Phibbs and Wells (1982) used positive
modeling, hydration to increase urination frequency, reinforcement for continence over gradually lengthen-
food and social reinforcement for urinating correctly ing time periods, with nightly awakenings at the begin-
and staying dry, reprimands and time-out for soiling, ning of wetting periods and restriction of fluids before
and shaping the self-initiation of toileting. Also in- bedtime. All accidents were eliminated after 12
cluded were long-term maintenance procedures. Al- months of treatment with no relapse in 1 year. In fact,
though previous methods of toilet training the retarded after 4 years, all residents remaining in the institution
required months of training and statistics to demon- were still accident free.
strate their effectiveness, Azrin and Foxx (1971) toilet
trained nine profoundly retarded adults in a median Feeding. Like toileting, self-feeding was given a
time of 4 days and 12 days to train all individuals. high priority because caring for oneself drastically re-
Other toilet-training programs have been effective, al- duces the amount of individualized attention neces-
though a combination of procedures is necessary, in- sary, allowing more time for active training in "higher-
cluding at least reinforcement, chaining and shaping, level" skills. Early programs emphasized task analy-
prompting, and punishment (e.g., Mahoney, Van ses of the steps involved in filling a spoon from a tray
Wagenen, & Meyerson, 1971). The Azrin-Foxx pro- or dish and moving the spoon toward and into the
gram virtually became the standard against which mouth (e.g., Zeiler & Jervey, 1968). Backward chain-
other techniques are compared. Several replications ing with manual guidance was employed, where the
have confirmed the effectiveness of the method (see individual's hand was guided in filling the utensil,
Bettison, 1986), although recent publications still re- bringing the spoon to the mouth, and releasing the
port earlier approaches. Richmond (1983), for exam- individual's hand just prior to the spoon's going into
ple, used fading-based toilet scheduling in which toi- the mouth. As progress occurred at each stage, the
leting intervals were increased from 15 minutes to 2 hand was released earlier and earlier in the chain until
hours over 4 weeks, whereas appropriate toileting was the child independently filled the spoon and ate. Aver-
reinforced and accidents resulted in a brief verbal rep- sive contingencies, such as food removal for inap-
rimand and simple correction. Even though such pro- propriate behavior occurring during training, also have
grams result in reduced accidents without specialized been added to increase effectiveness (e.g., Barton,
staff training, special apparatus, or large increases in Guess, Garcia, & Baer, 1970).
staff time, it should be noted that the reduction of acci- Azrin's group once again developed a multicompo-
dents and self-initiated toileting are rather different nent package (O'Brien, Bugle, & Azrin, 1972). Later,
outcomes. the technology was refined by using frequent "mini-
Elimination of enuresis is of related interest. Sloop meals" (spaced practice) served regularly throughout a
and Kennedy (1973) found that individuals treated 9-hour training period (Azrin & Armstrong, 1973).
with the pad-and-buzzer method met criterion more The increased number of training sessions, combined
often than control subjects. Four of the 11 successful with reinforcement, graduated guidance, mastery of
individuals, however, relapsed within 72 days and each utensil, multiple trainers, error correction, and
only one third of the treated group remained dry. positive practice, resulted in the rapid acquisition of
Radler, Hudson, and Boag (1982) found no improve- feeding skills in previously unmanageable adult re-
ment after over 4 months of bell-and-pad treatment; tarded persons. An independent replication demon-
strated that all the individuals achieved correct eating Several operant procedures for teaching dressing
to nearly optimal levels, that incorrect eating was re- skills have been described in detail (e.g., Ball et ai.,
duced to minimal levels, and that inappropriate or dis- 1971; Minge & Ball, 1967). All have several common
ruptive behaviors were virtually eliminated (Stimbert, characteristics: food or praise as reinforcers; reinforce-
Minor, & McCoy, 1977). Follow-up data at intervals of ment for completion of putting on or taking off a spe-
up to 1 year indicated that program effects were quite cific garment; prompts to begin each trial; backward
durable and justified the effort expended in training. chaining where the instructor puts on or takes off the
Other work has concentrated on teaching more ad- garment, having the individual do only the final steps;
vanced eating skills, such as utensil and napkin use mastery on one garment before moving to the next; and
(e.g., Matson, Ollendick, & Adkins, 1980; Sisson & fading of the instructions and reinforcers. Generally,
Dixon, 1986). Wilson, Reid, Phillips, and Burgio brief sessions of about 15 minutes were used over a
(1984) used a forward chaining procedure, with a de- period of weeks or months.
creasing prompt sequence and contingent reinforce- Azrin, Schaeffer, and Wesolowski (1976) devel-
ment, to successfully teach several family-style skills oped a promising procedure for training more impaired
to profoundly retarded adolescents. Skill mainte- individuals. In contrast to earlier programs, it included
nance, as well as the social validity and acceptance by rather lengthy and intensive training sessions, forward
staff trainers, were reported, although anticipated co- rather than backward chaining, graduated and inter-
rollary changes, such as increased peer communica- mittent manual guidance, continuous talking and
tion, were not evident. praising, graduated-sized clothing, and an emphasis
Problems behaviors associated with feeding have on reinforcers natural to the dressing process. In val-
also been addressed, including food refusal, selec- idating the procedure, Azrin et ai. (1976) were able to
tivity, spillage, and eating rate (e.g., Cipani, 1981; train 7 out of 10 profoundly retarded adults both to
Riordan, Iwata, Wohl, & Finney, 1980). For instance, dress and to undress themselves in an average of 12
Favell, McGimsey and Jones (1980) taught profoundly hours distributed over 3 or 4 training days. A systemat-
retarded rapid eaters to spoon dip at normal rates with a ic replication (Diorio & Konarski, 1984) showed of
nonaversive package consisting of praise and food re- three profoundly retarded adults, two attained the cri-
inforcement for successively longer independent terion for independent undressing, although none
pauses between bites and steadily diminishing phys- reached criterion on dressing with as much as 108
ical prompts for pausing. The treatment resulted in a hours of training. These findings contrast sharply with
reduction from an average of 10.5 to 3 bites per 30- Azrin et ai. (1976), where all individuals reached crite-
second interval. The improvements persisted during rion on all skills in an average of onl y 12 hours, leading
maintenance as individual attention and prompting Diorio and Konarski (1984) to suggest that more re-
were withdrawn and pausing was intermittently search is needed to identify critical variables that may
reinforced. account for the differences.
More recent work focuses on parametric refine-
Dressing. Although most children learn to dress ments. For example, training using lO-minute sessions
themselves without special training, moderately to twice daily for 15 days resulted in superior learning
profoundly retarded individuals are unlikely to learn and generalization to sessions 10 times daily for 3 days
even minimal dressing skills without special training. (Inglesfield & Crisp, 1985). Day and Homer (1986)
Initial programs, such as Bensberg's (1965), offered compared single instance and general case instruction
hope that lower-functioning retarded persons could be for putting on pullover shirts. Following training that
taught to dress themselves. The procedures that were used only a single shirt, individuals exhibited limited
developed, however, were effective only for higher- success with nontrained probe shirts, but when the
functioning individuals. Minge and Ball (1967) training involved a range of shirts, successful gener-
trained six profoundly retarded girls for 30 hours and alization was observed, suggesting that the variations
found some improvement in dressing skills develop- taught during general case instruction played a major
ment. Ball, Seric, and Payne (1971) found only slight role in performance across nontrained shirts.
improvement in dressing skills after 90 training days.
Such results led Watson (1972) to estimate that 8 to 12 Grooming and Personal Hygiene. Beginning
months would be required to teach the profoundly re- with the Parsons project (Girardeau & Spradlin, 1964),
tarded to dress themselves. token reinforcement has been used for grooming and
personal hygiene skills. Hunt, L. C. Fitzhugh, and K. sistance. Half received token plus social reinforce-
B. Fitzhugh (1968) also used token reinforcement to ment, while the others received social reinforcement
improve personal appearance. Initially, continuous re- only. All individuals showed improved toothbrushing,
inforcement was given for meeting criterion, with sub- with six correctly performing all steps in two of three
sequent intermittent reinforcement. Individuals im- consecutive sessions. Although other researchers
proved with the greatest gains under the intermittent (e.g., Abramson & Wunderlich, 1972) have reported
schedule. When reinforcement was totally withdrawn, toothbrushing programs, these results appear to be the
personal appearance deteriorated, possibly due to no most effective to date.
embedded reinforcement in the natural environment. Richman and her colleagues (Richman, Pontic as ,
Token reinforcement programs continue to be used. Page, & Epps, 1986; Richman, Reiss, Bauman, &
Jarman, Iwata, and Lorentzson (1983), for example, Bailey, 1984) developed programs to teach menstrual
developed and maintained a complete morning self- care skills to five mildly to severely retarded women.
care routine, consisting oftoileting, showering, dress- Skill areas were task analyzed and taught through se-
ing, toothbrushing, bedroom cubicle cleaning, and quential simulation. The package was successful in
bed linen removal in 40 adolescent and adult institu- teaching these skills, and the women continued to per-
tionalized, multiply handicapped persons. After initial form the skills during naturally occurring menses for
training and baseline, token reinforcement was pro- up to 5 months following the study. Consistent im-
vided for each skill separately in a multiple-baseline provement and generalization were reported with
design. Improvement occurred in all but one behavior. maintenance for up to 30 weeks.
Finally, tokens could be earned only if all six behaviors
were completed; performance of each skill either in-
Speech and Language
creased further or was maintained.
More recently, other procedures have been reported. Basic language skill and speech deficiencies are
Barry, Apolloni, and Cooke (1977) assessed the effects common with the retarded. Four steps to language and
of contingency contracting on personal hygiene, in- speech training are needed with this group: attention,
cluding clean and combed hair, clean teeth, and ab- nonverbal imitation, verbal imitation, and functional
sence of body odor, demonstrating that low levels of speech (Harris & Wolchik, 1982). Initially, a rate prob-
baseline responding could be increased significantly. lem is usually encountered; verbal operants must be
Petroski, Craighead, and Horan (1983) varied practice established and increased. Later, the concern becomes
sessions and modeling types (other, self, or none) in a stimulus control, or training the individual to emit the
design which also included a high demand, verbal- appropriate verbal responses to various stimuli.
instructions-only control condition. At posttest and
follow-up, all active treatment conditions were signifi- Vocal Communication. With severe deficien-
cantly superior to the control but did not differ from cies, the priority is teaching simple vocal imitation
each other. Modeling and behavior rehearsal were both skills, usually by prompting behaviors in response to a
effective, with no advantage from combining them. model and reinforcing the "imitative response" (e.g.,
Independence training (social reinforcement, informa- Garcia, Baer, & Firestone, 1971). Often simple motor-
tional feedback, modeling, and evaluation of self and response imitation (e.g., Baer, Peterson, & Sherman,
others) was examined for teaching showering to 36 1967) is taught first to build the response class of imita-
institutionalized moderately-to-severely retarded tion needed for early language training. At first, only
adults (Matson, DiLorenzo, & Esveldt-Dawson, reinforced imitative responses occur; later, gener-
1981). Individuals in the treatment group performed alized imitation emerges where both reinforced and
significantly better than controls on both posttest and nonreinforced behaviors are imitated. Once imitation
3-month follow-up evaluations. is established, verbalizations are then brought under
Homer and Keilitz (1975) developed a comprehen- control of the appropriate stimuli, such as pictures and
sive toothbrushing program with a task analysis and objects. The basic training procedure has been to pre-
specific procedures for each component. Eight resent a picture or object and ask, "What is this?"
tarded adolescents in two groups received individual Through prompting and reinforcement procedures, the
acquisition training that included scheduled oppor- individual learns to label objects correctly (e.g.,
tunities for independent performances, verbal instruc- McMorrow, Foxx, Faw, & Bittle, 1987) while prompts
tion, modeling, demonstration, and physical as- and reinforcement are gradually faded. Hupp, Mervis,
Able, and Conroy-Gunter (1986), for example, com- used these alternatives as an aid in teaching language
pared receptive versus expressive training, using ver- skills to hearing and deaf individuals (e.g., Deich &
ballabels and manual signs, on referential label ac- Hodges, 1982; McIlvane, Bass, O'Brien, Gerovac, &
quisition by severely retarded children. Receptive Stoddard, 1984). VanBiervliet (1977) demonstrated
training resulted in more accurate generalization to that institutionalized retarded males were able to learn
novel category members. Labeling training is often manual signing to establish words and objects as func-
structured to occur within daily activities rather than in tionally equivalent. Keogh, Whitman, Beeman, Hal-
isolated sessions. For example, breakfast serving was ligan, and Starzynski (1987) taught nonverbal retarded
modified by Halle, Marshall, and Spradlin (1979) to individuals interactive signing in a naturalistic snack
include brief delays that cued verbal requests by half time setting, although extensive training was required
the individuals. Others required modeling or intensive and only partial generalization occurred. The teaching
training (massed trials of delay and modeling). of sign language to retarded individuals is still fraught
After labeling has been established, generative with difficulties, especially given the complex motor
speech is taught so that a number of phrases and sen- skills involved.
tences occur without specific training for each. Gener- The use of pictorial symbols (communication
ative speech training involves reinforcing responses to boards) has become more widespread because they are
some elements of a given response class in order to more easily taught and more readily adapted to indi-
establish a more general use ofthat class (e.g., Lutzker viduals with motor disabilities. In one study, indi-
& Sherman, 1974; Rust & Garcia, 1981). For exam- viduals were taught to use a head pointer, or to point
ple, Lutzker and Sherman (1974) established appropri- with the hand, while using a communication board
ate subject-verb agreement by providing training in (Reid & Hurlbut, 1977). Importantly, it was shown
selected subject-verb combinations. With increased that the trained individuals could express themselves
exposure, the individuals began to use correct subject- to people who previously could not understand their
verb combinations never encountered in training. communication attempts. The acquired skills were
Receptive communication skills have customarily maintained through a 7-month follow-up period. Pic-
included establishing generalized instruction follow- torial communication skills have also been taught
ing, including pointing to pictures and following ac- using an interrupted behavior sequence strategy where
tion instructions, through procedures similar to those operant instructional trials were inserted into ongoing
for teaching imitation (e.g., Kazdin & Erickson, behavioral sequences, such as making toast or washing
1975). An instruction is given, the response is prompt- dishes (Goetz, Gee, and Sailor, 1985).
ed, usually through physical guidance, and the emitted
response is then reinforced. Over time, a number of Speech Problems. Other commonly encountered
commands can be followed without specific training communications problems include dysfunctions in
on each. As an illustration, Streifel, Wetherby, and speech components, such as speech dysfluencies,
Karlan (1976) trained retarded children to respond to echolalia, and perseveration. A common proble:n has
various verb-noun combinations that were joined into been voice volume, since many retarded individuals
new combinations. As the training increased, the chil- speak either too softly or too loudly. Jackson and Wal-
dren were able to respond correctly to novel noun- lace (1974), for example, used a microphone system to
verb combinations on the first trial. In fact, both imita- quantify volume and delivered reinforcement for
tion and instruction following appear to be in the same speech that exceeded criterion. Voice volume in-
response class; the difference is that imitation is an creased and eventually generalized to the classroom.
exact reproduction, while instruction following is the The disruptively loud voice volume of three adults was
generation of the behavior after a topographically dis- reduced (Allen, 1982) by using a "tok-back" device
similar command. The primary task is to train respond- which fit over the mouth and ears to provide feedback.
ing to a given stimulus with the "correct" response-a In the first experiment, the device was placed over the
problem in establishing appropriate stimulus control. face after each scream and remained for a specified
period of quiet, resulting in substantially lessened
Nonvocal Communication. Because many re- screaming. A second experiment compared the effects
tarded individuals' speech is limited by structural ab- of cueing and tok-back conditions on responses to sim-
normalities, communication skills have also been ple conversational questions given at low volume. The
trained using sign language, communication boards, tok-back condition resulted in more low-volume re-
or other symbol systems. Some investigators have sponses than either baseline or cueing.
Social Skills specifically trained for such generalization. Singh and
Millichamp (1987), for example, used prompts and
Social behavior deficits are often cited as a major
graduated physical guidance to develop social play in
problem of retarded persons, particularly institu-
profoundly retarded females. Positive changes were
tionalized persons (Wallander & Hubert, 1987). Social
observed, and inappropriate play and stereotypy de-
skills training with the retarded has increased substan-
creased. Although studies have shown that develop-
tially within the last several years with several reviews
ment of these types of behaviors is not particularly
published (Davies & Rogers, 1985; Matson, Di-
difficult, an issue arises when responses must be gener-
Lorenzo, & Andrasik, 1983; Singh & Winton, 1983).
alized to new settings or new individuals. Participation
Basic strategies have included enrichment of the living
levels have also been increased with "room mangers,"
environment, direct reinforcement in the natural en-
who ensure that materials are available, prompt par-
vironment, and training of specific component social
ticipation, and provide differential positive attention
skills (Mayhew, Enyart, & Anderson, 1978). Environ-
(e.g., Mansell, Felce, de Kock, & Jenkins, 1982),
mental enrichment and direct reinforcement tend to be
which is more effective than merely prompting indi-
used mostly with the severely retarded, while social
viduals not engaged in interactive activities (e.g., Por-
learning methods, consisting of instructions, model-
terfield, Blunden, & Blewitt, 1980).
ing, performance feedback, social reinforcement, role
playing, and real-life practice, are more common with
Social Learning Programs. The third approach
the mildly impaired.
has been social learning programs, involving direct
training in specific response components, primarily in
Enrichment Programs. Enrichment programs group settings. The emerging literature in this area is
are designed to improve or at least maintain existing extensive and only a few examples are provided. Re-
social skills. Individuals in such programs typically views by Matson et al. (1983) and Davies and Rogers
encounter more informal and formal training situations (1985) report that procedures incorporating active re-
in comparison with the regular ward routine, as well as hearsal were more successful than instruction, rein-
a more favorable staff-client ratio (Mitchell & forcement, or demonstration alone. Overall, proce-
Smeriglio, 1970). Harris, Viet, Allen, and Chinsky dures consisting of models or instructions, active re-
(1974) suggested that certain activities often reported hearsal, and contingent reinforcement were used most
as enriching have only a minimal beneficial impact. In frequently and were the most successful.
fact, Wheeler and Wislocki (1977) demonstrated that Foxx and McMorrow reported a series of studies
peer conversation decreased rather drastically when using commercial table games to teach social skills
aides were present on the ward, certainly an undesir- (Foxx, McMorrow, & Schloss, 1983; Foxx, McMor-
able condition. Fortunately, the systematic removal row, & Mennemeier, 1984; Foxx, McMorrow, Storey,
and subsequent gradual reintroduction of these aides & Rogers, 1984). In 1985, Foxx and McMorrow re-
allowed higher levels of social behavior to continue. ported maintenance and generalization after six to
eighteen months with individuals from the previous
Direct Reinforcement. The second approach to studies. A series of reports by the Wildmans concen-
social response development is the direct reinforce- trated on group conversational skills. For example, B.
ment of specific social behaviors, such as cooperation G. Wildman, H. E. Wildman, and Kelly (1986)
(e.g., Samaras & Ball, 1975; Whitman, Mercurio, & trained mildly and moderately retarded adults in a
Caponigri, 1970). Singh and Winton (1983) reviewed group social skills program designed to improve com-
studies that focused on training severely and proponents, such as asking questions about the conversa-
foundly retarded individuals in social skills, primarily tional partner, giving compliments, and appropriately
cooperative responding during play, nonverbal phys- disclosing information about oneself. Ratings of gen-
ical or close-proximity interactions, and conversa- eralization tapes indicated substantial improvements
tional skills. Training procedures varied but usually in skills as well as improvements in social perceptions
involved combinations of physical and verbal prompt- of individuals. Tofte-Tipps, Mendonca, and Peach
ing, modeling, shaping, and social and edible rein- (1982) evaluated a social skills training package for
forcement. The studies provided strong evidence that mildly retarded children. A multiple baseline revealed
interpersonal skills can be taught to severely and pro- posttraining improvement in all targeted behaviors and
foundly retarded individuals. Only some studies tested generalization to novel role-play scenes and to un-
for generalization of treatment effects and only a few structured conversations with familiar and unfamiliar
adults, although effects did not transfer to conversa- Community Preparation

tions with unfamiliar children.
Assertiveness training also has been employed. Community skills training has taken on increasing
Fleming and Fleming (1982), for example, compared importance, largely because of the emphasis on plac-
structured teaching (videotaped modeling, role-playing retarded individuals in community settings rather
ing, and reinforcement) alone or with coping models to than segregating them in specialized residential ser-
teach passive and aggressive educably retarded chil- vices (Madle & Deutsch, 1983). Such skills are typ-
dren appropriate assertive responses. Although all ically considered developmental tasks of late adoles-
children showed greater learning than controls on cence and adulthood. Martin, Rusch, and Heal (1982)
question and answer measures, transfer to in vivo sit- pointed out that in vivo community training may be
uations was limited. Bregman (1984) also reported more effective than institutional programs. Supporting
that individuals who received personal adjustment this, Schalock, Gadwood, and Perry (1984) compared
training showed a greater ability to communicate as- skill acquisition in moderately retarded adults who re-
sertively but not to discriminate between passive, ag- ceived individualized programming in either their
gressive, and assertive behaviors. staffed apartment or a group home adjacent to a devel-
Matson and his associates reported a series of stud- opmental center. The apartment-trained individuals
ies comparing different methods of training social gained three times the skills. Significant predictors of
skills. These researchers suggested that social skills success included assessed number of social behavior
training is superior to contingent attention (Matson, A. skills, number of instructional steps in the task analy-
M. Zeiss, R. A. Zeiss, & Bowman, 1980), in vivo ses developed, and programming frequency. A
contingent reinforcement (Hazinski & Matson, 1985), number of studies have emerged in this area in recent
and traditional psychotherapy (Matson & Senatore, years.
1981). Senatore, Matson, and Kazdin (1982) also Various studies have reported training complex
found that the inclusion of active rehearsal was superi- meal-planning and preparation skills. Wilson, Cuvo,
or to social skills training alone, using an in vivo test in and Davis (1986) trained five individuals to plan nu-
a party situation. tritious meals, write accurate grocery lists, stay within
Maintenance and generalization of social behaviors a weekly food budget, and then shop systematically,
continue to be problematic and specific procedures for using classroom-based modeling, rehearsal, and ex-
generalization are needed. Mayhew et al. (1978) in- perimenter and peer feedback for the first three skills.
vestigated whether generalization in social skills might Meal plans, which were nutritionally deficient during
partly be due to the failure ofthe environment to main- baseline, met or exceeded criterion after instruction.
tain the behaviors. In a reversal design, severely and Grocery list writing skills improved from under 30% to
profoundly retarded institutionalized adolescents were more than 90% correct, with similar improvements in
alternately ignored or given social reinforcement for grocery costs and systematic shopping. Generalization
appropriate social behaviors. Social behavior in- from the training store to two other stores was ob-
creased during the reinforcement conditions. It was served, as well as skill maintenance on follow-up, rein-
suggested that deficits in the social behavior of re- forcing results from earlier studies (e.g., Sarber &
tarded persons may be due to the failure of their en- Cuvo, 1983). More impaired individuals have also
vironment to maintain such behavior rather than to a been taught grocery shopping using various prosthetic
lack of social skills or "social deficit." However, a aids to compensate for reading and computational defi-
number of methods have shown good generalization, ciencies (e.g., Aeschleman & Schladenhauffen,
including using mUltiple trainers and settings (Lowther 1984). As an illustration, McDonnell and Homer
& Martin, 1980) and correspondence training (Ralph (1985) trained eight moderately to severely retarded
& Birnbrauer, 1986). Matson and Andrasik (1982), high school students to locate grocery items using ei-
however, compared the effectiveness of social skills ther in vivo training alone or with simulations and
training in a therapy room with self-monitoring and found that generalization was more likely when in-
reinforcement in a natural setting as methods of pro- class simulations were included.
moting generalization and reported that generalization Johnson and Cuvo (1981) taught retarded adults to
to the natural environment improved when self- cook using pictorial recipes, prompts, and positive
monitoring and reinforcement in the natural environ- consequences. Results showed relatively rapid skill
ment were used. acquisition, substantial maintenance, and idiosyncrat-
ic patterns of generalization within and between the Money handling is also important, and Bourbeau,
cooking methods, and some generalization from the Sauers, and Close (1986) used a simulated classroom
training setting to the home. Picture cues also were bank to train banking skills with mildly retarded young
used by Martin, Rusch, James, Decker, and Trtol adults. Performance improved markedly, with gener-
(1982) in establishing preparation of complex meals alization to real community settings, although addi-
and Kayser, Billingsley, and Neel (1986) in teaching tional in vivo training was required to achieve perfect
snack-making procedures. performance. Aeschleman and Gedig (1985) reported
In related areas, Reitz (1984) evaluated the use of similar results with adolescents whose performance
instructions, self-monitoring and praise, and cash rein- after training compared favorably to that of volunteer
forcement to teach formerly institutionalized males to college students.
eat well-balanced diets. During baseline, they aver- Several studies have focused on using the telephone.
aged only 6.7 appropriate food servings each day. In- Risley and Cuvo (1980) trained making emergency
structions and self-monitoring and praise had little ef- calls and showed that when criterion was met for the
fect, while cash reinforcement increased the number of first emergency call type, generalization occurred to
appropriate servings to 10 per day. Van den Pol et al., the other types. Karen, Astin-Smith, and Creasy
(1981) used classroom-based modeling, role playing, (1985) studied telephone-answering skill acquisition
and simulated ordering to teach fast-food restaurant (e.g., calling someone, dealing with wrong numbers,
skills. Periodic probes in a MacDonald's showed per- and taking messages) and, although all individuals
formance improvements and generalization to a novel learned the problems, large individual differences
setting (Burger King) with performance comparable to were observed throughout the study. Probes revealed
that of a sample of nonretarded persons. Sprague and retention, cross-problem transfer, and generalization
Homer (1984) trained vending machine use by moder- across caller sex and request style. Matson (l982a)
ately or severely retarded high school students and showed that independence training was more effective
found that using multiple types of vending machines than simple modeling or no treatment with mildly re-
proved an effective method of obtaining generalized tarded adults in remediating deficits in telephone con-
responding. versation skills.
Williams and Cuvo (1986) taught apartment upkeep Another problem associated with community living
skills to severely handicapped individuals. They were is the increased need to travel about safely and effec-
taught to perform upkeep on their air conditioner and tively. Marchetti, McCartney, Drain, Hooper, and Dix
heating unit, electric range, refrigerator, and electrical (1983) taught pedestrian skills using either classroom
appliances with successful long-term maintenance and or community training. Community training resulted
generalization of the skills to a nontraining apartment. in significant improvement with no significant change
Morrow and Bates (1987) used a school-based pro- in the classroom group. In a comparison of two modes
gram to teach community laundry skills to adolescents of pedestrian-skills training (individualized classroom
with severe handicaps. Instruction included artificial training using a scale model of an intersection vs. inde-
(e. g. , pictures) and simulated materials. After instruc- pendence training with a full-size mock-up of an inter-
tion, 10 community-training trials were provided; a section), Matson (1980) found that independence
final assessment was conducted in both trained and training was significantly more effective than class-
untrained community settings. Most individuals in- room training. Colozzi and Pollow (1984) also ob-
creased their laundry performance; however, gener- tained rapid acquisition and maintenance in training
alization was limited in the community settings. Direct retarded children to walk from their school entrance to
training in one community setting resulted in improved their classroom using a prompt-fading sequence. Ear-
acquisition and enhanced generalization. In an earlier lier studies (e.g., Neef, Iwata, & Page, 1978) reported
study, Thompson, Braam, and Fuqua (1982) used methods for training community pedestrian and bus-
graded prompts and token reinforcement to teach sort- riding skills.
ing, washing, and drying clothes. Skills generalized to Another area showing high activity is emergency
a public laundromat and were maintained at a 10- skills, especially dealing with fire emergencies. Katz
month follow-up. Cuvo, Jacobi, and Sipko (1981) also and Singh (1986) taught retarded adults to exit a burn-
taught laundry sorting and washer and dryer skills ing building, properly report the fire, and extinguish a
using prompt sequences, praise, and response-con- fire on oneself or another person through instructions,
tingent feedback. modeling, rehearsal, feedback, and social and descrip-
tive reinforcement. Haney and Jones (1982) investi- formance feedback with mildly to moderately retarded
gated maintenance of responding by severely to mod- sheltered workshop employees. As with earlier stud-
erately retarded adolescents following training of ies, the program significantly increased the produc-
socially validated methods of exiting from a burning tivity, which decreased to pretreatment levels after
house. Training included instructions, modeling, be- intervention. Later, they examined the use of self-
havioral rehearsal, social and tangible external rein- monitoring, which was not effective in improving pro-
forcement, and self-reinforcement. The procedure was duction. In another study, Ackerman and Shapiro
effective in both training and maintaining emergency (1984) used self-monitoring alone to maintain produc-
exiting skills in the simulated setting, with limited gen- tivity rates, which had been increased with verbal
eralization to the children's own rooms. praise, prompts, and physical encouragement. Several
Other community skills that have been reported in- others have reported productivity improvements with
clude clothing selection (Nutter & Reid, 1978), house- self-monitoring (e.g., McNally, Kompik, & Sherman,
keeping (Bauman & Iwata, 1977), and leisure-time 1984). Mank and Homer (1987) also reported the use
skills (Johnson & Bailey, 1977). of a self-management procedure to improve and main-
tain work performance. Individuals were taught to
self-monitor work rate onjob tasks, evaluate daily per-
Vocational Preparation
formance against a criterion, and recruit contingent
Vocational preparation of the retarded typically feedback from supervisors. Self-monitoring of work
takes place either in a sheltered workshop setting or a rate alone was not a consistently effective maintenance
specifically designed task -analyzed program for teach- strategy. Mace, Shapiro, West, Campbell, and Altman
ing job skills. Many applications of behavioral tech- (1986) found that while reinforcement alone increased
niques with the retarded have been concerned with productivity, it was to a lesser degree and with less
"motivation" and "productivity," the traditional con- consistency than when combined with self-monitor-
cerns in the world of work. Early studies focused ing. Self-monitoring alone, however, did not increase
largely on the use of reinforcement and punishment productivity.
contingencies to increase worker productivity (e.g., Vocational research has also been concerned with
Evans & Spradlin, 1966; Hunt & Zimmerman, 1969). the methods for training complex tasks, such as assem-
In one early study, for example, Zimmerman, Stuckey, bling bicycle brakes. Cipani (1985), for example,
Garlick, and Miller (1969) used token reinforcement found that partial task training, consisting of present-
to increase the productivity of 16 multiply handi- ing mini tasks with reinforcement for each task, de-
capped individuals. Feedback alone, and later tokens, creased off-task behavior and substantially increased
were given for meeting or exceeding production crite- the number of pieces completed. Total task presenta-
ria. Although feedback alone was effective, even tion has also been found to be effective in complex
greater improvements were seen when tokens were assembly task training (Martin, Koop, Turner, &
added. The elimination of tokens , however, resulted in Hanel, 1981). Walls, Dowler, Haught, and Zawlocki
significant productivity decreases. Zimmerman, Over- (1984), on the other hand, found that progressive pro-
peck, Eisenberg, and Garlick (1969) also reported an cedures using time delays and forward chaining re-
avoidance procedure in which clients worked at an quired fewer prompts and errors, although the training
isolated workstation if individualized production goals time was greater than with total task training. Sowers,
had not been met the previous day. The avoidance pro- Verdi, Bourbeau, and Sheehan, (1985) examined the
cedure consistently improved performance, and when use of picture cues and self-monitoring to initiate tasks
the contingency was finally withdrawn the gains in of varying types and order in severely to moderately
production were maintained for up to 2 weeks and did retarded students. Individuals learned to use the pic-
not return to baseline levels. ture-cue system to change tasks as trainer feedback and
Productivity still is a primary concern in this area, presence were decreased. Finally, two individuals ex-
although the techniques have changed. Several more posed to novel photographs were independently able to
recent studies have applied self-management tech- initiate tasks after only minimal training, suggesting
niques to productivity, generally with mixed results. that the use of the picture-cue system had become a
Shapiro and Ackerman (1983) used a classroom pro- generalized skill. Schepis, Reid, and Fitzgerald (1987)
gram consisting of prompting, social praise, and per- reported a group instruction program for teaching pro-
foundly retarded women to stamp addresses on enve- compared to behavioral procedures. These findings are
lopes. The skill was acquired, generalized to an un- congruent with trends to discourage and often prohibit
trained type of envelope, and maintained. the use of restrictive and aversive techniques (e.g.,
Much work on teaching actual community-based Egelston, Sluyter, Murie, & Hobbs, 1984). In-
jobs to retarded individuals continues to consist of an- creasingly, the focus of programming for maladaptive
ecdotal case studies. Cuvo, Leaf, and Borakove behaviors is on positive approaches, both in terms of
(1978), however, described empirical research on procedures and behavioral development, rather than
teaching janitorial skills. A task analysis of janitorial mere behavior elimination. Given the volume of the
skills required for cleaning a restroom was developed. literature in this area, the focus will be on broad find-
A total of six subtasks, consisting of 181 component ings. Additional detail and early references can be
responses, was identified. Individuals progressed found in referenced reviews (especially O'Brien,
through a series of four prompt levels ordered from 1981; S. R. Schroeder, C. S. Schroeder, Rojahn, &
more to less assistance for 20 of the most difficult Mulick, 1981; and Repp & Brulle, 1981).
component steps. The remainder of the responses were
taught using prompts, ordered from less to more direct Self-Stimulatory and Self-Injurious Behav-
assistance. The individuals progressed to the next, iors. Retarded persons frequently engage in stereo-
more intense prompt level, contingent on their failure typed acts, self-stimulatory behaviors (SSBs), and
to respond appropriately with less assistance. The re- self-injurious behaviors (SIBs) that appear to have no
sults showed rapid response acquisition, skill gener- functional value. A survey of over 100 profoundly
alization to a public restroom, and maintenance of the retarded, institutionalized individuals revealed that
newly learned behaviors. The Cuvo etal. (1978) study 34% exhibited one or more classes of SSB (Dura,
is a model for future research. Mulick, & Rasnake, 1987). Although often viewed as
unusual, SSB and SIB are shared by many popula-
tions, ranging from the retarded and autistic to normal
Maladaptive Behaviors
individuals. In deviant popUlations, the problem is
Retarded individuals may be more likely to experi- usually one of form and intensity rather than rate. SSB
ence various maladaptive behaviors and psychiatric and SIB can be relatively innocuous, such as hand
disturbances because of their limited coping skills waving and rocking, or self-injurious, such as slap-
(Robinson & Robinson, 1976). Generally, the same ping, biting, and head banging. Various behavioral
techniques used with other populations apply to the causes of SSB and SIB have been posited, including
retarded, although certain changes may be needed to social reinforcement, frustration, demand situations,
adjust for developmental levels. Therefore, we will and sensory stimulation (Iwata et al., 1982). For exam-
highlight only some trends and recent studies. Lennox, ple, Lovaas, Newsom, and Hickman (1987) discuss
Miltenberger, Sprengler, and Erfanian (1988) recently SSB as an operant maintained by the perceptual stimuli
summarized selected studies on treating behavior it produces, whereas Durand and Carr (1987) viewed
problems in the retarded, including self-stimulatory SSBs as socially mediated. Other researchers follow a
and self-injurious behavior, aggression, and psychi- stimulation deficiency model, reporting that increased
atric disturbances. They arrived at several conclu- environment stimulation (e.g., Goodall & Corbett,
sions, including some about treatment effectiveness, 1982) or reinforcing high stimulation activities, such
as well as treatment by behavior interactions. In the as toy use (e.g., Eason, White, & Newsom, 1982),
area of treatment by behavior interactions, for exam- results in decreases in these behaviors.
ple, exclusionary time-out was the least effective pro- Even though the results of behavioral studies are
cedure for self-injury, while it was highly effective for promising, Altmeyer et al. (1987) concluded that
aggressive and disruptive/destructive behaviors. sparse treatment, insufficient use of behavioral tech-
Overall, it is interesting to note that the positively ori- nology, and use of physical and chemical restraints
ented techniques showed a mean effectiveness of 62%, continued to be problems. SSB and SIB treatment re-
while the two more intrusive classes of interventions search has been detailed in several recent reviews.
(e.g., overcorrection, response cost, restraint, noxious Gorman-Smith and Matson (1985) concluded that
stimuli) showed only 54% and 52%. They also noted profoundly retarded persons 16 years of age and over
the low effectiveness of psychotropic medications were the most likely to be treated effectively, and the
behaviors most frequently treated were head hitting result, a number of "less aversive" punishment pro-
and body rocking. The greatest effectiveness was ap- cedures have been developed.
parent with differential reinforcement of other behav- Positive practice overcorrection, or requiring an in-
ior (ORO), lemon juice therapy, time out, air splints, dividual to practice acceptable incompatible behaviors
and ORO plus overcorrection, although it also ap- contingent on SSB/SIB, is one. For example, Azrin,
peared that reinforcement was more effective than Kaplan, and Foxx (1973) found that combined practice
frequently believed, a finding reaffirmed by Lennox and reinforcement procedures rapidly reduced rocking
et al. (1988). LaGrow and Repp (1984) also reported and head weaving to almost zero; other studies have
that body rocking was the most common target behav- confirmed this effectiveness (e.g., Barrett & Linn,
ior, with mouthing and complex finger and hand 1981; Singh & Winton, 1985). On occasion, however,
movements also frequently addressed. About three overcorrection has actually increased target behaviors
quarters of the studies used aversive techniques, with (Holbum & Dougher, 1985). Reinforcing correct prac-
shock as the most effective one. However, positive tice has yielded faster training with an equivalent re-
procedures and overcorrection also were well repre- duction of stereotypic behavior. Gibbs and Luyben
sented and found effective. In an earlier review, (1985) further reported the ineffectiveness of noncon-
Schrader, Shaull, and Elmore (1983) concluded that tingent positive practice, supporting its categorization
ORO, overcorrection, response interruption, and sen- as punishment. Maintenance and generalization are
sory extinction techniques were effective, but they still in question with only some studies reporting
differed on factors, such as ease of implementation, positive results (e.g., Czyzewski, Barrera, & Sulzer-
practicality, ethicality, and potential for negative side Azaroff, 1982) and others not (e.g., Coleman, Whit-
effects. man, & Johnson, 1979). Halpern and Andrasik (1986)
In early studies, punishment was commonly used treated head banging with overcorrection and found
with great effect; a major advantage being its relatively that I-year follow-up data revealed that while head
rapid impact, especially when combined with ORO banging occurred, it was well below baseline levels.
and DRI (differential reinforcement of incompatible Matson and Stephens (1981) reported no generaliza-
behavior). Shock has effectively eliminated such be- tion across settings until the trainer, who had become a
haviors as rocking, head banging, and face slapping in discriminative stimulus, was faded out of treatment.
a number of studies. Contingent aromatic ammonia Another positive alternative is response interrup-
has been used successfully as an alternative to shock tion, that is, brief contingent interruptions with DR!.
(e.g., Baumeister & Baumeister, 1978), as have lemon Azrin and Wesolowski (1980) used response interrup-
juice (Gross, Wright, & Drabman, 1980), Tabasco tion as an alternative to overcorrection with pro-
sauce (Altmeyer, Williams, & Sams, 1985), slapping foundly retarded adults. During baseline, SSB oc-
(Cavalier & Ferretti, 1980), and application of ice curred 66% of the time and decreased to less than one
(Blount, Drabman, Wilson, & Stewart, 1982). In a response per half-hour with treatment. In classroom
comparison of ORO, overcorrection, lemonjuice, and situations, SSB decreased to less than one stereotypy
aromatic ammonia, Rapoff, Altman, and Christo- per hour. The authors concluded that interruption
phersen (1980) found that ORO and overcorrection seems preferable to overcorrection because of its rela-
were both ineffective. Lemon juice suppressed the be- tive nonaversiveness. A mild response interruption
havior, although ammonia produced greater suppres- procedure combined with either ORO or DR! also has
sion. More recently, water mist sprayed to the face been found to be more effective than either ORO or
has been employed (e.g., Dorsey, Iwata, Ong, & DRI alone with SSBs (Fellner, Laroche, & Sulzer-
McSween, 1980; Singh, Watson, & Winton, 1986). Azaroff, 1984), although new stereotypies appeared
Dorsey et at. (1980), for example, found that pre- which required interruption to decrease them. Inde-
viously ineffective verbal reprimands became effective pendent toy play also increased as a by-product of the
punishers when paired with water mist. Although aver- treatment. Response interruption is also more effective
sive stimuli can be effective, such procedures are now than ORO, DRI, or instructional prompting alone
prohibited or discouraged in many settings. A survey (Azrin, Besalel, & Wisotzek, 1982; Slifer, Iwata, &
of psychologists in facilities for the retarded revealed Dorsey, 1984). Wesolowski and Zawlocki (1982),
they would be hesitant to employ aversive stimuli, however, found that response interruption was ineffec-
such as shock in the treatment of SSB and SIB (Wal- tive in reducing eye-gouging behavior.
lace, Burger, Neal, van Brero, & Davis, 1976). As a Another relatively harmless, effective procedure is
visual/facial screening (Lutzker & Wesch, 1983). The Pace, Iwata, Edwards, and McCosh (1986) and Cun-
procedure should be applied contingently on a continu- ningham and Peltz (1982).
ous schedule, using an opaque screen left in place for SIB also can be decreased through time-out. Al-
30 seconds to 1 minute after the target behavior has though time-out may rapidly suppress behaviors, a de-
stopped. It appears that visual blocking is the key ele- tailed analysis of existing contingencies is required.
ment in screening procedures (Watson, Singh, & Win- Time-out also is not likely to work if the individual's
ton, 1986). Overall, it appears that visual screening is environment contains few positive reinforcers. Nunes,
an easily administered, effective, and durable pro- Murphy, and Ruprecht (1977) demonstrated an effec-
cedure for controlling a variety of SSBs. Visual tive time-out procedure in which a vibratory stimulus
screening was also effective in reducing behaviors, was provided and then withdrawn contingent on SIB.
such as visual/auditory SSB, stereotypic fabric pull- A nonexclusionary time-out procedure involving a dis-
ing, self-mutilative ear bending, thumb biting, and criminative stimulus (e.g., a ribbon or badge) to signal
stereotypic screaming (Dick & Jackson, 1983; reinforcement and its contingent removal to signal
McGonigle, Duncan, Cordisco, & Barrett, 1982; Sin- time-out from reinforcement has also been reported
gh, 1980). (Foxx & Shapiro, 1978; McKeegan, Estill, & Camp-
Historically, physical restraints were used to control bell, 1984).
SIB and SSB, with little attention to making them ef- Extinction procedures have been only moderately
fective as behavior change procedures. Recent work successful with SSB and SIB. The major problem is
shows increased attention to developing treatment determining exactly what reinforcers are maintaining
properties of restraint. Schroeder, Peterson, Solomon, the behaviors. In many cases this has been virtually
and Artley (1977), for example, found contingent re- impossible. In an attempt to deal with this problem,
straint decreased head-banging behavior more effec- Neisworth, Hunt, Gallop, and Madle (1985) designed
tively when combined with deep muscle elec- a "reinforcer displacement" procedure-the use of
tromyographic (EMG) feedback. Contingent restraints extrinsic continuous reinforcement for SSB followed
with DRI and DRO have been used effectively in sever- by sudden extinction. They hypothesized that this pro-
al cases (e.g., Ball, Campbell, & Barkemeyer, 1980; cedure would rapidly weaken SSBs by bringing them
Dorsey, Iwata, Reid, & Davis, 1982; Parrish, Iwata, under control of identifiable, accessible contingencies
Dorsey, Bunck, & Slifer, 1985). Noncontingent re- prior to extinction. The procedure produced substan-
straint application has also been effective. For exam- tial decreases in targeted behaviors for two adoles-
ple, Silverman, Watanabe, Marshall, and Baer (1984) cents, although some recovery to baseline levels was
used protective clothing to reduce face punching and observed for one. Using a similar procedure, Schmid
leg kicking. A padded helmet substantially reduced (1986) treated six mildly to moderately retarded chil-
face punching and arm self-restraint while padded slip- dren and found significantly lower rates of responding
pers reduced leg kicking and leg self-restraint. in the return to baseline condition.
Unfortunately, overuse of restraint sometimes cre- Various reinforcement-based procedures, such as
ates "restraint-seeking behavior." In one report, re- DRO, DRI, and DRL (differential reinforcement of
straint actually functioned as a positive reinforcer low rates of behavior), have been employed for SSB
(Favell, McGimsey, & Jones, 1978). By requiring in- and SIB (e.g., Foxx, McMorrow, Fenlon, & Bittle,
creasing periods without SIB to gain access to physical 1986; Heidorn & Jensen, 1984). Differential reinforce-
restraint, SIB decreased drastically. Foxx and Du- ment procedures have generally been found to be effec-
frense (1984) employed fading with an institu- tive when consistently applied. Typically, studies have
tionalized male who found restraint reinforcing. After shown that DRI, in which a specific incompatible be-
reinforcement with restraint for increasingly longer havior is identified, produces superior effects to DRL
periods of noninjury, he was given time-out from re- or DRO (e.g., Tarpley & Schroeder, 1979; Tierney,
straint for SIB. At the end of this phase, less than one 1986). For example, Eason et al. (1982) reinforced
episode of SIB occurred per day, but he had begun self- increasing durations of appropriate toy use with praise
restraint by holding objects in his hands. The objects and food play in retarded and autistic children as a
then were faded in size to a point where he ceased means of reducing SSBs. No consequences were deliv-
holding them. Eventually, eyeglasses were sub- ered for self-stimulation. The reinforcement substan-
stituted, and he continued to wear them after 4Y2 years. tially increased independent, appropriate toy play and
Similar procedures for self-restraint were reported by decreased SSBs to negligible levels. McClure, Moss,
McPeters, and Kirkpatrick (1986) have even partially reduced fluid consumption, and fading (Barton & Bar-
automated DRI for SSB. Hand mouthing was treated ton, 1985) as weII as spaced food intake and the teach-
successfuIIy, using an automated device that delivered ing of slower eating (Azrin, Jamner, & Besalel, 1986).
music and vibration when both hands were placed on
hand switches. Aggressive and Disruptive Behaviors. The
Two classes of SIB, pica and ruminative vomiting, elimination of aggressive and other forms of disruptive
merit separate mention since they more closely resem- behaviors has also been frequently examined. Besides
ble "compulsions" rather than stereotypies. Pica-the the Lennox et al. (1988) review, Harris and Ersner-
compulsive eating of inedible substances-is a wide- Hershfield (1978) and Matson and Gorman-Smith
spread condition in the severely and profoundly re- (1986) reviewed this area. Inappropriate verbal re-
tarded. Although its etiology is unclear, it can be sponses are most commonly treated, foIIowed by ag-
usefully viewed as learned behavior amenable to be- gression toward others, and noncompliance (Matson
havioral treatment. Singh's (1983) recent review sug- & Gorman-Smith, 1986).
gested that a small number of studies using behavioral As with SSB and SIB, shock has been used to reduce
procedures suggest that overcorrection, physical re- aggressive! disruptive behavior, particularly during the
straint, time out, and screening are somewhat effective 1960s. The use of shock has virtually disappeared in
in controlling pica. Since that review, additional stud- recent work (Lennox et al.. 1988). Other forms of
ies have supported visual screening (Singh & Winton, direct punishment used include reprimands (Connis &
1984), overcorrection (Singh & Bakker, 1984; Singh Rusch, 1980), contingent restraint (Bitgood, Peters,
& Winton, 1985), and physical restraint (Singh & Bak- Jones, & Hathorn, 1982; Tomporowski, 1983), aver-
ker, 1984). Mace and Knight (1986) also designed a sive tickling (Greene & Hoats, 1971), and unpleasant-
program based on a functional analysis of a profoundly tasting or -smelling liquids (Sajwaj, Libet, & Agras,
retarded male's pica that used no aversive components. 1974). More recently, water mist (Gross, Berler, &
Frequent staff-client interaction resulted in 25% and Drabman, 1982) and ammonia (Doke, Wo1ery, &
66% less pica than with limited or no interaction, Sumberc, 1983) have been used. Doke et al. (1983),
respectively. Paniagua, Braverman, and Capriotti for example, suppressed aggression abruptly with con-
(1986) further emphasized the need to use multitechni- tingent ammonia. Concurrently, levels of untreated in-
que treatment packages rather than single methods to appropriate vocalizations decreased and participation
enhance efficiency. in planned activities increased. One-minute facial
Winton (1984) reviewed the literature on rumination screening was used to suppress screaming by Singh,
and concluded that positive reinforcement of desirable Winton and Dawson (1982), whereas Zlomke. Smith,
behaviors should always be used, even when aversive and Piersel (1986) used contingent visual screening for
methods are also employed, and two less aversive pro- excessive and inappropriate verbalizations. A delayed
cedures should be combined when one alone only par- punishment procedure, in which a short segment of
tially eliminates rumination rather than increasingly recorded tantrum behavior several hours after the tan-
escalating punishment intensity. Rumination has been trum occurred immediately followed by punishment,
successfuIIy treated through procedures, including produced reductions in tantruming (Rolider & Van
punishment, such as contingent pinching (Minness, Houten, 1985a).
1980), lemon juice (e.g., Marholin, Luiselli, Robin- Overcorrection has been extremely effective in re-
son, & Lott, 1980), alum (Beukelman & Rogers, ducing a number of behaviors, such as hitting, biting,
1984), overcorrection (Singh, Manning, & Angell, and throwing objects (Davidson-Gooch, 1980; Foxx &
1982), satiation (e.g., Rast, Johnston, Drum, & Con- Azrin, 1972; Matson & Stephens, 1977), object de-
rin, 1981), and positive reinforcement (e.g., Conrin, struction (Altman & Krupsaw, 1983), stealing (Mat-
Pennypacker, Johnston, & Rast, 1982). Satiation and son, Coleman, DiLorenzo, & Vucelic, 1981), and spit-
other food manipulations show considerable promise. ting (Clements, Ditchbum, & Grumm, 1982). Dis-
For example, Rast et al. (1981) varied food quantity ruptive acts generally are treated with restitutional,
from regular portions to satiation levels and obtained a rather than positive practice, overcorrection, in which
clear functional relation to rumination, with satiation the client restores the environment to a state far better
producing rapid and large decreases in both frequency than it was before the inappropriate behavior occurred.
and duration. Other programs have used peanut butter, Generally, overcorrection has been shown to be more
effective than several other interventions, such as sim- whereas two different time-out procedures had failed
ple correction (Azrin & Wesolowski, 1975), DRO previously. Repp and his associates (Dietz, Repp, &
(Foxx & Azrin, 1973), and verbal warnings with a Dietz, 1976; Repp & Dietz, 1974) reported the suc-
response cost procedure (Azrin & Powers, 1975). cessful use of DRO for both aggressive behavior and
Foxx and Livesay (1984) discussed problems with im- inappropriate classroom behaviors. Luiselli and Re-
plementing this technique. Besides the level of effort isman (1980) also found that DRL (reinforcement fol-
involved, they reported that as more time passed, the lowing less than or equal to a prescribed number of
less likely that programs would be reinstated when responses in an interval) to be effective in reducing
misbehavior occurred. Staff and institutions tend to aggressive and disruptive behaviors. Reese, Sherman,
return to the status quo after the expert leaves, es- and Sheldon (1984) used combined self-recorded
pecially when treated clients are low functioning. DRO, point fines, social skills training, and relaxation
Generally the contingent removal of reinforcement to reduce agitated/disruptive behavior, such as curs-
(as in time-out and response-cost) has proved moder- ing, hitting, kicking, throwing objects, and verbal
ately effective in dealing with aggressive and disrup- threats. They reported that the self-recorded DRO ap-
tive behaviors (e.g., Gresham, 1979; Mace, Page, peared to the critical variable to effectiveness by re-
Ivancic, & O'Brien, 1986). Barton, Brulle, and Repp cruiting social approval from others. Barton, Brulle,
(1987) reported an effective differential schedule of and Repp (1986) reported that a momentary DRO-
time-out where one maladaptive response per interval, reinforcement delivery if the behavior is not occurring
which received a warning, was allowed before time- at the end of the interval-maintained suppression of
out was implemented. This also resulted in the devel- maladaptive behaviors (e.g., stereotypic behaviors,
opment of self-control after the warning. Restraint noncompliance) at a level comparable to that obtained
procedures and differential reinforcement have also by whole-interval DRO.
been combined with time-out (Friman, Barnard, Al- Other positively oriented techniques have been used
tman, & Wolf, 1986; Luiselli, Suskin, & Slocumb, to deal with aggressive and disruptive behavior. Re-
1984). Nonexclusionary time-out has also been em- cently, social skills (Matson & Stephens 1978) and
ployed (Huguenin & Mulick, 1981), as has movement assertion training (Fleming, 1976) have been em-
suppression time-out with DRO (Rolider & Van ployed successfully. Immediate and dramatic results
Houten, 1985b). were obtained in using a six-step compliance training
Extinction has been minimally useful, although on procedure, incompatible with severe aggressive and
occasion it has been effective (e.g., Martin & Foxx, tantrum behaviors, and reinforcement (Mace, Kra-
1973). Williamson, Lemoine, Coon, and Cohen tochwill, & Fiello, 1983). Bachman and Fuqua (1983)
(1983) reported that sensory extinction reduced dis- examined the effects of several levels of exercise on
ruptive behaviors and increased appropriate ones in a inappropriate behaviors and found a decrease in inap-
profoundly retarded male. Other studies have demon- propriate behaviors with an inverse relationship be-
strated no decrease in behavior when extinction pro- tween the level of exercise and the amount of inap-
cedures were initiated (e.g., Sajwaj, Twardosz, & Bur- propriate behavior. Gardner, Cole, Davidson, and
ke, 1972). The ineffectiveness of extinction may Karan (1986) discussed stimulus control procedures
possibly be due to the difficulty in identifying reinfor- for aggression involving the identification and modifi-
cers maintaining the behavior (Solnick, Rincover, & cation of immediately preceding stimulus events that
Peterson, 1977). Also, extinction often fails to weaken instigate aggressive behaviors. Several uses of behav-
behavior in simple operant tasks in a retarded popula- ioral "self-management" methods to reduce aggres-
tion (e.g., Cairns & Paris, 1971). sion/ disruption, consisting of techniques, such as self-
DRO and DRI can be effective and should be seen as monitoring, self-evaluation, and self-consequation,
the first choice of techniques for dealing with inap- have been reported (Gardner, Cole, Berry, & No-
propriate behavior, since they do not rely on aversive winski, 1983; Robertson, Simon, Pachman, & Drab-
procedures which raise ethical concerns (e.g., Luiselli man, 1979). After training mildly and moderately re-
& Reisman, 1980; Luiselli & Slocumb, 1983; Page, tarded adults who displayed chronic and severe
Finney, Parrish, & Iwata, 1983). Frankel, Moss, behavioral/emotional difficulties in self-monitoring,
Schofield, and Simmons (1976) reported dramatic de- self-evaluation, "self-consequation", and self-in-
creases in aggression and head banging through DRO, struction, Cole, Gardner and Karan (1985) found im-
mediate, clinically significant, and durable reduc- ance of escalators in retarded adults (Runyan et al.,
tions. 1985), as well as stair avoidance behavior in a severely
retarded male (Burgio et al., 1986).
Psychiatric Disorders. Only relatively recently Stephens, Matson, Westmoreland, and Kulpa
have clinicians become interested in working with tra- (1981) treated mildly to severely retarded chronic
ditional psychiatric disorders in the retarded. Little schizophrenics for psychotic speech (e.g., relevance
research has been conducted on behavioral approaches of responses, changes of subject, speech disturbances)
to depression in the retarded (Matson, 1982b). Frame, using instruction, audiotape feedback, modeling, and
Matson, Sonis, Fialkov, and Kazdin (1982) effectively speech rehearsal. Treatment resulted in rapid changes
treated several symptoms of depression (inappropriate that generalized over settings. A mildly retarded
body position, lack of eye contact, poor speech, and female with severe emotional disturbance was treated
bland affect) in a retarded youngster, using instruc- by Burgio, Brown, and Tice (1985) for frequent dis-
tions, modeling, role-playing, and feedback. Matson ruptive outbursts. Using instructions, modeling, con-
(1982c) also reported treatment of depressive behav- tingent verbal reprimands, time-out from eating, and
iors in four retarded adults in the mild-to-moderate DRO, the treatment focused on delusional verbaliza-
range. Treatment consisted of information, perfor- tion, which decreased markedly. Correlated decreases
mance feedback, and token reinforcement of correct were also observed for disruption, screaming, and out-
responses. All improved significantly on the target be- of-seat behavior.
havior, and effects were maintained at follow-up (4-6 Matson (1982d) reported the treatment of three
months later) using social validation criteria. mildly retarded males for obsessive-compulsive behav-
Although phobias and fears are common in the re- iors: c1othes- and body-checking for extended periods
tarded (Harvey, 1979), their treatment has been ne- of time. Treatment consisted of DRI, as well as over-
glected until the past few years. The earliest work correction for inappropriate responses. To establish a
focused on operant techniques, such as extinction and social validation criterion, community members rated
token reinforcement, for fears of physical examina- videotapes of behavior from baseline to posttreatment;
tions (Freeman, Roy, & Hemmick, 1976) and car rides the ratings showed significant improvement on the be-
(Mansdorf, 1976). Reisinger (1972) used similar haviors. Similar improvement occurred on frequency
methods plus response cost for anxiety-based crying. counts and self-ratings of anxiety. Psychosomatic com-
More recent work being done generally applies similar plaints (stomachache, headache, and multiple phys-
techniques to those used with children and adoles- ical complaints) were also treated with a combination
cents: participant modeling (Feltz, 1980; Jackson & of token reinforcement, performance feedback, in-
Hooper, 1981; Matson, 1981b) and contact desensi- structions, and modeling in mildly retarded females
tization (Burgio, Willis, and Burgio, 1986; Runyan, (Matson; 1984). Target behaviors decreased to near
Stevens, & Reeves, 1985; Wilson & Jackson, 1980). zero, and comparison to adult community members
More recently, Chiodo and Maddux (1985) described showed no difference in complaints after treatment.
the successful use of cognitive restructuring, motoric, Foxx, Bittle, Bechtel, and Livesay (1986) presented a
and biofeedback strategies to treat anxiety problems in thorough review of behavioral treatment of sexual de-
two mildly retarded females. As with young children, viations in the retarded.
imagery relaxation is of marginal use (Peck, 1977).
Jackson and Hooper (1981) used participant modeling Seizure Disorders. Several studies report on be-
to treat a dog phobia in a mildly retarded adult female. havioral approaches to seizure disorders in the re-
Matson (1981 a) used participant modeling with mildly tarded. Zlutnick, Mayville, and Moffat (1975) investi-
to moderately retarded individuals with fears about gated the effects of interruption and differential
community shopping. Treatment consisted of role- reinforcement on seizures. Seizures were viewed as
played rehearsal, then going to a community grocery the last link in a behavioral chain, and this strategy
store with the therapist. After 4 months, the results attempted to identify early elements in the chain for
showed that modeling was significantly more effective interruption. Seizure activity was reduced in four of
than a no-treatment control condition. In a second five individuals. Iwata and Lorentzon (1976) success-
study, Matson (1981 b) used similar procedures to treat fully reduced a long-standing seizurelike behavior in a
fear of strangers. Contact desensitization and con- 41-year-old retarded male using increased activities,
tingent social approval were used to decrease avoid- DRO, and time-out. Cue-controlled relaxation was
Table 1. Summary across Time of Bebavioral Literature
with the Retarded on Selected Variables
Year
Pre-1973 a 1976-1978 1984-1986
Category/factor n % n % n %
Age
Birth-21 36 87.8 104 79.5 104 55.6
Over 21 5 12.2 27 20.5 83 44.4
Retardation
Mild 9 19.2 44 32.4 32 17.1
Moderate 14 29.8 34 25.0 47 25.1
Severe/profound 24 51.0 58 42.6 108 57.8
Setting
Institutional 38 92.7 59 39.3 56 40.6
Community 3 7.3 91 60.7 82 59.4
Techniques
Reinforcement 21 51.2 96 73.3 121 64.7
DROIDRI 2.4 7 5.3 21 11.2
Prompting 11 26.8 43 32.8 20 10.7
Fading 4 9.8 15 11.5 11 5.9
Extinction 2 4.9 4 3.1 5 2.7
Punishment 6 14.6 18 13.7 18 9.6
Time-out 10 24.4 13 9.9 9 4.8
Response-cost 4 9.8 7 5.3 11 5.9
Overcorrection 0 0.0 11 8.4 12 6.4
aBased on Kazdin and Craighead (1973).
employed by Wells, Turner, Bellack, and Hersen of clients, intervention setting, and selected tech-
(1978) to reduce seizure frequency in a retarded indi- niques used.
vidual. Burgio, Tice, and Brown (1985) dealt with Several trends emerge from this comparison. First,
uncontrolled seizurelike behavior using a half-hour settings are shifting away from institutions to the home
walk with a preferred staff member made contingent and community. Also, clients involved in published
upon 24-hours without seizurelike behaviors. Seizure research are older than previously; this is consistent
frequency decreased from a 0.70 per day during base- with the increased attention the adult and aged retarded
line phase to 0.36 during final treatment, and the dura- person has been receiving in general (Seltzer &
tion decreased from 50 to 17 minutes per seizure. Krauss, 1987). Although there was a shift to the more
mildly impaired in the mid-1970s, attention has re-
turned to the severely and profoundly retarded as they
Future Perspectives and Directions are now being placed in community settings, although
this may also reflect the difficulties encountered by
Some trends over the past several years are evident researchers in gaining access to individuals in group
in Table 1, where three publishing intervals are com- homes. With respect to techniques employed, there is
pared. The first two points, taken from an earlier ver- a relatively stable use of reinforcement-based meth-
sion of this chapter, cover the pre-1973 and 1976- ods, but an increase in the use of reinforcement for
1978 literature. The third was obtained from a review behavior reduction (DRO/DRI). Most punishment
of 187 articles appearing in the interval from 1984- techniques continue to show declines, which is con-
1986. 2 The articles were coded on the ages and levels sistent with overall trends. There is, however, still sub-
stantial attention to behavior reduction. The relatively
2The authors would like to thank John Keb1es for his assistance in low occurrence of prompting and fading suggests that
coding the studies for the 1984 to 1986 interval. many studies deal with strengthening or weakening
behaviors rather than systematically teaching new reduction of problem behaviors (see Graziano &
ones. Mooney, 1984). Although there has been increased
In addressing the status of the field, as well as emphasis on using positive techniques to alter behav-
needed directions, we shall highlight the major com- iors, the selection of positive, constructive alternative
ponents of the service delivery process. behaviors has received too little consideration. Occa-
sional efforts in this direction are seen. Carr and Du-
rand (1985), for example, replaced serious mis-
Behavioral Assessment and Target
behavior by socially appropriate alternatives by
Behavior Selection
assessing situations in which aggression, tantrums,
As Shapiro and Barrett (1983) recently noted, ad- and self-injury were most likely to occur. After finding
vances in behavioral assessment with the retarded have that both low levels of adult attention and high levels of
not paralleled corresponding progress in interventions. task difficulty prompted misbehavior, they taught indi-
Although there have been isolated improvements, such viduals appropriately to solicit attention, assistance, or
models need to include methods of choosing behaviors both from adults. Overall, however, there still seems
to target for intervention, for assessing behavior in to be a preoccupation with behavioral reduction or
generalization as well as in training settings, and for elimination, particularly in the areas of social and per-
assessing behavior in complex physical and social con- sonal maladaptation. Even though this preoccupation
texts (e.g., Gardner & Cole, 1987; Powers, 1985). is rationalized on the proposition that interfering be-
Additionally, increasing attention is being placed on haviors must be eliminated, rarely do positive behav-
ecobehavioral assessment where behavior is assessed iors emerge spontaneously. Without this orientation,
in context rather than isolation (e.g., Vyse, Mulick, & behavior modification becomes a substitute for other
Thayer, 1984). suppressive and reductive approaches rather than an
At least two levels of behavioral assessment are instructive, constructive therapy.
needed. The first, which is relatively well established,
consists of methods to inventory individual strengths
Technique Selection and Development
and needs. Various scales and checklists have been
developed for this purpose (e.g., Walls, Werner, Since the earliest behavioral applications in retarda-
Bacon, & Zane, 1977). Interview and observational tion, the manipUlation of consequences has received
methods are also useful, although they are less stan- the greatest attention. Various reinforcers have been
dardized and objective. Recently, microcomputers used, including food, feedback, social approval, ac-
have even been used to improve the practitioner's abil- tivities, and tokens. Each of these has been used appro-
ity to summarize and synthesize the mass of data priately in different situations and with varied sched-
needed (Gardner & Breuer, 1985). The second level, ules of reinforcement. Although primary reinforcers
functional analysis, relates more to technique selection were used early, and still continue to be used, more
and will be discussed in that section. recent work appears to emphasize "higher order" rein-
Two issues stand out in target behavior identification forcers, such as informational feedback, social ap-
and selection. Both relate to concepts, such as nor- proval, activity reinforcers, and even self-reinforce-
malization and humanistic legalism (McCarver & Cav- ment. Generally, the trend appears to be away from
alier, 1983). Normalization is a treatment philosophy "artificial" reinforcers to more sophisticated rear-
that emphasizes that goals should be based on the types rangements of existing natural consequences. One
of normal behaviors exhibited by age-mates in the area needing additional attention is the identification
community (Wolfensberger, 1972). Similar orienta- and delivery of effective reinforcers. Typically rein-
tions may also be seen in such concepts as "functional forcer selection is staff determined and aversive tech-
skill training" (Brown et al., 1979) and "social valida- niques are resorted to because of failure to identify
tion" (Woods, 1984). Unfortunately, targets are often reinforcers for specific individuals. But staff judg-
selected arbitrarily, with little regard to skills needed in ments of what is reinforcing often do not correspond to
the community, or at least in the environment where reinforcers selected through empirical methods (Green
the individual will live, work, and play. et at., 1988). Reinforcer identification has become
The second issue concerns attention to the develop- more critical with increased stress on using reinforce-
ment of constructive behaviors rather than the mere ment-based rather than aversive procedures, with in-
creasing emphasis on reinforcer identification being haviors. Generally, this work has taken one of three
evident (Pace, Ivancic, Edwards, Iwata, & Page, approaches. In a post hoc approach (e.g., Barrett,
1985). Even the basic theoretical conditions determin- Matson, Shapiro, & Ollendick, 1981), potential tech-
ing what constitutes a reinforcer (Konarski, 1987) have niques are applied using an alternating treatment de-
been reexamined. sign, with the most effective treatment systematically
The use of negative or aversive consequences has extended to additional settings. In the second ap-
been widespread. Considerable recent work has been proach, theoretical considerations are tested in either a
devoted to developing less aversive-appearing pro- simulated or naturalistic situation and then interven-
cedures because of ethical and legal concerns (Repp & tion is selected based on the assessment outcomes
Dietz, 1978). More and more, we see reductions in the (e.g., Carr & Newsom, 1985; Iwataetal., 1982). This
use of shock and other aversive stimuli and their rework has almost exclusively focused on maladaptive
placement with more natural punishers, such as over- behaviors, although it could be extended to any type of
correction, response interruption, satiation, and senso- frequency problem. The third approach is correlational
ry extinction. Punishment unquestionably has a direct (e.g., Vyse eta!., 1984) and uses statistical analyses of
and immediate reductive effect; the challenge is the observational data to assess response probabilities un-
creative application of solid, positive behavioral tech- der varying conditions. This then can lead to prescrip-
nology to limit the need for punishment. tive technique selection. A drawback to this approach
Since much work in teaching new skills to the reis the amount of time and effort needed, although some
tarded involves shaping, chaining, and prompting, procedural improvements have been made. For exam-
substantial effort has been invested in identifying the ple, Linscheid, Feiner, and Sostek (1984) recorded
most effective procedures (e.g., forward vs. backward behaviors of retarded children with time-lapse video
chaining). Generally, the results in this area are mixed, recorders and obtained a 92% reduction in the time
with no clear-cut methods emerging as better than oth- required to score the tapes.
ers (Spooner & Spooner, 1984). It seems likely that There is also a continuing need for validated, dis-
therapist skill is more important than the specific pro- seminable packages that can be used by parents and
cedural variations. More recent work on skill acquisi- paraprofessionals. For behavior modification to real-
tion has stressed the use of socialleaming methods, ize its potential impact, a series of carefully devel-
including modeling and behavior rehearsal, or such oped, valid programs that can be consistently applied
cognitive-behavioral techniques as self-control (see by trained paraprofessional entry-level personnel is
Browder & Shapiro, 1985). It appears that increasing needed (Azrin, 1977). Too much of the reported work
diffusion of techniques is occurring from other popula- continues to explore fundamental principles and iso-
tions, even with severely retarded individuals. lated techniques that must be applied by professional-
A challenge faced by the field at this point is the level practitioners.
second level of behavioral assessment, that is, pre-
scriptive, functional assessment aimed at identifying
the controlling contingencies which will lead to appro-
Generalization and Maintenance
priate and effective technique selection. Such behav-
ioral assessment has only recently become an issue in Generalization and maintenance of treatment effects
retardation. Increasing attention has been paid to de- continue to be problematic with retardation, perhaps
veloping systems to identify comprehensively behav- more so than with most other disorders. Baine (1980),
ior-contingency linkages with specific behaviors. Only for example, surveyed selected experimentally estab-
recently has the notion of functional analysis (posed lished methods of achieving generalization with the
earlier by Bijou, 1966) received much attention, and retarded, including using multiple-training environ-
generally only with maladaptive behaviors. ments, using multiple trainers, modifying the training
Only a few studies have described assessment strat- environment to approximate the natural environment
egies that prescriptively arrive at intervention strat- in terms of materials, reinforcement, and language
egies. As a result, the development of most procedures cues, modifying the natural environment, discrimina-
for the retarded still requires extrapolation from the use tion training, teaching functional skills, and teaching
of behavioral techniques in other settings. A need ex- self-monitoring and reinforcement. All have been ef-
ists to develop methods for functionally analyzing be- fective as demonstrated in the studies reported earlier;
however, attention must be devoted to planning and staff available to conduct programs. This has been im-
implementing these strategies when interventions are plemented in the extensive literature on training resi-
planned. Various studies have reported methods of en- dential staff (e.g., Kissel, Whitman, & Reid, 1983),
hancing generalization and maintenance (e. g., Ka- parents (e.g., Cowart, Iwata, & Poynter, 1984), and
prowy, Norton, & Melnychuk, 1986; Smeets, Lan- other groups, including elementary and high school
cioni, & Hoogeveen, 1984). Another problem in students (e.g., Sisson, Van Hasselt, Hersen, & Strain,
maintenance is the failure to analyze functionallyex- 1985) and even retarded individuals (e.g., Dy, Strain,
isting contingencies maintaining behaviors. Many Fullerton, & Stowitschek, 1981).
times selected techniques will, in fact, modify a behav- When mediated approaches are used, training must
ior through "brute force," but the behavior will return be provided to these individuals. Untrained indi-
to preintervention levels when the natural contingen- viduals usually show inappropriate responding to cli-
cies regain control. ent behaviors (Felce et al., 1987). Emerson and Emer-
In particular, Spradlin and Saunders (1984) dis- son (1987), for example, found that while behavioral
cussed ways in which unrelated stimuli can be estab- techniques were viewed as useful, staff knowledge lev-
lished as members of the same stimulus class and sug- els were minimal. The available evidence suggests that
gested that such classes may explain individual's such training must employ behavioral tactics, such as
abilities to behave in appropriate ways in novel situa- modeling, prompting, shaping, and reinforcement, to
tions. They suggested that the continued, systematic be effective (e.g., Gardner, 1973; Nay, 1975). Typ-
analysis of the important conditions for learning classically, traditional lecture-based workshops have little
es is needed to understand and solve the present in- effect on skills, although knowledge increases are ob-
ability to provide normal repertoires to retarded served (Gardner, 1972). Cowart et al. (1984), for ex-
children. ample, found that a systematic training program, in-
cluding written handouts, slide sequences, role-played
instruction, and performance feedback, produced no-
Treatment Delivery and Management ticeable gains in both caregiver and student perfor-
Development of behavioral programs for the re- mances. The use of mediated intervention also gener-
tarded also requires attention to the strategies used for ally requires attention to effective behavioral monitor-
delivery. Most commonly, programs have been deliv- ing and supervisory techniques (Madle, 1982). A
ered in individual sessions by professionally trained number of studies have demonstrated the effectiveness
change agents. Although this approach optimizes proof supervisory techniques, such as providing goal-set-
gram effectiveness, it also limits the number of indi- ting, self-recording, self-reinforcement, external
viduals reached. Other approaches available, which monitoring, and reinforcement, in producing im-
improve the trainer-to-client ratio, include the use of proved staff performance in training retarded indi-
group-oriented programs or mediated interventions. viduals (e.g., Jones, Evans, & Blunden, 1984; Par-
One approach is the use of group-based token econ- sons, Schepis, Reid, McCarn, & Green, 1987).
omies, although these are perhaps best suited to deal
with "motivational" problems rather than intensive
behavior change. More recently attention has focused Summa..:-y
on improving group-based strategies (e.g., Favell,
Favell, & McGimsey, 1978; Storm & Willis, 1978). Research in behavior analysis and intervention con-
Polloway, Cronin, and Patton (1986) suggested the tinues to report often strong and socially useful effects.
advantages of group over one-to-one instruction are Elaboration, extension, and refinement of principles
better use of change agent time, more efficient client and techniques are building a solid literature that con-
management, minimization of economic limitations, firms the fundamental premises of a functional analy-
increased generalization of skills, and increased insis of behavior. The recent shifts to natural settings and
struction time. Favell etal. (1978), for example, found the use of paraprofessionals is encouraging, as is the
at least equal learning in group situations as in one-to- increased attention to functional analysis, which is
one, with increased activity and socialization. A emerging. The continued preoccupation with "behav-
number of recent techniques, such as social skills ior management" and the paucity of attention to re-
training, actually best lend themselves to this format. search on the use of developmental objectives to ex-
The other alternative is to increase the number of pand the retarded individuals repertoire are not so
CHAPfER 34 • MENTAL RETARDATION 753
encouraging. The most pressing need seems to be for individuals. American Journal ofMental Deficiency, 7B, 241-
an inclusive model of retarded development that sys- 248.
Azrin, N. H., Schaeffer, R. M., & Wesolowski, D. (1976). A
tematically delineates targets, settings, delivery strat- rapid method of teaching profoundly retarded persons to dress
egies, techniques, and evaluation procedures. As was by a reinforcement-guidance method. Mental Retardation,
mentioned, Bijou's (1966) model may provide a basis 14,29-33.
for such a comprehensive, programmatic guide to be- Azrin, N. H., Besalel, V. A., & Wisotzek, I. E. (1982). Treat-
ment of self-injury by a reinforcement plus interruption pro-
havioral interventions for remediation and prevention cedure. Analysis and 1ntervention in Developmental Dis-
of difficulties in our retarded citizens. abilities, 2, 105-113.
Azrin, N. H., Ianmer, J. P., & Besalel, V. A. (1986). Vomiting
reduction by slower food intake. Applied Research in Mental
Retardation, 7, 409-413.
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CHAPTER 35
Infantile Autism
Laura Schreibman, Robert 1. Koegel,
Marjorie H. Chariop, and Andrew 1. Egel
Autism is a severe form of psychopathology in child- most effective probably because they are soundly
hood and is characterized, in general, by severe with- based on systematic analyses of behavior, do not de-
drawal and lack of social behavior, severe language pend heavily on the child's verbal skills, nor the practi-
and attentional deficits, and the presence of bizarre, tioner's knowledge of the etiology of the disorder.
repetitive behaviors (1. K. Wing, 1966). The severity
ofthe behavioral deficits and excesses in such children
frequently causes great turmoil in the family, affecting Overview
not only the lives of the child and immediate family,
but the community as well. Autism occurs approx- The purpose of this chapter is to provide the reader
imately in one out of every 2,500 children and is often with a comprehensive discussion of autism and behav-
not diagnosed until the child is between 1 and 5 years iorally oriented treatment programs. Any discussion of
of age. Although there are currently many theories autism must begin with a description ofthe syndrome.
relating to the etiology of the disorder, there is no This is particularly so because the syndrome is com-
consistent evidence in support of anyone of them plex and because the behavioral treatment of the disor-
(Egel, Koegel, & Schreibman, 1980; Schreibman, der heavily emphasizes the treatment of specific be-
1988). Most professionals, however, now take the haviors. In addition, a brief historical perspective is
position that autism is of organic etiology and that the provided to help elucidate the evolution of the diag-
disorder is probably present from birth. The nature and nosis and of treatment approaches.
range of deficits associated with the disorder make it Following the description of the syndrome and the
resistant to most forms of treatment intervention. Be- historical perspective is a discussion of prior etiologi-
havioral treatment procedures have proven to be the cal hypotheses and past treatment approaches. This is
followed by a discussion of the behavioral treatment of
autism, including discussion of theoretical perspective
Laura Schreibman • Department of Psychology, University (and how it differs from the previous psychodynamic
of California at San Diego, La Jolla, California 92093. Robert
L. Koegel • Department of Speech and Hearing Sciences, position), and a description of specific treatment pro-
University of California at Santa Barbara, Santa Barbara, Califor- cedures directed at eliminating behavioral excesses in
nia 93106. Marjorie H. Charlop • Department ofPsy- autism (e.g., disruptive behaviors, self-stimulation)
chology, Claremont McKenna College, Claremont, California
and remediating behavioral deficits (stimulus func-
91711. AndrewL.Egel. DepartmentofSpecialEduca-
tion, University of Maryland at College Park, College Park, tions, attentional deficits, motivation, generalization).
Maryland 20742. The next section of the chapter focuses upon the expan-
763
sion of behavioral interventions into the child's other agnostic instrument(s) applied. What follows are de-
relevant environments, such as the home and school. scriptions of those behaviors most often associated
Then parent training, classroom instruction, and spe- with the diagnosis.
cially designed residential programs are discussed. Fi-
nally, a relatively recent method of behavioral assess-
Social Behavior
ment, social validation, is presented along with
research results suggesting that the behavioral treat- The social behavior of a child with autism is pro-
ment of autism accomplishes goals that are judged to foundly impaired, and many professionals have indi-
be socially important. This social validation meth- cated that abnormal social and emotional behaviors are
odology serves as an important adjunct to more tradi- primary to the diagnosis (e.g., Denkla, 1986; Fein,
tional behavioral assessment. Pennington, Markowitz, Braverman, & Waterhouse,
1986; Rimland, 1964; Rutter, 1978; L. Wing, 1976,
1978). Generally, such children do not interact with
Diagnosis people and seem to prefer being alone. If they do in-
teract, they tend to treat others more like objects than
Leo Kanner first described the syndrome of autism like people (Schreibman & Koegel, 1981). A child
in 1943. He called the disorder "early infantile au- with autism, for example, may put his arms around his
tism" because the children tended to be aloof, with- mother, not to give her a hug, but to reach behind her
drawn, and "autistic" from the beginning of life for a toy. As infants, these children may lack attach-
(Rimland, 1964). Kanner's description of autism was ment behavior and typically do not posturally conform
based on 11 cases with striking similarities. These to their parent's body when held. They may remain
children did not relate to people and the environment stiff and rigid or may "go limp" when picked up.
normally, and Kanner called their preference to be When older, they may seldom seek out their parents for
alone "extreme autistic aloneness" (Kanner, 1943). comfort (Rutter, 1978). In addition, such youngsters
He pointed out that the children lacked appropriate often lack eye-to-eye contact, may actively avoid the
speech, noting instances of echolalia as well as failure social overtures of others, ignore peers, and generally
to use pronouns correctly. The children engaged in seem aloof from their social environment (e.g.,
monotonous, repetitive movements and vocalizations, Schreibman, 1988).
had an obsessive insistence on the preservation of
sameness in the environment, and manifested surpris-
Speech and Language
ingly good rote memories (Eisenberg & Kanner, 1956;
Kanner, 1943). Autistic children typically do not use language to
Kanner described autism as a syndrome differing communicate (Omitz & Ritvo, 1976; J. K. Wing,
from other disorders and characterized by the behav- 1966; L. Wing, 1976, 1978). Approximately 50% of
iors mentioned above. He later reduced the symptoms such individuals never develop functional speech
required for the diagnosis to two essential ones; (1) (Rutter, 1978), and those who do speak charac-
extreme aloneness and (2) preservation of sameness teristically display speech that is qualitatively different
(Eisenberg & Kanner, 1956). Interestingly, this article than the speech of normal children and children with
omitted language abnormalities as an essential symp- other language disorders (e.g., Bartak, Bartolucci, &
tom which Kanner had stressed in his earlier writings. Pierce, 1977; Ricks & Wing, 1975; Rutter, 1965,
Rutter (1978) delineated three general groups of symp- 1978; L. Wing, 1976). Speaking autistic children com-
toms present in children with autism, and these are monly display echolalia, the repetition of words or
today considered to be the main features of the disor- phrases spoken by others (Fay, 1969). The two most
der. These include the manifestation of a profound and common forms of this speech anomaly are immediate
general failure to develop social relationships, lan- echolalia and delayed echolalia (Carr, Schreibman, &
guage abnormalities, and ritualistic or compUlsive be- Lovaas, 1975; Schreibman & Carr, 1978). Immediate
havior (the insistence on sameness). In addition, the echolalia occurs when the child repeats a word or
onset of the disorder must be before the age of 3 years. phrase just heard. For example, someone may ask the
Although these three categories of behavior are still child, "How was school?" to which the child might
generally considered the main features of autism, there respond, "How was school?" Delayed echolalia oc-
are some variations in emphasis depending on the di- curs when the repeated phrase was heard sometime in
CHAPTER 3S • INFANTILE AUTISM 765
the past. Thus, the child, sitting at the dinner table, 1976; Rimland, 1964). It is not surprising that many
may begin repeating his teacher's instructions from parents have described their autistic child as "living in
earlier that·day, from last week, or perhaps last year. a world of his own" (Koegel & Schreibman, 1976).
Another common characteristic of the speech of au- Many children with autism engage in self-stimulato-
tistic individuals is pronominal reversal wherein the ry behaviors (e.g., Egel et al., 1980; Lovaas, New-
child uses the incorrect pronoun (Kanner, 1943; Rut- som, & Hickman, 1987; Ornitz & Ritvo, 1976;
ter, 1978) with reversal of "I" and "you" being the Rimland, 1964) These are stereotyped, repetitive
most common (e. g., "You want to go outside" instead movements, which seem to do nothing other than pro-
of "/ want to go outside"). In addition, the speech of vide sensory input for the child (although Durand &
these children is often characterized by dysprosody Carr, 1987, offer evidence of another function of this
where the melodic features of the speech are inaccurate behavior). The most common forms of self-stimulation
(Ba1taxe, 1981; Baltaxe & Simmons, 1975; Schreib- (also called stereotypy) involve the arms and hands
man, Kohlenberg, & Britten, 1986; Simon, 1976). (Ornitz & Ritvo, 1976). The child repeatedly waves or
Thus, their speech tends to be inaccurate in pitch, flaps the hands, usually in front of his or her eyes.
rhythm, inflection, intonation, pace, and/or articula- Other self-stimulation involves the torso, such as
tion. rhythmic body rocking or swaying, repeatedly turning
around in circles, quick darting movements, and body
posturing. Toe walking, head rolling, and head bang-
Ritualistic Behavior and the
ing are also frequently observed (Ornitz & Ritvo,
Insistence on Sameness
1976), while more subtle forms of self-stimulation,
Rutter (1978) has delineated four common phe- such as gazing at lights and repeatedly rubbing the
nomena that fall within this category. First, children hands along a textured surface, also occur. When the
with autism often engage in limited and rigid play pat- children engage in such behaviors, they often appear
terns. They may repeatedly line up toys or household much less responsive to the surrounding environment
goods, or they may collect many objects of a special (Lovaas, Litrownik, & Mann, 1971; Ornitz & Ritvo,
shape or texture. Second, they may become so at- 1976; Schreibman & Koegel, 1982).
tached to a specific object that they must have it at all Related to self-stimulatory behavior is the autistic
times. If the object is taken away, the child will vehe- child's lack of appropriate play (Koegel, Firestone,
mently protest. Third, many of these children have Kramme, & Dunlap, 1974). Such children seldom play
unusual preoccupations with such things as numbers, with toys in the manner in which normal children do
geometric shapes, bus routes, and colors. Fourth, such but usually manipulate them in a self-stimulatory man-
children may display a marked resistance to changes in ner. Typically, when given a car or truck to play with,
the environment. They often maintain rigid routines the autistic child merely spins the wheels rather than
and are extremely distressed by even a small change in running the toy along the floor.
their daily routines. Similarly, they might become dis- Self-injurious behavior (SIB) is also present in many
tressed if their physical environment is altered (e.g., children who are autistic. This behavior involves any
furniture rearrangements) or if a familiar route of travel behavior in which the individual inflicts physical
is changed. damage to his or her own body (Carr, 1977; Tate &
Baroff, 1966). The most common forms of SIB in the
autistic population include head banging and self-bit-
Other Characteristics of Autism
ing of hands or wrist (Rutter & Lockyer, 1967). Other
Individuals with autism frequently appear to possess common forms of SIB are elbow or leg banging, hair
a sensory deficit. That is, they display an unusual re- pulling or rubbing, face scratching, and self-slapping
sponsiveness to external stimulation (e.g. Lovaas, of face or sides. This behavior can vary in intensity
Koegel, & Schreibman, 1979; Ornitz & Ritvo, 1976; from relatively benign (gentle head banging against
Rimland, 1964; Schreibman & Koegel, 1981, 1982; soft surfaces) to extremely intense to the point of being
Schreibman & Charlop, in press). At times, the child potentially life-threatening (e.g., Carr, 1977; Lovaas
may respond quite normally and at other times may not & Simmons, 1969; Schreibman, 1988).
respond at all. Because of this unresponsiveness, such Autistic children often display flattened, excessive,
children are often incorrectly suspected of being deaf or otherwise inappropriate affect (e.g., American Psy-
or blind (Koegel & Schreibman, 1976; Ornitz & Ritvo, chiatric Association, 1987; Rimland, 1964). Some
children have tantrums or laugh hysterically for no opmental aphasia, mental retardation, and environ-
apparent reason. Other children seldom display any mental deprivation.
emotion at all. Often, the affect is inappropriate for the Although schizophrenic children share several fea-
situation. For example, these children may lack fear tures of autism, including sustained impairment in so-
when they are in real danger, such as playing near the cial relations, resistence to change in environment,
deep end of a swimming pool. Conversely, they may speech abnormalities, and constricted or inappropriate
become terrified of something harmless, such as a spe- affect, there are differences that allow for a differential
cific toy or a room (L. Wing, 1976). diagnosis. One of the main differences is age of onset.
In order to be diagnosed as autistic, the child should Autistic children exhibit the disorder prior to the age of
display a majority, but not necessarily all, of the behav- 3 years, whereas schizophrenic children typically ex-
iors described above. For a discussion of the specific hibit the symptoms between the ages of3 and 12. Also,
diagnostic procedures and criteria currently in use, the children with schizophrenia more closely resemble
reader is referred to Schreibman (1988) and Schreib- schizophrenic adults in symptomatology (American
man & Charlop (1987) and the Diagnostic and Statis- Psychiatric Association, 1987). In general, autism is
tical Manual of Mental Disorders (3rd ed., rev.) characterized by early onset, less common family his-
(American Psychiatric Association, 1987). tory of mental illness, normal or above average motor
In addition to these major characteristics, children development, lower IQ, no period of normal develop-
with autism tend to be healthy and have none of the ment preceding the appearance of the symptoms, good
physical stigmata characteristic of many other disor- physical health, and a failure to develop complex lan-
ders (Dunlap, Koegel, & Egel, 1979; Kanner, 1943; guage and social skills. In contrast, children with
Rimland, 1964; Schreibman, 1988). These children schizophrenia are characterized by a later onset, a fam-
were initially thought to be quite intelligent (Eisenberg ily history of mental illness, poor physical health, poor
& Kanner, 1956; Kanner, 1943), although today nor- motor performance, higher IQs than typically found in
mal or above-normal intelligence is not usually autism, periods of remissions and relapses (and a peri-
thought of in association with autism (e.g., Rutter, od of normal development preceding morbidity), high-
1978; Schreibman & Koegel, 1981, 1982; Schreib- er levels of language skill, and the presence of delu-
man, 1988). Research estimates indicate that approx- sions and/or hallucinations (Mesibov & Dawson,
imately 60% of these children have measured IQs be- 1986; Rimland, 1964; L. Wing, 1976).
low 50, 20% measure between 50 and 70, and 20% The diagnostic category of Pervasive Developmen-
measure 70 or above (Ritvo & Freeman, 1978). Al- tal Disorder (Not Otherwise Specified) has been incor-
though most autistic children score in the retarded porated into the classification system of the American
range, many of these children do show isolated areas Psychiatric Association (1987) for children who do not
of skilled performance, especially in the areas of musi- manifest the behaviors of schizophrenia nor the specif-
cal, mechanical, or mathematical skills (Applebaum, ic features of autism. (Autism is considered another
Egel, Koegel, & Imhoff, 1979; Rimland, 1978). This form of Pervasive Developmental Disorder in this
"autistic savant" behavior often accompanies below- classification system.) The children receiving the di-
age-level functioning in most, if not all, other areas. agnosis of Pervasive Developmental Disorder (Not
Otherwise Specified) exhibit impairment in social re-
lationships, but this does not necessarily take the form
Differential Diagnosis
of u~sponsiveness. The language problems of these
Autism shares several central features with other children may be less severe or may be of different
childhood disorders. Impaired cognitive ability is a forms than seen in autism. Also, motor abnormalities
feature autism shares with mental retardation, deficits and other behavioral oddities are more frequently seen
in language are evident in children with autism, retar- in this population than in autism (American Psychiatric
dation, and aphasia. It is apparent that the diagnosis of Association, 1987; Mesibov & Dawson, 1986).
autism overlaps with other diagnoses, and one may In developmental aphasia, the children fail to devel-
need to address the differences between them. The five op or are delayed in the development of comprehen-
major developmental disorders with which autism is sion and vocal expression of language. These children
most frequently associated are schizophrenia (child- share some specific behaviors with autism, including
hood type), pervasive developmental disorder, devel- echolalia, pronominal reversal, sequencing problems,
and difficulties in comprehension (Churchill, 1972). iors are similar to those seen in autism, deprived chil-
They may have difficulties in the social arena, but dren typically show marked improvement once the en-
these are usually secondary to the problems with lan- vironment is enriched such that they catch up on
guage (Ornitz & Ritvo, 1976). The language deficits in language and motor skills and regain an interest in
autism are more severe and widespread than those typ- social relationships (Ornitz & Ritvo, 1976; Schaffer,
ically seen in aphasic children (Churchill, 1972; Rut- 1965). In addition, neglected children do not exhibit
ter, Bartak, & Newman, 1971). Also, aphasic children the repetitious, stereotypical play, echolalia, pro-
generally make eye contact, communicate mean- nominal reversal, and avoidance of social contact char-
ingfully via gestures, exhibit emotional intent, and en- acteristic of children with autism (Omitz & Ritvo,
gage in imaginative play (American Psychiatric Asso- 1976).
ciation, 1987; Griffith & Ritvo, 1967;L. Wing, 1976).
These characteristics are not typical of children with
autism. In addition, aphasic children are more likely to
be of normal intelligence (Shea & Mesibov, 1985). Etiology and Past Treatment
Both children with autism and children with retar- Approaches
dation share poor intellectual ability that persists
throughout their lifespans (e.g., Lockyer & Rutter, When discussing the etiology of autism, Kanner be-
1969; Rutter, 1978). They also share several behav- lieved that the disorder was due to innate inabilities.
iors, such as echolalia, self-stimulation, SIB, and at- He believed, however, that the innate nature of autism
tentional deficits. There are, however, several charac- was confounded by emotionally cold, detached par-
teristics that differentiate the two diagnoses. Many ents. Kanner noted the coincidence that autistic chil-
children with retardation exhibit appropriate social be- dren might typically belong to parents who tended to
havior. Similarly, these children are often commu- be intelligent, educated, and sophisticated, but who
nicative and while their abilities to communicate may were also cold, preferred to be alone, and lived in an
be impaired, the intent and motivation are apparent. emotionally detached, mechanical manner (Eisenberg
Children with autism usually show a normal physical & Kanner, 1956; Kanner, 1943, 1949).
development, whereas mentally retarded children do From 1943 until the 196Os, the psychogenic model
not (e.g., Schreibman & Mills, 1983). Perhaps one of of autism prevailed. Cold, "autistic-like" parents
the most interesting differences between the two popu- were thought (primarily by Bettelheim, 1967) to be
lations is the pattern of intellectual impairments. Al- causative agents in the development of autism in their
though children with retardation tend to show impair- children. The psychogenic approach implied that the
ments over a wide range of functioning, children with child remained in a "disease state" of autism, caused
autism usually display a more variable pattern. Thus, by parental deficiencies in emotional responsiveness.
they tend to score more poorly on assessments of the In particular, inadequate mothering and the failure to
use of language meaning and concepts (Rutter, 1978) form a normal mother-child bond during infancy were
while doing better on nonverbal assessments, such as thought to be the crux of the disease (Bettelheim,
those measuring visual-spatial abilities. Also, as indi- 1967; O'Gorman, 1967). The behaviors of the child
cated earlier, children with autism may show isolated (the autistic symptoms discussed earlier) were said to
areas of good, or even outstanding, ability. be suggestive of the etiology of the disorder. That is,
Some characteristics of autism have been likened to autistic behaviors expressed hostility and indifference
behaviors seen in children suffering from environmen- to the parents (Bettelheim, 1967; Kugelmass, 1970).
tal deprivation (Schreibman, 1988). Maternal depriva- Since the mothers responded to their children with
tion, anaclitic depression, and hospitalism are all char- withdrawal, rejection, and hostility, the autistic behav-
acterized by developmental delays resulting from ior was the child's way of adapting to the cold, harsh
neglect, abuse, and/or institutionalization. Children environment (Bettelheim, 1967).
subjected to environmental deprivation may be with- Such "adaptive" behaviors were the expression of
drawn and disinterested in their surroundings, display the child's sickness and his or her means of coping with
delays in motor skills and speech development, engage the environment. Thus, it was important to accept the
in unusual motor behaviors, and show little interest in child's behavior and to allow him or her to engage in
toys (Ornitz & Ritvo, 1976). Even though these behav- autistic behaviors (Bettelheim, 1967). These psycho-
dynamic treatment approaches concentrated on estab- tulating a specific etiology of autism (with the excep-
lishing environments in which the child no longer tion of Ferster, 1961), the behavioral approach views
needed to express hostility toward his or her parents the disorder as a cluster of behaviors and has sought to
via autistic behaviors (Bettelheim, 1967; Kugelmass, promote specific changes in behavior that can be ob-
1970). According to this approach, the ego develop- served and measured directly. Behaviorists have sug-
ment of the child was encouraged in an environment gested that child development consists primarily of the
that maintained a balanced combination of gratifica- acquisition of behaviors and stimulus functions
tion and frustration. As the child's sense of self (Lovaas & Koegel, 1973; Lovaas & Newsom, 1976;
emerged, and his or her autistic barrier began to deteri- Lovaas, Schreibman, & Koegel, 1974). Stimulus
orate, the therapist began to make small demands on functions refer to those aspects of the environment that
the child (Kugelmass, 1970). The therapist provided acquire "meanings" for the child, for example, the
the child with complete understanding and acceptance. child's acquisition of secondary or conditioned rein-
The child eventually saw an environment that was not forcers. Ferster (1961) suggested that the failure of
hostile, and the autistic behaviors decreased. autistic children to develop normally results from a
Although Bettelheim (1967) reported a high success failure to be affected by conditioned reinforcers. Thus,
rate from this type of treatment paradigm, he has been behavior modification seeks to understand the behav-
criticized for offering subjective case descriptions iors of autistic children from an analysis of the vari-
without supporting empirical evidence (e.g., ables that influence the acquisition of behavior and
Rimland, 1964; Rutter, 1971; Schopler & Reichler, stimulus functions (Lovaas & Newsom, 1976; Lovaas
1971; 1. K. Wing, 1968). In addition, researchers have et al.. 1974; Schreibman & Koegel, 1981). From a
failed to find a disproportionate incidence of emo- behavioral perspective, one would attempt to increase
tionally cold parents with autistic offspring (Creak & the deficit behaviors by reinforcing their occurrence
Ini, 1960; Freeman & Ritvo, 1984; Pitfield & Oppen- and to reduce the behavioral excesses by systemat-
heim, 1964; Koegel, Schreibman, O'Neill, & Burke, ically removing the reinforcers that may be maintain-
1983; Kolvin, 1971). It has, in fact, been suggested ing those behaviors. Similarly, one might attempt to
that any pathological behavior on behalf of the parents treat autistic children by manipulating antecedents and
may indeed be a reaction to rather than the cause of the consequences to make aspects of their environment
child's disorder (Rimland, 1964; Rutter, 1978; more "meaningful" to them. These areas are covered
Schopler & Reichler, 1971). It has also been suggested in greater detail later in this chapter.
that institutionalization (often a treatment of choice for The work of Ferster and DeMyer (1962) is important
the disease model of autism) may worsen the child's in that it was the first empirical demonstration that the
condition (Lovaas, 1979). Recent literature stresses systematic manipulation of environmental contingen-
the importance of involving the family in the treatment cies could result in the acquisition of new behaviors in
of their child and, when possible, keeping the child out autistic children. Later studies (e.g., Wolf, Risley, &
of institutions and in the home (Koegel, Schreibman, Mees, 1964; Wolf, Risley, Johnson, Harris, & Allen,
Britten, Burke, & O'Neill, 1982; Lovaas, Koegel, 1967) confirmed and extended the findings of Ferster
Simmons, & Long, 1973; Schopler, 1971; Schopler & and DeMyer. These studies demonstrated that by ar-
Reichler, 1971; Schreibman & Koegel, 1975; Whit- ranging an extensive system of contingent rewards and
taker, 1975). It was in light of the above criticisms that punishments, the behavior of autistic children could be
other approaches, most importantly the behavioral modified. Perhaps the major contribution of these ex-
model, became prominent in the study and treatment perimental studies and in the steady line of productive
of autism. studies to follow them lie in the cumulative aspect of
the scientific method. That is, piece by piece, the be-
havior of autistic children is becoming relatively well
understood. It has not been necessary to accomplish
Behavior Modification the perhaps impossible task of understanding the entire
disorder all at once. Nor has it been necessary for
Theoretical Perspective
therapists to reinvent the wheel with every new genera-
Because of its emphasis on the scientific method, tion, as is the case when a treatment is based upon an
the behavioral model differs greatly from the psycho- individual therapist's artful skill, instead of upon a
dynamic approach described above. Rather than pos- replicable, written scientific procedure.
CHAPTER 35 • INFANTILE AUTISM 769
Treatment Procedures gio, Iwata, & Ivancic, 1988). This emphasis has
grown out of both logistical and ethical concerns.
Within the above scientific context, behavior modi-
Thus, several rules of thumb are generally applied
fication has sought to develop procedures for changing
when using reductive procedures. First, positive rein-
individual behaviors based on an analysis of the vari-
forcement for appropriate behaviors is always used in
ables that might influence them. An important aspect
conjunction with a reductive procedure with a recom-
of a behavioral treatment program is its emphasis on
mended ratio of 2: 1 (positive reinforcement to reduc-
the objective measurement of all phases of the program
tive procedure). Second, the least intrusive procedures
(Kozloff, 1974). Continuously measuring a behavior
are attempted first with more intrusive treatment used
allows a therapist to assess whether or not the treat-
only if other procedures fail. Finally, a functional anal-
ment is having any impact on the child's behavior.
ysis of the inappropriate behavior should be under-
A first step in developing a behavioral treatment
taken to determine the possible motivation for such
program is to identify and to define operationally those
behavior and to subsequently suggest an individual-
behaviors in the natural environment (cf. Johnson &
specific treatment (Carr, 1977; Carr & Durand, 1985;
Koegel, 1982) that the therapist desires to change.
Iwata, Dorsey, Slifer, Bauman, & Richman, 1982).
Thus, the therapist will be able to make a precise dis-
Reductive procedures have been applied to two general
crimination of the correctness of a response and to
categories of behavior: (1) disruptive behaviors, such
determine the direction of the treatment. Once the tar-
as tantrums, aggression, and self-injurious behavior,
get behaviors have been operationally defined, the
and (2) self-stimulatory behaviors.
therapist should determine the natural antecedents and
consequences of the behaviors to be modified. Isolat-
ing these variables enables the therapist to manipulate Disruptive Behavior
them in order to facilitate the acquisition of appropriate
Disruptive behaviors are one of the most pervasive
behaviors and stimulus functions. For example, the
obstacles in teaching autistic children new skills. Start-
type of instruction presented (antecedent event) may
ing with the less intrusive procedures, extinction can
influence whether the child responds correctly.
be effective in reducing such interfering behaviors as
Schreibman and Koegel (1981) suggested that instruc-
tantrums, aggression, and even self-injurious behavior
tions that are long and complicated may contain a
(Matson & Dilorenzo, 1984). This procedure gener-
number of irrelevant stimuli that make it difficult for a
ally consists of withholding or removing a reinforcer
child to discriminate the intent of the instruction. Such
that was maintaining the behavior (e.g., attention).
points are described below in more extensive detail.
Thus, a "planned ignoring" procedure is put into ef-
fect. Although effective, extinction has its drawbacks.
First, there is generally a gradual reduction in the be-
Eliminating Behavioral Excesses havior rather than a quick decrement (Lovaas & Sim-
mons, 1969). Extinction therefore may be ethically
Autistic children often display a large number of unacceptable for behaviors that are physically
inappropriate behaviors that interfere with learning. harmful, such as aggression and self-injurious behav-
Although these behaviors sometimes decrease as the ior (Repp & Deitz, 1978). Second, there is usually an
child increases his or her repertoire of appropriate be- initial "burst" or increase in the behavior that may be
haviors, inappropriate behaviors often remain an en- dangerous or may interfere with the continued use of
during obstacle to treatment. Thus, it is often neces- the procedure.
sary to reduce or eliminate such maladaptive behaviors Other mild reductive procedures include certain
through reductive procedures. forms of punishment. A frequently used procedure is
Reductive procedures include a wide range of tech- time-out. White, Nielsen, and Johnson (1972) have
niques ranging from less intrusive procedures, such as defined time-out as an "arrangement in which the oc-
extinction, verbal reprimands, and time-out, through currence of a response is followed by a period of time
more intrusive procedures, such as contingent presen- in which a variety of reinforcers are no longer avail-
tation of physical aversives, including water mist and able" (p. 111). Examples of the use of time-out in-
electric shock. Researchers and clinicians have more clude placing the child in a small, bare room for a
recently become concerned with emphasizing less specific period of time following the undesirable be-
aversive forms of reductive procedures (Charlop, Bur- havior, or having the therapist look away from' the
child, thus withdrawing attention. Although time-out searchers reported that time-out used as a consequence
has been shown to be efficacious in reducing undesir- for every third or fourth occurrence of an inappropriate
able behavior, there are several important parameters behavior was nearly as effective as a continuous sched-
to consider when implementing the procedure, one of ule. Dunlap, Koegel, Johnson, and O'Neil (1987) sup-
which is the duration that a child should be placed in port such a notion of delayed and intermittent contin-
time-out. Time-out intervals ranging from 2 min gencies:
(Bostow & Bailey, 1969) to 3 hours (Burchard & Tyler, Foxx and Azrin (1972) reported on a method they
1965) have been used successfully. White et al. (1972) called overcorrection for eliminating physically dis-
noted that a majority of investigators reported suc- ruptive acts. Their procedure has two objectives: (1) to
cessful results using time-out durations in the range of overcorrect the environmental effects of an inappropri-
5 to 20 min. There is, however, no consensus on an ate act, and (2) to require the disruptor to practice
"optimum" duration for time-out. Additionally, there overly correct forms of appropriate behavior. The first
is uncertainty whether the use of a contingent delay objective is achieved through the use of restitutional
with time-out procedures is most effective. Contingent overcorrection. This procedure requires the disruptive
delay is defined as an additional period in which the individual to return the disturbed situation to a greatly
child remains in time-out because of the occurrence of improved state, thus providing an instructive situation
inappropriate behavior while in time-out (Bostow & in which the individual is required to assume personal
Bailey, 1969). Although Hobbs and Forehand (1975) responsibility for the disruptive act. For example, a
demonstrated the superiority of time-out with a con- child who smeared paint on a floor might be required to
tingent delay, others have found no difference (Mace, clean up the mess and then vacuum and wax the area.
Page, Ivancic, & O'Brien, 1986). The second objective is achieved through positive
Solnick, Rincover, and Peterson (1977) suggested practice overcorrection. In this procedure, the child
that there is no "standard" time-out procedure that will who smeared the paint on the floor, rather than on an
effectively reduce problem behavior. These re- appropriate sheet of paper, might be required to paint
searchers examined the possible punishing as well as appropriately on the paper several times. When no
reinforcing effects of time-out and found that in one environmental disruption occurs, the restitutional
case when time-out was employed to suppress tantrum overcorrection is not applicable and only the positive
behavior, it had the opposite effect. That is, time-out practice is used. The effectiveness of overcorrection as
resulted in a substantial increase in the frequency of a procedure for eliminating aggressive disruptive be-
tantrums. Upon further analysis, it was shown that the havior was clearly demonstrated by Foxx and Azrin
time-out period was used by the child to engage in self- (1972). They employed an overcorrection procedure to
stimulatory behavior. reduce aggressive behavior (e.g., physical assault,
The effectiveness of a time-out procedure also may property damage, tantrums, and biting). The results
be influenced by the nature of the "time-in" setting showed that while time-out and social disapproval had
(Solnick et al., 1977). Solnick et al., found that when all been ineffective in eliminating aggressive behav-
the time-in setting was not highly reinforcing (i.e., iors, overcorrection reduced the disruptive behaviors
was "impoverished"), time-out was ineffective. In a to a near-zero level within 1 or 2 weeks. Overcorrec-
situation such as this, time-out may serve as a negative tion thus appears to be a viable means of reducing
reinforcer in that the child's behavior removes her or aggressive behavior. In addition, the procedure (as de-
him from an undesirable situation. However, when the scribed by its proponents) may minimize some of the
time-in environment was highly reinforcing ("en- negative properties of other punishment procedures; it
riched"), the same time-out procedure was effective in may also educate the individual in appropriate behav-
reducing the undesirable behavior (Carr, Newsom, & ior; and it appears to require relatively little staff train-
Binkoff, 1976; Solnick et al., 1977). ing (Foxx & Azrin, 1972). Further research, however,
One final point to note about time-out is that in some appears necessary to substantiate these latter points.
cases time-out may be costly in terms of available Many problems remain with the use of reductive
teaching time, because it requires the child to be re- procedures. For example, these procedures are often
moved from the teaching environment each time the ineffective due to previous inconsistent and incorrect
inappropriate behavior occurs. As a result, an intermit- use. Thus, children with extensive histories of reduc-
tent schedule of time-out may be a useful alternative tive procedures often pose a real challenge to re-
(Clark, Rowbury, Baer, & Baer, 1973). These researchers and clinicians. One way to use commonly
practiced procedures in a speedy and effective manner Therapeutic procedures utilized in attempts to sup-
has been proposed by Charlop et al. (1988). They com- press self-stimulation have varied, as have the results.
pared the use of mild punishers presented in two for- One procedure involved reinforcing responses incom-
mats; the presentation of varied punishers (presenta- patible with self-stimulation. Mulhern and Baumeister
tion of one of three available punishers) was compared (1969) reinforced two retarded children's sitting still in
with conditions of the single presentation of one of the an attempt to reduce their self-stimulatory rocking be-
three punishers. Results suggested that the varied havior. They found that this procedure reduced the
punisher format was slightly more effective than the rocking behavior by about one third. Others (e.g.,
single presentation of punishers. Charlop et al. (1988) Deitz & Repp, 1973; Herendeen, Jeffrey, & Graham,
advocate the use of varied punishers as a means of 1974) have also employed reinforcement to reduce
enhancing less intrusive procedures. self-stimulatory behavior substantially. However, this
Finally, a quite promising line of research on elim- procedure has not been successful in completely sup-
inating disruptive behavior is the use of a functional pressing self-stimulatory behavior. Furthermore, oth-
analysis. A functional analysis studies the variables ers using this procedure (e.g., Foxx & Azrin, 1973)
that set the occasion or reinforce the disruptive behav- have not obtained decreases in self-stimulatory behav-
ior. Then, the environment is changed in accordance ior of the magnitude previously reported.
with the specific finding (Carr, 1977; Carr & Durand, A second procedure that has been used effectively to
1985; Iwataetal., 1982). For example, Carr & Durand reduce and eliminate self-stimulatory behavior em-
(1985) performed a functional analysis of self-inju- ploys punishment. The punishment has taken the form
rious behavior (SIB), which revealed that some chil- of contingent electric shock (Lovaas, Schaeffer, &
dren were using their SIB as a means of communica- Simmons, 1965; Risley, 1968), contingent slaps on the
tion. Treatment consisted of teaching appropriate hand or the thigh (Bucher & Lovaas, 1968; Foxx &
communication means which resulted in a decrease in Azrin, 1973; Koegel & Covert, 1972); and contingent
SIB. With this approach, a functional analysis to deter- restraint (Koegel et al., 1974). Each of these studies
mine treatment is imperative in that each child's "rea- has demonstrated that contingent physical punishment
son" for the inappropriate behavior is likely to be dif- is a highly effective method for suppressing self-stim-
ferent (Iwata et al., 1982). ulation. However, because of the difficulty of using
physical punishment, extensive efforts are currently
being devoted to the development of nonaversive treat-
Self-Stimulatory Behavior
ment procedures (Koegel & Koegel, 1989).
Self-stimulatory behavior is considered one of the One "mild" punishment procedure that has been
most defining characteristics of autistic children. It is shown to be extremely effective in suppressing self-
also one of the most formidable obstacles in educating stimulation is overcorrection. Foxx and Azrin (1973)
these children. Lovaas, Litrownik, and Mann (1971) compared several techniques used to suppress self-
observed that responding to previously functional au- stimulation (including punishment by a slap and rein-
ditory cues was disrupted when a child was engaged in forcement for not engaging in self-stimulation) with
self-stimulatory behavior. They suggested that when a positive practice overcorrection. Their results showed
child is engaged in self-stimulation, she or he may not that the only procedure that eliminated self-stimulation
attend to more relevant stimuli. With this issue in was the positive-practice-overcorrection procedure.
mind, Koegel and Covert (1972) attempted to teach a Furthermore, the results suggested that a verbal repri-
discrimination task to three autistic children with high mand in conjunction with an occasional application of
levels of self-stimulatory behavior. The results clearly the overcorrection procedure was sufficient to main-
established that self-stimulatory behavior interfered tain reduced levels of self-stimulation. Other investi-
with the acquisition of the discrimination. However, gators (Azrin, Kaplan, & Foxx, 1973; Epstein et ai.,
when self-stimulation was suppressed, the children ac- 1974; Harris & Wolchik, 1979; Herendeen et al.,
quired the discrimination. This apparent inverse rela- 1974) have confirmed and extended the above find-
tionship between self-stimulation and the acquisition ings. Thus, overcorrection appears to be a viable meth-
and performance of new, appropriate behaviors has od for substantially reducing self-stimulatory behav-
been repeatedly demonstrated (Epstein, Doke, Sajwaj, iors. Even though positive practice overcorrection
Sorrell, & Rimmer, 1974; Foxx & Azrin, 1973; Koegel offers an effective alternative to intense physical
etal., 1974; Risley, 1968). punishment, its practicality in applied settings may be
limited because of the demand on the therapist's time suggested that the procedure requires very little staff
and energy. training or child surveillance, has an immediate effect,
Despite some success by the above procedures in and should require relatively little effort in program-
reducing self-stimulation, the "generalized, durable ming the generalization and maintenance of treatment
elimination of self-stimulatory behavior" has not yet gains.
been achieved (Rincover & Koegel, 1977a,b). Re- From a theoretical point, the above information sug-
cently, investigators have suggested that the difficulty gests that self-stimulatory behavior may function as a
in eliminating self-stimulation may be a function of its competing reinforcer with most normal types of input
internal reinforcing properties. That is, self-stimula- that the environment provides (Dyer, 1987). Because
tion may be conceptualized as operant behavior main- of this postulated relationship Dyer (1987) speculated
tained by its sensory consequences (Lovaas et al., that some natural and normal environmental events
1987; Rincover, Newsom, Lovaas, & Koegel, 1978). could conceivably be more powerful reinforcers than
For example, a behavior, such as finger flapping, may self-stimulation. As such, she developed an assess-
be maintained by the resulting proprioceptive feed- ment procedure for identifying such powerful reinforc-
back. Because self-stimulatory behavior seems to rein- ers. Further, she found that employing such reinforcers
force its own existence, several traditional approaches served to suppress self-stimulation, possibly because
to its elimination have failed to yield much success. the newly assessed reinforcer favorably competed with
For example, time-out, instead of punishing self-stim- self-stimulation.
ulatory behavior, seems instead to provide an oppor- Operating from a similar theoretical framework
tunity for the behavior to occur, and thereby to rein- Kern, Koegel, Dyer, Blew, and Fenton (1982) and
force itself (cf. Solnick et al., 1977). Kern, Koegel, and Dunlap (1984) found that other ap-
In summary, with the exception of a few socially propriate behaviors, such as vigorous physical exer-
motivated self-stimulatory behaviors (cf. Durand & cise, could be taught, with the end result of reducing
Carr, 1987), most self-stimulation seems to be moti- stereotypic behavior. Again, the authors hypothesized
vated primarily by its sensory consequences. The most that the vigorous exercise might be favorably compet-
effective procedures currently available have utilized ing with the reinforcing properties of self-stimulatory
this information to either mask the sensory conse- behavior, at both a behavioral and a physiological
quences, and/or to provide alternate means for the level. f
individuals to obtain other powerfully reinforcing, but

more appropriate, types of sensory input (Koegel &
Koegel, 1989b). Acquisition of New Behaviors and
The conceptualization of self-stimulatory behavior Stimulus Functions
as behavior maintained by the auditory, propriocep-
tive, or visual consequences has led to the develop- The previous investigations have described a behav-
ment of another procedure for eliminating self-stim- ioral approach to reducing or eliminating behaviors
ulation. This procedure, sensory extinction, is based that significantly interfere with the learning process.
on the notion that self-stimulatory behavior should ex- The manipulation of antecedent and consequent vari-
tinguish when the reinforcing (sensory) consequences ables is also crucial in the teaching of new behaviors
are removed. Rincover (1978) found that self-stimula- and stimulus functions. In a behavioral treatment pro-
tion reliably extinguished when specific sensory con- gram, the antecedent variables usually manipulated
sequences were removed and increased when those are the instructions (SD) and the prompt stimuli. As
consequences were permitted. Since the sensory rein- previously suggested, the manner in which an instruc-
forcers maintaining the self-stimulation were distinct tion is given can influence whether a child learns a
across children, different sensory extinction pro- particular response. The therapist must make sure that
cedures were required for different self-stimulatory be- the child is attending to the instruction and that the
haviors. For example, for one child, a blindfold was instruction serves as an easily discriminable cue for a
used to eliminate the visual feedback produced by particular response (Schreibman & Koegel, 1981).
twirling objects, while for another child, a carpeted The establishment of a stimulus as discriminative
area was used to mask the auditory feedback produced for a response (SD) is one aspect of the acquisition of
by plate spinning. The results of this procedure have stimulus functions. In this case, the child learns to
far-ranging clinical implications. Rincover (1978) make a certain response when presented with a specific
SD and not to make the response when the SD is absent. component cue in the context of other cues. Since the
Carr et al. (1975) demonstrated how a particular ante- original demonstration by Lovaas, Schreibman,
cedent event influenced immediate echolalia. They Koegel, and Rehm (1971), this finding has been repli-
found that the children tended to echo only those ques- cated in a two-cue situation (Lovaas & Schreibman,
tions and commands that had not previously been es- 1971), with simultaneous visual cues (Koegel &
tablished as discriminative for a specific response. For Wilhelm, 1973; Schreibman, 1975), and with cues
example, a child might respond appropriately to the presented in the auditory modality (Reynolds, News-
question, "What's your name?" but would echo a non- om, & Lovaas, 1974; Schreibman, 1975; Schreibman
sense phrase, such as "min dar snick." These authors et al., 1986).
suggested that those stimuli that were not discrimi- The implications of these findings become apparent
native for a response were meaningless to the children. when one considers the number of situations encoun-
The children tended to respond appropriately only to tered that require response to multiple cues. Over-
those stimuli that were meaningful. Lovaas and News- selectivity has been discussed as a variable influencing
om (1976) have also noted the importance of the ac- language acquisition (Lovaas, Schreibman, Koegel, &
quisition of stimulus functions in the development of Rehm, 1971; Reynolds et al., 1974; Schreibman et al.,
language. They pointed out that aspects of the child's 1986), social behavior (Schreibman & Lovaas, 1973),
environment must acquire discriminative properties observational learning (Varni, Lovaas, Koegel, &
(i.e., become functional) that serve to control verbal Everett, 1979), prompting (Koegel & Rincover, 1976;
behavior. For example, one of the first steps in teach- Rincover, 1978; Schreibman, 1975), and generaliza-
ing language to autistic children may be to establish the tion (Rincover & Koegel, 1975).
therapist's vocal instruction as meaningful for an im- The severity of overselectivity and its negative im-
itative vocal response on the part of the child. pact on many areas of functioning have motivated re-
searchers to investigate treatment techniques to re-
mediate overselectivity or to ameliorate its effects.
Stimulus Overselectivity
Because the overselectivity research had revealed that
Characteristic of many autistic children is stimulus under some conditions the overselectivity effect disap-
overselectivity, the tendency to respond to only a very peared (Koegel, Schreibman, Britten, & Laitinen,
restricted portion of their environment (e. g. Lovaas et 1979; Schover & Newsom, 1976; S-chreibman,
al., 1979; Lovaas, Schreibman, Koegel, & Rehm, Koegel, & Craig, 1977), the potential for remediating
1971). Specifically, it appears that when such children the deficit was apparent.
are presented with a learning situation requiring re- Capitalizing on these promising findings, Koegel
sponse to multiple cues within a complex stimulus, and Schreibman (1977) decided to approach the prob-
their behavior comes under the control of a very lim- lem directly by investigating whether autistic children
ited portion of those cues. In the first experimental could learn a conditional discrimination. A conditional
demonstration of this problem, Lovaas, Schreibman, discrimination is one in which the discrimination task
Koegel, and Rehm (1971) taught normal, retarded, must be solved by responding to multiple features.
and autistic children to respond in the presence of a These investigators taught four autistic and four nor-
complex stimulus consisting of visual, auditory, and mal children a conditional discrimination requiring re-
tactile cues. When the components of the stimulus sponse to multiple crossmodal (auditory and visual)
complex were then presented individually, the experi- cues. The results showed that the autistic children
menters found that the normal children responded learned the discrimination, although they did not learn
equally to all three of the component cues, whereas the it with ease, nor in the same manner as normal chil-
autistic children responded primarily to one of the dren. These children persistently tended to respond at a
component cues. In other words, each of the separate higher level to one of the component cues (auditory
cues was equal in controlling the behavior of the nor- alone or visual alone), and only after many (typically
mal children, but in marked contrast, the autistic chil- hundreds) of trials did they learn to respond on the
dren responded primarily in the presence of the audito- basis of both cues. Further, Schreibman, Charlop, and
ry component (three children) or the visual component Koegel (1982) found that children with autism who
(two children) only. These investigators also demon- had previously failed to transfer from a pointing
strated that this deficit was not a function of a specific prompt (teacher points to correct stimulus) in a diffi-
sensory impairment, but a problem in responding to a cult discrimination could subsequently transfer and
learn from the prompt after training on a series of suc- child to benefit from prompting procedures. Basically,
cessive visual conditional discriminations. In this these prompts involve exaggerating the relevant com-
experiment the children were presented with a condi- ponent of a stimulus, and after the child reliably re-
tional discrimination, and if they responded overselec- sponds to this component, gradually fading the exag-
tively to one of the two relevant components, they geration until the component is in its normal state. This
were trained until they responded on the basis of both. is called "within-stimulus" prompting because the as-
They were then presented with another conditional dis- sistance is provided by altering the relevant component
crimination, and so forth, until they approached two of a discrimination such that the child need only attend
consecutive conditional discriminations on the basis of to this single component and not to multiple cues (e. g. ,
mUltiple cues. It was after this training that the children an "extra-stimulus" prompt and a training stimulus).
could utilize the pointing prompt on a difficult discrim- (An example would be teaching the discrimination be-
ination. tween "E" and "F" by first exaggerating the bottom
It appears that many of these children can learn to line of the "E" and then fading it to its normal size.)
respond to the environment in a manner more similar Schreibman (1975) found that using within-stimulus
to normal children, and they therefore are in a better prompts, children with autism learned difficult dis-
position to benefit from the teaching strategies com- criminations that they previously did not learn without
monly used in classrooms as well as from their social a prompt, or with an extra-stimulus (therapist point-
environment. It has further been demonstrated that re- ing) prompt. The strength of the within-stimulus
duced stimulus overselectivity (via successive condi- prompt procedure is that the child is never required to
tional discrimination training) is associated with in- respond to simultaneous multiple cues, and the initial
creased social responsiveness and use of incidental phases of the training ensure the child is responding to
language cues (Burke & Koegel, 1989). It is apparent the relevant feature of the discrimination. Rincover
that reduction of overselective responding and in- (1978) elaborated on these findings and demonstrated
crease in responsivity to multiple cues leads to positive the importance of using the "distinctive feature" ofthe
collateral behavior changes. discrimination.
Although the above approach is certainly encourag-
ing in that it suggests a treatment for overselectivity,
there are some children for whom these procedures fail Motivation
and they remain overselective. To allow these children
to learn, special techniques have been developed that Attention is fundamental to the acquisition of spe-
involve designing the educational situation such that cific behaviors and, as seen above, changes in atten-
the child can learn even though he or she is overselec- tion are associated with improved learning, social
tive. As described above, many teachers use prompts, responsiveness, and so forth. In a similar vein, moti-
or added cues, to assist learners with new discrimina- vation to respond (and thus learn) is fundamental to the
tions. Often these prompts are in the form of extra acquisition of behaviors and is notoriously poor in
stimuli added to lead the child to the correct response. these children. Researchers have thus focused on es-
Examples of this type of prompt include pointing to the tablishing motivation as an important factor in the
correct choice, underlining, and using different colors. treatment of these children.
Such prompts are commonly used and are gradually Initially, researchers viewed the characteristic lack
faded until the child responds correctly without the of motivation in autism as a result of the saliency or
prompt (i.e., control of the response transfers from desirability of available reinforcers (e.g., Ferster,
the prompt to the training stimulus). Unfortunately, 1961; Lovaas & Newsom, 1976). More recently, re-
the total removal of a prompt can be problematic in the searchers have studied the motivational deficits of au-
case of the overselective child in that the child may tistic children by addressing not only the type of rein-
respond only to the prompt and fail to attend to the forcers and the manner in which they are delivered, but
training stimulus. by also addressing the learning environments in which
Prompt fading is a very useful technique for bring- autistic children are treated (e.g., Dunlap, 1984;
ing about correct responding and one a therapist can ill Koegel & Mentis, 1985; Koegel, O'Dell, & Koegel,
do without. To address this problem some investiga- 1987). Thus, our discussion will address both these
tors (e.g., Rincover, 1978; Schreibman, 1975) have areas.
sought to develop prompts that allow an overselective Many therapists and teachers working with autistic
children have relied upon primary reinforcers, such as one particular edible reinforcer (stimulus-specific con-
food, to motivate and maintain the children's behavior dition), performance is better as compared with a var-
because social reinforcers (e. g., praise) have been ex- ied reinforcer format or when just one salient rein-
tremely difficult to establish (Lovaas & Newsom, forcer is available. Thus, change in the response-
1976). However, the use of food as reinforcers has reinforcer relationship increased the effectiveness of
posed its own problems, including (I) primary the reinforcer. Along these lines, Koegel and Williams
reinforcers becoming artificial for older children, (2) (1980) and Williams, Koegel, and Egel (1981) demon-
primary reinforcers existing in only limited settings, strated that when a reinforcer was obtained as a natural
such as treatment sessions, and therefore interfering part of the task, it was more effective than when pre-
with generalization to other environments in which sented in a task-independent manner. For example,
food may not be available, and (3) children easily be- when teaching the preposition "in," the edible rein-
coming satiated with food reinforcers and discontinu- forcer would be placed inside the task stimulus (direct
ing working. reinforcer) as opposed to merely handing the edible to
Recently, researchers have begun to examine pro- the child (indirect reinforcement). In summary, thera-
cedures for possibly decreasing the likelihood of satia- pists and teachers can sustain a relatively high level of
tion and ultimately increasing the effectiveness of rein- motivation by systematically varying the presentation
forcers in motivating autistic children. One procedure of previously functional reinforcers.
has been to manipulate the novelty of the reinforcing Researchers have also addressed the use of other
stimuli. Such research has demonstrated that the chil- aspects of reinforcer delivery. Of great importance is
dren are more motivated to respond to novel, un- the development of procedures for establishing func-
familiar stimuli (e.g., Berlyne, 1955; Cantor & Can- tional secondary reinforcers, or social reinforcers,
tor, 1964; Hutt, 1975). Further, it has been argued that such as praise, hugs, smiles, and approval. This is
continued exposure to a familiar stimulus will result in because such reinforcers occur in so many nontreat-
satiation (Glanzer, 1958; Wilson, 1974). Thus, satia- ment settings and support so much behavior in normal
tion might be prevented by merely changing or varying individuals. Early studies had some success in estab-
the reinforcing stimuli. lishing functional social reinforcers (e.g., Lovaas et
Based on this literature, two directions have been aI., 1965, 1966), but the autistic child's typical unre-
taken in the treatment of autistic children that have sponsiveness to social stimuli makes this a most diffi-
proved favorable. Egel (1979, 1980) demonstrated cult undertaking when addressing motivation. How-
that rapid satiation, typically found when using edible ever, some research by Dyer (1987) and by Koegel,
reinforcers, could be reduced if the reinforcer was var- Dyer, and Bell, (1987) suggests that social respon-
ied as opposed to being held constant. He compared siveness may be improved greatly by allowing the
the children's behavior during conditions when one (of child to take a more active role in choosing the
three) highly preferred edible reinforcer at a time was reinforcers, and the tasks. Another promising area has
available contingent upon correct responses (constant been the study of the reinforcing properties of self-
condition), to conditions when all three of the highly stimulatory behavior. The sensory events this behavior
preferred edible reinforcers were varied. The results provides must have some powerful reinforcing proper-
indicated that satiation occurred more rapidly when ties since autistic children characteristically spend so
each of the reinforcers was individually presented than much time engaged in such behavior (e.g., Lovaas,
when a reinforcer was presented from a pool of several Litrownik, & Mann, 1971; Rimland, 1964). Rincover
available reinforcers. Rincover and Newsom (1985) et al. (1978) investigated the reinforcing properties of
found similar results when they compared the effects sensory stimulation by first identifying the preferred
on behaviors of presenting four reinforcement condi- sensory stimuli for each child (e.g., looking at lights)
tions: constant edible, constant sensory, varied edible, and then providing such stimulation contingent upon
and varied sensory. Overall, their results showed that a an operant response. These investigators reported that
varied reinforcer presentation was more effective, with such sensory reinforcement was not only effective but
varying sensory reinforcers most effective. relatively resistant to satiation. Taking this orientation
In another direction, Litt and Schreibman (1981) further, Rincover and Devaney (1979) demonstrated
increased reinforcer effectiveness by providing stim- the efficacy of self-stimulation as a reinforcer (e.g.,
ulus-specific reinforcers. These researchers demon- Hung, 1978; Wolery, Kirk, & Gast, 1985).
strated that when a particular task is associated with Recently, in a comprehensive study, Charlop and
Greenberg (1985) compared traditional (food) rein- that the interspersal must include maintenance tasks,
forcers to self-stimulation as a reinforcer in a multiele- and that merely interspersing several acquisition tasks
ment design. In the Self-stimulation Condition, each did not facilitate learning. Finally, Charlop, Kurtz, and
child was allowed to engage in self-stimulation for 3-5 Milstein (1986) combined task variation procedures
sec after each correct response. In the Food Condition, with varying reinforcement contingencies to further
only food was available as a reinforcer. In the Self- assess motivation. Task variation procedures with food
stimulation/Food Condition, self-stimulation or food reinforcers available contingent upon correct acquisi-
was available, and randomly presented contingent tion task response were in effect throughout all condi-
upon correct responding. For all five children, the tions and baseline. Superior performance on the ac-
highest percentage of correct responses occurred in quisition task was seen when edible reinforcers were
conditions in which self-stimulation was used as a re- not administered for maintenance tasks' responses or
inforcer. Importantly, the overall frequency of self- when praise only was provided for maintenance tasks'
stimulation and other inappropriate behaviors (e.g., responses. These results suggest that motivation may
tantrums) did not increase during or after sessions in be further enhanced when task variation is used in
which self-stimulation was used as a reinforcer. Thus, conjunction with a "richer" schedule of reinforcement
sensory reinforcement provides a feasible and power- in favor of the acquisition task.
ful protocol for motivating autistic children. The research on motivation has provided several
The learning environment in which autistic children promising avenues of research and generated several
are typically taught has also recently been addressed as treatment techniques. The data suggest that much can
a means of increasing motivation in these children. For be done to enhance the motivation of autistic children.
example, in the past a typical learning environment The more motivated they are, the more likely they are
contained a structured setting in which several trials of to make significant improvement (Koegel & Mentis,
the same task were presented. Although designed to 1985).
decrease off-task and disruptive behavior (e.g., tan-
trums, self-stimulation, noncompliance), such learn-
ing environments may have led to a decrease in moti- Generalization
vation and an increase in boredom (Dunlap, 1984). In
an attempt to increase autistic children's motivation to The previously described treatment procedures have
respond, task variation procedures have been used. been successful in teaching autistic children appropri-
This generally entails setting up the learning environ- ate behaviors and in decreasing inappropriate behav-
ment to provide both the presentation of new target iors. However, treatment gains do not always gener-
behaviors interspersed with the presentation of pre- alize to nontreatment environments, across untreated
viously learned (maintenance) tasks. Thus, rela- behaviors, or over time. Often, improvement is setting
tionship of reinforcer to response would be highlighted and task specific (Schreibman, Charlop, & Britten,
to associate learning per se with reinforcement 1983). Clearly, treatment is of only limited value if
(Koegel & Egel, 1979; Koegel & Mentis, 1985) and generalization does not occur. Thus, many treatment
the provision of maintenance tasks to further enhance procedures now being explored incorporate provisions
motivation (Dunlap, 1984; Koegel & Koegel, 1986). to facilitate generalization and maintenance of behav-
Such increases in motivation have also been very ior change.
powerful when researchers have reinforced the chil- As a starting point, a number of strategies, dis-
dren's attempts at correct responses, instead of waiting cussed by Stokes and Baer (1977) have been added to
for only exactly correct responses before delivering a the treatment of autistic children to promote gener-
reinforcer (Koegel, O'Dell, & Dunlap, 1988; Koegel, alization. One approach to facilitating generalization
O'Dell & Koegel, 1987). of treatment gains is to make the treatment environ-
The literature on task variation has been quite prom- ment more similar to the natural environment (Stokes
ising. Dunlap and Koegel (1980) demonstrated that & Baer, 1977). The use of intermittent schedules of
higher percentages of correct responding occurred reinforcement during treatment provides an atmo-
when tasks were varied than when a single acquisition sphere that is more like the natural environment where
task was presented throughout the child's work ses- behaviors are seldom reinforced on a continuous
sion. Dunlap (1984), Koegel and Koegel (1986), and (CRF) basis. Several studies (e.g., Koegel & Rin-
Neef, Iwata, and Page (1980), further demonstrated cover, 1974, 1977; Rincover& Koegel, 1977a,b) have
suggested that intermittent schedules have increased would be to train sufficient exemplars (Stokes & Baer,
the durability of treatment gains by reducing the dis- 1977). For example, Stokes, Baer, and Jackson (1974)
criminability of the reinforcement schedules used in demonstrated that when teaching greeting responses to
treatment and nontreatment environments. Addi- retarded children, the children did not generalize such
tionally, intermittent schedules have served to main- behavior to any other persons besides the experiment-
tain treatment gains, allowing naturally occurring in- er. However, where two persons (exemplars) served as
termittent reinforcers to easily "take over" in natural experimenters, the children's behavior generalized and
environments. they greeted more than 20 other persons.
The use of naturally maintaining contingencies As with sequential modification, training sufficient
(natural reinforcers) during treatMent will liken the exemplars can often be tedious when many exemplars
treatment environment to nontreatn. ,nt settings (e. g. , are needed. Also, it is difficult to know a priori how
Stokes & Baer, 1977). Thus, reinforcers should be many exemplars will be necessary. Thus, Stokes and
similar to those that are likely to be encountered in Baer (1977) discussed one additional approach to fa-
natural settings and behaviors should be taught that are cilitate generalization. Mediated generalization refers
likely to acquire such reinforcers. Several studies to the use of behaviors that are likely to occur in both
along these lines have provided encouraging results treatment and nontreatment settings that occasion the
with autistic youngsters. For example, Carr (1980) occurrence of the target response. The most common
taught autistic children to use sign language to request mediator is language. For example, the child might
items that were likely to be found outside the treatment learn to give self-instructions in different environ-
environment. The children were taught to spon- ments.
taneously request their favorite foods and toys as op- Although little research has addressed mediated
posed to common but nonfunctional items (e.g., pic- generalization with autistic children, there is some in-
tures offarm animals). Thus, when the children signed dication that this may be a promising avenue to pursue.
for a preferred food, they were likely to receive that Charlop (1983) used autistic children's immediate
food at home or school, which constituted reinforce- echolalia as a verbal mediator. Six autistic children,
ment for generalizing. Charlop, Schreibman, and three echolalic and three nonverbal, were taught two
Thibodeau (1985), taught verbal autistic children to receptive labeling tasks. For one task, the children
spontaneously request their preferred food item were allowed the opportunity to echo the experiment-
through time-delay procedures. The children not only er's verbalization of the object's label (e.g., echoed
acquired the target behavior (spontaneous requests for "boat") before handing the experimenter the object
preferred foods) but generalized such requests to other, upon request (boat). For the other receptive labeling
nontreatment environments. Finally, this approach in- task, the children were not allowed the opportunity to
corporates the use of common stimuli: those found in echo the experimenter's request before placing the ob-
treatment and in nontreatment settings (Stokes & Baer, ject in the experimenter's hand. The children learned
1977). the tasks faster when taught with the "echo pro-
Another approach to facilitating generalization is to cedure." Importantly, generalized treatment gains
use procedures that directly occasion generalization. were seen for the echolalic children with this pro-
Sequential modification is such a procedure where cedure but not for the nonverbal children. Charlop sug-
generalization is programmed in every nongeneralized gested that the mediated generalization occurred for
condition (e.g., across persons, settings, stimuli). For the echolalic children because, unlike the nonverbal
example, if the children learned speech at speech ther- children, they provided their own self-imposed dis-
apy, but did not speak at home, parents would be criminative stimulus (echo for the object's label) be-
taught to teach speech to their children in the home (see fore handing over the requested object in the gener-
section on "Parent Training" below). alization setting.
Sequential modification can often be a tecl.ous pro- Recently, in an attempt to incorporate many of the
cess, especially in situations when generalization above procedures to enhance generalization, re-
needs to occur across many stimuli (e. g. , each time the searchers have explored the use of the natural environ-
child sees a different printed version of the letter "A" ment for treatment. As a result, several promising
when learning the alphabet) or across many settings techniques have emerged. These include time delay,
(e.g., home, school, grandparents' home, day care, incidental teaching, and NLP (Natural Language Para-
camp). A more feasible approach in this situation digm). Time delay uses natural stimuli in natural set-
tings. For example, with this procedure, the teacher acquisition and generalization as compared with tradi-
presents a desired object to the child (e.g., cookie) and tional speech protocols. Recently, the efficacy ofNLP
models the appropriate response "I want cookie." As has been demonstrated with parents using the pro-
the child begins to imitate the modeled response, the cedure in their home (Laski, Charlop, & Schreibman,
time between the presentation of the object and the 1988). As discussed below, the use of parents and
modeled response is lengthened. Thus, stimulus con- teachers as therapists has been quite successful.
trol of the child's verbalization is transferred from the
teacher's model to the object. Eventually, the child
learns to spontaneously request the desired item before
the teacher's model. The time period used to transfer
Treatment Environments
stimulus control from the teacher's model to the pres-
Parent Training
ence of the object serves as a natural prompt that can
occur in a variety of settings and can be used for a The importance of including parents as intervention
variety of behaviors (Chadop & Walsh, 1986; Chadop agents with autistic children was demonstrated very
et al., 1985; Touchette, 1971). clearly by Lovaas and his colleagues in their longitudi-
Incidental teaching procedures embed teaching tri- nal study of 20 autistic children (Lovaas et al., 1973).
als within the child's daily activities. For example, One to four years after the original behavioral treat-
McGee, Krantz, and McClannahan (1983) taught au- ment program was discontinued, the authors found
tistic children to receptively learn labels of objects that the only children who continued to improve were
used in meal preparation (e.g., knife, sandwich). The those whose parents had received training in behav-
training occurred in the kitchen of the children's resi- ioral principles. In stark contrast, treatment gains were
dential facility, when preparing the day's lunch, with not maintained in children institutionalized following
theircareprovider. This "loose structure" in the teach- training or who remained with parents who had not
ing situation (wherein the child can sample a range of received training.
correct responses and reinforcers) helps promote gen- A variety of programs/models have been developed
eralization (Stokes & Baer, 1977). Incidental teaching for training parents and are reviewed by Polster and
has been effective in facilitating generalization of a Dangel (1984). In general, parents of children with
variety of behaviors, such as sign language (Carr & autism and other disabilities have been taught behav-
Kologinsky, 1983), prepositions (McGee, Krantz, & ioral principles and procedures, such as reinforce-
McClannahan, 1985), and reading skills (McGee, ment, punishment, error correction, prompting, shap-
Krantz, & McClannahan, 1986). ing, chaining, and/or appropriate instructional deliv-
A third promising procedure, specifically to teach ery. Training methods have included (either separately
speech, is the Natural Language Paradigm (NLP). or, more typically, in combination) discussion and
NLP has been designed to incorporate procedures to written materials, behavioral rehearsal and feedback,
increase motivation (e.g., child's initiation, taking and modeling of procedures presented in vivo and
turns, interspersing maintenance tasks, reinforcing at- through videotapes (e.g., Cordisco & Strain, 1986;
tempts) with procedures for promoting generalization Friman, Barnard, Altman, & Wolf, 1986; Harris,
(loose structure, common stimuli, natural environ- Wolchik, & Milch, 1983; Howlin, 1981; Koegel,
ment). During NLP, the child and the therapist interact Glahn & Nieminen, 1978; Koegel et ai., 1982;
in a play setting with a variety of toys. The child ini- Kozloff, 1984; McClannahan, Krantz, & McGee,
tially chooses which toy he or she would like to "talk 1982).
about" and play with. The therapist then models an Regardless of the procedures used, most programs
appropriate verbalization for the child to imitate (e.g., focus on teaching parents a general set of skills (based
"I want car"). When the child makes any commu- on behavioral principles) that enable them to respond
nicative attempt (imitates phrase or part of phrase, to a variety of child behaviors (e.g., Polster & Dangel,
gestures toward the toy), the toy is given to the child as 1984). For example, Koegel et al. (1978), as part of a
a reinforcer. Then it is the therapist's "tum" to play multicomponent study with parents of autistic chil-
with the toy, and the therapist either models a different dren, compared this approach with one that taught par-
verbalization (e.g., "car is blue") or provides a new ents how to teach one specific behavior at a time. Their
referent for the initial verbalization. Koegel, O'Dell, results demonstrated that teaching parents to modify
and Koegel (1987) demonstrated that NLP facilitated an individual behavior was an effective approach for
changing that specific behavior; however, parents' also explain why parent training effects may not main-
teaching abilities generalized to novel tasks only after tain with some families. Laski et al. suggested that
they received training in general behavior management training parents in the use of natural teaching pro-
procedures. Similar findings were reported by Cor- cedures (e. g., incidental teaching, time delay, mand-
disco and Strain (1986) for parents of autistic pre- model) may facilitate continued strategy use over time
school children. and across settings. The results of this research (dis-
Evaluation of parent training programs have typ- cussed earlier) demonstrated that, after training in the
ically involved measuring changes in parent and/or Natural Language Paradigm (Koegel, O'Dell, &
child behavior. How the family functioned as an in- Koegel, 1987), parents increased substantially their
teractive system was, in most cases, treated as a side use of NLP procedures and the majority continued to
issue unrelated to the training process. Thus, a body of use them after training.
information on family functioning was unavailable to Overall, the results from studies in both areas are
evaluate (1) why some parents did not acquire or main- very promising. However, much work remains to be
tain the use of the teaching strategies, and (2) why done in order to develop empirically based models of
some children did not improve (either at all or at the parent training that will have a sustained impact on
same rate) over time (Baker, Heifetz, & Murphy, both the autistic child and the family system.
1980; Harris, 1986; Harris, Wolchik, & Weitz, 1981;
Holmes, Hemsley, Rickett, & Likierman, 1982). This
has led to the recent acknowledgment by numerous
Classroom Instruction
researchers that behavioral parent training, as tradi-
tionally implemented, may be insufficient for some Prior to the passage of Public Law 94-142, students
families if lasting change is to occur (e. g., Dadds, with autism were educated in classrooms, clinics, and
Sanders, & James, 1987; Egel & Powers, 1989; Griest programs located in private and residential treatment
& Forehand, 1982; Harris, 1982, 1988; Helm & centers, special schools, and university clinics
Kozloff, 1986; Kaiser & Fox, 1986; Koegel et aI., (Gaylord-Ross, 1979). Since the implementation of
1982; Lutzker, McGimsey, McRae, & Cambell, 1983; PL 94-142 in 1977, the array of services has expanded
Thrnbull, Brotherson, & Summers, 1985). These in- to include classes in special programs and schools at-
vestigators have just begun to address the need for tended by nonhandicapped or less handicapped stu-
expanding services so that behavioral parent trainers dents (Brinker, 1985; Donnellan & Neel, 1986; Lan-
can assess problems related to the family system and sing & Schopler, 1978; Warren, 1980).
can develop intervention programs to address these Recently, several authors (e.g., Donnellan, 1980;
broad-based areas. Egel & Neef, 1983; Gaylord-Ross & Pitts-Conway,
Koegel and his colleagues (Koegel et al., 1982; 1984; Gradel & Pomerants, 1984; Neel, Billingsley, &
Koegel, Schreibman, Johnson, O'Neill, & Dunlap, Lambert, 1983) proposed guidelines for educational
1984; Schreibman, Koegel, Mills, & Burke, 1984) re- programs for students with autism that were based on
ported one of the only empirical investigations to as- previous discussions and guidelines for the develop-
sess the effects of behavioral parent training on the ment of appropriate programs for other severely handi-
families of autistic children. These authors obtained capped students (e.g., Bates, Renzaglia, & Wehman,
pre- and posttreatment data on a variety of family vari- 1981; Brown et aI., 1979; Wilcox & Bellamy, 1982)
ables (in addition to traditional measures of child im- Although many of the specific guidelines have not yet
provement and parental skill usage), including parent- been empirically validated, all are based on analyses of
child interactions at home, personality and marital ad- the learning characteristics of autistic and other se-
justment, time allocation, and parental expectations verely handicapped students. The following is a brief
and satisfaction. The results showed that behavioral discussion of selected characteristics that highlight
parent training promoted widespread improvement in some of the features critical to providing effective
family functioning. Attention to family variables, such classroom instruction for autistic children and adoles-
as those measured by Koegel and his colleagues, may cents.
help to identify more clearly the reasons why some
families do not maintain the skills they have learned. Functional Activities. Bates et al. (1981) de-
Laski et al. (1988) suggested that the structured fined functional activities as those programs that pro-
teaching format parents are typically taught to use may vide instruction on skills that are immediately useful
,.
and that employ materials that are likely to be found in Social Integration. There are currently two
the students' everyday environment (e.g., home, com- global models of integration. At the preschool level,
munity). The importance of using functional activities integrated programs have typically involved providing
becomes even more obvious when one considers the instruction to autistic (e.g., Hoyson, Jamieson, &
frequently cited problems teachers of autistic children Strain, 1984) or severely handicapped children (e.g.,
have in producing generalized skill performance (e. g. , Bricker & Bricker, 1977) in the same classroom with
Carr, 1980; Egel, 1982; Homer, Dunlap, & Koegel, nonhandicapped children. For older students, integra-
1988; Rincover & Koegel, 1975). Unfortunately, re- tion has involved locating classrooms for autistic
cent evidence suggests that the use of functional ac- and/ or other severely handicapped students in regular
tivities in classrooms for autistic and severely handi- public schools and, more importantly, providing sys-
capped students occurs very infrequently (Green et aI., tematic instruction with nonhandicapped students in a
1986). Studies validating methods for increasing variety of settings outside of the classroom (e.g.,
teachers' ability to identify and implement functional Gaylord-Ross & Pitts-Conway, 1984; Gradel &
activities are clearly needed (Dyer, Schwartz, & Luce, Pomerantz, 1984; Hamre-Nietupski & Nietupski,
1984; Reid et ai., 1985). 1981; Neel et aI., 1983; Sasso, Simpson, & Novak,
1985; Voeltz, 1984).
Age-Appropriate Curricula and Materials. Evaluation of integration efforts have focused on
The issue of age appropriateness has been discussed at several variables: (1) changes in reciprocal social in-
great length in the literature (e.g., Bates et ai., 1981; teraction, (2) changes in attitudes of nonhandicapped
Brown et ai., 1979; Donnellan, 1980; Johnson & peers, and (3) changes in developmental/educational
Koegel, 1982). It refers to the requirement that curricu- progress of handicapped and nonhandicapped peers.
la and materials used within a classroom should be
representative of the students' chronological rather Changes in Social Interactions. Access to socially
than developmental age. Age appropriateness may be competent peers is a primary reason cited in support of
less of an issue with very young autistic children (e.g., an integrated educational model. Segregated (e. g. , au-
less than 4 years) because the gap between chronologi- tistic only) programs provide environments with very
cal age and developmental level may not be as pro- limited opportunities for reciprocal interactions be-
nounced as at older chronological ages. cause of the members' lack of social responsiveness.
The identification of age appropriateness as a crit- In such an environment, there is a greater probability
ical component is based more on logic and the princi- that any social behavior that was exhibited would
ple of normalization than on empirical data. However, rapidly extinguish (Strain, 1983; Strain & Fox, 1981).
the logic behind this component is very persuasive, The question of whether or not integrated versus
especially when considering the issue of generaliza- segregated settings for autistic children provide en-
tion. A clear example of the importance of assessing vironments where more opportunities for social in-
and teaching to the age-appropriate standard was pro- teraction are available has been addressed by Strain
vided by Gaylord-Ross and Pitts-Conway (1984) in and his colleagues (e.g., Hecimovic, Fox, Shores, &
their description of a program for autistic adolescents. Strain, 1985; Strain, 1983, 1984). These authors dem-
The authors noted that, in order to program for gener- onstrated that autistic and other developmentally dis-
alized interactions between autistic and nonhandi- abled children engaged in substantially higher rates of
capped adolescents, they had to identify both the in- reciprocal interactions when placed in integrated, as
teraction patterns characteristic of the nonhandicapped opposed to segregated, environments. Similar results
adolescents and where these interactions took place were obtained with students labeled severely handi-
(e.g., "hanging out" at lockers, sharing video games capped (Brinker, 1985).
in the courtyard). Based on this assessment, initiation
skills were taught to the autistic students that had a Changes in Developmental/Educational Progress.
high probability of being reciprocated. The results The effects of integration on the educational and devel-
demonstrated that reciprocal interactions between the opmental progress of autistic or other severely handi-
autistic and nonhandicapped students increased sub- capped students has been addressed by a few authors.
stantially. These results would not have occurred had Strain (1986) completed the most thorough examina-
the authors selected target behaviors based solely on tion of an integrated program for autistic preschool
the autistic students' developmental age. children in a study comparing a comprehensive, segre-
gated preschool program (control group) with the inte- child's chances of remaining in the home and out of an
grated program (experimental group) described by institution, it is apparent that some autistic children
Hoyson et al. (1984). Children in both groups were cannot live in their own homes. Placing the child out-
essentially equivalent at the beginning of the investiga- side the home typically includes these reasons: (1) the
tion on such variables as intelligence, language ability, child becomes a young adult and the parents become
deviant behavior, age, and family income. The results older and unable to take care of the child; (2) the child's
at the fIrst follow-up point demonstrated that autistic behavior problems are so severe that untrained parents
children in the integrated program when compared to cannot cope with them; (3) the parents divorce or sepa-
the segregated classroom showed significant improve- rate, and neither can care for the child; or (4) such other
ment on measures of cognitive functioning (perfor- factors are present as the emotional stability of the
mance scores near age level) and expressive language. parents, family illnesses, and the presence of many
Furthermore, direct observation in the two classrooms other children.
showed that children in the integrated classroom en- For whatever reason, many autistic children are
gaged in signifIcantly more appropriate language, on- placed in institutional settings. There are several prob-
task behavior, and sitting, as well as demonstrated sig- lems associated with institutionalization in "mental
nifIcantly less deviant behaviors. Finally, six of the hospitals" (Glahn, Jones, Lichtenstein, & Redlich,
seven autistic children in the integrated classroom 1987). First, the children may acquire behaviors that
were enrolled subsequently in regular class place- are appropriate to the hospital environment but that
ments, whereas all of the children from the control will not help them function in the natural environment.
group remained in special education programs. The Second, the hospital contingencies are typically so dif-
effect of the program on the nonhandicapped peers was ferent from those of the natural environment's (e.g.,
reported by Strain, Hoyson, and Jamieson (1986) in a the home's) contingencies that behavioral improve-
comparison of their performance with that of 40 non- ments are not likely to generalize from the hospital to
handicapped "stars" from nonintegrated classrooms. the home. A third problem is the tremendous costs
Outcome measures from the integrated classroom associated with building, staffing, and maintaining
showed that the peers engaged in less disruptive behav- such institutions. Fourth, institutionalizing a child cre-
ior and equivalent levels of on-task behavior, appropri- ates a distance between the child and the parents. Fifth,
ate language, and positive interactions. Furthermore, the reliance on three shifts of staff has produced numer-
Strain et al. (1986) reported that the nonhandicapped ous problems in trying to maintain continuity of treat-
peers gained two months developmental growth on ment programming.
target behaviors for each month in the integrated pro- In response to the problems associated with the in-
gram. These data are important in that they help to stitutional treatment of autistic children, the concept of
refute the notion that integrated programs, especially community-based "teaching homes" has been intro-
those that enroll handicapped children with severe be- duced (Glahn, Chock, & Mills, 1984; McClannahan &
havior problems characteristic of autistic children, are Krantz, 1979). These homes are adapted from the
detrimental to the development of the nonhandicapped Achif'vement Place model for treating delinquent
peers. youths developed by Montrose Wolf and his col-
Other factors have been identified as critical compo- leagues (cf. Phillips, Phillips, Fixsen, & Wolf, 1974;
nents of classrooms for autistic children, including Wolf et al., 1976). These homes are as much as pos-
data-based instruction, instruction in nonschool en- sible like the child's natural home and are staffed with
vironments, and high levels of appropriate engage- "teaching parents" specifIcally trained to work with
ment. Overall, the data are clear that skills critical to autistic children. The homes provide a treatment en-
independent functioning can be acquired by autistic vironment that helps rectify some of the prominent
children and youth when a majority of these compo- problems of institutions. First, the behaviors that the
nents are brought together. children acquire are those behaviors associated with
living in a home. These include self-help skills, clean-
ing up their rooms, preparing food, and table manners.
Teaching Homes In other words, rather than learning ward-appropriate
behaviors, they learn home-appropriate behaviors.
Although parent training has proven itself to be a Second, the contingencies in the homes are made as
form of treatment that can substantially improve the natural as possible and as similar as possible to those
likely to be encountered in the child's natural home. In the first social validation of the effects of behav-
Third, this approach helps to maximize generalization ioral treatment on autism, Schreibman, Koegel, Mills,
for those children who are to return to their natural and Burke (1981) sought to determine the relationship
homes (or to foster-home placements in the communi- between objective, observational measures of pre- and
ty). Fourth, teaching homes are more cost-efficient posttreatment change in autistic children and the sub-
than costly institutional environments (Glahn et al., jective impressions of change formed of those children
1984; Phillips et al., 1974). Fifth, since multiple shifts by untrained, naive observers. First, undergraduate
of staffing are not required, continuity of programming students were asked to view segments of videotapes
throughout the day is simplified. showing the children interacting with their mothers in
The goal of the teaching-home model for providing a room full of toys. The students were asked to write
treatment to autistic children is to help institutionalized essays describing the children. A rating scale, consist-
autistic children learn skills that will increase the like- ing of 19 Likert items, was derived from these essays
lihood that they can leave the institution and go to a encompassing the areas of language, play, social in-
home environment. In addition, these homes may teractions, and behaviors, such as restlessness, wan-
serve as an alternative placement for children who can- dering attention, and repetitive behaviors. Following
not live at home. Perhaps children can go to a teaching the development of the scale, five more groups of un-
home for treatment first, followed by parent training, dergraduates (the group size ranged from 25 to 40)
thus eliminating the necessity of institutional place- were asked to view 5-min videotape segments of 14
ment at all. The preliminary reports on this model are autistic children taken before behavioral treatment and
very encouraging, and we await more research on its after 6 months of treatment (the pretreatment and post-
effectiveness. treatment tapes were presented in a randomized order)
and to rate the children on the Likert-item rating scale.
This scale provided a measure of the subjective im-
Social Validation of Treatment Effects pressions of the children.
and Targets For the objective measures, two trained observers
scored the same sr)gments of videotape for the percent-
The behavior modification treatment of autism has age of occurrence of eight behaviors that are typically
typically been considered successful if it can be shown regarded as clinically important, including self-stim-
that specific, objectively measured target behaviors ulation, play, tantrums, appropriate language, psy-
change in a positive direction as a function of the treat- chotic language (e.g., echolalia), social nonverbal be-
ment. For example, we typically measure treatment havior, and noncooperation.
gains in terms of the percentage of occurrence changes When the judges' subjective ratings were correlated
in self-stimulation, psychotic speech, appropriate with the percentage occurrence of the observed behav-
play, appropriate verbal behavior, and so forth. Al- iors, the investigators found a strong relationship be-
though we may be able to produce consistent and reli- tween the two. That is, when looking at children who
able changes in these specific behaviors, we can also showed improvement on the behavioral measures from
ask just what these behavioral changes mean in terms pre- to posttreatment, there was a significant corre-
of more global judgment of the child's progress. Thus, sponding increase in the judges' subjective impres-
are the objectively measured changes in behavior such sions. On these measures, these children were seen as
that the child is seen as more "normal looking," more significantly more skilled in language, more socially
"likable," and less likely to be institutionalized? That desirable, and more likable at posttreatment than at
is, can these objective measures be correlated with pretreatment. In contrast, children who showed very
subjective judgments of change provided by naive ob- little or no gains in appropriate behavior on the objec-
servers? Obviously, any form of treatment that cannot tive measures were seen by the judges as unchanged or
produce changes that are not apparent to others cannot worse. In addition to this global result (that the judges
be said to be truly effective. The assessment of the could subjectively see the changes in the children's
social acceptability and significance of treatment ef- behavior), it was found that there were high correla-
fects, treatment targets, and treatment procedures is tions between the measured objective behaviors (e.g.,
called social validation and has become increasingly "self-stimulation") and specific items on the subjec-
useful as an adjunct to objective assessment in evaluat- tive questionnaire (e.g., "child engages in repetitious
ing and planning behavioral treatment programs. behavior"). These results strongly suggest that the ob-
jectively measured changes in the behavior of autistic sider aberrant speech to be a very important focus of
children are apparent to naive judges and that the be- treatment as compared to other behaviors. Teachers,
haviors focused upon for treatment are socially however, rated speech as a more important target for
important. treatment. Because we know that language skill is
Because one might argue that college undergraduate highly correlated with treatment prognosis, it is per-
students are not the most relevant consumers of the haps important to educate the parents about the signifi-
treatment of children with autism, this line of social cance of certain behaviors. The social validation of
validation research has been extended to include more behavior therapy targets and effects has proven to be an
relevant consumers-parents, teachers, and normal important adjunct to traditional assessment of behavior
peers. Using the same basic methodology as in the change. Further, assessing the social validity of our
original study described above, Schreibman, Runco, treatment ensures that we will remain sensitive to the
Mills, and Koegel (1982) replicated the social valida- community in which we wish these children to func-
tion of treatment effects with teachers making the sub- tion.
jective judgments. Elementary school teachers per-
ceived the efficacy of the behavioral treatment, as
evidenced by the difference between the pre- and post- Conclusion
treatment ratings. In addition, they viewed the specific
and global behaviors in a way that was similar to that of It is the authors' hope that with the above discussion
the trained observers who used the objective scoring the reader has acquired both an appreciation for this
scheme. A second major result was that certain behav- most challenging childhood disorder and for the behav-
iors (i.e., social behavior, cooperation) seemed to be ioral-treatment model. Perhaps the major strength of
especially significant in influencing the teachers' judg- the behavioral model is its foundation in, and emphasis
ments about the children. Such behaviors might be on, objective empirical support for its direction. It is
especially important targets for behavior change if we hoped that the reader can see from our discussion the
wish to influence the children's acceptability into the cumulative nature of the work in this area and how
community. behavior therapists are focusing more and more upon
Perhaps an even more appropriate consumer group wider, more global issues (e.g., motivation, gener-
for assessing efficacy of behavioral treatment are the alization, extended treatment environments, social
parents of children with autism. In a further social validation) in the design and evaluation of treatment.
validation investigation, Runco and Schreibman Autism is a complex disorder and its treatment requires
(1983) asked parents of autistic and parents of normal us to address and acknowledge its complexity in our
children to view videotapes of autistic children before treatment interventions.
and after behavior therapy. Using the same basic meth-
odology as the previous studies, these investigators
asked the parents to rate the children on a variety of References
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CHAPTER 36
Medical Disorders
Lizette Peterson and Cynthia Harbeck
Behavioral Interventions reports are rewarded), trauma (where such techniques

in Pediatric Psychology as reward for cooperative behavior, meditative breath-
ing, and distraction assist burned patients in coping
Stresses accompanying medical illness and threaten- with treatments), and invasive surgical and diagnostic
ing medical procedures may be even more challenging procedures (where preventive programming involving
for children than for adults because these stresses oc- models, self-instruction, and cue-controlled relaxation
cur in addition to rapidly changing developmental de- reduce distress and increase cooperation).
mands. During the past 20 years, the field of pediatric Within the present chapter, we separate the behav-
psychology has grown to meet the challenges for chil- ioral techniques most commonly used in pediatric psy-
dren that are found in medical settings. Although many chology from descriptions of a single disease or pro-
questions remain, currently a large number of psycho- cess and describe these interventions generically by
logical interventions have received empirical demon- type of technique. In this fashion, we offer the reader a
stration of their effectiveness with ill or injured sample of the wide variety of ways in which familiar
children. behavioral tools are implemented with children in
The large majority of therapeutic interventions cur- medical settings. We provide only a sample; it is not
rently used in pediatric psychology involve behavioral possible to offer, in one brief chapter, a comprehensive
or cognitive-behavioral techniques (Peterson & Har- listing of even a single type of technique used in this
beck, 1988; Roberts, 1986). Descriptions of such tech- emerging area. However, this discussion provides an
niques are most typically found embedded in articles overview of the literature that substantiates the effec-
dealing with diverse topics, such as chronic disease tiveness of behavioral interventions within pediatric
(where interventions may involve compliance to medi- psychology.
cal regimens, behavioral training and monitoring of Our discussion will begin with response-enhancing
self-medication, and relaxation or token systems to techniques, such as reinforcement and modeling. We
assist physical therapy efforts), childhood pain (where then consider response reduction techniques that focus
interventions can range from biofeedback and relax- on anxiety (such as modeling, relaxation, and system-
ation to token economies where the absence of pain atic desensitization) and traditional operant response
reduction techniques, such as differential reinforce-
Lizette Peterson and Cynthia Harbeck • Department of
ment of other behavior (DRO), differential reinforce-
Psychology, University of Missouri-Columbia, Columbia, Mis- ment of alternative behavior (DRA), overcorrection,
souri 65211. time-out, and punishment. Finally, we will briefly
791
sample "packages" of behavioral techniques that are imately 18 points for $2 in value. Several days a week,
used in a variety of areas and will consider research subjects were dialyzed and received 2 or 3 points for
challenges for the future. maintaining acceptable levels of weight, potassium,
and BUN (a measure of protein breakdown). This pro-
gram effectively diminished BUN and potassium lev-
els in those children who had experienced problems in
Response Enhancing Techniques baseline, and consequently, weight fluctuations (indi-
cating differing levels of fluid retention) were substan-
Reinforcement
tially reduced. Withdrawal of the points resulted in
Undoubtedly, reinforcement is one of the most increased weight fluctuation.
straightforward and easy to administer behavioral Although the diet was reexplained to the subjects
techniques, yet one of the most effective. It is used in when the token system began, the critical aspect
one form or another in almost all of the programs to be seemed to be the contingent points rather than acquisi-
described in this chapter. In this section, we consider tion of new dietary skills. Further, this method did not
those programs where the primary intervention is rein- require any intervention on the part of the family. Per-
forcement. These interventions, of course, rely on the haps most important, for these older children and ado-
same basic principles as reinforcement programs in lescents, it was not necessary to reward the actual tar-
other settings. The response must be clearly defined, get behavior of eating appropriate foods directly; the
and the subject must have the ability to perform the outcome blood measures sufficed. It is unclear if re-
response (thus, shaping is often used). The reinforcer warding this more distal measure would be as effective
must have a functional relationship to the target re- with younger children.
sponse. That is, the reinforcer must have a causal rela- The use of such metabolic outcome measures is crit-
tionship to later instances of the response. Pragmat- ical to many chronic childhood diseases. Diabetic chil-
ically, this often means that the child must be willing to dren, for example, require urine and blood testing sev-
emit the target response in order to achieve this partic- eral times daily to maintain the optimal balance
ular reward. between insulin, sugar intake, and exercise. Carney,
Often, the child in the studies to be reviewed has Schechter, and Davis (1983) utilized a reinforcement
actively resisted or claimed to be unable to emit the procedure to increase blood glucose monitoring in
target response. Parents and health care agents have three insulin-dependent diabetic children, who were
expended a great deal of time and energy nagging, 10, 11, and 14 years qld, respectively. Three times a
threatening, and cajoling the child. Thus, it is often day, parental praise plus one point was applied con-
very surprising to them that a reward of very little tingent upon appropriate blood testing. Parents were
monetary value (often less than $2) can have such a allowed to remind a child once, but then were in-
large impact on the child's responding. There are many structed to ignore noncompliance. Points were ex-
issues involved in this interaction. First, attention is changed for money, special time with parents, and ac-
shifted to the target response rather than being elicited tivities like going to a movie. Two of the three subjects
by the absence of the target response, which is the case showed dramatic improvements, from less than 5%
with nagging and cajoling. Consistent contingency compliance at baseline to 87% and 93% after interven-
management is also a key, as are instructions, praise, a tion. The child who failed to improve had parents who
sense of achievement, and so forth. regarded the reinforcement as a "bribe" for something
Reinforcement programs are thus very appropriate the child "should be doing," which is a familiar theme
for many types of pediatric interventions. A good ex- in failed reinforcement programs.
ample of the use of reinforcement can be found in an Diabetic children not only must test blood or urine to
early study on increasing compliance in a chronically ascertain blood glucose levels but also must adhere to a
ill pediatric population. In this study, Magrab alld Pa- strict exchange diet and must perform other self-care
padopoulou (1977) rewarded hemodialysis subjects, activities, such as appropriate foot washing and in-
ages 11 to 18, using a point system entitled "Specially spection to avoid diabetic gangrene. Lowe and Lutzker
for You." Subjects selected individualized prizes, such (1979) described a multicomponent intervention for 9-
as puzzles, comic books, knitting books, model car year-old Amy who was a diabetic. In baseline, Amy's
kits, and earrings. The exchange rate was approx- pediatrician reviewed her medical regimen, noting the
CHAPTER 36 • MEDICAL DISORDERS 793
areas of noncompliance and providing training. This Modeling and Behavior Rehearsal
intervention failed to improve Amy's behavior. Then,
Most modeling programs involve some sort of be-
the experimenter demonstrated the criterion behavior
havioral demonstration of the criterion behavior. This
for Amy and wrote them down for her. These written
demonstration can be provided live by the adult experi-
instructions resulted in some uneven improvement in
menter, on film by a child peer, or even by a puppet.
foot care, urine testing, and dietary adherence. The
The important components appear to be that the child
addition of a point system resulted in 100% com-
or parent views the behavior, can recall it clearly, and is
pliance, which continued to the lO-week follow-up.
motivated to imitate it.
All these studies have focused on generating behav-
ior that the children apparently were fully capable of
performing. Reinforcement procedures are also useful Child-Based Programs. The ability to take oral
for skill acquisition. For example, Manella and Varni medication successfully in the form of pills and cap-
(1981) described the use of successive approximations sules is important in the treatment of acute and of
and rewards to teach a 4-year-old myelomeningocele chronic diseases in children. Compliance to and ac-
(spina bifida) victim to stand and to walk. After six curacy of dispensing liquid medication tend to be
months of physical therapy, this little girl persisted in lower than pill and capsule form, yet some children
crawling, scooting, or remaining in a stroller. Refusals have particular difficulty swallowing pills and cap-
to try to walk were accompanied by tantrums in base- sules. Blount, Dahlquist, Baer, and Woori (1984) de-
line. Treatment first consisted of clear instructions to scribed an easy-to-administer program that involves
stand with her crutches. When she complied, she was modeling and behavioral rehearsal of successive ap-
praised and allowed to play briefly with colorful proximations to pill swallowing. In their study, six
stuffed animals. Gradually, the requirement was in- children observed a model swallow "pills" of different
creased to standing erect, ambulating a few feet, and sizes, ranging from oblong "sprinkles" used for cake
finally ambulating 160 feet. The child's mother re- decorations and slightly larger spherical silver cake
ceived training and continued the program at home. decorations to 1.5 cm x .5 cm capsules. The model
Anecdotal evidence suggested that as the child's abili- demonstrated a flat tongue, taking water into the
ties to walk increased, her negative emotions in re- mouth, head tilt, and swallowing. Each time a child
sponse to intervention decreased. At the end of the successfully swallowed the smaller "pill," he or she
program, the child was walking to all school functions. was praised, given a prize from a grab bag of small
The parent's participation in this study was not inde- gifts, and asked to observe and then imitate the model
pendently assessed, but in many programs, parental swallowing the next larger size. At follow-up, all chil-
assistance is central to the success of the intervention. dren were able to swallow vitamins or pills at home.
In some cases, in fact, the parent rather than the child is Although pill swallowing may be difficult for some
the direct recipient of an intervention to improve the children, the administration of medication by injection
child's health care. For example, Friman, Finney, is an even more difficult skill to acquire. Gilbert et al.
Rapoff, and Christopherson (1985) described a pro- (1982) described color videotapes for use with diabetic
gram to increase pediatric appointment keeping. In children that portrayed a model performing insulin in-
this intervention, parents received not only prompts (a jections. The subjects were 15 girls and 13 boys, ages
mailed reminder 5 days before the appointment and a 6-9, who were attending a diabetic summer camp.
telephoned reminder the day before the appointment) One film showed a 6-year-old black boy and an 8-year-
but also a reduced response requirement-a parking old white girl self-injecting, with narration designed to
pass which allowed the parents to park next to the provide information, a description of feelings, appro-
clinic. This intervention increased appointment keep- priate coping statements, self-instructions, and self-
ing across clinics 15% to 20%. praise. The other film utilized an adult-administered
More than simple shaping and reward is necessary instruction program. All children then met one-on-one
to increase some behaviors in parents and in children. with an instructor who taught each child how to self-
For more complex series of responses, modeling in inject. Contrary to hypotheses, the type of film did not
conjunction with rehearsal and reinforcement has been influence children's anxiety about self-injecting. How-
found to successfully increase desired behaviors of ever, the peer film did enhance skill levels, especially
children and their parents. in the oldest group of girls. It appears that at least for
some diabetic subjects, a peer film model can be very form factor replacement therapy (FRT) for their child
useful. The next section describes the successful use of at home. FRT is necessary any time the child experi-
peer models to decrease anxiety rather than to increase ences a bleeding episode. Conducted in a timely fash-
skillful behavior. ion, it can prevent the crippling effects of internal hem-
Self-injection requires substantial ability and judg- orrhaging. However, if sterile techniques and
ment, yet relatively young children can acquire suffi- appropriate procedures are not used, then loss of factor
cient skill to inject themselves safely and effectively. concentrate potency, infection, and damage to veins
Similarly, other investigators have taught children rel- could result. Parents were trained in the complex 36-
atively complex preventive behaviors designed to step procedure by observing a model who demon-
avoid injury. For example, Jones and Haney (1984) strated each step, asked the parents to imitate, gave
taught children to use a complex decision-making tree feedback, and continued to observe and praise the par-
to evaluate safe exiting from a fire. Children learned to ents' emerging skill. All parents completed over 95%
drop to the floor and to crawl, to feel a door with the of the steps correctly at follow-up. The authors stressed
back of their hand, and if it was hot, to retreat to the importance of behavioral rehearsal, social rein-
another exit. If the door was cool to the touch, children forcement, and corrective feedback.
were taught to open the door and evaluate the situation. Thus, the use of modeling, together with behavioral
If the path to an exit was clear, children were to exit rehearsal and feedback, has extensive application
immediately; if blocked by fire, they learned to access within pediatric psychology for increasing skillful be-
other options. Similarly, Yeaton and Bailey (1978) im- havior. However, a large proportion of interventions
proved safe pedestrian behavior in preschool children for children in medical settings targets the reduction of
using the same set of behavioral procedures, including a maladaptive response rather than the enhancement of
modeling, behavioral rehearsal, and rewards in the an adaptive response. Interestingly, modeling is a
form of praise and small prizes. useful technique for response reduction as well.
Peterson (1984b,c; Peterson & Mori, 1985) and her
colleagues have conducted a series of studies in which
children acquire skills in a wide variety of preventive
Response Reduction Techniques
behaviors, including everyday living skills (e.g., se-
lecting adaptive after-school activities, preparing safe
Modeling for Anxiety Reduction
and nutritious snacks), ability to encounter strangers
(e.g., talking to a stranger on the telephone, at the One of the earliest uses of a model to reduce anxiety
door, or outside of the house), and emergency respond- in hospitalized children was reported by Cassell
ing (e.g., dealing with cuts and burns, safely exiting a (1965). She presented several puppet models to chil-
fire, and responding to a tornado warning). These stud- dren who were to undergo cardiac catheterization. The
ies indicated that nonbehavioral methods of teaching, puppets represented a doctor, nurse, boy, girl, father,
such as mere discussion of safe alternatives or becom- and mother, with miniature equipment, including
ing aware of safe behaviors, are far less effective than stethoscope, syringe, and X-ray equipment. The thera-
methods which rely on modeling, response' genera- pist used the puppets to demonstrate dramatically what
tion, behavioral rehearsal, feedback, and reward. would happen during the procedure. The child was
The same techniques that allow children to acquire then allowed to act out his or her understanding and
relatively complex skills can alter parent behavior as express any concerns. Children receiving this prepara-
well. In some cases, the physical requirements of the tion demonstrated less emotional disturbance (e.g.,
task and the level of task complexity suggest that the complaining and crying) and more willingness to re-
task is better suited for parental responding. The tech- turn to the hospital for additional treatment than chil-
nology for behavioral intervention, moreover, remains dren who did not view the puppets.
the same. Vernon and Bailey (1974) used a film of four child
models, a 5-year-old boy and girl, an 8-year-old boy,
and a 9-year-old girl, to demonstrate adaptive respond-
Parent-Based Programs. Sergis-Deavenport and ing to anesthesia induction. The film showed the chil-
Varni (1983) described a complex training program for dren entering the operating room, one at a time, on a
parents of child hemophiliacs. This intervention gave 5 stretcher, having their blood pressure and heart rate
parents with 3- to 6-year-old children the skills to per- monitored, and receiving the anesthetic mask. Each
child appeared to fall asleep quickly. Children who sponsible for the change. However, both the child and
viewed this film were rated by observers as less anx- the mother strongly credited the relaxation therapy for
ious and more cooperative during entry to the operat- the improvement, and controlled studies with adults
ing room and during anesthesia induction than children have demonstrated the effectiveness of relaxation
who did not view the film. training for reduction of insomnia.
Melamed and her colleagues (e.g., Melamed, Another disorder in which relaxation therapy seems
Meyer, Gee, & Soule, 1976; Melamed & Siegel, clearly indicated is asthma. Tension can induce respi-
1975, 1980) have provided extensive demonstration of ratory resistance and thus lowering tension can im-
the utility of filmed models to reduce distress both prove pulmonary functioning. Feldman (1976) de-
before and after surgery for children who are undergo- scribed a training program in which four asthmatic
ing elective surgery. Peterson, Schultheis, Ridley- children were taught to relax and to match their
Johnson, Miller, and Tracy (1984) provided com- breathing to a simulated breathing sound. They re-
parison data suggesting that the format of the model ceived continuous feedback on their total respiratory
preparation (i.e., film or videotape of a live child ver- resistance (TRR). Following this intervention, all sub-
sus an in vivo puppet demonstration) was not as impor- jects showed improvements in all three measures of
tant as the information and behavioral alternatives pro- airway obstruction-total respiratory resistance, peak
vided by the model, at least for children experiencing flow, and maximum midexpiratory flow rate. Feldman
minor elective surgeries. Finally, Peterson and argued that the active ingredient was relaxation of air-
Shigetomi (1981) demonstrated that adding cognitive way smooth muscle tone achieved through TRR feed-
behavioral components, such as self-instruction, im- back. The extent to which TRR feedback versus relax-
agery, and relaxation, to a modeling preparation en- ation alone influenced this outcome is unclear.
hanced the effectiveness of the modeling film. However, because naturalistic studies of successful in-
The mechanism by which modeling has effected re- terventions for asthma often reveal relaxation as a stan-
sponse reduction has never been demonstrated. Imita- dard helpful intervention (e.g., McNabb, Wilson-
tion of adaptive responding or information about what Pessano, & Jacobs, 1986), it seems likely that future
to expect in the modeled situation may be the causal research will demonstrate more definitively that relax-
agent. Alternatively, some investigators suggest that ation contributes to such effects.
the child who is observing the model undergoes Relaxation training also seems implicated where
vicarious desensitization, as described by Bandura muscle tension per se is the problem. La Greca and
(1969). The active ingredient in relaxation and system- Ottinger (1979) described a child named Chris, whose
atic desensitization (to be discussed next) is also cur- cerebral palsy had left her with poor motor coordina-
rently unclear. However, the effectiveness of the tech- tion, making walking especially difficult. Daily exer-
niques has been definitively demonstrated in applica- cise of stretching her hip and leg muscles promised to
tion to a variety of medical problems. improve her ability to walk, but Chris rarely exercised
and when she did, crying, extreme tension, resistance,
and even physical fighting resulted. Progressive mus-
cle relaxation was introduced in weekly therapy ses-
Relaxation Therapies
sions and was prescribed prior to exercise periods; this
One of the most intuitively appealing applications of alone increased her amount of exercise. Then, the
relaxation training has been to decrease childhood in- child was taught to self-monitor the antecedents and
somnia. Anderson (1979) described a child who had a consequences to her exercising. Follow-up indicated
sleep onset latency of2 to 3 hours 6.3 nights per week, that the exercises were taking place the prescribed 5-7
with multiple wakenings. The boy received three 1- times per week and that the crying and complaining
hour training sessions using progressive muscle relax- had disappeared. Thus, relaxation and self-monitoring
ation. In addition, the mother was asked to withdraw successfully facilitated the stretching exercises. The
her sympathetic attention to the child prior to bedtime most obvious contribution of the relaxation was to
and during the night. This combined treatment reduced make the muscles more capable of stretching, a purely
sleep disturbance to 1.25 nights per week over the first physical effect. However, it is also possible that the
eight weeks and a zero rate the next 8 weeks. No rever- relaxation reduced the child's fearfulness of pain and
sal was deemed appropriate, and thus there is no defin- actual sense of pain.
itive demonstration that relaxation training was re- Siegel and Peterson (1980) used an abbreviated ver-
sion of progressive muscle relaxation together with DROIDRA

reassuring self-instructions, such as "Everything will
be all right in a little while," and imagery, such as Differential reinforcement of other responding
"Imagine sitting in the warm sun, eating your favorite (DRO), also known as omission training, is an interval
kind of ice cream cone," to prepare lower so- schedule in which the child is rewarded for withhold-
cioeconomic status preschool children for their first ing a target behavior (like a complaint of pain) for a
dental intervention. In comparison with unprepared given period of time. Differential reinforcement of al-
children, children who had received the relaxation, ternative responding (DRA) is a response-based
instruction, and imagery training had lower heart schedule in which some behavior judged to be incom-
rates, exhibited less distress, and were more cooper- patible with the target response is rewarded. Thus,
ative. Reduction of some of the threat and even some both of these schedules attempt to decrease maladap-
of the negative sensations associated with the novo- tive responding through the use of reinforcement (Ho-
caine injection, drilling, and restorative filling may mer & Peterson, 1980).
have resulted from this preparation. It seems especially Sank and Biglan (1974) reported on the successful
noteworthy that these techniques were effective after treatment of C. J., a lO-year-old boy who had a 2.5-
only one short teaching session with preschool chil- year history of recurring abdominal pain. Although the
dren, in the absence of their parents. child had experienced three separate diagnostic work-
Similar techniques have been used with children ups, no organic reason for his pain was found. C. J.
who have problems with chronic pain. Varni (1981) had missed over 60% of school days in the last year.
described a procedure in which deep muscle relaxation His" attacks" of severe pain were also disruptive to his
was combined with images of warmth, such as sun- mother, because she was obliged to stay at home with
shine and warm colors. Children with severe arthritic him.
pain because of hemophilia were taught to utilize these C. J. was treated with a DRO schedule administered
techniques to decrease pain and to increase mobility. by his mother. This schedule utilized a point system in
The intervention was successful on both counts, yet which points could be exchanged for money (a nickel a
did not interfere with the child's ability to respond point) or for favorite meals, toys, books, and family
adaptively to acute bleeding pain. outings. Verbal praise and attention accompanied the
It was essential to this program's success that the awarding of points. Points were earned initially simply
child discriminate which type of pain should cue the for the absence of severe attacks, with one point for
relaxation/imagery treatment. Hemophilia, as most each half-day. Then, he was rewarded for having pain
readers know, causes sudden and abrupt bleeding epi- ratings under 5.5 (on a 1 = no pain to 10 = the most
sodes. The bleeding can occur internally as well as severe pain ever experienced scale) and, later, to rat-
externally and is extremely dangerous. For some chil- ings under 3.5. He also received a point for every half-
dren, immediate treatment through the use of factor day he attended school but could not attend unless he
replacement infusion (described earlier in this chapter) was below the pain criteria. This type of escalating
will end the bleeding episode. However, not all readers schedule, in which the response requirement or the
will be aware that over time bleeding into the joints length of time the response must be withheld is gradu-
results in changes within the joints, with crippling ar- ally increased, is likely to be the most successful meth-
thritis-like pain and immobility. This pain is chronic; it od of decreasing a chronic maladaptive response.
does not signal the need for intervention. Thus, the Also, concomitant reinforcers for pain behavior, such
ability of this relaxation and imagery program to differ- as television or storybooks, were removed during
entially influence acute bleeding pain and chronic ar- treatment, which probably also strengthened the
thritic pain is very important. schedule's effectiveness. After an extensive period of
Relaxation and imagery procedures appear to be the zero rates of pain behavior, C. J.'s school attendance
treatment of choice for many types of child disorders, and "well" behavior (no pain complaints) were
particularly where there is evidence of organically switched to a variable reinforcement period of 1- to 3-
based pain. In some other cases, especially where the and later 3- to 6-day periods. He remained pain free at
physical basis for the pain has been disputed, some l20-day follow-up.
investigators have attempted a more straightforward, Chronic recurrent abdominal pain is a very difficult
operant approach to the child's problem. to treat problem, especially so when it is realized that
many cases which do not produce organic signs on first seizure, the girl began to have a variety of somatic
initial diagnosis later are found to have an organic complaints, and initially the parents attended to them.
basis. Thus, careful selection and monitoring of oper- Then, as the parents withdrew attention for the com-
ant programs to reduce pain reporting is advisable. In plaints, the child had a series of severe temper tan-
C. l's case, and in the case to follow, all possible trums to which the parents initially attended. Finally,
medical work-ups had been conducted, and the child's the child reportedly had a seizure. Treatment required
health was monitored by a physician during the the parents to ignore temper tantrums, somatic com-
intervention. plaints, and all seizure behavior and to reward differen-
Ramsden, Friedman, and Williamson (1983) de- tially such alternative behaviors as cooperative play
scribed a case of a 6-year-old girl who had a history of and helping mother. The child was, of course, under
severe headaches for 3 years. The child had been seen continual medical supervision. The rate of all three
by a series of experts, including a pediatrician, an ENT target behaviors (complaints, tantrums, and seizures)
(ear, nose, and throat) specialist, a sinus expert, and a fell to zero over a 2-week period.
chiropractor. A food and behavior diary had revealed This case was unusual in that the author conducted a
no relationship between antecedent events and the reversal, requesting the parents once again to attend to
headache, but considerable attention from the child's maladaptive complaining and tantruming. Within 24
mother and her teacher was reliably a consequence for hours of the reinstatement of parental attention, the
reports of pain. child experienced another seizure. When the DRA
The first intervention was entirely school based. In procedure was again put into effect, the child experi-
the school, the absence of reports of headache pain was enced no further seizures.
rewarded by the child's selecting one preferred activity Such interventions have been effective with
at the end of that day or for the following day on the organically based epileptic seizures as well. For exam-
DRO schedule. The child was also allowed to partici- ple, Balaschak (1976) reported on the classroom-
pate in Monday recess, but only if a predetermined based treatment of Joan, an ll-year-old girl who had
(and escalating) criterion of headache-free days had been diagnosed at 18 months as having epilepsy (join-
been reached the week before. ing one of her parents and two of her siblings in this
Six weeks after the school program began, the home diagnosis). Prior to treatment, Joan experienced sei-
program was begun. A DRO schedule was employed zures on 60% of school days. Joan's teacher was then
with a favorite mother-daughter activity contingent asked to institute a DRO program, rewarding the ab-
upon no headache reports used as a reward. A weekend sence of seizures for three time periods during the day
special activity bonus for 5 (later increased to 7) head- (morning, lunch, and afternoon) with a checkmark.
ache-free days was also offered. By the end of treat- The therapist intended to use an escalating schedule,
ment and at lO-month follow-up, the rate of headaches beginning with a low criterion for reinforcement of 7
remained at zero. of 15 checks per week and then increasing the demand.
The experience of pain, either abdominal pain or However, the teacher misunderstood and set the crite-
headache pain, seems relatively involuntary and yet, in rion initially at 15 of 15 possible points. When the
some cases, pain reports can be clearly controlled by teacher tried to rectify this, Joan objected. She wished
their consequences. This does not mean that the pain is to keep the criterion a perfect score. During treatment,
not real or that the child is malingering. Rather, it her rate of seizures dropped from 60% to 16.7% of
indicates that pain functions in some cases as an oper- possible school days. Joan became ill with mono-
ant. DRO and DRA schedules can be useful in reduc- nucleosis and missed two months of school. When she
ing other types of responding, such as seizures, as returned to school, the teacher was unwilling to re-
well. For example, in an early report in this area, institute the DRO program. Thus, this case study also
Gardner (1967) described the treatment of a lO-year- presented a reversal design. Joan's seizures again rose
old girl who was experiencing apparently psychogenic to 62% of class periods. Unfortunately, a second re-
(nonorganic) seizures. The parents had, by report, induction was not attempted.
advertently begun a shaping process in which they DRO and DRA procedures have been used for a
would attend to a maladaptive behavior for a time and variety of other behavioral problems initially seen by
then ignore it, until an increase in intensity would physicians, ranging from maladaptive responding,
again draw their attention. Several weeks before her such as pica in which nonfood material is ingested
(e.g., Madden, Russo, & Cataldo, 1980), to fecal in- like. For a time, hair pulling was punished via re-
continence (e.g., Roberts, Ottinger, & Hannemann, sponse-cost, but this seemed to elicit bursts of hair
1977). DROIDRA procedures are a preferred method pulling and was discontinued. Rates remained at un-
of response elimination for many therapists because acceptable levels. Finally, Gray recommended that the
they use positive reinforcement. However, their use mother deliver four hard slaps to the child's hand im-
necessitates a relatively high-rate target behavior and mediately upon observing hair pulling. Rates quickly
the presence of a reinforcer that exerts more control fell to zero and remained there at 4O-week follow-up.
than the ongoing consequences of the target behavior. A self-stimulatory behavior like trichotillomania is
Thus, for some types of behaviors, it is not possible to the type of response likely to require aversive conse-
use DRO/DRA procedures. In such cases, other clas- quences. Friman, Finney, and Christopherson (1984)
sic response reduction techniques, such as time-out or reviewed common treatments of trichotillomania and
punishment, have been successfully used. noted a variety of successful interventions, such as
rubber-band snaps, sit-ups, and the imagination of
stressful events contingent upon the urge to pull or
Punishment and Time-Out
pulling. They reported that the most often validated
Whenever possible, positive rather than aversive procedure is habit reversal, consisting of awareness
techniques are preferred. This is particularly the case training, practice of a motor response incompatible
within pediatric medicine, where medical staff who with the target behavior, a review of all of the inconve-
may need to assist with the program are more suppor- niences caused by the habit, solicitation of social sup-
tive of techniques employing positive consequences port, and self-monitoring. Such programs have been
(Tarnowski, Kelly, & Mendlowitz, 1987). However, found to be very successful in eliminating trichotillo-
there are various child disorders for which positive mania (Friman et at., 1984).
intervention alone may be ineffective. These include The use of aversive consequences, overcorrection,
behaviors that are linked to naturally occurring reinfor- or time-out is even more important when the behavior
cers or behaviors too dangerous or costly to tolerate a to be eliminated is both self-reinforcing and dan-
slower decrease that might occur if positives alone are gerous. Mathews, Friman, Barone, Ross, and
used. . Christopherson (1987) described the use of time-out
Gray (1979) described a typical situation in which with four l-year-old infants' dangerous play behav-
the use of an aversive consequence seemed warranted. iors. In baseline, the children were found to emit po-
The subject was a 5-year-old girl of high average intel- tentially dangerous behavior in 32% to 55% of the 10-
ligence who was a victim of trichotillomania (disfigur- min intervals observed. Parents were taught to alter the
ing, self-stimulatory hair pulling). The child's hair environment to remove hazards wherever possible
pulling had rendered her almost totally bald since the ("child proofing"). They then learned to consequate
onset of the disorder at about age 1 year. She had dangerous behavior by saying "no" firmly directly
received a large number of parental treatments in following the unsafe behavior and by placing the infant
the past, including ignoring, distraction, scolding, alone in the playpen until he or she was quiet for 5-10
threats, response prevention (by taking her hand sec. This treatment resulted in rates of dangerous be-
down), and inconsistent physical punishment. In addi- havior near zero after treatment and at 7-month follow-
tion, the child's therapist had attempted a point sys- up. This result is most impressive, given the age of the
tem, response-cost, mild sedation, paradoxical inten- subjects.
tion (encouraging the hair pulling), the use of a mitten Snyder (1987) described a different use of time-out
to "punish the hand that pulled the hair" (p. 126), hair for a case in which an adolescent was endangering
cutting/ shaving contingent on hair pulling, and a hairy himself through poor diabetic self-care. This 14-year-
doll and a hairy blanket to be used as substitutes. old boy was involved in a variety of types of delinquent
Gray's treatment began with a visually salient DRO behavior, including stealing, cutting school, and drug
token system-colored marbles were placed in a trans- and alcohol use. His poor adherence to self-care reg-
parent glass jar for every hour the child did not pull her imens involving regular meals, glucose testing of
hair, and the full jar was exchanged for toys, candy, urine, and self-injection of insulin had begun 2 years
and parent-child activities. This treatment resulted in before. From age 6 to 12, his diabetes had been in
a slight decrease in hair pulling. Naturalistic rewards fairly good control. However, a highly problematic
were added, such as barrettes, ribbons, combs, and the relationship with his mother, father absence, and
school problems appeared to be leading to poor ad- differing parent-child dyads tend to select different
herence since the onset of adolescence. techniques as being optimally effective.
A token system exchanging money for appropriate In our first investigation (Peterson & Shigetomi,
blood glucose levels was intermittently successful, 1981), for example, we worked with parents and elec-
with periods of poor care interspersed. Snyder utilized tive surgery pediatric patients. Our treatment utilized
a lag correlational analysis of self-care, maternal con- information, modeling, and a "package" of three be-
flict, and antisocial behavior, and suggested that the havioral coping techniques-cognitive distraction, re-
three were functionally related. In the beginning of a laxation, and self-instruction. Although it might be of
cycle, the boy would engage in good self-care, feel some conceptual interest to know how coping tech-
well, and engage in antisocial behavior. The mother niques would contribute in the absence of relevant in-
would increase her nagging and threats, at which point formation, it seems difficult to imagine actual preven-
the boy would decrease his good self-care in a move to tive presurgical preparation in which patients would be
counter maternal control. This reaction, however, taught how to cope without being told what the
would result in his feeling ill and a subsequent reduc- stressors they would be coping with would be. Thus,
tion in antisocial behavior, which would, in tum, nega- procedural information and coping techniques seem
tively reinforce his mother's aversive responding. logically joined.
Snyder broke the cycle by recommending that The coping techniques we employed rely on differ-
whenever the boy had a hyperglycemic episode (the ing kinds of skills. Progressive muscle relaxation is
end result of poor self-care), he be admitted to a private primarily a motor response, whereas imagery is a cog-
hospital room for 36 hours with no visitors, TV, books, nitive-visual response, and self-instruction a cog-
and so forth. This treatment resulted in improved self- nitive-verbal response. Few families reported using all
care with fewer fluctuations. three coping techniques (11 %). When asked their pre-
Because positive techniques are preferred over more ferred technique, 41 % indicated relaxation, 41 % indi-
negative interventions, many studies that have ulti- cated imagery, and 22% indicated self-instruction
mately relied on aversive consequences have begun by (these sum to more than 100%, because some parents
using positive strategies. For some particularly chal- listed more than one preferred technique). Because
lenging behaviors, the use of multiple strategies ap- parents and their child used different procedures, mul-
plied simultaneously may be more effective than any ticomponent programs like this one may offer flexibil-
single strategy alone. In the next section, interventions ity not available in single-component interventions.
that rely on a treatment "package" of several different Finally, multicomponent programs may offer more
strategies are considered. power, in that different treatments may have an ad-
ditive effect. For example, we found that children who
had viewed a modeling film and who had received
Combined Treatments
coping training were less behaviorally distressed and
One of the problems with interventions that employ were more cooperative in high-stress situations, such
multiple techniques simultaneously rather than se- as getting a blood test or an injection, than were chil-
quentially is the difficulty in identifying the "active dren who received either coping or the modeling film
ingredient" or the precise technique responsible for alone (Peterson & Shigetomi, 1981).
saltatory effects. For responses that have been viewed The need for a very powerful program is nowhere
as treatment challenges, however, there is increasing more evident than in the treatment of burned children.
tolerance for multicomponent interventions, which, if Such children not only suffer intense pain and dis-
successful, can be followed by dismantling procedures figurement, but also isolation because of concern
in which the individual components are assessed. about infection. Because most pain killers will also
In many multicomponent programs, it seems likely reduce fluid intake and compromise respiratory func-
that the sum will be greater than its parts and that for tioning, these children cannot depend on medication
some programs, no single ingredient will be responsi- for the relief of pain. Elliott and Olson (1983) de-
ble for the entire intervention's success. In our own scribed an innovative program that was used to assist
work with presurgical preparation, for example, we burned children in dealing with painful medical treat-
have found that some techniques make more sense to ments. They broke the medical intervention into three
patients when used in combination and that when fami- phases. During Phase 1, bandages were unwrapped
lies are offered a variety of different behavioral skills, and removed. During Phase 2, 15 min of hydrotherapy
removed dead skin and old medicine. During the final proved, pain-free behavior. Sanders et al. noted that
phase, physical therapy took place and the burned pain was often accompanied by very dependent behav-
areas were rewrapped. ior, and that there was concern that decreasing pain
Psychological preparation involved training in a va- behaviors might also increase children's oppositional
riety of techniques, such as attention distraction (e.g., behavior. Home observations revealed no such in-
searching visually for hidden objects in the room), re- crease, however.
laxation breathing, emotive imagery (e.g., imagining Decreasing distressed behavior and reports of pain
the child is saving his friends following a boating acci- are challenging aspects of pediatric care, but there are
dent), and reinforcement contingent on the use of the other types of disorders that present multiple goals as
stress management behaviors. Reinforcers included well. For example, this chapter has already discussed
toys, ,use of electronic games, model cars, and the like. the numerous goals for successful treatment of child
This multimodal treatment resulted in substantial de- diabetics. Epstein et al. (1981) described a program
creases in distress behavior for three of the four chil- that utilized several modules to improve regimen ad-
dren who were treated. The fourth child's parents re- herence in diabetic children. The first module involved
fused to use back-up reinforcers contingently, and thus teaching the parents to use token systems and praise
this child probably did not experience the same treat- and then teaching both parents and child how to do
ment package as the other children. accurate urine-glucose testing. The second session in-
Measurements taken when the therapist was there to structed parents how to adjust insulin dosage depend-
coach the child and when no therapist was present ing on the urine-glucose and acetone values. Further
revealed that another important ingredient was the need to adjust dosage depending on illness or stress
therapist's presence. The intervention was successful was described.
only when the therapist was present. Thus, it appeared The third module involved teaching children the
that several of the components interacted to produce traffic-light diet: "Red" foods indicate stop! Avoid
maximally effective treatment. these foods because they are high in sugar, salt, and
Multicomponent treatment programs also seem in- fat; "yellow" foods can be eaten with care; and
dicated when there are multiple goals for treatment. "green" foods can be eaten with no restrictions. The
Sanders et al. (1989) described a multicomponent fourth module focused on exercise as an important
treatment for chronic abdominal pain. It has been esti- counterpart to eating, and on the importance of match-
mated that over 10% of children, ages 5-12 years, ing extra exercise with a snack to avoid hypoglycemia.
report such pain and a sizeable minority of these chil- The fifth module taught self-injection, the sixth mod-
dren experience sufficient discomfort that it interferes ule focused on methods of dealing with stress, includ-
with such daily activities as school. Although there are ing adjusting insulin dosage, and the final module
a number of organic causes ranging from peptic ulcer dealt with identification of insulin reaction (hypo-
and spinal cord tumor to lactose intolerance and con- glycemia) and how to treat it.
stipation, organic etiologies are identified immediate- Children viewed appropriate models and received
ly in only about 10% of the cases investigated (Barr & developmentally appropriate instruction. They were
fieuerstein, 1983). There have been few reports in the rewarded on a point system for demonstrating good
literature of successful treatment of this disorder (one metabolic control and good self-monitoring. Therapist
case, the treatment of "e. 1." with a DRO procedure, praise and weekly telephone contact with parents and
was described earlier). children were also used.
Sanders et al. attempted simultaneously to assist the The program increased the proportion of urine tests
child in coping with the pain and to reward the absence showing no glucose from a mean of 27% at pretreat-
of pain behaviors and competing activities. First, par- ment to 39% at posttreatment and 45% at follow-up.
ents were taught to ignore pain behaviors and to reward The authors concluded that though further increases in
days with no pain behavior using a token system. At negative urine tests would be desirable, the program
the same time, the child was taught cue-controlled had successfully increased the number of desirable
relaxation and self-reinforcement. Imagery in which urine results. Children receiving this training were bet-
the child's favorite cartoon character ate away the pain ter equipped to engage in diabetic self-care.
was also employed. This treatment method resulted in All of the interventions described in this chapter,
seven of the eight treated children remaining pain free whether package programs or individual techniques,
at follow-up and corresponding teacher reports of im- must be judged by the same yardstick-that of cost-
CHAPl'ER 36 • MEDICAL DISORDERS 801
effectiveness. The benefit o.f any interventio.n o.r set o.f co.mpatible. Do.ing well in scho.o.l may place extra
interventio.ns must be weighed against the Co.st o.f im- stress o.n the child asthma victim, fo.r example. Suc-
plementing the interventio.n. For so.me multico.mpo.- cessful co.ping with accepting o.ne's cancer diagno.sis
nent pro.grams, eliminating techniques that do. no.t co.n- may result in diminished mo.tivatio.n to. engage in che-
tribute substantially to. the o.verall program's success mo.therapy. Improved peer relatio.ns may make reg-
will be necessary. In o.ther cases, co.mbining individual imen adherence mo.re difficult fo.r the ~o.lescent dia-
techniques used in the past may result in little in- betic. In this chapter, we have presented o.ne technique
creased Co.st but large improvements in impact. Thus, fo.r o.ne aspect o.f a diso.rder at a time in o.rder to. illus-
the ideal co.mbinatio.n o.f techniques fo.r any given pedi- trate the applicatio.n o.f such pro.cedures. Ho.wever, the
atric problem remains a to.pic fo.r future research. practitio.ner needs to. co.nsider the ill child in the co.n-
text o.f his o.r her family, scho.o.l, and peer system, and
to. balance the many differing go.als o.f the child. Being
very familiar with the needs o.f a given child will be
Issues for the Future impo.rtant here. On a larger scale, being aware o.f dif-
fering develo.pmental demands fo.r children o.f different
Establishing Goals
ages can also. be very valuable.
One o.f the mo.st impo.rtant issues fo.r the future has
bo.th co.nceptual and metho.do.lo.gical implicatio.ns. Es-
Developmental Concerns
tablishing clear-cut go.als fo.r interventio.n influences
bo.th theo.ry and research in pediatric psycho.lo.gy. We began this chapter with the statement that the
Often, pediatric psycho.lo.gists have no.t adequately de- stresses acco.mpanying medical illness and medical
fined what the go.al o.f therapeutic interventio.n sho.uld procedures are po.tentially mo.re challenging fo.r chil-
be. Fo.r example, within the field o.f preparatio.n fo.r dren than fo.r adults, because children must alSo. meet
medical procedures, researchers have typically mea- the co.nco.mitant challenges o.f develo.pment. It seems
sured several physio.lo.gical, o.bservatio.nal, and self- fitting that we co.nclude this chapter by co.nsidering the
reported indices o.f anxiety and pain. Interventio.ns are unique demands o.f childho.o.d.
targeted to. decrease distress, but the specific mo.dality One o.f the mo.st o.bvio.us differences in treating the
is o.ften no.t specified. If these three measures tended to. child patient is that the child is rarely self-referred and
be highly co.rrelated, this wo.uld no.t be a problem but, thus mo.st o.ften the psycho.lo.gist is wo.rking with an
co.unterintuitively, it is o.ften the case that diminished individual who. is less than mo.tivated. It is o.ften neces-
anxiety as measured within o.ne medium is no.t seen in sary to. wo.rk through a third perso.n, and so. the pedi-
o.ther measures. With many measures taken o.ver many atric psycho.lo.gist o.ften attempts to. alter the parent's,
occasio.ns, it is easy to. enco.unter change by chance the teacher's, o.r the nurse's behavio.r which, in turn,
alo.ne and to. mistake this change fo.r therapeutic effec- will alter the child's behavio.r. The match o.fthe adult's
tiveness. We have described this problem in more de- withdrawing support as the child gains in competence
tail elsewhere (Peterso.n, 1984a). Perhaps it will suf- is difficult to. achieve smo.o.thly even in a healthy child.
fice to. say that it is easier to. target and evaluate change Within a medical setting, the pediatric psycho.lo.gist
if a specific measure o.f change is identified a priori. may need to. ensure that parental support is no.t pre-
So.metimes, pediatric psycho.lo.gists must use a maturely withdrawn o.r may need to. assist the parent to.
proxy measure fo.r the actual behavio.r of interest. allo.w the child to. take o.ver so.me respo.nsibility fo.r
Urine-gluco.se levels as an index o.f adherence to. in- self-care. In an illness where a mistake can be life
sulin, exercise, and eating regimens were co.nsidered threatening, this is o.ften a very difficult task.
in the previo.us sectio.n. The difficulty is that illness, The child's ability to. fo.rm discriminatio.ns and to.
stress, and o.ther metabo.lic facto.rs also. influence these recall co.mplicated chains o.f necessary behavio.rs is
levels and they, in turn, influence different diabetic stro.ngly influenced by his o.r her develo.pmentallevel.
children in differing degrees. For clinical use, reco.gni- The use o.f fading and o.verrehearsal can be very help-
tio.n o.f the inaccuracy o.f proxy measures and a search ful here, but it also. seems important to. be aware o.f the
fo.r even better measures may be valuable in so.me limitatio.ns o.f yo.unger children to. accurately perceive,
cases. interpret, and remember earlier events.
Finally, it may o.ften be the case that multiple go.als Children seem particularly susceptible to. disto.rtio.ns
exist and that the go.als may no.t always be mutually in medical info.rmatio.n at different ages. Co.nsider, fo.r
example, the child who assumed that "eye surgery" treating ill and injured children. It remains for future
meant the removal of the eyes or the child who thought research and practice to fully recognize the value of
she was going to die, because she heard the physician these interventions.
discussing her diagnosis of diabetes ("die of betes").
Sensitivity to such distortions is necessary to effective
interventions with children. References
Perhaps most important is an awareness of the nor-
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from burns to resume her studies. Her developing brief, effective method of teaching children to swallow pills.
Behavior Therapy, 15, 381-387.
sense of self will also need intervention if her bums are Carney, R. M., Schechter, K., & Davis, T. (1983). Improving
disfiguring. The preadolescent "guy" (not a boy any- adherence to blood glucose testing in insulin-dependent dia-
more but not a man) whose hair is falling out from betic children. Behavior Therapy. 14. 247-254.
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needed had he experienced the same medical condition gy,29, 1-8.
and treatment several years earlier. There are a myriad Elliott, C. H., & Olson, R. A. (1983). The management of
children's distress in response to painful medical treatment for
of such developmental considerations in this chapter. bum injuries. Behaviour Research and Therapy. 21, 675-683.
The literature we have overviewed in this chapter Epstein, L. H., Beck, S., Figueroa, J., Farkas, G., Kazdin, A.
describes an exciting basis for the application ofbehav- E., Daneman, D., & Becker, D. (1981). The effects oftarget-
ioral techniques to children who are ill or injured. As ing improvements in urine glucose on metabolic control in
children with insulin dependent diabetes. Journal of Applied
noted, simple techniques, such as positive reinforce- Behavior Analysis, 14, 365-375.
ment, can teach a skill like medication swallowing, Feldman, G. (1976). The effect of biofeedback training on respi-
can increase compliance, and can assist the child to ratory resistance of asthmatic children. Psychosomatic Medi-
cine, 38, 27-34.
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Modeling can teach complex skills to prevent injury Behavioral treatment of trichotillomania: An evaluative re-
(such as escaping a fire) or to treat a disorder (such as view. Behavior Therapy. 15, 249-265.
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E. R. (1985). Improving pediatric appomtment keeping with
and increase cooperation. Relaxation procedures can reminders and reduced response requirement. Journal of Ap-
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31, 209-212.
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very helpful with dangerous responding, such as fail- Silverstein, J. H., & Rosenbloom, A. (1982). The effects of a
ing to take necessary insulin, or with responding that peer-modeling film on children learning to self-inject insulin.
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mania. All ofthese endeavors, however, require a clear treatment of childhood trichotillomania. Journal of Behavior
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Homer, A. L., & Peterson, L. (1980). Differential reinforcement
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The studies reviewed in this chapter provide demon- cedure. Behavior Therapy, 11.449-471.
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4,49-54. & Tracy, K. C. (1984). Comparison of three modeling pro-
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Madden, N. A., Russo, D. C., & Cataldo, M. F. (1980). Behav- ment of childhood headache reports with contingency man-
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CHAPTER 37
Anorexia N ervosa and

Bulimia Nervosa
David M. Garner and Lionel W. Rosen
Introduction Definition of Terms

The essential features of BN are: (1) recurrent epi-
The apparent increasing incidence of anorexia nervosa
sodes of binge eating, (2) a feeling of lack of control
(AN) and of bulimia nervosa (BN) has resulted in a
over eating behavior during the eating binges, (3) self-
sur~e of interest in effective treatment methods among
induced vomiting, use of laxatives or diuretics, strict
a wIde range of health professionals. The aim of this
dieting or fasting, or vigorous exercise in order to pre-
chapter is to provide a practical overview of treatment
vent weight gain, and (4) persistent overconcern with
principles that have been identified as useful in the
body weight and shape (Diagnostic and Statistical
management of these eating disorders. Emphasis will
Manual ofMental Disorders-DSM-III-R, American
be given to cognitive-behavioral (CB) methods that
Psychiatric Association [APA] , 1987). In order to
may be justified for BN by the growing body of em-
qualify for the DSM-III-R diagnosis, binge eating epi-
piricalliterature indicating that these methods are ef-
sodes must have occurred at least twice a week for at
fective for many patients (Fairburn, Kirk, O'Connor,
least 3 months.
& Cooper, 1986; Freeman, Barry, Dunkeld-Turnbull,
The requirements for a diagnosis of AN are: (1)
& Henderson, 1988; Giles, R. R. Young, & D. E.
refusal to maintain a normal body weight, (2) intense
Young, 1985; Hsu & Holder, 1986; Kirkley,
fear of gaining weight or becoming fat, even though
Schneider, Agras, & Bachman, 1985; Lee & Rush,
underweight, (3) a distorted body image, and (4)
1986; Leitenberg, Rosen, Gross, Nudelman, & Vera,
amenorrhea in females (DSM-III-R, APA, 1987).
(1989); Ordman & Kirschenbaum, 1985; Schneider &
There are at least two conclusions that may be drawn
Agras, 1985; Wilson, Rossiter, Kleifeld, & Lindholm,
from these definitions. First, they may be somewhat
1986; cf. Gamer, 1987; Gamer, Fairburn & Davis
narrow for clinical purposes in that treatment may be
1987). The rationale for the application of CB inter~
warranted for individuals presenting with only some of
ventions to AN is based almost entirely on clinical
the required features. Second, except for presenting
experience since comparative treatment trials have not
weight, few differences in clinical features or psycho-
been reported.
metric profile have been identified between bulimic
AN and BN patients (Gamer, Garfinkel, & O'Shaugh-
Davi~ M. G~n~r and Lionel W. Rosen • Department of
Psychiatry, Michigan State University, East Lansing Michigan nessy, 1985).
48824. ' Because disordered eating may occur in other psy-
805
chological and medical conditions, it is necessary for interview, with its obvious opportunities for probing,
the clinician to be aware of possible differential diag- functional analyses, and determination of the complex
noses (Garfinkel, Gamer, Kaplan, Rodin, & Kennedy, meaning behind symptom expression, should be the
1983). For example, severely depressed patients may primary source of diagnostic and clinical information.
lose their appetite and experience significant weight
loss. Schizophrenic patients may develop delusions
The Interview
regarding the act of eating as well as toward certain
foods. Some patients display eating symptoms, such The goals of the initial assessment interview are to
as vomiting, that have a specific meaning and function obtain accurate information regarding (1) the symptom
analogous to a conversion disorder. Individuals who picture, including weight, weight history, eating pat-
have had chemotherapy, radiation treatment, or phys- terns, weight-losing methods, and attitudes toward
ical illness may continue to display nausea, vomiting, weight and shape; (2) present as well as premorbid
food avoidance, and weight loss even after treatment psychological, social, and familial functioning; (3)
has ended or the illness has resolved. In all of these physical complications; and (4) motivation for change.
instances, the patient lacks particular concerns about Table 1 provides a checklist for specific areas of inqui-
weight and shape, which are characteristic of typical ry. Care should be taken to explore the range of psy-
eating disorders. Applying the treatment strategies chological and interpersonal themes that have been
recommended for AN and BN to these individuals will identified as relevant to eating disorders (cf. Garfinkel
delay the application of the appropriate treatment or & Gamer, 1982; Johnson & Connors, 1987). It is
even worsen the primary condition. important to differentiate potential predisposing or
precipitating factors from those that currently maintain
the eating disorder. For example, families of patients
Causal Factors
with eating disorders often have been described as en-
Earlier psychological theories attributing eating dis- meshed, overprotective, and hypersensitive to phys-
orders to exclusive developmental, familial, cultural, ical illness; however, there is little information avail-
or personality factors have tended to be replaced by able on the changes that could be expected in a normal
multidimensional models that emphasize that the char- family once one of its members develops a life-threat-
acteristic symptom picture may evolve from a different ening illness. Similarly, depression has been given
blend of predisposing factors for different individuals etiological significance by recent theorists and un-
(Andersen, 1984; Garfinkel & Gamer, 1982; Gamer & doubtedly plays an important role in the development
Garfinkel, 1980; Lucas, 1981; Strober & Yager, of some cases. Nevertheless, compelling evidence in-
1985). One of the most important advances in recent dicates that, in many instances, mood disturbances and
years has been the improved understanding of the pro- associated vegetative signs are secondary to the eating
found psychological, interpersonal, and physical con- disorder (Strober & Katz, 1988). This may be ex-
sequences of starvation and how these have been er- tended to other areas, since recent studies have indi-
roneously described as part of the primary cated that BN patients' reports of psychological dis-
psychopathology. With this in mind, the various treat- tress, social maladjustment, and symptoms reflective
ment options may be specifically derived from a care- of personality disturbances improve remarkably with
ful evaluation for each patient of antecedent factors, as amelioration of the chaotic eating patterns (Gamer,
well as those variables that serve to maintain the eating 1987).
disorder. Assessment of specific symptoms of the eating dis-
order may be accomplished in a standardized manner
with the Eating Disorder Examination (EDE) (Cooper
Assessment Framework & Fairburn, 1987). The EDE is a carefully validated,
structured interview that allows the systematic gather-
The clinical features and background information ing of data for both clinical and research purposes.
that dictate the approach to treatment for eating disor-
ders are best derived from the clinical interview and a
Psychometric Instruments
complementary psychometric assessment. Self-report
instruments have the advantages of economy, actuarial The psychometric evaluation of the eating disorder
scoring, and standardized administration, which may patient may be divided into two broad areas. First is the
make them useful in many situations. However, the appraisal of attitudes toward weight and shape, as well
CHAPTER 37 • ANOREXIA NERVOSA AND BULIMIA NERVOSA 807
Table 1. Clinical Interview Checklist as symptoms that are core features of the eating disor-
der. Second is the assessment of psychological symp-
I. Demographic features and treatment history
toms, personality features, and social functioning that
2. Body weight and weight history are often associated with eating disorders and that may
(a) Current weight and height illuminate the different themes that must be addressed
(b) Weight range at current height during the course of treatment. Various instruments
(i) Highest and lowest weight have been introduced to measure eating disorder symp-
(ii) Highest stable weight prior to disorder onset toms, and two that have been used widely in clinical
(iii) Chronology of weight changes year by year
and research settings are the Eating Attitudes Test
3. Weight controlling behavior (frequency, intensity, dura-
(EAT) (Garner & Garfinkel, 1979; Garner, Olmsted,
tion) Bohr, & Garfinkel, 1982) and the Eating Disorder In-
(a) Dieting, fasting ventory (ED!) (Garner & Olmsted, 1984; Garner,
(b) Vomiting Olmsted, & Polivy, 1983). The EAT has a number of
(c) Spitting food advantages as a screening instrument in nonclinical
(d) Exercise samples, as well as a measure of disturbed attitudes
(e) Substance abuse to control weight
toward eating and weight in clinical groups. The ab-
-Laxatives -Amphetamines
-Diuretics -Cocaine breviated version (EAT-26) is brief (26 items), yields
-Emetics -Alcohol three factor scores (Dieting, Bulimia, and Oral Con-
trol) that may be related to clinical and nonclinical
4. Binge eating and eating behavior norms (Garner, Olmsted, Bohr, & Garfinkel, 1982),
(a) Frequency of binge eating over past 3 months (note and has been employed in a considerable number of
fluctuatons and longest period of abstinence) studies over the last decade. The ED! was designed to
(b) "Binge foods" (foods eaten and those which trigger
go beyond the specific eating symptoms measured by
episodes)
(c) Typical times and settings for binge eating the EAT and tap various psychological dimensions that
(d) Mood before, during, and after episodes have been identified in anorexia and in bulimia ner-
(e) Experience of loss of control? vosa. It has subscales that assess attitudes regarding
(f) Description of eating eating and shape (Drive for Thinness, Bulimia, and
-Intake when adhering to restrictive dieting Body Dissatifaction), as well as those that tap general
-Intake when violating restrictive pattern
organizing constructs conforming more closely to
-Estimated caloric intake when adhering to restric-
"underlying assumptions" (Beck, 1976) or "deep
tive pattern
-Specific dietary "rules" structures" (Hollon & Bemis, 1981) (i.e., Ineffec-
tiveness, Perfection, Interpersonal Distrust, In-
5. Attitudes toward weight and shape teroceptive Awareness, and Maturity Fears). It should
(a) Level of disparagement (whole body and specific re- be remembered that it is inappropriate to use these and
gions) other self-report measures to arrive at clinical diag-
(b) Misperceptions of shape noses. Nevertheless, in nonclinical populations, they
(c) Hypothetical question: "If gaining 5 pounds would
may provide an economical initial step in a two-stage
eliminate all symptoms, could you tolerate the gain?"
What effect would the gain have on mood and self- screening process in which individuals with elevated
esteem? scores participate in a clinical interview that is de-
(d) Frequency of weighings, weight preoccupations, in- signed to arrive at a diagnostic formulation. Although
trusive thoughts about weight, response to weighing self-report instruments have been criticized as being
(e) Perception of others' attitudes about patient's weight vulnerable to under-reporting of symptoms (Van-
dereycken & Vanderlinden, 1983), it would seem that
6. Physical symptoms (see Mitchell, Hatsukami, Goff, Pyle,
a low score by an identified patient would tell the clini-
Eckert, & Davis, 1985, for details)
cian something quite valuable about the patients's psy-
7. Psychological and interpersonal chological state and motivation for treatment at the
Cover all standard assessment areas with particular em- time of testing.
phasis on depression, substance abuse, impulse control, The second area of psychometric assessment for the
sexual abuse, vocational capacity, and quality of interper- eating disordered patient is aimed at general psycho-
sonal and family relationships. Specific psychological social functioning and is recommended for a complete
themes that have been identified in eating disorders
evaluation. The range of options should include mea-
should be explored to detennine their relevance.
sures of mood, psychological distress, self-esteem,
personality, and social functioning. As mentioned ear- several issues deserving mention before specific inter-
lier, it is important to recognize that starvation, severe vention strategies are described. First, because there
dieting, and the chaotic eating patterns characteristic are major theoretical differences among the CB treat-
of most patients with eating disorders may influence ments reported in the literature, one must become
test scores even with the use of instruments which are aware of the relevant points of debate before applying
purported to measure relatively stable traits. the techniques (Gamer et aI., 1987). Second, given the
range of physical and psychosocial features associated
with eating disorders, it is necessary to be able to select
General Treatment Principles from a range of available treatment options depending
upon the individual patient's needs. Decisions about
There are two general principles that should be cen- optimal treatments or treatment sequences are dictated
tral to any treatment approach to AN and to BN; they by considerations, such as the age of the patient, cur-
will only be briefly mentioned here because they have rent living arrangements, duration of the disorder, cur-
been elaborated in depth elsewhere (Fairburn, 1985; rent symptomatology, previous treatments, premorbid
Gamer, 1986; Gamer & Bemis, 1982, 1985; Gamer & functioning, and medical complications; specific rec-
Isaacs, 1985; Gamer, Garfinkel, & Bemis, 1982; ommendations about the sequencing and integration of
Gamer, Garfinkel, & Irvine, 1986). These principles interventions have been presented in detail elsewhere
include the importance of the therapeutic relationship (Gamer, Garfinkel, & Bemis, 1982; Gamer et al.,
and the two-track approach to treatment. 1986).
The Therapeutic Relationship Cognitive-Behavioral Methods
Although Beck and his colleagues (Beck, 1976; Beck and his colleagues have delineated a number of
Beck & Emery, 1985; Beck, Rush, Shaw, & Emery, specific cognitive-behavioral procedures for the treat-
1979) have emphasized that cognitive-behavioral (CB) ment of depression and other emotional disorders
treatment, as with other approaches, presupposes a (Beck, 1976; Beck et aI., 1979; Beck & Emery, 1985).
trusting, warm, and empathic relationship with the For an elaboration of the rationale for selecting CB
therapist, this essential ingredient is sometimes over- methods with eating disorders as well as the adaptation
looked in discussions of the technical aspects of cog- of standard procedures for AN and BN, we refer the
nitive therapy. Rather than representing a "non- reader to earlier publications (Fairburn, 1981, 1985;
specific" element in the treatment of eating disorders, Gamer, 1986; Gamer & Bemis, 1982, 1985). Our aim
a strong therapeutic relationship should be regarded as here is to provide a synopsis of what we consider to be
integral to change. the critical components of CB interventions followed
by specific examples of common beliefs that can be-
come the focus of cognitive restructuring. CB treat-
Two-Track Approach to Treatment ment for eating disorder patients may be somewhat
arbitrarily divided into three areas: (1) normalizing
Throughout all stages of treatment we recommend a
eating and weight, (2) cognitive restructuring related
"two-track" approach, in which the first track pertains
to target symptoms, and (3) cognitive restructuring
to issues related to weight, bingeing, vomiting, stren-
related to basic psychopathological themes that either
uous dieting, and other behaviors aimed at weight con-
directly or indirectly relate to the development or
trol. The second track addresses th~ psychological
maintenance of the eating disorder.
context of the disorder, including beliefs and thematic
Previous descriptions of CB techniques have gener-
underlying assumptions that are relevant to the devel-
ally focused on beliefs and assumptions related to
opment or maintenance of the disorder.
weight and shape. However, the CB approach is also
ideally suited for addressing developmental and in-
teractional themes that have been described best by
Intervention Strategies psychodynamic and family theorists. Themes repre-
sented by such concepts as transference, fears of psy-
Selection of Treatment Approaches chobiological maturity (Crisp, 1970), the struggle for
Although there are various sources of support for the autonomy and control (Bruch, 1973; Casper, 1982;
use of the CB model with eating disorders, there are Strober & Yager, 1985), overprotectiveness, enmesh-
ment (Minuchin, Rosman, & Baker, 1978), fears of ploying other treatment modalities in which the best
engulfment versus abandonment (Masterson, 1977; outcome results have been achieved (cf. Garner, 1987;
Sours, 1980), separation-individuation (Masterson, Garner et al., 1987). Although most researchers would
1977), self-guilt (Goodsitt, 1985), and false-self adap- agree that self-monitoring is important, the actual de-
tation (Johnson & Connors, 1987; Swift & Stem, tails of self-monitoring procedures vary somewhat
1982) all involve distorted meaning on the part of the across programs. In some studies, the emphasis is on
individual or the family. Although dynamic writers monitoring affective and interpersonal antecedents of
have provided invaluable clinical descriptions that are episodes of bingeing and vomiting. Although this ap-
congruent with the experiences of many patients, in proach may be valuable in some circumstances, it has
our view, some of the formulations involve exclusive been our clinical impression and that of others that the
and occasionally esoteric explanatory systems that most useful targets for self-monitoring are the quantity
force all cases into the same developmental or interac- and quality of food intake (Fairburn, 1985; Garner,
tional framework. The language, style, and practice of 1986; Giles et al., 1985; Mitchell et al., 1985; Leiten-
psychotherapy from a dynamic orientation may differ berg et al., 1989; Wilson et al., 1986). In this in-
sharply from the CB approach; however, common stance, the aim of self-monitoring is the detailed exam-
ground exists in their mutual concern for erroneous, ination of specific attitudes about weight, shape, and
distorted, or outdated patterns of meaning. It is pos- eating that appear to underlie the core symptoms of
sible to maintain complete fidelity to the CB model, those patients with eating disorders. The patient
while drawing from certain useful dynamic formula- should be encouraged to record all food and liquid
tions, by giving priority to the distorted or anachronis- ingested as soon after consumption as is possible. Epi-
tic meaning systems inherent to these phenomena and sodes ofbingeing, vomiting, laxative abuse, and other
not imposing the theoretical requirement that they be weight-losing behaviors as well as feelings and
linked to predetermined developmental stages or expe- thoughts surrounding eating should be included. Sup-
riences (Guidano & Liotti, 1983). When themes paral- plying the patient with written instructions for self-
leling specific developmental theories apply to a par- monitoring and with sample self-monitoring forms are
ticular patient, it has been our experience that CB useful for many patients (Fairburn, 1985). The self-
techniques may offer many specific strategies for help- monitoring forms should then be reviewed in depth
ing the patients develop realistic or appropriate in- during each meeting with the aim of identifying and
terpretations over time. then altering harmful views about eating and shape.
Most BN patients are willing to adopt self-monitoring
procedures when they are provided with the explana-
Normalizing Eating and Weight
tion that the relatively simple task of recording behav-
There are numerous methods that have been advo- ior may, itself, help to reduce symptom levels, and that
cated for helping the patient normalize eating and it will provide the basis for understanding the factors
weight. Some are specifically designed to interrupt the that maintain their eating disorder.
bingeing and purging cycle in the subset of patients For patients who are very reluctant to alter their
with this behavior; others are aimed at facilitating eating behavior because they do not find their eating
weight gain in emaciated patients. Still others are gen- symptoms particularly distressing (i.e., many restrict-
erally applicable to patients with both of these symp- ing anorexic patients and some bulimic patients), de-
tom patterns. Several of the most useful methods will tailed meal planning with the gradual introduction of
be briefly outlined; however, the reader is encouraged avoided foods may be accomplished without written
to consult other primary source material for fundamen- records. In these instances, a more gradual approach
tals (Fairburn, 1985; Garner & Bemis, 1982, 1985; can be effective if the details of eating behavior are
Mitchell et al., 1985; Rosen & Leitenberg, 1985; reviewed in sessions with a focus on explicit meal
Wooley & Kearney-Cooke, 1986). planning, introduction of avoided foods, and a review
of adherence to the meal planning. The patient should
know that if this less structured approach fails, then
Self-Monitoring
formal self-monitoring is the next reasonable alterna-
Self-monitoring is both a valuable assessment tool tive.
and an effective intervention. This procedure has been Self-monitoring is a powerful method that illustrates
consistently recommended in CB research studies with the interplay between the "cognitive" and the "behav-
BN and has also been a component in the studies em- ioral" elements of the CB model. Thus, helping pa-
tients to identify and modify dysfunctional beliefs is may gain considerable weight with normalization of
often necessary in order to initiate self-monitoring. eating because their presentation weight is unrealistic
Furthermore, the behavioral task of self-monitoring in light of a premorbid weight that reflects a constitu-
provides the opportunity to uncover distorted beliefs tional predisposition toward obesity (Gamer & Fair-
about foods, eating, and weight. Finally, self-monitor- burn, 1988). There are no absolute rules for determin-
ing provides a focus for practicing more adaptive eating a precise body weight for an individual patient with
ing patterns (e.g., exposure to feared foods and inhibi- either AN or BN. Several principles, however, should
tion of the urge to vomit) that contradict beliefs that be considered: (1) Body weight, which like other phys-
have perpetuated avoidance behavior. For example, a ical attributes, is probably normally distributed in the
patient may leam that consuming a feared food does population (Gamer, Rockert, Olmsted, Johnson &
not precipitate an enormous weight gain. Because self- Coscina, 1985). (2) Genetic pedigree plays an impor-
monitoring increases the likelihood that the patient tant role in determining body weight (Stunkard et al.,
will actively confront feared situations, it invariably 1986) and thus, weight goals must be adjusted to meet
elicits highly emotionally charged beliefs that become the needs of the individual patient. (3) Virtually all
the focus of meaningful cognitive restructuring. eating disorder patients initially prefer a weight that is
unrealistically low (Garner & Fairburn, 1988). (4) It is
unlikely that body weight can be held at levels below
Introduction of Avoided Foods
the biological optimum without producing excessive
There is considerable evidence that weight suppres- cravings for food (Russell, 1979).
sion and the avoidance of desired foods precipitate Because body weight is influenced by constitutional
cognitive or physiological conditions that increase the factors, it is as much of an abuse of aggregate statistics
probability of binge eating (Gamer, Rockert, Olmsted, to infer individual expected weight from weight norms
Johnson, & Coscina, 1985; Polivy & Herman, 1985; as it would be to derive expected height from tables of
Russell, 1979; Wooley & Kearney-Cook, 1986). norms for height. Timing and sensitivity are essential
Therefore, a standard component of CB programs for in relating this information to patients, because pre-
BN involves the gradual introduction of previously maturely recommending a higher weight that is terrify-
avoided foods into the daily food intake. Leitenberg et ing may drive the patient from treatment, whereas
al. (1989) reported significant improvement in pa- avoiding the topic entirely may fail to address a pri-
tients whose treatment involved exposure to forbidden mary treatment issue and may likely lead to a therapeu-
foods during treatment sessions, but also demonstrated tic impasse. Where weight gain is required, it is often
nearly as good results for CB treatment in which pa- helpful to propose initially gaining a small amount of
tients were strongly encouraged to expose themselves weight as part of an "experiment" with recovery. From
to forbidden foods outside of the treatment setting. The the experiment, the patient will be able to gather infor-
same principles of exposure to previously avoided mation to determine the degree to which their experi-
foods as well as the ingestion of more appropriate ences have been clouded by the sequelae of dieting or
quantities of foods have been recommended clinically starvation. Moreover, the patient will be able to test the
in CB treatment Jor AN (Gamer & Bemis, 1982, validity of beliefs regarding the impact of weight gain
1985). In fact, this principle has been one of the foun- with the explicit proviso that the option exists of re-
dations of well-established treatment programs for turning to the former weight if the new weight is found
anorexia nervosa (Crisp, 1970; Russell, 1970). Antici- to be intolerable. Framed in this way, the prospect of
pated or actual exposure provides a wealth of material weight gain becomes more palatable for those patients
for examining beliefs related to eating, shape, and who find the thought of a "permanent commitment" to
weight as well as other more basic underlying assump- a higher weight unacceptable.
tions related to self-esteem and interpersonal function-
ing.
Inpatient Treatment
The topic of inpatient treatment for AN and BN is
Normalizing Body Weight
extraordinarily complex and well beyond the scope of
Although it is evident that most BN patients can this chapter. Nevertheless, it is critical for the clinician
improve or recover with minimal or no weight gain involved in the management of eating disorders to be
(Fairburn et al., 1986), there are some patients who aware that a subgroup of patients may require or bene-
fit from hospitalization. The primary objectives of Eating disorder patients typically fail to interpret
hospitalization are: (1) weight restoration or interrup- their food preoccupations, urges to binge eat, emo-
tion of steady weight loss, (2) interruption of unremit- tional distress, cognitive impairment, and social with-
ting bingeing and vomiting, (3) treatment of medical drawal as secondary to their severe attempts to reduce
complications, (4) management of associated condi- or control their weight. Patients are encouraged to read
tions, such as severe depression or substance abuse, accounts of the effects of weight suppression and diet-
and (5), occasionally, disengagement of patients from ing (Gamer, Rockert, Olmsted, Johnson, & Coscina,
a social system that both contributes to the mainte- 1985); these issues are reinforced at strategic points
nance of the disorder and disrupts outpatient treat- throughout therapy. Table 2 is a summary of the effects
ment. When hospitalization is chosen to treat medical of semi starvation derived from the well-known Keys,
complications, it should be clearly distinguished from Brozek, Henschel, Mickelsen, and Taylor (1950)
inpatient treatment aimed at recovery from the eating study. Providing patients with supportive evidence that
disorder. In the former instance, it should be presented their distressing physical and emotional experiences
as an urgent medical priority that does not necessarily are the result of periodic or chronic caloric restriction
require a strong commitment by the patient to recover. and weight suppression is likely to impact on them in a
On the other hand, if hospitalization is intended to treat
the psychological as well as the physical aspects of the
disorder, every effort should be made to enlist the pa- Table 2. The Effects of Semistarvation
tient's commitment to participate actively in the treat- from the 1950 Minnesota Study
ment process. Preadmission interviews should include
Attitudes and behavior toward food
a clear description of the program, which is aimed at
Food preoccupation
normalization of eating and weight as well as other
Collection of recipes, cookbooks, and menus
details regarding the ward regime. The patient should Unusual eating habits
be given the reassurance that psychotherapy will be Increased consumption of coffee, tea, and spices
provided to assist in dealing with the concerns regard- Gum chewing
ing eating and weight, as well as to address psycholog- Binge eating
ical issues that may be unique. This approach will Emotional and social changes
reduce the likelihood that the patient will make a pre- Depression
mature discharge request from the hospital. Anxiety
If an outpatient fails to normalize eating and weight Irritability, anger
Lability
over time, then hospitalization must be presented as an
"Psychotic" episodes
obligatory next step. This may be misunderstood as a
Personality changes on psychological tests
threat or abandonment but should be interpreted as a Social withdrawal
humane alternative to the tremendous emotional and
Cognitive changes
financial expense of prolonged and unproductive out-
Decreased concentration
patient therapy, which cannot proceed past a certain Poor judgment
point in the presence of the severe limits imposed by Apathy
starvation.
Physical changes
Sleep disturbances
Weakness
G I disturbances
Prominent Themes in Cognitive Hyperacuity to noise and light
Restructuring Edema
Hypothermia
Paresthesia
Reattribution of Symptoms Related to Decreased BMR
Dieting or Starvation Decreased sexual interest
Note. Adapted from "Psychoeducational principles in the treatment of
Assumptions: "I must first resolve underlying conflicts before I
bulimia and anorexia nervosa" by D. M. Garner, W. Rockert, M. P.
can tackle eating symptoms." "I can recover without giving up Olmsted, C. Johnson, & D. V. Coscina in Handbook of Psychotherapy
dieting or weight suppression techniques." "My current mood for Anorexia Nervosa and Bulimia (pp. 513-572), edited by D. M.
and feelings do not have anything to do with my weight or Garner and P. E. Garfinkel, 1985, New York: Guilford Press. Adapted
restrictive eating." by permission.
number of ways. Patients often are reassured by the inadvertently attacking the personal values on which
notion that there is a "common cause" serving to inte- the woman bases self-esteem is a delicate task requir-
grate their experiences. However, they may also being thoughtfulness, respect, and a trusting therapeutic
come distressed by the assertion that the only way in relationship. Examples of these attitudes and possible
which they will be able to be free of many of their intervention strategies will only be briefly outlined
unpleasant symptoms is to normalize eating and per- here because they have been well described (Fairburn,
haps gain weight. Most patients' resistance to this ar- 1985; Garner & Bemis, 1982,1985; Garner, Rockert,
gument may be characterized as the "anorexic wish." Olmsted, Johnson, & Coscina, 1985).
Patients often report feeling "self-righteous," "vir-
tuous," "in control," "safe," and "superior" when
Confronting the "Anorexic Wish" they engage in the myriad of specific activities, such as
weight control, dieting, or exercise. These rituals have
Assumption: "I can recover emotionally without normalizing
eating and weight." been imbued with such strong positive valences that
they elicit an almost involuntary flooding of positive
The notion that recovery is possible without gaining thoughts, feelings, and images. On the other hand,
weight (in the case of AN) or without abandoning diet- extremely negative thoughts and emotions are evoked
ing, vomiting, or other weight suppression techniques by behaviors that are inconsistent with the "supreme
(in the case of both AN and BN) is a major obstacle for goal" of weight control. The potency of the disparag-
eating disorder patients. We often refer to this as the ing thoughts and affiliated emotions is illustrated by a
"anorexic wish" and point out that it is certainly un- pilot experiment in which patients were asked to report
derstandable within the context of their disorder but the background color for words that were classified as
that it reflects the desire for two mutually exclusive "weight-schema" related (e.g., fat, stomach) and
events. It is impossible to identify accurately, let alone "non-weight-schema related." Reading the weight-
resolve, genuine psychological themes if the patient's schema words was so distressing to some patients that
phenomenology has been distorted by the emotional we elected to discontinue the project.
sequelae to starvation, dieting, or chronic electrolyte Constructs, such as competence, control, attrac-
disturbances. Ijpatients make the choice to overcome tiveness, self-worth, and self-discipline, have become
their eating disorder, then they must normalize eating closely associated with dieting and weight control in
and weight. Resistance to this argument must be met our culture. Helping patients develop more sophisti-
with extraordinary reassurance that (1) treatment will cated working definitions of these constructs can be
provide explicit advice on how to accomplish this task, tedious with recurrent vacillation between old and
and that (2) once the eating symptoms are ameliorated, emergent value systems. It is important that patients
if other emotional or interpersonal issues remain, they come to see their own positive attributions to thinness
will be actively addressed in psychotherapy. and dieting, as well as their prejudice against obesity
as a direct product "f distorted and simplistic societal
values. As they come to see themselves as victims of
Attitudes toward Weight, Shape, and Eating this set of cultural stereotypes, which are all too often
unscrupulously directed toward women, they will be
Assumptions: "I must be thin in order to be happy." "Being thin less prone to experience gUilt associated with their own
means being in control." "If! am thin, people will like me. If!
am fat, everyone will hate me." "I can't stand fat on my body." thinking. They will be more open to exploring evi-
"Thin people are more competent, attractive, desirable, fit, con- dence indicating that these values, particularly if they
fident, ... therefore, I must be thin." "My stomach (or other are interpreted literally or in the extreme, are (1) inac-
body parts) is too large." "Others will notice if! gain 5 pounds." curate, (2) arbitrary, (3) inhumane, (4) inconsistent
"I should avoid 'fattening' foods." "I must eat the same foods
every day." "I can't eat in front of others." "Eating diet foods or with other principles that they hold in higher esteem,
dieting makes me feel safe, virtuous, competent, etc." and (5) clearly self-defeating. For example, most pa-
tients will readily endorse the view that if human worth
These themes are extensive and relate not only to is judged at all, then it should be based upon complex
current cultural values associated with thinness but traits, such as benevolence, generosity, strength, per-
also the affiliated idiosyncratic meaning that thinness ceptiveness, kindness, honesty, competence, and the
has for the individual. Challenging the cultural values like. Putting aside for the moment that most patients
related to shape as oppressive toward women without feel woefully inadequate on these dimensions, it is
possible to help them see that their veneration and perfection, and fitness (Gamer, Rockert, Olmsted,
virtual worship of thinness dictates that they view their Johnson, & Coscina, 1985). Again, in challenging the
world and themselves in a superficial manner not un- positive image that these disorders may have acquired,
like deplorable individuals who judge women strictly great care must be exercised to avoid directly confront-
in terms of physical appearance. When such indi- ing patients in a destructive manner. Although patients
viduals are depicted in the therapeutic setting, they are may have organized their identity around the disorder,
viewed by patients as truly contemptible and loath- it is possible for the therapist to indicate that this is not
some. At this point, patients may be asked how their the basis for a judgment of the patient and then to
own pattern of rating self-worth exclusively in terms of reframe the disorder in less glamorous terms. Also, it
their physical appearance is any less dehumanizing is possible to argue that AN is the antithesis of "con-
and abhorrent. This and similar analogies are particu- trol" since it involves confor:ming to rigid behavioral
larly potent because they create powerful dissonance directives that allow few options and little control in
between the meaning that thinness has had for patients life pursuits.
and the contemptible image created by the analogy.
Following the analogy above, patients can be encour- Assumptions: "Having this disorder has resulted in people caring
aged to take particular notice of individuals who view for me." "My eating disorder has given me an identity." "Illness
women in these disparaging terms and recognize the provides justification for nurturance in my family."
parallel between these oppressive views and their own
hallowed view of thinness. Obviously, great care has In a minority of cases, the eating disorder is at least
to be taken to ensure that patients are not depreciated in partially maintained by the assumption (sometimes
any way through this and similar exercises. It presup- based in fact) that it has resulted in increased caring on
poses good timing, a trusting therapeutic relationship, the part of others. Sometimes this relates to the fact
articulation of the therapist's conviction that patients that family members have understandably expressed
have inner worth and that their overvaluation of thin- intense worry, distress, and attentiveness as a result of
ness has been an unfortunate consequence of their lack the serious illness that has aftlicted a member of the
of confidence in their inner strengths, which has been family. In the extreme, this has been interpreted by
reinforced by a culture which has increasingly mea- some theoreticians as overprotectiveness or enmesh-
sured women and men in terms of a thin silhouette ment on the part of the family; however, in the absence
standard. of data indicating the "normal" response to having an
Once tentative agreement can be achieved about the extremely ill member in a family, it is most appropriate
desirability of shifting away from an "outmoded" to interpret the behavior as very reasonable, despite the
view, patients should strongly be encouraged to engage possibility that it unwittingly may have had a role in
in specific behavioral exercises consistent with the new maintaining the disorder. The patient's assumption
position. For example, once patients begin to recog- that the disorder is providing greater nurturance can be
nize that there are major flaws in the inference that met with a detailed exploration of the "pros and cons"
avoiding sweets reflects self-discipline, they should be of maintaining the disorder. It is helpful to precede this
prompted to engage in the strategic task of consuming exercise by the acknowledgement that should the con-
a sweet in a predetermined situation. Rehearsing the clusion be reached that it is truly beneficial to maintain
more adaptive view of this behavior in advance as well the disorder, then the therapist would support the pa-
as carefully monitoring thinking during the event are tient's freedom to do so within the limits of medical
often worthwhile exercises. safety. Not only is this a manifest truth, but also it has
the effect of diminishing the patient's resistance to ex-
ploring the alternative to his or her current view. Sever-
Attitudes toward Anorexia Nervosa and
Bulimia Nervosa al lines of argument can be explored: (1) even if the
patient is receiving greater care for maintaining the
Assumptions: "AN is a sign of self-control and self-discipline." disorder, it is (and will continue to be) terribly self-
"AN is a form of suffering in the interest of a higher good." defeating in that it is emotionally and socially crip-
pling, and (2) the initial intensification of family con-
Unfortunately much of the coverage in the press has cern is usually replaced by resentment, disaffection,
subtly dignified or glamorized AN by associating it and ultimate disengagement. Patients should be en-
with such traits as intelligence, beauty, self-discipline, couraged to review various dimensions of their life and
compare their current functioning with the past and impoverishment. Assumptions about "how they
with potential future fulfillment without the inherent should feel" versus "how they actually feel" are not
limits imposed by their eating disorder. With this type always articulated clearly but gradually emerge as pa-
of direction, patients are often able to recognize that tients reveal their antipathy toward certain feelings.
their interpersonal relationships were much more satis- Initially, this may be manifest as an adamant denial of a
factory in the past. The social restrictions imposed by particular emotional state in the presence of precursors
bizarre eating patterns preclude any type of "normal" that would typically lead to that feeling state. Another
relationship. In the past, at least they had the pos- clue that certain affective states are "unacceptable" is
sibility of vocational success, whereas now their full- when patients consistently interrupt them by episodes
time "occupation" is weight control. They have lim- of bingeing, vomiting, or other events, such as intense
ited personal freedom in the sense that they will be exercise, which produce highly salient sensations.
reliant on parents, hospitals, and therapists for the
foreseeable future. Their current cognitive and emo- Assumptions: "I can't stand these feelings. They are too strong."
"I don't feel anything. 1 just binge."
tional responses are often blunted; while this currently
may be serving a protective function, it sets an incredi-
bly low ceiling on their future performance. Although the "numbing" effect of symptomatic be-
Carefully undermining the positive associations that havior has been described often and has received vari-
patients may have developed toward their eating disor- ous interpretations, we believe that it is valuable to
der, as well as a thoughtful delineation of its disadvan- begin by exploring the meaning behind the aborted
tages, gradually increases motivation for change. This affect by searching for erroneous assumptions related
should be met with specific behavioral exercises that to its expression. Faulty inferences or predictions are
are consistent with recovery. Occasionally, failures in often related to historical material identical to that
these exercises reflect the ambivalence associated with identified by our psychodynamically oriented col-
the previously mentioned" anorexic wish." Within the leagues. However, the CB approach allows explora-
context of trust and support, encouraging patients to tion of the antecedent basis for the distortion and offers
imagine the logical conclusion of their symptomatic practical strategies for change without its having to
behavior and then to recognize that this is inconsistent conform to a particular developmental paradigm that
may not apply to a significant subgroup of patients.
with their wish to recover can result in increased moti-
vation for change.
Attitudes about Interpersonal Situations
Assumptions: "I can't tolerate being dependent or needy." "I

Attitudes about Affective States must be strong." "I never want to get close to people so that 1 can
avoid being rejected."
Assumptions: "I do not know how 1 feel." "I do not experience
pleasure." "I never feel angry." "I am always energetic and
never get tired." "I admire others who don't show their The CB methods for addressing fears of interper-
feelings." sonal closeness and dependence are similar to those
outlined above; the process may be broken down into
Clinicians representing a wide range of theoretical the following elements:
orientations have described deficits in the identifica-
tion or the expression of affect as common in eating 1. Identification of the feared interpersonal situa-
disorders, and thus, specific CB interventions have tion or emotion
been proposed for dealing with this area (Garner & 2. Identification of the distorted attitudes about
Bemis, 1985). The strategies are based on the assump- these experiences
tion that difficulty in accurately reporting affective 3. Gradual correction of these convictions by cog-
states is the ultimate consequence of conflict between nitive methods
these internal experiences and attitudes about these 4. Practice in responding to previously avoided
experiences specifically related to their legitimacy, ac- experiences
ceptability, desirability, or appropriateness. Over 5. Reinforcement of the patient's independent ex-
time, the inconsistency between patients' experience pression of previously avoided interpersonal sit-
of an emotion and their judgments about its propriety uations, emotions, or sensations (Adapted from
lead to vagueness, confusion, and apparent emotional Garner & Bemis, 1985)
The process of identifying and revising patients' assertiveness, and the pursuit of purely pleasurable
negative view of their own affective state, sense of activities. Specific CB strategies to achieve this end
dependence, personal fears, and so forth must be done have been described (Garner & Bemis, 1985). They
gradually with an emphasis on highlighting the legiti- rely on guiding the patients in first identifying and then
macy and then the merit of such feelings. For example, searching for evidence for their implicit assumption
some patients evaluate themselves exclusively in that they are fundamentally flawed. During this pro-
terms of achievements and deny interpersonal depen- cess, the patients are encouraged to operationalize
dence because it is perceived as a glaring deficiency. "self-acceptance" in a manner that is not rigidly tied to
Encouraging patients to develop less rigid concepts of performances, achievements, and acceptance from
dependence and independence may be conducive to others.
their acceptance of both of these qualities in them-
selves. For those who believe that dependence is invar-
iably pejorative, we will recommend reframing it as Conclusion
"interdependence" within the context of Gilligan's
(1982) writings. This chapter has provided a broad overview of a
multidimensional model for understanding eating dis-
Self-Esteem Tied to External Standards orders. Basic assessment techniques and treatment
principles have been outlined with an emphasis on the
Assumptions: "I must be successful in everything I do." "My cognitive-behavioral approach. Specific components
self-worth is directly related to my performance." "I cannot
of treatment are recommended, such as self-monitor-
stand it ifI think that someone disapproves of me." .. My worth is
related to my shape or weight." "lfI can't get an 'A' in a course, ing, introduction of avoided foods, and normalizing
then I will drop out." body weight where appropriate. Assumptions that typ-
ically become the focus of cognitive restructuring are
Although weight-preoccupation may be the social reviewed, and a sampling of strategies for addressing
norm, the eating disorder patient embraces this pro- these was provided. One of the major benefits of CB
clivity in an absolute and implacable manner. As indi- methods is that they are not necessarily incompatible
cated earlier, weight and shape become the exclusive with other models for understanding eating disorders.
or predominant frame of reference for inferring self- In light of the growing body of empirical support for
esteem for the eating disorder patient. This tendency the effectiveness of CB methods in the treatment of
has been described as a reflection of a more general BN, they should be considered the standard against
inclination to evaluate exclusively self-worth in terms which other methods are measured. The conclusions
of external frames of reference (Garner & Bemis, for the value of CB treatment for AN must be tentative
1985). Basing self-evaluations on personal achieve- at present because there have been no controlled trials
ments and evaluations from others is probably com- in which their efficacy has been systematically exam-
mon and certainly is promoted in our culture; however, ined.
many eating disorder patients carry this questionable
formula to an unrealistic or rigid extreme. This is often
ACKNOWLEDGMENTS. We are grateful to Christine
done within the context of a conviction in some pa-
Shafer, M.D., for comments on this chapter and to
tients that they are intrinsically defective, inadequate,
Barbara Rood for preparing the manuscript.
and incompetent. All of the exceptional performances
are desperate attempts to conceal or rise above this
perceived deficit. The cognitive technique of decenter-
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66-69. (pp. 476-502). New York: Basic Books.
CHAPTER 38
Childhood Obesity
Allen C. Israel
The treatment of obesity was one of the earliest arenas tions and limitations that should be acknowledged. For
of behavioral research. Much of this early attention one, it might be argued that overweight is not equiv-
focused on adults. Indeed, the vast majority of re- alent to overfat. The usual example offered is of the
search on childhood obesity has occurred during the individual, perhaps an athlete, with exceptional mus-
present decade. The increased attention given to this cle development. However, the measurement of pro-
problem is reflected by the inclusion, in this volume, portion of body fat is not without its own difficulties.
of a separate chapter on the subject. This is compared Underwater weighing has obvious practical as well as
to a section of a chapter in the previous edition. How- technical difficulties. Skinfold measures are, there-
ever, there still has been comparatively little systemat- fore, the preferred mode of measurement. These mea-
ic research regarding this problem. What research has sures of body fatness, however, are less reliably ob-
been done has been able to benefit from research on tained than is weight for height, and large population
behavioral treatment of other childhood problems, and norms are not available for all measures (Franzini &
from the adult obesity literature. One of the probable Grimes, 1976; LeBow, 1984). Given these limitations
reasons for interest in childhood obesity was a hope for on measuring body fat, one must consider the over-
greater success with early intervention. Both a learn- estimation concern. Will use of relative weight result
ing perspective and potential biological influences in overestimates of obesity in individuals who are real-
were consistent with this belief. In addition, it was ly only very muscular? This seems unlikely to be the
hoped that early intervention might avoid the repeated case in very young children or among clinical popula-
weight losses and gains often associated with adult tions. Furthermore, available data do not suggest that
obesity. such overestimation occurs. Johnston and Mack
(1978) found, among black youths aged 9 to IS, that
estimates of obesity as judged by triceps skinfold
Definition and Measurement thickness and relative weight were 27.5% and 16.4%,
respectively, for boys. The comparable estimates for
Obesity in children is most typically defined as girls were 21.85% and 23.3%. Thus, forbciys, the use
being 20% above the median weight for height, age, of relative weight resulted in judgments of a lesser
and gender. Although, for the most part, this is proba- rather than greater prevalence of obesity, whereas for
bly an adequate definition, there are certain considera- girls the estimates were equivalent. Although it would
probably be best to obtain both measures, relative
Allen C. Israel • Department of Psychology, State Univer- weight would seem to be a reasonable index of obesity
sity of New York at Albany, Albany, New York 12222. in children. The judgment of relative weight. however,
819
is not without its own limitations. Weight tables based television and the prevalence of obesity has been re-
on risk, similar to those for adults, are not available for ported (Dietz & Gortmaker, 1985).
children. Rather, what is available are norms for height Psychologists might also find reason for interest and
and weight by age and gender. Thus, it should be rec- concern outside of the health risks associated with
ognized that selection of ideal weights are not "abso- childhood and later obesity. A National Institutes of
lute" and are limited by the potential for change in Health panel recently concluded that "obesity creates
norms. Whatever measure is employed in treatment an enormous psychological burden. In fact, in terms of
research, it is important that it be a relative measure. suffering, this burden may be the greatest adverse ef-
With children, expected growth dictates against using fect of obesity" (NIH, 1985, p. 4). Indeed, children
absolute measures. enrolling in a weight reduction program have been
shown to exhibit behavior problems at a level greater
than would be the case in a normal population and, in
Prevalence and Significance some instances, at levels similar to children for whom
psychological assistance is sought (Israel & Shapiro,
Childhood obesity is a prevalent and significant 1985). There are also numerous reports of findings
health problem (cf. Aristimuno, Foster, Voors, Sri- indicating that obese children are stigmatized by both
nivasan, & Berenson, 1984). It is a problem whose peers and adults. Even though these findings are meth-
prevalence increases with age during childhood (Garn odologically controversial, the issues addressed clear-
& Clark, 1976; Garn, Clark, & Guire, 1975; Ginsberg- ly deserve continued research and clinical attention
Fellner, 1981; Huse, Branes, Colligan, Nelson, & Pal- (Jarvie, Lahey, Graziano, & Framer, 1983; Woody,
umbo, 1982). There is also an increase with age in the 1986). In addition to potential associated psychologi-
percentage of obese children who will become obese cal difficulties, there are other reasons for ongoing and
adults (Abraham, Collins, & Nordsieck, 1971; Abra- increased attention by clinicians and researchers to the
ham & Nordsieck, 1960; Charney, Goodman, problem of childhood obesity. In coming to understand
McBride, Lyon, & Pratt, 1976; Garn & LaVelle, 1985; the process of change for this difficult and resistant
Stark, Atkins, Wolff, & Douglas, 1981), although the problem, much can be learned regarding the treatment
relationship is clearly not a simple one (Garn, LaVelle, of childhood and family problems, in general. It has
Rosenberg, & Hawthorne, 1986; Rolland-Cachera et been suggested, in particular, that obesity may serve as
al., 1987). Furthermore, current reports suggest that a model for the development of family-based treatment
there have been recent increases in the prevalence of programs for health problems shared by several family
childhood obesity (Gortmaker, Dietz, Sobol, & members (Epstein & Wing, 1987).
Wehler, 1987; Raymond, 1986). Obese children are,
thus, at increased risk for the health problems associ-
ated with adult obesity (Bray, 1985; Garfinkel, 1985; Research Findings
Garrison & Castelli, 1985; Hubert, Feinleib,
McNamara, & Castelli, 1983; Lew, 1985; National Earlier reviews of the behavioral treatment of child-
Institutes of Health Consensus Developmental Panel hood obesity examined its superiority to no treatment
on the Health Implication of Obesity, 1985). For exam- controls and alternative treatments (cf. Brownell &
ple, data from the Bogalusa Heart Study indicate that Stunkard, 1978; Coates & Thoresen, 1978; Israel &
consistent obesity early in life is associated with ad- Stolmaker, 1980). These reviews and more recent re-
verse lipid and lipoprotein levels and blood pressure search that has included such comparisons (e.g., Ep-
(Aristimuno et at., 1984). Also, childhood obesity was stein, Wing, Koeske & Valoski, 1984; Israel, Stol-
indicated as a major risk factor for increasing and maker, Sharp, Silverman, & Simon, 1984; Epstein,
maintaining high blood pressure levels over a four year Wing, Woodall, et at., 1985) in general support the
period in a national probability sample taken in the superiority of the behavioral programs. The present
United States (Lauer, Anderson, Beaglehole, & review will therefore focus on research examining
Bums, 1984). The concern with childhood obesity also various aspects of behavioral interventions and their
interfaces with other societal concerns such as more effectiveness.
general concerns with health and fitness among Amer- Research on the treatment of childhood obesity has
ican children. There is also an interface with concern in many ways paralleled the related adult literature.
over the impact of increased television viewing. A For example, in both instances, the notion that obesity
significant association between time spent watching is due to an imbalance between energy intake and ex-
CHAPTER 38 • CHILDHOOD OBESITY 821
penditure is basic and, therefore, issues of diet and Two studies followed from the above findings.
exercise are central to all treatment programs. The Based on the superiority of the life-style approach,
third aspect of all multifaceted treatment programs Epstein, Wing, Koeske, and Valoski (1984) compared
(e.g., Israel & Solotar, 1988b) is the various cognitive a diet alone condition to a diet plus life-style exercise
and behavioral procedures employed to change condition. The combined effect of diet plus exercise
weight-related life-style. Both adult and child research was not superior to diet alone. At a I-year follow-up,
has, therefore, examined the effects of diet and exer- children in the two groups exhibited equivalent per-
cise recommendations and, most particularly, the issue centage overweights. The authors' interpretation of
of adherence to such changes. The issue of self-control these findings suggests that children in the combined
has also been central in both literatures. In the child- condition may not have complied with the exercise
hood literature, the additional question of the transfer program which was performed at home and, therefore,
of regulation from the parent to the child and of the unsupervised. Epstein, Wing, Koeske, and Valoski
appropriate balance between the two adds a somewhat (1985) again compared the life-style and aerobic exer-
different dimension. The child literature has by the cise approaches and added a control condition that
nature of the problem focused a large part of its atten- provided a timed low-caloric expenditure exercise pro-
tion on issues of parental involvement in the treatment gram. This group was included to examine the non-
process. In the present chapter, greater emphasis is specific effects of exercise when added to other com-
given to that portion of the literature that is different in ponents of a weight-loss program. The three groups
focus from its adult counterpart. were equivalent up to 1 year following the initiation of
treatment, suggesting some impact of the "non-
specific" aspects of exercise programming. However,
Diet, Exercise, and Adherence
by the 2-year point, children in the life-style condition
Issues of diet, exercise, and adherence to program maintained their weight losses, whereas children in the
prescriptions clearly overlap with the adult literature. aerobic and calisthenic conditions did not.
In treating children, the issues, however, become ex- Taken together, these studies suggest that life-style
panded to parent and child adherence. The behavior of exercise programming leads to improvement in
significant others is clearly an issue in the adult liter- weight-loss efforts. The interpretation that this is due
ature, but parental behavior is central to child efforts. to greater adherence to such programming is supported
The child literature also provides additional informa- by a meta-analysis across four studies conducted by
tion regarding diet, exercise, and adherence that will the Epstein group (Epstein, Koeske, & Wing, 1984).
apply to the adult literature as well. Because of the fitness improvement associated with
Epstein and his colleagues have conducted a series aerobic exercise, however, exploring methods for
of studies on the exercise component of childhood achieving greater adherence to such programming may
obesity treatment programs. These studies, in addition prove beneficial. These results may also suggest the
to providing information about this specific compo- value, at least initially, of providing exercise activities
nent, also address issues of adherence. One aspect of that are of low intensity and incorporated into the fami-
this research has been to compare different forms of ly's life-style. Indeed, existing programs often make
exercise. Epstein, Wing, Koeske, Ossip, and Beck use of such mechanisms (e.g., Israel & Solotar,
(1982) compared aerobic and life-style exercise pro- 1988b). For example, families can first be trained in
grams (these were equivalent in their caloric expendi- "taking the long road." This is done in order to counter
ture) combined with diet and no-diet conditions. The a set to always look for the shortest and easiest way.
two exercise conditions produced equivalent weight Emphasis here is not so much on the increase in caloric
reduction during the initial treatment period. How- expenditure achieved by these often minimal changes,
ever, by follow-up, at 17 months after the beginning of but rather on shaping behavior patterns that will alter
treatment, the life-style exercise was superior to the energy expenditure behaviors. The findings of Ep-
aerobic condition. The aerobic exercise was based on a stein, Wing, Koeske, and Valoski (1985) regarding
consistent high-intensity activity that improves car- nonspecifics may be a similar phenomenon.
diovascular fitness. It might be, however, that this Adherence to the caloric intake aspects of treatment
high-intensity pattern also results in lower rates of is, of course, also important. Epstein, Wing, Koeske,
long-term compliance. The life-style exercise, in con- and Valoski (1984) also found that treatment success
trast, allowed for integrating lower intensity activities was significantly correlated with dietary record keep-
into a flexible daily routine. ing and reduced consumption of high-calorie foods.
822 PART V • iNTERVENTION AND BEHAVIOR CHANGE: CIDLDREN AND ADOLESCENTS
Israel and his colleagues have also addressed the centrality of family environment in both the etiology
question of adherence and outcome. Israel, Silverman, and treatment of the disorder (e.g., Dietz, 1983;
and Solotar (1988) measured overall adherence and Khoury, Morrison, Laskarzewski, & Glueck, 1983).
adherence to various categories of assignments (com- An emphasis on the parental role can also be appreci-
pleting food intake records, activity records, and nutri- ated in the context of research concerning the role of
tion summaries, staying below calorie limits, meeting significant others in management of adult obesity
activity goals, and following cue control rules) for (e.g., Brownell, Heckerman, Westlake, Hayes, &
each family in a treatment program. Overall adherence Monti, 1978; Foreyt & Kondo, 1984; Israel & Sac-
and the various subcategories of adherence were relat- cone, 1979) as well as in the context of work on other
ed to success during treatment. However, monitoring childhood problems.
of food intake emerged as the best predictor of treat- The parent is centrally involved in food preparation
ment success. In addition, correlations among ad- and availability, particularly for the young child. Par-
herence scores indicated that adherence to anyone ents are also likely to be central in establishing knowl-
aspect was associated with adherence in all other edge of nutrition as well as attitudes toward and pat-
areas. One possible interpretation of such a finding terns of food consumption (cf. Harper & Sanders,
might lead to the conclusion that a variable that inter- 1975; Klesges et at. , 1983; Klesges, Malott, Boschee,
feres with adherence to one component of a program & Weber, 1986; Laskarzewski et at., 1980; Rozin,
may also interfere with other components as well. For Fallon, & Mandell, 1984). There is also the other half
example, if adherence to high-intensity exercise is of the energy balance equation. Although often given
poor, adherence to reductions in high-calorie snacking less attention, the parents' role in the child's activity
may also suffer. Such an interrelationship among as- level and energy expenditure demands attention as
pects of adherence is also supported by the Epstein, well (e.g., Klesges etat., 1984,1986). Perhaps most
Koeske, and Wing (1984) meta-analysis. Israel et at. importantly, any attempt to work with the obese child
(1987) have also shown that adherence may help iden- will in some way involve the parent in the task of
tify those who are likely to complete treatment. Fami- managing the child's behavior and achieving a devel-
lies were requested to monitor the child's food intake opmentally appropriate level of parental control and
and physical activity for a 2-week period prior to the child self-control. Planned involvement of the parent,
beginning of treatment. Parents and children were in- of course, does not occur in the absence of existing
structed to share this task and not to make any changes patterns. The parent is likely to be already involved in
in their usual behavior during this baseline period. Of various roles: controller of environment, model of be-
the families with 90% to 100% adherence, 87% com- havior (in its broadest sense), and regulator of behavior
pleted treatment. This rapidly dropped off to 57% for (e.g., Birch, Marlin, & Rotter, 1984; Harper & Sand-
those who adhered 74% to 88% with the monitoring ers, 1975; Klesges et at., 1983, 1984, 1986). How
task. Only 40% of families whose adherence scores then is the involvement of the parent in the therapeutic
were below 50% completed treatment, and none of the process best operationalized?
families who did not complete the task at all remained Perhaps the most direct definition of this involve-
in treatment. Thus, anything but the highest levels of ment is parental attendance and/or participation in
adherence would seem to indicate considerable risk. treatment. Indeed, to date, most behavioral programs
Most adherence research has focused on the child's have included parents in treatment. In one of the ear-
weight loss; however, it is important to remember that liest studies of behavioral treatment for childhood
the adherence of parents and perhaps other family obesity, Kingsley and Shapiro (1977) experimentally
members is needed as well. Indeed, a need for atten- defined parental involvement as attendance at ses-
tion to this issue is suggested by available research sions. Their study compared the weight loss of chil-
(e.g., Israel, Solotar, & Zimand, in press). dren who attended sessions with their mother, children
who attended alone and whose mothers received hand-
outs, and children whose mothers attended sessions
Parental Involvement
without them. Although the mother-child group tend-
Involving parents in the treatment of obese children ed to do best during follow-up, there were no signifi-
is supported by both logic and empirical evidence. For cant differences between groups during either treat-
example, epidemiological examinations of the prob- ment or follow-up. Kirschenbaum, Harris, and
lem of childhood obesity are clearly consistent with the Tomarken (1984) also found no differences in success
CHAPTER 38 • CIDLDHOOD OBESITY 823
at weight loss between conditions where the parent participating parent. The advisability, in all cases, of
attended and participated, or participated but did not employing parental weight loss as the mechanism of
attend sessions. However, the later condition did result change is the other consideration. A family behavior
in greater rates of attrition. Brownell and his col- change focus suggests sensitivity to certain questions.
leagues demonstrated that, for adolescents, employing For example, parent-child competition/comparison
separate groups for parents and adolescents was supe- and the need for the child to feel he or she is receiving
rior to groups which included both together and to a special attention may arise from broader clinical con-
condition in which the adolescents were seen but par- siderations. Also, what is the potential impact of pa-
ents were not involved (Brownell, Kelman, & rental failure or relapse in instances where change has
Stunkard, 1983). These findings also alert us to pos- been defined as parallel weight loss? Indeed, these
sible developmental aspects of parental involvement issues may be raised by the families themselves.
(Harris & Ferrari, 1983; Israel etat., 1984). Thus, it may be necessary to consider strategies
It might, given the above findings and the impor- other than parental weight loss as an alternative focus
tance of parental behavior, seem reasonable to assume of parental involvement. A reasonable alternative is to
parental attendance and to consider variations in the define explicitly parental change in the helper role.
participation dimension. For example, Epstein and his This strategy is natural in that asking the parent to
colleagues (Epstein, Wing, Koeske, Andrasik, & Os- serve as a change agent (helper) is inherent in most
sip, 1981) employed variations in contingencies to ad- existing behavioral interventions. The issue is then one
dress parental participation. Interventions were ap- of emphasis and the explicitness of this focus.
plied to both parent and child weight loss, child weight Israel and his colleagues undertook a comparison of
loss alone, or to a nonspecific target. Again, though no these two mechanisms for insuring parental involve-
overall group differences emerged, a significant cor- ment and targeting behavior change (Israel et at.,
relation between parent and child weight loss during 1984). In a multifaceted behavioral treatment program
treatment was reported. Of particular interest was the for overweight children between 8 and 12 years of age,
finding that long-term follow-up indicated a distinct the weight-loss role stipulated that parents had to en-
superiority for the parenti child condition compared to gage in their own weight-loss effort. Explicit parental
the other two groups (Epstein, Wing, Koeske, & Val- weight-reduction assignments and behavior change
oski, 1987). The average percentage overweight for targets paralleled those of the child and were clearly
children in this condition was below baseline levels, explicated as the focus of the parents' behavior change
whereas the average of children in each of the other efforts. In contrast, though the program was structured
two conditions had returned to or exceeded baseline to have all participating parents assist the child in her or
levels. his weight-loss efforts, parents in the helper role had
Available research, therefore, would appear to sup- this task more clearly explicated. That is, their assign-
port the value of targeting both child and parent behav- ments, monitoring, and behavior change targets
ior change. Indeed, the impelling logic of such a strat- focused on these helping behaviors. Thus, both sets of
egy would suggest that where investigators have failed parents were, necessarily, involved in their child's
to find significant differences, this can be attributed to weight-loss efforts. For one group, however, greater
the particular definition of parental intervention em- emphasis was given to this helper role, and this was the
ployed. This then suggests the exploration of alter- focus of their behavior change.
native strategies for targeting parental change. Children in the helper and weight-loss conditions
One aspect of the parental involvement concept is achieved comparable weight reductions during treat-
the question of how parents are to be involved; that is, ment, whereas waiting list controls had experienced a
how would their role in the treatment process be imple- weight gain. Similarly, at I-year follow-up, the two
mented? How would their behavior be targeted for parental involvement conditions did not differ signifi-
change? Expecting parents to engage in their own cantly. The levels of weight loss in this program, like
weight-loss effort is the mechanism by which many most others, did point to the need for improved treat-
programs involve parents. This is clearly a logical im- ment and maintenance strategies. In the present con-
plementation and a potentially successful one (e.g., text, however, it would appear that both parental in-
Epstein et at., 1981). There are, however, two possible volvement roles are equally efficacious. In a
limitations to this approach. The more obvious is that subsequent investigation, the helper and weight-loss
this limits involvement to families with an overweight roles were compared over a 6-month treatment period
that allowed parents to be supervised in their role for a these skills. Aragona, Cassady, and Drabman (1975)
longer period of time (Israel, Solotar, & Zimand, in compared two conditions for consequating changes. A
press). Again, the two parental involvement conditions response cost plus reinforcement condition was com-
produced equivalent changes in child percent over- pared to response cost alone. Parents in the first group
weight during both the treatment and follow-up were also provided with some training in general child
periods. management skills. Analysis employing a weight re-
One qualification of the above conclusion, how- duction index (Edwards, 1978) suggested better main-
ever, may also be suggested by the earlier findings tenance in the combined condition. Although small
(Israel etal., 1984). For older children (10-12 years of • sample size and other considerations suggest caution
age) the helper role may have been more successful in drawing conclusions, these results and the logic of
during treatment, while during the follow-up period, behavioral interventions are consistent with the view
no differences between roles were suggested for this that explicit attention to child management skills is
age group. Younger children (8-10 years of age), how- likely to facilitate sustained weight loss by the child.
ever, may have benefited more with the weight-loss This issue was addressed directly in a study by Israel
role during both periods. Statistical comparisons of et al. (1985). Overweight children, 8 to 12 years of
these data were prohibited by the small sample sizes. age, and their parents were assigned to one of two
Even though these findings suggest considerable cau- treatment conditions or a waiting list control. Partici-
tion in drawing conclusions, they are consistent with pants in the Weight Reduction Only (WRO) condition
being sensitive to developmental issues in implement- received a multifaceted behavioral treatment program.
ing parental involvement, or indeed any intervention. In addition to receiving instructions in all areas, the
One additional finding related to parental role is program required parents to define problem behaviors
worth noting. A number of investigators have reported and to monitor and consequent behaviors. Parents
greater correlations between child and parent weight were instructed and guided in these procedures. Thus,
change during periods of reduced contact or follow-up training in child management skills was inherent and
than is the case during treatment itself (e.g., Epstein, addressed in this condition. Parents in the Parent
Wing, Koeske, & Valoski, 1985; Israel, Stolmaker, & Training (PT) condition, however, received this "stan-
Andrian, 1985). Particularly intriguing is one finding dard" program, but also had training in child manage-
that when parents attended sessions, this pattern oc- ment skills enhanced and emphasized. Prior to the start
curred, as in the above research, as a positive correla- of the weight reduction program, PT parents read a
tion. However, when the parents did not attend, the child management text and attended two sessions in
relationship between parent and child success was an which they were instructed in behavioral child man-
inverse one (Kirschenbaum et al .• 1984). It is clear that agement skills. Concepts presented during these ses-
the question of parent and child change over extended sions were systematically referred to and applied dur-
periods is a complex one. The complexity of long-term ing the ensuing child weight-reduction program. Other
considerations must be given serious attention in eval- than the text, the two-session course, and continued
uating parental involvement. At present, however, lit- review of child management principles, the two
tle knowledge of the relationship between parental and groups received identical treatment.
child change during extended periods of reduced treat- Both treatments were superior to the control condi-
ment contact is currently available and, thus, should be tion and resulted in equivalent absolute weight loss and
a priority. That the relationship is not a simple one is comparable numbers of children meeting prescribed
suggested not only by the above results, but also by the weekly weight-loss goals during the treatment period.
difficulty, to date, in achieving consistent long-term However, WRO children achieved a greater reduction
success. in percentage overweight than did the PT children. By
the I-year follow-up, however, children in the PT con-
dition evidenced a nonsignificant mean decrease in
Parenting Skills
percentage overweight, whereas WRO children exhib-
The ability to apply the parenting skills necessary ited a significant mean increase. Thus, though the
for implementing child behavior change is another groups were probably comparable during treatment,
important aspect of the parental involvement issue. there is the suggestion of better maintenance with a
The results of an early behavioral childhood obesity relatively small increment in child management skills
treatment study suggest the importance of addressing training. This conclusion is reinforced by analysis of
CHAPTER 38 • CIDLDHOOD OBESITY 825
the parents' child management knowledge. PI parents tion to relationships with treatment outcome, the ques-
had achieved greater knowledge of these principles by tions of who seeks treatment and who prematurely
the end of treatment. There was not, however, a signif- terminates treatment were explored. The impact of
icant correlation between these scores and change in well-developed interventions is greatly reduced if a
the child's weight status during treatment. At the 1- large number of families do not seek treatment or if
year follow-up, PI parents maintained their higher they drop out of treatment prematurely.
scores, and higher scores at this point were related to The investigated sample consisted of 91 families
greater success in the child's weight-loss effort. Clear- with a designated obese child between the ages of 8 to
ly, these results directly address only the parent's 13. In examining the issues of who presents for treat-
knowledge of these principles. Actual measurement of ment and the child's initial weight status, a number of
parenting skills would be desirable. However, the ob- interesting findings emerged. Although the data do not
tained relationship to long-term outcome and the con- necessarily tell us which family factors "cause" child-
dition differences are consistent with a conclusion that hood obesity, they do give us a better picture of the
this knowledge is being translated into action by families who seek services. The attending parent's
parents. weight status was a significant predictor of the child's
Another parenting skill that is inherent in most be- initial weight status among both intact families and
havioral treatment programs for obese children and, single-parent families. Socioeconomic status (SES)
indeed, is inherent in most training in child manage- among intact families and sibling weight status among
ment skills is problem solving. In a manner similar to single-parent families also emerged as significant pre-
the Israel et at. (1985) evaluation of child management dictors of initial weight status.
training, Graves, Meyers, and Clark (1988) investigat- Children of overweight attending parents were
ed the addition of explicit parental problem-solving found to be heavier than those of nonoverweight at-
training to a multifaceted behavioral program. Both tending parents. This might be thought to reflect noth-
treatment conditions for children 6 to 12 years old and ing more than the well-known adage that obesity "runs
their parents were similar for the first 40 min of each of in families." Several factors mitigate against this ex-
the eight sessions. Although parents in the behavioral planation, however. Neither the weight status of the
condition exchanged recipe and exercise ideas, parents nonattending parent nor the number of overweight par-
in the problem-solving condition received 20-min ses- ents was related to the child's initial degree of over-
sions of problem-solving training. Both of the treat- weight. Also the relationship is with degree and not
ment conditions resulted in significant decreases in prevalence of childhood obesity. A possible explana-
children's percentage overweight, whereas an instruction for these findings addresses the issue of when, in
tion only control condition did not. Decreases were the weight-gain process, parents seek assistance for
greater in the problem-solving group than for children their child. Parents of normal weight status may be
in the other two conditions, and these condition dif- quicker than overweight parents in seeking profes-
ferences were maintained through a 6-month follow- sional help when they notice their child gaining exces-
up. Parents in the problem-solving condition exhibited sive weight. That is, they may seek treatment earlier,
significant increases in problem-solving ability, before the problem becomes severe.
whereas parents in the other two conditions did not. In Information regarding the siblings of the children
addition, greater decreases in children's weight were presenting for treatment is consistent with this in-
associated with improved parental problem solving. terpretation. Approximately 16% of the children pre-
Although it is not clear if the behavioral condition in senting for treatment were only children, and 16% had
this study included the problem-solving orientation one or more overweight siblings; 68% had siblings but
characteristic of other programs, these results suggest were the only overweight child in the family. In con-
the value of an explicit emphasis on parental problem- trast, childhood obesity prevalence data suggest the
solving training. greater likelihood of families with overweight siblings
and only child families (cf. Dietz, 1983). Being one of
several overweight children may decrease the like-
Family Variables and Treatment Outcome
lihood of the problem's being seen as one requiring
Israel, Silverman, and Solotar (1986) examined a action. Also, parents who have other children who are
number of attributes of families who were seeking be- not overweight may be more likely to view obesity as a
havioral treatment for their overweight child. In addi- problem and seek professional help for the targeted
child. It may also be the case that a single overweight of the family variables studied were clear predictors of
child among nonoverweight siblings causes greater within-treatment change. However, there were several
difficulties for the family system. It would also appear interesting trends in the findings that are-with appro-
that this pattern among obese children for whom treat- priate caution-worth mentioning. Children from in-
ment is sought is a "sibling influence" and not a func- tact families (but not single-parent families) tended to
tion of parental weight status (and thus "overweight be more successful if their attending parent was over-
families"). Both overweight and nonoverweight at- weight. Also, intact families with nonsatisfactory mar-
tending parents had equivalent distributions of only riages seemed to be disproportionately represented
children, only overweight children, and children with among extremely successful children. A tentative ex-
one or more overweight siblings. planation that incorporates these findings might view
Consistent with reports of associations of SES and the parent as the child's advocate. An overweight at-
the prevalence of obesity (e.g., Gam & Clark, 1976), tending parent may serve as a more cooperative and
children of lower SES families were more overweight sympathetic ally. This may be especially true in an
prior to treatment than children of middle and higher environment where the other parent may be less com-
SES families. However, once again, it is possible that mitted to weight loss or, indeed, may provide influ-
this fmding with degree of overweight indicates some- ences that run counter to therapeutic goals. The need to
thing more. Unlike middle and higher SES families, balance such influences may be reduced or absent in
lower SES families may seek assistance only when single-parent families and may be less relevant to the
their child's weight problem becomes severe. Finally, attending parent from an intact but unsatisfactory mar-
there was no difference in the child's initial percentage riage. On the other hand, large family size might miti-
overweight between intact and single-parent homes. gate against a parent serving as an active ally and/or
Also, marital satisfaction among intact families did not advocate for the child.
appear to be related to the child's degree of initial There was also a tendency for weight loss to be
overweight. smaller for children who had siblings but who were the
The impact of these family variables on treatment only overweight child. Perhaps the child contrasts the
dropout was also assessed. Families of lower SES and changes that are expected with the relative lack of de-
of single-parent status had the highest dropout rates. mands placed upon his or her siblings. Also, there may
The already strained resources of these families proba- be real environmental differences. High-calorie snacks
bly accounts for their greater rate of attrition; a finding made accessible to nonoverweight siblings may be a
and conceptualization not dissimilar to those noted in potential obstacle to the obese child. These and related
other problem areas (e.g., Dumas & Wahler, 1983). issues arc likely to contribute to a more difficult change
Relatedly, in the area of childhood obesity treatment process for the child who has siblings of normal weight
itself, there is some evidence that children whose fami- status.
ly environments are characterized as chaotic are more Beyond the family patterns mentioned above, it is
likely to drop out of treatment (Kirschenbaum et al., likely that other aspects of family functioning influ-
1984). Such a conceptualization might suggest making ence outcome. A consistent attitude among family
programmatic alterations and providing special as- members regarding the child's weight and change is
sistance to these families, particularly during the initial one potential agenda. This attitude, a sense of family
phase of treatment. This view is also consistent with cohesiveness, an organization for problem solving,
data on the importance for treatment completion of and communication skills all seem, according to
high levels of early adherence (Israel et al., 1987). clinical reports, to be characteristic of many successful
Identification of the variables that make some families families. A related issue is the ability of the parents to
"invulnerable" to influences causing dropout will also adopt a consistent, rather than short-term, parenting
inform our understanding of the treatment process in style. Both these impressions find some limited em-
general. pirical support in the Kirschenbaum et al. (1984) find-
In an investigation of the influence of family vari- ing of short-term increases in factors, such as cohe-
ables on child weight loss during treatment, Epstein, sion, mutual support, and expression of feeling among
Koeske, Wing, and Valoski (1986) found that treat- families undergoing behavioral treatment for child-
ment success was related to family size and gender. hood obesity. High levels of these qualities were also
The single child and those who had fewer siblings were related to short-term success.
more successful. In the Israel et al. (1986) study, none The findings described above apply to within-treat-
ment change and different sets of variables may be One needs also to address the transfer of control to the
related to longer term change. For example, the above child at a rate that is appropriate and does not merely
findings suggest that parental weight status is unrelat- represent abandonment of parental responsibility.
ed to within-treatment outcome (Epstein, Koeske, Thus, questions of the appropriate distribution of con-
Wing, & Valoski, 1986; Israel et al., 1986). Epstein trol and changes in responsibility over time are of great
and his colleagues have also reported no such dif- importance.
ferences at 3 years following the initiation of treatment Less research attention has been given to these is-
(Epstein, Wing, Koeske, & Valoski, 1986). However, sues than to parental involvement questions. However,
their results do suggest a more rapid weight gain dur- self-regulation skills, such as self-monitoring, self-re-
ing follow-up for children of obese parents. Israel and ward, resisting temptations, and dealing with high-risk
Solotar (l988a) also found that long-term outcome, situations, are incorporated into most intervention pro-
assessed at 1 year following the end of treatment, was grams, and their contribution and relation to parental
related to sibling weight status, SES, marital status, behavior deserves attention. A retrospective study by
and the weight status of the nonattending parent. For Cohen, Gelfand, Dodd, Jensen, and Turner (1980)
example, those children who were most successful suggested the importance of these issues. Assessed at
were more likely to have a nonattending parent who some period of time following treatment completion,
was not overweight and to have fewer than two over- those children who had maintained their weight loss
weight parents. These findings suggest that family in- reported more self-regulation behaviors related to
fluences may increase as formal programming is with- weight management. In contrast, parental regulation
drawn. Thus, they are suggestive of the important of weight management characterized those children
influence these variables may exert on long-term who had regained weight. These results suggested that
change. This finding would also suggest the need for parents who regulate behaviors with little attention to
explicit programming in response to these indi- child self-regulation do not facilitate maintenance of
vidualized family influences. child weight-loss. Many of the participants in the Co-
hen et al. study may have been in early adolescence.
Attention to age of subjects in future research seems
Self-Regulation and Parental Control
likely to yield interesting and useful information.
From the beginning, the history of behavioral inter- Epstein and his colleagues (Epstein, Wing, Valoski,
ventions with obese adults had the issue of self-control & Gooding, 1987) examined behavior regulation ex-
at its core. Thus, self-control was part of interventions perimentally. In one condition, parents were trained in
designed for childhood obesity as well. In the child the control of contingencies and in the other, children
literature, the issue of self-control has an additional learned these skills. In both conditions, the therapist
facet. As indicated above, control by others is inti- initially determined when eating and exercise goals
mately related to the child's weight-related behaviors. were met by the children in order to reinforce them.
The balance between self-regulation and control by Parents then took over this task. In the child self-con-
others is, therefore, particularly salient. The balance trol condition, the task was then faded to the child.
between parental and child control and the appropriate However, in both conditions, parents remained in con-
timing and transfer of control are issues of research and trol of back-up reinforcers. No significant differences
clinical importance. This is, also, another area that in weight loss between the two conditions were found
highlights the importance of adopting a developmental over a 5-year period. The authors view these findings
perspective to the treatment of obese children. as suggesting that children can be trained to manage
As indicated above, it is essential to assure parental the contingencies involved in a weight-loss program.
involvement and control of the child's behavior if one There have also been more recent findings that indi-
is to conduct a successful weight-reduction program. cate that children who were most successful at losing
Similarly, the nature of behavioral approaches and the weight reported using a variety of self-regulatory tech-
fact that the child is often in situations in which the niques more f!'equently (Flanery & Kirschenbaum,
parent is not present require attention to self-regulatory 1986). An investigation of the contribution of explicit
behavior on the child's part. The task faced by the and enhanced training in multiple child self-regulation
clinician is then one of ensuring parental involvement skills has also been conducted (Israel, Andrian, Zi-
and control while, at the same time, being sensitive to mand, Baker, & Silverman, 1988). During treatment,
the need to develop self-regulation skills in the child. and to a I-year point following the end of treatment,
equivalent changes in weight status were achieved by haps intervention, whose goal is either to produce
children in both the enhanced and' basic conditions. modest reductions or to prevent further increases in
However, between this I-year point and a 3-year fol- degree, and whose other focus is on limiting the poten-
low-up, the children in the basic condition exhibited tial negative consequences of being overweight, also
increases in their percentage overweight to approx- deserves our attention.
imately baseline levels. In contrast, children who had Making decisions regarding which issues or route to
received enhanced self-regulation training did not ex- pursue is clearly a complex and difficult task with po-
hibit an increase in percentage overweight and re- tential rewards and dangers for each alternative. The
mained below baseline levels. In addition, assessment orientation to the problem of childhood obesity, and
of child self-control and parental control at the end of the general approach being taken by behaviorally ori-
treatment indicated that both higher child control and ented researchers and clinicians, however, seems well
lower parental control scores were predictive of great- suited for a wide variety of choices.
er long-term success. Furthermore, parental monitor-
ing of children's behavior during the later part of treat-
ment indicated that children who used skills to resist
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Israel, A. c., Silverman, W. K., & Solotar, L. C. (1988). The Laskarzewski, P., Morrison, 1. A., Khoury, P., Kelly, K., Glat-
relationship between adherence and weight loss in a behav- felter, L., Larsen, R., & Glueck, C. 1. (1980). Parent-child
ioral treatment program for overweight children. Behavior nutrient intake interrelationships in school children ages 6 to
Therapy, 19, 25-33. 19: The Princeton school district study. American Journal of
Israel, A. C., Solotar, L. C., & Zimand, E. (in press). An inves- Clinical Nutrition, 33, 2350-2355.
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1. (1983). Parent-offspring and sibling body mass index asso- cine, 103, 1024-1029.
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Kirschenbaum, D. S., Harris, E. S., & Tomarken, A. J. (1984). conspire to increase incidence of obesity. Journal of the Amer-
Effects of parental involvement in behavioral weight loss ther- ican Medical Association, 256, 2157-2158.
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CHAPTER 39
Physically Disabled Persons

Vincent B. Van Hasselt, Robert T. Ammerman, and
Lori A. Sisson
The past decade has witnessed an upsurge of clinical disabled is the proliferation of research in the area of
and investigative interest in the behavioral assessment social skills and interpersonal effectiveness. The im-
and treatment of physically disabled children and portance of an adequate repertoire of social behaviors
youth (see Hersen & Van Hasselt, in press; Van in childhood and the relationship between early inter-
Hasselt, Strain, & Hersen, 1988; Varni & Wallander, personal competence and adult adjustment are well
1988; Wallander & Hubert, 1987). The increased ac- documented (see reviews by Christoff & Myatt, 1987;
tivity in this area is partly associated with the burgeon- Combs & Slaby, 1977; Van Hasselt, Hersen, White-
ing physically disabled population. Indeed, Bowe hill, & Bellack, 1979). Moreover, the deleterious im-
(1980) estimated that 36 million persons in the United pact of disability on social development and interper-
States have some form of disability. This is consistent sonal interaction has been consistently demonstrated
with a 1976 census survey that revealed a figure of (e.g., Lindemann, 1981; Matson, DiLorenzo, & An-
13.6% (United States Bureau of the Census, 1976). drasik, 1983; Van Hasselt, 1983). As Richardson
Moreover, it appears that as many as 10% of children (1976) aptly stated, "no further research is needed to
under age 21 are disabled (Gliedman & Roth, 1980). show that it is socially disadvantageous to be phys-
Of particular concern is the greater number of multi- ically handicapped in ... social encounters" (p. 32).
handicapped individuals (e.g., deaf-blind, cerebral The acceleration of behavioral efforts with the phys-
palsied-deaf, blind-mentally retarded). The rapid ically disabled also is tied to legal and legislative ini-
growth of this group is largely a function of improved tiatives that have called for the expansion of services
prenatal care; decreased infant mortality because of and research efforts with this population. For example,
advances in medical and surgical procedures, and the Education of All Handicapped Children Act of
strides made in research and treatment of several infant 1975 made available free and appropriate public edu-
diseases (Mulliken, 1983). cation to all disabled children in the least restrictive
Another impetus for the heightened activity with the setting possible. This has led to a shift of placement for
thousands of disabled children from more restrictive
(institutions, residential schools) to less restrictive
Vincent B. Van Hasselt • Department of Psychiatry and (public schools, special education classrooms, group
Human Behavior, University of California at Irvine, and Fair- homes) learning and living environments. To some
view Developmental Center, Costa Mesa, California 92626.
extent, this has forced educators, mental health profes-
Robert T. Ammerman and Lori A. Sisson • Western
Pennsylvania School for Blind Children, Pittsburgh, Pennsylva- sionals, and other service providers to face a number of
nia 15213. new challenges. Today, aberrant behaviors (e.g., self-
831
injury, aggression) and skill deficits (e.g., mobility, Hearing impairment is usually classified into hard
adaptive living) must be dealt with in more "main- of hearing (those in whom the sense of hearing, al-
streamed" settings. Consequently, behavior manage- though defective, is functional with or without a hear-
ment strategies that have shown potential in remedia- ing aid) and deaf(those in whom the sense of hearing is
tion of such difficulties are in greater demand than ever nonfunctional for ordinary purposes of life). As with
before. vision, the disorder also is defined in terms of degree
In a further attempt to normalize the living condi- and function, age of onset, degree ofloss, and quantity
tions of severely disabled youth, there has been a con- and quality of early experiences. A 1974 survey by
certed effort by legislators, state and federal agencies, Adler and Williams revealed that the number of
and advocacy groups to provide training and services school-aged children with hearing impairments totaled
that will facilitate vocational opportunities. Earlier, the approximately 90,000; two thirds of this population
Rehabilitation Act of 1973 prohibited discrimination were in elementary school.
against handicapped persons in federally funded pro- Children with orthopedic impairments include those
grams. In recent years, the U. S. Department of Edu- "whose nonsensory physical limitations or health
cation has increased funding of research and training problems interfere with their social attendance or
centers directed toward enhancing the work adjust- learning to such an extent that special services, train-
ment and quality of life in physically disabled and ing, equipment, materials or facilities are required"
multihandicapped children. The millions of dollars in (Hallahan & Kauffman, 1978, p. 172). Orthopedically
grants awarded by the Office of Special Education Pro- impaired children often require physical, environmen-
grams for projects designed to facilitate educational tal, and personal adaptations for full involvement in
and vocational adjustment and transition of deaf-blind daily activities. The present chapter also will include
persons aged 0 through 21 is another example of the studies of those with multiple afflictions, such as the
greater fiduciary support provided by the federal gov- deaf-blind and the blind-mentally retarded. As men-
ernment. Here again, a perusal of research on these tioned, medical technology has reduced infant mor-
topics reveals the widespread utilization and effective- tality considerably. However, advancements in medi-
ness of behavioral assessment and treatment tech- cal science have contributed to an increase in multiple
niques in most of these investigations (cf. Matson & birth defects because more severely involved infants
Helsel, 1986; Sisson, Van Hasselt, & Hersen, 1987). are now being saved (Hart, 1988). Thus, it is antici-
The purpose of this chapter is to review behavioral pated that the population of children with a combina-
assessment and intervention efforts that have been dition of physical and developmental disabilities will be
rected toward children with some form of physical expanding rapidly and will perforce be the focus of
disability. This population is characterized by a phys- increased attention from behavioral researchers in the
ical or sensory deficit that interferes with normal func- future.
tioning and generally includes persons who are visu- In this chapter, clinical and experimental efforts
ally, hearing, or orthopedically impaired. The first of with physically disabled and multihandicapped chil-
these disorders, visual impairment. is present in indi- dren in each of the following categories will be exam-
viduals whose degree of corrected vision in the better ined: (1) behavior problems, (2) adaptive living skills,
eye is 20/200 or worse, or in those who have a severe (3) vocational skills, (4) social skills, and (5) family
restriction in the visual field. The term includes both adjustment. Then, conclusions and suggestions for di-
partially sighted and blind persons. Visual impairment rections that future research might take will be offered.
may exist along a continuum from total blindness to
normal central vision with a peripheral field loss or to
normal peripheral vision with a central field loss. The
effect of a visual impairment on a child depends on Behavior Problems
degree of vision loss, age of onset, location of loss,
stability of the disease process, and quality and quan- Many physically disabled children and adolescents,
tity of environmental experience (Biglan, Van Hasselt, particularly those with multiple handicapping condi-
& Simon, 1988). It is estimated that almost 37,000 tions, display a disproportionate amount of maladap-
children in the United States have a significant visual tive and disruptive behaviors relative to nonhandi-
impairment (National Society to Prevent Blindness, capped peers (Rutter, Tizard, & Whitmore, 1970).
1980). Some of these include self-stimulation, self-injury,
CHAPTER 39 • PHYSICALLY DISABLED PERSONS 833
and aggression. The occurrence of such behavioral dis- ioral interventions have been developed to treat this
orders is partly dependent upon the type, etiology, and problem. Positive reinforcement strategies, particu-
severity of physical impairment. On the whole, in- larly differential reinforcement of other behavior
creased behavioral disturbance is associated with more (ORO) and differential reinforcement of incompatible
severe and extensive disabilities (Matson & Helsel, behavior (DRI) schedules, have been employed be-
1986; Van Hasselt et al., 1988). Behavior therapists cause they are less intrusive than aversive approaches
were among the fIrst to develop effective interventions and satisfy requirements for use of the least restrictive
for the behavior problems displayed by these popula- treatment method (see Reese, 1982). For example,
tions. However, outcome research with physically dis- Luiselli, Myles, Evans, and Boyce (1985) used ORO
abled and multihandicapped children has lagged be- to reduce eye pressing in a lO-year-old blind and hear-
hind similar efforts with their mentally retarded and ing-impaired female. In this study, the subject was
autistic counterparts (see Van Hasselt, Ammerman, & reinforced by being allowed to play with a favorite toy
Sisson, 1988). More recent investigations in this area, contingent on absence of eye pressing during a I-min
on the other hand, have yielded promising results in the interval. Following successful response suppression,
development of remedial strategies for behavior prob- this interval was gradually increased. Gains were
lems in physically disabled children and youth. maintained at a 3-month follow-up.
This section will review research on the use of be- Despite additional reports of the effective imple-
havioral strategies in the treatment of behavior prob- mentation of positive reinforcement interventions
lems in physically disabled and multihandicapped (e.g., B. S. Miller&W. H. Miller, 1976), otherinves-
children and adolescents. It is beyond the scope of this tigators have noted that: (1) behavioral improvements
chapter to provide an exhaustive review of relevant resulting from positive reinforcement schedules often
studies. Rather, selected investigations will be pre- are not durable (Rincover & Koegel, 1977), (2) such
sented to illustrate the use of different behavioral tech- approaches alone often fail to reduce maladaptive be-
niques. The reader is referred to more comprehensive haviors (Reilich et al., 1984; Sisson, Egan, & Van
reviews forfurther information (S. L. Harris & Ersner- Hasselt, 1988), and (3) they may be time-consuming to
Hershfield, 1978; Johnson & Baumeister, 1978). implement and impractical in settings with limited re-
sources (Lutzker, 1978). Because of these difficulties,
other studies have utilized punishment or a combina-
Self-Stimulatory Behavior
tion of positive reinforcement and punishment. Com-
Self-stimulatory or stereotypic behavior is "any rep- monly employed aversive strategies include overcor-
etitious, typographically invariant motor behavior or rection, visual or facial screening, and contingent
action sequence in which reinforcement is not spec- water mist. Caetano and Kauffman (1975) used both
ifIed or is noncontingent and the performance of which overcorrection and positive reinforcement to decrease
is regarded as pathological" (Baumeister & Forehand, body rocking in two visually handicapped females.
1973, p. 57). Examples include body rocking, mouth- Substantial reductions in rocking were observed, and
ing, spinning, head weaving, inappropriate body generalization of gains across settings was noted.
movements, hand flapping, and nonfunctional manip- Horton (1987a) carried out visual screening (con-
ulation of objects. Self-stimulatory behaviors can have tingent application of a soft towel covering the face
a profound adverse impact on learning and social func- for 3 sec) to diminish mouthing of objects in a 4-year-
tioning. Although factors that maintain self-stimula- old girl with cerebral palsy and moderate mental retar-
tion are not fully understood, it is generally accepted dation. A reversal design indicated an elimination of
that three consequences serve to strengthen stereotypic the behavior as a function of the intervention. Also,
responding: (1) positive reinforcement in the form of these effects were still observed at follow-up intervals
contingent social attention, (2) negative reinforcement of 6, 12, and 18 months. Sisson et al. (1988) em-
as in escape or avoidance of demanding tasks, and (3) ployed lemon juice treatment to treat chronic rumina-
sensory and/or proprioceptive reinforcing feedback tion in a lO-year-old female with profound mental re-
(see Reilich, Spooner, & Rose, 1984; Schrader, tardation, visual impairment, cerebral palsy, and a
Shaull, & Elmore, 1983). seizure disorder. A combined multiple-baseline and
Modification of self-stimulation generally is based reversal design revealed a reduction in the behavior to
on a functional analysis of antecedents and conse- near zero levels. Improvement continued at a I-month
quences (Schrader et al., 1983). A variety of behav- follow-up.
Self-Injurious Behavior treatment. In another study, Parrish, Iwata, Dorsey,

Bunck, and Slifer (1985) found that a combination of
Self-injurious behavior is a common and potentially continuous protective equipment, DRO, and toy play
dangerous disturbance in many multihandicapped was most effective in reducing head hitting and head
children (Schroeder, Schroeder, Smith, & Dalldorf, banging in a 17-year-old male with visual and hearing
1978). Such responses interfere with learning and so- impairments as well as severe mental retardation. Fur-
cialization and place the individual at increased risk for ther, treatment effects generalized to other settings fol-
permanent physical injury and, in some cases, even lowing training of residential staff. The utility of com-
death. A variety of behavioral approaches have been bined protective equipment and reinforcement strate-
used to treat self-injury, which may be grouped into gies was further demonstrated by Dorsey, Iwata, Reid,
three categories: (1) positive reinforcement para- and Davis (1982), who found no added benefit of con-
digms, (2) aversive methods, and (3) combined current application of an aversive procedure (i.e.,
positive reinforcement and aversive strategies. water mist) with three multihandicapped adolescents.
Tiemey (1986) used positive reinforcement to sup- Finally, Mace and Knight (1986) reported that en-
press head hitting and finger biting in a 14-year-old vironmental enrichment in the form of increased social
profoundly mentally retarded male afflicted with tu- activity was superior to wearing a helmet in the modifi-
berous sclerosis. The subject was led to a chair and cation of pica in a profoundly retarded and spastic
instructed to sit calmly following occurrence of self- quadriplegic male.
injurious behavior. Orange juice and praise were used Numerous investigations have employed punish-
to reinforce calm sitting behavior. An A-B design rep- ment to eliminate self-injury (e.g., Altman, Haavik, &
licated in three settings suggested that the intervention Higgins, 1983; Altmeyer, Williams, & Sams, 1985;
was successful in reducing self-injury to acceptable Rojahn, McGonigle, Curcio, & Dixon, 1987; Singh,
levels. Slifer, Iwata, and Dorsey (1984) implemented Watson, & Winton, 1986). Altman et al. (1983) used
a response interruption and positive reinforcement contingent restraint, differential reinforcement of ap-
program for eye gouging in a 6-year-old multihand- propriate behaviors, and contingent application of Ta-
icapped male. A multiple-baseline design across basco sauce to decrease self-biting in a female infant
settings demonstrated the utility of the combined strat- with spina bifida. Interestingly, the subject exhibited
egies. Further, low levels of self-injury were main- decreased pain sensivity secondary to neurological im-
tained 6 and 9 months after treatment. pairments related to her birth defect. A reversal design
Several investigators have examined the use of re- revealed substantial reduction of self-biting as a func-
straint and protective equipment to treat self-injurious tion of treatment, particularly after the use of Tabasco
behaviors thought to be reinforced by sensory conse- sauce. Anecdotal follow-up indicated maintenance of
quences. Luiselli (1986) treated a 16-year-old deaf- gains 3 years subsequent to the intervention. Altmeyer
blind male, who exhibited severe face hitting and head et al. (1985) also found Tabasco sauce effective in
banging. The subject was previously unresponsive to reducing self- and outwardly-directed biting in a 16-
DRO and aversive strategies. The intervention consist- year-old blind female with severe mental retardation.
ed of contingent 30-sec application of a modified foot- In this investigation, contingent Tabasco sauce was
ball helmet and padded mittens. In addition, DRO was applied with time-out and DRO.
applied throughout baseline and treatment. Results of Singh et al. (1986) compared the relative efficacy of
an A-B-A-B design indicated a dramatic reduction in water mist spray and facial screening in the treatment
self-injurious behavior that was maintained at 2- and 6- of self-injury in three multihandicapped adolescents.
month intervals. In addition, a social validation pro- They found that while water mist led to reductions in
cedure revealed a high degree of staff satisfaction and self-injurious behaviors, it was not as effective as fa-
acceptability of the program. cial screening or forced arm exercise (a form of over-
Pace, Iwata, Edwards, and McCosh (1986) evalu- correction). Further, the latter two interventions were
ated the effects of differential reinforcement and associated with moderate to substantial increases in
prompting while fading the use of self-restraint for appropriate social interactions. However, Rojahn et
hand biting in an 18-year-old multihandicapped male. at. (1987) reported water mist to be useful in the elim-
Results showed that reinforcement was successful in ination of pica. They contrasted water mist and aro-
suppressing levels of self-injury during fading. Also, matic ammonia in a simultaneous treatment design
these gains were maintained up to 2 years following with a 16-year-old female diagnosed with autism, se-
vere mental retardation, cerebral palsy, and a seizure with hearing-impaired children in reducing problem
disorder. Although both treatments suppressed pica, behaviors in the classroom (Osborne, 1969), increas-
ammonia led to an initial increase in the behavior fol- ing attending and sitting, reducing screaming and cry-
lowed by a reduction. In addition, there was a cor- ing (Garrard & Saxon, 1973), and eliminating disrup-
responding decrease in other self-injurious behav- tiveness (Van Houten & Nau, 1980).
iors. These improvements were noted at a 3-month Weeks and Gaylord-Ross (1981) evaluated the role
follow-up. of task difficulty in eliciting aggressive behavior in
three multihandicapped children. A preliminary as-
sessment revealed that subjects exhibited higher levels
Aggressive and Disruptive Behaviors
of aggression during more demanding instructional
Aggression and acting out frequently are reported in tasks. Subsequent manipulation of these tasks to incor-
physically disabled and multihandicapped children porate errorless learning procedures resulted in a dra-
and adolescents (see Van Hasselt et at., 1988). Such matic decrease in aggression. The investigators rec-
behavior problems can cause physical injury to the ommend that changes in curriculum be considered to
child, peers, classroom or treatment staff, and parents. reduce frustration in aggressive multihandicapped
In most instances, aggression is controlled and main- children.
tained by environmental contingencies (i.e., positive Slifer, Ivancic, Parrish, Page, and Burgio (1986)
reinforcement in the form of attention or task avoid- also identified task avoidance as a maintaining factor
ance). As with self-injurious and stereotypic behav- in the severe aggression and property destruction dis-
iors, various reinforcement and punishment pro- played by a 13-year-old male with profound mental
cedures have been used to treat aggression. retardation, blindness, and a seizure disorder. Treat-
Luiselli and his colleagues (Luiselli, 1984; Luiselli ment consisted of preventing escape from instructional
& Greenidge, 1982; Luiselli, Myles, Evans, & Boyce, tasks by providing manual guidance following non-
1985; Luiselli & Slocumb, 1983) have consistently compliance, and positive reinforcement of compliant
demonstrated the value of reinforcement strategies in behavior. A multiple-baseline across individuals im-
reducing aggression in multihandicapped children. For plementing treatment (staff and family members) indi-
example, Luiselli and Slocumb (1983) employed a cated significant improvement in response to treat-
DRO schedule (praise and edible reinforcers) to de- ment. In addition, parent training resulted in
crease aggression, spitting, and tantrums in a 9-year- generalization of gains across settings; these were
old female described as autistic and severely mentally maintained at a 3-month follow-up probe.
retarded. Results of a reversal design indicated a sig- Using a different approach, Strawbridge, Sisson,
nificant reduction in these maladaptive behaviors as a and Van Hasselt (1987) employed contingent-inter-
function of treatment. Follow-up at 5 months showed rupted stimulation to treat disruptive crying and
maintenance of treatment gains. Luiselli, Myles, screaming in a 10-year-old multihandicapped female.
Evans, and Boyce (1985) employed DRO with a cue to Initially, contingent-interrupted tactile stimulation
treat aggression in a 15-year-old deaf-blind female. (i.e., vibration) was found to be ineffective. Next, the
The intervention successfully diminished levels of ag- efficacy of contingent-interrupted auditory stimulation
gression, which remained low following fading of the was evaluated in a multiple-baseline design across set-
cue and transfer to a token reinforcement system. tings. Results of this analysis showed that disruptive
A multiple-component treatment program was util- behaviors were almost eliminated. Further, gains were
ized to treat an extremely aggressive 15-year-old male maintained at 5 months after fading of the auditory
with hearing loss and visual impairment (Luiselli, stimulus.
1984). Here, DRI (tokens), response cost, and relaxa- The utility of aversive procedures in modifying ag-
tion training resulted in substantial reductions in aggressive and disruptive behaviors also has been docu-
gression that were maintained 1 and 2 years after treat- mented. For example, Horton (1987b) used facial
ment. In two other investigations, DRO was less screening to target spoon banging in an 8-year-old mi-
effective in controlling disruptive behavior until it was crocephalic female. Contingent application of a soft
combined with removal of teacher attention or isola- towel for 5 sec was assessed in a reversal design. The
tion time-out (Luiselli &. Greenidge, 1982; Luiselli, intervention successfully decreased spoon banging,
Myles, & Littman-Quinn, 1985). Positive reinforce- and improvements remained in effect at 6-, 10-, and
ment approaches also have been successfully utilized 16-month follow-ups.
The combination of positive reinforcement and across experimental phases (Gutierrez-Griep, 1984;
aversive strategies appears to have value in reducing Sandler & McLain, 1987), (2) providing a two-choice
aggressive behavior in physically disabled and multi- lever switch (Friedlander & Knight, 1973), or (3) ar-
handicapped children. In some cases, multielement ranging lever-pressing consequences according to a
treatment packages have been needed to fully suppress multiple schedule (Remington et at., 1977). Results of
aggressive and disruptive responding (Luiselli, 1984). these investigations have consistently shown that mul-
The data clearly support the initial use of reinforce- tihandicapped children have strong preferences for
ment approaches for these problem areas. Subsequent stimuli; further, these preferences are idiosyncratic
use of aversive methods often have been effective across participants.
when reinforcement strategies have failed to reduce Some severe physical impairments preclude chil-
aggression to acceptable levels. dren from grasping and moving levers. As a result,
alternative behavioral responses for reinforcement
have been designated. Piper and MacKinnon (1969)
Identification of Positive Reinforcers
used food delivered directly into the stomach through a
Identification of positive reinforcers for physically fistula in the abdominal wall to condition a severely
disabled individuals is a prerequisite to subsequent de- disabled 'adolescent to raise her arm. The presence of
velopment of behavioral skills training strategies. This food in the stomach (in the absence of oral stimulation)
is particularly important with multihandicapped per- was found to be reinforcing. Dewson and Whitley
sons, given the potential deficits in motoric, sensory, (1987) presented auditory, visual, and vibratory stim-
and/or cognitive functioning that often impair respon- uli to eight multihandicapped children contingent on
siveness to environmental events and contingencies. head turns. In this study, several combinations of sen-
The usual methods of identifying reinforcers, such as sory events resulted in increased performance.
asking subjects what they prefer (B. H. Barrett, 1962) Microswitches appear to be a promising method for
or exposing them to an array of stimuli and recording assessing a person's response to various stimuli be-
the duration or frequency of contact with each item cause they can be activated by subtle motor move-
(Quilitch, Christopherson, & Risley, 1977), have not ments. For example, a mercury switch activates bat-
consistently yielded useful information. Conse- tery-operated or electrical devices when a pre specified
quently, other procedures for isolating stimulus prefer- movement by the individual causes mercury to flow to
ences have been developed. one end of a container, thus completing an electrical
The earliest evaluations of positive reinforcers for circuit. In one study (Wacker, Berg, Wiggins" Mul-
physically disabled children involved establishing a doon, & Cavanaugh, 1985), five children were trained
lever-pressing response. For example, Bailey and to raise their arm or head which, in tum, activated a
Meyerson (1969) mounted a padded lever in the crib of micros witch connected to battery-operated toys and
a multihandicapped 7-year-old youngster. Lever- devices. When the microswitches activated the de-
pressing was observed at low levels when no conse- vices, an increase in the duration of motoric respond-
quences followed. However, responding increased ing was observed for all students. In addition, some
dramatically when each lever press produced 6 sec- children performed differentially across devices, sug-
onds of vibration. Predictably, lever-pressing dimin- gesting reinforcer preferences. Similar findings were
ished rapidly to baseline rates when vibration was dis- reported by Dattilo (1986) for three disabled subjects.
continued. Thus, vibration was considered to be a Finally, in three investigations (B. S. Egan, Sisson,
reinforcing consequence for this child. Van Hasselt, & Hersen, 1986; Green et at., 1988;
Other studies have used similar procedures to ascer- Pace, Vancic, Edwards, Iwata, & Page, 1985), poten-
tain stimulu~ events that serve as reinforcers for se- tially reinforcing stimuli were presented individually
verely disabled children. Such events include auditory to multihandicapped children and adolescents and
stimulation (e.g., rhymes, music, and tones) (Reming- their approach to them (reaching for or consuming)
ton, Foxen, & Hogg, 1977), visual stimulation, such was systematically monitored. Most participants dem-
as lights at different intensities (Friedlander & Knight, onstrated clear stimulus preferences as reflected by
1973), and vestibular stimulation (e.g., swinging) frequent or consistent approach responses. Further-
(Sandler & McLain, 1987). Further, the relative rein- more, preferred events increased a simple motor re-
forcing value of various stimuli has been determined sponse when provided as consequences for perfor-
by (1) following lever-pressing with different events mance, thus demonstrating their value as reinforcers.
Interestingly, Green et al. (1988) found that results of identified preferred stimuli in the initial phase of a
systematic preference assessment did not concur with behavioral intervention designed to reduce maladap-
results of a more traditional, caregiver-opinion method tive behaviors in three, 4-year-old blind multihand-
of identifying preferences. In addition, stimuli listed icapped children. The procedure for stimulus identifi-
as preferred by caregivers failed to function as cation involved presenting 4 to 5 of 18 predetermined
reinforcers unless those stimuli also were identified via stimulus items five times (in counterbalanced order)
the systematic preference assessment procedure. over eight assessment sessions; thus, each stimulus
The above-mentioned studies suggest that strategies item was presented 10 times. Figure I shows the per-
exist for determining preferred stimuli for physically centage of approach responses to each of the stimuli
disabled and multihandicapped children, and that pre- across subjects. As the figure indicates, the partici-
ferred stimuli often serve as reinforcers for simple pants differentially approached the assessment stimuli.
motor behaviors. Whether the identified stimuli will In the second part of the study, the most preferred
serve as reinforcers for other, more complex, behav- stimuli were used as positive reinforcers in momentary
iors is yet unclear. Further, preliminary data conflict DRO (M-DRO) (i.e., reinforcement was administered
with regard to the utility of preferred items and events if responding was not occurring at the particular mo-
in DRO paradigms for eliminating maladaptive re- ment of observation) behavior management programs
sponding (Sisson, Van Hasselt, Hersen, & Aurand, to reduce disruptive and/or stereotypic behaviors.
1988; Sisson, Van Hasselt, Hersen, & Egan, 1987; However, evaluations of behavioral interventions indi-
Steege et aI., in press). For example, Sisson, Van cated that M-DRO failed to have an impact on level of
Hasselt, Hersen, and Aurand (1988) systematically maladaptive responding in two of the subjects. In these
I-
z :I: a:
(/) L1.I
a: ::J a: >-
a::
L1.I ~ j L1.I a: Ina: 0 ~
!;( L1.I
Z ~ L1.I I- ~ !r ..J ~ :I: L1.I ..J Q.
~I ~I ~I ~I~ ~ ~~~ ~I ~I ~I ~I ~I
)£
U < t!l
!r ::;; ~ :I: i= u
..J ::J
:I:
100
WILL
50
JOSHUA
• -'-- ELLIE
50
Figure 1. Percentage of approach responses to each of the 18 stimuli for each of the 3 participants. From "Tripartite Behavioral
Intervention to Reduce Stereotypic and Disruptive Behaviors in Young Multihandicapped Children" by L. A. Sisson, V. B. Van
Hasselt, M. Hersen, and 1. C. Aurand, 1988, Behavior Therapy, 19, Fig. 1, p. 508. Copyright 1988 by the Association for
Advancement of Behavior Therapy. Reprinted by permission.
cases, the addition of more restrictive treatments Adaptive Living Skills

(overcorrection, immobilization time-out) was neces-
sary to achieve clinically significant improvement (see One of the most challenging tasks facing special
Figure 2). These results support findings of research educators and personnel in related fields who work
discussed earlier that demonstrate the frequent failure with physically disabled children is teaching new
of reinforcement procedures alone to reduce high-rate adaptive living skills. Evidence of the difficulties en-
maladaptive behavior in multihandicapped children countered in training with this population exists in the
(e.g., R. P. Barrett, Matson, Shapiro, & Ollendick, recognition that many physically disabled and multi-
1981; Foxx & Azrin, 1973). handicapped persons have participated in extensive
iJ
M-DRO
(20 S)
BSLN M-DRO DC M-ORO (20 S) + OC (90 S)
":::!'.. .
(30 S)
JOSHUA
100
50 .,,- - V
'll\ ,
100
FREE, V
50
~
~
0 ~ __~____- L____-L____~____~~=-L- __ ____ ____ ___
~ ~ ~
a:
~ 100
;!; IND. SESSION
............
100
FREE PLAY
50
o L -_ _ ____ __ ____ ____ __ ____ __ ____ __
5 10 15 20 25 30 35 40 45
• STEREOf. BEH.
6 .4PPROPR. PLAY
Figure 2. A multiple-baseline analysis of percentage of maladaptive behavior during baseline, momentary DRO (M-DRO), and
combined treatments (M-DRO plus overcorrection) across three settings. The fourth panel shows percentage of appropriate play
during baseline and intervention for maladaptive behavior, in Free Play only. From "Tripartite Behavioral Intervention to Reduce
Stereotypic and Disruptive Behaviors in Young Multihandicapped Children" by L. A. Sisson, V. B. Van Hasselt, M. Hersen, and 1.
C. Aurand, 1988, Behavior Therapy, 19, Fig. 3, p. 515. Copyright 1988 by the Association for Advancement of Behavior Therapy.
Reprinted by permission.
training programs with only a modicum, if any, im- ment) as well as for wetting of pants (cueing delivery
provement (Bailey, 1981). Reasons for this lack of of clean-up consequences) (Azrin, Bugle, & O'Brien,
positive response are numerous, and include (1) the 1971; Song, Song, & Grant, 1976; Van Wagenen,
presence of interfering, maladaptive behaviors, (2) ex- Meyerson, Kerr, & Mahoney, 1969).
tremely limited pretraining behavioral repertoires, and Several approaches to increasing independent self-
(3) inadequate adaptation of materials for use by phys- feeding responses in developmentally and physically
ically disabled clients. Nevertheless, a small but ex- disabled children have been evaluated (see review by
panding literature has focused on skills training with Sisson & Van Hasselt, 1989). In behavior shaping, the
physically disabled children. process of self-feeding is viewed as a sequence of re-
sponses and is task-analyzed into discrete behavioral
components. Then, successively larger combinations
Self-Help Skills
of separate behaviors are systematically reinforced in
Self-help skills training, including the promotion of order to form more complex skills. Chaining of feed-
independent toileting, dressing, and feeding, received ing responses can be in a forward format by sequen-
much attention in the 1960s and 1970s when behav- tially training each behavior in the order in which it
ioral strategies were initially applied to change levels normally occurs, or in a backward format by teaching
of responding by institutionalized developmentally the steps in a reverse order. Forward chaining was
and physically disabled individuals. The impetus for employed by Whitney and Barnard (1966) with a non-
activity in this area was a desire to improve the quality ambulatory, profoundly mentally retarded adolescent.
oflife of severely disabled persons by increasing inde- The subject was fed a small piece of food from her
pendence and improving social acceptability. Al- meal when she displayed increasingly advanced be-
though many of the early reports lack adequate experi- havior. Initially, she merely had to look at her spoon.
mental control, they suggested possible heuristic Next, she was required to look at and reach for the
strategies for enhancing self-help skills. More re- spoon. Then, looking at, reaching for, and grasping
cently, several replication studies have appeared that the spoon were required before food was forthcoming.
are more methodologically rigorous. Additional behaviors in the chain were not described
In the area of toilet training, operant procedures in- but undoubtedly included scooping, bringing food to
volving presentation of reinforcing stimuli (e. g. , food, her mouth, placing food in her mouth, and chewing
praise) for voiding in the toilet and aversive stimuli and swallowing the food. Results showed that inde-
(e.g., restraint, reprimand) for accidents, were found pendent spoon-feeding was acquired in only five feed-
to be effective with five mentally retarded children, ing sessions. Similar positive results have been re-
one of whom was blind (Giles & Wolf, 1965). The ported by researchers who utilized a backward
method developed by Foxx and Azrin (1973) was em- chaining approach with multihandicapped subjects
ployed by 1. F. Butler (1976) to increase bladder con- (Lemke & Mitchell, 1972; H. R. Miller, Patton, &
trol in a 4Y2-year-old child with spina bifida men- Henton, 1971; O'Brien, Bugle, & Azrin, 1972).
ingomeyelocele. In this procedure, bladder training Graduated guidance, originally described by Azrin
was initiated by providing a large amount of fluids. and Armstrong (1973), is an alternative strategy to
Then, the child was directed to the toilet and required chaining for teaching feeding skills. In this technique,
to sit until he voided or until 10 min had elapsed. If children are taught using a forward sequencing format.
voiding occurred, praise and edibles were provided. Gentle manual guidance is employed to ensure that
Edibles also were administered when pants were dry at each response is completed correctly. The trainer be-
ongoing checks, which were carried out every 5 min gins by molding his or her hand around the subject's
throughout the day during the onset of the program. hand and guiding the entire self-feeding response. As
Finally, accidents were followed by cleanliness train- the client learns to grasp the utensil, guidance is prog-
ing (cleaning up) and positive practice (repeated ressively reduced at the hand to a gentle touch. Then
bathroom trips). Gradually, the intervals for toileting the locus of guidance is faded up the arm to the fore-
and pants checks were faded, and self-initiated toilet- arm, elbow, upper arm, shoulder, and upper back. Fi-
ing was required for reinforcement. This type of incon- nally, guidance is withdrawn completely. Another
tinence treatment has been facilitated by special appa- important characteristic of graduated guidance is high-
ratuses that cause an auditory signal upon urination in density reinforcement. Children receive verbal and
the toilet (signaling the trainer to provide reinforce- physical reinforcement (e.g., praise, pats, hugs) al-
most continuously during training. In addition, pri- disabilities. First, detailed task analyses were devel-
mary and secondary reinforcers are administered upon oped for putting on socks, pants, and shirt. Training
completion of each training trial. Meals often are di- consisted of guidance through all steps in the task anal-
vided into several smaller portions to permit several ysis for each garment, continuous verbal instructions
training sessions per day and to control for satiation. during dressing actions, and praise plus tangible rein-
Restitution and positive practice overcorrection are forcement once the garment was on correctly. Guid-
employed to correct errors. For example, when spill- ance was gradually and systematically faded from
ing occurs, the client must clean up the area (restitu- hand-over-hand manual guidance to verbal prompt
tion) and demonstrate the correct form of the response only. Daily unassisted probes with garments showed
across several practice trials (positive practice). Stim- that dressing skills improved with treatment, although
bert, Minor, and McCoy (1977) have provided a con- rate of acquisition varied considerably across partici-
trolled investigation that attests to the effectiveness of pants in relation to the degree of physical impairment.
graduated guidance in teaching self-feeding to multi- Further, skills generalized across garments and were
handicapped children. maintained over time (McKelvey et al .• in press; Sis-
Behavior shaping and graduated guidance have been son et al .• in press).
used to foster very elementary eating behaviors, such Day and Homer (1986) used massed practice with
as spoon feeding. Once early skills are mastered, other the trainer providing physical, verbal, and gestural
strategies often are employed to produce more ad- prompts, praise for correct performance, and interrup-
vanced mealtime responses. Cipani (1981) rewarded tion/redirection for errors to teach six mentally re-
neatness at meals with chocolate milk and tokens (to be tarded adolescents and young adults (two of whom
traded for conversation time) in an adolescent with also had sensory impairments) to dress in a shirt. The
severe mental retardation and multiple physical dis- unique aspect of this program was a comparison of
abilities. In addition, a 30-sec time-out from eating Single Instance Training (training to dress in one shirt)
followed spilling. Use of a withdrawal design demon- with General Case Training (training with a variety of
strated the controlling effects of treatment on rate of shirts) in terms of generalization of dressing skills to
food spillage. In another investigation (Luiselli, nontrained probe shirts. Generalization in the former
1989), the rate of eating was modified in three severely case was poor, whereas generalization in the latter case
mentally retarded, sensory impaired children. Inter- was 100% for all but one subject.
vention consisted of a combination of physical In summary, a number of investigations have been
prompting (to slow eaters) plus reinforcement (access focused on the development and evaluation of methods
to food and praise) for appropriate pauses between for teaching basic self-care skills to physically dis-
bites of food. Sisson and Dixon (1986) trained multi- abled and multihandicapped children. These investi-
ple-utensil use and napkin use in a young girl who gations have attempted to first demonstrate, and later
suffered from blindness and severe mental retardation. refine, the use of operant interventions in specific
Their strategies included instructions, manual guid- areas of performance (i.e., toileting, feeding, and
ance, behavior rehearsal, praise for desired table man- dressing). However, little controlled research has ex-
ners, and a lO-sec time-out from eating when inap- amined methods of combining individual self-care
propriate behaviors occurred. skills into extended behavioral chains. The develop-
Fewer studies have addressed self-dressing training ment of such repertoires is important for increased
with physically disabled children. Forward and back- independence and placement in the least restrictive
ward chaining, as well as graduated guidance, are rec- environment because optimal performance in every-
ommended for teaching mentally retarded clients to day situations requires the execution of a series of self-
dress themselves (Azrin, Schaeffer, & Wesolowski, care behaviors closely linked in time.
1976; Bensberg, Colwell, & Cassell, 1965; Lent, One study is noteworthy in that it addressed compre-
1975). These strategies are likely to be effective with hensive self-care programming with multihandi-
physically disabled individuals as well. Sisson and her capped individuals. In this ambitious project, Jarman,
colleagues (McKelvey, Sisson, Van Hasselt, & Iwata, and Lorentzson (1983) worked with 40 men-
Hersen, in press; Sisson, Kilwein, & Van Hasselt, tally retarded, cerebral-palsied adolescents and adults
1989) evaluated the use of graduated guidance with in a residential facility. Following the completion of
children who suffered from a combination of severe individualized training in each of six skill areas (toilet-
mental retardation, sensory impairments, and physical ing, showering, dressing, toothbrushing, cleaning up
living space, removing bed linens), two reinforcement ments experimental design to evaluate the relative ef-
contingencies were implemented to improve daily per- fectiveness of ankle-foot orthoses versus no orthoses
fonnance. First, token reinforcement was provided for in promoting standing balance (a prequisite ambula-
the completion of each skill. A multiple-baseline de- tion skill) in a child with cerebral palsy. Results
sign across behaviors showed perfonnance increases showed a definite improvement in the subject's ability
in five of the six behaviors, with some response decre- to maintain independent standing while wearing the
ment over time. During a final condition in which no orthoses. Anecdotal follow-up reports indicated that
tokens could be earned unless all six behaviors were he eventually learned to take a few steps while wearing
completed, perfonnance of each skill either increased the devices.
further or was maintained at a high level. This investi- Finally, Strawbridge, Drnach, Sisson, and Van
gation should serve as a model for future efforts in self- Hasselt (1989) described an effective approach to am-
help skills training with multihandicapped individuals. bulation training with a child who was profoundly
mentally retarded, deaf, and blind, and who had failed
to walk despite years of physical therapy exercises.
Mobility Skills
The intervention consisted of two parts. First, in-
Ambulation deficits are common among children creased compliance with task requirements (i.e., hold-
who are physically disabled. Remediation of these ing on to both handles of a walker) was targeted using a
problems is important for future placement of multi- contingent-interrupted auditory stimulation pro-
handicapped children. Indeed, a major criterion for the cedure. According to this strategy, an audiotape re-
shift from an institution to a community-based pro- cording of folk songs was played, starting at the begin-
gram often is ambulation ability (R. I. Walker & ning of a session, and continued until the child released
Vogelsberg, 1985). Children who do not walk fre- the handles of the walker. Once on-task behavior was
quently come to the attention of physical therapists established, independent stepping with the walker was
rather than behavior therapists. Treatment generally promoted using physical prompts delivered according
consists of facilitation exercises that vary across indi- to a hierarchy of intrusiveness. Withdrawal sin~1e
viduals and time. Over the past two decades, several case experimental designs demonstrated the control-
investigators have successfully integrated physical ling effects of treatments; I-year follow-up probes doc-
therapy and behavioral approaches to improve ambula- umented the maintenance of treatment gains.
tion in children with multiple handicapping condi- Beyond improving mobility, interventions for am-
tions. For example, Chandler and Adams (1972) rein- bulation often have facilitated acquisition of other
forced improved perfonnance by an 8-year-old child, adaptive behaviors. Reports have demonstrated the
who suffered from visual impainnent and mental retar- following concurrent effects: increased prosocial be-
dation. The youngster was required to increase the havior (C. Butler, 1986; Chandler & Adams, 1972),
number of unassisted steps to gain access to 30 seconds improved physical condition and reflexes (Chandler &
of music from a portable radio. In this case, the pro- Adams, 1972; Westervelt & Luiselli, 1975), more self-
cedure was modified to.a contingent-interrupted rein- initiated behavior including play (c. Butler, 1986),
forcement paradigm in which the child maintained the and diminished self-stimulation responses (Straw-
music stimulus by walking; the music was turned off bridge et ai., 1989; Tarnowske & Drabman, 1985).
when he reached out for support or fell. Finally, to Given the encouraging findings from these studies, it
enhance gains, contingent-interrupted reinforcement is likely that increased attention to mobility of multi-
was supplemented with delivery of candy for increased handicapped individuals using behavior therapy tech-
independent steps. niques will be a profitable area of research.
In anothf' investigation, Westervelt and Luiselli Most early skills training research with physically
(1975) combined physical prompting with edible and disabled children emphasized the establishment of
socia: reinforcement to promote standing and walking very elementary skills. Now, with the national move-
by an ll-year-old multihandicapped child. Horner ment toward deinstitutionalization and nonnalizing
(1971) also used prompting and reinforcement to living environments, independent self-help behaviors
shape appropriate use of parallel bars, and eventually may be a necessary but insufficient goal; more com-
crut-:hes, by a 5-year-old child with spina bifida and plex responses must be shaped. Awareness of this need
mOl.1~rate mental retardation. More recently, S. R. is reflected by the burgeoning literature examining the
Harris and Riffle (1986) employed an alternating treat- community and vocational adjustment of developmen-
tally disabled individuals. Several investigations have tion with photo slide sequences, a simulated ordering
included subjects with motoric and sensory disabilities counter, and adaptive materials for communication
as well. Research on the training of community adap- (e.g., plastic laminated sheets of cardboard with pre-
tive and leisure skills, as well as vocational work and printed questions, generic item names, and spaces for
social skills, in children with physical disabilities is written cashier responses). A multiple-baseline design
presented in the sections that follow. across subjects demonstrated treatment efficacy. Peri-
odic probes at McDonald's or Burger King restaurants
indicated that performance in these settings improved
Community and Leisure Skills
with treatment and was maintained over time at levels
A major goal of habilitative and rehabilitative equal to those achieved by a normative sample of non-
efforts for disabled individuals is to teach them to live retarded persons.
as independently as possible. Early programs could be Finally, Lancioni and his colleagues (Lancioni,
characterized as providing instruction on nonfunc- Oliva, Adorni, Guzzini, Locatelli, & Spinaci, 1988;
tional, paper/pencil tasks that have little, if any, direct Lancioni, Smeets, & Oliva 1988) trained low-func-
application to real-work demands (Langone, 1981; tioning blind and/ or deaf individuals to perform sever-
Nietupski, Welch, & Wacker, 1983). Recently, how- al basic household tasks (e.g., washing fruit, collect-
ever, a number of investigators have recognized the ing clothes, sorting kitchen utensils) and occupational
importance of teaching functional skills in natural activities (e.g., connecting parts of a stool, attaching
community environments (Bates, Renzaglia, & sticks to brooms, putting cups into bags). However,
Wehman, 1981; Nietupski et al., 1983). A further em- subjects did not engage in these activities without su-
phasis has been on training disabled persons to use pervision. Thus, in one study, a computer-operated
leisure time in a wise and productive manner (Halasz- system of providing picture prompts and token rein-
Dees & Cuvo, 1986). Although the literature is replete forcement for task completion was devised to promote
with program descriptions of community adaptive and activities independent of the trainer's presence (Lan-
leisure skills training (e.g., Inana, 1980; Stewart, Van cioni, Smeets, & Oliva, 1988). In the second investi-
Hasselt, Simon, & Thompson, 1985), empirically gation, a computer system controlled the presentation
based studies are beginning to appear. of picture prompts and the opening and closing of gates
A skill necessary for independent community func- leading to the areas where the activities had to be ex-
tioning is the ability to make purchases. Nietupski et ecuted (Lancioni, Oliva, et ai., 1988). Results of both
ai. (1983) taught four moderately and severely men- studies indicated that the computer-aided programs
tally retarded young adults to use a pocket calculator were successful in increasing unsupervised activities
plus picture prompt cards to purchase supermarket by the disabled subjects for periods of up to 30 min.
items. One of the participants also was motorically and Unsupervised time routinely is evident after daily
sensorily impaired. A multiple-probe design demon- school or work activities. An alternative approach to
strated the effectiveness of an instructional procedure encouraging better use of unprogrammed time periods
involving modeling, behavior rehearsal, praise, and by multihandicapped persons is to provide adapted lei-
feedback on errors in promoting completion of an sure materials. In a recent investigation (Realon,
eight-step task analysis of purchasing behaviors in an Favell, & Dayvault, 1988), the independent leisure
analogue situation. Then, 12 additional students were activity offive mentally retarded, nonambulatory ado-
taught the purchasing skills. Follow-up probes showed lescents and adults living in a state institution was in-
that skills did not generalize completely to the natural creased simply by providing electrically operated ma-
environment, but that classroom training facilitated terials and demonstrating their functioning. Results of
acquisition of target behaviors in the supermarket. Fur- a withdrawal design demonstrated that availability of
ther, responses were maintained over a 3-month period adapted materials positively affected use of leisure
during which instruction was not provided. time. In five other cases, simply making the devices
In another study, van den Pol et ai. (1981) examined available was insufficient to improve participation in
classroom-based instruction in restauranting skills for activities during unstructured periods. These five indi-
three multihandicapped youths. Several skill compo- viduals were taught to interact with the adapted toys
nents were taught in sequence, including locating the using verbal prompts, social reinforcement, and grad-
counter, ordering, paying, eating, and exiting. Train- uated physical guidance. Training resulted in in-
ing consisted of modeling and role-playing in conjunc- creased interaction with the leisure materials. Further,
two subjects continued to switch-activate the devices disabled individuals. The U. S. Office of Education,
after all prompts and reinforcement were withdrawn. along with the American Vocational Association and
One limitation of the Realon et at. (1988) study is the Council for Exceptional Children, has sponsored
that age-inappropriate leisure materials were em- efforts to develop and disseminate materials and pro-
ployed with participants. It is unclear whether age- grams pertaining to vocational training for disabled
appropriate devices would have been more effective in persons (see Brolin & D' Alonzo, 1979). Technological
increasing engagement. A large number of training innovations are permitting these individuals to be more
programs that focus on age-appropriate recre- mobile and to interact and communicate more effec-
ation/leisure skills have been developed for severely tively, thus making participation in work settings in-
handicapped individuals without physical or sensory creasingly possible. Moreover, as the disabled ad-
impairments (Wuerch & Voeltz, 1982). Further, ex- vance in age, less funding is available for program-
perimental studies have documented the utility of spe- ming in educational and other areas.
cific instructional procedures in training these persons Greater sensitivity to the need for vocational train-
to participate in such activities as bowling (Schleien, ing for disabled persons has had minimal impact on
Certo, & Muccino, 1984), dancing (Lagomarcino, actual educational practices, however. A significant
Reid, Ivancic, & Faw, 1984), and playing darts portion of this population is not receiving training in
(Schleien, Wehman, & Kiernan, 1981). Harnre- work-related skills. In 1976, Stacts reported that less
Nietupski, Nietupski, Sandvig, Sandvig, and Ayres than 2% of the estimated 10% of handicapped school-
(1984) described a program of systematic leisure skills aged individuals were being served by vocational edu-
instruction with deaf-blind severely handicapped cation. Although this percentage should have im-
young adults in a residential setting. They were taught proved over the subsequent decade, recent data indi-
to operate an eight-track tape player using backward cate that the situation has not changed dramatically. A
chaining through the steps of a task analysis, a gradu- naturalistic, observational analysis of 43 self-con-
ated hierarchy of assistance, and positive reinforce- tained classrooms serving severely handicapped stu-
ment (praise and music) for performing task require- dents revealed that only one third of their time on-task
ments correctly. Results showed that subjects acquired involved functional instructional materials (i.e., mate-
the leisure skill and maintained it over a 2-month rials that would be encountered in a work or leisure
period. situation or that would be used by nonhandicapped
It is apparent from these few investigations that persons of the same age) (Green et al., 1986).
there is a paucity of information relating to the type of As with work in the area of community and leisure
community adaptive and recreational skills disabled skills training, vocational programming with phys-
individuals can learn, and the most effective methods ically disabled children is relatively rare and essen-
for training. Information concerning the adaptation of tially nonempirical. Most reports merely describe pre-
household and age-appropriate leisure materials for vocational/vocational training approaches (Busse,
use by motorically and sensory-impaired children is Romer, Fewell, & Vadasy, 1985; Freedman, 1978). A
scarce. Further, cost-efficient ways to supervise and major emphasis in these articles is on the value of
facilitate ongoing community and leisure activities of integrating techniques used by vocational rehabilita-
disabled persons remains an important issue. Although tion counselors into classroom activities in preparation
innovative, the elaborate computer-aided program de- for eventual placement into community settings.
scribed by Lancioni (Lancioni, Oliva, et at., 1988; These strategies include "assembly line-type tasks that
Lancioni, Smeets, & Oliva, 1988) may be impractical require sequencing, left-right orientation, on-task be-
in most settings. Finally, the degree to which the quali- haviors, high rate productivity, completion of piece-
ty of life for a person with physical disabilities is en- work, and self-correction" (Sims-Tucker & Jensema,
hanced by systematic training in community and recre- 1984, p. 310).
ational activities has yet to be determined. Prerequisite behaviors of sitting and attending have
been shaped in blind (Stolz & Wolf, 1969) and deaf-
blind (Yarnall & Dodgion-Ensor, 1980) children.
Vocational Skills Everson and Goodwyn (1987) trained three adoles-
cents with cerebral palsy to use switches to activate
In recent years, there has been a heightened computer programs. Then, using a multielement ex-
awareness of the importance of career education for perimental design, three different switches (e.g., pil-
low switch, pad switch, foot switch) were compared in work station, (3) independently locate the break area,
terms of the student's productivity with each. Results (4) respond appropriately to change of supervisor, and
pointed to the best switch for each participant. (5) improve attention to task. Treatments consisted of
More complicated responses were established by positive reinforcement for desirable behavior and
Rusch, McKee, Chadsey-Rusch, and Renzaglia prompting for undesirable behavior, with levels of re-
(1988) and Gaylord-Ross, Forte, Storey, Gaylord- inforcement and prompting fading gradually over
Ross, and Jameson (1987). In the first investigation time. A multiple-baseline analysis across behaviors
(Rusch et aI., 1988), a 16-year-old male with severe revealed that implementation of treatment resulted in
mental retardation and cerebral palsy who worked in a criterion levels of performance in approximately 4
supply room was taught to make requests for materials months.
under two conditions: when he ran out of supplies, and
when there were not enough supplies to complete an
order. The procedure included teaching self-instruc- Social Skills
tional statements though instructions, behavioral re-
hearsal, and performance feedback. The results indi- The psychosocial functioning of physically disabled
cated that such instruction did not result in the children has received increased attention from clini-
generalization of performance to the production period cians and researchers (see Hersen & Van Hasselt,
at the work site. Self-instructional statements and im- 1989; Routh, 1988; Strain, 1982; Varni & Wallender,
proved performance were noted during the production 1988). The impetus for the heightened activity in this
period only when systematic feedback was provided. area stems from early work on the effects of physical
A multiple-baseline design across behaviors demon- stigma and interpersonal attraction in children. For ex-
strated the efficacy of the treatment strategy. ample, several studies have documented the negative
In the second study (Gaylord-Ross et al., 1987), 12 attitudes of nondisabled individuals toward children
developmentally disabled adolescents (one subject with disabilities or deviations in physique (e.g., Dion,
also was deaf) participated in a community-based vo- 1972; Kleck, Richardson, & Ronald, 1974). Further, it
cational training program. Each individual was taught is apparent that many physically disabled children and
to carry out three chemical tasks (chosen from those youth are socially isolated (e.g., Eaglestein, 1975; Van
performed by lab technicians on an ongoing basis) in Hasselt, 1983), receive inaccurate feedback regarding
chemical laboratories of the Chevron Research Com- their interpersonal behavior from their environment
pany. Training was conducted by a teacher who pro- (Richardson, 1969; Scott, 1969), and are more likely
vided verbal prompting, modeling, behavioral re- to interact with peers who exhibit social skill deficien-
hearsal, and feedback on errors. Multiple-baseline cies themselves (Centers & Centers, 1963).
analyses across tasks indicated that all disabled partici- The problems in social adjustment of disabled chil-
pants were able to master at least one of the three tasks dren have perhaps been most clearly illustrated in blind
and demonstrated significantly improved performance or visually impaired children. Mental health profes-
on tasks in which criterion performance was not sionals and special educators generally agree that these
achieved. In addition, nondisabled judges who ob- individuals often are passive, withdrawn, and unasser-
served subjects' work performance on videotape rated tive (see review by Van Hasselt, 1983). Behavior ther-
the students as more vocationally competent after apists have responded by using a variety of treatment
training. techniques and targeting a wide range of interpersonal
Gaylord-Ross et al. (1987) observed that, in addi- behaviors. In one of the first behavioral treatment
tion to learning specific laboratory tasks, students ac- efforts focusing on this population, Farkas, Sherick,
quired several generic vocational skills, such as inde- Matson, and Loebig (1981) administered braille-
pendent travel to the work site, grooming, functional coded tokens (exchangeable for backup reinforcers)
money and math skills, prosocial interactions with co- for reduced rates of stereotypic responses (tapping,
workers, and functional reading of signs at the work- rocking, and hand flapping) and poor motoric orienta-
place. These associated work skills were targeted in an tion in a 12-year-old blind girl. A multiple-baseline
investigation by I. Egan, Fredericks, and Hendrickson analysis demonstrated the efficacy of this program in
(1985). Five severely handicapped adolescents (one of modifying her maladaptive behaviors and enhancing
whom was deaf-blind) were trained to (1) respond ap- her social functioning.
propriately to co-workers, (2) independently locate the Van Hasselt and his colleagues have carried out a
series of social skills assessment and training investi- the controlling effects of treatment and overall mainte-
gations with visually impaired as well as blind multi- nance of gains at a lO-week follow-up probe.
handicapped children and adolescents (Ammerman, The social adjustment of hearing-impaired children
Van Hasselt, & Hersen, 1985; Sisson, Babeo, & Van also has been a concern of behavioral investigators in
Hasselt, 1988; Sisson, Van Hasselt, Hersen, & Strain, recent years (see Matson, Macklin, & Helsel, 1985;
1985; Van Hasselt, Hersen, Egan, McKelvey, & Sis- Van Hasselt et al., 1988). In a comprehensive review
son, 1989; Van Hasselt, Hersen, Kazdin, Simon, & of deafness and psychiatric illness, Cooper (1976)
Mastantuono, 1983). In one study, Van Hasselt et al. commented on the social isolation experienced by
(1983) employed a skills training package consisting many deaf and hearing-impaired individuals which
of direct instructions, behavioral rehearsal, modeling, "results primarily from sensory defect which directly
performance feedback, and manual guidance to im- impedes communication and social interchange, but is
prove behavioral components of assertion (direction of also the inevitable consequence of social withdrawal
gaze, posture, voice tone, requests for new behavior) which so frequently accompanies the feelings of in-
in four visually impaired female adolescents 14 to 20 feriority and social inadequacy associated with this
years of age. Subjects received 3 to 4 weeks of asser- particular form of physical disability" (p. 220).
tion training involving five 15- to 30-min sessions per Despite recommendations to implement social skills
week. As illustrated in Figure 3, a multiple-baseline interventions with the hearing-impaired (Hummel &
analysis across social skill components demonstrated Schirmer, 1984; Koetitz, 1976), few such strategies
TRAINING SCENES
Follow-up
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Baseline Social Skills Trainmg
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Probe Sessions Weeks
Figure 3. Probe sessions during baseline, social skills treatment, follow-up, and booster assessment for S1. A multiple-baseline
analysis of posture, gaze, hostile tone, requests for new behavior, and overall social skills. From "Social Skills Training for Blind
Adolescents" by V. B. Van Hasselt, M. Hersen, A. E. Kazdin, 1. Simon, and A. K. Mastantuono, 1983, Journal o!Visuallmpairment
and Blindness, 75, Fig. 1, p. 201. Copyright 1983 by the American Foundation for the Blind. Reprinted by permission.
have been carried out to date. In one investigation, evidence severe social skill deficits, social with-
Barton and Osborne (1978) employed a teacher-as- drawal, and low rates of interpersonal interaction
sisted positive practice approach to train initiation and (Wilson, 1974; Yarnall & Dodgion-Ensor, 1980). This
reciprocation of sharing (physical and verbal) in a kin- is particularly disconcerting in light of data showing a
dergarten class of five hearing-impaired children (5 to relationship between early social functioning and
6 years of age). Positive practice consisted of instruc- long-term vocational and community adjustment in
tions, modeling, and rehearsal, in which a nonsharing disabled individuals (e.g., Brolin & D'Alonzo, 1979).
student practiced verbally the role of initiator (the per- In one of the few studies specifically targeting social
son who asked another to share a toy) or the acceptor behavior in young, blind, multihandicapped children,
(the person who agreed to share). Results revealed a Sisson, Van Hasselt, Hersen, and Strain (1985) util-
threefold increase in the subjects' physical sharing of ized a peer-mediated intervention approach. Two non-
toys although verbal sharing was minimally effective. handicapped peers were trained to direct social initia-
Gains were still in effect at a 15-week follow-up. tions to handicapped participants (9 to 11 years of age),
More recently, Lemanek, Williamson, Gresham, who were mentally retarded as well as legally blind. A
and Jensen (1986) applied a multielement social skills multiple-baseline analysis across subjects indicated in-
training program (instructions, performance feedback, creased rates of social behaviors in mUltihandicapped
modeling, behavior rehearsal, social reinforcement) to children as a function of play facilitation by nonhandi-
treat specific skill deficits in four hearing-impaired capped peer trainers. Generalization probes conducted
children and adolescents, ages 11 to 18 years. The during conditions in which no treatment occurred
intervention entailed eight training sessions with role- showed a moderate transfer of treatment effects. The
play test items (assertion, giving and accepting help durability of the intervention was apparent at a 4-
and praise) employed as the vehicle for behavioral as- month follow-up.
sessment and treatment. A multiple-baseline design Sisson, Babeo, and Van Hasselt (1988) modified the
across targeted skill components (speech duration, re- above-mentioned procedure for use in a group training
sponse latency, content, smiles) indicated that skills format. In this investigation, five multihandicapped
treatment led to improved social behavior for all sub- boys (9 to 12 years of age) were trained to initiate
jects. In addition, the effects generalized to novel (un- social interactions, to respond to initiations by others,
trained) role-play scenes and a 5-min interaction with a and to maintain social interchanges during social skills
confederate. These improvements were still evident 2 "lessons" that were incorporated into the ongoing
months after termination of training. classroom curriculum. Observations in free-play set-
Beene and Beene (1980) developed a positive rein- tings revealed higher rates of social responses, and
forcement (counselor attention) program to increase lower rates of isolative behaviors with training. fur-
participation in social and recreational activities in ther, levels of social behavior displayed by the handi-
eight deaf adolescents and young adults who were re- capped subjects were found to closely approximate
siding in a halfway house facility. Five of the eight those of nonhandicapped peers in similar situations,
subjects had additional handicapping conditions (cere- thus providing social validational support for the treat-
bral palsy, epilepsy, or mental retardation) and dis- ment procedure.
played low rates of social interaction. To determine the
effectiveness of treatment, the number of participants'
social interactions for three successive weekends be- Family Adjustment
fore reinforcement were contrasted with their interac-
tion frequency on the same number of weekends fol- Families of disabled children are receiving in-
lowing intervention. A significant increase in weekend creased attention from behavioral clinicians and re-
social activities was noted after treatment was searchers. As Schilling and Schinke (1988) have
instituted. pointed out, these families "must deal with the reality
Professionals serving children and adults with dual of the child's condition and they must face a series of
sensory impairments (i.e., the deaf-blind) have con- challenges associated with the care of a handicapped
sistently articulated concerns about the problems these child. Some of these challenges are immediate and
individuals have in social adaptation (see review by overwhelming. Others develop into chronic stressors"
Sisson, Van Hasselt, & Hersen, 1987). There is a gen- (p. 90). Most investigators in this area have discussed
eral consensus that most multihandicapped children the initial reactions of parents to the diagnosis of a
disability in their child. These include shock, grief, in order to improve compliance in her 4-year-old child,
and disappointment (e.g., Froyd, 1973; Solnit, 1984). who suffered from severe developmental and physical
A disabled child also may place increased social, phys- disabilities. A multielement behavioral treatment
ical, and economic demands on the family. The com- package (direct instructions, role-playing, modeling,
plexity of teaching basic self-care skills (e.g., toilet- behavior rehearsal, performance feedback) was em-
ing, feeding, and dressing) to severely disabled ployed to teach the mother to make definitive com-
children alone is considerable. mands, provide appropriate positive attention, and
The problems of families of blind and visually im- persist with commands during social interactions with
paired children have been examined for several years her child. Results of a multiple-baseline design across
now. Froyd (1973) and others have contended that the mother's responses indicated that improvement in sit-
physical, cognitive, and emotional needs of the blind uations where toys were present or absent was a func-
child may be so great that the parents eventually be- tion of the intervention. In addition, considerable im-
come overwhelmed. Further, many parents of visually provement in the child's compliance with mother's
impaired children have been characterized as insular, commands followed introduction of parent training.
socially withdrawn, overly cohesive, and psychi- Further, positive concurrent effects included the
atrically vulnerable (Lambert & West, 1980; Sarason, child's increased time on-task and decreased opposi-
1959; Schaffer, 1964). Also, there is increasing evi- tional behavior. All gains were maintained at 6-month
dence of problem parent-child interactions occurring follow-up probes.
as early as in the blind child's infancy (see Van Hasselt, In an extension of this work, Van Hasselt, Ammer-
1987; Williams, 1968). Lairy and Covello (1973) man, and Hersen (1987) have examined social adjust-
stated that, at this point, it is particularly important for ment and family interactions in families with visually
parents to stimulate the child. However, early findings handicapped children. Specifically, the parents of vi-
attest to the neglect and rejection of some blind infants sually handicapped (VH) adolescents, aged 10-17,
upon their parents' realization of their impairment were contrasted with the parents of adolescents with
(Barry & Marshall, 1953; Blank, 1959). Typically, the spina bifida (SB) and the parents of nonhandicapped
parents' sustained anxiety, depleted energy level, and (NC) adolescents (N = 25 per group). The Marital
feelings of guilt have been implicated in such re- Interaction Coding System (MICS-III) (Hops, Wills,
sponses. Patterson, & Weiss, 1972) was used to evaluate the
As part of an ongoing program of research on blind problem-solving discussions of husband-wife dyads.
and multihandicapped children and their families, Van Preliminary data indicate few differences between VH
Hasselt and his associates (Klein, Van Hasselt, and NC families. However, marital disharmony, as
Trefelner, Sandstrom, & Snyder, 1988; Van Hasselt, reflected by increased communication deviance (e. g. ,
Ammerman, Hersen, & Moore, 1987; Van Hasselt, blaming, criticizing) appears to be greatest in SB par-
Hersen, Moore, & Simon, 1986; Van Hasselt, Sisson, ents. Similarly, Ammerman, Van Hasselt, Hersen, and
& Aach, 1987) have designed family assessment and Moore (1989) found more evidence of social dysfunc-
treatment programs specifically geared to the unique tion in SB children and parents when comparing the
problems and issues in this population. In the Parent aforementioned groups on a role-play test of interper-
and Toddler Training (PATT) project (Klein et at., sonal skill.
1988), interventions are implemented with parents to Varni and Wallander (1988) recently reviewed re-
increase their parenting skills, enhance the social research and clinical reports concerning the psycho-
sponsivity of their visually impaired or multihandicap- social functioning of families with a child with spina
ped infants, and improve their overall psychological bifida. They concluded that "while general family ad-
adjustment and the quality of family life. This is ac- justment has been investigated only descrip-
complished via a curriculum covering a wide range of tively . . . it appears that there are negative effects
topics: early child development, family reactions to a from having a child with spina bifida as a family mem-
handicapped child, social development, behavior ber" (p. 208). These effects appear to pertain particu-
management techniques, methods of enhancing infant larly to mothers of these children who have been de-
development, and conflict-resolution and problem- scribed as distressed, depressed, and socially isolated
solving skills training for parents. (Domer, 1975; Tew & Laurence, 1973; J. H. Walker,
Van Hasselt et at., (1987) initiated a training pro- Thomas, & Russell, 1971).
gram to modify a mother's behavior management skills Surprisingly little research has emerged that at-
tempts to ameliorate the problems of such family sys- Deficiencies related to hearing loss in such areas as
tems. In one of the few studies in this area, Feldman, early spontaneous mimicry and acquisition of verbal
Manella, and Varni (1983) trained four single mothers language have been associated with malformation of
of children with spina bifida (4 to 10 years of age) in the attachment bond between child and parent (Alt-
behavioral techniques in order to teach their children shuler, 1974). Cantor and Spragins (1977) contend that
seven self-help skills: putting on socks, sweeping, put- "parents need guidance in dealing with child care,
ting on pullover shirt, taking off shirt, buttoning the special needs of the hearing impaired child, devel-
blouse, controlling temper tantrums, and performing oping independence and responsibility in the child,
daily household chores. Intervention consisted of nine and specific techniques for changing behavior"
weekly 2-hour group sessions which incorporated (p. 334).
feedback, suggestions, a behavior problem manage- In one of the first applications of behavioral strat-
ment manual, an audiovisual behavioral teaching pro- egies to families with a deaf child, Mira (1972) re-
gram, and videotapes of skills training sessions by par- ported a series of case studies targeting a variety of
ents in previous efforts. maladaptive responses. For example, a mother was
Results indicated that mothers were able to success- trained in the use of extinction (turning her back and
fully train their children in the targeted self-help skills. walking away) to reduce aggressive episodes that had
Average self-help skills performance increased from been resistant to her previous disciplinary efforts. An
18% correct during baseline to 99% correct over a 5- A-B design revealed that rates of aggression dropped
month follow-up interval. Feldman et al. (1983) also from an average of three to four hits per day to zero
underscored the importance of mutual social support within 4 weeks of intervention. Gains were maintained
and advice that parents provided one another while at a 3-month follow-up. Another case involved a 3Y2-
participating in training. They also noted an improved year-old boy who refused to wear his hearing aid. The
sense of competence and control in mothers who felt a positive-reinforcement strategy initiated for this child
stronger sense of contributing to their child's develop- consisted of allowing him to watch his favorite TV
ment. shows or play his record player once each day con-
Rowley, Van Hasselt, and Hersen (1986) described tingent on wearing his hearing aid for a specified time
the Behavioral Family Treatment (BFf) program that period. Increased wearing of the hearing aid occurred
was developed to improve functioning in families con- within a week. When the approach was modified so
taining adolescents with spina bifida. In BFf, an as- that reinforcement was provided for wearing the aid
sessment battery is initially administered to identify during the previous 3 hours, the child wore the aid the
areas of difficulty in the family system. Measurement entire day.
instruments include self-report questionnaires, parent In an attempt to shift from targeting of individual
ratings, child ratings, and interviews. Assessment data deviant child behaviors to more general parent man-
are utilized for intervention in such areas as commu- agement competencies, Forehand, Chaney, and Yoder
nication and problem-solving skills, social indepen- (1974) evaluated the utility of a program developed to
dence, domestic autonomy, and assertion. Within each modify parent-child interactions. The 7-year-old deaf
of these categories, a multiple-component treatment male in this study had a history of noncompliance (run-
package (direct instructions, performance feedback, ning or turning away, tantrums, and physical re-
modeling, behavior rehearsal, role-playing) is em- sistance) in response to maternal commands. Behav-
ployed to effect behavior change in participating fami- ioral intervention involved teaching the mother to be a
lies. Single-case experimental designs and goal attain- "more effective reinforcing agent" by expanding the
ment scaling are utilized to evaluate treatment efficacy. range and frequency of her social rewards. Also, use of
The program consists offour stages: (1) family assess- parental questions and commands that were incom-
ment, (2) family treatment, (3) booster sessions, and patible with rewards were diminished. Through a com-
(4) follow-up. Booster sessions are incorporated to bination of modeling, discussions, behavioral rehears-
consolidate initial gains and to remediate any post- al, and role-playing, the mother acquired reinforce-
training response decrements. The efficacy of BFf is ment techniques not dependent on hearing (e.g.,
currently undergoing empirical verification. affectionate physical contact and smiling). This led to
The effects of a child's deafness on the family also an increase in the mother's rate of rewards and a de-
have been investigated (see Stein & Jabaley, 1981). crease in the use of questions and commands. Time-
out was employed in the latter stages of treatment to with disabled children and adolescents because of the
further suppress noncompliance. This approach re- low prevalence of many disabilities. Enhanced meth-
sulted in improved percentages of child compliance odological sophistication, on the other hand, will
and parental rewards relative to the number of child greatly enhance the heuristic value of behavioral re-
compliances. Forehand et al. (1974) reported that all search with these populations.
gains were still observed at a 3-month follow-up An additional concern for future endeavors is the
assessment. need for extended follow-up assessments. Follow-ups
of more than 6 months are rare. In fact, some investi-
gations fail to provide any data pertaining to treatment
durability. Also, the possibility of deterioration of be-
Conclusion havioral gains underscores the need for periodic boost-
er sessions to ensure long-term positive change
There has been a substantial increase in behavioral (Hersen, 1981). This strategy is particularly pertinent
research with physically disabled and multihandi- with severely disabled individuals who may be highly
capped children and adolescents. Significant gains in resistant to behavior change efforts.
application of behavioral interventions have been Another relevant issue is generalization of treatment
made, particularly in the areas of behavior manage- effects. Relatively few investigations have examined
ment and social skills training. However, behavioral the transfer of improvements to other settings or across
efforts with these populations clearly are at the nascent conditions. Several studies, however, have clearly
stage. Indeed, far more empirical attention has been shown that generalization of treatment gains may not
directed toward children with developmental dis- occur unless specific steps are taken to maximize
abilities. Continued investigation is needed to expand transfer of newly learned behaviors (Parrish et al.,
the behavioral treatment strategies developed to date in 1985). In response to these findings, some investiga-
the areas reviewed in this chapter. In particular, future tors have incorporated procedures that are designed to
work should emphasize improved methodological promote generalization (Slifer et al., 1986). These
rigor in treatment outcome studies. Shortcomings in efforts are necessary if behavioral interventions are to
experimental design have limited the utility of much of have a positive impact across disparate settings. Future
the research that has been conducted. For single-case outcome studies also should direct attention to en-
designs, it is imperative that the controlling effects of vironmental factors that inhibit (e.g., lack of con-
the interventions be demonstrated. Multiple-baseline sistency) and promote (e. g., parent training) gener-
and, where appropriate, reversal designs are superior alization of gains in disabled children.
to A-B designs in achieving this objective. Several researchers have stressed the need to assess
With regard to group research, a variety of meth- collateral behaviors throughout treatment and follow-
odological concerns need to be addressed. First, ap- up (Rojahn et al., 1987; Singh etal., 1986). Such data
propriate control groups must be utilized. Although it would have potential value in revealing additional ben-
is often difficult to identify adequate control popula- efits of treatment as well as any negative side effects.
tions given the differences in etiology and manifesta- Further, some studies have attempted to socially vali-
tions of disabilities, several studies have utilized both date treatment impact (see Luiselli, 1986; Tiernery,
disabled and nondisabled samples. Use of disabled 1986). Inclusion of social validational procedures is
control groups may permit determination of difficul- important to ascertain (1) the clinical as opposed to
ties that transverse disabilities as well as those that are "statistical" significance of findings, and (2) the ac-
specific to a particular disorder. Second, it is important ceptability and appropriateness of behavioral interven-
to match groups on relevant variables, such as age, tions to staff and family members. The latter issue is
gender, SES, IQ, and level of impairment. Further, particularly salient given the negative reactions to
researchers should investigate more homogeneous dis- aversive approaches sometimes expressed by profes-
abled groups rather than combining children who vary sionals and parents.
in terms of type of impairment, extent of disability, and A topic that has received relatively little investiga-
age of onset. It is acknowledged, however, that the tion with physically disabled children is the incidence
above methodological criteria frequently are ex- of emotional problems, especially internalizing disor-
tremely difficult to meet when conducting research ders. Despite preliminary data suggesting elevated
rates of anxiety and depression in disabled children Altman, K., Haavik, S., & Higgins, S. T. (1983). Modifying the
and adolescents (see reviews by Ammerman et al., self-injurious behavior of an infant with spina bifida and di-
minished pain sensitivity. Journal of Behavior Therapy and
1985; Ammerman & Van Hasselt, 1987; Matson & Experimental Psychiatry, 14, 165-168.
Helsel, 1986; Van Hasselt, Ammerman, & Sisson, Altmeyer, B. K., Williams, D. E., & Sams, V. (1985). Treat-
1988), behavior therapists have yet to empirically eval- ment of severe self-injurious and aggressive biting. Journal of
uate these problems. This requires the development of Behavior Therapy and Experimental Psychiatry. 16. 159-
167.
assessment strategies to measure the incidence and Altshuler, K. Z. (1974). The social and psychological develop-
forms of internalizing disturbances in these children. ment of the deaf child: Problems, their treatment and preven-
Then, behavioral approaches that are effective with tion. American Annals of the Deaf. 119. 365-376.
Ammerman, R. T., & Van Hasselt, V. B. (1987). The handi-
nondisabled children could be adapted or modified for
capped adolescent. In V. B. Van Hasselt & M. Hersen (Eds.),
use with physically disabled populations (see Hersen, Handbook of adolescent psychology (pp. 413-423). New
1989). York: Pergamon Press.
Finally, there is an urgent need for increased and Ammerman, R. T., Van Hasselt, V. B., & Hersen, M. (1985).
Social skills training for visually handicapped children: A
expanded training in behavioral assessment and treat- treatment manual. Psychological Documents. 15. 6(MS. no.
ment methods with professionals and paraprofes- 2684).
sionals who work with disabled children. Various ser- Ammerman, R. T., Van Hasselt, V. B., Hersen, M., & Moore,
vice providers are involved in evaluation and L. E. (1989). Assessment of social skills in visually impaired
adolescents and their parents. Behavioral Assessment, 11,
intervention with disabled children, including special 327-351.
educators, psychologists, psychiatrists, rehabilitation Azrin, N. H., & Armstrong, P. M. (1973). The "mini-meal"-
counselors, nurses, and child development specialists. A method for teaching eating skills to the profoundly retarded.
Mental Retardation. 11. 9-13.
These individuals differ considerably with regard to Azrin, N. H., Bugle, C., & O'Brien, F. (1971). Behavioral
their expertise in the use of behavioral strategies. All engineering: Two apparatuses for toilet training retarded chil-
too often, professional training programs do not in- dren. Journal of Applied Behavior Analysis. 4. 249-253.
clude any instruction in the use of behavioral methods. Azrin, N. H., Schaeffer,R. M., & Wesolowski, M. D. (1976). A
rapid method of teaching profoundly retarded persons to dress
Typically, the individual must acquire "on the job by a reinforcement-guidance method. Mental Retardation.
skill," usually with inadequate supervision. All of 14,29-33.
these specialties, however, would benefit from train- Bailey, 1., & Meyerson, L. (1969). Vibration as a reinforcer with
a profoundly retarded child. Journal of Applied Behavior
ing in behavioral assessment and treatment techniques
Analysis, 2. 135-137.
for use with disabled children. It is anticipated that Bailey, 1. S. (1981). Wanted: A rational search for the limiting
such a background could do much to promote more conditions of habilitation in the retarded. Analysis and Inter-
effective mental health and educational services. vention in Developmental Disabilities. 1. 45-52.
Barlow, D. H., & Hersen, M. (1984). Single case experimental
designs: Strategies for studying behavior change (2nd ed.).
ACKNOWLEDGMENTS. Preparation of this chapter was New York: Pergamon Press.
facilitated in part by grant No. 0008720109 from the Barrett, B. H. (1962). Reduction in rate of multiple tics by free
National Institute on Disabilities and Rehabilitation operant conditioning methods. Journal ofNervous and Mental
Disease. 135. 187-195.
Research, U. S. Department of Education, and a grant Barrett, R. P., Matson, 1. L., Shapiro, E. S., & Ollendick, T. H.
from the Vira I. Heinz Endowment. However, the (1981). A comparison of punishment and DRO procedures for
opinions expressed herein do not necessarily reflect treating stereotypic behavior of mentally retarded children.
Applied Research in Mental Retardation. 2. 247-256.
the position of policy of the U. S. Department of Edu- Barry, H., & Marshall, F. E. (1953). Maladjustment and mater-
cation or the Vira I. Heinz Endowment, and no official nal rejection in retrolental fibroplasia. Mental Hygiene. 37.
endorsement should be inferred. The authors wish to 570-580.
thank Mary Jo Horgan for her assistance in preparation Barton, E. 1., & Osborne, 1. G., (1978). The development of
classroom sharing by a teacher using positive practice. Behav-
of the manuscript. ior Modification. 2. 231-250.
Bates, P., Renzaglia, A., & Wehman, P. (1981). Characteristics
of an appropriate education for severely and profoundly handi-
capped students. Education and Training of the Mentally Re-
tarded. 16, 142-149.
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Mastantuono, A. K. (1983). Training blind adolescents in Wallander, 1. L., & Hubert, N. C. (1987). Peer social dysfunc-
social skills. Journal of Visual Impairment and Blindness, 77, tion in children with developmental disabilities: Empirical
199-203. basis and a conceptual model. Clinical Psychology Review, 7,
Van Hasselt, V. B., Hersen, M., Moore, L. E., & Simon, 1. 205-221.
(1986). Assessment and treatment of families with handi- Weeks, M., & Gaylord-Ross, R. (1981). Task difficulty and
capped children: A project description. Journal of Visual Im- aberrant behavior in severely handicapped students. Journal of
pairment and Blindness, 80, 633-635. Applied Behavior Analysis, 14, 449-463.
Van Hasselt, V. B., Ammerman, R. T., Hersen, M., & Moore, Westervelt, V. D., & Luiselli, 1. K. (1975). Establishing stand-
L. E. (1987). Interactions and marital adjustment in parents of ing and walking behavior in a physically handicapped, re-
visually handicapped adolescents. Unpublished manuscript, tarded child. Physical Therapy, 7, 761-765.
University of California, Irvine. Whitney, L. R., & Barnard, K. E. (1966). Implications of oper-
Van Hasselt, V. B., Sisson, L. A., & Aach, S. R. (1987). Parent ant learning theory for nursing care of the retarded child.
training to increase compliance in a young multihandicapped Mental Retardation, 4, 26-29.
child. Journal ofBehavior Therapy and Experimental Psychi- Williams, C. E. (1968). Behavior disorders in handicapped chil-
atry, 18, 275-283. dren. Developmental and Medical Child Neurology, 10, 736-
Van Hasselt, v. B./ Ammerman, R. T., & Sisson, L. A. (1988). 740.
Psychological therapies for sensory impaired children and Wilson, D. A. (1974). Teaching multiply handicapped blind
youth. In 1. L. Matson (Ed.), Handbook of treatment ap- persons in a state hospital. New Outlook for the Blind, 68,
proaches in childhood psychopathology (pp. 555-586). New 337-343.
York: Plenum Press. Wuerch, B., & Voeltz, L. (1982). Longitudinaiieisure skills for
Van Hasselt, V. B., Strain, P. S., & Hersen, M. (Eds.). (1988). severely handicapped learners: The Ho' onanea curriculum
Handbook of developmental and physical disabilities. New component. Baltimore, MD: Paul H. Brookes.
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Van Hasselt, V. B., Hersen, M., Egan, B. S., McKelvey, 1. L., tive reinforcers for a multiply handicapped student. Education
& Sisson, L. A. (1989). Increasing social interactions in deaf- of the Visually Handicapped, 12,11-20.
CHAPTER 40
Habit Disorders
Vincent J. Adesso
Knight Dunlap, in his book, Habits: Their Making and well. Despite these negative consequences, the behav-
Unmaking (1932), is credited with being the first thera- iors are continued.
pist to use the term habit disorder. He viewed habits as This chapter reviews the behavioral treatment liter-
fixed, stereotyped responses acquired through learn- ature on thumbsucking and nailbiting, and, briefly, on
ing. In his book, he articulated a theory based on prin- trichotillomania. These habits were selected because
ciples of learning to explain the development and the treatments involved in their alleviation are repre-
maintenance of habits and a treatment for eliminating sentative ofthose used with other habit disorders, such
them. He construed habit disorders as behavior pat- as tics, pica, and tantrums. Other disorders, such as
terns that are detrimental to the individual and that can Gilles de la Tourette's syndrome, stuttering, enuresis,
be modified through relearning. The behaviors he and encopresis, nave also been dealt with using these
described as amenable to treatment by his method approaches, as well as with other, more specialized
of negative practice were wide ranging and included techniques. For each disorder, the review will begin
stuttering, nailbiting, daydreaming, inattention, tics, with information on its prevalence, typical treatment
thumbsucking, masturbation, and homosexuality. populations, and target responses for treatment. The
Dunlap saw these various behaviors linked by their behavioral intervention literature will then be re-
common foundation in learning and relearning. In cur- viewed. The chapter will conclude with an overview of
rent nosologic practice, as indicated, for example, by the current status of the behavioral treatment of habit
the Diagnostic and Statistical Manual of Mental Dis- disorders.
orders (DSM-III-R, American Psychiatric Associa-
tion, 1987), some of these disorders fall under a
number of different diagnostic categories whereas oth- Nailbiting
ers are not even included. What they continue to have
in common from Dunlap's day to the present is that, to Of a sample of 3,000 children, over one quarter
some extent, they have all been construed as learned engaged in chronic nail biting (Wechsler, 1931). Mas-
and susceptible to modification through behavioral sIer and Malone (1950) and Birch (1955) found that
treatment techniques. These learned habits all evoke 41 % of 4,587 children and 51 % of 4,223 children,
distress from others and, often, from the individual as respectively, bit their nails. Among college students,
surveys indicate that between 25% and 36% habitually
Vincent J. Adesso • Department of Psychology, University bite their nails (Coleman & McCalley, 1948; Smith,
of Wisconsin-Milwaukee, Milwaukee, Wisconsin 53201. 1957; Vargas & Adesso, 1976). Thus, nailbiting is a
857
prevalent behavior among children, adolescents, and 1970). Varying degrees of success were reported,
adults. which led to the conduct of more controlled studies on
Children are rarely brought into treatment for nail- aversive contingencies. For example, Vargas and Ade-
biting, probably because the behavior is viewed as one sso (1976) compared four groups (shock, negative
that will remit with age. In fact, only two case studies practice, bitter substance, and attention-placebo con-
involving behavioral approaches to treatment of nail- trol) in which half the subjects self-monitored and half
biting among preadolescent children were located did not. All groups experienced increases in nail
(Azrin & Nunn, 1973; Barmann, 1979). Nailbiting is length, but the groups did not differ. However, self-
particularly likely to attract therapeutic attention if it monitoring subjects exhibited greater increases in nail
occurs in conjunction with other habitual behaviors length than non-self-monitoring subjects. Similarly,
(e.g., DeLuca & Holborn, 1984). As the individual Davidson and Denny (1976) obtained equivalent re-
moves into adolescence and adulthood, the desires to sults for information and covert sensitization groups.
have better looking nails and to avoid the embarrass- The consistent failure to find differential treatment ef-
ment occasioned by the act of nailbiting, as well as fectiveness led some investigators to examine the role
possible dental problems, probably increase moti- of nonspecific treatment factors. Adesso et al. (1979)
vation for treatment (Smith, 1957). Therefore, most of compared the role of self-monitoring (with positive
the literature focuses on the alteration of nailbiting and negative incentives) to that of therapist contact,
behavior in adolescents and adults, and most studies and interpreted the lack of group differences in nail
use some combination of these popUlations. Hadley length at follow-up to indicate that the attention to
(1984) has written an overview of all aspects of the one's nails, occasioned by self-monitoring plus mini-
nailbiting literature. mal therapist attention, were the effective ingredients
Nailbiting has been operationalized as including not in treatment. Azrin, Nunn, and Frantz (1980) deline-
only those occasions in which a biting response is actuated the components responsible for the improvements
ally performed, but all instances in which a finger is found in prior research as heightened awareness of
inserted between the lips in such a way that contact nailbiting (either through increased attention to one's
between a fingernail and one or more teeth is estab- own nails or through contact with a therapist for mea-
lished (Adesso, Vargas, & Siddall, 1979). A variety of surement or other treatment regimen) and the expecta-
indices of change have been utilized. These include tion of treatment benefit.
frequency of nailbiting episodes or number of nails One reaction to this failure to find differential suc-
bitten, measures of nail growth or length, and nail cess rates for single treatments has been to investigate
appearance. Smith (1957) developed a scheme for rat- the effectiveness of minimal therapist contact treat-
ing nailbiting severity. 1\vo studies (Davidson, Denny, ments through the use of self-help manuals. Glasgow
& Elliott, 1980; Frankel & Merbaum, 1982) also mea- et al. (1981) compared two commercially published
sured self-control. Outcomes with these various in- t:reatment manuals (Azrin & Nunn, 1977; Perkins &
dices have proved them to yield highly consonant re- Perkins, 1976) with a self-monitoring only control
sults (e.g., Adesso et al., 1979; Frankel & Merbaum, condition. The three treatments were either self- or
1982, Horan, Hoffman, & Macri, 1974; Vargas & Ad- therapist-managed. Although substantial reductions in
esso, 1976). Kazdin (1977) has indicated the impor- nailbiting were obtained, there were no differences
tance of socially validating the results of treatment among groups at posttreatment or follow-up either in
outcome through normative comparisons and change nailbiting frequency or in satisfaction with the treat-
ratings. Most of the work with behavioral treatments of ments. Frankel and Merbaum (1982) evaluated Azrin
nailbiting, evaluating as it does changes in behavior and Nunn's (1977) self-help treatment manual across
and cosmetic appearance, as well as reactions from three therapist-contact conditions: weekly, individual
significant others, appears to have implied but not meetings; weekly, brief phone calls; and, no therapist
given explicit evidence of its social validity. The liter- contact. Again, all groups improVed in nail length,
ature contains few reports of subject satisfaction with cosmetic appearance, and self-control scale scores,
treatment (e.g., Glasgow, Swaney, & Schafer, 1981). but the groups did not differ. Frankel and Merbaum
Early case studies investigated the efficacy of a vari- (1982) did point out, however, that the group that met
ety of aversive contingencies to suppress nailbiting weekly with the therapist haJ the highest number of
(e.g., Butcher, 1968; Smith, 1957; Stephen & Koenig, people who stopped nailbiting at both posttreatment
CHAPTER 40 • HABIT DISORDERS 859
and follow-up. Unfortunately, neither of these studies At posttreatment and 6-month follow-up, all subjects
reported whether the subjects in the no-contact condi- evidenced substantial gains in nail length. A third case
tions knew whether they would be returning for eval- study of a 9-year-old retarded female by Barmann
uation at posttreatment and follow-up. (1979) evaluated the application of artificial nails and
A second, and related, reaction to absence of differ- two types of overcorrection (Foxx, 1976): positive
ential outcomes across different treatments was a shift practice in which the hands are raised to the lips, with-
to the use of treatment packages. The treatment pack- out actual contact, then lowered to the side and folded
age that has attracted the most research attention is the for 2 sec; and, restitution, which promptly follows
habit reversal method developed by Azrin and Nunn positive practice and involves immediate grooming of
(1973, 1977). This approach, derived from an operant a bitten nail and all remaining nails as well as the nails
framework, was originally developed to treat the au- of another person. Nail length was increased and biting
tistic behavior of retarded children who exhibited un- nearly eliminated after 3 weeks of treatment; these
desirable oral habits (Azrin, Kaplan, & Foxx, 1973; changes were maintained at a 1O-week follow-up. De-
Foxx & Azrin, 1973) but has subsequently been ap- Luca and Holborn (1984) sequentially applied relaxa-
plied to a variety of habit disorders, including nailbit- tion training and the competing response training com-
ing. The habit reversal method consists of 13 compo- ponent of the habit reversal package to a 17-year-old
nents, all of which have frequently been administered female who engaged in hair pulling and nailbiting.
in a single session of about 2-hours duration. The com- Although the relaxation proved ineffective, the com-
ponents are: (1) competing response training, in which peting response training produced a nearly immediate
the subject pairs an inconspicuous competing re- elimination of both behaviors, which was maintained
sponse, such as grasping or clenching the fists, with over a 2-year follow-up. In a conceptually similar
the habit; (2) awareness training, in which the subject study, Barrios (1977) found that, using cue-controlled
self-observes in a mirror to increase awareness of the relaxation as a competing response, nailbiting was
specific movements involved in the habit; (3 & 4) iden- substantially reduced in two adults. These subjects
tifying response precursors and habit -prone situations; maintained the reductions at follow-up and also re-
(5) relaxation training; (6 & 7) habit prevention and ported using the competing response in situations un-
interruption training, in which the competing response related to nailbiting.
is immediately practiced for 3 min whenever the habit The habit reversal method has also been evaluated in
might or does occur; (8) positive attention overcorrec- a number of controlled studies. Nunn and Azrin (1976)
tion, in which the subject practices a positive and relat- compared a habit reversal group with a waiting list
ed alternative to the habit (such as grooming the nails); control group. All habit reversal subjects stopped bit-
(9) daily practice of the competing reaction in front of a ing; however, follow-up data were available for less
mirror; (10) self-recording of both impulses and in- than half the subjects, and some of these had tempo-
stances of the habit; (11) display of improvement by rary relapses. Azrin, Nunn, and Frantz (1980) com-
entering habit-prone situations; (12) social support, in pared habit reversal with negative practice. Over a 5-
which a significant other is taught positive ways to month follow-up, negative practice yielded a 60% re-
encourage and remind the subject to stop the habit; and duction in nailbiting episodes while habit reversal pro-
(13) annoyance review, in which the problems caused duced a 99% reduction. In addition, about 40% of the
by the habit are reviewed to increase motivation and to habit reversal subjects had eliminated nailbiting com-
identify sources of reinforcement. pared to 15% of the negative practice subjects.
Habit reversal has been employed in several case Ladouceur (1979) compared self-monitoring, habitre-
studies. In one of their early case studies on the habit versal, and daily graphing of nailbiting and found the
reversal method, Azrin and Nunn (1973) found that treatments equally effective in reducing nailbiting.
nailbiting was eliminated after a single day of treat- Home and Wilkinson (1980) compared four groups of
ment in three adults and one child. However, one adult subjects to evaluate the effectiveness of the competing
discontinued the treatment. The remaining subjects response (fist clenching) and positive practice (nail
apparently maintained the gains over a several month grooming) components of the habit reversal package
follow-up. In another case study, Delparto, Aleh, and the use of on-going nail-length target goals. Their
Bambusch, and Barclay (1977) applied the habit rever- four groups were: a competing response plus positive
sal method over a period of 8 weeks to three subjects. practice group; a habit reversal, positive practice, and
on-going target goals group; a positive practice and on- tained superior results to those who received the sup-
going target goals group; and, a waiting list control pression training. The subjects who received both
group. Subjects in all four groups were instructed to forms of training did better than those who received
self-monitor nailbiting and had minimal therapist con- only suppression training but not as well as those who
tact. At posttreatment, the control group improved less received only substitution training. The results were
than the treatment groups, which did not differ from interpreted as supporting the notion that the suppres-
each other. However, at 8-week follow-up, the habit- sion of maladaptive behavior is not sufficient to pro-
reversal-only group (competing response plus positive duce enduring change. An alternative response ap-
practice) had the smallest number of relapses and the pears to be a necessary component.
on-going target goals group had the largest. These re-
sults suggest that, although the competing response
and positive practice elements of the habit reversal Summary
procedure may not be the essential ingredients for
elimination of nailbiting, they are superior to the use of The major conclusion from the foregoing is that
on-going target goals and to no treatment. Finally, nailbiting can be successfully suppressed in nearly all
adults with a variety of habit disorders were compared people and eliminated in a sizeable percentage of them
in a study by Miltenberger and Fuqua (1985). A group with simple, economical behavioral treatments. Three
of subjects trained to use a competing response con- other conclusions seem apparent from this review of
tingent on the occurrence of the habit was contrasted the literature. First, nonspecific awareness factors play
with a group trained to use the competing response an important role in the reduction of nail biting behav-
noncontingently. The contingent competing response ior. These nonspecific factors seem to include atten-
group, which also received awareness training, evi- tion to the nail biting act, attention from a therapist or
denced greater reductions in the habits, including na- involvement in a treatment program, and an expecta-
ilbiting. Two of the subjects in the noncontingent tion of benefit from treatment. It may be that engaging
group were subsequently given contingent competing in some alternative activity, whether it be simple
response training, and their habits were further re- graphing or self-monitoring or some incompatible
duced. One of these individuals was a nailbiter, who competing response, is also a necessary ingredient in
evidenced a complete suppression of nail biting 6 successful treatment. Thus, future research will cer-
months after the termination ofthe contingent compet- tainly need to include controls for these nonspecific
ing response training. factors to demonstrate the superior efficacy of any
Another package treatment, composed of both sub- treatment regimen. Second, package treatments, par-
stitute skill training and training in suppression skills, ticularly the habit reversal method with its emphasis on
shares many elements with habit reversal (Davidson et substituting alternative responses for maladaptive
aI., 1980). This package and its components were as- ones, on awareness training, and on reinforcement of
sessed by comparing five groups: a combined substitu- change, appear to hold greater promise for completely
tion and suppression group; a substitution group; a eliminating nailbiting than single-component treat-
suppression group; a placebo control group; and a ments. Isolation of the important change ingredients in
waiting list control group. Substitution training sub- this package seems like a worthwhile endeavor. How-
jects received instruction in a variety of behaviors that ever, as only Glasgow et al. (1981) have given some
could serve as alternatives to nailbiting, including re- indication of client satisfaction with habit reversal for
laxation, hand and finger exercises, hand massage, nailbiting, its social validity can only be inferred.
nail care, and self-reinforcement. The suppression Third, treatment efficacy cannot be evaluated simply
training consisted of stimulus control techniques, aver- in terms of reductions in nailbiting but must also in-
sive imagery, negative self-verbalization, and self- clude assessment of nailbiting cessation. Although the
punishment. All treatment groups evidenced gains habit reversal method has resulted in the highest
compared to the waiting list control group. As this number of subjects who cease nailbiting, the actual
comparison included the placebo control group, the cessation figure could certainly be improved. David-
importance of nonspecific factors in the treatment of son et al. (1980) have noted that nailbiting may bear
nailbiting is again suggested. In addition, subjects who more similarity to addictive behaviors, such as smok-
received a treatment with the substitution training ob- ing, drinking and overeating, than was originally con-
ceived. If this is the case, future research may be prof- done exclusively with children, probably because of
itably addressed to strategies for the prevention of its low frequency among adults. Also, compared to
relapse. nailbiting, treatments for thumbsucking are not self-
managed but are administered by parents, teachers,
siblings, therapists, and dentists. Finally, like nailbit-
Thumbsucking ing, thumbsucking frequently occurs in conjunction
with other maladaptive behaviors (e.g., Azrin, Nunn,
Of a sample of 482 children, aged 6 to 12, some & Frantz-Renshaw, 1980; Friman & Hove, 1987).
10% engaged in thumb- or finger-sucking activity A number of aversive treatments have been applied
(Lapouse & Monk, 1958). Honzik and McKee (1962) to thumbsucking. A common example of this tech-
observed these behaviors among 42% of 2-year-olds, nique is the application of bitter-tasting substances
46% of 3-year-olds, and 37% of 4-year-olds. Lichstein (e.g., Ross, 1975). Azrin, Nunn, and Frantz-Renshaw
(1978) found a decreasing incidence from about 20% (1980) have noted the lack of success with this ap-
at age 5 to about 5% at age 10. No prevalence figures proach, yet Friman and Hove (1987) have recently
were found for adults; however, one report (Azrin, reported success with it in two children. A method
Nunn, & Frantz-Renshaw, 1980) noted that three widel y viewed as successful is the insertion of a palatal
adults applied for treatment. Thumbsucking is ex- arch or crib that may include spurs to discourage
pected to decrease with age, and some researchers thumbsucking. Haryett, Hansen, and Davidson (1970)
have not viewed it as a serious problem in young chil- reported that the palatal crib with spurs eliminated
dren even though it is considered socially undesirable. thumbsucking in nearly all children if worn for more
However, thumbsucking after age 4 has been associ- than 6 months. They added, however, that the crib
ated with dental problems (Wright, Schaefer, & Sol- produced emotional problems and difficulties in
omons, 1979), and, the longer a child continues the speech and eating.
habit after the age of 6 and the development of perma- Several early case studies used the withdrawal of
nent teeth, the greater the risk of a number of types of reinforcement contingent on thumbsucking, a form of
serious dental malocclusions (Lichstein, 1978). time-out, and demonstrated stimulus control of thumb-
Thumbsucking may also interfere with, and preclude, sucking. Among these studies, which were conducted
other activities, especially speech, and may evoke in a variety of settings and using similar reinforcers,
negative attention from peers and family. Therefore, it were those of Baer (1962; laboratory setting, cartoon
is not surprising that parents would have considerable presentation), Bishop and Stumphauzer (1973; labora-
interest in the elimination of this habit. tory setting, cartoon presentation), and Ross (1975;
Thumb- or finger-sucking behavior has been defined home setting, withdrawal of television viewing by
as any contact of any portion of the thumb or finger parents).
with the lips or mouth. This behavior has been mea- Other early case studies demonstrated stimulus con-
sured primarily in terms of frequency of occurrence. trol of thumbsucking through differential reinforce-
Azrin, Nunn, and Frantz-Renshaw (1980) have noted ment of other behavior (DRO) in a number of settings
that this is possibly because parents and other socializ- and with a variety of reinforcers. DRO is a reinforce-
ing agents tend to interrupt the behavior immediately ment schedule for not responding. Reinforcement is
upon detecting it. However, one study (Lichstein & given when the subject has not made the target re-
Kachmarik, 1980) did use duration of sucking as the sponse for some specified period of time. In escalated
dependent measure. In addition, H. Hughes, A. DRO, consistent increases in the length of the interval
Hughes, and Dial (1979) used litmus paper (which required for reinforcement are used. In the home set-
reacts with a color change to saliva) affixed to the ting, Knight and McKenzie (1974) and Kauffman and
thumb with adhesive tape to detect thumbsucking. Scranton (1974) used reading by parents contingent on
Most studies note both suppression and elimination the absence of thumbsucking to suppress thumbsuck-
rates, and several have evaluated generalization and ing. In the classroom setting, classmates of the target
social validation of treatment. child were reinforced for the absence of thumbsucking
A wide variety of treatments has been proposed and in the target child (Ross & Levine, 1972) or for detect-
attempted with thumbsucking. In contrast to the work ing thumbsucking by the target (Ross, 1974). Teacher
on nailbiting, the work on thumb sucking has been attention contingent on behaviors incompatible with
thumbsucking has also been reported (Skiba, Pet- their hair and fondled their bed clothing during thumb-
tigrew, & Alden, 1971). Other social and material rein- sucking, these habits were eliminated along with
forcers have been shown to exercise stimulus control thumbsucking.
over thumb sucking (e. g., praise and stars, Kauffman The negative side effects, as well as the maintenance
& Scranton, 1974; candy, Hughes et ai., 1979; Repp, and generalization effects, of DRO were compared
S. M. Deitz, & D. E. Deitz, 1976). Infrequent checks with those of habit reversal in an ambitious and well-
on such factors as generalization to other settings, the designed controlled study by Christensen and Sanders
reactions of the children to the treatments, and the (1987). Thirty children were randomly assigned to
durability of changes limit the conclusions that can be habit reversal, DRO, or waiting list control groups.
drawn from these studies. Parents were trained in groups to administer these
Lowitz and Suib (1978) employed an escalated treatments. Parents and trained observers monitored
DRO procedure in a reversal design to eliminate thumb sucking and oppositional behavior in three sepa-
thumbsucking in an 8-year-old girl. Treatment was ini- rate home settings. The groups did not differ at base-
tiated in a clinic setting, where the therapist reinforced line. At the 3-month follow-up, the waiting list group
intervals of increasing duration with pennies while the did not decrease thumb sucking , but the DRO and habit
girl watched television. Thumbsucking was elimi- reversal groups did. However, the two latter groups did
nated. Reversal was instituted, and thumb sucking re- not differ in degree of reduction, suggesting the pos-
turned to near-baseline levels. Next, while still in the sibility that nonspecific factors operate in treatments
clinic, the mother began to administer the rewards to for thumbsucking as in those for nailbiting. Thumb-
facilitate generalization to the home setting. The moth- sucking was eliminated in few of the children in either
er then transferred the DRO procedure to television treatment group. Both treatment groups evidenced
watching at home. Throughout treatment, thumb suck- generalization from the training setting to the other two
ing was also monitored in an additional setting, bed- settings at posttreatment and at follow-up. At posttreat-
time story reading. In the home setting, thumbsucking ment' children from the treatment groups showed an
occurred only a few times, and DRO was reinstituted increase in oppositional behavior, which was no longer
briefly. The results suggested that, although the bed- present by the time of the follow-up. Based on parents'
time thumbsucking took longer than did the daytime responses to a social validation questionnaire, the au-
thumbsucking, both were eliminated within 2 months thors concluded that habit reversal may have an edge
of the transfer to the home setting and remained so at over DRO in that parents considered it to be more of a
12-month follow-up. It is interesting to note that this collaborative endeavor and viewed it as associated
child had unsuccessfully used an oral device for 3 with fewer negative side effects than the DRO
months prior to treatment with DRO. procedure.
Lichstein and Kachmarik (1980) employed an esca- Azrin and Nunn (1973) reported the elimination of
lating DRO procedure in a multiple-baseline design thumbsucking in two children with the habit reversal
across three settings with two children. The interven- method; but the follow-up data they provided are un-
tions occurred at home and at school and were admin- clear. Azrin, Nunn, and Frantz-Renshaw (1980) com-
istered by parents and teachers. Thumbsucking was pared 18 children in a habit reversal program with 14 in
suppressed in both children in all settings during peri- a control treatment consisting of the application of a
ods when the contingencies were in effect. However, bitter-tasting substance. Habit reversal children and
at follow-up, thumbsucking had returned to baseline their parents were instructed in the procedure during a
levels in all situations for both children. In addition, single session. Control parents were instructed by tele-
one of the children evidenced an increase in opposi- phone. Habit reversal children had a mean reduction of
tional behaviors during treatment. An increase in 89% over an up to 20-month follow-up; control chil-
other, undesirable behaviors has been noted by other dren had a mean reduction of 34% to 44% over a 3-
authors who attempted to treat thumbsucking (e.g., month follow-up. In addition, at the 3-month follow-
Doke & Epstein, 1975; K. Ottenbacher & M. Otten- up, 47% of the habit reversal children had eliminated
bacher, 1981). This finding is in striking contrast to thumb sucking compared to 10% of the control chil-
that of Haryett, Hansen, and Davidson (1967), who dren. These findings suggest that the habit reversal
claimed that in no child in their sample was suppres- method is successful in reducing thumbsucking. How-
sion of thumbsucking accompanied by an increase in a ever, as no reliability data on the observations were
substitute problem. In fact, for children who twisted obtained, these results must be viewed with caution.
No generalization or social validation data were pro- prevention method and various techniques of restraint
vided. Three studies examined the use of a part of the fading. In the first study, feedback about performance,
habit reversal procedure, overcorrection, to reduce reinforcement (praise and candy for wearing the re-
thumbsucking (Doke & Epstein, 1975; Freeman, straint and not thumbsucking), and response cost con-
Moss, Somerset, & Ritvo, 1977; K. Ottenbacher&M. tingencies (loss of television viewing time for removal
Ottenbacher, 1981). All reported success with this ap- of the restraint or thumbsucking) were used in addition
proach. However, as noted above, two of them (Doke to the restraint. Restraint began with a boxing glove,
& Epstein, 1975; K. Ottenbacher & M. Ottenbacher, gradually switched to absorbent cotton, followed next
1981) reported negative side effects in conjunction by a fingertip bandage, and concluded with no re-
with this technique. Perhaps the aversiveness of the straint. At posttreatment and 2-year follow-up, thumb-
particular overcorrection techniques used contributed sucking was completely absent. In the subsequent
to this finding. For example, Doke and Epstein's three studies, they demonstrated that the reinforce-
(1975) overcorrection consisted of briskly brushing ment and response cost contingencies without re-
the child's teeth for 2 min with undiluted Listerine. sponse prevention were not sufficient to eliminate
Nonetheless, negative side effects may be sequelae to thumbsucking, that less restrictive restraints worked as
the treatment of thumb sucking through habit reversal. well as more restrictive ones, and that fading (as op-
In some children, thumbsucking occurs primarily or posed to abrupt removal of) the restraint appears
exclusively at night. The treatment that has been most important for some children. The parents of the chil-
used with nocturnal thumbsucking is response preven- dren in these four studies were reportedly pleased with
tion. This procedure involves using some form of the technique and the results. Thus, the combination of
physical restraint to prevent the behavior and, then, reinforcement and response cost contingencies with
gradually fading the restraint. For example, Garliner response prevention appears to be a highly effective
(1976) wrapped the arm with an elasticized bandage. method for eliminating nocturnal thumbsucking. Its
Also, the use of the palatal crib with spurs might repre- utility for daytime thumb sucking may be more difficult
sent a form of response prevention (Haryett et al., to assess unless an unobtrusive restraint can be devel-
1970), as might the taped strip of litmus paper used by oped. However, Krumboltz and Krumboltz (1972)
Hughes et al. (1979). Lassen and Fluet (1978) reported provided an anecdotal report of a child who used part
an early use of response prevention. In their case study of a popsicle stick taped to his thumb to eliminate
of a 10-year-old girl who sucked her right thumb while daytime thumb sucking.
sleeping, they unsuccessfully tried to use a commer-
cial substance to inhibit thumbsucking. They followed
this with the use of a thin cotton glove worn on the Summary
girl's right hand while she slept. Thumbsucking was
eliminated in 3 weeks and was maintained at 12-month The behavioral treatments developed thus far have
follow-up. However, no independent assessments consistently proved effective in suppressing thumb-
were obtained. Using a reversal design, Lewis, Shil- sucking. However, there is conflicting evidence about
ton, and Fuqua (1981) employed two forms of reside effects and consumer satisfaction. Nevertheless,
sponse prevention and reinforcement contingent on habit reversal (for daytime thumb sucking) and re-
compliance to eliminate nocturnal thumbsucking. The sponse prevention (for nocturnal thumbsucking) ap-
first response prevention technique involved having pear to have good elimination rates. The possibility
the parent wrap the child's arm in a bandage. This that nonspecific factors are contributing to treatment
technique proved ineffective and was abandoned be- outcomes needs to be evaluated more directly. The
cause the bandage was applied either too loosely or too inclusion of indicators of social validity in several
tightly. The second response prevention technique in- studies is commendable, as are the attempts to assess
volved taping a plastic finger splint onto the child's generalization and maintenance. As with nailbiting,
thumb at bedtime. The splint eliminated thumbsucking the zeitgeist for treatment seems to be moving toward
when it was used. When reversals were instituted, multicomponent package approaches. An abiding
however, thumbsucking returned to baseline levels. weakness in the thumbsucking treatment literature,
Finally, Van Houten and Rolider (1984) used a multi- however, is the relative paucity of controlled studies.
ple baseline across children design in four separate As with nailbiting, there are some authors who have
studies to investigate the effectiveness of the response drawn parallels between thumbsucking and addictive
behaviors (Lichstein & Kachmarik, 1980), because in has consistently incorporated independent observa-
both habits short-tenn reductions in the behavior are tions of the target response. Unlike the literatures for
poorly correlated with long-tenn abstention. nailbiting and thumbsucking, there exists a recent and
exhaustive critical review of the behavioral treatment
literature for trichotillomania (Friman, Finney, &
Christophersen, 1984; Friman, Finney, & Christo-
Trichotillomania phersen, 1985). Therefore, after a brief summary of
the conclusions of Friman et al. (1984), the studies
The actual prevalence of trichotillomania, or hair completed since its publication will be examined.
pulling, is unknown. The only incidence data available Friman et al. (1984) concluded that, among the
are from those seeking treatment. Gathering incidence many self-management strategies available for hair-
data is complicated by two factors: (1) individuals with pullers capable of conducting their own treatments,
this habit seek treatment from both mental health and habit reversal appeared most effective, though covert
dennatological sources, so sampling from one popula- sensitization merits further investigation. For develop-
tion may omit those in the other; and (2) most indi- mentally handicapped hairpullers, whether children or
viduals with this habit probably hide it and avoid treat- adults, facial screening (in which a client's face and
ment. The meager data that are available (e.g., hair are briefly covered with a soft terrycloth bib con-
Mannino & Delgado, 1969; Mehregan, 1970) suggest tingent upon a target behavior; e.g., Barmann & Vi-
an incidence of less than I % among mental health and tali, 1982) appeared to be the most effective and ac-
dennatological referrals. Thus, even though some au- ceptable therapist-mediated technique. For develop-
thors assert that its incidence may be higher in the mentally nonnal children, parent-mediated tech-
general population (Azrin & Nunn, 1977; Krishnan, niques, including those aimed at improving parent-
Davidson, & Guajardo, 1985), trichotillomania is a child interactions, while concurrently observing
relatively rare disorder, predominantly of children. covarying habits (e.g., Altman et al., 1982), show
However, excessive hair pulling can occur across the promise, but problems with either experimental design
entire life span and has been observed in both infants or parental compliance obscured conclusions about
and older adults (Wright et al., 1979) and in indi- their efficacy.
viduals who are developmentally nonnal and those A large number of case studies have appeared in
who are not. Hair pulling may result in baldness (al- which some of the techniques previously described in
opecia), local tissue irritation, and even tissue damage. this chapter have been used to treat trichotillomania.
Trichotillomania has not been well operationalized. Six of these involve application of part or all of the
It typically refers to excessive or compulsive pulling habit reversal procedure either alone or in conjunction
out of hair. Principally, scalp hair is pulled but eye- with some other treatment (DeLuca & Holbom, 1984;
brows, eyelashes, mustaches, and beards are also fre- Fleming, 1984; Friman & O'Connor, 1984; Milten-
quently used. Hairs from the other bodily areas are less berger & Fuqua, 1985; Stevens, 1984; Tarnowski,
commonly involved. Of the three disorders considered Rosen, McGrath, & Drabman, 1987). The report of
in this chapter, only trichotillomania is classified as a Tarnowski et al. (1987) is especially noteworthy be-
disorder in DSM-III-R (APA, 1987), under the rubric cause of its use of peer consensus ratings of pho-
of impulse control disorder. Trichotillomania fre- tographs as a social validation measure. Three studies
quently occurs in conjunction with other habit disor- used hypnosis in conjunction with other behavioral
ders (e.g., Altman, Grahs, & Friman, 1982; DeLuca & techniques (Barabasz, 1987; Friman & O'Connor,
Holbom, 1984; Matson, Stephens, & Smith, 1978; 1984; Krishnan et al., 1985). Response pre~ention has
Sanchez, 1979). A wide variety of indicators of sever- also been successfully applied in one case study (Dahl-
ity and change have been used. These include frequen- quist & Kalfus, 1984). Finally, Friman and Hove
cy of hair pulling or urges to pull (Taylor, 1963), (1987) used a combination of withdrawal and noncon-
number of hairs pulled (e.g. Wolfsohn & Barling, current multiple-baseline designs to treat thumbsuck-
1978), hair length (e.g., Anthony, 1978), and size of ing and found that hair pulling was also eliminated in
bald spots (Bomstein & Rychtarik, 1978). These mea- two young children. The results of these studies pub-
sures can be collected with or without independent lished subsequent to the review of Friman et al. (1984)
corroboration. Several of these measures have been do not alter their conclusions. The only addition to
used without reliability checks, but recent literature their conclusions might be that hair pulling may also be
successfully treated with hypnosis combined with a ences, individual differences, and extraneous vari-
behavioral technique. ables can be more carefully scrutinized. Better opera-
tionalization of each habit and more refined and
reliable measurement strategies are clearly required.
Summary There is no doubt that more attention also needs to be
given to issues of social validation and generalization
Behavioral treatment of trichotillomania seems to be of treatment effects. Finally, the issues of positive and
highly successful. This appears to be true across the negative side effects of treatment of one habit disorder
life span and with nonnal and developmentally handi- on others need careful study.
capped individuals. It also appears to be true whether All the above-noted suggestions appear to represent
hair pulling is treated directly or whether it is treated a methodological consensus in the treatment and study
indirectly by focusing on a coexisting habit disorder. of other habit disorders, such as enuresis (e.g., Houts,
However, the literature consists primarily of case stud- Peterson, & Whelan, 1986) and stuttering (Saint-Lau-
ies and few reports using experimental designs exist. rent & Ladouceur, 1987). Behavioral treatment of na-
This weakness may be difficult to remedy given the ilbiting, thumb sucking , and trichotillomania will like-
low incidence of this habit. Nonetheless, more ly continue to move in the same direction.
rigorous application of single-subject experimental de-
signs would clearly be desirable, as would increased
use of social validation, generalization, and mainte-
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CHAPTER 41
Substance Abuse
Gary W. Holden, Michael S. Moncher, and
Steven P. Schinke
Introduction In recent years, behavioral scientists have begun to

realize that there is promise in the design, execution,
Illicit substance use rates among American youth are and testing of learning theory-based preventive inter-
the highest in the industrialized world (Johnston, ventions. Still, much more work remains before pre-
Bachman, & O'Malley, 1988). Consequently, and de- vention technologies are proven and available for
spite earnest attempts to combat substance use prob- large-scale dissemination. Toward advancing the sci-
lems, tobacco, alcohol, and drug abuse continue to ence of substance abuse preventive intervention, this
threaten the development and well-being of many chapter reviews current knowledge on the extent, con-
young Americans. Early substance use in childhood sequences, and prevention of tobacco, alcohol, and
and adolescence poses immediate problems academ- drug abuse among American children and adolescents.
ically, socially, and emotionally. Later unabated sub-
stance use in adulthood can lead to physical, mental
health, financial, employment, and interpersonal Overview
problems.
The costs of tobacco, alcohol, and drug abuse are To begin, the chapter gives the most recent preva-
levied not only on substance users, but also on users' lence rates on substance use among youth in the United
families, friends, co-workers, and employers. Ameri- States. Because of ethnic-racial differences, we dis-
can society, too, pays for substance misuse and abuse cuss cultural differences in substance use problems
in added health care costs, law enforcement and legal among the major ethnic groups in the United States.
expenses, accidents, property loss, and reduced pro- Then, the chapter addresses the effects of discrete sub-
ductivity. Few people will argue that substance abuse stance use and the salience of the most popular the-
problems in this country do not warrant professional oretical etiological models for explaining substance
intervention. Likewise, most people will agree that of use and abuse. Particular focus is placed upon minority
all the available substance abuse interventions and tar- youth.
get populations, prevention aimed at children and ado- The chapter devotes most attention to behavioral
lescents holds the greatest promise. research on effective preventive intervention strat-
egies. The Life Skills Training model is reviewed con-
ceptually and through examples from the authors' orig-
Gary W. Holden, Michael S. Moncher, and Steven P.
Schinke • School of Social Work, Columbia University, inal research. The chapter concludes with a discussion
New York, New York 10025. of future research directions for understanding and re-
869
mediating substance abuse problems among American Johnston et al. are daily smokers by the time they leave
children and youth. high school. According Johnston et al. (1988),
More [of youths surveyed] will convert from occasional to reg-

ular smoking in the years following high school. Most of these
Prevalence young people began smoking by age 13, and their pattern of
smoking in adolescence is highly predictive of their smoking
Lest any doubt remain, recent reports confirm that behavior through adulthood. (p. 5)
substance use and abuse are serious problems in this
country. In New York City alone, one half of all homi- Worth mentioning are caveats by Johnston et al. that
cides-totaling 1,672 in 1987-are attributable to their data are to be interpreted with caution. This cau-
drug use and drug trafficking. In northern Manhattan, tion is warranted because the data do not reflect the
drugs are implicated as a major factor in nearly all activities of adolescents who would be high school
homicides (Raab, 19~8). seniors but who have dropped out of school. Indeed,
Nationwide, according to data from the Monitoring data from Pirie, Murray, and Luepker (1988) show
the Future longitudinal study conducted by Johnston et significantly higher rates of cigarette smoking among
al. (1988) at the University of Michigan Institute for adolescents who have dropped out of school relative to
Social Research, American adolescents' use of licit adolescents who have remained in school. Therefore,
and illicit substances remains high. The Johnston et al. substance use rates reported by Johnston et al. and by
(1988) national survey found that in 1987,57% of high other national survey researchers may underestimate
school seniors had tried an illicit drug. Of these se- actual use. In sum, adolescent substance use in the
niors, 36% had used an illicit drug other than mari- United States continues to be a significant public
juana. Although alcohol use among adolescents in the health problem.
United States had been dropping in the 3 years prior to
1987, the decline did not continue in that year, accord-
Ethnic-Racial Group Differences
ing to the Johnston et al. national survey. Johnston et
al. also found that 92% of all high school seniors sur- In most parts of the United States, substance use
veyed had tried alcohol, and 66% youths indicated that rates among children and youth differ by ethnic-racial
they were current users. About 5% of adolescents in group membership. For example, in comparing alco-
the survey reported drinking dail~. hol use among 10th to 12th grade black and white high
Perhaps of greatest concern, 37.5% of all high school students, Singer and Petchers (1987) found that
school students surveyed reported at least one occasion white males demonstrated the highest rate of alcohol
of heavy drinking in the 2-week period prior to the use on all measures. In the same study, both black
study. Adapted from Johnston et al. (1988), Table 1 males and black females reported higher abstinence
shows the percentages of surveyed high school seniors rates than their white counterparts.
who reported use of various substances for selected Certain multiple substance use patterns are more
graduating classes from the past 13 years. Although prevalent among black youth than among white youth.
Table 1 does not reflect use of tobacco products, other Relative to Hispanics and whites, black youth have the
data show increased use of smoked tobacco and highest combined use rates of alcohol and heroin, alco-
smokeless tobacco (moist and dry snuff, chewing to- hol and phencyclidine (PCP) , and cocaine and heroin
bacco, and related products) by youth from some so- (Bachman, Johnston, & O'Malley, 1981, 1984; Har-
cioeconomic and ethnic groups (Brunswick & Mes- ford, 1985; O'Malley et al. 1984). Further, in New
seri, 1984; O'Malley, Bachman, & Johnston, 1984; York City and in other urban areas, cocaine smoked as
Polich, Ellickson, Reuter, & Kahan, 1984; Schinke, the derivative crack is disproportionately used by
Orlandi, Botvin, Gilchrist, Trimble, & Locklear, black youth.
1988; Schinke, Palleja, Schilling, Moncher, Orlandi, Including Colombian, Cuban, Dominican, Mex-
& Botvin, 1988; Schinke, Schilling, & Gilchrist, ican, and Puerto Rican Americans, Hispanics are our
1986a, 1986b; Schinke, Schilling, Gilchrist, Ashby, & fastest growing and youngest minority population. Po-
Kitajima, 1989). In fact, cigarette smoking has not lice records show arrest rates for drunkenness of 138
dropped among the Johnston et al. national survey and 38 (per 100,000 population) among Hispanic and
group of graduating high school seniors since 1984. non-Hispanic youth, respectively (Maddahian, New-
Almost 20% of high school seniors surveyed by comb, & Bentler, 1985). Such rates likely influenced
CHAPTER 41 • SUBSTANCE ABUSE 871
Table 1. Percentages of High School Seniors Reporting Use of Various Substances
in Past Year for Graduating Classes 1975 to 1987
1975 1980 1985 1986 1987
Substance (9,400) (15,900) (16,000) (15,200) (16,3OO)a
Marijuana/hashish 40.0 48.8 40.6 38.8 36.3

Inhalants b NA 4.6 5.7 6.1 6.9
Hallucinogens 11.2 9.3 6.3 6.0 6.4
Cocaine 5.6 12.3 13.1 12.7 to.3
Crack c NA NA NA 4.0 NA
Heroin 1.0 .5 .6 .5 .5
Other opiates d 5.7 6.3 5.9 5.2 5.3
Stimulants d.e NA NA 15.8 13.4 12.2
Sedatives 11.7 to.3 5.8 5.2 4.1
Tranquilizers d 10.6 8.7 6.1 5.8 5.5
Alcohol 84.8 87.9 85.6 84.5 85.7
Note. From "Summary of 1987 Drug Study Results" by L.D. Johnston, J. G. Bachman, and P. M. O'Malley, 1988,
University of Michigan News and ['!formation Service Press Release. Copyright 1988 by Johnston, Bachman, and O'Mal-
ley. Adapted by pennission.
NA = data not available.
a Approximate number of population of students.
bBased on four different questionnaire forms. Sample size is four-fifths of number of population for these classes.
C Based on two questionnaire fonns. Sample size is two-fifths of number of population for this class.
dlncludes drug use not authorized by physician.

e Attempts to exclude nonprescription stimulant use.
the greater concern expressed by Hispanic respon- with marijuana, as gateway substances to other, more
dents, relative to non-Hispanic respondents, that teen- severe substance use and abuse.
age drinking is a major societal problem (Bruns & In light of such associations, and because of other
Geist, 1984). serious health consequences from chronic substance
Relative to all Americans, Hispanics generally use use, the gateway theory cannot be deemphasized (cf.
drugs earlier, more often, and in greater amounts Kandel, Kessler, & Margulies, 1978; Oetting & Beau-
(Comas-Diaz, 1986; Malone, 1986, Trimble, Padilla, vais, 1987). Marijuana, the most popular of illicit sub-
& Bryan, 1985). Multiple substance use is also high stances, in addition to its well-documented moti-
among Hispanic adolescents relative to Asian and non- vation-reducing psychoactive effects, has also been
minority youth (Brunswick & Messeri, 1984). Al- identified as a cofactor for long-term chronic obstruc-
though national statistics are lacking, Hispanic Ameri- tive lung disease and pulmonary carcinogenicity.
cans' substance use can be estimated from regional When combined with tobacco use, the effect regarding
data (Blount & Dembo, 1984; Dembo, Blount, chronic lung disease may be synergistic (Cohen,
Schmeidler, & Burgos, 1986; Tucker, 1985). 1981).
Sniffing of volatile solvents is of particular danger
for adolescent users because of their availability, low
Effects of Substance Abuse cost, and potential short- and long-term dangers.
Moreover, compared with the incidence of most illicit
The adverse consequences of drug use and abuse drugs, inhalant use continued to rise in 1987 (Johnston
vary with the index substance. According to Johnston et ai. 1988). In some areas, solvents may be the drug of
et al. (1988), "Cigarette smoking-[is] the substance initiation among grammar and junior high school stu-
using behavior that will take the lives of more dents (Carroll, 1977). Studies have described sudden
. . . young people than all of the others combined" (p. sniffing deaths (Bass, 1970), as well as potential long-
5). In addition to the association of tobacco and alcohol term neuropsychological deficits (Berry, Heaton &
use with chronic diseases in adulthood, and the rela- Kirby, 1979).
tionship between the use of these substances and in- Use of cocaine and its derivatives has shown a slight
creased risk of injury and death resulting from acci- decrease in incidence and prevalence in 1987 (John-
dents, tobacco and alcohol have been associated, along ston et ai., 1988, p. 1). However, Johnston et ai. cau-
tion that the decline may be illusory, since a group for In New York City, American Hispanics dispropor-
which the crack epidemic is particularly serious has tionately account for 42% of all drug-related deaths-
not been sampled. This group of high school drop outs far in excess of their distribution in the city's popula-
comprises 15% to 20% of the population. Both the tion. Further, Hispanic women suffer from esophageal
social costs of crack smoking, and the physiological cancer 20% more often than non-Hispanic American
effects, including severe pulmonary damage and sud- women-possibly because of heavy smoking and
den death, are still in incipient stages of documenta- drinking (Bobo, Gilchrist, Schilling, Noach, &
tion. Schinke, 1987). Other data "suggest that rates
Opiate use is strongly associated with disease be- of . . . cigarette-linked diseases among Latino males
cause of widespread and unsanitary user techniques. may increase within this decade, and continue to in-
Hepatitis, endocarditis, thrombophlebitis, and numer- crease into the next century" (Marcus & Crane, 1985,
ous other infections are common among intravenous p. 171). Liver cirrhosis, suggestive of alcohol abuse, is
(IV) opiate users. Today, Acquired Immune Deficien- more common for Hispanics than for non-Hispanics
cy Syndrome (AIDS) and Human Immunodeficiency (Caetano, 1986; Comas-Diaz, 1986; Coombs &
Virus (HIV) infection are perhaps the most notable Globetti, 1986).
examples of septicity. By injecting drugs, users of her-
oin and other substances contract and transmit AIDS
through shared needles, syringes, and related para-
phernalia (Drucker, 1986; Frank, Hopkins, & Lipton, Theoretical Etiological Models
1986).
Overview
Ethnic-Racial Group Differences A variety of explanations for substance abuse have
emerged in the literature over the past two decades,
Relative to nonminority Americans, blacks have
each with a particular emphasis on certain biopsycho-
higher rates of health problems related to tobacco use
social correlates. A review of these models is included
(Schinke et al. 1986a). By the year 1990, rates of lung
here, utilizing the framework set forth by Oetting and
cancer-largely attributable to smoking-will in-
Beauvais (1986, 1988). Some researchers postulate
crease by 99% for black women (vs. 82% for white
that the socialization process, including large-scale so-
women) and by 32% for black men (vs. 21 % for white
cial forces-norms, for example-when combined
men). Black Americans also have problems with alco-
with demographic variables, including socioeconomic
hol and drug abuse. For instance, alcohol-related cir-
status (SES), ethnicity, age, employment, and educa-
rhosis among black Americans occurs at double the
tion, may be influential in substance use onset (cf.
rate of white Americans (Herd, 1986).
Josephson & Carroll, 1974). Lukoff (1980) has noted
The Centers for Disease Control report that 51 % of
that
all AIDS patients who also have injected drugs are
black (Morbidity and Mortality Weekly Report, 1986).
About one half of all black adults with AIDS have been age of onset of drug use serves as a surrogate index for an impor-
the heterosexual partners of IV drug users. A study of tant dimension of socialization, namely, the unfettering of the
bonds of social control. Early onset reflects the premature seg-
New York City'S drug treatment agencies found AIDS mentalizing, or insulation, of youthful activities from the nor-
virus antibodies in 42% of all black patients, but in mative system of the adult community. (p. 207)
only 14% of white patients (Schoenbaum, Selwyn, &
Klein, 1986). In other studies, black drug users are
also identified as more often seropositive with the Others have focused on intrapersonat factors, hy-
AIDS virus compared to nonminority drug users pothesizing early childhood experiences as anteced-
(Chaisson, Moss, Onishi, Osmond, & Carlson, 1987; ents of later substance use (Block, Block, & Keyes,
Drotman, 1987). Drug and alcohol abuse are impli- 1988; Lerner & Vicary, 1984; Valliant & Milofsky,
cated in black Americans' heightened rate of mor- 1982; Vicary & Lerner, 1986).
bidity, unemployment, and educational disruption More generally, some theorists posit that adoles-
(Dawkins & Dawkins, 1983; Dembo et at., 1986; cents utilize substances as a means for need fulfill-
Hewitt, 1982; Lee, 1983; Lipscomb & Goddard, ment, to compensate for negative self-feelings and in-
1984). securities, or to bolster real or perceived charac-
terological deficits (Friedman, Glickman, & Utada, by that research team, the need for a multivariate ap-
1985). Positive expectancies and behavioral intentions proach to the problem is obvious:
regarding use have also been examined as intraper-
sonal correlates (Chassin, Presson, S~erman, Corty, & Disease-addiction theories point clearly to the power and danger
Olshavsky, 1984). of drugs. Gateway theories emphasize the progression of one
drug to another. Social theories help counselors understand some
In the combined psychosocial realm, numerous of the outside forces that create pressures to use drugs. Psycho-
studies have provided a host of correlates, including logical theories describe the basic personal problems that make a
school, neighborhood, peers, and family (Brower & few young people particularly sensitive to the psychoactive ef-
fects of a specific drug. . . . The psychosocial theories include
Anglin, 1987; Dembo, Allen, Farrow, Schmeidler, &
both personal characteristics and the social environment. The
Burgos, 1985; Dembo, Schmeidler, Burgos, & Taylor, life-style theories are compelling in describing how drugs relate
1985). to membership in and identification with the kinds of groups that
Problem-behavior theory, developed by the Jessor are very important in adolescent life. (p. 19)
group, is particularly salient. The theory emerged from
their findings that many problem behaviors were corre- In a persuasive synthesis, Oetting and Beauvais
lated. These problem behaviors tended to be nega- (1988) have postulated the Peer Cluster Model, based
tively correlated with conventional and conforming on findings across studies that peer involvement is the
behaviors. most consistent, significant correlate for adolescent
Additionally, these problem behaviors were corre- substance use. While recognizing the relevance of so-
lated with unconventional personality and social en- ciocultural, psychological and socioeconomic/envi-
vironmental variables (Donovan & Jessor, 1985; ronmental characteristics, their theory suggests that
Jessor 1986; Jessor, Chase & Donovan, 1980; Jessor, these forces are mediated by the effect of peer clusters.
Donovan & Costa 1986). Based on recent factorial Peer clusters are the smallest set of an adolescent's
analyses, this group has hypothesized "that the com- interpersonal associations, representing more intimate
mon factor underlying the syndrome of problem be- and influential relationships than terms such as peer
havior reflects a general dimension of unconven- group might imply.
tionality-in both personality and the social Rather than unidirectional forces (peer pressure),
environment" (Donovan & Jessor, 1985, p. 901). these theorists see multidirectional shaping of attitudes
Stage theory emphasizes the progression from so- and behavior between members of a peer cluster. Fur-
called soft substances, including alcohol and tobacco, ther, they believe that "the relationships between other
to more serious illicit use (cf. Kandel, 1982, Kandel, psychosocial characteristics and drug use can be essen-
& Logan, 1984; Kandel et al. 1978; Kellam, En- tially accounted for by their influence on peer drug
sminger, & Simon, 1983). The progression is not uni- associations" (Oetting & Beauvais 1988, p. 147). Al-
form across groups. Kandel (1982) noted that "although these authors note that there are likely re-
though involvement follows a: well-defined order, not ciprocal relationships between psychosocial charac-
all adolescents who experience a particular stage go on teristics and peer clusters-for example, poor school
to experiment with a stage later in the sequence. Only a adjustment could lead to associations with a peer clus-
subgroup at a particular stage are at risk for progres- ter of other poor students, with the group reinforcing
sion to the next stage" (p. 343). continued or increased educational maladjustment-
The physiologically oriented disease models focus the critical element in substance use appears to be in-
on the psychoactive and addictive properties of various volvement with a drug-using peer cluster.
substances. An example is the often cited loss-of-con- In a recent study conducted by this group (Binion,
trol hypothesis (Jellinek, 1960). This hypothesis pos- Miller, Beauvais, & Oetting, 1988), questionnaires
tulates that an abstinent alcoholic cannot take even a were administered to both Native American and other
single drink without relapse. eight graders to ascertain their own rationales for use
of substances. Although both groups rated altered af-
fect as the primary reason for use, peer-related vari-
ables were considered very important by many. The
Peer Cluster Theory
authors concluded that "while peer influence is cer-
Oetting and Beauvais (1986) concluded that none of tainly important in drug use, its importance may be
these models should be dismissed wholesale for impor- that the individual's social needs of affiliation and ac-
tant contributions can be pulled from each. As noted ceptance are met at the same time that pleasant sensa-
tions and relief from negative affect are also taking black youth, the latter reselP"ch can yield these same
place" (Binion et al., 1988, p. 61). Results of this findings when accompanied by multivariate, repeated
study also confirmed the importance of differential ex- measures assessment batteries (cf. Block et aI., 1988).
amination of use correlates. Concurrently, intervention outcome research will pro-
duce empirical data on the effects of one or more pre-
vention strategies that can iteratively inform future re-
Minority Youth
search, policy, and practice.
Particularly among youth frdm American ethnic-
racial minority groups, many possible explanations
exist for substance abuse and substance-related prob-
Life Skills Training
lems. The prevalence, and the negative health conse-
quences of use among these groups, have already been
Overview
discussed. Explanations of substance use among mi-
nority youth include such interdependent influences as Recent years have seen much research on skills in-
economic disadvantages, social and institutional rac- terventions for preventing substance abuse among
ism, substandard housing, cultural fatalism, negative children and adolescents (Botvin & Wills, 1985;
peer and adult modeling, family breakups, and easy Schinke & Gilchrist, 1985). Skills interventions-so
access to licit and illicit substances (Barnes, 1984; called because of their emphasis on learning theory-
Dawkins, 1980; Orlandi, 1986; Public Health Service derived interpersonal skills, cognitive-behavioral
et aI., 1981). Admittedly, many of these influences do skills, or life skills-teach youths to avoid drug and
not lend themselves to facile preventive intervention alcohol abuse through a repertoire of prevention strat-
strategies (Bachman et al., 1984; King, 1982; Mad- egies. Encompassing problem solving, personal cop-
dahian et al., 1985). ing, and interpersonal communication, skills interven-
Aside from descriptive studies, scientific knowl- tions help youths prevent substance abuse by
edge on why black adolescents and young adults mis- managing themselves, others, and high-risk situa-
use substances is scarce. Notwithstanding the need for tions.
speculative and correlative studies on explanations of Increasingly, skills interventions also emphasize
drug and alcohol abuse risk among black Americans, health and life-style promoting strategies. Through
research on preventive interventions is essential. Crit- these strategies, youths learn to advance their lives
ics may question the wisdom of studying preventive educationally, vocationally, and socially while they
interventions among black youth without the benefit of avoid drug and alcohol abuse. Illustrative are cog-
comprehensive epidemiological data. Doubtless, nitive-behavioral interventions. As the present authors
these data would enhance the precision of subse- and others have developed and tested them, cognitive-
quently designed preventive interventions, and prior behavioral interventions help adolescents apply prob-
epidemiological data might cast new light on foci and lem solving, self-appraisal, nonverbal and verbal com-
targets for prevention research. munication, and social skills to avoid drug and alcohol
But to delay the development and testing of preven- abuse and to promote their lives in positive ways.
tive interventions until definitive etiological, descrip- To date, skills interventions to prevent substance
tive, or explanatory results are available on drug and abuse among adolescents have been mostly tested with
alcohol abuse among black Americans seems overly middle-class, nonminority populations. This limited
conservative. To not aggressively research effective testing is partly a function of the suburban school sys-
interventions for preventing black Americans' sub- tems that have been field research settings for the bulk
stance abuse, furthermore, appears neither responsible of skills intervention studies. To a lessor though not
nor ethical in the face of serious and growing drug and insignificant extent, the absence of skills interventions
alcohol use among future generations of this country's for black and Hispanic adolescents is also explained by
largest ethnic-racial minority population. a paucity of research aimed expressly at these young
Also, the ends of epidemiological and intervention people, particularly research with black and Hispanic
research are not mutually exclusive. Whereas the for- youth from disadvantaged, inner-city communities.
mer research could yield findings on the nature, corre- The many studies of skills interventions with nOll-
lates, and explanations for substance abuse among minority, middle-class youth and the paucity of such
intervention research with black, disadvantaged youth it is not surprising that education-only interventions
are not unrelated. The demands of longitudinal studies regarding the potential harm of substances are more
along with the realities of public school enrollments often than not ineffective among adolescents. Such
create a climate that fosters intervention studies with egocentrism, however, seems to dissipate in the pres-
stable, compliant, homogenous populations. Commu- ence of social interaction. Exposure to the beliefs and
nities predominated by black youth at risk for drug and experiences of others is likely to provide a smoother
alcohol abuse are less conducive to longitudinal out- sequence of assimilation and accommodation, leading
come research. High rates of student absenteeism and to an ultimately more realistic belief system (Schinke
drop out would vitiate both descriptive and longitudi- & Gilchrist, 1984).
nal intervention outcome studies. To a degree, social learning theory plays a role in
this process. Bandura and others postulated behavior
as the observed effect of a transactional process be-
Theoretical Rationale
tween the internal environment and the external en-
Theory to support life skills training can proceed vironment (Schinke & Gilchrist, 1984). Development
from two unrelated dimensions. The first dimension is is a reciprocal process of thought-action alignment in
adolescent cognition theory that is based primarily response to observations about consequences ofbehav-
upon the work of Piaget (Piaget, 1967, 1972). The iors of oneself or others. People tend to act in accor-
second dimension to support life skills training is dance with expectations regarding reinforcement or
Bandura's development of social learning theory punishment as shaped by the social environment.
(Bandura, 1977; McAlister, 1982). A third aspect, Social learning theory teaches that success in task
more practical in nature, is not to be overlooked. Edu- performance leads to perceptions of increased self-
cation-only interventions have not proven effective efficacy. Bandura (1982) stated that "self-percepts of
(Green, 1984), whereas programs incorporating cog- efficacy influence thought patterns, actions, and emo-
nitive-behavioral approaches have demonstrated sig- tional arousal. In causal tests, the higher the level of
nificant impact (Botvin & Eng, 1980, 1982; Botvin, induced self-efficacy, the higher the performance ac-
Eng, & Williams, 1980; Schinke & Gilchrist, 1985). complishments and the lower the emotional arousal"
In terms of cognitive development, neo-Piagetian (p. 122). He has shown that the most potent sources of
theorists have moved from his original conception of efficacy information derive from instances where an
an individual being· in a particular developmental individual achieves successful performance of a par-
phase, to the notion of developmentally phase-related ticular target behavior (enactive mastery).
behavior. Also, the individual is viewed as possessing Perceived efficacy will increase the likelihood that
differential proportions of phase-related abilities. Gen- the same behaviors will be repeated. Repeated practice
erally, with age, sensorimotor and preoperational will generate higher levels of skill and confidence in an
thought processes decrease, as concrete and formal ongoing spiral, and the mere observance "of others
operational thought increase. performing some action can lead to the initial trial that
If, as these theorists posit, skills acquisition is situa- initiates this cycle" (Schinke & Gilchrist, 1984, p. 9).
tion-dependent, what the observer may view as un- Life skills training provides a process whereby such
evenness in cognitive development may rather denote learning cycles can be accelerated. This model as-
a failure to generalize newly acquired skills to novel sumes that adolescent problem behavior results from
situations (Fischer & Lazerson, 1984). Refusal skills, dystonic equilibration patterns rather than psycho-
for example, might be well developed in certain situa- pathology. Through utilization of its various compo-
tions to which the adolescent has been repeatedly ex- nents, life skills training aims to provide situations in
posed. These skills, however, may not be employed in which both cognitive and behavioral competencies can
previously unexperienced situations. The implications be learned, practiced, and generalized beyond the in-
for substance use prevention are obvious. tervention situation.
Adolescent egocentrism is an oft-noted phe-
nomenon that can be observed in youths' propensity
Components of Intervention
for risk taking, seemingly based on the belief that they
are special and immune to aversive consequences re- The life skills approach focuses on six general areas:
sulting from their behavior. Given this cognitive state, information, problem solving, self-instruction, cop-
ing, communication, and support systems. Each will mechanisms for tangible self-reward if such a circum-
be discussed in turn. stance is successfully overcome.
Information. Information regarding the adverse Communication. If they are to achieve academ-
health, social, and legal consequences of substance ically, socially, and professionally, adolescents must
abuse is supplemented by information regarding the learn both nonverbal and verbal behavior traditionally
actual prevalence of use in adolescents and adults. The associated with assertiveness training. Hence, com-
pressures of media advertising to use licit substances munication skills are integral to the life skills training
are discussed as well. model. To this end, both live and symbolic modeling
are employed, and youths practice what they learn
Problem solving. The life skills approach teaches through role-playing. Professional and peer reinforce-
problem solving through a stepwise process. Adoles- ment are employed for feedback purposes, and vid-
cents review chronic problem situations in their lives eotaping is often utilized as an additional feedback
and brainstorm potential solutions. Solutions are mechanism.
ranked according to their attractiveness and feasibility.
Through such a review of the costs and likely conse- Support Systems. That a supportive social net-
quences of particular solutions, an optimal course of work is important for successful transition to
action is arrived at. The completion of problem-solv- adulthood is well known. Oetting and Beauvais's
ing flow charts is often incorporated into homework (1988) discussion of the critical role played by the peer
assignments for purposes of practice. cluster in substance use initiation and maintenance em-
phasizes the salience of support systems in adolescent
Self-Instruction. Mussen (1963, p. 46) exempli- development. Utilization of the components of the
fies a long recognized tenet of developmental theory, model discussed above will serve to enhance and ex-
stating that "children over 5 years of age function and pand youths' competence in building, negotiating, and
control their behavior primarily by means of verbal maintaining positive, supportive familial, peer and
mediation." Such modules, often called "self-talk," community social networks. The model attempts to
are therefore incorporated into life skills interventions. illustrate how integrated utilization of its various mod-
Self-instructional counseling is employed through ules can help the adolescent achieve this end.
modeling and rehearsal of events based upon thoughts
that accompany typical daily adolescent routines. In-
Research Illustration
ner dialogues that are appropriate for the decisions
they might make are chosen and practiced by youths. To review in greater depth the state of substance
The acronym SODAS (Stop, Options, Decide, Act, abuse prevention research with children and adoles-
Self Praise) is an example of a self-instructional teach- cents, we will describe one of our past projects util-
ing aid that carries over into various other components izing social learning theory approaches to prevent to-
of the model as well. bacco use among 1,281 fifth and sixth graders from
westem Washington state (Schinke, Bebel, Orlandi, &
Coping. As noted above, studies have confirmed Botvin, 1988). The protocol called for random assign-
the importance of substance use as a means of coping ment by school into two treatment conditions, skills
with stress. Research data attest that when the novelty training and discussion, and discussion only, as well as
of the psychoactive effects fade, adolescents continue a control condition.
substance use as a maladaptive stress coping mecha- The discussion-only intervention involved delivery
nism (Kellam et at., 1980). Coping skills training re- of tobacco use information in several formats. Exam-
quires that an adolescent be taught to anticipate and ples included films, guest speakers, and peer testi-
prepare for stressful and unpleasant situations, diffi- monials. The skills training and discussion interven-
cult obstacles, and challenges. tion offered training in self-statement, problem
Regardless of its target, both covert and overt cop- solving, communication, coping, and discrimination
ing mechanisms must be taught. Covert coping con- skills. Examples of these are noted.
sists of developing cognitive processes that will aid Self-statements involved rehearsal of cognitive
youths to successfully confront potentially high-risk stratagem to be employed by subjects when encounter-
situations, whereas overt coping involves learning ing high-risk situations. For instance, if offered a ciga-
rette by an influential peer, a youth might say to him- been observed, the overall level of use in this country
self, "What am I going to do .... I don't want to remains alarmingly high. Nor do sampling procedures
smoke, but I don't want him to think I'm a drone. I reach the particularly high-risk group of school drop
could just take the cigarette and leave, but then he'll outs. Thus, reported prevalence rates are conservative.
just ask me again later. What if I just tell him I don't In addition to health-related issues, delinquency and
smoke. If he gets bent out of shape, I've got lots of incipient adult criminality loom large. Ethnic-racial
other friends." minority communities are being especially hard hit.
Problem-solving methods focused on the cognitive Although various etiological models have been pro-
processes of generating solutions, weighing the short- posed, recent years have seen the development of more
and long-term consequences of each, and deciding on comprehensive psychosocial theories. Not only have
the most appropriate course. This training module em- these theories provided more substantive understand-
ployed an intervention using the acronym SODAS, ing regarding substance use initiation, but they have
which was discussed above. The subjects were taught, also laid the foundation for development of more re-
through modeling, role-play and homework assign- fined, holistic intervention strategies. The refinement
ments, skills requisite for the delay of impulsive be- of cognitive-behavioral methodology has contributed
havior through application of an approach designed to much to the development of an effective prevention
foster a more thoughtful response. stratagem surrounding substance use.
Communication skills included role-playing of re- We have devoted special attention to the promise of
fusal skills with other subjects, emphasizing how eye life skills training approaches in the prevention of sub-
contact, verbal voice intonation, affect, and word stance abuse among children and adolescents. Life
choice can be effective in making a point. Addi- skills training brings together our recent etiological
tionally, nonverbal communication skills were prac- advances with cognitive-behavioral techniques to pro-
ticed. Modeling, feedback, and praise by interven- vide an effective framework for the development, im-
tionists were important components of this module. plementation, and evaluation of substance use preven-
Coping skills were also modeled by trainers, and tion efforts.
included cognitive and behavioral strategies of self- Clearly, much work lies ahead. We have reviewed
instruction and progressive relaxation techniques. Dis- the differential prevalence rates and health conse-
crimination skills interventions were designed to help quences of substance use among various ethnic-racial
youths anticipate, and therefore avoid, potential high- groups in the United States. We have also noted the
risk situations. For example, subjects would be asked need for culturally sensitive intervention development
to make lists of times, locations, and peer or family and application. If substance use preventive interven-
situations where they might be most tempted to use tions are to transfer successfully within and across di-
tobacco or other substances. verse populations, these issues must be given more
Although across conditions, semiannual measures attention than they have received to date.
showed rising tobacco use, a smaller increase was re- Too, current technological advances, including
ported by skills condition subjects. Unremarkable out- computer-aided instruction, offer potent interventive
comes for those in the discussion condition alone indi- possibilities for the future. The economies of scale
cate that skills condition outcomes were not they may achieve, the sensitive monitoring oppor-
attributable to placebo effects. At 24-month follow-up, tunities they would provide, and the relative ease of
the group receiving life skills training reported using technology transfer they may allow require intensive
both smoked and smokeless tobacco at significantly investigation. Perhaps this review of the current state
lower rates than either the discussion-only group or the of substance abuse problems in America with an em-
control group. phasis on promising intervention approaches will stim-
ulate badly needed research in these and other areas of
import.
Summary and Conclusions
The problems of adolescent substance abuse in the

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Index
A-B-A designs, 177, 185-197 Autism (cont.)

Abuse, 535-539 eliminating behavioral excesses, 769-772
child, 535-536, 707-726 etiology and paSt treatment, 767-768
spouse, 535-536 ritualistic behavior, 765
Achievement Place, 530-531, 679; see also Community- self-stimulatory ~havior, 771-772
based programs social behavior, 764
Acquired Immune Deficiency Syndrome, 386-388, 872 speech and language, 764-765
Affect, 93-94 stimulus overselectivity, 773-774
Aggression, 523, 669-673 teaching homes, 781-782
Agoraphobia, 285-291, 643-644 Aversive techniques, 18,234-235,419,440-441,569-571,
Alcohol and drug problems, 415-431, 437 861-862
behavioral treatments for, 417-426 client rights, 232-234
relapse, 420, 422-423 Avoidance learning, 32, 38-39
Analogue research, 44-45
Animal psychology, 7-8 Baseline, 182-187
Anorexia nervosa, 805-815 choosing, 182-185
Anxiety, 16, 268-273, 283-300, 585, 633-645 multiple, 197-200
agoraphobia, 285-291, 643-644 patterns of, 182-185
assessment, 634-639 Basic Id, 92-93
classification, 633-634 Behavior modification, 8-9
generalized anxiety disorder, 296-299 characteristics of, 13-14, 29-30
obsessive-compulsive disorders, 272-273, 307-326 history of, 3-21, 28-29
panic, 291-293 terminology and, 8-10, 12-13,216
posttraumatic stress disorder, 295-296 Behavior therapy, 8, 28
social phobia, 293-295 definition of, 28, 215-216
treatment, 640-645, 794-795 ethical issues, 227-248
Anxiety management training, 297-299 historical precursors of, II
Applied behavior analysis, 13, 19, 67-82 journals in, 82, 175
characteristics of, 68-70 legal issues, 227-248
principles of, 70-81 training in, 213-224
Assertion training: see Social skills training Behavioral assessment, 87-100, 107-129,487-488
Assessment, 87-100, 107-129, 160-167, 181,357-359, computer applications, 99-100, 116-117
406-409, 438, 456, 492-493, 565, 636, 650, 806-808; decision making, 99
see also Behavioral assessment issues in, 94-%, 97
Autism, 763-783 methods of, 88
acquiring new behaviors, 772-773 models of, 89-91
classroom instruction, 779-781 purposes of, 88
diagnosis, 764, 766-767 repeated measurement in, 181-182
881
882 INDEX
Behavioral assessment (cont.) Client rights (cont.)

treatment, 97-98 right to be free from harm, 228-229
Behavioral family therapy, 362-365 right to treatment, 227-228
skills trained in, 364 Cognitions, 53, 482-484
Behavioral marital therapy, 475-496 in depression, 335-338
affect, 477-479 in marital distress, 482-484
development of, 475-477 Cognitive models, 42-44, 55
effectiveness of, 494-496 leamed helplessness, 43-44, 655
Behavioral medicine, 20, 372, 585-586 of pain, 405-406
computers in, 388-390 Cognitive behavior therapy, 53-63, 215, 286-289, 321-322,
history of, 372-374 333, 459, 485, 560, 691-696
See also Medical disorders assumptions of, 56
Behavioral neuropsychology, 139-148 characteristics of, 56-57
attention, 143 definitions, 55-56
brain damage, 145-146 and depression, 57, 63, 333-349
language, 145 and drugs, 274
leaming disability, 146-147 for eating disorders, 808-809
memory training, 143-145 for marital distress, 485-486
See also Medical disorders for pain, 407-408
Behavioral observation, 107-129,357-359 foundations of, 54-55
reliability of, 121 in treatment of fear and anxiety, 286-289, 293-294, 298
validity of, 126-128 operations in, 62-63, 343-348
See also Observational methods Community-based programs, 251-268, 698-699
Behaviorism, 3-7, 47, 90 Community intervention, 19, 20-21, 251-265, 528-534
methodological, 54, 215 consultation, 260
radical, 67-68, 81, 90-91, 215 guidelines for, 263-264
Biofeedback, 298-299, 376, 379, 571, 619-620 models and tactics, 259-260
Bulimia, 805-815 settings for, 252-255
techniques, 261-262
Chaining, 77 Conditioning, 29-30
Changing-criterion design, 200-202 classical, 30-32, 35-36, 386, 400-402, 417
Child abuse, 535-536, 707-726 covert, 54
Child problems higher-order, 77
anxiety, 633-645, 696-698 operant, 10, 14, 31-32, 34-35, 403-405, 674-682
assessment of, 636-639, 650-655, 660-661, 700 verbal, 14-15
autism, 763-783 See also Learning
conduct disorder, 669-702 Conduct disorders, 669-702
depression, 649-662 characteristics of, 669-673
eating disorders, 805-815 treatments for, 674-699
medical disorders, 791-802 Contingency contracting, 532
nail biting, 857-861 Contingency management, 261, 427-429
obesity, 819-828 Coping skills, 57
physical disability, 831-850 Covert conditioning, 54
posttraumatic stress disorder, 645-722 Covert sensitization, 533, 571-572
sexual abuse and, 707-726 Crime, 523-540, 718-720
substance abuse, 869-877 assessment of, 525-526
thumbsucking, 861-864 community programs, 528-534
trichotillomania, 864-865 institutional programs, 526-528
Cigarette smoking, 437-445, 871-872 prevention of, 534-535
alternative treatment methods, 439-443
assessment, 438-439 Delinquency, 523-540
nicotine regulation, 441-443 Dementia, 588
Classical conditioning, 10, 30-32, 35-36, 386, 400-402, Depression, 273-276, 333-349, 495, 508, 590-591, 649-
417 662
Classroom behavior, 779-781 assessment of, 650-655
Client rights, 227-248 cognitive models of, 335-338
peer review, 239-245 interventions, 273-276, 338-349, 657-659
protection, 229-232 See also Social skills training
INDEX 883
Desensitization: see Systematic Desensitization Human Rights Committee, 232-248
Diagnosis, 91, 161-162,354,416,550-552,633-634, composition, 232
649-650, 700, 764, 766, 805 education, 234
interviews for, 636-637 peer review committee, 239-242
reliability of, 634-635 purpose, 233-234
Discrimination training, 78 review process, 234-236
Drug abuse: see Alcohol and drug problems right to treatment, 227-228
Drug treatment, 267-276, 462, 658 right to be free from harm, 228-229
anxiety disorders, 268-272 Hypertension, 374-375
and behavior therapy, 267-276, 322-324
Imitation, 17; see also Modeling
Eating disorders, 805-815 Implosion, 39; see also Flooding
assessment, 806-808 Institutional programs: see Token economy system
causes, 806
treatment strategies, 808-811 Language, 80-81
Escape, 71 Learning, 7, 10, 29, 30-33
Ethical issues in behavior therapy, 227-248 avoidance, 32-33
Exercise, 375, 454, 458, 466, 821-822 conditioning, 30-32
Experimental analysis of behavior, 178 theories of, 33-38, 42-44
Experimental design, 151-171 See also Conditioning
assessment, 160-166 Legal issues in behavior therapy, 227-248
group comparison designs, 177-178 Life skills training, 874-876
pretest-posttest design, 188-189
specifying the population, 161 Marital distress, 475-496
treatment integrity, 166-167 affective disorders and, 480-481
treatment outcome, 162-165 assessment, 486-492
See also Single-case experimental designs Marital therapy: see Behavioral marital therapy
Exposure, 285-289, 293-294, 311-324 Medical disorders, 371-391, 791-802
imagined vs. in vivo, 316-317 cancer, 381-384
processes during, 319-321 cardiovascular disorders, 374-376
See also Flooding coronary artery disease, 376-378
Extinction, 31, 75-76, 772 gastrointestinal system, 378-379
headache, 381
Fading, 78-79, 774 pain, 380-381
Family Systems, 94 psychoneuroimmunology, 384-386
Family Therapy, 724-725 respiratory disorders, 379-380
Flooding, 39, 284 See also Behavioral neuropsychology
imaginal versus in vivo exposure, 285 Medication: see Drug treatment
See also Exposure Mental retardation, 731-753, 767
Functional analysis, 89-90, 548 community preparation, 740-742
Functional family therapy, 689-691 definition, 731-732
maladaptive behaviors, 743-749
Gender identity disorders, 577 normalization, 750
Generalization, 79-80, 141-143, 158-159, 180-181,685, selecting treatment, 750-751
751-752,776-778 self-care skills, 734-735
Geriatric populations, 581-593 self-injurious behavior, 743-746
self-care, 591-592 social skills, 739-740
social behavior of, 581-585 speech and language, 737-739
Group comparison designs, 177-178 vocational preparation, 742-743
Group homes, 529-531 Modeling, 17, 157,261,317,793-795,802
participant, 157, 160
Habit disorders, 857-865 Multimodel behavior therapy, 20, 419
nail biting, 857-861
thumbsucking, 861-864 Nail biting, 857-861
trichotillomania, 864-865
Habit reversal, 859-860, 862, 865 Obesity, 449-468, 587, 819-827
Habituation, 320 causes of, 450-455
Headache, 586 in children, 819-828
884 INDEX
Obesity (cont.) Punishment, 31, 73-74, 677-679, 682, 750, 769-772, 798-
classification, 455-456 799, 835-838; see also Aversive techniques
diets, 462-464
eating, 453-454, 458 Rational-emotive therapy, 287, 322
exercise, 375, 454, 458, 466, 821-822 Reinforcement, 71-73, 674-677, 792-793
maintenance, 464-467 differential, 745, 747, 796-798, 837-838, 861-862
phannacotherapy, 462 schedules of, 76, 80, 682, 776
risk factors for, 450-453 Relapse, 420, 431
Observational methods, 107-129 prevention, 422-423, 443-444
designing observation systems, 108-110 Relaxation, 296-298, 375-376, 385-386, 795-796
generalizability, 122-126 Reliability, 121-126
observer effects, 117-119 Response cost, 73, 678-679
reactivity, 117 Response prevention, 313-319
reliability, 121-126 Role-play, 218-219
scheduling observations, 112
selecting recording techniques, 112-114 Schizophrenia, 353-365
selecting settings, 1l0-111 assessment, 357-359
technological aids, 114-117 characteristics of, 354-357
training observers, 119-121 diagnosis, 354
validity, 126-128 treatment of, 359-365
Obsessive-compulsive disorders, 307-326, 644-648 Seizure disorders, 748-749
assessment, 309-31 0 Self-control, 18, 827-828
behavioral methods for, 311-319 Self-help, 18, 439-440
cognitive treatments for, 322 Self-instructional training, 286-287
description, 307-309 Self-management, 18, 286, 419, 423-425, 827-828
medications for, 272-273, 322 Self-monitoring, 457, 809-810
Operant conditioning, 10, 14, 31-32, 34-35, 403-405, 674- Sex therapy, 547, 568
682 Masters and Johnson approach, 547-557
Overcorrection, 73, 678-679, 771 Sexual abuse, 707-726
prevention programs for, 707-714
Pain, 399-411 treatments of, 708-717, 720-725
assessment of, 402-404, 406-409 Sexual deviation, 565-578
models of, 400-408 assessment of, 565-568
Panic, 291-293 treatment, 568-578
Paradoxical intention, 288 Sexual dysfunction, 547-562
Parent training, 685-689 assessment of, 548-550
for autistic children, 778-779 diagnosis of, 550-552
for child behavioral problems at home, 794, 824-825 female dysfunctions, 556-559
Physically disabled persons, 831-850 male dysfunctions, 552-556
adaptive living skills, 838-839 treatment techniques, 552-562
behavior problems, 832-833, 835-836 Shaping, 75-77, 284
community skills, 842-843 Simultaneous-treatment design, 202-203
family adjustment, 846-849 Single-case experimental designs, II, 19, 175-207
mobility skills, 841-842 A-B-A designs, 177, 185-197
self-help skills, 839-841 baselines, 182-185
self-injurious behavior, 833 changing-criterion design, 200-202
self-stimulatory behavior, 834-835 drug evaluations, 194-197
social skills, 844-846 group designs, 177-178
vocational skills, 843-844 history of, 176-177
Positive reinforcement, 15,31,71-73,674-677,687,792- interaction designs, 193-194
793, 834 issues in, 178-181
Posttraumatic stress disorder, 295-296, 645, 722 multiple-baseline designs, 197-200
Prevention, 376 procedures of, 181-182
medical disorders, 376-378 replication, 204-207
sexual abuse, 707-714 reversal in, 186-187
substance abuse, 874-878 simultaneous-treatment, 202-203
Psychotherapy, 12, 27-28, 348 statistical evaluation in, 183, 203-204
INDEX 885
Social anxiety, 293-295 Substance abuse (cont.)
Social dysfunction, 503-519 prevalence, 870
Social learning, 19, 215, 219 Successive approximation, 76
Social perception training, 517-518 Systematic desensitization, 16-17, 283, 572-574
Social skills, 503-519
assessment, 509-511 Target behaviors, 13-14,97, 110
components of, 506-509 Teaching-family model, 529-531
conceptual issues, 504-505 Thumbsucking, 861-865
Social skills training, 221, 255, 294-295, 359-362, 514- Time-out, 73, 677-678, 686, 769-771, 798-799
517, 532-533, 683-685 Token economy system, 15-16,76-78,674-677,679-682,
associated factors, 512-514 686
components of, 506-507, 515-517 Training, 213-224
Social validation, 782-783, 858 history of, 214-215
Spouse abuse, 535-536 models of, 218-220
Statistical analysis, 123-126, 167-168, 183,202-204 Trichotillomania, 864-865
Stimulus control, 31, 772-773
Stuttering, 599-623 Validity, 126-128
development of, 601-610 Variability, 178-181
treatments for, 613-620 as related to generality, 181
Substance abuse, 869-877 intersubject, 179-180
effects, 871-872 intrasubject, 178-179
ethnic-racial group differences, 870-872 Verbal conditioning, 14-15
models of, 872-874 Visual inspection, 167-168, 203-204

Bellack, Hersen - Kazdin (Eds.) (1990) - International Handbook of Behavior Modification End Therapy

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Bellack, Hersen - Kazdin (Eds.) (1990) - International Handbook of Behavior Modification End Therapy

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International Handbook of

PLENUM PRESS • NEW YORK AND LONDON

© 1990, 1982 Plenum Press, New York

A Division of Plenum Publishing Corporation

Vincent J. Adesso Laura Cleere

Gregory M. Alberts Denise D. Davis

David M. Gamer University of Ottawa

Michel Hersen Robert L. Koegel

Ronald A. Madle Clifford R. O'Donnell

Jan B. Sheldon Dennis C. Turk

Chapter 1 History of Behavior Modification 3

Chapter 2 The Experimental and Theoretical Foundations of

Counterconditioning Models of Behavior Change .............................. 36

Chapter3 Cognitive Behavior Therapy ................................... 53

Chapter4 Applied Behavior Analysis ........ '" . . .. . .. ... . .. . ... . .. . . . .. . 67

PART II ASSESSMENT AND RESEARCH

Chapter 5 Behavioral Assessment: A Contemporary Approach... . . . .. . . . .... 87

Chapter 6 Observational Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Introduction ............................................................ 107

Observers: Errors and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 117

Chapter 7 Behavioral Neuropsychology 139

Introduction ............................................................ 139

Chapter 8 Experimental Design in Group Outcome Research. . . . . . . . . . . . . . . .. 151

Chapter 9 Single-Case Experimental Designs 175

PART III GENERAL ISSUES AND EXTENSIONS

Chapter 10 Training in Behavior Therapy ................................ . 213

Chapter 11 Balancing Clients' Rights: The Establishment of

Chapter 12 Community Intervention Guided by Theoretical Development ..... . 251

Chapter 13 Drugs Combined with Behavioral Psychotherapy ................ . 267

Introduction ........................................................... . 267

Summary .............................................................. 276

PART IV INTERVENTION AND

Chapter 14 Anxiety and Fear ........................................... . 283

Historical Perspective ................................................... . 283

Chapter 15 Obsessional-Compulsive Disorders ............................ . 307

Description and Classification ............................................ . 307

Chapter 16 Cognitive Therapy of Depression ............................. . 333

Introduction ........................................... : ............... . 333

Chapter 17 Schizophrenia ............................................. . 353

Behavioral Interventions for Schizophrenia ................................... 359

Chapter 18 Adult Medical Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

Chapter 19 Pain ...................................................... . 399

Introduction ............................................................ 399

Chapter 20 Alcohol and Drug Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 415

Introduction ............................................................ 415

Chapter 21 Cigarette Dependence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 437

Tolerance and Dependence ................................................ 437

Thoughts for the Future .................................................. , 444

Definition and Epidemiology .............................................. 449

Chapter 23 Marital Distress ............................................ , 475

Introduction and Overview ................................................ 475

Chapter 24 Interpersonal Dysfunction 503

Social Skills: Conceptual/Theoretical Issues .................................. 504

Chapter 25 Crime and Aggression/Child and Spouse Abuse. .. .. . . . .. . .. . . . .. 523

Assessment of Crime and Delinquency ...................................... 525

Chapter 26 Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 547

Treatment of Sexual Dysfunction ........................................... 547

Chapter 27 Sexual Deviation ............................................ 565

Assessment of Paraphilias ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 565

Chapter 28 Geriatric Populations 581

Social Behavior ......................................................... 581

PART V INTERVENTION AND BEHAVIOR CHANGE:

Chapter 29 Stuttering ................................................. . 599