ABSTRACTS

Bridging the Gap Between Scientists and Practitioners: The Challenge Before Us

Linda Carter Sobell, Addiction Research Foundation and University of Toronto, Canada

The need to develop effective and efficient strategies for the dissemination of evidence-based health care has been recognized by governments, researchers, and clinicians alike. However, recognition and implementation are separate issues. If scientists are to have a significant impact on clinical practice, they will have to learn a new way of "doing business." Lessons from the business community and from the field of diffusion of innovations research (dissemination research) have direct applicability to disseminating science-based clinical procedures. This paper presents two examples of the successful integration of science and clinical practice. The goal in each case was to address problems fundamental to dissemination research, specifically for addictions treatment. The first example demonstrates how scientists and practitioners successfully worked hand-in-hand to integrate science and practice, by creating a clinical protocol that subsequently served almost 300 clients. The second example describes the successful dissemination of a clinical research intervention into community settings. The key to effective dissemination was to make practitioners true partners in the research, development, and dissemination process. For the effective wedding of clinical science and practice on a wide scale, dissemination must be adopted as a value and become a major objective of health care organizations. Current health care emphasis on evidence-based practice suggests that alliances between practitioners and scientists will point the way to clinical standards of practice for the next millennium.



Comorbidity of Sexual Problems and Posttraumatic Stress Disorder in Female Crime Victims

Elizabeth J. Letourneau, Heidi S. Resnick, Dean G. Kilpatrick, Benjamin E. Saunders, and Connie L. Best, National Crime Victims Research and Treatment Center, Medical University of South Carolina

The present study examined the relationship between Posttraumatic Stress Disorder (PTSD) and sexual problems using data from a subset of women (n = 391) interviewed about history of crime victimization and DSM-III-defined mental health problems (American Psychiatric Association, 1980). The sample was subdivided based on positive (n = 228) or negative (n = 165) history of sexual problems. These two groups were compared on a number of demographics, crime characteristics, and mental health variables. Variables significantly related to sexual problems included having experienced (a) some form of criminal victimization, (b) completed rape, (c) physical injury during the crime, (d) depression, and (e) PTSD. A logistic regression was conducted with these significant variables. The PTSD variable was entered into the regression model last and was found to contribute a significant amount of the variance after accounting for variance contributed by the other variables. This finding supports the hypothesis that PTSD may act as a moderating variable on the development of sexual problems in women with sexual and nonsexual trauma histories. The findings from the present study are largely consistent with learning theory models of posttraumatic adjustment. Clinical and research implications are discussed.



A Reflection on the Popularity Construct: The Importance of Who Likes or Dislikes a Child

Douglas W. Nangle, Cynthia A. Erdley, and Joel A. Gold, University of Maine

This study examined the relations between children's peer status and the status of the groups of children who reported liking or disliking them. Ninety children completed a battery of sociometric measures at three time periods. Results showed that children tended to be liked by peers who were similar, and disliked by peers who were dissimilar, in social status and behavioral style. Compared to "dislikers," the groups of children who liked a particular child were more homogeneous, and their relative social status was more stable across time. The importance of these results for understanding the group processes that cause and maintain peer rejection is discussed with a focus on intervention implications.



Errorless Compliance to Parental Requests III: Group Parent Training With Parent Observational Data and Long-Term Follow-Up

Joseph M. Ducharme, Chedoke-McMaster Hospitals and University of Toronto, Michelle Popynick, Edite Pontes, and Sharon Steele, Surrey Place Centre

Errorless compliance training has recently been developed as a nonintrusive approach to improving generalized child cooperation (Ducharme & Popynick, 1993; Ducharme et al., 1994). In the present study, we investigated issues of efficiency, durability, and generality of treatment effects to ensure optimal treatment utility. Parents of five children with developmental disabilities and severe oppositional behavior were trained in a group format to conduct errorless compliance assessment and treatment procedures. Parent-collected data and research assistant-collected videotape data were used to determine generality of effects. We examined long-term maintenance by conducting intensive follow-up assessment up to 15 months after treatment completion. Both parent and research assistant-collected data suggested that the froup format for errorless compliance training was effective in enhancing treatment and generalization effects. The effects were also durable, with all children demonstrating high levels of compliance during long-term follow-up assessment.



Deviancy Training in Male Adolescent Friendships

Thomas J. Dishion, Oregon Social Learning Center, Eugene, Oregon, University of Oregon, Kathleen M. Spracklen, David W. Andrews, and Gerald R. Patterson, Oregon Social Learning Center, Eugene, Oregon

The conversations of 186 adolescent boys (13 to 14 years old) and their friends were videotaped and analyzed to understand the processes of influence associated with antisocial behavior. The videotaped discussions were coded with a system that captured the general topics (Normative vs. Rule-Breaking) as well as the reactions of the listener (Laugh vs. Pause). Matching law analyses confirmed a linear relationship between the dyadic rate of Rule-Breaking talk and contingent positive reactions. Sequential analyses revealed a statistically reliable reciprocal pattern between Rule-Breaking talk and Laugh in the delinquent (both boys arrested) dyads, whereas in the mixed (one arrested) and nondelinquent (neither arrested) dyads, reciprocation occurred between Normative talk and Laugh. Longitudinal analyses of the boys' behavior over the ensuing 2 years revealed that the deviancy training sequence was prognostic of increases in self-reported delinquent behavior, even after controlling for prior levels of delinquency. It appears that discussions of deviancy play a critical role in organizing positive affective exchanges, thereby establishing problem behavior as a common ground activity that potentially exacerbates adolescent social maladjustment. These findings are discussed with respect to developmental theory and intervention science.



Systemic Alarms in Fear Conditioning II: An Experimental Methodology Using 20% Carbon Dioxide Inhalation as an Unconditioned Stimulus

John P. Forsyth, Georg H. Eifert, and Risa N. Thompson, West Virginia University

We present a conditioning methodology to examine the role of abrupt aversive systemic bodily responses (alarms) in human fear acquisition and extinction in a non-clinical student population (N = 64). Animated fear-relevant and fear-irrelevant video stimuli referring to either the body (internal) or environment (external) were paired with an unconditioned stimulus (UCS) of 20 sec inhalations of 20% carbon dioxide (CO2)-enriched air. Measurements of psychophysiological responses, such as electrodermal, electromyograph (EMG), heart rate, and Subjective Units of Distress Scale (SUDS) to fear-relevant stimuli were more easily acquired, were of higher magnitude, and showed greater resistance to extinction compared with measurements for fear-irrelevant stimuli. Conditioning was more pronounced to external (snake) than to internal (heart) phobic stimuli. Findings support the viability of using co2-enriched air as an alternative to commonly used peripheral UCSs (e.g., shock) to mimic the role of alarms as conditioning events in human fear acquisition. We discuss the relevance of this methodology for understanding fears that develop without identifiable environmental trauma.



Acceptance and Change in the Treatment of Eating Disorders and Obesity

G. Terence Wilson, Rutgers University

Recently it has been argued that the explicit focus on behavior change in behavior therapy must be complemented by recognition of the value of acceptance, and the importance of the relationship between these two treatment goals. The same dialectic is central to the treatment of eating disorders and obesity. Having made nutritionally sound and psychologically adaptive lifestyle changes, patients need to accept whatever shape and weight these changes produce. Treatment strategies for overcoming obstacles to acceptance are discussed. These include education, the use of the therapeutic relationship, and cognitive restructuring. Acceptance is an active process of self-affirmation rather than passive resignation to an unhappy fate. It involves emotional processing as well as cognitive and behavioral change. The focus on acceptance and the empirical evidence on the effectiveness of cognitive behavioral therapy (CBT) in promoting self-acceptance in patients with eating disorders contrasts with the treatment of obesity where the value of self-acceptance has received less research attention. Aside from being important in its own right, enhancing self-acceptance might lead to more lasting changes in health-relevant eating and exercise behavior.



Systemic Alarms in Fear Conditioning I: A Reappraisal of What Is Being Conditioned

John P. Forsyth and Georg H. Eifert, West Virginia University

Many behavior therapists have questioned the adequacy of direct respondent conditioning for explaining phobic fear acquisition because fears may develop in the absence of direct experience with environmental trauma. Much of the debate has been fueled by confusion about what constitutes a traumatic event, and what is it that is being conditioned in phobic fear. The purpose of this paper is to (a) review recent arguments for and against direct traumatic conditioning based on clinical observation and laboratory conditioning studies, and (b) present an alternate view of direct conditioning that does not require a readily identifiable conditioned stimulus (CS) or unconditioned stimulus (UCS). What is required is a negatively evaluated abrupt and aversive systemic response (alarm) that constitutes the primary conditioning event in human fear acquisition. Using examples of specific phobias and illness fears, we illustrate how alarms can account for fear acquisition without a readily identifiable aversive environmental event.



Panic Disorder Associated With Blood-Injury Reactivity: The Necessity of Establishing Functional Relationships Among Maladaptive Behaviors

Kent W. Anderson, Steven Taylor, and Peter D. McLean, University of British Columbia

Cognitive behavior therapy for panic (CBTP) is an effective treatment that often produces enduring therapeutic effects. However, relapses occur, and little is known about why this happens. This issue was examined in a case study of panic disorder that appeared to arise from preexisting vasovagal (fainting) reactions to blood-injury stimuli. CBTP effectively reduced our patient's panic disorder in 1992, but panic attacks recurred in 1994 after particular events in his life caused him to be re-exposed to blood-injury stimuli. It appeared that CBTP reduced panic disorder but did not change his reactivity to blood-injury stimuli, and that in order to successfully treat the panic disorder, it was necessary to treat the blood-injury sensitivity. Accordingly, in 1994 we treated the patient with CBTP, and panic attacks were reduced. To demonstrate that the blood-injury reactivity was unchanged, and that it contributed to panic disorder, we exposed the patient to blood-injury stimuli. This caused panics to reoccur. Finally, the patient received a treatment for blood-injury phobia known as applied tension, which reduced blood-injury phobia and eliminated panic attacks. Gains were maintained at follow-up, and relapse of panic did not occur when the patient was re-exposed to blood-injury stimuli. This case illustrates one mechanism of relapse of panic disorder and highlights the importance of considering the functional relationship between panic attacks and other maladaptive behaviors when planning treatments for panic disorder.



Maintenance of Remission Following Cognitive Behavior Therapy for Panic Disorder: Possible Deleterious Effects of Concurrent Medication Treatment

Michael W. Otto, Mark H. Pollack, and Susan A. Sabatino, Massachusetts General Hospital and Harvard Medical School

In a prospective, naturalistic study, we examined the long-term outcome of patients with panic disorder who entered remission following cognitive behavior therapy (CBT) alone or CBT plus medications (combined treatment). Similar to previous studies, severity of the panic disorder and agoraphobic avoidance served as predictors of relapse in a survival analysis. However, the most powerful predictor of maintenance of remission was treatment type. Despite ongoing pharmacotherapy, patients who entered remission with combined treatment and continued their pharmacologic treatment relapsed sooner than patients treated with CBT who entered remission medication-free. Consideration of baseline levels of anxiety severity, comorbidity, and history of previous remissions did not account for the prediction afforded by consideration of treatment type. These findings are discussed in the context of other evidence for deleterious effects of concomitant pharmacotherapy on the long-term outcome of patients with panic disorder treated with CBT. Treatment implications are discussed.