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Dissemination Of Effective Methods: Behavior Therapy's Next Challenge

Jacqueline B. Persons, Center for Cognitive Therapy

Dissemination of effective interventions developed by behavior therapists is one of behavior therapy's most important tasks now and in the coming years. I argue that dissemination is timely when a treatment is supported by efficacy data from randomized controlled trials or from a large series of single case studies. I offer recommendations for improving dissemination of empirically supported behavioral interventions and methods.

Dissemination Of Cognitive Behavioral Treatments: Commentary On "Dissemination Of Effective Methods: Behavior Therapy's Next Challenge"

G. Terence Wilson, Rutgers University

Demonstrably effective cognitive behavioral treatments for a number of clinical disorders are underutilized in clinical practice. Improving dissemination presents a challenge as Persons (1997) argues. In this commentary, reasons for dissemination failures, and suggestions for promoting empirically supported treatments, are discussed.

The Effect Of Values On Scientific And Clinical Judgment In Behavior Therapy

Ian M. Evans, University of Waikato, Hamilton, New Zealand

Although a strong scientific orientation continues to be a hallmark of behavior therapy, clinicians and researchers have discovered that they cannot simply rely on traditional experimental paradigms to answer policy questions, solve individual problems, or directly produce clinical judgment. Over the years, both practical and ethical dilemmas have arisen that reflect complex social and professional values. The explicit statement of these values, far from something to be avoided, actually enhances the integrity of behavior therapy. Many social concerns have become reflected in the decision making processes that underlie clinical judgment. By understanding the nature of such judgment, an expanded model of applied science emerges that is more reflective and less rule-bound than some of the earlier insistence on empirical data as the only foundation for practice. These arguments are illustrated by a personal selection of issues arising in the past 30 years of behavior therapy.

Commentary On "The Effect Of Values On Scientific And Clinical Judgment In Behavior Therapy"

Lizette Peterson, University of Missouri, Columbia

Evans' article (1997) on the role of values in behavior therapy is both an inspirational reflection of the past and a mandate for the future of behavior therapy. Here, I comment on some of the similarities and differences between behavior therapists trained in the 1960's and 1970's, and join with Evans in stressing the importance of values in behavior therapy. It is suggested that value-based considerations pertain not only to Evans' examples of severely disturbed populations, but also to pediatric and, more generally, child clinical therapies and to preventive as well as remediative interventions.

Manualized Behavior Therapy: Merits And Challenges

Georg H. Eifert, West Virginia University, Dietmar Schulte, Ruhr Universität Bochum, Germany, Michael J. Zvolensky, C. W. Lejuez, and Angela W. Lau, West Virginia University

Treatment manuals have been hailed as an important breakthrough in the development, evaluation, and dissemination of empirically validated therapies. Yet manualized behavior therapy also seems contradictory to the model in that (a) practice involves the application of validated principles of behavior rather than the application of fixed strategies, and (b) successful behavioral interventions must be based on an idiographic functional problem analysis and tailored to each individual patient. This article evaluates the relative merits, potential limitations, and misconceptions about the use of manuals. We conclude that individualizing treatment and manual use are not mutually exclusive and propose that manuals be used in a flexible theory-driven fashion guided by empirically tested clinical decision rules.

Individualizing Treatment Manuals As A Challenge For The Next Generation: Commentary On "Manualized Behavior Therapy: Merits And Challenges"

Gayle Y. Iwamasa and Susan M. Orsillo, Oklahoma State University

Eifert, Schulte, Zvolensky, Lejuez, and Lau (1997) present their views on the merits and challenges of manualized treatments for behavior therapy. In this commentary, we provide a "new generation" behavioral perspective on the future of such treatments. We discuss the importance of training issues and the development of problem-focused manualized treatments as opposed to diagnosis-focused manualized treatments. It is concluded that continued research in the development and improvement of manualized behavior therapy will place behavior therapists at the forefront of cutting-edge mental health services.

Technology, Theory, And The Alleviation Of Human Suffering: We Still Have Such A Long Way To Go

Steven C. Hayes, University of Nevada, Reno

Behavior therapy promised more adequate behavior change technologies through scientific validation, more adequate theories of behavior change, and widespread social betterment and alleviation of human suffering. The promise of scientific validation has been fulfilled, but the technical and theoretical progressivity of the field is still limited due to an emphasis on empirical method over an understanding of change processes. Creating widespread alleviation of suffering will require more attention to technical and theoretical progressivity and the practical demands of the health care system.

Is Behavior Therapy Ready For The Long Run?: Commentary On "Technology, Theory, And The Alleviation Of Human Suffering: We Still Have Such A Long Way To Go"

W. Stewart Agras, Stanford University School of Medicine

The initial accomplishments of behavior therapy may have been the easiest part of our task in alleviating those aspects of human suffering with which the field is concerned. Comments on Hayes' (1997) illuminating paper are directed at underlining and clarifying the problems that may be encountered as the field moves forward into the next century, and providing some thoughts about possible solutions.

Behavior Therapy's Promise For Child Treatment: Where We've Been, Where We May Be Going

Lizette Peterson, University of Missouri-Columbia

Outlining the beginning of behavioral treatment of children, this article describes the early experimental work on behavior analysis, with its inherent promise and limitations. Challenges to this early work promoted an even more promising technology for behavior therapy with children. Attention to several considerations drawn from past research is needed to enhance behavioral techniques, including attending to the complexity of the child's world, the child's developmental level, the unique demands of adolescence, and the powerful role of preventive interventions. Promises that remain to be fulfilled and future challenges to research and treatment are considered, with particular attention to the need for strong child advocacy.

Children, Promises, And Behavior Therapy: Commentary On "Behavior Therapy's Promise For Child Treatment"

Bruce F. Chorpita
University of Hawaii

As Peterson (1997) observes, children are in a unique position. They represent a diverse and complex population that, at times, has been undervalued by the mainstream of psychology. Thus, child behavior therapy has often lagged behind developments in the adult area. However, somewhat ironically, the unique characteristics of children as a population may also serve as an advantage for the development of increasingly sophisticated behavioral techniques. Capitalizing on these unique qualities may be one important step toward fulfilling behavior therapy's promise.

Science And Treatment Development: Lessons From The History Of Behavior Therapy

Kelly G. Wilson, University of Nevada

The behavior therapy movement has led psychology in the development of empirically validated treatment approaches. Three features of the behavior therapy movement distinguish it from other applied approaches and have contributed to its success: (a) defining problems in terms of identifiable behavioral excesses and deficits, (b) derivation of treatment strategies from the findings of basic psychological science, and (c) rigorous examination of treatment efficacy and mechanisms of action. Each of the three defining features are discussed as central to the continued success of behavior therapy. Recent years have witnessed some drift from this tradition. Arguments for adherence to this formula will be provided. Examples of adherence and drift will be discussed.

The Uniquely Human Side Of Treatment Development: Commentary On "Science And Treatment Development: Lessons From The History Of Behavior Therapy"

Albert Ellis, Albert Ellis Institute for Rational Emotive Behavior Therapy, New York, NY

K. G. Wilson (1997) discusses the value of using empirically validated treatment approaches in behavior therapy, while also acknowledging their limitations. In addition, Wilson advocates the derivation of treatment strategies from the findings of basic psychological science and rigorous examination of efficacy and mechanisms of action. It is agreed that Wilson makes some good suggestions for improving the scientific basis of behavior therapy and cognitive behavior therapy. In this commentary, it is suggested that behavior therapy has many implicit cognitive elements, and therefore, Wilson's suggestions may be relevant for both "different" forms of treatment.

Behavior Therapy: Distinct But Acculturated

Rosemery Nelson-Gray, Scott T. Gaynor, and William J. Korotitsch, University of North Carolina at Greensboro

Over the last 30 years, behavior therapy has gone from being a contentious outlier in the clinical sciences to an acculturated and respected participant. Behavior therapy has achieved acculturation through increasing recognition of its many efficacious treatments and increasing investment in psychopathology research. With the trend toward acculturation and confederation with the larger psychological community comes the risk and potential cost of losing our unique identity. It is argued that acculturation has not threatened behavior therapy's distinctive foundation in behavior principles and learning theory. Recently developed behavioral psychotherapies are described as examples of behavior therapy's ability to retain its distinct theory-driven basic science foundation. It is concluded that meeting the challenge of acculturation need not compromise behavior therapy's unique identity as a paradigm within psychology.

Through A Different Lens: Commentary On "Behavior Therapy: Distinct But Acculturated"

Arnold A. Lazarus, Rutgers University–The State University of New Jersey

Nelson-Gray, Gaynor, and Korotitsch (1997) point out that several behavioral researchers and clinicians have made assiduous and vigilant efforts to identify empirically validated therapies (I prefer the term "empirically supported methods"). In this commentary, I agree that the identification of empirically supported methods and the use of sophisticated manual-based treatments offer hope for a scientific psychotherapy. I describe how my multimodal approach can provide a broad-based framework to accommodate and enhance the synergistic merging of robust methods from diverse disciplines. The use of effective techniques within the context of appropriate relationship styles, coupled with broader areas of clinical research, may eventually witness the end of nonempirical and unsubstantiated theories that still appeal to the majority of clinicians.

Since The Operant Chamber: Is Behavior Therapy Still Thinking In Boxes?

Bruce F. Chorpita, University of Hawaii

Over the last 30 years, behavioral treatments have developed with increasing sophistication in the tradition of demonstrable efficacy. However, many of the more recent gains have occurred within the context of a nonbehavioral ideology. It is argued that the greatest advances for behavior therapy now await the popular acceptance of true behavioral ideology within mental health service delivery, and that such a framework will encourage the reintegration of many of the more theoretical elements of behaviorism into existing behavioral treatments. Given the widespread attention earned by recent empirical achievements in behavior therapy, the occasion for promoting a behavioral ideology in health care delivery may be near. Although recent behavioral protocols have demonstrated considerable success in clinical trials, continued efforts to develop approaches less consistent with a behavioral ideology are likely to limit further advances of disseminable behavior therapy techniques.

Why Managed Care Is Ripe For Market-Oriented Behavior Therapy: Commentary On "Since The Operant Chamber: Is Behavior Therapy Still Thinking in Boxes?"

Steven C. Hayes, University of Nevada

Chorpita (1997) has rightly diagnosed a significant problem. In the 1980's and 1990's behavior therapy has progressed, in part, because it embraced the technological model of treatment development, but that model cannot take behavior therapy to the next level. An industrialized health delivery system needs science to succeed. The existing models of treatment development and dissemination have inherent limitations in such an environment, however. Behavior therapy needs to go beyond the technological model of treatment development to link its knowledge base to the modern world of behavioral health care. The purpose of my comments are to elaborate on this basic point.

Promises To Keep

David H. Barlow, Center for Anxiety and Related Disorders and Boston University

I describe a personal odyssey beginning in the early years of behavior therapy when, as a student, I had the good fortune to work and train with the founding pioneers. I continue with a description of the status of behavior therapy in the early 1980s when I was heading up a number of behavior therapy institutions and made, at that time, some predictions about the future of behavior therapy, at least one of which was very wrong. I conclude with observations on distortions to the original goals of behavior therapy that have occurred over the decades and outline some objectives that have yet to be realized.

The Revolution To Come: Commentary On "Promises To Keep"

Kelly G. Wilson, University of Nevada

Barlow (1997) reminds us of the revolutionary beginnings of the behavior therapy movement, and points to the need for broader dissemination of our treatments. In this commentary, changes in health care delivery are examined, along with the role of doctoral-level psychologists within the emerging health care system. With behavior therapy's history of clearly specified treatment procedures and expected outcomes, we are uniquely well positioned to join our own revolution to the larger health care revolution. Suggestions are made for rethinking the role of doctoral-level psychologists in the modern health care milieu.

Beyond The Efficacy Ceiling? Cognitive Behavior Therapy In Search Of Theory

Edna B. Foa and Michael J. Kozak, Allegheny University of the Health Sciences

The enterprise of behavior therapy began with enormous optimism that was reinforced by early clinical impressions. As the field developed, there has been a growing recognition that the efficacy of behavior therapy is limited, as many patients do not improve and some do not maintain their gains. In this paper we take a historical view of behavior therapy with a focus on the limits of its efficacy and on the influence of experimental psychology on its development. We have considered several possible explanations for the findings indicating limited success of behavior therapies. We suggest that the advance of cognitive behavior therapy may be slowed, in part, by alienation from experimental psychology and psychopathology research.

Commentary On "Beyond The Efficacy Ceiling": Responses To An Irrelevant Subtitle

Joseph Wolpe, Pepperdine University

Foa and Kozak (1997) appear to have been led by the irrelevant subtitle of this special issue into discussing a number of matters unworthy of their efforts, including the mundane observation that behavior therapy is not without failures, and the unsupported contention that behavior therapy is in search of a theory. However, the authors draw needed attention to the fact that the cognitive contribution to behavior therapy is not derived from experimentation and that experimental findings are not as much drawn upon as they should in behavior therapy.

In The Name Of The "Advancement" Of Behavior Therapy: Is It All In A Name?

John P. Forsyth, University at Albany, State University of New York

Almost since its inception, the behavior therapy movement has defined itself in terms of advancement. Advancement, in turn, implies progress or moving forward, not stagnation, or regress and moving backward. Over the last 30 years, behavior therapy has witnessed notable advancements, but also periods of stagnation, and at times regress. The challenge of advancement entails progress both from within behavior therapy and from without. Recent trends within the field suggest more attention to the latter than the former. Behavior therapy, therefore, is at risk of failing to advance as a progressive basic and applied science. For the science and practice of behavior therapy to be a viable force within the larger psychological community, health care, and society, it must revisit its theoretical and basic science foundations and continue to move forward from within.

Advancing Behavior Therapy Means Advancing Behaviorism: Commentary On "In The Name Of The 'Advancement' Of Behavior Therapy: Is It All in a Name?"

Neil S. Jacobson, University of Washington

Forsyth (1997), a third-generation self-described member of the behavior therapy movement, suggests that behavior therapy has had a checkered history over the past 30 years: at times progressing, at times stagnating, and at other times regressing. He laments the decline of theory, and the lack of influence by basic research, as two primary elements missing from contemporary behavior therapy. I agree with almost everything Forsyth says, but would cast the problem in a somewhat different context. In this commentary I suggest that the problem is not the absence of theory in contemporary behavior therapy, but rather the absence of behaviorism. Behaviorism, in my view, is not a theory, but an epistemology that provides a methodology for studying and changing behavior. I do believe that there is very little in basic science that is relevant to the practice of behavior therapy, and that theory is all too plentiful, rather than absent. However, plentiful does not necessarily mean helpful.

Thirty Years Of Behavior Therapy

Joseph Wolpe, Pepperdine University

From its beginnings, behavior therapy stood apart from all other psychotherapies in one important respect—its methods were derived from experimentally established paradigms. Behavior therapy's most direct influence was in the area of the anxiety disorders, where its most powerful impact was the weakening of anxiety by the simultaneous evocation of a competing response. Practical success depends greatly on systematic attenuation of anxiety based on hierarchical presentation of stimuli. Success can be widened if advantage is taken of a range of implementations of a paradigm. Yet, we need to keep in mind that not all behaviorally based paradigms are useful, and that some useful methods, such as Beck's cognitive approach, are not based on experimental paradigms.

Can Behavior Therapy Be Saved From Triviality?: Commentary On "Thirty Years Of Behavior Therapy"

Robert P. Hawkins
West Virginia University

Wolpe's (1997) concern about behavior therapy's drift away from experimental psychology seems valid. Behavior therapy's initial integration with basic science assured that, as the basic science progressed, so would behavior therapy. However, the seduction of lay language, combined with clinical tradition, has led us away from both behaviorism and all basic science. It is predicted that the eventual result of this drift will be that the applied science of behavior therapy will be left further and further behind and its progress will become increasingly tivial while the basic science continues to progress. Recommendations are made for steps that could reverse this unfortunate drift.