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Group Cognitive Behavior Therapy for Depression in a Community Setting: A Clinical Replication Series

Alan L. Peterson and T. Scott Halstead, RAF Lakenheath Hospital, England

Several controlled treatment-outcome studies have demonstrated the clinical efficacy of group behavioral and cognitive behavioral treatments for depression. However, there is a significant lack of evidence on mental health outcome evaluation studies for depression conducted in nonresearch clinical settings. Subjects in research settings may represent only about 20% of the clinical population because of stringent inclusion criteria, requirements to accept random assignment to conditions, etc. The present study is a clinical replication series of the effectiveness of group cognitive behavior therapy for depression administered in a nonresearch community setting. The subjects included 138 adult patients referred by mental health clinic providers for participation in a six-session (12-hour) depression management group. Outcome measures using the Beck Depression Inventory indicated that the level of depression was decreased for 84% of the participants, the average reduction in depression as measured by the BDI was 38%, and 43% of the patients had a greater than 50% reduction in their BDI score. The results indicated that group cognitive behavior therapy can be effectively applied in a clinical setting with a heterogeneous patient population, although the magnitude of the treatment effect was somewhat less than found in research settings (38% reduction on the BDI as compared to 57%). Group cognitive behavior therapy is a cost-effective treatment approach and the potential for benefits significantly outweighs the cost. In this era of managed care initiatives, group cognitive behavior therapy for depression should be considered as a first-line treatment intervention for many patients with depression as part of a stepped-care treatment approach to provide "the best treatment at the best value."

Controlled Comparison of Individual Versus Group Cognitive Therapy for Irritable Bowel Syndrome

Alisa Vollmer and Edward B. Blanchard, Center for Stress and Anxiety Disorders, University at Albany-SUNY

Thirty-two patients with irritable bowel syndrome were randomly assigned to one of three treatment conditions: cognitive therapy in small groups of 3 to 5 individuals; cognitive therapy in an individual format; or an 8-week symptom-monitoring wait-list control. Treatment consisted of 10 sessions. Pre- to posttreatment evaluations showed significantly greater gastrointestinal symptom reduction on a composite measure for the treated subjects than for the symptom-monitoring condition (p = .01); the group cognitive treatment and individual cognitive treatment conditions did not significantly differ. At posttreatment, 64% of the group cognitive treatment condition and 55% of the individual cognitive treatment condition showed clinically significant improvement (at least a 50% reduction in the composite measure) as compared to 10% of the monitoring group. Treatment gains were maintained for those who responded (12 of 22 treated subjects) to a 3-month follow-up study.

Assessing the Field Effectiveness of Acceptance and Commitment Therapy: An Example of the Manipulated Training Research Method

Kirk D. Strosahl, Group Health Cooperative of Puget Sound, Seattle, Washington, Steven C. Hayes, University of Nevada, John Bergan, and Phyliss Romano, Group Health Cooperative of Puget Sound, Seattle, Washington

Health care reform and managed care have produced a growing emphasis on field effectiveness research. The present paper proposes a simple methodological model for conducting such research that can assimilate all of the setting features of effectiveness questions while not requiring that researchers abandon experimental controls in favor of survey methods. This "manipulated training method" is then applied to an analysis of the field effectiveness of Acceptance and Commitment Therapy (ACT). Seventeen master's-level therapists and one psychologist (those not receiving training = 10; receiving training = 8) participated in a 1-year project. The training package consisted of a didactic workshop, an intensive clinical training, and monthly supervision groups. Prior to training and following training the clients of all clinicians in the project were assessed. Among other findings, clients of ACT-trained therapists reported significantly better coping than the clients of untrained therapists and were more likely to have completed treatment in the five months following initiation of treatment. A structural equation model indicated that ACT training accounted for differential coping outcomes. There was also evidence that training improved clients' self-ratings of psychological acceptance. At 5 months following the initial session, clients of ACT-trained therapists were more likely than clients of untrained therapists to have concluded therapy, and were more likely to agree with their clinician regarding the ongoing status of therapy. Implications for research on clinical effectiveness and technology transfer of behavior therapy are discussed.

Should Behavior Therapists Stop Using Reinforcement? A Reexamination of the Undermining Effect of Reinforcement on Intrinsic Motivation

John S. Carton and Stephen Nowicki, Jr., Emory University

In two experiments the effect of monetary reinforcement on college students' intrinsic motivation was examined in an attempt to compare two competing explanations of the effects of tangible reinforcement on intrinsic motivation: discrimination training and cognitive evaluation theory. In experiment 1, students were administered the typical methodology used to study the effects of tangible reinforcement on intrinsic motivation with the addition that the verbal instructions prior to the posttreatment session that inform participants regarding the lack of reinforcer availability were manipulated experimentally. The results supported the hypothesis that discrimination training accounts for the undermining effect. Experiment 2 replicated the findings of Experiment 1 and included tests of the cognitive evaluation theory account of the undermining effect. Several results of Experiment 2 were inconsistent with predictions based on cognitive evaluation theory, whereas the discrimination training hypothesis received additional support. The advantages of the discrimination training account of the undermining effect and the implications for the use of reinforcement in applied settings were discussed.

Broadening the Parameters of Investigation in Treating Young Children's Chronic Food Refusal

Mary A. Werle, Tria B. Murphy, Illinois Institute of Technology, and Karen S. Budd, DePaul University

We evaluated the relationship of contextual variables and contingent mother-child interactions to feeding behaviors at home for 3 children (ages 18 to 43 months) with chronic food refusal problems. Previous research suggests that contingent attention (i.e., specific prompts, approval) affects feeding, but contextual variables (i.e., mealtime location, seating arrangement, number of meals and snacks offered daily, persons present during meals) have not been systematically examined. Using a nonconcurrent multiple baseline design across mother-child dyads, we assessed the effects of parent training in contingency management skills on maternal contingent attention, child food intake, and contextual variables of mealtimes. Parent training resulted in planned increases in contingent attention and child acceptances of target foods for each dyad. Concomitant with this training, 2 children showed positive changes in contextual variables (e.g., reduced frequency of daily meals and snacks to a recommended level, increased proportion of meals eaten at a table), and 1 child evidenced mild deterioration in contextual variables. A second parent training condition directed at correcting specific ecological parameters with 2 dyads effectively modified these variables, but its impact on child food acceptance was unclear. These findings suggest that some contextual conditions covary with children's feeding patterns and should be monitored in planning and evaluating feeding intervention.

Prescriptive Treatment for Generalized Anxiety Disorder in Children

Andrew R. Eisen, Child Anxiety Disorders Clinic, Fairleigh Dickinson University, and Wendy K. Silverman, Child and Family Psychosocial Research Center, Florida International University

This investigation compared the preliminary efficacy of prescriptive and nonprescriptive cognitive-behavioral interventions (i.e., cognitive therapy/exposure or relaxation training/exposure) for problematic response classes (cognitive or somatic symptoms) of 4 overanxious children (8 to 12 years) using a multiple baseline design across subjects. Participants also met DSM-IV criteria for generalized anxiety disorder. All children improved on pre-post child and parent self-report measures, independent clinician ratings, and physiologic recordings. Treatment gains were generally maintained at 6-month follow-up. Although both treatments were effective, only prescriptive treatments produced sufficient improvement for participants to meet positive end-state criteria. Implications for the prescriptive treatment of anxiety disorders in children are discussed.

Efficacy of Eye Movement Desensitization and Reprocessing: Implications for Behavior Therapy

Jeffrey M. Lohr, David F. Tolin, University of Arkansas, and Scott O. Lilienfeld, Emory University

The commitment of behavior therapy to empiricism has led it to a prominent position in the development of validated methods of treatment. The recent development and rapid expansion of Eye Movement Desensitization and Reprocessing (EMDR), a treatment that bears a resemblance to behavioral techniques and that has been proposed as an alternative to such techniques for numerous psychological disorders, raises important questions for the field of behavior therapy. In this article, we examine 17 recent studies on the effectiveness of EMDR and the conceptual analysis of its mechanisms of action. The research we review shows that (a) the effects of EMDR are limited largely or entirely to verbal report indices, (b) eye movements appear to be unnecessary for improvement, and (c) reported effects are consistent with non-specific procedural artifacts. Moreover, the conceptual analysis of EMDR is inconsistent with scientific findings concerning the role of eye movements. Implications of the empirical and theoretical literature on EMDR for behavior therapy are discussed.

Effectiveness of a Cognitive Behavioral Treatment Program for Trichotillomania: An Uncontrolled Evaluation

Julie Lerner, Martin E. Franklin, Elizabeth A. Meadows, Elizabeth Hembree, and Edna B. Foa, Allegheny University of the Health Sciences

The effectiveness of a cognitive behavioral treatment program for trichotillomania was examined in an uncontrolled study. Immediately following treatment, 12 of 14 treatment completers were classified as responders (> 50% improvement on NIMH Trichotillomania Severity Scale). However, only 4 of 13 treated patients were classified as responders at follow-up (M = 3 years, 9 months); one posttreatment responder was lost to follow-up. Long-term symptom severity was also assessed in a subset of treatment refusers and dropouts; 4 of 10 available treatment refusers and dropouts were classified as improved at follow-up (M = 3 years, 2 months). Our findings suggest a significant risk for relapse following successful cognitive behavioral treatment of trichotillomania. Recommendations to address this problem include extending treatment length to achieve greater initial symptom reduction and expanding the focus on relapse prevention strategies.