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Adherence, compliance and generalization in behavioral medicine
&hiw. Re\. T/m-. Vol. 23. No. 2. pp. 229-237. Pergamon Press Ltd. Prrnted III Great Brat&
1985
BOOK N.
J.
MACKINTOSH: Conditioning
und Associadce
Learning.
REVIEWS Oxford
Univ. Press (1983). 306 pages. f17.50.
After producing his monumental work. The Ps_vchoiogJ?of Animal Learning, what, one wonders, can remain for Professor MacKintosh to write about? A revision? Certainly, in time one will be required. The present book is, in part, a loose continuation of the earlier volume. but more importantly, a detailed analysis of some of the outstanding problems of associative learning. Mackintosh makes no concessions to his readers and assumes an easy acquaintance with contemporary knowledge of animal learning and the main debates about that knowledge. The chapters cover classical and instrumental conditioning, appetitive and aversive reinforcement, avoidance leamrng and discrimination learning. The author launches into the key issues without delay or distraction and the result is an interesting and stimulatmg book, but one that demands close attention. It is not intended to be a comprehensive account of animal learning (he has already provided that), still less of human learning. and its main value is provocative. What does MacKintosh say about this problem? How would he explain this phenomenon, and so on? It is excellent material for debate-and for demanding tutorials. No doubt, the book will be argued backwards and forwards for some time. (In my copy, the chapter on avoidance is scored with marginal notes and queries.) The specific topics include discrepancy theory, learned irrelevance, latent inhibition, blocking, habituation, taste aversions. preparedness and many others. Nevertheless it is not a quibble to complain that readers would have wished to read MacKintosh on the Seligman-Johnston theory of avoidance. reciprocal inhibition, Gray’s analysis of avoidance, safety signals and numerous other subjects. In passing, MacKintosh observes that even simple examples of animal behaviour can defy satisfactory explanation. “That effects should be so simple makes it all the more humiliating that we should remain in almost total ignorance of the nature of the processes responsible for the effects” (p. 233). This book reveals the very many complexities in seemingly straightforward behaviour: traps abound. It is a stimulating and rich book, but a selective one. S. RACHMAN
J. M. GARDNER: Training xviii + 179 pages.
Non-professionals
in
Behauiour
Modification.
Witwatersrand
Univ. Press, Johannesburg
(1981).
This well-written and well-organized book is intended for students of behaviour modification and for those engaged in training others in this field. Training in behaviour modification techniques is spreading rapidly, with a variety of professional groups and non-professionals being given training in the application of these techniques at many levels and in many settings. The value of such training with groups like parents, nurses and teachers is now established. This book starts with an overview of behaviour modification. both conceptual and historical, foliowed by a summary of techniques. The section on training covers the major issues very wetl: the different leveis of training and how they are to be determined. phases and stages of training. and ethical issues. The analysis of levels is both illuminating and useful; five levels are distinguished-applicator. technician. specialist, generalist and consultant. The final section is about research on teaching behaviour modification. This reviews the available, limited and generally inadequate research in this area, and draws a few general conclusions. It is argued that behaviour modification training programmes should take mto account the available research findmgs. rather than each trainer/practitioner doing ‘his own thing’. On the whole. this 1s a commendable effort. Not only is it a good account of the topic it covers; it is also an excellent model of hoN a book such as this should be written and organized. If one is to look for flaws, the main one would be the selectivity of the literature discussed. Much of recent British work is ignored; and there is no reference to Eysenck and Rachman’s Caasr arid Cures of Neuroses (1965) which was highly influential in determining the direction behaviour therapy took in the late srxties. But such flaws should not detract from the overall value of Gardner’s book. It is a volume which all teachers of behaviour therapy should be familiar with. P. DE SILVA
Eysenck H. J. and Rachman S. (1965) Causes
K. B. STUART (Ed. ): Adherence. x + 398 pages. 830.00.
Compliance
and Cures qf Neuroses.
and Generalization
Routledge Br Kegan Paul, London.
in Behavioral
Medicine.
Brunner/Mazel,
New York (1982).
Technical solutions to illness problems represent only the tirst stage in the provision of health care. Chnicians then face the serious challenge of persuading their clients to follow the advice that they have given. In the area of behavioural medicine 229
BOOK REVlEWS
230
especially. issues of generalizationand adherence are central. because the essence of many treatments is long-term change in well-established patterns of behaviour. This series of papers. sponsored by the Banj,jInternarionai Conferences 011 Behavior .Mod(fication. offers a wide choice of theoretical and empirical perspectives on generalization and compliance problems m medical settmgs. Baer (Chapter 8) and Marlatt (Chapter 14) argue convincingly for the adoption of treatment strategtes in which generalizatton and relapse prevention are butlt into the programme. They also suggest a wide assortment of practical alternattves to the ‘tram and hope’ approach. Haynes (Chapter 3) summarizes his critical analyses of the myths and knowledge prevatling in the area of compliance wtth medical advtce. and the remaining chapters cover a variety of topics including obesity. diabetes and hypertenston. Clinicians from all fields could not fail to find this book stimulating and useful. JANEWARDLE
J. WOLPE: 771~Pracrice of Behnvior
Therapy.
3rd edn. Pergamon
Press. New York (1982). xiv + 389 pages. f6.20.
Behaviour therapy has grown to the stage where it is impossible for any single person to review the enttre area and this book deals mainly with the neuroses. that term eschewed by the DSM-III though still in European parlance. Wolpe is one of the pioneers who put behaviour therapy on the map, from the standpoint of a clintctan. and his immense chnical experience shines through this volume. It contains many interesting anecdotes of treatment of a wide variety of patients. and this is one of the most valuable aspects of the book. There is a refreshing exposition of Ryle’s crittque of dualism. of the ghost in the machine, and a good discussion of the shortcomings of learned helplessness as a model for depression. Though similar points couid be levelled against animal ‘neuroses’ as models for human anxiety, they are blythely accepted as “indistinguishable from those of humans when allowance ts made for differences among species” (p. 37). Theoretical discussions in the book contain much that is intriguing but are largely uncritical. Conditioning’ is used as an all-explanatory principle which is not distin~ulshed from other forms of learning. There is some discussion of the literature on preparedness but it is not Integrated into the rich literature on the maturation and development of behavtour. The role of trauma in the development of phobias IS dwelt on, but some of the instances cited seem to indicate the presentation of conditioned stimuli which are already far from neutral at the start rather than of the pairing of unpleasant unconditioned stimuli with neutral conditioned stimuli (e.g. p. 30. Case 6). Another problem is the absence of a succinct review of the immense literature on controlled studies of behaviour therapy in the neuroses, uncontrolled work bemg expounded at some length. Negative data not supportmg the author’s vrews are usually given short shrift or omitted, e.g. work showing that relaxation does not contribute to the efficacy of desensitizatton or other forms of exposure. The practice of behavtour therapy whtch is described IS a bit out of date. The work of Jannoun. Mathews, Greist and others on self-exposure does not appear, and the reader could not guess from the text that selfexposure is now one of the dommant and effective forms of treatment for most patients with phobias and rituals. needmg little investment of therapists’ time. Most of the emphasrs IS still on fantasy desensitization, in cico methods of exposure featuring little. and the role of exposure homework is underplayed. Social skills training is not indexed, though one aspect of it. assertive training, is described. Though hardly definitive. the book has usefui ideas for clinicians from one of those who helped the field onto its feet.
P. C. KENDALL (Ed.): ~drunces xiii + 324 pages. $39.00.
in Cognitive-Behavioral
Research
and Therupy,
Vol. I. Academic
Press. New York (1982).
P. C. KENDALL (Ed.): Advunces xiti + 310 pages. $34.50.
in Cognitive-Behavioral
Research
and Therapy,
Vol. 2. Academic
Press. New York (1983).
These volumes represent the initiation of a series devoted to theoretical. empirical and therapeutic issues related to cognitive-behav~ourai research and application. Edited by Philip Kendall. the overall aim of the series is to provtde a forum for discusston of a diversity of topics dealing wtth assessment issues, theoretical analyses, treatment strategies for specific clinical disorders, fundamental issues in psychology and psychopathology, and advanced research methodoiogies as these bear on an understanding of the interplay between cognitions and behaviour. Volume I begins with two excellent theoretical arttdes by Amkoff and Glass in which the more prevalent constructs utilized by cogntttve-behavioural theorists are evaluated, with particular emphasis on issues related to their assessment. Next. Zettle and Hayes present a reconceptualization of cognitive-behavioural theory and practice as rule-governed behaviour as vtewed from a radical behavioural perspecttve. whtle Kirschenbaum and Tomarken discuss In a most detailed and thorough manner issues and research related to the problem of the generalizatton of behavtour change. The volume ends wtth two clintcally-oriented articles: one by D’Zurilla and Nezu on the theoretical and emptrical status of social problem-solvtng therapy, and an arttcle by Holroyd and Andrasik on their cognitive-behavioural treatment of recurrrent tenston and migratne headaches. examining a number of common constructs and processes endorsed by Volume 2 opens with two papers cogntttve-behaviourai theortsts. Turk and Speers provide an excellent discussion of the more salient theoretical and empirtcal issues relatmg to cognttive processes and schemata, whtle Goldfried and Robins discuss how the concepts of self-
1985
BOOK N.
J.
MACKINTOSH: Conditioning
und Associadce
Learning.
REVIEWS Oxford
Univ. Press (1983). 306 pages. f17.50.
After producing his monumental work. The Ps_vchoiogJ?of Animal Learning, what, one wonders, can remain for Professor MacKintosh to write about? A revision? Certainly, in time one will be required. The present book is, in part, a loose continuation of the earlier volume. but more importantly, a detailed analysis of some of the outstanding problems of associative learning. Mackintosh makes no concessions to his readers and assumes an easy acquaintance with contemporary knowledge of animal learning and the main debates about that knowledge. The chapters cover classical and instrumental conditioning, appetitive and aversive reinforcement, avoidance leamrng and discrimination learning. The author launches into the key issues without delay or distraction and the result is an interesting and stimulatmg book, but one that demands close attention. It is not intended to be a comprehensive account of animal learning (he has already provided that), still less of human learning. and its main value is provocative. What does MacKintosh say about this problem? How would he explain this phenomenon, and so on? It is excellent material for debate-and for demanding tutorials. No doubt, the book will be argued backwards and forwards for some time. (In my copy, the chapter on avoidance is scored with marginal notes and queries.) The specific topics include discrepancy theory, learned irrelevance, latent inhibition, blocking, habituation, taste aversions. preparedness and many others. Nevertheless it is not a quibble to complain that readers would have wished to read MacKintosh on the Seligman-Johnston theory of avoidance. reciprocal inhibition, Gray’s analysis of avoidance, safety signals and numerous other subjects. In passing, MacKintosh observes that even simple examples of animal behaviour can defy satisfactory explanation. “That effects should be so simple makes it all the more humiliating that we should remain in almost total ignorance of the nature of the processes responsible for the effects” (p. 233). This book reveals the very many complexities in seemingly straightforward behaviour: traps abound. It is a stimulating and rich book, but a selective one. S. RACHMAN
J. M. GARDNER: Training xviii + 179 pages.
Non-professionals
in
Behauiour
Modification.
Witwatersrand
Univ. Press, Johannesburg
(1981).
This well-written and well-organized book is intended for students of behaviour modification and for those engaged in training others in this field. Training in behaviour modification techniques is spreading rapidly, with a variety of professional groups and non-professionals being given training in the application of these techniques at many levels and in many settings. The value of such training with groups like parents, nurses and teachers is now established. This book starts with an overview of behaviour modification. both conceptual and historical, foliowed by a summary of techniques. The section on training covers the major issues very wetl: the different leveis of training and how they are to be determined. phases and stages of training. and ethical issues. The analysis of levels is both illuminating and useful; five levels are distinguished-applicator. technician. specialist, generalist and consultant. The final section is about research on teaching behaviour modification. This reviews the available, limited and generally inadequate research in this area, and draws a few general conclusions. It is argued that behaviour modification training programmes should take mto account the available research findmgs. rather than each trainer/practitioner doing ‘his own thing’. On the whole. this 1s a commendable effort. Not only is it a good account of the topic it covers; it is also an excellent model of hoN a book such as this should be written and organized. If one is to look for flaws, the main one would be the selectivity of the literature discussed. Much of recent British work is ignored; and there is no reference to Eysenck and Rachman’s Caasr arid Cures of Neuroses (1965) which was highly influential in determining the direction behaviour therapy took in the late srxties. But such flaws should not detract from the overall value of Gardner’s book. It is a volume which all teachers of behaviour therapy should be familiar with. P. DE SILVA
Eysenck H. J. and Rachman S. (1965) Causes
K. B. STUART (Ed. ): Adherence. x + 398 pages. 830.00.
Compliance
and Cures qf Neuroses.
and Generalization
Routledge Br Kegan Paul, London.
in Behavioral
Medicine.
Brunner/Mazel,
New York (1982).
Technical solutions to illness problems represent only the tirst stage in the provision of health care. Chnicians then face the serious challenge of persuading their clients to follow the advice that they have given. In the area of behavioural medicine 229
BOOK REVlEWS
230
especially. issues of generalizationand adherence are central. because the essence of many treatments is long-term change in well-established patterns of behaviour. This series of papers. sponsored by the Banj,jInternarionai Conferences 011 Behavior .Mod(fication. offers a wide choice of theoretical and empirical perspectives on generalization and compliance problems m medical settmgs. Baer (Chapter 8) and Marlatt (Chapter 14) argue convincingly for the adoption of treatment strategtes in which generalizatton and relapse prevention are butlt into the programme. They also suggest a wide assortment of practical alternattves to the ‘tram and hope’ approach. Haynes (Chapter 3) summarizes his critical analyses of the myths and knowledge prevatling in the area of compliance wtth medical advtce. and the remaining chapters cover a variety of topics including obesity. diabetes and hypertenston. Clinicians from all fields could not fail to find this book stimulating and useful. JANEWARDLE
J. WOLPE: 771~Pracrice of Behnvior
Therapy.
3rd edn. Pergamon
Press. New York (1982). xiv + 389 pages. f6.20.
Behaviour therapy has grown to the stage where it is impossible for any single person to review the enttre area and this book deals mainly with the neuroses. that term eschewed by the DSM-III though still in European parlance. Wolpe is one of the pioneers who put behaviour therapy on the map, from the standpoint of a clintctan. and his immense chnical experience shines through this volume. It contains many interesting anecdotes of treatment of a wide variety of patients. and this is one of the most valuable aspects of the book. There is a refreshing exposition of Ryle’s crittque of dualism. of the ghost in the machine, and a good discussion of the shortcomings of learned helplessness as a model for depression. Though similar points couid be levelled against animal ‘neuroses’ as models for human anxiety, they are blythely accepted as “indistinguishable from those of humans when allowance ts made for differences among species” (p. 37). Theoretical discussions in the book contain much that is intriguing but are largely uncritical. Conditioning’ is used as an all-explanatory principle which is not distin~ulshed from other forms of learning. There is some discussion of the literature on preparedness but it is not Integrated into the rich literature on the maturation and development of behavtour. The role of trauma in the development of phobias IS dwelt on, but some of the instances cited seem to indicate the presentation of conditioned stimuli which are already far from neutral at the start rather than of the pairing of unpleasant unconditioned stimuli with neutral conditioned stimuli (e.g. p. 30. Case 6). Another problem is the absence of a succinct review of the immense literature on controlled studies of behaviour therapy in the neuroses, uncontrolled work bemg expounded at some length. Negative data not supportmg the author’s vrews are usually given short shrift or omitted, e.g. work showing that relaxation does not contribute to the efficacy of desensitizatton or other forms of exposure. The practice of behavtour therapy whtch is described IS a bit out of date. The work of Jannoun. Mathews, Greist and others on self-exposure does not appear, and the reader could not guess from the text that selfexposure is now one of the dommant and effective forms of treatment for most patients with phobias and rituals. needmg little investment of therapists’ time. Most of the emphasrs IS still on fantasy desensitization, in cico methods of exposure featuring little. and the role of exposure homework is underplayed. Social skills training is not indexed, though one aspect of it. assertive training, is described. Though hardly definitive. the book has usefui ideas for clinicians from one of those who helped the field onto its feet.
P. C. KENDALL (Ed.): ~drunces xiii + 324 pages. $39.00.
in Cognitive-Behavioral
Research
and Therupy,
Vol. I. Academic
Press. New York (1982).
P. C. KENDALL (Ed.): Advunces xiti + 310 pages. $34.50.
in Cognitive-Behavioral
Research
and Therapy,
Vol. 2. Academic
Press. New York (1983).
These volumes represent the initiation of a series devoted to theoretical. empirical and therapeutic issues related to cognitive-behav~ourai research and application. Edited by Philip Kendall. the overall aim of the series is to provtde a forum for discusston of a diversity of topics dealing wtth assessment issues, theoretical analyses, treatment strategies for specific clinical disorders, fundamental issues in psychology and psychopathology, and advanced research methodoiogies as these bear on an understanding of the interplay between cognitions and behaviour. Volume I begins with two excellent theoretical arttdes by Amkoff and Glass in which the more prevalent constructs utilized by cogntttve-behavioural theorists are evaluated, with particular emphasis on issues related to their assessment. Next. Zettle and Hayes present a reconceptualization of cognitive-behavioural theory and practice as rule-governed behaviour as vtewed from a radical behavioural perspecttve. whtle Kirschenbaum and Tomarken discuss In a most detailed and thorough manner issues and research related to the problem of the generalizatton of behavtour change. The volume ends wtth two clintcally-oriented articles: one by D’Zurilla and Nezu on the theoretical and emptrical status of social problem-solvtng therapy, and an arttcle by Holroyd and Andrasik on their cognitive-behavioural treatment of recurrrent tenston and migratne headaches. examining a number of common constructs and processes endorsed by Volume 2 opens with two papers cogntttve-behaviourai theortsts. Turk and Speers provide an excellent discussion of the more salient theoretical and empirtcal issues relatmg to cognttive processes and schemata, whtle Goldfried and Robins discuss how the concepts of self-