Behavioral treatment of chronic psychiatric disorders: Publication trends and future directions

BEHAVIORTHERAPY24, 527-550, 1993

Behavioral Treatment of Chronic Psychiatric Disorders: Publication Trends and Future Directions JOSEPH R . SCOTTI

West Virginia University MARTIN J. MCMORROW

Choate Mental Health and Developmental Center, Anna, IL

ANTHONY L. TRAWITZKI Binghamton, N Y The historical roots of behavioral psychology are entwined in the treatment of chronic psychiatric disorders. Despite the many noteworthy accomplishments of early researchers in this area, there are recent signs of a relative lack of a behavioral focus within many inpatient psychiatric settings, as well as evidence of a decreased representation in the published literature of behavioral applications with persons exhibiting chronic psychiatric disorders. We reviewed the behavioral treatment literature in nine journals from the period 1963 through 1988, locating some 256 reports of behavioral treatments of chronic psychiatric disorders. The results document the movement of behavioral clinicians away from this important area of applied clinical research, and suggest certain areas of weakness (e.g., lack of follow-up data, absence of functional analysis) in the work that has been done by behavioral psychologists. We discuss possible reasons for the flight of behavioral psychology from this area of treatment, and make suggestions for reversing the trend.

Background As early as 1932, it was an explicit part of B. E Skinner's "campaign" to provide functional analyses of the concepts and terms employed in psychology Portions of this paper were presented at the annual convention of the Association for Behavior Analysis, May, 1990. Sections of this paper were completed while the first author was supported by a Dissertation Year Fellowship from the State University of New York at Binghamton, which is acknowledged with gratitude. A complete bibliography of the articles reviewed is available from the Educational Resources Information Center, ERIC Document No. ED 325 759 0991). The authors thank Drs. Kennon A. Lattal, Georg Eifert, Ian M. Evans, Judith R. Mathews, and anonymous reviewers for their helpful comments on earlier drafts of this manuscript. Correspondence concerning this article should be sent to Joseph R. Scotti, Department of Psychology, West Virginia University, P.O. Box 6040, Morgantown, WV 26506-6040. 527 0005-7894/93/0527-055051.00/0 Copyright 1993 by Association for Advancementof Behavior Therapy All rights of reproduction in any form reserved.

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(Skinner, 1979), a goal he partially accomplished in the clinical area in Science andHuman Behavior (1953). Skinner's foundations not only helped establish the tenets upon which a "science of human behavior" could develop, they set the stage for the dramatic entrance of behavioral scientists into the clinical arena. As practitioners emerged from the animal laboratory in the mid-tolate 1950s and early 1960s and began to focus on various human problems and conditions, no serious student of psychology over the next decade could have avoided exposure to certain classic works that appeared in the literature. Indeed, just the mention of certain clinical participants (e.g., the woman whose broom-holding was reinforced; Ayllon, Haughton, & Hughes, 1965), interventions (e.g., token economies; Atthowe & Krasner, 1968; Ayllon & Azrin, 1968), texts (e.g., Case Studies in Behavior Modification, by Ullmann & Krasner, 1965; Psychotherapy by Reciprocal Inhibition, by Wolpe, 1958), and settings (e.g., the Behavior Research Laboratory at Anna State Hospital, Metropolitan State Hospital, the Maudsley Hospital in London) might have set the occasion for hours of fine discussion and reminiscing by a broad range of students from the succeeding era. After all, these were formative years in which there was a great sense of optimism concerning the potential of the developing technology. Amidst the many stimuli that attract the attention of the casual historian of behavioral psychology, it may be easy to overlook the fact that much of this early work was conducted with persons exhibiting chronic psychiatric disorders who were residing in inpatient hospital settings (cf. Bellack, 1986; Kazdin, 1977). In fact, it could be argued that such early clinical applications (e.g., Ayllon & Michael, 1959; Hutchinson & Azrin, 1961; Issacs, Thomas, & Goldiamond, 1960; Lindsley, 1956; Skinner, Solomon, & Lindsley, 1954) and related theoretical considerations (e.g., Skinner, 1953; Skinner, 1956/1982; Staats, 1957; Staats & Staats, 1963) constituted the major focus of the young discipline.

Chronic Psychiatric Disorders Considering the seemingly rapid deployment of behavioral technology toward the solution of human problems and other indicators that suggest the discipline is thriving (e.g., the foundation of organizations such as the Association for Behavior Analysis and the Association for Advancement of Behavior Therapy; the growth of behavioral journals, including Behavior Therapy, Behaviour Research and Therapy, and Journal of Applied Behavior Analysis, as documented by Wyatt, Hawkins, and Davis, 1986; and the generation of rules for the conduct of the discipline as provided by Baer, Wolf, and Risley, 1968), we have become concerned about the lack of participation by persons with behavioral expertise in certain clinical arenas. Specifically, although most of the early work cited above was conducted with persons who had been diagnosed as experiencing chronic psychiatric disorders, current literature and clinical observations suggest that participation by behaviorists in this clinical area has declined. We have noticed what appears to be a decreased representation of behavioral applications in the psychiatric treatment literature, and subsequently have wondered what had become of such notable programs as those at Anna State Hospital (now Choate Mental Health and Developmental Center)

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529

or the University of Mississippi/Jackson Veterans Affairs Medical Centers (see Agras, 1976; Hersen, Eisler, Smith, & Agras, 1972). Where was the major revolution in the care of persons exhibiting chronic psychiatric disorders that should have followed on such inspiring works as those of Gordon Paul and his colleagues (see Paul & Lentz, 1977) and of Robert Liberman and his associates at Camarillo State Hospital (see Liberman, King, & DeRisi, 1976; Liberman et al., 1984)? Despite the early promise, Boudewyns, Fry, and Nightingale (1986) have documented the near-total absence of token economy/social learning programs within Veterans Affairs (VA) Medical Centers. Their survey found that fewer than 7°70 of VA Medical Centers were operating a token economy program, and that these were serving only approximately 1070of the psychiatric inpatients in the extensive VA system. A subsequent analysis by Glynn (1990; see also Dickerson, 1989, and Vogeltanz, Plaud, & Ackley, 1993) suggests that this represents an actual decline in the use of token economy programs. We may speculate that this decline has as much to do with the increased effectiveness of psychotropic medications as with the perhaps overstated effectiveness of token economy systems. In either case, these findings suggest, for the chronic psychiatric inpatient setting, a promise from behavior therapy that has gone largely unfulfilled. It is little wonder that schizophrenia has been lamented as "behavior therapy's forgotten child" (Bellack, 1986). Furthermore, behavioral applications also appear to be poorly represented in the psychiatric treatment literature. In a series of brief newsletters distributed by the American Psychiatric Association (1989) as a part of "Mental Illness Awareness Week," the lack of acknowledgment of behavioral contributions to the treatment of chronic psychiatric disorders was striking. References to treatment were almost exclusively limited to statements about the efficacy of medication and individual psychotherapy. In fact, in the five newsletters, we found only one brief comment concerning behavior therapy: "In treating phobic disorders, medications often are combined with behavior therapy, which exposes a patient to the source of his fear under controlled circumstances" (American Psychiatric Association, 1989, Column #3). Perhaps most troubling was our concern that the treatment of chronic psychiatric disorders failed to constitute a major focus even within the applied behavioral literature. In examining the indexes of the Journal of Applied Behavior Analysis, we located only two treatment reports pertaining to adults with diagnoses of schizophrenia, psychotic disorders, or "mental illness" (Stewart, Van Houten, & Van Houten, 1992; Wong et al., 1987) that had been published subsequent to a 1980 book review of Gordon Paul's work (Liberman, 1980). In his review, Liberman noted the "astonishing" successes of Paul's social learning program, including long-term community placement (up to the five-year period of the study) in 9707o of the patients. It is noteworthy, however, that even in 1980, Liberman was decrying the poor survival rate of many innovative behavioral programs, including the termination of Paul's extensive project, a point later echoed by Boudewyns et al. (1986) and Glynn (1990). The above observations, combined with some of our own recent clinical experiences while working in inpatient psychiatric settings, set the stage for

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the present investigation. There appeared to be a marked contrast between the "promise" that accompanied the early behavioral literature, and the "outcome" that we have observed in recent years. Consequently, we began to speculate as to whether some change had actually occurred over the years with respect to the involvement o f behavioral clinicians in the treatment of chronic psychiatric disorders, and whether that change could be empirically documented. This study, then, represents a longitudinal analysis of the publication rates in certain behavioral and nonbehavioral journals o f behavioral applications with individuals who exhibit a chronic psychiatric disorder. Our primary question was whether the publication rate o f behavioral studies had decreased in recent years. However, we also were interested in determining whether other patterns or shifts in emphasis were present in the literature (e.g., between types of psychiatric disorders), and, if so, what factors might account for such shifts.

Method Journal and Article Selection Nine journals were selected for review, including those representative of psychiatry (American Journal o f Psychiatry, Archives o f General Psychiatry), general psychology (Journal o f A bnormal Psychology, Journal o f Consulting and Clinical Psychology), and behavior therapy or applied behavior analysis

(Behavior Modification, Behavior Therapy, Behaviour Research and Therapy, Journal of Applied Behavior Analysis, Journal of Behavior Therapy and Experimental Psychiatry). It should be noted that much of the early behavioral work in this area was published in "nonbehavioral" journals due to the nonexistence o f behavior therapy and applied behavior analysis journals. These nine journals were selected as well-recognized representatives o f their respective fields, and because they are known historical sources for this particular literature. Additionally, we were primarily interested in behavioral interventions, thus the focus on the major behavioral journals. The sample of journals seemed adequate for the present purposes of investigating publication trends of behavioral interventions, and it was not meant to be as comprehensive as would be required by a meta-analysis. The review covered the 26-year period from January, 1963 (the year during which the first of the behavior therapy journals, Behaviour Research and Therapy, was established), through December, 1988. Initially, each journal was screened by two of the authors (JRS and ALT) for treatment articles that met the following three criteria: (a) the participants were adults (age 18 years or older) with a diagnosis o f either anxiety disorder or chronic psychiatric disorder (as defined below); (b) the participants were treated with a recognized behavior therapy technique, as defined by the inclusion of that technique in the Dictionary of Behavior Therapy Techniques (Bellack & Hersen, 1985); and (c) the article reported treatment outcome data in either a descriptive, statistical, or graphic format. Basic experimental psychopathology research (e.g., the elec-

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531

trodermal response of persons with schizophrenia to certain categories of words) was excluded.

Variables Coded Specific analyses were performed on the identified subset of articles reporting participant diagnoses of a chronic psychiatric disorder. Chronic psychiatric disorders were defined as including: organic mental disorders (e.g., dementia); schizophrenia; psychotic and delusional disorders; mood disorders (e.g., bipolar disorder, depressive disorder); somatoform disorders (e.g., conversion disorder, somatization disorder); dissociative disorders (e.g., multiple personality, psychogenic fugue); and personality disorders, as defined in the Diagnostic and Statistical Manual, 3rd edition, revised (DSM-III-R; American Psychiatric Association, 1987). Each of the identified articles could contain one or more studies, a study being defined by a separate method and results sections. For the purpose of comparing publication frequencies, articles that reported on the behavioral treatment of anxiety disorders (e.g., posttraumatic stress disorder, obsessive-compulsive disorder, agoraphobia) also were identified. (Social or simple phobias were not included in the review, as our interest was primarily in disorders likely to lead to hospitalization.) Anxiety disorders were treated as a separate, comparison category, but not because they are necessarily less severe or even less chronic. Rather, this distinction was made because it is specifically the disorders here classified as chronic psychiatric disorders that we suspected to have fallen out of favor. Each of the identified studies was reviewed by one of two authors (JRS or ALT) and coded on each of nine variables, including: (a) participant diagnosis; (b) number of participants; (c) treatment setting (inpatient or outpatient); (d) evidence of a functional analysis (descriptive or direct experimental manipulation); (e) target behavior; (f) behavioral treatment technique employed; (g) experimental design (quasi-experimental: AB, Pre-Post, treatmentonly designs; or experimental: withdrawal, multiple baseline, group designs); (h) form of data presentation (single-subject versus group); and (i) evidence of a follow-up (short-term: less than six months' duration; or long-term, duration of six months or longer). Articles reporting on the treatment of anxiety disorders were not coded on these variables, as those articles were included only for the purpose of comparing publication rates.

Results Interrater Agreement Interrater agreement was calculated for the identification of articles to be included in the review. The mean interrater agreement was calculated by the formula: [(Total Agreements)/(Total Agreements + Total Disagreements)] x 100070, on a randomly selected sample of 36°70 of the journal issues. Interrater agreement was determined to be 90.1070 across this sample. Interrater agreement scores were also calculated on 1507o of the sample for the coding of the

532

SCOTTI ET AL. TABLE I NUMBER OF ARTICLES REPORTING BEHAVIORALTREATMENT OF CHRONIC PSYCHIATRIC DISORDERS AND ANXIETY DISORDERS FOR EACH OF THE NINE JOURNALS REVIEWED

Journal

Archives of General Psychiatry American Journal of Psychiatry Journal o f Abnormal Psychology Journal of Consulting and Clinical Psychology Behavior Modification Behaviour Research and Therapy Behavior Therapy Journal of Applied Behavior Analysis Journal o f Behavior Therapy and Experimental Psychiatry Totals

Chronic psychiatric disorder 8 10 17 43 13 45 38 23 59 256

Anxiety disorder 15 4 0 9 12

102 43 0 56 241

dependent variables. The mean interrater agreement on the nine variables was 93070 (range: 850/o-98070). The Sample A total of 497 articles were identified: 256 reporting behavioral treatments of chronic psychiatric disorders and 241 reporting behavioral treatments of anxiety disorders (as defined above). Table 1 displays the total number of behavioral treatment articles in these two categories that were published in each of the nine journals during the 26-year period of the review. Publication Rate: Types of Disorders Across Years Figure 1 depicts the annual publication rate of articles for the two diagnostic categories (i.e., chronic psychiatric and anxiety disorders) combined across all nine journals for the years 1963-1988. Although published articles containing reports of behavioral studies relating to the treatment of anxiety disorders have consistently increased during the time period covered here, articles containing behavioral treatment studies of chronic psychiatric disorders first increased during the late 1960s and early 1970s and then declined during the 1980s. The publication rate of articles more than tripled in both diagnostic categories from the period 1963-1969 (means of 4.3 and 2.9 articles per year for chronic psychiatric and anxiety disorders, respectively) to 1970-1979 (means of 15.5 and 9.2 articles per year for chronic psychiatric and anxiety disorders, respectively), coincident with the establishment of three additional behavioral journals during this time period (1970: Behavior Therapy and Journal o f Behavior Therapy and Experimental Psychiatry; 1977: Behavior Modification). However, although the annual publication rate for anxiety disorder articles continued to increase during the 1980s by a factor of 1.5 (mean of 14.3 articles per year), the annual publication rate for chronic psychiatric treatment articles decreased by half, to a mean of 7.9 articles per year. Statistical tests sup-

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CHRONIC PSYCHIATRIC DISORDERS

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Year l~o. 1. A n n u a l publication rate of articles by diagnostic category (chronic psychiatric disorders versus anxiety disorders) across the 26-year period of the review.

port the significance o f the visual analysis presented in Figure 1, Chi-square (~(2) (2) = 34.5, p < .001.

Publication Rate: Types of Disorders by Journal Type Although this initial analysis provided evidence o f a decline in the annual publication rate of behavioral treatment studies related to chronic psychiatric disorders during recent years, the publication pattern across types of journals is also of interest. O f the 497 identified articles, 106 appeared in the nonbehavioral journals (psychiatric and general psychology) and 391 in the behavioral journals. Figure 2 depicts, for each journal type (labeled "nonbehavioral" and "behavioral") across the three decades, the percentage of articles related to chronic psychiatric disorders (out of the combined total of anxiety and chronic psychiatric disorder articles). These data clarify the previous findings of a decline in the publication of behavioral treatments of chronic psychiatric disorders, as compared to the treatment of anxiety disorders, and show that the decreasing trend is not related to journal type. In other words, publication of behavioral treatments o f chronic psychiatric disorders has declined during the 1980s in both nonbehavioral (psychiatric and general psychology) and behavioral journals. Additionally, it appears that the reduction of studies in the area of chronic psychiatric disorders is correlated with an increase in published studies in the area of anxiety disorders. Data are not available that might further elucidate whether the decline is unique to behavioral treatment studies

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SCOTTI ET AL.

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Decade Fig. 2. Percentage of chronic psychiatric disorder articles (out of the combined total of anxiety disorder and chronic psychiatric disorder articles) by journal type (nonbehavioral versus behavioral), across the three decades covered by the review.

per se, or to all forms of clinical intervention, behavioral and nonbehavioral, applied to chronic psychiatric disorders.

Analysis of Studies of Chronic Psychiatric Disorders Individual articles could contain more than one treatment study; thus, for the 256 articles within the category of chronic psychiatric disorders, 272 separate studies were identified. These 272 studies were analyzed with respect to the nine variables of interest to determine possible causes for the decline of published works in this area. Overall, 61.4% of these 272 studies involved the diagnostic categories of psychotic disorders and schizophrenia (henceforth jointly referred to as psychotic disorders). The next-largest group of studies, 27.6%, focused on the treatment of mood disorders. This was followed by organic mental disorders (13.2%), personality disorders (9.6%), and dissociative disorders (2.6%). Many of the chronic psychiatric treatment studies included participants from multiple diagnostic categories; thus, these percentages exceed 100%; additionally, some 7.4% of studies also included in the treatment sample a number of participants with primary or secondary diagnoses of anxiety disorder. Finally, 11.8% of the studies did not provide clear diagnostic information beyond such descriptive terms as "chronic mental patients," "back-ward mental patients," or "hard-core psychiatric patients." Since the categories of psychotic disorders and mood disorders represented the two

535

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Decade FIG. 3. Mean publication rate per year of articles in each of two diagnostic categories (psychotic disorders versus mood disorders), displayed for each of the three decades covered by the review.

largest diagnostic groups, accounting for 89°70 of the studies (79070 of the articles), it was decided to further examine the pattern for publishing articles in these two categories. Figure 3 depicts the mean number of articles per year for each of the three decades of the review across the two major diagnostic categories of psychotic disorders and mood disorders. The pattern of articles dealing with patients diagnosed as exhibiting psychotic disorders is similar to the overall publication trend for chronic psychiatric disorders, increasing in the 1970s, then declining in the 1980s. However, articles targeting persons diagnosed as exhibiting mood disorders have increased steadily during the same time period. These findings suggest that, although there is an overall decline in the research reported in this area, within the area of chronic psychiatric disorders a shift in focus has occurred, with movement away from the diagnostic category of psychotic disorders toward the mood disorders. Statistical analysis supports this finding, Xz (2) = 33.9, p < .001.

Target Behavior and Treatment Categories Although studies typically targeted several behaviors at once, the categories of social behavior (e.g., increasing eye contact, conversation, and interactions; decreasing screaming and chronic complaints) and activities of daily living (ADL; e.g., eating, grooming, dressing, leisure activities) were targeted

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SCOTTI ET AL. TABLE 2 PERCENTAGE OF EACH DIAGNOSTIC CATEGORY FOR WHICH EACH TARGET BEItAVIOR CATEGORY WAS IDENTIFIED

Target behavior Social behavior Activities of daily living Depressive behavior Psychotic behavior Aggressive behavior Vocational behavior Treatment compliance Anxiety-related behavior Dissociative and conversion symptoms Psychometrics Note.

Diagnostic category

Total sample

Psych

Mood

OMD

Pers

Dis/Con

34.9 25.0 16.5 16.2 15.1 11.0 7.0 6.3 2.6 8.1

42.5 25.1 3.0 25.1 18.6 12.6 8.4 5.4 0.6 6.0

24.0 13.3 57.3 6.7 10.7 12.0 8.0 8.0 1.3 16.0

33.3 88.9 0 2.8 11.1 8.3 11.1 0 0 2.8

46.2 19.2 0 0 34.6 23.1 15.4 15.4 0 7.7

0 0 14.3 0 14.3 0 0 28.6 100.0 0

Total sample column is percentage of 272 chronic psychiatric studies utilizing each target behavior category. For each diagnostic category, percentages in columns represent the percentage o f studies in which each target behavior category was reported. C o l u m n percents sum to greater than 100070, as studies reported multiple target behavior categories. P s y c h - P s y c h o t i c Disorders (n = 167), M o o d - M o o d Disorders (n = 75), O M D Organic Mental Disorders (n = 36), P e r s - Personality Disorders (n = 26), D i s / C o n Dissociative and Conversion Disorders (n = 7).

most frequently, being reported in 34.9% and 25°7o of the 272 studies, respectively (see Table 2). Of particular interest was the finding that psychotic behaviors (e.g., hallucinations, delusions, idiosyncratic repetitive body movements or speech) were targeted rather infrequently (16.2°70 of studies), in spite of the fact that the majority of the studies (61.4°70) focused on the diagnostic group of psychotic disorders in which these are the prominent symptoms. Other target behavior categories included: (a) depressive behavior (16.5%), such as crying, negative thoughts, and depressed mood; (b) aggressive behavior (15.1%), including physical violence, tantrums, and self-injurious behavior; (c) vocational behavior (I1%), such as work activities at sheltered workshops; (d) anxietyrelated behavior (6.3%), such as fears and obsessive thoughts; (e) treatment compliance (7%), including keeping therapy appointments and self-administration of medications; (f) dissociative and conversion disorder symptoms (2.6%), including paralysis, amnesia, and multiple personalities; and (g) changes in scores on psychometric batteries or observational measures (8.1%), such as fear surveys and intelligence tests. These percentages sum to greater than 100°70, as many studies employed multiple target behavior categories. Similarly, multiple intervention strategies often were reported within one study. Nine behavioral treatment categories were identified (see Table 3), the most frequently reported strategies being reinforcement-based procedures: 31.6°70 of studies reported positive reinforcement strategies (e.g., shaping, fading) and 25.4°7o of the studies reported contingency management procedures (e.g., token economies, group contingencies, and contingency con-

537

CHRONIC PSYCHIATRIC DISORDERS TABLE 3 PERCENTAGE OF EACH DIAGNOSTIC CATEGORY FOR WHICH EACH TREATMENT CATEGORY WAS UTILIZED

Treatment Reinforcement-based Contingency m a n a g e m e n t Skills training package Modeling Punishment-based Cognitive-behavioral techniques Self-control strategies Exposure-based Relaxation Note.

Diagnostic category

Total sample

Psych

Mood

OMD

Pers

Dis/Con

31.6 25.4 20.2 17.6 18.4 13.2 12.1 6.6 5.9

34.1 31.7 16.8 13.8 22.2 6.6 7.2 6.0 2.4

18.7 17.3 32.0 14.7 6.7 32.0 29.3 10.7 14.7

52.8 41.7 0 25.0 22.2 8.3 2.8 0 0

23.1 34.6 34.6 11.5 15.4 7.7 3.8 11.5 11.5

42.9 14.3 28.6 0 0 14.3 0 42.9 42.9

Total sample column is percentage o f 272 chronic psychiatric studies utilizing each treatment category. For each diagnostic category, percentages in columns represent the percentage of studies in which each treatment category was reported. C o l u m n percents sum to greater t h a n 100%, as studies reported multiple treatments. P s y c h - P s y c h o t i c Disorders (n = 167), M o o d - - M o o d Disorders (n = 75), O M D - O r g a n i c Mental Disorders (n = 36), P e r s - P e r s o n a l i t y Disorders (n = 26), Dis/Con--Dissociative and Conversion Disorders (n = 7).

tracting). The least reported interventions were exposure-based procedures (6.6°70; e.g., flooding, implosive therapy, desensitization) and techniques employing relaxation (5.9070; e.g., deep muscle relaxation, cue-controlled relaxation, biofeedback). Other treatment procedures reported in this literature included: (a) skills training packages (20.2%), such as assertiveness training, social skills training, family-based interventions, and problem-solving training; (b) modeling procedures (17.6070), including behavioral rehearsal, prompting, and feedback; (c) cognitive-behavioral techniques (13.2070), such as rationalemotive therapy, thought-stopping, and cognitive therapy; and (d) self-control strategies (12.1070), consisting of procedures such as self-monitoring, selfpunishment, and self-reinforcement. Punishment-based procedures (e.g., electrical aversion, overcorrection, negative practice) were employed in 18.4070(50) of the studies. Of particular interest, the great majority of the studies employing punishment-based procedures (37 of 50) involved participants in the diagnostic category of psychotic disorders. Also, there was an apparent trend in this literature away from the use of punishment-based procedures, as evidenced by a total of 30 studies utilizing such procedures during the period 1970-1979, and only 8 such studies during the period 1980-1988, X2(2) -- 11.3, p < .005 (adjusted for unequal expected proportions).

Interactions Among Target Behavior, Treatment, and Diagnostic Categories Analyses were performed to determine whether target behavior and treatment were selected differentially on the basis of diagnostic category, presup-

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SCOTT1 ET At.

posing that diagnostics reflect differential characteristics of the participants and that treatment is appropriately matched to those characteristics. These analyses are presented in Tables 2 and 3 for the five diagnostic categories of psychotic disorder, mood disorder, organic mental disorder, personality disorder, and dissociative and conversion disorder. The small sample of anxiety disorder cases that were intermixed with the samples of chronic psychiatric disorders were excluded from this analysis, as was the category in which diagnosis was not clearly reported. Table 2 reveals apparent differences in the target behavior identified for each diagnostic category. For example, studies including the diagnostic category of psychotic disorder were most likely to focus on the target behavior categories of social behavior (42.5o70 of this group), ADL (25.1070) and psychotic behavior (25.1°70). Social behavior and aggressive behavior were the most likely targets for the category of personality disorder, with 46.2°/o and 34.6°10 of this diagnostic group receiving interventions targeting these behaviors, respectively. Depressive behavior was the most frequent target for those participants in the mood disorder category (57.3°7o), with social behavior being the next most likely target behavior to be identified for this group (24O7o). Nearly all of those studies that included persons with a diagnosis in the organic mental disorders category identified ADL as the target of intervention. Similarly, dissociative and conversion symptoms were targeted in all studies concerning the diagnostic category of dissociative/conversion disorders, with anxiety-related behaviors (28.6o70) being the next most frequent target for this group. Table 3 presents the relation between the five diagnostic categories and the nine categories of treatment techniques. These data suggest that the more verbal and instructional strategies (such as cognitive-behavioral techniques, multicomponent skills-training packages, and self-control procedures) were more likely to be employed with the mood disorders. Conversely, techniques more directly linked to basic behavioral principles (such as contingency management strategies and reinforcement-based and punishment-based procedures) were more often selected for those participants included in the categories of psychotic disorder and organic mental disorder. Participants with labels of personality disorder appear to fall midway between these other diagnostic groups, being equally likely to receive contingency management procedures and skills-training packages. Those studies focusing on the dissociative and conversion disorders had the highest likelihood of utilizing exposure-based and relaxation techniques. These findings suggest that target behavior and treatments are differentially selected on the basis of specific diagnostic entities. Analysis of this question can proceed one step further, however, as presented in Figure 4. These data show the different treatment techniques that were employed with two specific diagnosis-target behavior combinations, namely: (a) the psychotic behavior of participants diagnosed as exhibiting psychotic disorders, which, as shown in Table 2, was targeted in 25.1°70 of the studies including psychotic disorder; and (b) the depressive symptoms of participants diagnosed as exhibiting a mood disorder, the target in 57.3 o70of those studies focusing on this diagnostic category. Figure 4 suggests that depressive behavior in participants exhibiting mood

539

CHRONIC PSYCHIATRIC DISORDERS 50%

Mood Disorder

1

Psychotic D i s o r d e r

o

(D 4 0 %

U

a0% O

U 20%

U

10%

a,

0%

Cognitive

Skills

Relax

Self-Control

Punish

Relnlorce

Treatment Category Fro. 4. Percentage of each of two diagnosis-target behavior combinations (mood disorder-depressive behavior, and psychotic disorder-psychotic behavior) for which each of six specific intervention classes were employed. ( C o g n i t i v e - Cognitive-behavioral techniques, S k i l l s - Skillstraining package, Relax - Rzlaxation, Self-Control- Self-control strategies, P u n i s h - Punishmentbased procedures, Reinforce--Reinforcement-based procedures.)

disorders tends to be treated with multicomponent skills-training packages, as well as with cognitive-behavioral and self-control strategies. Conversely, punishment-based and reinforcement-based strategies are more likely to be the treatments of choice with the psychotic behavior o f those participants exhibiting a psychotic disorder. These data suggest that the treatments employed with chronic psychiatric disorders are selected according to diagnosis and the specific behavior being targeted for change. This differential selection of treatments might have been the result o f a careful functional analysis, o f a consideration o f theoretical issues, of the following o f established treatment precedents within a given diagnostic area, or simply o f trial and error. Each study was thus coded as to whether it provided evidence of the performance of a formal functional analysis in an attempt to identify the controlling variables (e.g., antecedents and consequences, setting events) relevant to the target behavior. Overall, 66°70 o f the 272 studies reviewed did n o t contain information concerning the performance of any form of a functional analysis. Another 31070reported only descriptive information regarding potential controlling variables as derived from established theories regarding the particular behavior pathology. Surprisingly, from a behavioral viewpoint, only 3 070(9 o f 272) o f the studies

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reported a formal functional analysis that included an experimental manipulation of potential controlling variables as an assessment procedure prior to the initiation of treatment. It seems that the majority of authors have merely followed established precedents in the selection of treatments, typically not providing reference to theory and very rarely performing direct manipulations in their functional assessments. Additionally, the rate of performing a functional analysis has decreased over time. That is, 46% of the chronic psychiatric studies published during the 1960s (17 of 37), 35% of the studies from the 1970s (56 of 161), and only 26% of those published in the 1980s (19 of 74) included either a descriptive or experimental functional analysis, a statistically significant decline, ~2 (2) = 19.6,p < .005 (adjusted for unequal expected proportions). Other Variables

Several other variables were examined that reflect both the quality and generality of the treatment research reviewed. The number of persons participating in each of the 272 studies ranged from 1 to 500, with a mean of 28.7 participants per study (median = 10; mode = 1). Twenty-eight percent (76) of the studies were reports concerning a single participant. Seventy-one percent of the 272 studies were conducted in inpatient settings, 25 % in outpatient settings, and 3% in both settings. However, the data indicated that research conducted in inpatient settings decreased over the period of this review. Specifically, 89% (33 of 37) and 81% (130 of 161) of studies were conducted in inpatient settings during the 1960s and 1970s, respectively, whereas only 41% (30 of 74) were conducted in such settings during the 1980s, a statistically significant reduction, ~2 (2) -- 69.2, p < .001 (adjusted for unequal expected proportions). This pattern also existed when studies of psychotic disorders conducted in inpatient settings were considered alone, ;~2 (2) = 56.8, p < .001 (adjusted for unequal expected proportions). Fifty-two percent of the 272 studies did not provide any follow-up data; 19% provided only short-term follow-up data (less than 6 months duration); and 30% provided long-term data (6 months or longer). The quality of experimental controls within individual studies appears to be high, in that 71% (193) of the studies employed an accepted experimental design (withdrawal design, multiple-baseline design, group design) and only 29% (79) employed a quasi-experimental design (AB, pre-post, treatment-only). The data were reported in single-subject format in 45% of the 272 studies; group designs were utilized in 51% of the studies; and 4% of the studies included both singlesubject and group data.

Discussion This examination of the behavioral treatment literature provides strong support for our informal observations that the publication rate of behavioral treatment reports on persons exhibiting chronic psychiatric disorders has declined in recent years. Specifically, reports of the behavioral treatment of chronic psychiatric disorders have decreased markedly in the last decade, while be-

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havioral treatment reports relating to another clinical problem, anxiety disorders, have continued to increase. These results were consistent regardless of the type of journal in which the studies were published; that is, behavioral treatment reports related to chronic psychiatric disorders have decreased both in general psychology and psychiatric journals and in journals devoted exclusively to the publication of behavioral interventions. Similarly, even within the studies related to persons exhibiting chronic psychiatric disorders, a decline in the behavioral treatment of schizophrenia and psychosis was evident relative to behavioral treatment in another diagnostic area, notably the mood disorders. Other chronic psychiatric disorders, such as personality disorders or dissociative disorders, have consistently received very little attention in the behavioral treatment literature. If publication rate can be taken to be a useful indicator of a discipline's involvement in a particular area, then we are left to speculate about the possible reasons for the "flight" of behaviorists from the treatment of chronic psychiatric disorders (to paraphrase Skinner, 1972). We at least need to understand the causes of a decline in published research in the area o f chronic psychiatric disorders. This study did not examine participation by behaviorists relative to any other discipline or branch of psychology. In fact, it is possible that the decline in behavioral research is simply representative o f a more general trend away from treatment research with persons exhibiting chronic psychiatric disorders, due, perhaps, to decreased funding opportunities, the movement toward deinstitutionalization, or the presumed sufficiency of psychotropic medications. There is no presently available evidence to suggest that the results are due to an actual decline in the prevalence of chronic psychiatric disorders within the general population. In fact, the epidemiologic literature is noteworthy for not addressing temporal trends in prevalence rates (National Institute of Mental Health, 1991; Regier et al., 1988). The available evidence suggests an increase in the rates for disorders such as major depression (Cross-National Collaborative Group, 1992). A marked shift has occurred with respect to the settings in which behavioral research has been conducted. Research conducted within inpatient settings decreased by over one half from the 1960s and 1970s to the 1980s. This finding is consistent with the movement towards deinstitutionalization during that same time period (beginning in the early 1970s). However, before explaining away our findings on the basis of these factors, it is important to note that there is little indication that these same factors have influenced the prevalence of behavioral research with other populations who have experienced similar changes in locus of service delivery (e.g., persons exhibiting developmental disabilities; see Scotti, Evans, Meyer, & Walker, 1991). Although there are some important differences in the structure and resources o f the settings that serve these two populations, treatment in natural, community environments can be accomplished, as evidenced by some 25 °7o of the studies analyzed here having been conducted in outpatient settings. Intervention in natural, community settings should be considered an essential treatment component if meaningful lifestyle changes are to be made (Leduc, Dumais, & Evans, 1990). We suspect that there are several reasons why many behaviorists have left

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or escaped, and others have avoided involvement in, the area of chronic psychiatric disorders. Most importantly, it appears that this may be due in large part to the prevalence of "competing models" in this area of treatment (cf. Bellack, 1986). For example, medical and cognitive psychology models are often presented as being opposed to a behavioral model on even the most basic issues, such as etiology (e.g., biologically based or mentalistic versus learned) and the matter of how mental illness should be treated (e.g., medication or psychotherapy versus contingency management or environmental modification). Clearly, such differences can be used as the basis of decision making or policy setting that can dictate not only what types of services an agency will provide but also who will be needed to provide them (e.g., psychiatrists, physicians, and nurses versus behaviorally oriented clinical psychologists and other service providers). Typically, persons with behavioral expertise are not well represented in the settings where such decisions are made and, as a result, may participate in service delivery in what they may view as an undervalued or even adversarial role. Factors within the behavioral field itself may have played a role in decreasing the attractiveness of involvement in clinical research with chronic psychiatric disorders. Problems associated with demonstrating experimental control over potentially confounding variables (e.g., "ancillary" treatments, such as medications; artificial time limits imposed on inpatient admissions; the transient nature of this clinical population; the cyclic nature of potential target behavior), establishing the social or clinical relevance or validity of typical behavioral intervention targets and outcomes, and obtaining adequate generalization and follow-up of treatment effects may have become too daunting a task for many applied researchers, particularly when they have limited control of available resources (see also Glynn, 1990; Hersen, 1979). One must also question the clinical relevance of interventions that focus on isolated target behavior (e.g., certain ADL skills), as opposed to behavior that characterizes particular disorders (e.g., hallucinations, delusions, aggression, social skills deficits, etc.). It is the advent of increasingly effective psychotropic medications that may have played a major role in the selection of target behaviors and perhaps in the decline of behavioral treatment research. We noted earlier that ADL skills, and not psychotic behaviors (i.e., hallucinations and delusions), were the primary focus of behavioral interventions with persons diagnosed with psychosis. ADL and social skills are ideal targets for behavioral intervention, and these behaviors are very unlikely to change rapidly as a result of antipsychotic medication alone (Wallace, Liberman, MacKain, Blackwell, & Eckman, 1992). Conversely, medication can result in swift amelioration of hallucinations and delusions, whereas in the past behavior therapy aproaches have been quite cumbersome, and primarily ineffective, when applied to such covert events. This explanation is perhaps satisfactory with regard to the psychotic disorders, but it does not help us understand the selection of target behavior with, say, individuals exhibiting personality disorders, where medication is not a particularly effective treatment. Unfortunately, the early focus on simple, isolated, and perhaps clinically irrelevant target behaviors may have led to behaviorists' failing to advance theory and technology in this area; and it certainly con-

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tributed little to the lives of the clients themselves (Evans & Scotti, 1989; Leduc, Dumais, & Evans, 1990). We have noted that behavioral treatment research in the area of anxiety disorders has increased, although the overall area of chronic psychiatric disorders has declined. Even within chronic psychiatric disorders, treatment research on the mood disorders has increased counter to the general trend in the area as a whole. This is not simply a result of shifting trends and interest patterns, a limited pool of researchers, or journal space. One factor that may unite the area of mood and anxiety disorders is the establishment of strong integrative behavioral models of pathology in these two areas (e.g., Beck, 1967; Keane, Fairbank, Caddell, Zimering, & Bender, 1985; Levis, 1985; Lewinsohn, Hoberman, Teri, & Hautzinger, 1985; Staats & Heiby, 1985). Conversely, the lack of comprehensive models of behavior pathology for other chronic psychiatric disorders, such as personality disorders (Staats & Burns, 1992) and particularly the psychotic disorders, is a serious handicap when performing treatment-outcome research. There are few comprehensive behavioral models of psychotic behavior. Although behavioral models of hallucinatory behavior have been proposed recently (Burns, Heiby, & Tharp, 1983, 1985; Clark, 1984; Layng & Andronis, 1984), as yet none of these have effectively impacted on treatment standards in this area. More sophisticated analyses may even take a biobehavioral approach such as was suggested by the early S-O-R models (Stimulus-Organism-Response; see Kanfer & Phillips, 1970). Behaviorists have failed to fully develop the concept or implications of organismic or organic factors in their theory building and analyses of pathological behavior (see Staats & Burns, 1992). Skinner (1953) stressed the importance of functional analysis in understanding and controlling human behavior, yet the data reported here reveal that this hallmark procedure of the behavioral therapies is underutilized within this area, even showing a decline over the period covered by this review. This is true even when considering less formal descriptive analyses. Behavioral models that view pathological behavior only as the result of positive reinforcement contingencies are too simplistic to account for complex behavior, and they do not take into consideration the full range of variables controlling behavior (see Michael, 1980). It is little wonder that the simple reinforcement and punishment procedures of the early work in this area had little lasting impact. An analysis of function must also include negative reinforcement contingencies, as well as the important contributions to pathology of escape and avoidance behavior (see Levis, 1981, 1985). Additionally, the role of setting events, stimulus control, and antecedent behaviors may be included into a functional analysis, but was rarely noted in those articles reviewed here. Hallucinatory behavior can be described as "conditioned seeing" (Skinner, 1953). A respondent conditioning model that leads to the use of imaginal exposure therapies with psychotic symptoms (Boudewyns & Shipley, 1983; Lyons & Scotti, in press) has implications that we feel have largely been ignored. The complexity of individual repertoires (e.g., response classes, chains, clusters) also should be considered when selecting target behavior and designing interventions (Scotti, Evans, Meyer, & DiBenedetto, 1991). Additionally, the declining

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use of punishment-based treatments with chronic psychiatric disorders, as documented here, may be as much a factor of the current zeitgeist as it is the result of recognizing that attempts to employ punishment contingencies to simply overwhelm the variables controlling behavior is inadequate if the function of that behavior has not been determined and adequately addressed. Even though the performance of a functional analysis with chronic pathological behavior may seem an impossible task, it can and has been done with good results, as demonstrated by Cox and Klinge (1976), McKnight, Nelson, Hayes and Jarrett (1984), and Turkat and Carlson (1984). Haynes and O'Brien (1990) provide thorough coverage of the application of functional analyses to behavioral therapy. Even the most thorough of analyses will be for nought, however, if adequate generalization and follow-up procedures are not implemented.

Future Directions Our interest here is not solely to document that behaviorists have become less active in research related to chronic psychiatric disorders. In fact, we believe that a great deal of meaningful work has been accomplished (see bibliography contained in Scotti, Trawitzki, Vittimberga, & McMorrow, 1991), and we would like to prompt a renewed interest among behaviorists in this area. Although there is little indication that the incidence of chronic psychiatric disorders has decreased, the psychiatric needs of many populations, such as women (Russo, 1990), minorities (Snowden & Cheung, 1990), the homeless (Levine & Rog, 1990), and persons living in rural settings (Hutner & Windle, 1991), are becoming increasingly well documented. Considering these needs and our findings regarding the reduced involvement of behaviorists in the care of chronic psychiatric disorders, the potential ramifications seem clear. Although there are many possible avenues of intervention that we feel could be expanded upon elsewhere, we would like briefly to highlight a few. Perhaps behaviorists have done less than an adequate job of informing other disciplines and consumers of the behavioral model and its potential benefits. In our opinion, there are several things that behaviorists could do to foster interprofessional relations and enhance the provision of quality behavioral treatment services for persons exhibiting chronic psychiatric disorders. First, they might set longer range personal goals and shape incorporation of behavioral approaches into the service protocols of the agencies by which they are employed. Second, they might focus their program development efforts on clinical issues that are directly relevant to other key professionals (cf. McMorrow et al., 1991). For example, noncompliance with medication regimens often is cited as the primary reason for readmission to mental-health facilities (Green, 1988) and represents a major concern for many medical professionals, Medication compliance is an ideal area for behavioral intervention (Boczkowski, Zeichner, & DeSanto, 1985), with extensive analyses of controlling factors already available (Mathews & Christophersen, 1988). Third, when interacting with other professionals, behaviorists might focus on shared concerns as opposed to orientation differences. In our experience, most mentalhealth professionals agree that psychiatric symptomatology may be exacerbated by "situational stressors" such as divorce, retirement, or criminal vic-

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timization (see Wasylenki, 1992). Agreement on these issues opens the door for the development of behavioral skills training and self-management approaches to treatment. Furthermore, despite an apparent preference for drug therapies in inpatient settings (Vogeltanz et al., 1993), there is a growing consensus that the use of medication does not necessarily obviate the need for behavioral intervention. The two approaches can and should complement each other (Agras, 1976; Bellack, 1986), particularly in the case of the psychotic disorders. We suggest that behavioral models of chronic psychiatric disorders are not well developed, and so many mental-health professionals may have been exposed only to basic behavioral tenets (e.g., behavior is a function of its consequences, especially of reinforcement) that may seem to contradict more commonly held notions that are at least in part supported by empirical evidence (e.g., "mental illness," or schizophrenia as a brain disorder) and that appear to lack relevance to complex behavioral disorders. Behaviorists might rectify this by spending more time within each treatment report addressing theoretical issues, in particular the role of functional analysis or behavioral diagnostics in treatment selection. Moreover, behaviorists need to consider how behavior therapy can optimally be combined with drug therapy. Although at times this practice might appear redundant to behaviorally trained peers, each research report might be viewed as an opportunity to inform other mentalhealth professionals that contemporary behavior analysis and therapy is more than just a collection of consequences. The tendency to assume that the behavioral explanation of a particular disorder is obvious and need not be delineated explicitly has potentially led behaviorists away from providing suitably complex analyses of the functional relations describing and controlling a particular disorder. One excellent model for the type of theory building we need to undertake is provided by Haynes' (1986) discussion o f paranoid behavior, even though it has had a limited impact on the field. Considering that "standards of practice" are now more clearly defined than ever before, that the discipline is better organized, and that behaviorists have experienced clear successes in other areas, such as developmental disabilities (i.e., inclusion in the treatment team and decision processes), there may also be actions that the field of psychology could take to enhance the involvement of its practitioners in the area of chronic psychiatric disorders. For example, editorial boards o f certain journals might be encouraged to adopt a policy that permits the publication of "the best that there is" within the area of chronic psychiatric disorders, rather than accepting "only the best," regardless o f research area. In our opinion, demanding that research with chronic psychiatric disorders be as methodologically rigorous as work with some other populations (e.g., those with developmental disabilities) not only represents a failure to acknowledge the current status of psychiatric research, but also helps ensure that it fails to progress via systematic replication (Sidman, 1960) by unintentionally excluding works from this area. Demonstrations of meaningful long-term clinical effectiveness (e.g., decreased symptoms, community placement, social and vocational adjustment) with the psychotic disorders is perhaps more difficult than in other areas, and this needs to be recognized by

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editorial boards and funding agencies. This is n o t a suggestion to loosen standards, but to acknowledge that the process of building a viable technology occurs in steps and will not simply appear in full bloom. Much o f the early research we reviewed in this analysis would not be publishable by today's standards, but it was work that helped the field progress. The field o f psychology also might attempt to provide more support for researchers who are currently involved in the area of chronic psychiatric disorders. Encouraging persons with expertise to participate more fully in discipline conferences, increasing efforts to market quality work, developing mechanisms to support student involvement, and enhancing participation with consumer/advocacy groups are just a few avenues that could be explored. In addition, we believe that agency administrators need to be informed that increased utilization of proactive/contemporary behavioral interventions can help reduce utilization of procedures that are considered restrictive and often produce potential liabilities (e.g., physical and chemical restraints, seclusion, etc.). This review was not intended to be a meta-analytic review of treatment effectiveness with chronic psychiatric disorders. We feel that the current status of the chronic psychiatric treatment literature would not have allowed such a statistical analysis, due in large part to the wide variety of diagnostic and target behavior categories and of behavioral treatment strategies. Nonetheless, these results might be interpreted as "bad news" with respect to the involvement o f behaviorists in the treatment of chronic psychiatric disorders (as well as for the persons for whom the technology may be useful if fully developed). Our hope, though, is that it will lead to an increase in the quality work that is currently being done, and will encourage an integrative biobehavioral approach to the theory and treatment of these disorders. The history of involvement by behavioral psychology in the area of chronic psychiatric disorders is a long one, although recently faltering. It is ironic, then, that the American Psychological Association (APA) recently has "rediscovered" the chronic patient. The Association's 1991 annual report (Fox, 1991) presents a resolution on the priorities for persons with serious and persistent mental illness. The several actions recommended by the Council o f the APA in order to address these priorities include: (a) encouraging psychology graduate and internship programs to provide training relevant to the delivery of services for this population, (b) promoting the career development o f psychologists working in this area, (c) increasing community-based programs and providing an appropriate continuum of care, (d) encouraging systematic evaluation of treatment services, and (e) advocating for increased research funding to foster further understanding of serious and persistent mental illness (Fox, 1991). Considering the last point, it may be that decreases in federal funding are related to the decline in behavioral research in this area (see comments by Glynn, 1990, and Liberman, 1980). We strongly concur with the above recommendations by the American Psychological Association, particularly in light of our present findings, and view such a comprehensive program as going far to address the deficits in the area of treating chronic psychiatric disorders. Each of the above suggestions should stimulate renewed interest by behaviorists in the treatment of persons exhibiting

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chronic psychiatric disorders. They would also serve to enhance the acceptance of behavioral psychologists by other professionals within the settings where such treatment would be provided. The chronic psychiatric disorders are not "too severe for behavior therapy," nor should any "biological basis" for these disorders rule out the use of behavior therapy as a primary or secondary treatment option. Neither of these factors has reduced the impact that behavioral psychology has had in the area of developmental disabilities, nor has it held back work in the area of anxiety disorders or depression. In the area of chronic psychiatric disorders, behavior therapists have slipped on the path. However, we feel that there may be real barriers to continuing on the path, including professional "turf" issues, administrative constraints, and insufficient collegial support, among others (Corrigan, Kwartarini, & Pramana, 1992). There even seems to be a perception concerning the ineffectiveness and limitations of behavioral interventions (Corrigan et al., 1992; Vogeltanz et al., 1993) that may lead practitioners away from this area. Behavioral theory and technology have changed and improved significantly since the 1960s and 1970s. Now is the time for behaviorists to apply this newer technology: to once again establish the discipline within the area of chronic psychiatric disorders and fulfill the promise and optimism felt some 30 years ago.

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