Limitations and problems in the clinical application of behavioral techniques in psychiatric settings

BEHAVIOR THERAPY 10, 65--80 (1979)

Limitations and Problems in the Clinical Application of Behavioral Techniques in Psychiatric Settings MICHEL HERSEN

Western Psychiatric Institute and Clinic and University of Pittsburgh School of Medicine Limitations and problems in the clinical application of behavioral techniques in psychiatric settings were examined with respect to: the use of drugs vis-/~-vis behavior therapy; the application of clinical techniques to patients based on findings with college students; nonresponders to selected treatment strategies; the insensitive clinician, usually the neophyte behavior therapist; and the continuous problems of obtaining generalization outside of the treatment setting and longterm maintenance of initial behavioral changes. The discussion is based on empirical studies, illustrative examples, and the author's experience in several psychiatric settings as educator, researcher, clinician, and consultant.

As behavior therapists, what has predominantly distinguished us from other practicing clinicians in the past has been our willingness to assess whatever we have done clinically, using the best of the scientific methods then at our disposal. When strategies have not worked or have only been partially effective, we have been quite willing to modify, discard, correct, and overcorrect. One would like to think that this feature has, and should continue to be, the prominent one associated with our discipline. Otherwise, we no longer have a discipline but have emulated our psychoanalytic forebears and have become a religious movement, with various leaders telling us the "truth." Thus, if data and/or clinical experience dictate otherwise, we should not bury our heads in the sand, but should react realistically to these unhappy findings. Unfortunately, in some instances the data simply do not support our cherished notions, theories, or techniques. Indeed, for those of us who attempt to apply behavioral strategies in the psychiatric setting, it is clear that often there is a wide gulf between theoretical expectation and pragmatic success. The psychiatric setting as an arena for the application of the behavioral The author thanks Alan S. Bellack and Samuel M. Turner for their critical commentary of the manuscript. Preparation of this paper was facilitated by Grant MH 28279-01A 1 from the National Institute of Mental Health. Requests for reprints should be addressed to Michel Hersen, Department of Psychiatry, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15261. 65 0005- 7894/79/010005 - 16501.00/0 Copyright© 1979by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any form reserved.

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therapies poses some unique problems (cf. Hersen & Bellack, 1978), not the least of which is that it is a medical setting, primarily administered by medically trained and medically oriented individuals, who typically support the so-called "medical model" of the psychiatric disorders (cf. Guze, 1977). Moreover, such personnel tend to use medical strategies (i.e., drugs) for the treatment of their patients. Also, at times, albeit rare, problems of a truly medical nature are seen to mimic the behavioral disorders (e.g., Adebimpe, in press). ~ Considering that most practicing behavior therapists in the psychiatric setting today are clinical psychologists, the possibilities for conflict, dissension, and chaos are enormous at the theoretical, administrative, and pragmatic levels. Another major problem in applying behavioral strategies in the psychiatric setting is that many of them are based on the thinking of academicians whose primary affiliation, of course, is in the universitybased department of psychology." Thus, not only are the theoretical hunches frequently hatched on the basis of work with subclinical populations much less severely disturbed than those typically encountered in the psychiatric setting, but the efficacy of resulting techniques is largely determined by experimentation with the college undergraduate subject (cf. Bernstein & Paul, 1971; Kazdin & Wilcoxon, 1976; Twentyman & Zimering, in press). Needless to note, despite the saying that "people are people," there is often a vast difference qualitatively and quantitatively between the college research subject who may be fearful and the distraught psychiatric patient who is fearful. Perhaps, then, "a rose is not always a rose," at least when testing behavioral stratagems. Thus, often is the case when one approach has been demonstrated to be effective with a given college population, but the clinical application with a severely disturbed psychiatric patient does not automatically follow. Yet another problem encountered is that some techniques seem to be quite effective with most patients, but a small yet significant percentage remains unaffected by the approach. This has been the case when wardwide token economies have been implemented (cf. Kazdin, 1972, 1973), as well as with the application of systematic desensitization with certain subcategories of phobia (e.g., Zitrin, Klein, & Woerner, 1978). When this happens one is always tempted to argue that the technique was misapplied or that the behavioral analysis was incomplete or inaccurate. This might be so. On the other hand, this simply may not be the case. Therefore, to further pursue this argument one may easily be accused of engaging in circular thinking. A somewhat different problem concerns how a behavioral approach is Of course, the word behavioral is subject to question inasmuch as some of the disorders seen in the psychiatric setting (unipolar psychotic depression, bipolar depression, schizophrenia) are now frequently conceptualized as being biological in origin (cf. Wolpe, 1970). 2 That is not to say that important discoveries are not being made on the basis of work with college students. But the point being underscored here is that the generality of such findings should not be taken for granted in the absence of empirical demonstration.

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originally presented to the patient and to the psychiatric staff involved in his or her treatment. Frequently a function of poor initial presentation, the patient will fail to fully understand the expectation of his or her role in the therapy and will not perform required homework assignments in between scheduled therapeutic sessions. Elsewhere I have referred to this problem as "patient resistance to direction" (Hersen, 1971). Although the term, for some, conjures up the horrific sounds of psychoanalytic jargon, the term describes a phenomenon that every practicing clinical behavior therapist has seen at one time or another. How many times has systematic desensitization failed, not because the technique is ineffective, but because our patients have not carried out the extra-treatment assignments (i.e., practicing relaxation, confronting the phobic stimulus in vivo) that are an integral aspect of the treatment package? Usually, when the case is examined in retrospect, one can detect a naive approach by a "beginning" therapist who not only failed to negotiate a valid behavioral contract with the patient, but also has not listened with his or her "third ear." Application of specific behavioral strategies can never be a total substitute for clinical sensitivity to the nuances of patient communications. But at times it seems to be so in spite of our best efforts at training our students. The final issue is the generalization and long-term follow-up of patients. As this issue has repeatedly been emphasized in the literature, I will try not to belabor it here. However, let me point out that with many of our clinical challenges we have developed refined strategies for modifying in-hospital and consultation room behavior. But, disappointing as it may seem, such refinement has not extended to the extra-hospital or natural environment of our patients. Thus, it is very clear that the most difficult work (clinical and research) needs to be done in the future. Otherwise, when contrasted on a long-term basis, it should not be surprising that our behavioral methods do not seem vastly superior to the traditional psychotherapeutic approaches (e.g., Luborsky, Singer, & Luborsky, 1975). As is well known, the natural reinforcers obviously do not automatically take over to maintain newly learned behaviors. Perhaps, as was suggested by Holland (1978), we need to look more closely at the environment into which we discharge our patients. Before going on to a discussion of these specific points that I have raised, let me issue what I perceive as a necessary disclaimer. I have been, and I am, a behavior therapist. However, more importantly, I first consider myself to be an empiricist. Thus, despite my avowed association with behavior therapy, I think that it is very important for us, at times, to evaluate what we have done from a wider viewpoint and perhaps even under the guise of outsider peering in. DRUGS From my perspective as internship training director, I have seen many new behavioral trainees enter our program with a preconceived bias against the use of drugs with severely disturbed psychiatric patients. There can be no doubt that in many instances such biases were acquired

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during the course of their preinternship training in their parent psychology departments. Undoubtedly, some of our interns' mentors sincerely believe that the use of drugs is unwarranted. Others, fueled by the traditional psychology-psychiatry split, have taken up this defensive posture, probably in retaliation for some of the transgressions (real and alleged) of our psychiatric colleagues. Perhaps an example will clarify the issues. On the basis of an analogue study, Davison and Valins (1969) concluded that the relaxation effects of drug-assisted desensitization were due to the patient's attribution of the drug's putative action rather than to learned self-control. On the other hand, Liberman and Davis (1975) argue that, "Legally prevented from administering psychotropic drugs, psychologists have used attribution theory to challenge the use of drugassisted desensitization . . . . Since drug-assisted desensitization has been empirically demonstrated to be effective repeatedly with the effects transferring to settings, the argument based on attribution theory may be little more than an academic polemic delivered by psychologists to medical psychiatrists" (p. 310). Whatever the reason for such negative biases, the facts about the role and efficacy of psychotropic agents need to be faced squarely. To begin with, for some of the diagnostic categories seen in the psychiatric setting, drugs are the only efficacious means of treatment developed to date (Baldessarini, 1977). In the case of manic-depressive psychosis (i.e., bipolar depression) lithium carbonate is the treatment of choice. I know of no reports showing the efficacy of behavioral therapy with this disorder. For unipolar psychotic depression, tricyclic antidepressants and/or electroconvuisive shock therapy are still the mainstays for overcoming the depth of the depression. Here too, there is little evidence in support of behavioral approaches. 3 In the treatment of schizophrenia, remission of major symptomatology (e.g., delusions, hallucinations, thinking disorders) is best accomplished with the antipsychotic agents (i.e., the phenothiazines and butyrophenones). Although there a r e reports in the behavioral literature of the successful use of operant strategies to reduce delusional speech in chronic schizophrenics (e.g., Liberman, Teigen, Patterson, & Baker, 1973; Turner, Hersen, & Bellack, 1977; Wincze, Leitenberg, & Agras, 1972), this approach is not widespread nor does it appear to be cost effective. Also, the evidence for generalization of treatment gains outside the immediate contingency situation is not impressive. Moreover, in the case of Wincze et al. (1972), implementation of a token economy system based, in part, on food deprivation is no longer consistent with the prevailing ethics of behavioral practice (cf. Hersen, 1976: Kazdin, 1977). Finally, in the case of most 3 This, of course, is not the case in nonpsychoticunipolar depression (the so-called neuroticor reactivedepression), whereevidencefor efficacyof the behavioraltechniquesis mounting(see Rehm& Kornblith,in press). In particular, Rush, Beck, Kovacs,and HoUon (1977) recentlypublisheda studyshowingthe superiorityof cognitivebehaviortherapyover imipramine (a tricyclic antidepressant drug) in the treatment of outpatient depressives. However, these findingsneedto be cross-validatedusinga morerigorouslydesignedstudy.

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seizure disorders seen in the psychiatric hospital, the anticonvulsants (e.g., Dilantin, Tegretol) still remain the major treatment modality, despite occasional reports describing successful use of behavioral techniques (Effort, 1957a, 1957b; Wells, Turner, Beilack, & Hersen, 1978; Zlutnick, Mayville, & Moffat, 1975). In addition to the use of drugs as the primary treatment agent in reducing symptomatology, there is a well-documented literature showing the interaction possible between pharmacology and behavior therapy (for reviews, see: Liberman & Davis, 1975; Liberman, Davis, Moon, & Moore, 1973; Stern, 1978). In some instances, medicating the patient first will remove symptomatology (e.g., delusions, hallucinations) which otherwise would interfere with learning new material when behavior therapy is applied. This certainly has been the case in our social skill training efforts with chronic schizophrenics (Bellack, Hersen, & Turner, 1976; Hersen & Bellack, 1976a; Williams, Turner, Watts, Bellack, & Hersen, 1977). Indeed, although we have not previously reported this finding in the literature, unless the medication of our schizophrenics is finely adjusted (i.e., correct dosage level), they simply do not show any evidence of learning in our social skills paradigm (consisting of instructions, modeling, feedback, behavior rehearsal, social reinforcement). Other colleagues working in this area in different centers have corroborated our finding during the course of discussions. It is quite clear to us that with distracting hallucinatory stimuli, the schizophrenic is unable to fully attend. Therefore, it should not be surprising that under such conditions learning is minimized. Drugs have also been used to facilitate implementation of a number of behavioral techniques. Just to list a few instances, Brady (Note l) found that methohexitone-assisted 4desensitization was most effective in improving performance in sexually dysfunctional women. In a case of spasmodic torticollis, Turner, Hersen, and Alford (1974) found that meprobamate (a minor tranquilizer) seemed to facilitate the subsequent application of massed practice. In an elegantly designed study, Marks, Viswanathan, Lipsedge, and Gardiner (1972) documented that in the flooding treatment of specific phobias, when diazepam (Valium) was administered (0.1 mg/kg) 4 hr prior to flooding sessions, greatest improvement was obtained when contrasted to diazepam administered 1 hr before flooding, or placebo given 1 or 4 hr before flooding. The superiority of diazepam given 4 hr before flooding was seen with regard to self-report and physiological changes in patients in addition to ratings of patient behavior made by clinicians. COLLEGE STUDENTS AND CLINICAL POPULATIONS In a recent review of the literature on behavior therapy for depression, Rehm and Kornblith (in press) pointed out the following concerning the use of college student populations for studying clinical phenomena. 4 This is an extremely short-acting (i.e., very brief half-life) drug o f the barbiturate family.

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MICHEL HERSEN One would generally assume subclinical severity in this population. College students can be assumed to be a relatively homogeneous population restricted not only in terms of education but also of age and probably socioeconomic and marital status. They probably represent a population that will benefit maximally from virtually any therapy procedure. While studies using college students can demonstrate innovations in procedure and evaluate the differential effectiveness of various strategies, the generality of findings to more clinical populations may be open to question.

Although we all are familiar with the thinking represented in the Rehm and Kornblith quote, some illustrative material should underscore the points at issue. For example, on the basis of four short-term treatment analogues (two therapy sessions) with unassertive college students, McFall and Twentyman (1973) concluded that, "The training components of rehearsal and coaching both made significant additive contributions to the improved performance on self-report and behavioral assertion measures: however, symbolic modeling added little to the effects of rehearsal alone or rehearsal plus coaching" (p. 199). Given that it may take very little to influence a college student from the therapeutic standpoint (cf. Rehm & Kornblith, in press), it is likely that with rehearsal and coaching an asymptote in performance had been reached, thus of course leaving little or no room for the effects of modeling to be seen. By contrast, given the extent of social disability observed in chronic psychiatric patients (e.g., Sylph, Ross, & Kedward, 1977), one would expect different findings with this population. That is, a more potent technique, such as modeling, would be required to bring about the same behavioral change. This certainly was and is the case! In a parallel set of short-term treatment studies (four therapy sessions) with male psychiatric patients hospitalized in a Veterans Administration Center, we found that modeling was the critical therapeutic ingredient accounting for behavioral change (Eisler, Hersen, & Miller, 1973; Hersen, Eisler, & Miller, 1974; Hersen, Eisler, Miller, Johnson, & Pinkston, 1973). No changes in patients' self reports of assertion were noted. The importance of modeling in the clinical treatment of chronic psychiatric patients has received considerable empirical confirmation (for reviews, see Hersen, in press; Hersen & Bellack, 1976b). Moreover, in a recent study by Eisler, Blanchard, Fitts, and Williams (1978), it was found that in the social skill training of schizophrenics, modeling was essential for improving their performance. However, for nonpsychotic patients, modeling was not required to bring about behavioral change. Thus, this study shows still further that for psychiatric patients as a category one cannot make generalized statements. To the contrary, it looks like specific strategies are required for different diagnostic groupings, at least when talking about social skills training. Given the discrepancy between work with college student and clinical populations in the social skills area, I think that it is instructive to note that more than 50% of all studies were done with college student populations (Twentyman & Zimering, in press). Only 30% of the studies have been carried out with psychiatric patients. However, in all fairness to

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McFall and Twentyman (1973), it should be noted that they do recognize that under certain conditions, rehearsal, coaching, and modeling may be differentially effective. Nonetheless, the less than careful reader could easily conclude that modeling is not a necessary condition for eliciting behavioral change in unassertive individuals on the basis of these four studies that were conducted with college students. Let me briefly review three additional instances of considerable discrepancy. First, many self-help manuals designed along behavioral lines (i.e., bibliotherapy) have been hailed as effective treatment methods for subclinical populations (e.g., Phelps & Austin, 1975; Wenrich, Dawley, & General, 1976). In a recent study by Monti, Fink, Norman, Curran, Hayes, and Caldwell (1978), a comparison of group social skills training bibliotherapy, and a ward conti'ol condition for hospitalized psychiatric patients failed to show any positive effects of bibliotherapy. Quite to the contrary, following bibliotherapy patients rated themselves as less assertive than they had pretreatment. A similar failure of a "do-it-yourself' manual for treatment of overweight recently appeared in the literature (Brownell, Heckerman, & Westlake, 1978). [See also Glasgow and Rosen (1978) for a critical review of the area.] Second, self-control strategies are considered to be an important contribution to the armamentarium of the practicing behavior therapist. Of course, most of the critical studies in this area were carried out with nonclinical populations (cf. Bellack & Schwartz, 1976). However, despite the theoretical promise such strategies might hold for extending therapeutic gains of psychiatric patients into the natural environment (cf. Hersen & Beilack, 1976b), the technology for carrying out such training with this kind of patient has not yet been developed. Our own attempts with schizophrenics and those of Liberman and his colleagues (Liberman, Lillie, Falloon, Vaughn, Harpin, Left, Hutchison, Ryan, & Stoute, 1977) have been most disappointing. Third, there are several hundred studies examining various aspects of systematic desensitization with "fearful" college students. Given the numerous methodological problems with most of these studies (see Kazdin & Wilcoxon, 1976), few meaningful conclusions can be reached on their basis at this time. However, let us look at one of the more interesting and better designed of these investigations in light of the previous discussion. In standard systematic desensitization, patients are exposed to fearproducing stimuli in an ascending order of aversiveness while under conditions of deep muscle relaxation. Krapfl and Nawas (1970) contrasted this standard presentation of items with four other conditions in 50 wellmatched snake-fearful college subjects. In addition to the standard ascending presentation of items, there was a condition involving the descending presentation of items, one involving a random presentation of items, a pseudodesensitization condition, and a no-treatment control. Results indicated that subjects in the three active treatment conditions showed significantly greater improvement than those in the two control groups (recall the quote by Rehm & Kornblith, in press). Interestingly

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enough, there were no differences between groups receiving the standard ascending presentation and the novel descending presentation. However, both did better than the group receiving a random presentation of items. On the basis of this study, Krapfl and Nawas (1970) argue that, "An ascending aversive order of stimulus presentation is not an essential and integral part of successful desensitization" (p. 333). But, to the best of my knowledge this study has never been replicated with a truly phobic patient population. Whether or not similar findings would emerge can only be a matter of conjecture in the absence of hard data. Thus, in my estimation their conclusion, beyond the limited conditions under which it was tested, was and still is premature. Of course, one can find parallels between flooding and the descending hierarchy used by Krapfi and Nawas (1970) in their study. Thus, given the fact that both flooding and desensitization are effective treatment strategies for clinical phobia (Marks, 1975), the argument is strengthened. But then again, there would be differences between a continuous 2- or 3-hr flooding session (in which anxiety attached to the stimulus presentation undoubtedly would diminish significantly) and the brief albeit repeated presentation of a high anxiety-arousing stimulus at the top of the hierarchy. Here, I am not convinced that dramatic decreases in anxiety would occur. I think it is quite likely that this difference would be underscored in clinically phobic patients who seek psychiatric treatment. NONRESPONDERS Whatever the treatment modali,ty, be it behavioral or medical, there is always a small percentage of patients that does not respond, seemingly despite our best efforts. There are many reasons for such lack of response to any given therapeutic strategy. One, previously noted in the introduction, is that the technique is misapplied. In behavior therapy with psychiatric patients this might mean an incomplete behavioral assessment, an insufficient amount of therapy time (e.g., discontinuation of flooding before anxiety fully dissipates), an insufficient number of therapy sessions, the application of the wrong technique, or some combination of the aforementioned factors. Let us consider an example of misapplication. During the course of my recent consultation at a local Veterans Administration Hospital, I was asked to interview and help devise a program for a 65-year-old male patient (diagnosis--simple schizophrenia) with an extensive history of brief hospitalizations (each of which was usually preceded by arrest for vagrancy) in many states for over a 40-year period. This patient was residing on a locked ward organized under token economic lines, but he was described as a nonresponder. While interviewing this patient, it became crystal clear that he had been living the life of a hobo (i.e., riding the freights, working when he required money, etc.), and that he thoroughly enjoyed this life, expressing absolutely no regrets about it. It is little wonder, then, that he was a nonresponder to the token system, particularly as he also was a nonresponder to the larger scaled token economy (middle-class America). Indeed, the ultimate "turn on"

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(reinforcer) for this patient was to roam the country as he had done so for 40 odd years. Given his lust for "freedom," it obviously was wrong, behaviorally and existentially, to attempt to get him to conform within the confines of the ward token economy. Therefore, I recommended that he be discharged, inasmuch as he certainly was of no danger to others or himself. A second reason for treatment failure is that the upper limits of the applicability of the specific technique have been reached. Such a case was clearly documented by Hersen and Barlow (1976, chap. 9) with regard to the technique of differential attention. There, we noted how, during the course of conducting direct and systematic replications with adults and children, the limits of differential attention were discovered. With oppositional children this technique clearly was not effective. In some instances differential attention with oppositional children only succeeded when combined with time out (Wahler, 1969). In still another study (Herbert, Pinkston, Hayden, Sajwaj, Pinkston, Cordua, & Jackson, 1973), application of differential attention with oppositional children who were also hyperactive and socially inappropriate not only was ineffective but actually worsened their behavior. This was clearly demonstrated in extensions of ABA single case designs. A third reason for failure, closely related to the second reason, is that for the general classification of any given disorder the specific technique appears to be very effective. However, when one begins to examine the extent of success with various subcategories of that diagnostic class, differential effectiveness of the technique becomes apparent. Let me now illustrate this latter point. It is now acknowledged (and confirmed by data) that systematic desensitization and flooding are the behavioral treatments of choice for clinical phobia. However, for those of us who have worked with agoraphobic patients who also experience panic attacks, we often have found that none of the behavioral strategies currently available seemed to alter this aspect of the disorder. On the other hand, there is very good evidence that the tricyclic antidepressant, imipramine (10-300 mg/day, mean = 180 mg/day), is the treatment of choice for such panic attacks (Zitrin et al., 1978). That is not to say that at some future time a new behavioral strategy will not be developed which can supplant the pharmacological approach. However, to date, the evidence is on the side of imipramine for bringing panic attacks associated with agoraphobia under reasonable control. THE INSENSITIVE CLINICIAN Behavior therapists have not cornered the market with regard to insensitivity in their work with clinical patients. Clinicians of all theoretical persuasions obviously i.lave their shortcomings. However, because our therapeutic strategies are specific and replicable and because we also collect data in baseline and treatment phases, there is no doubt that we, as therapists, are much more open to public inspection and critical scrutiny. (Parenthetically, let me say that I think this is a very fine feature of

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behavior therapy. Perhaps if our fees were totally contingent on achieving success with patients, we might also be more attuned to the more subtle communications of our patients and, of consequence, be yet more effective.) In general, my experience dictates that insensitivity in behavioral clinicians is most frequently encountered in graduate student therapists. Of course, some of these graduate students never matriculate clinically and remain insensitive as senior professionals. Insensitivity in the behavioral clinician often is tied into his or heF credo of immediately doing something for the patient or applying a very specific technique (e.g., response prevention, thought stopping, systematic desensitization, etc.) without a sufficiently extensive and thorough evaluation. In this connection, in his or her zeal to do, the clinician often does not listen (i.e., to what the patient really is saying). In talking about our nonbehavioral colleagues, we often are critical for their being inactive or not doing the right thing. However, one thing they do exceptionally well is that they listen and know how to listen to patient communications. Perhaps in this respect we have failed in our training of the younger behavior therapists. Let me now illustrate by considering the following. A height-phobic young lady, who has been under systematic desensitization treatment for several weeks, has learned muscular relaxation, and has progressed half-way up the hierarchy of phobic items. She comes for her eighth therapy session apparently distraught, breaks into tears, and describes the recent dissolution of a long-standing love relationship with a boyfriend. Our neophyte therapist listens for a few minutes, makes a few casual but seemingly appropriate remarks, and then impatiently directs the patient to a continuation of systematic desensitization treatment. Indeed, the greater portion of the eighth therapy session is concerned with desensitization. The patient returns for session nine the following week, but upon questioning reports that she did not practice relaxation nor did she carry out in vivo assignments related to heights. Our neophyte therapist is rather surprised and admonishes the patient for not doing her homework. He emphasizes the importance of doing homework when a patient is receiving behavior therapy. Of course, presumably the seasoned clinician would know better, might even have omitted any systematic desensitization for session eight, looking into how this important (to the patient) relationship began, progressed, and finally ended, etc. Moreover, the astute clinician would explore the patients' reactions to the dissolution (i.e., depression, suicidal ideation, bodily functioning: sleep, appetite, sexual desire, elimination). Further, if upon questioning it emerges that this kind of pattern is recurrent, certainly the interpersonal functioning of the patient would become an integral aspect of her behavioral treatment. There is nothing sacred about discontinuing systematic desensitization in favor of helping a patient with a more immediate and pressing problem. Nor is there any contraindication to dividing the therapeutic hour with respect to several problem areas that may require concurrent attention. Most of our patients (phobic or otherwise), contrary to the classic case descriptions, rarely are mono-

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symptomatic. Thus, behavioral strategies should be directed to all aspects of malfunctioning, especially if permanence of treatment is to be achieved. As a further example, years ago one of our trainees began the inpatient treatment of what ostensibly was a severe elevator phobic. Being in an environment where we stressed objective measurement, our trainee seized upon this phobic element and began what appeared to be a very nice in vivo treatment, operantly based. However, she found that very little success was being obtained with her operant approach to the phobic problem. When our trainee finally presented the case at grand rounds, it became very clear to me that the patient primarily was suffering from unipolar nonpsychotic depression, with the phobic features being secondary. Thus, it was suggested that she refocus treatment around the patient's depression and that the phobia, if still present, receive direct attention at a later time. Needless to say, behavioral treatment of the patient's depression proved successful, with the secondary phobic symptom lifting as the depression improved. Although we, as behavior therapists, generally eschew psychiatric diagnosis (cf. Hersen & Bellack, 1976c), attention to the primary and secondary symptoms of our patients can be of considerable importance in making the correct behavioral diagnosis. If a correct behavioral diagnosis is made, then of course an appropriate treatment strategy may be selected and applied. GENERALIZATION AND LONG-TERM FOLLOW-UP In spite of some of the limitations of the behavioral approach that I have tried to document, there is extensive and impressive evidence of our positive achievements. This evidence has received periodic review over the last decade in many books (cf. Bandura, 1969; Bellack & Hersen, 1977; Franks, 1969; Gambrill, 1977; Hersen & Bellack, 1976c, 1978; Kanfer & Phillips, 1970; Kazdin, 1975; Leitenberg, 1976; Paul & Lentz, 1977; Yates, 1970; Wolpe, 1973). When one examines the evidence for behavior therapy as a treatment for psychiatric disorder in particular (Hersen & Bellack, 1978), it is clear that a very nice technology has been developed to bring about behavioral change during the course of inpatient and outpatient treatment. Following Baer, Wolf, and Risley's (1968) oftquoted admonishment that "generalization should be programmed rather than lamented," workers in the psychiatric arena have made valiant attempts in this direction (e.g., half-way houses run under token economies) foster home care, contracting with patients and families, self-control procedures integrated in treatment prior to actual discharge, etc.). Of course, a considerably greater effort in this direction needs to be made, particularly in light of the fact that as behavior therapists (although we should know better in terms of our background in learning theory), we are still returning our patients to the very same environments that produced the disorder in the first place and that undoubtedly will reinforce psychopathology in the future. [For an elegant and fuller discussion of the issues, see Holland's (1978) provocative paper.] Of course, one of our greatest current deficiencies is in the documenta-

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tion of the permanence of treatments (i.e., long-term follow-up). Some of our psychoanalytic colleagues (cf. Bruch, 1974) have acrimoniously challenged us in this regard. Aside from the acrimony accompanying such critiques, they are not entirely wrong. In the relatively few reports where follow-up exceeds 12 months (e.g., Erwin, 1977; Ollendick, in press), the evidence is not overly impressive. Indeed, most reports involve followups that generally do not exceed 6 months' duration. As an eager contributor to journals, as reviewer, and moreover as journal editor, I fully understand the enthusiasm, exigencies, and press to publish. However, looking at the issues from a broader perspective (the psychiatric field as a whole), we definitely warrant better documentation of permanence. Perhaps one of our errors in judgment, despite our obvious knowledge to the contrary, is that gains are expected to be maintained in the absence of further intervention. I now think this is absolutely wrong! I think that during follow-up we should systematically program periodic booster treatment sessions. This certainly would prove much more cost effective than having the patient return 1 or 2 years later with a need to recommence treatment at a basic level. Just as in the case of pharmacological management of patients whose maintenance chemotherapy is required, with patients administered behavioral treatment, periodic reevaluation and reassessment should lead to administration of booster behavior therapy sessions. Let me underscore that this in no way would, and should, be interpreted as a negative evaluation of the original behavioral intervention!

CONCLUDING COMMENTS In this very brief concluding section, I wish to comment a bit further on two of the points raised earlier in the paper. The first concerns the issue of drugs and behavior therapy. For behavior therapists who have functioned in the psychiatric setting, we are very well aware of the struggles most of us have experienced with traditional psychiatry: (1) as psychologists working in a medical setting, and (2) as behavior therapists once again challenging the psychotherapeutic establishment. Although the struggles surely are not yet over, in most settings behavior therapy, at the very least, has established a necessary "beachhead," while in some it has established itself as one of the recognized treatment modalities. However, this struggle vis-~.-vis psychiatry and the establishment should not blind us as to the important contribution the medical approach is able to make to the overall care of the "mental patient." The various combinations and permutations of drugs and behavior therapy as outlined by Liberman and Davis (1975) and Stern (1978) are exciting and should lead to further innovation. Even for those diagnostic categories where drugs alone seem to be the treatment of choice, nonmedical behavioral practitioners need not despair. Drugs may relieve florid psychopathology, but they will never be able to resolve interpersonal distress, which is the target of most of the contemporary psychotherapies, including behavior therapy. Second remains my overriding concern as to how young behavior

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therapists are being trained. I think because of our own penchant for data collection, precision of thinking, and specificity of technique, many of our trainees who come into behavioral internships in leading medical centers have a tremendous advantage over their psychiatric resident counterparts (who have not had exposure to the behavioral model). However, when it comes to specifically dealing on a face-to-face basis with patients, this advantage often is lost. Although I certainly would not advocate a return to the "traditional" model of training graduate clinicians, I would like to see greater emphasis directed (in graduate school clinical programs) toward training students how to interact with patients, how to elicit information from patients, how to listen to their communications, how to understand their communications, and how to delay treatment until the appropriate medical and behavioral assessments have been concluded. Only at that point should effective treatment strategies be implemented. The old adage of the West "to shoot first and ask questions later" does not apply to patient care. REFERENCE NOTE 1. Brady, J. P.Behavioral treatment of sexualfrigidity. Paper presented at the Fourth Annual Southern California Conference on Behavior Modification, Los Angeles, October 1972.

REFERENCES Adebimpe, V. R. A rationale for DSM III's medical model. American Psychologist, in press. Baer, D. M., Wolf, M. M., & Risley, T. R. Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1968, 1, 91-97. Baldessarini, R. J. Chemotherapy in psychiatry. Cambridge, MA: Harvard Univ. Press, 1977. Bandura, A. Principles of behavior modification. New York: Holt, Rinehart & Winston, 1969. Bellack, A. S., & Hersen, M. Behavior modification: An introductory textbook. Baltimore: Williams & Wilkins, 1977. Bellack, A. S., Hersen, M., & Turner, S. M. Generalization effects of social skills training in chronic schizophrenics: An experimental analysis. Behaviour Research and Therapy, 1976, 14, 391-398. Bellack, A. S., & Schwartz, J. S. Assessment for self-control programs. In M. Hersen & A. S. Bellack (Eds.), Behavioral assessment: A practical handbook. NY: Pergamon, 1976. Bernstein, D, A., & Paul, G. L. Some comments on therapy analogue research with small animal "phobias." Journal of Behavior Therapy and Experimental Psychiatry, 1971, 2, 225-237. Brownell, K. D., Heckerman, C. L., & Westlake, R. J. Therapist and group contact as variables in the behavioral treatment of obesity. Journal of Consulting and Clinical Psychology, 1978, 46, 593-594. Bruch, H. Perils of behavior modification in treatment of anorexia nervosa. Journal of the American Medical Association, 1974, 230, 1419-1422. Davison, G. C., & Valins, S. Maintenance of self-attributed and drug attributed behavior change. Journal of Personality and Social Psychology, 1969, 11, 25-33. Efron, R. The effects of olfactory stimuli in arresting uncinate fits. Brain, 1957a, 79, 267-281. Efron, R. The conditioned inhibition of uncinate fits. Brain, 1957b, g0, 251-262.

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Eisler, R. M., Blanchard, E. B., Fitts, H., & Williams, J. G. Social skills training with and without modeling for schizophrenic and non-psychotic hospitalized psychiatric patients. Behavior Modification, 1978, 2, 147-172. Eisler, R. M., Hersen, M., & Miller, P. M. Effects of modeling on components of assertive behavior. Journal of Behavior Therapy and Experimental Psychiatry, 1973, 4, 1-6. Erwin, W. J. A 16-year follow-up of a case of severe anorexia nervosa. Journal of Behavior Therapy and Experimental Psychiatry, 1977, 8, 157-160. Franks, C. M. (Ed.), Behavior therapy: Appraisal and status. New York: McGraw-Hill, 1969. Gambrill, E. D. Behavior modification: Handbook of assessment, intervention, and evaluation. San Francisco: Jossey-Bass, 1977. Glasgow, R. E., & Rosen, G. M. Behavioral bibliotherapy: A review of self-help behavior therapy manuals. Psychological Bulletin, 1978, 85, 1-23. Guze, S. B. The future of psychiatry: Medicine or social science? Journal of Nervous and Mental Disease, 1977, 164~ 225-230. Herbert, E. W., Pinkston, E. M., Hayden, M. L., Sajwaj, T. E., Pinkston, S., Cordua, G., & Jackson, C. Adverse effects of differential parental attention. Journal of Applied Behavior Analysis, 1973, 6, 33-47. Hersen, M. Resistance to direction in behavior therapy: Some comments. Journal of Genetic Psychology, 1971, 118, 121-127, Hersen, M. Token economies in institutional settings: Historical, political, deprivation, ethical, and generalization issues. Journal of Nervous and Mental Disease, 1976, 162, 206-211. Hersen, M. Modification of skill deficits in psychiatric patients. In A. S. Bellack, & M. Hersen (Eds.), Research and practice in social skills training. New York: Plenum, in press. Hersen, M., & Barlow, D. H. Single case experimental designs: Strategies for studying behavior change. NY: Pergamon, 1976. Hersen, M., & Bellack, A. S. A multiple-baseline analysis of social-skills training in chronic schizophrenics. Journal of Applied Behavior Analysis, 1976a, 9, 239-246. Hersen, M., & Bellack, A. S. Social skills training for chronic psychiatric patients: Rationale, research findings, and future directions. Comprehensive Psychiatry, 1976b, 17, 559-580. Hersen, M., & Bellack, A. S. (Eds.), Behavioral assessment: A practical handbook. NY: Pergamon, 1976c. Hersen, M., & Bellack, A. S. (Eds.), Behavior therapy in the psychiatric setting. Baltimore: Williams & Wilkins, 1978. Hersen, M., Eisler, R. M., & Miller, P. M. An experimental analysis of generalization in assertive training. Behavior Research and Therapy, 1974, 12, 295-310. Hersen, M., Eisler, R. M., Miller, P. M., Johnson, M. B., & Pinkston, S. G. Effects of practice, instructions, and modeling on components of assertive behavior. Behaviour Research and Therapy, 1973, 11,443-451. Holland, J. G. Behaviorism: Part of the problem or part of the solution? Journal of Applied Behavior Analysis, 1978, 11, 163-174. Kanfer, F. H., & Phillips, J. S. Learning foundations of behavior therapy. New York: Wiley, 1970. Kazdin, A. E. Nonresponsiveness of patients to token economies. Behaviour Research and Therapy, 1972, 10, 417-418. Kazdin, A. E. The failure of some patients to respond to token programs. Journal of Behavior Therapy and Experimental Psychiatry, 1973, 4, 7-14. Kazdin, A. E. Behavior modification in applied settings. Homewood, Illinois: Dorsey Press, 1975.

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Kazdin, A. E. The token economy. New York: Plenum, 1977. Kazdin, A. E., & Wileoxon, L. A. Systematic desensitization and nonspecific treatment effects: A methodological evaluation. Psychological Bulletin, 1976, 83, 729-758. Krapfl, J. E., & Nawas, M. M. Differential ordering of stimulus presentation in systematic desensitization. Journal of Abnormal Psychology, 1970, 75, 333-337. Leitenberg, H. (Ed.), Handbook of behavior modification and behavior therapy. Englewood Cliffs, NJ: Prentice-Hall, 1976. Liberman, R. P., & Davis, J. Drugs and behavior analysis. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol 1). New York: Academic Press, 1975. Liberman, R. P., Davis, J., Moon, W., & Moore, J. Research design for analyzing drugenvironment-behaviorinteractions. Journal of Nervous and Mental Disease, 1973, 156, 432-439. Liberman, R. P., Lillie, F., Falloon, 1., Vaughn, C., Harpin, E., Leff, J., Hutchison, W., Ryan, P., & Stoute, M, Social skills training for schizophrenic patients and their families. Unpublished manuscript, 1977. Liberman, R. P., Teigen, J., Patterson, R., & Baker, V. Reducing delusional speech in paranoid schizophrenics. Journal of Applied Behavior Analysis, 1973, 6, 57-64. Luborsky, L., Singer, B., & Luborsky, L. Comparative studies of psychotherapies. Archives of General Psychiatry, 1975, 32, 995-1008. Marks, I. M. Behavioral treatments of phobic and obsessive-compulsive disorders: A critical appraisal. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 1). New York: Academic Press, 1975. Marks, I. M., Viswanathan, R., Lipsedge, M. S., & Gardiner, R. Enhanced relief of phobias by flooding during waning diazepam effect. British Journal of Psychiatry, 1972, 121, 493-505. McFall, R. M., & Twentyman, C. T. Four experiments on the relative contributions of rehearsal, modeling and coaching to assertion training. Journal of Abnormal Psychology, 1973, 81, 199-218. Monti, P. M., Fink, E., Norman, W., Curran, J., Hayes, S., & Caldwell, A. The effects of social skills training groups and social skills bibliotherapy with psychiatric patients. Unpublished manuscript, 1978. Ollendick, T. H. Behavioral treatment of anorexia nervosa: A five-year study. Behavior Modification, in press. Paul, G. L., & Lentz, R. J. Psychosoeial treatment of chronic mental patients: Milieu versus social-learning programs. Cambridge, MA: Harvard Univ. Press, 1977. Phelps, S., & Austin, A. The assertive woman. San Luis Obispo, CA: Impact, 1975. Rehm, L. P., & Kornblith, S. J. Behavior therapy for depression: A review of recent developments. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 7). New York: Academic Press, in press. Rush, A. J., Beck, A. T., Kovacs, M., & Hollon, S. D. Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1977, 1, 17-37. Stern, R. S. Behavior therapy and psychotropic medication. In M. Hersen & A. S. Bellack (Eds.), Behavior therapy in the psychiatric setting. Baltimore: Williams & Wilkins, 1978. Sylph, J. A., Ross, H. E., Kenward, H. B. Social disability in chronic psychiatric patients. American Journal of Psychiatry, 1977, 134, 1391-1394. Turner, S. M., Hersen, M., & Alford, H. Effects of massed practice and neprabamate on spasmodic torticollis: An experimental analysis. BehaviourResearch and Therapy, 1974, 12, 259-260.

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Turner, S. M., Hersen, M., & Bellack, A. S. Effects of social disruption, stimulus interference, and adversive conditioning on auditory hallucinations. Behavior Modification. 1977, 1, 249-258. Twentyman, C. T., & Zimering, R. T. Behavior training of social skills: A critical review. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 6). New York: Academic Press, in press. Wahler, R. G. Oppositional children: A quest for parental reinforcement control. Journal of Applied Behavior Analysis, 1969, 2, 159-170. Wells, K. C., Turner, S. M., Bellack, A. S., & Hersen, M. Effects of cue controlled relaxation on psychomotor seizures: An experimental analysis. Behaviour Research and Therapy, 1978, 16, 51-53. Wenrich, W. W., Dawley, H. H., & General, D. Systematic desensitization: A guide for the client, student, and therapist. Kalamazoo, MI: Behaviordelia, 1976. Williams, M. T., Turner, S. M., Watts, J. G., Bellack, A. S., & Hersen, M. Group social skills training for chronic psychiatric patients. European Journal of Behavioural Analysis and Modification, 1977, 1, 233-234. Wincze, J. P., Leitenberg, H., & Agras, W. S. The effects of token reinforcement and feedback on the delusional verbal behavior of chronic paranoid schizophrenics. Journal of Applied Behavior Analysis, 1972, 5, 247-262. Wolpe, J. The discontinuity of neurosis and schizophrenia, BehaviourResearch and Therapy, 1970, 8, 179-187. Wolpe, J. The practice of behavior therapy. Long Island City, NY: Pergamon, 1973. Yates, A. J. Behavior therapy. New York: Wiley, 1970. Zitrin, C. M., Klein, D. F., & Woerner, M. G. Behavior therapy, supportive psychotherapy, imipramine, and phobias. Archives of General Psychiatry, 1978, 35, 307-316. Zlutnick, S., Mayville, W. J., & Moffat, S. Modification of seizure disorders: The interruption of behavioral chains. Journal of Applied Behavior Analysis. 1975, 8, 1-12. RECEIVED: July 3, 1978; REVISED: July 18, 1978 FINAL ACCEPTANCE: August 7, 1978