Matching treatments to client problems not diagnostic labels: a case for paradigmatic behavior therapy

A new conception and subsequent taxonomy of clinical psychological problems

BACKGROUND

A taxonomy of the objects of study, theory, assessment, and intervention is critical to the development of all clinical sciences. Clinical psychology has been conceptually and administratively dominated by the taxonomy of an adjacent discipline - psychiatry's Diagnostic and statistical manual of mental disorders (DSM). Many have called for a 'paradigm shift' away from a medical nosology of diseases toward clinical psychology's own taxonomy of clinical psychological problems (CPPs), without being able to specify what is to be listed and classified.

MAIN TEXT

An examination of DSM's problems for clinical psychology, especially its lack of clinical utility, and a search for the essence of CPPs in what clinical psychologists actually do, leads to the proposal that: The critical psychological-level phenomenon underlying CPPs is the occurrence of 'problem-maintaining circles' (PMCs) of causally related cognitions, emotions, behaviours, and/or stimuli. This concept provides an empirically-derived, theory-based, treatment-relevant, categorical, essentialist, parsimonious, and nonstigmatizing definition of CPPs. It distinguishes psychological problems in which PMCs have not (yet?) formed, and which may respond to 'counseling', clinical psychological problems in which active PMCs require clinical intervention, and psychopathological problems which are unlikely to be 'cured' by PMC-breaking alone.

CONCLUSION

A subsequent classification and coding system of PMCs is proposed, and expected benefits to research, communication, and the quality of case formulation in clinical psychology are described, reliant upon a development effort of some meaningful fraction of that which has been devoted to the DSM.

Positive Behavior Support as a Model for Promoting Educational Inclusion

Positive behavior support (PBS) has been advanced as a model for effectively managing behavior in school settings and facilitating inclusive education. Numerous systems adaptations and administrative supports, however, are necessary for the successful application of PBS in the schools. This article identifies difficulties in the application of best practices within current school systems, and considers federal and state laws, school system organization, the roles of teachers and administrators, and other factors that are relevant for inclusive education. Issues pertinent to the application of PBS are discussed, and practical steps for achieving progress are recommended.

Interventions with Challenging Behavior of Persons with Developmental Disabilities: A Review of Current Research Practices

The published intervention research on the remediation of challenging behavior of persons with developmental disabilities was reviewed. A total of 179 studies over a recent 5-year period (1988 through 1992) were reviewed for adherence to certain standards of practice, including the use of functional assessment, function-treatment matching, level of intervention intrusiveness, monitoring of collateral behaviors, follow-up, and generalization. Results are presented with regard to each standard of practice and the relations among practices. The results largely support meaningful improvements in the state of the intervention literature since the time of several previous reviews. Areas of progress are noted and continuing deficits are discussed.

Functional Analyses of Challenging Behaviours of Two People with Intellectual Disability

Carers observed problem behaviours of two people with intellectual disability in natural settings. Data recorded on Antecedent-Behaviour-Consequence (A-B-C) charts were analysed quantitatively by calculating the relative likelihoods of each target behaviour occurring in different situations. Functional analyses were conducted, and individualised interventions were based on these. In one case, a client behaved differently in different situations. Interventions were introduced to teach the client to emit a different prosocial behaviour in each situation. The second client behaved similarly in two situations, suggesting that the behaviours were functionally equivalent for the client. The behaviours of both clients were interpreted as attention seeking behaviours as both antecedents and consequences involved the provision of attention by carers. However different interventions were used in the two cases, and were effective in reducing target behaviours both immediately and in follow-ups.

Cardiophobia: An Anxiety Disorder in Its Own Right?

Cardiophobic persons repeatedly present with complaints of chest pain and heart palpitations accompanied by fears of having a heart attack and of dying. They focus attention on their heart when experiencing stress and arousal, perceive its function in a phobic manner, and continue to believe they suffer from an organic heart problem despite repeated negative medical tests. To reduce anxiety, they seek continuous reassurance, make excessive use of medical facilities, and avoid activities believed to bring on symptoms. This article analyses the evidence for viewing cardiophobia as a phobic disorder in its own right rather than merely a problem of non-organic chest pain with some overlay of anxiety and depression. Despite some overlapping symptoms shared with persons who suffer from panic disorder, illness phobia, and extreme health anxiety, a number of central and defining features of cardiophobia are identified to differentiate cardiophobia from other anxiety disorders. An integrative model for understanding the origin and maintenance of cardiophobia (Eifert, 1990) is summarised and some treatment recommendations are derived from this model to target the central problems of persons with cardiophobia. Directions for future research are also discussed.

Psychological behaviorism and behaviorizing psychology

Paradigmatic or psychological behaviorism (PB), in a four-decade history of development, has been shaped by its goal, the establishment of a behaviorism that can also serve as the approach in psychology (Watson's original goal). In the process, PB has become a new generation of behaviorism with abundant heuristic avenues for development in theory, philosophy, methodology, and research. Psychology has resources, purview and problem areas, and nascent developments of many kinds, gathered in chaotic diversity, needing unification (and other things) that cognitivism cannot provide. Behaviorism can, within PB's multilevel framework for connecting and advancing both psychology and behaviorism.

Behavioural Analysis: Does It Matter?

Behavioural or, in more general terms, problem analysis is usually regarded as the prerequisite of behaviour therapy. In behaviour therapy research, however, problem analysis does not play a key role. Patients are usually assigned to treatment methods on the basis of clinical diagnosis. It could be assumed that the lack of attention to the patient's individual characteristics should lead to poorer therapy outcome results. However, empirical data of a project reviewed in this paper in fact showed that assigning patients to standard treatment merely on the basis of clinical diagnoses provides results equal to or even better than those of optimized individual therapy strategies. Two premises of problem analysis were therefore tested. It could be shown that therapists would diagnose different problem conditions not only for patients with different types of phobia, but also, as expected, for patients with identical diagnoses. However, this did not—as would be expected according to the second premise of problem analysis—result in choosing different individual therapy strategies. One reason for these findings could be that behaviour therapy research has been able to provide treatment programs that have been differentiated and gradually optimized for specific diagnostic groups. To decide on the application of these treatment programs, clinical diagnoses are necessary. It is suggested that clinical diagnosis and problem analysis should be complementary. An integrative model is suggested.

Positive Association of Child Involvement and Treatment Outcome Within a Manual-Based Cognitive-Behavioral Treatment for Children With Anxiety

Ratings of child involvement in manual-based cognitive-behavioral treatment for anxiety were associated with the absence of primary anxiety diagnosis and reductions in impairment ratings at posttreatment for 59 children with anxiety (ages 8-14 years). Good-to-excellent interrater reliability was established for the independent ratings of 237 therapy sessions, and strong psychometrics were established for the involvement measure. Child involvement at midtreatment, just prior to in vivo exposures, was positively associated with treatment gains but earlier involvement was not. Increased involvement during therapy (positive involvement shifts) may provide a useful index of change and may also predict outcomes. Involvement was not associated with client demographics or diagnostic category. Implications for treatment and measurement of psychotherapy process within manual-based treatments are discussed.

When syndromal similarity obscures functional dissimilarity: distinctive evoked environments of externalizing and mixed syndrome boys

This research examined how syndromal approaches to assessment can obscure differences between children in the quality of their social interactions. Mixed boys (high for externalizing and internalizing problems) showed heterogeneity in the responses they evoked from others: For one subgroup, aggression and withdrawal evoked aversive responses from others, and even prosocial behavior evoked hostile peer responses; for the other, aggression and withdrawal evoked positive peer responses. Externalizing boys also showed heterogeneity in the patterning of their evoked responses. Within-group heterogeneity was not explained by boys' syndrome scores but was linked to their reactions to specific antecedent events. The results illustrate how a contextualized analysis of behavior can reveal distinctive social interactional patterns that underlie similar overall rates of problem behaviors.

Retrospective self-reports of therapist flexibility in a manual-based treatment for youths with anxiety disorders

Evaluated retrospective therapist ratings of the flexibility used when applying the procedures and strategies prescribed in the treatment manual. Flexibility ratings were collected from 18 therapists who had treated 148 children with anxiety disorders (ages 9 through 13). Analyses revealed strong reliabilities for a flexibility questionnaire and that flexibility was used by therapists; however, significant relations between therapist-rated flexibility and treatment outcome were not found. Discussion focuses on the role of flexibility in manual-based psychological treatments and future directions for study.

Influence of Emotional Intensity and Frequency of Positive and Negative Events on Depression

This study replicates and extends aspects of psychological behaviorism's analysis of the role of positive and negative events in depression. As a first step, four pilot studies were conducted to develop a positive and negative events rating scale. This measure assesses the emotional intensity of positive and negative events (i. e., the strength of the positive or negative emotional response produced by the event) as well as the frequency of occurrence of the positive and negative events. A sample of 1089 college students then completed the Beck Depression Inventory and this new life events measure. Consistent with psychological behaviorism's analysis that emotional intensity involves a personality process and frequency an environmental process, the results showed that the emotional intensity of positive and negative events as well as the frequency of positive and negative events had independent roles in the prediction of depression (i. e., each of the four variables predicted depression after controlling for the other three). In addition, the results supported the personality and environmental subtypes of depression as specified by the theory. Suggestions are made for how subsequent research can test more explicitly this theory of depression.

Valuable, but not maximal: it's time behavior therapy attend to its behaviorism

The field of behavior therapy is not in touch with itself in terms of its overarching behaviorism. Many erroneously consider its basic behaviorism to have been radical behaviorism and continue to look to develop behavior therapy (including behavior analysis and behavioral assessment) within that framework. But that approach turns out to be much less than maximal because there is a more advanced, better developed behaviorism within which to conduct and project the field. There is much that behavior therapy is not doing in practice and research because it is not making full use of that behaviorism foundation.

"Cleaning-up cognition" in triple-response fear assessment through individualized functional behavior analysis

Improvements in behavioral assessment spurred by the triple-response concept have been overshadowed by a preoccupation with content of assessment and a lack of regard for the context of assessment. The aims of this article are to (a) clarify the imprecise use of the verbal-subjective-cognitive mode and to reinterpret cognitive events based on evidence and methods derived from clinical behavior analysis, (b) discuss the limitations of the triple-response assessment framework, and (c) suggest an alternative functional idiographic approach to assessment and treatment that may direct attention toward behavior relations understood functionally within the context of environmental contingencies; an approach that once was the hallmark of behavior therapy and the basis for therapeutic interventions.

How can behavior therapy treat the same disorder with different techniques and different disorders with the same technique?

Traditional psychiatric diagnostic labels fail to differentiate patients on the basis of the function of the problematic behavior because such labels do not specify the nature of the individual's behavioral deficits or excesses. In contrast, behavior therapy strives to classify clinical phenomena based upon their functional characteristics guided by theoretical considerations. Yet, the anomaly exists that for a given disorder there is frequently a long list of suggested treatments that all have some degree of demonstrated efficacy. Similarly, there are a number of apparently different disorders that have been successfully treated with the same general technique. The implications of this paradox will be discussed in the context of treatments for depression. Our recent work suggests that different types of depression respond to different interventions depending on whether interventions match or do not match those types.

Tailor-made and standardized therapy: complementary tasks in behavior therapy. A contrarian view

In medicine, decisions about treatment selection are mainly based on clinical diagnoses, whereas behavior therapists have typically assumed that it is necessary to tailor treatments based on individual problem analyses. However, various studies (including our own using patients with phobic anxieties) have failed to demonstrate an advantage for this procedure. At least for some disorders, clinical diagnosis appears to be a relevant and sufficient criterion for treatment selection. A process model is presented that views treatment individualization and standardization as complementary strategies. Although the application of techniques should be standardized as much as possible, translating general method rules into a concrete intervention for a particular person will remain a task of individualization. Individualization will also remain necessary for the other primary task of the therapist: promoting basic patient behavior that is conducive to treatment and a precondition for the successful application of interventions.

More theory-driven and less diagnosis-based behavior therapy

Individualized treatment based on a functional analysis of problem behavior used to be considered a hallmark of behavior therapy. Yet the relative success of recently developed treatment manuals for DSM-defined disorders has cast doubts as to whether treatment individualization is really necessary. This article evaluates some of the relative merits of assessments and manualized treatments based on DSM categories and discusses data that indicate when a protocol treatment approach is sufficient and when it is not. Finally, a theory-driven approach to conducting behavior therapy is proposed as a way to complement individualized and manualized treatments. This approach is illustrated by presenting a model-based assessment and treatment approach to overcome excessive heart-focused anxiety (cardiophobia).

Manual-based treatments: the clinical application of research findings

In addition to their now required use in controlled outcome studies, treatment manuals offer important advantages for clinical practice. Manual-based treatments are often empirically-validated, more focused, and more disseminable. They are useful in the training and supervision of therapists. Criticisms of manual-based treatments center on five main themes: they are conceptually at odds with fundamental principles of cognitive-behavioral therapy; they preclude idiographic case formulation; they undermine therapists' clinical artistry; they apply primarily to research samples which differ from the patients practitioners treat; and they promote particular 'schools' of psychological therapy. This paper emphasizes the inherent limitations of idiographic case formulation. It is argued that treatment manuals are consistent with an actuarial approach to assessment and therapy, which, on average, is superior to individual clinical judgment. Available data suggest that standardized treatment is no less effective than individualized therapy. Manual-based treatment demands therapist skill in its implementation. In suitably chosen therapists these skills are more a function of training than amount of clinical experience. Treatment manuals are likely to encourage a pragmatic approach to therapy and should not discourage clinical innovations.

Multi-dimensional child behavior therapy in the treatment of medically-related anxiety: a practical illustration

This paper provides a practical illustration of a four-component model for conducting child behavior therapy. It describes the treatment of a 7-year-old boy, whose fears and anxieties regarding impending surgery were interfering with his sleep, concentration, and academic performance. Such childhood difficulties are encountered in primary care medical settings and it is likely that mental health practitioners will be increasingly called upon to treat them. The model provides a framework for selecting, organizing, and implementing strategies based on behavioral principles, with the goal of: (a) reducing the probability of the behavior by ecological change; (b) manipulating the immediate consequences of the problem behavior; (c) facilitating acquisition of new, more adaptive behaviors; and (d) long-term prevention by remedying fundamental deficits. The strategies used for each goal and the success of the overall intervention are described.

Unifying the field: developing an integrative paradigm for behavior therapy

The limitations of early conditioning models and treatments have led many behavior therapists to abandon conditioning principles and replace them with loosely defined cognitive theories and treatments. Systematic theory extensions to human behavior, using new concepts and processes derived from and built upon the basic principles, could have prevented the divisive debates over whether psychological dysfunctions are the results of conditioning or cognition and whether they should be treated with conditioning or cognitive techniques. Behavior therapy could also benefit from recent advances in experimental cognitive psychology that provide objective behavioral methods of studying dysfunctional processes. We suggest a unifying paradigm for explaining abnormal behavior that links and integrates different fields of study and processes that are frequently believed to be incompatible or antithetical such as biological vulnerability variables, learned behavioral repertoires, and that also links historical and current antecedents of the problem. An integrative paradigmatic behavioral approach may serve a unifying function in behavior therapy (a) by promoting an understanding of the dysfunctional processes involved in different disorders and (b) by helping clinicians conduct functional analyses that lead to theory-based, individualized, and effective treatments.

Commentary: the cognitivist oversell and comments on symposium contributions

During the 1980s the behavior therapy movement was infiltrated by cognitivists, people who believe that all maladaptive fears are based on wrong beliefs and all can be overcome by cognitive correction. This article asserts and defends the following propositions: (1) There are numerous maladaptive fears demonstrably immune to cognitive correction but removable by deconditioning. (2) These conditioning based fears constitute the majority, but there are also some based on mistaken beliefs. (3) Proponents of the cognitivist viewpoint have overrated the outcomes of cognitive therapy, because they have not realized the fact that conditioned anxiety is often inadvertently weakened by simultaneous competing emotions (nonspecific therapeutic effects). (4) This overrating led to the fiction that cognitive-behavior therapy is behavior therapy's best resource to overcome non-psychotic depression, a fiction that was exposed by cognitive-behavior therapy's inferior performance in the National Institute of Mental Health's Collaborative Research Project. (5) There is data to suggest that use of the full resources of behavior therapy would have produced notably superior results. The commentary concludes with comments on the other contributions to the symposium, From Behavior Theory to Behavior Therapy.

Personality theory, abnormal psychology, and psychological measurement. A psychological behaviorism

Behaviorism, because it has not had a theory of personality, has been separated from the rest of psychology, unable in large part to draw from or contribute to it. Traditional psychology has not had a theory of personality that says what personality is, how it comes about, or how it functions. An antagonism has resulted that weakens rather than complements each tradition. Psychological behaviorism presents a new type of theory of personality. Derived from experimentation, it is constructed from basic theories of emotion, language, and sensory-motor behavior. It says personality is composed of learned basic behavioral repertoires (BBRs) that affect behavior. Personality measurement instruments are analyzed in terms of the BBRs, beginning the behaviorization of this field and calling for much additional research. These multilevel developments are then basic in psychological behaviorism's theory of abnormal behavior and of clinical treatment. The approach opens many new avenues of empirical and theoretical work.

Cardiophobia: a paradigmatic behavioural model of heart-focused anxiety and non-anginal chest pain

Cardiophobia is defined as an anxiety disorder of persons characterized by repeated complaints of chest pain, heart palpitations, and other somatic sensations accompanied by fears of having a heart attack and of dying. Persons with cardiophobia focus attention on their heart when experiencing stress and arousal, perceive its function in a phobic manner, and continue to believe that they suffer from an organic heart problem despite repeated negative medical tests. In order to reduce anxiety, they seek continuous reassurance, make excessive use of medical facilities, and avoid activities believed to elicit symptoms. The relationship of cardiophobia to illness phobia, health anxiety, and panic disorder is discussed. An integrative psychobiological model of cardiophobia is presented which includes previous learning conditions relating to experiences of separation and cardiac disease; deficient and inappropriate behavioural repertoires which constitute a psychological vulnerability for cardiophobic problems; negative life events, stressors, and conflicts in the person's present situation that trigger and contribute to the symptoms; current affective, cognitive, and behavioural symptoms and their stimulus properties; and genetic and acquired biological vulnerability factors. Finally, recommendations for the treatment of cardiophobia are derived from the model and areas of future research are outlined.

The triple response approach to assessment: a conceptual and methodological reappraisal

Despite its positive effects on the increased use of multiple assessments and improved assessment validity, the triple-response concept has led to some conceptual and practical confusion. This is mainly due to two problems: (1) a confounding of the content and method of assessment; and (2) an imprecise and vague use of the 'verbal-subjective mode' which has been expanded to include cognitive elements since the introduction of cognitive-behavioural theories and treatments. A new matrix is proposed that clearly distinguishes content and method of assessment. It also defines a separate cognitive/information-processing content area and introduces affect as an additional content area. Thus, four content areas are suggested: behavioural, physiological, cognitive, and affective, which can be measured in three different ways: by means of self-report, observation, and instruments or technical equipment. We point out the implications of these changes for (1) a more appropriate selection of assessment procedures and outcome measures in clinical research; (2) a more adequate individualization of treatment through matching individual response profiles to specific treatments; and (3) an improved understanding of the interrelationship between behavioural, physiological, cognitive, and affective processes in anxiety and depression. Finally, we suggest that the lack of agreement between measures of physiological, cognitive, behavioural and affective changes in some studies may be as much a reflection of the lack of agreement arising from spurious sources of variance within content areas as it is a reflection of the operation of different processes and systems.