Commentary: the cognitivist oversell and comments on symposium contributions

Cognitive versus behavior therapy: processes of change in the treatment of obsessive-compulsive disorder

BACKGROUND

Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up.

METHODS

We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first.

RESULTS

Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions.

CONCLUSIONS

These results suggest that reduction of compulsions is the process through which both ERP and CT affect change.

Toward a dimensional and psychometrically-informed approach to conceptualizing psychopathology

Most modern research on psychopathology is framed by the categorical model of mental disorders embodied in the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). Nevertheless, the categorical model of the DSM is incompatible with robust empirical observations about psychopathological variation, such as the tendency for multiple, putatively distinct mental disorders to occur in the same persons. The goal of this invited essay is to outline a potential alternative to the DSM's categorical approach: a dimensional and psychometrically-informed approach to conceptualizing and studying psychopathology. We discuss the advantages of the dimensional approach, some modern statistical technologies that can be recruited in the service of the dimensional approach, and ways of integrating the dimensional approach with a behavioral approach to psychopathology assessment and research.

The transfer of avoidance evoking functions through stimulus equivalence classes

Recent research in the area of stimulus equivalence suggests that transfer of function via members of stimulus equivalence classes may have relevance to human emotional responding and the development and generalization of certain psychological disorders. This study investigated the transfer of avoidance evoking functions through equivalence classes. Eight subjects were trained in the necessary relations for two-four member stimulus equivalence classes to emerge. Next, using an on-baseline classical conditioning procedure, one member of one class was paired with shock while one member of the other class was presented without shock. Then, while subjects engaged a key-press task, a differential, signalled avoidance task was introduced wherein shock was avoided if a response occurred to the stimulus previously associated with shock. The remaining stimuli from both classes were then presented. The behavior of all eight subjects showed the differential transfer of the avoidance evoking function. The clinical and theoretical implications of the results are discussed.

"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.

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).

One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions

The purpose of this study was to investigate the effectiveness of a single session of cognitive restructuring in a sample of phobic dental patients. Fifty-two patients were randomly assigned to one of three conditions: cognitive restructuring (modification of negative cognitions), provision of information (about oral health and dental treatment), and a waiting list control condition. Both interventions maximally lasted one hour. In comparison with the waiting list control condition and the information intervention condition, the cognitive intervention condition not only showed a large decrease in frequency and believability of negative cognitions, but also exhibited a clear decline in dental trait anxiety. Analysis at a follow-up of one year demonstrated a further, drastic reduction in dental anxiety in both intervention conditions, wherein the difference among these conditions was not maintained. It is concluded that it is possible to obtain substantial reductions of dental trait anxiety through a single session of cognitive restructuring. Nevertheless, repeated exposure to the dental situation seems necessary for a further reduction of anxiety.

Matching verbal repertoires: understanding the contingencies of practice in order to functionally communicate with clinicians

The low utilization rate of empirically proven treatment techniques, the lack of adequate training being received by practitioners in such techniques, and the systemic resistance within the APA to changes designed to increase the dissemination of and support for empirically validated psychological service delivery lead to one conclusion: changes need to be made to increase the knowledge of and use of empirically supported treatment techniques. Such changes are unlikely to come from traditional psychology organizations. This article focuses on how scientist-practitioners can increase both the knowledge base and the utilization rate of empirically validated treatments by practitioners through understanding the contingencies under which practitioners must operate.

Remedying the Achilles heel of behavior research and therapy: prescriptive matching of intervention and psychopathology

Recent calls for eclecticism in clinical practice have been fueled by the putative limitations of behavioral techniques in treating a variety of psychological problems. However, calls for such integration do not appear to be justified for two related reasons. First, the precise conditions under which behavioral interventions are and are not effective have not yet been adequately delineated. Consequently, rejection of behavioral interventions in favor of relatively indiscriminate application of cognitive strategies is premature. Second, behavior therapy has as its hallmark a thorough grounding in inductive empiricism, while cognitive/dynamic theories are wholly based in deductive rationalism. As a result, wholesale acceptance of alternative theories and techniques by behaviorists is both inconsistent and retrogressive. Cognitive interventions have their place, but only when cognitive distortions have been specifically identified. Therefore, refinement of behavioral treatments into prescriptive interventions is warranted. The parameters of prescriptive behavior therapy are described in this paper.

Behavior and cognitive therapies in France: an oral history

Interviews were conducted with French psychologists and psychiatrists among those responsible for the evolution of behavioral and cognitive therapies in France. Their views are combined with information gathered from the literature to trace the history of French behavioral and cognitive therapies from their 19th century clinical precursors, through the 20th century progression from Pavlovian research to current therapeutic trends. Cultural factors favorable and unfavorable to their dissemination are discussed, as are the strategies that have been adopted by the French Association of Behavior and Cognitive Therapy to enhance its public and professional image. Particular emphasis is given to the role of an institutional context dominated by psychoanalysis.

Pain ameliorating effect of eye movement desensitization

This study explores the efficacy of eye movement desensitization and reprocessing (EMD/R) in the management of acute pain induced by hand exposures to ice water. Thirty participants were randomly assigned to one of the following interventions: (a) eye movement desensitization and reprocessing, (b) eye movement desensitization with music (EMD/M), and (c) control. The EMD/R participants focused on negative experiences associated with exposure to ice water, generated positive self-talk, and diverted their attention away from pain by focusing on a rapidly moving light on a monitor. The EMD with music group received eye movement desensitization coupled with preferred music. Repeated measures univariate and multivariate analysis of covariance was used to analyze the data. Results indicated that both procedures alleviated participants' pain to a similar degree and significantly more than the control, P < 0.05.