The progressive development of vocal responses in a 72-year-old male schizophrenic patient with a history of 48 years of complete mutism is described. The emergence of recognizable words and phrases is closely linked to the application of a range of behaviour modification procedures. The programming of generalization of treatment effects across individuals and across settings is also described.

This is a series of short invited contributions from therapists and research workers who have volunteered to answer the following question: “If your fairy godmother were to wave her magic wand and give you an immediate answer to a question or questions, without having to do the relevant research, what would you most like to know?”

In recent years, I have become increasingly interested in the question of self-initiated behavior change or the process by which individuals come to change their own behavior without the assistance of external treatment programs or formal intervention techniques. Based on a preliminary study of New Year's Resolutions as a framework within which to study self-initiated change (Marlatt and Kaplan, 1972), my interests have recently focused on addictive behaviors as an arena of investigation. Specifically, I am interested in studying the process of self-initiated change in individuals who attempt to modify or discontinue their use of alcohol and tobacco.

Sixty-four patients suffering from primary major depressive illness from hospital and general practice clinics were randomly allocated to three treatment groups: drug of choice, cognitive therapy and a combination of the two. Looking at end-point scores on two rating scales of depression, there was no difference in the proportion of responders to the three treatments in the hospital group, but in the general practice, significantly less patients treated with drugs improved. Looking at group mean changes from baseline, all groups improved significantly on most variables except for the general practice drug group. The potential value of cognitive therapy for therapy-resistant hospital patients and for general practice patients is discussed.

Stimuli related to blood, injury and illness (BII) evoke a unique psychophysiological response, with signs of both sympathetic and parasympathetic arousal. Fainting, which occurs commonly in BII phobias, may represent the extreme of this reponse pattern. Data from the assessment and cognitive–behavioural treatment of a BII phobic subject are presented. At assessment the patient showed a massive bradycardia and near loss of consciousness on exposure to blood. This responded rapidly to treatment, although with some desynchrony between subjective and autonomic responses.

A case of depression related to justifiable homicide was successfully treated with a combination of imaginal exposure and cognitive restructuring. No previous report on comparable cases has been found in the behavior therapy literature.

An 11-year-old boy who suffered panic and anxiety during separations from his mother was successfully treated by in vivo systematic desensitization in 10 sessions. His mother was actively involved in the treatment. The manifestations of separation anxiety in school had disappeared by the end of treatment. No further problems were shown at 3-month and 15-month follow-up. The case is discussed in the context of the behavioural treatment of school refusal.

Despite much evaluative research on alcoholism services, the effectiveness of treatment is still an unsettled matter. The inconclusive results of empirical studies comparing different methods and extensive statistical analysis of their findings do not point a clear way forward for future evaluative efforts. Using a sample of follow-up data from an evaluation study of three residential units (not considered here) this report sets out to demonstrate that dynamics in individual drinking patterns make surveys of studies which have applied different outcome criteria very unreliable. The feasibility of the single controlled study in evaluation is also questioned and attributed to the inappropriate use of a “quality control” model. An alternative approach which avoids the methodological and practical difficulties of the conventional design examines the use made of treatment by clients. A more realistic account based on individual cases is urged which recognizes that seeking help for a drink problem is only one of a number of ways in which the treatment episode fits into the lives of problem drinkers. Some observational evidence is presented and a reinterpretation of Costello' successful and unsuccessful treatment groupings is made in support of a treatment-use approach to evaluation.

Therapist instructions and patient expectations appear to yield good treatment results with placebo pills. In this study the smoking cessation rate was studied after administration of a placebo smoking withdrawal chewing gum. Two groups from two factories were recruited and given instructions that they were to receive an effective chewing gum for smoking cessation. One group was told that the gum contained nicotine while the other was told that it worked through its special taste. At follow-up periods of 1, 3 and 8 weeks those given the nicotine instructions were superior to those given the taste instructions, although not significantly so. When nicotine dependence was taken into consideration it was found that the more nicotine dependent half of the subjects responded significantly better to the nicotine instructions as compared to the low dependent subjects.

This paper describes in detail the treatment of a 6-year-old elective mute who had not spoken either at playgroup or school since the age of 3½ years. Treatment was carried out in school using an approach which combined both stimulus fading and positive reinforcement. At the end of a 7-month treatment period she was able to read aloud in class, convey messages and converse spontaneously. This behaviour was still being maintained 9 months after treatment ended.

Four pedophiles, one sado-masochist, and one rapist were treated by varying different aspects of a single paradigm of masturbatory conditioning. In the basic paradigm, subjects masturbate to ejaculation while speaking their fantasies aloud. Weekly blocks of five trials with a deviant theme are alternated with weekly blocks where the theme is nondeviant. Evaluation sessions to assess levels of response to deviant and nondeviant slide stimuli are typically conducted later in each treatment day. The usual result is an increase in nondeviant arousal with a concomitant decrease in deviant arousal.

Variations in the masturbation procedure included shortening the treatment week from 5 days to 2 or 3, alternating themes on a daily rather than weekly basis, and omitting the use of deviant imagery. In the evaluation sessions variations included the preparation of individually tailored audiotaped fantasies precisely expressive of the subjects' interests, the use of videotaped simulations of rape, assault, and consenting intercourse, and obtaining numerous measures of the subjects' cognitive changes during the treatment process. All six subjects showed the effect of decreasing their deviant sexual arousal and increasing their nondeviant arousal. The results were discussed from various viewpoints employing a cognitive-behavioral model.

The review evaluates the contribution which behaviour modification has made to the outstanding behavioural problems in dentistry: the treatment and management of the fear of routine conservation; the prevention of tooth and gum disease; the management of acute operative pain and chronic facial pain.

Investigations of dental fear and operative pain have been limited perhaps too much to patients, especially children, who attend for dental treatment. Behaviour modification has yet to help adequately those patients who avoid dentists and who may be the most acutely afraid and the most intolerant of dentistry. More adequate contributions here could be made if behavioural sciences were much more satisfactorily taught in dental undergraduate and postgraduate curricula than at present.

Useful contributions to preventive dentistry have already been made. The successful treatment of chronic facial pain will have to depend, at least in part, on a more adequate understanding of the psychophysiological mechanisms of the complaint. The nature of the placebo effect in treatment here also needs to be more thoroughly understood.

Correlations were evaluated between personality factors, as measured by the EPI, and treatment outcome in obsessional–compulsive patients. The results suggest that extraverts have a slightly better outcome than introverts when treatment is carried out with a time-limit. After treatment to criterion extraversion failed to correlate with outcome. The Neuroticism scale (N) correlated with assessment variables before treatment as well as after. There was, however, an indication that high N scores were predictive of elevated anxiety ratings after treatment. None of the results applied to the sub-group taking clomipramine at the time of assessment.

The known physiological and cognitive characteristics of vasodepressor syncope were accounted for in the development of an effective multimodal behavioral treatment for recurrent injury-scene-elicited fainting. Skeletal muscle tensing was employed as an immediate coping response to prevent fainting in situ, while cognitive–attentional retraining with graded exposure was employed to modify maladaptive cognitions.

Behavioural psychotherapy has many roots, and experimental psychology is but one of many “idols of origin” which is in any case largely ignored by behavioural practitioners. The conditioning model of neurosis has shortcomings, and cognitive explanations alone are not satisfactory. It may be necessary to think in terms of failed extinction of phobias and rituals rather than of enhanced acquisition. Aetiological theories need not be related to effective treatment, nor are they necessary for clinicians to carry out successful behavioural treatment. For therapists, paradigms are more useful when derived from clinical experiments rather than from the laboratory. A critical task concerning treatments to reduce anxiety is to investigate those parameters which decide when exposure will be habituating and when it will be sensitizing. To this end, analogue research is less relevant than clinical experiments whose results can be used directly by clinicians. Ten theoretical problems with exposure are noted.

The demand for behavioural psychotherapy exceeds the supply of therapists. Paraprofessionals and self-help methods can help to bridge the gap, while preventive measures may prevent the development of some pathology. Most clinical psychologists and psychiatrists are overqualified merely to deliver behavioural services; there is no evidence that such qualifications add to effectiveness, though they are invaluable for research and teaching.

Behaviour therapists are using psychophysiological measures to an increasing extent for evaluation of treatment outcome. The main areas of use which are discussed here comprise measures and concepts of treatment of phobic anxiety and clinical application of biofeedback procedures. Finally, a brief summary of measures of sexual arousal is given at the end.