Evidence is now accumulating for cognitive therapy as a promising treatment for depression. However, there is as yet little indication as to how it achieves its effects. The paper addresses this issue as it relates to the immediate impact of therapy, the achievement of change over the course of treatment as a whole, and the maintenance of improvement and prevention of relapse.

In the most recent edition of the Annual Review of Behavior Therapy (Franks et al., 1982) the point is made that behavioral assessment has moved simultaneously in two different directions. In one direction we see the heartland of assessment being entered via a more basic concern with the reliability and validity of behavioral assessment procedures. In the other direction we observe behavioral assessment to be taking a wider cut, expanding into the arena of cognitive-behavioral assessment. While the reasons for the reliability and validity studies may be apparent (i.e. to assure psychometric credibility), some have questioned the soundness and legitimacy of our excursion into the “mind”.

The use of benzodiazepines during behavioural treatment is frequently encouraged. However, this review of clinical studies failed to find any beneficial effect of the drugs on therapy outcome. An examination of drug effects on different response variables revealed conflicting results concerning behaviour, i.e. approach. Whilst the anxiolytic nature of the drugs is well established in results on autonomic measures in the absence of the phobic object, they had no effect during its presence. Verbal report data again favour administration of benzodiazepines but studies on cognitive effects of long-term use are still to come. It is recommended that the use of this group of drugs as an adjunct to behaviour therapy should be discouraged.

For some years now, working with long-stay populations such as the mentally handicapped and elderly mentally infirm has been a “Cinderella” area with difficulties in attracting high quality staff and resources. This has resulted in poor quality of care. There may be many reasons for the relative lack of interest shown by professionals in the problems of long-term care, but two stand out as potentially important:

(a) the rate of client behaviour change and

(b) the permanency of client behaviour change.

Within the areas of out-patient neuroses and other similar nonchronic problems, it is often expected that change can be brought about relatively quickly by trained therapists (cf. Marks, 1981a, b). With chronic problems, however, the situation is quite different. Usually change is only brought about slowly, if at all.

Secondly, with an out-patient population, given new ways with which to cope with their problems, we hope that somehow the natural contingencies will “trap” (Baer and Wolf, 1970) the new repertoires. The client gets better, stays better, and does not come back. From our own experience of this type of work, the situation is rarely so sanguine and with chronic populations, there isn't usually even much reason for hope. We are all too familiar with changes occurring and then the group of clients begins rapidly to slip back to where they started from (or beyond!). We have become accustomed to blaming poor motivation, inadequate training, organizational variables, Hawthorne effects, and so on. Almost anything except ourselves.

In this paper, we look at some failures and some relative successes in achieving desired change in long-stay institutions, and ask the questions “How?” and “Why?”. It should be obvious before we go any further that we do not have definite answers, but the questions are still worth asking. Work with long-stay populations can be extremely exasperating and demanding, but appeals to abandon the large institutions where such groups reside are defeatist.

This study reports an evaluation of the effectiveness of a communitybased treatment for adolescents with social difficulties. In an earlier study (Jackson and Marzillier, 1982) we described how a therapeutic youth club was set up and subjected to preliminary evaluation. In this study we report on findings from a controlled evaluation in which adolescents with social difficulty were randomly assigned to two conditions, the therapeutic youth club and a waiting list control condition. Change was assessed on a range of measures including self report measures of social problems, a conversation test, social diaries, a self-esteem inventory and parent questionnaires. While the youth club proved to be a success in practical terms, the results of this study failed to demonstrate its superiority to waiting list control procedures. The results suggest that further evaluation of this type of delivery of therapeutic services is necessary.

Self-controlled relaxation training was combined with assertion training to treat a 22-year-old woman with a 2-year history of chronic headaches following a traumatic injury to her head and neck. There was a substantial drop in the frequency of headaches and medication use with the introduction of both components of treatment. Gains were maintained at a 6-month follow-up. The case is presented in the context of a general treatment plan for modification of traumatic headaches. The plan combines a focus on both antecedent (i.e. environmental stress) and consequent (i.e. pain behavior reinforcers) events as possible factors influencing chronic post-traumatic head pain.

Seventeen female agoraphobic patients were treated in three groups by in vivo exposure over 10 sessions. Dependent measures comprised an assessment using a behavioural hierarchy and an assessment of subjective anxiety. Pre-treatment assessment of the number of problems and fears, interpersonal variables and personality as measured by the E.P.P.S. were also carried out. Correlational evidence was sought of relationships between pre-treatment assessment variables and treatment outcome. It was found that low scores for “Aggression” on the E.P.P.S. and the rated ability of designated significant others to manage the agoraphobics' behaviour successfully were predictive of good outcome. Possible reasons for and implications of these findings are discussed.

Twenty-eight young adult out-patients with social interaction difficulties were assessed in an attempt to measure the three variables of social performance, social anxiety and self-esteem. A non-clinical comparison group comprising 32 subjects from a university subject panel were assessed on the same measures. There were significant differences in the patient and non-clinical group on anxiety and esteem, however, some patients scored well within the range of the non-clinical group and had adequate social performance. The patient group was characterized by high social anxiety which was more often related to low self-esteem than adequacy of social performance. We concluded that interaction difficulties are multiply determined and social performance, social anxiety and self-esteem are potentially independent variables. The implications of this for therapy were discussed.

Some aspects of the literature on the aetiology and classification of faecal soiling are reviewed briefly, and behavioural treatment approaches described. A case study—a 4-year-old girl with faecal soiling—is presented using a behavioural strategy. The case highlights the clinical importance of systematic fading of treatment contingencies, and a detailed analysis of the presenting problem in more recalcitrant cases.

In a recent paper Eysenck asked why conditioned responses show incrementation. In several publications he has provided the outline of an answer, which he has used in proposing a theory of the development of neuroses. It is suggested here that in the way he sets out the problem and in the development of his theory of incubation he overstates the applicability of the theory, incorporates questionable assumptions, and omits thorough consideration of competing accounts. The theory focuses on classical conditioning to the near-exclusion of other processes of behaviour change, ignores the consequences and social context of neurotic behaviour, and provides an incomplete discussion of the temporal patterning of relevant events. By taking a view which is broader in terms of psychological processes, environmental events, and temporal sequences, alternative models of the development of phobias can be offered. These involve classical and operant conditioning, and observational and informational learning.

A multiple baseline design was used to investigate the efficacy of a verbal feedback procedure in increasing the performance of pressure relief exercises in a spinal injury patient. Results showed that the procedure resulted in substantial increases in rates of lifting, with concommittent improvements in pressure sores. At 2½ months follow-up the patient's skin was still clear, but it is unlikely that this can be attributed to continued good performance of pressure-relief exercises.

In a previous study, Ascher and Turner (1980) accounted for differential results of two types of paradoxical intention administrations by suggesting that in one case subjects were encouraged to follow the explicit demands of the instructions which adversely effected performance. It was the purpose of the present study to determine the effect of employing a procedural component to emphasize the explicit demands of paradoxical intention instructions. Two groups received identical paradoxical intention instructions. One was required to present “objective” data along with their subjective sleep report—the other had only to present the subjective data. Two control groups were included in the design which employed sleep onset latency as a dependent variable. As hypothesized, results indicated that the paradoxical intention group submitting “objective” data reported latencies which were significantly longer than those of the no-treatment control, while the paradoxical intention group that was not required to submit “objective” data reported sleep onset latencies which were significantly shorter than those of the no-treatment control group.

To determine the role played by peripheral autonomic arousal in reducing avoidance behavior, 16 spider phobics were randomly assigned in a double blind fashion to either a propranolol (a drug which blocks beta-adrenergic activity) or to a placebo group. Subjects in the propranolol group performed significantly better than those given placebo although the magnitude of the effect was small. All subjects later received 90 min of participant modeling. They performed significantly better with participant modeling and there were no differences between the groups in their final performance. Implications of the data for theories of fear and avoidance behavior are discussed.

Fourteen long-stay psychiatric patients on a token economy ward were divided into two groups to assess whether the giving of tokens affects staff–patient interaction. Group one received contingent praise and tokens; Group two contingent praise and non-contingent tokens. The length of time and frequency of nurse–patient interactions was measured in both groups over a 5-month period. Several significant differences between groups were found. The giving of contingent tokens affected nurses' behaviour in the following ways.

Assertiveness skills training is frequently a component of current behavioral treatments of alcohol abuse. Although the results of several uncontrolled and controlled evaluations generally suggest the efficacy of using assertiveness training, methodological problems in this research prevent firm conclusions. Thus, before conditions under which assertive skills training with alcohol abusers are most effective can be delineated, additional evaluation correcting these problems is needed.

This study tested the hypothesis that operant response suppression strategies function more effectively when predetermined stimulus context variables are explicitly manipulated as “intervention facilitators”. Specifically, the self-stimulatory “book flipping” behaviours of a young autistic child were subjected to a brief immobilization contingency both in the presence and the absence of a contrived Sd stimulus comparison factor. An ABCBC multiple baseline across settings analysis of the subject's self-stimulatory responding under these conditions revealed a clear enhancement of response suppression effects when the above stimulus control feature was incorporated into the strategy. Results are discussed in light of contextual vs. absolute criteria for defining behaviour as undesirable, and the implications of stimulus control knowledge for suppression programming in general are explored.

Seventeen chronic pain patients at a rehabilitation center participated in an investigation of the effects of applied relaxation on chronic pain. The experimental group received regular rehabilitation treatment plus intensive training in applied relaxation. One control group received the regular rehabilitation treatment only, while another control group consisted of patients waiting for treatment. Results indicated that the applied relaxation group did significantly better than the control group(s) on measures of subjective pain, medication intake, activity, and overall evaluation of the treatments. This suggests that applied relaxation can be a valuable addition to chronic pain treatment programs.

Recent years have seen a growing concern in the psychometric properties of behavioural assessment procedures. The present study addresses itself to the question of the possible reactivity of the behavioural assessment of fear, a situation predicted both by the experimental extinction and incubation models.

In a single case study it was found that a 50% reduction in self-reported fear was associated with the behavioural assessment, though there was no evidence of a reduction of fear associated with “verbal therapy”. It is suggested that: (i) behavioural assessments of fear are reactive; (ii) that they produce a reduction in fear; and (iii) that this is consistent with an extinction model.