Behavioral Psychotherapy Research Paper

BT and CBT interventions have not always enjoyed such valued status. For example, in a debate conducted during the late 1960s at the University of Illinois between Leonard Ullmann (a behaviorist) and Charles Patterson (a distinguished Rogerian therapist and writer), the latter described BT as only a “passing fad.” When we first began using BT procedures at Pennsylvania State University in the early 1970s, a Philosophy professor called for a faculty council meeting to prohibit these interventions in the Psychology Clinic, even labeling them “unethical.” Although controversial in the beginning, BT and subsequently CBT overcame and survived such criticisms, as well as the widely held view that direct modifications of clinical problems would result in “symptom substitution.” A description of the background and brief history of BT and CBT will elucidate how these psychotherapies achieved the positive stature they currently enjoy.

Origins, Background, and Brief History

Development of Behavior Therapy

BT grew out of the conceptual framework of Behaviorism, which may be traced to a variety of influences from around the world. In the United States, John B. Watson (1878–1958) is usually credited with changing the focus of psychology from introspection of Structuralism and Functionalism to the study of observable behaviors. Watson defined Psychology as the “science of behavior,” which limited the scope of psychological inquiry to directly observable, objectively verifiable events and behaviors. Because of Watson’s influence in America as well as the research on conditioning in Russia and animal behavioral research in Europe (especially England), behaviorism became the primary conceptual framework underlying most basic psychological research from the 1920s through the 1970s.

Although there were sporadic studies evaluating the clinical application of behavioral interventions prior to World War II, it was the emergence of Clinical Psychology following that war that produced more extensive developments within BT (see W. E. Craighead, Craighead, & Ilardi, 1995). The primary defining characteristic of BT was the application of principles of behaviorism to clinical phenomena as psychology moved from the basic science laboratories to inform clinical interventions. Behaviorism focused on how learning occurs, and several theories of learning emerged over the 50-year period dominated by Behaviorism (see Kazdin, 1978, for details). However, principles of learning from two of these learning theories guided the development of BT during the 1950s: (a) the application of principles of operant conditioning (first labeled behavior modification, but now most commonly called applied behavior analysis) championed by Skinner (1953) and his colleagues; and (b) the application of principles of classical conditioning (at least metaphorically) by Wolpe (1958) in his description of behavioral treatments for anxiety. Similar developments, exemplified by Eysenck (1960) and his colleagues at the Institute of Psychiatry in London, occurred concurrently in Europe.

In addition to utilizing principles drawn from learning theory to guide the development of intervention procedures, another fundamental hallmark of BT has been its insistence on the empirical evaluation of the BT interventions. In the final analysis, it has been this empirical emphasis that has given BT its staying power and supported its efficacy with a wide range of clinical disorders (see L. W. Craighead, Craighead, Kazdin, & Mahoney, 1994; Kazdin, 1994). BT began with a focus on treatment of “anxiety” problems, largely because anxiety was viewed as the core of “neuroses” within the prevailing psychodynamic model of psychopathology and treatment. As we shall see later in this research paper, applications were soon developed for a variety of other clinical disorders. During the 1970s, however, a confluence of factors resulted in a large percentage of behavior therapists shifting their focus to internal cognitive processes; these factors produced the therapies now subsumed under the rubric of CBT.

Emergence of Cognitive-Behavior Therapy

The fundamental factor effecting a shift to a more cognitive focus within BT was the shift in the focus of basic psychology. During the late 1960s and the early 1970s basic psychology underwent what Kuhn has labeled a “paradigm shift” (Kuhn, 1962). Because it focused on observable behaviors (stimulus-response relationships), basic psychology, guided by Behaviorism, had eschewed the human “black box,” but with the “cognitive revolution” (see Dember, 1974) there was a shift to the study of internal cognitive processes (e.g., information processing, memory, problem solving, etc.).

Because behavior therapists were guided by basic psychology, the cognitive shift in basic psychology had a direct impact on the models and procedures of their clinical endeavors. This shift implied a central role for cognitive processes in the mediation of behavior and thereby legitimized cognition as a viable target for clinical intervention. Just as with BT, the specific definition of CBT has not been monolithic, and over 20 different approaches to CBT have been identified (Mahoney & Lyddon, 1988). We can now trace these CBT therapies to three major influences. First (as just noted) was the application of basic cognitive psychology constructs by empirically oriented clinicians to the development of models and procedures of clinical intervention (e.g., Bandura’s 1969 use of information processing in the development of his social learning theory). The second major influence was the reformulation of behavioral self-control procedures as cognitive interventions (e.g., Thoresen & Mahoney, 1974). Finally, there was the emergence of Ellis’s (1962) and A. T. Beck’s (1964, 1970) cognitive therapies (CT), which were developed within a clinical setting and initially based on clinical experience rather than findings of basic psychology (see W. E. Craighead et al., 1995, for detailed discussion of these influences).

BT and CBT share the same basic assumptions; namely, basic psychological research can inform clinical models and procedures, and one should evaluate the efficacy and effectiveness of clinical interventions. The major difference between BT and CBT lies in the conceptualization of the psychopathology and the specific intervention programs for the various clinical disorders. Many behavior therapists who label themselves applied behavior analysts may still avoid the use of cognitive models and strategies. Similarly, there are those who see themselves as strict cognitive therapists, and they may view behaviors as important only because they can become the basis for discussion and modification of cognitive styles associated with those behaviors. In the main, however, BT and CBT models are conceptually quite similar, and the procedures from both are complementary in the clinical process. J. S. Beck (2001) recently suggested a need to distinguish between CT and CBT, but then she described an intervention program for a depressed patient that was as behavioral as it was cognitive. Her description also demonstrated an extremely important clinical factor, which we shall note in several places in this research paper: Both BT and CBT are usually compatible with appropriate medication interventions.

Within the remainder of this research paper we describe and discuss BT and CBT interventions for most of the major clinical disorders. We have organized the following section according to the disorders treated, rather than according to the various clinical procedures employed. In order to avoid redundancy, wedescribeeachtreatmentprogram(e.g.,A.T.Beck’sformof CBT) only the first time it is noted. We conclude with some comments about future directions for relevant conceptual issues and clinical research.

Clinical Research on Behavior Therapy and Cognitive-Behavior Therapy

Anxiety Disorders

Phobias

Because the treatment of anxiety disorders with BT began with an emphasis on fear, anxiety, and avoidance, we begin our discussion with phobias. Wolpe (1958) provided the first comprehensive discussion of BT treatments of anxiety in his classic book, Psychotherapy by Reciprocal Inhibition. Concurrently, Eysenck (1960) and his colleagues were challenging the psychodynamic concept of anxiety as the core of neuroses.Wolpe argued that anxiety, and specifically phobias, represented conditioned autonomic nervous system responses to certain environmental situations or stimuli. Based on laboratory research, primarily with cats, he posited several BT interventions to alleviate the conditioned anxiety responses. Two of those procedures that have been widely studied are systematic desensitization (including relaxation training) and assertion training.

The diagnostic system at that time did not include the level of differentiation currently in place for anxiety disorders. Nevertheless, systematic desensitization was evaluated for a number of problems that currently would be labeled phobia or social phobia (see Paul, 1969). Systematic desensitization comprises three procedures: training in progressive muscular relaxation; development of a hierarchy of stimulus situations ranging from those that trigger very low levels of anxiety to the one (e.g., flying in a plane) that elicits the phobic reaction; and sequential visualization of the hierarchy of situations while remaining relaxed in the therapist’s office. Early BT research demonstrated that systematic desensitization was effective inreducing anxiety associated with social interactions, public speaking, and a variety of phobic situations (Paul, 1969). Progressive muscular relaxation continues to be widely used as a part of BT/CBT treatments for virtually all anxiety disorders. Systematic desensitization is primarily used for treatment of those disorders for which exposure-based treatments (described in the next paragraph) are not appropriate or as a first step in an exposure treatment program.

Utilizing principles of both operant and classical conditioning, other behavior therapists in the United States (e.g., Agras, Leitenberg, & Barlow, 1968) and in England (e.g., Marks, 1969) developed another procedure, “in vivo exposure,” to treat phobias. With in vivo exposure, the phobic individual, frequently accompanied by the therapist, is gradually placed in the presence of the phobic object. The person is asked not to avoid or escape the situation until the anxiety is habituated or significantly decreased. Although some anxiety situations (e.g., anxiety regarding sexual interactions) necessitate the use of imaginal exposure as used in systematic desensitization, in vivo exposure has generally been found to be the more efficacious of the two procedures (see Barlow, 1988). Consistent with his social learning model of therapeutic change, Bandura added a cognitive component (e.g., selfinstruction training) to both systematic desensitization and in vivo exposure and suggested that the therapist model both the behaviors and the cognitive component as part of the therapy (see Bandura, 1977).

In the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV; American Psychological Association [APA], 1994), phobias were divided into five categories: blood-injection-injury, situational, natural environment, animal, and other (e.g., choking). With all types of phobias for which it is possible, an exposure-based intervention, structured and implemented by a clinician, is the most effective BT method. In addition, because of the risk of fainting during in vivo exposure for blood-injection-injury phobia, the patient needs to be taught how to tense various muscle groups in order to keep the blood pressure high enough to prevent fainting (Ost, 1992). Recently, Ost and his colleagues have utilized massed (e.g., all-day) exposure, which is effective for most individuals with phobias and may be completed in one session (Hellstrom, Fellenius, & Ost, 1996; Ost, Ferebee, & Furmark, 1997). Although these procedures may seem simple, they need to be implemented by a clinician according to principles of learning and extinction. Self-administration or administration by an untrained therapist is typically not effective and can even make the problem worse because of inadequate or inappropriate exposure.

One of the clinical problems for which exposure therapies have been especially useful is now called agoraphobia. Research has gradually demonstrated that patients diagnosed with agoraphobia frequently suffered from panic attacks and that exposure therapy alone was not a particularly effective intervention for those comorbid panic attacks. This led to the development of BT and CBT interventions designed specifically for the treatment of panic disorder (PD) with and without agoraphobia (see Barlow & Lehman, 1996, for discussion of this issue as well as treatments of other anxiety disorders).

Panic Disorder

Barlow and his colleagues (e.g., Barlow & Craske, 1994) have developed an effective CBT program called Panic Control Therapy (PCT), for treating PD. The treatment consists of: (a) progressive muscular relaxation and breathing retraining; (b) interoceptive exposure (exposure to clinically induced physiological arousal cues that mimic panic attack symptoms, e.g., by use of hyperventilation, exercise, etc.); and (c) cognitive restructuring aimed at correcting misconceptions about anxiety and pain as well as overestimates of the threat and danger of panic attacks. Clark and his colleagues (Clark, 1989; Salkovskis & Clark, 1991), working in England and utilizing a cognitive theoretical model of PD, developed a program that is quite similar to Barlow’s PCT. It has the same major components, including the focus on correction of misperceived physiological cues, but it places greater emphasis on the intervention’s cognitive restructuring phase, which is more similar to the cognitive approach of A. T. Beck’s CBT.

Barlow’s PCT program, which has been extensively evaluated by its originators, was recently compared to imipramine (Tofranil), CBT plus imipramine, CBT plus placebo, and placebo alone in a four-site randomized control trial (RCT; Barlow, Gorman, Shear, & Woods, 2000). All active treatments were more effective than placebo alone. Imipramine produced a slightly higher initial quality of response, but CBT was more durable and somewhat better tolerated. Only CBT alone and CBT plus placebo were superior to placebo alone at the 6-month follow-up. It is interesting to note that the combined CBT-imipramine condition, which produced slightly superior acute treatment results, had a large relapse rate and was not superior to placebo alone at the 6-month follow-up.

Research with Clark’s CBThas providedresults fairly similar to those obtained with Barlow’s PCT. For example, Clark et al. (1994) found that approximately 75% of panic patients treated with CBT were panic free, and this compared to 70% for those who received imipramine and 40% who received applied relaxation training.At a 9-month follow-up, only 15% of the CBT patients had relapsed, whereas the relapse rate for the imipramine patients was 40% and for the applied relaxation patients was 53%; CBT was significantly more effective than either of the other two conditions at follow-up.

The combination of CBT with high-potency benzodiazepines appears to be one of the areas in which CBT and medications are incompatible. For example, both Brown and Barlow (1995) and Otto, Pollack, and Sabatino (1995) have found that the effects of CBT are weakened by the concurrent administration of benzodiazepines. Because of this and because of the high rate of relapse following typical termination of benzodiazepines, which are frequently prescribed by physicians for anxiety disorders, Otto et al. (1993) and Spiegel, Bruce, Gregg, and Nuzzarello (1994) have developed effective programs for the tapering of benzodiazepines while patients receive CBT/PCT.

The cumulative data for these CBT programs suggest that CBT may very well be the treatment of choice for PD. It appears to be as effective as medications, and it appears to be more enduring. Of course, these findings will have to be replicated in subsequent comparisons to newer medications (e.g., selective serotonin reuptake inhibitors, SSRIs) in order for this conclusion to stand.

Obsessive-Compulsive Disorder

The most effective psychosocial treatment for obsessivecompulsive disorder (OCD) is a BT procedure called exposure and ritual prevention (EX/RP; Franklin & Foa, 2002). EX/RP derives from the following conceptualization of OCD: Obsessions evoke pathological and unrealistic anxiety, and compulsions are performed in order to reduce that obsessional anxiety. Treatment consists of repeated exposures to situations (stimuli) that evoke the obsessions and the associated urges to perform compulsions (i.e., ritualize). These procedures produce a gradual reduction (i.e., habituation) of the obsessional anxiety and, consequently, a decrease of urges to ritualize. In EX/RP individuals suffering from OCD are exposed to the stimuli that trigger obsessional thoughts, and the therapist assists in preventing ritualistic behaviors and obsessional thoughts by verbally guiding the patient in their abstinence. In addition to overt behaviors, the program can also be implemented with mental rituals such as fear of swearing in church or continuous counting.

Treatment programs vary with respect to the length, number, and spacing of exposure sessions (Foa & Franklin, 1999). In the “intensive program,” developed by Foa and her colleagues (Franklin, Kozak, Levitt, & Foa, 2000), patients typically participate in 15 exposure sessions (imaginal and in vivo) of 90-min duration conducted over 3 to 4 weeks. The program utilizes homework assignments, which require the patient to practice EX/RP between sessions.

Foa and Liebowitz and their colleagues (Kozak, Liebowitz, & Foa, 2000) conducted an extensive two-site RCT comparing EX/RP to clomipramine, their combination, and pill placebo conditions. Preliminary results indicate that EX/RP was more effective than clomipramine alone (which was more effective than placebo), and the combination of clomipramine and EX/RP was no more effective than was EX/RP alone. Furthermore, meta-analytic studies of EX/RP and SSRIs revealed the treatment effect sizes to be somewhat greater for EX/RP (van Balkom et al., 1994).

The few treatment studies with adequate follow-up data have demonstrated a very high relapse for medication treatments but only modest relapse for EX/RP, particularly when a relapse-prevention component is included in the treatment program (Hiss, Foa, & Kozak, 1994). Nevertheless, some patients are reluctant to participate in EX/RP because they fear that their OCD symptoms will increase rather than diminish; such patients may benefit from treatment that begins with medication (an SSRI or clomipramine) followed by EX/RP (Foa & Wilson, 2000). Use of EX/RP requires expertise in BT, in general, and training in the specific intervention procedures; thus, it is not yet widely available even though it appears to be the treatment of choice for OCD when properly delivered.

Social Phobia

Although there were several early studies regarding BT procedures for public speaking anxiety (e.g., Paul, 1966), it is only recently that the treatment of social phobia has been systematically studied. Social phobia is a very prevalent disorder that interferes substantially with work (including school), social interactions, and intimate relationships. Several studies have demonstrated that exposure therapy and cognitive restructuring are effective BT-CBT interventions (see Barlow, 1988).

Heimberg, Liebowitz, and their colleagues have conducted the most extensive and clinically relevant work. Heimberg and his colleagues developed a group behavioral and cognitive therapy (GBCT) that includes social exposure exercises and cognitive restructuring implemented within a group therapy setting. In their first systematic study, they compared GBCT to an educational supportive group therapy (ESGT; Heimberg et al., 1990). GBCT was superior to ESGT on most measures employed in the study, and these superior effects were sustained at various follow-ups concluding at 5 years.

The results of the preceding study led to a multisite study comparing GBCT with the monoamine oxidase inhibitor (MAOI) phenelzine, pill placebo, and ESGT (Heimberg et al., 1998). Because one site developed GBCT and the other is well known for the treatment of social phobia with medications and because of the inclusion of appropriate control groups, this study provided an excellent test of treatment efficacy and allegiance effects. Both phenelzine and GBCT were found to be superior to both control groups. However, phenelzine appeared to work faster and was superior on a few of the outcome measures, although these were minimal differences. There were no substantial effects for treatment sites, suggesting that therapeutic allegiance made little difference in this study. Liebowitz et al. (1999) followed the patients in the phenelzine and the GBCT conditions for 6 months of maintenance therapy and an additional 6 months during which they received no treatment. Slightly more phenelzine patients relapsed during the treatment-free period, so that by the end of follow-up there were very few differences between the two groups. The slight superiority of phenelzine during active treatment seems to be offset by the greater relapse during the follow-up, so the treatments appear to be equally effective for social phobia.

Posttraumatic Stress Disorder

BT treatments of posttraumatic stress disorder (PTSD) have included a variety of exposure-based procedures. CBT approaches have been broader and typically include some type of exposure procedure plus training in progressive muscular relaxation, problem solving, emotional regulation, and cognitive restructuring. Most of the studies evaluating these interventions have included patients who have suffered from a specific traumatic event (e.g., rape) rather than patients who have suffered repeated traumas such as having been in an incestuous relationship (many of these patients suffer from primary problems in addition to PTSD). The major exception to this has been the treatment of war-related traumas (e.g., Keane, Fairbank, Caddell, & Zimering, 1989).

Exposure-based therapies for PTSD have been evaluated as treatments for sexual and nonsexual assault as well as warrelated traumas (see Bryant, 2000; Rothbaum, Meadows, Resick, & Foy, 2000). In general, in vivo exposure has been more effective than imaginal exposure, and whenever possible in vivo exposure should be incorporated into the intervention program. About 50% of PTSD patients are responsive to the best exposure therapies (Foa & Meadows, 1997; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998). Nevertheless, exposure therapy appears to be superior to wait-list and usual treatments for PTSD and indeed among the most effective treatments available for this serious and complicated clinical problem (Bryant, 2000).

As with OCD, some patients choose not to participate in exposure therapy because of fear that it will exacerbate their problems. Some of these individuals may be making an adaptive choice because preliminary data suggest that individuals with extreme levels of anxiety (Ehlers et al., 1998) and high levels of anger (Riggs, Rothbaum, & Foa, 1995) may not be appropriate candidates for this type of therapy. However, Lovell, Marks, Noshirvani, Thrasher, and Livanou (2001) demonstrated that exposure was equivalent to CBT in alleviating both behavioral and emotional symptoms of PTSD; both were superior to a placebo control group. Nevertheless, it needs to be noted that incorrect use of exposure procedures (e.g., not following standard time parameters) has the potential to be detrimental to various types of anxious patients, and especially patients suffering from PTSD (Bleich, Shalev, Shoham, Solomon, & Kotler, 1992; Pitman et al., 1991). As noted in the treatment of OCD, exposure therapy is among the most powerful interventions, and it should be used cautiously by well-trained mental health professionals.

Because of the hypothesized role of cognitive factors in the development and maintenance of PTSD, several authors have developed typical CBT programs for the treatment of this disorder, although there is a greater than usual emphasis on emotional regulation. Resick and Schicke (1992) developed a specific CBT program, cognitive processing therapy, which they have found to be effective for the treatment of rape trauma. Both Marks et al. (1998) and Tarrier et al. (1999) found CBT to be an effective treatment for trauma caused by a wide range of multiple events in patients’ lives. As noted, however, exposure was just as effective as CBT in the Marks et al. study (Lovell et al., 2001).

The most controversial treatment for PTSD is probably Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1995). In EMDR the client, while tracking the therapist’s finger as it is moved within the client’s field of vision, visualizes or remembers as vividly as possible the traumatic situation. Most of the research on this procedure has been seriously flawed, and the only firm conclusion that can currently be reached is that the eye movement component of the therapy is not critical to whatever gains may be attained by EMDR (Pitman et al., 1996). If EMDR does prove to be effective for some PTSD patients, it is likely that “exposure” is the effective ingredient inherent in the procedure; more efficacious exposure procedures clearly are available for the clinician (see Bryant, 2000).

Eating Disorders and Obesity

Anorexia Nervosa

Operant techniques (BT), primarily returning privileges or delivering reinforcers contingent on weight gain and contracting to maintain the weight gained, were first introduced into inpatient settings for the treatment of anorexia nervosa (AN) in the early 1960s. The approach was so effective it has been incorporated, either implicitly or explicitly, into most current hospital programs (see review by Touyz & Beumont, 1997). Touyz and colleagues demonstrated that more flexible BT programs were as effective as were the early, rigid programs. Both programs promoted weight gain at a rate of about .2/kg per day, but the flexible program required less nursing time and was more acceptable to patients, and the same percentage of patients were able to reach goal weight. CBTinterventions, developed initially for bulimia (discussed later), have been adapted to the treatment ofAN (see the description in Garner, Vitousek, & Pike, 1997). These procedures are widely used clinically, but they have not been rigorously evaluated. It has not been possible to determine the specific contribution of the cognitive component, particularly within comprehensive inpatient programs. Only one outpatient trial has been reported; Channon, De Silva, Hemsley, and Perkins (1989) found no differences in outcome among BT, CBT, or traditional weight monitoring, but the study’s small sample size precludes definite conclusions. The most recent innovation has been the incorporation of motivational interviewing into treatment for AN (see Treasure et al., 1999) as a way to address the client’s ambivalence about weight gain. Behaviorally oriented family systems therapy has been applied to AN; the one study available supported its effectiveness compared to ego-oriented psychotherapy (Robin, Siegel, & Moye, 1995).

Bulimia Nervosa

In contrast to AN, there are over 50 randomized clinical trials that clearly establish CBT as the treatment of choice for bulimia nervosa (BN; see review by Wilson & Fairburn, 2002). This intervention, first described by Fairburn (1981), has been evaluated in both group and individual formats. CBT typically consists of about 19 outpatient sessions occurring during a 20-week period. Two treatment manuals are available (Apple & Agras, 1997; Fairburn, Marcus, & Wilson, 1993). CBT utilizes behavioral strategies to interrupt the cycle of restraint, binge eating, and purging; establish a normalized eating pattern (3 meals and 2 snacks); and reintroduce forbidden foods. Cognitive restructuring is added to challenge the dysfunctional attitudes and beliefs that perpetuate disordered eating. Relapse prevention strategies are used to facilitate maintenance of changes.

Wilson and Fairburn’s (2002) review supports the following conclusions. CBT leads to significant improvements on the focal symptoms, binge eating and purging (average 85% reduction in frequency; 55% remitted), attitudes toward weight and shape, and general psychological functioning. Maintenance at 1-year follow-up is favorable, and one 6-year follow-up has been reported (Fairburnetal., 1995). A subset of BN patients can be effectively treated with abbreviated, guided self-help versions of CBT (Treasure et al., 1994). A specific behavioral procedure, exposure and response prevention (for purging), does not appear to add significantly to the CBT package. Comorbid personality disorder is a negative predictor for all interventions for BN. Intensive day treatment and inpatient programs are available for outpatient nonresponders; however, only one study (Maddocks, Kaplan,Woodside, Langdon, & Piran, 1992) has reported on such a program.

CBT is more effective at the end of treatment than are any nondirective, supportive, or psychodynamically oriented psychotherapies (see Wilson & Fairburn, 2002). Recently, a large multisite, controlled trial (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000) replicated an earlier finding that patients receiving Interpersonal Psychotherapy (IPT) do not improve as much by the end of treatment. However, they continue to improve during follow-up, whereas CBT subjects maintain their improvement. Thus, the differences at 1-year follow-up (40% remitted with CBT vs. 27% with IPT) no longer reached significance. Unfortunately, no predictors of differential response to the two treatments have been found.

Comparisons between CBT and pharmacotherapy (antidepressant medication) generally favor CBT at follow-up assessments, even when end-of-treatment effects have been equivalent (see Wilson & Fairburn, 2002). Support for additive effects of combining the two treatments is relatively weak. Walsh et al. (1997) combined CBT with a two-stage antidepressant medication protocol (a second antidepressant was employed if the first was ineffective or poorly tolerated). This combined condition reduced depression (but not focal symptoms) more than did CBT alone. However, medication was most effective for patients with a family history of depression and patients with a positive dexamethasone suppression test. Thus, future research is likely to identify subgroups of patients who benefit from this combination of treatments.

Obesity

Obesity was a very popular treatment target of early (1960s) behavioral weight loss (BWL) interventions; this was probably due to the clearly observable outcome measure of weight. These BWL programs were short-term interventions that had a relatively narrow focus on altering eating behavior and used functional analyses of behavior. Stimulus control procedures were used to alter antecedents to eating, and contingency management was used to alter consequences for eating. It quickly became clear that while superior to other available interventions, these BWL programs led to quite modest weight losses that were not well maintained (see review by Grilo, 1996). Thus, longer, more comprehensive programs were developed. Currently, BWL interventions include multiple components such as nutrition education, exercise programs, lifestyle change, and relapse prevention strategies.

Grilo (1996) summarized the major conclusions that can be reached about BWL programs. BWL is moderately effective in the short run, but the long-term outcome is not as positive. Weight loss seems to peak at about 6 months of treatment. Few patients achieve goal weight; most lose about 10% to 15% of their body weight. On average patients regain one third to one half of the weight lost during the year after treatment. Very low calorie diets do not improve the long-term results achieved with the more moderate restriction advocated in BWL. Sustained exercise consistently emerges as a correlate of successful long-term maintenance, even though initiating exercise by itself does not generally lead to significant weight loss. It is not clear whether adding specific cognitive interventions is helpful, but participants like them.The addition of relapse prevention strategies or booster sessions has not been shown significantly to improve long-term outcome.

Recognition of the strong genetic and metabolic components of obesity has led to a growing consensus that obesity may be better conceptualized as a chronic disease. It may require intermittent or even continuous treatment to be effective, at least with more severe cases. Wilson (1994) argued that pharmacological interventions will likely need to be added to BWL programs for some patients. Unfortunately, at the current time no effective appetite suppressant medications have turned out to be safe for long-term use. Research continues to evaluate medications, including antidepressants such as buproprion (e.g., Wellbutrin) and fluoxetine (e.g., Prozac), which may be found to be safe and effective adjuncts to BWL.

Binge Eating Disorder

The subset of obese patients who also have difficulty with binge eating (eating large amounts and feeling loss of control) have been given the (provisional) diagnosis of binge eating disorder (BED). Although it is not clear whether individuals with BED who participate in standard BWL programs do more poorly, some evidence suggests that they drop out at higher rates and show greater relapse (see Johnson, Tsoh, & Varnado, 1996). Because CBT interventions successfully reduced binge eating in BN, they were adapted (see Marcus, 1997) for use with BED. Several trials support the effectiveness of CBT for BED in reducing binge eating, but it did not lead to weight loss.

Only one study has directly compared CBT to BWL (Marcus, 1995). Both interventions were effective in stopping binge eating, but only BWL led to modest weight loss— about half of which was maintained at follow-up. Agras, Telch, Arnow, Eldredge, and Marnell (1997) found that abstinence from binge eating was critical to sustaining weight lost in a BWL phase (which followed the initial CBT phase). For clients who are resistant to the food monitoring central to CBT, appetite monitoring is an equally effective alternative (Craighead, Elder, Niemeier, & Pung, 2002). Findings from Agras et al. (1994) suggest that antidepressants may lead to modest improvements in weight loss. Other psychosocial interventions, specifically IPT, are as effective as CBT in the long run but are less effective at the end of treatment, just as with BN (see Wilfley et al., in press). Regardless of weight loss, reductions in binge eating are clearly associated with improvements in psychosocial functioning and with prevention of further weight gain—a substantial accomplishment for individuals with BED.

Summary

For AN, BT procedures are clearly effective in promoting weight gain during inpatient hospitalization, but the utility of cognitive techniques in addressing the broader issues associated with AN has not yet been adequately documented. For BN, CBT is clearly the treatment of choice; no other intervention has been shown to work as quickly to reduce binge eating, purging, and dietary restraint. The cognitive component also effectively addresses weight and shape concerns and low self-esteem. For obesity, comprehensive BWL programs are clearly the treatment of choice, although long-term outcome is still far from satisfactory. For obese individuals with BED, CBT effectively reduces binge eating, but BWL is also needed to achieve even modest weight loss. Thus, it appears that BT/CBT procedures are quite effective in altering current problematic eating behaviors; normal eating patterns can be established. These more normal patterns are adequate to achieve some weight gain (in AN) as well as to prevent weight gain (in BED). However, achieving substantial, longterm weight loss is far more difficult. Long-term, and possibly medical, approaches are likely to be needed.

Major Depressive Disorder

Individual Behavior Therapy

Several variants of BT have been developed for the treatment of major depressive disorder (MDD); they all share the assumption that MDD is related to a decrease in behaviors that produce positive reinforcement. Behavior therapies for depression have, therefore, focused largely on monitoring and increasing positive daily activities, improving social and communication skills, increasing adaptive behaviors such as positive and negative assertion, increasing response-contingent positive reinforcement for adaptive behaviors, and decreasing negative life experiences.

In several studies during the 1970s and early 1980s, Lewinsohn and his group demonstrated that relative to various control groups, BT increased pleasant experiences and reduced aversive experiences, which produced concomitant decreases in depression symptomatology (see summary in Lewinsohn & Gotlib, 1995). Building on Lewinsohn’s work, Bellack, Hersen, and Himmelhoch (1981, 1983) and Hersen, Bellack, Himmelhoch, and Thase (1984) studied the effects of BT with clinical patients. They found that BT was as effective as was the antidepressant amitriptyline (Elavil) in reducing depression during a 12-week treatment period; these effects were maintained over a 6-month follow-up period during which patients were given 6 to 8 BT booster sessions.

McLean and Hakstian (1979) added problem solving and self-control (see Rehm, 1977) procedures to BT and conducted a 10-week clinical trial comparing this expanded BT intervention to relaxation therapy, insight-oriented psychotherapy, and amitriptyline. The BT program was equal or superior to each of the other treatment conditions. These results were maintained at a 27-month follow-up, at which time the BT group was more socially active and productive than were participants in the other treatment conditions (McLean & Hakstian, 1990). Rehm’s (1977) self-control therapy, when administered alone, has also been found to be superior to nonspecific psychosocial treatments and no-treatment controls (Rehm, 1990), but it has not been compared to standard antidepressant treatment.

Keller and colleagues (2000) recently completed an extremely important and well-designed evaluation of a form of BT. They treated 681 adults with chronic major depression (MDD of at least 2 years’ duration, current MDD superimposed on a preexisting dysthymic disorder, or recurrent MDD with incomplete remission between episodes and a total duration of continuous illness of at least 2 years). These individuals were randomly assigned to 12 weeks of treatment consisting of either the cognitive-behavioral analysis system of psychotherapy (CBASP), the antidepressant nefazodone (Serzone), or the combination of CBASP and nefazodone. CBASP (McCullough, 2000) focuses on the consequences of patient’s behavior and the use of social problem solving to address interpersonal difficulties. Patients receiving nefazodone had a more rapid reduction in symptoms during the first four weeks of treatment, but the overall rate of response was equivalent for the CBASP and nefazodone groups. Furthermore, at posttreatment the combination of CBASP and nefazodone was superior to either treatment given alone. Follow-up data for this trial have not yet been published.

In summary, consistent findings support the efficacy of BT for depression; nevertheless, BT has been overshadowed by subsequent outcome studies that have focused on CBT and IPT as psychosocial interventions for MDD. However, given the relative efficacy, efficiency, and endurance of behavioral interventions, as well as the recent results for CBASP, it seems that this has been a premature turn of events. From a historical perspective, it was most likely due to the exclusion of BT from the well-publicized National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP; Elkin, Parloff, Hadley, & Autry, 1985), rather than to the relative scientific merit and empirical outcomes of the comparative treatment studies.

Behavior Marital Therapy

Behavioral marital therapy (BMT) has been evaluated as a treatment for individuals suffering concurrently from MDD and marital distress. Both O’Leary and colleagues’ and Jacobson and colleagues’standard BMT (Beach, Sandeen, & O’Leary, 1990; Jacobson, Dobson, Fruzetti, Schmaling, & Salusky, 1991; O’Leary & Beach, 1990) have been demonstrated to be equal to individual CBT for the alleviation of depression among individuals with both MDD and marital discord. BMT appears to have the added advantage of being superior to individual CBT in the reduction of marital discord. None of these studies employed appropriate follow-up procedures to permit a determination of whether BMT confers greater prophylactic effects than individual CBT for the prevention of relapse of an MDD following successful treatment. However, given that “marital disputes” is the most frequently discussed topic among depressed patients in maintenance therapy (Weissman & Klerman, 1973) and that marital friction is an enduring problem among formerly depressed patients even when they become asymptomatic (Bothwell & Weissman, 1977), it seems likely that successful BMT is likely to reduce the rate of relapse among successfully treated MDD patients in discordant marriages. Because these BMT studies have included small numbers of severely depressed patients, it is not known whether the presence of severe depression will necessitate treatment with antidepressants administered either alone or in combination with BMT.

Cognitive-Behavior Therapy

The most extensively evaluated psychosocial treatment for MDD isA.T. Beck’s CBT(A.T. Beck, Rush, Shaw, & Emery, 1979). This form of CBT is a short-term (16 to 20 sessions over a period of 12 to 16 weeks), directive therapy designed to change the depressed patient’s negative view of the self, world, and future. The therapy begins with the presentation of the rationale, which is designed to inform the client of the cognitive formulation and conceptualization of the process of therapeutic change (A. T. Beck, 2001). Following this, early CBT sessions consist of the implementation of behavioral strategies. The purpose of increasing behaviors is to provide the future opportunity for monitoring the behaviors and their associated thoughts and feelings; behavioral changes are not posited to be responsible directly for decreases in depression. During the third week, expanded self-monitoring techniques are introduced in order to demonstrate the relationship between thoughts and feelings; subsequently, patients are taught to evaluate their thought processes for logical errors, which include arbitrary inference, selective abstraction, overgeneralization, magnification and minimalization, personalization, and dichotomous thinking (A. T. Beck, 1976). At about the middle of therapy (around session 8 or 9), the concept of schemata, or beliefs underlying negative and positive thoughts, is introduced, and therapy begins to focus on changing those negative schemata that are posited to have been activated, thus precipitating the MDD. Near the end of therapy (around sessions 14 to 16), the focus shifts to termination and the use of cognitive strategies to prevent relapse or a future recurrence of depression.

A number of studies have compared the effectiveness of CBT to several tricyclic antidepressant medications (Elkin et al., 1989; Hollon et al., 1992; Rush, Beck, Kovacs, & Hollon, 1977; Simons, Murphy, Levine, & Wetzel, 1986). With the possible exception of the TDCRP (Elkin et al., 1989), the bottom-line finding in all these studies is that CBT is as effective as tricyclic antidepressant medication in alleviating MDD among outpatients. Similarly, CBT is as effective as the MAOI phenelzine (Nardil), and is more effective than pill placebo, in the treatment of atypical depression (Jarrett et al., 1999). CBT also was as effective as antidepressant medication when study physicians were free to prescribe the antidepressant of their choice (and free to switch medications during the treatment trial), provided that they prescribed at or above established therapeutic doses (Blackburn & Moore, 1997). Currently, trials comparing CBT and SSRIs are in progress, but because the efficacies of the tricyclics and the SSRIs are very similar, it seems unlikely that different conclusions will be reached in these studies.

Jacobson et al. (1996) tested A. T. Beck’s hypothesized theory of mechanisms of change in cognitive therapy by comparing the full CBT package to its component parts: behavioral activation (BA) and behavioral activation plus modification of automatic dysfunctional thoughts (AT). The BA treatment was similar to the behavioral interventions previously reviewed and included such techniques as monitoring daily activities, assessing pleasure and mastery of activities, assigning increasingly difficult activities, imaging behaviors to be performed, discussing specific problems and identification of behavioral solutions to those problems, and intervening to ameliorate social skills deficits. The major finding of this study was that BAwas as effective as both AT and the full CBT package, both immediately after the 20-session treatment trial and at 6-month follow-up. Furthermore, BA performed equally well over a 2-year follow-up period, with patients across the three treatments having equivalent rates of relapse, time to relapse, and number of well weeks (Gortner, Gollan, Dobson, & Jacobson, 1998). This is currently the only direct comparison of BT and CBT. However, in a study initiated by the late N. S. Jacobson, investigators at the University of Washington are currently conducting a replication study in which they are comparing BA to CBT, antidepressant medication (paroxetine), and pill placebo among 400 depressed adults (Dobson et al., 2000).

In summary, typically, 50% to 70% of MDD patients who complete a course of CBT no longer meet criteria for MDD at posttreatment, and 30–40% are rated as “recovered.” Furthermore, among the samples studied, CBT appeared to confer someenduringprophylacticeffects;only20%to30%ofthose successfully treated relapsed during the first year following treatment. Indeed, 16 weeks of CBT produced a 1-year follow-up success rate that equaled or slightly exceeded that achieved by a full year of antidepressant treatment (Evans et al., 1992). Furthermore, CBT’s maintenance effects are clearly superior to short-term (16-week) antidepressant treatment; of course, 16 weeks is not the recommended treatment period, but it is, unfortunately, fairly comparable if not worse in clinical practice (Hirschfeld et al., 1997; Keller et al., 1986).

Perhaps the major issue in psychotherapy research regarding MDD is whether BT, CBT, and IPT are effective for severely depressed patients (see W. E. Craighead, Hart, Craighead, & Ilardi, 2002).This issue arose primarily because the outcomes of the TDCRP suggested that CBT was not equally effective to the antidepressant with severely depressed patients. The TDCRP (Elkin et al., 1989) was the first largesample RCT for MDD, and it compared the effects of a tricyclic (imipramine), a pill placebo plus clinical management, and CBT and IPT treatments; study sites included three major medical centers. Even though the overall sample sizes were fairly large (N about 60 per condition at beginning of treatment), unfortunately there were 15 or fewer severely depressed patients in each condition. Furthermore, as Jacobson and Hollon noted (1996), there was a treatment by severity by site interaction for the major outcome measures. Nevertheless, based largely on the TDCRP, the American Psychiatric Association published treatment guidelines (APA, 1993), which indicated that psychosocial treatments alone were not appropriate for severely depressed patients. This conclusion, based on one study with a small sample of severely depressed patients, was unwarranted (W. E. Craighead et al., 2002; Persons, Thase, & Crits-Christoph, 1996). This question of whether severely depressed patients should be treated with psychotherapy alone is currently being extensively investigated in a multisite study by Hollon and DeRubeis and also by Jacobson’s successors. Thus, a clearer answer regarding this important issue should soon be available from these clinical research centers.

Bipolar Disorder

There have been several studies evaluating the effects of combining BT and CBT with mood-stabilizing medications. The following sections describe and review the individual and family therapy studies; a summary and critique of the group therapy studies, which are based largely on other therapeutic models, are available in Huxley, Parikh, and Baldessarini (2000).

Individual Cognitive-Behavior Therapy

A small number of very well conducted studies have evaluated the efficacy of individual CBT used in conjunction with mood stabilizing medications for the treatment of bipolar disorder (BD). CBT assumes that BD mood swings are partially a function of negative thinking patterns (self-statements, cognitive processes, and core dysfunctional schemata) that can be alleviated by a combination of BAand cognitive restructuring interventions. CBT for BD includes education regarding the disorder, a focus on medication compliance, behavioral management (e.g., assertion training, anger management), and cognitive restructuring.

In the first systematic study of individual CBT for BD, 14 out of 28 newly admitted lithium-treated outpatients were randomly assigned to receive only lithium, whereas the other 14 received both lithium and an additional preventive compliance CBT intervention (Cochran, 1984). The CBT program, comprising six weekly, individual, 1-hr therapy sessions, was designed to alter specific cognitive styles and behavioral patterns hypothesized to interfere with medication adherence.At both posttreatment and 6-month follow-up assessments, patients who received the combined CBT/lithium intervention exhibited significantly greater medication adherence. During the 6-month follow-up period, the combined intervention group also had significantly fewer hospitalizations (2 vs. 8). Although the groups did not differ significantly in total number of relapses (9 vs. 14), patients in the CBT/lithium group had significantly fewer mood disorder episodes (5 episodes experienced by 3 patients vs. 11 episodes experience by 8 standard-treatment patients) judged to be precipitated by medication nonadherence.

A randomized pilot study (Lam et al., 2000) further supports the short-term efficacy of CBT for BD. This 6-month CBTprogramwasallowedtovarybetween12and20sessions; it focused on strategies for relapse prevention, sleep-wake stabilization (similar to the Frank’s et al., 1999, Interpersonal and Social Rhythm Theory, or IPSRT, approach), and BA. The investigators randomized 25 patients to CBT plus medication management or medication management alone. The 12-month follow-up data indicated that CBT plus medication management was more effective than was medication management alone in reducing rates of relapse, improving medication adherence, and improving psychosocial functioning.

In the largest randomized CBTstudy (N 69) of treatment of BD, Perry, Tarrier, Morriss, McCarthy, and Limb (1999) compared patients who received medication management alone with patients who received medication management anda7-to12-sessionCBTintervention.ThefocusoftheCBT differed from that employed by Cochran (1984); rather than focusing on medication compliance as Cochran had done, Perry et al. taught patients to recognize emerging symptoms of bipolar disorder when they occurred and to seek appropriate preventive interventions. During an 18-month follow-up period, time to manic relapse was significantly longer among bipolar patients in the CBTversus the medication-only group; no differences were found in survival times for depressive relapses. CBT and medical management also had a stronger impact on social and occupational functioning than did medication management alone. There were no between-group differences for compliance with medication regimens. The effects of CBT and medication management were primarily on the manic phase of the disorder; thus, it may be wise to combine CBT with interpersonally oriented or family-marital psychoeducational interventions, which seem to have a larger impact on depressive phases of the disorder (Frank et al., 1999; Miklowitz et al., 2000).

Although the previous studies have employed small samples, they have consistently found positive effects for supplementing mood-stabilizing medications with individual CBT. The mechanisms of action of the adjunctive CBT treatments—whether they have a direct impact on patients’cognitive styles and core dysfunctional beliefs or whether they increase the patients’ knowledge of BD and use of disorder management strategies (e. g., medication adherence, seeking emergency interventions prior to relapses, or BA)—have not been examined. Effectiveness studies, including more participants in clinical settings and with a longer follow-up, are currently needed.

Behavioral Family Therapy

Research groups at the University of Colorado, the University of California–Los Angeles (UCLA), and Brown Medical Center have conducted systematic studies of family dysfunction associated with BD. Each group has also developed an intervention program that is loosely based on principles of BT and is designed for use in conjunction with moodstabilizing medications. Clarkin and his colleagues have also conducted family and marital therapy studies for families with an adult member who has BD, but these therapies appear to be less behaviorally focused (see W. E. Craighead & Miklowitz, 2000).

The University of Colorado and UCLA Studies of Family-Focused Treatment. Family-focused treatment (FFT; Miklowitz & Goldstein, 1997) is a 9-month psychoeducational treatment for bipolar patients in any type of family milieu. It is delivered in three modules over 21 sessions (weekly for 12 weeks, biweekly for 12 weeks, and monthly for 3 months). In the first module, called psychoeducation, patients and relatives learn about the nature of, etiology of, and treatments for BD. They are taught to recognize the signs and symptoms of new episodes and to develop a relapse prevention plan. The second module focuses on behavior rehearsal exercises designed to enhance communication between patients and relatives (e.g., active listening, delivering positive feedback). The third module trains patients and relatives to define and solve specific family problems.

One RCT of FFT has been conducted at the University of Colorado (Miklowitz et al., 2000; Simoneau, Miklowitz, Richards, Saleem, & George, 1999) and another at UCLA (Goldstein, Rea, & Miklowitz, 1996; Rea et al., in press). In both studies patients had suffered a recent and acute episode of BD and were being maintained on mood-stabilizing medications (typically lithium or one of the anticonvulsants, with adjunctive medications as needed). In the Colorado study, FFT was compared to a crisis management group, which was given two sessions of family education and individual crisis sessions as needed over 9 months. The UCLA study compared FFT to an individual intervention that focused on symptom management and problem solving, and it was delivered on the same schedule as FFT (21 sessions over 9 months).

In the Colorado study, FFT-medication patients reported lower rates of relapse than did patients in the comparison medication–crisis management intervention (29% vs. 53%). Survival analysis found FFT to produce longer delays prior to relapse over the 12 months than crisis management. Among treatment completers (n 79), patients in FFT had less severe depressive symptoms over the 12 months than did those in the crisis management control, a difference that was not observed until 9 months into treatment. Medication regimes or compliance did not account for the results. In evaluating changes in communication patterns among patients who participated in FFT, Simoneau et al. (1999) found that both patients and relatives increased the number of positive interactions in FFT relative to crisis management, but there were no differences for negative interactions. Additional analyses demonstrated that the effects of FFT were largely on positive nonverbal (e.g., smiling, nodding, affectionate voice tone) rather than verbal (e.g., statements of acceptance or acknowledgement) behaviors.

In the UCLA study (N 53) no effects of FFT were found for the first year of treatment. However, during the 2-year follow-up, FFT was consistently more effective in reducing time to relapse and time to rehospitalization. Again, results could not be accounted for by medication variables. The delay in observed effects of FFT in both studies suggests that patients and family members require some time to absorb the education and skill-training materials into their day-to-day lives before these new skills have ameliorative effects on BD.

The Brown Study of Group Family Therapy. Miller, Keitner, and their colleagues at Brown Medical Center have completed two studies of behaviorally oriented family therapy for BD. The first was a small study that compared the effects of adding family therapy to standard medication treatment. Based on pilot studies of families that included an adult BD patient, they predicted that an intervention that focused on improving family functioning might lead to both improved family functioning and decreased rates of relapse or recurrence of the disorder as well as decreased rehospitalizations. In a pilot study of 14 patients they found that family therapy for bipolar patients in dysfunctional families improved the quality of family life and decreased the rate of relapse of bipolar disorder (Miller, Keitner, Bishop, & Ryan, 1991).

In a larger follow-up study (Miller, Keitner, Ryan, & Solomon, 2000) these investigators studied 92 very carefully diagnosed patients with BD. They compared the effects of three treatments: (a) standard treatment (medication plus clinical management), (b) standard treatment plus family therapy given separately to each participating family, and (c) standard treatment plus multifamily therapy, in which treatment was delivered to groups of families. Family therapy consisted of 6 to 8 sessions delivered during the first 4 months of treatment with booster sessions as clinically indicated. Multifamily therapy comprised 4 to 6 patients and their families, who met for 90 min for 6 consecutive weeks; there were “reunion” meetings every 6 months. In all patients, treatment continued for 28 months. Using strictly defined criteria, slightly over 30% of the patients in each of the family therapy conditions were recovered, but fewer than 20% of the standard treatment patients were recovered. Perhaps the most important finding of this study was that the effects of family interventions on the symptomatic outcome of patients were especially pronounced for families who exhibited poor family functioning prior to treatment. Among dysfunctional families, there was a significant difference favoring the two family therapy conditions over the standard treatment in terms of the proportion recovered; however, the two family therapy conditions did not differ from each other. There were no significant treatment effects for families with good functioning prior to treatment; indeed, patients in these families showed very little symptomatic improvement regardless of the treatment condition in which they participated.

The results of these three studies suggest that behaviorally based family therapies are efficacious adjuncts to pharmacotherapy for bipolar patients who are recovering from an episode of mood disorder. Positive changes in the postepisode family interactions may reduce external life stressors and protect the patient from early relapse. The subtypes of bipolar patients who do and do not benefit from family intervention have not yet been clearly identified, although the Brown study suggests that family therapy is most appropriate for dysfunctional families that include a bipolar patient.

Schizophrenia

Appropriate psychotropic medications, currently atypical antipsychotics, are the primary interventions for schizophrenia. The following BT/CBT interventions, however, are useful as adjunctive therapies to antipsychotic medications: behavior modification, social skills training, family therapy, cognitive coping strategies, and supported employment (see Penn & Mueser, 1996, and Kopelowicz, Liberman, & Zarate, 2002, for detailed reviews).

Specific maladaptive behaviors or deficits associated with chronic schizophrenia were the targets of early behavioral interventions. Starting in the 1970s, extensive research establishedtheusefulnessofbehaviormodification–tokeneconomy programs (see Paul & Lentz, 1977) for treating chronic, severely debilitated, and treatment-refractory schizophrenic patients. It is important to note that as a result of these BT interventions many patients were able to function at least semiindependently in community settings. During the past two decades, enormous progress has been made in broader applications of BT with a greater range of patients diagnosed with schizophrenia. These programs, focused largely on social skills training, have improved levels of social functioning and quality of life beyond those obtained with medications and case management, but reductions in relapse and improvements in community functioning have been less clear (see Liberman, DeRisi, & Mueser, 1989; Penn & Mueser, 1996).

Family therapy, in conjunction with medication, has also been used extensively in the treatment of schizophrenia.There are many forms of family therapy, but behavioral family therapy and psychoeducational family therapy have been the most extensively studied. The components of these family therapies typically include education, communication coping skills (focused on reducing “expressed emotion” in family members, i.e., criticism, intrusiveness, and negative verbal interactions), and problem-solving skills (see Goldstein & Miklowitz, 1995). In their review of several family therapy studies, Penn and Mueser (1996) wrote, “The studies reviewed all lead to the conclusion that long-term family intervention is effective for lowering relapse rate, reducing expressed emotion, and improving outcome (e.g., social functioning) among individuals with schizophrenia. The superiority of family intervention over customary outpatient care has been demonstrated. Furthermore, there is some evidence that family intervention reduces family burden” (p. 612).

Another important recent development has been the programs, based on principles of BT, that are best referred to as supported employment (see Wehman & Moon, 1988). Such programs lead to more successful vocational adjustment and less relapse than do more standard vocational follow-up procedures. Supported employment focuses both on rapid job identification and placement and on long-term support for the patient to engage in competent work behaviors.

1. T. Beck (1952) and Hole, Rush, and Beck (1979) first described case studies utilizing cognitive techniques to reduce delusional beliefs. This approach was more fully developed and evaluated by a number of English researchers over the next two decades. Tarrier et al. (1993) utilized the term coping strategy enhancement to refer to applications of CT/CBT techniques to reducing the frequency, or negative impact, of delusions and hallucinations.

Cognitive coping strategies are employed as an adjunct to pharmacotherapy and also have been used to enhance compliance with medications (Kemp, Hayward, Appleyard, Everitt, & David, 1996). Generally, psychotic activity is considered too severe and overwhelming for the patient to be responsive to a purely psychological intervention, so treatment is typically instituted after an appropriate medication regime has been established. Most of the empirical studies have focused on the reduction of residual psychotic symptoms that have not responded to medication. However, Drury, Birchwood, Cochrane, and MacMillan (1996) demonstrated that CT might be a useful treatment during the acute stage of schizophrenia; CBT resulted in decreased positive symptoms and reduced times to recovery compared with a minimal treatment control.

The cognitive model of schizophrenia clearly acknowledges the presence of neurodevelopmental abnormalities that render individuals more sensitive to normal life stressors. It is hypothesized that internal biological processes generate affective responses that are usually activated only by external events. The activated person searches for a cause or interpretation for this activation, but the explanations arrived at are likely to appear inexplicable (“delusional”) to others. Once such a “delusional” belief (explanation) is in place, the CT model contends that it is maintained by the same biased thinking processes that are involved in the maintenance of irrational beliefs in other disorders. These irrational beliefs in turn lead to maladaptive behaviors. Cognitive interventions (see Nelson’s, 1997, treatment manual) are designed to activate patients’ latent rationality to correct the cognitive errors maintaining their maladaptive beliefs or delusions; correct their maladaptive beliefs about their psychotic symptoms and about suffering from a chronic, severe disorder; and combat their apathy and social withdrawal (negative symptoms). Typical procedures include: providing a normalizing rationale for delusions and hallucinations; recognizing and labeling delusional ideas; developing challenges and reality tests relevant to those ideas; developing cards with coping statements and strategies; developing strategies to reduce the interference of voices; and challenging beliefs that voices “speak the truth” and must be obeyed.

Recent, larger RCTs (Kuipers et al., 1998; Pinto, La Pia, Menella, Giorgino, & De Simone, 1999; Tarrier et al., 2000) have clearly supported the effectiveness of CBT plus routine care in reducing positive symptoms. Effects on negative symptoms were weaker. Low dropout rates and high patient satisfaction with the intervention were also reported. The superiority of CBT was maintained at 2-year follow-ups. However, the specific effectiveness of the cognitive restructuring component is not yet clearly established (Sensky et al., 2000; Tarrier et al., 2000).

In summary, BT/CBT interventions (specifically social skills training, family therapy, supported employment, and cognitive coping skills training) are important, effective adjunctive psychosocial interventions for schizophrenia. Because most programs include several components, investigators have not yet identified which aspects of the programs account for their positive effects. It is clear that BT and CBT of various types enhance the effects of medication and appear to be more beneficial than the minimal supportive counseling thatcomprises“routinecare”forthisseveredisorder.Asnoted by Kopelowicz et al. (2002), these interventions are “most efficacious when delivered in a continuous, comprehensive, and well-coordinated manner through a service delivery systems” (p. 201).

Personality Disorders

Early behaviorists eschewed the concept of “personality,” focusing instead on changing specific problem be haviors. Evolutionary changes in the diagnostic criteria for personality disorders (PDs), however, have rendered them more behaviorally based. This has led to improved diagnostic reliabilities, which has made these disorders more amenable to the empirical evaluation required by the behavioral approach. Cognitive therapists, in particular, have extended their conceptual model to address PDs and have provided extensive clinical descriptions of the application of CT for these disorders (A.T. Beck & Freeman, 1990). Nevertheless, RCTs evaluating these applications have been almost nonexistent; this is likely due to the unique methodological problems of dealing with more chronic, less clearly distinguishable problems. Unfortunately, no other types of psychosocial interventions have been evaluated either, so there is little scientific basis for recommending specific treatments for PDs. There are some data suggesting the efficacy of specific BT/CBT interventions for avoidant personality disorder (APD) and borderline personality disorder (BPD).

Behavioral treatments that were first developed for social phobia have been applied to APD. Three variations of group BT (graded exposure, social skills training, and intimacy-focused social skills training) were all superior to no treatment at 10 weeks (posttest) and follow-up (Alden, 1989). Unfortunately, these patients were still not functioning at the level of “normal” comparison samples; this suggested that longer treatment might be necessary for this more pervasive disorder. Post hoc analyses of these data suggested that patients with problems with distrust and anger benefited primarily from exposure; those who were less assertive benefited from all three treatments, although they did some what better as a result of the intimacy-focused social skills training therapy.

BPD is the only PD for which a specific CBT approach has been systematically developed and evaluated. Emerging from a behavioral tradition, Linehan’s work first targeted a population with a specific problem behavior, chronic parasuicidal behavior. It was only later that she began to use the descriptor BPD because it became clear that the majority of the individuals with whom she worked met those criteria. Linehan (1993) provided a model of BPD that assumes that individuals with BPD have a basic dysfunction in emotion regulation, which presumably begins as a biologically based dysfunction. She posits that the emotion dysregulation is exacerbated by developmental experiences with significant others, who not only invalidate the individuals’inner experiences but also fail to teach them appropriate emotion regulation skills that they need even more than do less vulnerable people.

Linehan’s CBT (also referred to as dialectical behavior therapy; DBT) for BPD is a complex, long-term (1 to 3 years), and intensive (weekly group and individual) intervention with multiple components including emotion regulation skills training, interpersonal skills training, distress tolerance–reality acceptance, problem solving, and extensive use of supportivevalidating techniques. Although DBT might be claimed as an example of a broadly integrated model of psychotherapy, Linehan (1993) clearly presented her model as having derived from and maintaining a behavioral focus. The first controlled trial, Linehan, Hubert, Suarez, Douglas, and Heard (1991), found that 1 year of DBT resulted in fewer and less severe episodes of parasuicidal behavior and fewer days of hospitalization than treatment as usual (TAU) in the community. However, there were no differences in depression, hopelessness, or suicidal ideation. The treatment did appear to be well tolerated by this difficult-to-treat population that may even be difficult to retain in treatment. Attrition was quite low (17%), especially when compared to the TAU (58%). Results at 1-year follow-up continued to be favorable (Linehan, Heard, & Armstrong, 1993). Similar positive findings were reported comparing 1 year of her CBT to TAU with substance-dependent women with BPD (Linehan et al., 1999). Additionally, uncontrolled studies have reported favorable adaptations of this intervention for adult inpatient units and for use with suicidal teens (Bohus et al., 2000; Miller, Rathus, Linehan, Wetzler, & Leigh, 1997). More extensive RCTs are in progress in Sweden; these studies are comparing different types of psychotherapy, including Linehan’s CBT, with BPD patients.

Other Disorders

BT and CBT have been used in the successful treatment of several other disorders, but space limitations preclude a detailed discussion of these interventions. These include sexual dysfunction, paraphilia, trichotillamania, drug and alcohol abuse and dependence (Hester & Miller, 1995), and a variety of physical health–related problems (e.g., pain, headache, etc.; see Baum, Singer, & Revenson, 2000). Recent descriptions of the procedures and systematic reviews of the relevant outcome studies are available (see Barlow, 1993; L. W. Craighead et al., 1994; Nathan & Gorman, 2002).

Conclusions and Future Directions

Conclusions

BT, which began in earnest during the 1960s, can trace its origins to the basic psychology laboratory and learning theory. CBT has multiple origins, including applications of basic cognitive psychology, cognitive conceptualizations of selfcontrol, and cognitive therapy. Specific BT and CBT procedures vary according to the nature of the disorder being treated. Some variant of BT and CBT has been demonstrated to be effective for most DSM-IV Axis I disorders and some Axis II disorders. Appropriate utilization of BT and CBT in the clinical setting requires a thorough understanding of the therapeutic model and treatment rationale as well as training in implementation of the specific procedures, even when they might appear simple to use. The endurance (maintenance) following these successful treatments are the best among psychotherapeutic interventions.

With many disorders, BT and CBT have been combined with pharmacological interventions to enhance acute treatment effects (e.g., schizophrenia and bipolar disorders), although with other disorders (e.g., depression) the value of combining BT and CBT with medications is less well established. In fact, with some disorders (e.g., bulimia nervosa) the addition of medications appears to weaken the acute effects of BT and CBT. Furthermore, with some disorders combining BT and CBT with medications to improve acute treatment effects appears to compromise the well-established maintenance or enduring effects of BT and CBT (e.g., panic disorder).

Future Directions

There are several exciting future directions for BT-CBT clinical research. For example, the relationship of behavioral and cognitive symptoms to neurobiological dysregulation may provide new conceptualizations of psychopathology as well as the refinement of current forms of these therapies and the development of new interventions. Indeed, some clinical scientists have begun to evaluate the mechanisms of change in BT and CBT compared to the biological changes of pharmacological agents; for example, Baxter et al. (1992) found that the neurobiological changes associated with BT for OCD are quite similar to those obtained with clomipramine.

BT and CBT need to be further evaluated as treatments for additional Axis II disorders. The limited evidence for treatment of APD and BPD has been encouraging. Empirical data clearly demonstrate that individuals suffering from Axis II personality disorders are among the most difficult to treat successfully, and pharmacological interventions do not appear to be particularly promising for these individuals (Ilardi & Craighead, 1994/1995). Even stronger evidence indicates that individuals with comorbid Axis I and personality disorders are much more likely to have a relapse or recurrence of the Axis I disorder even when they have been successfully treated. Thus, development of effective treatments for personality disorders, either alone or when comorbid with Axis I problems, is an essential step for BT-CBT research.

The investigation of the relationship of emotion to behavioral, cognitive, and neurobiological components of various disorders (especially Axis II personality disorders) is another area for future investigation. Clinical data suggest that it will be important to develop and systematically evaluate programs that include attention to emotional dysfunction, volatility, and dysregulation. One avenue of increasing attention to emotion would be the integration of BT and CBT with IPT. It is also possible that new findings in basic neuroscience of emotion may lead to the modification of current programs or the creative development of new interventions.

Even when treated with the most effective psychotherapy procedures available and pharmacotherapy, a goodly percentage of patients will suffer a relapse or recurrence of the disorder. Thus, it is important to expand current BT-CBT treatments to include a relapse prevention emphasis toward the end of therapy; some of the programs reviewed in this research paper have already done this. Alternatively, for those patients who have been successfully treated or have made it through an episode of a disorder and are essentially symptom free, BT-CBT programs might be developed specifically for the prevention of relapse or recurrence of the disorder.

Because the probability of recurrence of most disorders increases with each episode, it is important to develop BTCBT primary prevention programs. Such programs are needed especially for individuals who can be identified as being clearly at risk for a disorder. Although such research is expensive and difficult to complete, even modest preventive effects could be of great personal and societal benefit.

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