Application of a Quality Improvement Process to Evaluate Self-Directed Therapy for Patients on a Waitlist in an Outpatient Anxiety Disorders Specialty Clinic

The demand for psychological services in the United States is higher than the available supply of qualified mental health professionals. As a result, there is a substantial need for low-cost interventions that are more accessible and amenable to scale-up independent of the availability of clinicians. Previous studies have found that self-directed bibliotherapy can be an effective intervention with minimal therapist contact. Using the Plan-Do-Study-Act (PDSA) improvement process framework, we implemented self-directed therapy in our outpatient anxiety disorders specialty clinic. We identified four self-directed therapy resources (two books and two smartphone apps) based on cognitive behavioral or acceptance and mindfulness principles. We conducted initial 30-minute billable bibliotherapy consultations with six patients on our waitlist, where we provided the rationale for self-guided treatment, introduced the four resources, helped the patient identify one resource to use, and answered any questions. Eight weeks later, we met with five of these patients for a second billable 30-minute consultation (one had already started individual therapy) and gathered information regarding feasibility and acceptability of these resources as well as helped the patient make continued or better use of the resource until beginning therapy. This case series suggests that self-directed interventions can be effectively implemented in this manner, though with mixed outcomes and effects on patients and their course of care. We describe improvements we intend to implement in future iterations of self-directed therapy.     

Methodological and theoretical issues in neuropsychological assessment

While there are philosophical and theoretical differences between neuropsychologists and behavior therapists, it is suggested that a significant reconciliation can be achieved in regard to assessment and treatment of the brain-damaged patient. While brain damage is often viewed as an irreversible disorder, there is evidence that substantial recovery of function can occur, particularly when adequate retraining is provided. There are practical and empirical considerations that suggest that neuropsychological tests are currently the best tools available for behavioral assessment of brain-damaged patients. However, the results of these tests can be used not only diagnostically but also to identify target behavioral deficits that may be rehabilitated through systematic retraining efforts. Such rehabilitation efforts can be optimally planned, implemented, and evaluated through an alliance between the neuropsychologist, who identifies the ability and deficit pattern, and the behavior therapist, who devises and evaluates the retraining program. It is possible that the successes of behavior therapy in numerous clinical and educational applications can be repeated in the cases of brain-damaged patients. However, such success would appear to be contingent on appreciation of the high degree of specificity often seen in neurological deficit patterns and the great complexities involved in the relationships between brain function and behavior.     

Long-term nurse-patient interactions: factors in patient compliance or noncompliance to the dietary regimen

Noncompliance to treatment regimens is a widespread, costly problem. The present study examines nurse-patient interactions as factors in compliance/noncompliance to the hemodialysis dietary regimen. Several research studies have evidenced these interactions to be central to patient compliance. However, no research has been reported that has controlled for the nature of the treatment regimen; rather, practitioners' interactions with patients who are being treated for a variety of disorders have been examined. An interaction-process-analysis technique was used to code the verbal behaviors that occur during treatment between 38 hemodialysis outpatients with chronic renal disease and the nurses who provide their treatment. These verbal interactions were analyzed in relation to levels of dietary compliance/noncompliance of patients and length of nursing tenure. It was found that emotionally positive and negative responses by nurses were both positively associated with noncompliance to the dietary regimen; however, treatment-related responses by nurses were not associated with compliance/noncompliance level. With regard to length of nursing tenure, it was found that emotionally positive and negative responses by patients were positively associated with nursing tenure and that treatment-related questions by nurses were negatively associated with nursing tenure.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

Telephone Assessment,Support, and Counseling for Depression in Primary Care Medical Clinics

The Telephonic Assessment, Support, and Counseling Program (TASC) was developed to improve access to behavioral health assessment, counseling, and evidence-based psychotherapy in a public health system with an underserved, diverse population. The program is described in detail with examples of materials that can be replicated in other sites. TASC was designed to augment the management of depression provided through primary care clinics, which is where most people in the United States receive treatment for depression. The program used behavioral activation treatment for depression (BA), a well-researched evidence-based form of cognitive behavioral therapy that can be delivered by telephone in a relatively brief time period. TASC also incorporated motivational interviewing (MI) strategies into medication adherence and depression counseling. The intervention was conducted with primary care patients diagnosed with depression by their PCPs through five telephone calls targeting education about depression, medication adherence, and strategies to teach patients to monitor their mood and daily activities and to increase the number of specific activities in which they engage. Prior to beginning BA treatment, the Patient Health Questionnaire-9 and the Mini-International Neuropsychiatric Inventory were conducted to effectively identify alternative diagnoses or serious comorbidities. Primary care clinics providing medical care to low-income, diverse populations have many patients who could benefit from contact with a mental health provider, and telephonic delivery of these services in a program such as the TASC model may be a viable and cost-effective option that can increase access.     

Behavioral Telehealth Consultation with Families of Children with Autism Spectrum Disorder

In this study, desktop video teleconferencing was used to facilitate behavioral consultation at a distance with three parents of school‐age children with autism spectrum disorders. Parents were supported via desktop video teleconferencing as they conducted functional analyses and learned to implement an antecedent manipulation strategy, functional communication training, and a consequence‐based strategy. Parents then conducted a brief multi‐element treatment comparison to evaluate the preliminary effectiveness of each intervention strategy on their child's challenging behavior. The results of this study provide additional support to previous research suggesting that a telehealth model of behavioral consultation may be an effective way to assist parents of children with autism spectrum disorders address challenging behavior that disrupts family routines. Suggestions for future research are discussed. Copyright © 2016 John Wiley & Sons, Ltd.     

A mathematical approach for establishing treatment priorities among patients

Medical decision making often utilizes subjective observations to arrive at concrete judgments. The decisions frequently affect who receives scarce medical treatments and, thus, who lives or dies. In this paper, a model health status index is described. It is specific for the problem of choosing patients for hemodialysis or transplantation. Such a health status index may be designed for any medical decision involving such issues as drug treatment priorities, identification of salvageable patients, and selection of patients for scarce medical treatment. This index (1) incorporates a physician's own medical criteria and values, (2) can be modified as the data base improves, (3) assures consistency from decision to decision, and (4) can be developed and used without the help of a mathematician or computer.     

Compliance during sessions and homework in exposure-based treatment of agoraphobia

The relationship between compliance with cognitive-behavioral treatment instructions and outcome was examined for 56 agoraphobic clients treated with in vivo exposure and training in anxiety management strategies. Clients who complied more often with anxiety management instructions during treatment sessions tended to improve more on a behavioral avoidance test than those who were less compliant, but did not differ on three other outcome variables. Compliance with instructions for self-directed exposure between sessions was examined in a subset of 28 of these Ss. Clients who spent more time doing homework reported significantly greater decrements in fear of fear than less compliant clients and also tended to report larger changes on avoidance behavior. However, a quasi-experimental comparison of homework vs no-homework treatment protocols yielded no difference in outcome. Less compliant clients were more symptomatic pretreatment and rated their therapists as less caring and less self-confident.     

Emotional consequences of collective action participation: differentiating self-directed and outgroup-directed emotions

The present research examines the emotional and behavioral consequences of collective action participation. It demonstrates that "positive" and "negative" emotions can be experienced simultaneously as a result of collective action participation, yet it is important to distinguish outgroup-directed from self-directed emotions. Results of two experiments (N = 71 and N = 101) that manipulated participation in collective action illustrate that whereas collective action participants experience more outgroup-directed anger and contempt, they feel more self-directed positive affect. Furthermore, collective action participation predicted willingness to engage in moderate and radical collective actions in the future. These relations were mediated by outgroup-directed, but not by self-directed, emotions, suggesting that outgroup-directed rather than self-directed emotions play a crucial role in the maintenance of protest behavior. Theoretical and practical implications of these findings are discussed.     

A comparison of self-directed and therapist-directed practice for fear reduction

Various amounts of self-directed and therapist-directed practice were evaluated in reducing fear of snakes. The conditions included an exclusively self-directed condition, a predominantly self-directed condition, a predominantly therapist-directed condition, and an exclusively therapist-directed condition. All treatments resulted in reduced fear on behavioral and self-report measures. The predominantly therapist-directed subjects showed more improvement than subjects in the exclusively self-directed and predominantly self-directed conditions, but not more improvement than subjects in the exclusively therapist-directed condition.     

Typologies of Alcohol Dependence. From Jellinek to Genetics and Beyond

The goal of typology research is to identify subtypes of alcohol dependent (AD) patients sharing fundamental characteristics and try to match each subtype, with the most precise treatment strategy. This review provides a comprehensive history of the literature on alcohol dependent subtypes starting from the earliest attempt made by Jellinek. The binary models identified most closely with Cloninger and Babor as well as the successively more complex classifications are discussed. Typology classification potentially useful in guiding the treatment of AD patients, especially in the case of the serotonergic medications. Contrasting data suggests that other factors could influence the response to a medication and/or that more complex typologies should be identified. In summary, typology models may assist in the ascertainment criteria for clinical trials performed in behavioral and pharmacotherapeutic interventions. Greater emphasis, however, must be made to more clearly delineate this field of research, while moving toward more standardized typologies.     

Developing Successful Communication Strategies: A Test of an Integrated Framework for Effective Communication1

In studies of advertising, many communication strategies have been formulated, but little research has been carried out on the process of deciding what strategy can be used best in a particular situation. In social psychology, models have been developed that specify a number of behavioral determinants. Though communication practitioners often use these models, scientific proof of the effectiveness of persuasive messages based on these models is largely absent. In this study, knowledge from advertising studies and social psychology is combined in an integrated framework for effective communication. In an experiment on chocolate‐bar buying behavior, we prove that by making use of this framework, we can predict which advertising strategy is the most effective.     

A multimethod investigation of the behavioral activation system in bipolar disorder

Dysregulation in behavioral activation system (BAS) activity has been implicated in the pathogenesis of bipolar disorder (BPD). To characterize BAS activity and related facets in this disorder, the authors compared 59 participants with BPD to 44 controls on multiple measures of BAS activity, including a standardized behavioral task, self-reports, and electroencephalographic indexes of regional cortical activity. Levels of putative BAS activity differed depending on assessment strategy. When a behavioral task indexing reward sensitivity was used, euthymic BPD patients showed evidence of higher BAS activity than either control participants or patients who were in a mood episode. Following a mood induction procedure designed to elicit BAS activity, currently episodic patients showed relatively greater left anterior cortical activity than either euthymic or control participants. Implications of the findings for future research on BPD vulnerability are described.     

Processes underlying generalization through participant modeling with self-directed practice.

Real-life exposure methods for avoidance difficulties are highly effective (Coleman, 1976), though generalization of therapy gains could improve (Bandura, Blanchard and Ritter, 1969; Bandura, Jeffery and Wright, 1974; Blanchard, 1970). Bandura, Jeffery and Gajdos (1975) recently demonstrated a procedure to enhance generalization of participant modeling effects through the addition of a period of self-directed exposure. While Bandura et al. (1975) emphasized the role of self-directed mastery, and the attributions of self-confidence which accompany, enhanced generalization might well have been due to additional exposure to the former threats. Individuals who received the self-directed practice addendum had an additional hour of exposure, nearly double that of the group which received participant modeling only. It is therefore important to further investigate self-directed practice to determine whether it enhances generalization effects more than additional exposure with the therapist present. Such a design would aid (a) in identification of the best programs for obtaining generalization and (b) in determination of the underlying processes involved in generalization.Bandura et al. (1975) included another group, varied self-directed practice, in which subjects, after participant modeling, practiced independently with the treatment and an additional snake. The rationale was that the more varied the threats mastered independently the more likely would be subsequent positive attributes of success. They found this group to be inferior to the self-directed group on several self-report measures of generalization, however, due to premature confrontation of the additional threat stimulus. We felt this procedure would be enhanced by graduating exposure to the varied threat stimuli during varied practice.In the present experiment adult female rat phobics received participant modeling with (a) an addendum of therapist-present overlearning, (b) an addendum of self-directed practice with the treatment rat, or (c) self-directed practice with varied rats. It was predicted that self-directed practice would result in more generalization than would overlearning and that graduated, varied self-directed practice would result in further improvements.     

Case study: The combined use of imipramine and behavior modification to reduce aggression in an adult male diagnosed as having autistic disorder

The present study examined the behavior decelerative effects of combined imipramine (tofranil) and behavior modification in a severely retarded, depressed autistic man. A simple interrupted time-series design was conducted and the primary data analytic techniques consisted of modified trend analyses and dependent samples t-tests. Consistent with previous theory and scant empirical research, results indicated that combined imipramine and behavior modification significantly reduced daily episodes of self-directed and other-directed aggression. Specifically, controlling for the effects of time, the combined treatment regimen led to significant reductions in both level and slope across three topographies of aggressive behavior. Limitations of the present study and recommendations for future research were discussed. It was concluded that combined imipramine and behavior modification may be an effective strategy for reducing aggression in the developmentally disabled.     

Stages of change and stuttering: a preliminary view

As a way to better understand the process of change that occurs in stuttering, Craig [Craig, A. (1998). Relapse following treatment for stuttering: a critical review and correlative data. Journal of Fluency Disorders, 23, 1-30] compared the behavioral changes that people who stutter often experience with and without treatment to those that have been observed for certain (non)addictive behavior disorders such as smoking, overeating, phobia and anxiety disorder. The process underlying these behavioral changes has been described by the transtheoretical or "stages of change" model, which is a model of behavior change that can illuminate "where" a person is in the process of change, and how this may relate to the outcome of either treatment or self-change attempts [Prochaska, J. O., & DiClemente, C. C. (1986). The transtheoretical approach. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy. New York: Brunner/Mazel]. The purpose of the present study was to analyze the extent to which the responses of adults who stutter on a modified Stages of Change Questionnaire yield interrelations among questionnaire items that are consistent with a stage-based interpretation. Results of both confirmatory and exploratory factor analyses indicated that while the modified questionnaire was a relatively good fit for participant responses, the structure derived from the exploratory analysis provided a significantly better fit to the observed data. Results suggest that a questionnaire incorporating items that better reflect the unique behavioral, cognitive and affective variables that characterize stuttering may better discriminate stages of change in people who stutter as they move through therapy, or are engaged in self-directed change. Educational objectives: After reading this paper, the learner will be able to: (1) describe the transtheoretical or "stages of change" model; (2) describe the various processes that are associated with different stages of change; (3) summarize research findings in stages of change as they apply to a variety of clinical populations; (4) discuss the applicability of the findings from the present study to stuttering treatment, and (5) relate conventional strategies and techniques used in stuttering therapy to different stages in the process of change.     

Behavior change and individual differences in self-control

The use of self-control has become a major emphasis in recent behavioral treatment approaches. This has been especially true for the modification of appetitive disorders: high frequency behavior with immediate positive and delayed negative consequences, such as smoking and overeating. While the results have. for the most part. been promising, they have been marked by a high degree of intersubject variability: even the most generally effective programs have had only selective success (Mahoney, 1972). This variability might well be a function of fundamental interindividual differences in the ability to implement various self-control procedures. Kanfer (1971) has conceptualized self-control as a three component, closed loop process: self-monitoring followed by self-evaluation followed by self-reinforcement. The utilization of each component, the nature of their interaction and their implementation are all learned. Given the complexity of the process and idiosyncratic learning histories, individual differences are to be expected in each component of the self-control sequence. The effectiveness of any therapeutic program emphasizing self-control should, therefore, be a function of the ability and disposition of the patients to implement the self-control sequence or the specifie component required by the procedure. An individual having low facility to administer effective self-reinforcement might, for example, do poorly in a program that required self-reinforcement by containing little or no external supports. Someone who has not learned to accurately selfevaluate might contravene a program by administering self-reinforcement inappropriately.One way to test this contention would be to administer a self-control based treatment to individuals identified as differing in self-control ability: high self-controllers would be expected to do better. That method of attack might, however, be deferred. Lichtcnstein (1971) has suggested that before conducting extensive, elegantly designed treatment research, clinical evidence supporting the efficacy of the procedures be gathered. That approbation can be applied to the evaluation of the general hypothesis presented above, which has not yet had direct empirical support. An alternative, more conservative research strategy would be to precede a treatment study with an examination of individuals who had already changed their own behavior: a process that by definition requires the effective use of self-control. Were the hypothesis valid, differences in the general predisposition (or ability) to emit self-control responses should be observed between individuals who have modified their own behavior (e.g., quit smoking, lost weight) and those unable to do so. The purpose of the present study was to offer some preliminary data on this issue by comparing a group of people who had lost weight or quit smoking with a group that had failed at either. The component of self-control selected for study was self-reinforcement. It was predicted that individuals able to modify their own behavior would have a greater predisposition to use positive self-reinforcement than those unable to do so.     

Vocational choice: A decision making perspective

We propose a model of vocational choice that can be used for analyzing and guiding the decision processes underlying career and job choices. Our model is based on research in behavioral decision making (BDM), in particular the choice goals framework developed by Bettman, Luce, and Payne (1998). The basic model involves two major processes. First, the selection of a decision strategy according to four choice goals: maximizing decision accuracy, minimizing cognitive effort, minimizing negative emotion, and maximizing justifiability of the decision. Second, the construction of situation-specific preferences, which can reflect irrelevant task and context factors such as the evaluation mode. This basic model is extended to account for social influences and the long decision time typical of most career and job decisions. We review research on vocational choice in light of this model, discuss normative implications for counseling, and outline a research agenda for studying vocational choice from a behavioral decision making perspective.     

Triple P-Positive Parenting Program: Towards an Empirically Validated Multilevel Parenting and Family Support Strategy for the Prevention of Behavior and Emotional Problems in Children

This paper outlines the theoretical and empirical foundations of a unique multilevel parenting and family support strategy designed to reduce the prevalence of behavioral and emotional problems in preadolescent children. The program known as Triple P-Positive Parenting Program is a multilevel system of family intervention, which provides five levels of intervention of increasing strength. These interventions include a universal population-level media information campaign targeting all parents, two levels of brief primary care consultations targeting mild behavior problems, and two more intensive parent training and family intervention programs for children at risk for more severe behavioral problems. The program aims to determine the minimally sufficient intervention a parent requires in order to deflect a child away from a trajectory towards more serious problems. The self-regulation of parental skill is a central construct in the program. The program uses flexible delivery modalities (including individual face-to-face, group, telephone assisted, and self-directed programs) to tailor the strength of the intervention to the requirements of individual families. Its multidisciplinary, preventive and community-wide focus gives the program wide reach, permitting the targeting of destigmatized access points through primary care services for families who are reluctant to participate in parenting skills programs. The available empirical evidence supporting the efficacy of the program is discussed and its implications for research on dissemination are discussed.     

THE EFFECT OF A TOKEN ECONOMY ON DIETARY COMPLIANCE FOR CHILDREN ON HEMODIALYSIS

Adherence to dietary restrictions is a recurring problem for children on hemodialysis. The effect of behavior modification in maintaining dietary control is reported for four patients aged 11 to 18 years. Weight gain, potassium level, and blood urea nitrogen were utilized as criteria measures. A token reinforcement program implemented by the hemodialysis team resulted in significant changes in the dietary pattern of the children. The average weight gain between dialysis sessions for the four subjects during treatment was reduced by 45% and the degree of weight fluctuation was lessened. Potassium levels and BUN were controlled to their appropriate level for subjects who initially exceeded the criterion level. With the withdrawal of weight gain from the contingency system, increase of weight gain between dialysis sessions was noted for all subjects.