No Easy Answers: Avoiding Potential Pitfalls of De‐implementation

In 2012, the Centers for Disease Control and Prevention (CDC) began to de‐emphasize and de‐implement multiple evidence‐based HIV prevention practices that had been around for 20 years, thus changing the scope of implementation across the globe. The authors provide evidence how existing interventions (e.g., CDC HIV interventions) may influence implementation of interventions that came after the program was discontinued. De‐implementation is an ecological event that influences, and is influenced by, many parts of a system, for instance, implementation of one type of intervention may influence the implementation of other interventions (biomedical and/or behavioral) after a long‐running program is discontinued. Researchers and policy makers ought to consider how de‐implementation of behavioral interventions is influenced by biomedical interventions mass‐produced by companies with lobbying power. The scientific study of de‐implementation will be inadequate without consideration of the political climate that surrounds de‐implementation of certain types of interventions and the promotion of more‐profitable ones.     

Treatment of Depression and Suicide in Older Adults

This article describes a cognitive behavior therapy (CBT) intervention for suicide prevention in older adults. Although many studies have found that CBT interventions are efficacious for reducing depressive symptoms in the elderly, researchers have yet to evaluate the efficacy of such interventions for preventing suicide or reducing suicide risk in older adults. In this article we describe a 12-session CBT protocol for reducing depression, suicide ideation, and other risk factors of late-life suicide. The following aspects of the treatment are described: assessing suicide risk, conceptualizing the problem through a cognitive behavioral framework, developing a safety plan, increasing hope and reasons for living, improving social resources, improving problem-solving skills and efficacy, improving adherence to medical regimen, and relapse prevention. In addition, we review other behavioral and cognitive strategies such as activity scheduling and cognitive restructuring that are commonly associated with CBT interventions for depression. We illustrate the application of these strategies through the use of case examples.     

Group interventions for patients with cancer and HIV disease: Part III. Moderating variables and mechanisms of action

Growing evidence supports the value of group interventions for individuals who are at risk for or have developed cancer or HIV disease. However, information is more limited concerning how these services can be delivered in an optimal manner, and what processes contribute to their benefits. Parts I and II of this review examined the efficacy of different interventions for individuals at different phases of illness, ranging from primary prevention to late-stage disease, in both psychosocial and biological domains. The current paper examines some of the factors other than phase of illness that might influence group treatment effects (e.g., intervention parameters, participant characteristics), and explores mechanisms of action.     

Behavioral Family Interventions for Improving Child-rearing: A Review of the Literature for Clinicians and Policy Makers

This paper reviews evidence that behavioral family interventions are effective at improving child-rearing in distressed families and families with children exhibiting disruptive behavior. Essential therapeutic strategies offered within a collaborative therapeutic process are identified. Exemplary materials for parents and clinicians are identified. Differences between behavioral family interventions and two popular press parenting approaches are highlighted, including the lack of empirical support for these widely used programs and the advice they offer which runs counter to behavioral approaches. Recommendations are offered for combining behavioral family interventions with other empirically supported approaches, promoting more widespread use of empirically supported treatments, such as behavioral family interventions, and the need for a public health perspective on family functioning, involving collaboration among clinicians, policy makers, and researchers.     

Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Potentials and limitations of cognitive treatments for obsessive-compulsive disorder

Exposure and response prevention (ERP) is a well-established treatment for obsessive-compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure-based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Teachers' resistance to the use of school-based interventions

This article focuses on consulting with teachers about the use of school-based interventions for the control and prevention of learning and adjustment problems. In the past, it has been assumed that teachers would want to use an intervention simply because it works (i.e., the intervention is effective in producing behavior change). However, it is becoming increasingly apparent that a teacher's decision to use an intervention is based upon a wide array of factors. Accordingly, this paper describes four factors that have been linked to teachers' decisions to utilize and to continue utilizing an intervention: effectiveness, time and resources required, theoretical orientation of the intervention, and ecological intrusiveness. Because they are recommended widely by school psychologists and because they sometimes lack acceptance among teachers, behavioral interventions represent a major focus of this review.     

Threatening communication: A qualitative study of fear appeal effectiveness beliefs among intervention developers,policymakers, politicians,scientists, and advertising professionals

Threatening communication is a widely applied method in behavior change interventions, which at the same time has been heavily criticized in the psychological literature. The current paper describes a study of the reasons for this persistent wide application of threatening communication. We conducted qualitative interviews with 33 key actors in behavior change intervention development in The Netherlands. Specifically, we interviewed intervention developers, policymakers, politicians, scientists, and advertising professionals. The interviews were transcribed and subsequently coded using NVivo. We found that participants most closely involved with the actual intervention development were generally convinced that threatening information was to be prevented, but often did not understand the exact processes involved. They were often under the impression that rather than a potent efficacy enhancing element, a behavioral suggestion would suffice to prevent threatening communication from backfiring. As participants were further removed from the actual intervention development, they generally tended to be more in favor of threatening communication. The main reasons for use of threatening information were to attract attention or prompt self‐reflection through confrontation, because target population members were assumed to like threatening information and respond rationally to increased risk perceptions by changing their behavior, or simply because no alternatives were available. In addition, intervention developers frequently had to deal with supervisors or funders who preferred threatening communication. Thus, when communicating with practitioners, it seems fruitful to provide them with a toolbox of evidence‐based behavior change methods that promote adaptive, rather than maladaptive, behavior; to promote basing interventions on the most relevant behavioral determinants as identified by determinant analyses; and to equip intervention developers with the tools to persuade other key stakeholders that fear is a bad counselor.     

Empirical and Theoretical Conclusions of an Analysis of Outcomes of HIV-Prevention Interventions

ABSTRACT— Over two decades of HIV-prevention attempts have generated a most impressive ecological data set for the test of behavioral-change and persuasion theories in the domain of condom use. An analysis of this evidence has yielded five important empirical and theoretical conclusions. First, interventions are more successful at achieving immediate knowledge and motivational change than they are at achieving immediate behavioral change. Second, the immediate motivational change decays over time, whereas behavior change increases over the same period. Third, interventions that engage audiences in particular activities, such as role-playing condom use, are more effective than presentations of materials to passive audiences. Fourth, interventions consistent with the theories of reasoned action and planned behavior, with self-efficacy models, and with information-motivation and behavioral-skills models prove effective, whereas interventions designed to induce fear do not. Fifth, expert intervention facilitators are more effective than lay community members in almost all cases. When populations are unempowered, expert facilitators are particularly effective, and they are most effective if they also share the gender and ethnicity of the target audience.     

Toward a technology of generalization: The identification of natural contingencies of reinforcement

Applied behavior analysts have directed a growing effort towards the development of a technology for behavioral generalization and maintenance over the past decade. Among the list of potential generalization promoters thought to exist is the natural contingency of social reinforcement (i.e., a behavioral trap) for new behavior in its untrained form or setting, or over time. Although past researchers have noted a need to program for the generalization and maintenance of behavior change, the current understanding of behavioral traps precludes the use of these contingencies to support behavioral changes when interventions are not in operation. This article describes five forms of evidence useful for the identification and analysis of natural contingencies of reinforcement. Examples from the applied research literature are provided to illustrate the kinds of studies that would greatly enhance our knowledge of behavioral traps and improve our ability to understand and program the generalization of trained behaviors across diverse forms and settings, and over time.     

A systematic review of primary prevention strategies for sexual violence perpetration

This systematic review examined 140 outcome evaluations of primary prevention strategies for sexual violence perpetration. The review had two goals: 1) to describe and assess the breadth, quality, and evolution of evaluation research in this area; and 2) to summarize the best available research evidence for sexual violence prevention practitioners by categorizing programs with regard to their evidence of effectiveness on sexual violence behavioral outcomes in a rigorous evaluation. The majority of sexual violence prevention strategies in the evaluation literature are brief, psycho-educational programs focused on increasing knowledge or changing attitudes, none of which have shown evidence of effectiveness on sexually violent behavior using a rigorous evaluation design. Based on evaluation studies included in the current review, only three primary prevention strategies have demonstrated significant effects on sexually violent behavior in a rigorous outcome evaluation: Safe Dates (Foshee et al., 2004); Shifting Boundaries (building-level intervention only, Taylor, Stein, Woods, Mumford, & Forum, 2011); and funding associated with the 1994 U.S. Violence Against Women Act (VAWA; Boba & Lilley, 2009). The dearth of effective prevention strategies available to date may reflect a lack of fit between the design of many of the existing programs and the principles of effective prevention identified by Nation et al. (2003).     

Information-motivation-behavioral skills model-based HIV risk behavior change intervention for inner-city high school youth.

This study assessed the effects of 3 theoretically grounded, school-based HIV prevention interventions on inner-city minority high school students' levels of HIV prevention information, motivation, behavioral skills, and behavior. It involved a quasi-experimental controlled trial comparing classroom-based, peer-based, and combined classroom- and peer-based HIV prevention interventions with a standard-of-care control condition in 4 urban high schools (N = 1,532, primarily 9th-grade students). At 12 months postintervention, the classroom-based intervention resulted in sustained changes in HIV prevention behavior. This article discusses why both of the interventions involving peers were less effective than the classroom-based intervention at the 12-month follow-up and, more generally, suggests a set of possible limiting conditions for the efficacy of peer-based interventions.     

Introduction: Using Evidence-Based Cognitive and Behavioral Principles to Improve HIV-Related Psychosocial Interventions

Behavioral interventions have been, and continue to be, a cornerstone of efforts to prevent new HIV infections, as well as to improve the physical and mental health of people living with the virus. Most existing efficacious behavioral interventions, many based on the principles of cognitive behavior therapy, have been developed and disseminated to focus on reducing unprotected sex, given that the HIV epidemic in the United States is primarily facilitated through sexual contact, and improving adherence to life-saving HIV medications. The new wave of behavioral HIV interventions builds on that strong foundation by integrating cognitive and behavioral techniques to ameliorate mental health symptoms, focusing content to be culturally tailored to unique subpopulations, and implementing novel delivery methods (telephone, family-based, etc.). The articles that appear in this special series report on the details of several novel, evidence-based, cognitive behavioral interventions related to HIV prevention or treatment.     

Determinants of Money Management Behavior

Financial debt continues to rise, especially among college students, indicating a need for behavioral research to develop more effective money-management interventions. This study examined social psychological variables relevant to money management decision making among college students. Attitude, affect, perceived ability, and past experience were found to influence money-management behavior (i.e., maintaining a budget). We also examined an attitude model of money management and found 9 variables (e.g., normative influence, perceived barrier, perceived control) that determined attitudes toward maintaining a budget. The relevance of our findings to debt prevention is discussed.     

Adapting Homework for an Older Adult Client With Cognitive Impairment

There is growing evidence that psychosocial treatments incorporating behavioral intervention strategies can be effective in the treatment of depression in older adults with cognitive impairment. However, less work with such cases has focused on the use of cognitive interventions in tandem with these behavioral intervention strategies. This case study describes how cognitive behavioral intervention strategies and related homework assignments were tailored and integrated to successfully treat depressive symptoms in an older African American diagnosed with probable Alzheimer’s disease. Examples of the homework strategies utilized are introduced by phase of treatment. We also discuss ways to overcome barriers to homework completion as well as methods to incorporate the client’s sociocultural context and personal history into homework.     

On the effectiveness of and preference for punishment and extinction components of function-based interventions

The current study describes an assessment sequence that may be used to identify individualized, effective, and preferred interventions for severe problem behavior in lieu of relying on a restricted set of treatment options that are assumed to be in the best interest of consumers. The relative effectiveness of functional communication training (FCT) with and without a punishment component was evaluated with 2 children for whom functional analyses demonstrated behavioral maintenance via social positive reinforcement. The results showed that FCT plus punishment was more effective than FCT in reducing problem behavior. Subsequently, participants' relative preference for each treatment was evaluated in a concurrent-chains arrangement, and both participants demonstrated a dear preference for FCT with punishment. These findings suggest that the treatment-selection process may be guided by person-centered and evidence-based values.     

The Behavior Education Support and Treatment (BEST) school intervention program: pilot project data examining schoolwide, targeted-school, and targeted-home approaches

As part of a pilot project, four elementary schools were randomly assigned to receive one of four interventions: (a) a schoolwide intervention that incorporated universal and targeted treatment, (b) a targeted-school intervention delivered to individual students in regular and special education classrooms, (c) a targeted-home intervention delivered in home and regular classroom settings, and (d) a control condition that did not receive a designated intervention. Results showed that the behavior of disruptive children in all schools improved during the course of the year, with some evidence that interventions provided complementary effects. These findings support the continued use of behavioral interventions in elementary schools and argue for interventions that combine different methods of delivering interventions.     

A Conceptual Model and Clinical Framework for Integrating Mindfulness into Family Therapy with Adolescents

Individual and group‐based psychotherapeutic interventions increasingly incorporate mindfulness‐based principles and practices. These practices include a versatile set of skills such as labeling and attending to present‐moment experiences, acting with awareness, and avoiding automatic reactivity. A primary motivation for integrating mindfulness into these therapies is compelling evidence that it enhances emotion regulation. Research also demonstrates that family relationships have a profound influence on emotion regulation capacities, which are central to family functioning and prosocial behavior more broadly. Despite this evidence, no framework exists to describe how mindfulness might integrate into family therapy. This paper describes the benefits of mindfulness‐based interventions, highlighting how and why informal mindfulness practices might enhance emotion regulation when integrated with family therapy. We provide a clinical framework for integrating mindfulness into family therapy, particularly as it applies to families with adolescents. A brief case example details sample methods showing how incorporating mindfulness practices into family therapy may enhance treatment outcomes. A range of assessment modalities from biological to behavioral demonstrates the breadth with which the benefits of a family‐based mindfulness intervention might be evaluated.     

Secondary prevention interventions for young drug users: a systematic review of the evidence

This paper reviews the international scientific evidence on the effectiveness of secondary prevention interventions for young drug users. The review provides insight into the effectiveness of interventions that have been evaluated using moderately strong research designs. Most of the studies included are from the United States of America. Some interventions are effective in reducing drug use and associated problems while others have no or mixed effect. Those successful in reducing drug use include behavior therapy, Minnesota 12-step programs, residential care, and general drug treatment. Those with either no effect or mixed effect include schools interventions. Involving parents and other agencies may enhance an intervention's effect. There is a lack of good quality studies outside the USA. Future interventions should focus on either low- or high-risk groups of young drug users. Future research should be conducted on a wider range of services for young people and include non-medical outcomes such as communication skills, schooling, employment, family relations, and economic costs.     

Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.