Interobserver agreement and procedural fidelity: An odd asymmetry

We examined articles with experiments published in the Journal of Applied Behavior Analysis and in Behavior Analysis in Practice from 2017 through 2021 to determine how frequently procedural fidelity was assessed. When procedural fidelity was assessed, we determined how often a measure of interobserver agreement for those fidelity data was provided. We also determined how often a measure of interobserver agreement for participants' behavior was provided. Across both journals and all years, 54.7% of relevant articles provided a measure of procedural fidelity. Of them, 17.7% provided a measure of interobserver agreement for procedural fidelity. In marked contrast, 96.4% provided interobserver agreement data for participants' behavior. It is unfortunate that applied behavior analysts frequently fail to provide procedural fidelity data and, when they do, often fail to provide interobserver agreement data for the fidelity data. Reviewers for, and editors of, behavior-analytic journals are encouraged to strongly consider the relative value of procedural fidelity and agreement on procedural fidelity measures when rendering recommendations on the suitability of a given submission.     

A Model for Adapting Evidence-Based Interventions to Be LGBQ-Affirmative: Putting Minority Stress Principles and Case Conceptualization Into Clinical Research and Practice

The mental health field now possesses clinical trials attesting to the efficacy of affirmative practice with sexual minority individuals. With the goal of efficiently moving the results of these clinical trials into real-world clinical practice, this paper offers a model for adapting existing evidence-based practices originally developed for the general population to be lesbian, gay, bisexual, and queer (LGBQ)-affirmative. The adaptation model presented here guides clinicians to incorporate six LGBQ-affirmative transtheoretical principles of change into practice. These principles facilitate raising awareness of the impact of minority stress on sexual minority clients’ mental health and on client self-evaluation while drawing upon sexual minority resilience and intersectional experiences to build empowering coping skills and validating relationships. The adaptation model also provides a transtheoretical approach to case conceptualization that directs clinicians to consider the role of early and ongoing minority stress on sexual minority clients’ cognitive, affective, motivational, behavioral, and self-evaluative experiences that maintain current distress. This case conceptualization approach highlights common associations among these experiences, suggesting clear routes of interventions for many sexual minority client presentations. Case examples from recent clinical trials of LGBQ-affirmative cognitive-behavioral therapy illustrate how these principles and this case conceptualization can be effectively utilized in practice. While the principles and case conceptualization are meant to be transtheoretical and therefore applicable across therapeutic techniques, to date they have been tested only in clinical trials for cognitive-behavioral treatments. Therefore, this paper concludes with a call for future research to determine the effectiveness of implementing this adaptation model across diverse therapeutic modalities and client presentations.     

Race in the Space: Clinical Considerations for Addressing Race in Treatment

During a period of intense racial unrest in the nation, we were working as clinicians delivering a manualized protocol to LGBTQ adults of varying racial and ethnic backgrounds. Intrigued by the differences in our modes of engagement with clients, we, a Black, cis female therapist and White, cis male therapist, set out to further explore how our positionalities informed our communications with, and expectations of, White and non-White clients during this time. In this paper, we reflect on these differences when delivering therapy in cross-racial and same-race dyads. We highlight where our experiences overlap as clinicians trained in the same program and where they diverge due to our respective worldviews. We conclude with considerations for practitioners to engage with race in psychotherapeutic treatment.     

On the longevity of behavioral interventions for challenging behavior

The capacity for a treatment to maintain its effects over time may be the most critical component of behavioral interventions for challenging behavior as treatments that fail to persist are likely to be of little value to society. We reviewed the quality and quantity of different types of post-intervention data for the treatment of challenging behavior in studies published over the last 7 years. We found that for the majority of participants at least one measure of maintenance, fading, or follow-up was reported but with limited information regarding the quality of those measures. Reports of secondary variables related to post-intervention data (e.g., latency to measurement) were also uncommon. We discuss possible explanations for the paucity of post-intervention data, barriers to obtaining post-intervention data, strategies for obtaining these data, and implications for the external validity of behavioral interventions for challenging behavior. We provide recommendations for increasing the probability that post-intervention data are included in applied research on challenging behavior.     

Treating Young Adult Depression With Text-Delivered Cognitive Behavioral Therapy: A Pilot Randomized Clinical Trial

Young adults (ages 18 to 25) in the U.S. suffer from the highest rates of past-year major depressive episode and are the least likely to receive treatment compared to other age groups. As such, we examined the feasibility, acceptability, and efficacy of a text-message delivered cognitive behavioral therapy: CBT-txt with young adults. The study was a 2-month pilot RCT to test a 4-week intervention for depression that contained 197 text messages (average 12 texts every other day). The sample, recruited via Facebook and Instagram, was 102 U.S. young adults who presented with at least moderate depressive symptomatology. Assessments occurred at baseline prior to randomization and at 1 and 2 months post enrollment. The primary outcome, severity of depressive symptoms, was assessed using the Beck Depression Inventory II. Feasibility benchmarks were met and participants reported high levels of engagement with and acceptability of the intervention. Logistic regression indicated that treatment participants were three times as likely to have minimal or mild depression symptoms at 2 months compared to waitlist control participants. Latent change score modeling found that the strongest significant treatment effect appeared at the 1-month follow-up period, particularly for participants who began with severe depressive symptoms. Mediation analysis revealed significant indirect treatment effects of increases in behavioral activation on reducing depressive symptoms, suggesting a mechanism of change. Limitations were that the sample was relatively small and consisted of primarily women. These results provide initial evidence for the feasibility, acceptability, and efficacy of a text-delivered treatment for young adult depression.     

The elderly and high technology medicine: A case for individualized,autonomous allocation

The issues involved in decision making about the aggressiveness of future medical care for older persons are explored. They are related to population trends, the heterogeneity of older persons and a variety of factors involved in individual preferences. Case studies are presented to illustrate these points, as well as a review of pertinent literature. The argument is offered that, considering these many factors, a system of flexible, individualized care by informed patient preference, is more rational than the rationing of technological services by age.     

Ethics in health care and medical technologies

In this paper a case is used to demonstrate how ethical analysis enables health care professionals, patients and family members to make treatment decisions which ensure that medical technologies are used in the overall best interests of the patient. The claim is made and defended that ethical analysis can secure four beneficial outcomes when medical technologies are employed: (1) not allowing any medical technologies to be employed until the appropriate decision makers are identified and consulted; (2) insisting that medical technologies be employed not merely to promote the medical interests of the patient but rather on the basis of their ability to contribute to the overall well-being of the patient; (3) challenging caregivers to reflect on the dynamic interplay between their conscious and unconscious values and consequent determinations of what is in the patient's best interests; and (4) providing a justification for selected interventions which makes possible rational dialogue between caregivers espousing different viewpoints about treatment options.     

Physicians,entrepreneurism and the problem of conflict of interest

This paper examines the ethical issues of conflict of interest raised by the burgeoning development of physician involvement in for-profit entrepreneurial activities outside their practice. After documenting the nature and extent of these activities, and their potential for conflicts of interest, the paper assesses the major arguments for and against physicians' referral of patients to facilities they own or in which they invest. The paper concludes that an outright ban on such activity seems ethically warranted.     

Medical hermeneutics: Where is the “text” we are interpreting?

The present paper is a commentary on an article by Drew Leder [1]. Leder identifies a series of texts in the clinical encounter, emphasizes the central role of interpretation in making sense of each of these texts, and articulates ordering principles to guide the interpretive work.The metaphor of clinical work as textual explication, however, creates the expectation that there is a text somewhere to be found. Such an expectation invites doctors and patients to search for the text and runs the risk of conceptualizing patients as more static than they are. If one is to use the textual metaphor, one must appreciate the radical extent to which the clinical encounter is a mutually produced and shifting entity. The qualities of mutuality and indeterminacy are not those one usually associates with texts. One might ultimately be better served by a different metaphor based more directly on uncertainty.     

Family preservation using multisystemic treatment: Long-term follow-up to a clinical trial with serious juvenile offenders

In a randomized clinical trial, multisystemic family preservation was shown to significantly reduce rates of criminal activity and incarceration in a sample of 84 serious juvenile offenders and their multi-need families. In the current study, archival records were searched for re-arrest an average of 2.4 years post-referral. Survival analysis showed that youths who received multisystemic family preservation were less likely to be re-arrested than were youths who had received usual services. Such results represent the first controlled demonstration that family preservation, when delivered via a clearly specified treatment model, has lasting effects with serious juvenile offenders. Implications for family preservation and juvenile justice research are discussed.