More theory-driven and less diagnosis-based behavior therapy

Pergamon J. Behav. Ther. & Exp. Psychiat. Vol. 27, No. 2, pp. 75-86, 1996

Copyright © 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved

S0005-7916(96)00008-0 0005-7916196 $15.00 + 0.00

MORE THEORY-DRIVEN AND LESS DIAGNOSIS-BASED BEHAVIOR THERAPY

GEORG H. EIFERT West Virginia University, U.S.A.

Summary -- Individualized treatment based on a functional analysis of problem behavior used to be considered a hallmark of behavior therapy. Yet the relative success of recently developed treatment manuals for DSM-defined disorders has cast doubts as to whether treatment individualization is really necessary. This article evaluates some of the relative merits of assessments and manualized treatments based on DSM categories and discusses data that indicate when a protocol treatment approach is sufficient and when it is not. Finally, a theory-driven approach to conducting behavior therapy is proposed as a way to complement individualized and manualized treatments. This approach is illustrated by presenting a model-based assessment and treatment approach to overcome excessive heart-focused anxiety (cardiophobia). Copyright © 1996 Elsevier Science Ltd

Individually-tailored treatments based on idiographic functional assessment, guided by psychological (mostly behavioral) theory, used to be one of the hallmarks and strengths of behavior therapy (Kanfer, 1985; Schulte, 1973, 1992; Wolpe, 1977, 1986, 1989). Yet, despite the initial success of this approach, a growing number of standardized treatment protocols are being developed for many common psychological dysfunctions with session-by-session prescriptions of techniques and ways of their implementation. These developments have culminated in the publication of a list of empirically validated psychological treatments (e.g., Task Force on Psychological Procedures, 1995) for patients who meet the diagnostic criteria for a given disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders- /V (DSM-IV; American Psychiatric Association, 1994). A list of manuals for such treatments has also been published recently (Sanderson & Woody, 1995).

Efforts to standardize and manualize treatments have largely arisen in response to changes in health care policies and pressures from insurance companies. On the surface, these efforts appear to constitute a return to the medical model of diagnosis and treatment that early behavior therapists have fought tooth and nail (e.g., Ullmann & Krasner, 1975). A closer examination, however, reveals this not to be the case. Persons (1991) indicates that in

Based on a paper presented in the symposium Standardized versus individualized behavior therapy: A critical evaluation (G. Eifert, Chair), conducted at the World Congress of Behavioral and Cognitive Therapies, Copenhagen, Denmark, July 1995.

Requests for reprints should be addressed to Georg H. Eifert, Department of Psychology, West Virginia University, Morgantown, WV 26506-6040, U.S.A.

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medicine, a diagnosis is intended to reflect underlying pathogenic mechanisms (cf. Schulte, this issue), and treatment is determined by diagnosis. In contrast, DSM-III or -IV diagnoses, which have come to dominate behavior therapy research and practice, are not based on, or defined by, underlying mechanisms and dysfunctional processes. Instead, problems are defined at the symptom level and discussion of underlying biological and/or psychological processes and mechanisms is explicitly avoided (cf. Persons, 1991). How can we then justify the development and implementation of one-fits-all-type treatment protocols in behavior therapy (or psychiatry, for that matter)?

Despite such thorny questions and all criticisms, it is a political, practical, and clinical reality that neither the DSM nor treatment manuals are going to disappear in the foreseeable future. Instead, we are likely to see a proliferation of manuals in coming years. The purpose of this article is to evaluate some of the relative merits of assessments and manualized treatments based on DSM categories, present data that indicate when a protocol treatment approach is sufficient and when it is not, and propose a theory-driven approach to conducting behavior therapy as a way to complement individualized and manualized treatments. The model-based assessment and treatment of excessive heart-focused anxiety (cardiophobia; Eifert, 1992; Eifert et al., 1996) will be used as an example.

Relative Merits of Assessments and Treatments Based on Syndromal Classification

Advantages

A categorical assessment system such as the DSM fulfills a basic need and function in any science, namely that of ordering and making sense of large amounts of complex information. The DSM provides a categorization and systematization of problems with detailed descriptions of abnormal behavior. It lists specific positive and differential diagnostic criteria of malfunctioning that can be helpful for practice and research. For instance, it alerts clinicians and researchers to sets of behavior that tend to cluster in persons with some degree of regularity.

Likewise, the development and systematic evaluation of DSM-based standardized treatment protocols, as one (rather than the only) approach to therapy practice and research, has its merits. A number of manuals and protocols exist that provide detailed descriptions and operationalizations of generally effective techniques. In addition, such manuals often contain easy-to-use measures that can be readily employed to evaluate pre-to-post and concurrent treatment changes. These features make manuals valuable tools for the training of students and for guiding therapy in general.

Moreover, in this era of managed care competition and increasing financial scrutiny from lawmakers and insurance companies, protocols have been used extensively to evaluate the general efficacy of behavioral interventions in a systematic way (cf. Barlow, 1994). A recent comprehensive analysis of the outcome research literature by Giles (1993) supports the general efficacy, and at times superiority, of behavioral interventions for a variety of common psychological dysfunctions. As an example, a manualized cognitive-behavioral treatment for panic disorder (Barlow & Craske, 1994) has been remarkably effective for patients with that diagnosis (Brown & Barlow, 1995; Craske et al., 1991). Such results cast doubt on the "dodo bird hypothesis", largely based on meta-analytic studies, that all forms of psychotherapy are more or less equally effective. These data are also important for practical and policy purposes

Theory vs. Diagnosis-driven Behavior Therapy 77

and are likely to give a boost to behavioral interventions and the profession at large (cf. Barlow, 1994; Hayes, 1995).

Disadvantages

There are, however, a number of serious problems and weaknesses with standardized treatment manuals and the "multicomponent package" approach to therapy:

(l) A syndromal system implicitly assumes more uniformity between persons with the same diagnosis than is justified. This "uniformity myth" (Kiesler, 1966; Persons, 1991) is foremost among the problems of the syndromal approach. Practitioners repeatedly remind researchers that patients and problems are more diverse than is implied by DSM categories, and many patients have multiple rather than single-category problems. As an example, a patient with panic attacks may also be depressed, have problems at work and with a spouse at home, suffer from serious medical problems such as diabetes, and drink too much alcohol. Patients with the same diagnosis may also differ in the relative intensity and combinations of diagnostic criteria and symptoms. Finally, some problems do not fit neatly in categories and, from a DSM perspective, represent combinations of disorders and syndromes. Examples are persons with "mixed anxiety-depression" or persons with excessive heart-focused anxiety or cardiophobia (Eifert, 1992; Eifert et al., 1996), which will be discussed later. In any case, disorder-based manuals are inappropriate and insufficient for persons with such problems.

(2) The rigid application of prescribed protocols can result in "therapy overkill". It is questionable whether all persons with a given DSM diagnosis really need all components of a multicomponent manual package. As a result, some patients receive more therapy than is necessary, which provides little or no benefit to those patients and, at worst, may be harmful. For instance, Persons (1991) gives the example of behavior exchange strategies that may be helpful to some couples but actually counterproductive for others. Other patients may become disgruntled and drop out of treatment because they feel they are being asked to engage in unnecessary or irrelevant tasks.

(3) "While response similarity in maladaptive habits provides a convenient basis for placing [persons] in diagnostic pigeonholes (e.g., anorexia, claustrophobia, or stuttering), common pigeonholes do not necessarily imply common [problems and] treatment, because the stimulus antecedents vary" (Wolpe, 1989, p. 9). Hersen (1995) also alluded to this Achilles heel of behavior therapy (Wolpe, 1977) and argued that whenever behavior therapy produces poor results, one of the likely culprits is incomplete or inadequate behavioral (functional) analysis. This lack of regard for differences between patients with the same DSM diagnosis is, at least in part, responsible for some of the frustrating results of group-based therapy outcome studies comparing the differential efficacy of behavioral vs. cognitive or drug interventions. Although many studies (e.g., Michelson et al., 1988) find significant pre-to- post within-group changes of patients in most groups, there are frequently no differences between treatment groups (see also Seligman, 1995, for an insightful discussion of these issues). Rather than being indicative of no differences between treatments, these studies may simply illustrate the point that there are differences between patient problems with the same diagnostic label.

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Evaluating Individualized and Standardized Multicomponent Treatments

In view of the problems with standardized treatments and the apparent merits of treatment individualization, one might be tempted to make a strong case for treatment individualization. Yet, the solution is not that simple or straightforward. Apart from the fact that it is unrealistic to assume that treatment manuals will simply disappear, individualized treatments are not without problems either. First, conducting a theory-driven functional analysis, and designing and implementing an individualized treatment derived from such an analysis, requires considerable expertise (training, skills, and practice) and time. Second, individualized treatments do not always result in superior treatment outcome when compared with multicomponent treatment packages. For instance, recent studies have shown that tailored treatment (based on individual functional analyses) did not yield superior results compared with standardized behavioral treatment for patients with obsessive-compulsive problems (Emmelkamp et al., 1994) and patients with phobic anxieties (Schulte et al., 1992) -- in fact, Schulte and colleagues found that standardized treatment was superior to individually tailored treatment.

Based on these findings, one could tentatively conclude that for some problems and people (but not for others!), clinical diagnosis is a relevant and sufficient criterion for treatment selection. Individualization appears to be less necessary for narrowly defined and well operationalized dysfunctions (e.g., phobic anxieties) and more homogeneous populations. A possible reason is that there is not only topographical, but also considerable functional similarity and overlap in the dysfunctional behavior of persons with phobic anxieties and obsessive-compulsive problems.

In any case, individualization is still necessary for problems that are topographically similar, but that are functionally dissimilar due to a multitude of etiological and maintaining factors. Some of the most compelling evidence attesting to the value of individualizing treatments based on a functional analytic approach is provided by treatment studies of persons with severe and/or multiple behavioral disabilities. For instance, Iwata (1994) reports a recent study covering 4000 treatment sessions of 152 single-subject functional analyses of self-injurious behavior (SIB). These analyses convincingly demonstrate the benefits of identifying the environmental determinants of SIB (e.g., antecedent and consequent events) on an individual basis: the probability of positive treatment outcome was directly related to whether treatment was relevant or irrelevant to a given function of SIB -- regardless of whether the topography of the specific behavior was similar or not (cf. Scotti et al., 1991).

Depression is another example of a problem that requires individualized assessment and treatment. Although many persons with a diagnosis of "major depressive episode" report similar symptoms (e.g., dysphoric mood and loss of interest in activities), the etiological and maintaining variables may vary significantly between persons with this diagnosis (cf. Eifert et al., in press). Although some studies have not supported individualization over standardized treatments for depression (Nelson-Gray et al., 1989), most have supported the superiority of individualized treatment (Heiby, 1986; McKnight et al., 1984; cf. Godoy et al., this issue). These latter studies employed a theory-driven matching of treatment techniques to specific problems or combinations of dysfunctional behavioral processes identified within different response classes of a given client. Indeed, the most important criterion for treatment assignment should be whether the behavior of persons (with the same or different DSM diagnoses!) is functionally similar, regardless of whether or not it is topographically similar. Similarly, Hersen (1995) recently called for methods of classification based on ethological


(functional) criteria. He argues that depression subtypes are likely to reflect etiological subtypes and that treatment outcomes are, at least in part, determined by how well clinical scientists (researchers and practitioners) pay attention to etiological differences between people in terms of different maintaining variables and subject characteristics. In turn, the degree of treatment success for depressed persons is likely to be influenced by how well patients in a particular treatment condition receive the type of treatment that most closely matches their etiological or functional subtype of depression - - either by accident in a randomized group outcome protocol or by foresight and planning in an individualized protocol•

There are also a number of general clinical situations that make an individualized approach essential (cf. Chorpita, 1995; Persons, 1992). For instance, a functional analysis is critical to analyse and cope with treatment failure of any kind (e.g., when a protocol-based treatment breaks down or with noncompliant patients) and for using the therapeutic relationship most effectively (Schulte, 1996; this issue)•

Finally, it should be noted that the distinctions between individualized and standardized treatments are less rigid than they may seem. For instance, the actual implementation of almost any manual still requires s o m e degree of adaptation to the specific problems and life circumstances of the individual case (cf. Schulte, this issue)• Some manuals consist of over a dozen chapters and are extremely detailed (e.g., Barlow & Craske, 1994), whereas others barely exceed a dozen pages and contain more general instructions for therapists (e.g., Schulte et al., 1992). Such d i f ferences be tween studies and def ini t ions of what const i tutes individualization vs. standardization make comparisons of the two approaches difficult•

Detailed comprehensive manuals, in particular, are also likely to cover and target so many aspects of a given problem ("shotgun approach") that therapists conducting individual analyses might not identify additional or different problems - - although they might discover fewer and only the most relevant problems, and, as a consequence, conduct fewer treatment sessions• Given the growing number of providers working in managed care settings, this could actually become an increasingly more important argument for conducting individualized assessments and treatments. Hayes (1995) pointed out that "manualized treatment programs are set up for several times the average length of outpatient t r ea tmen t . . , which is 4 to 6 sessions per client. • . . If patients are only going to come in 4 to 6 times, therapy should make a big difference in 4 to 6 sessions" (p. 184). This can only be achieved if we focus on the most relevant treatment targets with the most individualized and effective interventions.

Complementary Use of Individual Functional Analysis and Multicomponent Treatment Manuals

Much of the debate between proponents of individualization and multicomponent treatment manuals has been unnecessarily divisive. The contributions in this symposium show that there are ways to combine id iographic and manua l ized mu l t i componen t approaches in a complementary fashion• An intriguing study by Jacobson et al. (1989) demonstrates that even standardized research protocols can be used in a more flexible way with long-term positive effects.

Treatment may indeed become more flexible through individualized combinations of modules based on functional theory-driven (model-based) analysis of the needs of the individual patient. For instance, many treatment manuals contain some modules that target dysfunctional processes and behaviors that may occur in different "disorders"• As an example,

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thoracic breathing and hyperventilation are frequent problems for persons with different DSM diagnoses (e.g., panic disorder and hypochondriasis). A module for teaching diaphragmatic breathing will be useful and beneficial for patients with either one or both of these diagnoses. On the other hand, since not all persons with a diagnosis of panic disorder or hypochondriasis hyperventilate, those who do not hyperventilate simply do not require that module. A functional analysis can reveal what particular modules need to be implemented for a person with a given diagnosis, which modules are not necessary, and what additional treatment should be applied. Such an analysis may also tell us how, when, and why dysfunctional behaviors occur (i.e., what is controlling their occurrence). A flexible and more theory-driven use of treatment manuals would allow us to preserve some of their advantages, while avoiding some of the pitfalls associated with their use.

Theory-driven and Model-based Treatments

The examples of self-injurious behavior and depression have shown that functional assessment and classification is crucial for persons presenting problems that have a multitude of etiological and maintaining factors. This is because the functional approach guides the clinician in the identification of the most relevant dysfunctional processes which are then targeted in treatment. We have termed this approach to assessment and treatment paradigmatic behavior therapy (Eifert & Evans, 1990; Eifert et al., 1990; Staats, 1990, 1995). One might also refer to it more generally as theory-driven assessment and people that exhibit symptoms (behaviors) of presumably several disorders, which is also referred to as "dual diagnoses" and "comorbidity". Both of these terms are misleading from a functional analytic perspective, because they imply that a person has two (or more) structural disorders that need to be assessed and treated. Instead, what assessment and treatment should focus on are the functional relations between behaviors belonging to different repertoires or response classes, regardless of whether they fit one or a number of DSM categories (cf. Forsyth & Eifert, this issue). An example of such a problem is excessive heart-focused anxiety of "cardiophobia" (Eifert, 1992; Eifert et al., 1996), which I will use to illustrate how a theory-driven approach to behavior therapy and problem-specific models may help therapists conceptualize complex clinical problems to design and implement individualized behavioral interventions. The select use of modules from treatment manuals may complement such interventions.

From a syndromal perspective, cardiophobia is a hybrid of (a) limited symptom panic disorder -- persons typically complain of chest pain and heart palpitations, which are misinterpreted as signs of physical heart disease, but report fewer and/or less intense other symptoms associated with "regular" panic disorder; (b) hypochondriasis or disease phobia -- despite numerous negative medical tests patients continue to suspect they have an undetected heart problem and are afraid of having a heart attack; and (c) obsessive-compulsive disorder -- to reduce their anxiety, patients continue to seek excessive medical help and reassurance from doctors and relatives (Eifert, 1992; Eifert et al., 1996). Yet, not every person with heart- focused anxiety presents with all of the above "symptoms" (behaviors) in the same way, that is, people exhibit different combinations of these behaviors and with varying frequency and intensity. Moreover, apart from any topographical similarities, these behaviors have different origins in different people, and they may serve quite different functions. It would therefore be inappropriate and inadequate to treat such persons simply with a manual for panic disorder, hypochondriasis, and/or OCD. What is required is an individualized theory-driven approach


that helps to organize and relate the various aspects of the problem and then targets the relevant maintaining dysfunctional processes.

Paradigmatic or psychological behaviorism (PB), an integrative multilevel theory originally developed by Staats (1975, 1990, 1995), could serve this organizing and guiding function. PB provides a bridge between the basic levels and principles of behavior (i.e., the physiological and conditioning bases of behavior) and the more advanced and specifically human levels of functioning (i.e., learning through language, thinking, and other symbolic processes). This human learning level of theory does not compete with but builds upon basic physiological and conditioning principles. In addition, a number of problem-specific models have been developed (Heiby & Staats, 1990; Staats, 1990, 1995) to relate the biological, emotional, conditioning, and personality processes in the etiology and maintenance of different types of dysfunctional behavior within one psycho-biological framework (cf. Staats & Eifert, 1990). In the past, language and other symbolic processes have frequently been omitted from or neglected in a functional analysis, which, incidentally, has contributed heavily to the ascendance of cognitive theories (cf. Eifert et al., 1993). In contrast, PB theory and models account for the functions of language in regulating human abnormal behavior by including semantic and other higher.-order classical conditioning principles (cf. Eifert et al., 1990; Staats, 1972). We have indicated elsewhere (Forsyth & Eifert, in press) how this approach is compatible with other recent behavioral approaches (e.g., Hayes & Hayes, 1992) that analyse the function-altering effects of language in abnormal behavior and behavior therapy. Wolpe (1981, 1993) has also repeatedly pointed out that language, thought, and imagery have always been intimately involved in clinical behavior therapy.

I have adopted this framework to integrate a large number of variables and processes that appear to be involved in the origin and maintenance of cardiophobic behavior (Eifert, 1992; Eifert et al., 1996). The areas covered are inherited and acquired biological vulnerability factors, historical antecedent events, psychological vulnerability in the form of deficient and inappropriate basic behavioral repertoires, current antecedent or precipitating events, and the stimulus properties and consequences of current dysfunctional behaviors. These variables are related in a manner that provides clinicians with a comprehensive understanding of heart- focused anxiety and with a useful tool for guiding the idiographic assessment and treatment of cardiophobic persons. Table 1 provides specific examples of dysfunctional processes identified in the PB model of cardiophobia. Since therapists can only target concrete behavior, Table 1 lists examples of specific dysfunctional behaviors that are related to the various dysfunctional processes. Intervention strategies, aimed at modifying dysfunctional processes, are derived from behavioral and other psychological principles. For implementation, therapists need to translate these intervention strategies into intervention techniques, that is, actual therapist behaviors that have the best chance of affecting a particular dysfunctional behavior.

One major dysfunctional process (or class of behaviors) is the person's fear of dying of a heart attack, which is indicated by verbal reports of fear, avoidance of feared cues, and avoidance of activities that are believed to harm the heart. This fear is extinguished by (a) exposing the patient to feared cues and (b) reinforcing the patient for engaging in strenuous exercise and other presumably "dangerous" activities. Another major dysfunctional class of behaviors is the person's belief of having heart disease. At a concrete behavioral level, persons will verbally insist on a medical diagnosis and reject a noncardiac diagnosis as well as alternative explanations of chest pain and heart palpitations. The general strategy to target this class of behaviors is to test alternative (nonmedical) explanations for symptoms (e.g., having tension or anxiety) and conduct therapy in the context of an experiment that provides an

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Table 1 Theory-driven and Model-based Treatment of Cardiophobia (cf. Eifert, 1992): Matching of (a) Dysfunctional Processes (Response Classes) with Intervention Strategies and (b) Dysfunctional Behavior with Intervention Techniques

Dysfunctional Process Intervention Strategy Dysfunctional Behavior Intervention Technique

Heart Disease Conviction

Verbal insistence on medical diagnosis Verbal rejection of nonorganic diagnosis Verbal rejection of muscle tension hypothesis

Fear of Dying of Heart Attack

Verbal report of fear

Avoidance of feared cues "Cardioprotective" avoidance behavior Avoidance of feared situations

Excessive Help/Reassurance Seeking

Request repeat tests Questions about diagnosis

Excessive pulse and blood pressure checking

Excessive Breathing and Arousal

Hyperventilation using chest muscles Muscles tightness (particularly chest wall)

Therapy as Experiment/Chance for Hypothesis Testing Testing of Alternative Explanations for Symptoms

Explain impact of anxiety~tension on body sensations (chest pain)

Discuss mind-body interrelatedness (avoid mind-body dichotomy)

Do chest muscle relaxation with EMG biofeedback

Extinction of Fear and Exposure to Avoided Activities

Withhold reassurance - Examine evidence for~against heart disease Review evidence for anxiety~tension hypothesis Exposure to interoceptive (particularly cardioceptive) cues

Reinforce "dangerous" behavior (e.g., strenuous exercise) Reinforce approach behavior (e.g., go to Cardiac ICU)

Extinction of Help and Reassurance Seeking

Refuse further tests -- Review results of previous tests Withhold reassurance -- Review conclusions f rom previous discussions

Do physical exercise and prevent pulse and blood pressure checking

Change Breathing Pattern and Reduce Tension

Teach slow diaphragmatic instead of thoracic breathing

Teach relaxation (particularly of chest muscles)

opportunity for testing alternative hypotheses. An intervention technique derived from this strategy is to provide a patient with a credible explanation of how anxiety and tension (particularly of chest wall muscles) can result in body sensations such as chest pain. In support of this reformulation, patients are given a chest-focused relaxation with EMG feedback that literally shows how they can change their chest tension levels.

Some dysfunctional behaviors of persons with panic disorder, such as hyperventilatory breathing, can also occur in persons with cardiophobia. In terms of treatment, it would be appropriate to use the relevant chapters and modules from the Mastery o f Your Anxiety and Panic manual (Barlow & Craske, 1994) to target this particular dysfunctional behavior. In contrast , other aspects of a cardiophobic person ' s behavior (e.g., excessive help and


reassurance seeking) are not covered in a panic disorder manual. These dysfunctional behaviors need to be targeted individually by (a) withholding medical and therapist reassurance and (b) teaching patients alternative behaviors such as learning to reassure themselves by reviewing results of previous tests and outcomes of behavioral exposure exercises.

Conclusions

The issues raised in this article, and throughout this symposium, point to several implications and recommendat ions for assessment and treatment. Probably the most fundamental and important conclusion is that instead of an overreliance on topographical symptom-oriented assessments and treatments, we should conduct more process-oriented assessments and treatments that aim to identify and change the actual conditions or context that maintain a given problem. As a result, the overall efficacy of behavior therapy interventions is likely to increase; in turn, we are also likely to learn more about behavior principles (cf. Eifert & Plaud, 1993). This may require developing a different or additional type of classification system -- one that uses functional criteria and that is based on etiological processes.

Overall, the existing data comparing individualized and standardized treatments are inconclusive. To determine under which conditions, and for which clients and problems, individualized theory-driven treatments are consistently superior, we need to go beyond traditional group outcome research. For instance, Seligman (1995) recently suggested prospective large-scale naturalistic consumer satisfaction surveys, and Hayes (1995) argued for field surveys of patients and therapists that use functional individualized case formulations within managed care settings. More and sophisticated series of single case design studies (Barlow et al., 1984) are also needed.

At this time, neither a rigid application of manuals nor their total rejection appears feasible or even desirable. A possible guideline emerging from past research is to use standardized protocols for "simple" cases (with focused problems and no comorbidity) and an idiographic treatment approach for complex cases (cf. Persons, 1995). Another suggestion is the flexible use of treatment manuals and modules based on individual case formulations that are derived from a functional analysis of patient problems. In any case, instead of attempting to assess and treat structural disorders with multicomponent intervention packages and fixed numbers of sessions, the most important task of behavior therapists is to conduct functional analyses of problem behaviors guided by problem-specific models. A theory-driven hypothesis-testing approach to conducting therapy, that is both flexible and patient-focused, is critical for the long-term survival and prosperity of behavior therapy in an era of managed health care.

Acknowledgements -- I wish to thank John Forsyth for his helpful input and suggestions, and Angela Lau and Carl Lejuez for their comments on a draft of this article.

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More theory-driven and less diagnosis-based behavior therapy