So where do we go from here?

BEHAVIOR THERAPY 18, 203-217, 1987

PRESIDENTIAL ADDRESS

So Where Do We Go From Here?

W. STEWART AGRAS

Stanford University School o f Medicine

The research and clinical enterprise of behavior therapy has prospered, having become the mainstream of psychotherapy research and a central aspect of clinical practice. The percentage of controlled clinical studies published in Behavior Therapy has steadily increased over the years, and studies now have a longer duration of follow-up. Despite this progress, a theme of discontent has been sounded in the literature. One source of discontent has been sown by the claim that all therapies are equal. Such a claim leads to a theoretical and therapeutic deadend. Rather, it is necessary to iden- tify the active ingredients of all therapies that have been demonstrated to work in particular conditions. Amongst the challenges and opportunities facing behavior therapy in the near term, are the facilitation of behavior change in the real world, a vigorous exploitation of the interaction between behavioral and pharmacologic therapies, and the development of a behavioral epidemiology focusing upon understanding the etiology of the conditions that we treat.

In the past few years, despite the ever-strengthening evidence for the efficacy of behavioral treatments, and the widening applications of such therapies, a theme of discontent has been sounded in the writings of many experts in the field. Krasner (1985) in his review of the thousand page "International Handbook of Behavior Modification and Therapy" asks "so where do we go from here? This handbook brings to a focus the crisis in the behavior modification field. It has lost its initial unity and theoretical cohesion. There is no coherent overall picture of the field or where it is going. I have no specific recommendations to remedy the situaton other than to call attention to the obvious and to suggest that we all focus some attention on these major problems of the behavioral movement, overload and fractionization."

Before addressing the question of where we are going, we first need to re- member, in this twentieth anniversary year of AABT's founding, where we have come from. The two major procedural origins of behavior therapy were operant conditioning and systematic desensitization, both stemming from a

This paper was presented as the Presidential Address to the Association for Advancement of Behavior Therapy, Twentieth Annual Meeting, Chicago, IL., November 1986. Requests for reprints should be sent to W. Stewart Agras, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA 94303.

203 0005-7894/87/0203-021751.00/0 Copyright 1987 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

204 AGRAS

learning theory base and moving from laboratory experiments to the clinic. These two approaches to changing human deviant behavior provide an interesting contrast. Desensitization was a largely cognitive procedure in which patients imagined approaching their feared situations while simultaneously practicing relaxation (Wolpe, 1958). This mode of treatment was convenient for the therapist who could see the patient in his or her office. Operant conditioning on the other hand, with its focus upon direct behavioral observation and alteration of the environment, necessitated changes in the behavior of the would-be therapist.

Lindsley (1960), in a pioneering adaptation of the methods of operant conditioning to the clinic, described his first experiments with chronic mental hospital patients in the 1950s. In these experiments, the "Skinner box" was moved from the animal laboratory to the hospital, so as to observe the lever-pressing of very disturbed individuals in response to various schedules of reinforcement. This report paradoxically provides us with an account of the effect of a human relationship on the behavior of a chronically psychotic individual. The patient had for many weeks emitted essentially no response in the "Skinner box," being apparently impervious to the reinforcing contingencies governing lever-pressing. Then a student nurse came onto the ward, and established what appears to have been a meaningful relationship with the patient. First, the patient stopped swearing, and then after being told by the nurse to "stop listening to your voices" he began to press the lever for reinforcement at a more normal r a t e - a rate that was the highest observed in this patient in over four years of measurement. This state of affairs continued quite happily for a time, until the nurse told that patient that she had "only two weeks left" on the ward. At that point the patient briefly increased his rate of lever-pressing and then reverted to his old ways as reflected by a return to the baseline rates of lever-pressing. This sad little story not only demonstrated that a rather crude measure of human functioning was sensitive enough to capture the effects of a human relationship on the behavior of a very disturbed person, but that the effects of such a relationship could generalize across situations and across time. Moreover, the dramatic albeit transient effects of a verbal communication upon behavior are also demonstrated in this case report.

As we know, this somewhat artificial mode of measurement was rapidly aban- doned in favor of direct observation of the behavior of interest. Simultane- ously, the environment of interest also changed, from the artificially contrived to the real, from the Skinner box to the mental hospital ward and to the school- room. The early successes of reinforcement therapy led to the notion of "Be- havioral engineering" (AyUon & Michael, 1959) and to a host of applications in closed environments in which a large number of important behaviors were found to be susceptible to change (Kazdin, 1977). In an early piece of work, Ayllon and Azrin (1965) demonstrated the effectiveness of using tokens with chronic psychotic patients in a series of single-case experiments. One of the most sophisticated applications and testing of a token economy system was the experiment conducted by Paul and Lentz (1977) comparing a social-learning program with a more traditional milieu therapy program. This experiment, as pointed out by Hartmann and Barrios (1980) in their review of the book

FUTURE DIRECTIONS FOR BEHAVIOR THERAPY 205

in which the results were reported in detail, had many noteworthy features including "the employment of multiple outcome measures, continuous monitoring of staff behavior to ensure proper operation of programs, collection of long-term follow-up data, and computation of comparative cost-effectiveness of programs." Patients in both treatment programs showed progress, but those in the social-learning program improved more, and maintained their gains more successfully during the eighteen-month follow-up. Moreover, the social learning program was the most cost-efficient of the two programs. This outstanding piece of work delineated effective and durable methods for the rehabilitation of the chronic mental hospital patient, pointing the way to the design of more humane environments in the mental hospital.

The story of systematic desensitization is somewhat different. In the case of most phobias we are dealing with free-roving adults, albeit a somewhat ambiguous term when applied to the agoraphobic! Nonetheless, there is no easily accessed "natural environment" in which to investigate or treat the problem. In response to this difficulty, an analogue experimental situation, in which snake-fearful young women stood in for the phobic, was devised. The use of an analogue of the phobia allowed for a more rapid and precise delineation of the active variables involved in the therapeutic procedure than would have been possible in the clinic. Desensitization did not seem to work by the method of reciprocal inhibition as originally proposed. Instead, after a decade or more of intensive experimentation with both analogue and clinical subjects, it became clear that the critical procedure in all psychotherapies that successfully treated phobia was practice in the feared situation, usually called exposure therapy. Thus the treatment of phobia moved from one largely based in the therapist's office to the real world. This was one of the first demon- strations in the behavior therapy literature that a particular procedure was not quite what it seemed, and that apparently different procedures worked as well as each other because they contained a common element.

This careful experimental dissection of active from inactive therapeutic procedures, an approach that has become a hallmark of work in behavior therapy, led to the establishment of rules for the conduct of psychotherapeutic experiments. Amongst these rules, is the key one that the therapeutic manual be used to guide the therapists and to allow replication by others. The therapeutic sessions should be tape-recorded and these tapes analyzed to confirm that the procedures were applied accurately. Measures, depending upon the problem being studied, should be at three levels: direct observation of behavior, a variety of self-reported measures, and physiologic measures. If the data are available-and this unfortunately is not often the case- the degree to which the various measures have been normalized during therapy should form one basis for an examination of outcome. Such assessment packages should be specific for each condition being studied, depending on our understanding of the factors involved in etiology and maintenance, and the building of a theoretical model of the problem behaviors and the variables controlling such behaviors.

There is no doubt that the research enterprise of behavior therapy has flourished; indeed it has become the mainstream of psychotherapy research.

206 A6~s

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I I I I I I I I /

- H T R E A T M E N T STUDIES i - O" " ° CONTROLLED TR EATM ENT STUDI i i " 1

0 112 314 5/6 718 9/10 11/12 13/14 15/16

VOLUME FIG. 1. The percentage of articles in a random sample from each of Volumes 1-16 of Be-

havior Therapy which are treatment studies (solid line) and controlled treatment studies (broken line).

In Figure 1, the percentages of articles presenting treatment studies and controlled treatment studies in the journal Behavior Therapy are presented. These data are an extension of those presented in an earlier paper (Agras and Ber- kowitz, 1980). As can be seen, after a slow start in the first four volumes of Behavior Therapy, the proportion of controlled treatment studies has steadily increased, reaching nearly 60°70 of articles in the most recently completed volume. The number of subjects involved in the studies over the years has not changed much, ranging from 12 to 30, and averaging 27 in the last four volumes of the journal, indicating that the usual study is small in scale. The duration of follow-up ranges from 8 weeks to 24 weeks over the 16 volumes, with a distinct tendency for longer lengths of follow-up in the last few years. Thus the average length of follow-up in the articles selected in the last four volumes of the journal is 21 w e e k s - a period close to that for controlled clinical trials reported in two research-oriented medical journals, the Lancet and the New England Journal o f Medicine (Fletcher and Fletcher, 1979). The average number of subjects reported in the controlled medical trials was 30, and the duration of follow-up was 26 weeks. Research in behavior therapy is maturing, at least in terms of duration of follow-up and the number of subjects involved in the studies reported, assuring more adequate study power and a more realistic assessment of the duration of therapeutic effects.

Relationship to Other Psychotherapies Although there have been many attempts to meld psychoanalytic and learning theories during the past fifty years (Goldfried, 1982), it is fair to say that be-

F U T U R E DIRECTIONS FOR BEHAVIOR THERAPY 207

havior therapy was born in counterpoint to psychoanalysis. The focus in behavior therapy on the symptomatic behavior brought a refreshing new look to psychotherapy research, and has resulted in a quarter century of quite remark- able research and clinical application. Sharply divergent views and models are often stimulating to science, and we should not feel that we should share a common theory with psychodynamic psychotherapy. Little has come of the many attempts at theoretical melding, in terms of an accepted common theory, in stimulating new research, or in devising new therapeutic strategies or procedures. What is needed to advance knowledge in the field of psychodynamic psychotherapy are outcome studies demonstrating the effectiveness of this approach to treatment and factorial studies aimed at isolating the effective ingredients of therapy. The findings from such studies might lay the ground- work for a common theory and practice between behavioral and psychodynamic therapies.

This topic leads me to the unfortunate superficial view now emerging in the literature that all psychotherapies have similar outcomes, a view based on the use of simplistic approaches to evaluation, such as box scores and meta- analysis (Luborsky, Singer, & Luborsky, 1975; Smith, Glass, & Miller, 1980). Taking the work of Kirkley et al. (1985) as an example, it is possible to inter- pret the results of this study of the treatment of bulimia nervosa as demonstrating that self-monitoring combined with nondirective psychotherapy is equivalent in effectiveness to the cognitive behavioral package used. Thus, there was no significant difference in outcome on a number of standard evaluation instruments such as the Beck Depression Inventory, the State-Trait Person- ality Inventory, the Assertion Inventory, and the Eating Attitudes Test, although both groups showed significant change from pre- to posttreatment on each of these measures. Yet when self-monitoring records of the patients were examined, significant differences were found between the groups in favor of cognitive behavioral therapy, in terms of binge eating and vomiting frequency. This suggests that outcomes may differ depending upon the measures used. Unfortunately, most meta-analytic comparisons of different treatments share only the more global "paper and pencil" measures, rather than the more pointed self-reported or directly observed behavioral measures.

Moreover, this spurious identity of effects between treatments is compounded by lumping together very different treatment approaches into the crude cate- gories of "psychotherapy" and "behavior therapy." Here we are being misled by labels. Take for example, an even finer discrimination, namely the procedural differences between existing controlled studies of psychotherapeutic treatments for bulimia (Fairburn, Kirk, O'Connor, & Cooper, in press; Kirkley et al., 1985; Lacey, 1983; Lee & Rush, 1986; Ordman & Kirschenbaum, 1986; Wilson, Rossiter, Kleifeld, & Lindholm, 1986; Wolchik, Weiss, & Katzman, 1986). As indicated in Table 1, these studies share the following procedures: self-monitoring, nutrition information, and shaping of meal frequency and content. Beyond these common procedures, some studies added relaxation training, others assertiveness training, and still others various forms of verbal psychotherapy, often poorly specified as to type and content. Add to these differences, variation in the number of therapeutic sessions, and the fact that

208 AORAS

T A B L E 1

DIFFERING THERAPEUTIC PROCEDURES REPORTED IN SEVEN CONTROLLED

TREATMENT STUDIES FOR BULIML~, ALL USING VARIANTS OF

COGNITIVE-BEHAVIORAL THERAPY

Self- N u t r i t i o n E a t i n g C o g n i t i v e R e l a x R e s p B o d y A s s e r t - P s y c h o -

A u t h o r M o n i t I n f o M e a l s B e h R e s t r u c t T r a i n i n g P r e y I m a g e iveness t h e r a p y

Lacey, + + + + + + + +

1983

K i r k l e y e t a l , + + + + + + - -

1985

O r d m a n & + + + - + - + -

K i r s c h e n b a u m ,

1985

L e e & R u s h , + + + + + + - -

1986

W o l c h i k e t a l , + + + - + - - +

1986

W i l s o n et a l , + + + - + - - -

1986 + + + - + - + -

F a i r b u r n e t a l , + + + + + - - -

(in p ress )

+ +

( ins ight )

-- +

-- +

(supportive) + -

some of these therapies were conducted in groups and others individually, not to mention differences in recruitment methods and participant characteristics, and the countries in which the studies were carried out, and we can see how ludicrous it is to lump such studies together for the purposes of statistical analysis. Interestingly, the three studies comparing different therapeutic procedures all found differences between those procedures in some aspect of outcome (Fairburn, Kirk, O'Connor, & Cooper, 1986; Kirkley et al., 1985; Wilson, Rossiter, Kleifield, & Lindholm, 1986). Yet, those differences would undoubtedly be blurred by a global comparison of outcomes.

These global comparisons, with their implicit message that it doesn't matter which therapeutic procedures are used, have, I believe, been responsible in part for a loss of direction in behavior therapy research. What does one do if every- thing is equal? It is a theoretical and therapeutic dead end. It is illuminating, therefore, to consider another therapeutic comparison, between more sharply differentiated therapeutic procedures, behavior therapy and psychopharmacologic agents.

Behavior Therapy and Psychopharmacology The relationship between behavior therapy and psychopharmacology has

altered over the years. Characterized in the early days by suspicion and some- times outright hostility, the attitudes of both behavior therapists and psycho- pharmacologist seem to be changing. In consequence, an emerging interaction between the two fields is taking place in the scientific literature. Problems of joint interest to psychopharmacologists and behavior therapists include

F U T U R E D I R E C T I O N S FOR BEHAVIOR T H E R A P Y 209

obesity, bulimia, anorexia nervosa, anxiety disorders, depression, smoking cessation, childhood hyperactivity, and chronic schizophrenia.

Several studies investigating the combination of fenfluramine and behavior therapy in the management of the obese patient have been reported during the past few years. In the most comprehensive study of this issue (Craighead, Stunkard, & O'Brien, 1981) obese patients were allocated at random to one of four groups: fenfluramine administered in a physician's office; group conducted behavior therapy; fenfluramine plus nondirective group therapy; and a combination of drug and behavior therapy. The least effective condition was fenfluramine administered in a physician's office with a weight loss of 6.4 kg after six months of treatment. Adding group support enhanced the efficacy of fenfluramine therapy, with patients losing 14.0 kg, presumably due to enhanced compliance with the drug regimen. Behavioral treatment led to weight losses averaging 10.9 kg, while the combination of drug and behavioral treatment led to a mean weight loss of 14.5 kg.

At one-year follow-up this picture had changed. Those receiving behavior therapy alone showed the least tendency to regain weight, thus losing significantly more weight at follow-up than those in the combined treatment condition. Participants who received fenfluramine without behavior therapy fared the worst. This finding underscores the usefulness of behavior change procedures in promoting maintenance of weight losses. Moreover, here is a clear case of different therapies not having equal effects either in the short or long term, and of the effects being reversed between short and long term assessments.

In the case of depression, several controlled studies have found that of patients who respond to therapy, those receiving cognitive-behavioral therapy either alone or in combination with a tricyclic antidepressant show less tendency to relapse than those receiving antidepressants alone (Hollon, Tuason, Weimer, deRubeis, Evans, & Garvey, 1983; Simons, Murphy, Levine, & Wetzel, 1986). Since patients receiving antidepressants tend to improve more quickly than those receiving cognitive-behavioral therapy (Roth, Bielski, Jones, Parker & Osborn, 1982), it would seem that in the case of depression the preferred treatment would be a combination of cognitive-behavioral therapy and an antidepressant. Similar indications of the superiority of a combination of pharmacologic agents and a behavioral procedure emerge in both the treatment of cigarette smoking and agoraphobia.

Cigarette smoking may be maintained in part by the need to maintain a constant level of nicotine in the blood, representing a physiological addiction (Russell, 1976). Nicotine chewing gum has been used to reduce the symptoms associated with smoking cessation, and placebo-controlled trials have shown that cessation rates at one-year post treatment are superior for those receiving the active nicotine gum (Raw, Jarvis, Feyerabend, & Russell, 1980). In one study, participants receive nicotine gum alone, self-regulation skills training, and a combination of these treatments (Killen, Maccoby, & Taylor, 1984). The combination treatment was statistically significantly superior at posttreatment, and showed a strong trend toward superiority at follow-up, with a 50% cessation rate for the combined treatment versus 23% and 30% for the gum and

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skills training alone, respectively. As might be expected, withdrawal symptoms were less evident for the gum users.

In the area of anxiety, psychopharmacological studies have tended to focus on the panic attack, whilst behavior therapy studies focused on the phobic limitation, an interesting example of therapists of differing orientation placing different values on different aspects of a syndrome. Thus comparisons across treatments are difficult to make, particularly since the measures of panic in the majority of studies reported to date have not been objective. A further confound exists in almost all the psychopharmacologic studies of agoraphobia reported to date, namely that exposure to the situations which participants feared has not been adequately controlled for. A recent small-scale study sug- gested that the combination of imipramine and exposure therapy was more effective across a variety of measures including panic, than either imipramine without exposure therapy, or exposure therapy alone, again suggesting a posi- tive interaction between pharmacologic treatment and behavior therapy (Telch, Agras, Taylor, Roth, & Gallen, 1985).

While differing from condition to condition, the results of studies examining the separate and combined effects of behavior therapy and psychopharmacologic agents suggest that while pharmacologic agents produce faster results in many cases, the addition of behavior therapy tends to produce less relapse. In some cases, for example obesity, pharmacological agents have not proven to be a particularly useful addition to behavior therapy. It should be noted that drop-out rates tend to be consistently higher with the use of pharmacologic agents than with the use of behavior therapy, a problem that requires further research. Could, for example, behavioral procedures be devised to reduce these drop-out rates? In addition, where different procedures produce different results, a study of the processes involved in recovery with each of the therapeutic procedures should add to our understanding of both therapies, as well as to our understanding of the condition being studied. This research area provides an interesting opportunity for both pharmacology and behavior therapy over the next few years.

Behavior Change in the Real World The problem of changing behavior in the free-roving adult looms large. For

the most part, such change is initiated with instructions and followed up with self-monitoring. The therapist is a long way from the action, a situation very different to studies of behavior change in closed environments such as the mental hospital ward or the classroom. Instead of direct observation of behavior and the circumstances surrounding it, the therapist relies on self-report. Instead of directly altering environmental contingencies, the therapist relies on the patient's own efforts to achieve such changes. Clearly this is less than satisfactory and much weakens the effectiveness of therapy. There have been attempted solutions to this problem. One of these is to contrive analogues of the natural environment which are directly under the control of the therapist, having such situations stand in for the real world, and hoping that the simulation is accurate enough for generalization to the individual's own envi-


ronment to occur. Such analogue situations have been used successfully, for example, in the treatment of phobia (Leitenberg, Agras, Butz, & Wincze, 1971).

The problem with changing behavior in the real world is twofold: first, the problem of assessing behavior that occurs with low frequency in a variety of circumstances, far from the therapist's office, and second, the problem of bringing therapeutic contingencies to bear in the real world for much of the time, rather than in the therapist's office for a little time. This problem is one of the key difficulties facing the behavior therapist in his or her daily work. Too often what we do still revolves around the fifty-minute hour, a focus that is most restrictive since we cannot expect automatic generalization from the therapist's office to the patient's world. Are there any solutions to this difficulty on the horizon?

One solution is to use computer technology to extend the range of the therapist. Ambulatory monitoring has long been used to measure behavior in the natural environment, particularly in the area of cardiovascular physiology. In one recent study, two dimensions of behavior were used to assess panic attacks as they occurred in the natural environment (Taylor, Sheikh, Agras, Roth, Margraf et al., 1986). Panic attacks are particularly difficult to study, since they rarely occur in the laboratory unless induced under very artificial circumstances. Moreover, they are relatively infrequent. Using a microcom- puter interfaced with a motion sensor and ECG electrodes, both activity levels and heart rate were collected and stored over a three-day period during which the subject wore this lightweight device night and day. Panic attacks were revealed as episodes during which activity levels were minimal and heart rates were high. The basic parameters of a panic attack occuring in the natural environment were thus revealed. Moreover, the validity of self-report could be examined, revealing overreporting of panic episodes.

The use of the computer in therapy began with the aim of simulating the interview behavior of a nondirective therapist (Weizenbaum, 1966). This program, "ELIZA," interesting as it was, demonstrated that not enough was known about the laws governing language processes to achieve this aim. Interest in computer-conducted therapy waned, until it was revived using behavior therapy procedures as the treatment modality. Behavior therapy, with it focus on specific problems, on pointed instructions regarding behavior change, assessment of the results of such change in a feedback mode, and reinforcing such changes, is ideally suited for duplication within a computer program. Lang, Melamed, and Hart (1970) were the first to develop a fully automated therapeutic inter- vention using a computer to control two tape decks in the presentation of scenes for the systematic desensitization of phobias. A simple feedback system allowed the computer to individualize the rate of presentation of the feared scenes, depending on the level of fear reported by the client. Patients thus treated improved to the same extent as those treated by a therapist. A more recent study replicated these findings in the treatment of college students with test anxiety (Biglan, Villwock, and Wick, 1979).

While the major principles of computer-based therapy were illustrated in these early studies, namely presentation of a graded task and alteration of the task based on participant feedback, such uses were relatively simple. Greist

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and his colleagues used a more sophisticated interactive program "MORTON" to deliver cognitive-behavioral therapy for the treatment of mild depression. Clients using this program begain treatment by typing responses on a keyboard to multiple choice assessment questions displayed on a computer ter- minal. Following assessment, the computer presents a rationale for treatment and begins a treatment program with a homework assignment. This program was recently tested in a controlled outcome study, and was found to be as effective as therapist-administered treatment using the same protocol (Selmi, 1983). A somewhat similar computerized treatment program for patients with agoraphobia was recently found to be as effective as both a therapist- administered version and bibliotherapy (Ghosh, Marks, & Cart, 1984).

In an interesting study comparing computer-assisted therapy with a state- of-the-art therapist-led behavioral weight loss program, computer-based therapy was found to be superior to the therapist-conducted condition (Foree-Gavert & Gavert, 1980). Those in the therapist-led behavioral program lost 6 kg, while those in the computer-therapy condition lost 14 kg over the course of a sixteen- week therapy program. These results are encouraging, suggesting that the cost of behavior therapy for several common problems might be reduced by using computer-assisted treatment, and that efficacy may also be enhanced.

In all these therapeutic applications, the computers were desktop models, thus the patients visited them, much as they would a therapist. The recent development of small lightweight computers, some of them now almost pocket- sized, offers a new opportunity to bring treatment into the situation where it belongs, namely, not the the therapist's office, but the patient's own environment. Moreover, such computers can be accessed whenever the patient wishes and can be used to record behavior as it occurs. Feedback concerning goal attainment can be given immediately when behavior is recorded, and praise statements can be delivered contingent upon performance in the natural environment.

Recently, a small-scale controlled study of the effectiveness of such a computer in the treatment of obesity was carried out in our laboratory (Burnett, Taylor, and Agras, 1985). The computer used was built especially for this pur- pose. It was capable of 45-day continuous operation, and the system included a keyboard for input of eating and activity data and a two-line liquid crystal display to allow instructions and feedback to be offered. The treatment procedures programmed into the computer were based on an operant shaping model and included auditory cueing to initiate self-reports, self-monitoring of activity levels and caloric intake, proximal goal-setting, immediate feedback in terms of goal attainment, and response-contingent praise statements. Subjects met with a therapist for 15 minutes weekly to discuss goals for the forthcoming week, answer questions about the operation of the computer, and be weighed.

Subjects were matched in pairs on body mass index and were allocated at random to either the computer-assisted therapy or a control condition in which participants monitored their behavior with paper and pencil methods and saw a therapist for the same time as subjects in the computer group. Mean weight loss for the eight-week treatment phase was 3.7 kg for the computer-treated subjects, and 1.5 kg for control subjects (p < .05). At eight months posttreat-


ment, without further access to the computer, those in the computer group had now lost an average 8.1 kg as compared with 1.1 kg for the control group.

Although deriving from a small-scale study, these results pose some interesting questions. First, it seems that given the same amount of therapist time, the computer-assisted group performed much better than the control condition, both over the short and long term. The long term results are particularly interesting, and suggest that those in the computer-assisted group had learned something, and were able to put those learned skills into effect without further interaction with the computer. This is what we might expect from therapy conducted in the patient's environment rather than in a therapist's office. Naturally there are some limitations of the present system. Thus the computer relies on self-report rather than automated data collection. It would be possible to objectively measure activity, with the system described above, and have those data automatically entered into the computer. Caloric intake may not be amenable to such objective assessment. Nonetheless, we would expect that the more objective the mode of data collection, the better the results would be.

Another Approach to the Real World--the Family The family comprises the environment in which most of us spend much

of our time. Much of the faulty learning leading to those difficulties that we categorize as behavior problems takes place within the family. The work of Patterson and his colleagues (Patterson, Chamberlain, & Reid, 1982; Patterson & Fleischman, 1979; Reid, Taplin, & Lorber, 1981) in examining and modifying the development of delinquent behavior is an excellent example of the usefulness of this approach. This work has resulted in the development of a mul- tistage model which begins with poor parental discipline leading to a coercive relationship between parent and child. This shapes a behavior pattern that leads to rejection of the child by peers, teachers, and parents, resulting in poor academic performance. This in turn enhances the probability of the child's joining a delinquent peer group, becoming involved in substance abuse, and performing pre-delinquent acts. Lack of parental monitoring at this stage rein- forces such activity, leading to a full-blown delinquent career. This model poses many interesting research questions and will undoubtedly be modified, but it is an excellent example of the type of research and model building that is necessary if behavior therapy is to progress. Not only does such a model in- crease our understanding of the processes by which deviant behavior arise, but it also allows the development of a more rational approach to treatment as Patterson and his colleagues have demonstrated, and may ultimately lead to methods to prevent the development of delinquency.

In another series of studies conducted both in England and the United States (Brown, Birley, & Wing, 1972; Vaughn, Snyder, Jones, Freeman, & Falloon, 1984), the families of schizophrenic patients were observed during an interview and a number of dimensions of interaction were measured. These included the number of critical comments made about family members, hostility,

214 AGV, AS

warmth, and emotional overinvolvement. A large number of critical comments and a high degree of emotional overinvolvement predicted a higher relapse rate for the schizophrenic patient in both studies. Apparently families in which much emotion is openly expressed are pathogenic for the returning schizophrenic. Interventions based in part upon these findings have been shown in controlled trials to improve the outcome of the treatment for schizophrenic patients. In one study schizophrenic patients received either individual therapy, or a behavioral family treatment aimed at improving problem-solving and reducing family stress. Those receiving family treatment showed a markedly reduced readmission rate as compared with those receiving individual treatment (Falloon, Boyd, McGill, Razani, Moss, & Gilderman, 1982).

Interestingly, in a study of depressed patients, only critical comments were predictive of relapse, not other components of expressed emotion such as emotional overinvolvement, suggesting a degree of specificity in the effect of family members upon one another (Vaughn & Left, 1981). These findings also suggest that family-based interventions aimed at reducing negative comments might not only accelerate the recovery of depressed patients, but might also help prevent further episodes of depression.

The development of models of family interaction that give rise to, or effect the course of deviant behaviors, is obviously a powerful research approach, particularly when based on detailed observational studies of the interactions of family members. This type of study heralds the development of a behavioral epidemiology, a necessary step, I believe, if we are are going to fully under- stand the role of learning in the development of deviant behavior, and if we are going to develop treatment procedures that are soundly based. Unfortu- nately, there are relatively few problems in which our understanding of the processes involved in their genesis and maintenance is complete enough to base a rational therapeutic approach upon. This comprises an urgent agenda for behavior therapy.

So Where Do We Go From Here? Behavior therapy is now the mainstream of psychotherapy research. Some

of the problems and uncertainties facing the field stem from this fact. It is easier to be the newcomer full of new ideas, than to be the mainstream, for it is now our own research that we and others criticize for its shortcomings. Moreover, the research has been prolific, making it difficult, nay impossible, for any one individual to grasp the field of behavior therapy. I have argued that behavior therapy should now vigorously pursue the ideal application of its theoretical position and research findings, namely, that the focus of treatment should be upon behavior, and that the place of treatment should be the situations in which the behavior problem is manifested- the patient's natural environment including the family. Many of our treatments fall short of this ideal and hence may not be as effective as they might be. We should not be satisfied with this state of affairs. We must use all our ingenuity to overcome these difficulties in measuring and influencing behavior in the real world. I would add a further item to this agenda for the near future, namely that be-


havior therapy needs to advance research into the etiology of the problems that it treats. This will mean bringing our theoretical position and measurement predilections to fields such as epidemiology.

Behavior change in the real world, the interaction between behavior therapy and biologic treatments, and the development of behavioral epidemiology- these are the challenges of the near future.

REFERENCES Agras, W. S., & Berkowitz, R. (1980). Clinical research in behavior therapy: Halfway there? Be-

havior Therapy, 11, 472-487. Ayllon, T., & Aza'in, N. H. (1965). The measurement and reinforcement of behavior of psychotics.

Journal of the Experimental Analysis of Behavior, 8, 357-361. Ayllon, T., & Michael, J. (1959). The psychiatric nurse as a behavioral engineer. Journal of the

Experimental Analysis of Behavior, 2, 323-324. Biglan, A., Villwock, C., & Wick, S. (1979). The feasibility of a computer controlled program

for the treatment of test anxiety. Journal of Behavior Therapy & Experimental Psychiatry, 10, 47-49.

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R~CEIVED: December 22, 1986 FINAL ACCEPTANCE: February 10, 1987.

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