Behavior Therapy

The present article presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more dependable the experiential sources, the greater are the changes in perceived selfefficacy. A number of factors are identified as influencing the cognitive processing of efficacy information arising from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. Possible directions for further research are discussed.

A meta-analysis of 128 studies examined the effects of extrinsic rewards on intrinsic motivation. As predicted, engagement-contingent, completion-contingent, and performance-contingent rewards significantly undermined free-choice intrinsic motivation (d = -0.40, -0.36, and -0.28, respectively), as did all rewards, all tangible rewards, and all expected rewards. Engagement-contingent and completioncontingent rewards also significantly undermined self-reported interest (d = -0.15, and -0.17), as did all tangible rewards and all expected rewards. Positive feedback enhanced both free-choice behavior (d = 0.33) and self-reported interest (d = 0.31). Tangible rewards tended to be more detrimental for children than college students, and verbal rewards tended to be less enhancing for children than college students. The authors review 4 previous meta-analyses of this literature and detail how this study's methods, analyses, and results differed from the previous ones.

Background: An integrative theoretical framework, developed for cross-disciplinary implementation and other behaviour change research, has been applied across a wide range of clinical situations. This study tests the validity of this framework. Methods: Validity was investigated by behavioural experts sorting 112 unique theoretical constructs using closed and open sort tasks. The extent of replication was tested by Discriminant Content Validation and Fuzzy Cluster Analysis.

The question of addiction speci cally concerns (1), the process by which drug-taking behavior, in certain individuals, evolves into compulsive patterns of drug-seeking and drug-taking behavior that take place at the expense of most other activities and (2), the inability to cease drug-taking; the problem of relapse. In this paper current biopsychological views of addiction are critically evaluated in light of the "incentivesensitization theory of addiction", which we rst proposed in 1993, and new developments in research are incorporated. We argue that traditional negative reinforcement, positive reinforcement, and hedonic accounts of addiction are neither necessary nor suf cient to account for compulsive patterns of drug-seeking and drug-taking behavior. Four major tenets of the incentive-sensitization view are discussed. These are:

In recent years, deficits in emotion regulation have been studied as a putative maintaining factor and promising treatment target in a broad range of mental disorders. This article aims to provide an integrative review of the latest theoretical and empirical developments in this rapidly growing field of research.

Observational studies indicate that psychologic factors strongly influence the course of coronary artery disease (CAD). In this review, we examine new epidemiologic evidence for the association between psychosocial risk factors and CAD, identify pathologic mechanisms that may be responsible for this association, and describe a paradigm for studying positive psychologic factors that may act as a buffer. Because psychosocial risk factors are highly prevalent and are associated with unhealthy lifestyles, we describe the potential role of cardiologists in managing such factors. Management approaches include routinely screening for psychosocial risk factors, referring patients with severe psychologic distress to behavioral specialists, and directly treating patients with milder forms of psychologic distress with brief targeted interventions. A number of behavioral interventions have been evaluated for their ability to reduce adverse cardiac events among patients presenting with psychosocial risk factors. Although the efficacy of stand-alone psychosocial interventions remains unclear, both exercise and multifactorial cardiac rehabilitation with psychosocial interventions have demonstrated a reduction in cardiac events. Furthermore, recent data suggest that psychopharmacologic interventions may also be effective. Despite these promising findings, clinical practice guidelines for managing psychosocial risk factors in cardiac practice are lacking. Thus, we review new approaches to improve the delivery of behavioral services and patient adherence to behavioral recommendations. These efforts are part of an emerging field of behavioral cardiology, which is based on the understanding that psychosocial and behavioral risk factors for CAD are not only highly interrelated, but also require a sophisticated health care delivery system to optimize their effectiveness. (J Am Coll Cardiol 2005;45:637-51)

Insomnia is the most prevalent sleep disorder in the general population, and is commonly encountered in medical practices. Insomnia is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.1 Insomnia may present with a variety of specific complaints and etiologies, making the evaluation and management of chronic insomnia demanding on a clinician's time. The purpose of this clinical guideline is to provide clinicians with a practical framework for the assessment and disease management of chronic adult insomnia, using existing evidence-based insomnia practice parameters where available, and consensus-based recommendations to bridge areas where such parameters do not exist. Unless otherwise stated, "insomnia" refers to chronic insomnia, which is present for at least a month, as opposed to acute or transient insomni...

The expansion and adoption of new methods of communication provide new opportunities for delivering health behavior change interventions. This paper reviews the current research examining mobile telephone short-message service (SMS) for delivering health behavior change interventions via text messages. This service has wide population reach, can be individually tailored, and allows instant delivery with asynchronous receipt, suggesting potential as a delivery channel for health behavior interventions.

Why do people's impulse controls break down during emotional distress? Some theories propose that distress impairs one's motivation or one's ability to exert self-control, and some postulate self-destructive intentions arising from the moods. Contrary to those theories, Three experiments found that believing that one's bad mood was frozen (unchangeable) eliminated the tendency to eat fattening snacks (Experiment 1), seek immediate gratification (Experiment 2), and engage in frivolous procrastination (Experiment 3). The implication is that when people are upset, they indulge immediate impulses to make themselves feel better, which amounts to giving short-term affect regulation priority over other self-regulatory goals. I count him braver who overcomes his desires than him who conquers his enemies, for the hardest victory is the victory over self.-Aristotle Everything that feels good is either illegal, immoral, or fattening.-Unknown The ability to control and regulate impulses, emotions, desires, performances, and other behaviors is one of the core features of the self. Given the adaptive benefits of being able to manage inner states and alter one's own behavioral responses, self-regulation is also vitally important for achieving success and happiness in life. Deficiencies and failures in impulse control have been linked to a broad spectrum of personal and social problems, including addiction and substance abuse, crime, domestic violence, teen pregnancy, school failure, debt and bankruptcy, sexually transmitted diseases, smoking, and obesity (see Baumeister, Heatherton, & Tice, 1994, for a review). Some self-regulation failures may occur because different regulatory goals are in conflict. The present investigation was concerned with one particular type of conflict, namely, between affect regulation and impulse control. In general, impulse control requires the person to stifle the quest for short-term, often pleasurable rewards so as to pursue distal goals. To achieve the optimal long-term outcomes, people must avoid responding only to the immediate stimulus environment so that they can pursue long-term strategies that produce significant (but delayed) benefits. In fact, one might plausibly speculate that the reason the human capacity

Subjects (A' = 970) representing five stages of smoking cessation (precontemplation, contemplation, action, maintenance, and relapse) were given a 65-item test measuring 10 basic processes of change. Subjects recorded the last time they quit smoking, their current use, the frequency of occurrence, and the degree of item helpfulness. A 40-item questionnaire provided highly reliable measures of 10 processes of change, labeled (a)consciousness raising, (b) dramatic relief, (c) self-liberation, (d)social liberation, (e) counterconditioning, (f) stimulus control, (g) self-reevaluation, (h) environmental reevaluation, (i) reinforcement management, and (j) helping relationship. In a confirmatory analysis, 770 subjects were assessed 6 months later. The analysis both confirmed the 10-process model and revealed two secondary factors, Experiential and Behavioral, which were composed of 5 processes each and reflected hou. individuals in particular stages use more lhan I process at a time. The transtheoretical model of change and available external validity evidence are reviewed.

Issues. Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials. Approach. A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects metaanalyses, subgroup and sensitivity analyses and meta-regression were conducted. Key Findings. The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week -1 , 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I 2 = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention.There was no significant difference in effect sizes for efficacy and effectiveness trials. Conclusions. Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care. [Kaner EFS, Dickinson HO, Beyer F, Pienaar E, Schlesinger C, Campbell F, Saunders JB, Burnand B, Heather N. The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug Alcohol Rev 2009;28:301-323]

There is growing evidence that well designed, targeted, theory-based behaviour change interventions can be effective in reducing the spread of HIV. Although each behaviour is unique, there are only a limited number of theoretical variables that serve as the determinants of any given behaviour. Understanding these variables and their role in behavioural prediction can guide the development of effective behaviour change interventions. This paper will describe and de ne these variables and show how they can be used in the development of behavioural interventions.

Self-monitoring is the centerpiece of behavioral weight loss intervention programs. This article presents a systematic review of the literature on three components of self-monitoring in behavioral weight loss studies: diet, exercise and self-weighing. This review included articles that were published between 1993 and 2009 that reported on the relationship between weight loss and these self-monitoring strategies. Of the 22 studies identified, 14 focused on dietary self-monitoring, one on self-monitoring exercise and six on self-weighing. A wide array of methods was used to perform self-monitoring; the paper diary was used most often. Adherence to self-monitoring was reported most frequently as the number of diaries completed or the frequency of log-ins or reported weights. The use of technology, which included the Internet, personal digital assistants and electronic digital scales were reported in five studies. Descriptive designs were used in the earlier studies while more recent reports involved prospective studies and randomized trials that examined the effect of self-monitoring on weight loss. A significant association between selfmonitoring and weight loss was consistently found; however, the level of evidence was weak because of methodological limitations. The most significant limitations of the reviewed studies were the homogenous samples and reliance on self-report. In all but two studies, the samples were predominantly White and female. This review highlights the need for studies in more diverse populations, for objective measures of adherence to self-monitoring, and for studies that establish the required dose of self-monitoring for successful outcomes.

This article develops the hypothesis that intervention strategies that cultivate positive emotions are particularly suited for preventing and treating problems rooted in negative emotions, such as anxiety, depression, aggression, and stressrelated health problems. Fredrickson's (1998) broaden-and-build model of positive emotions provides the foundation for this application. According to this model, the form and function of positive and negative emotions are distinct and complementary. Negative emotions (e.g., fear, anger, and sadness) narrow an individual's momentary thought-action repertoire toward specific actions that served the ancestral function of promoting survival. By contrast, positive emotions (e.g., joy, interest, and contentment) broaden an individual's momentary thought-action repertoire, which in turn can build that individual's enduring personal resources, resources that also served the ancestral function of promoting survival. One implication of the broaden-and-build model is that positive emotions have an undoing effect on negative emotions. By broadening the momentary thought-action repertoire, positive emotions loosen the hold that negative emotions gain on an individual's mind and body by undoing the narrowed psychological and physiological preparation for specific action. Indeed, empirical studies have shown that contentment and joy speed recovery from the cardiovascular aftereffects of negative emotions . Stepping off from these ideas and findings, a range of intervention and coping strategies are reviewed, including relaxation therapies, behavioral therapies aimed at increasing rates of pleasant activities, cognitive therapies aimed at teaching optimism, and coping strategies marked by finding positive meaning. These strategies optimize health and well-being to the extent that they cultivate positive emotions. Cultivated positive emotions not only counteract negative emotions, but also broaden individuals' habitual modes of thinking and build their personal resources for coping.

Results: Mean weight change from baseline in the intervention group was 24.4 kg at 6 months, 22.0 kg at 18 months, and 20.2 kg at 36 months. Mean weight change in the control group at the same time points was 0.1, 0.7, and 1.8 kg. Blood pressure was significantly lower in the intervention group than in the control group at

We report 10-year treatment outcomes for obese children in 4 randomized treatment studies. At 10 years, 34% decreased percentage overweight by 20% or more, and 30% were not obese. Significant effects were observed when parents and children were targeted and reinforced for weight loss in comparison with nontargeted controls and for children given lifestyle or aerobic exercise in comparison with a calisthenics control. Thirty-four percent of the variance in change in percentage overweight was predicted from sex, baseline percentage overweight, self-monitoring weight, meals eaten at home, and family and friends' support for eating and exercise. Results show long-term changes in children depend on the treatment, and evidence converges on the importance of the family and other sources of support for eating and activity change.

Trisomy 21, the chromosomal condition responsible for Down syndrome (DS, OMIM #190685), is the most common identifiable genetic cause of intellectual disability. Approximately half of all children with DS are born with a significant congenital heart defect (CHD), the most common of which is an atrioventricular septal defect (AVSD). As children with comorbid DS and CHD increasingly survive cardiac surgery, characterization of their early developmental trajectories is critical for designing early interventions to maximize individual potential. Herein, the developmental domains (cognitive, language, and motor) of children with DS and AVSD (DS + AVSD, n=12) were compared to children with DS and a structurally normal heart (DS -CHD, n=17) using the Bayley Scales of Infant and Toddler Development III. The DS + AVSD cohort mean age was relatively the same as controls with DS -CHD, 14.5 ±7.3 months compared with 14.1 ± 8.4 months, respectively. Although the motor domain was the only domain that showed a statistically significant difference between groups (p < .05), both cognitive standard scores (p = 0.63) and language composite standard scores (p = 0.10) were lower in the DS + AVSD cases compared with the DS -CHD controls although it is not statistically significant. Since this is the first study to examine the early developmental outcomes of children with DS + AVSD, the findings may be useful for clinicians in providing anticipatory guidance.

Three variants of a behavioral family intervention (BFI) program known as Triple P were compared using 305 preschoolers at high risk of developing conduct problems. Families were randomly assigned to enhanced BFI (EBFI), standard BFI (SBFI), self-directed BFI (SDBFI), or wait list (WL). At postintervention, the 2 practitioner-assisted conditions were associated with lower levels of parent-reported disruptive child behavior, lower levels of dysfunctional parenting, greater parental competence, and higher consumer satisfaction than the SDBFI and WL conditions. Overall, children in EBFI showed greater reliable improvement than children in SBFI, SDBFI, and WL. By 1-year follow-up, children in all 3 conditions achieved similar levels of clinically reliable change in observed disruptive behavior. However, the EBFI and SBFI conditions showed greater reliable improvement on parent-observed disruptive child behavior.

reviewed the treatment literature on attention-deficit=hyperactivity disorder (ADHD) and concluded behavioral parent training (BPT) and behavioral classroom management (BCM) were well-established treatments for children with ADHD. This review updates and extends the finding of the prior review. Studies conducted since the 1998 review were identified and coded based on standard criteria, and effect sizes were calculated where appropriate. The review reinforces the conclusions of Pelham, Wheeler, and Chronis regarding BPT and BCM. Further, the review shows that intensive peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are also well-established. The results of this update are discussed in the context of the existing treatment literature on ADHD. Implications for practice guidelines are suggested, as are directions for future research.

Recognition that social, economic, political, and environmental factors directly aff ect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear defi nition; lack of operational guidance; and limited data on the eff ectiveness of structural approaches to the reduction of HIV incidence. In this paper we build on evidence and experience to address these gaps. We begin by defi ning structural factors and approaches. We describe the available evidence on their eff ectiveness and discuss methodological challenges to the assessment of these often complex eff orts to reduce HIV risk and vulnerability. We identify core principles for implementing this kind of work. We also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

The article reports our intervention work with Alcohol and Other Drug Abusing (AOD) People Living With HIV (PLWH). Present research has involved adapting Cognitive Behavioral Stress Management (CBSM) and other strategies to improve quality of life and health outcomes for PLWH. Historically, CBSM has used relaxation and coping skills training to reduce negative mood and improve coping behaviors. The efficacy of CBSM interventions to improve functioning has been demonstrated in many disease groups and, more recently, in ethnic-minority HIV+ samples in the US CBSM HIV risk reduction interventions are similar to other cognitive-behavioral therapies in emphasizing skills training and stress reduction. Among the most precarious and challenging clinical populations are HIV infected individuals with a history of alcohol and/or drug abuse. Compared to their counterparts with no history of alcohol or drug abuse, not only are they more likely to transmit the virus to others, but they are also at risk for problems in adhering to antiretroviral regimens. A main focus of this article is to report on our intervention work with very resource-limited, ethnicminority PLWH with substance abuse problems, particularly our NIH funded projects in Miami and Haiti and the opportunities presented by the emerging science of biological vulnerability and genomic factors.

Objectives: This study investigated the relationships between a mindfulness-based stress reduction meditation program for early stage breast and prostate cancer patients and quality of life, mood states, stress symptoms, lymphocyte counts, and cytokine production. Methods: Forty-nine patients with breast cancer and 10 with prostate cancer participated in an 8-week MBSR program that incorporated relaxation, meditation, gentle yoga, and daily home practice. Demographic and health behavior variables, quality of life (EORTC QLQ C-30), mood (POMS), stress (SOSI), and counts of NK, NKT, B, T total, T helper, and T cytotoxic cells, as well as NK and T cell production of TNF, IFN-␥, IL-4, and IL-10 were assessed pre-and postintervention. Results: Fifty-nine and 42 patients were assessed pre-and postintervention, respectively. Significant improvements were seen in overall quality of life, symptoms of stress, and sleep quality. Although there were no significant changes in the overall number of lymphocytes or cell subsets, T cell production of IL-4 increased and IFN-␥ decreased, whereas NK cell production of IL-10 decreased. These results are consistent with a shift in immune profile from one associated with depressive symptoms to a more normal profile. Conclusions: MBSR participation was associated with enhanced quality of life and decreased stress symptoms in breast and prostate cancer patients. This study is also the first to show changes in cancer-related cytokine production associated with program participation.

Cigarette smokers who quit on their own (n = 29) were compared with subjects from two commercial therapy programs: Aversion Group (n = 18) and Behavior Management Group (n = 16). Subjects were administered a Change-Process Questionnaire and a demographic and smoking-history questionnaire within seven weeks of successful cessation, then interviewed again in five months. Using a transtheoretical model of change developed by Prochaska (1979) six verbal and four behavioral processes of change and three stages of change (Decision to Change: Active Change; Maintenance) were analyzed. Subjects in each treatment group were middle class, heavy-smoking adults. The change-process analysis of cessation discriminated between the self-quitters and therapy quitters and between the two groups of therapy subjects on five variables. Stages of change interacted with the processes of change in the cessation of smoking behavior. Verbal processes were seen as important in making the decision to change while action processes were critical for breaking the actual smoking habit. Maintenance of cessation was related to, but not dependent on, how subjects actively changed smoking behavior.

No clinical treatment for nervous habits has been generally effective. The present rationale is that nervous habits persist because of response chaining, limited awareness, excessive practice and social tolerance. A new procedure was devised for counteracting these influences: the client practiced movements which were the reverse of the nervous habit, he learned to be aware of each instance of the habit and to differentiate it from its usual response chain and he was given social approval for his efforts to inhibit the habit. The treatment was given during a single session to 12 clients who had diverse nervous habits such as nail-biting, thumb-sucking, eyelash-picking, head-jerking, shoulder-jerking, tongue-pushing and lisping. The habits were virtually eliminated on the very first day for all 12 clients and did not return during the extended follow-up for the 11 clients who followed the instructions.

Background: Attention Bias Modification Treatment (ABMT) is a newly emerging, promising treatment for anxiety disorders. Although recent randomized control trials (RCTs) suggest that ABMT reduces anxiety, therapeutic effects have not been summarized quantitatively.

OBJECTIVE: Although four meta-analytic reviews support the efficacy of pharmacotherapy and behavior therapy for the treatment of insomnia, no meta-analysis has evaluated whether these treatment modalities yield comparable outcomes during acute treatment. The authors ...

Nonoverlap of All Pairs (NAP), an index of data overlap between phases in single-case research, is demonstrated and field tested with 200 published AB contrasts. NAP is a novel application of an established effect size known in various forms as Area Under the Curve (AUC), the Common Language Effect Size (CL), the Probability of Superiority (PS), the Dominance Statistic (DS), Mann-Whitney's U, and Sommers D, among others. NAP was compared with 3 other non-overlap-based indices: PND (percent of nonoverlapping data), PEM (percent of data points exceeding the median), and PAND (percent of all nonoverlapping data), as well as Pearson's R 2. Five questions were addressed about NAP: (a) typical NAP values, (b) its ability to discriminate among typical single-case research results, (c) its power and precision (confidence interval width), (d) its correlation with the established effect size index, R 2 , and (e) its relationship with visual judgments. Results were positive, the new index equaling or outperforming the other overlap indices on most criteria.

This paper deals with questionnaires tapping fears of snakes, spiders, mutilation, and public speaking. Psychometric description of the scales across several samples indicated consistent distribution characteristics. In addition, consistently high reliability estimates were obtained; available results on test-retest reliability and validity were also encouraging. Correlations of these tests with one another and with general measures of anxiety indicated little shared variance. Inclusion of these scales in fear assessment procedures is suggested to promote standardization of evaluation and comparability of results across samples and laboratories.

Objective: The purpose of the study was to test the relative and combined efficacy of clomipramine and exposure and ritual prevention in the treatment of obsessivecompulsive disorder (OCD) in adults. Serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy by exposure and ritual prevention are both established treatments for OCD, yet their relative and combined efficacy have not been demonstrated conclusively.