ASSOCIATION for BEHAVIORAL and ISSN 0278-8403 ABCT COGNITIVE THERAPIES

▲ VOLUME 40, NO. 5•JUNE 2017 the Behavior Therapist

Contents CLINICAL TRAINING Training in Integrated Clinical Tr aining Behavioral Health Care: Ana J. Bridges, Timothy A. Cavell, Carlos A. Ojeda, Samantha J. Gregus, Debbie Gomez Dipping a Toe or Training in Integrated Behavioral Health Care: Diving In Dipping a Toe or Diving In • 169

Clinical Dialogues Ana J. Bridges, Timothy A. Cavell, Ari Lowell and John C. Markowitz Carlos A. Ojeda, Samantha J. Gregus, You Mean I Have to Talk About Feelings? One CBT Therapist’s Debbie Gomez, Experience With Interpersonal Psychotherapy • 181 University of Arkansas Science Forum IT IS ESTIMATED that one out of four individu- als in the United States meets criteria for a psy- R. Trent Codd, III chiatric disorder (Kessler & Wang, 2008), but Protecting the Scientific Lexical Canon • 185 only one-third of those individuals actually receives mental health treatment (Kessler et al., Book Review 2005). Most patients with mental health con- Thad R. Leffingwell and Emma Brett cerns are treated by a primary care physician, Doing CBT Will Help You Do CBT • 191 and this pattern is especially strong among underserved patient populations, including members of ethnic/racial minority groups and News families living in rural areas (Kessler et al.). Peter J. Norton, Ali Gorji, and International Scientific Committee Mental health care problems are also linked to of the International Anxiety Congress physical health problems in a reciprocal fashion Trauma, Anxiety, and Depression in Iran:A Report From the (World Health Organization, 2004). 3rd International Anxiety Congress in Iran • 192 Health care reform efforts in the U.S. over the past decade were designed to broaden Katherine J. W. Baucom health care coverage and increase patient access Featured Award Recipient: Outstanding Service Award • 194 to needed services, thereby reducing health dis- parities among Americans. Numerous efforts to repeal the Patient Protection and Affordable At ABCT Care Act (111-148) have been unsuccessful and Election Results • 170 it appears the law will remain in effect for the foreseeable future. An important feature of health care reform is the integration of primary CLASSIFIED • 180 medicine and behavioral health into a collabo- rative, interdisciplinary-based team model of service delivery and changes in how health care services are reimbursed, with a greater focus on health promotion, disease prevention, and

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June • 2017 169 the Behavior Therapist ABCT Published by the Association for Behavioral and Cognitive Therapies Election Results 305 Seventh Avenue - 16th Floor New York, NY 10001 | www.abct.org (212) 647-1890 | Fax: (212) 647-1865 Bruce Chorpita, Ph.D. Editor: Kate Wolitzky-Taylor President-Elect, 2017–2018 Editorial Assistant: Bita Mesri

Associate Editors RaeAnn Anderson Risa B. Weisberg, Ph.D. Katherine Baucom Representative-at-Large, 2017–2020 Sarah Kate Bearman and liaison to Membership Issues Shannon Blakey Angela Cathey All three bylaw changes were approved: Mission Statement, Purposes, and Trent Codd changes to our membership categories. The membership has voted to revise our mission statement to read: David DiLillo The Association for Behavioral and Cognitive Therapies is a multidisciplinary Lisa Elwood organization committed to the enhancement of health and well-being by advanc- Clark Goldstein ing the scientific understanding, assessment, prevention, and treatment of human David Hansen problems through behavioral, cognitive, and biological evidence-based principles. Katharina Kircanski While ABCT’s name and identity will ensure that we maintain our core focus on Richard LeBeau Behavioral and Cognitive Therapies, the Board hopes that our slightly revised Angela Moreland mission statement will encourage further exploration and collaboration in a Stephanie Mullins-Sweatt broader range of range of mental health areas, including biological mechanisms of behavioral and cognitive therapies. In this way, we seek to foster a welcoming and Amy Murell innovative environment for a range of researchers and clinicians who are passion- Alyssa Ward ate about advancing empirically effective cognitive and behavioral treatments. Tony Wells We are excited about the opportunities that lie ahead. Please join us in congratu- Steven Whiteside lating our new leaders Bruce and Risa. Monnica Williams

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170 TRAINING IN INTEGRATED BEHAVIORAL HEALTH CARE addressing the behavioral components of little time to address significant barriers The IBHC Model health. The integrated behavioral health that arise when chronic disease regimens Integrated behavioral health care care (IBHC) model represents a paradigm demand fundamental change in a patient’s (IBHC) is a health care delivery model in shift for health service psychology, one that lifestyle (Robinson & Reiter, 2006). PCPs which diverse health professionals, includ- requires new roles, different skills, and are prone to prescribing action-oriented ing mental health professionals, actively expanded competencies (McDaniel et al., interventions, even though the majority of work together to target patient health care 2014). To keep pace with these changes in patients are not ready to change or have needs (O’Donohue, Cummings, Cucciare, health care delivery, doctoral programs in never contemplated change (Prochaska, Runyan, & Cummings, 2006). While many psychology may want to provide students DiClemente, & Norcross, 1992). PCPs also models of mental and physical health col- with some level of IBHC training. In this prescribe the majority of psychotropic laboration exist (for a review, see Blount, article, we present a framework to guide medications, which introduces additional 1998), the IBHC model strives for the high- programs seeking to add or expand IBHC health care costs and widens further the est level of integration where all a patient’s training, with a particular focus on primary gap between patients who can afford to be needs are addressed in one medical home care psychology or what is called primary treated and those who cannot (Regier et al., by a diverse team of health professionals care behavioral health (Robinson & Reiter, 1993). who can deliver needed care in a single, col- 2006). Although many models of inte- Calls for increased collaboration among laborative system rather than having health grated care exist (e.g., Peek, 2013), the pri- health care professionals began in the med- professionals work in silos. This integra- mary care behavioral health model is par- ical field, although early efforts to promote tion means team members meet regularly ticularly novel for psychologists because of interprofessional training did not include to coordinate patient care, medical records significant practice shifts away from tradi- psychology (Interprofessional Education are housed in one location and shared by tional models of care, as we detail below. Collaborative Expert Panel, 2011). More all health care team members, and services Because doctoral programs will vary in recently, however, the role of psychologists are delivered at the time a need is addressed their readiness for or investment in IBHC on the health care team has been recog- rather than in some distant future. This training, this framework offers multiple nized by numerous health professionals. integration is theorized to not only reduce options rather than a single standard. For instance, a recent editorial in the Jour- lag time between when needs are identified Guided by this framework, programs inter- nal of the American Medical Association and appropriate services are received, but ested in the IBHC model can choose to dip notes the benefits, both financially and eth- also to reduce the stigma and increase the a toe or dive in to training. ically, of providing mental health care for primary-care patients in an integrated acceptability of behavioral health care Rationale for Integrated Care fashion (Schwenk, 2016). The Substance interventions. Abuse and Mental Health Services Admin- Psychologists who work in IBHC set- The lifetime prevalence of mental istration (SAMHSA) and the U.S. Depart- tings find this model requires a change in health problems ranges from 12% to 47.4% ment of Health and Human Services/ the way behavioral health care interven- of the population (Kazdin & Blase, 2011). Health Resources and Services Adminis- tions are delivered so that the pace and In any given year, approximately 25% of tration (HRSA) actively promote inte- patient flow match that of primary care the population is in need of mental health grated behavioral health care, maintaining (Robinson & Reiter, 2006). This is often in services (Kazdin & Blase). However, the a resource-rich website (www.integra- stark contrast to the traditional method of majority of these individuals do not receive tion.samhsa.gov) and many federal fund- service delivery that comprises individual appropriate care. Reasons include a short- ing opportunities in health care service sessions, typically of a 50-minute or 1-hour age of mental health professionals, a lack of delivery focus on combining physical and duration and typically lasting for many health insurance coverage, limited access to behavioral/mental health care. weeks or months. The mental health pro- care, and stigma associated with seeking The American Psychological Associa- fessional is introduced to the patient by the therapy. The unmet need for mental health tion (APA) has been a strong advocate for primary care provider as Behavioral Health services is greatest in underserved, ethnic patient-centered care and IBHC service Consultant (BHC), a member of the minority populations (Kessler et al., 2005). delivery (APA, Presidential Task Force on patient’s health care team who specializes In this country, most individuals with Integrated Health Care for an Aging Popu- in behavior change. Then, the BHC and mental health problems are treated by pri- lation, 2008). As APA President, Suzanne other members of the health care team mary care physicians (PCPs) and not Bennett Johnson (2012) argued that inte- (e.g., primary care provider, nurses, nutri- mental health specialists (McDaniel et al., grated, patient-centered care that blends tionists, case managers, and other allied 2014; Regier et al., 1993). Depression is the medical and mental health services can health professionals) focus on providing third most common reason for a PCP visit provide better and more cost-effective care, early interventions for patients with (Uniform Data System, 2007) and many greater access, less stigma, and greater lifestyle- and stress-related disorders and patients suffer chronic medical conditions patient satisfaction than traditional forms chronic illness. Although the primary care (e.g., chronic pain, hypertension, diabetes) of health care delivery. To ensure that psy- manager (e.g., physician) remains in that are frequently comorbid with behav- chologists are not left out of these trends in charge of the treatment plan, BHCs do not ioral health risk factors, such as smoking or health care reform, APA has called for a operate solely as consultants—they also obesity (Bodenheimer, Chen, & Bennett, redefinition of psychology as a health ser- provide brief interventions, behavioral 2009). Unfortunately, less than 50% of vice profession (vs. a mental health care health assessments, and follow-ups (usu- patients with depression are correctly diag- profession) and for integrating profes- ally within a month) with primary care nosed by PCPs (Fernandez et al., 2010), sional psychology into primary health–care managers on health-related issues and care and PCPs typically lack the training needed settings (Belar, 2012; Johnson, 2012). (Dobmeyer, Rowan, Etherage, & Wilson, to treat psychosocial concerns and have 2003).

June • 2017 171 BRIDGES ET AL.

BHC professionals’ repertoire of clini- tation and/or assessment in primary care can incorporate IBHC training into their cal strategies address issues related to settings. Some programs specifically iden- curricula; however, even when these teaching prevention techniques, early tify as providing trainees with experience resources are in abundance, programs may recognition of problems, or working with in integrated care. not be certain of which ones to prioritize or diverse populations (e.g., patients with lim- APA’s list is noteworthy in that the total how to approach such a training shift. ited English proficiency). In addition, number of programs is rather small. Of the However, even absent a primary care part- assessment interventions are adapted to 307 APA-accredited clinical and counsel- ner, McDaniel, Belar, Schroeder, Hargrove, conditions in primary care settings ing psychology doctoral training programs and Freeman (2002) noted that exposure to (approximately 5–10 minutes) instead of currently in the U.S., only 29 (9.4%) iden- interdisciplinary health care teams in other long sessions (e.g., at least an hour) in tify as providing training in primary care health care settings is beneficial for doc- mental health settings. In IBHC settings, psychology (http://www.apa.org/ed/ toral students who eventually may practice empirical interventions are often educa- accreditation/programs/). Doctoral pro- or train in primary care. Below we describe tional and directive (e.g., problem-solving grams on this list are further categorized how we went from no exposure or training advice, pamphlets), emphasizing preven- according to whether training involves (a) in IBHC to incorporating it as a major tion strategies (e.g., self-monitoring), and exposure (a training opportunity limited in training focus of our doctoral program. built around structures that support skills, extent and intensity; e.g., 1–2 courses), (b) such as long-term change, self-manage- experience (somewhere between exposure Example of IBHC Training for and emphasis; e.g., 1–2 courses, a ment, and self-efficacy (Robinson & Reiter, Doctoral Students at the 2006). Taken together, the IBHC para- practicum), (c) emphasis (in-depth oppor- digm shift challenges psychology profes- tunities to learn about the primary care University of Arkansas sionals to provide interventions that specialty area; e.g., numerous courses and Psychology training programs cannot address mental health concerns while func- 2 practica), or (d) a major area of study be all things to all students and decisions tioning as full members of a health care (intense and highly involved training that about training emphases are typically a team. includes multiple years of didactics, clini- function of current training faculty, avail- cal training, and research in primary care). able funding, and potential clinical training Efforts to Promote IBHC Training None of the doctoral programs indicated settings. There can be significant, practical primary care psychology as a major area of To the extent that psychology is indeed constraints to changing or expanding a study and only 7 indicated an emphasis in program’s training model, from that which facing a paradigm shift toward integrated this specialty area. Perhaps most striking is health care delivery (Johnson, 2012), train- is functional and familiar to that which is how these numbers compare to training currently trending. Even programs with ing at the predoctoral, internship, and emphases found in internship settings. A strong interest in IBHC training will by postdoctoral levels will need to keep pace search of the 461 U.S.-based APA-accred- necessity have to weigh the costs and bene- (Larkin, Bridges, Fields, & Vogel, 2016). ited predoctoral internship programs listed fits of such a move. Rozensky (2012) has argued that the future in the online directory of the Association of In our own program at the University of of psychological care depends on efforts to Psychology Postdoctoral and Internship Arkansas, we began with no faculty with prepare current trainees in competencies Centers (APPIC) revealed that 42% of IBHC expertise and no courses that cov- needed to work in an integrated, interpro- internship programs provide training in ered content relevant to IBHC. However, fessional environment. The HRSA Gradu- primary care. Specifically, 102 (22%) pro- ate Psychology Education (GPE) program, grams had a major rotation in primary care when we were approached by a local pri- the only federal program that funds psy- and an additional 94 (20%) programs had mary care clinic and asked to design a pro- chology education and training, has an minor rotations in primary care. It appears gram for the clinic that would allow their explicit focus on preparing psychologists to that despite increased demands for psy- patients to have better access to mental provide integrated health care to under- chologists to work in primary care settings, health services, a willing faculty member served populations. Thus, GPE-funded doctoral training programs have been slow whose research focused on reducing health training programs often place psychology to expand the focus of training to include disparities and access to mental health care trainees in federally qualified health centers IBHC or primary care psychology. (the first author) eagerly agreed to assist. (FQHCs) that require delivery of mental Many practical limitations to incorpo- To begin, we researched different models health and substance abuse services along rating IBHC training into doctoral pro- of collaboration between primary care and with primary medical care. grams can create significant barriers, even specialty mental health care. The first Data gathered by APA in 2015 show for programs highly motivated to move in author and members of the primary care that a growing number of programs are this direction. These may include a lack of team also attended a conference on collab- training students to practice in primary (a) access to partnering primary care sites; orative care to learn more about what care settings (http://www.apa.org/ed/ (b) faculty with knowledge or expertise in options were available. After this, we set- graduate/primary-care-psychology.aspx). this area; (c) space in the training curricu- tled on the primary care behavioral health This webpage lists doctoral, internship, lum to include additional courses, clinical model of integrated behavioral health care and postdoctoral programs that offer edu- experiences, or other training activities; (d) (Robinson & Reiter, 2006). As we moved cation or training in primary care psychol- funds to support training activities specific towards the design and implementation of ogy. Each of these programs trains students to IBHC; and (e) partnering health pro- the program, we sought consultation from to provide psychological services in pri- grams (e.g., nursing, public health, medi- other experts who had already developed mary care settings to patients and families cine, social work) for interdisciplinary well-functioning programs to guide us. We with both physical and mental health prob- training. Without these resources, pro- also sought funding (from service-based lems; many also provide training in consul- grams will be limited by how much they grants to research and training grants) to

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Hogrefe Publishing 30 Amberwood Parkway Ashland, OH 44805, USA Tel. 800 228-3749 (toll-free in North America) Fax 419 281-6883 [email protected] www.hogrefe.com BRIDGES ET AL. help provide funds for the infrastructure information to guide those programs that training in IBHC; other faculty can con- and initial start-up costs. are unsure of the level of investment tinue to provide instruction as usual with Our program benefited from GPE needed. To help guide programs looking to minimal interruption in the program’s funding that allowed us to expand both expand in this direction, we offer the IBHC training mission. Training at this level does coursework and clinical experiences Training Matrix. We drew from existing assume, however, that other faculty mem- related to IBHC training. For instance, one program models and our own experience bers are supportive of efforts to expose stu- of us (first author) developed a semester- with IBHC training to develop this guiding dents to IBHC. It would be difficult for a long course in integrated care and evi- framework. We make the assumption that program to move forward if core faculty dence-based psychology practice. The programs will differ in the degree to which saw little value in IBHC training or consid- course introduces students to key topics in IBHC training is currently a valued or ered it antithetical to the program’s philos- IBHC, including application of evidence- prominent training goal. For some pro- ophy or approach to evidence-based clini- based clinical services to the primary care grams, giving students a cursory overview cal psychology. Level I is comparable to the setting, behavioral health issues that com- or an introductory exposure to the IBHC exposure many clinical psychology train- plicate management of chronic diseases, model will suffice; other programs might ing programs provide students in fields biological bases of psychiatric conditions, be inclined to restructure their program such as forensic or health psychology when and use of informatics for clinical decision- model and begin providing extensive there is no formal training track or area of making (see Spring, 2007; Walker & IBHC training that includes rich and varied emphasis within the program. Programs London, 2007). We also infused instruction opportunities across multiple domains can simply introduce students to the IBHC in medical consultation into our graduate (research, didactics, and clinical practice). model, offering it as one approach among course in consultation and supervision To be useful across a wide range of pro- several by which clinical psychologists can (taught by the second author). Perhaps the grams, our training matrix describes three deliver their services. An important benefit most salient aspect of IBHC training for levels of training depth or program invest- of this training level is that it requires rela- our students is a clinical clerkship at a local ment. At each level, we provide examples tively little change in infrastructure and FQHC that provides integrated care to for how programs can address four differ- only modest support from the broader pro- low-income, often minority patients. Each ent training domains: (a) program culture gram or department (e.g., funds to bring in year, a limited number of graduate student or identity, (b) preparatory steps and colloquium speakers, support efforts to clinicians have the opportunity to learn needed infrastructure, (c) focal training make minor modifications to course con- firsthand about providing behavioral goals, and (d) sample training activities tent). health services to primary care patients. (Table 1). This matrix and its three levels Although Level I provides minimal Approximately two-thirds of patient con- are merely heuristic, designed to help pro- exposure to IBHC, it is important to recog- tacts are unscheduled, warm handoffs by grams work through decisions about a nize that even this level of exposure can be medical providers, while the remaining move toward IBHC training. More impor- enormously beneficial to trainees. Predoc- third are follow-up sessions with patients tant, each level represents its own end point toral internship training directors and for whom a single session was insufficient as it relates to a program’s training model; directors of IBHC in primary care settings to address their acute behavioral needs. there is no implication in our three levels often lament the lack of knowledge mental Apart from these formal training activities, that programs should eventually move health professionals have about this model our program regularly invites community toward the highest level of investment. and many are excited at the possibility of leaders and nationally recognized scholars, Programs could also elect to invest in one training students or recent graduates who including internship directors, to our domain of IBHC training (e.g., didactics) have some familiarity with the basic tenets campus to give colloquia on behavioral while maintaining status quo with other of IBHC (e.g., Perez, August 2012, personal health topics. We have also made efforts to training domains (e.g., research and communication; Shuler, September 2012, expose undergraduate students to psychol- practicum). This framework is also not personal communication). As internship ogy’s role in health service delivery. We meant to be prescriptive or comprehensive. slots and job opportunities continue to have given modest fellowship awards to Programs need not implement all identi- expand to include more opportunities for undergraduate students who show promise fied training components and we suspect IBHC, even minimal exposure could pro- in research and professional development there are many other valuable training vide a valued benefit to trainees, one that sets them apart in the eyes of training selec- in the area of primary care and health psy- components missing from our matrix. tion committees. chology. More recently, we developed an Finally, our suggestions for training activi- undergraduate course in interprofessional ties are only meant to illustrate what might Moderate Investment: approaches to health care service. We have be consistent with that level of program Enhancing Depth investment. With those caveats in place, we continued expanding our partnerships Level II, the intermediate level of invest- begin discussion of the training matrix at (e.g., school-based health clinic, university ment, moves IBHC training to a more cen- the modest level of program investment. health center), to infuse IBHC-related con- tral position within the program. No longer tent into additional clinical clerkships, to Modest Investment is it peripheral to the program’s training develop interprofessional courses at the Level I, the most basic level, provides mission but instead is a bona-fide training graduate level, and to hire new faculty with opportunities for students to become component that a significant number of expertise in team-based approaches to care. exposed to IBHC without the training pro- students will seek. Programs may elect to have an area of emphasis in IBHC (i.e., not The IBHC Training Matrix gram having to undergo a dramatic shift in its identity or training mission. In fact, this quite a formal track, which would be more Knowing how other programs structure level may involve only one faculty member IBHC training is useful but lacks sufficient who has interest in increasing students’ [Continued on p. 178]

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Preparation Culture/Identity & Infrastructure Training Goals Sample Training Activities

Level I: Modest Investment

• Program faculty com- Preparation • Introduction to IBHC Didactics fortable with and com- • At least one faculty model and supporting • Supplementing existing courses with IBHC-relevant con- mitted to its current member with prior research literature tent (e.g., psychotherapy, clinical science, biological bases (non-IBHC) training training in IBHC or a • Exposure to IBHC of human behavior) model strong interest in learn- practice settings • Invited talks or colloquia by IBHC scholars or practition- • Faculty cautious but ing the IBHC model ers (such as a DCT at an IBHC internship site) open to IBHC-related • At least one faculty training “trials” member willing to Clinical • Students involved in champion and launch • Shadowing opportunities at a primary care clinic IBHC training are exclu- IBHC training sively advisees of faculty • Locate nearby commu- Research who champion IBHC nity health centers • Reading some primary research, attending a conference (CHCs) and build rela- talk, conducting a literature review on IBHC tionship with CHC directors

Infrastructure • Existing curriculum allows for the pursuit of optional training experi- ences (e.g., IBHC) if minimally disruptive to program advancement • Faculty free to include IBHC-relevant material into existing courses • Costs associated with IBHC training impact minimally on participat- ing faculty and students and the program as a whole

Level II: Moderate Investment

• IBHC considered a vis- Preparation • Working knowledge of Didactics ible and viable training • At least one faculty IBHC model and sup- • Dedicated course to IBHC for clinical psychology option in the program member who obtains porting research litera- students • Broad faculty accep- specialty training in ture tance of and support for IBHC, possibly leading • Exposure to IBHC- Clinical IBHC training options to certification related clinical experi- • Some clinical experience in IBHC service provision • Faculty involved in • Seek IBHC-related ences through an externship/practicum of moderate duration IBHC training are main- practicum opportunities, • Emerging identity as ly IBHC champions perhaps with local CHCs IBHC service provider Research • Strong student interest • Cultivate opportunities • Some data collection and smaller projects occurring at in IBHC training, espe- to partner with local primary care clinics cially among advisees of FQHC in pursuing grant • Secondary data analyses of publicly available data sets IBHC champions funds for IBHC with health and mental health variables • IBHC champions con- duct or oversee IBHC- Infrastructure related research projects • Strong working alliance with local CHC • Training curriculum allows for IBHC-focused seminar • Faculty member will- ing/able to offer IBHC seminar [Table continued on p. 177]

176 the Behavior Therapist Table 1, Continued

Preparation Culture/Identity & Infrastructure Training Goals Sample Training Activities [Level II, continued] • Program support for IBHC-related clinical practicum • Faculty member will- ing/able to supervise IBHC practicum • Students participate in IBHC-related seminars and practica • Active recruitment of students with interest in IBHC training

Level III: Major Investment

• Program identifies as • Majority of faculty and • Strong foundation in Didactics IBHC-focused training students involved in the IBHC model and its • A sequence of courses, specialized curricula, and inter- model IBHC training activities supporting research lit- professional training opportunities (e.g., courses that • IBHC training is codi- • Majority of faculty and erature include nursing and psychology trainees as well as courses fied in program’s train- students participate in • At least one year of offered by other professionals) ing goals IBHC-related research clinical training in an • Program has national • Faculty actively IBHC setting Clinical reputation as IBHC involved in IBHC-relat- • Strong identification • Clinical experience in multiple (2+) primary care clinics training program ed journal submission with IBHC service (OB-GYN, family practice, pediatrics, internal medicine). • Majority of faculty review process delivery model Vertical team models of supervision—more senior stu- identify as IBHC-related • External funds support • Theses and dissertation dents with 1+ years of clinical experience providing super- professionals IBHC training or projects are IBHC- vision of more junior clinicians. Expectations that students research related will complete IBHC-related internships. • Established, stable rela- • Students seek and tionships with IBHC obtain IBHC-focused Research clinical training sites clinical internships • Clinical trials in IBHC, program evaluation, multi- • Multiple IBHC clinical method, multi-informant projects that make use of elec- training sites tronic medical records, BHC data, provider data, and • Paid clerkships offering patient data. Publications and conference presentations. IBHC-related clinical training • Vertical teams used to increment IBHC-related clinical training for stu- dents at different levels • Didactic training addressing role of inter- professionalism in IBHC • Students actively engaged in interprofes- sional clinical work • Faculty retreat to dis- cuss model implementa- tion and training goals

June • 2017 177 BRIDGES ET AL. in line with Level III) that includes (a) a with internship sites that provide training self-study could be repeated at a later time clinical practicum team or an externship in the IBHC model. point as a way to note programmatic opportunity that involves work in a pri- progress towards IBHC-related training Major Investment: mary care setting, (b) a full semester course goals. in IBHC, and (c) opportunities to conduct Enhancing Depth and Breadth IBHC-related research projects that are Finally, at a Level III, the program has Conclusions modest in scale. Trainees at this level not fully committed to having IBHC training Our goal in writing this paper was to only acquire greater knowledge about as a major focus area or track. At this level, help training faculty move forward on an IBHC, but also gain experience in provid- most faculty members are involved in issue that appears to be increasingly impor- ing clinical services to primary care IBHC-related training and research and tant for students they are currently training patients. Research projects may be small- the program has specifically identified itself and will be training in the future. McDaniel scale studies conducted in integrated pri- as one that specializes in IBHC. Students and colleagues (2014) have argued that to mary-care sites, or may make use of pub- are provided with an explicit set of compete in the changing climate of U.S. licly available data sets and data sequenced training activities related to health care, psychologists must be health repositories (see www.apa.org/research/ IBHC, including a series of dedicated service providers whose work is not limited responsible/data-links.aspx for a list of courses and multiple clinical experiences in to mental health specialization. Nowhere is such resources). The program’s culture and primary care settings. In line with the inter- this more evident than in the recent fund- identity will necessarily need to shift from professional nature of IBHC, some of these activities should include training alongside ing for and increased focus on psycholo- passive acceptance to a more active inte- allied health professions, such as nursing, gists’ role within integrated behavioral gration of IBHC training. Ideally, at least pharmacy, medicine, or social work. Psy- health care. Doctoral training faculty can two faculty members will be actively chology trainees might take courses offered survive being “late adopters” in the IBHC involved in IBHC training efforts; one may in these other health disciplines or psychol- marketplace, but their students will be be a liaison or administrative contact for ogy faculty might team teach IBHC-related aided and grateful for training that pre- the primary care training site and one or courses to health care trainees. Students at pares them for newer roles in health service more may be involved in clinical supervi- this level of training are involved in delivery. Doctoral psychology training pro- sion and didactic training. With increased research projects, including theses or dis- grams will vary in their eagerness to incor- emphasis in IBHC training, there’s a con- sertations that address various issues porate IBHC-related training activities, but comitant need for increased resources within IBHC, including efficacy and effec- even programs ready to add some level of from the program or academic depart- tiveness of IBHC interventions, cost-effec- IBHC training might lack useful informa- ment. At this level of investment, programs tiveness research, and program evaluation. tion to begin a shift in that direction. will need to dedicate some training funds At the conclusion of doctoral training, stu- Offered here is a conceptual framework specifically to support IBHC-area students dents would be expected to pursue IBHC- that can be used to guide programs consid- or work with primary care sites to generate related internships and continue their pro- ering a shift, however slight, toward IBHC stipends that can be used to fund students fessional development as emerging leaders training. Described are potential pathways enrolled in clinical externships that offer in the field of primary care psychology. that programs can use when making mini- IBHC training. Affiliated faculty members Once a program has identified the mal, moderate, or major investments in can also pursue grants (e.g., GPE) to help appropriate level of IBHC training and IBHC training. At each level of investment, provide funds for IBHC-focused training. investment, it is critical to engage in a pro- programs have a range of options across An established relationship with a primary grammatic “self-study.” This will help pro- key program domains (i.e., identity, infra- care site is critical at this level, as is a super- grams gauge the degree to which they have structure, goals, training activities) and can vising psychologist who is trained in and resources needed for the chosen level of even stagger newer training efforts across identifies with the IBHC model. Because training and will facilitate efforts to identify these domains. We believe this framework trainees in primary care settings tend to see specific areas needed for expansion. The can be useful to a range of programs, many patients in a given week, supervision self-study may be guided by the recently including those wary of any kind change can be more time intensive and is best developed IBHC competencies articulated toward IBHC training. IBHC training is an when it combines traditional supervisory by McDaniel and colleagues (2014). A important and accessible goal for all psy- meetings (group and/or individual) with survey of training experiences, course cur- chology training programs (McDaniel et real-time shadowing of interns on a regu- ricula, clinical expertise, knowledge and al.), and the training matrix presented here lar basis. Supervising faculty can request content domains of students, supervisor is one guide in making that investment. departmental, college, or university sup- appraisals, and even outside expert consul- port (e.g., reduced demands for other ser- tants can help provide programs with feed- References vice- or training-related activities) for their back about the degree to which the pro- efforts to provide instructional time away gram is adequately covering IBHC American Psychological Association [APA], Presidential Task Force on Inte- from campus. Programs operating at Level competencies. A road map for how the grated Health Care for an Aging Popula- II would benefit from including informa- program can shift towards IBHC training tion (2008). Blueprint for change: Achiev- tion about their IBHC training on their is thus one outcome of a self-study. This ing integrated health care for an aging websites, in program brochures, or in other road map will not only articulate what population. Washington, DC: American materials used to advertise to applicants the changes need to be made by the program, Psychological Association. unique training opportunities available. but also who is responsible for each com- Belar, C. D. (2012). Reflections on the Programs at this level can also benefit from ponent and set time lines for when the pro- future: Psychology as a health profession. more focused and intentional connections posed changes might take place. The initial Professional Psychology: Research and

178 the Behavior Therapist TRAINING IN INTEGRATED BEHAVIORAL HEALTH CARE

Practice, 43(6), 545-550. doi: Johnson, S. B. (2012). Psychology’s para- tion in Professional Psychology, 10, 14-23. 10.1037/a0029633 digm shift. Can psychology successfully doi: 10.1037/tep0000099 Blount, A. (1998). Integrated primary care: transition from a mental health to a McDaniel, S. H., Belar, C. D., Schroeder, The future of medical and mental health health profession? APA Monitor, 43, 5. C., Hargrove, D. S., & Freeman, E. L. collaboration. New York: Norton. Kazdin, A. E., & Blase, S. L. (2011). (2002). A training curriculum for profes- Bodenheimer, T., Chen, E., & Bennett, H. Rebooting psychotherapy research and sional psychologists in primary care. D. (2009). Confronting the growing practice to reduce the burden of mental Professional Psychology: Research and burden of chronic disease: Can the U.S. illness. Perspectives of Psychological Sci- Practice, 33, 65-72. doi: 10.1037/0735- health care workforce do their job? ence, 6, 21-37. doi: 7028.33.1.65 Health Affairs, 28, 64-74. doi: 10.1177/1745691610393527 McDaniel, S. H., Grus, C. L., Cubic, B. A., 10.1377/hlthaff.28.1.64 Kessler, R. C., Berglund, P., Demler, O., Hunter, C. L., Kearney, L. K. ... Johnson, S. B. (2014). Competencies for psychol- Dobmeyer, A., Rowan, A., Etherage, J., & Jin, R., Merikangas, K. R., & Walters, E. ogy practice in primary care. American Wilson, R., (2003). Training psychology E. (2005). Lifetime prevalence and age- Psychologist, 69, 409-429. doi: interns in primary behavioral care. Pro- of-onset distributions of DSM-IV disor- 10.1037/a0036072 fessional Psychology, 34, 586-594. doi: ders in the National Comorbidity Survey 10.1037/0735-7028.34.6.586 O’Donohue, W., Cummings, N., Cucciare, Replication. Archives of General Psychia- M., Rumyan, C., & Cummings, J. (2006). Fernandez, A., Pinto-Meza, A., Bellón, J. try, 62, 593-602. doi: 10.1001/ Integrated behavioral health care. A A., Roura-Porch, P., Jaro, J. M., Autonell, archpsych.82.6.593 J., ... Serrano-Blanco, A. (2010). Is major guide to effective intervention. Amherst, depression adequately diagnosed and Kessler, R. C., & Wang, P. S. (2008). The NY: Humanity Books. treated by general practitioners? Results descriptive epidemiology of commonly Peek, C. J. (2013). Integrated behavioral from an epidemiological study. General occurring mental disorders in the United health and primary care: A common lan- Hospital Psychiatry, 32, 201-209. doi: States. Annual Review of Public Health, guage. In M. R. Talen & A. B. Valeras 10.1016/j.genhosppsych.2009.11.015 29, 115-129. doi: 10.1146/annurev. (Eds.), Integrated behavioral health in Interprofessional Education Collaborative publhealth.29.020907.090847 primary care: Evaluating the evidence, Expert Panel. (2011). Core competencies Larkin, K. T., Bridges, A. J., Fields, S. A., & identifying the essentials (pp. 9 – 31). for interprofessional collaborative prac- Vogel, M. E. (2016). Acquiring compe- New York: Springer. tice: Report of an expert panel. Washing- tencies in integrated behavioral health Prochaska, J. O., DiClemente, C., & Nor- ton, DC: Interprofessional Education care in doctoral, internship, and post- cross, J. C. (1992). In search of how Collaborative. doctoral programs. Training and Educa- people change: Applications to addictive

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June • 2017 179 BRIDGES ET AL.

(continued from p. 179) CLASSIFIED behaviors. American Psychologist, 47, 1102-1114. doi: 10.1037/0003- The University of Florida is located in 066x.47.9.1102 University of Florida, College of Medi- Regier, D. A., Narrow, W. E., Rae, D. S., cine, Department of Psychiatry: Assis- Gainesville, a city of approximately 125,000 residents in North-Central Manderscheid, R. W., Locke, B. Z., & tant/Associate Professor - Psychiatry Florida; Visit the City of Gainesville Goodwin, F. K. (1993). The de facto US mental and addictive disorders service Website http://cityofgainesville.org/ REQUISITION NO: 502039 system: Epidemiologic catchment area community/aboutGainesville.aspx WORK TYPE: Faculty Full-Time prospective 1-year prevalence rates of LOCATION: Main Campus (Gainesville, disorders and services. Archives of Gen- eral Psychiatry, 50, 85-94. doi: FL) The University of Florida is an equal 10.1001/archpsych.1993.01820140007001 CATEGORIES: Health Profession opportunity institution dedicated to build- Robinson, P. J., & Reiter, J. T. (2006). DEPARTMENT: 29120000 - MD-PSYCHI- ing a broadly diverse and inclusive faculty and staff. Behavioral consultation and primary ATRY care: A guide to integrating services. New Classification Title: Assistant / Associate Advertised Salary: The University of York: Springer. Professor Florida offers a highly competitive salary Rozensky, R. H. (2012). Health care and benefits package. Starting salary and reform: Preparing the psychology work- The University of Florida Department of start-up support for research costs is nego- Psychiatry and Center for OCD, Anxiety force. Journal of Clinical Psychology in tiable, commensurate with education and Medical Settings, 19, 5-11. doi: and Related Disorders (COARD) are experience. 10.1007/s10880-011-9287-7 recruiting for a full time (1.0 FTE) non- Schwenk, T. L. (2016). Integrated behav- tenure or tenured faculty member at the Minimum Requirements: Applicants with a Ph.D. from Clinical, Counseling, or ioral and primary care: What is the real Assistant and/or Associate Professor level cost? Journal of the American Medical with clinical and research expertise in School Psychology programs or with a Ph.D. from Social Work programs are Association, 316, 822-823. doi: OCD, anxiety, and/or related disorders 10.1001/jama.2016.11031 encouraged to apply. (e.g., hoarding disorder, tic disorders, body Uniform Data System (UDS). (2007). The dysmorphic disorder). Frequent inter-dis- Preferred Qualifications: The position Health Center Program: National Aggre- ciplinary collaborations are a goal of the requires clinical and research experience gate Data. Retrieved April 2, 2009, from Center and facilitate joint learning experi- with OCD, OC related disorders (OCRDs) http://bphc.hrsa.gov/uds/ ences and clinical opportunities. The and/or anxiety disorders in adults, adoles- Walker, B. B., & London, S. (2007). Novel Center includes faculty members, postdoc- cents, and/or children and will be an inte- tools and resources for evidence-based toral fellows, interns, graduate students, gral part of the Center research programs. practice in psychology. Journal of Clini- cal Psychology, 63, 633-642. doi: and undergraduate trainees from a variety Special Instructions to Applicants: Special 10.1002/jclp.20377 of disciplines, colleges, and departments Instructions: Interested applicants are World Health Organization. (2004). Pro- throughout the University of Florida. required to apply through Careers at UF moting mental health: Concepts, emerg- COARD’s mission is to conduct interdisci- website http://jobs.ufl.edu or plinary clinical and translational research ing evidence, practice: Summary report. http://explore.jobs.ufl.edu/cw/ Geneva, Switzerland: Author. in OCD, anxiety, and related disorders that en-us/job/502039/assistantassociate- sets the frame for outstanding evidence- professor-psychiatry based cross-disciplinary clinical services. ... Applicants must attach their Curriculum Individuals within the program work Vitae, a letter of interest, and three letters of closely with the Divisions of Child and This article was supported in part by a grant recommendations. Adolescent Psychiatry, Adult Psychiatry, from the Department of Health and Human and Medical Psychology in the Depart- Services/Health Resources and Services Final candidates will be required to provide ment of Psychiatry. 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180 the Behavior Therapist CLINICAL DIALOGUES harm if administered incorrectly. To this mindset, CBT was an obvious choice: it’s hard to beat a highly structured, inherently You Mean I Have to Talk About Feelings? logical mental health treatment, complete with a veritable avalanche of “how-to” One CBT Therapist’s Experience With treatment manuals, research evidence, Interpersonal Psychotherapy training programs, and experienced super- visors. It seemed as though CBT works well for practically everything (Butler, Chap- Ari Lowell and John C. Markowitz, Columbia University Medical man, Forman, & Beck, 2006). So why try Center, New York State Psychiatric Institute anything else? Yet, CBT has its limitations. As Dr. Michelle Craske (2016) noted in her presi- “I don’t know why she said that to me. I “How did you feel when she said that to dential address at ABCT’s Annual Conven- guess she’s right, I am stupid, a loser, I don’t you?” I ask. tion, despite CBT’s extremely impressive do anything right.” My patient, a heavyset “How did I what?” history, about 20% of patients don’t get better. Some argue that CBT’s claim of man in his late 40s, sighs deeply, crossing his “How did you feel?” superiority to other forms of therapy, par- legs and looking down at the floor. Although ticularly psychodynamic psychotherapy, is the session has been plodding and slow so In graduate school, I was immediately drawn to cognitive behavioral therapy greatly overblown (Baardseth et al., 2013; far, my CBT-honed instincts kick into high- (CBT). And indeed, why not? CBT holds Shedler, 2010). But even without wading gear. A distortion! A cognitive distortion! great appeal for any young, inexperienced more deeply into the sludge of the CBT Eagerly I lean forward, ready to challenge therapist eager to enter the world of psy- versus psychodynamic psychotherapy the errant thought. And then I remember: chotherapy. To myself and many of my debate, there is certainly evidence that CBT I’m doing Interpersonal Psychotherapy now. classmates, the concept of therapy was does not work for everyone. What would an IPT therapist do? I squeeze something ephemeral and mysterious, I have been a fairly gung-ho CBT thera- my chair’s armrests to steady myself and powerful and yet subtle, holding great pist. In my career, I have focused on the take a breath. promise, yet carrying a risk of causing great treatment of veterans and their families,

June • 2017 181 LOWELL & MARKOWITZ and have used CBT effectively for the treat- Enter IPT. attachments and social roles; (b) social sup- ment of depression, generalized anxiety port protects against psychopathology; and disorder, panic disorder, and PTSD. For The patient is crying softly. I consciously (c) working on changing social functioning the latter, I have been an adherent of such resist the urge to hand him a tissue, in the “here and now” improves symptoms. approaches as Prolonged Exposure (PE) instead allowing him—and reminding To accomplish symptom improvement, and Cognitive Processing Therapy (CPT), myself—to sit with the emotions in the IPT focuses on affective (rather than cogni- and I have repeatedly been impressed by room. After a few moments, he wipes his tive) understanding and engagement (i.e., the capacity of patients to improve using eyes and tries to shift us away. embracing and expressing emotions as an these highly structured treatment recipes. “Well, the truth is that she is right, important part of living: negative affects But I have also encountered patients what she’s saying about me.” like anger are not harmful and provide who just don’t seem to improve, for many “Wait, hold on there for just a important information about interpersonal reasons. For some, it’s about the home- moment, let’s stay with those feelings for a conflict), bolstering social engagement and work, and having difficulty resolving little bit. You told me just a moment ago support, and enabling the patient to make avoidance sufficiently to complete expo- that when your wife was speaking to you proactive, effective interpersonal choices. sure exercises, a well-known challenge in this way, you were feeling sad, and dis- IPT therapists never assign homework, but CBT-oriented treatment (Cowan et al., missed, and lonely, and upset. Do you do encourage patients to “live dangerously” 2007; Decker et al., 2016; LeBeau, Davies, think these feelings make sense? Is it okay (i.e., experiment while in treatment in Culver, & Craske, 2013). For others, I have to feel this way?” trying things differently to see what hap- wondered if it may be an issue of being pens). IPT’s time-limited approach subtly overly cerebral; i.e., patients who can intel- I first encountered IPT at Columbia encourages movement and action. IPT is lectually or philosophically grasp the con- University Medical Center/New York State an active treatment in which the therapist cepts and behaviorally complete the exer- Psychiatric Institute while working with works to keep the patient engaged emo- cises, but who seem detached from the Dr. Yuval Neria, director of the PTSD tionally. actual emotional process of therapy and Research and Treatment Program, and Dr. IPT has three phases. In the first phase who struggle to engage in a meaningful John Markowitz, a leading psychotherapy (roughly three sessions), the therapist gath- way. Still others seem to just suffer without researcher. Dr. Markowitz had conducted ers an interpersonal inventory, a sort of his- any clear reason as to why they’re not get- research using IPT for PTSD, and showed tory of the patient’s past and particularly ting better; no matter how much effort and that IPT might do better than PE for a present relationships, and the patient’s pat- work I or these patients put into treatment, subset of patients with PTSD and comor- terns in those relationships. After conduct- they don’t seem to be able to pull them- bid depression (Markowitz, 2016; ing a thorough assessment, the therapist selves out of their respective holes. CBT has Markowitz et al., 2015). To a CBT therapist delivers a clear diagnosis. The patient is tools for handling these situations, of like me, experienced in PE and CPT, the assigned the “sick role,” and as with any course, such as identifying barriers to treat- concept of treating PTSD with IPT, which medical condition, the patient is told that ment and navigating around them, does not include exposure, sounded ludi- it’s harder to function when not feeling addressing distortions related to the treat- crous. But I’ve always prided myself on well. The therapist explains that the ment process, etc. But sometimes these being open-minded and flexible, and patient’s condition is no fault of the strategies inexplicably fail. All too often in invested in learning anything that will help patient’s own, and that the condition is these situations we fall back on an old me be a better therapist. So, I skeptically treatable. Finally, the therapist gives the standby, the dirty secret of failed psy- but gamely agreed to attempt IPT. patient a formulation. The formulation chotherapy: blame the patient (Gunder- IPT was difficult for me to learn. links the patient’s condition either to a role man, 2000). “They don’t want to get Although the concepts are relatively transition, in which there was a significant better.” “They’re not really trying.” “They simple, and some of the core principles life change (or in the case of PTSD, onset of can’t be helped.” “I did everything I could share commonality with CBT, it is truly a a significant condition); a role dispute, in think of.” The comforting phrases we tell very different form of treatment, having its which the patient’s symptoms link to the ourselves to absolve ourselves of guilt or roots more in attachment theory and psy- onset of a fundamental personal disagree- maybe the secret fear that we’re not doing a chodynamic psychotherapy than anything ment and conflict with another person; particularly good job. else. IPT was originally developed in the unresolved grief, if the patient never fully An alternative explanation for lack of 1970s by Dr. Gerald Klerman and Dr. processed the death of someone important; improvement may be that CBT was just not Myrna Weissman as part of a study of or if none of the above apply, the therapist a good fit for these patients. Yet, I was hes- amitriptyline for depression. IPT empha- may opt for an interpersonal deficit, an itant to accept this idea. I often felt as sized what was then a novel concept: unfortunately named grouping that is though there weren’t any good alternatives depression is a medical illness that is not intended for those who do not fit well into to CBT, perhaps because my training had the patient’s fault, and it can be improved the other categories (Weissman, Mark- been CBT-focused to the near total exclu- through socially oriented interventions owitz, & Klerman, 2007). sion of other approaches. I imagine this (Klerman, Weissman, Rounsaville, & In the second phase of treatment, the view may be shared by many others of my Chevron, 1984; Markowitz & Weissman, therapist begins each session by asking, generation of therapists, especially as CBT 2012). “How have things been since we last met?” has become the best disseminated evi- IPT has three basic principles: (a) what- The patient responds by reporting how he dence-based mode of therapy in graduate ever may have “caused” a depressive or she is feeling, or what has happened psychology and other training programs episode or other mental health disorder, it recently. The therapist helps the patient (Weissman et al., 2006). occurs in an interpersonal context and connect mood to life circumstances, com- tends to involve disruption of important menting that it makes sense that the patient

182 the Behavior Therapist INTERPERSONAL PSYCHOTHERAPY feels worse when bad things happen, and acknowledges that separation can be “bit- man, Scarvalone, & Perry, 2000; see Table better when good things happen. In dis- tersweet.” The therapist attempts to relieve 1). Besides the structural issues of, for cussing incidents, the therapist asks: guilt and self-blame if the treatment was example, homework or agenda-setting, What happened? not fully successful, and explores other IPT generally targets emotions, whereas What did you feel? options with the patient as warranted. CBT primarily targets cognitions, viewing Did your feelings make sense? emotions as more of an outcome or mea- And what happened next? “Okay. We’ve established that you were surement variable. Furthermore, IPT feeling sad, and angry, and that these focuses on emotions within interpersonal The goal of these questions is to help the patient recognize what the patient may be feelings made sense; in fact, most people contexts and exploration of interpersonal feeling, understand why the patient may be would probably feel as you did if spoken effectiveness with other human beings, feeling this way, and allow the patient to to the way that you were. So what hap- rather than on a patient’s internal, cogni- experience and express this emotion. The pened next? What did you do?” tive dysfunctions. Which is not to say that therapist then moves to the next question: “I didn’t do anything. I mean, I apolo- cognitive distortions or misperceptions are What are your options in this kind of situ- gized. I said I was sorry.” never addressed in IPT; but they are not a ation? What would be helpful? Often, the “You apologized?” primary focus and are certainly no sine qua IPT therapist will role-play scenarios with “Yeah.” He pauses. “I know, stupid, non. the patient to help the patient arrive at a right? I don’t know what to do.” This was hard to wrap my head around satisfactory interpersonal choice that vali- “Well, what are your options?” when I first started conducting IPT for dates and honors the patient’s feelings. depression and PTSD. No homework In the third and final phase, the thera- To even a casual observer, there are assignments? No discussion of trauma? No pist helps prepare for termination, and as many noticeable differences between IPT direct addressing of avoidance? We’re just in other forms of therapy, discusses what and CBT, which are also readily visible on supposed to talk about feelings? worked and what didn’t, bolsters a sense of standardized adherence scales (Hill, “Yes,” I learned. The key difference independence and competence, and O’Grady, & Elkin, 1992; Markowitz, Spiel- between IPT and exposure treatments for

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Early Entry Application: Start Early! Application fee is discounted from $125 to $25 for graduate students, interns, and residents: http://www.abpp.org/i4a/pages/index.cfm?pageID=3299 Senior Option: With 15 years of postdoctoral experience in cognitive and behavioral psychology there is flexibility in the requirement for a practice sample: http://www.abpp.org/i4a/pages/index.cfm?pageID=3299 When are Exams Conducted? Exams are conducted in different places, but are usually done at the APA (Washington, DC, 1st week in August 2017) and ABCT (San Diego, 3rd week in November 2017) annual conferences. This year exams can also be conducted at the ABPP conference in San Diego in early May 2017. Other exams can be arranged in other locations on a case-by-case basis. Note: At ABCT in November, we will have a Q & A session for those who want more information about board certification

June • 2017 183 LOWELL & MARKOWITZ

PTSD is that exposure treatments target thoughts or startle reflex, and seek appro- getting better, or who may especially bene- reminders of and the narrative of the trau- priate support for these feelings, rather fit from an affect- or interpersonally matic event itself, whereas IPT targets the than pull away from others and remain iso- focused treatment. As a therapist, I am interpersonal sequelae of trauma—that is, lated and alone, burying or hiding their grateful for how IPT has broadened my withdrawal and isolation, distrust of others, feelings. I have been impressed as patients, perspective, and I encourage other CBT “interpersonal hypervigilance,” impaired who at the onset of treatment appeared therapists to give it a try as well. social and marital functioning (Markowitz, timid, depressed, and avoidant, become 2016). confident, mature individuals with the References I have had many uncomfortable skills to successfully navigate their inter- Baardseth, T. P., Goldberg, S. B., Pace, B. moments while conducting IPT. Focusing personal environments. T., Wislocki, A. P., Frost, N. D., Siddiqui, on feelings rather than thoughts has meant I have also been surprised by IPT’s J. R., … Wampold, B. E. (2013). Cogni- having to be more in touch and present effects on me as a therapist: I have gradu- tive-behavioral therapy versus other with my own feelings, including feelings of ally noticed that I have become more therapies: Redux. Clinical Psychology pain and discomfort, when my natural patient, more comfortable with emotions, Review, 33(3), 395–405. empathy connected me to my patient’s and better able to support patients in find- https://doi.org/10.1016/j.cpr.2013.01.004 experiences. I have learned to be less quick ing their own solutions to problems Butler, A. C., Chapman, J. E., Forman, E. to hand tissues to patients, and more will- (although I’m sure Dr. Markowitz would M., & Beck, A. T. (2006). The empirical ing to sit back and allow feelings just to be. say, correctly, that I still have plenty of status of cognitive-behavioral therapy: A It has also been hard to resist “fixing” room to grow). I find myself doing less review of meta-analyses. Clinical Psychol- patients’ thoughts. When I hear a distorted mental juggling during IPT sessions in ogy Review, 26(1), 17–31. cognition,I always want to change it, shape terms of what skills to focus on and what https://doi.org/10.1016/j.cpr.2005.07.003 it, correct it, challenge it—something! In the patient needs to learn, and being more Cowan, M. J., Freedland, K. E., Burg, M. IPT, though, pulling the patient away from in the moment, allowing the process of M., Saab, P. G., Youngblood, M. E., Cor- feelings is actually counterproductive. It therapy simply to be. And, I will admit, it nell, C. E., … ENRICHD Investigators. distracts from the primary task of under- has been incredibly freeing to get away (2007). Predictors of Treatment Response for Depression and Inadequate standing, labeling, and accepting an emo- from homework, and from endless, awk- Social Support – The ENRICHD Ran- tion, and being willing to generate ways to ward discussions of why a patient didn’t domized Clinical Trial. Psychotherapy honor and act on that feeling in an effec- complete a particular assignment. I look and Psychosomatics, 77(1), 27–37. tive, interpersonally savvy way. forward to my IPT sessions, and find https://doi.org/10.1159/000110057 In somehow enduring and overcoming myself immensely enjoying the sense of Craske, M.G. (2016, October 29). Honor- these and other challenges, however, I have adventure that comes with not knowing ing the past, envisioning the future. Presi- made a startling discovery: IPT works! what has happened in the past week, what dential address presented at the Annual While this outcome is of no surprise to emotions have been stirred up, and learn- Convention of the Association for those already familiar with IPT’s consider- ing what patients have attempted on their Behavioral and Cognitive Therapies, able research support (Cuijpers et al., 2011; own. New York, NY. Negt et al., 2016), it has been eye-opening I have no intention of abandoning CBT, Cuijpers, P., Geraedts, A. S., van Oppen, to see how patients get better simply by and continue to regularly use CBT treat- P., Andersson, G., Markowitz, J. C., & focusing on feelings and using them to ments, including PE. There are unques- van Straten, A. (2011). Interpersonal psy- explore how to interact with others in dif- tionable advantages to exposure-based and chotherapy for depression:A meta- ferent, more effective ways. I have also other CBT approaches for PTSD, depres- analysis. American Journal of Psychiatry, 168(6), 581–592. https://doi.org/10.1176/ found, anecdotally, that patients with sion, anxiety, and other problems, and appi.ajp.2010.10101411 PTSD gain perspective on their traumatic much proven success. However, as no Decker, S. E., Kiluk, B. D., Frankforter, T., experiences and memories even without treatment works for all patients, it is Babuscio, T., Nich, C., & Carroll, K. M. addressing them directly. They learn to extremely comforting to know that IPT is (2016). Just showing up is not enough: identify the feelings that arise from trauma- available for patients who don’t seem to be Homework adherence and outcome in related symptoms, such as intrusive a good “fit” for CBT, who don’t seem to be cognitive–behavioral therapy for cocaine dependence. Journal of Consulting and Clinical Psychology, 84(10), 907–912. https://doi.org/10.1037/ccp0000126 Table 1. Similarities and Differences Between CBT and IPT Gunderman, R. (2000). Illness as failure. Category CBT IPT Blaming patients. The Hastings Center Report, 30(4), 7–11. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/ Goal Correct distorted thinking Improve interpersonal functioning 10971886 Target of Hill, C. E., O’Grady, K. E., & Elkin, I. (1992). Applying the Collaborative Study interventions Cognitions and behaviors Emotions Psychotherapy Rating Scale to rate thera- (and interpersonal behaviors) pist adherence in cognitive-behavior Focus Diagnosis-, present-focused Diagnosis-, present-focused therapy, interpersonal therapy, and clini- cal management. Journal of Consulting Use of homework Yes No and Clinical Psychology, 60(1), 73–9. Time-limited Usually Yes Retrieved from http://www.ncbi.nlm.nih. gov/pubmed/1556289

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Klerman, G. L., Weissman, M.M., Roun- symptoms. Journal of Psychotherapy New York: Oxford University Press. saville, B., & Chevron, E.S. (1984). Inter- Practice and Research, 9(2), 75–80. https://doi.org/10.1093/med:psych/9780 personal psychotherapy of depression. Retrieved from http://www.ncbi.nlm.nih. 195309416.001.0001 New York: Basic Books. gov/pubmed/10793126 Weissman, M. M., Verdeli, H., Gameroff, LeBeau, R. T., Davies, C. D., Culver, N. C., Markowitz, J. C., & Weissman, M. M. M. J., Bledsoe, S. E., Betts, K., Mufson, L., & Craske, M. G. (2013). Homework com- (2012). Interpersonal psychotherapy: … P, C.-C. (2006). National survey of pliance counts in cognitive-behavioral Past, present and future. Clinical Psychol- psychotherapy training in psychiatry, therapy. Cognitive Behaviour Therapy, ogy & Psychotherapy, 19(2), 99–105. psychology, and social work. Archives of 42(3), 171–179. https://doi.org/10.1080/ https://doi.org/10.1002/cpp.1774 General Psychiatry, 63(8), 925. https://doi.org/10.1001/arch- 16506073.2013.763286 Negt, P., Brakemeier, E.-L., Michalak, J., psyc.63.8.925 Markowitz, J. C. (2016). Interpersonal psy- Winter, L., Bleich, S., & Kahl, K. G. chotherapy for posttraumatic stress disor- (2016). The treatment of chronic depres- der. New York: Oxford University Press. sion with cognitive behavioral analysis ... Markowitz, J. C., Petkova, E., Neria, Y., system of psychotherapy: A systematic Van Meter, P. E., Zhao, Y., Hembree, E., review and meta-analysis of randomized- Correspondence to Ari Lowell, Ph.D., … Marshall, R. D. (2015). Is exposure controlled clinical trials. Brain and New York State Psychiatric Institute & necessary? A randomized clinical trial of Behavior, 6(8). Department of Psychiatry, College of interpersonal psychotherapy for PTSD. https://doi.org/10.1002/brb3.486 Physicians and Surgeons, Columbia Univer- American Journal of Psychiatry, 172(5), Shedler, J. (2010). The efficacy of psycho- sity, Unit #69, 1051 Riverside Drive, New 430–440. https://doi.org/10.1176/ dynamic psychotherapy. American Psy- York, NY, 10032; appi.ajp.2014.14070908 chologist, 65(2), 98–109. [email protected] Markowitz, J. C., Spielman, L. A., Scarval- https://doi.org/10.1037/a0018378 one, P. A., & Perry, S. W. (2000). Psy- Weissman, M. M., Markowitz, J. C., & chotherapy adherence of therapists treat- Klerman, G. L. (2007). Clinician’s Quick ing HIV-positive patients with depressive Guide to Interpersonal Psychotherapy.

SCIENCE FORUM ioral decrease process: punishment. Clarifi- cation regarding the precise behavioral def- inition of this term has been attempted Protecting the Scientific Lexical Canon many times, but with little effect. Scientists refine their concepts over time. For example, reinforcement, one of R. Trent Codd, III, Cognitive-Behavioral Therapy Center of Western the most fundamental concepts in behav- North Carolina, P.A. ior analysis, is currently the subject of some debate. The dominant view has been that WORDS MATTER IN SCIENTIFIC PRACTICE. foundational concepts (e.g., tact, mand, reinforcement involves the strengthening They matter because they can facilitate or intraverbal, etc.). of behavior, though other theories dispute hamper clear communication among sci- Rather than construct new words, some this (e.g., Davison & Nevin, 1999). Scien- entists about phenomena, which are often scientists approach this difficulty by tific communities are slow to modify their complex. They also matter because they attempting to clearly define their novel use foundational concepts, but always remain impact the clarity of communication of existing terms. This is problematic, how- open to modification if conceptual and empirical analyses reveal more effective between scientists and the lay public. ever, because despite careful attention to specification. Words, if properly formulated, afford eco- definitional matters, many people will still Words impact scientific behavior when nomical communication and enable the confuse the new use of the term with its they influence the ways scientists view their successful pursuit of scientific goals such as preexisting use. A well-known example of subject matter, the manner in which they accurate interpretation of findings and this is the long-standing and widespread make interpretations, and the ways that facilitation of procedural replication confusion surrounding the term “negative terminology affects conceptual under- (Chiesa, 1994). reinforcement.” Scientists of behavior use standing. As such, scientific communities Scientific communities construct their this term with precision; they use it when attend to the controlling effects their words vocabularies with various considerations in making reference to a process wherein have on their behavior (Chiesa, 1994). mind. First, they consider “entymological environmental events that immediately Finally, scientific communities take sanctions” (Skinner, 1957), which is to say follow a behavior, and which involve the substantial measures to protect their pre- they try to avoid the use of words that termination of an aversive condition, lead cise subject-specific terminological use. already have meaning for many people. For to an increased probability of that behavior They accomplish this through the arrange- example, when Skinner labeled his concep- in similar conditions. In other words, this ment of contingencies that socialize junior tual analysis of language, he chose the term refers to a process that leads to an increase members in terminological precision and “verbal behavior” rather than “language” in behavior. Yet many laypeople, and even weaken or prevent subsequent terminolog- because the latter already had meaning that many professionals, use this term to refer ical drift. differed from his view of the phenomena. to environmental events that lead to a The effectiveness of arranging such Similarly, he often contrived novel words decreased probability of responding. There contingencies differs across scientific com- free from preexisting meaning to label his is an existing term for this type of behav- munities. Behavioral scientists have gener-

June • 2017 185 CODD ally been less effective than other sciences terminological use, they must attend to ify that one component be weighted more in this regard, perhaps because their termi- their language practices. heavily than another, as they are all consid- nologies overlap more frequently with lay Unfortunately, significant terminologi- ered to be of equal value.1 terminology than do those of other sci- cal imprecision and drift is present in the Another difficulty is the use of differing ences. Consequently, behavioral scientists CBT community. In this paper three key terms to refer to evidence-based practice. A must be even more steadfast in protecting examples are noted and described, fol- nonexhaustive list of examples includes: terminological precision with respect to lowed by suggestions for enhancing the “evidence-informed practice,” “the evi- their lexicon. community’s language practices. Two dence based approach” (emphasis added), Concerns about terminological use in related issues involve the precise use of sci- “evidence-based practices” (italics mine), psychology, in both research and applied entific terms among the lay public and “evidence-based protocol,” and “empiri- contexts, is not new (e.g., Miller & Pollock, across scientific disciplines, but these are cally supported treatment.” These terms 1994; Stanovich, 2012). A number of not addressed here. are often used as synonyms. They are also authors have noted the difficulty that psy- frequently used to solely mean a treatment chological scientists have in using the same Current Examples or a list of treatments with scientific sup- term for different constructs as well as of Terminological Imprecision port. EBP, however, does not refer to a list referring to the same constructs with dif- of treatments, but rather a model for pro- Many examples of imprecise and drift- ferent labels (Block, 1995; Markon, 2009). fessional decision-making. In contrast, the ing terminological use in the CBT commu- One striking example is the documented term "empirically supported treatments" is nity are available, but due to space limita- use of 15 different terms to refer to the derived from a movement involved in tions only three are presented. Terms were “false consensus effect” (Miller & Peder- developing evidentiary standards and dis- selected from three different categories: (a) son, 1999). Further, a recent paper dis- seminating lists of interventions meeting a clinical decision-making process, (b) a cussed the imprecise use of 50 psychologi- those standards (Chambless & Hollon, clinical procedure, and (c) a method of cal and psychiatric terms (Lilienfeld et al., 1998). The ability to identify and deliver inference considered foundational to sci- 2015), including their identification and scientifically supported interventions is an entific practice. Within each example the examples of their misuse. Words are important element of evidence-based prac- precise scientific term is noted, examples of tice, but it only represents one third of the important tools in a scientist’s armamen- its misuse described, and examples of neg- evidence-based-practice decision-making tarium and, clearly, confusion is mini- ative consequences of the imprecision process (i.e., best available research, but not mized when each word is restricted to a specified. single meaning. clinical expertise or client culture and pref- The field of applied behavior analysis Example 1: “Evidence-Based” erences). Finally, since "empirically sup- (ABA) has also recognized this problem “Evidence-based” is a descriptor pri- ported treatment" is already an established and has been more proactive than other marily intended to modify the term “prac- term for referencing a psychological treat- areas of behavioral science at protecting its tice,” as in evidence-based practice. How- ment meeting specific evidentiary stan- own lexical canon. For example, applied ever, it is often used incorrectly, for reasons dards, it is unnecessary and confusing to behavior analysts dedicate a section in one discussed below, to modify the noun “treat- make use of additional terms (e.g., “evi- of their primary journals, The Behavior ment,” (i.e., evidence-based treatment). dence-based treatment”) to refer to the Analyst, to this specific issue. The section, This misuse appears to be a consequence of same thing. Moreover, because differing “On Terms,” focuses on one technical term verbal drift. classification systems for determining what at a time and, as of 2016, there are more Adding to the confusion, numerous satisfies the designation “evidence-based” than 36 of these articles. The authors of the technical definitions have been presented exist, each with their own unique evalua- section clarify technical terms with defini- in the literature. Fortunately, most con- tion criteria (e.g., California evidence- tions and descriptions of proper termino- verge on common considerations and the based clearinghouse, SAMHSA’s NREPP, logical use (Carr & Briggs, 2011). key commonalities are captured by the def- National Association of Public Child Wel- Recently in the CBT community, there inition of evidence-based practice (EBP) fare Administrators), the term evidence- has been some interest in clarifying impor- offered by the American Psychological based treatment (EBT) is not precise. tant terms. For example, Sauer-Zavala et al. Association: ‘‘the integration of the best The terminological difficulties do not (2017) clarified differing uses of the term available research with clinical expertise in end with communication problems; the “transdiagnostic,” specifying their conse- the context of patient characteristics, cul- confusion also frustrates dissemination quences and offering guidance on how to ture, and preferences’’ (APA, 2005, p. 5). efforts. Many consumers have learned to engender consensus around the term. In When one examines this definition one seek out treatments with the designation contrast, others have stipulated lack of pre- discovers that evidence-based practice “evidence-based,” but they have done so cision as “middle terms” to avoid the mis- involves the integration of three distinct without awareness that this is only one perception of precision before supporting components during clinical decision- component of evidence-based practice, data (Hayes, Strosahl, & Wilson, 2012). making: (a) the best available research evi- albeit an important one. Certain practi- Verbal behavior evolves and over time dence, (b) one’s clinical expertise, and (c) tioners, including those who do not oper- words accumulate additional meaning. the patient characteristics, culture, and ate from an EBP framework, have come to This occurs naturally in everyday language; preferences. The definition does not spec- use that term because it produces business. scientific verbal communities are not immune to the phenomenon. So if scien- 1However, some recent recommendations are for differential weighting in favor of the empiri- tific communities are going to retain the cally supported treatment component (e.g., Lilienfeld, Ritschel, Lynn,& Latzman, in press; important benefits of precise and reliable Tolin, McKay, Forman, Klonsky, & Thombs, 2015).

186 the Behavior Therapist SCIENTIFIC LEXICAL CANON

The use of the term serves a marketing consequences relative to functional analy- conditions that set the occasion for behav- function, and for it to function as intended, ses (Hall, 2005; Hurl, Wightman, Haynes & ior that produces certain consequent the meaning of the term must be protected. Virues-Ortega, 2016; Lerman & Iwata, events. Additionally, in describing their It is, of course, a common pseudoscientific 1993; Mace & Lalli, 1991; Piazza et al., 2003; assessment approach one finds this lan- tactic to use terms that sound scientific to St. Peter et al., 2005; Thompson & Iwata, guage: “. .. use a functional analytic frame- gain credibility, despite referring to some- 2007). Because FA involves experimental work, in which the drinking response (R) is thing else (Ruscio, 2002). procedures it is the only functional assess- elicited by . . .” (p. 538). Although we are In sum, the negative consequences pro- ment method that can identify a functional addressing misuse of the descriptions of FA duced by these confusions include the relation (i.e., a “causal” relationship). For as a procedure, we’ve discovered another emphasis of one component of EBP (i.e., this reason, FA is considered the gold-stan- example of terminological misuse along the treatment) rather than the appreciation of dard functional assessment procedure. way. There is a well-established difference all three elements (i.e., treatment, clinical Although the CBT community makes between elicited and evoked behavior, and expertise, and client characteristics/prefer- use of functional assessment procedures, the meaning of these terms are quite pre- ences) and the inappropriate controlling they often refer to those procedures incor- cise. Elicited is used to refer to respondent effects on consumer behavior through the rectly. In fact, the CBT literature is replete behavior, whereas evoked is used to denote misappropriation of the term. An addi- with examples of the misuse of this term. operant behavior. Drinking, the focus of tional consequence is that it impedes clini- Given the frequency with which this term this chapter, is evoked, not elicited, behav- cian pursuit of evidence-based practice is misused, a comprehensive listing of ior. when they dislike the concept based on examples is not possible. In general, when The examples of misuse provided are inaccurate information (e.g., “I don’t like one reads descriptions of procedures not meant to suggest that these authors are evidence-based treatments because they labeled as functional analyses in the CBT guilty of terminological malpractice. are rigid and neglect the client’s values”). literature one typically does not discover Rather, they are provided to illustrate that reports of functional analyses, but rather all scientists, including senior ones, are Example 2: “Functional Analysis” indirect functional assessment procedures. equally susceptible to verbal drift, and to Functional assessment is an approach to That is, these depictions do not describe an demonstrate the nature of the digression. the assessment of problem behavior experimental method for determining the Importantly, “functional analysis” provides focused on identifying environmental function of client behavior, which is the key a nice example of terminological use that events thought to maintain those behav- definitional element of this procedure. has experienced drift to incorrect usage iors. The primary goal with this type of Notably, this terminological misuse is that is so substantial within a particular assessment is the identification of environ- readily found in popular CBT texts and community (e.g., the CBT community) mental contexts that immediately precede chapters written by prominent scholars in that its improper use appears to be the rule problem behavior (antecedents) and events the field (e.g., Dimidjian, Martell, Herman- rather than the exception. Scientific com- that immediately follow the behavior (con- Dunn and Hubley, 2014; Kaplan & Harvey, munities should only modify the meaning sequences). Functional analysis (FA) is a 2014; Martell, Addis, & Jacobson, 2001; of their terms when empirically or philo- specific type of functional assessment pro- McCrady, 2014; Payne, Ellard, Farchione, sophically justified. That is, there must be cedure, which involves the use of the exper- Fairholme, & Barlow, 2014). Referring to some usefulness in relation to the meaning imental method. The experimental proce- indirect functional assessment methods as modification. Scientists should not modify dure renders it distinct from the other two FAs is roughly analogous to referring to their terms solely because the community methods of functional assessment—indi- correlational procedures as experimental has digressed so substantially that most rect and observational—in that it affords procedures. This is problematic because members are using the terms improperly. the analyst the ability to specify causal rela- doing so suggests a causal relation can be To understand functional assessment, tionships between environmental events revealed when only associative relation- one must understand the meaning of the and problem behavior. In essence, FA ships have the possibility of discovery. Fur- term “function.” It has two definitions. The allows the clinician to experimentally thermore, many indirect functional assess- first involves the effect produced by the determine the function of the target behav- ment methods, as previously noted, are behavior. This is akin to asking, “What is ior, which then allows him or her to design poor at accurately identifying correlations the function of the heart?” The answer: to an effective intervention. (see previous citation). These methods typ- pump blood. FA is precisely defined by the commu- ically involve interviewing clients about The second involves the question, nity that created the procedure (i.e., applied these relationships, which is problematic “What is the effect of environmental events behavior analysis), and that verbal commu- because most clients are not trained on behavior?” This question asks whether nity has academic and journalistic contin- observers, do not possess the tools to the consequences function as a reinforcer gencies in place to protect its meaning. The improve accuracy, and must rely on their or a punisher. Questions such as, “What is FA procedure is well-articulated, sup- recall. the function of the behavior?” are not the ported by several decades of research and Another example of improper usage is questions that are answered by functional discussed in more than 2,000 chapters and found in McCrady (2014) in a section on analysis. Indirect and observational func- articles. The discrimination between FA FA that describes the method as “. .. assess- tional assessment methods, as described in and other functional assessment proce- ment techniques . . . used to identify the above referenced manuscripts, can pro- dures is crucial because the literature is antecedents to drinking” (p. 548). Func- vide evidence about the types of environ- clear that they differ in effectiveness. For tional assessment methods are primarily mental events produced by the behavior example, it is well established that indirect interested in consequent events (although (e.g., the behavior produces attention, functional assessment methods are gener- the entire four-term contingency is appre- escape, access, etc.). However, clinicians ally ineffective at identifying maintaining ciated), not just immediately antecedent need answers to a different question,

June • 2017 187 CODD namely, Which of the produced conse- however, is in their restricted ability to gen- addition, generality can be conveyed with quences is functioning as a reinforcer for eralize beyond the individuals studied" an actuarial depiction or with a description the behavior of interest? In other words, (Nock, Janis, & Wedig, 2007; p. 203). Curi- at the individual level. The ability to dis- not all the consequences produced by a ously, this sentence was written in the con- criminate between types of generality and behavior are maintaining that behavior. A text of the authors’ encouragement of read- between actuarial and individual levels of behavior might produce both attention and ers to make use of single case research examination is crucial because such dis- escape. A good FA might reveal that escape designs (SCRDs). They noted that use of criminated behavior reveals different types is the reinforcer, not attention. Some refer these designs by clinical researchers has of research activity produces different to the former as an establishing function declined substantially in recent years, types of information and deeper under- and the latter a partial function (Marsh, except within a restricted range of circum- standing of the methods necessary to pro- 2013). This can only be determined stances. They observed that SCRD use has duce each kind. Indeed, some authors sug- through an FA, not the indirect functional largely been confined to use as a comple- gest the research concerns within the assessment methods described in the mentary research strategy to between- overall field of psychology, of which CBT is above-referenced literature. groups randomized controlled trials a part, can and should be conceptualized It’s worth noting that the term “func- (RCTs), to examination of novel treatment into two distinct approaches—one con- tional analysis” itself is at odds with ordi- approaches and to the preliminary exami- cerned with individual behavioral nary usage. What generally is meant by the nation of interventions in advance of processes and one concerned with actuarial term is an analysis of function, or function embarking on an RCT. They apparently science—but that the dominance of group- analysis. For the analysis to be functional, endorse the migration of this research based methods have masked this distinc- it must lead to something else, like effective practice pattern to these restricted circum- tion (see Branch & Pennypacker, 2013, for treatment (see Hineline, 1980; Hineline & stances largely because of their perspective a full discussion of this point). Groeling, 2011). regarding SCRDs and generality, which Group designs, which produce actuarial These examples of terminological con- they seemingly view as limited, relative to accounts, have their own limitations with fusion impede communication between group designs. There are several types of respect to generality when considering how the CBT community and the ABA commu- generality, but these authors do not specify they are executed in actual practice, and nity, and they hide the relative strengths the type of generality to which they refer, these limitations are frequently underap- and weaknesses of each functional assess- leading to communication that lacks preci- preciated. Although they examine general- ment method from the CBT community. sion. One might infer they are referring to ity across participants, they do not, for generality in an actuarial sense. If that is example, typically examine generality Example 3: “Generalization” their intention, then they are correct in across therapists or settings (Barlow & Generalization is used in several ways noting SCRDs are restricted in that regard Hersen, 1984). This puts them in a position within psychology and related disciplines. or, more precisely, in their ability to permit of silence on these relevant matters of gen- For example, the term is used to label the inferences about population parameters erality. An additional concern about the phenomenon known as response and stim- relative to between-groups designs. How- generality of group-based data involves ulus generalization, as well as the generality ever, their expressed concerns regarding randomization. It is well known that an of experimental findings. The latter use of SCRDS and generality involve several important ingredient in the ability to gen- the term is our focus here and for the sake unarticulated assumptions worth examin- eralize from those data is random partici- of clarity we will use Johnson and Penny- ing. Most notably we might ask whether: pant selection. However, while random packer’s (2009) robust definition of this (a) The type of generality they emphasize is assignment may occur during these exper- type of generality, which is: “The meaning- the only form of generality important to iments, random selection is seldom, if ever, fulness of experimental interpretations psychotherapists? (b) This kind of general- achieved (Areán & Kraemer, 2013). Failing under circumstances different from those ity is the most important and relevant type such randomization in a between-groups that generated the data” (p. 341). When of generality to psychotherapists? and (c) comparison compromises the kinds of gen- one asserts that a set of experimental results The SCRDs are robust at producing other eralization possible. Furthermore, even if is high in generality, one is indicating that types of generalizable data, and if so, how perfectly randomized, group mean results generalization from those findings to novel important and relevant those data are to provide no direct implication about gener- individuals and conditions is reasonable.2 psychotherapists? We examine the answers ality across individuals. This is because, at The misuse of this term is perhaps the to these questions below. best, sample means permit inferences most concerning of the three examples As noted, there are many subtypes of about where a population mean might be, provided because it directly impacts the generality and they are fully detailed and but they are silent with respect to what hap- methods emphasized for scientific discov- articulated by Johnson and Pennypacker pens to any individual (see Penston, 2005, ery. Examples of misuse of this term are (2009) as well as Branch and Pennypacker and Williams, 2010, for additional discus- readily found in the CBT literature, and are (2013), so they will only be mentioned sion of group mean inadequacies in the captured by the following quote found in a briefly here. For example, there is general- context of RCTs). popular research methods text. The ity of variables; procedures and processes; A more substantial concern is the authors assert, “Perhaps the greatest limi- and generality across participants, apparent misunderstanding or undervalu- tation of [single case research designs], response classes, settings, and species. In ing of the most relevant type of generality to a psychotherapist and how that type of generality is achieved. Psychotherapists 2Generality, generalization, and generalizability are interchangeable in this paper. The differing work with individuals; therefore, a primary usage is solely reflective of their use as different parts of speech. The important discriminations aim of the psychotherapy researcher is to for the reader are found across the different types of generality. be able to produce data with generality at

188 the Behavior Therapist SCIENTIFIC LEXICAL CANON an individual participant level (sometimes decades). A clinician working with an indi- may be due in part to the overreliance on called individual subject validity). If one vidual client, however, is tasked with trying group designs. applies Johnson and Pennypacker’s (2009) to determine an appropriate course of The example of generality illustrates definition of generality, it is unclear how action with respect to an individual client how one’s understanding of a term impacts drawing a sample from a population, and over a shorter time frame (i.e., hours or scientific practice. Since generality of making inferences about that population days). These data offer little use in this con- experimental findings is an important (actually, population parameters) on the text. objective of research activity, if one believes basis of the drawn sample, and then Replication is at the heart of individual that group-based designs are more likely to making inferences back to individual cases, subject validity. Once a causal relation is produce this result, one would be more is accomplished. In fact, it is impossible identified, attempts at replication can vary likely to design these types of experiments unless data from individuals are examined, key parameters. Through many replication to the exclusion of SCRDs. one by one. Recognizing this concern, attempts, noting where the causal relation some journal editors are now specifically survives and where it does not, scientists Protecting Our Lexical Canon requiring the simultaneous reporting of all discover the domain of generality (Lykken, individual data when reporting the results 1968; Sidman, 1960, Chps 3-4). SCRDs A first step in remedying these difficul- of randomized controlled trials (Hanley, emphasize replication. For example, ties is the recognition of the importance of 2017). An additional impediment to gener- assume a single participant in a basic ABA scientific vocabularies as well as the resolve ality occurs when, or if, a representative design where a treatment effect is revealed. to defend them. While these are necessary sample is achieved. A representative At least two replications of the causal rela- conditions for safeguarding this important sample, by definition, is heterogeneous tion are immediately apparent, once aspect of scientific practice, they are not with respect to participant characteristics during the B phase and a second during the sufficient because they are antecedent and those variations frustrate generality withdrawal phase. In most studies each interventions, and as such, can only set the back to an individual (Barlow & Hersen, phase (e.g., baseline and treatment) occasion for behavior. Because consequent 1984). Between-groups designs were con- involves a series of observations and each events are usually necessary to maintain structed for a different subject matter, of those observations is also an attempt at behavior, the cognitive and behavioral which involve actuarial questions, and they replication. Extending the example further verbal community must ensure its partici- are robust with respect to that subject with three participants, as is typical with pants contact reinforcement for appropri- matter. However, their usefulness for psy- SCRD studies, one would observe at least ate terminological use. chotherapy, where individual subject valid- six replications of the causal relation when Here are some additional recommenda- ity is most pertinent, is overstated unless considering the B and A phases for each tions: the goal of therapy is to improve the aver- participant. In contrast, a between-groups 1. Design graduate and other training age behavior of a group of clients. To be RCT contains a replicability ceiling, in that with fluent terminological performance in clear, actuarial methods do produce data it can only demonstrate an effect once per mind. This is necessary because students do that are useful to mental health profession- experiment. not acquire fluent terminological reper- als and so should not be discarded. How- Group designs involve the aggregation toires by mere reading of definitions. ever, their limitations with respect to indi- of data into group means. The process of Empirically supported instructional meth- vidual subject validity should be averaging masks individual differences and ods such as precision teaching (Kubina & recognized. More crucially, the importance thus substantially frustrates the ability to Yurich, 2012), which is designed to bring and relevance of individual subject validity, generalize group-based findings to the performance to fluent levels, should be along with the advantages of SCRDs in this individual level. Moreover, it is common to used. regard, should be fully understood. Ideally, use meta-analytic procedures to summa- 2. Construct journal guidelines that spec- this different understanding would pro- rize many experiments by combining these ify that appropriate and precise use of terms duce a different scientific practice pattern.3 averages, further camouflaging individual are required. One set of guidelines, Uni- Scores of example difficulties with gen- values. In contrast, evaluating effects on formed Requirements for Manuscripts eralizing from actuarial data to individuals many different individuals, as one would Submitted to Biomedical Journals (ICMJE, can be given, but only one is provided here. do with SCRDs, enhances generality by 1997), adhered to by over 500 journals Several studies have identified risk factors presenting it directly. (Bhopal, Rankin, & Bennett, 2000), pro- for suicidal behavior, which include demo- In essence, when one speaks of general- vides an example of an initial attempt to graphics such as race, age, marital status, ity, regardless of the type of generality, one outline requirements for precise termino- and so on (Chiles & Strosahl, 2008). Gener- is speaking of the parameters necessary to logical use, although within a limited range ally, these factors identify high-risk groups, produce certain outcomes. Systematic vari- of vocabulary. For example, one of their and while group membership points to ele- ation in a group design if it failed to repli- guidelines states that “The definition and vated risk, most members of such groups cate would not make clear the reasons for relevance of race and ethnicity are ambigu- will not die by suicide. Furthermore, the the failure of replication. An SCRD, on the ous. Authors should be particularly careful predictive validity of group membership other hand, would. Indeed, psychology is about using these categories” (p. 311). with respect to completed suicide may be currently experiencing a “replication crisis” While bringing attention to the issue of expressed over a long time horizon (i.e., (Open Science Collaboration, 2015), which vague terminological use, the guidelines don’t go far enough. It would be useful if the requirements for terminological clarity 3 See lecture by Neville Blampied, Ph.D., for a thorough discussion of these two experimental went beyond those terms to all of their dis- designs and generality: https://www.youtube.com/watch?v=LcU6nhiTse4. cipline’s terms, and if guidelines stronger

June • 2017 189 CODD than “be careful,” which itself is ambigu- References of mindful change (2nd ed.). New York: ous, were provided. The Guilford Press. American Psychological Association. Hineline, P. N. (1980). The language of 3. Engineer effective listserv practices. (2005). Policy statement on evidence-based behavior analysis: Its community, its func- Listservs, as verbal communities, will be practice in psychology. Retrieved from tions, and its limitations. Behaviorism, more helpful if the members have been http://www.apa.org/practice/ 8(1), 67-86. trained to discriminate between more and resources/evidence/evidence- basedstatement.pdf Hineline, P.N, & Groeling, S.M. (2011). less useful talk, specifically during graduate Behavior-analytic language and interven- training, and if that training has increased Areán, P. A., & Kraemer, H. C. (2013). High tions for autism. In J.A. Mulick & E.A. their verbal repertoire to fluent levels. quality psychotherapy research: From con- Mayville (Eds.), Behavioral foundations of ception to piloting to national trials. New Acquiring this discriminative repertoire effective autism treatment (pp. 35–55). York: Oxford University Press. will allow its members to shape more useful Cornwall-on-Hudson, NY: Sloan. Barlow, D. H. (Ed.). (2014). Clinical hand- Hurl, K., Wightman, J., Haynes, S. N., & talk by new and junior members, as well as book of psychological disorders: A step-by- to maintain consequences for all members. Virues-Ortega, J. (2016). Does a pre-inter- step treatment manual (5th ed.). New vention functional assessment increase Consider the method used by parents to York: The Guilford Press. intervention effectiveness? A meta-analy- teach their children to become speakers Barlow, D. H., & Hersen, M. (1984). Single sis of within-subject interrupted time- and listeners in their native language, and case experimental designs. Needham series studies. Clinical Psychology Review, recall that some parents are more skilled Heights, MA: Pergamon Press. 47, 71-84. teachers than others. The most effective Bhopal, R., Rankin, J., & Bennett, T. (2000). International Committee of Medical Jour- parents are highly skilled speakers and lis- Editorial role in promoting valid use of nal Editors. (1997). Uniform require- teners themselves (i.e., they talk usefully concepts and terminology in race and eth- ments for manuscripts submitted to bio- nicity research. Science Editor, 23(3), 75- medical journals. New England Journal of about their environments), interact fre- 80. Medicine, 336, 309-316. quently with their children, and those Block, J. (1995). A contrarian view of the Johnston, J. M., & Pennypacker, H. S. interactions primarily involve positive five-factor approach to personality (2009). Strategies and tactics of behavioral reinforcement relative to negative rein- description. Psychological Bulletin, 117(2), research (3rd ed.). New York: Routledge. forcement or punishment. Interactions 187-215. Kaplan, K.A., & Harvey, A.G. (2014). Treat- characterized primarily by negative rein- Branch, M. N. and Pennypacker, H. S. ment of sleep disturbance. In Barlow, forcement and punishment are likely to (2013). Generality and generalization of D.H. (Ed.), Clinical handbook of psycho- decrease the frequency of interactions once research findings. In G. J. Madden (Ed.), logical disorders: A step-by-step treatment manual (pp. 640-669). New York, NY: children learn how to escape and avoid APA Handbook of Behavior Analysis, Vol. The Guilford Press. them. Somewhat analogously, we need to 1 (pp. 151-175). Washington DC: APA Publications. Kubina, R. M., & Yurich, K. K. (2012). Pre- engineer professional verbal communities Carr, J. E., & Briggs, A. M. (2011). A cision teaching book. Lemont, PA: Great- to maintain useful speaking and writing as resource on behavioral terminology: An ness Achieved Publishing. professionals transition from training to annotated bibliography of on terms arti- Layng, T. J., Twyman, J. S., & Stikeleather, practice communities. The same variables cles in the behavior analyst. The Behavior G. (2004). Engineering discovery learning: apply. Members of the practice community Analyst, 34(1), 93-101. The contingency adduction of some pre- must be trained as effective speakers and Chambless, D. L., & Hollon, S. D. (1998). cursors of textual responding in a begin- listeners. Properly trained speakers can Defining empirically supported therapies. ning program. The Analysis of Verbal Behavior, 20, 99. provide models of, and instructions for, Journal of Consulting and Clinical Psychol- Lerman, D. C., & Iwata, B. A. (1993). effective speaking and as listeners, they are ogy, 66(1), 7. Chiesa, M. (1994). Radical behaviorism: The Descriptive and experimental analyses of able to reinforce such speaking. If properly variables maintaining self-injurious philosophy and the science. Sarasota, FL: trained, they will positively reinforce suc- behavior. Journal of Applied Behavior Authors Cooperative. cessful talk by prompting and shaping pro- Analysis, 26(3), 293-319. Chiles, J. A., & Strosahl, K. D. (2008). Clini- Lilienfeld, S.O., Ritschel, L.A., Lynn, S.J., & cedures. And if there are opportunities for cal manual for assessment and treatment Latzman, R.D. (in press). Evidence-Based frequent interaction between members of of suicidal patients. Washington, DC: Practice: Its insufficiently Appreciation such a verbal community, they will main- American Psychiatric Publishing. Raison d'etre. In S. Dimidjian (Ed.), Evi- tain useful ways of talking about their prac- Davison, M., & Nevin, J. A. (1999). Stimuli, dence-based therapy in action. New York: tice. reinforcers, and behavior: An integration. Guilford. 4. Routinely dedicate journal space to Journal of the Experimental Analysis of Lilienfeld, S. O., Sauvigné, K. C., Lynn, S. J., terms. The Behavior Analyst’s “On Terms” Behavior, 71(3), 439-482. Cautin, R. L., Latzman, R. D., & Wald- is a useful model. This practice affords con- Hall, S. S. (2005). Comparing descriptive, man, I. D. (2015). Fifty psychological and ceptual development, emphasizes the experimental and informant-based assess- psychiatric terms to avoid: A list of inac- ments of problem behaviors. Research in importance of scientific word use, and curate, misleading, misused, ambiguous, Developmental Disabilities, 26(6), 514- and logically confused words and phrases. assists with recalibrating terminological 526. Frontiers in Psychology, 6. use among readers who’ve drifted. Hanley, G. P. (2017). Editor's Note. Journal Lykken, D. T. (1968). Statistical significance Words are an important part of the of Applied Behavior Analysis, 50, 3–7. in psychological research. Psychological behavioral scientist’s armamentarium and, Hayes, S. C., Strosahl, K. D., & Wilson, K. Bulletin, 70, 151-159. as such, require active attention from the G. (2012). Acceptance and Commitment Mace, F. C., & Lalli, J. S. (1991). Linking verbal community. Therapy (ACT): The process and practice descriptive and experimental analyses in

190 the Behavior Therapist BOOK REVIEW

the treatment of bizarre speech. Journal of Open Science Collaboration. (2015). Esti- Stanovich, K. E. (2012). How to think Applied Behavior Analysis, 24(3), 553-562. mating the reproducibility of psychologi- straight about psychology (10th ed.). New Markon, K. E. (2009). Hierarchies in the cal science. Science, 349. York: Pearson. structure of personality traits. Social and Payne, L.A., Ellard, K.K., Farchione, T.J., St. Peter, C. C., Vollmer, T. R., Bourret, J. Personality Psychology Compass, 3(5), Fairholme, C.P., & Barlow, D.H. (2014). C., Borrero, C. S., Sloman, K. N., & Rapp, 812-826. Emotional disorders: A unified transdiag- J. T. (2005). On the role of attention in Marsh, W., (2013). A functional analysis nostic protocol. In D.H. Barlow (Ed.), naturally occurring matching relations. methodology for identifying motivating Clinical handbook of psychological disor- Journal of Applied Behavior Analysis, operations of behavior. Presented at the ders: A step-by-step treatment manual (pp. 38(4), 429-443. 39th Annual Convention of the Associa- 237-274). New York, NY: The Guilford Thompson, R. H., & Iwata, B. A. (2007). A tion of Behavior Analysts International, Press. comparison of outcomes from descriptive Minneapolis Convention Center, Min- Penston, J. (2005). Large-scale randomised and functional analyses of problem behav- neapolis, Minnesota. trials–a misguided approach to clinical ior. Journal of Applied Behavior Analysis, Martell, C. R., Addis, M. E., & Jacobson, N. research. Medical Hypotheses, 64(3), 651- 40(2), 333-338. S. (2001). Depression in context: Strategies 657. Tolin, D. F., McKay, D., Forman, E. M., for guided action. New York: WW Piazza, C. C., Fisher, W. W., Brown, K. A., Klonsky, E. D., & Thombs, B. D. (2015). Norton & Co. Empirically supported treatment: Recom- Shore, B. A., Patel, M. R., Katz, R. M., ... mendations for a new model. Clinical Psy- McCrady, B. S. (2014). Alcohol use disor- Blakely‐Smith, A. (2003). Functional chology: Science and Practice, 22(4), 317- ders. In Barlow, D.H. (Ed.), Clinical hand- analysis of inappropriate mealtime behav- 338. book of psychological disorders: A step-by- iors. Journal of applied behavior analysis, step treatment manual (pp. 533-587). New 36(2), 187-204. Williams, B. A. (2010). Perils of evidence- York, NY: The Guilford Press. based medicine. Perspectives in Biology Ruscio, J. (2002). Clear thinking with psy- Miller, N., & Pedersen, W. C. (1999). and Medicine, 53(1), 106-120. chology: Separating sense from nonsense. Assessing process distinctiveness. Psycho- Belmont, CA: Wadsworth Publishing. logical Inquiry, 10(2), 150-156. ... Sauer-Zavala, S., Gutner, C. A., Farchione, Miller, N., & Pollock, V. E. (1994). Meta- T. J., Boettcher, H. T., Bullis, J. R., & analysis and some science-compromising The author would like to thank Marc Barlow, D. H. (2016). Current definitions problems of social psychology. The Social Branch, Ph.D., and Martin Ivancic, Ph.D., Psychology of Science, 230-261. of “transdiagnostic” in treatment develop- ment: A search for consensus. Behavior for helpful comments on an earlier draft of Nock, M. K., Janis, I. B., & Wedig, M. M. Therapy, 48, 128-138. this paper. (2007). Research designs. In A.M. Nezu & C.M. Nezu (Eds.), Evidence-based out- Sidman, M. (1960). Tactics of scientific Correspondence to R. Trent Codd, III, come research: A practical guide to con- research: Evaluating experimental data in Ed.S., BCBA, CBT Center of Western North ducting randomized controlled trials for Psychology. New York: Basic Books. Carolina, P.A., 1085 Tunnel Rd., Suite 7A, psychosocial interventions (pp. 201-218). Skinner, B. F. (1957). Verbal behavior. Brat- Asheville, NC 28805; New York: Oxford University Press. tleboro, VT: Echo Point Books & Media. [email protected]

BOOK REVIEW particular type of problem but rather how CBT strategies can be applied across a diverse array of symptoms and clients. The Doing CBT Will Help You Do CBT section closes with an explanation of how these processes might be integrated into Thad R. Leffingwell and Emma Brett, Oklahoma State University useful case conceptualizations, complete with several case examples. These illustra- tions are helpful in providing concrete examples of effective CBT treatment plan- DAVID TOLIN’SNEW BOOK, Doing CBT ion throughout but promising to tell the ning that specifically targets a client’s prob- (2016; Guilford Press), tries to be many reader when he is doing so. Further, the lem areas. things to many people, and succeeds ably emphasis on theory-driven techniques and The second section of the book—“How in the attempt. The book’s subtitle— science-based conceptualizations is main- Do We Help”—comprises the meat of the A Comprehensive Guide to Working With tained without jargon, making the text book. Several chapters lay out the major Behaviors, Thoughts, and Emotions— easily digestible for clinicians of all back- intervention strategies of modern CBT, captures the goal and central thesis of the grounds and experience levels. including behavioral interventions like book. Tolin intended to create a resource The book opens with a four-chapter contingency management, behavioral acti- for both novice cognitive-behavioral ther- section titled “Why People Suffer” that lays vation, and exposure; cognitive interven- apy (CBT) learners and seasoned practi- out the CBT framework of interacting tions like cognitive restructuring, accep- tioners that would provide both practical behaviors, cognitive processes, and emo- tance, and bias correction; and emotion advice and a rich understanding of the var- tions. These chapters are rich with theory regulation strategies like distress tolerance ious approaches under the ever-broaden- and scientific grounding, and the reader is and emotion modulation. Each chapter is ing umbrella of modern CBT. His left with an understanding of how a CBT written in an accessible and readable style, approach is described well in the preface, therapist approaches presenting problems. sometimes funny or even poignant. Chap- with no denying his use of personal opin- Importantly, Tolin does not focus on one ters feature break-out boxes that focus on

June • 2017 191 NORTON ET AL. the science behind the approach (“The Sci- Form” that he uses to illustrate CBT case book for courses introducing evidence- ence Behind It”) and common clinical formulation. They are a useful addition. based CBT techniques to new therapists, challenges or misunderstandings (“Things The strength of the book is its attempt and an excellent resource for professionals That Might Bug You About This”). This to be comprehensive and integrative in who want a resource for broadening and section manages to be comprehensive and introducing the reader to the varieties of honing their skills. clear, with concise descriptions of inter- modern CBT interventions. In its early his- vention techniques without forgoing tory, behavior therapy was a principle- References essential information. The reader is left driven approach that was tailored to indi- with a good understanding of both the why vidual clients by the expertise of the Barlow, D. H., Farchione, T. J., Fairholme, and the how of each of the interventions behaviorist. As the field moved toward C. P., Ellard, K. K., Boisseau, C. L., Allen, covered. empirically supported treatments and pri- L. B., & May, J. T. E. (2010). Unified pro- The book concludes with three com- oritized writing and testing specific CBT tocol for transdiagnostic treatment of plete case examples that include assess- protocols for specific disorders, the field of emotional disorders: Therapist guide. ment information, conceptualization, CBT seemed less like a single entity and New York: Oxford University Press. treatment plans, and progress of treatment, more like a collection of loosely related Tolin, D. (2016). Doing CBT: A compre- particularly helpful for novice therapists cognitive-behavioral therapies, some more hensive guide to working with behaviors, given that comprehensive case conceptual- behavioral and some more cognitive. thoughts, and emotions. New York: Guil- ization is often difficult for less experienced Books often include chapters on CBTs for ford Press. clinicians. It also includes several helpful specific disorders. Recently, the field has ... forms that can be used with clients, with begun moving toward reunification of a unlimited reproducible downloads avail- principle-driven but flexible CBT (Barlow Correspondence to Thad R. Leffingwell, able to purchasers of the book. For exam- et al., 2010), and Tolin’s book is an impor- Ph.D., Oklahoma State University, Dept. of ple, one handout provides the blank ver- tant reflection of that important and badly Psychology, 116 N. Murray, Stillwater, OK sion of Tolin’s “Meaty Conceptualization needed reintegration. It is a perfect text- 74078; [email protected]

NEWS for institutions in LMICs, are a valuable step to reduce barriers in knowledge shar- ing, scientific publications represent only Trauma, Anxiety, and Depression in Iran: one pathway for the dissemination of mental health knowledge. A Report From the 3rd International Anxiety Mental health conferences, which can more easily blend scientific dissemination Congress in Iran (e.g., research symposia) with skill transfer strategies (e.g., training workshops or Peter J. Norton, Monash University and Monash Institute of Cognitive demonstrations), are an additional path- and Clinical Neuroscience way. However, most of the leading mental health–oriented gatherings are localized in Ali Gorji, Shefa Neuroscience Research Center, Khatam-Alanbia high-income countries due to both regional affiliations (e.g., American Psychi- Hospital and Westfälische Wilhelms-Universität Münster atric Association, British Psychological Society) and the infrastructural and eco- International Scientific Committee of the International Anxiety nomic challenges of LMICs to host large- Congress scale international gatherings such as the World Congress of Behavioral and Cogni- tive Therapies. The economic burden on THE SUBSTANTIAL UNMET mental health tion of LMIC-based individuals on the edi- scientists and practitioners from LMICs to need and disparity in access to evidence- torial boards of leading psychiatric journals travel to and attend major conferences and based treatment for mental health disor- is 3.5%, with one journal, World Psychiatry, congresses can be overwhelming, despite ders in low- to middle-income countries accounting for nearly half of the editorial many organizing bodies providing scholar- (LMIC) is widely recognized (Demytte- board members from LMICs (Pike, Min, ships or reduced registration rates for indi- naera et al., 2004). A particular barrier Poku, Reed, & Saxena, 2017). Finally, viduals from LMICs. As such, a “bring relates to imbalances in the ability to access access to current published mental health them to us” approach to mental health and contribute to scientific mental health research in LMICs is limited, with most knowledge dissemination needs to be research (Joint Statement, 2004; Saxena, subscriptions to leading mental health reconsidered in favor of a “bring us to Paraje, Sharan, Karam, & Sadana, 2006). journals coming from high-income coun- them” framework. A recent example of the For example, Saxena and colleagues (2006) tries (Joint Statement). While efforts such success of this strategy was the 3rd Interna- identified that high-income countries con- as the WHO Health InterNetwork Access tional Anxiety Congress in Tehran, Iran, tributed 94% of the total authorships of to Research Initiative (http://www.who.int/ held in November 2016. mental health publications indexed in the hinari/; accessed February 16, 2017), which One of the oldest continuous major civ- ISI Web of Science database. Representa- provides free or low-cost access to journals ilizations, Iran has had a tumultuous his-

192 the Behavior Therapist 3 RD INTERNATIONAL ANXIETY CONGRESS IN IRAN tory, recently including the coup supported tional health care gaps between prosperous Increasing Treatment” (Brett Deacon— by the United States of America and Great and developing nations. Australia), as well as a number of scientific Britain in 1953; the Islamic Revolution, In response, the Shefa Neuroscience presentations by Iranian mental health sci- overthrow of Shah Mohammad Reza Research Center of the Khatam Alanbia entists and professionals. Pahlavi, and formation of the Islamic Hospital, the governmental Foundation of Across the scientific presentations, sev- Republic of Iran in 1979; the Iran-Iraq war Martyrs and Veterans Affairs, and the Iran- eral consistent themes were highlighted. from 1980 to 1988; the U.S. and interna- ian Center for Emergency Medical Services First, and most central to the goals of the tional economic sanctions and embargoes sponsored and organized the 3rd Interna- congress, was an overarching emphasis on from 1979 to 2016; and uncertainty regard- tional Anxiety Congress at the Khatam the importance of utilizing evidence-based ing the shorthanded approach by the new Alanbia Hospital in Tehran to bring Iran- interventions and providing summaries of U.S. administration regarding travel ian scientists and mental health practition- the empirical evidence supporting various restrictions and sanctions following the ers together with international experts interventions. The second theme revolved presidential election. Such political, mili- from Australia, Germany, Switzerland, the around identifying and targeting transdi- tary, and economic upheaval, in addition to U.K., and the U.S., to advance mental agnostic mechanisms, particularly the high rates of road accidents and several health knowledge and patient care. This presence of comorbid psychological diag- natural disasters in the last decade, has had congress was held in official cooperation noses (e.g., anxiety and depression, trauma a significant impact on the mental health with the Monash Institute of Cognitive and and substance use) or co-occurring psy- needs of Iran, in particular high rates of Clinical Neuroscience (Australia) and chological and physical concerns (e.g., combat-related PTSD following the Iran- Basel University (Switzerland). Held over sleep and PTSD, mental health and physi- Iraq war. two consecutive days (November 23–24, cal activity). Finally, many of the interna- 1 Despite the clear need for effective evi- 2016), the international scholars at the 3rd tional and Iranian scholars spoke on the International Anxiety Congress program importance of adapting evidence-based dence-based mental health care, the eco- addressed critical topics such as “Posttrau- interventions into the unique cultural, reli- nomic sanctions resulting from political matic Stress Disorder and Substance Use gious, and political contexts existing in conflicts between Iran and many Western Disorder” (Christi Cabrera—USA), Iran, including incorporating an Islamic governments have limited the ability of the “Review of Evidence-Based and Experi- worldview into treatment and specific Iranian mental health workforce to access mental Treatment of Posttraumatic Stress combat-related PSTD factors commonly contemporary mental health science and Disorder” (Markus Burgmer—Germany), seen in veterans of the Iran-Iraq war. training in evidence-based mental health “The Mechanistic Role of Sleep in Post- Further, a series of practical training interventions. Similar concerns have been traumatic Stress Disorder” (Sean Drum- workshops were delivered, including previously raised regarding access to med- mond—Australia), “The Impact of Physi- “Relaxation and Imagery Techniques to ical supplies and pharmaceuticals as a cal Activity on Posttraumatic Stress Improve Sleep in Patients with Posttrau- result of the economic sanctions (Gorji, Disorder” (Simon Rosenbaum—Aus- matic Stress Disorder and to Reduce Night- 2013), which have been partially alleviated tralia), “The Impact of Neuroscience in mares” (Serge Brand and Dena Sadeghi by a report to the United Nations General Understanding Posttraumatic Stress Dis- Bahmani—Switzerland), “The Role of Art Assembly and subsequent medical exemp- order” (Markus Burgmer—Germany), Therapy (Music and Psychodrama) on tions to the sanctions (Setayesh & Mackey, “Cognitive Appraisals and Social Support Improvement of Anxiety in Children with 2016). Scientific knowledge and practical in Predicting Children’s Posttraumatic Autism Spectrum Disorders” (Kaveh therapeutic skills in treating mental health Stress” (Caitlin Hitchcock—UK), “Recent Moghaddam—Iran), “Cognitive Behav- disorders in Iran, however, remains limited Developments in the Treatment of Anxi- ioral Therapy for Insomnia in Posttrau- due to the aforementioned barriers to ety, Trauma, and Emotional Disorders” matic Stress Disorder” (Sean Drum- knowledge dissemination. Further, (Peter Norton—Australia), “Autobio- mond—Australia), and “Cognitive Beha- master's-level training in clinical psychol- graphical Memory, Trauma, and the vioral Approaches for the Treatment of ogy in Iranian universities began in the Development of Memory Interventions” Trauma and Anxiety (Peter Norton & Brett 1970s (with a subsequent period of inter- (Caitlin Hitchcock—UK), “How Do Con- Deacon—Australia). Consistent with the ruption) and the Ph.D. in clinical psychol- cepts of Evolutionary Psychology and Evo- goals of the congress, the workshops were ogy was developed in 2011 (Birashk, 2013). lutionary Psychiatry Explain Anxiety Dis- specifically selected and designed to facili- Legal regulation and registration of psy- orders?” (Serge Brand—Switzerland), tate the transfer of the scientific presenta- chology and counseling practitioners was “Social Cognition in Patients with Anxiety tions into immediate clinical practice. only initiated in 2004 (Khodayarifard, Disorders” (Dena Sadeghi Bahmani— Within the workshops, for example, atten- Rehm, & Khodayarifard, 2007). Although Switzerland), “The Benefits of Increased dees were provided direct instruction and formal practitioner therapeutic orientation Physical Activity and Higher Cardiorespi- practice with strategies for developing fear surveys have not been conducted, Iranian ratory Fitness in People Living with Mental hierarchies for use in exposure therapy, training programs in counseling and psy- Health Disorders, with Specific Emphasis alongside video and live demonstrations of chotherapy (Birashk) and psychiatry on Anxiety Disorders” (Philip Ward— in vivo exposures, imaginal trauma and (Tavakoli, 2014) cover a broad range of Australia), and “Exposure Therapy’s Two worry scripting, and interoceptive expo- non-evidence-based and evidence-based Cultures: Anxiety-Reducing vs. Anxiety- sure; demonstrations on the use of art and therapeutic approaches in their curricula. As a result, dissemination, training, and availability of efficacious evidence-based 1The full abstract book (available in English and Farsi) of the 3rd International Anxiety mental health treatments is limited despite Congress is available at http://shefayekhatam.ir/browse.php?a_id=993&slc_lang=en&sid high need, further widening the interna- =1&ftxt=1

June • 2017 193 NORTON ET AL. music in therapy with children; live prac- the American Medical Association, 291, NEWS tice with relaxation and imagery tech- 2581-2590. niques; and practical guidelines for imple- Gorji, A. (2013). Health care: Medical sup- menting evidence-based strategies for plies in Iran hit by sanctions. Nature, Featured Award improving sleep in insomnia. 495, 314. Beyond the expected educational and Joint Statement (2004). Galvanizing Recipient: Outstand- clinician training outcomes of the con- mental health research in low- and ing Service Award gress, an additional benefit arose after the middle-income countries: Role of scien- organizing and funding bodies of the con- tific journals. Bulletin of the World Health Organization, 82, 226-228. gress specifically solicited recommenda- Katherine J. W. Baucom, Chair, tions from the congress delegates on prior- Khodayarifard, M., Rehm, L. P., & Khoda- Awards & Recognition ities for meeting the mental health needs of yarifard, S. (2007). Psychotherapy in Iran: A case study of cognitive-behav- Committee the aging Iranian population in general, ioral family therapy for Mrs. A. Journal and elderly veterans with PTSD in particu- of Clinical Psychology, 63, 745-753. lar. Training of the patients and their fam- Pike, K., Min, S-H., Poku. O. B., Reed, G. This month we are ilies on age-related physiological changes, M., & Saxena, A. (2017). A renewed call pleased to feature Patrick screening of somatic disorders, daily exer- for international representation in edito- Kerr, Ph.D., recipient of cise, and specific evidence-based PTSD rial boards of international psychiatry the 2016 Outstanding Ser- treatment programs for veterans were sug- journals. World Psychiatry, 16, 106-107. vice Award. This award gestions of congress for follow-up of these Saxena, S., Paraje, G., Sharan, P., Karam, recognizes ABCT mem- groups of patients. As a result of these rec- G., & Sadana, R. (2006). The 10/90 divide bers who have made sig- ommendations, a new office was estab- in mental health research: Trends over a nificant contributions to lished within the Foundation of Martyrs 10-year period. British Journal of Psychi- the organization as a whole. and Veterans Affairs to follow up all rec- atry, 188, 81-82. Dr. Kerr is an Associate Professor of ommendations and introduce their 1-year Setayesh, S. & Mackey, T. (2016). Address- Behavioral Medicine and Psychiatry at experience in the next congress in 2017. ing the impact of economic sanctions on West Virginia University’s Health Sciences While political tension and conflict Iranian drug shortages in the joint com- Center. Dr. Kerr joined ABCT as an between various nations will always exist, prehensive plan of action: Promoting undergraduate in 2001 and it quickly access to medicines and health diplo- this does not supersede Principle 1 of the became his professional home. He joined macy. Global Health, 12, 31. United Nations Principles for the Protec- the Listserve Committee as a postdoctoral tion of Persons with Mental Illness and for Tavakoli, S. (2014). The place of psy- fellow and moved into the position of List- chotherapy in contemporary psychiatry. the Improvement of Mental Health Care serve Moderator in 2013 and Listserve Iranian Journal of Psychiatry and Behav- Committee Chair in 2014, positions that (United Nations General Assembly, 1991) ioral Sciences, 8(4), 1-6. that “all persons have the right to the best he still holds today. United Nations General Assembly. (1991). In his role as Listserve Committee available mental health care.” It is hoped General Assembly Resolution that the model and success of the 3rd Inter- Chair, Dr. Kerr has made it a priority to A/RES/46/119: The protection of persons shape the list’s policies and procedures on national Anxiety Congress in Tehran, Iran with mental illness and the improvement an ongoing basis in an effort to keep pace will serve as a benchmark both to national of mental health care. Geneva, Switzer- with the opportunities and vulnerabilities governments and funding agencies, as well land: World Health Organization. inherent in the ever-evolving frontier of as scholars, treatment developers, and communication technology. He also prior- mental health practitioners, to work out- ... itized and successfully implemented a shift side of the prevailing political climates in in listserve operation to an unscreened an effort to jointly work to increase dis- The International Scientific Committee was format, which now permits instantaneous, semination and training in order to comprised of Dena Sadeghi Bahmani (Uni- free-flowing conversations between mem- improve the quality of mental health for all versity of Basel; Switzerland), Serge Brand, bers, including everything from rich dis- persons regardless of nationality. (University of Basel; Switzerland), Markus cussions about fascinating cases to debates Burgmer (Universität Münster Hospital; about mechanisms of change. This format References Germany), Christi Cabrera (Private Practice; shift also means staying constantly alert to Birashk, B. (2013). Counseling and psy- USA), Brett Deacon (Illawarra Anxiety potential side effects of the new format; he chotherapy in Iran. In R. G. Moodley, U. Clinic; Australia), Sean P. A. Drummond therefore continually monitors the list’s P. Gielen, & R. Wu (Eds.), Handbook of (Monash University; Australia), Caitlin traffic throughout each day to ensure that counselling and psychotherapy in an Hitchcock (MRC Cognition and Brain Sci- this avenue of communication functions international context (pp. 361-370). New ences Unit; UK), Simon Rosenbaum (Uni- optimally for our members. As Executive York: Routledge. versity of New South Wales; Australia), and Director Mary Jane Eimer described, “He Demyttenaera, K., Bruffaerts, R., Posada- Philip Ward (University of New South is quick to catch potential problems and Villa, J., Gasquet, I., Kovess, V., Lepine, Wales; Australia). handles them with grace and professional- J., ... WHO Mental Health Survey Con- ism.” ABCT and its members have benefit- Correspondence to Peter J. Norton, Ph.D., sortium. (2004). Prevalence, severity, and ted tremendously from Dr. Kerr’s service. unmet need for treatment of mental dis- School of Psychological Sciences, Monash orders in the World Health Organization University, Clayton, VIC, 3800 Australia; World Mental Health Surveys. Journal of [email protected].

194 the Behavior Therapist European Association for Behavioural and Cognitive Therapies

Time to update your passport and network globally: The 47th congress of the European Association for Behavioural and Cognitive Therapies (EABCT) will be held in Ljubljana between September 13-16, 2017

THEME: Bridging Dissemination With Good Practice.

www.eabct2017.org

the next ABCT Webinar JUNE 16,2017 Behavioral Treatment of Insomnia in Children: Beyond the Basics [ Candice Alfano, Ph.D., Associate Professor of Psychology and Director of the Sleep and Anxiety Center of Houston (SACH) at the University of Houston

• 11:00 A.M.–12:30 P.M. Eastern | 10:00 A.M.–11:00 A.M. Central | 9:00 a.m.–10:30 A.M. Mountain | 8:00 A.M. – 9:30 A.M. Pacific • $30 for members | $45 for nonmembers

Adequate sleep is essential for all age groups, but sleep during childhood is particularly critical based on its temporal overlap with brain development and physical growth. In addition to sleep problems that persist into adulthood, insomnia in childhood is a potent risk factor for a wide range of negative outcomes including overweight/obesity, inattention, hyperactivity, learning problems, conduct problems, substance use, anxiety, and depression. Unfortunately, up to 70% of children in the U.S. age 10 and under experience a sleep problem several times per week. Effective, evidence- based treatments are available, but the number of providers with training in behavioral sleep inter- ventions is limited. This webinar will provide a comprehensive overview of insomnia in children. Following brief review of the essential role of sleep in childhood and specific factors that give rise to poor sleep, validated assessment tools that provide a comprehensive understanding of children’s sleep problems will be discussed. Evidence-based treatment strategies will then be presented and discussed in the context of a case example. Register at www.abct.org

June • 2017 195 the Behavior Therapist PRSRT STD Association for Behavioral U.S. POSTAGE and Cognitive Therapies PAID 305 Seventh Avenue, 16th floor New York, NY 10001-6008 Hanover, PA 212-647-1890 | www.abct.org Permit No. 4

ADDRESS SERVICE REQUESTED

ABCT 50th Anniversary Album PLAY IT FORWARD

To celebrate the 50th anniversary of Jon Abramowitz, Ph.D.• Jon Comer, Ph.D.• Aaron Fisher, Ph.D.• ABCT, Play It Forward has released a Elizabeth Hall, Ed.D., Ph.D.• Steve Hayes, Ph.D.• Jon Hershfield, compilation album featuring 14 songs MFT• David Juncos, Psy.D.• Reed Kendall • Sam Kramer, MA • written and performed by ABCT mem- Adam LaMotte, M.A. • Jaimie Lunsford, B.S. • Steve Mazza, M.A. • bers. Proceeds go to the ABCT student research grant and travel award funds. To ny Puliafico, Ph.D.• Jose Soler-Baillo, M.A. • Dennis Tirch, Ph.D. • Tim Verduin, Ph.D.• Jerome Yo man, Ph.D., ABPP Those who donate at least $10 will receive a CD in the mail in addition to the digital download

Now available for download All donations go to ABCT

MINUMUM DONATION: $5.00

donate here! https://www.playitforward.com/projects/14