Association for Behavior Analysis International

Over the past decades, behavioral techniques have become a staple of "mainstream" psychotherapy. Behavioral and cognitive-behavioral therapies are now the treatment of choice in major healthcare systems that support evidence-based practice. To facilitate the implementation of behavioral technologies on large scale, behavior-analytic interventions have been translated into to treatment packages and manuals accessible to mental health practitioners with varied backgrounds and training. However, this good news about the uptake of behavioral approaches is accompanied by significant limitations in the efficacy and reach of manualized behavior therapy. Behavioral treatment packages demonstrate superior efficacy to non-behavioral control therapies, but yield relatively small effects compared to the early treatments developed by pioneers of applied behavior analysis. For many problems, manualized behavioral treatments fail with a majority of patients. Where has the power of our interventions gone? We argue that packaged behavioral therapies retain our techniques, while underemphasizing (or omitting) the function-based approach that is hallmark of contemporary applied behavior analysis. We discuss this issue as it relates to the implementation of behavioral treatments for several common behavioral/psychiatric problems. Factors contributing to this phenomenon, relevant clinical trials data, and potential remedies are discussed.

Disruptive behavior problems are among the most prevalent child health problems in the U.S. In the 1960s, behavior analysts began to develop powerful behavioral parent training (BPT) interventions, grounded in principles of learning, that led to behavioral normalization in a majority of treated children. These interventions have gained mainstream popularity, with major physician-led bodies now recommending them as a first-line treatment for disruptive behavior in typically developing children. To increase BPT's reach, various treatment packages and manuals aimed at non-behavior-analytic providers have been developed and disseminated. In clinical trials, these treatments demonstrate superior efficacy to waitlist or non-behavioral controls. However, their effectiveness is often suboptimal, with only a minority of children demonstrating a clinically significant response in some studies. Reasons for this variability in child outcomes are discussed from a function-analytic perspective. It is suggested that overreliance on group teaching formats, insufficient function-based individualization, and suboptimal programming for parent behavior change may account for many "treatment failures" observed in applied practice. Strategies and tactics for addressing these issues and strengthening the public health impact of BPT are discussed.

The ideographic tailoring of treatment to a clients specific needs is a central feature of clinical behavioral analysis (CBA). However, contemporary CBA-based therapies are disseminated as packages of techniques as well as conceptual frameworks for conducting treatment with particular populations of clients. In the absence of adequate training in behavior analysis, therapists on the receiving end of dissemination and implementation efforts can only relate to these therapies as collections of techniques. One way to anchor CBA-based therapies to a behavior analytic conceptual frameworks is to have measures of the functional dimensions of clinical presentations guide treatment selection and progress. Unfortunately, we have yet to develop a bank of such measures in CBA. Molar functional relations and metrics from behavioral economics will be presented as measurement opportunities that can help fulfill this need. Second, CBA-based treatment packages need to be dismantled into multiple modules that each address particular functional concerns. This would serve the multiple exemplar learning needs of both therapists and clients and pave the way for ideographic treatment tailoring grounded in CBA-based measurement. IF CBA-based therapies are to be functional as well as popular, we will have to lead the way.

Pioneers such as Lindsley (1964) and Goldiamond (1974) introduced behavior analytic approaches to living well with cognitive difficulties more than half a century ago. Since then, interventions rooted in behavior analysis and targeting individuals who acquired problems remembering, thinking, reasoning, or problem-solving later in life, have been packaged and widely disseminated within the mainstream healthcare landscape (see Projects REACH I and II, for example). Questions have been raised regarding the utility and clinical significance of many of these intervention packages (e.g., Schulz, 2002). We will argue that an understanding of neurocognitive loss and its associated behavioral and emotional changes from a functional perspective is countercultural and thus difficult to acquire without individualized instruction. In effect, most formal and informal caregivers are not able to gauge the deficits and the strengths of the person for whom they care, and packaged interventions do not help caregivers interpret a person’s narrowing skill set from a functional perspective based on behavioral principles. Unsupportive and often coercive environments are inadvertently propagated, even when caregivers receive services in the form of treatment packages. Best practices will be suggested.