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Dissemination of EST's (November 2009)

Response to the attack article written by Siev and Chambless appearing in the April 2009 Behavior Therapist.

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Dissemination of EST's (November 2009)

  1. 1. ISSN 0278-8403 ASSOCIATION FOR BEHAVIORAL AND COGNITIVE THERAPIES VOLUME 32, NO. 7 • OCTOBER 2009 the Behavior Therapist Contents President’s Message President’s Message Sunk Costs: Backward- Robert L. Leahy Sunk Costs: Backward-Looking Decisions • 137 Looking Decisions Series on Technology Robert L. Leahy, American Institute for Michael D. Anestis and Joye C. Anestis Cognitive Therapy Using Social Media Tools in Clinical Psychology: e are all familiar The Experience of Psychotherapy Brown Bag • 140 Research Forum Bruce E. Wampold, Zac E. Imel, and Scott D. Miller W with the following: You pay good money for a suit or dress, take it home, look at it, and hang it Barriers to the Dissemination of Empirically Supported in the closet. Years go by, you Treatments: Matching Messages to the Evidence • 144 take it out and look at it and say, “It’s not me—I’ll wear something else.” You Book Review can’t seem to throw it out although you really know you won’t wear it again. You say, “I can’t Reviewed by Chad E. Drake throw it out. It’s hardly been used. I paid good Roemer & Orsillo (2009), Mindfulness- and Acceptance-Based money for it.” Or, more significantly, you have Behavioral Therapy in Practice • 156 been stuck in a dead-end relationship that has dragged on for years. You know—“ratio- Multimedia Journal nally”—it makes sense to get out, but you can’t. Your friends urge you to look at the costs and Maureen Whittal benefits of staying versus getting out. You know Looking to the Future of Cognitive and Behavioral Practice • 157 rationally they are right, but you can’t pull the plug. In both cases, you are “honoring” the sunk Letter to the Editor costs of prior decisions. You can’t abandon the sunk cost because you believe you have to justify Patti Lou Watkins and George A. Clum why you have stayed in so long. You say, “If I left Empirically Evaluated Self-Help Therapies • 157 it would mean I wasted all that time”; “I can’t stand the feeling of loss”; “If I left it would prove At ABCT I am a failure”; or “You don’t understand. There really are good things there. I just have to wait Kristene A. Doyle for things to turn around.” In fact, your reasons To Lead or Not to Lead? • 159 for staying may continue to change—because Virginia Rutter you are highly motivated to prove that you are Three Recipients of the Neil S. Jacobson Research Award not wrong in staying in the first place. Your deci- sion is “backward-looking,” attempting to jus- for Outstanding and Innovative Clinical Research • 160 tify what you have done in the past. Ironically, CALL for AWARD NOMINATIONS • 161 the longer you stay in, the greater the sunk cost and the greater the need to justify your decision WELCOME, NEW MEMBERS • 162 to stay. You are making decisions looking back- October • 2009 137
  2. 2. the Behavior Therapist Published by the Association for Behavioral and Cognitive Therapies 305 Seventh Avenue - 16th Floor New York, NY 10001-6008 (212) 647-1890 / Fax: (212) 647-1865 EDITOR · · · · · · · · · · · · Drew Anderson Editorial Assistant . . . . . . . . Melissa Them Behavior Assessment . . . Timothy R. Stickle Book Reviews · · · · · · · · · · · C. Alix Timko Clinical Forum · · · · · · · · · · · John P Forsyth . Clinical Dialogues . . . . . . . Brian P Marx . International Scene . . . . . . . . Rod Holland Institutional Settings. . . . . . . . . . . . . . . . . David Penn Tamara Penix Sbraga Lighter Side · · · · · · · · · · · · Elizabeth Moore List Serve Editor . . . . . . . . Laura E. Dreer News and Notes. . . . . . . . . David DiLillo Laura E. Dreer James W Sturges . Public Health Issues. . . . Jennifer Lundgren Research-Practice Links · · · · · · · · · · · · · · · · David J. Hansen Research-Training Links · · · · · · · · · · · · · · · · Gayle Y. Iwamasa Science Forum · · · · · · · · · · · Jeffrey M. Lohr Special Interest Groups · · · · · · · · · · Andrea Seidner Burling Technology Update. . . . . . James A. Carter INSTRUCTIONS Ñçê AUTHORS ABCT President . . . . . . . Robert L. Leahy The Association for Behavioral and Submissions must be accompanied by Executive Director · · · · · · Mary Jane Eimer Cognitive Therapies publishes the Behavior a Copyright Transfer Form (a form is Director of Education & Therapist as a service to its membership. printed on p. 24 of the January 2008 issue Meeting Services . . . . . . Mary Ellen Brown Eight issues are published annually. The of tBT, or contact the ABCT central of- Director of Communications David Teisler purpose is to provide a vehicle for the rapid fice): submissions will not be reviewed without dissemination of news, recent advances, a copyright transfer form. Prior to publication Managing Editor . . . . . Stephanie Schwartz and innovative applications in behavior authors will be asked to submit a final therapy. electronic version of their manuscript. Copyright © 2009 by the Association for Behavioral Authors submitting materials to tBT do so and Cognitive Therapies. All rights reserved. No Feature articles that are approximately part of this publication may be reproduced or trans- 16 double-spaced manuscript pages may with the understanding that the copyright mitted in any form, or by any means, electronic or of the published materials shall be as- mechanical, including photocopy, recording, or any be submitted. information storage and retrieval system, without signed exclusively to ABCT. Submissions Brief articles, approximately 6 to 12 via e-mail are preferred and should be sent permission in writing from the copyright owner. Subscription information: the Behavior Therapist is double-spaced manuscript pages, are to the editor at published in 8 issues per year. It is provided free to preferred. ABCT members. Nonmember subscriptions are Please include the phrase tBT submission available at $40.00 per year (+$32.00 airmail Feature articles and brief articles in the subject line of your e-mail. Include postage outside North America). should be accompanied by a 75- to the first author’s e-mail address on the Change of address: 6 to 8 weeks are required for address changes. Send both old and new addresses to 100 -word abstract. cover page of the manuscript attachment. the ABCT office. Letters to the Editor may be used to By conventional mail, please send manu- ABCT is committed to a policy of equal opportu- nity in all of its activities, including employment. respond to articles published in the scripts to: ABCT does not discriminate on the basis of race, Behavior Therapist or to voice a profes- Drew A. Anderson, Ph.D. color, creed, religion, national or ethnic origin, sex, sional opinion. Letters should be lim- sexual orientation, gender identity or expression, SUNY–Albany age, disability, or veteran status. ited to approximately 3 double-spaced Dept. of Psychology/SS369 All items published in the Behavior Therapist, manuscript pages. 1400 Washington Ave. including advertisements, are for the information of our readers, and publication does not imply endorse- Albany, NY 12222 ment by the Association. 138
  3. 3. ward to past investments and not making make the trap more familiar (Leahy, 2000). References decisions based on future utility. Third, you can divide (or bifurcate) the deci- Arkes, H. R. (1996). The psychology of waste. Rational decision-making models argue sion: “If you had never gotten into this be- Journal of Behavioral Decision Making, 9, 213- that we make choices based on future util- havior, would you make a decision to get 224. ity, but evidence for sunk costs suggests that into it now?” Fourth, the patient can exam- Arkes, H. R., & Ayton, P (1999). The sunk cost . we are often trapped by past commitments ine the justifications and challenges to these and Concorde effects: Are humans less ratio- and investments. Indeed, the greater the rationalizations: “I have too much invested nal than lower animals? Psychological Bulletin, sunk cost, the greater the escalation of com- 125, 591-600. to walk away”; “I now have a responsibility mitment. There are endless examples of Arkes, H. R., & Blumer, C. (1985). The psychol- sunk costs. Along with your out-of-style to make it work out”; or “I’m not frivo- lous—I don’t walk away from my commit- ogy of sunk cost. Organizational Behavior & jacket or dress, there are sunk costs in rela- Human Decision Processes, 35, 124-140. tionships, careers, purchases, and even in ments.” These assumptions may be Festinger, L. (1957). A theory of cognitive disso- foreign policy. The Vietnam War is a much- examined utilizing cognitive therapy tech- nance. Palo Alto, CA: Stanford University agreed-on sunk cost, but when the United niques: “What if you looked at your prior Press. States was engaged in that war a significant investments as lost costs that you can never Festinger, L. (1961). The psychological effects of majority of Americans supported the war. recover? How would putting more of your- insufficient rewards. American Psychologist, An entire nation at times was committed to self into this help you achieve your ultimate 16, 1-11. honoring sunk costs. President Johnson in goals?” Fifth, you can externalize the deci- Gilovich, T., & Medvec, V H. (1994). The tem- . fact made the bold sunk-cost justification sion by asking, “What if your friends had to poral pattern to the experience of regret. for staying, claiming that we couldn’t give make the decision for you? What would Journal of Personality & Social Psychology, 67, up because we had lost so many men. Sunk they decide?” This helps decouple the decider 357-365. costs are common in behavioral finance from the decision. Sixth, you can identify the Gilovich, T., Medvec, V H., & Chen, S. (1995). . where investors double-up on a losing in- Commission, omission, and dissonance re- fear of “wasting,” which often underlies the duction: Coping with regret in the “Monty vestment to “get their money back.” We often “ride a loser.” fear that walking away from the sunk cost is Hall” problem. Personality & Social Psychology Humans are the only animals who honor an admission of having wasted time and re- Bulletin, 21, 182-190. sunk costs (Arkes & Ayton, 1999). sources. This fear can be addressed by rec- Jones, E. E., & Davis, K. E. (1965). From acts to Laboratory rats may show a burst of activity ognizing that losses (or wasting) are always dispositions: The attribution process in per- as they face extinction trials when reinforce- involved in decision making, but the self-in- son perception. In L. Berkowitz (Ed.), ments have been eliminated, but they terest strategy would be not to throw good Advances in experimental social psychology (Vol. 2, pp. 219-266). New York: Academic Press. quickly learn to look somewhere else for re- money after bad. Seventh, many people wards. Why are rats “smarter” than hu- stay in sunk costs because of the fear of hu- Kahneman, D., & Tversky, A. (1979). Prospect theory: An analysis of decision under risk. mans? Or are we too smart for our own miliation: “I would be telling everyone that Econometrica, 47, 263-291. good? Unlike the “rational” rat, humans I was wrong and they were right.” This con- Kiesler, C. A., Nisbett, R. E., & Zanna, M. P . appear condemned to continually reflect on cern can be addressed by recognizing that (1969). On inferring one’s beliefs from one’s their past decisions, attempting to make most friends will be happy to have you behavior. Journal of Personality & Social “sense” of them and to justify their future agree with them and happy that you are out Psychology, 11, 321-327. decisions by reference to the past. Honoring of your misery but, in the event that they Leahy, R. L. (2000). Sunk costs and resistance to sunk costs can be explained by loss aversion change. Journal of Cognitive Psychotherapy: an use this as a reason for criticism, it may be a (Wilson, Arvai, & Arkes, 2008), commit- International Quarterly, 14, 355-371. ment theory (Kiesler, Nisbett, & Zanna, price worth paying to cut your losses. Eighth, some people fear the flood of nega- Leahy, R. L. (2004). Decision making processes 1969), cognitive-dissonance theory and psychopathology. In R. L. Leahy (Ed.), (Festinger, 1957, 1961), prospect theory tive feelings following abandoning a sunk Contemporary cognitive therapy: Theory, research, and loss frames (Kahneman & Tversky, cost. This can be addressed by an analogy of and practice (pp. 116-138). New York: 1979), fear of wasting (Arkes, 1996; Arkes pulling a splint from a toe. It hurts until it Guilford Press. & Blumer, 1985), attribution processes (for stops hurting and then it is followed by re- Wilson, R. S., Arvai, J. L., & Arkes, H. R. (2008). example, Jones & Davis, 1965), and inac- lief. Being stuck in a sunk cost is the ulti- My loss is your loss...sometimes: Loss aver- tion inertia (Gilovich & Medvec, 1994; mate helplessness and is a guarantee for sion and the effect of motivational biases. Gilovich, Medvec, & Chen, 1995). In each depression, anger, and hopelessness (Leahy, Risk Analysis, 28, 929-938. case it is the absence of reward that makes 2000, 2004). this puzzling until we recognize that it is the . . . We often get trapped by our need to jus- “interpretation” of change and the “need to tify the decisions that have continued our explain” the past that keeps us trapped. misery—looking backward to the past for Correspondence to Robert L. Leahy, Ph.D., How can we liberate ourselves from the American Institute for Cognitive Therapy, 136 justification, rather than committing to ac- sunk cost trap? First, standard cognitive E. 57th St., Suite 1101, New York, NY therapy inquiries can be used, but may lead tions for future utility. Focusing on valued 10022; nowhere. For example, one can ask about goals rather than valuing our past can help the costs and benefits of continuing in the liberate us from commitments whose pay- course of action. Patients often say, “I know offs have turned into deficits. Our “rational- it’s irrational, but I can’t get out.” Second, ity” may be less logical than we think and educating the patient about sunk costs (the more determined by rationalizing the past jacket in the closet) immediately helps to rather than pursuing a better future. October • 2009 139
  4. 4. Series on Technology stand that our colleagues are extremely busy and that our invitations could serve as a bit of a burden, so we have had to develop Using Social Media Tools in Clinical tactful, understanding approaches to mak- ing such offers in order to entice contribu- Psychology: The Experience of tors without becoming a bother. Our efforts to develop a steady list of guest contributors Psychotherapy Brown Bag are still ongoing and, as such, the workload in these early days of the business is fairly Michael D. Anestis and Joye C. Anestis, Psychotherapy Brown Bag high as we take on the vast majority of the and Florida State University writing. As with any new online business, one of our initial priorities was to maximize traffic E DITOR ’ S N OTE : This article marks ing tools (e.g., Typepad versus Blogger) and to the site and general knowledge of our the first of a series of articles looking at po- the best way to obtain a domain name, and goals. We found ourselves somewhat un- tential uses of new technologies for ABCT we spent a considerable amount of our early sure about how to develop a following for members. If you have any ideas or sugges- PBB days brainstorming on the design of the site, as there did not seem to be an obvi- the site—but these activities were actually ous method by which to alert a wide audi- tions for articles, please send me an email. quite enjoyable, as they marked the begin- ence to our project. Granted, a significant —D.A. portion of the global population suffers with ning of an exciting new business venture in which we wholeheartedly believe and to or knows an individual suffering with a s a pair of advanced graduate stu- A dents trained in the clinical science tradition, the struggles of dissemi- nating empirically supported treatments which we are fervently devoted. In our first 6 months, we have incurred some costs, as we invested in professional services to design a banner for the page and optimize our visi- mental illness, but the general knowledge regarding ESTs for mental illness and re- search findings in clinical psychology is lim- ited enough that a website with our goals (ESTs) in a world full of misinformation has must seek out readers rather than simply often been at the forefront of our minds. In bility in search engines (e.g., Google), but we counter these costs through the use of scoop up an already existing audience. The fact, we have at times been downright de- constraints of the graduate student wallet moralized that all of this great research and advertisements and the creation of an online store run in cooperation with Amazon prevented us from utilizing high-cost, more these effective treatments exist, yet so few traditional advertising opportunities. As people know about them. We knew we through which we recommend research- based books, DVDs, and Kindle products such, we needed to find an alternative way wanted to do something about it, but found to promote our services in a cost-effective ourselves unsure how to make a difference. about psychology. PBB is updated every weekday, exclud- manner that would enable us to reach as After years of brainstorming ways in which broad an audience a possible, encompassing we could effectively sing the praises of ESTs ing holidays and vacations, and we take both professionals and nonprofessionals. to a wide audience while we are on graduate turns supplying articles. One of the lucky This is where social media tools became cru- student wallets (which are slim) and sched- things about running a business with your cial in our efforts. ules (which are full), we decided to stick our spouse is that your business partner always Our first attempt at publicity was simple toes into the world of blogs (although we knows your work availability, so it is easy to word of mouth. Through conversations and tend to say “online magazine”) and distribute tasks between us! The average ar- e-mails, we alerted family, friends, and col- launched Psychotherapy Brown Bag ticle takes us approximately 1 to 3 hours to leagues. This resulted in substantial encour- ( write. For some this might seem like too agement, but only a small flurry of visits to on March 1, 2009. The central aims of PBB much time outside of our academic respon- the site. Our next step was to create a pres- are to disseminate research findings in clini- sibilities, but to us it is definitely worth it. ence on Facebook (, a cal psychology and information on ESTs for We also welcome articles from anyone who social media website that allows individuals mental illness to the general public (both wants to write one, as long as the informa- to follow the lives of others as well as to re- clinicians and consumers, thus ostensibly tion discussed is consonant with the goals of ceive news regarding causes, individuals, helping to bridge the research-practice gap) PBB. On the first weekday of every month, and organizations of interest (e.g., political and to help individuals find local clinics that we post a guest article from a distinguished figures, celebrities, support groups for par- provide such services. member of the clinical psychology commu- ticular illnesses). We already had experience The actual creation of PBB was far sim- nity—a professor, researcher, or clinician with Facebook, having maintained personal pler than we ever anticipated. In fact, the who is willing to contribute. Past featured pages for several years and being involved most difficult part of the process was com- contributors have included Robert Leahy, with several organizations via the website ing up with a plan for continuously updat- the current president of ABCT, as well as (including ABCT). Creating a Facebook ing the website and selecting a name. Once Craig Bryan of the United States Air Force, presence for Psychotherapy Brown Bag was those decisions were made, the rest was easy. Jill Holm-Denoma of the University of the next logical step. We created two types of We selected a blogging service, purchased a Denver, Sarah Fischer of the University of pages: a group (285 members as of domain name, and PBB was born! In all, Georgia, and several other notable profes- 9/8/2009) and a fan page (150 fans as of about 3 weeks lapsed between the day we sionals. Perhaps our greatest obstacle has 9/8/2009). Facebook has provided an av- began researching this endeavor and the been our own anxiety about approaching enue through which individuals we might launching of the website. We did have to others to write for the site. As graduate stu- not otherwise meet could discover PBB, spend time researching the best blog host- dents in a demanding program, we under- glance at links to our articles, recommend 140 the Behavior Therapist
  5. 5. Behavior Therapy Associates, P.A. Proudly Celebrates Its 30th Anniversary 1979–2009 Behavior Therapy Associates, P.A. Towne Park Professional Center 35 Clyde Rd., Suite 101 Somerset, NJ 08873 Steven B. Gordon, Ph.D., ABPP Michael C. Selbst, Ph.D. Director Associate Director Board Certified in Cognitive Certified School Psychologist and Behavioral Psychology NJ Lic. #3779, PA #9320 Clinical Psychologist NJ Lic. #936 Michael J. Asher, Ph.D., ABPP Debra G. Salzman, Ph.D. Mark Cooperberg, Ph.D. Board Certified in Cognitive Clinical Psychologist Clinical Psychologist and Behavioral Psychology NJ Lic. #3160 NJ Lic. #4365, PA #15827 Clinical Psychologist NJ Lic. #2792 Postdoctoral Fellows Rory Panter, Psy.D. Lisa Spano, Psy.D., BCBA BTA provides clinical services, consultation, and training using evidence based approaches within the context of sensitivity and compassion, while recognizing the uniqueness of each individual and setting. PHONE: 732-873-1212 • FAX: 732-873-2584 • E-MAIL: October • 2009 141
  6. 6. the site to others, and communicate with the process of writing guest articles for our Study Professional Psychology us. After we publish a new post on site on areas that are outside of our areas of in the Pacific Northwest Psychotherapy Brown Bag, we alert indi- expertise but consistent with the overall viduals following us through Facebook by goals of PBB. So just like Facebook, Twitter PSY.D. in posting a link to our new article. Each has afforded us an opportunity to reach a C l iniCal week, we email all Facebook users following our group page and provide a list of the global audience with little effort and no cost on our part. PS Y C h ologY week’s articles as well as any news pieces of Our third and final significant interac- interest. With just a small amount of effort tion with social media tools has been with on our part and at absolutely no cost, Reddit ( Individu- • APA accredited Facebook almost does the work for us, as als sign up for Reddit and post links either Psy.D. degree fans of PBB alert their friends to our pages to the general site or to one of the subhead- and services and those friends pass along in- ings. In our case, the psychology subheading • Practitioner-scholar formation again, and so on. ( model; contemporary From here, our next move was to create a /psychology) has proven to be the most use- curriculum presence on a similar social media site, al- ful. As of September 8, 2009, the psychol- beit one with which we had less personal ex- ogy subheading of Reddit had over 8,600 • School-operated perience: Twitter ( subscribers. Subscribers click on links and training clinic and Twitter allows users to post links and com- evaluate them by providing a score, either a APA-accredited ments and to follow the comments of other plus or minus one. Links thus receive a total internship program individuals. In doing so, individuals can also score based upon the summed opinions of follow global conversations on particular readers. The higher the score, the further up • Near Portland, Mt. topics (e.g., depression, a particular on the list of headlines it appears, thus in- Hood, and the celebrity, a sporting event) or simply engage creasing the likelihood that it will be seen Oregon coast in conversations with an individual or group and read by a greater number of individuals of individuals on a smaller scale. Each mes- (although there are separate tabs for “dis- Faculty interests include: sage is brief— limited to a total of 140 char- liked” and “controversial” links as well for assessment, behavior therapy, child acters—so each post essentially serves as a individuals who wish to search for articles headline. It was our belief that by entering not necessarily popular with other readers). psychopathology, empirically sup- these conversations and posting links to our Subscribers also have the option of posting ported treatments, forensic psychol- articles, we could increase the degree to comments regarding the link, thus provid- ogy, health psychology, integra- which individuals know about, visit, and in- ing an additional opportunity to interact tive approaches, neuropsychology, teract with our site. This belief has thus far with readers, clarify any confusion, and as- organizational behavior, bilingual proven to be true. We were recently named sess which topics might interest readers psychotherapy with Latinos, psycho- as one of the top 100 science resources on more than others. Thus far, readers have therapy with minorities, and single Twitter by and, as of been directed to our site through Reddit case research. September 8, 2009, we have more than from every continent except Antarctica, 1,800 individuals and organizations follow- with particularly heavy traffic in Europe. As ■■ ing our daily updates. That’s nearly 2,000 such, we have managed to develop new CONTACT US AT: people who are receiving daily information connections with individuals we would oth- Pacific University on ESTs—quite a success, in our opinion! erwise not have had any opportunity to Office of Admissions Additionally, Twitter has developed a social meet while simultaneously accomplishing HPC/Pacific University code by which individuals interact with one our goal of disseminating accurate, re- another. When one individual finds another search-based information on psychopathol- 222 SE 8th Avenue, Ste 212 individual’s post interesting, he or she ogy and psychological treatments. Again, Hillsboro, OR 97123 “retweets” the comment. Retweeting is a we reiterate this was low-effort and entirely 503-352-2218 slang term that refers to making the same free advertising. 800-933-9308 comment as another poster, crediting the Overall, our experience with social original poster for the comment (including media tools has been positive. Traffic on our a link to that poster’s profile), and thus website continues to increase substantially, making the comment visible to all people enabling us to reach hundreds of readers per following his or her feed. As such, a single day. We remain optimistic that these tools comment can be made visible to thousands will continue to help our company grown of individuals in mere moments. This has and to reach a broader global audience. We proven to be a highly valuable form of free have also begun experimenting with addi- advertising. Additionally, because individu- tional social media tools such as Digg als only follow the comments of people they ( and StumbleUpon choose, the site provides an opportunity for ( and antici- like-minded individuals to network and de- pate experimenting with others as we learn velop professional connections. In this about them. It remains to be seen whether sense, we have found several individuals these sites are as useful as traditional adver- who have expressed an interest in or begun tising methods, but without question, they 142 the Behavior Therapist
  7. 7. are a quick and cost-effective means to interpret and links to alternative sources through which to increase awareness of a of information that might explain the topic Study Evidence-Based Therapies cause, issue, company, or service and to tar- in a manner more easily understood by the in the Pacific Northwest get a particular audience likely to interact reader. In fact, we are not the only website with whatever is being marketed. Perhaps out there promoting mental health care and Master of arts in most importantly, utilizing social media tools can help a website like ours or even a we frequently link to such resources as we learn about them. Given the sensitive na- C ou n s e l in g therapist in private practice to keep up with ture of much of the material covered by PsyCholo g y current trends in the field, issues that are clinical psychologists, whether they work as gaining significant interest, and prominent therapists, researchers, or educators, such names receiving attention on particular considerations are pivotal, otherwise read- • Two-year program topics. Although the goal of our site is to ers will be hurt and, in all likelihood, turn to with late afternoon provide articles on a comprehensive variety other sources for information that might and evening classes of psychology-related topics, we also strive rely less upon research and, as such, be more to ensure that readers are able to find a mul- likely to encounter misinformation. A final • Emphasis on titude of articles on topics directly related to consideration for professionals considering Evidence-Based their interests. By interacting with readers incorporating social media tools into their Practices in Counseling on social media websites, we have been able lives is the issue of personal privacy. We un- (Child and Adult) to develop a greater sense of what topics derstand from discussions with colleagues and Elective Training currently spark the most interest amongst (for example, subscribers to the ABCT list- the widest array of individuals, thus helping serve) that many professionals are nervous in Organizational to capture a larger audience likely to return about having an online presence because of Behavior and Latino to the site and engage with other materials the potential for blurred therapist-client Mental Health we publish. boundaries. This is a legitimate concern, Despite all of the positive aspects of so- but one that can be avoided by being smart • Meets Oregon cial media tools, we remain cautious with and careful in one’s use of these technolo- LPC educational respect to how we present ourselves on gies. For example, on Facebook, we have requirements these websites, as we believe there are sev- been able to maintain both professional and eral potential risks that must be considered. personal identities by taking advantage of Faculty members are experienced Perhaps the greatest of these risks is the po- the many privacy options that Facebook in both practice and research. Their tential for individuals in crisis to misinter- provides. We have limited what the public interests include: behavioral and pret our services and seek emergency can see on our personal sites, while keeping cognitive behavioral therapy, child interventions through our website or our the Psychotherapy Brown Bag pages open and adolescent psychopathology, profiles on various social media tools. As to the public (see the Facebook blog post, anxiety and mood disorders, orga- such, we are careful to clearly state that “10 Privacy Settings Every Facebook User Psychotherapy Brown Bag is an educational Should Know” for details on how to do this: nizational behavior, program evalu- tool, not a therapy provider, and to provide ation, mindfulness-based therapies, resources such as the National Suicide book-privacy/). Other social media sites can and multicultural counseling. Prevention Lifeline (1-800-273-TALK) for also be navigated and protected in a similar ■■ individuals in crisis. This is an equally im- manner. CONTACT US AT: portant consideration for therapists consid- In weighing the costs and benefits of uti- ering utilizing social media tools, as it is lizing social media tools, there is one final Pacific University entirely possible that individuals seeking point worthy of consideration: regardless of Office of Admissions immediate help will stumble upon a web- whether or not a particular psychologist HPC/Pacific University site and mistakenly interpret it as a source chooses to utilize these tools, other individu- 222 SE 8th Avenue, Ste 212 of help when, in fact, better alternatives als will make the choice to do so. Hillsboro, OR 97123 exist for their immediate situation. An addi- Unfortunately, many of those individuals tional risk—one more unique to the ser- will offer ineffective therapeutic interven- 503-352-2218 vices provided by Psychotherapy Brown tions or attempt to perpetuate misinforma- 800-933-9308 Bag—is the potential that individuals will tion. These individuals will, in large part, misinterpret our postings in a manner that not do so out of malice, but rather igno- would result in the proliferation of misinfor- rance. Whether this represents a lack of ed- mation or, on a more personal level, hurt ucation regarding research methods and feelings. Translating complex research find- data analysis, a philosophical devotion to a ings published in fairly esoteric psychology particular therapeutic modality not sup- journals into prose more consistent with ported by research, or a bad personal experi- what one would read in a popular magazine ence with an otherwise effective treatment can be difficult, as some topics require a sig- approach, the end result is the same: a nificant amount of background information voice, widely accessible to the public, mak- in order to be explained clearly. As such, we ing claims that contradict empirical facts. take care to provide several different expla- Readers—consumers of psychological ser- nations for findings that might be difficult vices and information—lack sure-fire October • 2009 143
  8. 8. methods by which to determine who is pro- In this sense, regardless of whether or not a Correspondence to Michael D. Anestis or viding accurate information and who is pro- clinical psychologist finds him- or herself in- Joye C. Anestis, Florida State University, 953, viding false hope. As such, if there are more terested in social media tools, it could be ar- Parkview Dr., Tallahassee, FL 32311 individuals utilizing social media tools who gued that it is beholden upon them to are peddling misinformation and doing so engage in this new source of knowledge in on a large stage in a charismatic manner, an effort to provide a voice to research and consumers will be defenseless and the pub- ESTs for mental illness. Psychotherapy lic will remain in the dark regarding data- Brown Bag is lending its voice to the de- driven conceptualizations of mental illness bate, and we hope others will join in the ef- and the most effective means for treating it. fort. Research Forum Psychotherapy Treatments and a Possible Future The history of psychotherapy is charac- Barriers to the Dissemination of Empirically terized by efforts to promote particular the- Supported Treatments: Matching Messages to oretical perspectives (Cushman, 1992; Fancher, 1995; Wampold, in press). The the Evidence claims of the superiority of one method over another were endemic from the origins of psychotherapy, as Freud and his disciples ve- Bruce E. Wampold, University of Wisconsin–Madison, Zac E. Imel, VA Puget hemently argued about theory and practice Sound Healthcare System–Seattle Division and University of Washington, and (Makari, 2008). The disputes proliferated as Scott D. Miller, International Center for Clinical Excellence the behaviorists criticized the psychoana- lysts, the humanists took a different tack al- together, cognitive constructs were iven the complexity of the thera- treatments, have been limited by percep- accommodated by behavioral theories G peutic endeavor, it is not surprising that interpreting the evidence is complex—if it were not, the debate sur- tions that all psychotherapies are equally ef- fective [the Dodo Bird verdict], and … ‘that common factors, therapist, and rela- tionship variables account for the majority (Fishman & Franks, 1992), a third wave of “acceptance based” behavioral treatments emerged (Hayes, 2004), and integrationists attempted to reconcile deficiencies in uni- rounding empirically supported treatments (EST) would be inconspicuously absent. of the variance in therapy outcome studies’“ tary theories (Norcross & Goldfried, 2005). Evidence is not simply observation of phe- (as quoted in Siev, Huppert, & Chambless, These efforts have resulted in hundreds and nomena, regardless of whether the observa- 2009, p. 69). DiGiuseppe offered three al- hundreds of approaches to psychotherapy. tions were derived in experimentally ternatives: “Either we rebut these conclu- Norcross and Newman (1992) said it aptly: manipulated environments (e.g., random- sions, conduct new research to show they ized controlled trials [RCTs]) or naturalistic are wrong, or we accept them and change Rivalry among theoretical orientations has a settings. Rather, evidence involves the in- our message” (as quoted in Siev et al., p. long and undistinguished history in psy- ferences that flow from observations. What 69). chotherapy, dating back to Freud. In the in- constitutes evidence is ultimately decided Siev et al. (2009) have accepted the fancy of the field, therapy systems, like by a confluence of two factors—the phe- premise that barriers to the dissemination of battling siblings, competed for attention nomenon itself and people (Hacking, 1983; ESTs are due to the rhetorical talents of the and affection in a “dogma eat dogma” envi- Latour, 1999). The phenomenon, under dodo birders and have chosen to rebut what ronment... Mutual antipathy and exchange various environmental conditions, is ob- they believe are misguided conclusions of puerile insults between adherents of rival served by people (i.e., the scientists), who about the nature of psychotherapy. orientations were much the order of the day. then draw conclusions about the phenome- Although their article purports to “respond (p. 3) non. The road from observation to conclu- to these contentions and to present an up- sion is saturated with social influences on date on recent research bearing directly on A seemingly reasonable way to settle the scientist. Ultimately, it is the scientific the Dodo Bird verdict” (p. 69), it mostly re- disputes between rival schools is to sift and community that decides which conclusions capitulates old criticisms and ignores con- winnow the various approaches based on are valid and disseminated. tradictory, and at times vast, evidence. their efficacy—treatments that produce Accordingly, publications are, in some Barriers to the dissemination of ESTs are not demonstrable benefits should be preferred sense, rhetorical devices, the purpose of the result of sophistry, but a rational reac- to others. Indeed, such logic gave birth to which is to influence the scientific commu- tion to an interpretation of the evidence. and guided the EST movement (Chambless nity about what is the “proper” evidence We take this opportunity to present evi- & Hollon, 1998; Task Force on Promotion (Latour, 1999). With respect to the ongoing dence that has been omitted and address and Dissemination of Psychological EST debate, Raymond DiGiuseppe (2007) several important questions raised by Siev Procedures, 1995). Unfortunately, agree- recently lamented that “efforts to dissemi- et al. ment about both the type and meaning of nate empirically supported treatments the evidence has proven to be more complex (ESTs), and especially cognitive-behavioral than anticipated. 144 the Behavior Therapist
  9. 9. The difficulty in using evidence from affect in the rational condition), the thera- what many consider the “gold standard” of pist redirected the patient to their cogni- sources—RCTs of psychological treat- tions about an event if the patient expressed ments—is illustrated by a taking a hypo- emotion. Additionally, therapists were pro- thetical visit to the future. scribed from using language that referenced emotion. The patient was encouraged to ex- A Hypothetical Future: The Ascendance of Affect plore their thoughts about events in their lives and the therapist was instructed not to POrtlAnd dBt In 2020, due to advances in affective focus on particular themes, but rather allow PrOgrAM, PC neuroscience (see Davidson, Sherer, & the patient to talk about what he or she 5200 SW Macadam Ave. Ste. 580 Goldsmith, 2003), Federico Perla devel- thought was important. Perla trained the Portland, Oregon 97239 oped a new psychotherapy, which he named four therapists used in Study 1 to conduct RC as well as ACP and supervised all treat- DBT is a research-supported treatment affect-centered psychotherapy (ACP). The that combines cognitive-behavioral premise of ACP is that affect evolved to reg- ment. One therapist was removed prior to the study because she could not adhere to theory and methods with Eastern ulate social interactions in nonhuman and meditative principles and practices. eventually human animals. The cognitions the requirement to ignore affect in the RC condition. Patients were randomly assigned The Portland DBT Program provides generated by individuals are post-hoc ex- treatment for adults, teens, couples, planations of experience that interfere with to conditions and adherence measures showed adequate fidelity. It was found that and families including: the encoding and decoding of emotion, • Standard DBT which in turn leads to dysfunction. ACP in- ACP was superior to RC on measures of anxiety but was not definitively superior on • DBT for Adolescents volves a systematic program to emphasize • DBT for Eating Disorders secondary measures of depression and qual- primary emotional responding and mini- • DBT for Substance Abuse ity of life. mize cognitive involvement. Similar to • Trauma Recovery Program Perla, having shown that ACP was supe- other therapies, ACP contains a number of • Medication Management Services rior to a treatment that contained the com- elements that are considered important and • DBT-informed Couples/Family Therapy mon factors (i.e., a relationship with a necessary but not constitutive of the treat- • DBT Training/Consultation Services therapist), was convinced that the focus on ment (Grünbaum, 1981), such as a rela- affect was critical to the successful treat- For more information please visit our tionship with a therapist, a cogent ment of GAD, sought to show that it was website at explanation, therapeutic actions, and ex- superior to a well-accepted treatment, or call 503-290-3291 pectations for change. Perla, a charismatic namely cognitive-behavioral treatment and persuasive scientist-practitioner, having (CBT) of GAD, a well-established EST for Subsequently, several other groups com- successfully treated many anxiety disorders GAD (Chambless et al., 1998). However, to pared ACP to CBT and found divergent re- with ACP designed three successive RCTs , ensure that CBT did not work through any sults. In one study, CBT was superior to to establish the efficacy and specificity of mechanisms related to the encoding or de- ACP on GAD measures, in two studies ACP . coding of emotion, the therapists adminis- there were no significant differences, and on Programmatic Research in ACP tering CBT, like those in the prior study a fourth, ACP was superior to CBT on using RC, were proscribed from engaging The first study involved a comparison of GAD measures, although the size of the ef- in any conversations about emotion, or ACP to a waitlist condition. Using four of using any affective language or display of fect was smaller than in Perla’s study (viz., d his therapists, Perla randomized 30 patients emotional responses, and, finally, instructed = .32 vs. d = 1.02, respectively). No differ- with generalized anxiety disorder (GAD) to to redirect any affect-laden material arising ences in studies were found on ancillary one of the two conditions. Not surprisingly, in session to cognitions. The basic CBT pro- measures. Perla reasoned that in the studies ACP was superior to no treatment on tar- tocol was otherwise left unchanged. A wait- in which CBT was equivalent to ACP CBT , geted measures (i.e., measures related to list control group was included as well. worked because the therapists were not pro- GAD) and on other measures (e.g., mea- Additionally, the same three therapists con- scribed from discussing affect and that the sures of depression and quality of life). ducted both ACP and CBT. Because Perla affective components of CBT were responsi- Encouraged by the results and con- received training in the United States by a ble for the benefits of CBT. Moreover, he vinced that the focus on emotion was criti- prominent CBT therapist, he trained the claimed that when CBT was superior to cal to the successful treatment of GAD, therapists in CBT and supervised both ther- ACP ACP was not delivered in an adequate , Perla designed a trial that would control for apists in both modalities. Patients were ran- way. A meta-analysis of these studies the common factors. The control condition domly assigned to both treatments. showed that the aggregate effect size for the in this case was called rational counseling As in the prior studies, fidelity measures five studies was significantly larger than (RC), which involved an engaged therapist showed the treatments were delivered ac- who probed the patient to express how they zero (d = .36) for GAD measures with no cording to their respective protocols. On thought about events in their lives; the thera- measures of GAD symptoms, ACP was su- differences on other variables of psychologi- pist reinforced the verbalizations about cog- perior to CBT (d = 1.02); there were few cal functioning. Based on the totality of the nitions, but did not convey any value about significant differences between ACP and results, it was concluded that (a) ACP the rationality of the thoughts (i.e., did not CBT on ancillary measures, including de- should be designated as an EST, (b) ACP discriminate between adaptive and mal- pression and quality of life. Both treatments works through the specific ingredient of at- adaptive thoughts). To establish internal va- were superior to the no-treatment condition tending to affect, (c) ACP is preferred as a lidity (i.e., control for potential focus on on all measures. treatment of GAD to other treatments. October • 2009 145
  10. 10. Problematic Conclusions both treatments by the developer of ACP . clusion that a focus on affect is a specific in- This failure of the double-blind is further gredient in the treatment of GAD. The history and conclusions about ACP exacerbated by the fact that the comparison Having briefly visited the past and fu- closely resemble developments in modern treatment, RC, is easily identified as a sham. ture of research on psychological treat- clinical practice—and are equally problem- For reasons of internal validity rather than ments, we now return to the present. In the atic. Anyone familiar with research on psy- quality of care, the therapists in the RC con- following sections, we apply the lessons chotherapy will not find the results of the dition were proscribed from actions that learned to the evidence reviewed by Siev et first trial, where ACP proved superior to no would be reasonable to most therapists al. (2009) and others (e.g., Crits-Christoph, treatment, surprising. Every reasonable (e.g., could not use language that referred 1997; Howard, Krause, Saunders, & treatment administered to patients seeking to affect). What consumer of mental health Kopta, 1997). treatment has been found to be effective rel- services would seek out a practitioner in any ative to no treatment, including such treat- The Complete Evidence Base: profession who believed the services being ments as eye movement desensitization and The Dodo Bird Redux offered were bogus? And yet, this is exactly reprocessing and present-centered therapy the case with the RC condition—therapists Siev et al.’s (2009) criticism of the dodo for PTSD (e.g., McDonagh et al., 2005; F. knew they were delivering a service that was bird conclusion that psychological treat- Shapiro, 1989). More importantly, studies not intended to be therapeutic. As such, the ments are equally effective is based largely comparing a treatment to a no-treatment finding that ACP was more effective is on two studies: (a) a meta-analysis pub- control do not indicate whether the sup- hardly surprising! lished almost 13 years ago (viz., Wampold, posed “active” or specific ingredients of the The third trial, in which it was found Mondin, Moody, Stich, et al., 1997) that particular treatment are responsible for the that ACP was superior to CBT, would rea- corroborated the dodo bird conjecture, and change (Wampold, 2001). In the case of sonably elicit the skepticism of CBT re- (b) a new meta-analysis (viz., Siev & ACP the benefits may be due to the fact , searchers. There are several consequential Chambless, 2007) that purportedly shows that ACP delivers a treatment that has a co- problems here. First, as was the case previ- the dodo bird conclusion to be false. Briefly, gent rationale, creates positive expecta- ously, the therapists had a clear allegiance to the study by Wampold, Mondin, Moody, tions, involves a relationship with a skilled ACP—they worked with Perla, were Stich, et al., utilized a test of effect size ho- therapist who collaborates with the patient trained by Perla, and were supervised by mogeneity to meta-analytically review all to set treatment goals and involves reason- Perla. Second, the CBT protocol was altered direct comparisons of psychotherapies and able tasks related to those goals (i.e., the to obviate any work on emotions, which, found that the results were consistent with components that form the working al- while justifiable as a research operation in- the dodo bird conclusion: There was not liance)—all factors known to be related to tended to tighten internal validity, an emo- sufficient evidence to reject the null hypoth- successful psychotherapy (Anderson, tionless CBT does not represent treatment esis that the effect size for the comparison of Lunnen, & Ogles, in press; Imel & as it would be delivered by a competent various treatments was zero. Said another Wampold, 2008). clinician. Moreover, the only significant dif- way, no evidence for differences in efficacy The second clinical trial, which com- ferences found were in the area of GAD between psychological treatments were pared ACP to RC, is also problematic. Over symptoms—both treatments were equally found. For many, particularly the advocates the years, the RCT has become the “gold effective in terms of addressing depression of ESTs and, for that matter, anyone who standard” of research in psychotherapy and and quality of life, which raises the issue of believes that the specific ingredients of par- medicine. As most know, an essential ele- whether ACP is truly superior to CBT or ticular treatments are responsible for the ment of the RCT in medicine is the double whether, as operationalized in this study, benefits of psychotherapy, this is a challeng- blind; both the patient and the provider of ACP is more focused on GAD symptoms, ing conclusion. treatment are unaware of whether they are raising the specter of reactivity of the mea- Although the conclusions of the providing the real or sham treatment. To sures (i.e., ACP was more focused on symp- Wampold, Mondin, Moody, Stich, et al. point out the obvious, RCTs in psychother- toms of GAD). (1997) meta-analysis were consistent with apy are not double blinded (Seligman, The superiority of ACP to CBT was previous ones that examined the dodo bird 1995; Wampold, 2001). Indeed, as based on only five studies and a reanalysis of conjecture (Grissom, 1994; D. Shapiro & Seligman has noted, “Whenever you hear these trials shows that the effect size for Shapiro, 1982a, 1982b; Smith, Glass, & someone demanding the double-blind GAD symptoms was due primarily to the Miller, 1980; see Wampold, 2001, for a re- study of psychotherapy, hold on to your one study conducted by Perla comparing view), a number of important issues that wallet” (p. 965). Unlike medicine, where a ACP and CBT (i.e., the Perla result was an limited the generalizability of the results pill that looks, tastes, and even mimics the outlier). Indeed, when the Perla study was were raised. In their article, Siev et al. side effects of the experimental drug makes removed from the meta-analysis, the aggre- (2009) combined these earlier criticisms of it difficult for providers to tell the difference gate effect size was not significantly differ- the Wampold, Mondin, Moody, Stich, et al. between the experimental and control ent from zero. Thus, in terms of GAD study with findings from the more recent treatments, control psychotherapies are symptoms, it would be difficult to conclude meta-analysis by Siev and Chambless easy to identify. In the ACP versus RC com- that ACP was superior to CBT. The equiva- (2007), identifying four specific method- parison, the therapists knew about both lence of ACP and CBT for ancillary mea- ological flaws with the evidence in support treatments they were delivering (i.e., the sures adds strength to the conclusion that of the dodo verdict: (a) meta-analyses that design was crossed). In addition, the thera- there may be negligible differences between aggregate data across disorders masks dif- pists were knowledgeable of the hypothesis ACP and CBT. This meta-analysis provides ferences between specific treatments for regarding the two therapies, had an alle- little evidence to suggest that CBT is not in- specific disorders; (b) meta-analyses that giance to one of those approaches (viz., dicated for GAD. In practical terms, there aggregate primary and secondary outcome ACP), and were trained and supervised in is insufficient evidence to support the con- 146 the Behavior Therapist
  11. 11. measures preclude the discovery of any spe- order (PTSD; Benish et al., 2008), depres- duced small to moderate effects in favor of cific effects for targeted treatments; (c) the sion (Wampold, Minami, Baskin, & CBT (d = .38, .32, and .20) or small effect in similarity between the treatments included Tierney, 2002), GAD (Siev & Chambless, favor of RT (d = -.20). Indeed, there was in the supporting meta-analyses accounts 2007), and pediatric disorders (Miller, relatively large heterogeneity among the ef- for the failure to find differences in out- Wampold, & Varhely, 2008, when alle- fects but the hypothesis of homogeneity come; and (d) the way these same meta- giance was controlled, which is discussed in was not rejected because five studies yields a analyses classify treatments as bona fide is a following section; Spielmans, Pasek, & drastically underpowered test of homo- circular, eliminating treatments that are not McFall, 2007). geneity (Siev and Chambless calculated efficacious. These issues are not new and The new meta-analysis cited by Siev et 37% of the variability in effects was due to have indeed been helpful in guiding and al. (2009) as evidence that “broad judg- between study variability, although we cal- structuring a program of systematic re- ments about the relative importance of culated 50%). search conducted over the last decade. As technique … can be misleading” (p. 75) was But here is what is very important: The will be discussed below, Siev et al. failed to conducted by Siev and Chambless (2007). advantage to CBT in the Siev and cite this body of research, thereby present- Briefly, the study compared CBT and relax- Chambless (2007) meta-analysis was en- ing an incomplete picture of the evidence. ation therapy (RT) for panic disorder with- tirely accounted for by the one study that We now respond to each of the points raised out agoraphobia and GAD. No differences found a large effect for CBT (d = 1.02), a by Siev et al., citing prior published re- were found between CBT and RT for GAD. study conducted by Clark et al. (1994) sponses to earlier criticisms, and presenting However, for panic disorder, CBT was supe- more than 15 years ago. When that single existing evidence. rior to RT for panic-related symptoms but study is eliminated, the aggregate effect size not for other symptoms of anxiety or de- for CBT versus RT is not statistically differ- Meta-Analyses Were Conducted Across pression. Based on these results, Siev and ent from zero and the between-study vari- Disorders Chambless concluded, “The finding that ability goes from 37% (50% in our Wampold, Mondin, Moody, Stich, et CT and RT do not differ in the treatment of calculation) to 0%. In other words, the al.’s (1997) conclusion about the lack of GAD, but do for PD [panic disorder], is ev- Clark et al. result is, statistically speaking, treatment differences was based on examin- idence for the specificity of treatment to dis- an outlier, without which there is no differ- ing direct comparisons of treatments pub- order, even for 2 treatments within a CBT ence between CBT and RT for any class of lished between 1970 and 1995 in six class, and 2 disorders within an anxiety measures. The basis of Siev et al.’s claim that the journals that typically publish psychother- class” (p. 513). Importantly, they arrive at dodo bird conjecture is false and that there is sub- apy RCTs, regardless of the disorders being such a conclusion despite the fact that (a) no stantial evidence for specificity rests solely on this treated. Siev et al. (2009) raised what was, a priori prediction of such a pattern of re- one study that found that CBT was superior to at the time the study appeared, an impor- sults was made, and (b) no description is RT. tant point to consider (Crits-Christoph, given of the specific mechanism believed to Some would argue that, rather than 1997; DeRubeis, Brotman, & Gibbons, be present in CBT for panic that is responsi- being an anomaly, an outlier might reveal 2005), namely that ignoring disorder may ble for the superiority for panic symptoms an important phenomenon that is obscured well mask differences between treatments only. Exactly what is the specific ingredient in other studies. With that possibility in for particular disorders. DeRubeis et al. of CBT that makes it more effective in re- mind, it is worth taking a closer look at this (2005) articulated this quite clearly: ducing panic-related symptoms in patients one study, as so much rests on its validity. Ignoring disorder “is akin to asking with panic disorder but has no effect on pa- The one outlier in favor of CBT is a study whether insulin or an antibiotic is better, tients with GAD and depression? Finally, it comparing CBT, RT, and imipramine for without knowing the condition for which is ironic that specificity based on a the treatment of panic disorder (a no-treat- these treatments are to be given…. GAD/panic disorder distinction is critical to ment condition was also included) con- Alternatively, researchers should begin with promoting and disseminating CBT when a ducted by Clark and colleagues (1994). a problem and ask how treatments compare perspicuous effort in CBT is to develop pro- There are several aspects of the Clark et al. in their effectiveness for that problem” (p. tocols that are effective across the range of study that are important to note when con- 175). emotional disorders, based on a common sidering the results. The relaxation treat- There are two responses to this argu- diathesis of such disorders (see, e.g., Moses ment in this study was Öst’s (1987) applied ment, however. First, the trials examined by & Barlow, 2006). relaxation, which was modified in two ways Wampold, Mondin, Moody, Stich, et al. Despite the relatively weak evidence for for the comparison with CBT. The first (1997) were, in each case, two treatments specificity, it could be claimed that the supe- modification was changing the rationale for a particular disorder—they were not simply riority of CBT to RT for the treatment of presented to the patients to exclude men- two treatments selected at random or arbi- panic seems to be a clear counter-example tioning that the premise of Öst’s applied re- trarily. Second, and more to the point, there to the dodo bird conjecture determined by laxation involved “a vicious circle in which have been numerous subsequent meta- meta-analytic methods. Let’s examine this the physical symptoms of anxiety are aug- analyses that addressed the criticism of dis- result on which so much rests. In the meta- mented by negative thoughts” (Clark et al., order heterogeneity that have found no analysis conducted by Siev and Chambless p. 761) and instead used a behavioral expla- differences among treatments for particular (2007), the conclusion that CBT was supe- nation that excluded mentioning that disorders, meta-analyses that Siev et al. rior to RT for panic-related measures and thoughts were involved. We would assume (2009) did not mention. These meta-analy- not for generalized anxiety or depression this was done to increase internal validity ses span a number of disorders, including al- was based on five studies. For the panic (thereby preventing excessive discussion of cohol use disorders (Imel, Wampold, Miller, symptom measures, one study had an effect thoughts) and not to improve the quality of & Fleming, 2008), posttraumatic stress dis- that was very large in favor of CBT (d = RT. 1.02) while the remaining four studies pro- October • 2009 147