March • 2014 53

the Behavior TherapistI S S N 0 2 7 8 - 8 4 0 3

VOLUME 37, NO. 3 • MARCH 2014

ContentsPresident’s MessageDeanMcKayMedia, Science, andCognitive-Behavior Therapy • 53

Clinical Training UpdateTorrey A. Creed, ShannonWiltsey Stirman,Arthur C. Evans, and Aaron T. BeckAModel for Implementation of Cognitive Therapy inCommunityMental Health: The Beck Initiative • 56

Science ForumMichele Berk,Molly Adrian, ElizabethMcCauley,Joan Asarnow, Claudia Avina, andMarsha LinehanConducting Research onAdolescent SuicideAttempters:Dilemmas andDecisions • 65

The Lighter SideJonathanHoffman andDeanMcKayCBTersASSEMBLE!! Episode 1: “ATweet for Help” • 70

At ABCTCall forApplicants • 75

ASSOCIATION FOR BEHAVIORALAND COGNITIVE THERAPIES

[continued on p. 55]

President’s Message

Media, Science, andCognitive-BehaviorTherapyDeanMcKay, FordhamUniversity

When The New York Times scratches its head, getready for total baldness as you tear out your hair.

—CHRISTOPHER HITCHENS

Science reporting in themedia can be the sourceof considerable frustra-

tion. For example, how oftenhave you thought that sciencereporting was oversimplified,and/or overly alarming? Howoften have you heard contra-

dictory science reports occurring within days ofone another? In a thorough evaluation of the fac-tors contributing to this, one would identifyproblems in science education, public interest insmall and easy-to-digest findings, and, in alllikelihood, a proneness by the media for sensa-tionalism. However, when it comes to how CBTis reported upon, it appears that change is slowlytaking place, and in a positive direction.A few years ago I reported in these pages on

media biases in how CBT was presented com-pared to psychoanalytic approaches and psy-chopharmacology (McKay, 2010). At that time,my concerns were significant. My survey of theavailable articles in The New York Times sug-gested that CBTwas mischaracterized, underre-ported, and/or unfairly lumped together withother approaches that had lower efficacy rates.CBT was also reported consistently as a newtherapy, despite these same reports presentingmethods that have been available for well over40 years, at least since the founding of ABCT. Bythe time I completed my article, my reaction

http://www.abct.org

Journals

the Behavior Therapist!

!

tBT is nowON-LINE

2005–present

54

the Behavior TherapistPublished by the Association for

Behavioral and Cognitive Therapies305 Seventh Avenue - 16th FloorNew York, NY 10001-6008

(212) 647-1890 /Fax: (212) 647-1865www.abct.org

EDITOR · · · · · · · · · · · · · · Brett DeaconEditorial Assistant . . . . . . . .Melissa ThemBehavior Assessment . . . . . .Matthew TullBook Reviews · · · · · · · · · · · C. Alix TimkoClinical Forum · · · · · · · · · · · · · Kim GratzClinical Dialogues . . . . . . . Brian P. MarxClinical Training Update . . .Steven E. BruceInstitutional Settings. . . . . . Dennis CombsLighter Side · · · · · · · · · · · · Elizabeth MooreMedical and Health CareSettings . . . . . . . . . . . . . . Laura E. DreerNews and Notes. . . . . . . . Nicholas Forand

James W. SturgesShannon Wiltsey-Stirman

Professionaland Legislative Issues . . . . . . Susan WenzePublic Health Issues. . . . . . . . . Giao TranResearch-PracticeLinks· · · · · · · · · · · · · · · · David J. HansenResearch-TrainingLinks · · · · · · · · · · · · · · · · · · · Stephen HuppScience Forum· · · · · · · · · · · Jeffrey M. LohrSpecial InterestGroups · · · · · · · · · · · · · · Aleta AngelosanteStudent Forum · · · · · · · · · · David DiLilloTechnology Update. . . . . . . Steve Whiteside

ABCT President . . . . . . . . . . Dean McKayExecutive Director · · · · · ·Mary Jane EimerDirector of Education &Meeting Services . . . . . . Mary Ellen BrownDirector of Communications David TeislerManaging Editor . . . . . Stephanie Schwartz

Copyright © 2014 by the Association for Behavioraland Cognitive Therapies. All rights reserved. Nopart of this publication may be reproduced or trans-mitted in any form, or by any means, electronic ormechanical, including photocopy, recording, or anyinformation storage and retrieval system, withoutpermission in writing from the copyright owner.Subscription information: the Behavior Therapist is

published in 8 issues per year. It is provided free toABCT members. Nonmember subscriptions areavailable at $40.00 per year (+$32.00 airmailpostage outside North America).Change of address: 6 to 8 weeks are required for

address changes. Send both old and new addresses tothe ABCT office.ABCT is committed to a policy of equal opportu-

nity in all of its activities, including employment.ABCT does not discriminate on the basis of race,color, creed, religion, national or ethnic origin, sex,sexual orientation, gender identity or expression,age, disability, or veteran status.All items published in the Behavior Therapist,

including advertisements, are for the information ofour readers, and publication does not imply endorse-ment by the Association.

The Association for Behavioral andCognitive Therapies publishes the BehaviorTherapist as a service to its membership.Eight issues are published annually. Thepurpose is to provide a vehicle for the rapiddissemination of news, recent advances,and innovative applications in behaviortherapy.

Feature articles that are approximately16 double-spaced manuscript pages maybe submitted.Brief articles, approximately 6 to 12

double-spaced manuscript pages, arepreferred.

Feature articles and brief articlesshould be accompanied by a 75- to100-word abstract.

Letters to the Editor may be used torespond to articles published in theBehavior Therapist or to voice a profes-sional opinion. Letters should be lim-ited to approximately 3 double-spacedmanuscript pages.

Submissions must be accompanied bya Copyright Transfer Form (a form isprinted on p. 35 of the February 2011issue of tBT, or download a form from ourwebsite): submissions will not be reviewedwithout a copyright transfer form. Prior topublication authors will be asked to sub-mit a final electronic version of their man-uscript. Authors submitting materials totBT do so with the understanding that thecopyright of the published materials shallbe assigned exclusively to ABCT.Electronic submissions are preferred andshould be directed to the editor atBDeacon@uwyo.edu. Please includethe phrase tBT submission and the au-thor’s last name (e.g., tBT Submission -Smith et al.) in the subject line of your e-mail. Include the corresponding author'se-mail address on the cover page of themanuscript attachment. Please also in-clude, as an attachment, the completedcopyright transfer document.

INSTRUCTIONS Ñçê AUTHORS

VOTINGe l e c t r o n i c

Once again, we offer you, the members of ABCT, the opportunity to elect officerselectronically. All full members and new member professionals who are in goodstanding will receive emails with a unique username and password for voting.We will alert you as to when the elect ion portal is open: April 1.We will send

emails to your primary email address only, where you receive emails fromABCT.

March • 2014 55

was largely consistent with how Hitchenssuggested one would be when reading thenewspaper of record for the United States.In the intervening years since my survey,

it appears that the situation has been im-proving for how CBT is portrayed in themedia. In my admittedly unscientific fol-low-up search of The New York Times for thepast 12 months (as of this writing, onJanuary 30, 2014), I found 11 articles inwhich CBT was featured.1 But in my esti-mation, what was more striking was thatsome of these articles emphasized the needfor consumers to seek out “evidence-basedtreatments” (i.e., Brown, 2013). This is amarked change from 2010, when the pic-ture I observed was fairly bleak.

Where Are Things Going?

Progress in how CBT is presented to thepublic via the media is indeed encouraging,if we rely on The New York Times as a guide.Nonetheless, we cannot afford to be com-placent. While the media portrayal has im-proved, ifThe New York Times is any guide, itis unfortunately just one outlet in an ever-expanding network of sources clients mayrely upon in learning about treatment. Toillustrate, Psychology Today has several blogswritten bymental health professionals. Onein particular has included questionable as-sertions about the research base for psy-chotherapy, especially CBT (Shedler, 2013).The blog post in question here, in my esti-mation, suggested that treatment as usual(that is, a general common factors ap-proach) is sufficient. The justification forthis assertion stems from a single study thatsuggested CBT practitioners routinely de-part from established therapy manualswhen delivering care (Waller, Stringer, &Meyer, 2012). The blog post author goes onto imply that the departures CBT-orientedtherapists take invariably involve ap-proaches that might be more traditionallypsychodynamic in nature. This is the kindof discourse that serves to confuse an al-ready ill-served public when it comes to re-ceiving sound recommendations for care.Now before I continue, allowme to pro-

vide a bit of full disclosure. I have disagreedwith Dr. Shedler in the public square previ-ously, as have other members of ABCT. Inone exchange Shedler (2010) asserted that ageneral, common factors approach to treat-

ment is sufficient and that the empiricallysupported treatments were no better thantreatment as usual. This drew a series ofcritical comments. Anestis, Anestis, andLilienfeld (2011) noted that Shedler washighly selective in his review of the litera-ture in drawing his conclusions. I noted thatShedler overlooked the absence of validatedmechanisms in general psychotherapy, andthat a common factors approach did notleave clinicians with guidelines shouldtreatment fail (McKay, 2011). Tryon andTryon (2011) noted that common factorswere part of any good therapeutic enter-prise at a minimum, and so any treatmentshould advance beyond the efficacy of gen-eral psychotherapy, which CBT succeeds inaccomplishing. Thombs et al. (2011) notedthat Shedler’s examination of existingmeta-analyses was flawed because of an un-critical acceptance of the available studies,rather than a more careful parsing of thefindings from well-controlled trials of psy-chodynamic therapy. Shedler, in his reply(2011), asserted, “Over the past twodecades or so, a ‘master narrative’ hasemerged in the academic world that psy-chodynamic therapy has somehow been dis-proven and that CBT has been scientificallytested against it and found superior. In theprevailing academic climate, the steadilyaccumulating scientific evidence for psy-chodynamic therapy has been repeatedlyoverlooked.” He goes on to suggest thatseveral of the commenters (myself included)were falsely holding themselves up as objec-tive purveyors of truth.I use the example of Shedler’s Psych-

ology Today blog to illustrate that there areindividuals with platforms that reach alarge number of individuals who can eithermischaracterize or erroneously report onhow CBT works or what our research sug-gests. The need tomeet the challenge inher-ent inmedia and public portrayals of CBT isnot trivial, and not just for the public whoseek therapy. Our own colleagues, particu-larly those who see CBT as a viable treat-ment modality but who were trained inother traditions, will benefit from exposureto better information about its efficacy. Bycreating a public perception of CBT thatmore closely matches the scientific evidence(and differentiates it from other nonempiri-cal approaches), we may increase the desir-

ability of training in our treatment meth-ods. This in turn will hopefully have the ef-fect of increasing the likelihood that clientsreceive empirically supported interventions.It is here that I would like to share an

anecdote. In my years as a practitioner, Ihave had many clients who have reportedreceiving non-empirically-based therapybefore coming to my office.Worse, many ofthese same clients knew the kind of treat-ment that was appropriate for their condi-tion, went to providers who claimed theycould and would conduct this form of treat-ment, only to later offer excuses for why itwas not applicable in the client’s particularcase. Informally, I will note that this uniquesubgroup of clients typically did their duediligence and asked prospective clinicians ifthey had been properly trained in themeth-ods of therapy they sought. The cliniciansall “passed” the client interview and wereable to substantiate that they had indeed re-ceived some form of training (typicallyworkshops). And yet, these clients did notreceive the treatment they sought—butthey had the kind of savvy to know whatthey needed. How many more lack this in-formation?2 And how many, if they could,would in turn pressure their clinicians toseek out the right kind of training? Mediaportrayals of the need for scientifically in-formed therapy would increase the oddsthat more savvy clients would question thetreatment they receive and alter the behav-ior of clinicians.

What CanWeDo?

How should we address this persistent,albeit improving, problem in how our ap-proach to treatment is presented to thepublic? Back in 2010 I recommendedadopting two broad strategies, one proac-tive and one reactive. The proactive one in-volves deliberate outreach to media sourcesto get the message out about efficacioustreatment. We clearly need more of that.The other, reactive, approach involves re-sponding to the inaccurate portrayals wemay receive in the media. The blog post Imentioned above (and a few others by thatsame author) was met with a litany of com-ments that challenged his assertions. Thisapproach can be frustrating, time consum-ing, and combative. However, I wouldstress that while you may not change anyminds of those who respond directly to thecomments, the comments are also read byothers who are unlikely to post any repliesat all. In short, the effort will not likely bewasted.

1 In my 2010 survey, I had noted that psychopharmacology coverage in The New York Times includedmarriage announcements. I amhappy to report that I identified onemarriage vow announcement in thepast year where one of the to-be betrothed self-identified as a CBT therapist. For that I say “bravo!”

2An important reminder: As a service to the public, ABCT has a series of fact sheets available on theirwebsite that describe treatment for different conditions.

56 the Behavior Therapist

The reactive approach is necessarilyproblematic without other proactive mea-sures. It ensures a defensiveness that can beunhelpful. So allowme to add tomy recom-mendations articulated in 2010. When wetalk among ourselves, such as during theannual conference, the scientific founda-tions reign supreme. It’s wonderful to shareideas with like-minded colleagues who un-derstand the importance of a scientific foun-dation for intervention development. But itcan also be an echo-chamber. Rarely arethere attendees at our annual conventionwho need convincing of the need for scien-tific bases of intervention. What is neces-sary now is a technology for speaking tonon-scientifically-minded mental healthproviders.While we are enthusiastically sci-entifically oriented in our approach to treat-ment delivery, my own experience has beenthat observing improvement when apply-ing an empirically grounded approach isalso profoundly gratifying. It would be-hoove us to highlight the dramatic emo-tional and functional benefit CBT bestowson clients, including the depiction of case il-lustrations. When case illustrations areyoked to scientific presentations of clinicalinterventions, clinicians show greater inter-est in receiving training (Stewart &Chambless, 2010). The media routinelydoes this now to make their point for a wide

range of topics. After all, that is the verypoint of so-called “man on the street” inter-views. If we were to start doing this, itwould connect the part we do so well (ap-peal to each other’s heads) with an aspectwe do less well (speak to the each other’shearts). Interestingly, there were no case il-lustrations as part of the 11 New York Timesarticles over the past year that describedCBT’s efficacy. Perhaps I am now gettinggreedy in my desire to see improved CBTcoverage in the media. Nevertheless, theimpact of coverage will be far better if theoutcomes can be made more vivid throughreal-life illustrations.

References

Anestis, M. D., Anestis, J. C., & Lilienfeld, S. O.(2011).When it comes to evaluating psycho-dynamic therapy, the devil is in the details.American Psychologist, 66, 149–151.

Brown, H. (March 23, 2013). Shift in mentalhealth care is slow.New York Times, D4.

McKay,D. (2010). Themainstream newsmedia,cognitive-behavior therapy, psychodynamictherapy, and psychopharmacology: An illus-tration using theNew York Times. the BehaviorTherapist, 33, 152-156.

McKay, D. (2011). Methods and mechanisms inthe efficacy of psychodynamic psychother-apy.American Psychologist, 66, 147–148.

Shedler, J. (2010). The efficacy of psychody-namic psychotherapy. American Psychologist,65, 98–109.

Shedler, J. (2011). Science or ideology? AmericanPsychologist, 66, 152-154.

Shedler, J. (Oct. 31, 2013). Where is the evi-dence for evidence-based therapy. PsychologyToday (http://www.psychologytoday.com/blog/psychologically-minded/201310/where-is-the-evidence-evidence-based-therapies).

Stewart, R.E., & Chambless, D.L. (2010).Interesting practitioners in training in em-pirically supported treatments: Research re-views versus case studies. Journal of ClinicalPsychology, 66, 73-95.

Thombs, B.D., Jewett, L.R., & Bassell, M.(2011). Is there room for criticism of studiesof psychodynamic therapy? AmericanPsychologist, 66, 148-149.

Tryon, W.W., & Tryon, G.S. (2011). No owner-ship of common factors.American Psychologist,66, 151-152.

Waller, G., Stringer, H., & Meyer, C. (2012).What cognitive behavioral techniques dotherapists report using when delivering cog-nitive behavioral therapy for the eating dis-orders? Journal of Consulting and ClinicalPsychology, 80, 171-175.

. . .

Correspondence to DeanMcKay, Ph.D.,Department of Psychology, FordhamUniversity, 441 East Fordham Road, Bronx,NY 10458; mckay@fordham.edu

The Patient Protection and AffordableCare Act (ACA) is now in full force,creating long-overdue opportunities

to grow the capacity of mental health sys-tems and meet the pressing needs of indi-viduals served by community mentalhealth. As of January 1, 2014, mental

health conditions and substance use disor-ders fall under the broad Essential Benefitspackage of services under the ACA, receiv-ing parity protection in comparison withmedical and surgical benefits (H.R.3590–111th Congress: Patient Protectionand Affordable Care Act, 2009). While

each state determines the specific benefits,coverage for mental health and substanceabuse services has substantially increasedwith the ACA, and, as a result, funding fortreatment services will likely expand. Achallenge to capitalizing on the ACA op-portunity, however, is the underdevelopedstate of evidence-based practices (EBPs) incommunity mental health. Unlike physicalhealth services, for which there is a robustfunctioning system, the delivery of evi-dence-based mental health services is lesswell developed. However, efforts to imple-ment EBPs in community mental healthhave moved to the forefront in the pastdecade, and these efforts may be even moreimportant in the context of the ACA. TheBeck Initiative is a collaborative clinical, ed-ucational, and administrative partnershipthat has successfully implemented cognitivetherapy (CT) across a diverse group of com-munity mental health care providers (agen-cies). This paper presents the BeckInitiative’s goals, training model, and out-comes to date, so that it might serve as asuccessful model for implementation forother networks.

Clinical Training Update

AModel for Implementation of CognitiveTherapy in Community Mental Health:The Beck InitiativeTorrey A. Creed, Perelman School of Medicine,University of Pennsylvania

ShannonWiltsey Stirman, The National Center for PTSD,VA Boston Healthcare System and Boston University

Arthur C. Evans, Perelman School of Medicine, University ofPennsylvania, and Philadelphia Department of Behavioral Healthand Intellectual disAbility Services

Aaron T. Beck, Perelman School of Medicine, University of Pennsylvania

March • 2014 57

Hogrefe Publishing · 30 Amberwood Parkway · Ashland, OH 44805Tel: (800) 228 3749 · Fax: (419) 281 6883E-Mail: customerservice@hogrefe.com

Special offer: Save 33% ontwo critically acclaimed books

on sexual dysfunction!

Scan the QR-Codefor details!

Order online atwww.hogrefe.com/books/book-series/TBT0314 or call toll-free (800) 228-3749 (US only)(Use code: TBT0314when ordering at www.hogrefe.com or by phone.)

“If you have time to read one book about femalesexual dysfunction, this should be the one.”

Irving Binik, Professor of Psychology,McGill University Montreal

“This up-to-date and concise textbook addresses avery difficult clinical subject [...]. Undoubtedly, allpractitioners will [take) a new and better approach(to) these problems after reading this textbook [...].”Prof. Paul Maria, Section Editor, in European Urology Today,

August/September 2012

Series Editor:DannyWedding

Associate Editors:Larry Beutler, Kenneth E. Freedland,Linda Carter Sobell, David A.Wolfe

“By far the best professional book ever publishedabout understanding, assessing, and treating malesexual dysfunction.”

Barry McCarthy, Professor of Psychology,American University, Washington DC

“This textbook, clearly and exhaustively written, (is)intended for most practitioners, including urologistsand sex therapists. Readers will obtain accurate infor-mation, which is very useful in daily practise.”

Prof. Paul Maria, Section Editor, inEuropean Urology Today, August/September 2012

Martha MeanaSexual Dysfunction inWomenVol. 25, 2012, x + 100 pp.,ISBN 978-0-88937-400-3

David RowlandSexual Dysfunction in MenVol. 26, 2012, viii + 108 pp.,ISBN 978-0-88937-402-7

58 the Behavior Therapist

Goals of the Beck Initiative

The Beck Initiative was established in2007 as a partnership among the Aaron T.Beck Psychopathology Research Center ofthe University of Pennsylvania (UPenn), thePhiladelphia Department of BehavioralHealth and Intellectual disAbility Services(DBHIDS), DBHIDS network providers,and the children, adolescents, and adults re-ceiving services in this large, urban behav-ioral health system. Although the BeckInitiative has successfully broadened itspartnership to include several other city-and state-wide mental health systems, thispaper focuses on the original PhiladelphiaBeck Initiative. The Beck Initiative part-ners share two key goals: to improve out-comes for people receiving services in theDBHIDS system, and to contribute to theimplementation science literature. In ordertomeet those goals, the Beck Initiative pur-sues the following aims: (1) to promotehope, autonomy, and engagement in con-structive activity for individuals served in

the network; (2) to establish CT as a stan-dard practice of care for people served in thenetwork; (3) to promote the sustained im-plementation of CT into the network; (4) toimprove the professional lives of front-linestaff in this system; (5) to conduct programevaluation to examine the feasibility, out-comes, and sustainability of high-qualityCT in the community; (6) to utilize CT as aroadmap for delivering recovery-orientedcare; and (7) to serve as a model for otherlarge mental health systems.

Training Protocol and Procedures

The network’s evolving priorities haveprompted adaptation of the training, apply-ing core CT concepts to diverse populationsand levels of care (for a discussion of the im-portance of real-time adaptations to meetthe needs of diverse stakeholders, seeChorpita, Daleiden, & Collins, 2013). CThas been implemented in settings as diverseas outpatient clinics, residential settings,schools, homelessness outreach teams,

Assertive Community Treatment (ACT)teams, addictions and methadone-assistedtreatment clinics, and extended acute careunits. Trainings are tailored for the level ofcare and the population served, includingdiverse age ranges (adults, families, youth)and presenting problems (e.g., depression,addiction, schizophrenia, recent incarcera-tion). The training protocol retains the flex-ibility to adapt as the DBHIDS prioritiesevolve, growing out of the ACCESS model(Stirman et al., 2010; see Table 1).

Step 1: Assess, Adapt, Engage

Engagement as a focus. The first step of theACCESS model is to promote engagementthrough the assessment of stakeholderneeds, goals, and readiness for change.Through this process, stakeholders are en-gaged in the process of planning and adapt-ing the training for the provider’s needs, aswell as engagement in the actual trainingprocess, beginning with the BeckInitiative’s first contact with the provider.When DBHIDS selects priority areas (e.g.,specific levels of care or services for specificpopulations) for CT training, a Request forApplications (RFA) is released to encourageactive provider engagement in the selectionprocess. Providers of the targeted servicesmay submit a proposal with a description oftheir ability and commitment to participatein the training program and sustained prac-tice. The RFA process was instituted in the2013-14 training year as a strategy for in-creasing active participation and engage-ment of administration. Prior to this,invitations for participation were based onthe DBHIDS priorities without any initialexpression of interest or effort by theproviders. Shifting to a competitive processwas an effort to increase the perceived valueof participation by the agencies, as well asan attempt to identify providers with someinternal motivation for participation. Basedon anecdotal observation of the 2013-14 se-lection process, these efforts have indeed re-sulted in greater demonstrated investmentamong administrators. In their RFA re-sponses, providers are strongly encouragedto make participation voluntary for staff, sothe application also solicits a statementfrom each staffmember whose participationis proposed, indicatingwhether their partic-ipation is by choice. This caveat was basedon previous feedback that indicated thatmandatory participation dampened theirenthusiasm, even among clinical staff whowere otherwise eager for CT training. Thestrength of the RFA submissions is evalu-ated by the Director of the Beck Initiative

Stage Intensive Model MilieuModel

Assess and adapt

Conveythe basics

Consult

Evaluatework samples

Sustain

Study outcomes

Stakeholders (e.g., administrators, supervisors, clinicians, individuals in recov-ery) are engaged in the process of planning and adapting the training for theprovider’s needs.

Intensive workshop is held for cliniciansto build knowledge from basic CT con-cepts through case conceptualization andintervention planning.

Weekly consultations are held to helpclinicians apply CT knowledge to helpindividuals in recovery move towardtheir goals, through intervention plan-ning, tape review, and case conceptual-ization.

Audio recorded CT sessions are evaluatedfor CT competency at 3- and 6-monthspostworkshop, as well as completion oftraining requirements (workshop, pro-gram evaluation measures, at least 85%of consultation meetings).

Sustained practice of CT is supported through access to a web-based trainingto build CT skills in additional clinicians, scheduled ongoing support fortrained groups, recertification expectations for clinicians, booster training, andquarterly meetings for trained provider groups.

Evaluate number of behavioral health professionals trained, retention in train-ing, achieved competency, rates of recertification, and differential outcomes inweb-based and live training.

Intensive workshop is held for mi-lieu clinical staff to create a CT-informed therapeutic culture.

Weekly consultations are heldwith instructors who model use ofCT skills for clinical staff and pro-vide feedback to clinical staffabout their developing skills.

Completion of training is evalu-ated, including all workshops,program evaluation measures, andat least 85% of consultation meet-ings.

Note. The Intensive and Milieu training models may be implemented individually or together within aprovider context. Adapted from Stirman et al. (2010) with permission.

Table 1. Implementation of CT Using the ACCESS Model

March • 2014 59

ISBN: 978-1608827091 / US $18.95

ISBN: 978-1608823345 / US $58.95ISBN: 978-1608828326 / US $16.95

Help for yourclient to buildhealthy habitsthat last

Streamlineand empoweryour ACTapproach

Powerful skillsto help yourclient regainintimacy andconnection

Essential Resources for Your Practice

newharbingerpub l i ca t ions1-800-748-6273 / newharbinger.com

ISBN: 978-1608821044 / US $18.95

ISBN: 978-1608829613 / US $49.95ISBN: 978-1608827664 / US $21.95

Help yourclient discovera life beyondwhat they seein the mirror

Help yourclient reduceanxiety anddevelop theirsocial “muscles”

Powerful skillsto help yourclient managetheir recurringdepression,hypomania,and anxiety

An Imprint of New Harbinger Publications, Inc.

Read a preview:newharbinger.com/

diet-trap

Read a preview:newharbinger.com/

act-matrix

60 the Behavior Therapist

(the first author) and DBHIDS representa-tives, and the final selection is approved bythe Commissioner of DBHIDS (third au-thor).Selected providers are notified and three

initial events are planned for each provider.First, the agency administrative contact(e.g., Chief Executive Officer, Director ofClinical Services), members of the clinicalstaff (typically one or more supervisors), theDirector of the Beck Initiative, two post-doctoral level Beck Initiative instructors,and a DBHIDS representative meet to re-view the components of the training plan,develop a time line, and resolve any chal-lenges. Further information is gatheredabout the provider’s mission, clientele, andtreatment context. For example, school-based services often emphasize group ther-apy with briefer individual sessions andcrisis management, whereas residential ser-vices may capitalize on milieu staff in dailycontact with individuals receiving services.Gathering information about the providerallows the instructors to begin to tailor thetraining to these characteristics.Next, an operational meeting is held

with the participants at the provider’s site sothat instructors can experience the treat-ment context. Instructors share informationabout training specifics, elicit feedbackabout the fit between the training modeland participants’ needs, and address anyquestions or hesitations. Open feedback isencouraged directly by limiting the atten-dance to the participant group, as adminis-trative presence could inhibit the expressionof questions or concerns. This early oppor-tunity for open discussion was prompted byearly training experiences in which clini-cians who were hesitant to participate re-mained disengaged until their hesitationswere openly discussed. Instructors describetraining as a partnership between the in-structors and participants, in which the in-structors bring CT expertise andparticipants bring expertise in theprovider’s mission, consumers, and strate-gies. The instructors are mindful that par-ticipants are professionals who strive toprovide good care, which requires a differ-ent approach and set of sensitivities thanone might have while training new profes-sionals. Baseline program evaluation dataare also gathered in the operational meetingto evaluate and improve the effectivenessand acceptability of the Beck Initiativetraining as the program progresses.The provider then holds a kickoff cele-

bration for participants, their colleaguesand supervisors, other staff and employees,board members, individuals receiving ser-

vices, and others. Refreshments are pro-vided and speakers, including the CEO orDirector of Clinical Training, the DBHIDSliaison, the Director of the Beck Initiativeand instructors, and other stakeholdersshare their enthusiasm about the trainingendeavor. The celebration sets a tone of re-spect for the commitments made, as well assolidifying the intentions to increase thelikelihood that they will translate to behav-ior (Godin, Belanger-Gravel, Eccles, &Grimshaw, 2008).Instructors also work with participants

throughout to develop strategies to engageindividuals in CT services. For example, aparticipantmay say, “I’m learning a new ap-proach called cognitive therapy, and when Ithought about who might be a great candi-date to try it out, you came to my mind.Could we talk about what that therapywould be like, and whether you would beinterested in trying it?” Participants thenorient the person to CT (e.g., session struc-ture, the cognitive model) and ask for feed-back about participation. Informationalflyers to orient individuals to CT are alsoavailable and are often located in theprovider waiting rooms.

Step 2: Convey the Basics

Training models. The two main trainingapproaches may be implemented indepen-dently or together, based on the needs of theprovider. The intensive trainingmodel aimsto build therapist CT competency to thelevel expected of clinicians in clinical trialsof CT. The milieu training model aims tobuild familiarity with CT concepts, inter-vention, and conceptualization for clinicalstaff who are not in traditional therapistroles. The differentiated approaches weredeveloped in response to the evolving prior-ities of DBHIDS, which in turn reflect thediversity of behavioral health settings. Earlytraining cohorts focused on services inwhich a traditional therapy-hourmodel wasused (e.g., outpatient clinics) and the inten-sive training model was developed to meettheir needs. Subsequent training cohortsalso included services in which the tradi-tional therapy hour was not the focus of ser-vices (e.g., residential services for peopleexperiencing chronic homelessness) or inwhich coordination of adjunctive serviceswere essential (e.g., school-based serviceswith individual and group therapy plus in-classroom support), so themilieumodel wasdeveloped as an alternative or additional ap-proach.Although either training model may

focus on a specific presenting problem, as in

the case of methadone-assisted treatmentclinics, training for generalist settings isnow transdiagnostic. Early trainings fo-cused on depression and suicide ideation asa vehicle for teaching CT skills, but thefeedback indicated that participants in-ferred from this approach that CT was onlyuseful for depression and suicide. There-after, trainings were adapted to focus on di-verse presentations. The instructors facili-tate this adaptation by presenting CTprinciples and engaging participants tojointly consider ways in which the principlesapply to specific individuals.Intensive training model. The intensive

training moves from workshop to groupconsultation, and then to internal groupconsultation. Therapists are not taught amanual; rather, they are taught the princi-ples behind the manuals so that CT can bedelivered with both flexibility and fidelity(Kendall & Beidas, 2007). This model is ap-propriate for participants whose job respon-sibilities include delivery of individualtherapy that is reimbursable within theDBHIDS network. Within most levels ofcare, therapists are required to have at leastamaster’s degree in social work, counseling,or related field, but in addictions services,bachelor’s-level therapists are also eligiblefor reimbursement and are therefore in-cluded in intensive training.Typically, intensive training model

groups include 6 core participants and 2 al-ternates. To successfully complete the pro-gram, core participants must (a) participatein all 22 workshop hours and at least 85%of the 6-month consultation meetings; (b)maintain at least four to five CT trainingcases; (c) submit at least 15 recorded ses-sions for review (with appropriate consent/assent); (d) complete all program evaluationmeasures; and (e) demonstrate sustainedCT practice after completion of the trainingthrough ongoing participation in internalconsultation groups and recertificationevery 2 years. Alternates participate in theworkshop and may join the consultationgroup if a core participant leaves (e.g., dueto turnover). Alternates are encouraged torejoin the core participants after 6 monthswhen the groupmoves to internal consulta-tion and apply for a certificate of compe-tency (see below).Intensive workshops, consisting of 22

hours over four to five weekly meetings,begin with the basics of CT and buildthrough complex case conceptualizationand intervention planning. Information ispresented through interactive methods in-cluding didactics, demonstrations, role-plays, paired practice, and discussion of

March • 2014 61

audio examples (for an example, see Creed,Reisweber, & Beck, 2011). Participantspractice the new CT skills between meet-ings and discuss these experiences in thesubsequent workshop. By the end of thisphase, the goal is for participants to share acommon language and understanding ofCT concepts. In addition to core and alter-nate participants, administrators, supervi-sors, psychiatrists, or other clinical staff whowill not be core participants or alternatesare also encouraged to attend.Milieu training model. Milieu training

builds familiarity with CT concepts, inter-vention, and conceptualization for nonther-apist clinical staff. These goals are reachedthrough use of workshops and supportedpractice. When paired with an intensivetraining, the goal of the milieu training isfor participants to support the CT deliveredby intensive training participants (Chang,Grant, Luther, & Beck 2013; Riggs,Wiltsey-Stirman, &Beck, 2012).When de-livered independent of an intensive train-ing, the goal is to create a CT-informedtherapeutic culture where staff use a com-mon, evidence-based approach to createconsistency among their therapeutic inter-actions. Milieu CT trainings have been suc-

cessfully implemented in settings as variedas residential programs for persons experi-encing chronic homelessness, inpatient ex-tended acute care units, ACT teams, andschools. As in the intensive training model,participants are taught the CT model andprinciples to be delivered with flexibilityand fidelity (Kendall & Beidas, 2007) ratherthan a manualized intervention. Milieutrainings include all staff in the therapeuticmilieu to shift the context to one that isguided by CT. Milieu participants’ job roleshave included case managers, outreachworkers, mental health workers, nurses,certified peer specialists, recovery coaches,administrators, occupational therapists,psychiatrists, and behavioral health work-ers.Milieu instructors often take an experi-

ential approach, beginning with basic caseconceptualization to help participants un-derstand a given person’s behavior in themilieu (Riggs et al., 2012). Specific inter-ventions are planned as a way to shift thatbehavior, and participants are encouragedto practice the interventions in their inter-actions with the individual. Experienceswith the intervention are reviewed and builtupon with new interventions and people re-

ceiving services in the milieu. Short work-shop meetings are typically held over 2 to 3months, providing opportunity for practiceand application of new skills. By the end ofthe workshops, the goal is for the milieuparticipants to be able to interact with per-sons receiving services in a cohesive, consis-tent, CT-informed manner, and whencoupled with an intensive training, to beable to support the skills built in individualsessions. For example, an ACT team leadclinician may share her case conceptualiza-tion of a man receiving services with theteam, including the man’s belief that he is“broken.” The team nurse may use thatconceptualization as a framework to under-stand the man’s reluctance to take medica-tion. (“Why bother? Nothing can help me.I’m too messed up.”) The nurse may workwith him to examine whether that belief isas accurate as it might initially seem to him,and whether the belief is helping him tomove closer to his goals.

Step 3: Consult

Intensive training model. When the inten-sivemodel workshop ends, core participantsshift to weekly 2-hour consultation meet-ings with the instructors. In each meeting,

Celebrat ing Its 40th Anniversary

Steven T. Fishman, Ph.D., ABPP | Barry S. Lubetkin, Ph.D., ABPPDirectors and Founders

Since 1971, our professional staff has treated over 20,000 patients with compassionate, empirically-based CBT.Our specialty programs include: OCD, Social Anxiety Disorder, Panic Disorder, Depression, Phobias, PersonalityDisorders, and ADHD-Linked Disorders, and Child/Adolescent/Parenting Problems.Our externs, interns, post-doctoral fellows and staff are from many of the area’s most prestigious universitiesspecializing in CBT, including: Columbia, Fordham, Hofstra, Rutgers, Stony Brook, St. John’s, and YeshivaUniversities.Conveniently located in the heart of Manhattan just one block from Grand Central Station. Fees are affordable,and a range of fees are offered.We are pleased to announce the Oct. 2013 opening of our new Post-traumatic Stress & Relationship TherapyCenter, focusing on the full range of trauma-related difficulties and directed by Heidi Kar, Ph.D.

New York CityINSTITUTE for BEHAVIOR THERAPY

For referrals and/or information, please call: (212) 692-928820 East 49th St., Second Floor, New York, NY 10017e-mail: info@ifbt.com | web: www.ifbt.com

62 the Behavior Therapist

participants share session audio to be dis-cussed by the group (facilitated by instruc-tors). Additional didactics are presented oninterventions and techniques in which theparticipants are building competency, aswell as other topics by participant request(e.g., interventions for specific presentingproblems, integration of family in sessions).Case conceptualizations are developed andrefined, then used to guide interventionplanning. The instructors, active in theearly consultationmeetings, slowlymove tothe background as the group becomes morepeer-led.During this phase, four key personnel

meetings are also attended by the adminis-trative point person, the instructors, theDBHIDS liaison, the Beck Initiative direc-tor, and a participant liaison nominated bythe participant group. These meetings pro-vide an opportunity for discussion ofprogress, successes, challenges, and anyneeded problem solving.By the end of the group consultation

phase, a group facilitator is identified withinthe participant group. That individualmustdemonstrate competency in CT, be willingto take on a facilitator role, and complete 4additional training hours in group facilita-tion. At the end of the 6-month group con-sultation, responsibility for the grouptransitions to the provider, with the expec-tation that the group will continue to meetweekly (1 hour) or biweekly (2 hours) tosupport sustained practice through peerconsultation.Milieu training model. Application of the

skills is supported by 6 to 8 months ofweekly on-site consultation with the in-structors who observe participants and pro-vide feedback, model skills with personsreceiving services in the milieu setting, par-ticipate in team meetings to help integrateCT into the team’s approach, and providefurther information as needed. As in the in-tensive model, four key personnel meetingsare held during this phase with discussionscentered on progress, challenges, and suc-cesses. By the end of the consultation phase,a point person is identified within the co-hort.Milieu participants are not expected tocontinue to meet biweekly, because unlike agroup of therapists, providers rarely haveregular supervision-like expectations formilieu staff. Sustained practice of thelearned CT skills is encouraged in teammeetings and clinical interactions, and theinstructors are available for additional sup-port as needed.

Step 4: EvaluateWork Samples

Intensive training model. Core participantsidentify an audio recording from the mid-point (3 months postworkshop) and end (6months postworkshop) of the consultationphase to be rated by the instructors usingthe Cognitive Therapy Rating Scale (CTRS;Beck & Young, 1980, 1988). Item scores, atotal score, and detailed feedback on each ofthe 11 items are provided to participants asa measure of their progress toward compe-tency in CT (see Creed et al., 2013, for de-tails). The gold-standard for CT clinicaltrials (CTRS total score ≥40; Shaw et al.,2009) is used to indicate competency in theBeck Initiative. A baseline audio (recordedprior to training) is also rated for programevaluation, but scores and feedback are notprovided to the participants.Three different certificates can be earned

by Beck Initiative participants in the inten-sive trainingmodel based on their participa-tion and demonstrated competency on theCTRS. Alternates who complete the work-shop are eligible for a certificate indicatingthat they have “completed a 22 hour work-shop in Cognitive Therapy in CommunityMental Health settings.” Core participantswho complete all of the participation re-quirements are eligible for a certificate indi-cating that they have “completed anintensive training in Cognitive Therapy in aCommunity Mental Health setting.” Coreparticipants who complete all of the partici-pation requirements and also earn at least atotal score of 40 on the CTRS are eligible fora second certificate indicating that theyhave “demonstrated competency inCognitive Therapy in a CommunityMentalHealth setting.” Alternates who join the in-ternal consultation group after the 6-monthconsultation then submit a recorded ther-apy session and earn at least a total score of40 on the CTRS are also eligible for the“demonstrated competency” certificate.Each certificate is recognized within theDBHIDS network as an indicator of famil-iarity and skill level in CT.The milieu training model. Beck Initiative

milieu participantsmay earn a certificate in-dicating that they have “completed amilieutraining in Cognitive Therapy in aCommunity Mental Health setting” uponcompletion of the training program if theycomplete all program evaluation measures,and attend all workshop meetings and atleast 85% of the consultationmeetings heldduring their scheduled work hours.

Step 5: Sustained Practice

Training and implementation of an EBP,in the absence of a plan formaintained prac-tice, may be destined for a very limited im-pact (Scheirer, 2005; Stirman et al., 2012).A number of sustainability elements havebeen incorporated to support the main-tained practice of CT over time, includingweb-based training, scheduled support forongoing groups, recertification expecta-tions, booster training, and quarterly meet-ings for the trained provider groups.Employee turnover can be a challenge to

sustaining services, and as Beck Initiativegraduates left the provider or advanced intoroles with less clinical contact, the need toreplenish the internal groups became clear.Greater penetration of CT was also desir-able, both within a provider (training morethan the core and alternate participants)and across providers (reaching moreproviders in an efficient and effective way).In 2011, a 22-hour web-based training(WBT) was launched with these goals inmind, presenting the material from the liveworkshops through detailed PowerPointslides and videotaped role-play examples.Access to the WBT was offered to thera-pists employed by providers who hadmoved to the internal group consultationphase of the intensive training model.Newly participating therapists completedthe online training in lieu of the workshoptraining, then joined the ongoing consulta-tion group of their trained peers. The peergroupmeetings served the same purpose forthe WBT participants as the initial 6-month consultation served for the originaltraining group.WBT participants who met the criteria

outlined for intensive trainingmodel partic-ipants (completion of all 22 hours of didacticlearning, participation in at least 85% ofongoing consultation meeting for 6months, submission of 15 training caseaudio recordings, demonstrated compe-tency on the CTRS) were then eligible for acertificate indicating that they “demon-strated competency in Cognitive Therapyin a CommunityMental Health setting.” Inaddition, each provider group that movedinto the internal consultation group phaseretained a generic provider login so that theongoing groups could access the WBT as aresource. In February 2014, an updatedWBT (WBT 2.0) will be released, reflect-ing updates to the training materials andthe advancing technology in online learn-ing. WBT 2.0 relies much less on partici-pants readingmaterial, and instead includesvoice-over of content, interactive activities

March • 2014 63

and games, broader video examples, anddownloadable therapy materials.The internal consultation groups also re-

ceive regular support from the BeckInitiative. Every 6 to 8 weeks, a BeckInitiative instructor participates in the in-ternal consultation meeting, offering addi-tional information about requested topics,feedback about audio or case conceptualiza-tion, support for the group facilitator, orother tasks as needed. However, providerswho have demonstrated success in sustain-ing CT may therefore not need this level ofregular contact from the Beck Initiative,and as each training year adds to the num-ber of providers receiving this support, theresources required to offer regular supporthave become unsustainable. Therefore,plans are being finalized to transition suc-cessful providers to amore independent sta-tus wherein support is available uponrequest but no longer scheduled by default.Providers who have not yet reached thislevel of independence will continue to re-ceive support, with the aim of helping themto develop independence.Even among the skilled, drift from the

model may be found over time (Waller,2009). Therefore, certificates of CT compe-tency require renewal every 2 years. Toapply for recertification, a therapist must (a)participate in at least 85% of internal groupconsultations during the 2-year period; (b)complete 4 CT- or CBT-related continuingeducation credits during the 2-year period;and (c) submit a recorded therapy session(with the permission of the person beingrecorded) demonstrating competency in CTas rated on the CTRS. Prior to the provider’srecertification date, a Beck Initiative in-structor offers a 4-hour on-site boostertraining to refresh therapists on the specificsof CT and the CTRS. These boosters areoften provided during two consecutive in-ternal group consultationmeetings tomini-mize burden on the therapists.All CT-trained providers, including their

administration, supervisors, Beck Initiativegraduates, and those interested in joiningthe Beck Initiative, are invited to partici-pate in a Beck Initiative quarterly meetingfour times per year. These meetings providean opportunity for administration andgraduates to refresh their enthusiasm andfine-tune their skills, for networking amongproviders delivering CT for the people theyserve, and a preview of CT and the BeckInitiative for individuals interested in join-ing. Quarterlymeetings begin with updateson the Beck Initiative, including newly par-ticipating or graduating providers, upcom-ing RFAs, and other news. Next, a group

discussion is facilitated among the stake-holders. For example, group feedback aboutthe WBT was solicited to shape the WBT2.0, and providers have shared strategies forintegrating CT principles into their docu-mentation. Finally, a clinical exercise is usedto refresh or sharpen participants’ CT skills.

Step 6: Study Outcomes:Preliminary Findings

Since 2007, The Beck Initiative has de-livered 44 training programs to 35 provideragencies, including 13 child-focused pro-grams, 12 programs for individuals experi-encing chronic homelessness, 9 generaladult outpatient programs, 4 addictions-services programs, 3 ACT teams, 2 ex-tended acute care units, and 1 programfocused on gay, lesbian, and transgenderadults.In total, 569 community mental health

care workers in Philadelphia have partici-pated in live workshop training aimed to di-rectly increase skills. (Close to 200additional professionals in Philadelphiahave attended other workshops to share in-formation about CT in the network, includ-ing care managers and other DBHIDSemployees.) Of those, 267 attended inten-sive training model workshops, and 302participated in milieu training. The inten-sive training workshops include core partic-ipants, alternates, and others in clinical careroles who attended the workshop portion oftraining to learn about CT. Among thoseattendees, only the core participants werealso intended to participate in the full com-petency training, so the numbers who at-tended the 6-month consultation andattempted to reach competency are smaller,but do not reflect high rates of dropout. Infact, 172 participants of the 267 in the in-tensive workshops have completed the full6-month consultation and submitted audioto try to earn a certificate indicating compe-tency in CT. Among the 95 other partici-pants who attended workshop but did notattempt tomeet competency criteria, only 1withdrew from the program because of adesire to stop participating. The remainingindividuals attended the workshop to learnabout CT but never intended to participatein the 6-month consultation (n = 63; e.g.,alternates, administrators, additional super-visors), or individuals who withdrew be-cause they no longer met criteria forparticipation (n=32; e.g., left the provideragency, moved to a role with no case load).In addition, 35 WBT participants havecompleted the online portion of the WBT

plus 6 months of internal group consulta-tion, submitting audio for certification.Among participants who have at-

tempted certification, 83% of those in thelive training and 71% of those in the WBThave reached a level of competence seen inclinical trials (Shaw et al., 2009). The newlylaunched WBT 2.0 is hypothesized to havehigher rates based on the integration ofnewer e-learning technology, but this em-pirical questionwill be answeredwhen suffi-cient comparison data are available. Similarrates of competency have been reached atthe 2- (n = 63; 86%) and 4-year (n = 24;83%) recertification point among eligibleparticipants who have been in the BeckInitiative long enough to submit for thesetime points. All participants who at-tempted recertification began in the livetraining, as theWBTbegan too recently forWBT participants to have reached the 2-year mark.

Implications for Disseminationand Training

As a model for implementing an EBP incommunity mental health, the BeckInitiative offers a method for maintainingthe rigor necessary for fidelitywhile retainingthe flexibility to adapt to treatment settingsand diverse behavioral health conditions.The model has grown from outpatient clin-ics to treatment milieus with a culture ofCT, and from a depression focus to trainingtailored for diverse behavioral health condi-tions, while achieving high standards ofcompetency similar to clinical trials (Shawet al., 2009). These changes reflect adapta-tions made in response to challenges in thetraining and implementation efforts. TheRFA process, voluntary participation forclinicians and open discussion of any hesita-tions, movement away from a depressionfocus, the intensive and milieu training ap-proaches, web-based training, and providertransitions to independence were all initi-ated to overcome implementation chal-lenges. The flexibility to make theseadaptations in response to the needs of di-verse stakeholders may be the biggest con-tributor to the success of the Beck Initiative(Chorpita et al., 2013).An emerging development represents

the ongoing spirit of this progression. Asthe penetration of CT into the network in-creases, the opportunity for the continuityof care across providers is building. A com-mon language and approach can be sharedacross levels of care or providers trained inCT to facilitate amore cohesive recovery ex-perience for an individual. Providers may

64 the Behavior Therapist

share information about a case conceptual-ization, goals that a person has identified orachieved, interventions that have met withsuccess, and skills that the person has built.When this information translates across aperson’s treatment experiences, opportuni-ties exist for cumulative progress ratherthan restarting with disparate therapeuticapproach.As the nation’s community mental

health systems continue to evolve in re-sponse to the mandates of the ACA (H.R.3590–111th Congress, 2009) and growingpressure to provide broad access to EBPs,the calls for models of implementation withboth flexibility and fidelity will increase.The Beck Initiative offers a collaborativeapproach to meeting this need for providersand networks, resulting in an increasedpresence of accessible evidence-based care.

References

Beck, A.T., & Young, J. (1980). Cognitive therapyscale. Unpublished manuscript.

Beck, A.T., & Young, J. (1988). Cognitive therapyrating scale: Rating manual. Unpublishedmanuscript.

Chang, N.A., Grant, P.M., Luther, L., & Beck,A.T. (2013, Dec 12). Effects of a recovery-oriented cognitive therapy training programon inpatient staff attitudes and incidents ofseclusion and restraint. Community MentalHealth, 49.

Chorpita, B.F., Daleiden, E.L., & Collins, K.S.(2013). Managing and adapting practice: Asystem for applying evidence in clinical care

with youth and families. Clinical Social WorkJournal, 1-10.

Creed, T.A., Jager-Hyman, S., Pontoski, K.,Feinberg, B., Rosenberg, Z., Evans, A.C.,Hurford, M.O., & Beck, A.T. (2013). TheBeck Initiative: A strength-based approachto training school-based mental health staffin cognitive therapy. International Journal ofEmotional Education, 5, 49-66.

Creed, T., Reisweber, J., & Beck, A.T. (2011).Cognitive therapy for adolescents in school settings.New York: Guilford Press.

Godin, G., Belanger-Gravel, A., Eccles, M., &Grimshaw, J. (2008). Healthcare profession-als’ intentions and behaviours: A systematicreview of studies based on social cognitivetheories. Implementation Science, 3, 36.doi:10.1186/1748-5908-3-36

H.R. 3590–111th Congress: Patient Protectionand Affordable Care Act. (2009). An act enti-tled The Patient Protection and Affordable CareAct. Retrieved January 4, 2014, fromhttp://www.govtrack.us/congress/bills/111/hr3590

Kendall, P.C., & Beidas, R.S. (2007). Smoothingthe trail for dissemination of evidence basedpractices for youth: Flexibility within fidelity.Professional Psychology: Research and Practice,38, 13-20.

Riggs, S., Wiltsey-Siteman, S., & Beck, A.T.(2012). Training community mental healthagencies in cognitive therapy for schizophre-nia. the Behavior Therapist, 35, 34-39.

Scheirer, M.A. (2005). Is sustainability possible?A review and commentary on empirical stud-ies of program sustainability. AmericanJournal of Evaluation, 26, 320-347.

Shaw, B.F., Elkin, I., Yamaguchi, J., Olmstead,M., Vallis, T., Dobson, K., . . . Imber, S.(2009). Therapist competence ratings in re-lation to clinical outcome in cognitive ther-apy of depression. Journal of Consulting andClinical Psychology, 67, 837-846.

Stirman, S.W., Kimberly, J., Cook, N., Castro, F.,& Charns, M. (2012). The sustainability ofnew programs and innovations: A review ofthe empirical literature and recommenda-tions for future research. ImplementationScience, 7, 17.

Stirman, S.W., Spokas, M., Creed, T.A.,Farabaugh, D.T., Bhar, S.S., Brown, G.K.,. . . Beck, A.T. (2010). Training and consulta-tion in evidence-based psychosocial treat-ments in public mental health settings: TheACCESS model. Professional Psychology:Research and Practice, 41, 48-56.

Waller, G. (2009). Evidence-based treatmentand therapist drift. Behaviour Research andTherapy, 47, 119–127

. . .

The authors wish to thankMatthewHurford,M.D., Regina Xhezo, M.A., and Abigail Pol,M.S., at the Philadelphia Department ofBehavioral Health and Intellectual disAbilityServices, Paul Grant, Ph.D., the BeckInitiative instructors and research assistants atthe Aaron T. Beck Psychopathology ResearchCenter, and the clinicians, administrators, andindividuals in recovery whose participation intraining and feedback allowed us to developand evolve the Beck Initiative.

Correspondence to Torrey A. Creed, Ph.D.,Aaron T. Beck Psychopathology Research

FRANK DATTILIO RECOGNIZED with AAMFT OUTSTANDING CONTRIBUTIONtoMARRIAGE and FAMILY THERAPY AWARD

October 26, 2013 – Frank Dattilio, Ph.D. was recognized as the 2013 Outstanding Contribution to Marriage and FamilyTherapy award winner by the American Association for Marriage and Family Therapy (AAMFT). The award, which recog-nizes exception and significant contributions to the field of marriage and family therapy, was formally given during theAssociation’s annual conference in Portland, Oregon.

Erin Schaefer, member of the AAMFT Board of Directors and Chair of its awards committee, noted that, “[Dr. Dattilio]has been a leader in the promotion of cognitive-behavior therapy with couples and families for several decades.”

Dr. Dattilio has delivered numerous lectures around the world and developed written works in 30 languages availablein over 80 countries. He currently serves as a faculty member with the Department of Psychiatry at Harvard MedicalSchool and at the University of Pennsylvania Medical School where he is responsible for training psychiatric residents inthe use of marriage and family therapy techniques.

He has also made significant humanitarian contributions to underprivileged nations around the world including thedonation of scholarship funds and training time.

Cloe Madanes, chair of the Board for the Council on the Human Rights of Children which Dr. Dattilio serves on,remarked, “Dr. Dattilio has devoted his life to bringing harmony to families and to the training of those who can carry onthe AAMFT mission.”

March • 2014 65

Suicide is the third leading cause ofdeath among 10- to 24-year-olds inthe United States (Centers for Disease

Control and Prevention, 2010). Recent sta-tistics from a nationally based survey ofhigh-school students in the United Statesshowed that 15.8% had seriously consid-ered attempting suicide in the past year,12.8% had made a plan about how theywould attempt suicide, and 7.8% had at-tempted suicide one or more times (Eatonet al., 2012). Among 15- to 24-year-olds,there are approximately 100 to 200 suicideattempts for every completed suicide(Goldsmith, Pellmar, Kleinman, & Bunney,2002) and prior suicide attempts are one ofthe strongest predictors of subsequent sui-cide attempts and suicide deaths in bothadolescents and adults (e.g., Harris &Barraclough, 1997; Lewinsohn, Rohde, &Seeley, 1994; Shaffer, et al., 1996).Currently, there are no treatments

specifically targeting suicide attempts inadolescents that meet criteria for a “well-established” empirically supported treat-ment (APA Presidential Task Force, 2006).As a result, guidelines for managing andtreating these high-risk adolescents arebased on a combination of “expert opinion”and a small number of randomized andnonrandomized intervention trials(Asarnow & Miranda, in press). There areonly eight randomized controlled trials(RCTs) of treatments for adolescent suicideattempters that targeted reduction in reat-tempts as their primary outcome. Only fourof these trials yielded significant results.These interventions consisted of (a) grouptherapy including both cognitive-behav-ioral and psychodynamic techniques(Wood, Trainor, Rothwell, Moore, &

Harrington, 2001); (b) multisystemic ther-apy (Huey et al., 2004); (c) mentalization-based treatment (Rossouw & Fonagy,2012); and (d) integrated CBT for comor-bid alcohol abuse disorders and suicidalthoughts or behaviors (Esposito-Smythers,Spirito, Kahler, Hunt, &Monti, 2011). Thegroup therapy approach failed to be repli-cated in two subsequent follow-up trials(Green et al., 2011; Hazell et al., 2009) andthe other three studies have yet to be repli-cated. The four trials that did not yield sig-nificant decreases in suicide attemptsincluded (a) a green card offering rapid, no-questions-asked hospital admission if re-quested (Cotgrove, Zirinsky, Black, &Weston, 1995); (b) a brief home-based

problem-solving intervention (Harringtonet al., 1998); (c) a skills-based approach tar-geting problem-solving and affect manage-ment (Donaldson, Spirito, & Esposito-Smythers, 2005; and (d) a youth-nomi-nated support team (plus a second trialusing a slightly modified version of the ap-proach; King et al., 2006, 2009). It is clearthat further research is urgently needed.Research on suicide attempters presents

multiple challenges for investigators, whichlikely accounts for the lack of needed re-search in this area (Iltis et al., 2013;Linehan, 1997; Pearson, Stanley, King, &Fisher, 2001). Challenges include manage-ment of the significant anxiety associatedwith working with suicidal individuals, per-ceived liability risks for investigators, theneed for sufficient expertise and resources tomonitor and treat suicidal subjects, and thelarge sample sizes needed for sufficient sta-tistical power to detect between-group dif-ferences in suicide-related outcomes(Pearson et al., 2001). In this article, we dis-cuss ways to address these issues based onour experiences conducting the Collabo-rative Adolescent Research on Emotionsand Suicide (CARES) study, the first RCT ofDialectical Behavior Therapy (DBT) thatspecifically targets adolescent suicide at-tempters with current high suicide ideation.Our goal is to facilitate additional researchin this understudied area by offering sug-gestions that reduce the stressors and con-cerns associated with studying highlysuicidal adolescents. First, we provide abrief description of the CARES study. Next,

Science Forum

Conducting Research on Adolescent SuicideAttempters: Dilemmas and DecisionsMichele Berk,Harbor-UCLAMedical Center/Los Angeles BiomedicalResearch Institute, David Geffen School of Medicine at UCLA

Molly Adrian and ElizabethMcCauley,University of Washington,Seattle Children’s Hospital, University of Washington

Joan Asarnow,David Geffen School of Medicine at UCLA

Claudia Avina,Harbor-UCLAMedical Center/Los Angeles BiomedicalResearch Institute

Marsha Linehan,University of Washington

Inclusion Criteria Exclusion Criteria

Elevated suicide ideation within the past month

History of at least one lifetime suicide attempt

Recurrent intentional self-injury:• History of at least 3 intentional self-injuries,one within 12 weeks of referral to the study

Presence of at least 2 BPD criteria besides therecurrent intentional self-injury criterion

12 to 18 years old

At least one family member or responsible adultagrees to participate in assessment and treat-ment

Adolescent is court-ordered to treatment

IQ score less than 70

Acute psychiatric or medical symptoms (e.g.,traumatic brain injury, substance dependencerequiring inpatient detoxification) that wouldinterfere with the adolescent’s ability to partici-pate in outpatient psychotherapy and/or studyassessments

Table 1. Inclusion and Exclusion Criteria for the CARES Study

66 the Behavior Therapist

we review multiple roadblocks that arelikely to be encountered when workingwith this population and strategies for ad-dressing them.

CARES Study

The CARES study is a multisite RCTbeing conducted at the University ofWashington, Seattle Children’s Hospital,Harbor-UCLA Medical Center, and theUniversity of California, Los Angeles. Atotal of 170 adolescents will be enrolled inthe study across sites. Inclusion and exclu-sion criteria are shown in Table 1.Adolescents whomeet study inclusion crite-ria are randomly assigned to receive 6months of either DBT or Individual andGroup Supportive Therapy (IGST).Outcome assessments are conducted at 3, 6,9, and 12 months. The primary outcomevariable is suicide events (suicide, suicide at-tempts, or emergency department visit orinpatient hospitalization for suicidality).Assessments also incorporate a number ofdomains that are associated with increasedrisk of suicide attempts, including multiplemeasures of psychopathology (e.g., moodand anxiety disorders, PTSD, psychosis,substance abuse, and borderline personalitydisorder traits), difficulties with emotionregulation, impulsivity, social adjustment,coping skills, and family functioning.Potential mediators of treatment outcomes,such as increased emotion regulation anddecreased family conflict, will also be exam-ined. At present, we have enrolled approxi-mately two-thirds of the sample.

Research on Suicidal Adolescents:Dilemmas andDecisions

Selection of an Experimental ConditionTwo factors are needed in selecting an

experimental treatment for study. First, thetreatment to be studied needs to haveenough preliminary evidence to warrant anRCT. Second, there has to be a need for an-other study, i.e., the studymust be designedto provide new information. DBT was se-lected because of its known efficacy withsuicidal adults (Koons et al., 2001; Linehan,Armstrong, Suarez, & Allmon, 1991;Linehan et al., 2006; Verheul et al., 2003).However, no RCTs on DBT have been con-ducted with adolescents selected for highsuicidality. This is a problem due to the factthat DBT is already being widely providedto adolescents in clinical settings in the ab-sence of data on efficacy. A number of pilottrials of DBT adapted for adolescents havebeen conducted demonstrating the feasibil-ity and promise of DBT for the adolescent

population (Fleischhaker et al., 2011; Katz,Cox, Gunasekara, &Miller, 2004; Rathus &Miller, 2002; Woodberry & Popenoe,2008). What is missing is a sufficientlypowered RCT of DBT for adolescents se-lected due to previous and current high sui-cidality. In sum, based on the strength ofthe data demonstrating the efficacy of DBTwith suicidal adults, the promising resultsobtained in small studies of DBTwith suici-dal adolescents, and the widespread dissem-ination of DBT for adolescents in responseto clinical need, without support from aRCT, it is clear that an RCT of DBT withadolescent suicide attempters is justifiedand is a critical next step in research on ado-lescent suicide prevention.

Selection of a Control Condition

An optimal control condition needs tobe safe, potentially effective, and desirableto participants. In one large-scale study oftreatment for adolescent suicide at-tempters, researchers were unable to con-duct an RCT as planned due to youth andparents’ unwillingness to be randomized tothe study conditions (which included CBT,medication, and CBT plus medication;Brent et al., 2009). Because we were inter-ested in maximizing internal validity, weused an active treatment control conditionin which we could control for as many as-pects of treatment delivery as possible. Asthere currently are no evidence-based treat-ments for suicidal adolescents, there was noclear choice of a control treatment (Spirito,Stanton, Donaldson, & Boergers, 2002).We selected IGST based on prior studiesshowing that supportive therapy led to de-creases in suicidality (defined as suicidalideation with a plan or a suicide attempt)equivalent to CBT and systemic behaviorfamily therapy in a sample of depressed ado-lescents (Brent et al., 1997) andwas equiva-lent to CBT in decreasing suicidal ideationand attempts in a sample of adolescent sui-cide attempters (Donaldson et al., 2005).Supportive therapy techniques were alsoshown to be the most commonly reportedelements of TAU in a sample of adolescentsuicide attempters (Spirito et al., 2002).Client-centered therapy has also been usedas a comparison group in multiple RCTsthat examined trauma-focused CBT withtraumatized youth (Cohen, Deblinger,Mannarino, & Steer, 2004; Cohen,Mannarino, & Knudsen, 2005). In order toenhance internal validity, IGST is designedto control for key treatment elements suchas hours of treatment provided, treatmentmodalities provided (e.g., both individual

and group therapy), therapy dropout poli-cies, therapist expertise, and availability ofsupervision.

Recruitment of High-Risk Adolescents

Although suicide is a leading cause ofdeath among adolescents, it occurs at a rela-tively low base rate in the general popula-tion. Hence, large samples are needed forsufficient statistical power to detect be-tween-group differences in suicidal behav-iors. Moreover, it is important thatresearchers use a sample at high risk for sui-cide so that enough suicidal behaviors occurduring the study to compare groups on sui-cide-related outcomes (Linehan, 1997). Inthe CARES study, the need for a large sam-ple size was addressed by conducting amul-tisite study. In order to ensure that werecruited a sample at high risk of engagingin suicidal behavior, we based our inclusioncriteria on documented risk factors for sui-cide and suicide attempts in adolescents (seeTable 1). Finally, over time, we establishedstrong referral networks with settings thatwere likely to treat highly suicidal adoles-cents, such as inpatient units, residentialtreatment programs, emergency rooms,psychiatric mobile response teams, andcommunity-based clinics. To the best of ourknowledge, we have recruited one of thehighest risk samples of suicidal adolescentsto date.

How to Safely Manage Suicide Risk

Working with such a high-risk samplerequires responsible suicide risk manage-ment protocols for both experimental andcontrol conditions. However, the use of in-tensive risk protocols across study condi-tions must also be balanced with thescientific concern of reducing power to de-tect between-group differences (Pearson etal., 2001). Further complicating thematteris the lack of ability to accurately predictwhich individuals will ultimately die by sui-cide. Taking into account these multipleconcerns, in order to ensure responsible riskmanagement that was consistent with thetwo treatments provided, we created sepa-rate, detailed risk-management protocolsfor each condition. Given that there are nostandard suicide risk-management proto-cols that are used uniformly across clinicalsettings in the United States, both risk-management protocols utilized in this studyare likely to be superior to TAU, providemanualized safety monitoring and riskmanagement, and are consistent with ethi-cal and legal requirements for the protec-tion of human subjects.

March • 2014 67

Clinicians providing IGST follow therisk-management procedures outlined inthe American Academy of Child andAdolescent Psychiatry’s Practice Parame-ters for the Assessment and Treatment ofChildren and Adolescents with SuicidalBehavior (Shaffer & Pfeffer, 2001). They areprovided with extensive training on how toassess suicide risk and on the standard safetyprecautions to be reviewed with both youthand parent (e.g., removal of lethal means,increased parental monitoring, provision oftelephone numbers of local emergency ser-vices) that are recommended in the practiceparameters. They are also provided withguidance on how to perform these proce-dures while staying within the nondirective,client-centered approach of the treatmentmodel. Youth and parents are also given thetelephone numbers of local and nationalsuicide hotlines that are available for 24-hour, 7-day-per-week crisis management.In the DBT condition, therapists follow

DBT assessment and treatment protocolsfor suicidal individuals, including theLinehan Risk Assessment andManagementProtocol (LRAMP; Linehan, 2009). TheLRAMP is a semistructured assessmentchecklist that guides clinicians through anextensive list of risk factors for imminentsuicide and enables him/her to conduct anddocument a comprehensive risk assessmentthat addresses liability concerns. It also as-sists the clinician in determining and justi-fying his/her course of action (e.g.,recommending hospitalization or not) andin creating a safety plan. The LRAMP iscompleted in the first session with a newclient and subsequently completed at anytime during treatment when the client re-ports self-injury, a suicide attempt, an in-crease in suicidal urges, or threatens suicide.As part of the standardDBT protocol, ther-apists also provide clients and parents with24-hour, 7-day-a-week telephone coachingwithin limits, with the goal of learning touseDBT skills in both suicidal and nonsuici-dal crises. In the absence of any data thathospitalization is an effective treatment forsuicidality (for reviews, see Bridge et al.,2006; Gould et al., 2003), DBT has astrong preference for avoiding hospitaliza-tion for suicidal individuals and rarely sug-gests inpatient care, although it is notprohibited if it is needed. Although DBTpromotes the use of coping skills instead ofpsychotropic medication (replacing pillswith skills) to manage negative emotions, italso includes a rescue medication protocol.In particular, the DBT therapist recom-mends immediate treatment with medica-tions in the following two instances, both of

which have been shown to be predictors ofimminent suicide: (a) severe insomnia com-bined with escalating agitation or suicideideation (Bernert & Joiner, 2007; Fawcett,2013; Linehan, 1981) and (b) a severe psy-chotic episode (Hawton, Sutton, Haw,Sinclair, & Deeks, 2005; Hor & Taylor,2010).Detailed safety protocols are also uti-

lized during study assessments across bothstudy conditions. Assessment interviewersutilize the Linehan Risk AssessmentProtocol (LRAP; Reynolds, Lindenboim,Comtois, Murray, & Linehan, 2006). TheLRAP includes an assessment of suicide andself-injury risk pre- and postassessment,strategies to decrease distress and relatedsuicidal and self-injurious urges, and proce-dures for when to increase the level of re-sponse (e.g., escorting the subject to thehospital). Of note, there is no evidence thatassessment of suicidal behavior (whether fortreatment or research purposes) “primes”vulnerable individuals and leads to in-creased suicide risk or risk of nonsuicidalself-injury (Biddle et al., 2013; Gould et al.,2005). Given that self-harm and suicidalbehaviors are inherent risks in a study thatrecruits expressly for highly suicidal people,and the importance of protecting our par-ticipants, the LRAP is administered as astandard part of each assessment battery.The LRAP includes a protocol for calling ina supervisor to speakwith the subject beforeshe/he is allowed to go home if the other el-ements of the LRAP do not sufficiently re-duce distress.Several additional steps have been taken

to enhance and manage safety. ThePrincipal Investigators (PIs) of the study areexperts in working with suicidal clients, aswell as in conducting large-scale clinical tri-als. Study PIs and clinical supervisors areavailable to study staff at all times for con-sultation regarding safety concerns. As de-scribed above, study therapists andassessors receive extensive training on riskassessment and management protocols. Asrequired by NIH for all intervention trials,the study has a Data Safety andMonitoringBoard that meets on a quarterly basis toevaluate the safety of the trial. There is alsoa study ombudsman designated at each sitewho is available to independently evaluatewhether or not a subject needs to be re-moved from the study protocol. Becausethere are no evidence-based treatments forsuicidal adolescents, and no data showingthat hospitalization or residential treatmentare superior to outpatient care (Bridge etal., 2006; Gould et al., 2003; Van der Sandeet al., 1997; Waterhouse & Platt, 1990),

there is no strong rationale for pulling sub-jects out of the study treatment just becausethey become more suicidal during thestudy. However, if at any time an individualinvolved in the adolescent’s treatment (e.g.,the therapist, the adolescent, the parent,the supervisor, the PI) feels that he/she isnot benefiting from the study treatment or isgetting worse, and there is reason to believethat an alternative treatment exists that hasa greater likelihood of addressing theclient’s needs, a meeting with the ombuds-man and the family is automatically initi-ated. The ombudsman makes the finaldecision as to whether or not the youthshould be removed from the study protocol.

How toManage Anxiety

Finally, and perhaps most important,working with highly suicidal adolescentscreates a great deal of anxiety among thera-pists and investigators. Indeed, the thoughtof a child dying by suicide is difficult to bearand the assessment, management, andtreatment of suicidal clients are among themost stressful tasks facing clinicians (Jobes,1995). It is critical that this anxiety is ade-quately addressed and managed in order toprevent it from interfering with the imple-mentation of appropriate safety procedures(Pearson et al., 2001). For example, thera-pists’ fears may compel them to eitherunder- or overassess suicidality, or to deviatefrom study protocols, which could lead tosuboptimal risk management. It is criticalthat the study is led by investigators andclinical supervisors who can tolerate theanxiety associated with working with suici-dal adolescents andmodel this for others. Inorder to address anxiety in our researchteams, we have (a) provided ongoing train-ing and education about risk managementprocedures, (b) provided education aboutthe limits of therapists’ ability to predictand prevent suicides, (c) had therapistsmeet regularly with clinical supervisors andin teams to provide each other with supportand guidance, (d) had PIs and clinical super-visors who are available 24/7 for consulta-tion, (e) given therapists small caseloads toprevent burnout and allow time for carefulmanagement of cases, (f) provided detailedsafety protocols to be followed, (g) con-ducted regular fidelity monitoring of ther-apy and assessment sessions, and (h)emphasized the critical importance of thework research teammembers are doing andthe potential for their work to save lives inthe future.

68 the Behavior Therapist

Conclusion

Adolescents who have attempted suicideare at high risk for subsequent suicide at-tempts and death by suicide and evidence-based treatment approaches are urgentlyneeded. However, at present, there is a rela-tively small amount of treatment researchthat has been conducted on this populationand no interventions meeting criteria for a“well-established” empirically supportedtreatment (APA Presidential Task Force,2006). The lack of research studies in thisarea is likely due to the multiple difficultiesencountered in working with a sample ofhighly suicidal individuals. In light of ourexperiences conducting the CARES study, alarge RCT examining the efficacy of DBTwith adolescent suicide attempters, we dis-cussed ways to address the issues that deterresearchers from conducting this research.In particular, we discussed how to select sci-entifically sound treatment and controlgroups, recruitment of high-risk adoles-cents, safety protocols, and managing anxi-ety. We hope that this article will beinstructive for investigators consideringdoing research on this topic and will facili-tate additional research.

References

APA Presidential Task Force on Evidence-BasedPractice. (2006). Evidence-based practice inpsychology. American Psychologist, 61, 271-285. doi:10.1037/0003-066X.61.4.271

Asarnow, J.R., & Miranda, J. (in press).Improving care for depression and suiciderisk in adolescents: Innovative strategies forbringing treatments to community settings.Annual Review of Clinical Psychology.

Bernert, R. A., & Joiner, T. E. (2007). Sleep dis-turbances and suicide risk: A review of theliterature. Neuropsychiatric Disease andTreatment, 3, 735-743.

Biddle, L., Cooper, J., Owen-Smith, A.,Klineberg, E., Bennewith, O., Hawton, K.,& ... Gunnell, D. (2013). Qualitative inter-viewing with vulnerable populations:Individuals' experiences of participating insuicide and self-harmbased research. Journal ofAffective Disorders, 145, 356-362. doi:10.1016/j.jad.2012.08.024

Brent, D. A., Greenhill, L. L., Compton, S.,Emslie, G., Wells, K., Walkup, J. T., & ...Turner, J. (2009). The treatment of adoles-cent suicide attempters study (TASA):Predictors suicidal events in an open treat-ment trial. Journal of the American Academy ofChild & Adolescent Psychiatry, 48(10), 987-996. doi:10.1097/CHI.0b013e3181b5dbe4

Brent, D. A., Holder, D., Kolko, D., Birmaher,B., Baugher, M., Roth, C., & ... Johnson, B.A. (1997). A clinical psychotherapy trial foradolescent depression comparing cognitive,

family, and supportive therapy. Archives ofGeneral Psychiatry, 54, 877-885.doi:10.1001/arcpsyc.1997.01830210125017

Bridge, J.A., Goldstein, T.R., & Brent, D.A.(2006). Adolescent suicide and suicidal be-havior. Journal of Child Psychology andPsychiatry, 47, 372-394.

Centers for Disease Control and Prevention,National Center for Injury Prevention andControl. (2010). 10 leading causes of death byage group. Retrieved from http://www.cdc.gov/injury/wisqars/pdf/10LCID_All_Deaths_By_Age_Group_2010-a.pdf

Cohen, J. A., Deblinger, E., Mannarino, A. P., &Steer, R. A. (2004). A multisite, randomizedcontrolled trial for children with sexualabuse-related PTSD symptoms. Journal of theAmerican Academy of Child & AdolescentPsychiatry, 43, 393-402. doi:10.1097/00004583-200404000-00005

Cohen, J. A., Mannarino, A. P., & Knudsen, K.(2005). Treating sexually abused children: 1year follow-up of a randomized controlledtrial. Child Abuse & Neglect, 29, 135-145.doi:10.1016/j.chiabu.2004.12.005

Cotgrove, A. J., Zirinsky, L., Black, D., &Weston, D. (1995). Secondary prevention ofattempted suicide in adolescence. Journal ofAdolescence, 18, 569-577. doi:10.1006/jado.1995.1039

Donaldson, D., Spirito, A., & Esposito-Smythers, C. (2005). Treatment for adoles-cents following a suicide attempt: Results ofa pilot trial. Journal of the American Academy ofChild & Adolescent Psychiatry, 44, 113-120.doi:10.1097/00004583-200502000-00003

Eaton, D. K., Kann, L., Kinchen, S., Shanklin,S., Flint, K. H., Hawkins, J., & ... Wechsler,H. (2012). Youth Risk Behavior Surveillance:United States, 2011. MMWR SurveillanceSummaries, 61, 1-162.

Esposito-Smythers, C., Spirito, A., Kahler, C.W., Hunt, J., & Monti, P. (2011). Treatmentof co-occurring substance abuse and suicidal-ity among adolescents: A randomized trial.Journal of Consulting and Clinical Psychology,79, 728-739. doi:10.1037/a0026074

Fawcett, J. (2013). Suicide and anxiety inDSM-5.Depression and Anxiety, 30, 898-901. doi:10.1002/da.22058.

Fleischhaker. C., Böhme, R., Sixt, B., Brück, C.,Schneider, C., & Schulz, E. (2011).Dialectical Behavioral Therapy for Adoles-cents (DBT-A): A clinical trial for patientswith suicidal and self-injurious behavior andborderline symptoms with a one-year follow-up. Child and Adolescent Psychiatry and MentalHealth, 5, 1-10. doi: 10.1186/1753-2000-5-3

Goldsmith, S. K., Pellmar, T. C., Kleinman, A.M., & Bunney,W. E. (2002). Reducing suicide:A national imperative. Washington, DC:National Academies Press.

Gould, M. S., Marrocco, F. A., Kleinman, M.,Thomas, J., Mostkoff, K., Cote, J., & Davies,

M. (2005). Evaluating Iatrogenic Risk YouthSuicide Screening Programs: A RandomizedControlled Trial. JAMA, 293, 1635-1643.doi:10.1001/jama.293.13.1635

Green, J.M., Wood, A.J., Kerfoot, M.J., Trainor,G., Roberts, C., Rothwell, J., . . . Harrington,R. (2011). Group therapy for adolescentswith repeated self harm: randomised con-trolled trial with economic evaluation.BritishMedical Journal, 342, 1-12. doi:10.1136/bmj.d682

Harrington, R., Kerfoot, M., Dyer, E.,McNiven, F., Gill, J., Harrington, V., & ...Byford, S. (1998). Randomized trial of ahome-based family intervention for childrenwho have deliberately poisoned themselves.Journal of the American Academy of Child &Adolescent Psychiatry, 37, 512-518.

Harris, E., & Barraclough, B. (1997). Suicide asan outcome for mental disorders: A meta-analysis. British Journal of Psychiatry, 170,205-228. doi:10.1192/bjp.170.3.205

Hawton, K., Sutton, L., Haw, C., Sinclair, J., &Deeks, J. J. (2005). Schizophrenia and sui-cide: Systematic review of risk factors. BritishJournal of Psychiatry, 187(1), 9-20.

Hazell, P. L., Martin, G., McGill, K., Kay, T.,Wood, A., Trainor, G., & Harrington, R.(2009). Group therapy for repeated deliber-ate self-harm in adolescents: Failure of repli-cation of a randomized trial. Journal of theAmerican Academy of Child & AdolescentPsychiatry, 48, 662-670.

Hor, K., & Taylor, M. (2010). Review: Suicideand schizophrenia: A systematic review ofrates and risk factors. Journal ofPsychopharmacology, 24(4 suppl), 81-90.

Huey, S. R., Henggeler, S. W., Rowland, M. D.,Halliday-Boykins, C. A., Cunningham, P. B.,Pickrel, S. G., & Edwards, J. (2004).Multisystemic therapy effects on attemptedsuicide by youths presenting psychiatricemergencies. Journal of the American Academyof Child & Adolescent Psychiatry, 43, 183-190.doi:10.1097/00004583-200402000-00014

Iltis, A.S., Misra, S., Dunn, L.B., Brown, G.K.,Campbell, A., Earll, S.A., . . . DuBois, J.M.(2013). Addressing risks to advance mentalhealth research. JAMA Psychiatry, 70, 1363-1371.

Jobes, D. A. (1995), The challenge and thepromise of clinical suicidology. Suicide andLife-Threatening Behavior, 25, 437–449. doi:10.1111/j.1943-278X.1995.tb00237.x

Katz, L. Y., Cox, B. J., Gunasekara, S., & Miller,A. L. (2004). Feasibility of dialectical behaviortherapy for suicidal adolescent inpatients.Journal of the American Academy of Child &Adolescent Psychiatry, 43, 276-282.doi:10.1097/00004583-200403000-00008

King, C. A., Kramer, A., Preuss, L., Kerr, D. R.,Weisse, L., & Venkataraman, S. (2006).Youth-Nominated Support Team for suicidaladolescents (Version 1): A randomized con-trolled trial. Journal of Consulting and Clinical

March • 2014 69

Psychology, 74, 199-206. doi:10.1037/0022-006X.74.1.199

King, C. A., Klaus, N., Kramer, A.,Venkataraman, S., Quinlan, P., & Gillespie,B. (2009). The Youth-Nominated SupportTeam–Version II for suicidal adolescents: Arandomized controlled intervention trial.Journal of Consulting and Clinical Psychology,77, 880-893. doi:10.1037/a0016552

Koons, C. R., Robins, C. J., Tweed, J., Lynch, T.R., Gonzalez, A. M., Morse, J. Q., & ...Bastian, L. A. (2001). Efficacy of dialecticalbehavior therapy in women veterans withborderline personality disorder. BehaviorTherapy, 32, 371-390. doi:10.1016/S0005-7894(01)80009-5

Lewinsohn, P. M., Rohde, P., & Seeley, J. R.(1994). Psychosocial risk factors for futureadolescent suicide attempts. Journal ofConsulting and Clinical Psychology, 62, 297-305. doi:10.1037/0022-006X.62.2.297

Linehan, M.M. (1981). A social-behavioralanalysis of suicide and parasuicide:Implications for clinical assessment andtreatment. In H. Glazer & J.F. Clarkin(Eds.), Depression: Behavioral and directive in-tervention strategies (pp. 229-294). NewYork:Garland.

Linehan,M.M. (1997). Behavioral treatments ofsuicidal behavior: Definitional obfuscationand treatment outcomes. In D. M. Stoff & J.Mann (Eds.), The neurobiology of suicide: Fromthe bench to the clinic (pp. 302-328).NewYork:New York Academy of Sciences.

Linehan, M.M. (2009). University of WashingtonRisk Assessment Action Protocol: UWRAMP.Unpublished manuscript, University ofWA.

Linehan, M. M., Armstrong, H. E., Suarez, A.,Allmon, D., & Heard, H. L. (1991).Cognitive-behavioral treatment of chroni-cally parasuicidal borderline patients.Archives of General Psychiatry, 48, 1060-1064.doi:10.1001/arcpsyc.1991.01810360024003

Linehan, M. M., Comtois, K., Murray, A. M.,Brown, M. Z., Gallop, R. J., Heard, H. L.,...Lindenboim, N. (2006). Two-year random-ized controlled trial and follow-up of dialecti-cal behavior therapy vs therapy by experts forsuicidal behaviors and borderline personality

disorder. Archives of General Psychiatry, 63,757-766. doi:10.1001/archpsyc.63.7.757

Miller, A. L., Rathus, J. H., & Linehan, M. M.(2007). Dialectical behavior therapy with suici-dal adolescents. New York: Guilford Press.

Pearson, J.L., Stanley, B., King, C., Fisher, C.(2001). Issues to consider in intervention researchwith persons at high risk for suicidality.Retrieved December 10, 2013, from theNational Institute of Mental Health website,http://www.nimh.nih.gov/health/topics/sui-cide-prevention/issues-to-consider-in-inter-vention-research-with-persons-at-high-risk-for-suicidality.shtml

Rathus, J. H., & Miller, A. L. (2002). DialecticalBehavior Therapy adapted for suicidal ado-lescents. Suicide and Life-Threatening Behavior,32, 146-157. doi:10.1521/suli.32.2.146.24399

Reynolds, S. K., Lindenboim, N., Comtois, K.,Murray, A., & Linehan, M. M. (2006). Riskyassessments: Participant suicidality and dis-tress associated with research assessments ina treatment study of suicidal behavior. Suicideand Life-Threatening Behavior, 36, 19-34.doi:10.1521/suli.2006.36.1.19

Rossouw, T. I., & Fonagy, P. (2012).Mentalization-based treatment for self-harmin adolescents: A randomized controlledtrial. Journal of the American Academy of Child& Adolescent Psychiatry, 51, 1304-1313.doi:10.1016/j.jaac.2012.09.018

Shaffer, D., & Pfeffer, C. R. (2001). Practice pa-rameter for the assessment and treatmentchildren and adolescents with suicidal behav-ior. Journal of the American Academy of Child &Adolescent Psychiatry, 40(Suppl 7), 24S-51S.doi:10.1097/00004583-200107001-00003

Shaffer, D., Gould,M. S., Fisher, P., Trautman, P.,Moreau, D., Kleinman, M., & Flory, M.(1996). Psychiatric diagnosis in child andadolescent suicide. Archives of GeneralPsychiatry, 53, 339-348. doi:10.1001/arch-psyc.1996.01830040075012

Spirito, A., Stanton, C., Donaldson, D., &Boergers, J. (2002). Treatment-as-usual foradolescent suicide attempters: Implicationsfor the choice of comparison groups in psy-

chotherapy research. Journal of Clinical Child& Adolescent Psychology, 31, 41-47.

U.S. Department of Health andHuman Services(HHS) Office of the Surgeon General andNational Action Alliance for SuicidePrevention. (2012). 2012 National Strategyfor Suicide Prevention: Goals and Objectives forAction. Washington, DC: Author.

van der Sande, R., van Rooijen, L., Buskens, E.,Allart, E., Hawton, K., van der Graaf, Y., etal. (1997). Intensive in-patient and commu-nity intervention versus routine care after at-tempted suicide: A randomized controlledintervention study. British Journal ofPsychiatry, 171, 35-41.

Verheul, R., van den Bosch, L. C., Koeter, M. J.,de Ridder,M. J., Stijnen, T., & van den Brink,W. (2003). Dialectical behaviour therapy forwomen with borderline personality disorder:12-month, randomised clinical trial in TheNetherlands. British Journal of Psychiatry,182, 135-140. doi:10.1192/bjp.182.2.135

Waterhouse, J., & Platt, S. (1990). General hos-pital admission in the management of para-suicide: A randomized controlled trial.British Journal of Psychiatry, 156, 236-242.

Wood, A., Trainor, G., Rothwell, J.,Moore, A., &Harrington, R. (2001). Randomized trial ofgroup therapy for repeated deliberate self-harm in adolescents. Journal of the AmericanAcademy of Child & Adolescent Psychiatry, 40,1246-1253. doi:10.1097/00004583-200111000-00003

Woodberry, K. A., & Popenoe, E. J. (2008).Implementing dialectical behavior therapywith adolescents and their families in a com-munity outpatient clinic. Cognitive andBehavioral Practice, 15, 277-286. doi:10.1016/j.cbpra.2007.08.004

. . .

This research was supported by grantsR01MH90159 and R01MH93898 from theNational Institute of Mental Health.

Correspondence toMichele Berk, Ph.D.,Harbor-UCLAMedical Center, 1000WestCarson Street, Box 498, Torrance, CA, 90509e-mail: mberk@labiomed.org

syllabi Please take advantage of ABCT's catalogue of psychology course syllabi.This list is constantly growing as ABCT member and allied professionaleducators generously share syllabi for public posting. If you are interestingin submitting your own syllabi for public posting, please email each file asan attached Word document to jlerner@kean.edu, and include "syllabussubmission" in the subject line. Thank you for your contribution to thisvaluable resource!

http://www.abct.org/Resources/?m=mResources&fa=Syllabi

70 the Behavior Therapist

This emergency psych. response be-gins with a tweet, a telling indica-tion of just how far we’ve come in

minimalist communication. Honestly, is ane-mailed “cry for help” just toomuch to askfor these days? A superhero fast runningout of pre-authorized sessions wants a con-sult ASAP with the CBT action team(CBT/AT). CBT/AT is for inordinatelycomplex cases, the kind you can’t search forin PubMed. ‘Nuff said, you ask? Certainlynot! He manifests characterological issuesin less than 140 characters. “Need yourhelp, fate of all humanity at stake—willyou take my plan? Referred by TheWatcher. S.” Says it’s a crisis, but doesn’twant to incur any out-of-pocket expenses.Classic.Even with the Affordable Healthcare

Act (ACA), we’re so far out of network thatProfessor X couldn’t locate us with his tele-pathic powers enhanced by Cerebro and setto scan managed care databases, and no,there isn’t any superhero courtesy. He does-n’t like this therapeutic stance; he’s used tocontinuous reinforcement schedules, VIPstyle. We won’t play his little entitlementgames, the ability to travel faster than lightdoesn’t translate into any “specialized” carein this clinical setting.2 After trying towheedle us into being “one-timeproviders”—the only contingency we’ll“provide” on this matter is broadening hisexperiential tolerance for the word “no”—he says he’ll self-pay, at least for now. Ourethical standards eschew profiling based onexpectancies, but he fits the demographicto a tee—sky’s the limit on the secret lair,has to have the latest intergalactic surf-board, but resents spending dime one on

clinical services. If he claims financial hard-ship, dollars to gluten-free doughnuts hecan’t provide adequate documentation toqualify for the sliding scale. Probably willexplain it’s on account of being self-em-ployed. We’ve heard that one before. Oneof us says, “Superhero? Super-Ego morelike it!” Inside joke. We both giggle likegrad students before qualifying exams.We obtain his informed consent for

treatment and this transcript; ’natch, weget both his superhero and alter ego signa-tures, in case he claims he’s got dissociativeidentity disorder and asks for a refund afterservices are rendered. It’s happened before(cf. Frank & Lee, 1989), and we have nowincorporated these additional safeguardsafter careful legal consultation and thor-ough examination of our local and inter-stellar HIPAA regulations. Well, anyway,he makes a big fuss about confidentiality,but protests way too much for us to vali-date. Most superheroes “say” they want tokeep things on the down low, even have“secret identities,” but somehow they al-ways manage to show up for the intake infull regalia. S. is no exception. He glidesinto our waiting room striking a yoga poseon a shiny glazed plank gratuitously hover-ing two feet off the ground, “HumbleWarrior” no less. As if! We have never seenso much overcompensating this early,worse even than the narcissistic CEO whoshowed up in an armed-to-the-teeth suit ofiron he desperately wanted us to believe hedesigned with no help from the legion ofMIT brainiacs he has on the payroll.Meanwhile, our new consult has limitedmindfulness, lacks inhibitory mechanisms,and craves attention, impulsively going forthe negative kind if he can’t get the posi-

tive. Problem for him is he needs us morethan we need him and he knows it. He’sseen the evidence base, recognizes we’reboard certified in CBT from ABPP to boot.

CBT/AT: So you’re the Surfer, eh?

S:What gave it away, that I’m literallyshining metallic or that I’m riding aboard that’s levitating in thin air violat-ing basic laws of physics? If that’s anexample of a cognitive behaviorist’s“powers” of observation, maybe I’d bebetter off seeking another theoreticalperspective. Come to think of it, canyou suggest an energy therapy practi-tioner who DOES take my insurance?

CBT/AT: Let’s bring the focus back toyou.When you contacted us, you ex-pressed urgently needing our help.

S: I don’t need anything, much lessurgently. [dramatic pause] I commandthe Power Cosmic.

CBT/AT: So then what brings youhere, besides your surfboard?

S: Look bub, if I want snarky com-ments, I’ll go over to DC and talk toBane. That joker’s always contextualiz-ing to justify himself. Uses analogiesand metaphors nobody understands orcares about, no coherent value systemto unpack. Fancies himself a “ThirdWaver,” about the only thing he everwaves is an unregistered firearm. Butback to me, you keep making me go offon tangents. Here I am because… Ijust care too much. Get too enmeshed,always gotta be the good egg. So, I’vegot a super friend who’s in a real pickle,stuck at the precontemplation stage—refractory to pschopharmacological ap-proaches, can’t stay consistent with hisPMR. No therapeutic wilderness pro-gram will touch him with a 30-footbranch!I chill wit’ a buncha other super-

heroes with dysfunctionalities too.Sometimes we do jobs together, some-times it’s like we aren’t even aware eachother exists. Yet, we’re all improbablyconnected. Every so often I get thefunny feeling that all of our actions arebeing operantly conditioned by anomniscient entity that’s calling all theshots beyond free will and dignity, onlymaking the obligatory cameo appear-ance from time to time.3 Marvelous,isn’t it? You know, I can refer you lots ofcustomers if you play your cards right.

The Lighter Side

CBTers ASSEMBLE!! 1

Episode 1: “A Tweet for Help”

JonathanHoffman,Neurobehavioral Institute

DeanMcKay, FordhamUniversity

1Dear reader, be advised that this article contains obscure “fanboy” references that may not reach .05statistical significance for some, OK virtually all, ABCTmembers.2There are protocols being developed now that handle mutants with supra-light speed.We are hop-ing to enlist heroes with similar abilities and pro homo-sapiens leanings to deliver the protocols toour predecessors when they bend time at their will.3We are concerned about S’s potential for paranoid ideation. Seems the “omniscient entity” to whichhe refers “revealed” himself at least once that is well documented (Lee & Kirby, 1964).

March • 2014 71

Sure I can’t get you on my insurancepanel?

CBT/AT:About the friend you men-tioned…

S:OK, OK. Here goes:When thisbozo I’m talkin’ bout gets all ticked off,his size like quadruples, his clothesshred, and his IQ—I suppose youeggheads would say his EQ too—dropsto the statistically deficient level. Hegets into these rages, often sans identifi-able triggers, literally turns green,starts regressively verbalizing in two-word sentences, and smashes every-thing in sight to a pulp.Then, after nothing’s left to clobber,

I mean mangle, he takes giant leaps towho knows where.When he wakes up,he’s practically naked. Can’t rememberanything, gets all socially phobic. It’svery embarrassing, and I’m not evenmentioning the potential liability is-sues.Worse, he’s a doctor, well maybe aPh.D.—no offense—an’ he started thiswhole mess doin’ some stupid N of 1research about Gamma Rays that wenthaywire. No IRB, no reversal of condi-tions, nothing, like he thinks all theother scientists are beneath him. Nowwe’re not even sure he graduated froman accredited program.

CBT/AT: I think I recall hearing aboutthis friend of yours.Wasn’t there an in-cident a long time ago at Alkali Lake,in Canada, involving him?

S:Wow, you hear of one hyper-steroidalrage and you overgeneralize to every-one, like you never heard of cognitivebiases??? That guy at Alkali Lake hadretractable adamantium claws, a barberwith an uncanny sense of humor, and,listen up, HEWASN’T GREEN! [S.throws head back in faux annoyance].4

CBT/AT:Why is this so important toyou?

S: Never mind all that. Look, can youdesign a Comprehensive BehavioralIntervention Treatment plan for him, orwhat?

CBT/AT: [He’s really grilling us hard—like we’ve never seen good eye contact before.]We get the picture, what’s your friend’sname? [As if we didn’t know.]

Diagnostic Impressionsand Initial Reactions

Okay, initial and raw responses: what’sthe dealio in this case? Is the “friend” thereal patient or just the poor patsy, er,“Identified Patient?” Does S. have a hiddenagenda? Lotsa questions, no diagnostic for-mulation so far, but it’s not as if some clerkwho won’t give us their last name is limit-ing the number of sessions available in aspecified time period. We have seen thiskind of presentation before (Parker &Watson, 1999), but those were case illus-trations, and besides, those clients had se-vere arm and neck trauma from spiderbites. If there’s an acceptance and commit-ment to attending therapy on a regularbasis, then we’re gonna get some closure.Believe it.Our treatment team begins to consider

transdiagnostic possibilities. Clearly, S. hasemotion regulation problems he does not“own,” and like so many that struggle withmanaging their affective states, perhaps his“friend” has this challenge too, without theinterplanetary itinerary.We begin to exam-ine our caseloads, wondering if a group willturn out to be the best modality to start allconcerned with in order to build skills fortheir subsequent courses of solution-focused individual psychotherapy. RaisingS.’s acceptance of his own issues parallelingthose of his alleged “friend” will task us, aswill be overcoming his anticipated self-sab-otaging efforts to evade the rigors of the in-terpersonal dynamic, but your friendlyneighborhood CBT/AT is up for it. BTW, if

you think forming a suitable group forthese sorts of patients would be difficult,think again. Just earlier this week one ofour consultants met with another colossuswith “issues”—this one covered in largefantastical orange rocks—who was inter-ested in “meeting like-minded others.”Also, on our wait-list was a man who calledhimself a Russian mutant (talk about self-esteem problems!) who could also converthis skin to metal at will. He said his namewas Piotr, which we determined was a fake.I mean, really, how pretentious! “Piotr”said he was sent byMagneto, but we doubtthe veracity of this self-serving explanation(see Kane & Cockrun, 1975). We considerthis group evidencing such interestingadaptations that we immediately began todevelop plans for a case paper, manualizedtreatment guide to follow, feeling opti-mistic that it would be appropriate forCognitive and Behavioral Practice, maybeeven as part of a special issue on modifyingtreatment for clients with bizarre ideationand genetic mutations.5 A nagging con-cern, what are the existing guidelines forconducting cybertherapy with a humanoidfromZenn-La hurtling through hyperspacesenselessly posturing on a surfboard? Nodoubt our State Licensing Board will beable to provide clarity on this matter if in-deed it arises.

Episode Next

Mo’ background details, mo’ problems.*In the ensuing installment, the CBT/ATfinds time in their busy schedule to do a di-agnostic work-up for an over-controlledhomeless scientist, his unpredictably ex-pansive 1200 lb. emerald-hued alter ego, orboth. Whatever, going forward a creditcard’s on file and there’s a charge for missedsessions not cancelled within 24 hours, un-less of course they have a semiplausible ex-planation. After all, it’s a practice, not abusiness.As Stan Lee, the Original Gangsta of

psychological dissemination, says—“Excelsior!!!”

* The work of the CBT/AT is supported by agenerous grant from SHIELD, BehavioralSciences Section, and the kind forbearance ofour colleagues.

* You have the data. In accord with the CYArisk management policies strongly suggestedby our attorneys at highly disproportionatehourly rates, we encourage you to forwardyour clinical impressions and recommenda-tions, i.e. know-it-all comments, regarding pa-tient S.’s initial presentation to Dr. Reed

4We checked later and felt a certain vindication that news accounts confirmed that the incident atAlkali Lake did indeed involve the green-muscled hero in question as well as a clawedmutant with re-markable restorative abilities. If we knew this at the time of our consultation, our own “here-and-now” focus would have been shelved to deliver a sharp rebuke; not helpful for therapeutic alliance,sure, but man, was S. smug. See Thomas and Lee, 1974, for the news account.5We received a separate invitation to contribute our unique treatment protocol to a special dedicatedissue of a different journal, but it was an open-access publication. The guest editor (D. “Doc”Sampson) claimed it would bewell cited, butwe had our doubts when it was accompanied by a requestto participate in a by-invitation-only symposium to be held on Asgaard, with a hefty prepayment forpublication of the article in the conference proceedings in addition to the journal itself. Our suspicionsdeepened when all correspondence from Sampson went straight to our spam filter. We hope we don’tface Odin’s wrath when we try to publish elsewhere, but we are working on a limited grant here andcan’t spare the funds to pay for open access or for the conference.

72 the Behavior Therapist

Richards, Baxter Building, 42nd & Madison,New York, NY. Best you not check on his li-cense to practice.

References

Frank, G., & Lee, S. (1989). Madman runsamok. The Incredible Hulk, 2 (363).

Kane, G., & Cockrun, D. (1975). Deadly gene-sis. The Uncanny X-Men, 1 (Giant Size 1).

Lee, S., & Kirby, J. (1964). Coming of Galactus.Fantastic Four, 1 (49).

Parker, P., & Watson, M.J. (1999). Sub-carotidhematoma induced by gamma radiation andcontact with Philodromus sp. (crab spider).

Journal of Mutantology and Neurocerebrosciences,12, ε–π.

Thomas, R., & Lee, S. (1974). And now…theWolverine! The Incredible Hulk, 1 (181).

. . .

Correspondence to Jonathan Hoffman,Ph.D., Neurobehavioral Institute, 2233NorthCommerce Pkwy, Ste #3,Weston, FL, 33326drhoffman@nbiweston.com

Call for Submissions

Graduate Student Research Grant◊ ◊ ◊

The ABCT Research Facilitation Committee is sponsoring a grant of up to $1000 to supportgraduate student research.

Eligible candidates are graduate student members of ABCT seeking funding for currentlyunfunded thesis or dissertation research. Grant will be awarded based on a combination ofmerit and need.

Applications are due May 1, 2014, and are based on current NIH proposal guidelines.

" 3-page document detailing significance, innovation, approach,and justification of need

" 1-page budget" Letter of support from faculty advisor

To submit an application, please e-mail all required documents to Dr. Kim L. Gratz atklgratz@aol.com.

The grant will be awarded in the Fall of 2014, with the winner announced at the 2014 annualconvention.

For more information on the grant and application procedures and requirements, please visit:http://www.abct.org/Members/?m=mMembers&fa=Students

JOB SEEKERS | EMPLOYERS

www.abct.org/Resources

Job seekers:Whether you're looking fora new job, or ready to take the next stepin your career, we'll help you f ind theopportunity that's right for you.Employers: Target your recruiting andreach qualif ied candidates quickly andeasily. Simply complete our onlineRegistration Form and start posting jobstoday!

So that we may continue to grow with you,please update your membership profile.

www.abct.org! member log in

s h i p p i n g & h a n d l i n gU.S./Canada/Mexico 1–3 videos: $5.00 per video

4 or more videos: $20.00

Other countries 1 video: $10.002 or more videos: $20.00

Name on Card

Card Number CVV Expiration

Signature

complex cases

master clinicians

live sessions

`äáåáÅ~ä

dê~åÇ

oçìåÇë

! Steven C. Hayes, Acceptance and Commitment Therapy! Ray DiGiuseppe, Redirecting Anger Toward Self-Change! Art Freeman, Personality Disorder! Howard Kassinove & Raymond Tafrate, Preparation, Change,

and Forgiveness Strategies for Treating Angry Clients! Jonathan Grayson, Using Scripts to Enhance Exposure in OCD! Mark G. Williams, Mindfulness-Based Cognitive Therapy and the Prevention

of Depression! Donald Baucom, Cognitive Behavioral Couples Therapy and the Role

of the Individual! Patricia Resick, Cognitive Processing Therapy for PTSD

and Associated Depression! Edna B. Foa, Imaginal Exposure! Frank Dattilio, Cognitive Behavior Therapy With a Couple! Christopher Fairburn, Cognitive Behavior Therapy for Eating Disorders! Lars-Goran Öst, One-Session Treatment of a Patient With Specific Phobias! E. Thomas Dowd, Cognitive Hypnotherapy in Anxiety Management! Judith Beck, Cognitive Therapy for Depression and Suicidal Ideation! Marsha Linehan, Dialectical Behavior Therapy for Suicidal Clients Meeting

Criteria for Borderline Personality Disorder—Opening Sessions! Marsha Linehan, Dialectical Behavior Therapy for Suicidal Clients Meeting

Criteria for Borderline Personality Disorder—The Later Sessions

3-SESSION SERIES! DOING PSYCHOTHERAPY: Different Approaches to Comorbid

Systems of Anxiety and Depression

(Available as individual DVDs or the complete set)

! Session 1 Using Cognitive Behavioral Case Formulation in Treating a ClientWith Anxiety and Depression (Jacqueline B. Persons)

! Session 2 Using an Integrated Psychotherapy Approach When Treating aClient With Anxiety and Depression (Marvin Goldfried)

! Session 3 Comparing Treatment Approaches (moderated by Joanne Davilaand panelists Bonnie Conklin, Marvin Goldfried, Robert Kohlenberg,and Jacqueline Persons)

TO ORDER

}

O R , O R D E R O N L I N E AT www.abc t .o rg | c l i ck on ABCT STORE

ABCT’S T R A I N I N G V I D E O S Deepen

yourunderstandingVisa | MasterCard | American Express

Individual DVDs— $55 each • “Doing Psychotherapy”: Individual sessions — $55 / set of three—$200

March • 2014 73

Learning doesn't need to stop at the Convention! ABCT is proudto provide online Continuing Education (CE) webinars for psy-chologists and other mental health professionals. Our webinarscan be attended live or viewed online at your convenience. Thewebinar series offers opportunities to learn about evidence-based treatments and latest research while earning CE creditsfrom the comfort and convenience of your own home/office.

Resick | CPT for PTSDCognitive Processing Therapy for PTSD: Does Child Sexual or PhysicalAbuse Make a Difference?

Herbert | ACTAcceptance and Commitment Therapy: A Radically Different yetRemarkably Familiar Approach to Behavior Change

Albano | CBT for Adolescent AnxietyAdolescents, Anxiety and Development: A Family-Focused CBT Approach

Harvey | CBT for Insomnia (CBT-I)Cognitive Behavioral Therapy for Insomnia and Transdiagnostic SleepProblems in Clinical Practice

Tirch | Compassion-Focused TherapyAn Introduction to Compassion Focused Therapy

Brown | CBT for Child TraumaCBT for Traumatized Youth: Components of Evidence-Based Practice

Barnett | EthicsEthical, Legal, and Clinical Considerations in Behavioral Telehealth

Miller | DBTDBT With Adolescents: Research and Clinical Developments

Abramowitz | Exposure for OCDExposure Therapy for OCD Symptom Dimensions

Friday, June 6, 201411:00 a.m. EST

Katherine Shear, M.D., ColumbiaUniversity School of Social Work,Columbia University College ofPhysicians and SurgeonsGetting Grief Back on Track:An Introduction to ComplicatedGrief and Its Treatment

ABCT ONLINE CE

WEBINARS

w w w . a b c t . o r g

UpcomingWebinars

Register today at www.abct.org | Earn CE all year long!

Watch Instantly

ABCT’s webinars

empower and support

you to learn and train

enduringly, from the

comfort of home

or office.

74 the Behavior Therapist

in-press

archive

Clinical Guide to the Evidence-BasedAssessment Approach to Diagnosisand Treatment“The reality of clinical practice isconstantly challenging. Realcases, like Lea, do not fit neatlyinto research boxes. Lea is enter-ing ‘emerging adulthood,’ still inschool, becoming increasinglyindependent. Which assessmentsare most age-appropriate? Whichnorms make sense to use? Whatare treatment goals that wouldengage Lea and motivate her tocontinue in therapy?…”Youngstrom et al.Cognitive and Behavioral Practicedoi: 10.1016/j.cbpra.2013.12.005

onlineMeet Our Featured Therapist:GEORGE WING

“[John] Dewey held that thereflex arc was not merely astimulus and response, but atotality of behavior and thatthe arc did not really have abeginning and end but that thephenomenon was circular. Theend of an arc was also thebeginning of another arc.”Harold H. Anderson“Circular Behavior”In Wolff & Precker (Eds.) (1952)Success in Psychotherapy

http://www.abct.org/Help/?m=mFindHelp&fa=ClinicianMonth

n w

March • 2014 75

Call for ApplicantsThe Association for Behavioral and Cognitive Therapies (ABCT,www.abct.org) invites applications for a Director of Outreach andPartnerships, with a likely start date in summer 2014. This full-timeposition with competitive salary and benefits reports to the ExecutiveDirector. ABCT is a 4,600 member-strong professional organizationcommitted to the advancement of scientific approaches to the under-standing and improvement of human functioning. Responsibilitiesinclude the development, implementation, and coordination of mem-bership growth and retention strategies; building partnerships withother professional and allied organizations to advocate for and advanceshared goals such as federal funding for behavioral research, recogni-tion/funding of evidence-based approaches to prevention and treatment;and advancing ABCT’s dissemination goals. The successful candidatewill be outgoing, dynamic, collaborative, and energetic; possess excel-lent communication skills and passion for the mission of ABCT; and beable to represent ABCT well to diverse constituents.

Required qualifications:

1. Doctoral degree in psychology or related field + ≥ five years’experience

2. Licensed or license-eligible3. Knowledge and passion about ABCT: cognitive-behavioralorientation and commitment to science and evidence-basedprinciples

4. Willingness to work in NYC

Preferred qualifications:

1. Experience with professional organizations2. Experience with outreach, membership, and marketing3. Expertise in public policy related to behavioral health and anappreciation of the political issues and participants affectingbehavioral health care

4. Experience building partnerships5. Experience with information technology including social media6. An academic background in population-based approaches todissemination (e.g., MPH)

ABCT is an Equal Opportunity/Affirmative Action Employer. Send CV, con-tact information for five references, and a letter addressing the align-ment of your experience with the qualifications toDirectorofOutreach@abct.org. Review of applications will begin onMarch 24, 2014 and continue until the position is filled.

PRSRT STDU.S. POSTAGE

PAIDHanover, PAPermit No. 4

the Behavior TherapistAssociation for Behavioraland Cognitive Therapies305 Seventh Avenue, 16th floorNew York, NY 10001-6008212-647-1890 | www.abct.org

ADDRESS SERV ICE REQUESTED

48th Annual Convention November 20-23, 2014Enhancing CBT by Drawing Strength From Multiple Disciplines PHILADELPHIA dialects, vocabulary,

food, & random facts you may or may not need

“D’jeet yet?”: One Philadelphian asking another if her or she has had lunch. • “Hoagie”: A classic sandwich, also known around thecountry as a “sub” or “hero,” this combination of a foot-long roll, lunch meat of your choice—lettuce, onion, tomatoes, hot peppers, pickle,oregano, and mayonnaise—originated in Philadelphia. Legend has it that the name comes from Hog Island where the steel workers atethese sandwiches every day for lunch. Although it is possible to order a vegan hoagie, who would want to? • “Scrapple”: A Philadelphiaoriginal, this breakfast food usually comes in slices from an entire loaf and is made of the parts of a cow that are not good enough to goin hot dogs. • “Yuz hava good wun”: The way Philadelphians say “see you later” or “good-bye.” • “Jimmies”: Sprinkles, as used togarnish ice cream (“Can I please have rainbow jimmies?”). “Yuengling”: Pronounced ying-ling, this beer has been made locally since1829 in American’s oldest brewery and is a town favorite. • “Wawa”: Named for the Pennsylvania town where the store originated, achain of convenience stores throughout the city that has been the saving grace of every Philadelphian who has needed an ATM at 3:00 inthe morning or a Philadelphia Inquirer from 3 days ago. They also make a surprisingly mean hoagie. • “Witterwitout”: Common ques-tion when ordering a cheesesteak (i.e., wit or wit-out onions). • “Down tha sheure”: Refers to the journey that brings you fromPhiladelphia to the NJ beaches. • “Don’t Forget to Bring a Tal”: “Don’t forget to bring a towel”(but don’t worry, the conference hotel will provide tals). Yea.mayor = mair • how = heaow • bagels = beggles • phone = phoon • water = wooter • about = uh-bowt = uh-beowt

If you have other examples of Philadelphia-speak, send them along to Mary Ellen at mebrown@abct.org