JOURNAL OF APPLIED BEHAVIOR ANALYSIS

OVERVIEW OF NIMH SUPPORT OFRESEARCH IN BEHAVIOR THERAPY'

STEPHANIE B. STOLZ

NATIONAL INSTITUTE OF MENTAL HEALTH

Many parts of the National Institute of Mental Health have explicit policies of en-couraging research on behavior therapy. The policies about behavior therapy research ofsub-units of NIMH are reviewed, as these policies existed in fiscal year 1973. Examplesare given of the type of behavior therapy research that NIMH was supporting in 1972.Particularly important is the evaluation of the efficacy of behavior therapy in comparisonwith standard treatment procedures.

Although the National Institute of MentalHealth (NIMH) has no institute-wide emphasison the support of research in behavior therapy,many parts of the Institute, whose programscould include research in this area, do haveexplicit policies of encouraging research on thistopic. This article describes these policies, as theyexisted in fiscal year 1973, for the various sub-units of NIMH, and gives some examples ofthe type of research currently being supported.More general information on support for re-search on psychological topics can be found inHicks, Liebowitz, Ross, and Paller (1970). Aswith that article, the purpose of the present oneis to help those with research ideas get informa-tion about those interested in supporting thatsort of research.

Behavior therapy, as used in this article, in-cludes the many types of programs based onlearning principles. Projects using individualtherapies, such as desensitization, implosivetherapy, or one-to-one behavioral shaping areincluded, as well as projects in which the unitbeing studied is a social system, such as a hos-pital ward or half-way house. Applied behavioranalysis is included, as is behavioral engineeringand biofeedback.

1I thank Dr. Jerome Levine for his suggestion thatI gather the data on which this report is based. Re-prints may be obtained from the author, SmallGrants Section, NIMH, 5600 Fishers Lane, Rockville,Maryland 20852.

This review covers only extramural researchprojects, that is, research carried out with thesupport of NIMH funds at universities, colleges,hospitals, research institutes, and other non-profit organizations. Fellowship and trainingsupport by NIMH is beyond the scope of thisarticle.

The research priorities of the NIMH as awhole are in the areas of research dealing withchildren, minorities, crime and delinquency,addictive drugs, and alcoholism. Research onthese topics tends to be given preference infunding.

Although NIMH does not emphasize researchon behavior therapy, projects involving behaviortherapy procedures and principles are currentlybeing supported by four of the divisions ofNIMH and by the National Institute on AlcoholAbuse and Alcoholism (NIAAA), which is lo-cated within NIMH.

Let me describe the present organization ofthe National Institute of Mental Health, to theextent that is relevant for this paper. The Insti-tute is composed of divisions, each of which hascomponents called branches or centers. In addi-tion, as mentioned above, the National Instituteon Alcohol Abuse and Alcoholism is locatedwithin NIMH. The parts of NIMH that supportresearch in universities, colleges, and other non-profit organizations are the Division of Extra-mural Research Programs (DERP), the NationalInstitute on Alcohol Abuse and Alcoholism

509

1973, 6, 509-515 NUMBER 3 (FALL 1973)

STEPHANIE B. STOLZ

(NIAAA), the Division of Narcotic Addictionand Drug Abuse (DNAD), the Division of Spe-cial Mental Health Programs (DSMH), and theDivision of Mental Health Service Programs(DMHS). In fiscal year 1972, the Division ofExtramural Research Programs provided morethan 40% of NIMH's support for research out-side the Institute.

Within the Division of Extramural ResearchPrograms, research is supported through the Be-havioral Sciences Research Branch, the AppliedResearch Branch, the Clinical Research Branch,the Psychopharmacology Research Branch, theCenter for Epidemiologic Studies, and the SmallGrants Program. The NIAAA supports re-search through its Extramural Research Branch;the Division of Narcotic Addiction and DrugAbuse, through the Center for Studies of Nar-cotic and Drug Abuse; the Division of MentalHealth Service Programs, through the MentalHealth Services Development Branch. The Divi-sion of Special Mental Health Programs has anumber of research-supporting centers, includingthe Center for Minority Group Mental HealthPrograms, the Center for Studies of Metropoli-tan Problems, and the Center for Studies ofCrime and Delinquency.

In this paper, I will discuss only those compo-nents of the NIMH whose programs are relevantto behavior therapy. The largest number of be-havior therapy projects is supported by the Divi-sion of Extramural Research Programs (DERP);other extensive programs in behavior therapyare supported by the Center for Studies of Crimeand Delinquency (DSMH), and the NIAAA.Including all the research grants in this area,NIMH support of behavior therapy research wassomewhat more than $3 million in fiscal year1972.

Policies of NIMH Programs

Some of the NIMH programs that supportbehavior therapy have explicit policies of en-couraging that kind of research; programs thatmay not have a particular emphasis on behavior

therapy are willing to consider applications inthat area. These latter programs will supportscientifically sound research in behavior therapy,if the projects receive a strongly favorablerecommendation from the review committees.This section discusses the various programs andtheir policies.

Clinical Research Branch (DERP). Thisbranch has a general interest in supporting well-designed research projects on psychotherapy.Within the branch, the section responsible forbehavior therapy is the Section on Psycho-therapy and Behavioral Intervention (Morris B.Parloff, Chief). In the recent experience of thisbranch, the review committee has been morefavorable to behavior therapy research than topsychotherapy research. This seems to be be-cause the outcomes in behavior therapy aremeasurable and specifiable, and because the in-vestigators have, on the whole, research, ratherthan clinical backgrounds.

In view of the staff of the Clinical ResearchBranch, an inevitable shift is occurring fromsupport predominantly for research on psycho-therapy to research on behavior therapy. Theyfeel that this shift is occurring because the be-havioral researchers tend to define their terms,define their interventions, and plan good re-search designs. Where behavioral projects were32% of the 61 projects supported by the Sec-tion on Psychotherapy and Behavioral Inter-vention in 1967, they were 54% of the 29active grants supported by that section in 1971.

The Clinical Research Branch is also develop-ing a program of support for therapeutic ap-plications of biofeedback procedures. Branchstaff feel that research in this area has potentialclinical impact.

Other DERP programs. At least two of theother components of the Division of Extra-mural Research Programs are currently support-ing research in behavior modification. The Ap-plied Research Branch and the Small GrantsSection do not have a differential priority forbehavior therapy research, although they recog-nize it as an important field. Few of the behavior

510

NIMH SUPPORT OF RESEARCH IN BEHAVIOR THERAPY

therapy applications currently being submittedfit within the guidelines of these two programs,so they are assigned only these few to review.

In general, the Applied Research Branch(Edward Flynn, Acting Chief) supports appliedprojects in the area of juvenile problems andsocial problems. There is a tendency to preferthat the work proposed have some impact ontheory within psychology and the social sciences,rather than emphasize technological develop-ment.

Research supported by this Branch in thesocial problems area focuses on the nature ofsocial problems and experimentation withmethods leading toward the solutions of suchproblems. Problems of special interest includethe changing role of the nuclear family; prob-lems of the socially and economically deprived;the process of social change, including the ca-pacity to tolerate change and impediments orresistances to change; alienation in contem-porary society as related to phenomena such asefforts to change institution and social structure,or those groups with different life styles whoorganize to bring about social change or greatersocial acceptance. Juvenile problems researchsupported by this Branch focuses on the prob-lems of children and youth from infancythrough college age, with particular emphasis onthe impact of social institutions, social condi-tions, family structure, and community resourcesthat affect learning and coping capacities relat-ing to the mental health of children and youth.Of special interest are problems such as earlychild care both in and out of the home, intel-lectual stimulation and cultural enrichmentprograms for children, experimentation withnew techniques in children's programs, mentalhealth programs in schools, early identificationand intervention techniques with emotionallydisturbed or culturally deprived ch ldren, andservices to adolescents in school and other com-munity programs. Problems of the retardedchild are appropriate if related to the psychiatricaspects of retardation, learning difficulties, orthe impact of cultural deprivation.

The Small Grants Section (Stephanie B. Stolz,Chief) supports 1-yr projects in any area relatedto mental health, with special emphasis on re-search proposed by younger investigators and onexploratory and pilot studies.

In all branches of the Division, the staffencourages prospective applicants to consultwith them before submitting the formal ap-plication.

National Institute on Alcohol Abuse andAlcoholism. The NIAAA has recently becomemore interested in psychosocial research and ap-plied research in general. In the past, it hassupported chiefly biological research related toalcoholism, although it has supported researchon the use of aversive stimuli to develop ab-stinence in alcoholic persons. In addition to con-tinuing support in this area, the NIAAA nowis supporting a number of innovative projectsthat treat alcoholism as a problem in living,that is, as a problem that can be ameliorated bya modification of the environmental conse-quences. In these projects, the researchers areattempting to retrain alcoholic patients by teach-ing them new skills for dealing with inter-personal situations. Many of these studies aim toteach the alcoholic individual to control hisdrinking, enabling him to drink moderatelywithout relapse, something that has not beenattempted in the past. This sort of research isvery controversial. The position of the NIAAAis that it is an empirical question whether mod-erate drinking can be achieved by alcoholic per-sons, and the Institute is willing to support re-search to see if it can. Albert Pawlowski is Chiefof the Extramural Research Branch, NIAAA.

Center for Studies of Narcotic and DrugAbuse (DNAD). Like the NIAAA, this centerhas recently begun to shift from support mainlyfor biological research to support for more psy-chological research. While the Center is cur-rently supporting little research in behavior ther-apy, an additional staff person (N. A. Krasnegor)was recently hired explicitly to develop applica-tions in that area. In line with this specific inter-est in behavioral research, the Center sponsored a

511

STEPHANIE B. STOLZ

small in-house meeting with about a half-dozenconsultants, all of whom are researchers prom-inent in applied behavior analysis, to discussspecific applications of behavioral technology todrug abuse problems.

Center for Studies of Crime and Delinquency(DSMH). This Center (Saleem Shah, Chief) hashad a continuing interest in the support of be-havioral research on applied problems since itsestablishment a few years ago. The objectives ofthe Center are to support the development ofmodels that are utilizable, practical, and eco-nomical. The emphasis is on research in whichthe target of intervention is a larger social sys-tem, such as a housing project or a schoolsystem, rather than on one-to-one clinical treat-nment. The Center's orientation to problems ofcrime and delinquency is inter-disciplinary.Moreover, since social deviance typically ismulti-determined, the conceptualization of suchphenomena as well as efforts to alter deviantbehavior will usually require a variety of ap-proaches and methods of intervention.The Center's support of behavior modification

is quite extensive at the present time. Staff feelthat the importance and necessity of supportingother program areas limit the number of ad-ditional projects in behavior modification thatcan be funded. Thus, any new proposals in thisarea would at least need to build on and extendexisting research programs, as well as incorpo-rating scientifically sound design and beingutilizable and concerned with cost and man-power implications.

Mental Health Services Development Branch(DMHS). This branch, within the Division ofMental Health Service Programs (DMHS), isactively interested in supporting more behaviortherapy projects. Projects appropriate for thisbranch would involve research related to the ap-plication of behavior therapy methods to a servicedelivery system, such as a community mentalhealth center or hospital ward. Of paramountconcern is research on the practicality of be-havior therapy methods, on integrating theminto a total treatment system, and on the accept-

ance of these methods by clients, staff, andcommunity. Howard Davis is Branch Chief.

NIMH-Supported Research ActivitiesHistorically, nearly all the early work in be-

havior therapy was supported by NIMH grants.It is not possible to list here all of the papersresulting from those grants, nor even to list allthe NIMH grantees who have done research onbehavior therapy. However, to give a smallsample, NIMH supported Ogden R. Lindsley'swork with psychotics, C. B. Ferster and Mari-lyn K. DeMyer's work with autistic children,and the work from the University of Washing-ton group on the use of operant conditioningprinciples for the amelioration of the behaviorproblems of preschool children, retarded chil-dren, and children with severe behavior prob-lems. NIMH supported 0. Ivar Lovaas' workwith autistic children, and provided partialsupport for Teodoro Ayllon and Nathan H.Azrin's development of the token economysystem. Peter J. Lang's experimental studies ofdesensitization were NIMH-supported, as wasAlbert Bandura's research on modelling, includ-ing his work on the use of filmed models toreduce children's phobias. Neal E. Miller's basicresearch that underlies biofeedback therapy wasalso done with the support of an NIMH grant.

Currently, NIMH is supporting research in awide variety of areas of behavior therapy. Anumber of the projects are quite innovative,involving the development of new proceduresor the application of established procedures tonew problems, new populations, or new settings;some projects involve the evaluation of well-es-tablished or new procedures; and, of course,some projects are continuations and extensions ofwork that has been on-going for some time. Theresearch described below is a sample of the proj-ects funded in fiscal year 1972.

Biofeedback. The newest form of behaviortherapy involves the application of the newlydiscovered procedures of biofeedback to clinicalproblems. NIMH is currently supporting foursuch projects: (a) Neal E. Miller (Cornell

512

NIMH SUPPORT OF RESEARCH IN BEHAVIOR THERAPY

University Medical Center), the discoverer of theoriginal phenomenon of the reinforcement con-trol of autonomic processes, is attempting toextend his laboratory research to cardiac patientsand to patients with spastic sigmoid colons; (b)Aman U. Khan (Children's Memorial Hospital,Chicago) is giving asthmatic children praise andother feedback for bronchodilation; (c) JoeKamiya (University of California Medical Cen-ter) is attempting to condition esophageal motil-ity; and (d) Pierre F. Renault (University ofChicago) is working with patients with gastrichyperacidity in an attempt to condition changesin gastric acid secretion. The first two projectsare supported by the Clinical Research Branch,DERP; the latter two by the Small Grants Sec-tion, DERP.

Alcoholism. In the alcoholism area, Roger E.Vogler, N. H. Azrin, and George E. Bigelow arethe researchers supported by the NIAAA whoare attempting to develop procedures wherebyalcoholic persons will be able to maintain drink-ing at a moderate level.

Vogler is continuing work at Patton StateHospital (California) that was begun by Hal-muth H. Schaefer, who has recently left thecountry. Schaefer's preliminary work, also sup-ported by NIMH, showed that most of the alco-holic patients he trained in the institution todrink moderately were able to maintain thispattern of behavior outside the institution for ex-tended periods of time. Like Schaefer's research,Vogler's is based mainly on the use of aversivecontrol, by means of which the alcoholic indi-vidual is taught to discriminate when his bloodalcohol concentration exceeds a specific level.The same sort of response consequences are alsoused to train alcoholic individuals to drinkslowly. Vogler is working both with chronicalcoholic in-patients and, through Pacific StateHospital, with out-patients. The patients are alsogiven assertive training and relaxation training,to reduce the tensions presumed to be related toalcoholism.

Azrin's program at Anna State Hospital (Illi-nois) is a massive life-intervention scheme based

on operant reinforcement principles. Alcoholicin-patients are given marital counseling and jobcounseling, and alcohol-free social situations areestablished for them. Bigelow's project (Balti-more City Hospitals) involves maintainingalcoholic in-patients on a token economy, andattempting to achieve abstinence in some, mod-eration in drinking in others.

Other current research. Some of the mostsignificant projects currently supported are thosethat take essentially established procedures andapply them in new ways. Some of these pro-grams are Peter M. Lewinsohn's work (Uni-versity of Oregon) with depressives, Lovaas'(UCLA) with autistic children, Richard B.Stuart's (University of Michigan) extension ofcontracting procedures involving teaching themto agency personnel, Gerald R. Patterson's (Uni-versity of Oregon) extension of therapy for de-linquents to include parents and teachers astherapists, and Montrose M. Wolf's (Universityof Kansas) halfway house for predelinquentadolescents.Two exciting applications of known proce-

dures to new settings are being supported by theMental Health Services Development Branch,DMHS. In these two projects, the investigatorsare attempting to extend the use of behaviormodification procedures to community mentalhealth centers. One (A. J. Turner, Huntsville-Madison County Mental Health Center) will at-tempt to use behavior modification procedures inall possible service areas of the center; the other(Robert P. Liberman, Camarillo State Hospital)will apply behavior modification procedures to arandomly chosen sub-set of the patients in theclinical programs of the center.

Todd R. Risley (University of Kansas), sup-ported by the Center for Studies of Crime andDelinquency, DSMH, is conducting an innova-tive pilot study in which he is attempting todevelop procedures whereby residents of a hous-ing project can establish a residents' code ofconduct that would also contain sanctions ratherthan relying on the police department for en-forcement. Henry M. Boudin (University of

513

STEPHANIE B. STOLZ

Florida) has begun a project in which he plansto use contingency contracting with drug abusersin an out-patient setting. Like the other projectsjust mentioned, this one applies an establishedtechnology, in this case contingency contracting,to a new sort of problem, drug abuse. The re-search task for Boudin's group will be to modifythe technology of contracting so that it can beeffective with the special behavior problemscharacteristic of drug abusers. Boudin's researchis supported by the Center for Studies ofNarcotic and Drug Abuse.Two other projects fall within the general

category of extensions of known technology tonew contexts: (a) Virgil W. Harris (IndianDevelopment District of Arizona, Phoenix),supported by the Center for Studies of Crimeand Delinquency, DSMH, is comparing a re-habilitation program for delinquent AmericanIndian youths in a halfway house with onedone in an institution. He hopes to develop pro-cedures that will facilitate transition from thetherapeutic setting to the natural conditions in acommunity. (b) Harry Lawrence, a social workerat the University of Michigan, is applying be-havior modification procedures to group therapyfor persons who seek help in social workagencies. In this sort of group therapy, theemphasis is on the group members' acquisitionof skills that they lack, and on their learning toadminister social reinforcers to others. Thisproject is supported by the Applied ResearchBranch, DERP.

Behavior therapy procedures of relaxationtraining, desensitization, and related methodsare being tried with some new clinical problems,such as insomnia (Richard R. Bootzin, North-western, supported by the Clinical ResearchBranch, DERP), asthma (Thomas Creer, Chil-dren's Asthma Research Institute and Hospital,Denver, same source of support), and heroinaddiction (Benjamin J. Auerbach, Departmentof Corrections, Sacramento, supported by Centerfor Studies of Narcotic and Drug Abuse). Hereagain, an established clinical procedure is beingtested with new sorts of problems.

Finally, a number of projects are concernedwith preventive mental health. In these projects,various ways are being tried to teach parentsand classroom teachers to use behavior modifica-tion, both before the children develop problemsand also while the problems are still relativelymild.

Those projects mentioned here are examplesof the most exciting ones from the point ofview of development of new therapeutic tech-nologies or of the extension of fairly establishedprocedures to new clinical or social problems.In the development of a therapeutic technologylike behavior therapy, this is where the innova-tions primarily come from.

Of course, there is also some research beingsupported by NIMH that is a continuation, orless innovative extension, of research with estab-lished procedures in populations and problemsalready frequently studied. These projects wouldinclude some that involve, for example, the useof contingency contracting in an attempt to getpersons to stop smoking, or the use of aversivecontrol, desensitization, implosive therapy, orrelaxation with alcoholic persons and homo-sexuals.

Evaluation designs. Many of the behaviortherapy projects currently supported by NIMHuse individual subject controls to evaluate theefficacy of the experimental procedure; othersuse a comparison of subjects who receive thetreatment with others who do not. These twokinds of evaluation design are important in theearly stages of the use of a new therapeutic pro-cedure, when the question being asked iswhether the new treatment is even any betterthan no treatment at all, that is, whether it hassome minimal efficacy. For behavior therapy, atthe present time it is generally conceded that theprocedures based on reinforcement principles doproduce more improvement than no treatmentat all, and this is probably also true for clinicalprocedures such as desensitization and relaxationtraining.Many persons are coming to feel that be-

havior therapy must now move on to the next

514

NIMH SUPPORT OF RESEARCH IN BEHAVIOR THERAPY 515

step in evaluation: comparative evaluation inwhich one group of individuals receives a stan-dard, well-accepted treatment, conscientiouslyapplied, while another receives some sort of be-havior therapy, again conscientiously applied.This sort of research design is addressed to theimportant questions of relative therapeutic effi-cacy and cost-effectiveness. By a comparison ofthe magnitude of results obtained with existing,standard procedures and with behavior therapy,researchers will begin to provide the evidencenecessary for deciding whether the costs of in-troducing new procedures-including staff train-ing, changes in supervision and record-keeping,and so on-will be adequately repaid in a sig-nificant improvement in the functioning of thepersons treated.NIMH is currently supporting some projects

that do compare the application of some sort ofbehavior therapy to the standard therapeuticprocedure for the same problem. For example,in a particularly well-designed and carefully con-ducted project, Gordon L. Paul (University ofIllinois) is comparing token economy proce-dures and milieu therapy with a traditionallytreated control group. Patients in all threegroups are being followed up extensively oncedischarged from the hospital. This project, origi-nally supported by the Applied ResearchBranch, is now being supported by the MentalHealth Services Development Branch, DMHS.

This latter Branch is also supporting Turner'sand Liberman's work, described above, in whichbehavior modification procedures are being usedin community mental health centers. In Turner'sproject, the results obtained on a wide varietyof measures administered to the patients in theexperimental community mental health centerwill be compared with results on the same

measures obtained from patients in a compa-rable community mental health center usingstandard procedures. In Liberman's project,progress reports and psychometric data on thepatients in the experimental day-treatmentcenter with the behavioral milieu will be com-pared to similar data on patients in a compari-son day-treatment program using standard pro-cedures and located in the same communitymental health center.

In all, eight of the more than 30 studies inbehavior therapy supported by NIMH includea comparison with a standard treatment pro-cedure. Given that this sort of evaluation isonly beginning to be used by researchers in thisarea, that is an unexpectedly high proportionof the active projects. Most of these compari-sons with standard treatments are newly initi-ated, but, given the youth of the field, perhapsit is to be expected that it would take 10 yearsor so of development before the therapeutictechniques of behavior modification wouldcome to the point at which people would beinterested in and able to do this sort of com-parison. Results of these eight studies, as wellas of any others like them, will provide im-portant evidence as to whether behavior therapyprocedures are a meaningful improvement overthe various psychotherapeutic procedures nowcommonly used.

REFERENCE

Hicks, L. H., Leibowitz, H. W., Ross, S., and Paller,M. A 1970 overview of sources of support forpsychological research. American Psychologist,1970, 25, 1013-1025.

Received 12 February 1973.(Final acceptance 21 May 1973.)

Comments by reviewer on following page