My primary training at the University of Oregon was in behavioral and cognitive psychotherapies. The main thrust of my work in this area if described in two other links on Behavioral Self-Control Training and on the Community Reinforcement Approach. This section describes other research in my lab group testing other behavior therapies that showed promise, and in extending behavioral treatment methods to new problems.
It so happened that in my practice at Behavior Therapy Associates I saw several clients one year who were suffering from disabling nightmares. They were literally afraid to go to asleep, and many of them had the same dream over and over again. Not having encountered this during my training, I went to the research literature to find out how best to help them. There was almost nothing of help. Case studies speculated on the deep-seated psychodynamic origins of nightmares. One report based a few female cases claimed that they were related to ornithophobia – a fear of birds. There were also stern warnings that any attempt to treat nightmares directly would result in symptom substitution. So I went back to my learning theory and particularly noted indications that people were more likely to have nightmares if they went to sleep in a higher state of autonomic arousal. Might it help to give them progressive deep muscle relaxation training, to be used regularly and particularly before bedtime? I also reasoned that systematic desensitization to the common content of the dreams might be helpful. So we advertised for people suffering from chronic nightmares, and found it was not that difficult to locate such individuals. We randomly assigned them to receive or not receive relaxation training or systematic desensitization (which includes relaxation training). The result: Both treatments significantly decreased nightmares, with systematic desensitization adding nothing beyond relaxation training itself. The simpler treatment seemed sufficient. Over the course of follow-up we found no evidence of symptom substitution.
Miller, W. R., & DiPilato, M. (1983). Treatment of nightmares via relaxation and desensitization: A controlled evaluation. Journal of Consulting and Clinical Psychology, 51, 870-877.
Aversion therapies, based on the Pavlovian method of counterconditioning, showed early promise in the treatment of alcohol dependence (Rimmele, Miller & Dougher, 1989). Because of this evidence base and a clear theoretical rationale for the treatment, we conducted three studies to see how helpful aversion therapy would be in our hands. The first of these was my dissertation (Miller, 1978) in which we used a form of electric shock (delivered to the hand) aversive counterconditioning as one of three treatments tested. Problem drinkers in this group did show significant reduction in their drinking, but no better than outcomes in the group receiving only behavioral self-control counseling. The use of electric shock was also distinctly unpleasant for counselor and client alike, and we thus saw no reason to continue it
Another form of aversion therapy, however, involves no physically painful or noxious stimulus. “Covert sensitization” is done entirely in imagination, pairing drinking with images that are particularly aversive to the individual. Prior studies by Ralph Elkins and others showed that one could establish conditioned aversion responses to alcohol by this method, and that the establishment of such conditioning predicted abstinence. There was also limited evidence for the efficacy of covert sensitization in alcohol treatment. Thus this seemed like a more feasible alternative that might help people with alcohol problems, and could be used in ordinary practice.
There were several ways to do covert sensitization, varying in the “unconditioned stimulus” (UCS) that was paired with drinking in imagination. The usual UCS involved scenes of nausea and vomiting. Some people, however, had difficulty getting this image, so there was also an assisted form in which nausea images were boosted by whiffs of a foul-smelling chemical substance. The third alternative did not involve nausea, but personally constructed scenes that the individual client found particularly distressing or noxious. In a preliminary study (Miller & Dougher, 1989) we found that we could produce conditioned aversion to alcohol by any of these three methods.
There followed a randomized trial that is one of the few studies I never published. We worked with alcohol dependent people and randomly assigned them to receive or not receive covert sensitization in addition to treatment as usual at the Albuquerque V.A. Hospital. We carefully documented the establishment of conditioned aversion responses to alcohol (whereby just imagining drinking yielded observable unpleasant reactions on at least two of three dimensions: self-report, behavioral observation, and polygraph. We were once again successful in producing conditioned aversion in a majority of clients treated by covert sensitization, and replicating Elkins, we found that those clients who had developed conditioned aversion were significantly more likely to remain abstinent during follow-up. Success – a treatment that works for the reason it is supposed to? Not really, because in comparison to the control group not receiving covert sensitization, the treated group did no better. Covert sensitization added absolutely nothing when it came to treatment outcome. In addition, it, too, was a very unpleasant treatment for both therapist and client. We thus concluded that therapists were very unlikely to want to learn this treatment methods, and indeed we found no persuasive reason for them to do so.
So what happened? Why did the establishment of conditioning predict better outcomes even though the treatment itself exerted no main effect on outcome? Perhaps it was conditionability that we were studying: that people who are more susceptible to imaginal conditioning are also for some reason more likely to succeed in treatment, whether or not it includes aversion.
Miller, W. R. (1978). Behavioral treatment of problem drinkers: A comparative outcome study of three controlled drinking therapies. Journal of Consulting and ClinicalPsychology, 46, 74-86.
Miller, W. R., & Dougher, M. J. (1989). Covert sensitization: Alternative treatment procedures for alcoholism. Behavioural Psychotherapy, 17, 203-220.
Rimmele, C. T., Miller, W. R., & Dougher, M. J. (1989). Aversion therapies. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches:Effective alternatives (pp. 128-140). Elmsford, NY: Pergamon Press.
Bibliotherapy for Depression
Having found in earlier studies that providing a self-help manual (“bibliotherapy”) was beneficial in helping problem drinkers decrease their alcohol use [Apodaca & Miller, 2003; see link on Behavioral Self-Control Training], we wondered whether the same might be true in other problem areas. Michael Schmidt designed his dissertation to examine the relative effectiveness of delivering cognitive-behavior therapy by individual counseling, group counseling, or bibliotherapy. As with our findings regarding alcohol problems, clients receiving the self-help manual responded, on average, just as well as those given individual or group therapy.
Schmidt, M. M., & Miller, W. R. (1983). Amount of therapist contact and outcome in a multidimensional depression treatment program. Acta Psychiatrica Scandinavica, 67, 319-332.
Apodaca, T. R., & Miller, W. R. (2003). A meta-analysis of the effectiveness of bibliotherapy for alcohol problems. Journal of Clinical Psychology, 59, 289-304.
Using Paraprofessionals in Treatment
Some behavior therapies are quite intensive, requiring a lot of in-person (and sometimes at-home) time to deliver. It seemed that this would be a sensible place to make use of trained paraprofessionals to help in administering such extended treatments over time (Christensen et al., 1978). We published a successful case study example of this, using paraprofessionals to help in delivering prolonged exposure therapy to a woman severely disabled by obsessive-compulsive disorder (Pruitt et al., 1989).
Christensen, A., Miller, W. R., & Muñoz, R. F. (1978). Paraprofessionals, partners, peers, paraphernalia, and print: Expanding mental health service delivery. Professional Psychology, 9, 249-270.
Pruitt, S. D., Miller, W. R., & Smith, J. E. (1989). Outpatient behavioral treatment of severe obsessive-compulsive disorder: Using paraprofessional resources. Journal of Anxiety Disorders, 3, 179-186.
Pathological gambling has often been grouped with the addictive behaviors more generally (Miller, 1980). When New Mexico experienced a steep increase in the prevalence of problem gambling after the opening of casinos, we reviewed the research literature to determine what treatment methods were yielding the best outcomes. The research pointed in general to behavior therapies (López Viets & Miller, 1997). We then developed a “Better Future” outpatient treatment program based on what we had learned, which is available at the Therapist Manuals link. Although it is founded on evidence-based treatment methods, we have not specifically evaluated this program.
López Viets, V. C. & Miller, W. R. (1997). Treatment approaches for pathological gamblers. Clinical Psychology Review, 17, 689-702.