Sixty-four patients suffering from primary major depressive illness from hospital and general practice clinics were randomly allocated to three treatment groups: drug of choice, cognitive therapy and a combination of the two. Looking at end-point scores on two rating scales of depression, there was no difference in the proportion of responders to the three treatments in the hospital group, but in the general practice, significantly less patients treated with drugs improved. Looking at group mean changes from baseline, all groups improved significantly on most variables except for the general practice drug group. The potential value of cognitive therapy for therapy-resistant hospital patients and for general practice patients is discussed.

An 11-year-old boy who suffered panic and anxiety during separations from his mother was successfully treated by in vivo systematic desensitization in 10 sessions. His mother was actively involved in the treatment. The manifestations of separation anxiety in school had disappeared by the end of treatment. No further problems were shown at 3-month and 15-month follow-up. The case is discussed in the context of the behavioural treatment of school refusal.

Four pedophiles, one sado-masochist, and one rapist were treated by varying different aspects of a single paradigm of masturbatory conditioning. In the basic paradigm, subjects masturbate to ejaculation while speaking their fantasies aloud. Weekly blocks of five trials with a deviant theme are alternated with weekly blocks where the theme is nondeviant. Evaluation sessions to assess levels of response to deviant and nondeviant slide stimuli are typically conducted later in each treatment day. The usual result is an increase in nondeviant arousal with a concomitant decrease in deviant arousal.

Variations in the masturbation procedure included shortening the treatment week from 5 days to 2 or 3, alternating themes on a daily rather than weekly basis, and omitting the use of deviant imagery. In the evaluation sessions variations included the preparation of individually tailored audiotaped fantasies precisely expressive of the subjects' interests, the use of videotaped simulations of rape, assault, and consenting intercourse, and obtaining numerous measures of the subjects' cognitive changes during the treatment process. All six subjects showed the effect of decreasing their deviant sexual arousal and increasing their nondeviant arousal. The results were discussed from various viewpoints employing a cognitive-behavioral model.

Behavioural psychotherapy has many roots, and experimental psychology is but one of many “idols of origin” which is in any case largely ignored by behavioural practitioners. The conditioning model of neurosis has shortcomings, and cognitive explanations alone are not satisfactory. It may be necessary to think in terms of failed extinction of phobias and rituals rather than of enhanced acquisition. Aetiological theories need not be related to effective treatment, nor are they necessary for clinicians to carry out successful behavioural treatment. For therapists, paradigms are more useful when derived from clinical experiments rather than from the laboratory. A critical task concerning treatments to reduce anxiety is to investigate those parameters which decide when exposure will be habituating and when it will be sensitizing. To this end, analogue research is less relevant than clinical experiments whose results can be used directly by clinicians. Ten theoretical problems with exposure are noted.

The demand for behavioural psychotherapy exceeds the supply of therapists. Paraprofessionals and self-help methods can help to bridge the gap, while preventive measures may prevent the development of some pathology. Most clinical psychologists and psychiatrists are overqualified merely to deliver behavioural services; there is no evidence that such qualifications add to effectiveness, though they are invaluable for research and teaching.

Marks's paper covers a wide range of different theoretical, clinical and methodological issues in the behavioral approach to the conceptualization and treatment of neurotic disorders. Accordingly, in response to the Editor's request to comment briefly on the paper, I shall necessarily be selective in the points I make, referring the reader to more extended discussions of these issues in other sources. Specifically, I address the following points: the applicability of behavior therapy; the nature and function of its theoretical underpinnings; research strategies; and recommendations for service delivery and training.

The effects of instructions and reinforcement on the handwriting of a 13-year-old boy in special education were studied. Both variables were found to be effective. A simple scoring method was used. It was found that the scoring system was easily learned by the child, and was sufficiently reliable to merit continued use under certain circumstances.