For some years now, working with long-stay populations such as the mentally handicapped and elderly mentally infirm has been a “Cinderella” area with difficulties in attracting high quality staff and resources. This has resulted in poor quality of care. There may be many reasons for the relative lack of interest shown by professionals in the problems of long-term care, but two stand out as potentially important:

(a) the rate of client behaviour change and

(b) the permanency of client behaviour change.

Within the areas of out-patient neuroses and other similar nonchronic problems, it is often expected that change can be brought about relatively quickly by trained therapists (cf. Marks, 1981a, b). With chronic problems, however, the situation is quite different. Usually change is only brought about slowly, if at all.

Secondly, with an out-patient population, given new ways with which to cope with their problems, we hope that somehow the natural contingencies will “trap” (Baer and Wolf, 1970) the new repertoires. The client gets better, stays better, and does not come back. From our own experience of this type of work, the situation is rarely so sanguine and with chronic populations, there isn't usually even much reason for hope. We are all too familiar with changes occurring and then the group of clients begins rapidly to slip back to where they started from (or beyond!). We have become accustomed to blaming poor motivation, inadequate training, organizational variables, Hawthorne effects, and so on. Almost anything except ourselves.

In this paper, we look at some failures and some relative successes in achieving desired change in long-stay institutions, and ask the questions “How?” and “Why?”. It should be obvious before we go any further that we do not have definite answers, but the questions are still worth asking. Work with long-stay populations can be extremely exasperating and demanding, but appeals to abandon the large institutions where such groups reside are defeatist.

Some aspects of the literature on the aetiology and classification of faecal soiling are reviewed briefly, and behavioural treatment approaches described. A case study—a 4-year-old girl with faecal soiling—is presented using a behavioural strategy. The case highlights the clinical importance of systematic fading of treatment contingencies, and a detailed analysis of the presenting problem in more recalcitrant cases.

In a previous study, Ascher and Turner (1980) accounted for differential results of two types of paradoxical intention administrations by suggesting that in one case subjects were encouraged to follow the explicit demands of the instructions which adversely effected performance. It was the purpose of the present study to determine the effect of employing a procedural component to emphasize the explicit demands of paradoxical intention instructions. Two groups received identical paradoxical intention instructions. One was required to present “objective” data along with their subjective sleep report—the other had only to present the subjective data. Two control groups were included in the design which employed sleep onset latency as a dependent variable. As hypothesized, results indicated that the paradoxical intention group submitting “objective” data reported latencies which were significantly longer than those of the no-treatment control, while the paradoxical intention group that was not required to submit “objective” data reported sleep onset latencies which were significantly shorter than those of the no-treatment control group.

Assertiveness skills training is frequently a component of current behavioral treatments of alcohol abuse. Although the results of several uncontrolled and controlled evaluations generally suggest the efficacy of using assertiveness training, methodological problems in this research prevent firm conclusions. Thus, before conditions under which assertive skills training with alcohol abusers are most effective can be delineated, additional evaluation correcting these problems is needed.

Several psychopathological conditions include delusional beliefs as central symptoms. A conceptual model highlighting the importance of cognitive factors in regulating the bizarre internal contingencies which characterize delusional systems is presented. Cognitive–behavioral treatment emphasizes the direct modification of expectations and beliefs as well as the disordered behavior patterns they support. The efficacy of neuroleptics in treating delusional states has also been reported. Two patients with predominate delusional beliefs were treated in a cross-over design by the sequential use of cognitive–behavior therapy and pimozide. A third patient received cognitive–behavioral training alone. The delusions as well as the anxiety associated with them diminished and behavioral functioning improved significantly following cognitive therapy. The relationship between delusional symptoms, perceptions of self, and social functioning, as well as the optimal application of cognitive–behavioral and psychopharmacological interventions are discussed.

The memory functioning of a 31-year-old Korsakoff syndrome patient was assessed in his everyday environment and in the laboratory and a programme devised to support residual memory capacity. The patient's wife was used as a monitor of input and retrieval conditions and taught how to seek situations in which her husband would be least impaired. Prompt cards and leaflets were provided for acquaintances in order to reduce the memory demands of the patient's environment.

Follow-up at 1 year showed that although tested memory functioning deteriorated, the patient's memory support system had continued. Additionally, an experiment demonstrated that retrieval could be boosted significantly by presentation of associative cues at storage and retrieval. These findings were used to guide further change in the way the patient's wife managed his memory impairments.

A case is described of an 11-year-old schoolgirl with both obsessive-compulsive rituals and tics of sudden onset following a traumatic event at the age of five. Treatment consisted of exposure in vivo and response prevention directed mainly towards her obsessive-compulsive rituals as they were considered the primary problem. Following the initial therapist–patient out-patient session and home treatment with her mother, the obsessive-compulsive rituals disappeared and the tics decreased. Three weeks later the tics disappeared without specific treatment and the patient has maintained her improvement at follow-up, 52 weeks later. The actual therapist–patient time was about an hour.