Comprehensive Clinical Psychology [Volume 6]

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Comprehensive Clinical Psychology

Comprehensive Clinical Psychology. Volume 6 Copyright © 2000 Elsevier Science Ltd. All rights reserved. Editors-in-Chief: Alan S. Bellack and Michel Hersen Table of Contents Volume 6: Adults: Clinical Formulation & Treatment Close Preface Contributors 6.01 Clinical Formulation, Pages 1-24, Gillian Butler SummaryPlus | Chapter | PDF (353 K) 6.02 Behavioral Approaches, Pages 25-49, Jürgen Margraf SummaryPlus | Chapter | PDF (376 K) 6.03 Cognitive Therapy, Pages 51-84, Ivy-Marie Blackburn SummaryPlus | Chapter | PDF (431 K) 6.04 Family Therapy and Systemic Approaches, Pages 85-105, Arlene L. Vetere SummaryPlus | Chapter | PDF (336 K) 6.05 Psychodynamic Approaches, Pages 107-134, Peter Fonagy SummaryPlus | Chapter | PDF (453 K) 6.06 Psychopharmacology, Pages 135-161, Philip J. Cowen SummaryPlus | Chapter | PDF (438 K) 6.07 Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches, Pages 163-181, Larry E. Beutler, Kevin Booker and Stacey Peerson SummaryPlus | Chapter | PDF (345 K) 6.08 Social Skills Training and Problem Solving, Pages 183-201, Kim T. Mueser SummaryPlus | Chapter | PDF (322 K) 6.09 Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis, Pages 203-227, Graham C. H. Turpin and Michael Heap SummaryPlus | Chapter | PDF (395 K) 6.10 The Therapeutic Relationship, Pages 229-249, Frank M. Dattilio Arthur Freeman and John Blue SummaryPlus | Chapter | PDF (356 K)

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6.11 Treatment Maintenance and Relapse Prevention, Pages 251-263, John W. Ludgate SummaryPlus | Chapter | PDF (310 K) 6.12 Use of Self-help Books in the Practice of Clinical Psychology, Pages 265-276, Michael V. Pantalon SummaryPlus | Chapter | PDF (283 K) 6.13 Preventive Goals and Indirect/Consultation Strategies: Meeting Current Needs Through a Recommitment to Underused Means and Ends, Pages 277-300, Raymond P. Lorion SummaryPlus | Chapter | PDF (372 K) 6.14 Working with Images in Clinical Psychology, Pages 301-318, Ann Hackmann SummaryPlus | Chapter | PDF (322 K) 6.15 Group Therapy: A Cognitive-behavioral Interactive Approach, Pages 319-337, Sheldon D. Rose SummaryPlus | Chapter | PDF (341 K) 6.16 Affective Disorders, Pages 339-366, Robert J. Derubeis Paula R. Young and Katherine K. Dahlsgaard SummaryPlus | Chapter | PDF (409 K) 6.17 Obsessive-compulsive Disorder, Pages 367-398, Gail S. Steketee Randy O. Frost SummaryPlus | Chapter | PDF (442 K) 6.18 Panic Disorder and Agoraphobia, Pages 399-437, Paul M. Salkovskis SummaryPlus | Chapter | PDF (489 K) 6.19 Worry and Generalized Anxiety Disorder, Pages 439-459, Thomas D. Borkovec and Michelle G. Newman SummaryPlus | Chapter | PDF (360 K) 6.20 Specific Phobias, Pages 461-474, Peter Muris and Harald Merckelbach SummaryPlus | Chapter | PDF (303 K) 6.21 Social Phobia, Pages 475-498, Harlan R. Juster Richard G. Heimberg SummaryPlus | Chapter | PDF (347 K) 6.22 Post-traumatic Stress Disorder, Pages 499-517, Lisa H. Jaycox and Edna B. Foa SummaryPlus | Chapter | PDF (351 K) 6.23 Psychoses: The Management of Severe and Enduring Mental Illness, Pages 519-541, Geoff Shepherd SummaryPlus | Chapter | PDF (318 K)

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6.24 Somatoform Disorders, Pages 543-565, George H. Eifert and Carl W. Lejuez Theo K. Bouman SummaryPlus | Chapter | PDF (376 K) 6.25 The Treatment of Substance Abuse and Dependence, Pages 567-585, Robin J. Davidson SummaryPlus | Chapter | PDF (312 K) 6.26 Cognitive Approach to Understanding and Treating Pathological Gambling, Pages 587-601, Robert Ladouceur Michael Walker SummaryPlus | Chapter | PDF (323 K) 6.27 Sexual Problems: Dysfunction, Pages 603-621, W. P. De Silva SummaryPlus | Chapter | PDF (349 K) 6.28 Relationship Problems, Pages 623-648, W. Kim Halford Howard J. Markman Peter Fraenkel SummaryPlus | Chapter | PDF (367 K) 6.29 Eating Disorders, Pages 649-667, Anita Jansen SummaryPlus | Chapter | PDF (327 K)

Preface Volume 6 For most clinical psychologists, conducting psychological treatment constitutes the major part of their day-to-day work. However, the range of problems to be treated and the variety of treatment approaches available mean that there is remarkably little uniformity in the detail of treatment. Few would regard psychological treatments as best conducted in a purely prescriptive way, which makes the issues of treatment integrity and quality control particularly complex ones. The development of DSM-III (American Psychiatric Association, 1980) confronted clinical psychology with a major problem. On the one hand, the availability of a reliable classification system appealed to those committed to a scientific approach to psychology; psychologists had long criticized diagnostic systems as intrinsically unreliable and therefore having no possibility of any validity, particularly predictive validity. DSM-III largely dealt with this issue. On the other hand, clinical psychology had long sought to avoid adopting the "medical model," seeking instead to conceptualize problems in terms of well-validated psychological processes. One of the first clinical psychologists to articulate this view clearly was Monte Shapiro, who suggested that the complexity of psychological problems could best be understood in terms of general psychological processes leading to highly specific behavioral outcomes. The most promising solution to the dilemma posed by the widespread adoption of DSM categories in the context of psychological treatment practice has been the development and adoption of manualized approaches to treatment. Implicit in this approach is the assumption that diagnostic categories do not file:///D|/1/CCP/06/00.htm (3 of 10)17.10.06 10:59:25

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necessarily "divide nature at the joints," but rather that they represent archetypes which can be characterized in terms of identifiable (and often interacting) psychological processes involved in the maintenance of psychological problems. This view suggests that particular problems can be treated by directly addressing maintenance processes specific to the problem, the person, and the person's situation. The flexible application of manualized approaches, together with improved training, holds the promise of more systematic and better quality treatment. This volume of Comprehensive Clinical Psychology, focusing on treatment in adults, seeks to further that process by providing a reference source for those wishing to conduct effective psychological therapies of all types. This perspective highlights one of the major changes which has taken place over the last century in terms of the way the process of psychological treatment is conceptualized, with the focus of theory and treatment having moved from identifying and dealing with the origins of psychological problems to identifying and dealing with those factors involved in the maintenance of such problems. Early approaches to psychological treatment emphasized the importance of dealing with the causes of psychological problems. This emphasis reflects the roots of psychiatry and psychotherapy in medical models, particularly "germ" and "lesion" theories. Early psychiatry was dominated by the discovery that General Paresis of the Insane, a progressive dementing syndrome which was the most common reason for admission to lunatic asylums during the nineteenth century, was in fact the result of tertiary syphilitic infection. Treatment of the syphilis arrested progression of the syndrome. It logically followed that the task of those seeking to understand and treat other psychiatric syndromes depended on the identification and effective treatment of the pathogens responsible. A great deal of psychiatric research conducted since that time has involved seeking the underlying biological or psychological "pathogen" involved in particular diagnostic categories. This notion remains with us in various forms. Brain lesion theories abound in psychiatry, fueled by modern brain imaging techniques which at times resemble a modern variant of phrenology. It appears that some researchers believe that, if a particular brain area "lights up" more in patients relative to nonpatients, then that brain area is responsible for the disorder! Hypothesized generalized neurochemical dysfunctions are another variant of this type of approach. Deficits or excesses in particular neurotransmitters are hypothesized as likely to be responsible for psychiatric diseases. Such theories are often derived from the observation that particular diagnostic groups are relatively responsive to some types of medication and not to others. This reasoning is similar to the idea that because headaches respond to aspirin, headaches are due to a lack of aspirin. The development of the absurd notion of the "obsessive-compulsive spectrum disorders" is a good example of this type of reasoning. How, then, to produce a reference text which characterizes good practice in clinical psychological treatment without embracing the more negative features and assumptions of medical models? The solution employed here was to include three types of chapters: on broad approaches and orientations in psychological treatment, on more general topics which tend to cut across such orientations, and on particular diagnostic categories. The Development of Psychological Treatments There can be little doubt that many modern ideas concerning psychological treatment can be more or less directly traced to Freud's concept of the "talking cure." More than a century later, treatment not dissimilar to that advocated by Freud is still practiced as described in Chapter 5 by Fonagy. It is reassuring to find little evidence in modern psychodynamic approaches of the dogma which led to file:///D|/1/CCP/06/00.htm (4 of 10)17.10.06 10:59:25

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profound schisms within the psychoanalytic establishment earlier in the twentieth century. A major landmark in the evolution of psychotherapy was the development of humanistic approaches (see Chapter 7 by Beutler and colleagues). Such approaches have been widely adopted over the past 40 years, with accurate empathy and nonpossessive warmth still being recognized as crucial basic and enabling ingredients of effective psychological treatment. During the 1950s, Hans Eysenck highlighted the lack of an empirical basis in psychotherapy, suggesting that it was not possible to rule out the possibility that the efficacy rates claimed for psychotherapy may be due to spontaneous remission. This line of argument was extremely influential as behavior therapy emerged in the late 1950s. Joseph Wolpe, the man who effectively founded clinical behavior therapy, adopted a formula which has since come to dominate scientific psychotherapy. Well-defined theory drives carefully designed experimental studies into psychological processes involved in psychopathology. The clinical generalizability of such studies is then evaluated in clinical populations using experimental designs ranging from intensive experimental investigations of the single case through to controlled trials evaluating the relative contribution of specific and nonspecific factors. This approach, often referred to as the "scientist¯practitioner" model, is the mainstay of behavior therapy (described by Margraf in Chapter 2) and of cognitive and cognitive-behavioral approaches (see Chapter 3 by Blackburn). Clinical psychology as a discipline has, for many years, been committed to "evidencebased" approaches of the type embraced, much more recently, by psychiatry. It seems likely that the clear and unambiguous demonstration of the efficacy of behavioral treatments for anxiety disorders was crucial in enabling the transition of clinical psychology as a discipline subsidiary to psychiatry, primarily concerned with testing and psychometric assessment, to a fully-fledged and independent profession primarily concerned with the management and treatment of psychological disorders. The more recent addition of "cognitive" to "behavioral psychotherapy" has resulted in a further remarkable expansion of the problems treated by clinical psychologists and made new techniques available to clinical psychologists for use with problems such as depression. Drawing upon the earlier work of George Kelly, Aaron Beck has been particularly influential in developing and elaborating a theory of emotional problems which draws cognition, affect, and behavior together whilst retaining a scientific (positivist) stance rather than reverting to earlier introspective approaches which led to so much criticism of early psychological theories. In parallel with the development of psychological treatments for psychological problems, increasingly effective pharmacological treatments have also evolved (see Chapter 6 by Cowen). Clinically, pharmacological and psychological treatments are often combined, and it seems likely that it is generally sensible to do this. However, it is clear that pharmacotherapy can be seen by both patient and clinician as an "easy option." The question of whether there may be long-term interactions involved in combination treatment is only now beginning to be addressed, and there are early indications in some disorders that in some instances the combination may result in better outcomes when compared with pharmacotherapy alone, and worse outcomes when compared with psychological therapy alone; there is no evidence of the reverse pattern. There is currently some controversy over the issue of "prescription privileges" for clinical psychologists; it is hard for this author to see this as anything other than a negative outcome. Specific Psychological Problems and General Topics

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A substantial proportion of this volume is given over to the consideration of the nature and treatment of specific problems. As described above, it is not intended to reify diagnostic categories where these are used, but rather to take these as archetypal examples of particular patterns of psychological processes and responses. These range from depression (see Chapter 16 by DeRubeis and colleagues) and anxiety disorders such as social phobia (see Chapter 21 by Heimberg and Juster) and generalised anxiety disorder (see Chapter 19 by Borkovec and Newman) through to less well-researched problems such as gambling (see Chapter 26 by Ladouceur and Walker), and so on. In most chapters, it is again evident that the emphasis is on identifying the key factors involved in the maintenance of psychological disturbance, with treatment involving helping the sufferer finding ways of dealing with them. It is an almost universal feature of people who suffer from psychological problems that they and/or those around them believe that they should "pull themselves together." Those of us who work with these problems also know that, if they could, our patients would do precisely that. In many of the problems we work with, our role as clinical psychologists is to help the person find ways of doing just that. One of the hallmarks of good psychological treatment is the way in which it empowers the sufferer, implicitly or explicitly providing them with skills to help them to deal better with their difficulties. Many of the chapters in this volume should help the psychologist to help their patients to help themselves; in some instances, self-help is the entire focus of interventions (see Chapter 12 by Pantalon). Many of the skills and much of the knowledge required in the practice of clinical psychology do not fall into diagnostic categories; indeed, some require a completely different framework (see Chapter 13 by Lorion). The chapters in this volume make clear the current strengths of treatment approaches in clinical psychology. However, complacency is not justified. Outcome research appears to suggest that the majority of the patients we seek to help get better. However, such research can be misleading. For example, in obsessive-compulsive disorder (see Chapter 17 by Steketee and Frost), the data suggest that 75% of patients improve in clinical trials. However, the 75% does not include 25% who refuse treatment and the 12% who drop out within the first two sessions. Some patients relapse within a year, and although the most severely disabled may improve substantially, many will remain severely handicapped at the end of treatment. For most of the problems dealt with in this volume, a similar pattern holds, and this is also true for pharmacological treatments. The challenge for the next decade is to improve on this, to make treatments briefer whilst increasing their power, and to reduce relapse rates (see Chapter 11 by Ludgate). This is a fundamental problem, requiring the development and implementation of new ideas and approaches. It is my view that the scientist¯practitioner model and evidence-based approaches will provide the framework required to achieve such goals. It is often suggested that the other challenge facing clinical psychology is to generalize from research trials to clinical practice. I believe this to be a "technical" problem which can be solved within the existing framework, by providing better training and resources. This volume is ample testimony to the maturity of clinical psychology as a profession with much to offer in the treatment and prevention of psychological distress. That the bulk of this has been achieved within the last 30 years is remarkable, and leads one to feel optimistic about the next 30. Acknowledgments Many people facilitated the production of this volume. Most of all, my wife, Lorna, and children

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Cora and Duncan have provided motivation and support. My colleague and friend David M. Clark provides continual inspiration and help, and I owe many things to him. Muriel Lumb and Monika Juskiewicz gave administrative support and encouragement. Alan Bellack has provided wisdom and support as needed. My special thanks to Angela Greenwell and David Hoole at Elsevier Science, who have been unfailingly patient, encouraging, and supportive as I have unfailingly failed to meet their deadlines.

Volume 6 Contributors BEUTLER, L. E. (University of California, Santa Barbara, CA, USA) *Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches BLACKBURN, I.-M. (Cognitive Therapy Centre, Saint Nicholas Hospital, Newcastle upon Tyne, UK and University of Durham, UK) Cognitive Therapy BLUE, J. (Philadelphia College of Osteopathic Medicine, PA, USA) *The Therapeutic Relationship BOOKER, K. (University of California, Santa Barbara, CA, USA) *Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches BORKOVEC, T. D. (Pennsylvania State University, University Park, PA, USA) *Worry and Generalized Anxiety Disorder BOUMAN, T. K. (University of Groningen, The Netherlands) *Somatoform Disorders BUTLER, G. (University of Oxford, Warneford Hospital, UK) Clinical Formulation COWEN, P. J. (University of Oxford, Warneford Hospital, UK) Psychopharmacology DAHLSGAARD, K. K. (University of Pennsylvania, Philadelphia, PA, USA) *Affective Disorders DATTILIO, F. M. (University of Pennsylvania School of Medicine, Philadelphia, PA, USA) *The Therapeutic Relationship DAVIDSON, R. J. (Belvoir Park Hospital, Belfast, UK) The Treatment of Substance Abuse and Dependence file:///D|/1/CCP/06/00.htm (7 of 10)17.10.06 10:59:25

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DE SILVA, W. P. (Institute of Psychiatry, University of London, UK) Sexual Problems: Dysfunction DeRUBEIS, R. J. (University of Pennsylvania, Philadelphia, PA, USA) *Affective Disorders EIFERT, G. H. (West Virginia University, Morgantown, WV, USA *Somatoform Disorders FOA, E. B. (Allegheny University of the Health Sciences, Philadelphia, PA, USA) *Post-traumatic Stress Disorder FONAGY, P. (University College London, UK) Psychodynamic Approaches FRAENKEL, P. (New York University, NY, USA) *Relationship Problems FREEMAN, A. (Philadelphia College of Osteopathic Medicine, PA, USA) *The Therapeutic Relationship FROST, R. O. (Smith College, Northampton, MA, USA) *Obsessive-compulsive Disorder HACKMANN, A. (University of Oxford, Warneford Hospital, UK) Working with Images in Clinical Psychology HALFORD, W. K. (Griffith University, Nathan, Qld, Australia) *Relationship Problems HEAP, M. (University of Sheffield, UK) *Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis HEIMBERG, R. G. (Temple University, Philadelphia, PA, USA) *Social Phobia JANSEN, A. (Universiteit Maastricht, The Netherlands) Eating Disorders JAYCOX, L. H. (Allegheny University of the Health Sciences, Philadelphia, PA, USA and RAND, Santa Monica, CA, USA) *Post-traumatic Stress Disorder

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JUSTER, H. R. (Pine Bush Mental Health, Albany, NY, USA) *Social Phobia LADOUCEUR, R. (Universit•aval, Qu c, PQ, Canada) *Cognitive Approach to Understanding and Treating Pathological Gambling LEJUEZ, C. W. (West Virginia University, Morgantown, WV, USA) *Somatoform Disorders LORION, R. P. (Ohio University, Athens, OH, USA) Preventive Goals and Indirect/Consultation Strategies: Meeting Current Needs Through a Recommitment to Underused Means and Ends LUDGATE, J. W. (Bristol Regional Medical Center, Bristol, TN, USA) Treatment Maintenance and Relapse Prevention MARGRAF, J. (Technische Universit•Dresden, Germany) Behavioral Approaches MARKMAN, H. J. (University of Denver, CO, USA) *Relationship Problems MERCKELBACH, H. (University of Maastricht, The Netherlands) *Specific Phobias MUESER, K. T. (New Hampshire–Dartmouth Psychiatric Research Center, Concord, NH, USA) Social Skills Training and Problem Solving MURIS, P. (University of Maastricht, The Netherlands *Specific Phobias NEWMAN, M. G. (Pennsylvania State University, University Park, PA, USA) *Worry and Generalized Anxiety Disorder PANTALON, M. V. (Yale University School of Medicine, New Haven, CT, USA) Use of Self-help Books in the Practice of Clinical Psychology PEERSON, S. (University of California, Santa Barbara, CA, USA) *Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches ROSE, S. D. (University of Wisconsin–Madison, WI, USA) Group Therapy: A Cognitive-behavioral Interactive Approach SALKOVSKIS, P. M. (University of Oxford, Warneford Hospital, UK) file:///D|/1/CCP/06/00.htm (9 of 10)17.10.06 10:59:25

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Panic Disorder and Agoraphobia SHEPHERD, G. (Health Advisory Service (HAS 2000), London, UK) Psychoses: The Management of Severe and Enduring Mental Illness STEKETEE, G. S. (Boston University, MA, USA) *Obsessive-compulsive Disorder TURPIN, G. C. H. (University of Sheffield, UK) *Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis VETERE, A. L. (University of Reading, UK) Family Therapy and Systemic Approaches WALKER, M. (University of Sydney, NSW, Australia) *Cognitive Approach to Understanding and Treating Pathological Gambling YOUNG, P. R. (University of Pennsylvania, Philadelphia, PA, USA) *Affective Disorders

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.01 Clinical Formulation GILLIAN BUTLER University of Oxford, Warneford Hospital, UK 6.01.1 INTRODUCTION

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6.01.2 DEFINITIONS: WHAT IS A FORMULATION?

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6.01.2.1 6.01.2.2 6.01.2.3 6.01.2.4 6.01.2.5 6.01.2.6

2 4 5 6 7 7

Main Principles Formulation and Diagnosis: Assumptions Formulation and Diagnosis: Controversial Issues The Difference Between a Formulation and a Model Types of Formulation Levels of Formulation

6.01.3 PURPOSES: WHAT A FORMULATION IS FOR

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Understanding: The Overall Picture or Map Prioritizing Issues and Problems Planning and Selecting Intervention Strategies Predicting Responses and Difficulties Determining Criteria for Successful Outcome Thinking About Lack of Progress

9 9 10 10 11 11

6.01.4 METHODS: HOW TO CONSTRUCT A FORMULATION

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6.01.3.1 6.01.3.2 6.01.3.3 6.01.3.4 6.01.3.5 6.01.3.6 6.01.4.1 6.01.4.2 6.01.4.3 6.01.4.4 6.01.4.5

12 14 17 18 19

Sources of Information Putting the Information Together Key Factors and Basic Elements Issue of Completeness Conceptualizing Processes of Change

6.01.5 ACCURACY: HOW TO TELL IF A FORMULATION IS RIGHT

20 20 20

6.01.5.1 Criteria of Accuracy 6.01.5.2 Questions for Research 6.01.6 USING THE FORMULATION: PRACTICAL ISSUES

21 21 21 22

6.01.6.1 The Value of Organizing and Clarifying 6.01.6.2 Developing an Internal Supervisor 6.01.6.3 Communicating a Formulation 6.01.7 CONCLUDING DISCUSSION

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6.01.8 REFERENCES

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thereby enabling the patient to regain his morale. (Frank, 1986)

6.01.1 INTRODUCTION Patients come to psychotherapy because they are demoralized by the menacing meanings of their symptoms. The psychotherapist collaborates with the patient in formulating a plausible story that makes the meanings of the symptoms more benign and provides procedures for combatting them,

Although not all therapists would be happy with the idea that they are ªformulating a plausible story,º the process of clinical formulation remains the lynch pin that holds theory and practice together. This is agreed by proponents 1

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of most major therapeutic traditions: for example, behavior therapy (Turkat & Maisto, 1985; Wolpe & Turkat, 1985), psychodynamic therapy (Barber & Crits-Christoph, 1993; Perry, Cooper, & Michels, 1987; Silberschatz, Fretter, & Curtis, 1986), family therapy (Minuchin, 1974), cognitive therapy (Freeman, 1992; Persons, 1989, 1993), cognitive analytic therapy (Ryle, 1978, 1990), and interpersonal therapy (Klerman, Weissman, Rounsaville, & Chevron, 1984). The attempt to construct and use a clinical formulation is central to the work of therapy. Various methods for systematizing the processes involved have recently been proposed (Horowitz, 1989; Luborsky & Crits-Christoph, 1990) and, thinking specifically about the issues involved in psychotherapy integration, Goldfried (1995) has put forward a case for developing a common language for case formulation that is independent of theoretical orientation. Personal discussions of many kinds may be more or less valued and helpful to someone experiencing a difficulty, including the informal advice traded between friends, but one of the major differences between informal discussions and responsible clinical practice is that they do not make use of the process of formulation. The attempt to formulate a case, so as to apply an appropriately chosen method of intervention in the light of a particular theory, is one of the activities that makes therapists, as opposed to friends, accountable for their practice. This chapter discusses issues concerning clinical formulation that are relevant to therapists from different theoretical backgrounds. However, the illustrations of the general points made will largely be drawn from the author's own experience and will therefore reflect the author's original cognitive-behavioral training, together with a more recent interest in exploring possibilities for integration between different kinds of psychotherapy. 6.01.2 DEFINITIONS: WHAT IS A FORMULATION? 6.01.2.1 Main Principles A formulation is the tool used by clinicians to relate theory to practice. Clinicians use theoretical as well as practical knowledge to guide their thinking about the problems and difficulties presented by the people who come to them for help, and this combination of ideas helps them decide how best to help those people. However, although the theories are relatively simple and clearÐadmittedly to varying degreesÐthe information brought to treatment, and gathered during the process of assessment, is always complex and often unclear. The process

of marrying theory and practice is therefore fraught with difficulty. As well as having different reasons for requesting psychological help, people vary in their ability to describe or name their difficulties, in their histories and relationships with their families, friends and colleagues, in their ability to relate to a therapist, degree of psychological-mindedness, and emotional expressiveness. As well as having different theories, training, and clinical experience, therapists vary in the ways in which they understand, communicate with, and relate to their patients. Therapists bring with them to therapy specific skills, expertise, and information, and also their individual personalities and inclinations. The process of formulation is influenced by all these disparate factors, and this makes learning how to formulate a case with the necessary objectivity, clarity, and attention to the individual to guide a successful treatment one of the most fascinating, rewarding, and difficult tasks faced by clinicians. The assumption that many clinicians of different orientations probably share about the psychological difficulties of others is this: at some level it all makes sense. Even though our understanding of the processes involved, and particularly of their inter-relationships, is incomplete, this assumption was given a simple, and relatively uncontroversial, diagrammatic form by Padesky and Mooney (1990). The difficulties that people describe to their therapists have four inter-related aspects (cognitive, affective, behavioral, and physiological), and change in any one of these variables affects all of the others, as shown by the bidirectional arrows in Figure 1. So, taking anxiolytic medication can make one feel calmer, think about problems more constructively, and do some of the things that previously seemed too difficult or overwhelming. Feeling more cheerful can lighten ones step, help one to feel more optimistic, and relate more productively to others. Changing ones perspectiveÐor way of thinkingÐcan provide the sort of new outlook that helps to dissipate distress, reduce tension, and encourage constructive activity, and so on. The four ways in which aspects of psychological life are conventionally categorized reflect the internal workings and psychological state of a person at a particular point in time. This person is at the same time relating to the external world through a personal social, political, and historical context. The factors that determine this context, and fashioned it to be the way that it now is, are not easy for psychological therapists to know about: hypotheses for explaining and understanding the way they interact with each of the four types of phenomena have been made. The overall configuration is the source of the narrative, or story, that a person brings to

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Definitions: What is a Formulation? therapy. If we understood the rules governing the relationships between all these factors we would, no doubt, be better able to help our patients. The business of therapy, to a large extent, involves intervening to facilitate change in (at least) one of the four main aspects of psychological life shown in Figure 1, and different kinds of therapy attend differently to these different aspects, entering the process of change through different gateways. The intention, however, is much the sameÐto help people solve the problem or problems that they bring to therapy. Pharmacological and traditional behavioral therapies provide perhaps the clearest examples as the methods that they use, and the formulations upon which these methods are based, can be isolated relatively easily. Cognitive therapies, which adopt both cognitive and behavioral methods, operate on at least two levels. They may concentrate on identifying and reexamining particular thoughts, thereby changing feelings and behavior, and/or they may focus on underlying meanings and beliefs and adopt more sophisticated and complex methods of intervention, often related to those used in more dynamic and experiential traditions. Experiential therapies make specialized use of the medium provided by the feelings and thoughts arising in the present context of therapy, and work with these to facilitate a dynamic process of change. In order to do this, it becomes essential to think about, and to formulate, what happens in the relationship

The environment: personal,social, historical context, etc.

between the two people involved in therapyÐ methods which were originally described and understood by proponents of the various psychodynamic schools of therapy. Interpersonal therapy and systems therapy also formulate problems in terms of relationships between the person requesting help and others around them, and use this understanding to help people change as they wish. All of these methods initiate the process of change in different ways, determined by the way in which they understand, or formulate, the problem presented, and it is this understanding that determines what therapists doÐwhat steps they take to alleviate the problem. The point is that the way in which a formulation is constructed will be influenced by the point at which a therapist enters, and attempts to influence, this dynamic relationship between these main aspects of psychological life. Some general points are important: (i) each aspect influences all of the others, so none of the therapies has the exclusive aim of changing one factor. Rather, by focusing the process of change in one place, the aim is to bring about the change that the patient desiresÐusually to ªfeel better,º in all the relevant respects. (ii) The main medium of therapy is languageÐwhat one person says or suggests, to another. To this extent, the cognitive, implicational context within which therapies take place provides the basis for the way in which the presenting problems will be formulated.

Cognition

Affect

Physiology

Behavior

Figure 1

Inter-relationships between aspects of functioning (Padesky & Mooney, 1990).

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Clinical Formulation

(iii) Understanding of other people, and hence the ability accurately to formulate their problems, develops within the context of the relationship between them, mediated by factors such as trust and acceptance as well as by language. (iv) Our understanding of the ways in which the aspects of psychological life are integrated is partial. At this point in time, psychology is an imperfect but developing science. The implication of this is that formulations for the purpose of therapy have to be speculative. Formulations can best be understood as hypotheses to be tested, and the most obvious, if not the most logical, test of a formulation will be the response to the selected interventions. This is not to say that an expected change following a specific intervention proves that the formulation on which it was based is accurate. Unfortunately, the reasons why change occurs are far more complex and difficult to discern than this. However, the formulation used in this way is perhaps the main tool that the therapist has from which to draw such conclusions in the individual case. Thus, working in an openminded way with a formulation provides a means of contributing as a therapist to the scientific endeavor involved in finding out which are the best, most effective, and most efficient, methods of treatment. Although a formulation provides the link between theory and practice, it does so at a different level of generality. A theory is the source of general explanations and general hypotheses, whereas a formulation is specific to the person to whom it applies, and therefore is the source of more specific explanations and hypotheses. The specificity of the formulation is the source of ideas about the selection of specific interventions and about how to adapt them for use with a particular person. It is for these reasons that Wolpe and Turkat (1985) describe a formulation as a theoretically guided way of structuring the information concerning a patient's problem. It reflects the product of taking an individual approach to clinical phenomena and combining this with knowledge of relevant theories, scientific principles, and research findings. It involves imposing an explanatory system upon the material presented, and raises questions concerning the degree to which this explanatory system should reflect every aspect of a problem. One view is that it should reflect everything, including a patient's past development, characteristic ways of behaving and forming relationships, emotions, beliefs, assumptions, attitudes, self-evaluations, expectations, attributions, appraisals, and so on. In practice, the degree of elaboration required depends upon the purpose for which the

formulation is made. At this point it is probably sufficient to enunciate one of the principles that will run through this chapterÐthat of parsimony. In principle, it is always better, and more useful, to keep the formulation as simple as possible. The temptation to elaborate a formulation is strong, especially when dealing with complex cases. However, the simpler and clearer it is the more readily will its implications be seen and the easier it will be to use. Theoretically speaking, the principles that guide the practice of formulation are derived from the way in which the concept is defined. The three main ones to be proposed here are: (i) A formulation should be based on a theory, reflecting an attempt to put the theory into practice. (ii) A formulation should be hypothetical in nature, so that it can be modified by information gained during the course of treatment. (iii) A formulation should be as parsimonious as possible.

6.01.2.2 Formulation and Diagnosis: Assumptions In psychological practice there appears to be a common assumption that only those patients who participate in research trials have simple diagnoses, for example, of the kinds defined in the various versions of the DSM. Diagnostic systems are useful for ensuring that the populations studied in different places are similar in the relevant respects, and they are useful for insurance purposes, but from the point of view of the therapist they have limitations in that they rarely provide specific implications for treatment. Besides, unselected samples of patients often do not have single, clear problemsÐindeed informally they are commonly said to ªfulfill criteria for an average of 2.3 diagnoses.º A formulation, however, is designed precisely to fit the individual and is intended to help therapists to derive theoretically-based hypotheses about factors that contribute to causing and maintaining their specific problemsÐto explain as well as to describe. Therefore, the argument runs, diagnoses are less useful than formulations, from which specific treatment implications can be derived, and they may be less necessary than formulations. For example, one depressed person's sense of failure may be triggered by an inability to live up to exacting standards and another person's by an inability to form close relationships (for any number of reasons, which may be discovered during therapy and included in the formulation). Only having the diagnosis tells the therapist nothing about this difference,

Definitions: What is a Formulation? and ignoring the difference will reduce the chances of achieving a satisfactory outcome. This argument has much to recommend it to the therapist, especially as diagnoses are largely atheoretical descriptions, and therapists can use their theoretical knowledge to construct formulations that are clinically useful. This does not mean thinking anew with each patient, but keeping in close touch with theoretical and clinical research so that, for example, empirically validated treatments can be selected when the diagnosis suggests they would be appropriate, and individual formulations then used to specify details of their application. Learning to work with a formulation instead of relying on a diagnosis also has advantages when the problems presented are unusually rare or complex and do not fit readily into a diagnostic system, or when the system does not succeed in ªcarving nature at the joints,º and the demarcation between one diagnosis and another is difficult to establish. Of course there are difficulties with this point of view. Seen from the patient's perspective, over-reliance on the process of formulation may involve a degree of risk. What if the theory is wrong? Or if the therapist is unclear about it? Or susceptible to bias? Or unable to come up with an adequate formulation? Or attempts to combine one theory with another without understanding sufficiently well the implications of doing soÐas when borrowing from experiential or dynamic ideas when doing cognitive therapy for instance? This risk can be reduced by formalizing the requirements of responsible clinical practiceÐby providing adequate training and supervision, by clarifying ethical guidelines, and by defining criteria for professional accountability, including the expectation that practitioners will keep in touch with the literature relevant to their practice. Ultimately though, the mysterious faculty of clinical judgment has also to be brought into play. Without thisÐwhatever it isÐclinicians may well run into difficulties, both making and using formulations. The implication of this argument is primarily that, much of the time, formulations are more useful than diagnoses, provided that therapists are well versed in the theories they are using, and that diagnoses, which can after all convey a large amount of information in a few words, may help to streamline the process of assessment, and may guide decisions about treatment in relatively straightforward cases. For example, knowing someone is socially phobic directs attention towards a fear of being humiliated or embarrassed, and knowing the diagnosis is of bulimia nervosa focuses attention on overconcern with shape and weight (among other things). Underlying problems of self-conscious-

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ness and poor self-esteem may be relevant in both cases, so the assessment which provides an adequate basis for a formulation, and for a specific treatment plan, must cover more than the criteria for inclusion and exclusion that determine whether or not someone qualifies for a diagnosis.

6.01.2.3 Formulation and Diagnosis: Controversial Issues The assumption behind the argument presented above is that a treatment plan based on a formulation will have a better chance of success than one based on a diagnosis. However, there is considerable debate about this issue, and some recent research suggests that the assumption could be false. Schulte, KuÈnzel, Pepping, and Schulte-Bahrenberg (1992) and Schulte (1997) found that patients with phobias, assigned to a standardized treatment (exposure in vivo) on the basis of their diagnoses, responded at least as well as, and possibly better than, patients whose treatments had been selected on the basis of individual problem analyses. With this finding in mind, Wilson (1996, 1997) summarized the arguments for using manual-based, empiricallyvalidated treatments, also selected on the basis of diagnoses, and argued that there are inherent limitations involved in basing treatment on idiographic case formulation. As he points out, making formulations involves making judgments and judgments are fallible. They are demonstrably susceptible to bias and using them introduces an additional source of error. It would be better, he argues, to adopt an actuarial approach to assessment and treatment as this is more likely to result in a superior outcome than using clinical judgment, at least when treatment manuals are available. The issue is complex (Beutler, Williams, Wakefield & Entwistle 1995; Hayes, Follette, Risley, Dawes & Grady, 1995; Norcross, Alford, & DeMichele, 1992; Seligman, 1995; Stricker & Trierweiler, 1995), and differences will not be settled here. Nevertheless, it is useful to clarify the basis of the disagreement, as two issues are frequently confounded. The first concerns the failure of practicing clinicians to adopt standardized practices and the second concerns the dangers of over-reliance on individual formulations. Those who argue against the use of formulations seem to forget that it is the job of practicing clinicians to bridge the gap between science and practice, and in doing so to balance the requirements of recommended procedures with clinical flexibility. A formulation, as defined above, is intended to facilitate this processÐto assist the clinician

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Clinical Formulation

in adapting the procedure to the particular circumstances. When treatments so adapted are reported to be less effective than expected, then many factors in addition to formulation could contribute to this finding. These include the quality, integrity, structure, and delivery of the treatment, the accuracy with which the effects of treatment can be measured, and the relevance of the measures used to the outcome desired by the patient. Proponents of the view that treatments can be selected on the basis of diagnoses alone seem to assume that case formulation is idiographic, in the sense that making one is unconstrained by theoretical ideas and using it to select interventions is independent of the findings of clinical research. Neither of these points is accepted here. Instead it is argued that individual case formulation is always relevant, even when applying a manual-based treatment (examples will be found below). It is also argued that formulations have to be rooted in theory to be useful, and that using clinical judgment is not providing a licence for subjectivity, but recognizing that at least some of the time clinicians will not be able to follow the rule book, even when there is one. Then they have to use their judgment. In doing so, they can appeal to many sources of understanding, including theories about psychological dysfunction, and their knowledge of the relevant literature. As Stricker and Trierweiler (1995, p. 997) put it ªit is likely that the practitioner always will be required to go beyond firm and available scientific knowledgeºÐless so when treating phobias than when treating a complex of depression and anxiety in someone with a dependent personality type, and not without keeping in touch with scientific advanceÐbut individual judgment and case formulation remain indispensable clinical tools. Using these tools does not exempt the practitioner from being aware of the pitfalls of basing decisions about treatment on anecdotal case material, intuition, or subjective impression. On the contrary, working with a formulation that can be explained to others provides a check on the use of too much speculation and too many far-fetched inferences. Therapists need to speak about their patients' problems in many settings and contexts, and to do so can make use of any of the available systemsÐlabels, diagnoses, descriptions, and formulations. Labels (e.g., manipulative, hysterical, narcissistic, personality disordered) are efficient but can bring assumptions with them (and in these examples, assumptions that may not be to the advantage of the person being labeled). Diagnoses reflect agreed systems of categorization and for the most part are based on particular kinds of descriptions rather than

on theories. They may or may not be subject to the same disadvantages as labels. Formulations differ in that they bring together the products of theoretical knowledge and clinical judgment. Their theoretical basis reflects ideas about the factors that cause and maintain problems, and that precipitate or prolong particular episodes of distress. This theoretical basis provides a framework for the type of personal, individual formulation on which precise decisions about treatment can be based. Their advantages and disadvantages are discussed further below.

6.01.2.4 The Difference Between a Formulation and a Model Models are ways of conceptualizing particular disorders (e.g., the cognitive hypotheses of obsessive-compulsive disorder and of health anxiety described by Salkovskis (1996), or of formulating particular patterns of functioning (e.g., the role±relationship models developed by Horowitz, Eells, Singer and Salovey (1995) or the functional analytic causal model of Haynes, Uchigakiuchi, Meyer, Orimoto, and Blaine (1993). Models, as understood here, are constructed from a particular perspective, so there are separate cognitive models of panic disorder (Clark, 1988) and social phobia (Clark & Wells, 1995), and the psychopharmacological or interpersonal psychotherapy models of panic disorder differ from the cognitive model. These differences are valuable in that they stimulate useful research, as well as the development of sets of coherent treatment strategies. Using the cognitive model of panic disorder as an example, this would suggest that catastrophic misinterpretation of bodily symptoms plays a crucial role in triggering panic attacks, and that understanding this will help people who suffer from panic disorder to identify the symptoms that trigger their panics. They will then be in a position to think again about the meaning of these symptoms, and to reinterpret them in terms of (harmless but distressing) panic rather than of real, impending catastrophe. In order to facilitate the therapeutic process, the model has to be translated into a conceptualization (or formulation), and structured systems for doing this can be developed, as in this case has been done by Dattilio (1994). So the model provides guidelines for an individual formulation which encourages a new explanationÐthe leap in my heart could be a response to the coffee I have just drunk, or a normal arrhythmia that I notice more readily than I used to because it frightens me, and not a sign of imminent cardiac crisis. Although a model has implications for treatment, it differs from a formulation in that

Definitions: What is a Formulation? it operates at a different level of generality, and has a different content. So, the way in which a formulation applies to particular people will depend upon their personal history and circumstances. One person's panic may be triggered by leaps in the heart and another's by losing concentration when being spoken to (and a third may find that memories of traumatic incidents, flashbacks, or nightmares precipitate panic, possibly because they trigger associated sensations that then trigger the panic attacks). There will in practice always be exceptions to the rule, cases in which, for example, no sensational trigger can be identified. Then the clinician may be best advised to base the formulation on a higher level theory rather than on the specific modelÐin this case on the general theory that cognitions, including meanings, are closely related to feelings and behavior, and that changing one is likely to change the others. Thus the formulation illustrates, in ways that are clinically relevant, how the model applies, and does not apply, to the case. It assists the therapist in looking for particular theoretical constructs or processes (catastrophic misinterpretations in this example), and also in making a judgment about the degree to which the case is typical. Atypical cases arise when patients have more than one difficultyÐsocial anxiety as well as panic disorder for exampleÐor when they have especially complex or rare problems such as panic attacks in the context of avoidant or borderline personality disorder. Then, conceptually speaking, it may be more useful to draw on more than one model to construct a single formulation, or to look for models with a higher order of generality. Writing about psychodynamic formulation, Perry et al. (1987) point out that overlapping models of mental functioning may emphasize different aspects of development and psychopathology. They distinguish ego-psychological, self-psychological, and object relations models, and make the important point that a certain amount of trial and error may be needed in constructing a formulation that explains the presenting data: ªthe absence of a meta-model to explain all data makes this trial and error unavoidableº (p. 546). What clinicians are looking for in a formulation is a way of explaining and understanding the relationship between a patients' inner lives and their outer lives that is the product of their personal history, explains present difficulties, and guides future therapy. Their sources in this search include knowledge of diagnostic systems, of relevant theoretical models, and of outcome research, as well as information about the individual caseÐotherwise they would have to reinvent the wheel each time.

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6.01.2.5 Types of Formulation Typically, different therapeutic schools are thought to use different types of formulation. In general, behavioral and cognitive therapies make use of more mechanistic formulations, based on theories about learning and detailed functional analysis (Hayes & Follette, 1992), or on theories about processes such as the supposedly circular relationships between thoughts and feelings, and more dynamic therapies employ more narrative-based formulations, placing current problems in the context of a developmental history. Some systemic and experiential approaches to therapy adopt a third, essentially dynamic, approach, claiming that formulations have constantly to be reformed in the present, as therapy focuses on moment-to-moment events (Goldman & Greenberg, 1997). They also point out that the process of formulation can be dangerous and limiting when it makes use of preset categories and ideas. A constantly changing situation then appears to be fixed, and opportunities for change may be obscured (Eells, 1996; Rosenbaum, 1996). However, the process of formulation is still thought to be essential, and its main purpose is still to look for patterns and links that assist in understanding, and to provide ideas about how to bring about change. So, distinctions can be applied too rigidly. The developmental history of a problem or a person, or the narrative, is always relevant (Nicholson, 1995; White, 1989), although it may be understood in different ways, and so are ideas about the mechanisms that precipitate an episode of distress or perpetuate a problem. Overt differences between types of formulation are therefore relatively unimportant to an understanding of the term, and of the functions that the activity of formulating a case performs for the therapist.

6.01.2.6 Levels of Formulation When making a formulation, it is necessary to think at many different levels, and the number of levels postulated obviously varies with the theory being applied. Taking an example from cognitive-behavioural therapy (CBT) to illustrate the point, at the most superficial level, or the level of ªovert difficultiesº (Persons, 1989), the main task is to define the problems and the ways in which they are maintained, usually in terms of vicious cycles. Someone who feels depressed may withdraw from company, think about being all alone, and become increasingly depressed. Even such a simple formulation suggests a focus for interventionÐworking to

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Clinical Formulation

reduce the withdrawal. Thinking about the factors that precipitated the depression adds another level to the formulation. The person might have become depressed when their job required them to move to a new place, when they got divorced, or when their children left homeÐfactors that would demand different types of adaptation, to be promoted by the therapist in different ways. Stressors are additive, so many factors may be involved, and an apparently minor stressor may be the straw that broke the camel's back (and relatively irrelevant to the formulation), or it may reflect a particular personal vulnerability. Factors that predispose someone to become depressed, biological as well as psychological factors, add a further level, and the way in which these are understood, and formulated, will again influence the selection of interventions. At the most profound level of all, assuming that ªat some level it all makes sense,º the formulation is supposedly capable of reflecting the meaning of structures through which people interpret and think about, remember and recount, their experiences, and theoretical assumptions about the origin of these things. This is the standard way in which psychiatric formulations have traditionally been madeÐin terms mainly of predisposing, precipitating, and perpetuating factors. However, there are yet other levels to consider, reflecting social, cultural, and historical factors. Social assumptions (ªmen should not show their feelingsº or ªwomen are bad organizersº) influence the views of therapists as well as patients, and cultural assumptions may or may not be shared between therapist and patient. Some cultures, for example, do not share the common Western therapeutic goal of autonomy, especially for women. Others assume that a relationship between a professional person and their client is one involving activityÐor authoritative pronouncementsÐon the one side, and passivityÐor receptivityÐon the other. In addition, different hierarchies of values can interfere profoundly with the therapeutic process. An example in our culture is when someone thinks it more important to avoid giving offence than it is to tell the truth. Although it is never possible to stand outside all of these factors, making a formulation helps therapists to think about them, to identify them clearly, and to become aware of their potential influence on the interpretation of other people's circumstances. It can help therapists to ensure that the ways in which they understand problems and select interventions are not influenced by unwanted biases. Seen in this way, a formulation assists therapists in achieving a relatively objective stance.

Formulations are always made from a particular perspectiveÐin the author's case made (usually) from a cognitive-behavioral perspective, and from that of a White woman of a certain age, living in Britain now, whose ways of thinking have been formed by her own learning and experience. A formulation is neither about fitting information about a patient to a predetermined formula, whether that formula be derived from a general theory or from a more specific model, nor is it a personal judgment, though both things are relevant. It is about developing the kind of understanding of another person, their circumstances and their difficulties, that enables a therapist to apply the theoretical knowledge acquired during training to help that person. There is no single right way of making a formulation. The general aim is to map the territory so that one can then explore the possibilities for change, and not to let these be influenced by factors that are irrelevant to, or unwanted by, the person who is receiving help.

6.01.3 PURPOSES: WHAT A FORMULATION IS FOR One common view of the purpose of formulation is that it is for explaining the past, making sense of the present, and suggesting what to modify in order to influence the future. It can also be an important means of communicating understanding, either to the patient or to another professional, whether in the role of supervisor or colleague. However, its prime purpose is to help therapists to apply the theory they have learned to their practice (a comprehensive account of different approaches to formulation is given by Eells (1997). In practice, there are many answers to the question ªWhat is a formulation for?º The main functions of formulation are listed in Table 1. The main point is that making formulations is an essential, and not an optional, element of the therapeutic process. Formulations do not have to be 100% accurate or complete in order to be useful precisely because they provide a source of testable hypotheses. They can be changed when they turn out to be wrongÐand nothing is lost by using a partial or partially mistaken formulation which can be improved and corrected as the process of therapy continues, and reveals the initial mistake. They guide questioning, and open the therapist's mind to the kind of understanding from which effective treatment strategies can be derived, applied, and evaluated. Therefore, the author would argue, that therapists should work with a formulation in mind right from the start. Ideas about people and their problems cannot be kept at bay or

Purposes: What a Formulation is for excluded, even when first meeting them or reading a referral letter about them. One way of trying to ensure that this information is openly received and accurately assessed is to engage immediately in the process of formulationÐin applying both theoretical and clinical knowledge to the particular case. Just as when first visiting a new place, a rough sketch map may set one on the right road at first, but will need expanding and revising if it is to guide more detailed exploration. 6.01.3.1 Understanding: The Overall Picture or Map A formulation ªprovides the map of the territory and once you have that you can use whatever vehicle you are most comfortable withº (Beck, 1991). Formulations, just like maps, provide an overall view (often in diagrammatic, conventional form) of something that it is not possible to see directly all at onceÐthe wood as well as the trees. They indicate which are the important features, their size and shape, and the way in which they relate to each other. Mapping the territory is clearly the product of accurate assessment (see Section 6.01.4), and formulating enables therapists to make and to justify such statements as ªthis lack of energy is part of the depression,º or ªin this case the anxiety seems to be primary and the depression secondary.º Similarly, formulations can indicate where information is missing and prompt appropriate questions: where did this low self-esteem come from? Why does it become apparent in the context of close personal relationships but not at work? 6.01.3.2 Prioritizing Issues and Problems An overall formulation helps to differentiate what is essential from what is secondary in a general sense. It also helps in a more particular way to decide which issues or problems should be prioritized. Someone who believes that they cannot change is unlikely to remain engaged in

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therapy unless they can see the point of it. Creating hope, or the context for a developing relationshipÐsomething with a future, in which change is inherent and undeniableÐthen becomes a priority. Likewise, an initial assessment may indicate primarily that inability to trust people will make it hard to disclose distressing material, and building trust within the therapeutic relationship is necessary before a more detailed and accurate formulation can be made. It is probably not unusual for patients and therapists to start the process of therapy with somewhat different priorities. Usually this problem can be overcome during assessment and those early stages of therapy during which goals become clear or are specifically agreed. But sometimes different priorities persist, and then the process of re-formulating can help to solve the problem. For example, an anxious and hypochondriacal patient who was worried, among other things, about seeing ªfloatersº in his visual field, started to respond well to treatment that was formulated in terms of his underlying sense of vulnerability. The formulation reflected the way in which his various concerns made him feel threatened, and think that he was at risk for being unable to handle a number of initially rather vaguely specified distressing eventualities. However, although his confidence increased, his distress about the floaters did not diminish. If anything it increased, in tune, it must be acknowledged, with the therapist's frustration when discussing this issue became his main priority. Focusing the work of one session on the meaning or understanding of this problem revealed (for reasons which later became clear) that visual anomalies for this person felt, in his words, ªlike a bereavement.º Formulating this aspect of the problem in terms of loss rather than in terms of vulnerability changed the focus of treatment, which then became more productive. This example also illustrates how characteristics of the process of therapy can contribute to ideas about the formulation, especially in those cases in which change is not proceeding as well as might otherwise be expected.

Table 1 Summary of the purposes of formulation. Clarifying hypotheses and questions Understanding; providing an overall picture or map Prioritizing issues and problems Planning treatment strategies Selecting specific interventions Predicting responses to strategies and interventions; predicting difficulties Determining criteria for successful outcome Thinking about lack of progress; trouble shooting Overcoming bias

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Clinical Formulation

6.01.3.3 Planning and Selecting Intervention Strategies Once a hypothesis about how the presenting problem can be understood has been formulated, the most important functions of a formulation are in planning a treatment strategy and selecting appropriate methods of intervention. Persons (1989) provides some lucid examples: someone who avoids exercise because they are bad at time management, scheduling, or self-organization has a different problem to overcome, and needs to acquire different skills from the person who avoids exercise because they are embarrassed about their appearance; insomnia that is associated with the fear of letting go may require different interventions from insomnia that results from overcommitment. The way in which a problem is formulated thus determines what should be done about it (Blackburn & Twaddle, 1996; Butler & Low, 1994; Eells, 1997). If avoidance maintains the problem, then facing the fear is likely to reduce it, and in individual cases the formulation helps to specify idiosyncratic aspects of the avoidance (the spider phobic who will not walk under trees; the social phobic who is more fearful of silence than of conversation). The general vicious cycle model is common to bothÐand indeed, a standardized method of treatment of proven effectiveness, exposure in vivo, is readily available. The individual formulation is still necessary because it specifies exactly what steps to encourage the person to take. Planning overall strategies is just as important a product of formulation as the selection of specific methods of intervention, but is a more complex task, and requires of the therapist more than one level of understanding. The way in which depression or anxiety is understood may suggest, for instance, that it would be helpful to increase levels of activity before discussing thoughts associated with depression; or to build up a repertoire of coping skills before facing fears. Many such imprecations are based on clinical judgment (or clinical intuition) as much as on theoretical or experimental work, and in these cases it is especially important that they should be made clear by means of a formulation. For example, it is often said that when working with people who have suffered abusive experiences in childhood, one should help them to develop a variety of support systems, ways of dealing with intense feelings or suicidal impulses and of creating around themselves a sense of safety, before exploring memories of early traumatic experiences, and the meanings of such events, in depth.

Clearly, this overall strategy reveals assumptions about how the effects of these events can be understood, about the effects of talking about them, and the interventions usedÐ assumptions which formulations clarify, and which are potentially amenable to research, but which will differ according to the therapist's theoretical orientation. A secondary purpose of clarifying the formulation and its function in selecting strategies and interventions is to facilitate evaluation of interventions.

6.01.3.4 Predicting Responses and Difficulties Because a formulation reflects theoretical assumptions, it helps therapists make two kinds of predictions that are essential in therapy: to predict the effect of the intervention, assuming it is successfully applied, and to predict the stumbling blocks and difficulties that will be encountered during therapy. An anxious person treated during a clinical research trial (Butler, Fennell, Robson, & Gelder, 1991) held the belief that ªall my ideas are bound to be wrong.º She became more confident as she learned to identify her ideas, to act upon them, and consciously to evaluate the consequences of doing so. Her formulation enabled us to predict first that she would feel especially vulnerable and be likely to overgeneralize and catastrophize the consequences when she made mistakes, and second, that she was likely to find it especially difficult to apply the new strategy when relating to her partner, but easier to build up the necessary skills (and courage), and to increase her confidence, in the context of other relationships (including ours). Treatment in this case was guided by the requirements of a treatment manual, and the example illustrates the important role played by clinical formulation in the application of standardized treatments. It is probably true to say that interpersonal difficulties are one of the most common sources both of patients' problems and of problems encountered during psychological therapy; for example, an ability to form superficial relationships without being able to sustain deeper friendships, or veering between passivity and aggression when interacting closely with others. Such difficulties also play their part within the therapeutic relationship, and they are much more easily dealt with if the processes involved have been understood in terms of the theory being used, and problems predicted in advance. Formulating helps people to recognize such patterns, to develop hypotheses about their origins, functions and effects, and to think about whether and how to engage in a process of change.

Purposes: What a Formulation is for 6.01.3.5 Determining Criteria for Successful Outcome Theoretically a formulation provides the basis for hypotheses about what needs to change for someone to feel better, or the goals of therapy in the broad sense of the term. This is obvious when a theoretical model for the condition being treated is available, but the point applies more generally as well. The present version of the cognitive model of social phobia (Clark & Wells, 1995), for example, suggests that self-awareness, or self-focused attention, plays a central role in the disorder. In outline, when in a socially frightening situation a social phobic feels self-conscious, notices symptoms of anxiety and tries to keep safe. An individual formulation based on this model would specify the way in which this actually happens. For example, when speaking to others (e.g., colleagues during a lunch break), Marie became aware of the sound of her own voice, felt anxious, flustered, hot, and shaky, and found it hard to listen to what was being said. She thought other people must be able to see how nervous she felt and tried to fade into the background as quickly as possible (keeping herself safe by avoiding eye contact, saying little, speaking in a quiet voice). Both general and specific goals for change can be derived from thinking along these lines. In simple terms, if Marie can focus her attention outside herself, and listen without self-criticism to those around her, if she can reverse the safety behaviors (make appropriate eye contact, speak more audibly, move around freely), she will break the cycle and start to feel less anxious. The general criteria for change are reflected in the three elements of the model specified here, the selfawareness, safety behaviors, and symptoms of anxiety, and specific ones reflect the individual ways in which these factors are manifested in the case of Marie. Of course this might not be the whole story. Marie's social anxiety may be based on a belief in her own unworthiness relative to others, and reflect an unhappy history of family relationships. Such formulations again indicate criteria for changeÐa sense of worthiness or the ability to form more satisfying relationships in the present. The difficulty here is that more abstract and general phenomena are harder to identify, define with any precision, and measure than more superficial and specific ones. Criteria for change are therefore more easily derived from formulations at lower than at higher levels of abstraction, and indeed the more specific the formulation the easier it will be to be clear about what exactly needs to change.

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6.01.3.6 Thinking About Lack of Progress There are many possible reasons for lack of progress in therapy, including working without making a formulation. The first line of defence when this happens must be to formulate or to reformulate the problem. The way in which this is done will have specific implications for the next steps in therapy. For example, if the problem is a long-standing, chronic one, it may be that much practice is needed and that it is unrealistic to expect faster change, in which case it may be important to think about how to keep the momentum of change goingÐabout how to maintain hope and create the energy for change when doing so is difficult. If the original formulation was inaccurate or incomplete, the failure to change may suggest that different strategies and interventions are needed. When lack of progress leads to frustration, and the reactions of both the patient and the therapist interfere with subsequent progress, including these factors in the reformulation can reveal ways of overcoming them. Blocks in treatment are nearly always informative and formulation skills should be used to identify their specific nature. Often this is complex and involves making hypotheses about past events, the exact nature of which can never be known. Possible formulations in these circumstances, often derived from a combination of observation and understanding of the apparent effects of the past on the present, can suggest which avenues to explore so as to make further progress. For example, a patient who provided a cold and dispassionate account of a childhood in which she was neglected, often frightened and sometimes threatened with physical abuse, appeared to have developed a variety of ways of controlling both the experience and the expression of her emotions. Many, but by no means all, of these ways were dysfunctional. A possible formulation of this case suggests that improvement will remain blocked unless or until she becomes able to experience and express the relevant feelings. Doing this is likely in the first instance, to precipitate periods of distress, and the precise implications for therapy to be derived from it will depend on both the skill and the emotional sensitivity of the therapist as well as on a willingness to adapt the formulation according to what happens. Drawing these points together, it is clear that formulations cannot be treated as a matter of last resort, only to be constructed and worked on when the going gets difficult, when dealing with chronic problems, when treatment has apparently gone on too long, or when preparing to report to someone else. Formulations do not

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Clinical Formulation

provide the answers to questions, but a rich source of questions and ideas of potential therapeutic value. They should not become the tool for applying a preconceived theoretical plan to someone for whom the plan does not fit, nor should they focus exclusively on someone's problems and difficulties. Accurate formulation takes account of a person's strengths as well as failures, talents and potential, as well as shortcomings and failures. If formulations can be so useful it is surprising that so little attention has been devoted to them both within training programs and in the literature. One reason for this may be that formulations were supposed to follow logically from the processes of assessment and functional analysis, and additional skills were not often specified. A more important one is probably that formulating is difficult. As already indicated, in practice it involves exercising clinical judgment as well as the ability to relate theory to practice. Also, until recently, there was less communication between people with different theoretical backgrounds, and fewer challenges to think about alternative methods of formulating specific cases. So, the next important question is ªHow do you construct a formulation?º 6.01.4 METHODS: HOW TO CONSTRUCT A FORMULATION The main reason for considering the purposes of formulation before thinking about how it should be done is that there is no single correct methodÐhow you do it is in general determined by understanding the purposes that it serves, and in particular by the theoretical orientation of the therapist. The end product should enable the therapist to relate theory to practice in a way that can direct and inform the process of therapy, and the methods used vary enormously. For the student this is both confusing and liberating, as it demands creativity and the ability to deal with abstractions as well as the more mundane skills primarily involved in assessment. Assessment is a necessary step in the development of a formulation, but it is not a sufficient condition for it. Unfortunately, it is possible to assess, in the data collection sense, without developing a formulation. 6.01.4.1 Sources of Information An account of presenting problems, informed by knowledge of psychological processes and diagnostic systems, provides a common starting point, and assessment covers all of the four aspects of functioning illustrated in Figure 1 and their determinants: cognition (thoughts, as-

sumptions, attitudes, beliefs, images, etc.); affect, behavior, and physiological sensation; the present context for the ways in which these things are manifested; and an account of their background and associated developmental history. It also draws on information gathered during the process of referral, such as a summary of the problems as understood by the referrer, of the reasons for requesting help and of responses to treatment received so far, and on the impressions and observations made during the first encounter with the therapist when the processes of mutual interaction are set in motion. Therapists use many skills in helping them to understand this material: theoretical knowledge; products of academic learning and professional training; and clinical judgment. The process of encapsulating this understanding in a formulation, which at first takes time and becomes quicker with practice, is facilitated by adopting a questioning stance. The aim would be to be able adequately to answer three of the key questions that patients ask: Why me? Why now? What keeps it going? and in doing so it helps to draw on a further set of questions central to the process of formulation, which therapists can pose either to themselves or to their patients: How do you understand that (or make sense of it)? What do you think is going on? How does this all fit together? What might be the missing links? What does that mean about you now? Is there a pattern here? Formulations are useful in helping people to think again about their difficulties, and see them in a new (e.g., clearer, more realistic, or more illuminating) light, and the process of assessment potentially reveals the patient's present point of view. In order to develop an understanding of such personal and unique phenomena, it is particularly useful to pay attention to the ways in which people react to their experiences. Their comments provide a rich source of such informationЪI have to keep controlº or ªI need to know I am succeedingº are remarks that suggest hypotheses about the self and about underlying processes and mechanisms. Ideas expressed about others, such as ªshe'll be miserable aloneº may fit with assumptions that precipitate or maintain presenting problems. General comments of the kind ªyou have to conform or you can't get onº reveal attitudes that may (or may not) dominate within the real world in which the person lives. Expectations about the future, including those about the process and outcome of therapy, are also revealing: ªI won't be able to do what is needed,º ªThere are some things I would rather not talk about,º ªI'm relying on you to make me better.º In order to formulate, it is important to

Methods: How to Construct a Formulation understand the personal significance of experiences as well as their phenomenology. These comments illustrate well how the processes of formulation and assessment meet, and indeed may overlap. Therapists assess to find out about problems and their context, and they formulate differently according to what they think their findings mean. Patients' comments may need clarifying during assessment if they are to inform the process of formulation maximally. Statements that are apparently clear to the person expressing them may not be clear to the therapist, or may reveal ambiguities and contradictions, as when angrily saying ªI'm not capable as a parentº (when sadness sounds more likely and, superficially, more appropriate), or when commenting wryly that ªI felt sorry for myself,º without elaborating on what that means. One of the most useful sources of information for formulation comes from the mutual reactions of the patient and therapist to each otherÐ information that is used differently in different types of therapy, and which is understood using different theoretical systems, of varying degrees of sophistication, but which is always relevant. The processes of assessment and formulation therefore go hand in hand, and inform each other, but they remain different processes. Ideas about how to understand (conceptualize or formulate) what is being said, about its personal meaning and implications for theorized psychological structures and processes, guide questions and observations. When formulating as well as when assessing, the information gathered changes and shapes these ideas as hypotheses are formed, revised, and (theoretically) refined. So, making a formulation is not a one-off activity that defines a fixed state, but the reflection of a dynamic process, and the resulting system of understanding develops and changes over time. This is why the process of formulation should start at the same time as the process of assessmentÐjust as the process of finding ones way around a new place starts with the first encounter with itÐand may be on paper rather than in person. Two points that follow from this line of argument help to determine how a formulation is made. First, if therapists are always formulating as well as assessing, then their questions and statements should be guided by conceptual hypotheses. They should always be able to answer the question ªWhy did you ask that then?º The answer should not just be phrased in terms of curiosity or information gathering, but should relate to a hypothesis about how to understand the minutiae of the case. The patient's response to the therapist's comment or question is then maximally in-

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formative. This may sound unrealistically demanding, as if every sentence the therapist utters should be shaped by the developing formulationÐindeed, it is intended as a rule of thumb rather than as a categorical imperative. However, it is less unrealistic than it might seem. The initial question in the therapist's mind could be quite a simple one, for example: Is the withdrawal described by this person associated with feelings of depression and sadness or is it a kind of avoidance motivated by fear? Will attentive listening help this person feel sufficiently comfortable to disclose significant material? Are my questions too specific and intrusive at this stage? Answers to these questions could of course lead to more complex ones: Is this person's reticence a product of experiences that have destroyed trust? Does it reflect a preference for an autonomous style of relating to others? Is it a product of inexperience and lack of practice or opportunity in talking about intimate and personal matters? Is this way of interacting culturally unfamiliar to them? The second point is that the process of therapy should not be artificially separated into discrete stages of assessment, formulation, and treatment (or intervention). It is not that these processes cannot be distinguished, or that one or other of them may not predominate at a particular time, but that they cannot in practice be wholly separated from each other. Thus, one of the hardest tasks therapists have to learn is how to bear all three of them in mind at onceÐhow to gather information, think about it in theoretical/structural terms, and remain aware of the various ways in which they are likely to exert an influence, so as to enhance the potential for productive change, rather than limit or delay it. The many sources of information available to therapists when starting to develop a formulation, assuming an adequate process of assessment has been set in motion, are summarized in Table 2. This list includes both direct and indirect sources of information, information from standardized questionnaires, and from initial interventions such as self-monitoring and homework assignments (when these are used). The purpose of this summary, in the context of the preceding discussion, is not to overwhelm therapists with long and exhaustive lists of material to be gathered, items to consider, processes to complete, and so on, but to illustrate that there is an enormously rich source of relevant material potentially available, and the process of formulation can draw on any of it, beginning anywhere. The process of formulation is essentially one of abstraction and it works by relating observable phenomena to hypothetical underlying processes and mechanisms. It is not

14

Clinical Formulation

necessary to observe everything before making a guess at what lies underneath. An (informed) guess may either indicate the need for more assessment or it can short circuit the process. Because formulating is a dynamic process, and depends on the ability of the therapist to retain an open mind, the process can productively start to serve the functions listed in the previous section straight away. Therapists can focus their minds on the process of formulation by asking more formal questions: How can I understand the information I have been given in terms that make theoretical sense? What implications does that understanding have for what to do next? What difficulties will I have, working with this person? What difficulties will they have (working in this way) with me? What use will this person be able to make of treatment? Answers help to determine how to intervene and to predict what will or will not happen as a consequence.

6.01.4.2 Putting the Information Together Given that a formulation provides connecting links between theory and practice, the precise form that it takes will be partly determined by the theoretical approach of the person making it. Nevertheless, some general points apply, and these are illustrated here using the cognitivebehavioral approach. First, initial formulations can provide crosssectional understanding of an aspect of the presenting problem. The most obvious example is probably that of a vicious cycle which summarizes the way in which a particular, readily accessible, symptom pattern is thought to be maintained. It is used here to illustrate the way in which a formulation helps to specify processes, links, and mechanisms. In this case the focus is on certain kinds of links. Other cross-sectional formulations might focus on

other patterns, for instance in interpersonal functioning, sequences of behaviors and their consequences; thoughts, feelings, attitudes, and beliefs; dilemmas and traps. In this example (Figure 2), a woman living through a stressful period described feeling tired much of the time and being unable to relax. Asked about what goes through her mind when trying to switch off, she described a stream of worries, most of which were rather vague and hard to specify in detail. The worry disturbed her sleep pattern, which exacerbated the tiredness. A cycle, which symbolizes how one thing leads to another, can easily be illustrated diagrammatically, and it has obvious implications. Breaking the links will help to solve the problem, and this can be done in various ways, such as learning to relax, identifying and dealing with the worries, or taking hypnotic medication. The assumption behind the formulation so far is that the problem will subside if the process that maintains it is interrupted, and the intervention selected could be determined by the preferences, understanding, or skill of either of the parties involved. However, a formulation essentially relates theory to practice. Applying the cognitive model to this case would suggest that a close relationship between thoughts and feelings is likely to be of central importance. There are at least three ways in which this initial formulation, in its hypothetical and simplified form, can help the cognitive therapist to focus on factors that theoretically are likely to be relevant. It identifies worry as an important cognitivemaintaining factor, it reflects an overall understanding of the problem, suggesting that the symptom pattern is recognizable, understandable, and changeableÐattitudes which may differ strikingly from those the patient starts withÐand it poses questions about the context of the problem. Nothing has been specified

Table 2 The main sources of information for use in formulation. Examples of direct information Reports of present phenomena: cognitive, affective, behavioral, and physiological The context: historical background and development, real life problems Reactions, comments, and expectations, about the self, others, therapy, events, etc. Interactions within therapy: ability to relate, tenor of relationships Observations of body position, movement, facial expression, eye contact, etc. The outcome of interventions such as self-monitoring, homework assignments, behavioral experiments, etc. Products of questionnaires, tests, standardized interviews, systematic observation, etc. Examples of indirect information Knowledge about diagnosis: DSM Referral information: summaries, previous treatment, opinions Knowledge of cultural norms (of the therapist and of the patient) The socioeconomic and political context

15

Methods: How to Construct a Formulation

Under stress

Feel tired and unable to relax

Can’t sleep well

Figure 2

Worries keep coming to mind

Example of a simple cross-sectional formulation: basis for a more complex formulation.

about why this is, for this person, a stressful period. Theory-driven questions help to develop more hypotheses: What does it mean about her habitual response to stress? How does she construe her present situation? What does her reaction to it mean to herÐabout herself, about other people, and/or about the world in which she finds herself? So, the initial formulation triggers further inquiry, and starting from a simple cross-sectional map can lead to more sophisticated levels of understanding, and to more complex formulations, as well as being practically useful. The precise way in which this happens will be determined by the theory being used. Cross-sectional formulations can also provide an outline summary of the way in which complex underlying factors are understood, or of the way in which aspects of a problem are linked. Three statements made by an unemployed, unconfident young man with a wide range of social, interpersonal, and affective problems were used as the starting point for the initial formulation illustrated in Figure 3: ªIf I

always please others they'll never find out about me,º ªI'll be OK if I stick to doing easy things,º and ªPeople will reject you if you don't toe the line.º In this diagram, three aspects of his problem are represented in different ways. First there is a rather shapeless ªthought bubbleº at the top in which hypotheses about underlying cognitive structures, beliefs, attitudes, and rules about himself have been put into words: ªI'm incompetentº; ªI have to do what others askº; ªI'm thick (stupid) . . . º These actual words were his responses to specific (theory-driven) questions, and they illustrate how the process of formulation interacts with that of assessment, and depends on the ability to abstract and to generalize. The broken line is labeled a ªprotective wallº because it represents the idea that the three statements listedÐstarting points for a more detailed formulationÐreflect behaviors that serve a function. Reacting in these ways protects him from having to confront (the hypothetical) underlying beliefs and attitudes, and prevents others from discovering them, both of which would be painful experiences for

16

Clinical Formulation

him. However, these protective reactions cause problems, not specified here but referred to in the box in Figure 3. This formulation contributed to the process of developing a shared understanding of some complex problems, and it was used to explain how change would probably involve working at all three levels. It also has implications for decisions about general aspects of therapy. For example, it suggests that at times this will be a distressing process that will demand sensitivity and a good sense of timing from the therapist. Cross-sectional formulations potentially reflect ideas about psychological processes and

mechanisms as well as about the relevance and relative importance of different facets of a problem. Longitudinal formulations reflect assumptions about etiology as well. They are used in most kinds of therapy, and are readily illustrated in the case of CBT. The basis for using this theoretical model in clinical practice has been summarized in the form of a template (Table 3) which can be used to illustrate how theoretical understanding can be translated into practice. This shows that, theoretically, experience, both early in life and subsequently, gives rise to a set of beliefs and assumptions about the world, about other people, and about the self.

I’m incompetent I have to do what others ask I’m thick

Protective wall: “If I always please others they’ll never find out” “I’ll be OK if I stick to doing easy things” “People will reject you if you don’t toe the line”

Me with my problems

Figure 3

Example of a cross-sectional formulation.

Methods: How to Construct a Formulation These beliefs are seen as a product of the ways in which earlier events have been perceived, understood, and remembered. They can be functional or dysfunctional, actively influential or latent at any particular time, and relatively easy or hard to identify and to recognize. A critical incident (see also below) is an event that fits with a beliefÐbeing rejected for someone who believes they are not socially acceptable, or being let down for someone who believes that other people are unreliable or untrustworthy. Critical incidents activate the relevant beliefs and assumptions, and thus produce negative automatic thoughts (NATs). Then a variety of interacting cognitive, affective, behavioral, and physiological reactions follows. At this level the problem is theoretically maintained by cyclical processes of the kind summarized in the crosssectional vicious cycle described above. Clearly a template such as this can be used to structure information about a patient, and this will have implications for what the therapist does. For instance, if it appears that dysfunctional beliefs play a small part in the presenting problem, or are well balanced by a set of positive beliefs, the theory (and the formulation derived from it) suggest that the work should focus predominantly on the level of maintaining factors. Another type of implication might reflect the degree of verification available for the theory. For example, psychologists do not yet know which are the most effective ways of changing beliefs (the cognitive frameworks with which people approach the world). One common strategy is therefore to begin working at the level of the NATs and to evaluate the degree of Table 3

17

belief change that follows. The processes of change may, or may not, be set in motion by work at this level. If not, then another hypothesis might be that one of the many processes now available for changing beliefs should be adopted as well as or instead of. This example is not meant to explain how to do CBT, but to illustrate how the internal map provided by a theoretical understanding relates to a specific formulation, and how therapists can use such maps as guides even when there is incomplete evidence for the theories upon which they are based. Doing so enables them to explain what they have been doing, and it enables others to decide whether their actions were skilful, appropriate, and so on.

6.01.4.3 Key Factors and Basic Elements This example also illustrates that when learning how to construct a formulation, it can be helpful to think in terms of key factors. Critical incidents provide a good example of these as they reflect the way in which hypothetical underlying mechanisms are manifested, and link these with observations about present phenomena. Critical incidents are ªcriticalº because they provoke a high degree of affect, often in excess of what might otherwise be expected (an over-reaction, such as becoming enraged if kept waiting for 10 minutes); they are easy to notice and remember, and are of special significance for the person who experiences them. Examining them potentially reveals other elements of the CBT template: underlying

Template for a longitudinal formulation using cognitive-behavior therapy. Experience (early or otherwise) ; Beliefs, about the self, the world, and others, which are expressed in categorical statements: I am . . . ; the world is . . . ; others are . . . ;

Assumptions derived from beliefs, which can be expressed in conditional statements: If I . . . then . . . ; One should . . . otherwise . . . ; Critical incidents ; Activated beliefs and assumptions ; Negative automatic thoughts (NATs) ; : Cognitive, behavioral, affective, and physiological reactions

18

Clinical Formulation

beliefs, preferred coping mechanisms, maintenance cycles, and so on. Focusing on critical incidents is thus theoretically helpful when stuck in constructing a cognitive formulation. This is not to say that all cognitive therapists think about them, or base their formulations upon them. An alternative method might involve working from a problem list, weighting the problems for importance, and going on to abstract and understand the connecting themes and links in ways that fit with the theory. The point is that within a particular method of working there are many ways of constructing a formulation, but it can be helpful to keep those factors in mind which play a central part in the theory, or in revealing the manifestations of important theoretical constructs whether these are core beliefs, core interpersonal schemata, or core conflicts. To repeat, there is no single correct method. Use of the word ªcoreº suggests that formulations may be thought to have certain basic elements, and that unless these are identified the formulation will, in Perry et al.'s words, ªlack an integrative coherence.º When writing about psychodynamic formulation and about central conflicts, Perry et al. (1987, p. 546) say ªThe aim is to find a small number of pervasive issues that run through the course of the patient's illness and can be traced back through his or her personal history, and then to explain how the patient's attempts to resolve these central conflicts have been both maladaptive . . . and adaptive.º The overall intention is clearly closely similar across different therapeutic orientations, as is the general approach: first, apply a particular, theory-driven model; if that does not in practice fit the particular case, explore further using questions and trial and error in the (scientific) search for a formulation that fits better. This process might be facilitated if there was agreement over which were the basic elements of a formulation and an atheoretical way of linking them together. One way of doing this has been developed by Goldfried and his collaborators. This transtheoretical coding system ªwas developed as a common language for use in conducting comparative process research across orientationsº (Goldfried, 1995, p. 222). It specifies which are the relevant components of functioning (e.g., self-observation, self-evaluation, intention, emotion, and action) and the types of links that can be made between them (vicious cycles, patterns, contradictions). These can be manifested both in intra- and interpersonal contexts, involving other people or not, over a particular time frame. One advantage of this type of formulation, the coding system of therapeutic focus (CSTF), is that it

indicates what the problem is, and where to intervene, but (being atheoretical) cannot indicate how to do so. It cannot therefore provide specific implications for treatment, but it does provide a common language, and using this it is potentially easier to find out precisely how theories differ when put into practice.

6.01.4.4 Issue of Completeness The formulations illustrated so far have been kept simple for the sake of clarity, to emphasize the point made at the beginning about the principle of parsimony, and because they demonstrate the point that it is never too soon to start formulating. They are examples of initial hypotheses. As treatment progresses they would be likely to become more complex and also to take more account of a person's developmental history and the supposed underlying mechanisms. This raises an important issue for discussion. Many people assume that formulating is a difficult and lengthy process, the aim of which is to encompass, systematize, and explain all relevant factors about a particular case. This view can lead therapists either to bypass the process of formulation and start treatment straight away, or to delay the start of treatment until they have got the picture right. Both of these reactions cause problems: bypassing the process makes it hard to move beyond the stage of trial and error; interventions are selected in the absence of a coherent underlying strategy. This seems to be successful when the patient responds well (as many patients do initially), but it leaves both parties feeling confused and unable to understand what has happened when half a dozen sessions later progress is halted and setbacks are encountered. It is rather like trying to stop a car rattling by cleaning and adjusting those parts of the engine that are most accessible. Delaying the start of treatment is another false economy, for many reasons: the initial momentum provided by a fresh start and a new encounter may be lost; the impact of being listened to, heard, and understood by someone new may be dissipated; and the goodwill, advice, and new ideas derived from interacting with a trained therapist may not be harnessed in a way that is either helpful or informative (or both). So, opportunities to test hypotheses may be lost. In an ideal world therapists, believing that ªat some level it all makes senseº, would be able to use their formulations to make sense of the material presented in a particular case. But at present complete formulations, like complete theories, are not possible. A person cannot be

Methods: How to Construct a Formulation summarized in a diagram. But some of their problems and patterns of behaving can be understood in theoretical terms and this understanding can be represented in a way that helps to guide treatment. The complexity and accuracy with which this is done varies according to the stage of treatment. The emphasis on completeness that is often found in discussions about conceptualization may be a consequence of the historical associations between medical practice, psychiatry, and psychology, and the common use of the word ªtreatmentº to refer to the actions of people trained in those professions when they are trying to help others. The assumption is that it could be dangerous to miss something serious or to apply the wrong treatment. So, a complete understanding is supposedly an essential (or important) prerequisite for deciding how to intervene. The situation is different in psychotherapy (or psychological therapy), first because the psychological influence of one person on another cannot be withheld (as can a medical treatment), and then applied when ready, in a self-contained package. Various (partially unspecified) factors are always operating, and in psychotherapy the ways in which these function will to some degree be influenced by the theoretical views and assumptions of the therapist (as well as by their personal characteristics). The business of formulating can direct this process, clarify what is intended, and make the way in which theories are being applied accessible. Formulations do not have to be complete to perform this function but the method of working with them does have to be in place. Second, when dealing with psychological matters, the process of formulation is overtly interactive. Patients' comments and reactions contribute to the process; their opinions are relevant, and these may change over the course of treatment.

6.01.4.5 Conceptualizing Processes of Change Therapists seek understanding of the way in which change takes place as well as of the way in which problems arise and persist, and they may also formulate this understanding in theoretical terms. Conceptualizing the processes of change is thus another way of relating theory to practice, and formulations may be technical, phrased in terms that are derived from the particular theory being used, or metaphorical. Technical formulations might explain how changing reinforcement patterns would change behaviors, how change in one person will prompt the system around them to adjust, or how changing patterns of defensiveness might change opinions of the self. Examples of

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metaphorical formulations are provided in this section to illustrate how metaphors can encapsulate information about complex processes that may be hard to specify otherwise. Some examples are well known and their use has become quite conventional, such as ªa journey of a thousand miles begins with the first step.º Others are created in a particular therapy context. For example, a manager of an engineering company, whose habitual rigidity was exacerbated by various (personal and industrial) crises, saw himself as ªhanging on for dear life,º and being unable to contemplate change. He was asked to think about how to build a building to withstand an earthquake. Thinking about this enabled him to reconceptualize change as a way of developing the combination of flexibility and rigidity needed to provide stability in difficult times. Another relatively simple way of representing and summarizing a complex process of change was spontaneously developed by a woman with longstanding problems involving low selfesteem and lack of confidence. She saw herself as ªwobblyº and at risk of falling, as if trying to sit on a two-legged stool. The process of change for her was like ªputting down the third leg.º In practice this meant many things that contributed to a sense of stability: developing new skills and abilities, thinking about herself in new ways, and making more respectful and open relationships with those around her. People often use metaphorical language to communicate their experience of distress. Indeed, it might be more accurate to say that it is difficult to describe such experiences without using metaphorÐpeople explain to clinicians how they feel broken, trapped, fenced in, cast adrift, close to the edge, messed up, out of reach, cut off, high, low, and so on. Perhaps the most common methaphors describe life as a journey and ourselves as traveling through different kinds of emotional weather. Patients' understanding (or personal formulation) of the processes involved is also reflected in the words used to describe their experiences: ªI've hidden myself away . . . built a protective wall around me . . . had to harden my shell . . . can't see my way out of the tunnel . . . waited to be rescued.º It is hardly surprising that the processes involved in therapy are similarly described. Someone who came to understand the stultifying and self-destructive effects of overt compliance with the wishes of those around her, despite her own inclinations, and the relationship of this pattern of behavior to the fear and anger for which she was requesting help, said that she felt as if she had spent her whole life trying to grow flowers in her garden and cutting off the buds before they could flower. She saw

20

Clinical Formulation

therapy as a process that would help her to allow the flowers in her garden to bloom. Undoubtledly, the process of developing a shared understanding is a complex one, and the more abstract the material considered, the more difficult this process will be. Although a metaphor is not a formulation, and it may reflect only part of what is involved, using one can help to fulfill some of the purposes of formulation that were described above, and it can do so with a startling degree of economy and emotional sensitivity because it operates at more than one level. These examples have been chosen because they illustrate a point not so far emphasized about formulation, that it is a way of summarizing meanings, and of negotiating for shared ways of understanding them and communicating about them. When these are complex it can be helpful to use metaphor, and of course this applies generally, not just when formulating processes of change. A formulation provides a source of common language, and when this is available it can then be used to relate a theoretical framework, at a high level of abstraction, to practice, so as to facilitate the process of change. 6.01.5 ACCURACY: HOW TO TELL IF A FORMULATION IS RIGHT Formulations can never be shown to be right as they are hypotheses not statements of facts. The evidence may support them or it may not, and they should be judged according to probabilities rather than on an absolute scale of rightness. Like other scientific hypotheses, formulations can only be shown, conclusively, to be wrong. Nevertheless, practical guidelines are useful, and a number of attempts have recently been made to evaluate their inter-rater reliability and predictive validity (Barber & Crits-Christoph, 1993; Horowitz & Eells, 1993; Persons, Mooney, & Padesky, 1995). 6.01.5.1 Criteria of Accuracy A summary of the kinds of practical guidelines that might provide clinicians with criteria of accuracy is given in Table 4. Unfortunately, the fact that a formulation makes good internal sense (provides a plausible narrative for instance) is not a guarantee of its accuracy, which should therefore be tested out in practice. It goes without saying perhaps that a formulation which is simple, clear, and easy to understand, and therefore easy to explain, is more readily testable than one which is overly complex. One which is more specific and low level will have

clearer implications than one which is phrased in more general, abstract, and high-level terms. Presenting the formulation to someone else, or putting it onto paper, is therefore a useful and revealing exercise.

6.01.5.2 Questions for Research It would probably be fair to say that, of the many questions that could be asked, few have been studied and none have been conclusively answered. Persons, Padesky, and Mooney (1996) found only moderately good inter-rater reliability of cognitive-behavioral formulations when tapes of initial therapy sessions were rated by a large group of therapists who had been trained in CBT, and who varied in their level of experience. Surprisingly perhaps, agreement was better with respect to underlying mechanisms than in listing patients' overt problems. Barber and Crits-Christoph (1993) found, when reviewing the psychodynamic literature, that when clinicians based their formulations on preset categories, formulations were more reliable, and in addition the predictions of the psychotherapy process and outcome were better. Both these findings fit with the view that the more clearly specified the activity (as in CBT and interpersonal psychotherapy, or when using clearly defined conceptual categories), the less room there is for wide-ranging, speculative inferences, and the more agreement there is both about particular case formulations and about their utility. As discussed above, there has been some suggestion that making overall decisions about treatment purely on the basis of a diagnosis may be at least as useful as basing them on an idiographic formulation. However, a diagnosis only enables therapists to make general decisions about which set of interventions to employ; for example, to use exposure in vivo to help someone with a simple phobia, or those techniques that will assist in resolving a role dispute in a case of depression treated with interpersonal psychotherapy. In both cases the actual steps used will still depend on the way in which the individual case is formulated (Markowitz & Swartz, 1997). The question as to whether treatment that is based on a formulation is more successful than treatment that is not is more complex than at first appears. Most clinicians bring their theoretical knowledge to bear in the way that they understand, and communicate understanding about, a case. They use covert formulations, which may not be made overtly communicable even though they inform and direct the process of treatment. This happens because, once therapists are

Using the Formulation: Practical Issues

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Table 4 Ten tests of a formulation. 1. Does it make theoretical sense? 2. Does it fit with the evidence? (symptoms, problems, reactions to experiences) 3. Does it account for predisposing, precipitating, and perpetuating factors? (both overall and with respect to episodes of difficulty) 4. Do others think it fits? (the patient, supervisors, colleagues) 5. Can it be used to make predictions? (about difficulties, aspects of the therapeutic relationship, etc.) 6. Can you work out how to test these predictions? (to select interventions, to anticipate responses and reactions to therapy) 7. Does the past history fit (with respect to the person's strengths as well as weaknesses) 8. Does treatment based on the formulation progress as would be expected, theoretically? 9. Can it be used to identify future sources of risk or difficulties for this person? 10. Are there important factors that are left unexplained?

thoroughly familiar with the theoretical background to their work, and with the process of map-making, the activity of formulation cannot be wholly suspended. Once able to recognize signs of core beliefs or core conflicts, for example, such theoretically meaningful constructs cannot suddenly be rendered invisible again. Formulation skills may still need sharpening, and there is certainly a need for more and better training (Sperry, Gudeman, Blackwell, & Faulkner, 1992), especially now that clinicians appear increasingly likely to incorporate ideas from theoretical orientations other than their main one into their work (Messer, 1996b). The effects of working with (or without) a formulation will remain hard to evaluate. The more important question, in practical terms, is whether or not a particular way of seeing things is put to good use, successfully to do the things that a formulation is for. The struggle is to find a way of seeing things that helps. Although the assumption that ªat some level it all makes senseº still underpins much clinical work, it is not necessary to believe that there is such a thing as a ªcorrectº formulation. As Messer (1996a, p. 136) says, ªAn alternative outlook is that there is no one version of truth possible because we largely construct our realities, which inevitably leads to multiple perspectives on that reality. Wearing different glasses provides different views of the world.º

6.01.6 USING THE FORMULATION: PRACTICAL ISSUES A formulation does not have to be correct, but it does have to be useful. The purposes of formulation are discussed in Section 6.01.3. Here, three practical factors that influence whether a particular formulation succeeds in fulfilling its purposes are mentioned briefly.

6.01.6.1 The Value of Organizing and Clarifying Formulating is a way of classifying information, putting it into (conceptual) boxes, and drawing links between them. It organizes information, treatment strategies, and the choice of interventions, and it also clarifies understanding of a case, and therefore the meaning of what is observed. This process has some less obvious advantages as well as the obvious ones. In particular, it helps therapists to see problems and difficulties as understandable, and this influences their attitudes and expectations. For example, hostile or passive±aggressive behaviors frequently create frustrations and difficulties for therapists, especially when they persist despite all their best efforts. Organizing and formulating the information helps therapists to see these as characteristic and predictable difficulties for which they can plan appropriate strategies.

6.01.6.2 Developing an Internal Supervisor The process of formulation provides therapists with an opportunity to achieve on their own many things that otherwise they would achieve through supervision. It prompts them to reflect about their work with individual cases, and to rethink when progress seems blocked. It helps them to become aware of their own assumptions and beliefs, and to look out for ways in which these may cause problems, such as making it hard for them to notice, understand, or work with particular issues. It helps them to work well with unusual cases or with types of problems that they have not previously encountered. In doing so it helps to build confidence. Formulation is no substitute for supervision but, used well, it complements and extends itÐprovided that the formulation does

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Clinical Formulation

not become a fixed way of seeing things that obscures the significance of information that does not fit.

6.01.6.3 Communicating a Formulation Some obvious principles can be derived from the preceding arguments: the simpler the formulation, the easier it will be to communicate; it should be presented as a hypothesis, not as fact; and initial guesses are worth checking out as they can indicate whether a particular way of seeing things is likely to be productive. To some degree a formulation is a matter of judgment. It is based on clinical judgment as well as on knowledge and facts. As judgments about people are bound to reflect some of the attitudes and assumptions of the person who makes them, the question arises as to what should be done with those judgments. Who should be told about them? Are there people who should not be told, or circumstances in which they should not be disclosed? Answers to these questions are partly determined by practitioners' ethical guidelines and procedures for professional accountability. They also depend partly on the theoretical orientation of the therapist. In cognitive analytic therapy, interpersonal psychotherapy, CBT, and in some forms of short-term psychodynamic psychotherapy, therapists make their formulations explicit, and have therefore considered carefully how and when this should be done (Beck, 1995; Beck, Freeman, & associates, 1990; Butler & Booth, 1991; Markowitz & Swartz, 1997; Ryle, 1995). The method used is immensely variable, using imagery, metaphor, diagram, or verbal explanation, presented in person or in a letter. There is room here for creative thinking, and sensitive adaptation of communication skills, though it may help to specify some general principles. Being on the receiving end of a formulation can feel like being weighed up, evaluated, or judgedÐlike being ªseen throughº or ªrumbledº rather than understood. This is less likely if the formulation is presented questioningly and collaboratively, at a time when therapists are clear that patients are able honestly to give feedback, and while thinking about how to facilitate the process of feeding back reactions in a way that is not just superficial or polite. It is important to focus on strengths as well as weaknesses, and to draw out implications for change, otherwise patients with chronic problems may conclude that ªthis is the way that they are,º and become hopeless about change. The language used should be

simple and jargon free. It may help to give a small amount of information at a time and to be ready to repeat explanations, or introduce technical terms, as necessary. Therapists often underestimate how much patients can themselves contribute to the process of formulation, for instance, by elaborating details, filling in missing links, or providing contradictory information that shows how the formulation can usefully be adjusted. Formulation thus goes hand-in-hand with reformulation, and it is this, as Rosenbaum (1996) points out, that stops it becoming a way of ªfitting something to a known formula.º

6.01.7 CONCLUDING DISCUSSION Formulations reflect the way in which therapists make sense of someone else's predicament. They reflect the assumptions brought to bear when thinking about it, the theories learned, and the meaning made of it. However, making sense is not the only thing that they do. All therapists are aware that sometimes (albeit rarely) providing a formulation can be sufficient to bring about change. Such cases show that formulations do more than supply understandingÐthey enable someone to see things differently, to reformulate, or to find a new meaning. A business executive whose whole career was threatened by an episode of severe stress and anxiety was suddenly able to see himself as engaged in a genuine struggle. It was then legitimate, in his view, to experience reactions indicative of both fight and flight. His symptoms became acceptable, diminished immediately, and he remained well over the following six months. Of course this could be understood in many ways: as a healthy consequence of a reformulation, as a miracle cure, or as a flight into health. So therapists are also in a predicament. Most of the time only some of the facts are available to them, whether these are about someone's past life, their internal experience or their present relationships, and the facts that are available are consistent with a wide range of plausible interpretations. Different mechanisms can be inferred from the same event, as in the example above, or from the same overt problemsÐthe bather's hand movements could signify waving or drowning. Equally, the same mechanisms could be inferred from different problemsÐa fear of abandonment could underlie both hostile and dependent behavior. The skills of functional analysis may help to advance the process of formulation here. To end where we began, Frank (1986, p. 343) said that ªthe best hope of bringing conceptual order into the field

References of psychotherapy may lie in thinking of all psychotherapeutic enterprises as lying in the realm of meaningsº . . . thinking, feeling, and behavior are . . . ªresponses to the meanings of events as much as to the events themselves.º Our assumptions and knowledge about the ways in which these meanings are stored, represented, and recalled, and about the degree to which they can be brought into awareness, will therefore greatly influence the meaning we give to our formulations and the uses we make of them. Therapy can be understood in many waysÐas managing anticipated transferences, countertransferences, and resistances; as seeking new perspectives and using these to restructure a belief system; as a process of constantly meeting and adjusting to what is happening each moment; or as a way of influencing the contingencies that relate behaviors to their antecedents and consequences. In all of them, the process of formulation serves similar functions. It is useful because it helps to determine what we, as therapists, do and enables us to understand and to explain that better. 6.01.8 REFERENCES Barber, J. P., & Crits-Christoph, P. (1993). Advances in measures of psychodynamic formulations. Journal of Consulting and Clinical Psychology, 61, 574±585. Beck, A. T. (1991). Workshop on cognitive therapy of personality disorders. Brighton, UK: Royal College of Psychiatrists. Beck, A. T., Freeman, A., & associates (1990). Cognitive therapy of personality disorders (chap. 4). New York: Guilford Press. Beck, J. S. (1995). Cognitive therapy: basics and beyond. New York: Guilford Press. Beutler, L. E., Williams, R. E., Wakefield, P. J., & Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American Psychologist, 50, 984±994. Blackburn, I-M., & Twaddle, V. (1996). Cognitive therapy in action: A practitioner's casebook. London: Souvenir Press. Butler, G., & Booth, R. (1991). Developing psychological treatments for generalized anxiety disorder. In R. M. Rapee & D. H. Barlow (Eds.), Chronic anxiety and generalized anxiety disorder (pp. 187±209). New York: Guilford Press. Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991). A comparison of behavior therapy and cognitive behavior therapy in the treatment of generalised anxiety disorder. Journal of Consulting and Clinical Psychology 59, 167±175. Butler, G., & Low, J. (1994). Brief psychotherapy. In M. Pokorny & P. Clarkson (Eds.), A handbook of psychotherapy (pp. 208±224). London: Routledge. Clark, D. M. (1988). A cognitive model of panic attacks. In S. Rachman & J. D. Maser (Eds.), Panic: Psychological perspectives (pp. 71±90). Hillsdale, NJ: Erlbaum. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. K. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69±93). New York: Guilford Press. Dattilio, F. M. (1994). SAEB: A method of conceptualisa-

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tion in the treatment of panic attacks. Cognitive and Behavioral Practice, 1, 179±191. Eells, T. D. (1996). Commentary on three case formulations of Jim. Journal of Psychotherapy Integration, 6, 119±126. Eells, T. D. (1997). Handbook of psychotherapy case formulation. New York: Guilford Press. Frank, J. (1986). PsychotherapyÐthe transformation of meanings: Discussion paper. Journal of the Royal Society of Medicine, 79, 341±346. Freeman, A. (1992). The development of treatment conceptualisations in cognitive therapy. In A. Freeman & F. Dattilio (Eds.), Comprehensive caseboook of cognitive therapy (pp. 13±23). New York: Plenum. Goldfried, M. R. (1995). Toward a common language for case formulation. Journal of Psychotherapy Integration, 5, 221±244. Goldman, R., & Greenberg, L. (1997). Case formulation in process±experiential therapy. In T. Eells (Ed.), Handbook of psychotherapy case formulation. New York: Guilford Press. Hayes, S. C., & Follette, W. C. (1992). Can functional analysis provide a substitute for syndromal classification? Behavioral Assessment, 14, 345±365. Hayes, S. C., Follette, V. M., Risley, T., Dawes, R. D., & Grady, K. (1995). Scientific standards of psychological practice. Reno, NV: Context Press. Haynes, S. N., Uchigakiuchi, P., Meyer, K., Orimoto, L., & Blaine, D. (1993). Functional analytic causal models and the design of treatment programs: Concepts and clinical applications with childhood behavior problems. European Journal of Psychological Assessment, 9, 189±205. Horowitz, M. J. (1989). Relationship schema formulation: Role-relationship models and intrapsychic conflict. Psychiatry, 5, 260±274. Horowitz, M. J., & Eells, T. D. (1993). Case formulations using role-relationship model configurations: A reliablity study. Psychotherapy Research, 3, 57±68. Horowitz, M. J., Eells, T., Singer, J., & Salovey P. (1995). Role-relationship models for case formulation. Archives of General Psychiatry, 52, 625±632. Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books. Luborsky, L., & Crits-Christoph, P. (1990). Understanding transference: The CCRT method. New York: Basic Books. Markowitz, J. C., & Swartz, H. A. (1997). Case formulation in interpersonal psychotherapy of depression. In T. Eells (Ed.), Handbook of psychotherapy case formulation. New York: Guilford Press. Messer, S. B. (1996a). Concluding comments: Special section: Case formulation. Journal of Psychotherapy Integration, 6, 135±137. Messer, S. B. (1996b). Introduction to special section: Case formulation. Journal of Psychotherapy Integration, 6, 81±83. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Nicholson, S. (1995). The narrative danceÐa practice map for White's therapy. Australian and New Zealand Journal of Family Therapy, 16, 23±28. Norcross, C. A., Alford, B. A., & DeMichele, J. T. (1992). The future of psychotherapy: Delphi data and concluding observations. Psychotherapy, 29, 150±158. Padesky, C. A., & Mooney, K. A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13±14. Perry, S., Cooper, A. M., & Michels, R. (1987). The psychodynamic formulation: Its purpose, structure and clinical application. American Journal of Psychiatry, 144, 543±550.

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Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: Norton. Persons, J. B. (1993). Case conceptualisation in cognitive behavior therapy. In K. T. Kuelwein & H. Rosen (Eds.), Cognitive therapy in action. San Francisco: Jossey-Bass. Persons, J. B., Mooney, K. A., & Padesky, C. A. (1995). Interrater reliability of cognitive-behavioral case formulation. Cognitive Therapy and Research, 19, 21±34. Rosenbaum, R. (1996). Form, formlessness and formulation. Journal of Psychotherapy Integration, 6, 107±118. Ryle, A. (1978). A common language for the psychotherapies. British Journal of Psychotherapy, 132, 585±594. Ryle, A. (1990). Cognitive-analytic therapy: Active participation in change. Chichester, UK: Wiley. Ryle, A. (Ed.) (1995). Cognitive analytic therapy: Developments in theory and practice. Chichester, UK: Wiley. Salkovskis, P. M. (1996). The cognitive approach to anxiety: threat beliefs, safety-seeking behavior, and the special case of health anxiety and obsessions. In P. M. Salkovskis (Ed.), Frontiers of cognitive therapy. New York: Guilford Press. Schulte, D. (1997). Behavioural analysis: Does it matter? Behavioural and Cognitive Psychotherapy, 25, 231±249. Schulte, D., KuÈnzel, R., Pepping, G. & Schulte-Bahrenberg, T. (1992). Tailor made versus standardised therapy of phobic patients. Advances in Behaviour Research and Therapy, 14, 67±92. Seligman, M. E. P. (1995). The effectiveness of psychother-

apy. American Psychologist, 50, 965±974. Silbertschatz, G., Fretter, P. B., & Curtis, J. T. (1986). How do interpretations influence the process of psychotherapy? Journal of Consulting and Clinical Psychology, 54, 646±652. Sperry, L., Gudeman, J. E., Blackwell, B., & Faulkner, L. R. (1992). Psychiatric case formulations. Washington, DC: American Psychiatric Press. Stricker, G., & Trierweiler, S. J. (1995). The local scientist; A bridge between science and practice. American Psychologist, 50, 995±1002. Turkat, I. D., & Maisto, S. A. (1985). Personality disorders: Application of the experimental method to the formulation and modification of personality disorders. In D. H. Barlow (Ed.), Clinical handbook of psychosocial disorders: A step by step treatment manual. New York: Guilford Press. White, M. (1989). The externalizing of the problem and the re-authoring of lives and relationships. Adelaide, Australia: Dulwich Centre Newsletter, Summer, 5±28. Wilson, G. T. (1996). Manual-based treatments: The clinical application of research findings. Behaviour Research and Therapy, 34, 295±314. Wilson, G. T. (1997). Treatment manuals in clinical practice. Behaviour Research and Therapy, 35, 205±210. Wolpe, J., & Turkat, I. D. (1985). Behavioral formulation of clinical cases. In I. D. Turkat (Ed.), Behavioral case formulation (pp. 5±36). New York: Plenum.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.02 Behavioral Approaches JUÈRGEN MARGRAF Technische UniversitaÈt Dresden, Germany 6.02.1 INTRODUCTION 6.02.1.1 One Behavior Therapy or Many Behavior Therapies? 6.02.2 WHAT IS MODERN BEHAVIOR THERAPY? 6.02.2.1 Definition 6.02.2.2 Basic Principles 6.02.2.2.1 Principle 1: behavior therapy is based upon empirical psychology 6.02.2.2.2 Principle 2: behavior is problem-oriented 6.02.2.2.3 Principle 3: behavior therapy addresses predisposing, triggering, and maintaining problem conditions 6.02.2.2.4 Principle 4: behavior therapy is goal-oriented 6.02.2.2.5 Principle 5: behavior therapy is action-oriented 6.02.2.2.6 Principle 6: behavior therapy is not limited to the therapeutic setting 6.02.2.2.7 Principle 7: behavior therapy is transparent 6.02.2.2.8 Principle 8: behavior therapy helps the patients to help themselves 6.02.2.2.9 Principle 9: behavior therapy strives for continuous development 6.02.2.3 Hollywood or Realistic Expectations: Treatment Goals in Behavior Therapy 6.02.2.4 Underlying Methodology 6.02.2.4.1 Different types of behaviorism 6.02.2.4.2 Guideline 1: the search for lawfulness 6.02.2.4.3 Guideline 2: observability 6.02.2.4.4 Guideline 3: operationalization 6.02.2.4.5 Guideline 4: empirical testability 6.02.2.4.6 Guideline 5: experimentation 6.02.2.5 The Etiological Approach of Behavior Therapy 6.02.2.6 Typical Therapeutic Methods 6.02.2.7 Indications 6.02.3 HISTORICAL DEVELOPMENT OF BEHAVIOR THERAPY 6.02.3.1 Situation at Onset and Precursors 6.02.3.2 The ªFounding Periodº 6.02.3.3 The Influence of Operant Approaches 6.02.3.4 Consolidation and Broadening of Scope 6.02.3.5 Integration of Behavioral and Cognitive Approaches 6.02.3.6 Continuous Development and the Future 6.02.4 EMPIRICAL STATUS OF BEHAVIOR THERAPY 6.02.4.1 Problems in Empirically Approaching Efficacy 6.02.4.2 Results of Outcome Research 6.02.4.3 Consequences of Research Findings 6.02.5 PROBLEMS AND CRITICISMS OF BEHAVIOR THERAPY 6.02.5.1 Misunderstandings About Behavior Therapy 6.02.5.2 Scientifically Well Established, Practically Neglected? 6.02.5.3 Current Criticisms of Behavior Therapy 6.02.6 CONCLUSIONS

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6.02.7 REFERENCES

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Behavioral Approaches

6.02.1 INTRODUCTION More than most other psychotherapeutic approaches, behavior therapy has been the subject of misunderstandings. While the selfimage of behavior therapists and research results consistently yield the positive image of a pragmatic, problem-solving, empathic, and frequently successful approach, the outside perception is often quite negative. The scientifically oriented language of behavioral publications seems to have led some observers to the conclusion that behavior therapy is a highly technical endeavor that neglects human relationship factors. Indeed, surveys of the acceptance of behavior therapy (EschenroÈder, 1994; Heekerenz, 1991; Lutz, Bezold, Bloem, Dietrich, & Wittmann, 1992; Woolfolk, Woolfolk, & Wilson, 1977) frequently show negative judgments which often are more pronounced in persons that have little information on the approach. A remarkable example on attitudes toward behavioral approaches is given below. ªA rose by any other name . . . : Labeling bias and attitudes toward behavior modificationº Using this title, Woolfolk et al. (1977) published two studies, in which beginning and advanced students in educational sciences had been shown a film excerpt of a teacher who applied reinforcement methods. Half of the subjects had been told that the film would show the application of ªhumanistic methods.º For the other half, the method was labeled ªbehavior modification.º This simple labeling massively influenced the ratings of the teacher and the session. With the ªhumanisticº label, subjects in both studies rated the teacher significantly more positive, competent, flexible, and personally attractive. Moreover, they expected clearly better academic results and emotional growth from the ªhumanisticº method. The authors attribute their results to the negative effects of a frequently technical and mechanistic presentation of behavioral methods. In addition to external misunderstandings, there are also ªself-misunderstandingsº and discrepancies that result from the broad and frequently stormy development of the behavioral approach. Today, there are many different types and opinions about behavior therapy. For example, the classical approach of Joseph Wolpe is as different from modern cognitive-behavior therapy as is traditional progressive muscle relaxation from OÈst's applied relaxation or the early operant treatment of depression from Beck's cognitive-behavioral approach. The reasons for the misunderstandings on behavior therapy have been sought in the polarizing form of its early self-presentation, in a lack of information of the public, in feelings

of threat in the face of superior proofs of efficacy, in hostility toward rational science, etc. But regardless of their origins, the misunderstandings clearly show how important an explicit discussion of the nature of behavior therapy is. In the ªfounding phaseº there was a relative consensus on the definition of the term ªbehavior therapy.º It was generally agreed that this was the clinical application of the learning principles that had been established by psychological research (cf. Eysenck, 1959). However, behavior therapy was even in its beginnings a heterogeneous movement of considerable broadness. Feedback from growing clinical practice and vivid research quickly softened the classical learning theory understanding of behavior therapy. Together with the progress in the underlying psychological science, its claim to be theoretically founded and empirically tested generated an ongoing discussion. It is therefore hardly surprising that a large number of definitions has been proposed.

6.02.1.1 One Behavior Therapy or Many Behavior Therapies? Definitions of behavior therapy typically have varied with respect to the broadness of theoretical orientation and underlying methodology. Wolpe (1976) saw behavior therapy solely as methods that have been derived from experimentally established principles and paradigms of learning. Similarly, Eysenck (1959) understood behavior therapy as an attempt to change human behaviors and emotions based upon the laws of modern learning theory. According to Agras, Kazdin, and Wilson (1979), behavior therapy included already in the 1970s behavioral and cognitive approaches. Even broader, Hollandsworth (1986) saw behavior therapy generally as the application of scientific methods to clinical problems. In the same vein, Yates' (1970) influential definition emphasized that behavior therapy utilizes all the scientific knowledge accumulated in psychology and its neighboring disciplines. Among other important definitions were those by the Association for the Advancement of Behavior Therapy (see Franks & Wilson, 1975) and by Rachman (1988). The considerable variability of these definitions makes it even more important to ask what constitutes modern behavior therapy. An ªeternalº answer to this question is not possible. The mere attempt to answer this question ªonce and for allº would counterproductively institutionalize the status quo and impair future developments. The continuous evolution of

What is Modern Behavior Therapy? behavior therapy implies that the question about its nature has to be discussed at more or less regular intervals. The next section is therefore devoted to a characterization of modern behavior therapy at the end of its first half century of existence. This is followed by a brief sketch of its historical development in order to better understand its present position. Section 6.02.4 is devoted to the important question of the empirical status of behavior therapy and the practical consequences that this should imply. The chapter ends with a discussion of some of the problems and criticisms of behavior therapy in today's practice and research. 6.02.2 WHAT IS MODERN BEHAVIOR THERAPY? A mere definition is not sufficient to adequately describe the nature of behavior therapy (Margraf, 1996; Margraf & Lieb, 1994). Any meaningful characterization that is open to the future needs to discuss the basic principles, methodological position, and etiological approach that underly the behavioral approach. Moreover, the characterization could easily become a listing of abstract statements if it does not include typical treatment methods and their indications.

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orientation rather than as a single therapy school or group of treatment methods (Margraf, 1996; Margraf & Lieb, 1994). Modern behavior therapy can then be defined as follows: Behavior therapy is a broad psychotherapeutic orientation that is based upon empirical psychology. It includes disorder-specific and general treatment methods that aim at a systematic improvement of target problems on the basis of as much as possible tested knowledge of disorders and psychological principles of change. Interventions have concrete and operationalized goals on the different levels of behavior and experience. They are derived from the diagnosis of disorders and individual problem analysis and target the predisposing, triggering and maintaining conditions of the problem. Behavior therapy is continuously evolving and explicitly asserts to test its statements empirically. The levels of behavior and experience can be conceptualized in different ways. In behavior therapy, they are typically defined according to Lang's three-systems model (1971). This includes a behavioral, a subjective, and a physiological level of response. Although this model can be criticized in some respects (e.g., Fahrenberg, 1987), a multimodal approach has become the standard in most of behavior therapy research (SeidenstuÈcker & Baumann, 1987). 6.02.2.2 Basic Principles

6.02.2.1 Definition Behavior therapy is a genuine psychological treatment approach that includes a large variety of specific techniques and interventions. In clinical applications, these different methods are utilized either alone or in combination depending on the nature of the problem to be treated. Behavior therapy can therefore not be understood as a single, circumscribed treatment method that relies on one single theoretical model. On the contrary, its theoretical background is composed of a multitude of general and disorder-specific etiological theories and psychological models of change. The common link is the orientation toward empirical psychology. A future-oriented characterization cannot limit itself to a list of present methods. The definition of behavior therapy therefore has to fulfill the following requirements: (i) the theoretical and methodological breadth of the behavioral approach needs to be included; (ii) in spite of broad borders the specific aspects of behavior therapy have to be named explicitely; and (iii) openess for future developments. This has led me to the proposal to consider the behavioral approach as a broad basic

More important than the abstract definition is a concrete description of the basic principles that underly all of behavior therapy. These can be conceptualized as follows (Margraf, 1996). 6.02.2.2.1 Principle 1: behavior therapy is based upon empirical psychology Empirical psychology is the scientific foundation of the behavioral approach. Behavior therapy therefore endeavors to operationalize its theoretical concepts and therapeutic methods and to test them empirically. Testing should be comprehensive using objective, reliable, and valid measurements. In addition to psychological knowledge on change principles and methods, the findings of nonpsychological neighbor disciplines such as biology or medicine are taken into account. 6.02.2.2.2 Principle 2: behavior is problemoriented Treatment as a rule aims at present problems. Therapeutic proceedings are as much as possible tailored to the respective disorders and individual patients. Thus, different disorders are typically treated in individualized form with

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Behavioral Approaches

different methods that are based upon empirical knowledge of the disorder. Beyond the solution of the actual problem treatment typically strives for a general increase in problem-solving capacities. This can be achieved indirectly by making the therapeutic interventions transparent or by promoting new experiences and directly by problem-solving trainings.

They do not, however, ensure transfer into the patient's individual environment. For this, the patient has to practice newly acquired strategies between sessions. Although behavior therapists frequently accompany their patients for exercises outside of their office, the ultimate goal is always to master problems without therapeutic assistance.

6.02.2.2.3 Principle 3: behavior therapy addresses predisposing, triggering, and maintaining problem conditions

6.02.2.2.7 Principle 7: behavior therapy is transparent

Behavior therapy distinguishes between predisposing, triggering, and maintaining factors. Interventions target those conditions whose alterations are regarded as necessary for a durable solution of the problem. Often these are the maintaining conditions, because they are especially important for future well-being. With respect to predisposing and triggering conditions, most often their present effects are at the center of attention, because these types of problem conditions typically cannot be changed post hoc. 6.02.2.2.4 Principle 4: behavior therapy is goaloriented Identification of the problem and the joint definition of treatment goals are integrative parts of behavior therapy. The problem is the target of the treatment, its solution means that the goal of treatment is attained and the intervention can be terminated. Ideally, the explicit agreement on treatment goals should prevent the pursuit of different goals by therapist and patient or the subsistence of unrealistic expectations. 6.02.2.2.5 Principle 5: behavior therapy is action-oriented The success of most behavioral treatments presupposes an active participation by the patient. Mere insight is not a sufficient condition for the alteration of fixed problems. Behavior therapy therefore does not limit itself to the discussion and reflexion of problems, but motivates the patient to actively try new behaviors, experiences, and problem-solving strategies. 6.02.2.2.6 Principle 6: behavior therapy is not limited to the therapeutic setting Behavior therapy strives for a generalization of therapeutic effects on everyday life. The therapeutic setting and a good therapeutic relationship offer the framework for learning and testing new behaviors and experiences.

Behavior therapy wants its patients to be informed and active. A plausible model of the disorder, an explicit treatment rationale, and the intelligible explanation of all aspects of the therapeutic interventions are parts of behavior therapy that fulfill the legitimate need of the patients for an understanding of their condition. They elevate treatment acceptance and help to prevent relapse. Transparence thus increases compliance, comprehension of the treatment process, and indirectly problemsolving capacity. In this way, the acquired skills are better available for application to future problems without requiring renewed therapeutic assistance. 6.02.2.2.8 Principle 8: behavior therapy helps the patients to help themselves Beyond the increase in general problemsolving capacity and the transparent derivation of therapeutic actions from an explanatory model of the disorder, the treatment aims at giving the patient skills for the independent analysis and mastery of future problems. Behavior therapy thus increases the patient's self-help potential and prevents relapses and the development of new problems. 6.02.2.2.9 Principle 9: behavior therapy strives for continuous development Behavior therapy's orientation on empirical psychology leads to a permanent process of evaluation and further differentiation of its theoretical concepts and practical procedures. Behavior therapy therefore continuously evolves. 6.02.2.3 Hollywood or Realistic Expectations: Treatment Goals in Behavior Therapy What claims should or may psychotherapy make? Some patients and therapists pursue a ªhollywood perspective,º in which the end of treatment should be like the happy end of a movie. After successful cure the patient disappears from the therapist's office into his life

What is Modern Behavior Therapy? like the victorious cowboy from the movie screen. Although it has become an acknowledged triviality that for instance love stories end regularly when the relationships and thus new challenges begin, the image of permanent happiness shows an astonishing persistence in the ªtherapy market.º Yet, far-reaching explicit or implicit promises of entire restructuring of personalities, complete freedom from problems, ªimplodingº symptoms, everlasting happiness, and perfectly painless mastery of life are not only unrealistic but also harmful. Disappointed hopes are especially embittering. Compared to the hollywood standard, one's own achievements and experiences may look like failures. They pursuit of chimeras wastes energy and diverts from realistic coping. The more one believes in ªhealing promises,º the more dependent one gets. Psychotherapy cannot mean lifelong guidance. Realistic treatment goals therefore have to be coping and help to self-help. Even in complex problem constellations, therapy can at best attempt to teach new ways of coping and to identify cardinal points that can be used to break old habits. Psychotherapy can teach swimming, but the swimming has to be done by oneself.

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object of psychological science is exclusively seen in observable (overt) behavior (prominent advocate: Watson). (ii) Radical behaviorism (also called analytical behaviorism) is a version of radical materialism which asserts that the world consists only of one matter. Mental phenomena are regarded as mere linguistic illusions that can therefore not be the object of scientific psychology (prominent advocate: Skinner). (iii) Opposed to these two types is methodological behaviorism that defines itself not through statements about the existence of mental phenomena but through methodological guidelines that distinguish scientific from nonscientific procedures. Even though many representatives do not use the term, methodological behaviorism represents the majority in today's empirical psychology, including, for instance, cognitive psychology. The basic guidelines of methodological behaviorism as it is applied today in clinical psychology and psychotherapy can be summarized as follows (Margraf, 1996; Reinecker, 1994; Westmeyer, 1984).

6.02.2.4.2 Guideline 1: the search for lawfulness 6.02.2.4 Underlying Methodology Behavior therapy sees itself as an applied science whose understanding of science is strongly influenced by methodological questions. Being that part of logics that deals with the logics of research and methods in general, methodology is a central constituent of the theory of science. It makes statements about questions such as ªwhat is a hypothesisº or ªwhat is the goal of scientific research.º The methodology of behavior therapy is typically called ªmethodological behaviorism.º This may not be confounded with other types of behaviorism. 6.02.2.4.1 Different types of behaviorism The term behaviorism was from its early beginnings part of the struggle of paradigms in psychology. Coined by Watson in order to push his view of scientific psychology, the term was later used primarily by the opponents of Watson, Skinner, and their followers. The intense debate frequently overlooked that there is not a single type of behaviorism; instead there are several competing positions. The most common classification differentiates three types of behaviorism. (i) Methaphysical behaviorism denies the existence of consciousness or mental events. The

The goal of scientific work is to find lawful relationships that permit description and explanation of the subject of investigation. ªLawsº do not have to be deterministic, probabilistic statements are also recognized. As a rule, different classes of causes are distinguished, although functional relationships traditionally have attracted most attention (see Section 6.02.2.5).

6.02.2.4.3 Guideline 2: observability Only observable events or phenomena that are regularly related to observable signs can be subject of scientific analyses. This does not imply the restriction to observable motor behavior as the exclusive subject of psychology. Today behavior and experience are the widely recognized subjects of the discipline. Interestingly, even Skinner did not refuse introspection as a method if it fulfilled the above requirement.

6.02.2.4.4 Guideline 3: operationalization Assessment of the subject of research has to be guided by explicit measurement instructions. Theoretical constructs have to be operationalized, that is, it must be stated in what way they are represented in variables that can be assessed empirically.

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Behavioral Approaches

6.02.2.4.5 Guideline 4: empirical testability Hypotheses principally have to be accessible to empirical testing, and they must be sensitive to experience. Immunizing strategies that attempt to make theoretical statements irrefutable are unacceptable because they prevent possible progress in scientific knowledge. Testing of hypotheses can operate through confirmation or refutation. Under the influence of Popper the possibility to falsify general hypotheses (ªfor all X is true . . . ,º e.g. ªall mental disorders derive from learningº) has gained great importance. Also relevant is the verification of hypotheses of existence (ªThere are some Y, for whom is true . . . ,º e.g., ªsome phobias are acquired by classical conditioningº). 6.02.2.4.6 Guideline 5: experimentation The best method to test statements is offered by controlled experiments (which do not necessarily have to be conducted in the laboratory). For ethical and pragmatic reasons, the experimental method has clear limits in clinical research. Often important variables cannot be varied arbitrarily as would be implied in a true experiment. Thus, it is ethically unacceptable to induce mental disorders for experimental reasons. At the most, weak experimental analogues for pathological states may be induced transitorily (e.g., hallucinations, sensorical deprivation, anxiety states, false feedback of performance). However, the question for the ethically acceptable limit has to be answered for each individual case. The opposite approach to reduce pathological states or to treat mental disorders also bears ethical problems when conducted in an experimental frame. For instance, randomization of patients to treatments presupposes informed consent. Therefore, research often has to rely on quasiexperimental designs.

behavioral or psychological syndromes or patterns that are accompanied by distress, disability, or reduced functioning on the behavioral, subjective, or social level. It is important to distinguish between different classes of ªcausalº factors and to investigate their relevance to therapeutic change. The basic approach of behavior therapy differentiates between three major classes of etiological factors: (i) Predisposing factors: These are also called vulnerability factors or diatheses. Pre-existing genetic, somatic, psychological, or social characteristics make the appearance of a disorder or problem possible or more probable. (ii) Triggering factors: Psychological, somatic, or social conditions (e.g., experiences, burdens, demands, events, ªstressº) elicit the first occurrence of a disorder or problem under the possible influence of an individual vulnerability. (iii) Maintaining factors: False responses (by the subject or its environment) or lasting demands prevent the quick reduction of the complaints and make the problem chronic. This ªthree-factor modelº (Margraf, 1996) is not meant to be an all-inclusive explanation of mental disorders. Instead, it is seen as a heuristic to help etiological research, the judgment of possible starting points for therapeutic change, and the formulation of individual models of pathogenesis. The three classes of causal factors can coincide or differ completely, they can be more or less accessible to change, etc. For instance, predispositions frequently cannot be changed or problem-evoking traumata typically cannot be undone. The modification of maintaining factors in contrast is often the central mechanism of change for future well-being. Behavior therapy therefore addresses exactly this point (e.g., reduction of avoidance behavior in phobias, training of social skills in schizophrenic or depressed patients).

6.02.2.5 The Etiological Approach of Behavior Therapy The time of the ªgreatº monistic theories to explain all mental disorders by one cause or constellation of causes is over. It has become obvious that such complex phenomena cannot be explained by simplistic or reductionistic ªsolutions.º Today, slogans such as ªbiopsychosocial approachº or ªvulnerability±stress modelº dominate the debate. These, however, can be criticized for being overly unspecific or lacking concrete content. The behavioral approach attempts to identify specific causal constellations for individual disorders. Mental disorders are regarded as clinically significant

6.02.2.6 Typical Therapeutic Methods One reason to conceptualize behavior therapy as a basic therapeutic orientation rather than as a single therapeutic school is the large number of often remarkably different methods that characterize the behavioral approach. Three classes of methods have to be distinguished. (i) Basic skills that apply to the therapeutic dialogue, the therapeutic relationship or treatment motivation. Although behavior therapists in clinical practice typically display high levels of relationship skills, they neglected to present

What is Modern Behavior Therapy? these basic aspects in their early writings. This may have contributed to the overly technical image of behavior therapy. Today it is clear that a good therapeutic relationship is typically a necessary although not sufficient condition for therapeutic success. (ii) General therapeutic methods that do address specific disorders. These are methods that every behavior therapist has to know and that need to be incorporated flexibly into individual treatment plans. A list of these methods is given in Table 1 (left column). Several of these methods have been the backbone of behavior therapy in its early beginnings (e.g., systematic desensitization, self-assertiveness training, relaxation training). (iii) Disorder-specific treatment programs that are tailored as much as possible to the specific characteristics of the different disorders. Such programs came later in the development of behavior therapy. Today, they have been developed and tested for most important mental disorders. Ideally, they rely upon psychological knowledge of the disorders and general change principles. Most widely disseminated are programs for various anxiety disorders, depression, schizophrenia relapse prevention, eating disorders, sexual dysfunctions or marital problems in adults, or enuresis, hyperactivity, and aggressiveness in children. A list of exemplary programs is also given in Table 1 (right column). Most of the general and disorder-specific methods are supported by detailed treatment manuals and a sufficient body of empirical research on efficacy. The mechanisms of change are often less clear. This question forms an important focus of process research in behavior therapy.

6.02.2.7 Indications The last important aspect that is needed for a sufficient characterization of behavior therapy are the indications or prescriptions for its application. Decisions about indication are made every day and in every type of therapeutic activity. This begins with the question whether treatment is at all indicated, continues with the choice between different treatment methods and their adaptation to the individual, and stops with the decision about termination. Indication decisions thus deal with the optimal fit between patients and treatments (and other conditions such as therapists, settings, etc.). Unfortunately, only a small proportion of these decisions are made by psychoherapists. Typically, it is the patient, his relatives, his physician, his health assurance, or other lay institutions that decide

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whether and what kind of psychotherapy is sought. Moreover, even in the case of psychotherapists these decions are often made in implicit or irrational ways. For example, one does what one has learned or what fits into one's therapeutic ideology. Empirically-based decisions are the exception rather than the rule in much of psychotherapy. This situation is partly due the research problems that make a fully satifactory scientific solution of the question of differential indication impossible. The most popular version of this question was formulated by Paul (1966, 1967) as early as 1966: ªwhich is the most effectice treatment for this individual with this specific problem, by whom and under which circumstances?º A complete answer to this question would involve large experiments with factorial designs that combine all factors. Considering the number of combinations, this is illusory. On the other hand, indication decisions cannot be avoided in clinical practice. Behavior therapy therefore pragmatically considers soluble partial questions. First, it is asked whether psychotherapy is at all indicated, then what type of treatment should be applied, and how it should be adapted to the individual case. For practical reasons, clinicians need to consider not only specific scientific knowledge but also sometimes untested assumptions, individual practical experience, expert or colleague opinions, and everyday practical knowledge. In this context, a very important achievement of behavior therapy is the development of disorder-specific treatment programs (Task Force, 1995). In its beginnings, behavior therapy meant to a large degree the application of general psychological (learning) principles to the individual case. Therapeutic procedures were therefore typically described in the rather abstract terms of general principles. Over the course of time, procedures were described in more concrete details. This led to the development of treatment manuals which were written for groups of patients rather than for individual cases. After its publication in 1980, the Diagnostic and statistical manual of mental disorders (3rd ed., DSM-III) and its succesors rapidly became the the basis for grouping patients. Standard programs for diagnostic groups often proved very efficacious in empirical testing. Thus, modern behavior therapy has two bases for its decisions: the general characteristics of the disorder and the individual characteristics of the patient. The pragmatic approach of behavior therapy to the difficult issue of differential indication can thus be summarized as follows: for specific disorders or problem constellations those methods should be preferred whose efficacy

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Behavioral Approaches Table 1 Overview of typical cognitive-behavioral treatment methods.

General methods

Disorder-specific programs

Exposure-based methods Systematic desensitization Flooding Response prevention Operant methods Positive reinforcement Extinction Response cost Time out Token economies Cognitive methods Self-instruction training Problem-solving training Modification of dysfunctional cognitions Reattribution Analysis of erroneous logics Decatastrophizing Modeling Social skills training Self-control methods Self-observation Self-reinforcement Stimulus control Multimodal therapy or broad-spectrum therapy

Agoraphobia Social phobia Specific phobia Panic disorder Generalized anxiety disorder Obsessive-compulsive disorder Post-traumatic stress disorder Depression Anorexia nervosa Bulimia nervosa Obesity Hypochondriasis and health anxiety Somatization disorder Somatoform pain disorder and chronic pain syndromes Schizophrenia Sexual dysfunctions Marital problems Hyperactivity and attention deficit disorder Aggressiveness Autism

has been validated empirically. Based on a detailed problem analysis and the course of treatment, standard interventions should be adapted to the individual case. This should take individual strengths and weaknesses, personality, life situation, and setting variables as well as possible interactions of these factors into account. The decision to apply a specific treatment program presupposes competence in the diagnosis of disorders and the analysis of problem constellations. The mutual completion of classificatory diagnosis and problem analysis is therefore the basis for rational indication decisions in behavior therapy. The explicit question for the optimal therapeutic method for a given disorder as well as the offer of concrete alternatives for disorder or problemoriented indication decisions are specific characteristics of modern behavior therapy. Examples of the various mental disorders for which treatment programs have been developed can be taken from Table 1 and Table 3. 6.02.3 HISTORICAL DEVELOPMENT OF BEHAVIOR THERAPY 6.02.3.1 Situation at Onset and Precursors Knowledge of the past may help understanding of the present. Behavior therapy

evolved from the application of the principles of experimental psychology to clinical problems (Kazdin, 1978; Schorr, 1984, 1995). Its growth was closely related the development of clinical psychology as an applied science. Although there had been sporadic early clinical applications of psychology (e.g., the case of ªlittle Peterº [Jones, 1924a, 1924b] or the early treament of enuresis [Mower & Mower, 1938]), a broad movement started only in the middle of the century when two conditions came together: (i) The enormous productivity of basic research on learning theory explications for clinical phenomena had become obvious (e.g., Mowrer's two-factor theory of phobias, research on experimental neurosis, Solomon and Wynne's work on traumatic conditioning, Dollard and Miller's experiments on originally psychoanalytic concepts). These findings demanded for clinical application and testing. (ii) There were strong criticisms of the low efficacy of the then available psychotherapeutic (i.e., psychoanalytic) methods and their poor empirical basis (e.g., Eysenck's criticism of psychoanalysis [Eysenck, 1952]). Such a fundamental critique immediately posed the question of alternatives. These of course were regarded especially critically by those who had been attacked before and thus received particular attention.

Historical Development of Behavior Therapy It was at this time that research groups in South Africa, England, and the USA at first independently reported great successes with learning theory-based methods in the treatment of anxiety and other clinical problems. Together with the two other named conditions these startling outcomes of the new, at first experimental methods gave the impulse for a development whose breadth and dynamic until today have no parallel in psychotherapy. 6.02.3.2 The ªFounding Periodº While England and the USA are widely regarded as the origin of behavior therapy, the contribution of South Africa is still underestimated although this is where many of the founding personalities of behavior therapy started their careers. The first publication of the term ªbehaviour therapyº in a scientific journal took place in the South African Medical Journal (Lazarus, 1958). Since the end of the 1940s and during the 1950s Joseph Wolpe tried to bring together learning theory and neurophysiology at the University of Witwatersrand. This was consistent with his training as a physician with central interest in learning psychology. Wolpe had been influenced by the American work of Masserman on experimental neurosis and by Salter on ªself-assertiveness training.º In South Africa he worked with psychologists such as Stanley Rachman and Arnold Lazarus who together with their compatriotes G. Terence Wilson and Isaac Marks belong to the most prominent founders of behavior therapy. In such groups experimental research was discussed and therapy sessions were ªsupervisedº and observed through one-way mirrors. In his research on ªexperimental neurosisº in cats, Wolpe developed new techniques to eliminate experimentally induced fear and avoidance. Based upon the notion that conditioned fear and food intake should be antagonistic and thus inhibit each other reciprocally, he assumed that feeding could be used to reduce fears resulting from specific situations. Wolpe demostrated this successfully in his animal subjects by systematically decreasing the distance between the feeding place and the place where fear had been conditioned using electric shocks. In an article entitled without modesty Reciprocal inhibition as the central basis of psychotherapy, Wolpe (1954) postulated reciprocal inhibition as a universal principle: ªFear reduction is achieved if fear inducing stimuli are presented together with stimuli that produce a dominant antagonistic response to fear (i.e., reciprocal inhibition).º To make certain that inhibition was stronger, he presented fear-

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inducing stimuli with increasing intensity, that is, in hierachical order (ªfear hierarchyº). In extending his results to humans, Wolpe primarily considered three response domains for reciprocal inhibition: sexual, assertive, and relaxation responses. Most widely employable seemed a modified version of Jacobson's (1938) progressive muscle relaxation. Wolpe believed relaxation and eating to lead to similar neurophysiological effects. In order to reduce fear responses by reciprocal inhibition, Wolpe first taught his patients progressive muscle relaxation and then encouraged them to go through their feared situations step by step while staying in the relaxed state. Originally Wolpe used exposure in vivo (i.e., in real life situations), but then he employed imagined situations (in sensu) because these were easier to realize and were better controllable. In addition, patients completed comprehensive homework in vivo (i.e., practiced in their natural environment) between therapeutic sessions. He called this approach ªsystematic desensitizationº and described it in his classical book Psychotherapy by reciprocal inhibition, (Wolpe, 1958) that was published by Stanford University Press in the USA after a recommendation by Albert Bandura. Systematic desensitization probably still is the most famous treatment method in behavior therapy, although there are now more effective methods for many clinical problems and reciprocal inhibition theory has been shaken by contradicting evidence. Wolpe's formulation of a theory on the basis of testable hypotheses with the goal of clearly defined treatment strategies for minutely described clinical applications had a tremendous impact on the development of behavior therapy. Many of the important actors of the South African behavioral scene pursued their work in the United States and England. Wolpe's publications came at a time where the efficacy of the psychoanalytic approach was severely attacked. Especially Eysenck's (1959) controversial argument that the success rates of psychotherapy (then largely identical to psychoanalytic therapy) were not better than spontaneous remission, that is, the percentage of improved patients was not higher with psychotherapy than without it, yielded vehement debates. It is not surpsing then that Eysenck's department was the European cradle of behavior therapy. Head of the famous Institute of Psychiatry at the Maudsley Hospital in London was Aubrey Lewis, a strong advocate of the relevance of psychological research for psychiatry. In 1950 he made Eysenck the first head of a psychological department of this leading institution. Soon collaborators such as Gwynne Jones, Victor Meyer, Aubrey Yates, or M. B. Shapiro

34

Behavioral Approaches

were interested in the application of conditioning theories to psychological problems. This group knew Wolpe's publications more than the operant work of Lindsley in the USA. Single case experiments and theoretical seminars that were at first purely diagnostical were soon extended to therapeutic topics. As early as 1957 Meyer emphasized the importance of a good relationship between therapist and patient for exercises in vivo. The first clinical application of a behavioral approach at the Maudsley Hospital occurred more or less by chance (Schorr, 1995). When drinking coffee with a medical student, Gwynne Jones and M. B. Shapiro discussed a patient that had been treated psychotherapeutically without success. The young dancer was unable to work because she had to urinate very frequently which had in the meantime led to secondary anxiety responses and a lack of self-confidence. The conversation led to the idea to attempt a new treatment approach using conditioning techniques. A combination of systematic desensitization in vivo for the main complaint and a stepwise training in vivo for the other anxiety responses outside of the hospital brought a treatment success that proved durable at fiveyear follow-up (Jones, 1956, 1960). In the 1960s the application of learning-based treatments was advanced at the Maudsley Hospital by Rachman, who had before worked with Wolpe and now had good contact with the psychiatric side of the Maudsley (personal communication by H. J. Eysenck, September 1995). Rachman played a central role in the development of aversion therapy (Rachman & Teasdale, 1969) (which was soon to be given up again), behavioral medicine, and the treatment of obsessive-compulsive disorder (Rachman & Hodgson, 1980). Other colleagues in hospitals in London and Oxford (Warneford Hospital) such as Gelder, Marks, and Mathews developed and tested exposure treatments for phobias. At the same time American researchers such as Davison (1968) investigated the process of desensitization and other anxiety reduction techniques in detail. They came to the conclusion that exposure in vivo was the most important and effective component of treatment (see also Kazdin & Wilcoxon, 1976). An important reason why behavioral approaches gained influence in the treatment of anxiety-related problems so fast was the fact that their efficacy was tested systematically in controlled studies. One such study that set standards for psychotherapy research was presented by Paul in 1966. In addition to the treatment of anxiety, such diverse problems as writer's cramp, tics, and stuttering were addressed. An important ele-

ment were the publications by Shapiro (1961) on experimental single-case methodology. Clinical single-case experiments typically involve a series of measurements of a clinically relevant variable in regular intervals (time series). At a predetemined point in this series an intervention is made and the effect of this intervention is then assessed by looking at the changes in the measured variable. In this way, the effects of most intervention strategies can be determined. Later, complex experimental designs were developed (see Barlow & Hersen, 1984) that made it possible to apply single-case experiments to a large number of clinical and scientific problems as a part of everyday work. Although this method is not limited to the behavioral approach, it has a close tie to it and plays an important role in its ongoing development. At the end of the 1950s and the beginning of the 1960s behavior therapy offered already a broad scope of therapeutic methods on the basis of experimental psychology. These became fast known outside the inner circle of active researchers. Important for the dissemination were publications and the international appointments of ªfounding personalitiesº to universities and clinical institutions. The volume Behaviour therapy and the neuroses edited by Eysenck in 1960 already included contributions from the USA, the UK, South Africa, and Czechoslovakia. In the early 1960s, Wolpe, Lazarus, and Cyril Franks accepted professorships in the USA. In 1963 Eysenck founded the journal Behaviour Research and Therapy, whose editor later became Rachman. At this time the new movement became known under the name ªbehavior therapy,º although alternative terms (e.g., ªbehavior modificationº which was preferred by the promoters of operant methods) existed and some prominent participants simply wanted to add explanatory elements to the traditional ªpsychotherapyº (e.g., Wolpe's ªpsychotherapy by reciprocal inhibitionº). It is hardly possible to determine who really first coined the term behavior therapy. This is primarily due to the fact that there was no single ªfounding father.º Instead, the behavioral approach developed as a relatively broad movement simultaneously in several places in South Africa, England, and the USA. For the same reason, only a starting period but not a single starting date can be given. The development as a broad movement based upon empirical psychology differentiates behavior therapy from all other forms of psychotherapy. These were regularly ªinventedº by single charismatic personalities with more or less distance to scientific psychology. It may be argued that behavior therapy's type of origin already contains the nucleus for the development of a

Historical Development of Behavior Therapy broad ªbasic orientationº rather than a narrow ªtherapy school.º At the same time this origin can also be seen as an important protection against dogmatic immobility and as an impetus for continuous development. Better than the invention of the term, its dissemination can be attributed. Its widespread usage goes back primarily to Hans J. Eysenck and Arnold Lazarus. While Wolpe rejected such a ªbrand name,º they postulated that the large differences to the traditional approaches should be underlined with a new name. The first printed appearance of Behaviour therapy was authored by Lazarus in 1958. The first public usage of the new term, however, was made by Eysenck in a talk entitled Learning theory and behaviour therapy (published in 1959). Here, the highly confrontative marketing strategy of Eysenck is clearly visible: he combined a fundamental and partly polemical critique of traditional methods with a partly overly optimistic view of the new approach. 6.02.3.3 The Influence of Operant Approaches The mainstream of behavior therapy at first developed outside of America where at that time the operant approach was very popular in psychology. This is perhaps one reason why the potential clinical applications of operant methods were hardly acknowledged. Another reason was the fact that operant researchers did not come out of the clinical sector. Skinner himself never worked clinically. But even those of his followers that moved into the clinical world typically did not limit themselves to it. Instead, they always saw other fields such as education, economy, or administration as important areas of applications for their methods. In the late 1950s, Skinner and Lindsley described the potential applications of operant methods. Corresponding therapies, however, were only conducted in the 1960s and at first with children and mentally handicapped adults. The first clinical applications are related to the names of Charles Ferster, Ivar Lovaas, Donald Baer, Sidney Bijou, Leonard Krasner, Leonard Ullman, Nathan Azrin, and T. Ayllon. The ªoperant groupº had constructed their own network of relationships and publication outlets. They utilized their proper, highly technical terminology and restricted themselves to the narrow approach of Skinnerian psychology whose clinical application they called applied behavioral analysis or behavior modification. The term behavior therapy was rejected as much as the term ªpatientº for the addressee of their interventions. Eysenck, Rachman, Wolpe, and their colleagues became aware of the clinical work of the American operant school only in the early and mid-1960s. Even after that commu-

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nication between the two groups was rather reluctant. Integration of the operant methods into the behavior therapy movement was not unproblematic. It was only since the 1970s that the terms behavior therapy and behavior modification became regarded as more or less equivalent. Until today, a small group of strictly operant researchers have kept their own tradition outside of the more clinically oriented behavior therapy (ªapplied behavior analysisº). All in all, the relevance of operant methods is frequently overestimated, especially from outside behavior therapy, although they are only rarely applied as sole treatment methods. They do, however, have a firm place in parts of behavior therapy, for instance in the treatment of childhood behavioral problems, mental retardation, or chronically institutionalized patients. Studies such as those on ªtoken economiesº in long-term institutionalized mental patients underlined the importance of social reinforcement for change in general, for longterm generalization and the maintenance of desired or acceptable behaviors (Ayllon & Azrin, 1968). More recent research, however, has yielded doubts about the theoretical basis of token economies and other methods that were originally conceptualized as purely operant techniques. Thus, it has been shown that social feedback and specific guidelines for action were the most important factors in such programs, more important than the ªtokensº themselves or the reinforcers they represented. In spite of this, the development of token economy programs was important beyond their immediate applications because they underlined the relevance of a comprehensive approach in rehabilitation. The usage of structured social reinforcement (e.g., praise) has been accepted more widely in clinical practice than the usage of tokens or symbols for reinforcement. Emphasizing the role of changing and structuring social interactions has for instance strong importance in the treatment of schizophrenic patients (Fallon, Boyd, & McGill, 1984; Hahlweg, DuÈrr, & MuÈller, 1994). Another very important influence of the operant approach was the acceptance of functional analysis (behavior or problem analysis). Behavior analysis in behavior therapy is based upon the Skinnerian concept of explaining behavior by studying the conditions under which it emerged. The relevance of living conditions, environmental factors, and social relationships had before been underestimated or even overlooked. 6.02.3.4 Consolidation and Broadening of Scope With the founding of clinical/scientific societies devoted to behavior therapy a first period of consolidation of the stormy development began.

36

Behavioral Approaches

The American AABT was founded in 1966 as the Association for the Advancement of Behavioral Therapies. Later, the plural was given up and the name was changed to Association for the Advancement of Behavior Therapy. The first members of AABT came largely from two groups: first, a primarily academic group of scientist-clinicians interested in ªclinical psychology as an experimental science,º who had been organized in a subgroup of the American Psychological Association (Division 12, Section 3); second, a primarily clinically active group that had been influenced directly by founding personalities of behavior therapy such as Wolpe, Franks, Salter, or Reyna. Cyril Franks was elected as the first president of AABT, the vice-president was Wolpe. The council of the society consisted of equal numbers of scientists and practitioners. While AABT experienced an enormous increase in membership, the European sibling society EABT (European Association of Behaviour Therapy) was founded in 1971. The intiative for this was taken by Johannes C. Brengelmann, who had spent long years with Eysenck in England and in the USA. He returned in 1967 to Germany and became Director at the Max-Planck-Institute of Psychiatry in Munich and head of its psychological department. Brengelmann, who was the decisive personality for the development of behavior therapy in Germany and several other European countries, became the first president of EABT. Before this, individual national societies for behavior therapy had been founded in several European countries (e.g., the German society was founded in 1968 and one year later had already 450 members). The members of EABT at first came from similar sources as those of AABT, namely academic researchers and practioners with a close contact to founding centers such as London or Munich. The ªofficialº founding of EABT took place during a congress in Munich, which was attended by 1200 participants from 14 countries. Consolidation was also furthered by a rapidly increasing flood of research works and publications in journals or books and by the implementation of the first teaching or training centers. In the 1970s behavior therapy therefore came to a first stage of maturity while there were still many new techniques being developed, tested and refined. Toward the end of the decade, most of these treatment approaches were internationally accepted. Behavioral methods were the treatment of choice for such diverse problems as phobias, obsessions and compulsions, sexual dysfunctions, or the rehabilitation of chronic mental patients. At the same time existing techniques were further developed (e.g., shortening of the duration of exposure or

relaxation treatments) and new methods were introduced or disseminated (e.g., social skills trainings in groups, behavioral treatment of depression). The treatment of sexual dysfunctions developed less from behavioral research on these disorders, but rather from the work of Masters and Johnson (1970) on the physiology of sexual responses. Even though this approach had an independent origin, it shared the emphasis on concrete operationalization of treatment strategies and on empirical testing with behavior therapy. This was the main reason for its rapid integration into behavior therapy which gives further testimony to the concept of behavior therapy as a broad basic orientation. A significant broadening of the behavioral approach was introduced by the development of behavioral medicine. The term had originally been used by Birk (1973) to describe the application of biofeedback to medical problems. In biofeedback, patients are given immediate information about relevant changes in their physiological system (e.g., by auditory or visual feedback) in order to acquire control even of involuntary physiological responses. Behavioral medicine soon extended to a substantially larger field. Today, it encompasses all applications of psychological knowledge and techniques to purely somatic problems (e.g., burnings, tumor pain), disorders of possible partial psychological origin (e.g., irritable bowel syndrome), or risk factors (e.g., smoking, nutrition, physical exercise). Behavioral medicine has become a largely interdisciplinary movement that has developed a multitude of applications. Another important development consisted of overcoming the narrow borders of the behavioristic heritage of the early learning theory-based behavior therapy. Strictly speaking, Mowrer's (1947) two-factor theory which was frequently used to explain phobias already contained a departure from behaviorism. The notion of negative reinforcement of phobic avoidance by anxiety reduction implied the concept of anxiety as an internal, ªmentalº state that was not directly observable. In addition, Eysenck and others had always accepted an influence of biological and genetic factors. Especially important for the advancement of behavior therapy, however, was the acceptance of the so-called ªthree-systems approach.º Peter Lang, Rachman, and others (Hodgson & Rachman, 1974; Lang, 1993; Rachman & Hodgson, 1974) argued that psychological reactions and problems related to them needed to be seen as multidimensional, loosely connected responses systems acting on different ªlevels.º The most popular classification differentiates between a subjective/cognitive, a behavioral, and a physiological level of response. Although these

Historical Development of Behavior Therapy response systems are interconnected, they do not necessarily have to change in the same direction, at the same time, to the same degree etc., a phenomenon that has been termed ªdesynchronyº by behavioral writers (Hodgson & Rachman, 1974; Rachman & Hodgson, 1974). This alternative to a uniform view of psychological problems was important because it allowed explanation of the wide variation in the symptom patterns reported by the patients. It also permitted a more systematic and precise assessment of treatment outcomes. In addition, differential outcomes could now be observed. Thus, relaxation exercises might influence the physiological aspects of a problem more readily than the behavioral or subjective problems. Moreover, the relevance of experience was more strongly acknowledged although a largely behavioristic, response-oriented language continued to be used. The threefold classification by Lang or Rachman has frequently been criticized. There is indeed no a priori reason to assume three levels rather than four or more response systems. Some authors argue that it would be better to distinguish between a cognitive and an affective system which would result in a four-systems approach. Other authors such as Fahrenberg (1987) pointed to the large body of findings that question the assumption of a unitarian, homogenous physiological level. Nevertheless, it was important to overcome the early monistic and onedimensional view of human responses. Today, a ªmany-systems approachº with its emphasis on desynchrony is generally accepted in spite of the ongoing discussion about the best classification of response systems. In clinical practice, Lang's (1993) three-systems approach is the established (although simplified) standard. At the end of the 1970s the usefulness of behavior therapy was widely accepted. Because researchers now no longer had to prove the general efficacy of their approach, some of them directed their attention to those patients that were not helped by behavior therapy, even when it was applied correctly. These studies culminated in the first scientific psychotherapeutic book on the failures of treatment by Foa and Emmelkamp (1983). Already in the late 1960s and early 1970s a beginning discontentment with the strict behavioristic guidelines of the early years was apparent. Especially Lazarus (1971) criticized the ªmechanisticº terminology of early behavior therapy. He argued that the multitude of behavior therapy's interventions could not be explained by learning theory alone. Instead, he proposed the introduction of ªbroad-spectrum behavior therapyº that should include all techniques with empirically demonstrated efficacy regardless of their theoretical

37

background. In clinical practice, this approach was accepted by an increasing number of behavior therapists. A further important development at this time was the attempt to apply behavioral methods to other mental disorders, especially depression. After Ferster (1965) and Lewinsohn (1974) had assumed that depression resulted from a lack of positive reinforcement, first treatment approaches consisted of elevating the rate of positive reinforcement. The success of this method stayed limited, perhaps because patients typically judged efforts and outcomes negatively even if they attempted to comply with the treatment regimen. This made the relevance of cognitive factors increasingly clear. The lack of satisfaction with the strictly behavioral techniques led to the attempt to add cognitive methods to them. This opened the way for a more systematic integration of these methods and for the development of new cognitive-behavioral approaches.

6.02.3.5 Integration of Behavioral and Cognitive Approaches Lang's theory of three relatively independent response systems had strengthened the basis for the acceptance of cognitive ideas within the behavioral approach. Empirical psychology had already acknowledged the relevance of cognitive variables to such a degree that the ªcognitive turning-pointº had been passed by most actors. The delayed integration of the cognitive dimension into behavior therapy probably had its roots in the continuing influence of Watson's rejection of introspection and in the experiences with its abuse potential in ªtalking curesº of limited success. In addition, the polemical position toward other psychotherapeutic approaches that behavior therapists typically took in the founding phase made it difficult to abandon identity-producing boundaries. Bandura's work on vicarious learning, however, had directed the attention even of behavior therapists toward cognitive factors. The fact that people were able to learn new behaviors by observing the behavior of others even without being reinforced themselves transgressed traditional learning theory. Later on, Bandura developed a model of self-regulation that he termed ªself-efficacy.º This approach postulates that any conscious behavior change is based on the subject's conviction of its capacity to perform this concrete behavior. The rigorous empirical methodology of Bandura's work facilitated its acceptance even by researchers and practitioners who had originally been behavioristically oriented. In addition, the increasing interest in the concept of self-control

38

Behavioral Approaches

had an important influence on the development of behavior therapy. People observe themselves, judge their own performance, and reinforce (or punish) themselves accordingly. On each of these levels, problems may arise and lead to clinical states such as depressed mood. Research into these phenomena led to the investigation of cognitive constructs including attribution and self-instruction. Perhaps the first cognitive therapeutic method that gained acceptance in behavior therapy was Meichenbaum's (1975) self-instruction training. The popularity of this approach was bolstered by its simple, consistent theoretical basis and its resemblance with the operant concept of ªcoverants.º Meichenbaum argued that behavior changes can be induced by changing the instructions that patients give themselves. Inadequate and negative thoughts should be transformed into more adequate statements. It is not by chance, that self-instruction training was first implemented in the treatent of impulsive children. The inner monologue and the thinking of these children were termed self-verbalizations and seen as equal to the coverants in operant terminology. The artifical term ªcoverantº was derived from ªcovertº and ªoperantº and thus denoted covert operant behavior. With the help of this terminology, mental contents were ªsmuggledº into the operant movement. In contrast, independent cognitive approaches that had developed outside of behavior therapy encountered much more hesitation. Although Beck's (1967) cognitive therapy and Ellis' (1962) rational-emotive therapy originated in the 1960s, it took many years before they grew together with the behavioral movement. Until late in the 1970s cognitive and behavioral approaches were seen as separate ªschools.º This led to sometimes inadequate differentiations or to attempts to prove that the other school was ªin realityº using methods of one's own school. It was only in the 1980s that the two movements converged and only in 1995 the first joint ªWorld Congress of Behavioural and Cognitive Therapiesº was held in Copenhagen. Integration also became obvious in the renaming of EABT into EABCT (European Association for Behavioural and Cognitive Therapies) in 1992 on the occasion of the 22nd Congress of the ªoldº EABT in Coimbra, Portugal. A common basis between the cognitive and the traditional behavioral movement were the methodological standards emphasizing operationalization, experimental research, and systematic testing of efficacy on the one hand and the rational, pragmatic orientation on the other. Today, cognitive, behavioral, and cognitive-behavioral treatments together form the broad basic therapeutic orientation alluded to in Section

6.02.2. There are, however, also critics of this convergence (for instance, Krasner's ªparadigm lost,º that eloquently mourns for the loss of the clear operant paradigm).

6.02.3.6 Continuous Development and the Future Modern cognitive-behavioral therapy attempts a true integration of its components. It aims to help patients recognize their individual structure of distorted thinking and inadequate behavior. Systematic cognitive restructuring and carefully structured behavioral tasks are designed to help the patients in dealing with problems in both domains. In the meantime, cognitive-behavioral treatment programs have been developed for most mental disorders that occur in everyday practice. In some instances it is the behavioral part, in others the cognitive part that dominates. Moreover, a host of findings from process research points out that even in classical behavioral treatments such as exposure in vivo cognitive processes may contribute as central mechanisms of change. The behavioral approach is still characterized by rapid change. One of the more important new achievements is the development of specific treatment programs for a rapidly increasing number of disorders or specific problem constellations. These are frequently represented in the form of concrete therapy manuals in order to facilitate practical implementation. Therapy manuals were originally used in treatment research as a mean to ensure treatment integrity in clinical studies. They were quickly disseminated in the practice sector, because they made therapeutic methods more concrete and thus accessible to the broad public of practitioners. Texts on psychotherapy had for a long time been overly abstract and often lacked any concrete descriptions or guidelines of what needed to be done in practice. Manuals with concrete guidelines therefore fulfilled an important need. The positive view of treatment manuals is reflected among others by the criteria for empirically validated treatments that were established by the Task Force on Promotion and Dissemination of Psychological Procedures of the American Psychological Association (APA). Their criteria see the existence of a manual as one precondition for any therapy method to be accepted as scientifically validated. Another important line of development is ongoing professionalization of behavior therapy in routine patient care and therapist training. Training issues are especially relevant in most European countries where a number of different private and public training models

Empirical Status of Behavior Therapy coexist. Several countries have passed laws regulating the practical application of psychotherapy including behavior therapy. These laws have important implications for research and practice as do managed care and health maintenance organizations in the USA. The historical perspective shows what developments have led to acknowledgment of the benefit that the behavioral approach has for most mental disorders. The vast amount of change in the past leads to the prediction that the future of behavior therapy will also be characterized by major modifications of present methods and concepts. This is facilitated by the fact that ongoing research and development are major attributes of behavior therapy. But even in its present form the behavioral approach offers effective help for patients as well as a valuable basis for the understanding of mental disorders. The empirical basis for these assertions is the topic of the following section. 6.02.4 EMPIRICAL STATUS OF BEHAVIOR THERAPY 6.02.4.1 Problems in Empirically Approaching Efficacy Psychotherapy research has moved from one difficulty to another: after a long period with a massive lack of empirical findings we now have the opposite problem. Largely due to the behavioral approach there are now so many studies on the outcome and process of psychotherapy that it has become hard for anyone to keep track. Aggregating findings across a vast number of different studies is a problem in itself (see below). Without any doubt behavior therapy is by far the most intensely researched type of psychotherapy (Grawe, 1992; Grawe, Donnati, & Bernauer, 1994). For behavioral and cognitive methods there have been over 10 times more published studies than for all other types of psychotherapy together (Grawe et al., 1994). Even some individual behavioral methods have been put to test more frequently than the whole group of psychoanalytic or humanistic approaches, respectively. In addition, behavioral methods have been applied to the broadest spectrum of mental disorders with typically positive results. However, such a general statement needs to be specified because ªautomaticº generalization across all disorders is senseless. Instead, individual disorders have to be regarded separately. Of course a larger number of studies does not necessarily imply better efficacy compared to other treatments. A more detailed assessment is thus needed although the whole body of psychotherapy research cannot be summarized here. I will

39

therefore only briefly summarize the findings on behavior therapy. How should treatment studies be aggregated? The most important approaches to the problem of secondary analysis used so far can roughly be classified into three groups: (i) Narrative summaries. Here, the collected studies on a topic are simply interpreted more or less intuitively and a personal judgment of their outcomes is given. A severe disadvantage of this approach is its lack of objectivity. It has been shown that most people distort their judgment in the light of pre-existing biases. Moreover, the rapidly increasing number of publications makes it very difficult for any individual to have a complete overview. (ii) Box-score method. Based on the justified criticisms of narrative summaries, this method attempts a more systematic and quantitative approach. It simply consists of counting the number of statistically significant effects that were obtained in the different studies. This, however, is subject to so many limitations that the approach is of dubious utility. Especially important is the problem of low statistical power in most psychotherapy studies. The difficulties in recruiting patients and conducting the studies typically result in small sample sizes that do not allow the detection of even clinically relevant effects with sufficient certainty. In addition, simply looking at statistical significance overlooks information about the strength of the effects (ªclinical significanceº). Moreover, it is unacceptable to give studies with widely varying methodological quality or very different outcome criteria equal weight. (iii) Meta-analysis. This last problem also applies to meta-analysis, which otherwise avoids the power problem of the box-score method. Meta-analysis is at present the most objective method for aggregating findings from different studies. It starts by calculating ªeffect sizesº for each measure taken in each study. Effect sizes express by how many standard deviations the mean of two groups (e.g., treatment and control group) or of one group at two times (e.g., pre- and post-therapy) differ. This standardization makes different measures directly comparable, even across separate studies. In a second step, all calculated effect sizes are then averaged to yield one ªintegratedº effect size as a global index of therapy outcome. As stated above, a criticism is that the methodological quality of the studies or even clinical relevance (e.g., clinical vs. analogue sample) typically are not taken into account. Of course, one could introduce weights for methodological quality or set methodological criteria for inclusion into the meta-analysis. However, this introduces, a subjective element and thereby

40

Behavioral Approaches

affects objectivity that together with its quantitative nature is a great advantage of the method. The utility of meta-analytic results has been challenged by referring to the fact that frequently very different studies are thrown together (ªcomparing apples and pearsº). In spite of these criticisms, meta-analysis has established itself as an objective statistical method for the aggregation of heterogenous findings across separate studies.

6.02.4.2 Results of Outcome Research The most comprehensive and differentiated analysis of outcome research so far has been published by Grawe and co-workers (1994). Shortly after this work appeared in print, it became a standard for any discussion of the topic. In contrast to earlier meta-analyses, Grawe et al. analyzed the methodological quality of the studies, took the different types of outcome measures into account, and included all controlled studies published until 1983 regardless of language, country of origin, or publication outlet in their thorough analysis. Table 2 shows the number of controlled studies that Grawe found for the different classes of therapy methods and for the individual cognitive-behavioral techniques. Table 3 shows for what types of disorders behavioral methods have been tested.

In these studies, behavioral methods have proved effective in achieving the immediate goals of treatment as well as generalized benefits that most of the individual techniques have to be given the status of empirically validated therapy methods (Grawe, 1992). Especially well researched are exposure techniques that were frequently applied to agoraphobia, obsessive-compulsive disorder, and specific phobias. They led almost always to massive improvement of the target symptoms, while the effects on general well-being and other masures were somewhat smaller. Well established is also the effect of systematic desensitization in treating anxiety disorders. A very broad range of effects was found for social skills training that almost regularly achieved significant positive changes beyond the target symptoms. Broad efficacy was also found for cognitive methods such as Beck's treatment for depression, rational-emotive therapy, Meichenbaum's self-instruction, and stress-inocculation trainings or problem-solving treatments. Studies revealed not only a very broad range of clinical applications but also some degree of specific relations between certain treatments and individual disorders. Thus, anxiety disorders were most frequently treated with exposure-based methods followed by systematic desensitization and cognitive methods. ªThe application of behavior therapy in clinical practice is thus based on a broad spectrum of treatment

Table 2 The number of controlled studies that were found by Grawe et al. in their meta-analysis of published therapy outcome studies.

Different types of therapy Cognitive-behavioral methods Progressive muscle relaxationa Autogenic training Hypnosis Meditation Psychoanalytic short-term treatments Psychoanalytic therapy Long-term psychoanalysis (Freud) and analytic therapy (Jung) Client-centered therapy Gestalt therapy Psychodrama and transactional analysis Marital therapy Family therapy Interpersonal therapy

Number of studies

Only cognitive-behavioral methods

Number of studies

567 66 14 19 15 27 12 each 0

Social skills training Exposure Biofeedback Systematic desensitization Cognitive coping methods Aversion therapies Problem-solving therapies Sexual therapy

74 62 62 56 38 31 25 22

35 7 each 6 35 18 10

Lewinsohn's therapy of depression Rational-emotive therapy Beck's therapy of depression Alcoholism programs Paradoxical intention Broad-spectrum behavior therapy

17 17 16 14 10 8

a The classifiaction of progressive muscle relaxation is controversial. It can be subsumed under behavioral methods (of which it typically was part) or counted as a separate entity. We chose the later approach in order to give more detailed information. Other methods not mentioned in the table were either not specfied clearly enough (unspecified humanistic therapies N = 11, encounter-groups N = 9, unspecified psychodynamic therapies N = 8, psychodynamic therapies with drugs N = 13, eclecticistic therapies N = 22) or counted only 1±3 studies (music therapy, body therapy, dance/art therapy, bioenergetics, Ich-Analyse, Individual therapy (Adler), Katathymes Bilderleben, Daseinsanalyse). Because many behavioral studies used combinations of methods, the numbers in the right column do not add to the total given in the left column for cognitive-behavioral methods.

Table 3 Types of mental disorders for which behavioral methods have been tested empirically in controlled treatment studies based on Grawe's 1994 meta-analysis. For each disorder, the number of studies published until 1983 is given.

Therapeutic method Cognitive Various Biofeedback Systematic desensitization Operant Social skills training Exposure Aversion Modeling Self-control Covert conditioning Speech therapy

Somatic V-codes for Organic Substance Disorders states with states without Childhood mental abuse Other Affective Anxiety Sexual of impulse Disorders psychological mental Additional disorders disorders disorders Schizophrenia psychoses disorders disorders dysfunctions cntrol of adaptation factors disorders codes 10 7 2 4 1

1

3 1 10

1

7

10 11 2 2

1 1 1 3

6 7

11 4

1 24 3 12 7

5 1 1

18 16 1 1

19 5 9 37

1 2 1 12

3 4

4 7

4 9

1 1 1

1 2

57 910 11 4 7

4 2

1

1 2

12 28

2 4

15 3 57 4

20 9 2 6

3 4

1 3

4 6

11 3

19 22

1 1 3 1

3

2

1 1 2 1

1

5

3 4 2 1

18 7 11

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Behavioral Approaches

Table 4 Results of meta-analyses comparing the efficacy of different types of psychotherapy. Because of the low number of studies, psychodynamic and humanistic methods were typically grouped together. Psychodynamic/ Cognitive-behavioral humanistic methods methods Meta-analysis Smith et al. (1980) Shapiro & Shapiro (1982) Nicholson & Berman (1983) Wittmann & Matt (1986) Grawe et al. (1994) (psychoanalytic methods) Grawe et al. (1994) (client-centered methods)a

Direct comparisons within one study

Mean effect sizes

Mean effect sizes

Difference between effect sizes

0.64 0.40 0.29 0.30/0.25 0.83

1.03 1.08 0.75 0.50 1.21

70.49 70.53 70.44 only direct comparisons

0.87

1.13

only direct comparisons

a Without the study of Angulo (1983; quoted in Grawe et al., 1994), whose results represent clear outliers (effect sizes for behavior therapy about 8, for client-centered therapy about 4, patients with obsessive-compulsive symptoms).

methods with proven efficacy. With a clear distance to other types of treatment, behavior therapy can therefore claim to have proven its effectiveness sufficiently for playing a prominent role in psychotherapeutic mental health careº (Grawe, 1992, p. 139). In addition to the general statements on the efficacy of behavior therapy, Grawe et al. (1994) also analyzed all studies directly comparing behavior therapy with psychoanalytic, client-centered, or systemic treatments that were published until 1991. Further inclusion criteria were at least three outcome measures, at least six hours of treatment duration, similar duration (ªdosageº) of the different treatment conditions (unless differences were explicitly justified on a theoretical basis), and the publication of means and standard deviations of outcome measures. In this way, they found 41 studies with a total of 1401 effect sizes. The large number of effect sizes results from the great number of treatment conditions and outcome measures. The direct comparisons underlined impressively the results reported above for the behavior therapy studies: The comparison with psychoanalytic (19 studies, 215 outcome measures, 487 individual comparisons), client-centered (10 studies, 133 outcome measures, 723 individual comparisons), and family-therapy methods (3 studies, 18 outcome measures, 40 individual comparisons) always yielded a clear-cut superiority of behavioral approaches. These results are in line with those of earlier meta-analyses as can be seen in Table 4. This table summarizes the effect sizes that have been calculated in the different metaanalyses. Because the calculatory basis differed considerably across meta-analyses, the comparison within each meta-analytic study should primarily be regarded (thus Wittmann and Matt (1986) included only German-language

publications that were in addition analyzed with a different algorithm; Grawe et al. (1994) analyzed only direct comparisons, etc.). In every meta-analysis cognitive-behavioral methods fared better than other treatments. This result holds up after methodological problems (such as restriction to direct comparisons, consideration of different types of outcome measures, limitation to certain types of disorders, liberal or conservative inclusion criteria, etc.) have been addressed. An important alternative to the meta-analytic approach was proposed by the Task Force on Promotion and Dissemination of Psychological Procedures of the APA (1995). Their approach takes into consideration one major criticism of most meta-analytic studies published so far, namely the neglect of the differences between the various mental disorders. It is inadequate to exclude the type of disorder treated in outcome research. The assumption that disorders as different as alcoholism, sexual dysfunctions, agoraphobia, or schizophrenia can be treated by the same method regardless of the specific characteristics of the disorder is unrealistic. The question for efficacy therefore always has to address clearly defined categories of problems or disorders. In addition, the APA Task Force considered treatment integrity. In contrast to, for instance, pharmacological treatments, psychotherapeutic approaches need to clarify what concrete actions are included under such labels as ªbehavior therapyº or ªclient-centered therapy.º For this purpose the treatment manuals mentioned above are pivotal. Moreover, the criteria reflect the notion that controlled treatment studies may be the best but not the only valid source of empirical information on treatment outcomes. For longterm treatments these studies have traditionally been regarded as being hard or even impossible

Empirical Status of Behavior Therapy to perform. Single-case experimental studies offer an alternative if they fulfill basic methodological standards. Another requirement was that positive reports on a treatment's efficacy should come from more than one independent center, thus avoiding situations where the ªfounderº of a therapy keeps finding his treatment perfectly useful. On the basis of these and additional considerations, minimal criteria for empirically validated treatments were established. In addition, the Task Force made a difference between ªwell-establishedº and ªprobably efficaciousº methods. The criteria are listed in Table 5. A first, still provisorial listing of treatments that fulfill the two sets of criteria is given in Table 6. The results of the APA Task Force resemble those discussed above for the meta-analytic approach. The vast majority of treatments listed in Table 6 come from the cognitive-behavioral approach. This is even more important, because the proposal for the APA criteria which also accepts single-case studies as valid data originated from an psychoanalytically oriented member of the Task Force (1995). Using a quite different approach, this Task Force composed of members with various therapeutic orientations came to the same result as Grawe et al. (1994) or the other quoted meta-analyses.

43

6.02.4.3 Consequences of Research Findings The behavioral approach therefore very clearly deserves the certificate of being the best validated psychotherapeutic orientation. In addition to the large number of studies on the efficacy of the individual treatment methods, the vast body of knowledge collected by clinical psychology and its neighboring disciplines on the etiology, diagnosis, and epidemiology of mental disorders contributes to this success. For most disorders, specific treatment programs tailored to their individual characteristics have been developed and tested. Behavioral treatments can therefore have very different contents depending on the nature of the problem to be treated. In principle, the superior empirical basis for behavioral treatments should imply that these methods should play a central role in psychotherapeutic patient care. However, one cannot derive from the research findings that behavioral methods are the only ones that should be applied. There are still no ª100% methodsº for most mental disorders. Even the best treatments yield a certain amount of failures. As long as this is the case, we need a broad spectrum of treatment options that address different facets of the problematic structures. Yet this does not mean that every

Table 5 Criteria for empirically validated treatments established by the APA Task Force on Promotion and Dissemination of Psychological Procedures (1995, 1998). Well-established treatments I.

At least two good between group design experiments demonstrating efficacy in one or more of the following ways: A. Superior to pill or psychological placebo or to another treatment B. Equivalent to an already established treatment in experiments with adequate statistical power (about 30 per group) OR

II.

A large series of single case design experiments demonstrating efficacy These experiments must have: A. Used good experimental designs and B. Compared the intervention to another treatment as in I.A FURTHER CRITERIA FOR BOTH I AND II:

III.

Experiments must be conducted with treatment manuals

IV. V.

Characteristics of the client samples must be clearly specified Effects must have been demonstrated by at least two different investigators or investigatory teams

Probably efficacious treatments I.

Two experiments showing that the treatment is more effective than a waiting-list control group OR

II.

One or more experiments meeting the well-established treatment citeria I, III, and IV, but not V OR

III.

A small series of single case design experiments otherwise meeting well-established criteria II, III, and IV

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Behavioral Approaches Table 6 Treatments named by the APA Task Force on Promotion and Dissemination of Psychological Procedures as examples of their criteria for empirical validation (1995). Well-established treatments Cognitive therapy for depression Behavior modification for developmental disorders Behavior modification for enuresis and encopresis Behavior therapy for headache and irritable bowel syndrome Behavior therapy for orgasm and erectile dysfunctions Behavioral marital therapy Cognitive-behavioral therapy for chronic pain Cognitive-behavioral therapy for panic disorder and agoraphobia Cognitive-behavioral therapy for generalized anxiety disorder Exposure therapy for phobias and post-traumatic stress disorder Exposure and response prevention for obsessive-compulsive disorder Psychoeducative family intervention for schizophrenia Cognitive-behavioral group therapy for social phobia Interpersonal therapy for bulimia Interpersonal therapy for depression Training programs for parents with behavior problems Systematic desensitization for specific phobias Token economy programs Probably efficacious treatments Applied relaxation for panic disorder Psychodynamic short-term therapy Behavior modification for sexual offenders Dialectical behavior therapy for borderline personality disorder Emotion centered couples therapy Habit reversal training and habit control training Psychoeducational therapy of depression

therapist can do what they want regardless of the research findings. We need to ask ourselves how to choose the most promising method for each individual case or for the rank order of the different approaches that could possibly be applied to the case. These decisions need to take into account other variables such as the motivation and personality of the patient, the possible existence of comorbidity, or the availability of treatments or therapists. In addition, it has to be clarified whether and when the patient should be transferred to another specialist and what role primary care physicians and self-help measures could play. As a general rule, measures with the best cost-benefit ratio should be tried first. These considerations lead to the proposal of more or less rational ªsequential modelsº for clinical practice (Margraf, 1996) such as the one detailed in Table 7. Of course, the model delineated below represents an abridgement, that in clinical practice needs to be specified according to disorders and other factors. The ideas behind this sequential model can be summarized as follows. (i) It is generally better if the patient is able to solve his problems himself. Therefore, given an adequate motivation the person should be encouraged to try self-help measures. The input

of lay personnel such as relatives or friends also belongs here. (ii) If self-help fails or is insufficient, however, professional help should be sought. Here we can distinguish between general, nonspecific counseling or supportive measures on the one hand and a specfic therapy for the mental disorder on the other. As long as there are no acute crises, suicidal ideation, active psychoses, or a long history of failed treatments, generalists such as the family physician can try to achieve improvement using nonspecific measures. (iii) If this does not lead to clear-cut improvement or the listed conditions are not met, a specific treatment of the mental disorder should be started as fast as possible in most cases, beacuse most mental disorders otherwise have a high risk of chronification. The decision between the competing psychological or pharmacological treatments should not simply be based on the personal preference of therapist or patient. Instead, it should consider probability of success, cost-benefit ratio, durability of treatment outcomes, and the other conditions discussed above (e.g., availability). (iv) Among psychological treatments, cognitive-behavioral methods should typically (for most disorders) form the first line of

Problems and Criticisms of Behavior Therapy

45

Table 7 A sequential model for choosing treatment interventions in clinical practice. 1. Self-help, lay interventions 2. Advice, counseling, supportive therapy 3. Specific treatment of the mental disorder 3.1. Behavior therapy 3.2. Other psychotherapeutic and pharmacological interventions 3.3. Long-term interventions after treatment failures Source: Margraf (1996).

intervention because their efficacy is best validated and they have a favorable cost-benefit ratio. Only if this does not lead to sufficient success should other types of psychotherapy be applied because these typically are less well established empirically and often involve greater expense (e.g., longer duration). (v) Similar considerations apply to the choice of pharmacological methods. Here, the questions of durability of outcomes or relapse after drug withdrawal and of side effects (costbenefit ratio) may lead to critical reflections. (vi) In some cases, the necessity of long-term support may arise. This could for instance be the case if intensive attempts have not led to clinically significant improvement. Here its is important to convey to the patient that he or she is not alone and to avoid making the patient ªguiltyº for failure. Of course, it needs to be clarified whether all promising treatment methods have been attempted competently. In clinical practice, one frequently sees cases where due to their training or theoretical orientation, care providers used only a narrow part of the total spectrum of treatment methods. In these cases, transfer to another specialist is often helpful. In other cases, however, all that is left is to convey to the patient a realistic notion of his chances for recovery and to support him in dealing with the chronic aspects of his condition. 6.02.5 PROBLEMS AND CRITICISMS OF BEHAVIOR THERAPY Like any other human endeavor, behavior therapy has its share of problems. These are for instance the treatment failures that may occur even with good motivation on the patient's side and optimal application on the therapist's side. Here, research is called for in order to ameliorate success rates, attrition, etc. Other important problems of behavior therapy lie in limiting setting factors such as lack of information of patients and professionals or obstinate misunderstandings about the behavioral approach. In addition, the availability of well-trained behavior therapists is a major problem in most parts of the world, even in those countries where the

behavioral movement started. Moreover, it is very difficult for patients or other physicians or psychologists to judge the competence of any given colleague. Many national health insurance schemes (or the lack of them) are responsible for limitations to the availability of competent behavior therapy. Another aspect are the wishes and prejudices of the patients that often come with strong feelings about their treatment. These are frequently conveyed by media, popular literature, friends, or relatives. Some decline any notion of pharmacological help (ªhow can pills help with psychological distress?º), others definitely do not want to be treated by psychotherapy (ªI am not crazy!,º ªThey only dig in the past!º). Some people, especially with an academic background, have powerful convictions even with respect to the specific kind of psychotherapy (ªin depth,º ªthorough,º ªexplain everythingº). All of these points together may be responsible for the fact that behavior therapy is applied far less frequently than one should assume on the basis of the research findings and the productive publication activities of its proponents. 6.02.5.1 Misunderstandings About Behavior Therapy An important obstacle to the dissemination of behavioral methods have been several obstinate misunderstandings about its nature or techniques (Baer & Minichiello, 1990; Yates, 1977). Some of these misconceptions will be briefly addressed here. (i) Behavior therapy does not lead to symptom substitution. (ii) The experience of strong emotions during exposure (e.g., in phobias, grief reactions, posttraumatic disorders, or eating disorders) is not dangerous for the patients. (iii) The thoughts and feelings of the patients are not ignored. Instead, they are addressed directly by a multitude of therapeutic interventions. (iv) Modern behavior therapy does not assume that all mental disorders have been acquired by simple conditioning processes.

46

Behavioral Approaches

(v) The use of medication is not generally incompatible with behavioral interventions. Inasmuch as these misunderstandings are being clarified and together with the mounting reception of the results of psychotherapy research, a growing interest in behavioral methods can be observed. But even today, the lack of well-trained specialists is a major problem.

6.02.5.2 Scientifically Well Established, Practically Neglected? A remarkable example of the underutilization of behavioral methods is given by the treatment of anxiety disorders. If anything, these disorders should be a primary area of application for behavioral methods. However, procedures such as exposure in vivo are apparently given only to a small minority of afflicted persons. Taylor et al. (1989) studied a large sample of patients with anxiety disorders that had applied for treatment to the anxiety disorders clinic at Stanford University School of Medicine. Although the region surrounding the clinic was densely populated with care providers, they found that less than 10% of agoraphobic patients had been given a trial of exposure. One criticism of this study can be seen in the fact that the nonrepresentative sample consisted of self-selected patients searching treatment. However, we recently found the same effect in a sample 3000 people representative of the German adult population (Margraf, 1996; Margraf & Poldrack, in press). The study investigated the prevalence of clinical anxiety in the general population using the Beck Anxiety Inventory using a cut-off score from clinical anxiety research. In face-to-face interviews, subjects who reported anxiety were asked whether (and if so, how) they had been treated for their anxiety problem. Results showed that even with the broadest definition of treatment only 40% of all afflicted persons had received some kind of treatment and that primary care physicians were by far the most frequent care providers (82% of all treated patients). Genuine specialists such as clinical psychologists (3%) or psychiatrists (6%) together performed fewer treatments than other somatic physicians (17%, multiple responses possible). With respect to the treatments used, there was a remarkable discrepancy between drugs (roughly 90% of all patients, multiple responses possible) and nonspecific advice (roughly 75%) on the one hand and psychotherapy (17%) on the other. In addition, an elevated rate of inpatient treatment (10%) became apparent. Yet the most impressive result to us was that psychotherapy consisted with roughly equal

numbers of relaxation methods (including hypnosis and autogenic training) and ªtalking curesº (i.e., primarily psychoanalytic or clientcentered methods), while cognitive-behavioral methods accounted for only 1% of all treatment cases. In view of this fact, it may seem less surprising that patients on the whole were not very satisfied with their treatment successes. For any type of treatment, the proportion reporting durable improvement was not attained even in one-third of respondents. The lowest success rate was given for psychotherapy with only 14% of respondents reporting lasting success (compared to 29% for drugs!). Of course, these results are limited by the fact that they are based on the patients' classification of the treatment received. However, assessment of treatments was not simply limited to giving labels such as ªbehavior therapyº or ªclient-centered therapyº that may be unknown to many patients. Instead we gave brief descriptions of various treatment methods (e.g., ªexposing yourself systematically to feared situations or objectsº). In any case, this study makes it possible to generalize from the findings from patients seeking treatment to the general public.

6.02.5.3 Current Criticisms of Behavior Therapy In addition to the problems caused by misunderstandings, misapplications, or the lack of application, there are several criticisms that apply to behavior therapy in its current form. In my opinion, behavior therapy at least partly has not addressed some of these criticisms well enough, which should make its proponents more modest. (i) Theory and practice frequently do not overlap very well (Eysenck & Martin, 1987; O'Donoghue & Krasner, 1995). For instance, exposure methods have a well-established efficacy in the treatment of phobias, but the theory upon which they are based (two-factor theory, habituation) are outdated in their classical form. In the same vein, functional behavior analysis classifies problematic into operant and respondent types although it is quite clear that most clinical problems are neither one nor the other. (ii) Because its treatment methods are most often disorder-specific and rely strongly on the empirical knowledge about these disorders, behavior therapy has neglected unspecific or diffuse complaints or problem constellations. The guidelines for dealing with the problem of comorbidity (common occurrence of more than one disorder, which is the rule rather than the exception) are sparse and often unsatisfactory. (iii) There are hardly any approaches to the problems of counseling, although this forms a

References large part of the work not only in couseling centers but (to a lesser degree) also in psychotherapy. How should one work through inadequate feelings of guilt after separation, deal with leaving-home situations, educational problems, existential problems, etc.? (iv) The strong emphasis on change together with the explicit induction of hope for improvement has not only positive consequences because there are limits for change and some situations should not not be changed at all (Wilson, 1996). An example of this problem is behavioral marital therapy. Not all partnerships can be optimally restructured, even in well-functioning partnerships there may be instances where the partners do not agree and that should not be changed. There is a danger of promising too much or things that cannot be attained (see the discussion of therapeutic goals in Section 6.02.2.3). (v) The ªclassicalº criticism of early behavior therapy, namely the neglect of experience compared to an overemphasis on behavior, does not apply to modern cognitive-behavioral approaches. It is, however, justified for those forms of behavior therapy that have not passed the ªcognitive turning-point.º

6.02.6 CONCLUSIONS This representation of the behavioral approach has attempted to give a satisfactory answer to the nature of this therapeutic orientation by describing its past and present and simultaneously trying to stay open to future developments. The close relationship between research and practice has always been a special advantage of the behavioral approach. It is to be hoped that this will not be lost as behavior therapy becomes a more and more professionalized endeavor. In psychotherapy we stand in front of the remarkable fact that we have a far from satisfactory state in practical patient care and at the same time highly effective methods to ameliorate this situation. We should not let ourselves be kept from bridging this gap. Problems such as the lack of application of successful methods, the widespread misallocation of resources, and the strong need for highquality psychotherapy point to urgent tasks for the health care system: (i) disseminate knowledge about already available methods; (ii) ameliorate the conditions for their implementation; (iii) ameliorate the assessment of mental disorders; (iv) develop simple interventions for routine care by nonspecialists;

47

(v) develop prevention programs; and (vi) routine evaluation and quality assurance. In dealing with these challenges we need to avoid the two contradictory dangers of trivializing or medicalizing psychological problems. Many psychological problems of a transitory or clearly subclinical nature should not be medicalized, that is, they should not be declared ªillnessesº requiring treatment (ªfor every bad feeling a therapyº). On the other hand, fullblown mental disorders may not be trivialized and thereby be withdrawn from adequate and necessary treatments (ªdepressed people simply need to get their act togetherº). As a rule, all concerned parties will only profit from a movement away from ideology and toward a more empirical approach in psychotherapy. Hopefully, the current debates on psychotherapy research will contribute to that process. 6.02.7 REFERENCES Ayllon, T., & Azrin, N. H. (1968). The token economy: A motivational system for therapy and rehabilitation. New York: Appleton-Century-Crofts. Agras, S., Kazdin, A. E., & Wilson, G. T. (1979). Behavior therapy: Toward an applied clinical science. San Francisco: Freeman. Baer, L., & Minichiello, W. E. (1990). Behavioral treatment for obsessive-compulsive disorder. In R. Noyes, M. Roth, & G. D. Burrows (Eds.), Handbook of anxiety (Vol. 4). The treatment of anxiety. Amsterdam: Elsevier. Barlow, D. H., & Hersen, M. (1984). Single case experimental designs: Strategies for studying behavior change (2nd ed.). New York: Pergamon. Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & Row. Birk, L. (1973). Biofeedback: Behavioral medicine. New York: Grune & Stratton. Davison, G. C. (1968). Systematic desensitization as a counterconditioning process. Journal of Abnormal Psychology, 73, 91±99. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. EschenroÈder, C. T. (1994). UÈber die schriftliche Darstellung der verhaltenstherapeutischen Praxis. Verhaltenstherapie, 4, 112±115. Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16, 319±324. Eysenck, H. J. (1959). Learning theory and behaviour therapy. Journal of Mental Science, 195, 61±75. Eysenck, H. J. (Ed.) (1960). Behaviour therapy and the neuroses. Oxford, UK: Pergamon. Eysenck, H. J., & Martin, I. (Eds.) (1987). Theoretical foundations of behaviour therapy. New York: Plenum. Fahrenberg, J. (1987). Zur psychophysiologischen Methodik: Konvergenz, Fraktionerung oder Synergismen? Aktivierungsforschung. Diagnostica, 33, 272±287. Falloon, I. R., Boyd, J. L., & McGill, C. W. (1984). Family care of schizophrenia. New York: Guilford Press. Ferster, C. A. (1965). Classification of behavioral pathology. In L. Krasner & L. Ullman (Eds.), Research in behavior modification. New York: Holt, Rinehart and Winston. Foa, E. B., & Emmelkamp, P. M. G. (1983). Failures in behavior therapy. New York: Wiley.

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Franks, C. M., & Wilson, G. T. (1975). Annual review of behavior therapy: Theory and practice (Vol. 3). New York: Brunner/Mazel. Grawe, K. (1992). Psychotherapieforschung zu Beginn der neunziger Jahre. Psychologische Rundschau, 43, 132±162. Grawe, K., Donati, R., & Bernauer, F. (1994). Psychotherapie im Wandel. Von der Konfession zur Profession. GoÈttingen: Hogrefe. Hahlweg, K., DuÈrr, H., & MuÈller, U. (1994). Familienbetreuung schizophrener Patienten. Weinheim: Beltz, Psychologie-Verlags-Union. Heekerenz, H. P. (1991). Zur sozialen Akzeptanz der Verhaltenstherapie. Verhaltensmodifikation und Verhaltensmedizin, 12, 221±236. Hodgson, R., & Rachman, S. (1974). Desynchrony in measures of fear. Behaviour Research and Therapy, 12, 319±326. Hollandsworth, J. G. (1986). Physiology and behavior therapy. Conceptual guidelines for the clinican. New York: Plenum. Jacobson, E. (1938). Progressive relaxation. Chicago: University of Chicago Press. Jones, H. G. (1956). The application conditioning and learning techniques to the treatment of a psychiatric patient. Journal of Abnormal and Social Psychology, 52, 414±420. Jones, H. G. (1960). Continuation of Yates' treatment of a tiqueur. In H. J. Eysenck (Ed.), Behaviour therapy and the neuroses. Oxford, UK: Pergamon. Jones, M. C. (1924a). The elimination of children's fears. Journal of Experimental Psychology, 7, 382±390. Jones, M. C. (1924b). A laboratory study of fear: The case of Peter. Pediatric Seminars, 31, 308±315. Kazdin, A. E. (1978). History of behavior modification. Baltimore: University Park Press. Kazdin, A. E., & Wilcoxon, L. A. (1976). Systematic desensitization and non-specific treatment effects: A methodological evaluation. Psychological Bulletin, 83, 729±758. Lang, P. (1971). The application of psychophysiological methods to the study of psychotherapy and behavior change. In A. E. Bergin, & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. An empirical analysis. New York: Wiley. Lang, P. (1993). The three-system approach to emotion. In N. Birbaumer & A. OÈhman (Eds.), The structure of emotion. Seattle, WA: Hogrefe & Huber. Lazarus, A. A. (1958). New methods in psychotherapy: A case study. South African Medical Journal, 32, 660±664. Lazarus, A. A. (1971). Behavior therapy and beyond. New York: McGraw-Hill. Lewinsohn, P. H. (1974). A behavioral approach to depression. In R. J. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. Washington, DC: Winston-Wiley. Lutz, R., Bezold, G., Bloem, R., Dietrich, M., & Wittmann, L. (1992). Sehen und gesehen werden. Neue Psychologien mit den alten Philosophien? GespraÈche mit erfahrenen VerhaltenstherapeutInnen uÈber Therapieziele und Prognosen. In H. Lieb & R. Lutz (Eds.), Verhaltenstherapie. Ihre EntwicklungÐihr Menschenbild. GoÈttingen: Verlag fuÈr Angewandte Psychologie. Margraf, J. (1996). Grundprinzipien und historische Entwicklung. In J. Margraf (Ed.), Lehrbuch der Verhaltenstherapie (Vol. 1). Berlin: Springer. Margraf, J., & Lieb, R. (1994). Was ist Verhaltenstherapie? Versuch einer zukunftsoffenen Neucharakterisierung. Editorial. Zeitschrift fuÈr Klinische Psychologie, 24, 1±7. Margraf, J., & Poldrack, A. (in press). Angstsyndrome in Ost- und Westdeutschland. Eine repraÈsentative BevoÈlkerungserhebung. Submitted for publication. Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Boston: Little, Brown.

Meichenbaum, D. (1975). Self-instructional methods. In F. H. Kanfer & A. P. Goldstein (Eds.), Helping people change: A textbook of methods. New York: Pergamon Press. Meyer, V. (1957). The treatment of two phobic patients on the basis of learning principles. Journal of Abnormal and Social Psychology, 55, 261±166. Mowrer, O. H. (1947). On the dual nature of learningÐa reinterpretation of ªconditioningº and ªproblem-solving.º Harvard Educational Review, 17, 102±148. Mowrer, O. H., & Mowrer, W. M. (1938). EnuresisÐa method for its study and treatment. American Journal of Orthopsychiatry, 8, 436±459. Nicholson & Berman (1983). Quoted in Shapiro, D. (1985). Recent applications of meta-analysis in clinical research. Clinical Psychology Review, 3, 13±34. O'Donahue, W., & Krasner, L. (Eds.) (1995). Theories of behavior therapy. Exploring behavior change. Washington, DC: American Psychological Association. Paul, G. L. (1966). Insight versus desensitization in psychotherapy. Stanford, CA: Stanford University Press. Paul, G. L. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology, 31, 109±118. Rachman, S. (1988). Verhaltenstherapie. In W. Arnold, H. J. Eysenck, & R. Meili (Eds.), Lexikon der Psychologie (6 Vols, pp. 2460±2469). Freiburg, Germany: Herder. Rachman, S., & Hodgson, R. (1974). Synchrony and desynchrony in fear and avoidance. Behaviour Research and Therapy, 12, 311±318. Rachman, S.J., & Hodgson, R.J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall. Rachman, S., & Teasdale, J. (1969). Aversion therapy and behavior disorders: An analysis. Coral Gables, FL: University of Miami Press. Reinecker, H. (1994). Grundlagen der Verhaltenstherapie. 2. Auflage. Weinheim: Psychologie-Verlags-Union. Schorr, A. (1984). Die Verhaltenstherapie. Ihre Geschichte von den AnfaÈngen bis zur Gegenwart. Weinheim: Beltz. Schorr, A. (1995). Behaviour therapy in Europe. A brief excursion into its history. In K. G. GoÈtestam & E. OÈ. Arnarson (Eds.), Twenty-fifth anniversary of the European Association for Behavioural and Cognitive Therapies (EABCT)ÐHistory. EABCT. SeidenstuÈcker, G., & Baumann, U. (1987). Multimodale Diagnostik als Standard in der Klinischen Psychologie. Diagnostica, 33, 243±258. Shapiro, M. B. (1961). The single case in fundamental psychological research. British Journal of Medical Psychology, 34, 255±262. Shapiro, D., & Shapiro, D. (1980). Meta-analysis of comparative therapy outcome research: A critical appraisal. Behavioural Psychotherapy, 10, 4±25. Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. Task Force on Promotion and Dissemination of Psychological Procedures (1995). Training in and dissemination of empirically-validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, 3±23. Task Force on Promotion and Dissemination of Psychological Procedures (1998). An update on empirically validated treatments. Washington, DC: Division of Clinical Psychology, American Psychological Association. Taylor, C. B., King, R., Margraf, J., Ehlers, A., Telch, M., Roth, W. T., & Agras, W. S. (1989). Use of medication and in vivo exposure in volunteers with panic disorder. American Journal of Psychiatry, 146, 1423±1426. Westmeyer, H. (1984). Von der Schwierigkeit, ein Behaviorist zu sein oder Auf der Suche nach einer behavioristischen IdentitaÈt. In H. Lenk (Ed.), Handlungstheorien ± interdiszilinaÈr (Band 3). Munich, Germany: Fink. Wilson, G. T. (1996). Acceptance and change in the

References treatment of eating disorders and obesity. Behaviour Therapy, 27, 417±439. Wittmann, W. W., & Matt, G. E. (1986). Meta-Analyse als Integration von Forschungsergebnissen am Beispiel deutschsprachifer Arbeiten zur Effektivitat von Psychotherapie. Psychologische Rundschau, 37, 20±40. Wolpe, J. (1954). Reciprocal inhibition as the main basis of psychotherapeutic effects. Archives of Neurological Psychiatry, 72, 205±226. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Wolpe, J. (1976). Behavior therapy and its malcontents. 1.

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Denials of its bases and psychodynamic fusionism. Journal of Behavior Therapy and Experimental Psychiatry, 7, 1±5. Woolfolk, A. E., Woolfolk, R. L., & Wilson, G. T. (1977). A rose by any other name . . . : Labeling bias and attitudes toward behavior modification. Journal of Consulting and Clinical Psychology, 45, 184±191. Yates, A. J. (1970). Behavior therapy. New York: Wiley. Yates, A. J. (1977). Falsche Auffassungen uÈber die Verhaltenstherapie: Ein Standpunkt. In H. Westmeyer & N. Hoffmann (Eds.), Verhaltenstherapie: Grundlegende Texte. Hamburg: Hoffmann & Campe.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.03 Cognitive Therapy IVY-MARIE BLACKBURN Cognitive Therapy Centre, Saint Nicholas Hospital, Newcastle upon Tyne, UK and University of Durham, UK 6.03.1 INTRODUCTION

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6.03.2 PRINCIPLES OF COGNITIVE THEORY OF EMOTION

52 52 53 54 56 56 57 60 60 62 62

6.03.2.1 A.T. Beck (Early Model) 6.03.2.2 The Evolution of Beck's Model 6.03.2.2.1 Personality variables 6.03.2.3 Interpersonal Processes 6.03.2.4 Constructivism 6.03.2.5 Information Processing and Cognitive Science 6.03.2.6 Other Cognitive Approaches 6.03.2.6.1 Rational-emotive therapy 6.03.2.6.2 Self-instructional training 6.03.2.6.3 Hopelessness theory of depression 6.03.3 APPLICATION OF COGNITIVE THERAPY

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6.03.3.1 General Principles of Cognitive Therapy 6.03.3.2 Treatment Methods 6.03.3.2.1 Behavioral methods 6.03.3.2.2 Cognitive methods 6.03.3.3 Developments

63 67 67 68 75

6.03.4 PROCESS OF COGNITIVE THERAPY

76 76 78

6.03.4.1 Mediators of Change in Cognitive Therapy 6.03.4.2 Moderators of Change in Cognitive Therapy 6.03.5 EFFICACY

78

6.03.6 CONCLUSION

79

6.03.7 REFERENCES

79

from the two embattled camps of psychoanalysis and behaviorism (Blackburn, 1986; Salkovskis, 1986). As with all ªnewº ideas, the cognitive movement did not arise de novo. Several influences within the general field of psychology and from clinical practice have been acknowledged, in particular Piaget (1972) who described the hierarchical structuring of knowledge; the ego analysts (e.g., Adler, 1936; Horney, 1950) who stressed patterns of thinking regarding the self

6.03.1 INTRODUCTION Nearly 40 years have elapsed since the early work of Beck and Ellis in the late 1950s and early 1960s in cognitive approaches to the treatment of emotional disorders. Both were reacting against classical psychoanalysis in which they had been trained and thus started what has been termed ªThe cognitive revolutionº (Dember, 1974) which, however, is probably best conceptualized as an evolution 51

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and the world as central to understanding feelings and behavior; Kelly (1955) who was a real ancestor in his descriptions of personal constructs; Arnold (1960) and Lazarus (1966) who stressed the role of cognition in their theories of emotion. Be it revolution or evolution, it can certainly be asserted that cognitive therapy has been a most successful movement, in view of the highly prolific research literature, the number of specialized journals, the demands for training courses in cognitive therapy, and continuous refinement of the underlying theoretical principles. The strength of cognitive therapy from its inception has been its emphasis on empirical backing. This tradition continues, both in experimental studies and in clinical outcome studies, and, consequently, the theory has not remained static, being also informed by advances in related areas of study, namely cognitive science, social science, and biology. This chapter will consider the key principles of the cognitive theory of emotion and how they apply to cognitive treatments. The range of approaches and recent developments will be discussed.

concept of basic structures or schemata derived from cognitive science (Bartlett, 1932; Neisser, 1976; Piaget, 1950) These represent the sum of previous experiences, serving as templates that direct attention, influence encoding and interpretation of stimuli, and facilitate recall. In depression, the schemata reflect themes of loss and of self deficiency, for example, ªunless I do everything perfectly, I am worthlessº or ªunless I do everything to please others, they will reject me.º It is noteworthy that at this stage of the theory, no differentiation was made between conditional schemata or basic assumptions, rules, and attitudes on the one hand, and unconditional schemata or core beliefs on the other, for example, ªI am inadequateº or ªI am unlovable.º An example linking the three elements described above would be: Schema: (conditional) ªIf people do not like me, I cannot be happyº Stimulus: ªA friend does not telephone as promisedº

;

6.03.2 PRINCIPLES OF COGNITIVE THEORY OF EMOTION

Interpretation: (Content of thought expressed in negative automatic thoughts) ªShe does not like meº

6.03.2.1 A.T. Beck (Early Model)

ªNobody likes meº

Beck's early work (1963, 1967), related to thinking style in depression and later expanded to other emotional disorders (1976). He described the typical negative content of thought in depression as a pervasive negative view of the self, of the environment, and of the future (the negative cognitive triad), expressed in automatic, habitual thoughts in reaction to trigger stimuli. The negative automatic thoughts are maintained by various processing errors with a negative bias (arbitrary inferences, selective abstractions, personalizations, overgeneralizations, minimizations, and magnifications). These processing errors do not differ necessarily from the type of processing errors made by nondepressed individuals (labeled heuristics by Kahnneman, Slovic, & Tversky, 1982), the difference being in the direction of the bias, which is usually positive in the nondepressed, expressed as a self-serving bias (Taylor & Brown, 1988). The consequence of processing information with a negative bias is a congruent negative emotion. Thus, the information processing model of emotional disorders was set in a straightforward vertical or unidirectional model, which has since been reviewed. To explain why some individuals process information with such unhelpful biases, Beck evoked the

ªI shall always be alone and miserableº

(arbitrary inference personalization) (magnification) (overgeneralization)

; Feeling: ªDown in the dumpsº

Once the negative feeling is triggered, it is likely to feed forward and lead to other stimuli being interpreted negatively in accordance with the schema which has been activated and which becomes progressively more widely applied to inappropriate stimuli. Similarly, maladaptive behaviors, such as ruminations and inactivity, become preponderant and increase the incidence of negative automatic thoughts and the corresponding dysthymic moods. The typical schemata, beliefs, rules, and attitudes reflect themes of love, approval, entitlement, omnipotence, perfectionism, autonomy, and achievement, as measured by the Dysfunctional Attitude Scale (DAS) which was developed specially to assess this aspect of Beck's theory (Weissman & Beck, 1978) The cognitive model of the anxiety disorders (Beck, 1976; Beck & Emery, 1985) followed the same principles, emphasizing specific patterns

Principles of Cognitive Theory of Emotion of thinking which differentiate these disorders from depression. Beck, Laude, and Bohnert (1974), in two studies designed to elicit thoughts and visual imagery associated with anxiety, found that anxious patients experience threatening thoughts or images which often precede attacks of anxiety. These thoughts relate to anticipated or visualized danger and extreme vulnerability. It was apparent that imagery was important in anxiety, an aspect that had not been stressed in depression, but which is emphasized in cognitive therapy (Edwards, 1989) The content of thought in anxiety was found to relate to an anxiogenic triad; seeing the world as threatening, the self as vulnerable, and the future as uncontrollable. This approach was similar to that of Lazarus (1966) who distinguished between two cognitive processes in anxiety, namely primary and secondary appraisal. Primary appraisal relates to an individual's evaluation of a situation as dangerous and threatening, whereas secondary appraisal relates to the evaluation of the self as not having the internal and/or external resources to deal with that situation. The processing errors in anxiety do not differ essentially from those described in depression, but the schemata are likely to be different, referring to themes of personal vulnerability, of unpredictability, and of threat, for example, ªIf I feel anxious, this means I have no control of myselfº or ªI must always be on my guard, if not something awful will happen.º As in depression, the dysfunctional schemata are self- or world-referent; they tend to be rigid and undifferentiated. These characteristics have been taken as implying that they have been learnt in early childhood and continue to survive through the process of assimilation, rather than accommodation (Piaget, 1977).

6.03.2.2 The Evolution of Beck's Model The implications of the original model were of a causative link between cognitions and emotions, assigning primacy to cognitions. This was challenged by Zajonc (1980) and Rachman (1981, 1984). Beck (1987) restated his approach more clearly, emphasizing that negative cognitions are inherent to depression, as delusions are inherent to psychosis, and that, therefore, they cannot be conceptualized as causing depression, as delusions cannot be said to cause psychosis. Negative cognitions are one side of the coin and biological changes the other side. While research findings have given ample evidence for a negative content of thought in depression (Haaga, Dyck, & Ernst, 1991) and thoughts relating to personal danger and inability to cope

53

in anxiety (Hibbert, 1984; Butler & Mathews, 1983), the causative role of cognitions, and the specificity of cognitive therapy, relative to antidepressants medication, in changing cognitions have not been demonstrated (Blackburn & Bishop, 1983; Simons, Garfield, & Murphy, 1984). Regarding particular biases in information processing, in general, studies support an attentional bias in anxiety and a memory bias in depression (Dalgleish & Watts, 1990; Mogg et al., 1991; Wells & Matthews, 1994; Williams, Watts, MacLeod, & Mathews, 1988) Williams et al. (1988) proposed that ªanxiety involves biased allocation of attention at the preattentive stage, and depression involves biased use of mnemonic cueing at the elaborative stageº (p. 181). Indeed, several studies have found no bias in memory for threat words in anxious subjects, inter alia (MacLeod, 1991; Mineka, 1992; Mogg, Mathews, & Weinman, 1987), while there is substantial evidence of a negative bias in retrieval process in depression (Blaney, 1986; Breslow, Kocsis, & Belkin 1991; Teasdale & Russell, 1983). The extensive research in information processing in depression and the anxiety disorders (reviewed by Wells & Matthews, 1994; Williams et al., 1988) directly inform cognitive therapy as applied to these disorders to date. The structural aspect of the cognitive model of the emotional disorders has been the most elusive of its components to put to experimental validation. As alluded to above, the term ªschemaº has been used differently by different authors and a reliable and valid methodology to measure and assess schemata is not well established. In the conceptualization of cases for the development of cognitive treatment strategies (Persons, 1989), it is usual to differentiate between conditional schemata or basic assumptions and core or unconditional schemata. Thus, in the example given in the previous section, the core schema may be ªI am unlovableº leading to the conditional schema ªIf people do not like me, I cannot be happyº and the rule ªI must do everything people ask of me.º The same basic or core schema may lead to the conditional schema ªIf people get close to me and get to know me, they will reject meº leading to the rule ªI must avoid close relationshipsº. This differentiation developed from the extension of cognitive therapy to personality disorders (Beck, Freeman, et al., 1990; Young, 1990); from greater emphasis on the role of conceptualization in treatment (Blackburn, Twaddle, et al., 1996); and from the clinical observation that although there seems to be a limited range of themes in basic schemata, there

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is a wide variety of conditional schemata leading to different behaviors, different ways of constructing the self and the environment, different mood states, and different disorders. The typical themes of core schemata relate to personal worth (e.g., I am worthless/useless), to moral worth (I am bad/evil), to abnormality (I am a freak/abnormal/different), and to personal ability (I am incapable/inadequate). Examples of how these different levels of the structural aspect of cognitive theory are used in case conceptualizations will be given in Section 6.04.3. The standard assessment tool of underlying cognitive structures remains the DAS, Form A, (Weissman & Beck, 1978), a 40-item, sevenpoint scales questionnaire which primarily is aimed at measuring the presence and intensity of belief in conditional schemata in depression. A questionnaire by Young (1990) attempts to measure core schemata (Early Maladaptive Schemata in Young's terminology), but the scale has not been validated adequately. Several studies, using the DAS, have shown that level of dysfunctional attitudes discriminates between depressed subjects and controls, inter alia (Blackburn, Jones, & Lewin, 1986; Hamilton & Abramson, 1983) and at post-treatment, predicts future levels of depression (Rush, Weissenberger, & Eaves, 1986; Simons, Murphy, Levine, & Wetzel, 1986). However, not surprisingly according to Beck's theory, the level of dysfunctional attitudes decreases markedly with remission and becomes indistinguishable from normal level (Blackburn, Roxborough, Muir, Glabus, & Blackwood, 1990; Simons et al., 1984). The endorsement of self-referent adjectives is another method of assessing the self-schema (Segal, 1988), which is more in line with the definition of schemata in cognitive psychology. Using this methodology, Teasdale and colleagues (Teasdale, 1988; Teasdale & Dent, 1987) found that subjects vulnerable to depression recall more global self-referent adjectives (e.g., ªpathetic,º ªworthless,º ªstupidº) than never depressed subjects who recall more specific and milder negative self-referent adjectives (e.g., ªrude,º ªthoughtless,º ªinconsiderateº). The number of global negative adjectives endorsed also predicted level of depression five months later in mildly depressed women. Teasdale (1988) put forward his differential activation hypothesis on the basis of such findings; this states that the type of thinking activated in milddysphoric moods, in combination with high neuroticism, a personality variable (Eysenck, 1970) which also affects selective recall of depressed memories, is likely to activate higher levels of depression. These globally negative

self-referent adjectives are likely to reflect core schemata. Figure 1 describes the generic model of the emotional disorders, following Beck's approach as developed from the original model, differentiating core schemata and basic assumptions. In Figure 2, the application of the generic model to a specific case is shown in a case formulation, where good as well as depressed periods can be understood through the individual's core schema.

6.03.2.2.1 Personality variables A further development in the area of vulnerability to depression has been the delineation of higher-order, more stable personality characteristics which may determine the content of dysfunctional schemata. These have been defined as sociotropy and autonomy by Beck and his colleagues (Beck, 1983; Beck, Epstein, & Harrison, 1983). An overly sociotropic individuals is described as socially dependent, highly invested in positive interchange with others, valuing above all acceptance, intimacy, support, and guidance. In contrast, an overly autonomous individual is highly invested in independent functioning, mobility, freedom, choice, achievement, and the integrity of the personal domain. A specially constructed scale, the sociotropyautonomy scale (SAS; Beck et al., 1983) consists of 60 items rated on five-point scales. A large number of studies have been conducted (Blackburn, 1996; Clark & Beck, 1991; Gilbert & Reynolds, 1990; Hammen, Ellicott, Gitlin, & Jamison, 1989; Moore & Blackburn, 1994; Robins, 1990) indicating that sociotropy is related to vulnerability to interpersonal life events, to level of depressive symptoms, to level of neuroticism, and to the subscale of the DAS which measures social approval. Moreover, Moore and Blackburn (1996) have shown, in a large clinical sample of depressed patients assessed pre- and post-treatment, that sociotropy, as assessed by the SAS, is relatively stable over time in contrast with level of dysfunctional attitudes as assessed by the DAS. On the other hand, the conceptual validity of autonomy has not been demonstrated. It has been shown to be only minimally related to level of depression (Gilbert & Reynolds, 1994; Moore & Blackburn, 1994, 1996), to correlate poorly with other measures of independence and not to predict consistently an interaction with negative achievement events (Hammen et al., 1989; Robins & Block, 1988). The autonomy scale of the SAS is in the process of being revised for new validation studies (Clark, Steer, Beck, & Ross, 1995).

Principles of Cognitive Theory of Emotion EARLY EXPERIENCE

DYSFUNCTIONAL ASSUMPTIONS SCHEMATA

CRITICAL INCIDENT

ASSUMPTIONS ACTIVATED

AUTOMATIC NEGATIVE THOUGHTS PHYSIOLOGICAL AFFECTIVE

MOTIVATIONAL COGNITIVE

BEHAVIORAL

}

PREDISPOSING/ VULNERABILITY FACTORS

}

PRECIPITATING FACTORS

}

MAINTAINING FACTORS

}

SYMPTOMS

55

Figure 1 Cognitive model of emotional disorders.

Depression: This is shameful. Change of job: Feels deskilled/devalued. “I’m no good.” “I can’t cope.” “It’s my fault.” Improved work conditions: Feels good. Depression: New job/difficulties at work. “I thought I was doing well, they don’t value me – I’m no good.” “All my efforts have come to nothing.” Marriage, good job: Feels happy.

Figure 2

“I am inadequate.” (Core schema)

“I should be able to cope – if not people will look down at me.” “It is shameful to be seen as not coping.” “I must be well organised and keep everything under control – if not I’m failing.” “If my personal relationships go wrong, it is my fault.” (Basic assumptions; conditional schemata)

Depression: “I have failed.” “I’ve put in all this effort for nothing.” “I feel dumped, abused.” “Cannot let anybody know.”

Works hard at school, university and at keeping a tenuous relationship going. Has cheated in an examination – guilt. “This is shameful; I’m not as good as Ann.” Takes an “easy” subject at university. The “better” students study medicine or science. “I am not good enough.” Depression: Examination time – “I won’t pass, I’m not good enough.” Breakdown of relationship.

Depression conceptualization (reproduced by permission of Souvenir Press from Cognitive therapy in action. A practitioner's case-book. Blackburn, Twaddle et al., 1996).

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6.03.2.3 Interpersonal Processes It may be that the relationship of sociotropy, and not autonomy, to depression simply reflects that interpersonal processes are of particular importance in depression, and possibly in other emotional disorders. Early descriptions of cognitive therapy were criticized for ignoring interpersonal processes (Coyne & Gotlib, 1983). Safran and Segal (1990) have made a welcome contribution emphasizing the role of interpersonal factors. They state ªthe individual must always be understood as part of the interpersonal systems in which he or she is participating. Thus, one cannot understand the patients in therapy independently of the therapistº (p. 5). They view the therapeutic relationship as central to cognitive therapy, in that it is through the therapeutic relationship that core dysfunctional interpersonal schemata can be revealed. The interpersonal schema is defined as a generic cognitive representation of interpersonal events which derives from interactions with attachment figures of the past and serves to predict future interactions with these figures and with others. The stress on the interpersonal perspective has exercised a strong influence on the practice of cognitive therapy, in that more emphasis is put on the therapeutic relationship and more attention is paid to developmental factors, especially in the treatment of personality disorders. Issues which might have been considered as stumbling blocks in therapy, for example, lack of trust, overdependence, avoidance, and aggression, can now be directly employed to guide formulation and questioning. For example, if the patient appears to be aggressive in therapy, the therapist may comment: ªIt seems to me that you feel angry with me. Is this how you feel at the moment?º ªIs it something that I have said or something about me?º ªIs there some other situation like this outside of therapy that made you feel the same?º ªDid this happen in your family?º Thus, the typical socratic questioning or guided discovery style of cognitive therapy is used to uncover possible core interpersonal schemata, rather than, perhaps more traditionally, just to elicit the current automatic thoughts so as to revaluate them and to look for disconfirming evidence. 6.03.2.4 Constructivism Mahoney (1993) suggests that one of the ªmajor conceptual developments in the cognitive psychotherapies over the past three decadesº has been the differentiation of rationalist and constructivist approaches to cognition. Constructivism or constructive metatheory

emphasizes the active and proactive nature of all knowing, the operation of tacit or unconscious processes, the complexity of human experiences, and the need for a developmental, process-focused approach to knowing. Some of the proponents of this approach, apart from Mahoney, are Neimeyer (1992, 1993), Guidano and Liotti (1983), and Anderson (1990) who are all indebted to Kelly's (1955) personal construct theory. Constructivism is contrasted by these authors to logical positivism and rationalism which are described as characterizing Beck, Rush, Shaw, and Emery's (1979) information processing model and Ellis' (1962) rationalemotive approach. Neimeyer (1993) considers constructivism to be predicated on a postmodern epistemology and gives a quote from Kelly (1977, p. 6) ªwhat we think we know is anchored only in our assumptions, not in the bedrock of truth itself, and that world we seek to understand remains always on the horizons of our thoughts,º as representing a quintessentially postmodern conclusion. Neimeyer (1993) contrasts traditional cognitive theory and therapy with constructivist theory and therapy. In so doing, he gives a distorted and narrow view of the Beckian approach, at least in its modern form. He interprets Beck et al. (1979) and Ellis (1973) in particular, as equating emotional adjustment with rationality (logical empiricism), so that when humans deviate from rationality and the scientific method, they form distorted views of themselves, their world, and their future, and experience dysphoric emotions and emotional disorders. The word ªrationalº may have been emphasized in earlier cognitive theory, but it is not now; the term ªdysfunctionalº being preferred, indicating that thoughts or attitudes are dysfunctional when they have negative consequences, not because they are irrational. These changes in the theory have followed research findings that indicate, for example, that depressed subjects do not have exclusive negative thoughts (Clifford & Hemsley, 1987), that depressed subjects choose as many positive as negative adjectives as self-descriptors (Derry & Kuiper, 1981), and that normal controls show a ratio of 1:17 of negative to positive thoughts. (Schwartz, 1986). Ellis (1993) has argued that even rational-emotive therapy (RET) has never been truly rationalistic, although he accepts that he too has moved from a more rationalistic to a more constructivist position. Cognitive therapy (Beck et al., 1979) has, in any case, always used questioning that stresses the disadvantages of thinking in certain ways and the advantages of thinking in alternative ways, rather than logical vs. illogical thinking.

Principles of Cognitive Theory of Emotion However, it must be acknowledged that a number of the changes in cognitive therapy, as it has evolved, have been influenced by the philosophical stance of constructivist theories. The examination of developmental factors to understand the cognitive structures through which an individual construes their world, the stress on interpersonal processes, and developments in the understanding of informationprocessing to explain individual emotional reaction, as described in the next section, probably reflect constructivist influences.

6.03.2.5 Information Processing and Cognitive Science Cross-fertilization from cognitive science has inspired a vast number of ingenious experiments to test various aspects of information processing in depression and anxiety disorders, and has prompted more complex models of information processing (Ingram, 1988; Teasdale, 1993; Teasdale & Barnard, 1993; Wells & Matthews, 1994; Williams et al., 1988). Ingram and Kendall (1988, p. 13) present a complex model which is adapted in Figure 3. These authors attempt to delineate the ªpattern of relationships among the various components of the cognitive taxonomic system.º The diagram indicates that the different components which may be involved in information processing operate in a reciprocal, interactional, and multidirectional fashion. Cognitive structure is defined as the architecture of the system in which information is stored and organized. This would consist of long- and short-term memories, sensory memories, and associative networks. Cognitive content represents the information that is actually stored, that is, the content of the cognitive structure, for example, semantic and episodic memory. The term schema, as used in cognitive therapy, is represented by both the cognitive structure and the cognitive proposition. Cognitive operations represent the various procedures by which information is processed, for example, attention, selection, encoding, interpretation, and retrieval. These represent the various cognitive processes which have been found to show particular biases in the emotional disorders (attentional biases in anxiety and retrieval biases in depression). Cognitive products represent thoughts, both automatic and controlled, and images. Arrows labeled as operations indicate cognitive processes leading to cognitive products, whereas arrows not labeled as operations indicate ªprocedures that may not be primarily cognitive,º for example, the interactions between affective, biochemical, and cognitive factors.

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The model suggests that behavior can be affected by a variety of sources, by cognitions, by cognitive structures directly (e.g., unconscious routines such as riding a bike), and by affective and biochemical factors. The acknowledgement of other cognitive structures, which remain undefined, recognizes that understanding of the cognitive system is still incomplete, particularly as regards unconscious structures. The model also suggests a generic model for the emotional disorders which can take into account similarities and differences across different disorders. For example, in depression and anxiety, the operation through which information is processed may be largely similar, but the content of the cognitive structures and the cognitive products differ as described in Section 6.03.2.2. Such a model would evidently be far too complex to use in therapy. Instead, as shown in Figure 4, a simplified generic model giving the same information can be given to patients (Greenberger & Padesky, 1995). The diagram indicates the interactions among all elements; biology (which includes physiological and biochemical changes), thoughts (automatic thoughts, beliefs, attitudes, schemata), emotions, and behavior and stresses that the individual exists within an environment which triggers their reactions and which reacts to their reactions. Bower (1981) presented his influential associative network theory of mood and memory which derived experimentally to explain the relationships between cognition and mood. According to this theory, emotions, as well as cognitions and events, are represented in the brain/mind by discrete nodes or units which are linked in an associative network. Thus, an emotion can be activated by an appropriate external stimulus or by the activation of other linked nodes in the associative network, for example, a sad memory or some physical sensation. Once activated, a depressed mood or an anxious mood will influence future information processing by the spreading of activation through the associative network, so that events or situations are more likely to be interpreted negatively or as denoting threat and danger. The prediction from Bower's (1981) paper was of a recriprocal relationship between mood and thinking, so that there would be mood state-dependant retrieval (superior recall of material retrieved in the same mood state as was present during learning) and mood-congruent retrieval (increased ease of recall of sad memories when in a depressed mood state). These predictions have been confirmed in several studies using both naturally occurring depressed moods (Clark & Teasdale, 1982; Miranda & Persons, 1988; Miranda, Persons, &

STIMULUS A friend does not telephone

COGNITIVE STRUCTURE Long- and short-term memory of past rejection/loneliness OTHER COGNITIVE STRUCTURES

Operations

COGNITIVE PROPOSITION I don’t have the necessary qualities to be loved. Life is not worth living if one is not loved

Operations Selective Abstraction Arbitrary Inference Overgeneralization

ns

tio

ra

pe O

BIOCHEMICAL FACTORS

AFFECTIVE STRUCTURES Sadness, anxiety, anger

COGNITIVE PRODUCTS She never calls She does not care Nobody cares It’s awful I’m too boring

BEHAVIOR

Ope

BEHAVIOR Crying Depressive Rumination

ratio

ns

SENSORY DATA Quiet, cold No stimulation

OTHER ENVIRONMENTAL SOURCES E.g. other’s behaviors

Figure 3 Information processing model and depression (Source: Ingram and Kendall, 1988).

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Principles of Cognitive Theory of Emotion

COGNITIVE STRUCTURE

THOUGHTS

PHYSICAL/ BIOLOGY

EMOTIONS

BEHAVIOR

Figure 4 Generic cognitive model of the emotional disorder (Source: Greenberger & Padesky, 1995).

Buyers, 1990) and in induced moods (Teasdale & Fogarty, 1979; Teasdale & Taylor, 1981). However, a number of disconfirming findings have also been reported, as seen in metaanalyses and Ucros (1989) and Bower (1987) concluded that his theory needed revising. Bower (1992) has expanded his theory by proposing that emotions may activate not only isolated semantic concepts, but wider rule-based action plans. Teasdale (1993) finds Bower's theory an improvement on Beck's theory, for several reasons: its clearly testable predictions; its acknowledgement that negative thinking can be an antecedent, as well as a consequence of depressed affect; its view of depression as an extreme form of the normal effect of mood on information processing, which thus provides an alternative view of cognitive vulnerability without having to evoke the matching of trigger events with dysfunctinal assumptions and schemata; and its ability to explain the maintenance of depression. In short, he considers Bower's theory more scientifically sound than Beck's. However, Teasdale (1993) and Teasdale and Barnard (1993) criticize Bower's theory on several counts and have put forward an alternative theory, the Interacting Cognitive Subsystems (ICS) framework which will be

described briefly because of its potential influence on cognitive therapy. ICS aims to bring to clinical psychology insights derived from cognitive science. Teasdale (1993) considers that Beck's model depends on lay concepts of cognition where cognitions refer only to consciously experienced thoughts and images and schemata to beliefs and assumptions. He considers that research studies and clinical observations have higlighted certain problems with cognitive therapy: cognitive therapy is not uniquely more effective than other psychological treatments (e.g., behavior therapy, Gallagher & Thompson, 1982; Interpersonal Psychotherapy, Elkin et al., 1989); antidepressant medication reduces negative thinking to the same extent as cognitive therapy (Simons et al., 1984); there is no evidence of dysfunctional assumptions in remitted patients (Blackburn et al., 1990); in therapy, it sometimes appears that patients can experience emotional reactions without identifiable negative automatic thoughts; rational argument in therapy often appears ineffective in changing emotional responses; and for more refractory problems, for example, personality disorders, noncognitive methods of treatment have had to be borrowed from other schools of therapy, for example, Gestalt therapy (Beck, Freeman et al., 1990).

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On the other hand, Bower's (1981) model, according to Teasdale (1993), fails because of the lack of differentiation in the semantic networks which are described. These appear to represent knowledge in a single format, so that specific concepts and the relationship between them is not differentiated. Higher order of meaning is not explained and, therefore, no distinction can be made between ªhotº cognitions which are associated with a high level of emotion and ªcoldº cognitions which are reported at an intellectual level, without accompanying emotions. Teasdale and Barnard (1993) describe ICS as an information processing model which attempts to take into account all aspects of information processing, and thus, probably succeed in developing in more detail Ingram and Kendall's (1988) model described earlier. They postulate nine types of information, encoded in separate mental codes, representing different aspects of experience; for example, sensory experience (sensory and proprioceptive codes); regularities in the sensory code patterns (intermediate structural description codes); specific and generic levels of meaning (meaning codes); and information required for effector action (effector codes). Each type of information is processed by its own specialized subsystem and encoded in separate memory stores. Information processing involves the transfer of information between subsystems and its transformation from one mental code to another. Importantly for cognitive therapy, in the ªmeaning codesº two different codes are described relating to two highly different levels of meaning. The propositional code encodes specific meanings, discrete concepts, and the relationship between them. This is akin to Bower's semantic network, for example, ªmy neighbour is gray haired.º The implicational code encodes generic, holistic levels of meaning which are difficult to convey in language: it relates to recurring very high order regularities across all information codes. Only this level of meaning is linked directly to emotion, with implicit meaning content, for example, ªsomething wrong.º Implicational meaning has a high level of abstraction; is influenced by contextual sensory features, for example, facial expression, tone of voice, bodily arousal; and represents generic features of experience which cannot be expressed in single sentences. The implicational code represents schematic models of experience with which mood biases are associated. Thus, depression is associated with the regeneration of depression-related schematic models when there is a shift in the prevailing high-order mental models of self and world which dominate

information processing. This shift in the interrelationship between high order mental codes, not the activation of a particular cognitive node, leads to a negative content of thought in the form of negative attributions, evaluations, and memories. Although this model appears at times overly complex and abstract, the clear differentiation between propositional and implicational levels of meaning is useful to understand the process of therapy and to make sense of failures and successes in therapy. The central goal of therapy is evidently to change implicational meaning related to depressive or anxious schematic models by substituting alternative patterns of meaning related to more adaptive schematic models. Since this abstract, generic level of meaning is made up of various elements, such as specific meanings, bodily state, and sensory information, such as tone and volume of voice and visual information, changes in any of the elements may bring therapeutic change. Therapy would thus involve different elements: change in meanings and/or change in sensory input, adding new elements to an experience through guided imagery, and paying greater attention to feelings through the use of emotional methods of treatment as used in Gestalt therapy. Interestingly, such therapeutic approaches have been adopted in cognitive therapy, especially for personality disorders. It seems that clinicians inspired by clinical insight have reached the same point as cognitive theorists, although through a different route, and perhaps without a proper rationale to explain their methods of treatment. 6.03.2.6 Other Cognitive Approaches Beck's theories in the original form, and as further developed through research and clinical experience, have been the main emphasis in the previous sections because it is the approach which has led most clearly to specific methods of treatment which have been tested widely in controlled outcome studies. However, some other approaches have also been influential, in particular Ellis' RET, Meichenbaum's selfinstructional training, and clinical developments of Seligman's learned helplessness theory by Abramson and her colleagues in the hopelessness theory of depression. These will be described briefly in this section. 6.03.2.6.1 Rational-emotive therapy Ellis (1989) describes himself as the first major cognitive-behavioral therapist in view of his writings and practice dating back to 1957

Principles of Cognitive Theory of Emotion (Ellis, 1957, 1962). RET, now relabeled REBT (rational-emotive-behavioral therapy), is based on an ªABCº theory of psychopathology, stating that activating events (A) do not directly cause emotional and behavioral consequences (C), but that the mediating variable of beliefs (B) about these events exercises the major influence on feelings and behavior. As such, the theory is quite close to Beck's, but the emphasis is clearly on beliefs only, as opposed to different aspects of cognition, for example, the content, form, and structure of thought. The therapeutic thrust of RET has, therefore, been on irrational beliefs as the cause of emotional problems. Rational beliefs are defined as those promoting survival and happiness and as likely to find empirical support in the environment, in contrast with irrational beliefs which are unlikely to find empirical support and reflect ªmustsº and ªshould.º Rational beliefs will lead to appropriate negative emotions (sorrow, annoyance, regret) in the face of losses or difficulties, whereas irrational beliefs will lead to inappropriate negative emotion (depression, extreme anger, guilt). Haaga and Davison (1993) argue that the definition of rationality and irrationality is problematic in that irrationality is not the prerogative of emotionally disturbed individuals. Extensive research has shown that much of the thinking of nondisturbed people is irrational (Alloy & Abramson, 1979; Taylor & Brown, 1988). Irrational beliefs in RET are often defined by lists of typical beliefs which are often encountered in clinical practice (Ellis, 1962), for example: (i) there is a dire necessity to be loved for everything one does; (ii) certain acts are awful and wicked and people should be punished who perform such acts; (iii) it is horrible when things are not the way one would like them; (iv) human misery is externally caused and is forced on one by outside people and events; (v) if something is or may be dangerous, one should be terribly upset about it; (vi) it is easier to avoid than face life's difficulties and self-responsibilities; (vii) one needs something other or stronger or greater than oneself on which to rely; (viii) one should be thoroughly competent, intelligent, and achieving in all possible aspects; (ix) because something once strongly affected one's life, it should indefinitely affect it; (x) one must have certain and perfect control over things; (xi) human happiness can be achieved by inertia and inaction; and (xii) one has no control over one's emotions and one cannot help feeling certain things.

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Such beliefs have been described in lists of a dozen to lists of several hundreds specific ones, to a few general categories with many exemplars (Ellis & Bernard, 1985). Specific questionnaires to measure irrational beliefs, such as the Rational Belief Inventory (Shorkey & Whiteman, 1977) and the Irrational Beliefs Test (Jones, 1968) have been criticized for confounding irrational beliefs with negative emotions. Ellis and Whiteley (1970) make a difference between ªelegantº and ªinelegantº RET techniques. Elegant or preferential RET involves forceful disputation of the patient's irrational beliefs with the aim of making profound philosophical changes in the patient. However, this approach is not suitable for all patients, for example, for those with limited intellectual resources or with poor motivation. In such cases other methods, as used in cognitive therapy, are acceptable. This is described as inelegant or general RET, involving manipulation of environmental circumstances, teaching coping strategies, and ªpersuading clients that their perceptions of events are incorrectº (Raitt, 1988, p. 202). Persuasion is, however, definitely not a Beckian method of cognitive therapy which advocates instead the use of inductive methods to guide patients to evaluate their cognitions and make their own discoveries. Ellis (1980), in his comparison of RET and cognitive behavior therapy, emphasizes the philosophical stance of RET which is that: (i) people create their own emotional disturbances through irrational, absolutistic beliefs; (ii) as people have free-will, they can choose to disturb themselves or not; (iii) to bring about change, active work at modifying thoughts, feelings, and behaviors is necessary; (iv) profound philosophical change will bring about modification in emotional and behavioral reactions; (v) long-range hedonism is more healthy than short-term hedonism; and (vi) a scientific outlook, rather than an unscientific religious or mystical outlook, is likely to bring greater emotional health and satisfaction. He rightly says that such a philosophical stance is absent in cognitive behavioral therapy which emphasizes evaluation and modification of cognitive processes to bring about long-term symptomatic changes, instead of deep philosophical changes. The efficacy of RET has been tested in a number of studies (Haaga & Davison, 1989; Kendall, 1984; Zettle & Hayes, 1980), with encouraging results. However, the studies have been highly criticized for their poor methodology, involving nonclinical samples, no followup evaluation, poor outcome measures, no attempt at measuring treatment adherence, and the lack of differentiation between the two versions of RET (Haaga & Davison, 1993).

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6.03.2.6.2 Self-instructional training Self-instructional training (SIT) is the therapeutic method described by Meichenbaum (1977) in cognitive-behavior modification (CBM). As the term indicates, CBM was a development of behavior therapy and behavior modification at the time when efforts were being made to incorporate cognition as a valid variable in behavior therapy (Mahoney, 1974), because of the growing dissatisfaction with the empirical and theoretical basis of radical behaviorism. Cognitive-behavior therapists proposed that cognitions could be viewed as covert behaviors, subject to the same laws of learning as overt behaviors. Homme (1965) coined the term ªcoverantsº to denote cognitions as covert operants, in Skinner's language, which are responsive to both external and internal contingencies and altered by contiguous pairings, through covert sensitization (Cautela, 1973). Meichenbaum (1993) describes the process as ªclient's self-statements and images were viewed as discriminative stimuli and as conditioned responses that come to guide and control overt behaviorº (p. 202). Following from that, SIT aimed to decondition maladaptive patterns of behavior by training in self-talk which would establish and strengthen new patterns of behavior and by rehearsing adaptive coping skills. ªThe technology of behavior therapy, such as modelling, mental rehearsal, and contingency manipulations, was used to alter not only clients' overt behaviors, but also their thoughts and feelingsº (p. 202) (Meichenbaum, 1993). Meichenbaum (1977) describes the application of SIT and successful outcomes in hyperactive and impulsive children, socially withdrawn children, adult schizophrenics, and in creativity training. An example of SIT with impulsive children involves the following steps: (i) an adult performs the task while talking to himself out loud (cognitive modeling); (ii) the child performs the same task under the direction of the model's instructions (overt, external guidance); (iii) the child performs the task while instructing himself or herself aloud (overt selfguidance); (iv) the child whispers to himself while he or she goes through the task (faded, overt selfguidance); (v) finally, the child performs the task while guiding his or her performance via private speech (covert self-instruction). Over a number of training sessions, the package of self-statements modeled by the experimenter and rehearsed by the child is enlarged by the means of response chaining

and successive approximation procedures. The skills which are taught through modeling are: problem definition, focusing attention and response guidance, self-reinforcement, self-evaluative coping skills, and error correcting options (I'm doing okay . . . if I make a mistake, I can correct it and go on more slowly). The same operant conditioning principles of chaining and shaping were used over a number of training sessions to teach schizophrenic patients to use complex sets of self-statements. The modification of self-talk or of automatic thoughts is central to cognitive therapy of the emotional disorders in adults, but the specific techniques of SIT appear particularly useful for patients with less well-developed verbal skills, for example, children, adults with learning difficulties, and severely impaired individuals such as schizophrenic patients. It has also been shown to be effective as a version of cognitivebehavioral therapy with phobic and anxious patients (Chambless & Gillis, 1993). 6.03.2.6.3 Hopelessness theory of depression Seligman's theory of learned helplessness (Seligman, 1975; Seligman & Maier, 1967), as a model of depression derived from animal experiments where uncontrollable shocks were administered, was criticized for not being an adequate model for depression in humans. The model did not appear to reflect the complexity of human depression and the varied presentation of depression. As a result, a reformulated learned helplessness model was proposed by Abramson, Seligman, and Teasdale (1978), based on attributional theory, which described a particular type of depression, namely hopelessness depression. In brief, the theory stated that when an individual makes causal attributions which are internal, global, and stable for negative events, but which are external, specific, and unstable for positive events, expectations are created that highly desired outcomes are unlikely to occur or that highly aversive outcomes are likely to occur and that the individual has no available response to change the likelihood of occurrence of these outcomes. These expectations and the occurrence of a negative event were seen as a sufficient proximal cause of depression. However, Abramson et al. (1978) were aware of problems in this analysis, in that not all highly improbable, but highly desired outcomes, will be a sufficient cause of depression. For example, it may be desirable to win several million dollars on the weekly lottery, but people do not generally become depressed if they fail to win. There are other characteristics of the desired outcomes, for example, how much concern exists about them and how possible

Application of Cognitive Therapy they are, which may determine whether their nonoccurrence is a sufficient proximal cause of depression. Abramson, Alloy, and Metalsky (1988) have clarified and revised the helplessness theory of depression. They describe it as a diathesis stress model, relevant to one hypothesized subtype of depression. The hopelessness theory specifies not only a proximal sufficient cause, but also potential distal causes. A negative life event is interpreted by an individual who has a depressogenic attributional style (the diathesis) as due to stable, internal, global factors and high importance is attached to the event. These attributions may be modulated by situational cues (consequences, consistency of occurrence, and distinctiveness). The depressogenic attributions lead to lowered self-esteem and to feelings of hopelessness (which can be increased by social factors, for example, lack of social support) which are seen as sufficient to lead to hopelessness depression. Hopelessness depression is characterized by retarded initiation of voluntary responses (motivation symptom), difficulty in seeing that similar or related outcomes can be controlled (cognitive symptom), and sad affect (emotion symptom). Although the specification of a subtype of depression as hopelessness depression in reaction to negative situations has not led to specific methods of treatment, the theory helps to give a cognitive rationale for the well established finding of the role of life events in depression (Brown & Harris, 1978). It also pinpoints the thinking style which may be of particular importance in situational depression, and which should, therefore, be targeted in cognitive therapy. 6.03.3 APPLICATION OF COGNITIVE THERAPY 6.03.3.1 General Principles of Cognitive Therapy There are several textbooks which describe cognitive therapy methods in detail for various psychiatric disorders: for depression (Beck et al., 1979; Blackburn & Davidson, 1995; Williams, 1992); for anxiety (Beck, Emery, & Greenberg, 1985; Blackburn & Davidson, 1995); for personality disorders (Beck, Freeman et al., 1990; Layden, Newman, Freeman, & Morse, 1993; Linehan, 1993; Young, 1990); for groups of disorders (Beck, 1995; Blackburn, Twaddle et al., 1996; Dobson, 1995; Hawton, Salkovskis, Kirk, & Clark, 1989; Padesky & Greenberger, 1995); for psychosis (Birchwood & Tarrier, 1994; Fowler, Garrety, & Kuiper, 1995; Kingdon & Turkington, 1994); for substance abuse

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(Beck, Wright, Newman, & Liese, 1993); for bipolar disorder (Basco & Rush, 1996); and for inpatients (Wright, Thase, Beck, & Gudgate, 1993). In this chapter, the general characteristics of cognitive therapy are described and attention is focused on developments which have evolved following the theoretical developments described above. Cognitive therapy was first developed as a short-term treatment of 12±16 weeks, for unipolar depressed outpatients (Beck et al., 1979). The extension of its application to an ever increasing range of conditions and of disorders may be a cause for concern for some, but need not be surprising in view of the fact that cognitive theory is meant to be a comprehensive theory of psychopathology. For each disorder, the underlying generic model is applied, with additional components specific to each disorder (see later chapters on specific disorders). Newer applications have not been tested in controlled outcome studies, but the empirical basis of cognitive therapy remains very much the tradition, with models tested in experimental studies, followed by case studies, and then by controlled trials. For most disorders cognitive therapy remains short-term, except in the case of personality disorders when therapy can extend to one or two years. Whereas in short-term cognitive therapy, weekly one-hour sessions are the norm, in personality disorders therapy sessions are often more infrequent, allowing the patient more time for homework assignments and more time to get over the high levels of emotion which may be stirred up during therapy. Typically, short-term therapy may last 10±20 sessions, although in some cases (especially in panic disorder) fewer sessions may suffice. Sessions are structured by the use of an agenda which is set collaboratively by the patient and the therapist. This ensures the active participation of the patient and the appropriate use of time. Generally, a session agenda will include a review of previous assigned homework; setting up one or two relevant areas for discussion, these being often related to previous homework; session feedback and deciding on appropriate homework for the coming week. Throughout therapy, the therapist must ensure that the process is collaborative, by giving and asking for feedback, by rehearsing, and by questioning. The therapist remains active and directive, but never prescriptive. The style is gentle and questioning, guiding the patient to elucidate their emotions and thoughts, to evaluate them, and to arrive at alternative interpretations and solutions. This style of questioning has been described as socratic questioning (Overholser, 1993a, 1993b). Questions are used for gathering

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Cognitive Therapy

information, for discovering new perspectives, for finding commonalities between situations, patterns of thinking and emotions (synthesis), and for achieving change. Overholser (1993a) differentiates between seven types of socratic questions: (i) memory questions (When did the problem first begin? When did it last happen? What did you do when it happened?); (ii) translation questions (What does it mean to you? How can we make sense of this?); (iii) interpretation questions (How are these situations similar? Do your problems at work seem similar in any way to your problems at home?); (iv) application questions (What have you tried in order to solve this problem? How will you go about making these changes?); (v) analysis questions (What evidence do you have for this? How could you tell if you are right or wrong?); (vi) synthesis questions (In what other ways could you look at this situation? What does all this say to you? What does it mean to you to be a mother?); and (vii) evaluation questions (What does it mean to you to be a success? How do you rate yourself as a person?). Another general characteristic of cognitive therapy is openness, that is, the therapist is explicit about the model of therapy, about the rationale for the procedures which are used, about the formulation of problems, about their own reaction in the therapeutic relationship, and about the rationale for homework assignments. Feedback is elicited not only regarding the content of therapy, but also about the patient's reaction to the therapist. This explicit and open style not only fosters collaboration, the model being of two scientists working together to solve problems, but also ensures that therapist and patient share a common understanding of what is going on in therapy. It is particularly important at the onset of therapy to explain the model of therapy by sharing the generic model of cognitive therapy with the patient, using the diagram shown in Figure 4, with real examples from the information gathered in the first assessment. Therapy is problem oriented: therapist and patient engage in a functional analysis of problems in the assessment stage, so that therapy remains focused. The functional analysis includes symptoms (panic attacks, mood, hopelessness, suicidal wishes or behaviors, situational avoidance, etc.), problem situations (work, marital relationship, interpersonal relationship, etc.), life condition (employment, social support, social network, etc.), proximal trigger situations (e.g., loss or threat situations), maintaining factors (current hassles and problems, coping strategies), distal factors (short developmental history), typical automatic thoughts, and typical behaviors. This analysis

leads to an agreed list of problems which can be prioritized and targeted for therapy. An example of assessment is given in Figure 5. Figure 5 indicates that although a detailed conceptualization, as shown in Figure 2, cannot be made at the assessment stage of therapy, nonetheless the therapist may already have some clues about the basic assumptions and the core schemata of the patient derived from the themes of the negative automatic thoughts and from the pattern of hypothesized predisposing factors from early childhood experiences. In the example, a basic assumption may be ªIf people do not treat me properly, this means I am worthlessº and a core schema may be ªI am worthless.º Through questioning (e.g., What do you think is the most pressing problem for us to work on? What would help you most at the moment?), problems are prioritized to bring about effective change quickly. This is a twoway process, so that the therapist and the patient reach conclusions collaboratively about what priorities suggest themselves. In the case described in Figure 5, the suicidal ideas and wishes of the patient would take priority and it is usual to work then at a symptom level, using behavioral methods of treatment to increase activity, in particular pleasurable activities. However, concurrently, during the therapy sessions, the therapist would start socializing the patient into cognitive methods of treatment to increase awareness of automatic thoughts, and to begin to evaluate these thoughts. An initial conceptualization can then follow at about the fifth or sixth session of therapy, which is shared with the patient. Conceptualization is an aspect of cognitive therapy which is more emphasized now than it used to be in the early days of cognitive therapy (Blackburn et al., 1996; Persons, 1989; see Chapter 6.02, this volume for a detailed discussion). An example of a conceptualization was given in Figure 2 above. The cognitive conceptualization of cases will vary from disorder to disorder and is done within the specific cognitive theory framework of that disorder. For example, a conceptualization of a case of panic disorder is given in Figure 6 to highlight the difference from the case of depression in Figure 2. As Persons (1989) points out, conceptualization plays a crucial role in cognitive therapy: (i) It helps the therapist to choose an intervention strategy, for example, it might indicate that environmental changes are possible and indicated or that the patient's view of themself as vulnerable and weak is more central than their avoidance behaviors. (ii) It helps to choose the treatment modality, couple therapy instead of individual therapy.

65

Application of Cognitive Therapy

Early Experiences

Predisposing factors forming psychological vulnerability

Mary * Oldest child with four brothers. * Relied upon by mother to help in the house. * Brothers cannot do anything wrong. Mary is chastised or blamed. * Made to leave school at 16, although top of her class.

Formation of Basic Assumptions and Core Schemata

Predisposing factors to the problem

Critical Incident Husband leaves her for a younger woman.

Situational factors No employment outside the home.

Basic Assumptions and Core Schemata Activated

Current hassles/problems Hyperactive son, aged 10. Daughter aged 14 acting out because of lack of attention.

Negative Automatic Thoughts

Social network No confiding relationship. Critical parents. Problems areas.

I’m not worthwhile. I’m inferior to other people. People take advantage of me. My life is finished. I will never be loved. Depressive Symptoms

Behavioral Stops doing her homework. Cries a lot. Avoids people.

Motivational Loss of pleasure. Indecision. Suicidal wishes. Affective Low mood. Hopeless.

Physiological/Biological Sleep disturbance. Loss of appetite. Sympathetic symptoms.

Figure 5 Examples of a functional analysis of a problem at assessment (Mary, age 42).

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Cognitive Therapy

Upbringing Issues * poor, inconsistent, chaotic and violent parenting * poor parental support * childhood anxiety * premature notions of responsibility

Events * use of diazepam * withdrawal of diazepam * preoccupation with health * use of alcohol * loss of career * current work problems * mother’s death and father’s dementia

Basic Beliefs Unconditional: “I’m vulnerable; my hearth is defective.” Conditional: “If I panic, I’ll lose control completely; if I get so frightened, my heart will stop.”

Stimuli/Situation visit to the bank manager to ask for loan

Perception of Threat “Fear”

Safety Behaviors * taking wife along * holding on tightly to briefcase * sitting near to door * continuously checking pulse at wrist * avoiding eye contact with bank manager

Bodily Sensations * chocking * palpitation * nausea * sweating

Catastrophic Thoughts * “My hand is shaking, she’ll see there’s something wrong with me.” * “My heart is racing, I’m going to break down in her office.” * “If she refuses my application I might panic – my heart might stop . . . If I die how will my wife and kids cope.” Figure 6 Conceptualization of a panic disorder case (reproduced by permission of Souvenir Press from Cognitive therapy in action. A practitioner's case-book. Blackburn, Twaddle et al., 1996).

(iii) It guides the therapist in the choice of an intervention point, for example, what changes are likely to bring about the most gain and are likely to have the biggest impact on the hypothesized basic assumptions and schemata. (iv) It helps the therapist to predict the patient's behavior, for example, is the patient likely to become over-dependent on the thera-

pist or likely to be noncompliant in terms of attendance and homework assignments? (v) It helps to make sense of the patient's relationship difficulties both in and out of therapy and this guides the therapist's behaviors. (vi) It may help to understand why therapy is not working. The formulation may be wrong

Application of Cognitive Therapy and the therapist needs to consider new information that might have transpired in the course of therapy and revise the original formulation of the patient's problems. (vii) Because a good formulation should lead to appropriate strategies, methods of treatment, and intervention points, length of treatment can be much reduced as time is used effectively and economically. 6.03.3.2 Treatment Methods Treatment strategies in cognitive therapy are driven by the case conceptualization which is itself firmly based in the cognitive theory of the emotions, as described in the earlier part of this chapter. Different targets of therapy may require a different balance of cognitive, behavioral, and emotional therapeutic methods, which emphasizes that cognitive therapy is not a series of techniques to be mastered and applied technically. It is a system of psychotherapy requiring a thorough understanding of the cognitive theory of the emotional disorders, familiarity with the experimental literature on which it is based, and knowledge and experience of psychiatric syndromes in general. In addition, the competent cognitive therapist needs to display the general qualities of a good psychotherapist; namely, genuineness, warmth, empathy, and understanding. 6.03.3.2.1 Behavioral methods Behavioral methods of treatment typically are applied early on in therapy as they can often provide relief for distressing symptoms which may prevent therapy from progressing. It is also perhaps easier for patients to master behavioral techniques, while concurrently getting socialized in cognitive techniques. Behavioral techniques are not used in cognitive therapy without examining concomitant effects on cognitions and emotions. Typical behavioral methods of treatment and the problems for which they are suitable are listed below: (i) Inactivity. Scheduling of graded activities with reasonable goals to approximate in the long run the patient's normal routine. (ii) Indecivesiveness. Planning daily activities and rescheduling activities for another day if the original plan has not been adhered to because of unforeseen circumstances. For life decisions, a more cognitive approach may be indicated (illustrated in Table 1). (iii) Procrastination. Establishing detailed daily plans of activities to reduce decision making. Again, it is necessary to ensure that the plans are feasible and attainable.

67

(iv) Lack of pleasure. Scheduling of potentially pleasurable activities and rating activities for pleasure. The therapist needs to ensure that the patient is not showing an all or none response, that is not rating activities as pleasurable or not pleasurable and not confusing ratings of pleasure with ratings of achievement (v) Lack of concentration. Practice engaging in activities (e.g., reading) in small bursts which are reinforcing, instead of persevering when concentration has gone or giving up altogether. The therapist must watch out for the patient's self-talk or automatic thoughts. (vi) Low mood. Engaging in distracting and pleasurable activities. Mental imagery of pleasant memories. (vii) Anxious mood. Distraction, relaxation techniques. Distraction techniques may involve focusing on an object and describing it in minute details; developing sensory awareness by concentration on visual, auditory, olfactory, and bodily sensations; mental exercises, for example, reading, watching a film, or doing the crosswords. Relaxation is an important technique for patients who feel they have no control over how they feel. Several relaxation methods have been described (Bernstein & Borkovec, 1973; Goldfried & Davison, 1976), however, the applied relaxation method described by Ost (1987) has been shown to be particularly effective. It involves eight stages which can be taught sequentially or in subsets: giving a rationale for relaxation training; recognizing the early signs of anxiety; progressive relaxation; relaxation exercises without tensing the muscles first; cue-controlled relaxation, that is, inhaling and relaxing to the cue word relax; differential relaxation, that is, learning to relax while engaged in everyday activities; rapid relaxation by using several cues in the patient's environment; and, finally, application training which involves applying the learnt relaxation in anxiety provoking situations. (viii) Lack of motivation. Schedule activities and grade for mastery and pleasure. The underlying rationale here is that the main problem lies in starting an activity and that, once started, motivation increases through the desire to finish the task (Zeigarnik, 1927) and the unexpected pleasure experienced, much as appetite may actually be stimulated by the act of eating, although there might not have been much desire to eat at the outset. (ix) Panic attacks. Respiratory control exercises which reduce panic symptoms due to hyperventilation (Clark, 1989). The exercises consist in pacing breathing to 12 breaths per minute or eight breaths per minute by breathing for two seconds ªinº and for two seconds ªoutº

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Cognitive Therapy

(12 breaths/min) or three seconds ªinº and three seconds ªoutº (eight breaths/min) (x) Avoidance. Exposure to avoided situations, in a graded and repeated fashion, for example, social, phobic, or agoraphobic situations. (xi) Safety behaviors. These are behaviors that anxious patients engage in when anxiety or panic feelings have already started, for example, holding on to solid objects, sitting down, pressing their head, checking their pulse rate. These behaviors can be very subtle and need to be elicited carefully or observed during a behavioral test. They need to be eliminated gradually as they maintain the patient's beliefs that symptoms are dangerous. (xii) Rituals. Deliberate exposure to previously avoided situations or feared stimuli (including thoughts) and prevention of compulsive rituals and neutralizing behaviors, including neutralizing thoughts. (xiii) Problem situations. Rehearsal in roleplays, with the therapist, of coping techniques and strategies, for example, assertiveness training, negotiations with a spouse or at work, and anger control. It is already evident from the list of behavioral methods described above that they are applied within a general cognitive strategy to help in identifying the cognitions which are related to the problems, to test the patient's predictions and to modify expectations about the self, the world, and the future. 6.03.3.2.2 Cognitive methods (i) Identifying automatic thoughts The main emphasis at the beginning of therapy, even while applying behavioral methods of treatment, is the patient's automatic thoughts, which are considered as the basic data of cognitive therapy. The patient needs to understand the nature of automatic thoughts and how they affect emotions and behaviors and this is done from the time of assessment, through questioning, noting spontaneous reports of examples of automatic thoughts, and including them in the model of therapy which is presented to the patient. Because the very nature of automatic thoughts indicates that they are habitual and involuntary, some patients have difficulty in getting access to their ªhotº automatic thoughts for several reasons: they have been used to taking them for granted; or they report a commentary about their automatic thoughts (thoughts about thoughts) through excessive intellectualization; or they feel embarrassed about their automatic thoughts; or they consider them as silly. A

great deal of socialization is, therefore, necessary to guide the patient early on in therapy. A good way for the therapist to decide whether they have accessed the right automatic thought is to ask themself: ªIs this thought consistent with the emotion that is reported?º, ªIs this thought consistent with the degree of emotion that is reported?º, and ªIf I had the same thought, would I feel as bad?º There are several methods to guide the therapist about how to access the patient's automatic thoughts: (a) Direct questions. ªWhat was going through your mind when you felt panicky?º; ªWhat went through your mind when your husband criticized your housework?º This is evidently the easiest method and it is surprising how often this is enough to trigger the appropriate negative automatic thoughts. This questioning also serves as a model for the patient to tap into their automatic thoughts at the time of strong emotions or of self-defeating behaviors. (b) If direct questions do not prove useful, the therapist poses a series of questions to guide the patient to access the automatic thoughts. This approach has been labeled ªguided discoveryº or ªsocratic questioning.º It is the main technique which cognitive therapists need to master. It demands good listening skills, an understanding of the patient's style of thinking and a formulation of the problems which acts as a guide or a map. (c) Sometimes the patient describes situations or events which may have caused problems in a detached way, the way they may describe a film or a book or a road accident that one might have witnessed. These are probably examples of propositional and not implicational meaning, as described by Teasdale (1993). In such cases, the therapist can use mental imagery to help the patient relive the actual situation as vividly as possible, with all the sensory input which might be involved. This method helps in triggering strong emotions and the accompanying automatic processing which might have taken place. (d) For interpersonal situations, role-plays serve the same purpose. Having elicited the details of what actually took place, the therapist reenacts the situation by playing the role of the other person involved as realistically as possible, using posture, tone, and volume of voice to trigger the emotions and, hence, the automatic thoughts. (e) Moments of strong emotions are, therefore, of crucial importance to access automatic thoughts. If emotion is not shown or expressed in therapy, the therapist tries to elicit emotions through imagery or role plays. If it is present during the session, the therapist uses the

Table 1

A method for dealing with indecisiveness. A married woman, with two school age children, having recovered from a depressive illness, cannot decide about her future plans.

Alternatives

Pros

1. Go back to the same job on a full-time basis

I enjoyed the job, because of its responsibility. I knew the job and could do it well. If I got depressed again I could have time off, as the employers were very understanding the last time. It gave me a good income of my own and made me feel independent.

2. Go back to the same job on a parttime basis.

3. Look for another parttime job which is less demanding

It would give me more time with the children. The part-time income would still make me feel independent. It would be less pressure and I might feel better. I would be able to move to full-time again when the children grow up.

It would involve regular hoursÐmore time at home. May be less interesting, but would get out of the house nonetheless. My husband would be happier with this. Less pressure would be better for my health.

Importance Cons 80 80 100 20 S+280 100 20 100

It was not a 9am-5pm job, so I never knew when I would get home and sometimes I had to take work home with me. The pressure might make me ill again. It was not fair on the children not to spend more time with them.

60 50 100

I would no longer have the responsibility which I enjoyed. It is a difficult job to do part-time. I might find myself doing as much as before for less money.

A lot of free time to do things with the children. I could use the spare time at home to study a language or something else. I could spend more time on my hobbies: gardening, cooking, going out. Both sets of parents and my husband would approve. May be better for my health.

100 30 20 50 100 S+300

Better the devil you know. A new job might turn out inappropriate. I get bored by routine jobs. Less money.

I would miss having an interesting job outside the home. I would be bored. I would be resentful. In nine years time, by the time children have grown up, I will be older and it would be more difficult to get into the job market.

S720

80 80

S+160

80 80 20 S7180

Final decision: There are advantages and disadvantages for all alternatives, but going back to the same job on a part-time basis is preferable. Source: Blackburn, 1993, pp. 94±97.

100

S7160

S+310 4. Not go back to work at all.

100 100

S+300

100 S+320 100

Importance Balance

S+130

100 50 50 20 S7220

S+80

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Cognitive Therapy

moment to help the patient access the automatic thought. It is particularly important to be aware of emotions which may not appear to be related to the current subject of discussion: the patient may become fidgety or tense, blush or start crying and the therapist then asks ªwhatºs going through your mind just now?º (f) Behavioral tasks have already been described in the previous section as an invaluable method to train the patient to become aware of their thoughts as they feel the negative emotions aroused while encouraging in behavioral tests. (g) At the beginning of therapy, patients can increase their awareness of negative thoughts by simply counting them, using some sort of counter which they keep with them at all times or keeping a tally on an index card. (h) The classical method of increasing awareness of negative automatic thoughts is the use of Dysfunctional thoughts records (DTRs) where the patient records the situation (what was going on) when they felt a strong negative emotion, what the emotion was and at what intensity and what were the automatic thoughts and what was their degree of belief in their automatic thoughts. Only these three columns are used at the beginning of therapy and they should be used in the session for training, before being given as a homework assignment. Several examples of DTRs have been given in cognitive therapy textbooks (Blackburn & Davidson, 1995; Hawton et al., 1989). (ii) Evaluating automatic thoughts In the therapy sessions and as homework assignments, the patient learns to evaluate their automatic thoughts. This can probably be considered the core of cognitive therapy, involving the acquisition of the necessary skills to distance oneself from one's automatic processing of information and to treat the products of thoughts as interpretations of reality, rather than reality itself. These skills are of crucial importance as they are generalisable to the evaluation of others and to basic assumptions and core beliefs as well. The evaluation of automatic thoughts is done through careful questioning to guide the patient to consider various alternatives to their original, automatic processing and to adopt more functional alternatives that they can test and come to believe in. The therapist's questioning becomes a model for the patient to apply to their thinking outside of therapy. Questioning may take the form of: (a) What is the evidence for this interpretation? (b) Are there alternative interpretations which may be more realistic?

(c) What is the effect of thinking that on me, on others? (d) What thinking errors am I making? (e) Am I jumping to conclusions? (arbitrary inference), (f) Have I considered all aspects of the situation (selective abstraction), (g) Am I using one instance to draw general conclusions, when there is no basis to do this? (overgenalization), (h) Am I catastrophizing? (minimization and maximization), (i) Am I taking this personally when it may have nothing to do with me? (personalization), (j) Am I thinking in black and white? (dichotomous thinking), (k) Am I applying arbitrary rules, ªshouldsº and ªmustsº when, in fact, there are no such rules? Table 2 gives a list of 20 questions which can be given as a handout to patients to help them evaluate their automatic thoughts. When the degree of belief in the original automatic thought is put in question, alternative interpretations can be considered, and the probability of these alternatives can be assessed. The alternative interpretation, after careful collaborative evaluation, can sometimes be seen clearly as more likely and more realistic, but even if this is not the case, when the alternatives are not more probable than the original interpretation, it is beneficial to see that one interpretationÐis not necessarily correct, so that the degree of belief in the distressing interpretation becomes reduced. In the process of revaluation, a negative event or outcome may be reattributed to external instead of internal, less global, and less stable causes (Abramson et al., 1978). It is particularly important that the alternative interpretations or conclusions that are arrived at be owned by the patient, rather than dictated by the therapist, as the degree of belief in the alternatives will depend on that. Degree of belief in the alternatives are rated and the resultant emotions rated. Thus, it is not taken for granted that because alternatives have been considered, the patient would automatically believe in them and feel better. The DTR, with the five columns, Situation, Emotion, Automatic Thought, Alternative Response, and Outcome is used for that purpose. An example is given in Table 3. To consolidate the patient's revaluation of their automatic thoughts and the degree of belief in them, several methods can be used, for example, rehearsal, role-plays, and behavioral tests. Rehearsal simply restates the same situation or equivalent situations and the typical automatic thoughts and the patient is invited to

Application of Cognitive Therapy

71

Table 2 Twenty questions to help challenge negative thinking. Question

Response

Am I confusing a thought with a fact?

The fact that you believe something to be true does not necessarily mean that it is. Would your thought be accepted as correct by other people? Would it stand up in court, or be dismissed as circumstantial? What objective evidence do you have to back it up, and to contradict it?

Am I jumping to conclusions?

This is the result of basing what you think on poor evidence. For instance, depressed people often believe that others are thinking critically about them. But none of us are mind-readers. How do you know what someone else is thinking? You may be right, but don't jump to conclusionsÐstick to what you know, and if you don't know, see if you can find out.

What alternatives are there?

Are you assuming your view of things is the only one possible? How would you have looked at this situation before you got depressed? How would another person look at it? How would you look at it if someone else described it to you?

What is the effect of thinking the way I do?

What do you want? What are your goals? Do you want to be happy and get the most out of life? Is the way you are thinking now helping you to achieve this? Or is it standing in the way of what you want?

What are the advantages and disadvantages of thinking this way?

Many distorted thought patterns do have some pay-offÐthat is what keeps them going. But do the disadvantages outweigh the advantages? If so, you can think out a new way of looking at things which will give you the advantages, but avoid the disadvantages of the old way.

Am I asking questions that have no answer?

Questions like ªHow can I undo the past?º ªWhy am I not different?º ªWhat is the meaning of life?º ªWhy does this always happen to me?º ªWhy is life so unfair?º Brooding over questions like these is a guaranteed way to depress yourself. If you can turn them into answerable questions, so much the better. If not, don't waste time on them.

Am I thinking in black-and-white, all-ornothing terms?

Nearly everything is relative. People, for instance, are not usually all good or all bad. They are a mixture of the two. Are you applying this kind of black-and-white thinking to yourself?

Am I using global words in my thinking?

Watch out for words like always/never, everyone/no-one, everything/nothing. The chances are that the situation is actually less clear-cut than that. Mostly it's the case of sometimes, some people, and some things.

Am I condemning myself as a total person on the basis of a single event?

Depressed people often take difficulties to mean that they have no value at all as a person. Are you making this kind of a blanket judgement?

Am I concentrating on my weaknesses and forgetting my strengths?

When people become depressed, they often overlook problems they handled successfully in the past and resources which would help them overcome current difficulties. Once they can change their thinking, they are often amazed at their ability to deal with problems. How have you coped with similar difficulties in the past?

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Cognitive Therapy Table 2 (continued)

Question

Response

Am I blaming myself for something which is not really my fault?

Depressed people, for instance blame themselves for being depressed. They put it down to lack of willpower, or weakness, and criticise themselves for not ªpulling themselves together.º In fact, scientists have been studying depression for many years and they are still not certain what causes it. Depression is a difficult problem to solve and blaming yourself for it will only make you more depressed.

Am I taking something personally which has little or nothing to do with me?

When things go wrong, depressed people often believe that in some way this is directed at them personally, or caused by them. In fact, it may have nothing to do with them.

Am I expecting myself to be perfect?

It is simply not possible to get everything right all the time. Depressed people often set unrealistically high standards for themselves. Then they condemn themselves for making mistakes, or acting in ways they would rather not have done. Accepting that you can't be perfect does not mean you have to give up trying to do things well. It means that you can learn from your difficulties and mistakes, instead of being upset and paralysed by them.

Am I using a double standard?

You may be expecting more of yourself than you would of another person. How would you react to someone else in your situation? Would you be so hard on them? You can afford to be as kind to yourself as you would be to someone else. It won't lead to collapse.

Am I paying attention only to the black side of things?

Are you, for instance, focusing on everything that has gone wrong during the day and forgetting or discounting things you have enjoyed or achieved?

Am I overestimating the chances of disaster?

Depressed people often believe that if things go at all wrong, disaster is sure to follow. If the day starts badly, it can only get worse. How likely is it that what you expect will really happen? Is there really nothing you can do to change the course of events?

Am I exaggerating the importance of events?

What difference does a particular event really make to your life? What will you make of it in a week, a year, 10 years? Will anyone else remember what you now see as a terrible thing to do? Will you? If you do, will you feel the same way about it? Probably not.

Am I worrying about the way things ought to be, instead of accepting and dealing with them as they are?

Are you allowing events in the world at large to feed your depression? Telling yourself life is unjust and people awful? It is sad that there is so much suffering in the world and you may decide to do what you can to change things, but getting depressed about it does nothing to help.

Am I assuming I can do nothing to change my situation?

Pessimism about the chances of changing things is central to depression. It makes you give up before you even start. You can't know that there is no solution to your problems until you try. Is the way you are thinking helping you to find answers, or is it making you turn down possible solutions without even giving them a go?

Am I predicting the future instead of experimenting with it?

The fact that you have acted in a certain way in the past does not mean to say that you have to do so in the future. If you predict the future, instead of trying something different, you are cutting yourself off from the chance of change. Change may be difficult, but it is not impossible.

73

Application of Cognitive Therapy Table 3 Example of automatic thoughts and how to answer them.

Situation Woke up and kept thinking of office situation

Emotion (rate degree, 0±100%)

Automatic thoughts (rate belief, 0±100%)

Disturbed, anxious, low (70%)

What mess am I going to have to go to? (70%)

Alternative responses (rate belief, 0±100%) I'm crystal ball gazing. It may not be a mess. However, if it is less organized than before, it will be the responsibility of the supervisor. I can only do my work as well as I can and let other people worry about their work (100%)

Outcome (re rate belief automatic thought and emotion) Automatic thought (10%) Anxious (20%)

Source: Blackburn, 1993, p. 66.

evaluate these thoughts along the lines of the preceding discussion. In role plays, the therapist may reenact a typical distressful scenario and elicit thoughts and emotions or the therapist may play devil's advocate and play back the patient's automatic thoughts which they then have to modify using the skills which have been practiced beforehand. This is a particularly impactful method which usually triggers high emotional responses. Several attempts using role reversals are usually necessary. Finally, behavioral tests of the new interpretation can be devised collaboratively to check whether the new interpretation is indeed more probable. These may involve polling friends and relatives to check their opinions in reality rather than mind reading; facing rather than avoiding a confrontational or self-assertive situation to assess others' reactions; engaging in, say, panic provoking situations, making predictions, and reviewing the evidence after the behavioral test and drawing conclusions. When dealing with automatic thoughts, several caveats need to be drawn to the attention of the therapist: working on peripheral rather than key automatic thoughts; dealing with questions instead of the underlying thought which prompts the question; buying into the patient's system instead of keeping to a questioning style; not engaging in a thorough evaluation of the thoughts; and not engaging in consolidation methods.

(iii) Basic assumptions and core schemata These have been described in previous sections and are an integral part of the information processing model of the emotional disorders. It is considered that therapy would be incomplete without dealing with this aspect

of the patient's cognitive system which underlies the way information is processed and which is considered to represent psychological vulnerabilities. Therapy at that level is therefore considered to be preventative. However, the relative emphasis put on eliciting and modifying core structures may vary from disorder to disorder, being most central in the personality disorders and in depression and general anxiety and possibly less so in obsessivecompulsive, panic, health anxiety, and psychotic disorders.

(iv) Determining basic assumptions and core schemata As therapy progresses, general themes in problem situations and in automatic thoughts become evident, as are personal rules, and these are discussed with the patient within the conceptualization of problems as shown in Figures 2, 5, and 6. The therapist listens attentively for the implicit meanings of the patient's statements and makes them explicit, as usual in question form, for example, ªDoes this mean that if people do not like you, you are no good?º; ªDoes this apply to everybody or only to some people?º; and ªDoes this mean that you are a failure?º It is interesting to note that often, quite early on in therapy, the patient may express an automatic thought such as ªI am a failureº which, in fact, is their core schema. At this stage, the patient may be totally unaware that this is their general view of themself and the therapist may have only an inkling that it is the patient's core schema. It is therefore advisable to treat the statement as an automatic thought at this stage, as the patient has not yet acquired the skills to evaluate automatic thoughts and an overall

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Cognitive Therapy

understanding of the common thread in all the problems has not yet been reached by the patient and/or the therapist. To bring out the common themes in the automatic thoughts, the therapist can use several examples to extract the general implications of the automatic thoughts. This method has been labeled the ªdownward arrowº technique, where the automatic thoughts are accepted as possibly true and their ulterior catastrophic implications arrived at through questioning. An example is given in Table 4. It is to be noted in the example illustrated in Table 4 that the patient is not encouraged to evaluate automatic thoughts at this stage, but instead is guided to consider the meaning implicit in the automatic thoughts which causes distress. At the end of this exercise, the therapist would help put the conclusion explicitly: ªIt seems from this that you are saying that people will not respect you if you do not do things perfectly? Is this right?º (basic assumption); ªYou also say that it would simply confirm the fact that you are worthless?º Other examples are then used to construct a consistent formulation which gives the patient an overall understanding. It may be an aid to therapy to use standard questionnaires to elicit basic assumptions and core schema, for example, the DAS (Weissman & Beck, 1978) or Young's schema questionnaire (1990). However, questionnaires should never be used by themselves, as discovery of the underlying structure needs to be a joint endeavor between therapist and patient. Ques-

Table 4

tionnaires are also open to response biases, and, by definition, cannot capture individual meanings and idiosyncratic terminology. (v) Modifying basic assumptions and core schemata Methods for modifying core structures are very similar to those used for the evaluation of automatic thoughts, using the same style of socratic questioning and of behavioral tests. They might be classified as cognitive, behavioral, emotional, and inerpersonal methods. A summary is presented below. (a) Cognitive methods. These involve weighing the advantages and disadvantages of thinking in certain ways, for example, ªI must do everything perfectlyº (see Table 5); examining the evidence for and against core beliefs, such as, ªI am worthlessº; establishing continua of zero to 100 to rate personal qualities; evaluating the validity of personal rules; contrasting the shortand long-term utility of personal rules; examining the validity of the conclusions drawn at the time when the basic schemata were arrived at in childhood; collecting evidence contrary to the basic schema. Padesky (1990) describes the selfschema as self-prejudice to explain to the patient how the basic schema acts to filter information, so that only negative confirming information is accepted and processsed, while disconfirming information is either transformed into confirming information or ignored or disqualified. Padesky (1994) describes in detail several cog-

Example of ªdownward arrowº technique to arrive at basic assumptions and core schemata.

Situation: This is Helen's first day at the office Emotions: Depressed (60%), anxious (70%) Automatic thoughts Helen

I'm really dumb. I should have organised myself better.

Therapist ;

Supposing that were true, what would it mean about you?

Helen

It means that I can never get things right or do things properly.

Therapist ;

Supposing that were true, what would it mean about you?

Helen

It would mean that people cannot trust me to do things perfectly.

Therapist ;

Supposing that were true, what would it mean to you?

Helen

It would mean that I am second rate, useless.

Therapist ;

Supposing that were true, what would it mean?

Helen

It would mean that nobody would respect me.

Therapist ;

And if nobody respected you, what would it mean?

Helen

It would mean what I've always knownÐthat I am worthless.

Application of Cognitive Therapy nitive change methods and methods for consolidating the new schema (e.g., keeping a positive data log). (b) Behavioral methods. These invlove engaging in activities which disconfirm the basic belief (e.g., do a piece of work in less than the usual time and testing whether not attaining perfection entails social or professional catastrophies); or stopping behaviors which maintain the belief (e.g., stop avoiding meeting people). (c) Emotional methods. These may involve some procedures from Gestalt therapy, for example, role plays of key painful experiences of the past, when the therapist, appropriately briefed by the patient, can play the role of a punishing parent or of an unfair teacher, and the patient plays the role of the child, but with an adult understanding. These role plays are rehearsed in role reversals several times, usually bringing strong emotional responses. Other emotional methods may involve examining key experiences of the past and using reattribution methods to decrease self-blame and guilt which might have been reinforced by critical parents in childhood. Figure 7 below describes the conclusions reached after discussing a patient's sense of responsibility for the unhappiness of her parents. (d) Interpersonal methods. These involve group,

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marital, or family therapy if indicated; but more usually; the therapist uses the interpersonal relationship in the therapeutic situation to develop ideas about problems in interpersonal style which are then discussed openly, as is usual in cognitive therapy. 6.03.3.3 Developments The area of cognitive therapy which has developed the most in the 1990s is the methodology for evaluating and modifying schemata. These changes have evolved gradually through theoretical developments (e.g., Teasdale & Barnard, 1993) and through the expansion of cognitive therapy to new areas of psychopathology, in particular to the personality disorders (Beck et al., 1990; Layden et al., 1993; Linehan, 1993; Young, 1990). Similarly, through, the influence of the constructivist approach (Guidano & Liotti, 1983; Mahoney, 1993) and because of the wider application of cognitive therapy, more emphasis is probably put on developmental and interpersonal issues in the formulation of cases. Another area of development is the application of relapse prevention methods at the end of treatment (Wilson, 1992). The importance of this stage of therapy is reflected in the dedication of a whole chapter to this topic in this volume.

Table 5 Weighing the advantages and disadvantages of a dysfunctional basic assumption. Basic assumptions: I must do everything perfectly, if not, people will not respect me and I am worthless. Advantages of this belief

Disadvantages of this belief

It makes me try hard to do well

It increases my anxiety, so that my performance suffers.

It makes me produce good work and be successful.

It stops me from doing many of the things I would like to do, because I may not succeed.

When something goes well, I feel really good.

It makes me very critical of myself, so that I cannot take pleasure in what I do. I cannot afford to let my mistakes be noticed by anyone, and therefore I probably miss out on valuable constructive comments. When I get criticized, I become defensive and angry. My successes are undermined, because any subsequent failure wipes out their significance. I become very intolerant of others. I find so many faults in others, that I cannot be warm and friendly. I will end up without any friends. I can never think well of myself because it is impossible to get it right all the time. Because I get so upset by failures, I cannot use them as valuable experiences to learn how to do things better next time.

Source: Blackburn, 1993, pp. 113±1140

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Mother’s depressive personality 35%

Socioeconomic conditions of country 8%

Father’s alcoholism 7% Myself 3%

World War II 7% Lack of employment facilities 15%

Marrying against parent’s wishes 25%

Figure 7 Responsibility pie chart. ªI was responsible for my mother's unhappiness.º

6.03.4 PROCESS OF COGNITIVE THERAPY A large number of controlled outcome studies, reviewed by Blackburn, Twaddle et al. (1996), attest to the efficacy of cognitive therapy in depression (Blackburn, Bishop, Glen, Whalley, & Christie, 1981; Elkin et al., 1989; Hollon et al., 1992; Murphy, Simons, Wetzel, & Lustman, 1984; Rush, Beck, Kovacs, & Hollon, 1977; Teasdale, Fennell, Hibbert, & Amies, 1984); in general anxiety disorders (Butler, Fennell, Robson, & Gelder, 1991; Durham et al., 1994; Durham & Turvey, 1987; Power et al., 1990); in panic disorder (Barlow, Craske, Cerney, & Klosko, 1989; Beck et al., 1992, 1994; Clark et al., 1994) and to a lesser extent in obsessive-compulsive disorder (Emmelkamp & Beens, 1991; Emmelkamp, Van der Helm, Van Zainten, & Ploghg, 1980; Van Oppen et al., 1995). However, there is little understanding of what are the actual critical components of cognitive therapy in effecting change and most of the work to date is in depression. Relevant studies have been reviewed by Whisman (1993) and by Robins and Hayes (1993). A summary of the main findings is provided here. Research has attempted to differentiate between mediators and moderators of change in cognitive therapy. Mediators are the mechanisms or the patients'

characteristics that are changed by treatment and which precede change in the dependent variable of interest (level of depression). In contrast, moderators are the variables that predict treatment outcome, for example therapists' competence level and patients' characteristics (gender, age, diagnosis).

6.03.4.1 Mediators of Change in Cognitive Therapy Cognitive therapy aims to bring about improvement by changing the hypothesized cognitive components which maintain the disorder. Cognitive changes after treatment have been found to correlate with level of improvement (Blackburn & Bishop, 1983; DeRubeis et al., 1990; Rush, Beck, Kovacs, Weissenburger, & Hollon, 1982; Seligman et al., 1988). Garamoni, Reynolds, Thase, Frank, and Fasiezka (1992) reported that the balance of positive to negative cognitions and related affect changed to an optimal range in responders to cognitive therapy, but not in nonrespondents. Persons and Burns (1985; 1986) also found that changes in negative-automatic thoughts within session were highly correlated with withinsession changes in mood. The covariation

Process of Cognitive Therapy between change in cognition and change in depression has been found in studies using selfrating measures (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), as well as observer ratings of depression (Hamilton, 1960). However, the effect of cognitive therapy on cognitive mediational variables is not unique to cognitive therapy, pharmacotherapy having the same effect (Simons et al., 1984). Blackburn and Bishop (1983) attributed the larger effect of cognitive therapy relative to pharmacotherapy on views of self, the world, and the future to the larger effect on level of depression at the end of treatment in patients treated with cognitive therapy relative to patients treated with pharmacotherapy. Hollon, DeRubeis, and Evans (1987) argued that covariation between change in cognitive variables and change in depression is not sufficient to prove that change in cognitive variables plays a causal mediational role in the recovery process with cognitive therapy. In addition, there must be a primary effect, that is, cognitive change must precede change in depression and experimental manipulation of the degree of change in cognition must correspond to the degree of change in depression. Few studies have succeeded in demonstrating the primary change in cognition. Rush, Kovacs, Beck, Weissenburger, and Hollon (1981), using cross-lagged correlations, found that during the first four of 11 weeks of cognitive therapy, improvement in hopelessness, in view of self, and in mood preceded changes in vegetative and motivational symptoms of depression. No specific pattern of change was found in patients treated with pharmacotherapy. DeRubeis et al. (1990) reported that changes in cognitive variables (attributional style, dysfunctional attitudes, and hopelessness) at midtreatment predicted overall improvement at the end of treatment with cognitive therapy, but not with pharmacotherapy. If this effect is replicated in future studies, these authors' conclusion, that cognitive constructs play a mediational role in cognitive therapy, but that this effect is not sufficient as it was not found in pharmacotherapy which was equally effective, will be an important one in the understanding of the mode of action of cognitive therapy and of medication. Experimentally, a number of studies have indicated that the manipulation of cognitive content, using the Velten procedure (1968) of reading self-referent sad statements, induces sad mood (Coleman, 1975; Hale & Strickland, 1976; Teasdale & Fogarty, 1979). These studies have been much criticized because of the experimental bias introduced by the inherent demand characteristics of the task. Perhaps more convincingly, Teasdale and Fennell (1982)

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compared effects on mood produced by 30 minutes of exploration compared with 30 minutes of active modification of depressive thoughts. They found, in a within-subjects design, that active modification led to a greater reduction of self-rated depression. When cognitive therapy has been broken down into components to analyze the different aspects of cognitive therapy, mixed results have been obtained. McNamara and Horan (1986) found that cognitive procedures reduced depressive cognitions and improved social skills more than behavioral procedures. Jarrett and Nelson (1987) divided the cognitive therapy package into three components: self-monitoring, logical analyses, and hypothesis testing. All subjects received each treatment component in one of two sequences. The results indicated that self-monitoring did not bring about a change in symptoms, but logical analysis and hypothesis testing brought about a decrease in depressive symptoms and in negative automatic thoughts, a better level of interpersonal relationships, and a greater frequency of pleasant activities. The two active components, logical analysis and hypothesis testing, were more effective in combination than singly. Jacobson et al. (1996) randomly allocated 150 outpatients with major depression to partial cognitive therapy (behavioral component and modifying automatic thoughts) or to full cognitive therapy (behavioral component, modifying automatic thoughts, and modifying core schemata). They found partial cognitive therapy as effective as full cognitive therapy at the end of treatment and at six months followup. Both the behavioral component and the automatic component were as effective as full cognitive therapy in altering negative thinking and dysfunctional attributional style. These results are in contrast with McNamara and Horan's (1986) and Jarrett and Nelson's (1987) findings, indicating that more work is required in this area. The debate about what type or level of cognitive change actually is achieved in cognitive therapy is unresolved. Persons (1993), in a theoretical paper, considers whether cognitive therapy changes the basic schemata which are presumed vulnerability factors or only teaches compensatory skills. The two models generate different predictions regarding the timing of change (which would occur earlier in the schema change model) and the generalizability of what is learned in therapy (the compensatory skills model providing more general skills which might provide more protection against future episodes of illness). The two models are empirically testable and answers may be provided in future studies.

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6.03.4.2 Moderators of Change in Cognitive Therapy The Cognitive Therapy Scale (CTS; Young & Beck, 1988) is a 13-item rating scale which evaluates several aspects of cognitive therapy, the therapeutic alliance, adherence to the procedures of cognitive therapy (including the structure and content of therapy), and competence or skill in application of the methods and techniques. The CTS has been found to have adequate psychometric properties (Dobson, Shaw, & Vallis, 1985; Vallis, Shaw, & Dobson, 1986), but the relationship of ratings on the CTS and outcome has not been demonstrated. The quality of the therapeutic relationship has been found by some researchers to be positively related to outcome (DeRubeis et al., 1990; Persons & Burns, 1985). In contrast, Bercham (1989) found no relationship between therapeutic alliance ratings during early sessions of cognitive therapy and outcome in the treatment of depression. DeRubeis and Feeley (1990) found that the ªfacilitativeº aspects of cognitive therapy (empathy, warmth, and understanding) and a measure of the helping alliance did not predict change in depression level after the sessions in which they were rated. However, ratings of the helping alliance made during later sessions of therapy were related to prior change in depression symptoms. Several studies have demonstrated that cognitive therapy can be discriminated reliably from other psychotherapies, for example, interpersonal psychotherapy (DeRubeis et al., 1990; DeRubeis, Hollon, Evans, & Bemis, 1982; Hill, O'Grady, & Elkin, 1992), indicating that the procedures of cognitive therapy are specific. Only one study, by DeRubeis and Feeley (1990), has examined the relationship between adherence to different aspects of the treatment protocol and outcome. These authors found that ªconcreteº and ªsymptom-focusedº methods of cognitive therapy predicted outcome, whereas ªabstractº discussions did not. Level of competence has been reported to be related to outcome (Beckham, 1990; Burns & Nolen-Hoeksema, 1992; Hollon, Shelton, & Davis, 1993), but contrary findings have been reported in psychotherapy (Shapiro et al., 1994). The issue of level of competence of therapists is of evident importance for outcome studies and for training courses. Since therapy involves a diadic relationship, patient's characteristics may be of equal importance as therapists' characteristics for outcome. Sociodemographic variables have usually been found not to be important in determining response to cognitive therapy, except that married status appears to be a

positive predictor (Jarrett, Eaves, Grannemann, & Rush, 1991; Sotsky et al., 1991). In terms of illness characteristics, several studies have shown that the endogenous subtype of depression responds as well to cognitive therapy as to antidepressant medication (Blackburn et al., 1981; Imber et al., 1990; Kovacs, Rush, Beck, & Hollon, 1981). Severity of depression was found to be a negative predictor of response by Elkin et al. (1989), but other studies have failed to replicate this finding (Hollon et al., 1992; McLean & Taylor, 1992; Thase, Simon, Cahalance, McGreary, & Harden, 1991). Since cognitive therapy targets cognitive dysfunction, it might be hypothesized that cognitive therapy would be relatively more effective than control treatments (e.g., pharmacotherapy) for patients with higher levels of cognitive dysfunction. In a review paper, Rude and Rehm (1991) conclude that research findings do not support this prediction. In terms of personal characteristics, level of intelligence has not been found to be related to outcome (Haaga et al., 1991) and the presence of a concurrent Axis II disorder (personality disorder) has been found to be related to more residual symptoms of depression at outcome and poorer social functioning (Shea et al., 1990). Simons, Lustman, Wetzel, and Murphy (1985) examined a number of predictor variables in an outcome study of depression and found that a cognitive variable, learned resourcefulness, was the only reliable predictor. High learned resourcefulness (as measured by the Self-Control Schedule; Rosenbaum, 1980) predicted better response to cognitive therapy and low learned resourcefulness predicted better outcome with pharmacotherapy. Learned resourcefulness refers to a set of coping and problemsolving skills that facilitate the monitoring, control, and change of dysfunctional or unpleasant events. However, the finding by Simons et al. (1985) has not been replicated (Beckham, 1989; Jarrett, Giles, Gullion, & Rush, 1991; Kavanagh & Wilson, 1989). The short preceding review of the process of action of cognitive therapy indicates that findings are limited as they relate primarily to depression. Both mediating and moderating variables remain relatively unclear or unreplicated.

6.03.5 EFFICACY The efficacy of cognitive therapy relative to other treatment methods has been well demonstrated, as can be seen in the various chapters of this volume relating to specific disorders. Of particular interest is the long-term or

References prophylactic effect of cognitive therapy. Cognitive therapy aims to decrease psychological vulnerabilities by targeting the underling cognitive structures which are hypothesized to make up these vulnerabilities. Whether it succeeds in doing so by modifying the underlying structures (schemata) or by teaching coping skill (Persons & Miranda, 1992), it would be expected to reduce the likelihood of relapse or recurrence of illness after successful treatment. In general, this expectation has been fulfilled in follow-up studies of depression (Beck et al., 1985; Blackburn et al., 1986; Evans et al., 1991; Kovacs et al., 1981; Shea et al., 1992; Simons et al., 1986). Fewer long-term studies have found the same prophylactic effect in general anxiety (Borkovec & Costello, 1993; Butler et al., 1991; Chambless & Gillis, 1993) and in panic disorder (Clark et al., 1994; Craske, Brown, & Barlow, 1991; Shea, Pilkonis, Cloitre, & Leon, 1994). Unfortunately, all follow-up studies have been primarily naturalistic, so that no control was exercised on what actually happened to the patients after the end of treatment of the acute episode. However, the data from various studies are sufficiently congruent to indicate that cognitive therapy does have a prophylactic effect. Better controlled studies are awaited. 6.03.6 CONCLUSION In this chapter, a general overview of the theories and research underlying cognitive therapy has been given. The application of cognitive therapy indicates an on-going crossfertilization between evolving theories, research, and practice. The fact that cognitive therapy has not remained static since its inception is a healthy sign of a growing and living theory. It is evident that future research is needed in information processing, in the bidirectional interaction between emotion and cognition and in the process of therapy to elucidate many of the issues raised in this chapter which still remain open. Moreover, as the methodology of outcome research improves and assessment measures get more sophisticated, clinicians will be able to make better predictions about which patient responds best to cognitive therapy. The expanding application of cognitive therapy remains to be tested. 6.03.7 REFERENCES Abramson, L. Y., Alloy, L. B., & Metalsky, G. I. (1988). The cognitive diathesis-stress theories of depression: Toward an adequate evaluation of the theories' validities. In L. E. Alloy (Ed.), Cognitive processes in depression (pp. 3±30). New York: Guilford Press. Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and

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Williams, J. M. G. (1992). The psychological treatment of depression (2nd ed.). London: Routledge. Williams, J. M. G., Watts, F. N., MacLeod, C., & Mathews, A. M. (1988). Cognitive psychology and emotional disorders. Chichester, UK: Wiley. Wright, J. H., Thase, M. E., Beck, A. T., & Ludgate, J. W. (1993). Cognitive therapy with inpatients: Developing a cognitive milieu. New York: Guilford Press. Young, J. E. (1990). Cognitive therapy for personality disorders: A schema-focused approach. Sarasoto, FL: Professional Resource Press. Young, J. E., & Beck, A. T. (1988). Cognitive Therapy Scale. Unpublished manuscript, University of Pennsylvania, Philadelphia, PA. Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 35, 15±175. Zeigarnik, B. (1927). UÈber das Behalten von erledigten und unerledigten Handlungen. Psychologische Forschung, 9, 1±85. Zettle, R. D., & Hayes, S. C. (1980). Conceptual and empirical status of rational-emotive therapy. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.) Progress in behavior modification (Vol. 9, pp. 126±166). San Diego, CA: Academic Press.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.04 Family Therapy and Systemic Approaches ARLENE L. VETERE University of Reading, UK 6.04.1 INTRODUCTION

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6.04.2 FAMILY SYSTEMS THEORY

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6.04.3 FAMILY LIFE CYCLE THEORY

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6.04.4 SOME MAJOR SCHOOLS OF FAMILY THERAPY AND SYSTEMIC PRACTICE

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6.04.4.1 Structural Family Therapy 6.04.4.2 Milan Family Therapy 6.04.4.3 Range of Therapeutic Techniques 6.04.5 DEVELOPMENTS IN FAMILY THERAPY THEORY AND PRACTICE

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6.04.5.1 Feminist-led Critiques 6.04.5.2 Constructivism and Social Constructionism 6.04.5.3 User-friendly Approaches 6.04.6 RAPPROCHEMENT WITH OTHER THEORETICAL APPROACHES

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6.04.6.1 Psychodynamic Influences 6.04.6.2 Cognitive Behavior Therapy Influences 6.04.7 ASSESSMENT IN FAMILY THERAPY AND SYSTEMIC PRACTICE

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6.04.8 THE PROCESS OF CHANGE IN FAMILY THERAPY

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6.04.9 CLINICAL PRACTICE PATTERNS OF FAMILY THERAPISTS

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6.04.10 FAMILY THERAPY AND SYSTEMIC PRACTICE OUTCOME RESEARCH

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6.04.11 TRAINING AND SUPERVISION

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6.04.12 SYSTEMIC CONSULTATION

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6.04.13 CONCLUSION AND THE WAY FORWARD

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6.04.14 REFERENCES

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functioning of individual members of the familyº (p. 565) The term ªsystemic psychotherapyº is a broader definition that includes, in addition, intervention in other groups and organizations using systems ideas and keeping a relational focus, for example, networking (Dimmock & Dungworth, 1985) and systemic consultation (Boscolo & Bertrando, 1993).

6.04.1 INTRODUCTION Gurman, Kniskern, and Pinsof (1986) defined family therapy as ªany psychotherapeutic endeavor that explicitly focuses on altering the interactions between or among family members; and seeks to improve the functioning of the family as a unit, or its subsystems, and/or the 85

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Systemic psychotherapy recognizes the recent important developments in family therapy theory and practice, building on the earlier pioneering work of the family therapists.

6.04.2 FAMILY SYSTEMS THEORY Family therapy developed during the 1950s and 1960s as practitioners experimented with involving family members in the treatment process. Early observations, such as ªsee-sawº effects in marriage, where improvements in the psychological well-being of one partner as a result of individual psychotherapy seemed to herald a worsening for the other partner's wellbeing; or ªstatus quoº effects where improvements in individually treated psychological symptoms were not sustained; or the inability of individual approaches to address relationship difficulties per se, led early family therapists to speculate as to the importance of the social and relational context for the genesis and/or maintenance of individual symptomatology. Thus, the family system or kinship network was successfully placed at the center of therapeutic thinking. However, the early practitioners found their practice had developed ahead of their conceptual thinking. They turned to general system theory (von Bertalanffy, 1968) for its potential for application to the study of family process and family therapy. Systems research is concerned with the concept of self-organized complexity in living systems, a central tenet of which was that a whole functions as a whole through the interdependence of its parts. General system theory attempted to explain how this obtained in the widest variety of systems, spanning the social, physical, and biological world. Thus, the theory attempted to classify systems according to the way the parts were interrelated, and to describe typical patterns of behavior for the different classes of systems as defined. Within the model of organized complexity, there exists a hierarchy of levels of organization, for example, organelle, cell, tissue, organ, organism, such that each level of organization is more complex than the one below, with each level characterized by emergent properties that do not exist at lower levels and as such are not reducible to previous events. Our example of a biological system is said to have emergent properties, such as reproduction, self-organization, and self-reflective behavior. Systems are described as open if they exchange materials, energies, and information with their environment. Thus, open systems can be considered subsystems of higher order systems, for example, the individual as a member of the family, the

family as part of the kinship network, the kinship network as part of a culture, and so on. In this way, general system theory was adapted to the study of complex organization and interaction in family household groups and kinship networks. A major contribution has been in the study of system adaptability, the balancing of the homeostatic tendency, and the capacity for transformation. The family system is defined in terms of its structure; its structure is defined as the network of relationships amongst its component members; and its relationships are defined in terms of interactions that are mediated by communication, information exchange, and the development and transmission of meaning. Thus, the family system is said to function to develop networks of operations suitable for coping with the varied and changeable environmental inputs and internal stresses to which it is subject. Family system theorists are concerned with the description of family rules, identifying hierarchies of feedback and control. Feedback or recursive processes are believed to be characteristic of social systems, such as family groups, where family members' output is recognized as input at some later stage. Thus, explanations of behavior embrace circular notions of causality. Boundaries are said to determine system and subsystem membership in family groups, with family rules operating to define who belongs to the subsystem and their roles and tasks within the subsystems. Boundaries are described as more or less open according to the degree of exchange with the system's environment. General system theory provided a conceptual framework for early attempts to describe complex, time-related interactional behavior amongst family members, for which psychological and sociological theories were not suited. It focused attention on the role of each family member in the maintenance of psychological symptoms and took account of the various social and cultural variables impinging on family groups. The development of individual distress was seen within a contextual, social matrix and the treatment process addressed both individual needs and the needs of other family members. For example, Prince and Jacobson (1995) examined the hypothesis that the treatment for depression in married women needed to address the interpersonal environment. They examined three recent studies which compared behavioral marital therapy for distressed couples with individual cognitive therapy where the women were diagnosed with unipolar depression. They found that both therapeutic approaches were successful in reducing depression at six and twelve month

Family Life Cycle Theory follow-ups, but that the couples therapy was effective in reducing the marital distress. The application of general system theory to the study of the family has been critiqued extensively (Pam, 1993; Vetere, 1987). Difficulties include a lack of clear conceptual definitions, necessary for operational definitions, and overlap between the description and the explanation of family system behavior. The conceptual and practical focus on relational processes led to a perceived diminution of the importance of individual emotional experiences and motivations, and the emphasis on circular causality led to a perceived diffusion of responsibility within family groups for unacceptable behaviors, such as violence and abuse. It is debatable to what extent family therapy practitioners took circular causality to mean that victims of violence played a part in the development of violent patterns of behavior for which they were accountable or blamed, or used the concept of circularity to understand how such processes arose. The current position separates the issue of responsibility for violence from the explanation of how violent behaviors occur. A linear moral stance is taken with respect to the responsibility of the perpetrator for the abuse, and then only working therapeutically, using explanations and notions of patterning and circularity, when the perpetrator has admitted responsibility and engaged in a nonviolence contract (Bentovim & Davenport, 1992).

6.04.3 FAMILY LIFE CYCLE THEORY It has been proposed that family groups pass through phases, whose characteristics are determined by changes within family members, the impact of external events on family members, and the influence of sociocultural norms and requirements (Carter & McGoldrick, 1989). Thus, the family system is seen to move through time, expanding and contracting its membership as individuals join and leave the system. The family is usually a multigenerational system at any time, so that each generation can be influenced by previous and later generations. Special challenges to the family's organization, membership, and belief systems, which may be experienced as stressful, are said to arise at transitional points in family development, such as the birth of children, or young adults establishing their own households, where there is a confluence of external and internal demands for changes, understood and interpreted by family members within the context of transgenerational influences, that is, the handing down of family cultural beliefs, expectations, and practices. So, for example,

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grandparents might have a similar or different set of expectations to the parents about their involvement in rearing their grandchild, or a young couple might experience some difficulty in establishing what is their province of decision making relative to that of their extended family. Carter and McGoldrick (1989) delineate a typical set of stages in development as follows: courting couples, couples without children, childbearing families with children in the preschool years, families with school-age children, families with adolescents at home, families with adolescents beginning to evolve separate lives, families with adult children, and families in retirement. Family members are said to face different challenges at different phases of the life cycle, with different expectations of self and others according to external demands and maturational and social demands for change and adaptation. The life cycle stage model has been critiqued as applying to Western, middle-class, nuclear families with less relevance for different family forms, some ethnic groupings, poor families, and so on (Vetere & Gale, 1987). Certainly, if we accept the concept that a family is made up of different individuals at different stages of growth, the concept of family is difficult to grasp within this model. However, as a model it should purport to show how transitions affect adaptation, which demands a longitudinal perspective within research. The model, while not easy to put to the test, has construct validity and its implications for other theories of family functioning is considerable. Definition of the family presents considerable difficulties for family researchers and therapists (Trost, 1990). Trost's survey of general public definitions of the family revealed little agreement, for example, with opinion literally divided over whether a heterosexual marital couple without children constituted a family or whether a lone parent and child constituted a family. The criteria for definition of the family used by respondents to the survey were legal ties, biological relatedness, common residence, and psychological significance, another concept which is difficult to define. In addition these criteria were weighted differently by the respondents. Thus, family researchers and therapists differentiate between definition of an individual's family, where an individual's perceptions of family life are accorded prominence, and definition of the family unit, which is believed necessary for the understanding of the development of family groups over time, family-wide difficulties, impact of traumatic effects on family processes, and so on. For many purposes therapists and researchers use the family household as the defining criterion.

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A fully comprehensive theory of family functioning is not available (Burr, Hill, Nye, & Reiss, 1979a, 1979b). Family therapy approaches involve a range of schools and theories. The rationale for family therapy assumes that most individuals are born into and develop in the context of family groups. The family is seen as the cradle and web of emotional development and the early source of our attitudes and beliefs about ourselves, our relationships, our past, present, and future circumstances. The family is the origin of our basic patterns of social interaction and interpersonal adjustment. Thus, the system that is seen to create and support patterns of behavior may be the means of describing, assessing, and changing interpersonal behavior. Family therapy is said to be indicated: (i) when a child or adolescent is the referred person; (ii) when family members define the problem as a family issue, such as relationship and communication difficulties; (iii) when relationship difficulties threaten the future of the couple relationship or the adequate care of the children; (iv) when the family has experienced recent stress, such as death, serious illness or injury, loss of employment, ªleaving homeº issues; (v) when psychological symptoms have secondary gain effects; and (vi) when family members become organized into ªhelpingº with the problem in such a way that the attempted solutions become problematic themselves. Family therapy is contra-indicated: (i) by practical limitations, such as the unavailability of key members or the unavailability of an experienced therapist; (ii) when family members are ªsentencedº to therapy by the courts as an alternative to legal proceedings and motivation to participate in therapy is highly ambivalent; (iii) when a family presents ªtoo lateº; (iv) when mediation might be more appropriate; (v) in circumstances of precarious emotional equilibrium or emotional deprivation, when family therapy is more appropriately considered part of a larger intervention programme, that might include individual therapy, social supports, and practical aid.

6.04.4 SOME MAJOR SCHOOLS OF FAMILY THERAPY AND SYSTEMIC PRACTICE The family systems tradition and the associated discipline of family psychology have given rise to a number of different schools of

family therapy, such as structural (Minuchin & Fishman, 1981), strategic/problem solving (Haley, 1976; de Shazer et al., 1986; Weakland, Fisch, Watzlawick, & Bodin, 1974), Milan (Selvini-Palazolli, Boscolo, Cecchin, & Prata, 1980a), transgenerational (Lieberman, 1979), constructivist and social constructionist (Andersen, 1987; Hoffman, 1993), and narrative (Freedman & Combs, 1996).

6.04.4.1 Structural Family Therapy Structural family therapy (Minuchin, 1974; Minuchin & Fishman, 1981) is a body of theory and techniques that approaches individuals in their social contexts and conceptualizes family interactions as habitual and sequential. Structure refers to the family's organizational characteristics, the subsystems it contains, and the rules which govern interactional patterns among family members. An aim of therapy is to alter organizational patterns, particularly where modes of communication among family members are seen to be dysfunctional. When the structure of the family group is transformed, the positions of members in that group are altered accordingly. As a result, each individual's experiences change. Thus, individual change is predicated upon system change. Structural theory has five principal features: (i) The family is a system which operates through transactional patterns, that is, repeated transactions establish patterns of how, when, and to whom to relate, and these patterns underpin the system. (ii) The functions of the family system are carried out by bounded subsystems. (iii) Such subsystems are made up of individuals on a temporary or permanent basis, and members can be part of one or more subsystems, within which their roles will differ. (iv) Subsystems are hierarchically organized in a way which regulates power structure within and between subsystems. (v) Cohesiveness and adaptability are key characteristics of the family. Structural family therapy is described in three stages: joining, middle therapy, and termination. Therapy is believed to be effective when the therapist forms a new system with the family. The therapist relies heavily on techniques of joining and accommodation, such as planned support for the existing family structure, tracking the process and content of family members' communication, and accommodating to the range and style of family affect. Middle therapy interventions confront and challenge family members at the three levels of symptomatic behavior, family structure, and family members'

Some Major Schools of Family Therapy and Systemic Practice beliefs, in the attempt to create therapeutic change. Interventions can include the enactment and re-enactment of interactional patterns, the development of negotiation and problem-solving skills, reinforcing parental authority, reframing interpersonal dilemmas, creating opportunities for empathic appreciation of others' perspectives and needs, providing support for change, and negotiating tasks within and between sessions. The therapy contract is terminated when the family members have rehearsed their ability to solve new problems and have had the opportunity to solve earlier ones.

6.04.4.2 Milan Family Therapy Milan family therapy approaches the family as a history-containing system with entrenched meanings (Selvini-Palazolli et al., 1980a). It is based on Bateson's (1972) circular epistemology and focuses on information and difference. The Milan family therapist searches for differencesÐin behavior, in relationships and in the way family members perceive and construe eventsÐand connections and links between ideas, behaviors, relationships and events. The approach assumes that these connections hold the system in balance. Milan family therapy has been described as ªlong brief therapyº (Tomm, 1984) with sessions usually held monthly over a one-year period. The therapists work as a team, with two therapists usually interviewing the family and observed by two colleagues from behind the one-way screen. The session format often consists of an interview, followed by a break when the two interviewing therapists retire behind the one-way screen to consult with their colleagues, and finishing with the delivery of a message to the family. The Milan interviewing techniques consist of hypothesizing, circular questioning, neutrality, positive connotation, and the use of rituals. Hypothesizing refers to the presession formulation when the team hypothesizes about what might be maintaining the family problems. Hypothesizing helps organize incoming information during the family session, and is constructed continuously as a result of feedback received from the family to the questioning developed from the original hypotheses. Circularity throughout the system is stressed; problems and events are depicted as interpersonal, such that a problem can be seen as an event between two people. The use of circular questioning in the family session reflects and is guided by systemic hypothesizing. Every question explores differences in family members' perceptions about

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events, relationships, beliefs, and the connections between them, illustrating Bateson's ideas about difference, information, and circularity. For example, different family members might be asked about their attitudes to a particular event, allowing the therapist to focus on difference without being too confrontational, exploring differences in meaning afforded to the same event. Triadic questioning, asking one person for their view of the relationship between two other family members, often produces changes in relationships as well as providing information for the therapists. Family members learn to think in circular fashion and to become observers of family process in a way that allows different views to be enlightening and helpful. Neutrality refers to the therapist's attempts to be even-handed in the session, allied to all without getting involved in family coalitions or alliances. It does not mean that the therapist is indifferent or ethically neutral, especially when working with abuse and violence in families. The therapist is more concerned with understanding the meanings in the system than with attempts to change the system. This is believed to be the process through which change occurs, that is, by not intervening to direct family members, the therapist encourages the family members' ability to generate their own solutions. Positive connotation is a form of reframing, whereby symptomatic behavior is seen as positive or helpful because it keeps the system in balance and furthers family cohesiveness. Thus, the intention behind symptomatic behavior is seen in a good light, preparing the family for a paradoxical injunction around the need for family cohesion apparently to require the presence of symptomatic behavior. Family rituals often mark and facilitate developmental transitions in family life. They may be developed as part of therapy to help clarify family dilemmas and promote new ways of doing things which may help family members change their views and attitudes and see different options for behavior.

6.04.4.3 Range of Therapeutic Techniques All family therapists use a range of therapeutic techniques, which vary somewhat according to school, such as problem-solving techniques, solution-focused techniques, directive techniques (e.g., enactment, restructuring boundaries), neutral techniques (e.g., emphasizing patterns in relationships), cognitive intervention (e.g., reframing of relationships), between-session activity (e.g., tasks, rituals), narrative and restorying techniques.

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The hallmark of the family systems approaches has been the development of methods of live supervision and consultation (Campbell, Draper, & Huffington, 1989), such as the use of video and live observation teams located behind one-way screens (Madanes, 1984; Whiffen & Byng-Hall, 1982), in-room supervision (Kingston & Smith, 1983), reflecting teams and reflective practice (Andersen, 1987), and so on.

6.04.5 DEVELOPMENTS IN FAMILY THERAPY THEORY AND PRACTICE Contemporary systemic thinking and practice represents a knitting together of different theoretical positions and concepts, such as: positive and negative feedback processes (recursiveness); hierarchy of system levels; boundaries (open and closed); pattern in relationships and meaning; family life cycle; communication theory; stability and change processes; symptomatic and system change; the position of the observer in the system; feminist critiques of gender, power, and inequality; narrative approaches; and solution focused approaches. Increased emphasis on the conceptual integration of different family therapy approaches (Burnham, 1992; Liddle, 1991a), the fit between therapist style and preferred models, and the needs of the family members and collaboration in the therapy endeavor (Hoffman, 1993) can be traced to recent theoretical developments in the field. For example, Goldner, Penn, Sheinberg, and Walker (1990) describe the integration of social learning, psychodynamic, sociopolitical, and systemic ideas in their therapeutic work with male violence in couple relationships. Current systemic thinking and practices have been strongly influenced by the feminist-led critiques of power and inequality in family life (Perelberg & Miller, 1990), the postmodern developments of constructivism and social constructionism, and the emergence of userfriendly approaches to family therapy (Reimers & Treacher, 1995). 6.04.5.1 Feminist-led Critiques The feminist-led critiques of family systems theory and practice heralded extensive rethinking and revision of the assumptions and models of working with families. Generation had long been recognized in the field as an important organizing feature of family life. Feminist family therapists pointed out the dimension of gender as another organizing feature of family life and proceeded to analyze and deconstruct

the concept of power and gender-based access to sources of power (Hare-Mustin, 1986; Goldner, 1985, 1988). The sociological structural-functional theories of Parsons, which posited that men held instrumental roles in family life and women held expressive roles, no longer went unchallenged. Thus, family therapy was seen as a political process, in that it dealt with the allocation and distribution of power among family members, the therapist and family members, and so on. Some significant contributions from feminist theorizing which influenced the development of family therapy thinking and practice included: (i) recognition that men and women have different experiences of self, of others, and of life; (ii) recognition that men's experiences had been more widely articulated than women's, which was underrepresented; (iii) recognition that women do not have equality of opportunity, despite recent legislation in both the UK and USA (Central Statistical Office, 1990); (iv) placing the family in a historical context and challenging accepted views of the family; and (v) calling for a re-examination of family life, such as redistributing household and ªmotheringº responsibilities, validating nontraditional sexual and living arrangements, campaigning for reproductive rights, and calling for an end to women's economic dependence on men. Such theorizing highlighted how slow family therapists had been to identify the links between social inequalities and psychological distress. Williams and Watson (1987) have argued that the issue of asserting authority and power and having it acknowledged and respected is particularly problematic for women in a variety of situations. In addition to the relative lack of experience with leadership roles and the overt use of power in public life and social institutions, most women are reared in a multitude of nonverbal behaviors that communicate submission and indecision. They suggest that men and women traditionally have had differential access to types of interpersonal power, and these means of access are determined largely by sexrole stereotypes and expectations. Women are said to influence others more indirectly and to rely on their own personal resources including attractiveness, kindness, empathy, warmth, and close interpersonal relationships for the exercise of referent power. Men are said to utilize more direct means of influence, relying on a different set of resources, such as strength, skill, and competence and tend to be more indifferent to the interpersonal/intimate dimension for the exercise of instrumental/expert power.

Developments in Family Therapy Theory and Practice The feminist critiques of differential genderbased access to power, and the new focus on gender as a once hidden dimension of family life, had enormous implications for the practice of family therapy. A gender-sensitive approach to family therapy developed, not as a set of specific skills or techniques, but as a process between therapist and family members which provided an opportunity for all family members to negotiate both their individual and system needs. Thus family therapists strived to be more aware of their own values regarding gender, as they are expressed in training, therapy and supervision; and began looking at the extent to which our ideas about differences between men and women are based on sexist stereotypes (Wheeler, Avis, Miller, & Chaney, 1989). Family therapists are curious about the ways in which gender roles and stereotyping affect each individual in the family, the relationships between family members, the relationships between family members and other social institutions, and relationships between family members and the therapist (Gregory & Leslie, 1996). They ask questions that make explicit the issues, expectations, decisions, and behaviors that demonstrate the degree to which equality of opportunity and reciprocity exist between men and women in the family. Using analyses of interpersonal power, family therapists formulate questions about how the presence or withdrawal of different sources of power affect everyday processes, such as decision making, negotiation, and conflict resolution. Family therapists can use positive reframing and relabeling to shift the conceptual and emotional perspective on an individual or a relationship. For example, what may have been seen as personal inadequacy may be reinterpreted as socially prescribed, by exploring with men and women what they have been taught about their own gender roles and each other's, such as passivity as a model for female behavior or emotional impassivity as a model for male behavior. Gender-sensitive family therapists can facilitate consideration of a wider range of perspectives, behavior, and solutions that are less constrained by more traditional definitions of roles and personal identity. For example, when discussing parental teamwork and shared responsibilities, attention can be paid to the implications for both partners by checking that the woman is willing to share parental responsibility and has other ways of expressing her competence, and that the man is willing to bear the cost in the workplace of being more involved in the family. Family therapists can use their ªgendered selvesº in therapy in a therapeutic manner, for example, by modeling alternatives to traditional roles.

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Recently, there has been a shift from a woman-centred focus to gender-sensitive family therapy to an incorporation of analyses of male psychological experience (Frosch, 1992; Mason & Mason, 1990). The debate on how to engage men/fathers in the therapy process has been informed by research which seems to indicate that men are less likely to seek help with emotional concerns than women (Verbrugge, 1985) and that when they do seek help, their problems are at a more serious stage of development (O'Brien, 1990). The risk of men not being engaged is heightened: (i) if family therapy is seen to take place in ªwomen's timeº and in a ªwoman's world,º so to speak; (ii) if men are slower on the whole than women to perceive indicators of relationship difficulties, and (iii) if expressive differences between men and women leave them believing that fathers get involved in therapy only when family distress is very high. The greater difficulty in engaging men in the therapy process leaves women shouldering the burden of the responsibility for change, with fathers, albeit inadvertently, made peripheral. Issues of culture and race have also been critically examined in the practice of systemic family therapists (Lau, 1987). Similar distinctions have been drawn between cultural awareness and culturally sensitive practices and the role of training in promoting sensitive practice (Hardy & Laszloffy, 1995). Reflexivity in the training process has led to examination of how therapists' cultural identities (which includes consideration of ethnicity, gender, social class, age, and so on) influence their understanding and acceptance of those who are both culturally similar and dissimilar. Falicov (1988) suggests that one way to help family therapists in training to think culturally is for them to interview a nonclinic family of a distinct ethnic or socioeconomic group. To date, the literature consists of theoretical critiques with clinical case descriptions of culturally sensitive practice.

6.04.5.2 Constructivism and Social Constructionism Constructivism and social constructionism have had a significant impact on contemporary systemic thinking and practice (Hayward, 1996). A postmodern perspective embraces issues of meaning and language, narrative, politics, and practices of power. Family therapy theory increasingly attends to the interpretive meaningmaking dimension of experience and the multiple contexts in which it occurs and evolves (Cronen & Pearce, 1985). The usefulness of systemic metaphors of family life has been welldocumented; their further development

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has been prompted by the interest in family members' beliefs and stories embedded in language, with family members' ability to reconstrue their worlds in accordance with values and aspirations seen as the central impetus to change (White & Epston, 1990). This contrasts with earlier notions of change in the field, where change at the level of a relationship was seen to lead to change in an individual's felt experience. Anderson and Goolishian (1988) argue that we are dialogical beings who evolve knowledge and meaning and attribute meaning to action through conversation and other forms of social interaction. These ideas suggest that we construct stories or accounts about ourselves, others, and our relationships through social interaction. The major implication of these ideas is to suggest that the therapist's task is to help family members construct more useful stories about themselves and their relationships, for example, by restorying the past and altering the definition of the problem to change its meaning and change its perceived effect on the present. The critical evaluation of systemic ideas and practice, alongside the recognition of ªobservercreated realityº has led to the development of reflective practice and reflecting teams (Friedman, 1995). Deriving from the work of Andersen (1987) and colleagues, reflecting team practices illustrate the notion of observing systems and the position of the observer in the system. Reflecting team practice assumes that the therapist and family form a new system during the process of therapy and that the supervising reflecting team can observe and reflect on the therapist/family system, family dilemmas and problems, creating an enriched image of the family and fresh perspectives on their problems and potential solutions. Since family members are invited to listen to the conversation of the reflecting team one or two times during each therapy session, family members themselves assume the position of the observer whilst listening, and when subsequently invited to comment on the reflecting team's conversation, we see an iterative process of both therapist's and family members' views and perspectives folding back on each other, much as in the way one might knead bread dough, as pointed out by Lax (1989). Andersen first outlined the reflecting team in his 1987 article. He suggested that the working assumptions of the reflecting team included the following: (i) The observer generates many of the views and distinctions we call ªreality,º with many possible interpretations present in those distinctions. (ii) When people share their views, each person hears many different versions of this

ªreality,º and these shared views constitute an ªecology of ideas.º (iii) At any point in time, people can only respond or take part in interactions that are within or partially within their known repertory and experience. (iv) Sharing different versions of the same world or reality creates the conditions for ªstuckº family systems to change, as family members realize that they have more than one perspective, option, or solution available to them. A fundamental tenet of this approach is that information needs to be shared rather than withheld. This view is held in common with ªuser-friendlyº approaches to family therapy, discussed below. There are several different guidelines available to the practicalities of reflecting team practice, although they all agree that discussion should positively connote family members' motivations where ethically feasible, and contributors to the reflecting team discussion should build their comments on previous comments so a coherent account emerges during the reflection. The theory and research underpinning this approach is still in the early stages of development. Jenkins (1996) has both critiqued the approach and begun research into the theoretical assumptions, techniques, model of change, indications and contra-indications, using the Delphi technique.

6.04.5.3 User-friendly Approaches User-friendly approaches to family therapy (Reimers & Treacher, 1995) developed in the UK in direct response to both a perceived diminution in significance of individual subjectivity within some areas of family systems theorizing and a lack of research attention to the experiences of family members in therapy. A recent book by Howe (1989) put forward some devastating criticisms of family therapy. Howe interviewed a small sample of families offered therapy by a team of social workers in social services in the UK. The therapy was a mix of brief strategic and Milan approaches undertaken by a single therapist, connected to a supervising team by closed circuit television and an ear bug. The majority of family members interviewed found the hi-tech approach very alienating and objected to ªtheirº therapist apparently being controlled by some all-seeing yet unknown team. Howe's book was helpful in that it mobilized a response to alienating practices, yet was flawed in that he failed to acknowledge the many developments in family systems theory

Rapprochement with Other Theoretical Approaches and practice, not least of which is a longstanding debate on the ethics of family therapy thinking (Walrond-Skinner & Watson, 1987) and the necessity for therapy to be both ethically and politically defensible (Waldegrave, 1990). User-friendly approaches recognize that many family members find it very distressing and problematic to come to therapy. Thus, it places a premium on providing adequate information about therapy and pays attention to convening and engaging family members (Treacher & Carpenter, 1983). The relationship of the therapeutic alliance to treatment effectiveness has not been researched in the field of family systems therapy anywhere near as extensively as in the individual psychotherapies, where the therapeutic alliance is held to be a common factor underlying much of effective helping. Research conducted by Bennun (1989) found that fathers were more likely to engage in therapy if they perceived the therapist to be competent, to show a positive liking for the family and to have a problem-solving orientation, whereas mothers preferred therapists to provide an opportunity for the airing of common concerns amongst the family members. Interestingly there seems to be a crossover effect in middle therapy, where mothers preferred a problem-solving approach and fathers had come to appreciate ªjust talking.º The effect of the therapist's race and gender on the engagement process has received little empirical attention in the family therapy literature, despite its prominence in family therapy discourse over the 1990s. Preliminary research by Gregory and Leslie (1996) with 63 adult heterosexual couples suggests that black females rate their initial sessions more negatively than white females when seeing a white therapist, and that black men had a more positive response than white men to the initial sessions, regardless of the race of the therapist. These differences decreased over time. They found no significant effects for gender of the therapist, which is consistent with the very limited research to date. Gregory and Leslie speculate as to the role of perceived racial difference in engaging family members in therapy and call for the identification of procedures which enhance the probability of family members staying in therapy.

6.04.6 RAPPROCHEMENT WITH OTHER THEORETICAL APPROACHES Family systems models and practice differ from individual psychotherapeutic approaches because they focus primarily on relationships. They emphasize relationships between people,

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events, beliefs, behaviors, and so on, as opposed to emphasizing the internal world of individuals, as in individual psychotherapeutic models. Thus, the emphasis in family systems models of the creation of meaning through interaction is different from a primary focus on the cognition of the individual. The understanding of psychological symptoms is rooted in explanations of interactional process. For example, individual development is conceptualized as a complex series of relationships which extend beyond the individual, so a child's development is influenced by the child's relationship with the mother, the mother's relationship with her partner, extended family relationships, prevailing economic and political conditions, and so on, in a rich contextual interplay of different system levels. It is assumed that individual development and maturation are important and the systemic approach focuses on how development is understood and how these meanings affect relationships. For example, a family systems approach recognizes the importance of the different meanings attached to a child's genetic condition and how those meanings might influence relationships.

6.04.6.1 Psychodynamic Influences Psychodynamic ideas have long informed family systems theory and practice as exemplified in the work of Ackerman (1958), Framo (1982), and Skynner (1976). The psychodynamic view of personal motivation and sources of anxiety and psychological discomfort has been generalized to the level of family group functioning. The psychodynamic systems approach seeks to understand how intrapersonal conflicts and motivations interlock and are expressed at the interpersonal level, with a specific focus on how such interlocking affects the development and expression of psychological symptoms in family members. Proponents of this approach would be interested in how couples bring to their relationship separate psychological heritages rooted in their past parent±child relationships and the extent to which past patterns of relating and introjection influence the current relationship. Applications in practice would seek to understand the extent to which such past attachments are problematic for family members in their current relationships and, by using processes of insight, attempt to bring about change in family members' relationships. Goldenberg and Goldenberg (1991) summarize the main differences between psychodynamic approaches to family therapy and systemic approaches in the differing

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emphasis on the role of past experiences and unconscious processes; the emphasis on insightvs. action-oriented techniques; the role of the therapist in making interpretations of individual and family behavior patterns; and the major focus on the individual, in which the way family members feel about each other is emphasized. Wachtel and Wachtel (1986), writing from the perspective of individual psychodynamic psychotherapists, suggest a number of ways in which systemic ideas can inform the thinking and practice of individual psychotherapists. They recommend that individual therapists explore the systemic meaning of psychological symptoms by asking such questions as: (i) What is the functional significance of the individual's symptom(s) for the family as a whole? (ii) How would the family be stressed if the individual were to change? (iii) Does the symptom serve to restabilize a family whose stability has been threatened? (iv) Is the symptom a result of an attempted solution to the problem that has in some sense ªbackfiredº and itself become the problem? (v) Is the symptomatic individual acting out someone else's distress? Such questions serve to contextualize our understanding of the meaning of symptoms within the individual's significant emotional relationships and puts the individual's problems in a larger framework. Wachtel and Wachtel also recommend the use of genograms (see Section 6.04.7) in individual psychotherapy. Genograms are useful tools for exploring the transmission of multigenerational patterns and influences, and provide a way of gathering information about an individual's implicit and explicit assumptions, wishes, fears, and values. Wachtel and Wachtel use the genogram like a projective test, a map of the unconscious. In addition they advocate the use of active interventions in individual therapy as developed in family therapy, for example, setting tasks (both individual and systems-oriented); devising rituals of celebration, mourning, and healing; using role play and role reversal interventions systemically; using systemic reframing and paradoxical tasks that embody collaboration; and predicting relapses. Finally, they recommend meeting ªthe cast of characters,º such as adult siblings and partners, rather than engaging them in the therapeutic process itself, with the following possible benefits: correcting the tendency to blame, sampling the individual's interactional style, helping the system become more receptive to individual change, and helping to reconstruct the past.

6.04.6.2 Cognitive Behavior Therapy Influences Behavior therapists and cognitive behavior therapists are interested increasingly in the utility of family systems ideas and practices. Emmelkamp and Foa (1983) have written about three sources of treatment failure, one of which is the neglect of, and/or the incomplete assessment of, the social contingencies and factors affecting clients' problems, in particular the extent to which a client's behavior is entrenched in habitual and longstanding patterns of family interactions and expectations. The recognition that some treatment failures might be the result of incomplete assessment of powerful social contingencies has led some cognitive therapists to address the question of what additional help clients might need in order to benefit from their therapies. Bandura and Goldman (1995) describe how they developed a family systems and cognitive behavioral analysis for use during assessment to address the above question. They recognize that family systems models and cognitive behavioral models have different theoretical underpinnings and do not attempt any theoretical integration. Instead they point to the areas of overlap and how the overlap can be useful in aspects such as the joint emphasis on beliefs and rule systems governing behavior, the importance of attributions and expectations in perceptions of self and others and the recognition of options for change, and the emphasis on problem-solving patterns and the significance of interpersonal contingencies to the understanding of symptomatic behavior. Thus in therapy, the focus on training in cognitive and behavioral skills to improve and enhance adaptive coping can involve the modification of environmental contingencies that influence clients' problems. This is an interesting and useful area of overlap, they would argue, because the family systems approaches also focus on interrupting interactional sequences that are thought to influence symptomatic behavior. Some of these interactional sequences are thought not to be reducible to the level of individual behavior as they are unique to systems functioning, examples are communication processes, power and hierarchy, patterns of disengagement and overinvolvement. Family systems ideas can thus help cognitive behavior therapists expand their functional analyses to include extended interactional analyses underpinned by models of circular causality rather than the linear models of reinforcement contingencies. Systemic analyses and practices can be used to help understand and overcome difficulties experienced by clients during the therapeutic change process, such as the broader costs associated with change, the client's involvement in familywide

Assessment in Family Therapy and Systemic Practice dilemmas, and the influence of family process on the content and function of schemata.

6.04.7 ASSESSMENT IN FAMILY THERAPY AND SYSTEMIC PRACTICE The current and most widely used diagnostic system, the Diagnostic and statistical manual of mental disorders (4th ed., DSM-IV) (American Psychiatric Association, 1994), assesses and diagnoses individual psychopathology, and largely ignores the significance of interpersonal context to the development and maintenance of psychological problems. The marital and family therapies are not covered by third party insurance payments in the UK and the USA, despite the overwhelming evidence of their efficacy. Assessing systems of individuals demands more complex methodology than individual assessment and differs in the following ways. Assessment in family therapy is an ongoing process, occurring simultaneously with treatment. It is based on an understanding of multiple levels of systems hierarchy and feedback processes within and between levels. Assessment guides intervention. It can be conducted either as a clinical process through interviewing and observation or as formal psychometric procedure using both ªinsiderº and ªoutsiderº reports. Minuchin (1984) writes that for therapy to be effective and for assessment to take place, the therapist needs to form a new system with the family: the therapist plus family system. In this, the therapist relies on techniques of accommodation and joining. Accommodation is the adjustment of the therapist to the family system. Aspects of accommodation are: maintenance, or planned support of the existing family structure; tracking, following the content and process of the family communication; and accommodating to the family's style and range of affect. Joining is the therapist's own method and style of helping to form the new therapist plus family system, so that the therapist does not lose the position of facilitator. The areas for assessment in systemic work with families cover the following: (i) the family's structure of subsystems, roles and boundaries, preferred transactional patterns, and available alternatives; (ii) family members' strengths, flexibility, and capacity for change as revealed by responses to changing circumstances, past and present; (iii) family members' perceptions of and sensitivity to each other's needs, behaviors, attitudes, and so on;

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(iv) the context of family life, with specific reference to sources of support and sources of stress; (v) both family and family members' life cycle stages and perceived expectations and tasks; and (vi) the meaning and significance of symptomatic behavior for family members. The emphasis on areas of assessment will vary according to the school of therapy. Common pitfalls of assessment include ignoring the developmental process, ignoring some family subsystem, and joining and supporting some family members at the expense of others. Gurman and Kniskern (1981) suggest that all family assessments should make clear at what organizational and psychological level the assessment is conducted, how soon therapy will follow assessment, and the relationship between the different methods for collecting data and the means by which the data should be collated. Selvini-Palazolli, Boscolo, Cecchin, and Prata (1980b) paved the way for including the referrer in the assessment process, partly to prevent the waste of family and staff time with inappropriate or ill-prepared referrals. Referrers are often invited to preliminary consultation meetings with family members and the therapy team or wider network meetings to establish who in the system wants the referral and any differing views and expectations of the referral. The importance of thinking of referrers systemically as part of the process of convening, engaging, and assessing families has tended to lead to a decline in nonattendance rates (Reimers & Treacher, 1995). Lieberman (1995) and his colleagues at the Prudence Skynner Family Therapy Clinic have developed an assessment and observation form that is used by both observing team members and the therapist to collate their views after the first family interview. They adapted the Current State Family Assessment (Loader, Burck, Kinston, & Bentovim, 1980) into five separate areas of observation: (i) process: (a) communication patterns, such as interruptions, listening, speaking for self and others, contradictory verbal and nonverbal messages; (b) family atmosphere, such as the predominant mood, whether it is shared by all, what makes it change; (c) family alliances, such as rigid vs. flexible alliances, presence of conflict and problem solving, scapegoating; (d) feelings, such as the range, intensity and expression of feelings, presence of empathy; (e) family boundaries, such as rigid or diffuse generational boundaries, cross-generational alliances, parental role responsibilities, differentiation, and connectedness;

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(ii) family seating arrangements; (iii) content of the interview; (iv) formulation and themes; and (v) feedback and tasks given to the family. A popular atheoretical assessment tool used by family therapists is the genogram, derived from the work of the transgenerational family therapists (McGoldrick & Gerson, 1985). As many families are made up of many people experiencing a multitude of events across many generations, recording this information in a concise and coherent way can be difficult. The genogram provides a vehicle for recording social, emotional, and demographic data across the generations, such as births, deaths, marriages, divorces, life events, emotional connectedness, and so on. It provides a means of exploring the meaning and impact of events across the generations, engaging all family members in the telling. Thus, the process of constructing a genogram allows the therapist and team to contextualize such assessment questions as ªwhat is the current family problem?,º ªwhat factors maintain the problem?,º ªwhy do family members come for therapy now?,º ªwhat are their expectations of therapy and the therapist?,º ªhow have they tried to solve the problem previously?º within an understanding of background data on the characteristics of both the household family group and extended family network. It has been noted by many beginning family therapists that constructing a genogram is a way of putting family members at their ease in the early stages of therapy, not to mention helping to reduce the anxiety of the therapist. It is a visual and active method that concentrates the attention of all participants, and provides a rationale for negotiating change. The construction of a genogram also has strong therapeutic influence as it can be used to reframe behaviors, events, relationships, and time connections; to make links across the generations and across emotional cut-offs; and to normalize some perceptions. It may facilitate alternate interpretations of a family's experience and point the way to new possibilities in the future. Other more formal, psychometric assessment methods are available, such as the Beavers Systems Model scales (Beavers & Hampson, 1990). These include the Beavers Interactional Competence and Style scales and the Self-Report Family Inventory. The Competence and Style scales are completed by observers, using videotaped family behavior as the basis of their ratings and the Self-Report Inventory is completed by all family members above the age of 12. The Competence scale is a 13-item structured observational rating scale, with ratings derived from trained observers' evaluations of family

interaction over a 10 minute period. The scale evolved from general system theory and studies of well-functioning vs. dysfunctional families. Competence is defined broadly as how well the family performs its necessary tasks, such as providing support and nurturance, establishing effective generational boundaries and leadership, promoting developmental separation and autonomy of offspring, negotiating conflict, and communicating effectively. The Style scale is a nine-item observational rating scale. The Style dimension represents elements of enmeshment and disengagement at its extreme points, such as extremes in binding and expelling patterns; and affective patterns, such as subdued conflict where anger is threatening vs. open conflicts and hostility. Families at similar ªcompetenceº levels may show different functional ªstylesº of relating. The model assumes that competence in small tasks is related to competence in larger domains of living. The Self-Report Family Inventory is a 36-item self-report scale and measures the major elements of family competence and style, the cornerstones of the Beavers Model. The scales have been developed during 30 years of research into normal family functioning. The internal consistency of the scales, their construct validity and inter-rater reliability have been extensively researched and demonstrate acceptable levels of reliability. Such rigorous attention to issues of reliability and validity requires considerable investment in the training of raters. Most family therapists and supervising teams are unable to invest such resources in training, so the more formal psychometric scales are rarely used in day-to-day practice, mainly being used in research trials. Family therapists rely on clinical interviewing and observation, teamwork, knowledge and experience of family patterns for the assessment and formulation of family difficulties, sometimes supplementing their assessment with more formal procedures. Termination of therapy will be discussed here as an assessment issue because the iterative and interactive nature of assessment and formulation in part determines the decision to end therapy. Theorizing and empirical research on ending therapy is under-represented in the family therapy field compared to the other psychotherapies (Treacher, 1989). Since family therapy was developed by and is often practiced by clinicians trained in other modes of therapy, notably individual therapies, there is a tendency in the family therapy literature to assume knowledge of both convening and engaging issues and termination issues in family therapy. Readiness for termination is assessed when family members resolve or learn to cope with the presenting difficulties, when they demonstrate

The Process of Change in Family Therapy increased independence and/or cooperation, when they display more ªopenº styles of communication, when they report an increased sense of security and show greater flexibility in performing family roles. According to the orientation of the family therapist and team, they will typically review whether family members' expectations of the therapy process have been met, summarize the treatment process and enquire about helpful and unhelpful aspects of the therapy, predict and rehearse future coping in similar situations, and offer a follow-up meeting far enough ahead for the family members to have tested out their newfound confidence.

6.04.8 THE PROCESS OF CHANGE IN FAMILY THERAPY The main change mechanisms in family therapy are considered to be at the symptomatic level, the level of family structure, and the level of beliefs held individually and collectively. The different schools vary in their emphases. Structural therapy posits change in individual experience as a result of change at the level of the family's organizational structure. For example, a child's experience of parenting is said to change if the two parents learn how to work as a team rather than undermining each other's decisions. Strategic and brief therapies focus on symptomatic change, and use an understanding of interpersonal dilemmas and difficulties as ineffective solutions to problems that are maintained because people are unable to generate alternative solutions. Milan therapy uses intervention questioning to identify and highlight connections between beliefs, behaviors, and relationships, with change occurring as a result of the development of new perspectives within relationships. These changes are achieved using a range of techniques, described earlier in the chapter. The following discussion will consider how the family therapy process studies have investigated the processes hypothesized to bring about change and actual change. Family therapy process studies investigate change mechanisms common to the various types of family therapy. To date, most research has focused on family therapy outcomes, demonstrating the efficacy of family therapy for many different psychological disorders as classified. The question of how interpersonal change is facilitated during family therapy is of most interest to the practicing family therapist, who is concerned with effective interventions, yet this is the area where there is a relative paucity of research. Thus family therapists tend to seek information on interpersonal change

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processes from theoretical articles, technical articles, and clinical workshops. This material tends on the whole to focus on what therapists should do, rather than considering what family members themselves need to do. The exception is the work of Kuehl and colleagues, who used ethnographic interviewing procedures in an iterative manner to elucidate accounts of interpersonal change from family members who had undertaken strategic/structural therapy for help with adolescent drug misuse (Kuehl, Newfield, & Joanning, 1990). It is important to note when reviewing family process studies, that family therapists are challenged by complex demands and intrapersonal and interpersonal tasks during the therapy session that do not occur during individual therapy. For example, the therapist may create interpersonal alliances with family members who may well be in conflict with one another, manages the multiperson conversation in a collaborative and facilitative manner to prevent it becoming destructive, uses family members as ªcotherapists,º assesses and intervenes in live enactments of problematic family interactions and problem-solving attempts, and so on. Friedlander, Wildman, Heatherington, and Skowron (1994) reviewed family process research, including naturalistic studies of conjoint therapy in which the focus of the study was verbal behavior of the therapy participants during therapy or their self-reported perceptions of actual interactions during therapy. Thirty-six studies, dating from 1963, met their inclusion criteria. Following Greenberg (1986), they organized their review hierarchically and focused on three levels of in-session behavioral processes: (i) speech acts during therapy, (ii) important incidents or change episodes during therapy, and (iii) the therapeutic relationship. Their review builds on the previous review of family process studies conducted by Gurman, Kniskern, and Pinsof (1986). The bulk of family process research has been conducted at the speech act level of analysis, where all behaviors occurring during a specified segment of interaction are observed. Frequencies or proportions of these observed behaviors, such as rates of participation, types of response, and modes of expression are compared or otherwise used to predict successful therapy outcome. The following questions have been addressed using speech act analyses: What factors predict premature termination of family therapy? What are the common and distinctive features across different modalities of therapy? What is the relationship between participants' gender and therapy process? What interpersonal changes take place during the course of therapy, and so on. For example, Alexander,

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Barton, Schiavo, and Parsons (1976) found that the proportion of defensive to supportive speech acts was significantly higher in families who terminated their therapy prematurely. Shields, Sprenkle, and Constantine (1991) compared families who ended therapy prematurely with those who completed therapy in agreement with the therapist. They found that families who ended therapy early were characterized by more in-session disagreements and more attempts to structure the therapist, compared to more family problem-solving conversations and more therapist structuring in response to family disagreements in families who completed therapy. The results suggest that defensiveness amongst family members may predict early termination, although we do not have other information about the families and their contexts, so that the correlations may be misleading. A study by Dowling (1979) examined the consistency of therapist verbal behavior according to their role, therapist versus cotherapist. She found that therapists behaved similarly with different cotherapists and with different families, supporting the notion that therapists had a consistent cotherapy style. Postner, Guttman, Sigal, Epstein, and Rakoff (1971) investigated family members' verbal behaviors as predictors of outcome. Interactional segments were analyzed at four points in therapy for 11 families. Speech acts were coded into emergency, welfare, or neutral emotional states. Outcomes were coded as good or bad by three independent judges. Results from the good outcomes showed that family members tended to speak more to each other during the course of therapy, that welfare statements increased during the course of the therapy, and that significant changes in emotional expression occurred between the second and sixth sessions. Unfortunately the speech act studies reviewed by Friedlander and her colleagues provide little accumulated knowledge towards answering how change occurs over time during successful therapy. Different investigators have used different coding systems within different theoretical frameworks, thus the generalizability of the findings is limited. There have been a few attempts to research therapeutic episodes in the hope that by identifying significant moments in therapy, interpersonal change processes will be more readily elucidated. An example is provided in the work of Patterson and Forgatch (1985), who identified and coded instances of maternal ªnoncompliance.º They found that noncompliance responses were more likely to follow therapists' attempts to ªteach or confrontº mothers, as coded, whereas a decrease in noncompliance was coded following therapists'

ªsupport or facilitateº interventions, as coded. Using a larger sample from the same child behavior management project, Patterson and Chamberlain (1988) identified instances of ªmother±father within-session conflictº and using path analyses suggested that extraneous forces, such as parental stressors, marital conflict, and depression, appear to increase the within-session conflict among family members. This study is important in elucidating the role of factors outside therapy sessions that have a bearing on behavior in therapy. In addition they found high correlations between in-session conflict and antisocial behavior scores for the children. Patterson and Chamberlain conclude that therapists should plan interventions that help to reduce external parental and marital stressors outside the sessions. The Patterson studies rely on small samples but do provide some interesting support for family systems ideas. The third level of analysis in the family process studies is the therapeutic relationship itself. Family therapists have not researched the ingredients believed to be important by individual therapists in establishing a therapeutic relationship, such as warmth, empathy, acceptance, and unconditional regard. Instead they have attended to the more strategic and systemic aspects of the therapeutic relationship, such as engaging and joining the family, and the development of therapeutic coalitions. Gurman and Kniskern (1978) concluded that the family therapist's ability to establish a positive therapeutic relationship with family members was most predictive of successful outcome. Since that time very few studies have been conducted and only six met the inclusion criteria of the Friedlander et al. review discussed here. Shapiro (1974) concluded that greater therapist emotional responsiveness to family members, as measured by questionnaire, predicted client continuance in therapy beyond the initial assessment phase. Families who were not seen in such a positive light by their therapists tended not to continue in therapy beyond assessment. These ratings are global with little psychometric support. Later research by Pinsof and Catherall (1986), using a more robust psychometric measure of therapeutic alliances, explored the development of therapeutic alliances across family therapy sessions, and found that such alliances often develop variably rather than uniformly. Their research showed a tendency for positive correlations between alliance ratings and therapist-rated outcomes, with most family members rating their therapist positively, and interestingly, that alliances are best understood as both multidimensional and occurring on multiple levels. Examples are:

Clinical Practice Patterns of Family Therapists whole system alliances, subsystem alliances, and individual alliances. The study by Kuehl et al. (1990), referred to earlier in this section, will be discussed here because it is an interesting exploration of family members' views of therapy and the change process. Twelve families (37 individuals) who had completed family therapy with successful outcomes for adolescent substance misuse were interviewed. Family members identified stages in the therapy process, collectively described as the introductory meeting, assessment, getting down to basics and generating suggestions, putting suggestions into practice, sharing successes with the counselor, and troubleshooting and follow-up. Satisfaction with the therapy seemed to depend on family members' perceptions of the therapist as caring and understanding and able to generate relevant suggestions, whereas dissatisfaction was reported if the therapist was thought to be on ªtoo strict a program.º The flexible use of theory was valued by family members. Where parents reported that they considered their marital problems to be contributing to their child's problem, there was a willingness to explore this connection. Where parents believed their own problems to be separate from those of the adolescent, attempts by the therapist to explore a possible connection was the point at which therapy was reported to ªstall.º Friedlander et al. (1994) conclude that most family therapy process studies are descriptive and at the speech act level of therapeutic process. Compared to the wealth of family therapy outcome research, there are few process studies, but a few conclusions are possible. These include: individual symptoms as observed in therapy occur in the context of predictable interpersonal events; there are more commonalities across family therapy approaches than differences, with therapists behaving consistently across family work, central in their position with families and skillful in indirect communications; changes over time in the course of therapy with positive outcomes as affective, cognitive, and behavioral, observed both interpersonally and intrapersonally; affective changes among family members appear to be crucial to effective therapy; family members' responses to their therapists and their therapists' responsiveness to them appear to be important; and finally, family members' motivations to engage in therapeutic activities are predictive of good outcome. More research is needed to address how family members themselves construe therapy and its effective ingredients. Observer ratings represent one possible viewpoint; the covert feelings and thoughts of family members have still to be

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explored alongside observer ratings. Interpersonal process recall as developed by Elliott (1984) in the context of exploring individual therapy process has promise for exploring family members' perspectives during family therapy. The bulk of the process studies have researched the more established styles and schools of family therapy, with the newer constructivist approaches remaining to be explored. But perhaps the real challenge to family process research lies in developing methods that both avoid isolating behavior from its social context and isolating individual behaviors from the stream of behaviors.

6.04.9 CLINICAL PRACTICE PATTERNS OF FAMILY THERAPISTS There is little published data on the clinical practice patterns of family therapists, whereas in both the UK and the USA there is a growing body of data on the practitioner demographics and clinical practice patterns of clinical psychologists, psychiatrists, and social workers (VandenBos & Stapp, 1983). Because of the increased interest in family therapy, its effectiveness as a mode of therapy (Pinsof & Wynne, 1995), and the expanding role of family therapists in larger health care teams, Simmons and Doherty (1995) surveyed the clinical practice patterns of marital and family therapists in Minnesota, USA. Marriage and family therapists are currently regulated in 31 states through State and Federal legislation. In the UK registration of family therapists is through the United Kingdom Council for Psychotherapy, and in Europe many countries require the registration of family therapists as specialist psychotherapists. Simmons and Doherty surveyed American Association for Marriage and Family Therapy (AAMFT) members from Minnesota (N = 76) for educational qualifications, demographic characteristics, and practice-related issues. In addition they sought data on 199 treatment cases involving a total of 351 clients, which they claim as a first in the field of marital and family therapy. Their major findings were that: (i) short-term therapy is practiced, with an average case involving 11 sessions over a four-month period; (ii) therapy with families (average of eight sessions) and couples (average of 10 sessions) is briefer than that with individuals (14 sessions average); and (iii) a wide range of serious problems were treated by the surveyed therapists, including marital problems, depression, anxiety, child problems, and parent±child problems. Although academic training in

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marital and family therapy seemed to result in a systemic orientation as exemplified by the tendency of respondents to identify family and larger system problems, there was consistency between the respondents and their psychology and social work trained counterparts in the types of client problems treated, the utilization of DSM diagnoses, and the lengths of treatment. Simmons and Doherty's overall conclusion was that the clinical practice patterns of marital and family therapists were similar to those of the other established mental health professions.

6.04.10 FAMILY THERAPY AND SYSTEMIC PRACTICE OUTCOME RESEARCH In both the UK and the USA there is an increased emphasis on the evaluation and audit of clinical practices and outcomes, aimed at the limitation of escalating health care costs whilst improving the quality of care. Family therapists have been collecting outcome data for many years. According to Bergin and Garfield (1994), marital and family therapy approaches have been subjected to rigorous scrutiny, with only a few other forms of psychotherapy studied as often. Different outcome studies have reported the use of single case designs and controlled and uncontrolled group comparison designs. These outcome studies have been reviewed by Hazelrigg, Cooper, and Borduin (1987) and Pinsof and Wynne (1995), and using meta-analytic techniques by Markus, Lange, and Pettigrew (1990) and Shadish, Ragsdale, Glaser, and Montgomery (1995). The overwhelming findings from all these reviews is that family therapy works compared to untreated control groups, with some demonstrated superiority to standard and individual treatments for certain disorders and populations. Meta-analysis demonstrates moderate, statistically significant and often clinically significant effects. The research literature supporting this conclusion is at least as robust as it is for other modes of psychotherapy. Shadish et al. (1993) conducted a metaanalysis of 163 randomized experimental comparisons of the effects of marital and family therapy (marital = 62; family = 101) with distressed clients, published up to 1988. Seventyone studies compared marital and family therapy to an untreated control group, and 105 compared it to another kind of marital and family therapy or to another model of psychotherapy. The number is higher than 163 because some studies contained multiple comparisons. The 71 studies showed that therapy clients were better off than the untreated

comparison group. The size of this effect was approximately half a standard deviation, which means that the odds of a treated client doing better at post-test than a randomly chosen control client are two out of three. The effect sizes for marital and family therapy were both significant and roughly similar. Comparisons are hard to make because marital and family therapies are offered for the treatment of different presenting problems. The review considered specific presenting problems for the family therapy studies and found that family therapy clients were significantly better off than control clients for general child conduct disorders, child aggression, global family problems, and communication/problem-solving difficulties. Their review included 23 studies that compared marital and family therapies to individual psychotherapies. The differences in outcomes were small and nonsignificant across a range of presenting problems. Chamberlain and Rosicky (1995), in their review of seven family intervention studies for adolescent conduct disorder and delinquency, published since the Shadish et al. (1993) metaanalysis which included 18 such studies, found that family therapy approaches appeared to decrease adolescent conduct problems and delinquent behavior when compared to individual therapy, treatment as usual, and no therapy, with similar effect sizes of 0.53. Treatment failure in the studies reviewed by Chamberlain and Rosicky correlated highly with poverty and/or social isolation for the family. The Florida Network Study (Nugent, Carpenter, & Parks, 1993) with high risk families found that families who received family therapy were four times as likely to stay together as families who did not, and families who received more than five treatment sessions were twice as likely to stay together as families who did not. So, for these high risk families, family therapy may be a necessary treatment component, but is not sufficient in itself. Despite the improvements to methodology in the outcome literature, we are still a long way from answering the specific family therapy outcome question posed by Gurman, Kniskern, and Pinsof (1986): ªWhat are the specific effects of specific interventions by specified therapists at specific points in time with particular types of clients with particular presenting problems?º (p. 569). Gale (1980) provided a series of useful questions to ask when evaluating the quality and character of extant family therapy outcome research, covering issues such as theoretical rational and therapeutic schools, methods of training for therapists, pretreatment characteristics of clients, techniques of treatment, and

Training and Supervision evaluation of treatment outcome. For example, we might ask: (i) Who has conducted the research, clinicians or researchers? (ii) Are the studies well designed and free from bias? (iii) Are control groups used for different types of family therapy, for family therapy and other forms of psychotherapy, for family therapy and no treatment control? (iv) Are the effects of the therapist shown independent of the type of treatment? (v) Are the outcome criteria for success and failure clearly specified? (vi) Are multiple outcome criteria used and do they intercorrelate? (vii) Is there a follow-up period and are the effects of treatment persistent over time? (viii) What characteristics of families/therapists are associated with success and failure? (ix) Are there nonspecific treatment effects? (x) What is the comparative cost of family therapy? Is there a cost to the community for failing to provide financial support for family therapy? Family therapists have a variety of therapeutic approaches to choose from; they are concerned increasingly to provide the best ªfitº for clients with their particular circumstances and presenting problems, often without clear evidence supporting one systemic approach over another (Orlinsky, Grawe, & Parks, 1994). When working therapeutically with severe problems, such as adolescent conduct disorder, there is increasing evidence of the value of treatment packages, of which family therapy is a part (Pinsof & Wynne, 1995).

6.04.11 TRAINING AND SUPERVISION Family therapy training courses at both introductory and qualifying level have been established in the UK since the 1970s, provided by family therapy training institutes. All courses are accredited by the Association for Family Therapy. The criteria for qualifying level training courses include completed training at introductory level, 320 academic hours, and 320 practice hours of which 40 are live supervised, and a personal development component which focuses on family-of-origin experiences and their effects on current thinking and practice. Many of the qualifying level courses are program-centered (Street, 1988) and concerned to identify theories and skills for systemic practice within their curricula. Thus, the focus of training is very much on the process of teaching. Reviewers of research on family therapy training in both the UK (Street,

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1988) and the USA (Liddle, 1991b) have expressed concern at the program-centered nature of the training and questioned to what extent courses address the dilemmas of adult education and adult centered learning, such as exploring the relevance of client change processes in family therapy to family therapy trainees, and learning from the experiences of other psychotherapy training courses. In addition, they point out that courses might do more to close the gap between clinicians and researchers said to exist in the family therapy field, by promoting reflective practice models and qualitative research methodology. Research into the effectiveness of family therapy training has been limited compared to the proliferation of regulated training courses. Avis and Sprenkle (1990) suggest there are many reasons for this, including the increased complexity of the training issues and their relationship to practitioner outcomes, problems of sampling and replicability, and a lack of reliable and valid measures of training effectiveness. Despite these limitations, Avis and Sprenkle conclude from their review of the training research that conceptual and executive skills may develop at different rates, that different training approaches can bring about similar conceptual and intervention skills developments, that introductory level assessment skills and concepts can be taught using lectures and textbook methods, and that ªin-houseº training courses for agency staff have been shown to be effective in promoting systemic practices and broadening the remit of mental health services. Breunlin and his co-workers (1989) attempted to predict which factors might contribute to improved performance in family therapy trainees before and after training on measures of conceptual, executive, and observational skills. Interestingly, previous family therapy experience did not appear significantly to affect change scores, although prior life experience and maturity did seem to be important, but only in changes on measures of executive skills, rather than conceptual and observational skills. Previous experience as an individual psychotherapist predicted improvement on conceptual skills change scores, perhaps suggesting that a previous training prepares trainee family therapists for thinking about therapy processes. Pulleybank and Shapiro (1986) were also interested in the acquisition of cognitive and therapeutic behavior skills during family therapy training. They suggest that their results indicate a developmental progression in learning, with cognitive skills acquired earlier in training, followed by development in planning and then intervention skills. Research by Anderson (1992) raised the knotty problem of how to reconcile

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differing observer opinions when assessing family therapy trainee performance. Anderson compared the assessments of placement supervisors, academic supervisors, and so-called neutral observers and found more change reported by placement supervisors than the ªneutralº observers. The role of evaluation in supervisors' judgments has yet to be systematically researched in the field. Researchers of family therapy training effectiveness have focused primarily on issues of skills acquisition, theory±practice linking, and preparing trainees for systemic practice outside of the somewhat protected environment of the training course. These issues continue to be of interest and when we map them on to Gurman and Kniskern's (1992) predictions for the future of the field, such as increased diversity of intervention formats and methods, increased recognition of the importance of the relationship between the family therapist and the family members, and increased interest in postmodern developments, the research agenda for training effectiveness into the first decade of the twentyfirst century becomes broader.

6.04.12 SYSTEMIC CONSULTATION Brunning and Huffington (1990) define consultancy as a direct or indirect process enabling individuals, groups, or organizations to fulfill their role, function, or tasks better. It is a process by which the person or persons seeking the consultation ask for help in identifying or clarifying concerns and in considering the options available for problem resolution. Thus, the consultees have legal, ethical, and administrative responsibility for initiative and action, as opposed to supervision where there may well be a hierarchical relationship between the supervisor and the supervisee, or therapy where there is pressure to accept suggestions or directives in order for the therapy to be effective. In the case of family consultation, it may well be a prologue or alternative to family therapy (Street, Downey, & Brazier, 1991). Wynne, McDaniel, and Weber (1986) discuss consultation with families as a process whereby the family members' responsible decision making is assumed and their resources and competence are directly tapped. The decision as to whom to invite to the consultation meetings will depend largely on where the impasse in the system is located. In addition, the systemic view of consultation would see the role of the consultant as a necessary participant in the system requiring consultation. The stages in the process of systems consultation have been described by Wynne,

McDaniel, and Weber (1986) as exploring, contracting, connecting, assessing, implementing, evaluating, and leaving. The stages are not mutually exclusive and represent a process that guides the activity of the consultant. Exploring involves clarifying both the request for consultation and who is requesting the consultation, by considering how the request came about, who approves the request and the role of the consultee in the team or organization requesting the consultation. In particular any political ramifications of the request are explored. Contracting is the process whereby agreement is reached on the goals of the consultation, the services provided by the consultant, consideration of the risks and consequences of the consultation, procedures for sharing information, and other practical arrangements. Connecting is the process of engaging key members of the consultation system in the consultation process and deciding how they will be involved in goal setting. Assessing refers to the methods used for gathering information and the systemic concepts used to understand the organization's structure, function, and dynamics. The assessment process particularly focuses on organizational life cycle issues, recent events triggering the consultation request, previous attempted solutions to the problem, and the belief systems of the consultee. Implementing involves specifying the systemic interventions chosen to meet the consultation request, decisions about whether education is provided, the means of collaborating with the consultee over implementation and procedures to ensure the maintenance of change. Evaluating is the process of deciding how the consultation goals and organizational changes have been met, who will take part in the evaluation process, plans for follow-up evaluation, and reflection on the process of consultation. Leaving describes the means by which a consultation is ended or the consultant renegotiates a different role within the organization. Campbell (1985) describes an alternative model of systemic consultation specifically designed to help other family therapists who are ªstuckº in their clinical work with a family. He adapts the Milan systemic model of family therapy to this task, using theoretical concepts of meaning, pattern, recursiveness, and difference. The consultation interview follows a similar procedure to a Milan-style family therapy interview with presession hypothesizing based on preliminary information, the use of circular questioning and reframing, characterized by the neutral stance of the therapist, and midsession breaks for team discussion and final formulation. The main aim of this style of

References consultation is to provide a space to comment on and clarify some of the confusions that arise when working in systems where different meanings for behavior arise from the differing perspectives from which that behavior is viewed. In summary, systems consultation has the advantages of not prejudging the nature of the problem requiring consultation; the consultant can take a meta position from which to develop a perspective on systemic relationships and patterns; the consultation process facilitates the reframing of problems and the search for competence and strengths; a more collaborative relationship between consultant and consultee can be established because the consultee is ªfreeº to take the advice offered or not; and the role of consultant does not preclude a shift to an alternative role, such as therapist.

6.04.13 CONCLUSION AND THE WAY FORWARD Looking ahead to the next millennium is both exhilarating and daunting. The development of family therapy and systemic approaches to practice has been rapid, encapsulating and condensing the natural history of the development of systems of thought and professional disciplines. A time for consolidation of practice and ideas would be welcome. Rapprochement with other psychotherapies proceeds apace. The emphasis on context as an infinitely layered and dynamic process has enormous implications beyond the practice of family and systemic therapies. An ecosystemic vision and practice awaits us all.

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Evaluating the effectiveness of family therapies: An integrative review and analysis. Psychological Bulletin, 101, 428±442. Hoffman, L. (1993). Exchanging voices. London: Karnac. Howe, D. (1989). The consumer's view of family therapy. London: Gower. Jenkins, D. (1996). A reflecting team approach to family therapy: A Delphi study. Journal of Marital and Family Therapy, 22, 219±238. Kingston, P., & Smith, D. (1983). Preparation for live consultation and live supervision when working without a one-way screen. Journal of Family Therapy, 5, 219-233. Kuehl B. P., Newfield, N. A., & Joanning, H. (1990). A client-based description of family therapy. Journal of Family Psychology, 3, 310±321. Lau, A. (1987). Family therapy and ethnic minorities. In E. Street & W. Dryden (Eds.), Family therapy in Britain (pp. 270±290). Milton Keynes, UK: Open University Press. Lax, W. (1989). Systemic family therapy with young children in the family: Use of the reflecting team. Journal of Psychotherapy and the Family, 5, 55±74. Liddle, H. A. (1991a). Empirical values and the culture of family therapy. Journal of Marital and Family Therapy, 17, 327±348. Liddle, H. A. (1991b). Training and supervision in family therapy: A comprehensive and critical analysis. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol. II, 2nd ed., pp. 638±697). New York: Brunner/Mazel Lieberman, S. (1979). Transgenerational family therapy. London: Croom Helm. Lieberman, S. (1995). How I assess for family therapy. In C. Mace (Ed.), Assessment in psychotherapy (pp. 61±77). London: Routledge. Loader, P., Burck, C., Kinston, W., & Bentovim, A. (1980). Method for organizing the clinical description of family interaction: The family interaction summary format. Australian Journal of Family Therapy, 2, 131±141. Madanes, C. (1984). Behind the one-way mirror. London: Jossey-Bass. Markus, E., Lange, A., & Pettigrew, T. (1990). Effectiveness of family therapy: A meta-analysis. Journal of Family Therapy, 12, 205±221. Mason, B., & Mason, E. (1990). Masculinity and family work. In R. J. Perelberg & A. C. Miller (Eds.), Gender and power in families (pp. 209±220). London: Routledge. McGoldrick, M., & Gerson, R. (1985). Genograms in family assessment. New York: Norton. Minuchin, S. (1974). Families and family therapy. London: Tavistock. Minuchin, S. (1984). Family kaleidoscope. London: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Urgent W. R., Carpenter, D., & Parks, J. (1993). A statewide evaluation of family preservation and family reunification services. Research on Social Work Practice, 3, 40±65. O'Brien, M. (1990). The place of men in a gender-sensitive therapy. In R. J. Perelberg & A. C. Miller (Eds.), Gender and power in families (pp. 195±208). London: Routledge. Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy. In A. Bergin & S. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 311±384). New York: Wiley. Pam, A. (1993). Family systems theory: A critical view. New Ideas in Psychology, 11, 77±94. Patterson, G. R., & Chamberlain, P. (1988). Treatment process: A problem at three levels. In L. C. Wynne (Ed.), The state of the art in family therapy research: Controversies and recommendations (pp. 189±226). New York: Family Process Press. Patterson, G. R., & Forgatch, M. S. (1985). Therapist

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Street, E. (1988). Family therapy training research: Systems model and review. Journal of Family Therapy, 10, 383±402. Street, E., Downey, J., & Brazier, A. (1991). The development of therapeutic consultations in childfocused family work. Journal of Family Therapy, 13, 311±334. Tomm, K. M. (1984). One perspective on the Milan approach: Part 1. Overview of development, theory and practice. Journal of Marital and Family Therapy, 10, 113±125. Treacher, A. (1989). Termination in family therapyÐ developing a structural approach. Journal of Family Therapy, 11, 135±148. Treacher, A., & Carpenter, J. (1983). On the failure to take convening strategies seriouslyÐa reply to Campion. Journal of Family Therapy, 5, 259±262. Trost, J. (1990). Do we mean the same by the concept of family? Communication Research, 17, 431±443. VandenBos, G. R., & Stapp, J. (1983). Service providers in psychology: Results of the 1982 APA human resources survey. American Psychologist, 38, 1330±1352. Verbrugge, L. (1985). Gender and health: An update on hypothesis and evidence. Journal of Health and Social behavior, 26, 156±182. Vetere, A. L. (1987). General system theory and the family: A critical evaluation. In A. Vetere & A. Gale (Eds.), Ecological studies of family life (pp. 18±33). Chichester, UK: Wiley. Vetere, A. L., & Gale, A. (1987). Ecological studies of family life. Chichester, UK: Wiley. Wachtel, E. F., & Wachtel, P. L. (1986). Family dynamics in individual psychotherapy: A guide to clinical strategies. New York: Guilford. Waldegrave, C. (1990). Social justice and family therapy. Dulwich Centre Newsletter, No. 1. Adelaide, Australia: Dulwich Centre Publications. Walrond-Skinner, S., & Watson, D. (1987). Ethical issues in family therapy. London: Routledge and Kegan Paul. Weakland, J. H., Fisch, R., Watzlawick, P., & Bodin, A. M. (1974). Brief therapy: Focused problem resolution. Family Process, 13, 141±168. Wheeler, D., Avis, J. M., Miller, L. A., & Chaney, S. (1989). Rethinking family therapy training and supervision: A feminist model. In M. McGoldrick, C. M. Anderson, & F. Walsh (Eds.), Women in families: A framework for family therapy (pp. 135±151). New York: Norton. Whiffen, R., & Byng-Hall, J. (Eds.) (1982). Family therapy supervision. London: Academic Press. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. Williams, J., & Watson, G. (1987). Sexual inequality, family life and family therapy. In E. Street & W. Dryden (Eds.), Family therapy in Britain (pp. 291±311). Milton Keynes, UK: Open University Press. Wynne, L., McDaniel, S., & Weber, T. (1986). Systems consultation: A new perspective for family therapy. New York: Guilford Press.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.05 Psychodynamic Approaches PETER FONAGY University College London, UK 6.05.1 THE ORIGINS OF PSYCHODYNAMIC THERAPY

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6.05.1.1 Definition of Psychodynamic Therapy 6.05.1.2 The Short-term Emphasis in Psychodynamic Therapy

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6.05.2 TECHNICAL ISSUES IN PSYCHODYNAMIC THERAPY

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6.05.2.1 Suitability for Psychodynamic Therapy 6.05.2.2 Formulation of Patients' Problems 6.05.2.3 Mechanisms of Defense 6.05.2.3.1 The concept of defense in various theoretical frameworks 6.05.2.3.2 Primitive defenses 6.05.2.3.3 Neurotic and mature defenses 6.05.2.4 The Context of Psychotherapy 6.05.2.4.1 The therapeutic contract 6.05.2.4.2 Abstinence and neutrality 6.05.2.4.3 Regression 6.05.2.4.4 Resistance 6.05.2.5 Transference 6.05.2.5.1 The history of the concept 6.05.2.5.2 The origin of the transference experience 6.05.2.5.3 The limits of transference interpretations 6.05.2.5.4 Special forms of transference 6.05.2.6 Counter-transference 6.05.2.6.1 History of the concept 6.05.2.6.2 Types of counter-transference 6.05.2.6.3 Counter-transference and interpersonal approaches 6.05.2.7 Therapeutic Interventions 6.05.2.7.1 Historical overview 6.05.2.7.2 Supportive and directive aspects of psychodynamic interventions 6.05.2.7.3 Interpretation in psychodynamic therapy 6.05.2.8 The Result of Psychodynamic Interventions 6.05.2.8.1 The role of insight 6.05.2.8.2 The role of working through 6.05.2.9 Ending Treatment 6.05.2.9.1 Indications for ending treatment 6.05.2.9.2 The process of ending treatment 6.05.3 ILLUSTRATION OF LONG-TERM PSYCHODYNAMIC THERAPY: PSYCHOTHERAPY FOR BORDERLINE PERSONALITY DISORDER

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6.05.3.1 Theoretical Approaches to Borderline Conditions 6.05.3.2 Treatment Strategies 6.05.3.2.1 Limits and boundaries 6.05.3.2.2 Interpretive focus 6.05.3.2.3 Counter-transference 6.05.3.3 Handling Crises 6.05.3.3.1 Desirable outcomes 6.05.3.4 Outcome Research

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6.05.4 FORMS OF BRIEF PSYCHODYNAMIC THERAPY

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6.05.4.1 The Historical Roots of Brief Psychodynamic Therapy 6.05.4.2 Indications for Brief Psychodynamic Therapy 6.05.4.3 Techniques of Brief Psychodynamic Therapy 6.05.4.3.1 Malan's brief intensive psychotherapy (BIP) 6.05.4.3.2 Sifneos' short-term anxiety-provoking psychotherapy (STAPT) 6.05.4.3.3 Davanloo's intensive short-term dynamic psychotherapy (ISTDP) 6.05.4.3.4 Luborsky's supportive-expressive time-limited therapy (SETLT) 6.05.4.3.5 Strupp's time-limited dynamic therapy (TLDP) 6.05.4.3.6 Weiss and Sampson's plan formulation method 6.05.4.3.7 Horowitz's person schema theory 6.05.4.3.8 Mann's time-limited psychodynamic therapy (TLPT) 6.05.4.3.9 Ryle's cognitive analytic therapy (CAT) 6.05.4.3.10 Hobson's conversational model

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6.05.5 CONCLUSIONS

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6.05.6 REFERENCES

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6.05.1 THE ORIGINS OF PSYCHODYNAMIC THERAPY 6.05.1.1 Definition of Psychodynamic Therapy The term ªpsychodynamic psychotherapyº covers a somewhat heterogeneous range of psychological interventions which draw their inspiration from psychoanalytic theory. Various implementations of this form of treatment (see Chapter 14, Volume 1) emphasize different aspects of this rich body of ideas including: (i) notions of psychic conflict as an all-pervasive aspect of human experience; (ii) the internal organization of the mind to avoid unpleasure arising out of conflict and maximize a sense of the experience of safety; (iii) the use of defensive strategies for the adaptive manipulation of ideas and experience to minimize unpleasure; (iv) a developmental view of psychopathology as arising out of the long-term adverse consequences of adaptations at earlier phases of development; (v) the organization of experience in terms of the internal representations of relationships between self and other throughout the life span; and (vi) the expectable reemergence of these experiences in the relationship with the therapist. Psychodynamic therapies are predominantly verbal and interpretive aimed at the modifications of restructuring of the representations of relationships primarily, but not exclusively, through the use of insight. 6.05.1.2 The Short-term Emphasis in Psychodynamic Therapy Psychodynamic psychotherapies are rooted in long-term, time-unlimited approaches, and many of the most important advances in theory and technique originate from this context. The emphasis in the present chapter will, however, be on short-term psychodynamic approaches. The rationale for this emphasis may be stated as follows: The demand for psychotherapeutic

treatment as either an adjunct to pharmacotherapy or as a unique treatment is considerable and has increased substantially over recent years as a function of cultural, social, and economic changes (e.g., lessened stigma attached to seeking assistance with psychological problems, increase in some risk factors for mental illness such as drug and alcohol use) and the greater availability of providers (Howard et al., 1996). Surveys of the delivery of psychotherapy in both public and private health care settings demonstrate that the majority of clients receive relatively short-term treatment. The majority of patients receive less than 10 sessions (DeLeon, VandenBos, & Bulatao, 1991; Olfson & Pincus, 1994), although therapists spend the majority of their time with the relatively small proportion (15±20%) who attend more than 26 sessions (Howard, Davidson, O'Mahoney, Orlinsky, & Brown, 1991; Taube, Kessler, & Feuerberg, 1984) and thus may come to believe that longterm treatment is more common than it actually is. It should be remembered however that estimates of the mean length of treatment for psychotherapy are reduced by the contribution that general (primary care) physicians make to this type of mental health care provision (approximately 30%), the majority of whom provide extremely brief forms of treatment (one to three sessions) (Olfson & Pincus, 1994; Olfson, Pincus, & Dial, 1994). Managed care, with its declared intention of cost containment for health care provision, requires a more structured, focused, treatmentgoal-oriented psychotherapeutic approach (Brosowski, 1995; Richardson & Austad, 1991). There has been a shift in the formulation of the nature of both psychological disorder and interventions aimed to address it from an acute to a chronic illness model: certain individuals are seen as requiring therapeutic input, briefly, but repeatedly, throughout the life cycle, especially in relation to life crises (Cummings, 1988; Kazdin, 1988; Roth & Fonagy, 1996).

Technical Issues in Psychodynamic Therapy 6.05.2 TECHNICAL ISSUES IN PSYCHODYNAMIC THERAPY 6.05.2.1 Suitability for Psychodynamic Therapy Whereas medical treatments tend to have clear indications and contraindications for specific interventions, the emphasis of assessment for psychodynamic therapy tends to emphasize the looser notion of general ªsuitabilityº (Tyson & Sandler, 1971). Nevertheless, some writers have made specific recommendations concerning suitability for long-term (e.g., Coltart, 1988) and short-term therapy (e.g., Malan, 1980). While some authors have suggested relatively systematic assessment, which yields both diagnostic and prognostic features (e.g., Kernberg, 1981), in terms of the developmental level of the patient's personality organization most psychodynamic clinicians rely on clinical judgments based on interpersonal aspects of their first meeting with the patient (Etchegoyen, 1991). The three areas of greatest relevance to suitability are: patients' personal history, content of the interview, and style of presentation. In terms of the patient's history, good evidence of personal achievement and at least one good relationship has been traditionally regarded as a good prognostic indicator (Malan, 1980). A history of psychotic breakdown, severe obsessional states, somatization, and a lack of frustration tolerance are normally regarded as contraindications. There are many psychodynamic clinicians who report working successfully with patients who in the past had been regarded as unsuitable because of their histories: for example, psychotic (Rosenfeld, 1952), learning disabled (Sinason, 1992), and chronically poorly controlled diabetic individuals (Moran, Fonagy, Kurtz, Bolton, & Brook, 1991). Psychodynamic clinicians treating clients in long-term psychotherapy, particularly those working intensively, are more likely to make such risky selections. There is even less agreement about suitability concerning the content of assessment interviews. In general, clinicians tend to make their judgment on the basis of the presence of a ªmutualityº between them and the patient and observed responses to ªtrial interpretationsº in which they attempt to summarize their initial impressions concerning the patients' presenting problem in the context of their current and past life situation (see below). In addition, therapists may try to identify if the patient has the capacity to respond emotionally within the sessions to allow feelings of fear, sadness, or anger to come to the surface (Orlinsky, Grawe, & Parks, 1994). Some clinicians, though by no means all,

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attempt to assess the patient's motivation for treatment. This is, however, hard to do as superficial expression of commitment may or may not predict the willingness to confront unpleasant aspects of oneself. For this reason it is probably impossible to obtain genuinely informed consent in psychodynamic psychotherapy research. More recently, psychodynamic therapists have paid more attention to the nature of the patient's discourse rather than just its content. Holmes (1995), for example, observes if the patient's narrative styles are markedly avoidant and dismissing of interpersonal issues or appear entangled and enmeshed with them with much current anger about past hurts and insults. There is at least one study that shows that the former type of patient has a somewhat better prognosis in psychodynamic therapy (Fonagy et al., 1996). Patients' narrative style may also be a clue to the extent of their reflectiveness: the capacity to see oneself from the outside (Sandler, Dare, & Holder, 1992), autobiographical competence (Holmes, 1992), the ability to reflect on one's inner world (Coltart, 1988), and fluidity of thought (Limentani, 1972) are all considered indicators of suitability.

6.05.2.2 Formulation of Patients' Problems Psychodynamic theory is too diverse to permit definitive formulations. Formulations identify central unconscious conflicts, maladaptive defenses, unhelpful unconscious fantasies and expectations, deficits in personality development and the like. Formulation depends on the theoretical orientation of the psychodynamic clinician. In Chapter 14, Volume 1 of this work we have reviewed the range of currently popular orientations. Agreements, however, are hard to reach even when clinicians follow the same orientation (Horowitz, Rosenberg, UrenÄo, Kalehzan, & O'Halloran, 1989). Some standardized approaches have, however, been developed (Perry, Cooper, & Michels, 1987; Perry, Luborsky, Silberschatz, & Popp, 1989). While there is no generally accepted schema for formulations, there are several key parameters that clinicians generally consider. These are: (i) the extent to which representations of relationships are mature, that is, involve three or more persons rather than just a two-person, self±other dimension (Karasu, 1990); (ii) the quality of psychic defenses, particularly the predominance of primitive defenses rather than more mature ones (Vaillant, 1992, and see below); (iii) the extent of whole, as opposed to part object relations (where individuals are represented as whole persons rather than just an

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aspect or a function of a person, e.g., feeding or nurturance, sexual gratification, a container for evacuation) (Kernberg, 1984). Considerations such as these usually serve two functions. The first of these is to suggest the likely effectiveness of the type of treatment: short vs. long-term, intensive vs. nonintensive psychodynamic therapy. On the whole, patients seen as more severe on parameters such as the three suggested above are less likely to do well according to most studies of psychodynamic treatment (e.g., Wallerstein, 1986). The second function of formulations is to give an initial focus to the clinical work, which in the case of brief therapy may be the sole focus of the treatment. In long-term therapy these formulations tend to change, sometimes radically, on the basis of information emerging in the course of treatment. Winnicott (1965) referred to psychodynamic treatment as ªan extended form of history taking.º 6.05.2.3 Mechanisms of Defense 6.05.2.3.1 The concept of defense in various theoretical frameworks Within classical theory, which sees conflict as the core of mental function (e.g., Brenner, 1982), defenses are seen as adaptations to intrapsychic conflict. Within object relations theories, defenses are seen as assisting the individual to maintain an authentic self-representation, a true (Winnicott, 1965) or nuclear (Kohut, 1984) self. Within attachment theory, defenses are seen as maintaining desirable relationships (Holmes, 1993). Within a Klein±Bion frame of reference, defenses are often conceived of in terms of complex structures or systems called organizations. The term underscores the relative inflexibility of some defensive structures. Personality types appear to be characterized by specific types of defensive organizations. For example, in narcissistic disorders idealization and destructiveness, the devaluation of genuine love and truth, may have been protective at one developmental stage but came to acquire a stability which seems to be based on the emotional pay-off from this form of adaptation (Rosenfeld, 1964, 1971; Steiner, 1982). 6.05.2.3.2 Primitive defenses Regardless of theoretical orientation, there is general agreement about common forms of defense and their relative sophistication from a developmental standpoint (Vaillant, 1992). The primitive defenses tend to be found together in certain individuals. Borderline individuals, who idealize and then derogate their therapists in

order to maintain their self-esteem, are using splitting and projection. Projective identification (Klein, 1946) is also common in this group. Projection, the simple ascribing of an undesirable mental state to the other, becomes a more powerful mechanism when the other can be unconsciously forced to accept the projection and experience its impact, thus the ªidentificationº is in the recipient of the projection. This current interpretation of the term is particularly well described by Ogden (1979). It clearly goes beyond Klein's original meaning: the patient fantasizing that the recipient of the projection acquired a part of the patient's self. Spillius (1994) suggests a helpful clarification; she calls projective identification which invites the therapist to actualize the projection, ªevocative projective identifications.º Either in fantasy or in actualized form, projective identification offers a primitive method of experiencing control over the other within a relationship (therapeutic or caregiving) (Bion, 1955). When parts of the self are experienced as being within another person, the individual frequently makes attempts to control these split-off parts by exerting total control over the recipient or container of the projection. Bion (1962) also stresses that good, as well as undesirable, aspects of the self may be externalized via this route, making projective identification one of the principle avenues for communication in infancy. Other functions of projective identification, beyond communication and control, include: the acquisition of the object's attributes in fantasy, the protection of a good quality from internal persecution by evacuating it into an object, and the avoiding or denying of separateness. It is thus a fundamental aspect of an interpersonal relationship focused on fantasy, and its appreciation is critical for adequate psychodynamic psychotherapeutic practice. 6.05.2.3.3 Neurotic and mature defenses Anna Freud (1936) is to be credited for the delineation of most of the mechanisms of defense commonly used in clinical formulations today. It is not possible to give detailed consideration to each of these and most are, by now, part of common parlance (and exist as terms of mild rebuke, at least between mental health professionals). Defenses involving access to mental representations (e.g., repression) or the attribution of emotional significance to these (e.g., denial or disavowal) are perhaps most commonly encountered as part of individual coping strategies. For example, jokes containing emotionally threatening, sexual, and aggressive material are notoriously hard

Technical Issues in Psychodynamic Therapy to remember. Denial of the emotional significance of incurable disease may be helpful in increasing the patient's chance of survival (Greer, Morris, & Pettingale, 1979). Turning a response into its oppositeÐterror into aggression (reaction formation)Ðis particularly common in children in response to abuse, and identification with the aggressor (becoming the tormentor instead of the victim) is common amongst maltreated children who become abusers in adulthood (Oliver, 1993). Other commonly noted neurotic defenses include: undoing (performing a magical reparative act), intellectualization and rationalization, and humor. The diagnostic significance of mechanisms of defense is controversial. Some workers claim predictive specificity for such assessments beyond that of psychiatric diagnosis (Perry et al., 1989; Vaillant, 1992). The theoretical ambiguity which surrounds the concept makes its widespread use as a diagnostic device unlikely, at least in the short term. Its inclusion in this chapter is justified by its heuristic value: conceptualizing patients' reactions in terms of defenses makes psychodynamic work practicable. All of these defenses are common reactions in psychodynamic therapy, particularly at times of emotionally challenging work. Recognizing them has to become part of the working routine of the psychotherapist. For example, the forgetting of material from last week's session is more common than remembering it, even amongst people whose memory for other, far more trivial, aspects of their daily life is nothing short of admirable. The psychotherapist recognizes the patient's defenses and mostly uses them as an indication of the presence of underlying anxiety rather than as occasion for confrontation (but see some brief therapeutic strategies below). 6.05.2.4 The Context of Psychotherapy 6.05.2.4.1 The therapeutic contract Although contracts are far more relevant for short-term than for long-term therapy, most psychodynamic therapists explicitly or implicitly convey objectives and expectations to their clients. The details of the agreement usually include time and place, the length and frequency of sessions and an initial idea concerning the likely duration of therapy, the expected behavior of the patient and the therapist and so on. It is the emotional context of this agreement that is often more important than the items which it includes. It implies a mutual recognition by both parties of the importance placed upon protecting the process of therapy.

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6.05.2.4.2 Abstinence and neutrality Freud (1915) originally wrote about the analyst resisting the temptation of gratifying the patient's sexual desires. Although this is clearly an ethical issue, it also pertains to analysts forgoing gratifying patients' curiosity, or using patients to gratify their own personal needs. Equally, the patient undertakes to forgo major life changes where these are currently the subject of psychotherapeutic attention. Whereas this is particularly important in short-term treatment, even long-term psychodynamic treatment can flounder if the emotional experiences of the therapy are obscured by the upheavals from major life events. Abstinence ensures therapeutic neutrality. Psychodynamic therapists go to great lengths not to direct their patients' associations and remain neutral no matter what the content of the patients' past experiences or fantasies may be. Although this is frequently caricatured, it is important for the psychodynamic therapist to retain a certain emotional distance from the client, sufficient for the latter's fantasies and hidden fears to emerge. Needless to say, neutrality must be balanced by sensitivity. The recent literature on the working alliance (see below) underscores that the therapist's genuine concern for the client must come through if significant progress is to be made. 6.05.2.4.3 Regression One aim of psychodynamic psychotherapy is to activate and explore aspects of personality functioning which are normally obscured behind the patient's need to adapt to the demands of everyday reality. Psychodynamic therapy, to a degree, encourages access to these representations through the process of regression. This is less of an active encouragement than a passive permission. Sandler and Sandler (1994) suggested that an ªantiregressive functionº is normally active in all of us, and psychotherapy can function as a way of disinhibiting this function in much the same way as intimate interpersonal and certain types of large group situations and alcohol appear to do. Some therapists consider regression to be an essential part of successful treatment (Balint, 1949; Winnicott, 1971). Certainly the fear of regression can become an important source of resistance (Sandler & Sandler, 1994). 6.05.2.4.4 Resistance Resistance is an essential component of psychodynamic treatment. The word dynamic implies the presence of forces rallied against

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change. Resistance, like regression, fluctuates in intensity across treatment and may serve different functions at different times and in different individuals. In narcissistic and borderline states, resistance may protect the patient's self-esteem (Kernberg, 1988; Kohut, 1984); in more neurotic cases it may focus around preventing the integration of experience (ThomaÈ & KaÈchele, 1987). It may also take different forms. Clients access to their mental life (e.g., remembering dreams) may be experienced as restricted (repression resistance). Others may wish to keep their relationship with their therapist at an extremely superficial level (transference resistance). Some patients show a paradoxical reaction to their treatment: The better it progresses the worse they feel (e.g., new symptoms emerge). Freud (1923) attributed this to unconscious guilt. In some patients, at least, it is more likely to be linked to their pervasive predisposition (envy) to destroy all things in their life which they experience as good but beyond their immediate control (Kernberg, 1975; Rosenfeld, 1975). 6.05.2.5 Transference 6.05.2.5.1 The history of the concept The concept of transference originated with resistance. In his work with the cathartic method (Breuer & Freud, 1895) Freud initially understood the patient's intense emotional reaction to the therapist as an interference with what was an essentially verbal method. He quickly realized that the patient's emotional experiences could be better understood as representations of earlier relationship experiences (particularly Oedipal strivings and disappointments) which could be understood in terms of past experience and in fact made that experience emotionally more meaningful for the patient (Freud, 1914). 6.05.2.5.2 The origin of the transference experience The patient's intense feelings of anger, suspicion, and disappointment, or love, admiration, and excitement about the person of the therapist are unlikely to be a realistic response, since two patients may experience such opposite feelings towards the same therapist at similar times. There are currently a range of views about the origin of transference experiences. Some believe that transference is based on actual past experience: the expression of expectations based on past experiences of relationships (Bowlby, 1980). In this view, transference distorts the

actual relationship; patients see what they expect to see and resist understanding by repeating past relationships in a rigid manner (Levenson, 1983). There is an implication in this view of a ªcorrespondenceº between present and past. Many therapists are reluctant to accept the idea of such a direct relationship. For them transference is an aspect of the patient's narrative; it gives ªcoherenceº to the patient's experience of the therapeutic relationship, but it is not an expression of an underlying truth about the patient's history (Gill, 1982; Spence, 1982). Transference is constructed in the present and cannot give us clues to the past. By contrast, some who work within a Klein±Bion perspective see transference as a unique window to the patient's current internal reality (e.g., Joseph, 1986). For example, confronted with an idealized transference they might see the patient's true state as organized around psychotic anxieties related to the death instinct. The idealization is a desperate defense against the destruction which they fantasize may engulf both them and the therapist. Cavell (1994) demonstrated that the dialectic between these conceptions of the transference has important philosophical roots in the debate between ªcorrespondenceº and ªcoherenceº models of truth. Additional suggestions by object relations theorists have in some ways complicated the issue. Here transference is based neither on expectations, defenses against expectations, nor constructions aimed to achieve coherence, but rather on a process of externalization of internal objects (Kernberg, 1984). Such representations cannot be seen as true or false; they are distorted by fantasy and defensive processes. 6.05.2.5.3 The limits of transference interpretations There is a further important debate with regard to the relevance of a transference focus in psychodynamic therapy. Some therapists are inclined to see transference as covering all aspects of the analytic situation. Joseph, (1986) for example, sees the total situation in the therapy as reflecting an internal state of affairs in the patient's mind. Thus other aspects of the therapeutic relationship, for example, the socalled alliance and the so-called real relationship, are all subsumed under the transference. By contrast, Strachey (1934) conceived of transference as externalization of the patient's superego. The therapist, unlike other people in the patient's life, does not accept this externalization, be it idealized, denigrated, or judgmental, and conveys his or her understanding of it by so-called ªmutative interpretations.º This

Technical Issues in Psychodynamic Therapy view implies that the only truly therapeutic interpretations are those which involve the transference, but clearly admits of other aspects of the relationship. Other therapists, particularly in the Freudian school (e.g., Anna Freud, 1936), see transference interpretations as just one category of interpretive intervention and give them relatively little particular priority. 6.05.2.5.4 Special forms of transference There are several psychodynamic observations concerning special forms of transference which are helpful to particular groups of patients. Kohut (1984) described some common transference patterns with narcissistic patients. Individuals whose self-objects (parents) failed in their mirroring function may continue to crave for approbation and admiration and manifest this pattern in therapy. This is termed the mirroring transference, which Kohut recommends the therapist should not puncture by premature interpretations. Idealizing transference similarly aims to meet defective self-esteem by vicariously identifying with the perfect therapist. It is a highly controversial recommendation of Kohut's for therapists to accept such transferences. On the one hand, behind such exaggerated accolades may lie deep frustration and even rage; on the other, if Kohut is correct, destroying this image of the therapist is tantamount to a destruction of the patient's self-regard. Erotic transference is also thought to have infantile roots and occurs relatively commonly in therapeutic relationships, whatever the gender of the therapist and the patient. It tends to be highly embarrassing for the patient and sometimes also for the therapist. Most agree that it is a distraction and some suggest that it is a manifestation of a defense against either recognizing damage done to the object or the fragmented state of the self (e.g., Steiner, 1982). Alternatively, from an attachment theory perspective, erotic transference may be a way of forcing the unresponsive object to pay attention. At the extreme end of this dimension is erotized transference where the demand for sexual gratification is not experienced by the patient as unrealistic (Etchegoyen, 1991). Such reactions are particularly common in severely traumatized individuals. 6.05.2.6 Counter-transference 6.05.2.6.1 History of the concept Counter-transference in its broadest sense refers to the thoughts and feelings of the therapist during a treatment session which are

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in some ways relevant to the patient's current experience and thus may be involved in illuminating the patient's reaction or, indeed, obscuring it. Langs (1976) usefully distinguished between counter-transferences which may be attributed to the patient and those which result from the analyst's neurotic reaction to some aspect of the therapeutic situation. The concept of counter-transference, like that of transference, is rooted in the notion of resistance. Freud, throughout his career, never recognized the value of counter-transference as an indicator of the patient's subjective state (Freud, 1912). Heimann (1950) expanded the usefulness of the concept by pointing out that the therapist's feelings and thoughts about the patient's communications, if reflected upon, could provide important clues about the patient's current state of mind. The idea was controversial (e.g., Fliess, 1953) yet it gradually gained acceptance. Those psychotherapists who were committed to an interpersonalist tradition (e.g., Sullivan, 1953), and saw the relationship aspect of psychotherapy as its most important facet, welcomed this expansion of the countertransference concept. From their point of view the omniscient neutral analyst was an anachronistic anathema; accepting the analyst's human reaction was a welcome democratic humanistic development (Abend, 1989). 6.05.2.6.2 Types of counter-transference Racker (1968) distinguished between complementary and concordant counter-transference. Concordant counter-transferences are based upon primitive empathic processes within the therapist. The latter resonates with as yet unverbalized experiences of the patient. Complementary counter-transferences arise when the patient treats the analyst in a manner congruent with an earlier relationship pattern. King's (1978) notion of ªreverse transference,º where patients treat the therapist as they felt treated when children, is a special instance of this category. The case of concordant counter-transference particularly raises the issue of the mechanisms by which analysts may become aware of the patient's unconscious experience. Sandler (1993) offers the notion of ªprimary identificationº as a rapid process of automatically mirroring one's partner in a communication and only becoming aware of this upon reflection. There is good evidence for such a process, particularly in the infant development literature (Osofsky, 1995). Only when such primary identifications touch on unconscious conflicts within the analyst, with a consequent mobilization of defensive

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processes, will counter-transference start to be a distorting process. Grinberg (1962) pointed out that such experiences could lead therapists to withdraw from the therapeutic relationship. Therapists sensitive to, and resonating with, feelings of inadequacy in patients may be made anxious by such feelings and become defensively angry or hypermotivated to show their effectiveness. To some degree this may be an inevitable part of the process with the therapists only gradually understanding the reasons behind their unusually defensive style of relating. Bion (1962) stressed the importance of the recipient of the projection (the container) being able to ªmetabolizeº and feed back the products of such primitive communications. Sandler (1976b) pointed out that therapists needed to allow themselves sufficient freedom of action to be able first to enact the patient's projection and then respond to the enactment in appropriate ways. Along similar lines, Brenman-Pick (1985) cautioned that the therapists' psychopathology frequently required that they worked through counter-transference identifications so that their wish not to know was turned into a potential for knowing. Not all counter-transference reactions are provoked by patients' projections or reactions to the anxieties that these create. Winnicott (1949) was perhaps the first to point out that the outrageous provocative behavior of certain borderline or psychotic patients produced a normal reaction of ªobjective hate.º Kernberg (1984) formalized this, suggesting that such behaviors activated primitive aspects of the therapist's personality. Understanding these reactions naturally helps the therapist empathize but it is neither a complementary nor concordant reaction, nor is it a defense against affective resonance. It is simply one further indication that the therapist too is human. 6.05.2.6.3 Counter-transference and interpersonal approaches Modern psychodynamic theory considers counter-transference as firmly located in the interpersonal field. The patient and psychotherapist are seen as two mutually influencing psychological systems (Langs, 1978). Both transference and counter-transference are seen as the product of a subtle interplay between conscious and unconscious systems of both patient and analyst. Influences occur in both directions at both conscious and unconscious levels (Arlow, 1993). Some writers go so far as to suggest that patient and therapist share an unconscious fantasy of creating an intersubjective field between them (Baranger, 1993). Whether correct or not, these modern ap-

proaches emphasize that it is no longer possible to consider the therapist's role as ªneutralº or ªmirror-likeº and that the psychotherapeutic process is a highly subjective admixture of a range of complementary processes that establish themselves in a unique configuration for each therapy. 6.05.2.7 Therapeutic Interventions 6.05.2.7.1 Historical overview There has been a dialectic throughout the history of psychodynamic approaches between orientations that emphasize insight and interpretation and those that stress the unique emotional relationship with the therapist as the primary vehicle of change. The controversy dates back to the earliest days of psychoanalysis, to Freud and Ferenczi, but re-emerged powerfully with first the work of Balint and Winnicott set against classical Freudian and Kleinian theorists, and later Kohut and self psychology opposing the classical ego psychology tradition. This dichotomy is clearly artificial, as it is hard to envision effective psychodynamic therapy without both components (see Wallerstein, 1992). It is nonetheless helpful in presenting the range of techniques used by most psychodynamic therapists which span the spectrum between emotional relationship-oriented techniques and insightoriented ones. Winnicott (1971) referred to this dimension as ªbeing withº versus ªdoing to.º As supportive interventions tend to suggest particular lines of association, an overlapping dichotomy exists between the use of directive and nondirective techniques. 6.05.2.7.2 Supportive and directive aspects of psychodynamic interventions There are a whole range of supportive techniques used more or less deliberately by psychodynamic psychotherapists. These include: explicit support and affirmation; concern and sympathy (e.g., in response to bereavement or major setback); reassurance, commonly concerning irrational anxieties about the therapeutic arrangements; empathy with the patients' painful internal struggles, and so on. The complexity of such interventions was well illustrated by Feldman (1993). He showed how patients may experience the therapist's submission to a demand for reassurance as anxiety provoking rather than calming, since they may be unconsciously aware that the therapist's genuine position is incompatible with offering such palliatives and are thus faced with the deep fears concerning their own

Technical Issues in Psychodynamic Therapy omnipotence and the therapist's weakness. Nevertheless, Kohut's (1984) emphasis on empathy was undoubtedly a welcome counterbalance to the rigid interpretive techniques of many classical ego psychologists and seems appropriate with patients who have experienced little genuine concern in their history. Psychodynamic therapists are most likely to use supportive and directive techniques which encourage the therapeutic process. Elaborative techniques, such as ªTell me more about that,º undoubtedly direct the patient's attention to specific issues and focus the treatment but may be essential precursors to interpretive work proper. Clarification is also a commonly used technique which involves a restatement of the patient's utterance or just offering a label (a symbol) for an internal state which the patient has limited capacity to represent. Clarifications shade into interpretations and the distinction is hard to draw in actual practice. Confrontation is a subtype of elaboration and clarification. The therapist, having identified inconsistency, brings this to the attention of the patient, usually in a supportive but firm manner (e.g., drawing the patient's attention to the absence of affect appropriate to a specific situation). 6.05.2.7.3 Interpretation in psychodynamic therapy Interpretation is the paradigmatic intervention. Perhaps not surprisingly therefore it is often idealized as the sole or uniquely effective method for bringing about psychic change. Menninger (1958) offered a useful classification for psychodynamic interpretation. He suggested that interpretations addressed principally one of three aspects of a conflict: the defense, the anxiety, or the underlying wish or feeling. The content of the interpretation could be further subdivided as concerning current external reality, the transference, and childhood relationships. The phase of the treatment is most likely to determine the therapist's choice. Commonly interpretations move from current events through the transference to the distant past. Similarly, generally interpretations start with the anxiety, through the identification of the defense to accessing the repudiated affects. In practice, neither of these patterns can be considered more than a guideline to be loosely applied. For example, very long-term therapy often ends up focusing on supportive exploration of current events (Blum, 1989). This is not surprising since the distant past can only be worked over a limited number of times. Similarly, defenses, if interpreted without regard to the anxiety, may well come across

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as implicit criticisms of the patient. Yet early interpretations of an unconscious wish can be puzzling and confusing even for relatively intact patients. Furthermore, severely personality disordered individuals respond poorly to interpretations of the distant past. Their reality testing may be too tenuous and they may overattribute their current experience to past events. It is clearly preferable to work with such patients uniquely in the here and now if gross distortions of history are to be avoided. (i) Transference interpretations Strachey (1934) placed transference interpretation at the center of psychodynamic work. As discussed above, his rationale for this was constructed as a route out of a vicious cycle of the external confirmation of the patient's repudiation of certain fantasies and feelings. Others, however, saw different strengths in ªworking in the transference.º A focus on the therapeutic relationship offers the patient the opportunity to internalize the thinking function of the therapist (Hoffer, 1950), the relationship with the analyst as a new object (Klauber, 1972), the therapist as a self-object (Kohut, 1977; Kohut & Wolf, 1978), or adopt a pretend stance facilitative of the development of an awareness of other minds (Fonagy, 1991, 1995). Steiner (1993) pointed to this latter aspect of interpretations when he distinguished ªanalystcenteredº and ªpatient-centeredº aspects of interpretations. When therapists interpret what they imagine to be going on in the patient's mind they make patient-centered interpretations; when they interpret the patient's reactions in terms of what they imagine the patient is thinking about what the therapist is thinking or feeling then this is an analyst-centered interpretation. Here the patient is directly learning about how minds interact within social relationships (Fonagy, Moran, & Target, 1993). Whereas the former type of interpretations, if used to excess, may appear to be blaming the patient, the latter type make the therapists appear as if their concerns were purely narcissistic and not sympathetic to the patients' real difficulties in the external world. (ii) Extratransference interpretations Most psychodynamic clinicians now agree that a balance needs to be struck between transference and extratransference interpretations (Stewart, 1989). O'Shaughnessy (1992) evocatively described how a treatment focused too much within the transference can become ªan over-close enclaveº and extratransference interpretations had the power to break the

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claustrophobic atmosphere. Sometimes, the spontaneous and direct communication of the analyst's experience of frustration (ªobjective hateº) may help the patient see the therapist as a real person and break a repetitive unproductive pattern in the therapy (Coltart, 1986; Symington, 1983). Kernberg (1995) is probably accurate in saying that patients in the borderline spectrum benefit specifically from well-structured, hereand-now transference interpretations. 6.05.2.8 The Result of Psychodynamic Interventions 6.05.2.8.1 The role of insight Just as interpretation is paradigmatic but by no means the sole effective component of psychodynamic interventions, so insight may be an oft idealized but, in reality, relatively rare outcome of therapeutic work. Insight is the conscious recognition of the role of unconscious factors (feelings, experiences, fantasies) on current experience and behavior. ªTrue insightº and mere and intellectual knowledge should be carefully distinguished (Zilboorg, 1952). ThomaÈ and KaÈchele (1987) identify insight as equidistant between the poles of pure intellect and simple emotional experience. Etchegoyen (1991) helpfully distinguished between descriptive or verbal insights on the one hand and ostensive or shown insights on the other. The latter is a more direct form of knowing and pertains to the common experience when one is in emotional contact with an event one has known before. There is general agreement that insight is an integrative experience (ThomaÈ & KaÈchele, 1987). Those who follow a Klein±Bion model would describe this as a healing of defensively instituted splits in the patient's mental representations of others and their relationships to them (e.g., Segal, 1962). In more general terms, it may be seen as an instance of a more general predisposition to think in terms of the mental states of one's objects and understand one's relation to them in mental state terms (Fonagy & Target, 1996). This tendency may also be described in terms of a willingness to see the interpersonal world from a ªthird-person perspectiveº (Britton, 1989, 1992). 6.05.2.8.2 The role of working through Neither intellectual nor emotional insight is sufficient for progress (Freud, 1914). The function of working through is to help the patient to practice a newly arrived-at integration. This has two components: first, to unlearn the implications of prior misconceptions, and

second to assimilate, and practice working with, new constructions. It is interesting to note that the literature on long-term therapy pays far less attention to this aspect of the outcome of interventions than the process of interpretation which merely is the starting point of the change process. Short-term therapies necessarily pay far more attention to the need to present and represent psychotherapeutic understanding. The relative effectiveness of short-term interventions may owe much of their potency to the systematic way in which the task of working through is tackled (see below). 6.05.2.9 Ending Treatment 6.05.2.9.1 Indications for ending treatment Like much of psychoanalytic psychotherapy, the ending of treatment is often idealized. The desirable final outcome is often stated in terms of the process of treatment. Kennedy and Moran (1991), following Anna Freud , helpfully separate the process aims from the outcome aims of psychodynamic treatment. The former is likely to be stated in theoretical terms (e.g., a move from paranoid to depressive anxieties, an increase in the coherence of the patient's narrative, an increased awareness of impulses and fantasies, a manifestation of genuine concern for others and so on). All these are observed in the context of the treatment and are at best loosely coupled with the goals the patient might have for ending the treatment. The latter are often external changes such as the decline of symptoms, improvement of relationships, decrease of unpleasant affect, an increased capacity for assertiveness, and so on. These external criteria are sadly regarded by many psychodynamic clinicians as superficial as they can be achieved without fulfilling the process aims of the treatment (GruÈnbaum, 1984). Evidence will have to be gathered which clearly demonstrates that external change associated with process change is more extensive or longer lasting than external changes achieved in isolation. 6.05.2.9.2 The process of ending treatment There is general agreement that ending treatment is ªa process.º Different authors identify different processes: a new beginning (Balint, 1949), weaning (Meltzer, 1967), mourning (Klein, 1950), detachment (Etchegoyen, 1991), and maturation (Payne, 1950). An inevitable part of ending is disillusionment with not having achieved the ideal (Pedder, 1988), and the loss of the object who has been the receptacle for projections (Steiner, 1993). As

Illustration of Long-term Psychodynamic Therapy part of this process, symptoms might return, if briefly, and problems already worked through may appear to resurface. Most clinicians agree that other than acknowledging the unconscious issues around ending, no specific technical maneuvers are indicated. 6.05.3 ILLUSTRATION OF LONG-TERM PSYCHODYNAMIC THERAPY: PSYCHOTHERAPY FOR BORDERLINE PERSONALITY DISORDER 6.05.3.1 Theoretical Approaches to Borderline Conditions Psychodynamic theories of borderline personality disorder (BPD) are discussed extensively in Chapter 14, Volume 1 and only a brief summary of these views will be presented here. Broadly there are two approaches to understanding this relatively rare but troublesome disorder characterized by intense but unstable personal relationships, self-destructiveness, impulsivity, poor social adaptation, self-damaging behavior or suicidality, chronic dysphoria, transient psychotic episodes, and so on. There are those who suggest conflict as the central theme and those who favor an explanation in terms of deficit. The conflict model is best represented by the Klein±Bion tradition (e.g., Steiner, 1993) as well as by the work of Kernberg (1984). A key feature of these formulations is the unsuccessful integration of good and bad part-objects, and the use of primitive defenses (particularly projective identification and idealization and derogation). It is assumed that children cannot deal with excessive aggression arising from abandonment experiences and are forced to split again and again their internal representations to protect their internal sense of good. By contrast, deficit models ascribe the internal fragmentation of borderline patients to deprivation experiences which leave the ego weak and unable to self-soothe. Consequently such individuals draw on exogenous stimuli such as drugs, binge eating, or self-harm to induce mood states (Adler, 1985). Narcissistic features which accompany borderline states are seen by Kernberg as representing the conflict between the individual's need for an object and the rage felt towards that object. They deal with the conflict by self-absorbedly becoming their own ideal self. For Kohut (1977) and Winnicott (1965) absent, insensitive, or abusive primary figures force children to retreat into themselves and become the missing ideal object. In both cases infantile omnipotence is maintained into adulthood.

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A critical feature from the point of view of treatment is the high prevalence of trauma in this group. A large proportion of hospitalized borderline individuals meet diagnostic criteria for post-traumatic stress disorder (PTSD) (Gunderson & Sabo, 1993) and 70±80% have histories of severe physical or sexual abuse (Herman, Perry, & van der Kolk, 1989). The almost ubiquitous presence of trauma may help bring together conflict or deficit theories, particularly since the trauma is frequently one of relatively late childhood or even adolescence. It is conceivable that certain individuals whose early attachment relationships were insecure, and who are consequently somewhat poorer at understanding mental states in others and in themselves, when confronted with an abusing relationship respond to it by selectively obliterating detailed representations of the mental states of other attachment figures (Fonagy et al., 1995). A number of common features of borderline personality disorder could be explained in terms of the defensively deactivated mentalizing capacity of such individuals in the context of attachment relationships (e.g., confusion in interpersonal relationships, apparent callousness towards others, poor capacity to communicate). 6.05.3.2 Treatment Strategies It is to be expected that two sets of theoretical approaches (conflict and deficit) lead to categorically different treatment recommendations. The former identifies the early interpretation of the negative transference as critical, whilst the proponents of the deficit view stress the importance of the holding environment and empathic responding. There is no shortage of forceful recommendations and warnings of the dire consequences should these not be followed (e.g., Kernberg, 1984; Ryle, 1994), but evidence supporting either position is at the moment sparse. A number of reviews have, however, brought together a generic framework for the psychodynamic treatment of borderline patients based on the assumption that both conflict and deficit models are of relevance and both would probably cause harm if inexperienced therapists were to follow the recommendations without qualification (see Gabbard, 1994; Higgitt & Fonagy, 1992; Waldinger, 1987). 6.05.3.2.1 Limits and boundaries The therapist needs to recognize the importance of both setting definite limits for patients and the patients' likely failure to keep to traditional boundaries. The setting must be

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protected from the overwhelming demands which such difficult patients may produce, yet must have the flexibility to contain the patients at times when self-regulatory capacities are no longer available to them. As these remarks suggest, there are major advantages to seeing the more severe cases in institutional (although not necessarily inpatient) rather than private settings. 6.05.3.2.2 Interpretive focus Psychological space must be created in the mind of the patient for interpretive work which assumes mentalizing (thinking about mental states in self and other). It is essential that moment-to-moment changes in affective states are noted and clarified by the therapist, even if the reason for these rapid changes of affect often remains obscure. Failures of understanding are often reacted to rather dramatically (with complete withdrawal, paranoia, physical violence, self-harming). The interpretation (more properly clarification) of these emotional reactions at their earliest stages may avoid a vicious cycle of ever-increasing anger and ever-decreasing possibility for genuine understanding. Therapists should aim to make ªmicrointerpretationsºÐsimple but frequent verbalizations which address states-of-mindÐ using words to make room for thinking and feeling without making assumptions that at times of intense affect the patient can understand complex causal relations between mental states. It should be remembered that the destruction of thought might be the strategy closest to hand for many of these patients and thus, unless cautious and nimble, the therapists may well find themselves squeezed out of the therapeutic space, where there is now no longer room for any kind of understanding. 6.05.3.2.3 Counter-transference Feelings with borderline patients are intense. From one meeting to the next, ªtherapist the saviorº may turn into ªtherapist the tormentor.º At these moments several things are hard to remember. First and most obvious, that there is no truth in either attitude and that all that is certain is that nothing is permanent. Second, that there is some painful element of truth to even the wildest projection and that the therapist is a real cause as well as an imaginary one. Third, that any pretense of being unaffected by the close proximity of such intense emotion creates an atmosphere of unauthenticity, not just between therapist and patient but also within the therapist. Unfortunately, the patients' intolerance of other minds causes them to attack the space which therapists usually

reserve for themselves for thinking. Mindless anxiety or a bewildered state of numbness can fill not just the session itself, but times for reflection before and after. 6.05.3.3 Handling Crises Crises in treating borderlines are inevitable but their timing may well be a surprise. The general advice of those who regularly deal with emergencies across a wide range of contexts is that disaster planning is best when it precedes rather than follows the event. A well-rehearsed contract with a patient may go some way to limit extremes of acting out, but having a plan for dealing with suicidality, self-harm, drunkenness, intrusiveness, and sometimes violence is the key. Knowing what to do will avoid acting out on the part of the therapist which mostly takes the form of aggressive, overpunitive, rejecting actions arising mainly out of damaged self-esteem: ªHow can you do this to me when I have tried so hard with you?º Good collaborative relationships with colleagues also working with the patient is a sine qua non of psychotherapeutic treatment. The management of crises, however, cannot be mechanistic. Careful scrutiny with the patient of thoughts and feelings that led up to the event must take place even if not at the time and not as part of the emergency procedures. The overarching goal is replacing action with mental work. Despite there being no foolproof way of preventing crises, certain patterns of therapeutic intervention (e.g., excessive passivity, complete nondirectiveness, or other expressions of rigidity and unthinking conduct) will inevitably cause these patients to incubate anxiety and ªblow.º 6.05.3.3.1 Desirable outcomes The goals of long-term psychodynamic therapy are ambitious in some contexts but have to be modest with borderline patients. The process goals are largely clustered around the notion of tolerance: tolerance for affect, for fantasy, for a variety of therapeutic interventions (particularly therapist errors). The external goals are also limited. Although anxiety may abate, depression rarely responds significantly. Interpersonal issues may improve but never become normal. The behavioral aspects are most likely to respond to treatment. 6.05.3.4 Outcome Research Evidence for the efficacy of psychodynamic therapy for borderline individuals is limited. A long-term naturalistic follow-up (Stone, 1993) of 500 patients demonstrated some degree of

Forms of Brief Psychodynamic Therapy spontaneous remission in middle life but also high suicide rates and selective response to treatment. Clearly, the DSM diagnosis describes several subgroups of patients probably with somewhat different etiologies and significant differences in expected outcomes. Work at Cornell Medical Center by John Clarkin, Otto Kernberg, and colleagues may provide us with a questionnaire instrument which will assist in the assessment of suitability. Treatment drop-out rates are very high, in one sample up to 50% (Aronson, 1989). Patients who stay in treatment appear to do relatively well with success rates of 60±70% reported from open trials (Rosser, Birch, Bond, Denford, & Schachter, 1987; Stevenson & Meares, 1992; Stone, 1993). 6.05.4 FORMS OF BRIEF PSYCHODYNAMIC THERAPY 6.05.4.1 The Historical Roots of Brief Psychodynamic Therapy Paradoxically, the prototypical long-term psychodynamic therapy, psychoanalysis, shares its roots with brief therapy. The psychoanalytic treatment of many of the pioneers of psychoanalysis would by present standards be considered brief, intensive psychotherapies. The early cathartic method advocated in Breuer and Freud (1895) may be construed as a focused hypnotic brief intervention. Freud's case load, even after his discovery of the method of free association, contained brief therapy cases including some very distinguished clients, Bruno Walter and Gustav Mahler amongst them. Three of the early generations of psychoanalysts sharing Hungarian origins contributed most directly to brief psychodynamic interventions. These are Otto Rank, Sandor Ferenczi, and Franz Alexander. Both Rank and Ferenczi were concerned that long-term therapy could reinforce regressed overdependent aspects of the client's personality and that the goal of psychoanalytic research through the in-depth exploration of the patient's psyche may at times conflict with the immediate aim of addressing the abnormal dynamics of the patient's mental life (Ferenczi & Rank, 1925, p. 52). Ferenczi was particularly keen to discover ways in which the process of symptomatic cure could be accelerated. In the course of this research he discovered many of the central principles of behavior therapy. Because of the conservative nature of the psychoanalytic establishment, these remained outside the psychodynamic frame of reference and became a major challenge rather than part of its armamentar-

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ium. There is no difficulty in incorporating these methods into modern psychoanalysis (Fonagy, 1989; Wachtel, 1977), just as Ferenczi had little difficulty in so doing. His discoveries included the principle of exposure to combat phobic avoidance, the principle of response prevention for obsessional rituals, and the focused elaboration of key ideas akin to some strategies of cognitive therapy. Ferenczi 's aim in these and other elaborations was to accelerate the process of change. Neither he nor Otto Rank shied away from the possibility of using techniques from other therapeutic modalities (e.g., hypnosis) if these were going to advance their underlying aim of enhancing the curative emotional experience of psychodynamic therapy (Ferenczi & Rank, 1925, pp. 63±64). Franz Alexander was influenced by Ferenczi in his training. Together with Thomas French, he elaborated Ferenczi's suggestion of provoking specific affective experiences in the therapeutic relationship. They advocated that the therapist should purposefully counteract the pathogenic influence of particular significant figures from the past. For example, the accepting attitude of the therapist may contrast with that of an excessively harsh and authoritarian parental figure. The choice of the therapist's attitude should be dictated by the history of the specific patient. Even more important than these controversial suggestions is the general framework advanced by Alexander and French which included a structured approach initiated by a detailed assessment followed by a comprehensive formulation, the setting of treatment goals, and the systematic anticipation of problems that may be encountered in the course of treatment. The total treatment package included homework assignments, a focus on current relationships, and an open acceptance of educational as well as insight-related goals of therapy. 6.05.4.2 Indications for Brief Psychodynamic Therapy The diagnostic groups that are likely to be considered for brief psychodynamic therapy are the less severe anxiety and depressive disorders, adjustment disorders, and some of the milder personality disorders. By contrast, individuals with a history of suicidal threats, alcohol and substance abuse, poor impulse control, incapacitating depression or anxiety, or dramatic cluster personality disorders are normally deemed unsuitable (Messer & Warren, 1995). Proponents of brief therapy normally add psychodynamic criteria to the phenomenological. Sifneos (1987) for example, suggested that,

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in addition to a circumscribed central complaint, suitable clients would have a history of at least one good childhood relationship, a capacity to relate flexibly to the interviewer, evident psychological mindedness and a motivation for change beyond symptom relief. By contrast, Malan (1976a) lists six dynamic exclusion criteria which are the mirror image of Sifneos' selection criteria: for example, the inability to make contact, lack of motivation for treatment, rigid defenses and severe dependence. Davanloo (1980) emphasizes the importance of ªtrial interpretations.º If clients respond to firmly put, but necessarily tentative hypotheses by a ªdeepening involvement,º they are more likely to be regarded as suitable than individuals whose response is decompensatory (e.g., anxiety, confusion, paranoia). Strupp and Binder (1984) also list current emotional discomfort. They suggest that patients have to be sufficiently uncomfortable with their feelings and/or behavior to seek help from psychotherapy. On the whole, brief psychotherapists recommend expressive techniques for healthier patients and supportive techniques for sicker ones (Luborsky & Mark, 1991). No formal, structured interviews and assessments have been developed to aid clinicians in these assessments. There is, however, significant empirical data available which suggests that some of these psychodynamic parameters are pertinent to the likely success of psychotherapy. Piper and his colleagues have, however, carried out a number of excellent studies validating some of the underlying concepts. Piper, de Carufel, and Szkrumelak (1985) demonstrated that the quality of object relations (QOR) and defensive style together predicted good outcome in time-limited psychodynamic therapy. The clinical judgment of the quality of object relations is based on an evaluation of the quality of object relation patterns throughout the life span, the capacity to regulate affect and self-esteem, and historical antecedents of these (Piper et al., 1985). Quasi-experimental studies demonstrated that clients with high QOR were more likely to benefit from therapy than low QOR ones to a clinically significant extent (Piper, Azim, McCallum, & Joyce, 1990a). QOR may be a better predictor of therapeutic alliance than measures of interpersonal functioning but may account for the latter's association with outcome (Piper et al., 1990). Norwegian studies have independently demonstrated that a clinical assessment of the patient's quality of interpersonal relations was a good predictor of longterm change following dynamic psychotherapy (Hùglend, 1993a, 1993b; Hùglend, Sùrlie, Heyerdahl, Sùrbye, & Amlo, 1993b).

6.05.4.3 Techniques of Brief Psychodynamic Therapy 6.05.4.3.1 Malan's brief intensive psychotherapy (BIP) David Malan, a British psychoanalyst working at the Tavistock Clinic alongside one of the pioneers of object relations theory, Michael Balint, was one of the first to adapt standard psychodynamic therapy as practiced in this psychoanalytically oriented outpatient public mental health facility for brief interventions (Malan, 1963, 1976a, 1976b). The normal length of BIP is approximately 20 sessions. In the initial session(s) central conflicts for the patient are identified and the therapist focuses on these selectively, ignoring other conflicts and interpreting only those aspects of the patient's material which pertain to these concerns. There is no particular type of conflict to which Malan's approach gives preference, although Malan offers an overriding structure, similar to that of Karl Menninger, which he regards as pertinent to all conflicts. The ªtriangle of conflictº includes: the impulse or affect, the defense erected against it, and the symptom or anxiety which ensues after the failure of defence. An example (Malan, 1980, pp. 178±184) of a focal conflict may be someone who is angry about being imposed upon but defends against this and manifests usually intense anxiety about asserting herself and becomes depressed as a consequence. Malan recommends addressing conflict in at least three contexts: in the patient's current life, with the therapist, and in relation to past caregiving figures. Perhaps because of its proximity to standard psychotherapeutic practice, Malan's Brief Intensive Therapy has been extensively validated empirically. Malan's own studies (Malan, 1976a, 1976b) are methodologically too weak to warrant review. However, the Canadian studies by Piper have provided evidence that (i) Malan's therapy is as effective as long-term individual or group psychotherapy (Piper, Debbane, Bienvenu, & Garant, 1984), (ii) patients undergoing this form of therapy are significantly better off in 78% of cases than untreated control patients (Piper et al. 1990), and (iii) that for highly object-related patients the accuracy of transference interpretations corresponded to outcome at six-month followup (Piper, Joyce, McCallum, & Azim, 1993). Norwegian studies demonstrated that level of insight gained (as assessed independently) in 43 outpatients correlated with overall dynamic change at four-year follow-up (Hùglend, Engelstad, Sùrbye, Heyerdahl, & Amlo, 1994). There are controversial findings concerning the role of transference interpretations. Malan

Forms of Brief Psychodynamic Therapy reported that the frequency of therapist, parent, current figures triangular interpretations correlated with therapeutic outcome (Malan, 1963, 1976b). This finding corresponds to Strachey 's classical assumptions concerning ªmutativeº aspects of interpretation (Strachey, 1934). Unfortunately, although preliminary replications confirmed Malan's observations (Marziali, 1984; Silberschatz, Fretter, & Curtis, 1986), more careful analyses by the Canadian group indicated that, for low QOR patients at least, the frequency of transference interpretation was associated with less rather than more symptom change (Hùglend et al., 1993a; Piper, Azim, Joyce, & McCallum, 1991). An interesting study by another Norwegian research group has demonstrated the effectiveness of Malan's BIP in reducing the relapse rate following clomipramine treatment of panic disorder (Wiborg & Dahl, 1996). Thus Malan's therapy is relatively well validated although the clinical groups on which the treatment was assessed are relatively heterogeneous. Studies also offer some indication that the treatment process corresponds to those hypothesized by the originator of the therapy, although evidence on this point remains equivocal. 6.05.4.3.2 Sifneos' short-term anxietyprovoking psychotherapy (STAPT) In the USA, short-term psychodynamic psychotherapy retained close links with the classical ego psychology tradition. Sifneos developed a psychodynamic treatment focused on the oedipal concern of individuals whose psychological problems could be relatively readily linked to this common type of unconscious conflict (Sifneos, 1979, 1987, 1992). Sifneos, probably accurately, pointed out that psychodynamic therapists were frequently more ready to acknowledge issues of dependency and frustration in relation to caregiving figures than concerns about childhood sexual fantasies about parents of the opposite gender. The recommended strategy is for the therapist to listen carefully for material pertaining to oedipal issues and to address this directly without regard to the defenses which individuals may have erected to protect themselves from the anxieties these thoughts might engender. Sifneos adopts a somewhat didactic stance and does not shrink from explaining his reasoning in identifying material as relating to oedipal anxieties. He also confronts patients' defenses, being particularly sensitive to instances of intellectualization. A strong point of his approach is the availability of a relatively comprehensive manual for short-term anxietyprovoking psychotherapy (Sifneos, 1992).

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There is only very limited evidence available to support the usefulness of this approach. Sifneos and colleagues reported a comparison of 22 treated patients and eight waiting list controls (Sifneos, Apfel, Bassuk, Fishman, & Gill, 1980). While 18 out of 22 were reported to have recovered in the treated group or to be much better, none of the waiting list group reported a similar degree of change. In a somewhat larger study reported in 1987, 30 of 36 patients were rated as having recovered or being much improved whereas 80% of the 14 waiting list patients were unchanged. Unfortunately in neither study were the measures sufficiently clearly described to permit generalization, nor were raters blind as to treatment group. Independent studies examining the relationship of therapeutic process to outcome found no evidence that therapists' competence at practicing STAPT predicted good outcome. In fact, competence was inversely related to improvement (Svartberg & Stiles, 1992, 1994).

6.05.4.3.3 Davanloo's intensive short-term dynamic psychotherapy (ISTDP) Davanloo's approach is also quite confrontational, aiming to create a degree of emotional arousal and even discomfort while trying to address presumed feelings in clients which they might have consistently avoided (Davanloo, 1978, 1980). Davanloo's aim is to intensify the emotional charge of the therapeutic situation so that within it important past emotionally charged experiences will once again come to life. The therapeutic strategy entails offering empathic support in relation to the past hardships suffered by the patient. Nevertheless, the pattern of interaction as revealed by Davanloo's detailed account is one of tenacious and unremitting confrontation of the patient, focused on the patient's problems and defenses against them, identified on an initial inquiry. There is a single trial which supports the effectiveness of this form of therapy (Winston et al., 1991). Thirty-two patients were assigned to one of two brief psychodynamic therapies. Patients assigned to the other therapy (brief adaptive psychotherapy) did comparably to those receiving ISTDP and both did substantially better than the waiting list controls. In a follow-up and extension of this investigation (Winston et al., 1991, 1994) a larger sample of patients were seen to maintain their improvement. An interesting feature of this investigation was the inclusion of some nondramatic Axis II patients. The study, however, only used self-report measures and did not succeed in differentiating the two forms of psychotherapy.

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6.05.4.3.4 Luborsky's supportive-expressive time-limited therapy (SETLT) Luborsky's brief psychodynamic approach is fundamentally an adaptation of psychodynamic therapy defined quite broadly (Luborsky, 1984). The technical principles are outlined by Luborsky and Mark (1991). They include recommendations for the therapist to be sensitive to allow the patient to form a ªhelping alliance,º to identify and respond about central relationship patterns, and identify where the client's symptoms fit into these. They explicitly recognize the patient's needs to test the relationship in transference terms and recommend that the patient's symptoms should be identified as problem-solving coping patterns. Thus, Luborsky's approach has two critical focuses. The first is the relationship patterns which they label as ªcore conflictual relationship themesº (CCRTs) (Luborsky & CritsChristoph, 1990). These themes consist of three components: the wish (or need), the anticipated response from others to this wish, and the response from the self to the other's response. These themes are conflictual because the response of the other to the wish is anticipated to be negative. The CCRT is derived from clinical material. ªRelationship episodesº are identified from transcripts of sessions where the patient narrates an episode of interaction. The CCRT represents a summary of the most frequent types of components. Luborsky and Schaffler (1990) offer an illustration of an individual whose wish is to be assertive, dominant yet reassured, but anticipates disapproval and is left feeling annoyed, angry, and upset about not feeling in control. It is important to note that relationship episodes may be drawn from narratives which apparently do not involve the self, and in this respect the method is analogous to psychodynamic psychotherapists' approach to the understanding of the transference. Considerable research supports the value of CCRTs (see Luborsky & Luborsky, 1995). The reliability of both the overall formulation and its components is relatively high when performed by trained judges (Crits-Christoph, Luborsky, Popp, Mellon, & Mark, 1990). The measure is also replicable across settings. The CCRT with the therapist parallels the CCRT for others in the patient's life (Fried, Crits-Christoph, & Luborsky, 1990) and even the CCRT derived from patients' dreams (Popp, Luborsky, & Crits-Christoph, 1990). The extent of these observed congruencies indicates that these patterns of representations of relationships are stable structures of the personality. It is an important validation of Luborsky's ap-

proach that the frequency of conflict themes negatively correlated with measures of change (Crits-Christoph & Luborsky, 1990). The second component of Luborsky's approach is the helping alliance. In addition to attending to current, past, and transference relationship fears, therapists are required, through their timing and restraint in responding interpretively to clients' material, to convey respect, acceptance, realistic optimism, to encourage self-expression and thus create a collaborative atmosphere (Luborsky, 1984, pp. 81±89). The helping alliance thus generated has two dimensions according to Luborsky: the patient perceives the therapist as a provider of help that is needed, and the patient perceives the therapy as a collaborative exercise (Luborsky, Crits-Christoph, Mintz, & Auerbach, 1988). Helping alliance has been shown to be positively associated with outcome. The duality of Luborsky's approach (CCRT and helping alliance) is supported by critical findings that the quality of the helping alliance and therapist accuracy (as defined in terms of the degree of correspondence with the CCRT) independently predict outcome (Crits-Christoph, Barber, & Kurcias, 1993; Crits-Christoph, Cooper, & Luborsky, 1988). In the more recent study, there was an indication that accuracy of early intervention had a positive impact later on in therapy. Thus it is possible that whilst the quality of the helping alliance may be the immediate cause of change, this aspect of the relationship may be enhanced by accurate formulations by the therapist. Although no randomized controlled trials compare Luborsky's supportive-expressive therapy with no treatment controls for milder neurotic disorders, the Penn project yielded numerous important findings concerning the outcome of this treatment. Most impressively, three-quarters of the large group of patients treated showed moderate or much improvement with an average effect size of over one standard deviation, and much of this gain was maintained at one-year follow-up (Luborsky et al., 1988). In addition, in a major study comparing supportive-expressive therapy, cognitive therapy, and drug counseling for opiate-dependent patients, Woody and his colleagues (Woody, Luborsky, McLellan, & O'Brien, 1990; Woody et al., 1983; Woody, McLellan, Luborsky, & O'Brien, 1987) found supportive-expressive therapy to be effective in reducing psychiatric symptoms, opiate-positive urine specimens, employment, and legal problems. In a replication study the same group demonstrated that supportive-expressive therapy was a useful adjunct to drug counseling as part of a typical community-based drug program (Woody,

Forms of Brief Psychodynamic Therapy McLellan, Luborsky, & O'Brien, 1995). It is notable that supportive-expressive therapy was particularly helpful in maintaining improvement at follow-up. Although studies on depressed or anxious individuals would be helpful, it is clear that supportive-expressive therapy is a valuable intervention strategy. 6.05.4.3.5 Strupp's time-limited dynamic therapy (TLDP) The hallmark of Strupp's model of therapy lies in its interpersonal emphasis and the persistent use of the transference relationship in the here and now. The therapy has its intellectual roots in Sullivan's (1953) interpersonal psychoanalytic tradition. Binder and Strupp (1991) understand psychopathology as arising out of cycling maladaptive patterns whereby patients perceive themselves in maladaptive roles with self-defeating expectations, negative self-appraisals and adverse affects consequent on these. The cyclical nature of the process arises out of the client's unconscious tendency to induce others to behave in ways that reinforce the patient's negative and painful expectations, thus further reinforcing these expectations and the interpersonal behaviors which arise from these. This formulation is close to that proposed by Joseph Sandler in the 1970s and early 1980s (Sandler, 1976b, 1990, 1992). Similarly to Luborsky, Binder and Strupp (1991) distinguish actions of the self, expectations about others' actions, acts of others towards the self, and acts of the self towards the self. Although these terms sound somewhat behavioral, from their description it is clear that the authors are concerned with mental representation of these interpersonal behaviors rather than the behaviors themselves. The cyclical maladaptive patterns are identified by the therapist on the basis of the client's characteristic patterns of relating which involve the patient's perception of self, others, and their interactions. In therapy, maladaptive patterns are identified, their meaning interpreted and the client is helped to articulate and modify entrenched and limiting views of the self, others, and their interaction. TLDP creates individualized theories for each client, making use of these four headings. The theories connect together behavioral and experiential phenomena which otherwise would appear discontinuous (Strupp & Binder, 1984). The patient's relationship with the therapist is seen as a key component of the change process. This new relationship may disconfirm maladaptive expectations of others and provides a chance to examine the way that patients' acts towards the self may ensnare them in mala-

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daptive patterns (Binder & Strupp, 1991, p. 142). The Vanderbilt University Project, of which Strupp's TLDP is a product, was key in identifying the therapeutic relationship and the nature of the patient's experience with this new figure as a key aspect of therapeutic change. An important finding of the project was that successful treatments could be predicted on the basis of the patient feeling accepted, understood, and liked by the therapist as early as the third session of treatment (Hartley & Strupp, 1983; O'Malley, Suh, & Strupp, 1983; Windholz & Silberschatz, 1988). The importance of the relationship is further underscored by the absence of an observed significant difference between trained psychotherapists and sensitive but untrained college professors in their ability to administer time-limited dynamic therapy (Strupp & Hadley, 1979). 6.05.4.3.6 Weiss and Sampson's plan formulation method Weiss and Sampson (1986) proposed a further useful framework for the articulation of clinical focus. At the core of the theory is the assumption that patients enter therapy with an unconscious plan about how they may overcome their problems with therapeutic help. Pathogenic beliefs are ªobstaclesº to this. Weiss and Sampson assume that patients will inevitably ªtest,º in the context of their therapy, whether their pathogenic beliefs are true. If the therapist ªpassesº the test, the patient's experience will contribute to the enlargement of understanding (ªinsightº) to counteract the pathogenic belief. An example of a pathogenic belief may be an individual with a mother unhappily married throughout the patient's childhood, unconsciously believing that her happiness means that her mother will feel hurt and abandoned. The patient might then test the therapist to see if the therapist also expects the patient to be self-sacrificing and feigns hurt if the patient attends ªselfishlyº to her own needs. Such an unconscious belief arises out of actual historical experience, rather than an unconscious wish to harm the mother (Sampson, 1992, p. 515). It follows that the principal therapeutic task of short-term dynamic psychotherapy is that the therapist should recognize the patients' conscious or unconscious attempts to replicate with the therapist their pathogenic situations or past life experiences. Therapists may be deemed to pass the patient's test by giving recognition of the situation through appropriate interpretation or nonverbal behavior, such as maintaining their therapeutic stance despite the patient's determination to traumatize and unsettle them.

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Thus the nonoccurrence of certain strongly anticipated outcomes may in and of itself be therapeutic. Research, building on this approach, has demonstrated that plan formulation may be reliably assessed using recorded clinical material (Curtis, Silberschatz, Sampson, & Weiss, 1994; Curtis, Silberschatz, Sampson, Weiss, & Rosenberg, 1988; Silberschatz & Curtis, 1993) and that such plans are stable over time (Collins & Messer, 1991). The compatibility of the therapist's interventions with independently assessed plans of the patient was found to predict progress in the early and middle phase of therapy (Messer, Tishby, & Spillman, 1992). One of the strengths of Weiss and Sampson's approach is that it may be assumed to apply to patient's behavior, regardless of the orientation of the therapist. Indeed, the Plan Compatibility of Interventions Scale predicts response to therapist intervention in cognitive-dynamic, as well as object-relations theory-based approaches (Tishby & Messer, 1995). It should be noted that in these studies outcome refers to relative improvements within the therapeutic process rather than overall improvements at the end of therapy. In fact, no large-scale study of Weiss and Sampson's method has as yet been undertaken. 6.05.4.3.7 Horowitz's person schema theory Horowitz (1988a, 1988b, 1991a) has offered a general systems theory reformulation of object relations constructs strongly influenced by Bowlby's (1973, 1980) notion of internal working models, Sandler's (1976a, 1976b) notion of role responsiveness, and Kernberg's (1975, 1984) model of self±object dyadic units, as well as current cognitive science. He proposes that through development the individual evolves multiple schemas of self and other which exist either as person schemas or as role-relationship models (RRMs). He defined the former as nonexperiential (codifications and) meaning structures with the potential to influence the formation of the self-concept. They are seen as combining in more complex schemata of the self-in-relationship-with-the-other (see also Stern, 1994). The self-schemas integrate the individual's prior experiences and, ideally, present a stable image of the self as invulnerable. These RRMs are templates of relationships which can affect the formation of the concept of relationships as well as actual patterns of interpersonal transactions. RRMs are assumed to specify interaction patterns as sequences, much like scripts of plays, but in terms of expectations, wishes, and appraisals of one person toward the other.

RRMs are organized into affectively coherent configurations (RRMCs) each of which are made up of RRMs with a set of wishes, fears, and defenses in relation to a specific theme. Desired RRMCs contain strong wishes, and dreaded RRMCs are made up of feared RRMs. The derivatives of defensive operations are compromise RRMs which can be either adaptive (if successful) or problematic (if not), but in either case the affective valence of the RRM has been attenuated. A problematic RRMC will contain either negative affects or maladaptive traits, at a more manageable level than in dreaded RRMs. If the enactment of a desired RRM is blocked by the threat of entry of a dreaded RRM, an attenuated solution to the desired RRM is found which provides a partial gratification of the wish. An RRMC may represent a firm linkage between RRMs so that a mental state organized by a desired RRM can trigger a mental state organized by a dreaded RRM. Such mental states may be represented by patterns of activation, such as those envisaged in parallel distributed computer models of neural activity. Horowitz (Horowitz, 1991a; Horowitz, Fridhandler, & Stinson, 1991) views anxiety as a mismatch between schemas and incoming information. If information is interpreted as suggesting a dreaded schema, anxiety will result. If a wished-for RRM is to be in relation with a powerful guiding figure but this brings with it a dreaded RRM of a state of exploitation, the individual will experience anxiety at the moment of being approached by an actually benign but powerful figure because this person's presence brings with it the threat of exploitation. This may put control processes in place which will reduce the distance of this figure. The anticipation of the dreaded RRM is experienced as anxiety without the dreaded RRM ever being fully activated (i.e., coming into awareness). The control processes can, in the extreme, become severe enough to imply personality disorder, in this case perhaps a somewhat schizoid state. In certain cases the dreaded RRM may be partly experienced and this is also expected to lead to anxiety. A woman who lost her husband, whom she felt was dependable but whom she did not love, may develop anxiety when she starts a relationship with another man for whom she has more intense feelings. The dreaded RRM which is briefly activated is the experience of seeing herself as the unfaithful wife humiliating her dependable but unexciting husband (see Horowitz, 1991a). In post-traumatic stress disorder an experience is vividly encoded in memory. Because it is not integrated into the individual's prior integrated self-schema, it is liable to be activated

Forms of Brief Psychodynamic Therapy as incoming information, and misinterpreted to imply the reoccurrence of the trauma. The trauma may also threaten to actualize a dreaded RRM, for example, of the self as weak and overwhelmed. The compromise state may be denial, depersonalization, restricted affect, and hypervigilance (see Horowitz, 1986, 1988a). In generalized anxiety disorder the dreaded RRM is seen as inescapable, either because a compromise cannot be reached or because the desired RRM contains some dreaded components (e.g., RRM of the self as blundering and stupid in face of punishing mentors in a situation which is experienced as one of constant evaluation). Horowitz's model is most extensively elaborated for the 12-session treatment of post-traumatic stress disorder (Horowitz, 1986, 1991b). The therapy is aimed at the realignment of RRMs. In the ªintrusive repetitive phase of the stress responseº the recommended strategy is largely supportive and ameliorative. The therapist takes on the auxiliary ego function of self-regulation and the reduction of overwhelming affect states. In the ªdenial numbing phaseº of the stress response, Horowitz emphasizes the reduction of controls over self-expression and emotional exploration. The stress event remains the therapeutic focus, serving to organize the therapist's activities in relation to the transference and other feared topics. Time limit and termination are also explicitly identified as themes to be addressed from as early as session six. Horowitz's model stands out among psychodynamic formulations for brief therapy in offering a comprehensive framework specific for a range of psychiatric disorders at the same time as remaining amenable to empirical examination. Clinical judges appear to be able reliably to assess roles, characteristics, and traits of self and others, link them in wish-fear dilemmas, and assemble them into presumed RRMCs of particular patients observed in psychotherapy sessions (Horowitz, Milbrath, Reidbord, & Stinson, 1993; Horowitz, 1995; Horowitz & Eells, 1993). There appears to be considerable convergence between RRMC formulations and Luborsky's core conflictual relationship theme approach (Horowitz, Luborsky, & Popp, 1991). Unfortunately, randomly controlled outcome studies on Horowitz's therapeutic strategies are lacking. 6.05.4.3.8 Mann's time-limited psychodynamic therapy (TLPT) Of the brief psychodynamic therapies it is perhaps Mann's approach that takes the timelimited nature of the intervention most ser-

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iously. He believes that the time limitations inevitably brings into the foreground the difficulty most of us experience with separation (Mann, 1973). Time-limited psychotherapy is focused on the patient overcoming separation± individuation issues through the mastery of separation anxiety. The conflicts encountered in this context concern independence, activity, self-esteem, and delayed grief. Mann suggests that the beginning of therapy recreates a symbiotic unity, the middle phase recreates ambivalence, whilst the end phase introduces the necessity to give up the object, but this time without hatred, anger, despair, or guilt. Mann's formulation focuses on clients' feelings about themselves in relation to the painful events described. He acknowledges the patients' active coping efforts and their experience of failure with regard to being able to adapt adequately to this distress. Patients' symptoms are not directly addressed but rather the underlying emotional state, particularly their injured self-esteem, is highlighted. In contrast to Sifneos and Davanloo, Mann is not at all confrontative and uses confirming and mirroring to bypass defenses rather than tackling them head on (Mann & Goldman, 1982). The therapy lasts 12 sessions excluding sessions for history taking. The initial phase of four sessions sets up an alliance generating hope and frequently a remission of symptoms. In the middle phase ambivalence sets in as patients come to recognize that their unconscious expectations will not be fulfilled. In this phase the therapist is no longer simply mirroring and affirming but is introducing clarifications, mild confrontations, and interpretations especially regarding the current situation of the person's life and thus directly reinforcing the patient's separateness. In the final four sessions the patient's reactions to termination are the focus. The therapist attempts to build a sense of mastery and competence at the same time as addressing the patient's disappointment and ambivalence concerning separation, often linked to past experiences of inadequate resolutions of separation and loss. In this therapy the time-limited nature of the intervention is used directly to elicit a set of conflicts associated with earlier separations and losses where maladaptive emotions were generated (anger, disappointment, sadness, guilt) which ultimately resulted in the disorder which led to the referral. The therapy creates a situation where separation can occur with a degree of resolution which is less contaminated by negative emotions. The internalizations thus lead to a less angry, more benign introject. Although Mann's therapy is well-established, it has not yet generated a great deal of research.

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A notable exception is a study reported by Shefler and colleagues (Shefler, Dasberg, & Ben-Shakhar, 1995). This was a randomized controlled trial with a waiting list control design. Only nine out of the 33 patients did not have a DSM diagnosis. The effect size was only fractionally below one on a range of measures. However, the patients accepted for the trial were highly selected and only 11% of those seen were included in the trial. In an uncontrolled trial, Joyce and Piper (1990) found that 14 patients diagnosed with separationindividuation problems were highly successfully treated in 12 sessions using Mann's technique and the results were maintained at six-months follow-up. There is further evidence that TLPT reduces drop-out rate (Sledge, Moras, Hartley, & Levine, 1990), and patients who do well show a trend towards increasingly appreciating their sessions as the treatment progresses (Joyce & Piper, 1990). Mann's approach has been criticized for attempting to provide a generic model on the basis of a specific model of pathogenesis (Grand, Rechetnick, Podrug, & Schwager, 1985; Westen, 1986). Some fundamentally disagree that termination is an inevitable crisis in therapy (Quintana, 1993). It is also unlikely that Mann's model of cure is accurate. A process such as internalization is more likely in longterm than in short-term therapy (Westen, 1986). However, although the treatment is only appropriate for a relatively limited group of patients, its very specificity may be its strongest feature. If a method was found to identify this group using reliable operational criteria which also matched concerns of purchasers of mental health care (e.g., generalized anxiety disorder), this form of therapy could be a valuable component of the repertoire of psychodynamic approaches. 6.05.4.3.9 Ryle's cognitive analytic therapy (CAT) Relatively unknown in the USA, but increasingly influential in the UK, is CAT, a timelimited integrative psychotherapy (Ryle, 1982, 1990). The procedural sequence model (PSM) is the framework used by Ryle to restate psychoanalytic ideas using cognitive language. The model conceptualizes intentional acts as procedures entailing a series of steps including appraisal of plans and predicted consequences, the evaluation of the consequences of the enactment, and the confirmation or revision of aims and means following this evaluation. The therapeutic method is centered on the process of reformulation. Over the course of the first month of the treatment, patients normally

engage in monitoring their symptoms, undesirable behaviors, and mood shifts. Neurotic patterns are described in terms of three categories: dilemmas, traps, and snags. Dilemmas, traps, and snags are described in the ªpsychotherapy fileº which is given to patients at the end of the first session. They rate items within it to indicate how characteristic they are of them. These ratings are discussed at subsequent sessions when main target problems (TPs) are also established, on the basis of the self-monitoring, together with the underlying dilemmas, traps, and snags. Traps are things we cannot escape from, such as ªa fear of hurting othersº trap, ªtrying to pleaseº trap, or ªsocial isolationº trap. Dilemmas are false choices about oneself or about one's relation to others, for example, ªeither I feel I spoil myself and am greedy or I deny myself things and punish myself and feel miserableº or ªeither I am a brute or a martyr.º Snags are ways we stop ourselves from changing, for example, ªfor fear of the response of others.º The dilemmas, traps, and snags characteristic of an individual are the target problem procedures (TPPs) which are thought to underlie that person's central problems. ªTPsº and ªTPPsº form the agenda of the therapy. The remaining sessions (usually once a week over three months) are devoted to recognition of the TPPs using diaries and other self-monitoring devices as well as close monitoring of the client's behavior in the therapeutic situation. Modification of TPPs is principally achieved through behavioral techniques such as role play, as well as enhanced self-reflection. The explicit noncollusive relationship with the therapist is also thought to facilitate the development of new procedures. Ryle (1985) incorporated object-relations theory into CAT introducing the notion of reciprocal role procedures. These are thought to develop on the basis of early object relationships. It is assumed that a relationship teaches children both the behaviors expected of them and the behaviors they expect of others. Selfmanagement is learned through incorporating into the child's behavioral repertoire the caretaker's behaviors. The emphasis in CAT is on early and profound deprivation as the cause of primitive defenses such as splitting, which characterizes individuals who fail to integrate their selfstructure and elicit confirmations from others for each of their split-off self states. Whereas neurotic clients restrict or distort their procedures, borderline personality disorder patients manifest dissociated self-states containing different procedures in each. Therapists summarize their assessments and present it to the client in writing after the fourth

Forms of Brief Psychodynamic Therapy session. These summaries represent client history and present circumstances and trace how current problematic procedures could be repetitions of early harmful patterns or are solutions to early situations. The accounts conclude with a list of problem procedures identified and attempt to anticipate how these may influence the course of therapy. A further tool used in CAT is the sequential diagramatic reformulation (SDR) which is a flow diagram representation of how TPPs maintain neurotic patterns. Thus CAT is a genuine integration of cognitive therapy (Beck, 1976) and objectrelations theory-oriented psychodynamic therapy (Ogden, 1986). The approach to psychodynamic diagnosis is similar to many considered above, particularly Luborsky and Horowitz. The therapeutic techniques suggested are innovative and share much with schema-oriented cognitive therapy where emotional problems are seen as the reactivation of schemas which have been dormant for many years (Beck & Freeman, 1990; Bricker & Young, 1993; Young, 1990). Ryle's integration also has much in common with other integrative models such as Gold and Wachtel's ªcyclical psychodynamics,º which also emphasizes self-maintaining vicious cycles and intra- and inter-psychological processes and structured intervention techniques (Gold & Wachtel, 1993). Safran (1990a, 1990b) also links concepts of interpersonal schema and the cognitive interpersonal cycle, and the therapy program outlined has as its target the disconfirmation of dysfunctional interpersonal schemas. CAT, however, is far more coherently integrated with the traditional psychodynamic formulations than any of these alternatives (e.g., 1992; Leiman, 1994b; Ryle, 1994). The procedural sequence object relations model (PSORM) illustrates the thoughtfulness of this integration. The PSORM identifies procedural patterns which explain the persistence of neurotic behavior. For example, selfdestructive acts may be attributed to a dilemma (ªas if I must harm myself or harm othersº) or to a snag (ªas if guilty and therefore self-punishingº). Within SDR the self-maintaining nature could be clearly demonstrated through the connection between procedures. For example, the expectation of abandonment may generate a dilemma between being involved and thus risking abandonment and avoiding closeness. Being involved thus necessitates procedures for controlling emotionally significant others by compensatory procedures such as bulimia, that are seen as a substitute for emotional emptiness. The PSORM postulates reciprocal role patterns which constitute a central core and are stated in terms of inner parent±inner child (IP±IC)

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relations. An example may be a powerfully rejecting inner parent relating to a submissive and needy inner child. The reciprocal nature of the role patterns encompass psychodynamic concepts such as identification, introjection, and projection, internal objects and partobjects. Roles which are experienced as untenable are projected, that is induced in the other, and can be replaced by symptomatic procedures or defensive ones. Procedures acquire their stability from confirming reciprocations which are generally readily elicited from others, thus leaving the central core repertoire unchanged. While Ryle and others writing from a CAT perspective are keen to acknowledge Soviet theoreticians such as Vygotsky, Bakhtin, and Leonjew (e.g., Leiman, 1994a), their views are consistent with psychoanalysts writing in the interpersonalists' tradition (e.g., Mitchell, 1988). The key difference between CAT and traditional psychodynamic therapy is the shift from interpretive work to description. The CAT therapist describes the state of affairs, often in writing, which is then subject to discussion and modification in direct therapeutic conversations. Ryle repudiates interpretive techniques as potentially regression-inducing, reflecting an unbalanced power relationship between client and therapist and feeding on the omnipotent fantasies of the therapist (Ryle, 1992, 1993). Ryle's approach lends more weight to conscious processes and his technique is based on insight coupled with the activation of self-corrective mechanisms. It is striking that, notwithstanding the emphasis on such mature mental processes, Ryle and his colleagues have reported significant successes in the brief psychotherapeutic treatment of borderline personality disorder. In an ongoing study, BPD patients are offered up to 24 sessions of CAT and follow-up sessions at one, two, three and six months. There is a threemonth and one-year follow-up. Initial results are promising (Ryle, 1995). Eight out of 13 patients no longer meet BPD criteria four months after termination but seven were rereferred for a variety of other treatments. Five patients assessed at one year all showed continuing reductions in symptomatology and only one has remained in treatment. A number of other outcome studies support the usefulness of CAT. A study of 48 outpatients randomly assigned to 12 sessions of CAT or Mann-type brief therapy demonstrated the superiority of CAT on a grid measure of change of construing problems (Brockman, Poynton, Ryle, & Watson, 1987). Unfortunately the measure was neither standardized nor sufficiently independent from the treatment to justify firm conclusions. A study of poorly

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controlled diabetics randomized 32 patients to intensive education or CAT (Fosbury, 1994). At nine-months follow-up CAT-treated patients had better diabetic control in terms of HbAlc levels. Other studies were either uncontrolled clinical reports (e.g., Cowmeadow, 1994; Duignan & Mitzman, 1994; Pollock & KearColwell, 1994) or yielded insignificant differences between CAT and control treatments (e.g., the outpatient treatment of anorexia; Ryle, 1995). Thus the empirical basis of CAT cannot yet be considered well-established (although relative to many other psychodynamic treatments its empirical status is highly favorable). 6.05.4.3.10 Hobson's conversational model An approach which integrates many of the characteristics of the brief psychodynamic approaches considered above is the conversational model outlined by Hobson and his colleagues (Goldberg et al., 1984; Hobson, 1985). The approach combines psychodynamic, interpersonal, and experiential concepts, and emphasizes the therapist±client relationship as the main vehicle for revealing and resolving interpersonal difficulties. In contrast to a number of other short-term therapies, therapists are encouraged to present their views as tentative statements rather than assertions and to make clear that these are open to correction and modification. The therapy is conceived of as an interpersonal negotiation, with therapists inviting elaboration of their ideas by the patient, as well as feedback. The language of the treatment is one of mutuality, with the therapist putting forward hypotheses concerning the client's experiences and possible relationships between these. The therapy has been manualized as part of the Sheffield Psychotherapy Project under the direction of David Shapiro (Shapiro & Firth, 1985). A unique outcome study by Shapiro and colleagues (Shapiro et al., 1994) assessed the effectiveness of this mode of intervention, contrasting it with cognitive-behavioral therapy in a sample of 117 patients. Both therapies were administered for either eight or 16 weeks. Overall, both therapies were found to be effective and to have comparable results. There was an interaction between initial symptom level and duration of therapy. Patients with severe depression showed significantly better outcomes when they received 16 weeks of therapy. Eighty-eight percent of the sample were followed up one year after the end of treatment (Shapiro et al., 1995). Of the 103 patients, 52% were defined as treatment responders (remained asymptomatic for four months). Of these, 57% maintained their gains,

32% partially maintained their gains, and 11% relapsed. No differences were found between cognitive-behavioral and psychodynamic therapy, although patients who only received eight sessions of psychodynamic therapy did less well than those who received eight or 16 sessions of CBT. While this particular form of therapy is neither widely known nor widely practiced, it is unique in terms of having been subjected to a rigorous randomized, controlled trial. As the methods used in Hobson's conversational model are fairly generic and consistent with most psychodynamic approaches, the Sheffield psychotherapy trial provides encouraging evidence for the value of brief psychodynamic approaches for the treatment of one of the most common disorders, major depression.

6.05.5 CONCLUSIONS This chapter has reviewed psychodynamic approaches to adult mental health problems. Psychodynamic therapy is most appropriate for individuals with psychiatric disorder who are relatively well-functioning and have a capacity to understand and respond to interpretive work. The chapter reviewed key clinical concepts in psychodynamic work and demonstrated an increasing concern among psychodynamic clinicians with feelings and ideas provoked by the therapeutic situation itself. Long-term psychodynamic therapy was illustrated in the review of therapeutic strategies with individuals with a borderline personality disorder diagnosis. Several forms of brief psychodynamic therapy were discussed, together with evidence for their effectiveness. No single approach to such brief treatments emerged as clearly superior to others. While there is a surprising amount of empirical work which has been performed over recent years, few of the studies appear to be conclusive. But, taken together, they underscore the merits of the psychodynamic approach. There is good evidence that psychodynamic therapy is effective with depressed, substance abusing, and some mixed groups of neurotic patients. There are indications of its appropriateness for individuals with PTSD, physical illnesses such as diabetes, and even BPD. Clearly much empirical work remains to be done to identify which of these treatments has the greatest potential value for which patient group. Work over the last few decades, however, goes a considerable way towards overcoming many of the weaknesses frequently noted in connection with this approach. A number of psychodynamic clinicians have done extensive

References work on operationalizing their interventions, specifying modifications to generic approaches to make them more appropriate with particular clinical groups, to provide information concerning the way theories of pathology may relate to aspects of technique, to focus and shorten interventions in order to enhance their cost-effectiveness, to provide empirical evidence concerning suitability, and develop specific measures of therapeutic outcome to relate the goals of interventions to the outcomes observed. Psychodynamic approaches have been around for over 100 years. Considering the mature nature of this category of clinical interventions, the amount of empirical work available in the literature is lamentably small. The underlying trend is for an improvement in this state of affairs. The integration of cognitive and psychodynamic approaches has certainly facilitated this process. Changes to the systems of health care delivery certainly represent a threat to psychodynamic approaches. However, the priority for psychodynamic researchers must be clearly to establish which clinical context is uniquely suited to this approach. There is no doubt that, in the past, psychodynamic clinicians have made exaggerated claims concerning the value of this mode of therapy. The first decade of the twenty-first century should be a period of readjustment where empirical work could establish the true value of psychodynamic therapy in specific clinical contexts. Purchasers and users of these services have been undoubtedly patient in waiting for such data. Their faith in this approach has probably been fueled by the exceptional intellectual contributions made by many of those who have occupied leadership positions in the psychodynamic field as well as the value of psychodynamic theoretical contributions. Equally there is no doubt that their patience is wearing thin and that compelling empirical data of efficacy is urgently required if this form of therapy is to retain a legitimate place in handbooks such as the present one. 6.05.6 REFERENCES Abend, S. M. (1989). Countertransference and and psychoanalytic technique. Psychoanalytic Quarterly, 58, 374±395. Adler, G. (1985). Borderline psychopathology and its treatment. New York: Aronson. Arlow, J. A. (1993). Discussion of Baranger's paper on ªThe mind of the analyst: From listening to interpretation.º International Journal of Psycho-Analysis, 74, 11471154. Aronson, T. (1989). A critical review of psychotherapeutic treatments of the borderline personality: Historical trends and future directions. Journal of Nervous and Mental Disease, 177, 511±528. Balint, M. (1949). On the termination of analysis. Interna-

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Consulting and Clinical Psychology, 62, 522±534. Shapiro, D. A., & Firth, J. A. (1985). Exploratory therapy manual for the Sheffield Psychotherapy Project (SAPU Memo 733). Sheffield, UK: University of Sheffield. Shefler, G., Dasberg, H., & Ben-Shakhar, G. (1995). A randomized controlled outcome and follow-up study of Mann's time-limited psychotherapy. Journal of Consulting and Clinical Psychology, 63, 585±593. Sifneos, P. E. (1979). Short-term dynamic psychotherapy: Evaluation and technique. New York: Plenum. Sifneos, P. E. (1987). Short-term dynamic psychotherapy: Evaluation and technique (2nd ed.). New York: Plenum. Sifneos, P. E. (1992). Short-term anxiety-provoking psychotherapy. New York: Basic Books. Sifneos, P. E., Apfel, R. J., Bassuk, E., Fishman, G., & Gill, A. (1980). Ongoing outcome research on short-term dynamic psychotherapy. Psychotherapy and Psychosomatics, 33, 233±241. Silberschatz, G., & Curtis, J. T. (1993). Measuring the therapist's impact on the patient's therapeutic progress. Journal of Consulting and Clinical Psychology, 61, 403±411. Silberschatz, G., Fretter, P. B., & Curtis, J. T. (1986). How do interpretations influence the process of psychotherapy. Journal of Consulting and Clinical Psychology, 54, 646±652. Sinason, V. (1992). Mental handicap and the human condition. London: Free Association Books. Sledge, W. H., Moras, K., Hartley, D., & Levine, M. (1990). Effect of time-limited psychotherapy on patient dropout rates. American Journal of Psychiatry, 147, 1341±1347. Spence, D. P. (1982). Narrative truth and historical truth. Meaning and interpretation in psychoanalysis. New York: Norton. Spillius, E. B. (1994). Developments in Kleinian thought: Overview and personal view. Psychoanalytic Inquiry, 14, 324±364. Steiner, J. (1982). Perverse relationships between parts of the self: A clinical illustration. International Journal of Psycho-Analysis, 63, 241±251. Steiner, J. (1993). Psychic retreats: Pathological organisations in psychotic, neurotic and borderline patients. London: Routledge. Stern, D. J. (1994). One way to build a clinically relevant baby. Infant Mental Health Journal, 15, 36±54. Stevenson, J., & Meares, R. (1992). An outcome study of psychotherapy for patients with borderline personality disorder. American Journal of Psychiatry, 149, 358±362. Stewart, H. (1989). Technique at the basic fault: Regression. International Journal of Psycho-Analysis, 70, 221±230. Stone, M. (1993). Long-term outcome in personality disorders. British Journal of Psychiatry, 162, 299±313. Strachey, J. (1934). The nature of the therapeutic action of psychoanalysis. International Journal of Psycho-Analysis, 50, 275±292. Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time-limited dynamic psychotherapy. New York: Basic Books. Strupp, H. H., & Hadley, S. W. (1979). Specific versus nonspecific factors in psychotherapy. Archives of General Psychiatry, 36, 1125±1136. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton. Svartberg, M., & Stiles, T. C. (1992). Predicting patient change from therapist competence and patient±therapist complementarity in short-term anxiety-provoking psychotherapy: A pilot study. Journal of Consulting and Clinical Psychology, 60, 304±307. Svartberg, M., & Stiles, T. C. (1994). Therapeutic alliance, therapist competence, and client change in short-term anxiety-provoking psychotherapy. Psychotherapy Research, 4, 20±33.

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Symington, N. (1983). The analyst's act of freedom as agent of therapeutic change. International Review of Psycho-Analysis, 10, 783±792. Taube, C. A., Kessler, L., & Feuerberg, M. (1984). Utilization and expenditures for ambulatory mental health care during 1980 (Data Report 5). Washington, DC: US Department of Health and Human Services. ThomaÈ, H., & KaÈchele, H. (1987). Psychoanalytic practice. I: Principles. New York: Springer-Verlag. Tishby, O., & Messer, S. B. (1995). The relationship between plan compatibility of therapist interventions and patient progress: A comparison of two plan formulations. Psychotherapy Research, 5, 76±88. Tyson, A., & Sandler, J. (1971). Problems in the selection of patients for psychoanalysis: comments on the application of concepts of ªindicationsº, ªsuitabilityº, and ªanalyzabilityº. British Journal of Medical Psychology, 44, 211±228. Vaillant, G. E. (1992). Ego mechanisms of defense: A guide for clinicians and researchers. Washington, DC: American Psychiatric Press. Wachtel, P. (1977). Psychoanalysis and behaviour therapy: Toward an integration. New York: Basic Books. Waldinger, R. J. (1987). Intensive psychodynamic therapy with borderline patients: An overview. American Journal of Psychiatry, 144, 267±274. Wallerstein, R. S. (Ed.) (1992). The common ground of psychoanalysis. Northvale, NJ: Aronson. Wallerstein, R. S. (1986). Forty-two lives in treatment: A study of psychoanalysis and psychotherapy. New York: Guilford. Weiss, J., & Sampson, H. (1986). The psychoanalytic process: Theory, clinical observations and empirical research. New York: Guilford. Westen, D. (1986). What changes in short-term psychodynamic psychotherapy. Psychotherapy, 23, 501±512. Wiborg, I. M., & Dahl, A. A. (1996). Does brief dynamic psychotherapy reduce the relapse rate of panic disorder? Archives of General Psychiatry, 53, 689±694. Windholz, M. J., & Silberschatz, G. (1988). Vanderbilt

Psychotherapy Process Scale: A replication with adult outpatients. Journal of Consulting and Clinical Psychology, 56, 56±60. Winnicott, D. W. (1949). Hate in the countertransference. International Journal of Psycho-Analysis, 30, 69±75. Winnicott, D. W. (1965). The maturational process and the facilitating environment. London: Hogarth. Winnicott, D. W. (1971). Playing and reality. London: Tavistock. Winston, A., Laikin, M., Pollack, J., Samstag, L. W., McCullough, L., & Muran, J. C. (1994). Short-term dynamic psychotherapy of personality disorders. American Journal of Psychiatry, 15, 190±194. Winston, A., Pollack, J., McCullough, L., Flegenheimer, W., Kestenbaum, R., & Trujillo, M. (1991). Brief psychotherapy of personality disorders. Journal of Nervous and Mental Disease, 179, 188±193. Woody, G. E., Luborsky, L., McLellan, A. T., & O'Brien, C. P. (1990). Corrections and revised analyses for psychotherapy in methadone maintenance programs. Archives of General Psychiatry, 47, 788±789. Woody, G. E., Luborsky, L., McLellan, A. T., O'Brien, C. P., Beck, A. T., Blaine, J., Herman, I., & Hole, A. (1983). Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry, 40, 639±645. Woody, G. E., McLellan, A. T., Luborsky, L., & O'Brien, C. P. (1987). Twelve-month follow-up of psychotherapy for opiate dependence. American Journal of Psychiatry, 144, 591±596. Woody, G. E., McLellan, A. T., Luborsky, L., & O'Brien, C. P. (1995). Psychotherapy in community methadone programs: A validation study. American Journal of Psychiatry, 192, 1302±1308. Young, J. E. (1990). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, FL: Professional Resource Exchange. Zilboorg, G. (1952). The emotional problem and the therapeutic role of insight. Psychoanalytic Quarterly, 21, 1±24.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.06 Psychopharmacology PHILIP J. COWEN University of Oxford, Warneford Hospital, UK 6.06.1 INTRODUCTION 6.06.1.1 6.06.1.2 6.06.1.3 6.06.1.4

136 136 137 138 138

History of Drug Treatment in Psychiatry Mode of Action of Psychotropic Drugs Pharmacokinetics of Psychotropic Drugs Prescribing Psychotropic Drugs

6.06.2 CLASSIFICATION OF DRUGS USED IN PSYCHIATRY

139

6.06.3 ANXIOLYTIC DRUGS

139 139 139 139 140 140 141 141 141 141

6.06.3.1 Benzodiazepines 6.06.3.1.1 Pharmacology 6.06.3.1.2 Compounds available 6.06.3.1.3 Adverse effects 6.06.3.2 Azapirones 6.06.3.3 Other Drugs Used to Treat Anxiety 6.06.3.3.1 Antidepressant drugs 6.06.3.3.2 Antipsychotic drugs 6.06.3.3.3 b-Adrenoceptor antagonists 6.06.4 HYPNOTIC DRUGS

141

6.06.4.1 Compounds Available

141

6.06.5 ANTIPSYCHOTIC DRUGS

141 142 142 142 142 143 143 143 144 144 144 145

6.06.5.1 Pharmacology 6.06.5.2 Compounds Available 6.06.5.2.1 Typical antipsychotics 6.06.5.2.2 Atypical antipsychotic drugs 6.06.5.3 Adverse Effects 6.06.5.3.1 Movement disorders 6.06.5.3.2 Autonomic and endocrine effects 6.06.5.3.3 Neuroleptic malignant syndrome 6.06.5.3.4 Other adverse effects 6.06.5.3.5 Adverse effects of clozapine 6.06.5.4 Dosage of Antipsychotic Drugs 6.06.6 ANTI-PARKINSONIAN DRUGS

145 145 145

6.06.6.1 Preparations Available 6.06.6.2 Adverse Effects 6.06.7 ANTIDEPRESSANTS

145

6.06.7.1 Mechanism of Action 6.06.7.2 Tricyclic Antidepressants 6.06.7.2.1 Pharmacological properties 6.06.7.2.2 Adverse effects of tricyclic antidepressants 6.06.7.2.3 Amoxapine 6.06.7.2.4 Clomipramine 6.06.7.2.5 Lofepramine 6.06.7.2.6 Maprotiline 6.06.7.3 Selective Serotonin Reuptake Inhibitors

135

146 146 146 146 147 147 147 148 148

136

Psychopharmacology 148 148 148 149 149 149 149 149 149 150 150 150 151 151 151 151 152 152

6.06.7.3.1 Pharmacological properties 6.06.7.3.2 Efficacy in depression 6.06.7.3.3 Unwanted effects of SSRIs 6.06.7.4 Monoamine Oxidase Inhibitors 6.06.7.4.1 Pharmacology 6.06.7.4.2 Compounds available 6.06.7.4.3 Efficacy of MAOIs in depression 6.06.7.4.4 Unwanted effects 6.06.7.4.5 Interactions with foodstuffs and drugs 6.06.7.4.6 Moclobemide 6.06.7.5 Other Antidepressant Drugs 6.06.7.5.1 Mianserin 6.06.7.5.2 Mirtazapine 6.06.7.5.3 Trazodone 6.06.7.5.4 Nefazodone 6.06.7.5.5 Venlafaxine 6.06.7.5.6 Bupropion 6.06.7.5.7 L-Tryptophan 6.06.8 MOOD-STABILIZING DRUGS

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6.06.8.1 Lithium 6.06.8.1.1 Pharmacology 6.06.8.1.2 Efficacy 6.06.8.1.3 Adverse effects 6.06.8.1.4 Toxic effects 6.06.8.1.5 Lithium and pregnancy 6.06.8.2 Carbamazepine 6.06.8.2.1 Pharmacology 6.06.8.2.2 Efficacy 6.06.8.2.3 Adverse effects 6.06.8.3 Sodium Valproate 6.06.8.3.1 Pharmacology 6.06.8.3.2 Efficacy 6.06.8.3.3 Adverse effects

153 153 153 153 154 154 155 155 155 155 155 155 155 155

6.06.9 CLINICAL USE OF PSYCHOTROPIC DRUGS

156

6.06.9.1 Anxiety Disorders 6.06.9.1.1 Generalized anxiety disorder 6.06.9.1.2 Panic disorder and agoraphobia 6.06.9.1.3 Obsessive-compulsive disorder 6.06.9.1.4 Social phobia 6.06.9.2 Insomnia 6.06.9.3 Depression 6.06.9.3.1 Choice of antidepressant 6.06.9.3.2 Prophylaxis of recurrent major depression 6.06.9.3.3 Psychological therapies and antidepressant drug treatment 6.06.9.4 Mania 6.06.9.5 Prophylaxis of Bipolar Illness 6.06.9.6 Schizophrenia 6.06.10 REFERENCES

6.06.1 INTRODUCTION It is only since the late 1940s that drug treatment has been able to play a useful role in the management of psychiatric disorders. Little is known about the pathophysiology of psychiatric illness, and the drugs that are currently in use were discovered by chance or by modification of compounds known to be efficacious. Indeed, such neurochemical theories as there are of psychiatric disorder have, in the main, been derived from a knowledge of the pharmacological effects of psychotropic drugs in animal experimental studies. Drug treatment now plays in indisputable role in management of severe psychiatric disorder, such as schizophrenia and bipolar

156 156 156 157 157 157 157 157 158 158 158 158 159 159

disorder. Drugs are also commonly used to treat less severe illnesses, such as depressive and anxiety disorders. Wherever drug treatments are used, they should form part of an overall management plan that takes into account psychological and social needs of the individual patient and their family. 6.06.1.1 History of Drug Treatment in Psychiatry Drugs that produce changes in the function of the central nervous system, such as opiates and anticholinergic agents, have been used in the treatment of mental disorders for hundreds of years. Although some of these drugs may have

Introduction had calming effects, they were of no specific value in the treatment of psychiatric disorders. Particular drug treatments tended to be used because their cause was espoused by vigorous and eminent physicians rather than on the basis of proven efficacy. In any case, assessment of efficacy depended on uncontrolled clinical observation. The first drug that was discovered to have a specific effect on a prticular psychiatric disorder was lithium (Cade, 1949; Table 1). Lithium is a toxic agent and Cade's important clinical observations did not make a significant impact on clinical practice until the following decades when controlled trials showed that lithium was effective in both the acute treatment of mania and the prophylaxis of recurrent mood disorders. In addition, monitoring of plasma lithium levels enabled safe dosing regimes to be established. Since the late 1960s there has been a period of consolidation in psychopharmacology during which clinical trials have been extensively employed to refine the indications of particular drug treatments and to maximize their benefit risk ratios. New compounds have continuously become available but because, in the main, these agents have been derived from previously described agents, their range of activity is not strikingly different from their predecessors. In general, however, the newer agents are better tolerated and are sometimes safer, and both these developments are important for clinical practice. It is, perhaps, possible now to be more optimistic about the prospects for advances in psychopharmacology. There is, for example, rapidly increasing knowledge about the nature of chemical signaling in the brain. A multiplicity of neurotransmitters and neuromodulators interact with specific families of receptors, many of which exist in several different subtypes. Several of these receptors have been cloned and selective agents for them are becoming available.

Table 1

Introduction of some drug treatments in psychiatry.

Year

Drug treatment

1949 1952 1954 1957 1957 1971 1980 1988

Lithium Chlorpromazine Benzodiazepines Iproniazid (MAOI) Imipramine Carbamazepine Selective serotonin reuptake inhibitors Clozapine for treatment-resistant schizophrenia

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We are also learning much more about how these chemical messengers may modify behavior through their interactions with specific brain regions and distributed neuronal circuits. The availability of novel compounds, likely to have a quite different range of behavioral effects compared to currently available drugs, will lead to some exciting developments in psychopharmacology. It seems probable, given the complexity and multifactorial origin of psychiatric disorders, that detailed knowledge of etiology and pathophysiology, may lag behind advances in therapeutics. This, of course, is not uncommon in general medicine but serves to reinforce the importance of controlled clinical trials in the assessment of new psychopharmacological treatments.

6.06.1.2 Mode of Action of Psychotropic Drugs Psychotropic drugs act in one way or another on the process of chemical signaling, a mechanism employed by the brain for the purposes of communication between neurones. Neurones make connection with each other at specialized regions of the cell membrane called synapses. Chemical transmission at synapses occurs when a chemical messenger or neurotransmitter is released from one neurone and interacts with a specific binding site or receptor on an adjacent neurone. In general, psychotropic drugs act to increase or decrease the impact of a neurotransmitter on its receptor. This can be achieved in a number of ways (Table 2). Much is known about the pharmacological effects of psychotropic drugs in experimental animal studies. However, it is much less clear how such pharmacological changes are translated into therapeutic benefit in patients with psychiatric disorders. Studies in healthy volunteers may not be helpful in elucidating this issue. For example, a therapeutic course of an antidepressant drug has no effect on the mood of an individual who is not depressed. A further complication is that most psychotropic drugs take a number of weeks before their full clinical effect becomes apparent (Table 2). From this it has been deduced that the therapeutic effect of drug treatment is likely to be due to slowly evolving adaptive changes in neurotransmitter mechanisms and the neuronal circuits that depend on them. (A review of the mechanisms of drug action is given by Stahl 1996.) When a patient has responded to psychotropic drug treatment it is usual for drug therapy to be continued for some time. Where a disorder is believed to run a self-limiting course, for example a single uncomplicated episode of major depression, it is customary to withdraw

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Psychopharmacology Table 2 Mechanism of action of some psychotropic drugs and time to onset of therapeutic effect.

Drug

Action

Time to onset of action

Antidepressant Antipsychotic Anxiolytic (benzodiazepine) Lithium

Increase action of noradrenaline and serotonin Block dopamine receptors Increase action of g-aminobutyric acid Decrease activity of receptor-linked enzyme systems

2±4 weeks 2±6 weeks immediate 2±4 weeks (mania)

treatment after about six months. However, many psychiatric disorders are persistent or highly recurrent, and here drug treatment may need to be continued in the longer term. Where circumstances are favorable it is often worthwhile trying to discontinue drug treatment, or at least lower the dose, while the patient is carefully monitored. In general, psychotropic drugs should not be discontinued suddenly because withdrawal symptoms may result. These are seen particularly with anxiolytic and antidepressant drugs. In addition, abrupt discontinuation of medication can sometimes result in ªreboundº illness. For example, sudden withdrawal of lithium in patients with bipolar disorder confers a risk of mania of about 50% over the next six weeks (Goodwin, 1994). This is substantially greater than that which would be expected from the natural history of the illness.

6.06.1.3 Pharmacokinetics of Psychotropic Drugs Before psychotropic drugs can produce their effects they need to reach the brain in adequate amounts. This depends on how well they are absorbed from the gastrointestinal tract into the blood stream and their ability to cross the blood±brain barrier. Subsequently, drugs are broken down or metabolized in the liver and then eliminated from the body in the urine by the kidney. Patients with liver or kidney disease can have exaggerated effects from small doses of drugs. Plasma concentrations of drugs throughout the day vary, rising immediately after each dose and falling at a rate that differs between individual drugs and to some extent between individual people. However, this rate of decline influences how long the drug persists in the body. The concept of plasma half-life is useful here. The half-life of a drug in plasma is the time taken for its concentration to fall by a half, once dosing has ceased. With most psychotropic drugs, the amount eliminated over time is proportional to plasma concentration and in this case it will take approximately five times the half-life for the drug to be eliminated from plasma. Equally, when dosing with a drug

begins, it will take five times the half-life for the concentration in plasma to reach a steady state. This can be important when planning treatment. For example, monoamine oxidase inhibitors (MAOIs) should not be given with selective serotonin reuptake inhibitors (SSRIs) because of the danger of drug interaction (see Section 6.06.7.4.5). If, for example, a patient is taking sertraline which has an elimination halflife of about 26 hours, it will be important to leave at least five times the half-life (a week is recommended) before starting MAOI treatment. When sertraline treatment begins, the plasma concentrations will continue to rise for about a week before reaching steady state. Most psychotropic drugs have fairly long half-lives and once or twice daily dosing is sufficient. This aids compliance. Some antipsychotic preparations are made in the form of long-acting intramuscular preparations. These depot injections may need only to be given only once or twice monthly, which again has advantages in terms of compliance for some patients.

6.06.1.4 Prescribing Psychotropic Drugs It is good practice to use well-tried drugs with therapeutic actions and side effects that are clearly understood. When a drug is prescribed it is necessary to determine the dose, the interval between doses and the likely duration of treatment. Until a clinician is thoroughly familiar with a drug it is important to consult the manufacturer's literature or other appropriate reference to decide the dosing schedule. Particular care should be taken to assess the possibility of drug interaction because many patients will be taking more than one kind of medicine. Before providing a prescription the clinician should explain what effects are likely to be expected on first taking the drug, for example, drowsiness or dry mouth with a tricyclic antidepressant. They should also explain how long it will be before therapeutic effects will appear and what signs a patient should look for. Many patients do not take their prescribed medication either because they do not perceive

Anxiolytic Drugs the need to take it or have fears about the possible consequences if they do. Time spent in discussing patient's concerns is well spent and is likely to improve compliance with medication. Written instructions (which are now often provided as inserts to drug packaging) can be a valuable adjunct. There are special problems about prescribing in pregnancy because of the risk that drugs might produce adverse effects on fetal development (teratogenesis). Withdrawal symptoms in the new-born may also occur. Where possible, therefore, psychotropic drugs should not be prescribed to women who are pregnant or who are considering becoming pregnant. Where drug treatment is strongly indicated, for example, in a psychotic illness or with severe depression, a careful clinical risk benefit assessment should be made and discussed with the patient. It is usually possible to select preparations that appear on current evidence to be unlikely to produce terratogenic effects.

6.06.2 CLASSIFICATION OF DRUGS USED IN PSYCHIATRY Psychotropic drugs are those whose main clinical effect is to produce a change in the psychological state. Psychotropic drugs used in psychiatry are conventionally divided into different classes, but the therapeutic actions of particular compounds are not confined to one diagnostic category. For example, SSRIs are classified as antidepressants and are effective in the treatment of major depression, but they also produce useful therapeutic effects in panic disorder, obsessive compulsive disorder and social phobia (Cowen, 1997). This breadth of effect does not mean that the latter syndromes are forms of depression. It merely emphasizes that the neuropsychological consequences of facilitating brain serotonin function may provide beneficial effects in a variety of psychiatric disorders. Although there is considerable understanding of the pharmacological actions of psychotropic drugs, little is known about the neuropsychological consequences of these pharmacological actions and about the ways in which neuropsychological changes are translated into clinical benefit in different diagnostic syndromes. At present, therefore, the best plan is to classify drugs according to their major therapeutic use but to bear in mind therapeutic effects of different classes of drugs may overlap (Table 3). These groups of drugs will be discussed in turn. Subsequently, general advice will be given about the use of psychotropic drugs in different

139

psychiatric disorders and how they may be combined with psychological methods of treatment. 6.06.3 ANXIOLYTIC DRUGS Anxiolytic drugs are indicated in the treatment of anxiety disorders. It must be remembered, however, that the classification of anxiety disorders in the Diagnostic and statistical manual of mental disorders (4th ed., DSM-IV) and the International classification of diseases (10th ed., ICD-10) subsumes a number of different disorders, some of which have a distinct drug response. For example, although benzodiazepines are effective in generalized anxiety disorder and to some extent in panic disorder, they are not useful in the treatment of obsessive compulsive disorder (Jenike, 1992). Anxiolytic drugs are prescribed widely and often inappropriately. There is evidence, however, that this trend may be subsiding (Tyrer, 1997). To some extent this may reflect substitution of antidepressant drugs for benzodiazepines, since the former are effective in the treatment of anxiety disorders and may be less likely to cause dependence. 6.06.3.1 Benzodiazepines 6.06.3.1.1 Pharmacology Benzodiazepines are anxiolytic, sedative, and in larger doses hypnotic. They also have muscle relaxant and anticonvulsant properties. Their pharmacological actions are mediated through specific receptor sites, located in a supramolecular complex with g-aminobutyric acid (GABA) receptors. Benzodiazepines enhance GABA neurotransmission, thereby altering indirectly the activity of many other neurotransmitters, for example, noradrenaline and serotonin (Stahl, 1996). 6.06.3.1.2 Compounds available Many different benzodiazepines are available. They differ both in the potency with which they interact with a benzodiazepine receptor, and in their plasma half-life. In general, high potency benzodiazepines and those with short half-lives are more likely to be associated with dependence and withdrawal. Benzodiazepines with short half-lives (less than 12 hours) include lorazepam and temazepam. Because of problems with dependence, long-acting compounds are preferable for the management of anxiety, even if such treatment is to be given intermittently and on an as-required basis. The longacting benzodiazepines include drugs such as diazepam and chlordiazepoxide.

140

Psychopharmacology Table 3 Classification of clinical psychotropic drugs.

Class of drug

Examples of classes

Indications

Antipsychotic

Phenothiazines, Butyrophenones, Dibenzazepine

Acute treatment of schizophrenia and mania; prophylaxis of schizophrenia

Antidepressant

Tricyclic antidepressants MAOIs SSRIs SNRIs

Major depression (acute treatment and prophylaxis); anxiety disorders; obsessive-compulsive disorder (SSRIs)

Mood stabilizer

Lithium, Carbamazepine, Valproate

Acute treatment of mania; prophylaxis of recurrent mood disorder

Anxiolytic

Benzodiazepines, azapirones (buspirone)

Generalized anxiety disorder

Hypnotic

Benzodiazepines, Cyclopyrrolones (zopiclone), imidazopyridine (zolpidem)

Insomnia

Diazepam is rapidly absorbed, and can be used both for continuous treatment of anxiety and for treatment as required. Alprazolam, a high-potency and long-acting benzodiazepine, is used widely outside the UK for the treatment of panic disorder. This therapeutic efficacy is not confined to alprazolam, however, because equivalent doses of other high-potency agents, such as clonazepam, are also effective (Nutt & Bell, 1997). Flumazenil is a benzodiazepine receptor antagonist. This drug produces little pharmacological effect by itself but blocks the action of other benzodiazepines (Nutt, Cowen, & Little, 1982). It is therefore used to reverse acute toxicity of benzodiazepines, but carries a risk of provoking withdrawal symptoms in chronic users. 6.06.3.1.3 Adverse effects Benzodiazepines are generally well tolerated. When they are given as anxiolytics, their main side effects are due to sedative properties that can lead to ataxia and drowsiness. A degree of cognitive impairment may be detectable, which is obviously a matter of concern when people are driving or operating machinery. The adverse effects of benzodiazepines are potentiated by alcohol. Although in some circumstances benzodiazepines may lower tension and aggression, in some people they can increase aggressive behavior, probably through disinhibition (Cowdrey & Gardner, 1988). They should therefore be prescribed only with great caution to those with a previous history of impulsive aggressive behavior. It is now generally agreed that physical dependence develops after prolonged use of benzodiazepines. The frequency depends on the

drug and the dosage, and has been estimated at between 5% and 50% among patients taking the drugs for more than six months. Although escalation during treatment is unusual, problems can appear when patients try to discontinue their medication, whereupon a withdrawal syndrome becomes apparent. This is characterized by anxiety, insomnia, nausea, and tremor, together with perceptual disturbances (Pertursson & Lader, 1984; Tyrer, 1997). Withdrawal symptoms generally begin within 2±3 days of stopping a short-acting benzodiazepine, or within about seven days of stopping a longer-acting one. The symptoms generally last for 3±10 days. If benzodiazepines have been taken for a long time, it is best to withdraw them gradually over several weeks under supervision (Tyrer, Rutherford, & Huggett, 1981). Despite this, a few patients either cannot discontinue their benzodiazepines satisfactorily or are troubled by persistent long-standing withdrawal symptoms for long periods of time after the drugs have been discontinued. 6.06.3.2 Azapirones The only drug in this class currently marketed for the treatment of anxiety is buspirone. This drug has no affinity for benzodiazepine receptors but stimulates a subtype of serotonin receptor called the serotonin-1A receptor. This receptor is found in high concentration in the raphe nuclei in the brain stem, where it regulates the firing of serotonin cell bodies. Administration of buspirone lowers the firing rate of serotonin neurones and thereby decreases serotonin neurotransmission in certain brain regions. This action may be the basis of its anxiolytic effects (Yocca, 1990).

Antipsychotic Drugs Buspirone is different to benzodiazepines in that its anxiolytic effects take several days to develop, whereas those of benzodiazepines are apparent very quickly. Its side effect profile also differs; for example, it is associated with lightheadedness, nervousness, and headache early in treatment. There is little evidence that tolerance and dependence occur during buspirone use, although such judgment must always be made with circumspection. There is some evidence that patients who have previously responded to treatment with benzodiazepines do not respond well to buspirone. Buspirone cannot be used to treat benzodiazepine withdrawal. Although buspirone appears to be effective in the treatment of generalized anxiety disorder, current evidence does not suggest that it confers benefit in the treatment of panic disorder (Cowen, 1992). 6.06.3.3 Other Drugs Used to Treat Anxiety 6.06.3.3.1 Antidepressant drugs Antidepressants usually ameliorate the anxiety that accompanies depressive disorders. In addition, tricyclic antidepressants and trazodone have been shown to be as effective as benzodiazepines in the management of generalized anxiety and panic disorder (Rickels, Downing, Schweizer, & Hassman, 1993). SSRIs and MAOIs are also effective in the treatment of panic disorder, but the selective noradrenaline reuptake inhibitor, maprotiline, is not (Den Boer & Westenberg, 1988). 6.06.3.3.2 Antipsychotic drugs These drugs are sometimes prescribed for their anxiolytic effect. They are not more effective than benzodiazepines, but may have a place in the group of patients who have become irritable and disinhibited with benzodiazepines. 6.06.3.3.3 b-Adrenoceptor antagonists These include drugs such as propanolol which are used to treat hypertension. Such drugs relieve some of the autonomic (peripheral) symptoms of anxiety, such as tachycardia and tremor, by blocking peripheral b-adrenoceptors. In general they are not particularly helpful in the treatment of patients with anxiety disorders, but can be helpful in otherwise healthy subjects who develop marked autonomic symptoms coupled to performance anxiety.

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are widely used as hypnotics. Most hypnotics in common use act at the benzodiazepine GABA receptor complex; this includes more recently introduced compounds such as zolpidem and zopiclone. Occasionally, low-dose tricyclic antidepressants are used as hypnotics because of their sedating effects. Similarly, sedating antihistamines such as chlopheniramine have been employed to promote sleep. Hypnotic drugs have two major problems; first, the development of tolerance, with rebound insomnia when medication is discontinued; and second, hangover effects that can compromise psychological performance the next day. 6.06.4.1 Compounds Available The most commonly used hypnotics are benzodiazepines with short half-lives, such as temazepam and lormetazepam. However, there is increasing use of nonbenzodiazepine drugs such as zopiclone, a cyclopyrrolone, and zolpidem, an imidazopyridine. With these shorter-acting compounds daytime hangover is less common but is still experienced by some patients. Both zopiclone and zolpidem bind to a site close to the benzodiazepine receptor, thereby facilitating brain GABA function. Zopiclone and zolpidem produce fewer changes in sleep architecture than benzodiazepines, and are also claimed to be less liable to produce tolerance and dependence (Langtry & Benfield, 1990). This has not yet been fully substantiated. The most common side effect of zopiclone is a bitter after-taste following injection, but behavioral disturbances including confusion, amnesia, and depressed mood have been reported. Zolpidem has also been associated with behavioral disturbances but more commonly causes nausea and dizziness. Other hypnotic drugs include chloral hydrate and chlormethiazole. The latter has a short halflife and is commonly used to facilitate sleep in the elderly. In addition, in some countries, chlormethiazole is used to prevent withdrawal symptoms in patients dependent on alcohol. For this reason it is sometimes thought, mistakenly, to be a suitable hypnotic for alcoholic patients. In fact, chlormethiazole has barbiturate-like actions and can cause respiratory depression when combined with alcohol or in overdose. 6.06.5 ANTIPSYCHOTIC DRUGS

6.06.4 HYPNOTIC DRUGS Hypnotic drugs are used to improve sleep. The benzodiazepine drugs described previously

This term is applied to drugs that reduce psychomotor overactivity and diminish symptoms of psychosis. Alternative terms for these

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drugs are neuroleptic and major tranquilizer. None of these names is wholly satisfactory. Neuroleptic refers to the side effects rather than to the therapeutic effects of the drugs, and major tranquilizer does not refer to the most important clinical action, that of ameliorating the symptoms of psychosis. Therefore, the term antipsychotic drug is preferred here. The main therapeutic uses of antipsychotic drugs are to reduce hallucinations, delusions, agitation, and psychomotor excitement in schizophrenia, mania, or psychosis secondary to a medical condition. The drugs are also used prophylactically to prevent relapse of schizophrenia and occasionally mania (Gelder, Gath, Mayou, & Cowen, 1996). 6.06.5.1 Pharmacology Antipsychotic drugs share the property of blocking brain dopamine receptors. Dopamine receptors are of several biochemical subtypes, but most antipsychotic drugs bind strongly to dopamine-D2 receptors, and this action appears to account both for their antipsychotic activity and their propensity to cause movement disorders. Actions at other neurotransmitter receptors may offset the liability of D2 receptor antagonists to produce movement disorders. For example, thioridazine is a potent antagonist at muscarinic cholinergic receptors, and anticholinergic drugs are known to possess antiParkinsonian effects. This might account for the diminished liability of thioridazine to cause movement disorders. Similarly, the lack of movement disorders associated with risperidone and olanzapine has been attributed to the ability of these drugs to block serotonin2 receptors as well as D2 receptors (see Stahl, 1996). 6.06.5.2 Compounds Available A large number of antipsychotic compounds have been developed. The main distinction of clinical utility is into typical and atypical antipsychotics. Atypical antipsychotics are so called because they have a decreased likelihood to cause extrapyramidal side effects or movement disorders. 6.06.5.2.1 Typical antipsychotics These drugs have comparable efficacy in the treatment of psychosis but different side effect profiles because of their other pharmacological properties. For example, phenothiazines such as chlorpromazine and thioridazine are sedating

and tend to lower blood pressure. They are, however, less likely to cause movement disorders than nonsedating phenothiazines, such as trifluoperazine and fluphenazine. The pharmacological profile of the thioxanthenes, such as flupenthixol and clopenthixol, resembles the nonsedating phenothiazines and the same is true of the butyrophenone, haloperidol. A number of typical antipsychotic drugs (the decanoates of haloperidol, fluphenazine, flupenthixol and zuclopenthixol) are available as long-acting intramuscular depot preparations, given at intervals of 2±4 weeks. For many patients continued medication is the only way to prevent psychotic relapse. In some subjects compliance with medication is better if they will accept a long-acting intramuscular preparation. Another intramuscular preparation is zuclopenthixol acetate whose action lasts for 1±2 days. This preparation can be useful in an acutely psychotic patient where antipsychotic medication is needed but where oral drug administration is ineffective or not possible. The disadvantage of this approach is that it is not easily possible to titrate the dosage of medication for an individual patient (Royal College of Psychiatrists, 1993). 6.06.5.2.2 Atypical antipsychotic drugs These include a number of compounds that differ strikingly in their structure and pharmacological properties. Sulpiride is a D2 receptor blocker, but it appears to act more selectively on D2 receptors on mesolimbic and mesocortical regions than on those in the basal ganglia. This might account for its reduced liability to cause extrapyramidal side effects. In contrast, risperidone is a potent D2 receptor antagonist but is even more potent at blocking serotonin2 receptors. Concomitant serotonin2 receptor blockade is believed to attenuate the movement disorders caused by unnopposed D2 receptor antagonism (Livingston, 1994). Olanzapine and sertindole are also serotonin2 receptor antagonists but have less effect than risperidone on D2 receptors. Both these factors may account for their decreased liability to cause movement disorders (Gerlach & Peacock, 1995; Reus, 1997). In addition, it has been claimed that risperidone, olanzepine, and sertindole are more effective than typical antipsychotics, particularly having some activity against so-called negative symptoms of schizophrenia, which are difficult to treat pharmacologically (Marder & Meibach, 1994; Tollefson & Sanger, 1997). These claims are currently being tested but clinically risperidone and olanzepine are being used increasingly in preference to typical antipsychotic drugs.

Antipsychotic Drugs Clozapine is an important drug because it is the only drug with established efficacy in patients who are resistant to other antipsychotic treatments (Kane, Honigfeld, Singer, & Meltzer, 1988). Clozapine has complex pharmacology with weak binding to dopamine-D2 receptors but strong antagonist properties at a variety of serotonin and noradrenergic receptors. Because of a rare but serious adverse effect on white blood cells, clozapine can be used only with special monitoring (see below). 6.06.5.3 Adverse Effects 6.06.5.3.1 Movement disorders Probably the most troublesome side effect of antipsychotic drugs, particularly typical antipsychotics, are movement disorders, which are a consequence of D2 receptor blockade in the basal ganglia. At least four different kinds of movement disorder are recognized: acute dystonia, akathisia (a Parkinsonian syndrome), and tardive dyskinesia (Table 4). Acute dystonia occurs soon after treatment begins, especially in young men. It is observed most often with drugs such as haloperidol and trifluoperazine. The main features are caused by acute contraction of muscle groups, resulting in torticollis (neck twisting), tongue protrusion, grimacing and oculogyric crisis (rolling upward of the eyes). These symptoms are distressing and alarming for patients, and can be controlled by anticholinergic drugs, such as benztropine or a benzodiazepine. Akathisia is an unpleasant feeling of physical restlessness, with a compelling need to move. Patients are usually very distressed by akathisia and can present in a state of severe agitation. It usually occurs in the first few weeks of treatment with antipsychotic drugs but may only begin after several months. Akathisia is not reliably treated by anticholinergic drugs, but may disappear when the dose of the antipsychotic agent is reduced. Some cases are helped by treatment with b-adrenoceptor antagonists,

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such as propranolol, and short-term benzodiazepine administration has also been employed. The Parkinsonian syndrome caused by antipsychotic drugs presents with the usual clinical triad of akinesia, tremor, and muscular rigidity. These symptoms can be controlled by lowering the dose of the antipsychotic drug or with anticholinergic agents (see below). The last syndrome, tardive dyskinesia, is particularly serious because, unlike the other extrapyramidal effects, it does not always recover when antipsychotic drugs are stopped. It is usually characterized by chewing and sucking movements of the lips and jaw, but can involve limbs and occasionally the whole body. Although this syndrome is seen occasionally among patients who have not taken antipsychotic drugs, clinical observations suggest it is much more common in those who have received antipsychotic agents for extended periods of time. Estimates of the frequency of the syndrome vary in different series, but it seems to develop in 20±30% of patients with schizophrenia treated with long-term antipsychotic drugs (Jeste & Caligiuri, 1993). Whatever the exact incidence, the risk of this syndrome should be a deterrent to the long-term prescription of antipsychotic drugs unless clearly indicated. Many treatments for tardive dyskinesia have been tried but none is universally effective. The antipsychotic drug should be stopped if the state of the psychiatric illness allows this. About 50% of cases may then remit. Where this in not possible, increasing the dose of antipsychotic drug may produce some suppression of movement symptoms but this relief is usually temporary. Sulpiride, however, may provide rather more sustained benefit with few adverse effects. Interestingly, treatment with vitamin E has been found useful in some studies (Jeste & Caligiuri, 1993). 6.06.5.3.2 Autonomic and endocrine effects Several of the antipsychotic drugs, particularly phenothiazines, such as chlorpromazine

Table 4 Some unwanted effects of antipsychotic drugs. Effect

Symptoms

Movement disorders

Acute dystonia, akathisia, parkinsonism, tardive dyskinesia

Autonomic and endocrine effects

Dry mouth, constipation, urinary hesitancy, blurred vision, sedation, postural hypotension, hypothermia, amenorrhoea, galactorrhoea, decreased libido

Other

Cardiac arrhythmias, weight gain, agranulocytosis (clozapine)

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Psychopharmacology

and thioridazine, are antagonists at muscarinic cholinergic receptors. This leads to dry mouth, urinary hesitancy and retention, constipation, reduced sweating, blurred vision, and rarely the precipitation of glaucoma. Phenothiazines, and risperidone also have strong antagonist activity at a1-adrenoceptors. This leads to sedation, hypotension and sexual dysfunction. Antipsychotic drugs that block histaminic and some subtypes of serotonin receptors can cause troublesome weight gain. This can be a particular problem with chlopromazine, thioridazine, clozapine, and olanzepine. Blockade of D2 receptors elevates plasma prolactin levels which can cause amenorrhoea and galactorrhoea in women and loss of libido in both sexes. The atypical antipsychotic drugs, with the exception of risperidone and sulpiride appear to have less effect on plasma prolactin. 6.06.5.3.3 Neuroleptic malignant syndrome This rare but serious disorder occurs in a small minority of patients taking antipsychotic drugs, particularly high-potency compounds. Most reported cases have followed the use of antipsychotic drugs for schizophrenia, but in some cases the drugs were used for mania, depressive disorder, and psychosis secondary to a medical condition. The clinical picture includes the rapid onset, over 24±72 hours, of severe motor, cognitive, and autonomic disorders. The prominent motor symptom is generalized rigidity. The psychological symptoms include mutism, stupor, or fluctuating levels of consciousness. Hyperpyrexia develops with evidence of autonomic instability in the form of rapidly changing blood pressure, tachycardia, excessive sweating and urinary incontinence. Plasma levels of the enzyme, creatinine phosphokinase, are increased to very high levels. The neuroleptic malignant syndrome has a significant mortality, which may be declining but is probably still about 10%. The syndrome lasts for 1±2 weeks after stopping an oral neuroleptic, but may last 2±3 times longer after stopping long-acting preparations. Patients who survive usually make a complete recovery but residual movement disorders are sometimes seen (Addonizio & Susman, 1991). The mainstay of treatment in neuroleptic malignant syndrome is symptomatic, with support in an intensive care unit if needed. No drug treatment is of definite utility. The dopamine receptor agonist, bromocriptine, is often tried, but there is no definite evidence of effectiveness. Patients who have developed neuroleptic malignant syndrome may need in the future to be treated with antipsychotic drugs. At least two weeks should elapse before

antipsychotic treatment is reinstated, and it is prudent to start treatment cautiously with an oral low potency drug such as thioridazine. 6.06.5.3.4 Other adverse effects A rare adverse effect, but one which is of particular concern, is the development of cardiac arrhythmias. Subclinical electrocardiogram (ECG) changes are not uncommon and usually take the form of prolongation of the QT interval. This appears to be more problematic with some drugs than others, for example, pimozide and sertindole, where the use of ECG monitoring has been recommended. It should also be noted that most antipsychotic drugs appear to lower the seizure threshold to some extent, so must be used with caution in patients with a tendency to seizure disorder. Typical antipsychotic drugs have not been shown to be teratogenic, but nevertheless should be used cautiously in early pregnancy. There is presently insufficient data on the possible teratogenic effects of the atypical antipsychotic drugs. 6.06.5.3.5 Adverse effects of clozapine As noted above, the use of clozapine requires special monitoring with regard to blood white cell count. For this reason both the hematological and other adverse effects of clozapine will be discussed here. The use of clozapine is associated with a significant risk of leucopenia (about 2±3%) which can progress to agranulocytosis (Krupp & Barnes, 1992). Weekly blood counts for the first 18 weeks of treatment and at two week intervals thereafter are mandatory. With this intensive monitoring the early detection of leucopenia can be followed by immediate withdrawal of clozapine and reversal of the low white cell count. This procedure greatly reduces, but does not eliminate, the risk of progression to agranulocytosis. It is usually recommended that clozapine be used as the sole antipsychotic agent in a treatment regimen. Clearly, it is wise to avoid concomitant use of drugs such as carbamazepine, which may also lower the white cell count. Because of its relatively weak blockade of dopamine D2 receptors, clozapine is less likely than other antipsychotic drugs to cause extrapyramidal movement disorders. It does not increase plasma prolactin, hence galactorrhoea does not occur. However, its use is associated with hypersalivation, drowsiness, postural hypotension, weight gain, and hyperthermia. Seizures may occur at higher doses. Rarely, myocarditis has been reported.

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Antidepressants 6.06.5.4 Dosage of Antipsychotic Drugs Doses of antipsychotic drugs need to be adjusted for the individual patient and changes should be made gradually. There is a growing trend for lower doses to be recommended. This is based in part on recent studies with positron emission tomography which have demonstrated that adequate dopamine D2 receptor blockade can be obtained with low doses of conventional antipsychotic drugs, for example, 5 mg a day of haloperidol (Farde, Wiesel, & Nordstrom, 1989) (Table 5). Such doses produce an adequate antipsychotic effect in the majority of patients. Higher doses may cause further calming but are also likely to be associated with significant adverse effects, some of which may be serious, for example, cardiac arrhythmias. A view of growing influence is that the combination of modest doses of antipsychotic drugs with a benzodiazepine is a safer and more effective means of producing rapid sedation than high doses of antipsychotic drugs (Pilowsky, Ring, Shine, Battersby, & Lader, 1992). The association of sudden unexplained death with antipsychotic drug treatment is a matter of continuing debate. For example, it is not established whether the rate of such deaths is greater in patients receiving antipsychotic drugs than in those receiving other treatments, or whether the rate in psychiatric patients is higher than in the general population. However, antipsychotic drugs are known to alter cardiac conduction (see above), and some drugs, such as chlorpromazine, also produce hypotension. Although the relationship between high doses of antipsychotic drug treatment and sudden death is not established, it is clearly prudent to use as low a dose of an antipsychotic drug as the clinical circumstances permit (Royal College of Psychiatrists, 1993). 6.06.6 ANTI-PARKINSONIAN DRUGS Although these drugs have no direct therapeutic use in psychiatry, they are often required to control the extrapyramidal side effects of antipsychotic drugs, particulary acute dystonia and symptoms of Parkinsonism. They are of modest benefit in akathisia and actually worsen tardive dyskinesia. The pharmacological effect of these drugs is to block peripheral and central muscarinic cholinergic receptors. 6.06.6.1 Preparations Available Many anticholinergic drugs are available and there is no reason for choosing one over the others for the treatment of neuroleptic induced movement disorders. Those most often used in

Table 5 Daily dose of different antipsychotic drugs required to produce greater than 70% blockade of D2 receptors in basal ganglia.

Drug

Dose (mg)

Chlorpromazine Thioridazine Trifluoperazine Haloperidol Flupenthixol Sulpiride

200 300 10 4 10 800

Source: Farde et al. (1989).

psychiatric practice are benzhexol, benztropine, procyclidine, and orphenadrine. An injectable preparation of biperiden is useful for the treatment of acute dystonias. 6.06.6.2 Adverse Effects In large doses these drugs may cause an acute organic syndrome, particularly in the elderly. Their anticholinergic activity can summate with those of antipsychotic drugs so that glaucoma or retention of urine in men with enlarged prostates may be precipitated. Drowsiness, dry mouth and constipation also occur. These effects tend to diminish as the drug is continued. Anticholinergic drugs can also exacerbate tardive dyskinesia but are probably not a predisposing factor in its development. Anticholinergic drugs can also be abused for their euphoriant and psychomimetic effects at high doses. 6.06.7 ANTIDEPRESSANTS Antidepressant drugs are indicated in the treatment of major depression and dysthymia. Certain antidepressants are also effective in the treatment of anxiety disorders, and the eating disorder bulimia nervosa. Currently used antidepressant drugs can be divided into three main classes, depending on their acute pharmacological properties. The first class consists of compounds that inhibit the reuptake of noradrenaline and/or serotonin. This class includes the tricyclic antidepressants and the SSRIs. The second class consists of drugs that inhibit the enzyme MAO. The third class consists of drugs with complex effects on monoamine mechanisms, for example, mianserin and nefazodone, which cannot be easily categorized under the first two headings. In the broad range of major depression, these drugs are of equivalent efficacy. The main

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Psychopharmacology

distinctions between them are in their adverse effects, toxicity, and cost (Table 6). These three classes of drugs will be considered in turn after some comments on the possible mechanism of action of antidepressants.

6.06.7.1 Mechanism of Action The primary pharmacological action of reuptake inhibitors and MAOIs can be detected within hours of the start of treatment, and yet the antidepressant effects of drug therapy can be delayed for a number of weeks. For example, it has been suggested that 4±6 weeks should elapse before an assessment of the effect of an antidepressant drug can be made in an individual patient (Depression Guideline Panel, 1993; Quitkin et al., 1996). In animal experimental studies, the acute effect of antidepressants to facilitate noradrenaline and serotonin neurotransmission is followed by numerous secondary adaptive changes in noradrenaline and serotonin pathways. It is thought that it is these neuroadaptive changes that lead to the clinical antidepressant effect, probably by further enhancing the acute potentiation that antidepressant drugs produce on noradrenaline and serotonin neurotransmission (Blier & Montigny, 1994; Svensson & Usdin, 1978). An important action observed in animal experimental studies following repeated administration of antidepressant drugs is a gradual desensitization of inhibitory autoreceptors on serotonin and noradrenaline cell bodies. These receptors normally have the effect of decreasing the firing of these cells, and hence their desensitization would be expected to add to the facilitation of neurotransmission produced by the antidepressant. Thus the clinical effects of antidepressant treatment may result from an increasing potentiation of noradrenaline and serotonin neurotransmission over time.

6.06.7.2 Tricyclic Antidepressants 6.06.7.2.1 Pharmacological properties Tricyclic antidepressants have a three-ringed structure with an attached side chain. The first tricyclic to be introduced was imipramine, and there have been many modifications, so that a range of tricyclic compounds is now available. These can broadly be divided into tertiary and secondary amines, the distinction being that tertiary have a terminal methyl group on the side chain, whereas the secondary amines do not. In general, compared with the secondary amines, tertiary amines have a higher potency to block the serotonin reuptake site and are stronger antagonists of noradrenaline a1-adrenoceptors and muscarinic cholinergic receptors. Therefore, in clinical use tertiary amines are more sedating and cause more anticholinergic side effects than secondary amines. In the UK, tertiary amines such as amitriptyline, dothiepin, and imipramine are popular in the treatment of depression, whereas in the USA secondary amines such as desipramine and nortriptyline are more commonly used. Antidepressant drugs also antagonize histamine H1 receptors, which can cause drowsiness and weight gain. Tricyclics also have quinidinelike membrane stabilizing effects. This may explain why they impair cardiac conduction and cause high toxicity in overdose. 6.06.7.2.2 Adverse effects of tricyclic antidepressants The adverse effects of tricyclic antidepressants can, in general, be derived from their receptor blocking properties (Table 7). As mentioned above, anticholinergic and antiadrenergic effects are common. In addition, the drugs can cause tiredness and drowsiness, although secondary amines, such as desipramine, can cause insomnia. Fine tremor and muscle twitching have been observed and like

Table 6 Side effect profiles of some antidepressant drugs. Drug Amitriptyline Desipramine Lofepramine Trazodone Nefazodone Mirtazapine SSRIs SNRI

Anticholinergic

Sedation

Insomnia

Cardiotoxic

Nausea/vomiting

+++ ++ ++ 0 0 0 0 0

+++ + + +++ + +++ 0/+ 0/+

0 + + 0 0 0 ++ ++

+++ +++ 0 + 0 0 0 0

0 0 0 ++ ++ 0 +++ +++

0 = not present; +++ = strong.

Antidepressants antipsychotic drugs, tricyclic antidepressants lower the seizure threshold, which means they must be used with caution in people predisposed to seizure disorders. Allergic skin rashes, cholestatic jaundice, and agranulocytosis, are seen rarely. Weight gain and sexual dysfunction are more common. Sudden withdrawal of tricyclics can produce an abstinence syndrome, characterized by nausea, anxiety, sweating, and insomnia. Current evidence does not suggest that tricyclics such as amitriptyline and imipramine are important human teratogens. There is less data about other tricyclic antidepressants. In overdose, tricyclic antidepressants produce a large number of effects, of which some are extremely serious. Therefore urgent expert treatment in a general hospital is required. The main danger comes from cardiovascular effects, which include cardiac arrhythmias with ventricular fibrillation. In addition, respiratory depression can occur, and the resulting hypoxia increases the likelihood of cardiac complications. Tricyclics delay gastric emptying, and so gastric lavage is valuable for several hours after the overdose.

6.06.7.2.3 Amoxapine Some tricyclics have pharmacological properties sufficiently distinct to be worth separate mention. Amoxapine is a fairly selective inhibitor of noradrenaline uptake but, unusually for a tricyclic antidepressant, produces significant blockade of dopamine D2 receptors. The combined effect of amoxapine to increase noradrenaline neurotransmission and antagonize D2 receptors has led to suggestions that this compound may be particularly useful in the treatment of depressive psychosis when combined treatment with antidepressant and antipsychotic drugs is often required. However, the

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use of a single preparation to produce combined pharmacological effect limits prescribing flexibility. Furthermore, as might be expected, the D2 receptor blocking properties of amoxapine may result in extrapyramidal disorders (Rudorfer & Potter, 1980).

6.06.7.2.4 Clomipramine Clomipramine is the most potent of the tricyclic antidepressants in inhibiting the reuptake of serotonin. Probably because of this, unlike other tricyclic antidepressants, clomipramine is useful in treating the symptoms of obsessive compulsive disorder whether or not there is a coexisting major depression (Jenike, 1992). Clomipramine is also available as an intravenous infusion, but in general this form of administration does not appear to produce better therapeutic effects than the oral route.

6.06.7.2.5 Lofepramine Lofepramine is a fairly selective inhibitor of noradrenaline reuptake, and has fewer anticholinergic and antihistaminic properties than amitriptyline. It has been widely compared with other tricyclic antidepressants, and in general its antidepressant efficacy is equivalent. Lofepramine is not sedating; early in treatment it can be experienced as activating, an effect which some depressed patients find unpleasant. Similarly, impaired sleep does not usually improve until the underlying depression remits. The most important feature of lofepramine is that in overdose it is not cardiotoxic and it is therefore much safer than conventional tricyclic antidepressants. Therefore lofepramine is likely to be safer than other tricyclics for patients with cardiovascular disease, although caution is still required (Lancaster & Gonzalez, 1990).

Table 7 Some adverse effects of tricyclic antidepressants. Pharmacological action

Adverse effect

Anticholinergic

Dry mouth, tachycardia, blurred vision, glaucoma, constipation, urinary retention, cognitive impairment

Antiadrenergic

Drowsiness, postural hypotension, sexual dysfunction

Histamine H1 receptor blockade

drowsiness, weight gain

Other

Cardiac conduction defects, cardiac arrhythmias, epileptic seizures, (all common in overdose), rash, oedema, sweating, low white cell count (rare)

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Psychopharmacology

6.06.7.2.6 Maprotiline Maprotiline is often referred to as a quadricyclic antidepressant because the tricyclic nucleus is supplemented by an ethylene bridge across the middle ring. It is the most selective noradrenaline uptake inhibitor of the tricyclic antidepressants currently available, but has moderate antihistaminic properties and rather less anticholinergic effects than imipramine. It appears as effective as reference tricyclics. The use of maprotiline at doses above 200 mg daily have been associated with a higher incidence of seizures than is usual during tricyclic treatment. Therefore a dose range of 75±150 mg daily has been recommended, and the coprescription of other drugs that may lower the seizure threshold, such as phenothiazines, should be approached with caution. Maprotiline has effects on the heart that are similar to those of conventional tricyclics, and in overdose it is at least as toxic (Rudorfer & Potter, 1989).

superior to placebo and are generally as effective as tricyclics antidepressants in the treatment of major depression. Most comparative studies have been of moderately depressed outpatients, and there has been concern that SSRIs may be less effective than conventional tricyclic antidepressants for more severely depressed patients. This is based to some extent on the work of the Danish University Antidepressant Group (1990), who found that the tricyclic clomipramine is significantly more effective than either paroxetine or citalopram in depressed inpatients. In addition, more recent meta-analyses have suggested that SSRIs may be slightly less effective than drugs that potently block the reuptake of both serotonin and noradrenaline. This categorization includes clomipramine and the new antidepressant, venlafaxine (Anderson, 1997) (see below).

6.06.7.3.3 Unwanted effects of SSRIs 6.06.7.3 Selective Serotonin Reuptake Inhibitors 6.06.7.3.1 Pharmacological properties Five SSRIs, citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline, are available at present for clinical use in the UK. SSRIs are a structurally diverse group, but they all inhibit the reuptake of serotonin with a high potency and selectivity. None of them has an appreciable affinity for the noradrenaline uptake site, and present data suggest that they have a low affinity for other monoamine neurotransmitter receptors (Stahl, 1996). 6.06.7.3.2 Efficacy in depression The SSRIs have been extensively compared with placebo and with reference tricyclic antidepressants. The SSRIs are all clearly

The SSRIs have a different side effect profile to tricyclic antidepressants and are somewhat better tolerated at therapeutic dosage (Table 8). In meta-analyses against conventional tricyclic antidepressants the drop-out rate due to adverse effects with SSRIs is about 25% less. Whether this confers significant cost benefit is controversial. The SSRIs are less cardiotoxic than tricyclic antidepressants and are safer in overdose. They also lack anticholinergic effects and are less sedating. Their adverse effect profile consists mainly of gastrointestinal symptoms and central nervous system effects. Sexual dysfunction is also common, occurring in up to about 25% of people. A rare but problematic side effect, more frequent in the elderly, is a low sodium state. They can rarely cause movement disorders. Discontinuation of paroxetine and sertraline

Table 8 Some side effects of SSRIs. Effect

Symptoms

Gastrointestinal

Common: nausea, appetite loss, dry mouth, diarrhea, constipation, dyspepsia Uncommon: vomiting, weight loss

Central nervous system

Common: headache, insomnia, dizziness, anxiety, fatigue, tremor, somnolence Uncommon: extrapyramidal reaction, seizures

Other

Common: sweating, delayed orgasm, anorgasmia Uncommon: rash, pharyngitis, dyspnoea, serum sickness, hyponatremia, alopecia

Antidepressants has been associated with a withdrawal syndrome consisting of nausea, irritability, impaired sleep and ataxia (Cowen, 1996). It is not clear whether SSRIs are human teratogens. Fluoxetine may increase rates of premature delivery and perhaps minor fetal abnormalties, but this is controversial (Chambers, Johnson, & Dick, 1996; Robert, 1996).

6.06.7.4 Monoamine Oxidase Inhibitors MAOIs were introduced just before the tricyclic antidepressants, but their use has been less widespread because of both troublesome interactions with foods and drugs and uncertainty about their therapeutic efficacy. Recent controlled studies have shown that in adequate doses MAOIs are useful antidepressants, often producing clinical benefit in depressed patients who have not responded to other medications or electroconvulsive therapy (ECT). In addition, MAOIs can be useful in refractory anxiety states (Nutt & Glue, 1989; Paykel, 1990). These beneficial effects have to be weighed against the need to adhere to strict dietary and drug restrictions in order to avoid reactions with tyramine and other sympathomimetic agents. In practice this means that MAOIs are very rarely used as first-line treatment. It remains to be seen whether this approach will be altered by the recent availability of MAOIs, such as moclobemide, that do not potentiate tyramine. 6.06.7.4.1 Pharmacology The MAOIs inactivate enzymes that oxidize noradrenaline, serotonin, tyramine, and other amines that are widely distributed in the body as transmitters, or are taken in food and drink or as drugs. Monoamine oxidase (MAO) exists in a number of forms that differ in their substrate and inhibitor specificities. From the point of view of psychotropic drug treatment it is important to recognize that there are two forms of MAO (type A and type B), encoded by separate genes. In general, MAO-A metabolizes intraneuronal noradrenaline and serotonin, whereas both MAO-A and MAO-B metabolize dopamine and tyramine. 6.06.7.4.2 Compounds available Phenelzine is the most widely used and widely studied compound. Isocarboxazid is reported to have fewer side effects than phenelzine and can be useful for patients who respond to the latter drug but suffer from its side effects of hypotension or sleep disorder. Tranylcypromine differs from the other compounds in combining the

149

ability to inhibit MAO with an amphetaminelike stimulating effect. There are more reports of adverse drug and food reactions with tranylcypromine than other MAOIs, so it should be prescribed with particular caution. Moclobemide is the most recently developed MAOI to be marketed. It differs from the other compounds in selectively binding to MAO-A, which it inhibits in a reversible way. This results in a lack of significant interactions with foodstuffs and a quick offset of action (see below). 6.06.7.4.3 Efficacy of MAOIs in depression For many years MAOIs were in relative disuse because several studies, in particular a large controlled trial by the Medical Research Council, found them no better than placebo in the treatment of depressive disorders (Clinical Psychiatry Committee, 1965). It seems likely that the doses of MAOIs were too low in these early investigations; in the Medical Research Council study the maximum dose of phenelzine was 45 mg daily as against the current practice of doses up to 90 mg daily if side effects permit. In this wider dose range MAOIs are superior to placebo and generally equivalent to tricyclic antidepressants in their therapeutic activity (Paykel, 1990). 6.06.7.4.4 Unwanted effects MAOIs have numerous unwanted effects (Table 9). In clinical practice the main problems are insomnia, weight gain, and postural hypotension. Ankle edema is also not uncommon. Phenelzine and isocarboxazid have been associated with hepatocellular jaundice. There are little data on the possible teratogenicity of MAOIs in humans. 6.06.7.4.5 Interactions with foodstuffs and drugs Some foods contain tyramine, a substance that is normally inactivated by MAO in the liver and gut wall. When MAO is inhibited, tyramine is not broken down and is free to exert its hypertensive effects. These effects are due to release of noradrenaline with a consequent elevation in blood pressure. This may reach dangerous levels and may occasionally result in cerebrovascular accident. Important early symptoms of such a crisis include a severe and usually throbbing headache. There have been reports of many foods being implicated in hypertensive reactions with MAOIs, but many of these have cited single cases and hence are of uncertain validity. Another complication is that the tyramine content of a particular food item may vary, as

150

Psychopharmacology Table 9 Adverse effects of MAOIs. Effect

Symptoms

Central nervous system

Insomnia, drowsiness, agitation, headache, fatigue, weakness, tremor, mania, confusion

Autonomic

Blurred vision, difficulty passing urine, sweating, dry mouth, postural hypotension, constipation

Other

Sexual dysfunction, weight gain, peripheral neuropathy (rare), edema, rashes, hepatocellular toxicity (rare), leucopenia (rare)

may the susceptibility of an individual patient to a hypertensive reaction. If a forbidden food has been consumed on one occasion without adverse effects, this does not preclude a future reaction. It has been concluded that the following foods and drinks should be avoided (Davidson, 1992): (i) all cheeses except cream, cottage, and ricotta cheeses; (ii) red wine, sherry, beer, and liquors; (iii) pickled or smoked fish; (iv) brewer's yeast products, for example, Marmite, Bovril, and some packet soups; (v) broad bean pods; (vi) beef or chicken liver; (vii) fermented sausage, for example, pepperoni, salami; and (viii) unfresh, overripe, or aged food, for example, pheasant, venison, unfresh dairy products. Despite this list, case reports suggest that cheese is the food most often incriminated in serious adverse reactions. Hypertensive reactions should be treated with parenteral administration of an a1-adrenoceptor antagonist, such as phentolamine. Chlorpromazine can be used if the latter is not available. Oral nifedipine may also be useful. Whatever treatment is given, blood pressure must be monitored carefully. A number of drugs cause serious interactions with MAOIs. In particular, drugs that increase brain serotonin function such as the SSRIs and clomipramine can cause a fatal neurotoxicity syndrome (Sternbach, 1991). In general medicine coadministration of opiate analgesics, particularly pethidine, can produce a similar effect. Finally, drugs that potentiate noradrenaline can cause serious hypertensive reactions. The importance of this is that such compounds are often present in ªover-the-counterº cold and flu remedies. Patients receiving MAOI treatment must be warned not to take any other medication until its safety with MAOIs has been specifically checked.

6.06.7.4.6 Moclobemide In its freedom from tyramine reactions, the reversible type A MAOI, moclobemide, has a clear advantage over conventional MAOIs (Simpson & De Leon, 1989). As with all new antidepressants, however, the therapeutic efficacy of moclobemide, particularly in severely ill patients is not as well established as that of phenelzine or tranylcypromine. Moreover, a recent meta-analysis suggested that it might be somewhat less effective than clomipramine and imipramine in depressed inpatients (Angst, Amrein, & Stabl, 1995). Moclobemide is better tolerated than conventional MAOIs but can cause insomnia and nausea. Caution still has to be exercised when moclobemide is coprescribed with other drugs. It is recommended that it should not be prescribed with SSRIs or clomipramine because of the risk of serotonin syndrome (see above). As for the irreversible MAOIs, moclobemide may react adversely with opiates and noradrenaline potentiating drugs. 6.06.7.5 Other Antidepressant Drugs Under this heading are discussed drugs whose mechanism of action cannot be easily grouped with tricyclic antidepressants, SSRIs, or MAOIs. These drugs also have differing adverse-effect profiles. They are therefore discussed individually below. 6.06.7.5.1 Mianserin Mianserin is a quadricyclic compound with complex pharmacological actions. It has weak noradrenaline reuptake inhibiting effects, and is a fairly potent antagonist at a number of neurotransmitter receptors, including serotonin2, serotonin3, and noradrenergic a1- and a2adrenoceptors. It is not a muscarinic cholinergic antagonist and is not cardiotoxic.

Antidepressants Controlled trials have shown that mianserin is superior to placebo in the management of depression, and comparative studies against imipramine and clomipramine have shown no difference in effect. These studies are difficult to assess because of the wide range of doses that have been used. Many early studies of mianserin used doses of 30±60 mg daily, whereas much higher doses of up to 200 mg daily have sometimes been advocated for inpatients (Montgomery, Bullock, & Pinder, 1991). The main adverse effects of mianserin are drowsiness and dizziness. Significant cognitive impairment is more likely with mianserin than with SSRIs, and weight gain is a common problem. The most serious adverse effect of mianserin is a lowering of the white cell count, and fatal agranulocytosis has been reported. It is recommended that a blood count be obtained before starting mianserin treatment, and that the white cell count be monitored monthly for three months after treatment has started. 6.06.7.5.2 Mirtazapine Mirtazapine is a new antidepressant which is structurally related to mianserin. Its pharmacological properties are similar but its noradrenergic a1-adrenoceptor blockade is less potent which means that in practice it is a little less sedating. Placebo-controlled trials have shown an efficacy in the treatment of major depression, although the relative efficacy of mirtazapine against other antidepressants is not fully clear (Bruijn et al., 1996; Davies & Wilde, 1996). Mirtazepine is generally well tolerated, with the most common side effects being drowsiness, dizziness, and weight gain. 6.06.7.5.3 Trazodone Trazodone is a triazolopyridine derivative with complex actions on serotonin pathways. Studies in vitro suggest that trazodone has some weak serotonin reuptake inhibiting properties but these are probably not manifest during clinical use. Trazodone is an antagonist at serotonin2 receptors but its active metabolite, m-chlorophenylpiperazine (mCPP), is a serotonin receptor agonist. Trazodone also blocks postsynaptic a1-adrenoceptors, which gives it a distinct sedating profile. Several placebo-controlled studies have shown that trazodone in doses of 150±600 mg is superior to placebo in the treatment of depressed patients. Trazodone also appears to have equivalent antidepressant activity to compounds such as imipramine. Many of these studies were carried out in moderately depressed outpatients, and the efficacy of trazodone in

151

depressed inpatients is not as well established (Rudorfer & Potter, 1998) The major unwanted effect of trazodone is excessive sedation, which can result in significant cognitive impairment. Nausea and dizziness are also reported, particularly if the drug is taken on an empty stomach. The a1-adrenoceptor antagonist properties of trazodone may lower blood pressure to some extent, and postural hypotension has been reported. Trazodone is less cardiotoxic than conventional tricyclics, but there are reports that cardiac arrhythmias may be worsened in patients with cardiac disease. Nevertheless, trazodone is much less toxic in overdose than tricyclic antidepressants. A serious side effect of trazodone is priapism. This reaction is seen rarely (about 1 in 6000 male patients). It can cause considerable problems, requiring the local injection of noradrenaline agonists or even surgical treatment (Rudorfer & Potter, 1989). 6.06.7.5.4 Nefazodone Nefazodone is related to trazodone but lacks a1-adrenoceptor antagonist properties and is therefore less sedating. Like trazodone it has mild serotonin reuptake blocking properties, and is metabolized to the serotonin receptor agonist mCPP. Controlled trials in patients with major depression have shown that in doses of 400 mg and greater, nefazodone is more effective than placebo and generally equal in therapeutic activity to comparator drugs (Rickels, Schweizer, Clary, Fox, & Weise, 1994). As with trazodone, these studies have focused on outpatients with moderate depressive disorders. Nefazodone is usually given in two divided doses starting at 200 mg daily with titration to 400 mg daily after about a week. The maximum dose is 600 mg. Nefazodone is generally well tolerated with the most common side effects being headache, loss of energy, dizziness, dry mouth, nausea, and somnolence. It appears less cardiotoxic than tricyclic antidepressants and is less likely than SSRIs to cause insomnia and sexual dysfunction (Robinson et al., 1996). 6.06.7.5.5 Venlafaxine Venlafaxine is a phenylethylamine derivative which produces a potent blockade of both serotonin and noradrenaline reuptake. In this respect the pharmacological properties of venlafaxine resemble those of clomipramine. However, unlike clomipramine and other tricyclic antidepressants, venlafaxine has a negligible affinity for other neurotransmitter receptor sites and so lacks sedative and

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Psychopharmacology

anticholinergic effects. Venlafaxine is classified as a selective serotonin and noradrenaline reuptake inhibitor (SNRI). Venlafaxine has been studied in both inpatients and outpatients with major depression and compared with placebo and active comparators. Current studies suggest that it is more effective than placebo and at least of equal efficacy to other available antidepressant drugs. Venlafaxine also appears to be effective in depressed inpatients, perhaps more so than fluoxetine (Clerc, Ruimy, & Verdeau-Pailles, 1994; Feighner, 1994). Venlafaxine has a wider dosage range than SSRIs, from 75 mg to 375 mg daily, in two divided doses. Higher doses are associated with a greater incidence of adverse effects. The usual starting dose of venlafaxine is 75 mg daily which may be sufficient for many patients. Upward titration can be considered where there is insufficient response, or if a faster onset of therapeutic activity is needed. The adverse effect profile of venlafaxine resembles that of SSRIs, with the most common adverse effects being nausea, headache, insomnia, and sexual dysfunction. Venlafaxine occasionally causes postural hypotension but, in addition, dose-related increases in blood pressure can occur. Blood pressure monitoring may be advisable in patients receiving more than 200 mg of venlafaxine daily. Sudden discontinuation of venlafaxine has been associated with symptoms of fatigue, nausea, and dizziness. It is recommended that the dose should be reduced gradually over at least a one week period. Preliminary evidence suggests that venlafaxine is less toxic in overdose than tricyclic antidepressants (Feighner, 1994).

6.06.7.5.6 Bupropion Bupropion is marketed for the treatment of depression in the USA but not in Europe. It is a unicyclic compound whose pharmacological properties are not well characterized. It may, however, have some activity as a dopamine and noradrenaline reuptake inhibitor (Ascher et al., 1995). Bupropion has activating properties, and early in treatment can cause restlessness and insomnia. However, it does not cause significant sexual dysfunction. Bupropion is associated with an increased risk of seizures, particularly where the dose exceeds 450 mg daily (Rudorfer & Potter, 1989). 6.06.7.5.7 L-Tryptophan L-Tryptophan is a naturally occurring amino acid, present in the normal diet. About 500 mg

of tryptophan is consumed daily in the typical Western diet. Most ingested tryptophan is used for protein synthesis and the formation of nicotinamide nucleotides; only a small proportion (about 1%) is synthesized to serotonin via 5-hydroxytryptophan. There is only weak evidence that L-tryptophan has antidepressant activity, although it may be superior to placebo in moderately depressed outpatients. There is rather better evidence that L-tryptophan combined with MAOI treatment can enhance the antidepressant effects of MAOIs. Similar synergistic effects have been reported in some studies of L-tryptophan combined with tricyclics, although overall the therapeutic effect of this combination seems inconsistent (Chalmers & Cowen, 1990). L-Tryptophan is generally well tolerated, although nausea and drowsiness soon after dosing are not unusual. In the early 1990s, the prescription of L-tryptophan began to be associated with the development of a severe scleroderma-like illness, the eosinophiliamyalgic syndrome, in which there is a very high circulating eosinophil count (about 20% of peripheral leucocytes). Associated symptoms were severe muscle pain, edema, skin sclerosis and peripheral neuropathy. Some fatalities occurred. It is now reasonably well established that EMS is not caused by Ltryptophan itself but rather by a contaminant formed in the manufacturing process used by a particular manufacturer (Kilbourne, Philen, Kamb, & Falk, 1996). L-Tryptophan remains available for the treatment of severe refractory depression when it is used as an adjunct to other antidepressant medication. Patients receiving L-tryptophan require close supervision, including monitoring for possible symptoms of EMS and regular blood eosinophil counts. L-Tryptophan should be withdrawn if there is any evidence that EMS may be developing.

6.06.8 MOOD-STABILIZING DRUGS Under this heading are grouped three agents, lithium, carbamazepine, and sodium valproate. These three drugs have efficacy in the prevention of recurrent mood disorders and also in the acute treatment of mania. Lithium also has useful antidepressant effects in some circumstances (Price, 1989), but the antidepressant activity of carbamazepine and sodium valproate is less well established. Lithium has also been shown to lower the frequency of aggressive behavior in patients with learning difficulties (Nilsson, 1993).

Mood-stabilizing Drugs 6.06.8.1 Lithium 6.06.8.1.1 Pharmacology The mode of action of lithium is uncertain. Lithium does not affect neurotransmitters or their receptors directly, but appears to have important effects on intracellular signaling molecules, or second messengers, that are activated when a neurotransmitter or agonist binds to a specific receptor. Through these actions lithium could exert profound effects on a wide range of neurotransmitter pathways. It has been proposed that the effects of lithium may be particularly apparent when the turnover and recycling of second messengers is increased, and accordingly lithium may act preferentially to inhibit overactive neurotransmitter systems (Lithium Mechanisms Study Group 1993). 6.06.8.1.2 Efficacy It is estimated that about 50% of patients with bipolar disorder will have a good prophylactic response to lithium. Some patients who respond well have a complete cessation of mood swings, whereas others experience markedly dimished symptomatology in which subclinical mood swings can still be discerned (Goodwin & Jamison, 1990). Lithium is also effective in the acute treatment of mania but may need to be supplemented with antipsychotic drugs if psychotic symptoms are present (Chou, 1991). About 50% of patients with a depressive syndrome unresponsive to antidepressant drugs will show a clinical response if lithium is added to their drug treatment (Price, 1989). Lithium alone has some acute antidepressant activity, most apparent in patients with an underlying bipolar disorder (Goodwin & Jamison, 1990). 6.06.8.1.3 Adverse effects Common side effects include tremor of the hands, dry mouth, a metallic taste, feelings of muscular weakness, and fatigue (Table 10). Thirst and increased urine volume are also common. Most patients taking lithium have some minimal defect of renal tubular concentrating ability, but this rarely leads to clinical problems. A few patients, however, develop a diabetes insipidus-like syndrome with frequent passage of large volumes of water. Weight gain during lithium treatment is quite common, and partial hair loss has sometimes been reported. Thyroid gland enlargement occurs in about 5% of patients taking lithium. Lithium also interferes with thyroid production, and hypothyroidism occurs in up to 20% of patients. Tests of thyroid function should be performed every six months

153

to help detect these changes, but patients should also be monitored clinically for signs of hypothyroidism, particularly lethargy and substantial weight gain. If hypothyroidism develops and the reasons for lithium treatment are still strong, thyroxine treatment should be added. Lithium has rarely been associated with elevated serum calcium levels in the context of hyperparathyroidism. Lithium is also associated with reversible ECG changes that do not seem to be of particular consequence for cardiac conduction. Other changes include an elevated white count and occasional rashes. Most concern around the adverse effects of lithium is centred on possible long-term renal damage. As mentioned above, most patients taking lithium have some mild impairment of renal tubular concentrating ability. However, this usually recovers when the drug is stopped, although there are some reports of persisting cases. There have also been reports of tubular damage in patients taking prolonged lithium treatment. Several follow-up studies have examined the effect of longer-term lithium maintenance treatment on glomerular function. It has been concluded that long-term lithium treatment, in the absence of toxic blood levels, does not result in a lowering of renal filtering ability (glomerular filtration rate) (Gelder et al., 1996). However, although lithium may not significantly lower the mean glomerular filtration rate in groups of patients with bipolar illness, there are case reports of increases in plasma creatinine in lithium-treated subjects when other causes of nephrotoxicity appear to be absent. Whether lithium treatment, in the absence of toxic blood levels, can cause frank renal failure is unclear (Gelder et al., 1996). With the current trends towards long-term prophylaxis of mood disorders, it is clearly wise to monitor biochemical measures of renal function regularly. It seems likely that the risk of nephrotoxicity will be minimized by avoiding toxic blood levels and maintaining plasma lithium levels at the lower end of the therapeutic range. Effects on memory are sometimes reported by patients who complain of every-day lapses of memory, such as forgetting well-known names. Although this impairment may be associated with the mood disorder rather than lithium, there is evidence that lithium can impair certain cognitive tasks in healthy volunteers (Glue, Nutt, Cowen, & Broadbent, 1987). Sudden discontinuation of lithium in patients with bipolar illness can result in the rapid development of mania in up to 50% of subjects. This is thought to represent a rebound phenomenon (Goodwin, 1994). Rates of relapse

154

Psychopharmacology Table 10 Some adverse effects of lithium and carbamazepine.

Effect

Lithium

Carbamazepine

Neurological

Tremor, weakness, dysarthria, ataxia, impaired memory, seizures (rare)

Dizziness, weakness, drowsiness, ataxia, headache, visual disturbance

Renal/fluid balance

Increased urine output with decreased urineconcentrating ability; thirst, diabetes insipidus (rare), edema

Low sodium states, edema

Gastrointestinal/hepatic

Altered taste, anorexia, nausea, vomiting, diarrhea, weight gain

Anorexia, nausea, constipation, hepatocellular damage

Endocrine

Decreased thyroxine with increase TSH,a goitre, hyperparathyroidism (rare)

Decreased thyroxine with normal TSHa

Hematological

Leucocytosis

Leucopenia, agranulocytosis (rare)

Dermatological

Acne, exacerbation of psoriasis

Rashes

Cardiovascular

ECG changes (usually clinically benign)

Cardiac conduction disturbances

a

TSH = thyroid-stimulating hormone.

are significantly less when lithium is stopped gradually over several weeks (Baldessarini, Tondo, Floris, & Rudas, 1997). 6.06.8.1.4 Toxic effects Toxic effects of lithium are related to dose. Because therapeutic blood levels (0.5±1.0 mmol/ 1) are close to levels at which toxicity may be experienced (4 1.5 mmol/l) it is important for both patient and clinician to be aware of symptoms of toxicity. They include ataxia, poor coordination of limb movements, muscle twitching, slurred speech, and confusion. Such symptoms constitute a serious medical emergency for they can progress through coma and fits to death. If these symptoms appear, lithium must be stopped at once and a high intake of fluid provided. In severe cases renal dialysis may be needed. There have been reports of permanent neurological damage in patients who have suffered from lithium toxicity. It is important to note that certain commonly used medical drugs, such as thiazide diuretics and nonsteroidal antiinflammatory drugs, can elevate lithium levels and cause toxic effects (Gelder et al., 1996). 6.06.8.1.5 Lithium and pregnancy Lithium crosses the placenta, and retrospective studies have found increased rates of

abnormalities in the babies of mothers receiving lithium in pregnancy. For example, a rate of 7% has been reported, with most abnormalities affecting the baby's heart. However, a prospective study of 148 women found no increase in congenital malformation in patients exposed to lithium in the first trimester of pregnancy compared with matched controls. These authors concluded that lithium did not appear to be an important human teratogen (Jacobson et al., 1992). However, this conclusion was based on relatively few patients. Clearly, it is desirable for patients to be medication-free during the first trimester of pregnancy, and the decision whether or not to continue with lithium treatment must be carefully weighed. Important factors include the likelihood of affective relapse if lithium is withheld. If pregnant patients continue with lithium, plasma levels should be monitored closely. Ultrasound examination and fetal echocardiography are valuable screening tests as the pregnancy progresses. Patients with a history of bipolar disorder have a substantially increased risk of psychotic relapse in the postpartum period. In such patients it may be worth considering the introduction of lithium shortly after delivery to provide a prophylactic effect. However, it should be noted that lithium is secreted into breast milk and that significant concentrations of lithium can be measured in the plasma of breast-fed infants.

Mood-stabilizing Drugs 6.06.8.2 Carbamazepine Carbamazepine was originally introduced as an anticonvulsant and was found to have useful effects on mood in certain patients. Subsequently it was found to be beneficial in many bipolar patients, including those who had proved refractory to lithium. The acute antidepressant effect of carbamazepine is not established (Post, 1991).

155

Carbamazepine has also been associated with low sodium states. The use of carbamazepine in pregnancy has been associated with neural tube defects in the fetus. The risk is diminished by adequate folate intake. 6.06.8.3 Sodium Valproate

Like certain other anticonvulsants, carbamazepine blocks neuronal sodium channels. It is unclear whether this action plays a role in its mood-stabilizing effects. Like lithium, carbamazepine facilitates some aspects of brain serotonin function.

Like carbamazepine, sodium valproate was first introduced as an anticonvulsant. In recent years there has been increasing interest in using the drug in the management of mood disorders, particularly acute mania and the prophylaxis of bipolar disorder in patients unresponsive to lithium and carbamazepine. There is presently little evidence that valproate has acute antidepressant effects (McElroy, Kerk, & Pope, 1987; Post, 1991).

6.06.8.2.2 Efficacy

6.06.8.3.1 Pharmacology

In the treatment of acute mania, carbamazepine is of about equal efficay to lithium. In the prophylaxis of bipolar illness, carbamazepine is also about as effective as lithium, although the quality of the trials has been criticized (Dardennes, Even, Bange, & Heim, 1995). Based on a survey of controlled and uncontrolled trials (Post, Denicoff, Frye, & Leverich, 1997) it is estimated that about 65% of patients with bipolar illness show a clinically significant prophylactic response to carbamazepine either given alone or added to lithium. However, there is some evidence that in some patients an initial response can diminish with time suggesting that tolerance to the mood-stabilizing effects of lithium can occur (Post, Leverich, Rosoff, & Altschuler, 1990).

Valproate is a simple branch-chain fatty acid with a mode of action that is unclear. However, there is some evidence that it can slow the breakdown of the inhibitory neurotransmitter GABA. This action could account for the anticonvulsant properties of valproate, but whether it also underlies the psychotropic effects is unclear.

6.06.8.2.1 Pharmacology

6.06.8.2.3 Adverse effects Adverse effects with carbamazepine are common at the beginning of treatment (Table 10). They include drowsiness, dizziness, ataxia, diplopia, and nausea. Tolerance to these effects usually develops quickly. A potentially serious side effect of carbamazepine is agranulocytosis, although this complication is very rare (variously estimated from 1 in 10 000 to 1 in 125 000 patients). A relative leucopenia is more common, with the white cell count falling in the first few weeks of treatment, though usually remaining within normal levels. Rashes occur in about 5% of patients. Elevations in liver enzymes may occur and, rarely, hepatitis has been reported. Carbamazepine can also cause significant disturbances of cardiac conduction, and therefore is contraindicated in patients with preexisting abnormalities of cardiac rhythm.

6.06.8.3.2 Efficacy There have been several controlled studies suggesting that valproate is effective in the acute management of mania, but there are no controlled investigations of its efficacy in the prophylaxis of bipolar disorder (McElroy, Kerk, Pope, & Hudson, 1992). There have, however, been numerous case series and open studies that have reported useful prophylactic effects of valproate in patients unresponsive to lithium and carbamazepine, including those with rapid cycling mood disorders (McElroy et al., 1987, 1992; Post, 1991). 6.06.8.3.3 Adverse effects Common side effects of valproate include gastrointestinal disturbances, tremor, sedation, and tiredness. Other troublesome side effects include weight gain and transient hair loss with changes in texture on regrowth. Patients taking valproate may have some elevation in hepatic transaminase enzymes; provided this increase is not associated with hepatic dysfunction the drug can be continued while enzyme levels and liver function are carefully monitored. However, there have been several reports of fatal hepatic toxicity associated with valproate; thus

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Psychopharmacology

far these reports have been confined to children taking multiple anticonvulsant drugs. Valproate must be withdrawn immediately if vomiting, anorexia, jaundice or sudden drowsiness occur. Valproate may also cause thrombocytopenia and may inhibit platelet aggregation. Acute pancreatitis is another rare but serious side effect, and increases in plasma ammonia have been reported. Other possible side effects include edema, amenorrhoea and rashes. The use of valproate in pregnancy has been associated with neural tube defects and bleeding in the neonate. 6.06.9 CLINICAL USE OF PSYCHOTROPIC DRUGS 6.06.9.1 Anxiety Disorders

Where psychological treatments have not helped or are not available, buspirone or antidepressant drugs rather than benzodiazepines should now be used for longer-term treatment of GAD. The choice will lie between a sedating compound, such as a tricyclic antidepressant, or nonsedating treatments such as buspirone or an SSRI. Although, sedation has some advantages for patients with sleep disturbance and agitation, in the longer-term, buspirone or SSRIs are likely to be as effective and have less risk of cognitive impairment. There is little information about the combined use of medication and psychological treatment in GAD. There has been concern, however, that the cognitive impairment produced by benzodiazepines may decrease the ability of the patient to carry out psychological treatments.

6.06.9.1.1 Generalized anxiety disorder In generalized anxiety disorder (GAD) drugs are generally used as an adjunct to psychological methods of treatment (Table 11). Benzodiazepines are now prescribed only for short-term use (2±4 weeks) in patients where anxiety is causing severe distress and functional impairment. Benzodiazepines have a number of advantages as short-term treatment in that they are rapidly effective and have a wide safety margin. It is usually best to give benzodiazepine treatment on an as-required basis in doses of 2.5±5 mg. Intermittent use of this nature is less likely to result in tolerance (Tyrer, 1997). Tricyclic antidepressant drugs and trazodone have also been shown to be effective in GAD in the same doses that are effective in treating major depression (Rickels et al., 1993). SSRIs have not been formally tested in this disorder but clinical impression suggests that they are likely to be useful. The azapirone buspirone is also effective in GAD, particularly in patients who have not received significant prior benzodiazepine treatment. All these treatments take longer to work than benzodiazepines. Their ultimate effect over 6±8 weeks, however, is at least as great (Cowen, 1997).

6.06.9.1.2 Panic disorder and agoraphobia A number of drug treatments are effective in panic disorder. These include high potency benzodiazepines such as alprazolam and clonazepam, as well as tricyclic antidepressants such as imipramine and clomipramine (Lydiard & Ballenger, 1987; Modigh, Westberg, & Eriksson, 1992). SSRIs are also effective and paroxetine is licensed for the treatment of panic disorder in the UK (Oehrberg et al., 1995). MAOIs are good antipanic drugs but are little used because of their adverse food and drug interactions (Nutt & Bell, 1997; Nutt & Glue, 1989). Overall, all these drugs have efficacy in both preventing panic attacks and lessening phobic avoidance. However, antidepressants are difficult to use in panic disorder because initial treatment often produces symptomatic worsening and jitteriness. For this reason a low starting dose and careful titration are required. However, to obtain the best clinical response it is necessary eventually to build the doses up so that they are similar to those required in major depression (Mavissakalian & Perel, 1995). The

Table 11 Spectrum of activity for anxiolytic drugs.

Drug Benzodiazepines Buspirone TCAs SSRIs MAOIs

Generalized anxiety disordera

Panic disorderb

Social phobia

Obsessive-compulsive disorder

+ + + ? ?

+c ± + + +

?c ? ± + +

0 0 0d + 0

a + = effective; ± = not effective, ? = uncertain. pam). dClomipramine effective.

b

With or without agoraphobia.

c

High potency compound (alprazolam, clonaze-

Clinical Use of Psychotropic Drugs high potency benzodiazepines, alprazolam, and clonazepam, have the advantage of not causing increased anxiety early in treatment and this makes them easier to use (Schweizer, Rickels, Weiss, & Zavodnick, 1993). However, withdrawal of these drugs in patients with panic disorder can be very difficult (Fyer et al., 1987). Cognitive behavior therapy is effective in panic disorder and has the advantage that relapse is less common after the end of treatment than it is after drug treatment is withdrawn (Clark et al., 1994). Antidepressant treatment retains a useful place in patients who are not able to benefit from cognitive therapy. It is posssible that the combination of behavior therapy and antidepressant treatment might produce increased efficacy (de Beurs, Vanbalkom, Lange, Koele, & Van Dyke, 1995). A small potentiation of treatment efficacy was also apparent when alprazolam was added to exposure therapy for patients agarophobia and panic. However, alprazolam-treated patients showed less improvement after the end of the study (Marks et al., 1993). Alprazolam also produced significant impairments on word recall tasks (Curran et al., 1994). 6.06.9.1.3 Obsessive-compulsive disorder Drugs that produce marked potentiation of brain serotonin function, such as SSRIs and clomipramine, are effective in obsessive-compulsive disorder (OCD). About 50% of patients are much improved, although recovery is rarely complete. Similar doses or somewhat higher are used in the treatment of OCD as in major depression. Both obsessional ruminations as well as rituals respond to drug treatment. The time course of response is rather longer than in major depression with a linear rate of improvement beginning at about 4 weeks and continuing for 12 weeks and more (Jenike, 1992). There is little evidence that drug treatment increases the effect of behavior therapy in patients able to comply with this treatment (Cobb, 1992). However, drug treatment has a role in patients who cannot undertake behavior therapy or who are unresponsive to it. Relapse rates are much less after successful behavior therapy than after withdrawal of antidepressant drug treatment. It has therefore been suggested that, where patients have improved with drug treatment, behavior therapy may be added with the aim of facilitating drug discontinuation (Cobb, 1992). 6.06.9.1.4 Social phobia There is less evidence about the utility of drug treatment in the management of social phobia,

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although there is evidence from controlled trials that treatment with SSRIs and MAOIs may confer benefit (van Vliet, den Boer, & Westenberg, 1994; Versioni, Nardi, & Mundim, 1992). Interactions of drug treatment with psychological treatment have not been systematically studied. 6.06.9.2 Insomnia Insomnia is a common health problem in community samples (Lasagna, 1995). Although hypnotic drugs such as temazepam and zopiclone are effective in the short term, continued use may result in tolerance and rebound insomnia often occurs upon drug discontinuation. It is recommended therefore that hypnotic drugs be employed only for short-term treatment. Many people with insomnia use other pharmacological remedies such as sedating antihistamines or alcohol (Lasagna, 1995). These measures are generally of limited utility. The role of the pineal hormone melatonin is arousing increasing interest but controlled longitudinal studies are rare (Gafinkel, Laudon, Nof, & Zisapel, 1995). There are a number of psychological methods of helping insomnia (Morin, Culbert, & Schwartz, 1994). These should be preferred to drug treatment in the first instance because they have fewer adverse effects and their benefits, if obtained, are likely to persist for longer. 6.06.9.3 Depression Antidepressant drugs are used in the treatment of major depression and dysthymia (Depression Guideline Panel, 1993). Antidepressant drugs appear to be of definite value in more clinically severe depressions, particularly those that meet criteria for melancholic features (DSM-IV) or somatic symptoms (ICD-10) (Depression Guideline Panel, 1993). Although some improvement in depressive symptoms may be seen in the first week of treatment, generally antidepressant drugs can take 4±6 weeks to exert clinically important effects (Depression Guideline Panel, 1993; Quitkin et al., 1996). 6.06.9.3.1 Choice of antidepressant As noted above several kinds of antidepressant treatment are available which are of generally equivalent efficacy in the broad range of depressed patients. For the more severely depressed subjects, however, treatment with a tertiary tricyclic antidepressant, such as amitriptyline or clomipramine or the SNRI venlafaxine, should be considered (Anderson, 1997).

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For other patients the choice can be made according to the symptom profile of the antidepressant and the needs of the patient. For example, in subjects striving to carry on with their usual work and social activities, relatively nonsedating compounds such as lofepramine, nefazodone, SSRIs or venlafaxine would be suitable. Tertiary tricyclics may be helpful when sleep disturbance is severe or when rapid sedation is needed. In some patients, however, tricyclic antidepressants will be contraindicated because of their anticholinergic and cardiovascular side effects. Sedating compounds suitable in this situation include trazodone and mirtazepine. With the exception of lofepramine, tricyclic antidepressants should not be prescribed where there is a risk of deliberate overdose. MAOIs will generally be used as second- or third-line drugs because of their food and drug interactions. 6.06.9.3.2 Prophylaxis of recurrent major depression Once a patient has responded to antidepressant drug therapy, drug treatment is usually continued for at least 6 months to prevent relapse of syptoms; this is called continuation therapy (NIMH Consensus Development Conference Statement, 1985). In patients with recurrent major depression longer-term prophylactic drug therapy is often required to prevent frequent disabling recurrences. Generally, if an antidepressant is effective in acute phase treatment, it will provide a useful prophylactic effect during long-term treatment (Quitkin et al., 1996). However, some patients respond better to lithium prophylaxis or to the combination of antidepressant and lithium. 6.06.9.3.3 Psychological therapies and antidepressant drug treatment Specific psychotherapies such as interpersonal therapy (IPT) and cognitive behavior therapy are effective in the treatment of major depression. In general, patients with more severe depression appear to do less well with psychotherapy. For example, both IPT and cognitive behavior therapy appear less effective in patients with disturbances of sleep architecture (Thase et al., 1997; Thase, Simons, & Reynolds, 1996), a common feature of depression with melancholic features. It has also been reported that patients who fail respond to cognitive therapy can subsequently show benefit with antidepressant medication (Stewart, Mercier, Agosti, Guardino, & Quitkin, 1993). There is a strong clinical impression that combinations of psychotherapy and antidepres-

sant medication may be more efficacious than either alone in patients whose depression is complicated by interpersonal and social difficulties, but few controlled trials exist to sustain this opinion (Depression Guideline Panel, 1993). There have been studies of drug and psychotherapy interactions in the longer-term treatment of depression. For example, Frank et al. (1990) found that interpersonal therapy given once monthly delayed, but did not prevent, depressive recurrence compared to placebo medication and clinical management. In the same study interpersonal therapy did not augment the effect of impiramine to prevent depressive recurrence. There is some evidence that cognitive therapy can decrease the risk of subsequent relapse (Blackburn, Eunson, & Bishop, 1986). If this is the case it could be a very useful treatment for the many patients who wish to discontinue medication but are unable to do so because of symptomatic recurrence. 6.06.9.4 Mania Mania is generally treated with moodstabilizing drugs and antipsychotic medication. In the USA antipsychotic drugs are avoided as far as possible because of the risk of movement disorders and treatment with lithium or valproate preferred (Chou, 1991). It is important to note that the plasma level of lithium effective in mania (0.8±1.2 mmol/1) is somewhat higher than the range recommended for prophylaxis (0.5±0.8 mmol/1) (Prien, Caffey, & Glett, 1992). In the UK, because of the risk of lithium rebound upon sudden disontinuation (Goodwin, 1994), antipsychotic medication tends to be used more in the treatment of acute mania. In general, conventional antipsychotic drugs such as chlopromazine and haloperidol are employed; there is little information on the efficacy of newer antipsychotic drugs such as risperidone and olanzepine. Benzodiazepines may be employed for sedation (Chou, 1991). The treatment of mania requires skilled nursing and psychological management but specific interpersonal or cognitive therapies are not generally used. 6.06.9.5 Prophylaxis of Bipolar Illness Bipolar illness is a recurrent disorder and prophylaxis with mood-stabilizing drugs is a mainstay of treatment. A major problem in the management of bipolar disorder is lack of compliance with treatment. This has a variety of

References causes, ranging from adverse effects of drugs to the difficulty that people experience in coming to terms with life-long serious illness which requires continued drug treatment. In addition, patients need to learn to recognize minor mood changes that may be the prodrome for more serious mood disturbances unless action is taken. It is possible to address these issues in a number of ways, ranging from education to formal cognitive behaviour therapy. Such measures improve the prognosis in bipolar disorder (Jamison, 1994).

6.06.9.6 Schizophrenia Antipsychotic drugs are necessary for the acute treatment of psychosis and are also required for long-term prophylaxis in many patients. First-line drug treatment has usually been with chlorpromazine or haloperidol. However, such drugs are likely to be gradually replaced with newer atypical agents such as risperidone and olanzepine because of the decreased incidence of movement disorders and somewhat greater efficacy of the latter agents (Marder & Meibach, 1994; Tollefson & Sanger, 1997). Atypical agents are not available yet in parenteral form and, where oral medication is not possible, intramuscular administration of conventional antipsychotic drugs has to be employed. As noted above, current trends are to use low doses of a high potency agent such as haloperidol with additional benzodiazepine medication if required (Pilowsky et al., 1992). For longer-term prophylactic treatment, again atypical agents may be preferred. If depot preparations are needed, however, conventional drugs such as flupenthixol, fluphenazine or haloperidol have to be used. Most patients with schizophrenia continue to experience a level of positive and negative symptoms despite drug treatment. There is growing interest in the use of cognitive behavior therapy in addition to medication in schizophrenia. There is evidence that combined drug and psychotherapy in selected patients can improve the resolution of delusions and hallucinations (Drury, Birchwood, Cochrane, & Macmillan, 1996). As with the long-term management of bipolar illness, lack of compliance with medication is a major problem in patients with schizophrenia. There is evidence that cognitive therapy designed to help the patient evaluate their attitudes to their illness and its treatment may improve the take up of drug therapy (Kemp, Hayward, Applewhaite, Everitt, & David, 1996).

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Goodwin, F. K., & Jamison, K. R. (1990). Medical treatment of acute bipolar depression. In F. K. Goodwin & K. R. Jamison (Eds.), Manic depressive illness (pp. 630±664). Oxford, UK: Oxford University Press. Jacobson, S. J., Jones, K., Johnson, K., Ceolin, L., Kaur, P., Sahn, D., Donnenfeld, A. E., Rieder, N., Santelli, R., Smyth, J., Pastuszak, A., Einarson, T., & Koren, G. (1992). Prospective multicentre study of pregnancy outcome after lithium exposure during the first trimester. Lancet, 339, 530±533. Jamison, K. R. (1992). Manic-depressive illness. In K. Hawton & P. Cowen (Eds.), Practical problems in clinical psychiatry (pp. 33±50). Oxford, UK: Oxford University Press. Jenike, M. A. (1992). Pharmacologic treatment of obsessive compulsive disorders. Psychiatric Clinics of North America, 15, 895±919. Jeste, D. V., & Caligiuri, M. P. (1993). Tardive dyskinesia. Schizophrenia Bulletin, 19, 303±315. Kane, J., Honigfeld, G., Singer, J., & Meltzer, H. Y. (1988). Clozapine for the treatment-resistant schizophrenic: A double blind comparison with chlorpromazine. Archives of General Psychiatry, 45, 789±796. Kemp, R., Hayward, P., Applewhaite, G., Everitt, B., & David, A. (1996). Compliance therapy in psychotic patients: randomised controlled trial. British Medical Journal, 312, 345±349. Kilbourne, E. M., Phiten, R. M., Kamb, M. L., & Falk, H. (1996). Tryptophan produced by Showa Denko and epidemic eosinophilia-myalgia syndrome. Journal of Rheumatology, 23(Suppl. 46), 81±88. Krupp, P., & Barnes, P. (1992). Clozapine-associated agranulocytosis: Risk in aetiology. British Journal of Psychiatry, 160(Suppl. 17), 38±40. Lancaster, S. G., & Gonzalez, J. P. (1990). Lofepramine: A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in depressive illness. Drugs, 37, 123±140. Langtry, H. D., & Benfield, P. (1990). Zolpidem: A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential. Drugs, 40, 291±313. Lasagna, L. (1995). Over-the-counter hypnotics and chronic insomnia in the elderly. Journal of Clinical Psychopharmacology, 15, 383±386. Lithium Mechanisms Study Group. (1993). Mechanisms of lithium action. Reviews in Contemporary Pharmacotherapy, 4, 287±317. Livingston, M. G. (1994). Risperidone. Lancet, 343, 457±460. Lydiard, R. B., & Ballenger, J. C. (1987). Antidepressants in panic disorder and agoraphobia. Journal of Affective Disorders, 13, 153±168. Marder, S. R., & Meibach, R. C. (1994). Risperidone in the treatment of schizophrenia. American Journal of Psychiatry, 151, 825±835. Marks, I. M., Swinson, R. P., Basoglu, M., Kuch, K., Noshirvani, H., O'Sullivan, G., Lelliot, P. T., Kirby, M., McNamee, G., Sengun, S., & Wickwire, K. (1993). Alprazolam and exposure alone and combined in panic disorder with agoraphobia. British Journal of Psychiatry, 162, 776±787. Mavissakalian, M. R., & Perel, J. M. (1995). Imipramine treatment of panic disorder with agoraphobia: Dose ranging and plasma level±response relationships. American Journal of Psychiatry, 152, 673±682. McElroy, S. L., Keck, P. E., & Pope, H. G. (1987). Sodium valproate: Its use in primary psychiatric disorders. Journal of Clinical Psychopharmacology, 7, 16±24. McElroy, S. L., Keck, P. E., Pope, H. G. & Hudson, J. I. (1992). Valproate in the treatment of biopolar disorder: Literature review and clinical guideline. Journal of Clinical Psychopharmacology, 12, 42S±52S. Modigh, K., Westberg, P., & Eriksson, E. (1992). Super-

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imipramine, trazadone and diazepam. Archives of General Psychiatry, 50, 884±895. Rickels, K., Schweizer, E., Clary, C., Fox, I., & Weise, C. (1994). Nefazodone and imipramine in major depressionÐa placebo controlled trial. British Journal of Psychiatry, 164, 802±805. Robert, E. (1996). Treating depression in pregnancy. New England Journal of Medicine, 335, 1056±1058. Robinson, D. S., Roberts, D. L., Smith, J. M., Stringfellow, J. C., Kaplita, S. B., Seminara, J. A., & Marcus, R. N. (1996). The safety profile of nefazodone. Journal of Clinical Psychiatry, 57 (Suppl. 2), 31±38. Royal College of Psychiatrists (1993). Consensus statement on the use of high dose antipsychotic medication. Council Report CR26. London: Royal College of Psychiatrists. Rudorfer, M. V., & Potter, W. Z. (1989). Antidepressants: A comparative review of the clinical pharmacology and therapeutic use of the ªnewerº versus the older drugs. Drugs, 37, 713±738. Schweizer, E., Rickels, K., Weiss, S., & Zavodnick, S. (1993). Maintenance drug treatment of panic disorder. 1. Results of a prospective, placebo-controlled comparison of alprazolam and imipramine. Archives of General Psychiatry, 50, 51±60. Simpson, G. M., & De Leon, J. (1989). Tyramine and new monoamine oxidase inhibitor drugs. British Journal of Psychiatry, 155 (Suppl. 6), 32±37. Stahl, S. M. (1996). Essential Psychopharmacology. Cambridge, UK: Cambridge University Press. Sternbach, H. (1991). The serotonin syndrome. American Journal of Psychiatry, 148, 705±713. Stewart, J. W., Mercier, M. A., Agosti, V., Guardino, M., & Quitkin, F. M. (1993). Imipramine is effective after unsuccessful cognitive therapy: Sequential use of cognitive therapy and imipramine in depressed outpatients. Journal of Clinical Psychopharmacology, 13, 114±119. Svensson, T. H., & Usdin, T. (1978). Feedback inhibition of brain noradrenaline neurones by tricyclic antidepressants: Alpha-receptor mediation. Science, 202, 1089±1091. Thase, M. E., Buysse, D. J., Frank, E., Cherry, C. R., Cornes, C. L., Mallinger, A. G., & Kupfer, D. J. (1997). Which depressed patients will respond to interpersonal psychotherapy? The role of abnormal EEG sleep profiles. American Journal of Psychiatry, 154, 502±509. Thase, M. E., Simons, A. D., & Reynolds, C. F. (1996). Abnormal electroencephalographic sleep profiles in major depression: Association with response to cognitive behaviour therapy. Archives of General Psychiatry, 53, 99±108. Tollefson, G. D., & Sanger, T. M. (1997). Negative symptoms: A path analytic approach to double-blind, placeboÐand haloperidolÐcontrolled clinical trial with olanzapine. American Journal of Psychiatry, 154, 466±474. Tyrer, P. (1997). Pharmacotherapy for anxiety disorders: Using the available drugs. Advances in Psychiatric Treatment, 3, 72±78. Tyrer, P., Rutherford, D., & Huggett, T. (1981). Benzodiazepine withdrawal symptoms and propranolol. Lancet, i, 520±522. van Vliet, I. M., den Boer, J. A., & Westenberg, H. G. M. (1994). Psychopharmacological treatment of social phobia: a double blind placebo controlled study with fluvoxamine. Psychopharmacology, 115, 128±134. Versiani, M., Nardi, A. E., & Mundim, F. D. (1992). The pharmacology of social phobia. A controlled study of moclobemide and phenelzine. British Journal of Psychiatry, 161, 353±360. Yocca, F. D. (1990). Neurochemistry and neurophysiology of buspirone and gepirone: Interactions of pre-synaptic and post-synaptic 5-HT1A receptors. Journal of Clinical Psychopharmacology, 10(Suppl. 3), 6S±12S.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.07 Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches LARRY E. BEUTLER, KEVIN BOOKER, and STACEY PEERSON University of California, Santa Barbara, CA, USA 6.07.1 INTRODUCTION

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6.07.1.1 The Diversity of Experiential Therapies 6.07.1.1.1 Experiential theory as a method of study 6.07.1.1.2 Experiential theory as a set of assumptions 6.07.1.1.3 Experiential theories view the source of behavior 6.07.1.2 Chapter Overview 6.07.2 HISTORICAL DEVELOPMENT

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6.07.2.1 Existential Models: The Rise of Logotherapy 6.07.2.2 Phenomenological Approaches: The Rise of Client-centered Therapy 6.07.2.3 Humanistic Approaches: The Rise of Gestalt Therapy 6.07.3 CONTEMPORARY DEVELOPMENTS

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6.07.3.1 Theoretical Developments and Applications 6.07.3.1.1 Existential theories 6.07.3.1.2 Phenomenological theories 6.07.3.2 Humanistic Theories 6.07.3.3 Research and the Status of Experiential Therapies

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6.07.4 CONCLUSIONS

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6.07.5 REFERENCES

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even minor disagreements with former disciples resulted frequently in the development of different ªschoolsº; old allegiances and friendships were lost, and theoretical constructs became rigidly reified by the vigorous defenses erected against annihilation by their proponents. This history of dispute and division left a legacy of fragmentation in psychotherapy theory; hundreds of schools of thought have evolved with the very nature of evidence being in hot dispute. As clients and prospective clients, as well as practitioners and scientists, this is the legacy that remains (Bergin & Garfield, 1994; Freedheim, 1992).

6.07.1 INTRODUCTION The theoretical development of psychotherapy has not been smooth; theories have evolved largely through conflict and revolution rather than through an orderly progression of evidence and discovery. From the beginning, Freud demanded unswerving loyalty to his viewpoints, an unrealistic expectation given that the topic of discourse was, at that time, so poorly understood, and that the concepts were so complex and subjective. Freud's lack of sympathy toward those whose perspectives came to diverge from his own extended to a point that 163

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In order to both capture the breadth of the field and to bring some order to it, it is useful to conceptualize the field as being composed of various overlapping levels of specificity. At least three such levels, systems, models, and theories, are necessary to capture the color and diversity of the field of psychotherapy. Most theorists generally identify psychotherapy as evolving from three major systems or schools (Rice & Greenberg, 1992). Each of these intellectual systems continue in somewhat modified form from their initial beginnings and in contemporary psychotherapy, are composed of models and theories, all of which share a common but distinctive view of what motivates behavior. The first system in this evolution is the collection of viewpoints that are often referred to as ªpsychoanalyticº or ªpsychodynamic.º This system is distinguished from the other two by its reliance on the concept of intrapsychic conflict as the basis of motivation and change. It arose with the ideas of Freud in the first two decades of the twentieth century, and expanded through the contributions both of Freud's (former) disciples and from the application of his ideas to the theories that are known as ego-psychology, self-psychology, and object relations. The second system in the evolution of psychotherapy came to prominence in the 1940s and 1950s. The behavioral school replaced the concept of intrapsychic conflict with ªReinforcementº as the basic motivating force of behavior. Conditioning, along with its variants of learning by association and consequences, became the primary explanatory construct. Experiential schools, the ªthird forceº in psychotherapy (Rice & Greenberg, 1992), in contrast to the first two, view motivation as an inherent struggle for integration and growth. Thus, rather than being either driven by base instincts, that were inherently destructive and negative, or by external consequences, that were inherently neutral in social value, self-actualization assumed a decidedly positive valence, moving the individual toward increasingly social and enhancing ends. Within each of these three systems there are a variety of more specific models that describe how the general system or movement is translated to the specific example of psychotherapy. Each of these models share the view of the larger group, the school, regarding the basis of motivation, but differ in how they think these motives are manifest in psychopathology and how they are addressed in psychotherapy. Specifically, for example, within the larger movement of ªPsychoanalytic Theory,º as has already been mentioned, there

are models based on ego-psychology, selfpsychology, and objects-relations theory. ªExperiential Theory,º likewise, is comprised of existential, humanistic, and person-centered models of psychotherapy; within the behavioral school are radical behaviorism, social learning theory, and cognitive models. Each of these models poses a slightly different view of how behavior is best changed and what aspects and patterns of motives are likely to be manifest in this process. A third and more specific ordering of theory identifies specific theories of psychotherapy. These theories typically are identified by certain strategies and techniques that distinguish them from others, even within the same model and system. Beck's theory of cognitive therapy is different from that of Ellis, for example, though they both are representative of a cognitive model of psychotherapy. Again, using the example of Experiential Theory, within the model of existentialism, Daseinsanalysis and Logotherapy represent different, specific, theoretical contributions; within the humanistic tradition, Gestalt Therapy and Redecision Therapy may be recognizable and distinct, and within a phenomenological model, client-centered and personcentered therapies represent a line of evolution within a single theory. It bears mentioning that some believe that two other systems or schools are sufficiently distinct from their roots and are vying for status as major, independent ªforcesº in psychotherapy. Cognitive models of behavior are certainly strong contenders for this status. Given that they pose the same motivational system that characterizes behavioral theories, however, it is unlikely that they qualify as a distinctive, major system of the order of psychoanalytic, behavioral, and experiential theories. Similarly, while integrative models are widespread and influential, it is difficult to find a characteristic, common, and distinguishing set of theoretical assumptions. These issues will likely prevent both cognitive and integrative models of intervention from being elevated to the level of a ªfourth forceº in psychotherapy. The very presence of these emerging and competing systems, however, and the many variations of theory that they represent, testify to the fragmentation of the field. Certainly, the diversity of psychotherapeutic approaches is substantially greater than might be judged if the view were only at the level of the three broad systems to which theorists often refer. Though it seems that no one has taken the time to count them, there are clearly more than 400 specific theories and an indefinite number of intermediate level models representing these.

Introduction 6.07.1.1 The Diversity of Experiential Therapies ªExperiential Therapyº is a broad designation within which there is a rich array of diversity. Humanistic, existential, and phenomenological models are well accepted as being subdivisions of this general system. The identity of the more specific theories that represent these models, however, is less consistent. Some theories are not easily classified within a single model while others are blends of two or more. Thus, some authors identify constructivist approaches such as that of Kelly (1955) as an experiential theory (e.g., Bugental & McBeath, 1995; Feshbach, Weiner, & Bohart, 1996), while others identify it as a variant of behavioral or psychodynamic schools (e.g., Mahoney, 1993). The basis of this disparity is not obvious. While this variability suggests that there is a lack of reliability in assigning at least some theories of psychotherapy to general models or schools, it also illustrates the cross-theory blending that is a part of the experiential movement itself. Culturally, experiential philosophies are ingrained deeply in the values of hard work and sacrifice, the values of the industrial and Protestant revolutions. The evolution of these theories was forever colored by the experiences of holocaust survivors and others who suffered the ravages of war and prolonged catastrophe (e.g., Frankl, 1961). While their theoretical roots date to the European philosophers of the eighteenth and nineteenth centuries, as a domain of practice and service, experiential therapies are largely a post-WWII development. They represent the ªtransplanting of existential thinking from their chiefly European intellectual roots to a broader US audience of nonmedical, unphilosophically sophisticated, practicing counselors and therapistsº (Bugental & McBeath, 1995, p. 112). Rice and Greenberg (1992; modified from Tageson, 1982) point out that the various theoretical variations within experiential theory share: (i) a reliance on phenomenology as a method of study, (ii) an assumption that in-born actualizing tendencies motivate behavioral development and change, and (iii) a belief in individual choice as the causal locus of behavior. 6.07.1.1.1 Experiential theory as a method of study The methods that are used by experiential psychotherapists are phenomenological and individualistic, contrasting with the objective, external, and pluralistic methods of psychoanalytic and behavioral models. It is assumed that healing of the most complex problem will occur naturally by acquiring a deep under-

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standing of each individual's unique personal experience of the world in which they live. An assessment of either the truth or value of this personal experience is not reliant on external criteria, but on the person's own subjective standard, their capacity to assess that standard through a process of reflective awareness, and the degree to which the resulting understanding furthers the self-actualization of the individual. Knowledge, as defined through the conventional scientific standards of empirical observation and externally measured but collective responses, is thought to be inadequate unless it deepens an understanding of the unique phenomenology of the person. The assumption that ªTruthº is in the patient's experience contrasts both with psychoanalytic and behavioral views. These latter views identify the therapist, rather than an external body, as the nucleus of knowledge. In psychoanalysis, for example, insight and knowledge come from the therapist's or analyst's interpretation, not from the patient, through the mechanism of interpretation. Thus, it is the analyst, not the analysand, who defines the veracity and validity of experience. Likewise, in behavioral models, the therapist is considered to be the expert or authority whose critical understanding of behavior serves as the guide for developing a technical correction. From the therapist, not the patient, come the suggestions and guidance that are then further supported by homework assignments from the therapist. In both of these views, the value of evidence is proportional to the degree to which the therapist-observer can remain objectively distant from the observed, the patient. In contrast, in existential/humanistic analysis, information flows from patient to therapist, rather than vice versa. The veracity of an experience is defined, for the experientialhumanist, by self-reflection and personal authenticity. The process of exploring and identifying the nature and content of selfappraisal is not controlled by the therapist; it is only facilitated and allowed to expand by a permissive clinician. It is this self-initiated growth that is the basis of healing. 6.07.1.1.2 Experiential theory as a set of assumptions Beutler, Bongar, and Shurkin (in press) emphasize that three assumptions both distinguish experiential therapy from psychoanalytic and behavior therapy and represent the bases that bind the specific theories within the domain of experiential models together. These binding assumptions include the beliefs that: (i) there is an innate process that directs emotional growth;

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(ii) constraining this inborn tendency from its normal process of unfolding produces distress and psychopathology; and (iii) removal of these constraints in a permissive environment releases the healing process. Among the various models and theories that constitute the experiential school, however, the priority and nature of these beliefs change. Within the mainstream of the tradition, selfactualization is the fundamental motivational force. It is an innate process that moves the organism to become increasingly complex, balanced, and integrated. Thus, self-actualization requires emotional and sensory as well as cognitive input. Sensory and emotional experiences are thought to be necessary in order to insure the adaptive incorporation of new cognitive information. As a person adapts, accommodates, and incorporates new information, they naturally become more differentiated and complex, both intellectually and interpersonally. Cognition becomes differentiated, emotions become more varied, and behavior is increasingly discriminating. Put in this way, self-actualization is not tied to a particular set of social values. However, some theories within the phenomenology and humanistic traditions extend the definition to include the view that this growth process includes a movement toward greater productivity, selfsufficiency, creativity, and social adaptability. These definitions add a dimension of social ªgoodnessº and tie the theory more closely to democratic social systems. The assumption that self-actualization is an inherent drive, drawing one toward growth and differentiation is probably less easily accepted by existential theorists than it is by humanistic and phenomenological theorists (Rice & Greenberg, 1992). In existential models, self-actualization assumes a teleological definition in which growth derives from a pull from individualized goals and aspirations rather than from a force that pushes one toward more abstract, societal goals. The second assumption underlying experiential models identifies the basis for psychopathology. This assumption points to social and familial constraint and restriction of emotional experience as a pathological force that constrains the natural process of growth and differentiation. Beutler et al. (in press) observe that most Western societies seek to restrain intense emotions and discourage the development and expression of emotions. Experiential theorists argue that this social constraint separates an individual from some of the experience that is necessary for effective information processing. This emotional constraint is based on three beliefs that are

considered by experiential theorists to be fallacious and mistaken: (i) cognitive knowledge can be separated from its emotional concomitants, (ii) destructive acts are the products of intense emotions, and (iii) constraint of emotions will protect the society from these destructive acts. Experiential theories assert that the very act of trying to protect a society by restricting the emotional experiences of its citizens has the paradoxical effect of increasing, rather than reducing, the likelihood of social discord and violence. In this view, human problems are caused, not by excessive expression, but by restraining and fragmenting the normal and necessary acts of thinking, feeling, sensing, and intuiting. Emotional constraint during the course of emotional development, in other words, prevents incorporation of the very information that promotes integration and emotional growth. Thus, rather than reducing the likelihood of destructive acts, the efforts of society and families to protect themselves from strong emotions is thought to interrupt and fragment the experiences that allow people to develop social conscience and constraint. By becoming separated from their feelings, individuals may then engage in destructive behavior without feeling and sensing the consequences of these experiences. Both the benign failure to actualize and grow from new experience and the malignant social destructiveness of impulsive behavior, therefore, are products of these misdirected societal efforts. The third assumption that characterizes the experiential movement identifies the basis of correcting the pathological effects of emotional constraint. This assumption defines the nature and objectives of psychotherapy. It assumes that self-actualizing tendencies and powers that have been aborted and fragmented can be reactivated in a therapeutic environment that is characterized by unconventional acceptance of emotional experience. Such an environment is thought to unencumber, allow, and encourage the reconnection of emotions and their expression. Behaviors become reattached to their emotional and sensory concomitants and consequences. By reconnecting these components of experience, self-actualization motives are reactivated, and the normal processes of growing is allowed to continue. Experiential therapies provide an environment that is free from those arbitrary constraints that are imposed against emotion and sensing by society and by families. The psychotherapist endeavors to focus on, facilitate, sometimes even to create experiences that will magnify emotional and sensory reactions so

Historical Development that it can penetrate defenses that have been deadened by societal rules. The idea that human emotional needs and drives are sources of prosocial and proindividual behavior stands in contrast both with the negative nature of humankind espoused by the id psychology of psychoanalysis and with the tabula rasa view of personal development that characterizes most modern reinforcement psychologies. 6.07.1.1.3 Experiential theories view the source of behavior Experiential philosophies view individuals as having ultimate control in their own lives. They are thought to be active, not only in selecting their own behavior, but in constructing their own realities. It is out of this human capacity to make their own meanings of experience that people construct goals and aspirations. It is also on these meanings that people rely when faced with oppression, physical restriction, and intellectual constraint in order to survive even the most atrocious of events. The internal construction of meaning and worth, in these eventualities, provides armor against external, destructive forces. Self-determinism, in other words, is the prevailing principle of the experiential movement, and applies as much to thoughts and feelings as it does to behaviors. Experiential models attempt to counter the victim-based mentality that characterizes both psychoanalytic and behavioral positions. These latter systems assign people to a position of being reactive either to instinctive urges, social disruption, or reinforcements. Unlike these alternative systems, experiential models assume that people have a proactive posture. They retain personal choice over their own perceptions and meanings. This choice is optimized when using and integrating information from the full range of sensory, perceptual, and cognitive experience. Both psychoanalytic and behavioral models are viewed as excluding sensory and emotional experience and of exaggerating the significance of societal standards, insight, and behavior. 6.07.1.2 Chapter Overview In the rest of this chapter, attention will turn to a variety of specific psychotherapy theories that represent three models of behavior within the experiential tradition: existential, phenomenological, and humanistic psychotherapies. The discussion will be restricted largely to post-WWII developments. Using representative approaches of each of the models that comprise

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the experiential school as examples, theories will be traced from their post-WWII roots to their status in the 1990s. The theoretical approaches that have been chosen to be representative of the development of the experiential system include the personcentered (or ªclient-centeredº) therapy of Carl Rogers as an example of phenomenological models; the Gestalt therapy of Fritz Perls as a representative example of humanistic models; and the Logotherapy of Victor Frankl as an example of existential models. These early theories will be traced through an evolution that has produced a large array of contemporary modifications, variations, and approaches. An exhaustive description of the offspring and research associated with the theories developed by Rogers, Perls, and Frankl is not possible within the framework of this chapter, but some representative descriptions of the progeny of each will be provided. The contemporary Gestalt therapies of Greenberg and Daldrup and their colleagues will be described; the contemporary experiential therapies of Gendlin and Mahrer and the contemporary existential therapies of May, Maslow, and Bugental. Following a description of the historical roots of the three general theories, a more general perspective of the experiential system will describe developments in theory and practice, with a review of the research. 6.07.2 HISTORICAL DEVELOPMENT 6.07.2.1 Existential Models: The Rise of Logotherapy Existential philosophy was transported to the field of psychotherapy from Europe via the immigration of victims of the holocaust following WWII. This philosophy found voice in the US through Frankl's (1963) Man's search for meaning, a treatise on survival in the concentration camps. Existential conceptualization of the individual sought to qualify and validate the experience of immediate existence, independent of the theoretical projections about human psychological functioning that were implicated historically by other theories of psychotherapy. Frankl observed that interpersonal alienation, related either to economic status or political posturing, in conjunction with the precarious stability of social (family) structures, had the capacity to invoke debilitative anxiety. Under a war-time period of constant life-threat, existentialism congealed as a response that restored the dignity of human life and resurrected the human spirit. Theories that explain motivation by reference to homeostasis alone were incapable of capturing the complexity of

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the human struggle. To Frankl, therefore, it was the act of striving for meaning that formed the basis of motivation and the impetus for change. Frankl was born in 1905 in Vienna, the seat of Freud's psychoanalysis. He founded the Youth Advisement Centers in 1928, in response to a long-standing interest in emotional well-being, shortly before completing the work for his M.D. degree (1930). As a psychiatrist and neurologist, he joined the faculty of the Department of Neurology at the Rothschild Hospital in Vienna in 1936 and rose to Department Head by 1942. He published papers in prominent journals on the topic of psychiatric and neurological treatment of neurosis, beginning in 1939, and became quite prominent in Vienna psychiatric circles even before Hitler's 1939 invasion of Poland (Patterson & Watkins, 1996). Frankl was interned both in Auschwitz and Dachau between the years of 1942 and 1945, where he lost virtually all of his family to the gas chambers. Man's search for meaning, which reported his experiences there, was published in Vienna shortly after the end of the war. Subsequently he lectured widely in North America, capturing the imagination both of postwar Europe and of the American public. In spite of his great influence on American psychotherapy, Frankl never immigrated to the United States. Following the war, he assumed a full-time faculty position at the University of Vienna where he rose to the rank of Professor in 1955. Frankl's experiences in Auschwitz and Dachau, and his intimate relationships with despair, hopelessness, depression, and imminent death, qualify him as an effective authority on suffrage and the human condition. Frankl found himself stripped to his naked existence by the atrocities of the Nazis; his father, mother, brother, and even his wife had been sent to the gas ovens. With the exception of his sister, Frankl lost his entire family to the Nazis. He faced the question of how a person who had lost virtually every possession, had every value destroyed, who was hungry and suffering with the constant thought of imminent extermination, could find life worth preserving. Responsibility and meaning are the hallmarks of Frankl's theoretical construct of ªbeing.º These concepts speak directly to the condition of the human sufferer who has made the concession that they have nothing to lose except life, and that life itself is irrelevant without value and choice. Reflecting on his own senseless suffering and misery, Frankl concluded that to live is to suffer, and to survive is to find meaning in the suffering. Frankl believed that each individual was responsible for finding a purpose in life and that each must accept the responsibility that is

prescribed by this meaning. Thus, Frankl believed, with Nietzsche, that he who has a ªwhyº to live can bear with almost any ªhow.º ªBeingº to Frankl was trivariate, comprising spirituality, freedom, and responsibility. Spiritual awareness was cardinal in the process of being, taking precedence over freedom and responsibility, what he called the ªpsychophysicum.º To reflect on one's self, to project meaning on experience, and to relate with forces that were bigger than one's self were the products of spiritual awareness. Freedom was second only to spirituality in the course of being. Freedom was defined as the capacity to rise above instincts, to reject or accept experience, and to do or not to do. Thus, a person had the freedom to pursue the objectives set by spiritual awareness, and this freedom represented a cardinal distinction between people and other animals. Yet the motivation to achieve meaning through spiritual consciousness and freedom were not driving but pulling forces. That is, to Frankl, freedom and striving for meaning were achieved because they drew people to action, not because it caused or compelled them to act. In his own struggle, Frankl was forced to deal with the conspiracy of the Nazis to force the oppressed to give up on life as they saw all of their familiar benchmarks, attachments, and goals ripped away. He discovered that when life is thus controlled, and external objects and relationships are lost, some basic ªhuman freedomsº remain; the God-given ability to choose the meanings that one assigns to experience and to choose the attitude one holds in and about the extant conditions and circumstances. It is this ultimate freedom to choose attitudes that both informed Frankl's experiences in the camps of Auschwitz and Dachau and that continue to have the capacity to guide modern people's resolution of the existential dilemma. The third factor in Frankl's conception of being was responsibility. He came to believe that spiritual awareness and choice were matters of responsibility. One is responsible both to find meaning in one's life and to act on that meaning. Logotherapy (Frankl, 1961), therefore, placed much emphasis on helping people assess the implied responsibilities associated with the meanings they gave to their lives, and to act on their own behalf. This process of developing meaning, claiming freedom, and taking on responsibility, however, was changing constantly with one's position and place in life. The emphasis given by existential theory to the ontological predisposition of the patient is the most fundamental and salient marker for human functioning, and is the lens through which one is viewed.

Historical Development In Logotherapy, human problems are seen as arising in the form of neurotic anxiety that becomes attached either to the somatic, psychologic, or spiritual aspects of one's life. Frankl gave special attention to the spiritual neuroses, those that arise from existential concerns as opposed to those arising from intrapsychic conflicts. Frankl had great faith in and hope for the capacity of humans to rise above these anxieties. His accounts of life as a prisoner resonate with examples of tremendous human resilience and surprising capacity, of the common man or woman, to transcend the spiritual emaciation and weakness that so often is associated with human suffering. Frankl bemoaned that spirituality, the experience which is so central to human experience, was ignored by Freud and his followers. He believed that it was from the spiritual sense of humankind that consciousness arose, and in a corresponding fashion, Frankl identified not only an instinctive unconscious, but a spiritual one. By the process of uncovering the spiritual unconscious, esthetic awareness, love, and life values arose. The will to live in the face of death, the will to hope in the presence of hopelessness, and ultimately the ªwill-to-meaningº in the presence of meaninglessness were the basis for psychotherapeutic applications of existentialism. Thus, Frankl's goal in psychotherapy was to help patients find meaning and responsibility in life independent of their life's circumstance. In an attempt to help ªgroundº his patients, he would often ask, ªWhy do you not commit suicide?º (Frankl, 1963). From their responses, he would seek the emotional basis for their existence. True to the phenomenological assumption that characterized all of the experiential system, Frankl placed trust in the struggles of lost or searching patients to find a meaning from which to extract the basis for existential preservation; personal elements and experiences with which to illuminate the meaning in their lives. For some, meaning may be found in love for family; for others it may be in a relationship with a church or organization. Whatever the scenario, the intricate and delicate processes of a therapeutic search for meaning involved in the integration or weaving together of these threads of broken lives into a supportive pattern.

6.07.2.2 Phenomenological Approaches: The Rise of Client-centered Therapy Like existentialism, client-centered therapy had its roots in religious tradition and practice.

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However, whereas existentialism arose from religious persecution and was supportive of contemporary religious views, the Client-centered movement began as a reaction against the attitudes and philosophies that characterized much of American Protestantism. Carl R. Rogers (1902±1987) was raised in a close-knit, Methodist family that was committed to the Protestant traditions of work and obedience. He struggled with the religious dogmas of his family, most of which seemed arbitrarily to dictate how he should feel and what he should do. He viewed these dictates as constraining both of his intellectual growth and of his enjoyment, and found little comfort in the admonition that they should be accepted on faith alone. When, as an adolescent, his family moved to a farm, Rogers became enthralled with the science of agriculture. He devoured articles and books describing agricultural research and, deriving support from the dictums of science, he began to question his family's religious traditions. He found in science the hope that abstract principles and assumptions could be put to a test. He also found hope for an escape from unbending religious doctrines. Eventually, the development of a nondirective, nondoctrinaire approach to helping people was his escape from the rigid views of a conservative ª(almost fundamentalist) Protestant Christianityº (Rogers, 1959, p. 184). The route to the development of clientcentered therapy passed through a number of stages as Rogers grappled with how to reconcile his scientific need for structure, his personal needs for freedom, and the dogmatic and controlling religion of his youth. Rogers originally called his approach to psychotherapy ªNon-directive,º a reflection of his de-emphasis on therapist authority. Later, he adopted the term ªClient-centeredº (Rogers, 1951) to place the focus on the process rather than the techniques. In later years, Rogers came to prefer the term ªPerson-centeredº to reflect his evolving interest in the application of his ideas to environments beyond that of psychotherapy. In adolescence, Rogers felt distant from the family religion, a distance that was exacerbated by the liberal views to which he was exposed at the University of Wisconsin, where he graduated with a B.A. degree in 1924. Still trying to maintain a foothold in religion, upon entering young adulthood, he sought out a liberal Christian denomination and undertook studies as a minister in the Union Theological Seminary. He found there a religious environment that gave him both the opportunity and the encouragement to engage in free, philosophical thought. This freedom of thought, however, ultimately moved him even further from his

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religious roots and he left the seminary after two years in order to enter the graduate program in clinical psychology at Columbia University's Teacher's College. Rogers graduated with an M.A. (in 1928) and a Ph.D. (in 1931), but during these years his break with formal religion became complete and he began to seek other avenues for expressing his humanistic values. Client-centered Therapy may well have been his long-sought alternative to religion in providing meaning and structure in his life. Rogers initially was encouraged to work with children and families, probably because in these prewar years this domain still offered the only significant opportunity for a nonphysician to offer treatment. In 1928, when he was nearing the completion of his Ph.D. work, Rogers was accepted as a Fellow at the Child Guidance Center in Rochester, New York. Here, he was exposed to a deeply ingrained Freudian viewpoint. He found the rigidity of this viewpoint at contrast to the free-thinking environment that had first attracted him to Union Theological Seminary, and reminiscent of the religion of his youth. Like religion, he found the speculative and nonempirical nature of Freudian methods to be remarkably at odds with the statistical and methodological rigor that characterized both the agricultural science of his youth and the curriculum at Teacher's College. Ultimately, he rejected the rigidity of Freudian dogma as he had rejected fundamental Methodism. In what was a compromise between the contrasting values that he held, at once favoring structure and needing freedom, he adopted the structure of the scientific method as a means of demonstrating the value of his freedom-giving psychotherapy procedures. After completing a Ph.D. degree from Columbia Teachers College, Rogers continued as a staff member and Director of the Child Study Center as it merged with the University of Rochester. He spent nine years in this position, ending his tenure there in 1940. During these years, America was in heated debate about entering the European war. Scant attention was given to other social ills. Rogers found that his interest in and work as a psychotherapist were not given great value either by his academic colleagues or by the courts and schools that purported to rely on psychological services. Yet, in the midst of an eclectic and supportive group of colleagues in Rochester, he began to formulate his ideas and to conduct experiments on the effectiveness of his nondirective methods. Rogers became familiar with the controversial works of Otto Rank, and with that of Rank's devotees at the Philadelphia Child Study Center, and this work left its mark on Rogers.

On the one hand, he found these approaches to be challenging because they forced him to search for and to find the order that he suspected to exist in clinical work. On the other hand, the stranglehold that psychoanalytic views held on clinical practice prevented his receiving the encouragement and assistance he needed to conduct research on his evolving theories. This led him to seek an academic environment in which he hoped to find more support for his research interests. Rogers took a position in the Department of Psychology and at the University Counseling Services at Ohio State University in 1940. His hopes that his evolving theory and research program were allied closely enough with experimentally based views of behavior to earn him support from colleagues in this environment proved to be frustrated. These were the war years, a time when the concepts of personal freedom were highly valued, but the encouragement of constraint, control, and obedience were also of signal concern. Devotion to personal freedom, a concept that represented a national mantra during that time, synergistically attached itself to Rogers' own history of constraint and structure. The product was a unique form of psychotherapy that valued freedom, that saw an environment (including a therapy environment) that reduced structure and authoritative demands as the avenue for its realization, and that, paradoxically, sought evidence of its value through the structure and rigor of the scientific method. At Ohio State University, Rogers discovered that his notions of the subjective were at odds with the rigid laboratory science of psychology that held sway in academia, however. It was through this experience that Rogers became convinced that his theoretical perspectives, indeed, represented a new direction in psychology. His ideas flowered while he was in Ohio, but the fruit emerged later, while he was at the University of Chicago (1945±1957). WWII opened the door for psychologists to provide services to adults. The needs, both for mental health treatment and for vocational guidance, that were exacerbated as veterans reentered society at the end of the war, became the means for counseling and clinical psychology to separate from school and child psychology, and to enter the world of adult mental health. Correspondingly, Rogers found his niche at the University of Chicago Counseling Center, where he served as the Executive Secretary and Director and enjoyed the richness of working with individuals of varied backgrounds. He taught students of psychology, theology, education, human development, and sociology, and carried on a practice that

Historical Development included work with veterans, families, and young adults. His teaching was supplemented by the responsibilities and excitement of a patient/client load that consumed 15±20 hours per week. It was during these years that clientcentered Therapy caught the imagination of the field and became firmly established within clinical and counseling psychology. In 1957 Rogers returned to his alma mater, the University of Wisconsin, where he was to serve on the faculties of both psychology and psychiatry. His research continued to earn widespread recognition there. His ideas caught on and widely dispersed research groups began developing and refining his ideas. Research on therapist-offered conditions promised both to establish psychotherapy's empirical base and provide a bridge across various theoretical points of view. In 1962, Rogers became a Fellow at the Center for Advanced Study in the Behavioral Sciences at Stanford, California. By this time, his interests in applying the client-centered approach to group therapy were well entrenched and his ideas were expanding to include community relations, education, and other nontherapy environments. To foster these ªperson-centeredº ideas, following his year at Stanford, Rogers became a Resident Fellow at the Western Behavioral Sciences Institute in La Jolla, California. He went on to found and direct the Center for the Studies of the Person there, and remained in that position, as Founding Fellow and Resident Fellow, until his death in 1987 (Patterson & Watkins, 1996). As might be guessed from his history, Rogers was preoccupied with establishing the science and the practice of psychology as an integrated discipline. Writing in 1959, he summarized the relationship between science and practice in very contemporary terms. He asserted that while research and theory share the common goal of bringing order to experience, their methods frequently are incompatible. However, he maintained that scientific knowledge can come from clinical observations as well as through controlled research; in fact, naturalistic observation is frequently the first step in empirical research. He considered traditional controlled research paradigms as being too simplistic to understand the complex variables that affect human growth in psychotherapy. Rogers observed that a progressive and helpful science capitalizes on serendipity and chance; it captures in unexpected moments kernels of truth that cannot be preordered on demand within the laboratory. Finally, he urged that the book should never be closed on any theory. Since every theory contains an unknown element of error, no

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theory is ever completely valid or invalid. The role of research is to see beyond the dogma of theory and search for the nuclear truths that were germane to and common among all theories and that transcend the clinic, the laboratory, and even the discipline of study. While phenomenological understanding was necessary on the personal, therapeutic level, understanding the nature of this phenomenological truth would require the objectivity of science. The structure of science provided the best available protection against self-deception. The structure of personality and the nature of adaptation outlined by client-centered therapy is found in the concept of the ªselfº (Rogers, 1951; 1961). The emergence of Self as a viable explanatory concept provided a base from which the therapist could justify a personal identity in therapy and could directly encourage and foster personal choice on the part of patients and clients. In its focus on choice and freedom, clientcentered therapy revealed its roots, not to be in existential crises, but in a reaction against controlling and oppressive religions that threatened moral choice and self-governance. Unlike Frankl, to Rogers the threat was not to physical existence and humanness, but to mental and moral autonomy. The correction was not to move closer to the mysteries of spiritualism and subjectivity, but further away, clearly reflecting the different religious experiences of the two authors. While Frankl found solace in religious philosophy, Rogers found it constricting. But client-centered therapy, no less than the whole of existential approaches, offered both a positive view of growth and hope for freedom from mental domination. Client-centered therapy added psychotherapy research methodologies to the other important and respected methods used by other humanists to understand the processes of change. The essence of client-centered therapy was summarized in Rogers (1993/1997) classic paper, ªThe necessary and sufficient conditions of therapeutic personality change.º Though subsequently criticized for assuming an allimportant position as both necessary and sufficient (Lambert, 1991), variations of these qualities have been adopted by most therapeutic approaches as, at least, ªhighly desirable.º The conditions emphasized the importance of an emotionally congruent therapist who is able to convey empathic understanding and positive regard. While frequently interpreted as being a philosophy only about therapist qualities, in truth, Rogers offered, in these principles, a view that included the patient variables and perceptions in creating necessary conditions for

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change. Specifically, he identified patient distress or incongruence as a motivational construct. This anxiety complemented the natural growth processes by providing the impetus to work and to engage the therapist. There were other patient qualities hidden in Rogers' treatise as well. For example, he asserted that the patient must perceive the therapist's empathic understanding and regard, implying that a degree of interpersonal facility and competence, as well as a capacity for realistic interpersonal appraisal, are necessary for effective work. In later explanations, it became clear that Rogers was not suggesting that this therapy would be ineffective with those who lacked these skills, but that all individuals had the capacity for the level and type of sensitivity that would allow them to benefit from a therapeutic environment. In his later book, On becoming a person, Rogers (1961) revealed his ties to existentialism and humanism as a method of understanding, as a set of assumptions about the nature of human problems, and as a philosophy about the causal locus of change (Rice & Greenberg, 1992). The famous Rogers±Skinner debates (Kirshenbaum & Henderson, 1989) highlighted Rogers' beliefs in personal choice and emphasized the value he placed on the patient's responsibility for their own change experiences. While considering the locus of change to be within the person, he asserted that free choice could only be expressed when certain environmental events and conditions are present. The therapeutic environment was designed to consist of those contextual conditions. The therapist's sensitive support and the client's willingness to explore work synergistically to foster the conditions for growth.

6.07.2.3 Humanistic Approaches: The Rise of Gestalt Therapy Gestalt psychotherapy took root as a counter-response to the negativism of psychoanalysis. It was a logical extension of the movement toward personal direction and freedom that characterized Logotherapy and clientcentered therapy. It did so, however, without relying on the abstract concepts of spirituality of these former approaches. Although the emergence of Gestalt therapy is generally thought to have been in the postwar years of the 1940s, its genesis actually was some 20 years earlier. Friedrich (Fritz) Perls (1893±1970) was born in Berlin (Patterson & Watkins, 1996). He obtained an M.D. degree from the Frederich Wilhelm University in 1920. Following his medical training, Perls worked under the

direction of Professor Kurt Goldstein at the Frankfurt Neurological Institute for BrainDamaged Soldiers. With the advent of WWII, Perls took his family to South Africa and in 1935, he established the South African Institute for Psychoanalysis. In 1946, he emmigrated to the US having become disillusioned with the arise of apartheid in South Africa. By training, Perls was a psychoanalyst, but he was heatedly dissatisfied with the dogma and structure of psychoanalysis. He was also influenced by the experimental work of Kohler, Wertheimer, and Lewin, with whose work he gained familiarity during his early years in Germany. Other existential philosophers with whose work he also became familiar also eventually affected his work, but initially he was too preoccupied with orthodox psychoanalysis to assimilate their work (Perls, 1947). Perhaps this is why he came to identify more closely with psychology than with psychiatry. Fritz Perls met Laura Posner in 1926 while she was working on her Ph.D. in psychology. She was to become his wife and cofounder of Gestalt therapy. Laura Posner Perls' family was very affluent and culturally enriched, while Fritz was from a lower middle-class Jewish family. These class distinctions were to influence their relationship for many years. Laura Posner Perls was heavily influenced by Martin Buber and Paul Tillich who were prominent contemporary existentialists. Laura and Fritz Perls worked closely together for nearly 25 years until they separated in the 1950s. Fritz Perls wrote his first book Ego, hunger and aggression subtitled ªA Revision of Freud's theory and Methodº in 1941 and 1942 while serving as a captain in the South African Medical Corps. Although it was not for many years that the name and character of ªGestalt therapyº was succinctly expressed, this first book introduced many of the Gestalt concepts which would later become central ideas in Gestalt therapy. During the years that Fritz and Laura Posner Perls were together, Gestalt therapy was developing and maturing, although the particular contributions of Laura Perls often are obscured in the available writings. Although Gestalt therapy was first introduced in the US by Fritz and Laura Perls, it was not until Fritz found a home at Esalen Institute at Big Sur, California, in the 1970s that Gestalt therapy was recognized nominally as an independent theory. It was Fritz, not Laura, who came to be recognized as the discoverer, the father, and developer of Gestalt therapy. His estranged wife, Laura Perls, was residing in New York City, outside the mainstream of the human potential movement which was beginning in

Contemporary Developments California. She published few papers, and her contributions to the theory and methods of Gestalt work were known only to a handful of people (Corsini & Wedding, 1989). Those familiar with the work of Laura, and Fritz Perls note interesting differences in how they implemented Gestalt therapy. One of the most noted of these differences pertained to the dimension of control and permissiveness that they applied in treatment. Laura employed procedures that were characterized by apparent permissiveness, while Fritz's work emphasized therapist authority and control (Hatcher & Himmelstein, 1976). The 1930s and 1940s were a dynamic time for Fritz Perls. He was heavily influenced by a number of prominent people including Wilheim Reich, who was Perls' analyst in the 1930s, Karen Horney, and Otto Rank. Horney was said to have directed the young and rebellious Perls to a very eccentric and rebellious Reich. Most notable in his influence was Reich, who introduced Perls to a theory of psychosomatic medicine that considered physical movement and symptoms as the body's armor against threat (Perls, 1947). The body work and physical techniques of Gestalt therapy was a product of this earlier association. However, it was Freud's theory of psychoanalysis that provided Perls with a theoretical framework for all of his future thinking; despite their differences, psychoanalytic theory was the major foundation upon which Perls built his understanding of human behavior, and it was psychoanalytic theory that he used as a standard against which to evaluate his own emerging theory. In Fritz Perls' autobiography, In and out of the garbage pail (Perls, 1969), he makes the following comment on Freud, ªRest in peace, Freud, you stubborn saint-devilgenius,º reflecting his own ambivalent attitude toward both Freud and psychoanalysis. Gestalt therapy differs from other systems and models in a number of important ways. For example, Perls accepted psychoanalysis as a general theory from which his own view derived. However, he chose to omit certain aspects of Freud's theory from his own view, such as psychosexuality, the tripartite anatomy of the personality (id, ego, and superego), and the nature of the unconscious. As applied to technique, these omissions led Perls to emphasize how rather than why, and explored experience within the ªhere and the nowº rather than the ªthere and then.º Another difference is in the value assigned to various bodies of scientific research. Gestalt therapy draws from a broader scientific literature than most systems of psychotherapy. It placed greatest value on research that describes

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the nature of perception and information processing, as well as from literature on defense and psychopathology. At the same time, traditionally it has eschewed psychotherapy outcome research. This priority of values contrasts with client-centered therapy, for example, that has always valued outcome research, but has given little acknowledgment to research on psychopathology and personality development. Still another distinguishing aspect of Gestalt therapy is its adoption of a holistic view of behavior. It regards individuals as being inherently integrated; their behavior reflects an integrated system whose collective activity cannot be understood by simply viewing isolated acts or structures. This humanistic view is borrowed from Rank, whose concept of the ªtotal organismº contrasts with the psychoanalytic view that separated mind and body and divided the psyche into discrete elements, for example, id, ego, superego, that engaged in a struggle for power over one another. Instead, Gestalt theory asserts that people struggle and experience conflict because of the difficulty of incorporating new information into perceptions based on old knowledge. Finally, Gestalt therapy defined self-actualization in a manner that contrasted with other experiential approaches. Self-actualization was reflected in balance, differentiation, and integration of cognitive, sensory, and emotional systems, rather than a motive toward social goodness. The ability of conceptual systems to communicate was manifest in the concept of self-response-ability, that is, the ability to choose to be active and to overcome apathy. Rather than encouraging social compliance, as might psychoanalytic therapy, Gestalt therapy encourages social rebellion and individualism.

6.07.3 CONTEMPORARY DEVELOPMENTS This section will summarize some of the most significant developments and extensions of existential, humanistic, and phenomenological traditions. Both in the interest of space and because time has resulted in an inevitable blurring of theoretical boundaries, no attempt will be made to maintain clear distinctions among these models. Existential theories have become more phenomenological and humanistic ones have become more existential. While some of the more visible theorists within these different systems will be mentioned no attempt will be made to be inclusive or exhaustive and detailed consideration to the fine distinctions among their points of view will not be given.

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This will allow a summary of the more important findings from the research. 6.07.3.1 Theoretical Developments and Applications 6.07.3.1.1 Existential theories Experiential theories have continued to expand, but probably at a lower rate than in their heyday of the 1970s. Theories have become more integrative of phenomonological, humanistic, and existential perspectives, and have been applied to an increasing array of problems, formats, and environments. Because they did not arise from a single strand of philosophy, it is difficult to find a coherent direction of development that has characterized the evolution of existential therapy. Several major authors, both European and American (e.g., Boss, Binswanger, Bugental, May, Maslow, Yalom), have offered contrasting directions. The works of May, Bugental, and Maslow have been particularly forward-looking and serve as a representative view of the field. Rollo May, a psychoanalyst by training and practice, probably is most responsible for introducing existential therapy to the United States (Rice & Greenberg, 1992). Along with Irvin Yalom, one of his major contributions (May & Yalom, 1984) was the blending of existential and phenomenological viewpoints. Adopting the phenomenological view, he believed that the personal experience of an individual person was the most important vehicle to knowledge and understanding, and emphasized that a person could be understood through their own experiences more adequately than through a therapist's theory about people (May, 1961; May & Yalom, 1984). Likewise, May thought that access to a patient's motivation for change was best obtained through an exploration of the meanings, ideals, and goals that directed their life. May's perspective began with a fascination with anxiety and its meaning. This topic served as the basis for his doctoral dissertation in 1950 as well as for a major book, The meaning of anxiety (May, 1977) that was revised and reprinted several times. He saw anxiety, defense, and abortion of developmental progress as the inevitable products of conflict between goals and aspirations and the demands and constraints of reality. However, in a viewpoint that was reminiscent of Rogers and others, he maintained that anxiety was growth enhancing. Pushing this point further, May launched an insightful and provocative attack against psychotherapy theory. He noted that psychotherapists, in the interest of effecting good therapy, observe and attribute meanings to patterns or

mechanisms of behavior, using language and concepts that are constructed by their theoretical orientation. He pointed out that both the experience of and resolution of anxiety was often aborted by therapists and other observers when they construed the patient's experience in ways that forced it into line with their own conceptual frameworks. The tendency of therapists to filter perceptions of the patient through a rigid lens of theoretical views clouded their ability to accurately perceive and relate to the patient. More importantly, it frustrated the objective of bringing the patient into contact with the anxiety, preventing self-knowledge and resolution. He pointed out that a rigid or dogmatic theory prevented the therapist from adopting a phenomonological perspective. The therapists' task is to separate themselves sufficiently from their own histories and dispositions to accurately perceive the meanings offered by a patient's own developmental history. Perhaps May's major contribution was his piercing questions of fellow therapists. He provocatively asserted the possibility that what therapists view as an understanding of the patient is, in reality, a projection of their own self-reinforcing theory. The foregoing is not to diminish May's contributions to experiential theory. May's vision was to understand how people become aware of their own growth and potential, that is one's ªbeingnessº (May, Angel, & Ellenberger, 1958). It is this phenomenon of becoming aware of one's beingness that characterizes May's most frequently noted contribution to theory, the ªI-Amº experience. The definition of the ªI-Amº includes the perception of what is real, but adds an awareness of some emerging or existent potential. Thus, a person exists in the present but with the potential to become (May, 1961). This dynamic aspect of self experience is central to the capacity to change; it is a precondition for their solution (May et al., 1958). The success of this solution, however, depends upon a therapist being able to help clients recognize and experience their own existence. May's ªI-Amº experience was so ontologically sound that it resonated through much of the existential movement. The value of his teachings seemed to help organize and guide the search for what Bugental (1976) calls the ªlost sense of being.º May's ªI-Amº experience was incorporated by Bugental into what he called the ªexistential sense.º Like May, Bugental identified existing or being alive as the fundamental concern of each human being. Bugental, however, emphasizes that the striving for existence supersedes the mere act

Contemporary Developments of being alive. It is a motivator that drives a person to become more vibrant and sensitive to life. This quest for more life was inextricably related to what he called the tragedy of the human condition, the inability both to recognize and seize opportunities for fuller living. Bugental's concept of the ªlost beingº is a person who was invisibly crippled, blind, and deaf to their own state of needing (Bugental, 1976, 1987). This blindness to one's own state of emotional impairment represented a loss of the inward vision that made it possible to assess how well outer and inner experiences match. Abraham Maslow was another major figure in blending existential and humanistic theory. His most noted contribution was his assertion of a jurisdiction for psychology which dealt explicitly with issues of growth, motivation, and creativeness (Maslow, 1968). His hierarchy of needs expressed his motivational theory and replaced the unimotivational concept of selfactualization, embodied in experiential theory, with a conception that arranged this drive within an array of more basic motives. The ultimate questions of, ªWho am I?º and ªWhat am I?º according to Maslow could only be answered by the individual asking the questions and proceeding through the hierarchically arranged answers. Another contribution of Maslow's was his conceptualization of inner awareness as a process of ªlistening to the impulse voicesº (Maslow, 1971). He proposed that failures in personal growth, such as neuroses, were conditions in which these ªimpulse voicesº or ªinner signalº became weak or disappeared altogether. With the inability to hear these signals, the person was incapacitated and became detached from their own essence. Maslow envisioned the result of detachment to resemble a zombie, the experientially empty person, rather than an anxious person as proposed by others. Anxiety represented a level of being aware of disconnection, but complete disconnection included a lack of awareness of this disconnection. Maslow viewed the disconnected person as one who was empty, and believed that recovering the self must include the recovery of the ability to have and recognize these inner signals (Bugental, 1987). One major implication of this theory was in the nature of obsessive and compulsive behaviors. The experientially empty person, lacking direction from within, turned to outer cues for guidance and reassurance of existence. This person relied on external cues, such as clocks, rules, calendars, schedules, agenda, and other people as a substitute for personal resources (Maslow, 1971).

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6.07.3.1.2 Phenomenological theories The persuasive power of Rogers' ideas, bolstered by ample research support (see Beutler, Machado, & Neufeldt, 1994; Orlinsky, Grawe, & Parks, 1994), ensured that the concepts of therapy process (therapist empathy, acceptance, regard, and congruence) have been absorbed into the body of psychotherapy. Virtually all schools of psychotherapy find common ground in the views that a helpful therapist is kind, respectful, caring, and understanding, the essence of the Rogerian ªnecessaryº conditions. The differences between the views of these therapist contributions and Rogers' earlier views are twofold: (i) these factors are considered to be minimal rather than optimal conditions for change, and (ii) none are considered to be necessary or sufficient of themselves. While there are a few ªpureº clientcentered theorists remaining, most within this tradition have accepted these modifications to Rogers' original tenets. Out of this perspective, the translation of Rogers' views over time are best embodied in extensions of his work to the broader domain of experiential therapy. The most prominent of these are represented by the writings of Laura Rice, Eugene Gendlin, and Alvin Mahrer. These authors have added several specific procedures and philosophies to the general framework of client-centered therapy. The major contributions of each of these writers, however, has been more often remembered for the technical procedures introduced than in the philosophical truths that they have added to understanding (Hart & Tomlinson, 1970; Wexler & Rice, 1974). Indeed, they all represent an emerging view that the therapist-offered conditions (empathy, warmth, positive regard, and congruence) are insufficient to assure change. Thus, they offer the beginnings of a technology to encourage and even to direct change (Rice & Greenberg, 1992). By the mid-1970s, client-centered therapy had become widely used as both a group and an individual therapy. It was also becoming more cognitive. Information-processing theory was popular and there was a concerted effort to integrate these views with the workings of client-centered therapy (Patterson & Watkins, 1996). Laura Rice proved to be one of the leaders in this movement. She formulated the therapist's role as an assistant to the patient; together patient and therapist embarked on a process of learning to symbolize experience. Rogers had discussed at length the idea that one of the goals of psychotherapy was for patients to begin to symbolize experience that was outside of their awareness. Symbolization

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represents the process of bringing information into focus and consciousness by giving it mental representation. This occurred largely, though not exclusively, through words. Rice (1974) proposed that symbolization was necessary in order to accurately process new information and suggested that this process could be facilitated by ªEvocative Reflection.º This technique involved efforts to reactivate emotional experiences by drawing the client's attention to key experiences. Then the client was asked systematically to process or talk through the experience in a heightened state of arousal. The emotional information was thought to be more easily recoded and integrated by maintaining a heightened state of arousal and this was, in turn, enhanced by emotion-focused reflections and focus. Gendlin (1981) took the concept of focus a further step, increasing the attention given to client-centered therapy's affect on sensory experiencing. Gendlin's method of focusing (Gendlin, 1981) included the use of nonverbal exercises, such as directed imagery and magnification of multisensory systems, designed to heighten awareness of sensory cues that signaled the presence of emotional experience. Gendlin (1969) defined focusing as the process in which people make contact with a special kind of bodily awareness known as the ªfelt sense.º This felt sense was neither an emotion nor an intellectual emotional derivative (cognition). Rather, it was a bodily sense or intelligence by which the body directs the person to answers for personal problems. Moving through the six stages of focusing, emotional and cognitive awareness were thought to emerge as by-products (Gendlin, 1969). While Rice's conceptualizations moved client-centered therapy ever closer to cognitive conceptualization, Gendlin's moved it closer to existential and Gestalt perspectives. Mahrer (1983, 1986, 1996) furthered this movement of client-centered therapy toward humanistic models, increasing its resemblence to Gestalt therapy. In Mahrer's Experiential therapy, the therapist and client both develop images, the therapist's being an effort to replicate that of the patient. Laying side by side, the patient's experience is recreated in the therapist's imagery and both attempt to focus and move closer to the source of intense sensory and emotional experience. Mahrer (1989) has attempted to manualize the key steps that a therapist and patient make in effecting his ªExperiential Therapy,º making this approach both more researchable and more easily applied than conventional applications. The steps of Mahrer's Experiential/Humanistic therapy are constructed to provide an

increasingly intense therapeutic experience (Mahrer, 1983). In this process, cognition and emotions are salient to the extent that they occur within this genre of client experiencing. Thoughts and feelings of the client are both accompanied and facilitated by focusing attention on bodily sensations. The key to unlocking the power of the therapy resides in the client's ability to allow these physical experiences to occur and to then give them meaning. In this process, feelings such as fear, anger, anxiety, excitement, gloom, as well as various cognitive postures such as confusion are identified as signals of the client's experience. Associations with these signals are then used to provide a landscape of meaning to the experiences.

6.07.3.2 Humanistic Theories Integration has characterized the development of humanistic models of psychotherapy. It is no longer easy to identify a psychotherapy that is only humanistic. The infusion and crossfertilization of cognitive therapy, experiential/ humanistic therapy, and client-centered therapy, with traditional Gestalt therapy, for example, have produced a rich array of interventions and novel directions to the conceptualization and application of psychotherapy. When cross-bred with the active orientation of Gestalt therapy, the experiential approaches of Gendlin and Mahrer have emphasized phenomenological interventions within a provocative and therapist-guided medium. Some developments have highlighted the bridging of cognitive and experiential theories while others have highlighted differences between two somewhat different strands of experiential therapy, the nondirective, person-centered approach of Rogers and the process-directive Gestalt approach (Greenberg, Elliott, & Lietaer, 1994). Drawing on classical client-centered theory, the person-centered approach regards the ªrelationshipº as necessary and sufficient for therapeutic change; humanistic experiential approaches advocate the importance of an active, process-directive intervention and cognitive therapies focus on the role of conceptual structures in emotional dysfunction. The result is a number of approaches that stress active interventions that utilize emotional access to facilitate a change of perspective and the power of which is deepened within the context of a person-centered relationship. These evolving experiential/humanistic models of therapy are applied in an increasing variety of formats. While most often used in an individual format (Greenberg et al., 1994),

Contemporary Developments group therapy formats are practiced widely (Daldrup, Beutler, Greenberg, & Engle 1988), and there are guidelines for their application to marital/couples therapy (Greenberg & Johnson, 1988). Focused Expressive Psychotherapy (FEP) is an integrated experiential method for resolving blocked affect that is based on Gestalt therapy concepts. FEP works with a full range of inhibited emotions such as anger, fear, joy, and sadness with a particular emphasis on the range of emotions that surround the blocked expression of anger (Daldrup et al., 1988). FEP, first attempts to access the client's schematic memory by directing attention to potential relationships in which these memories developed. That is, the client is directed to painful memories involving interactions with parents, spouses, children, and other significant members. Therapy is then designed to heighten the intensity and expression of emotion associated with the memories so that new schematic structures can be realized (Engle, Beutler & Daldrup, 1991). Although FEP attends to a full range of emotions which may be blocked or inhibited in an individual, particular attention is given to the emotion of anger. FEP assumes a five-step process that identifies emotions, specifies targets, determines markers of their presence, implements experiments in change, and evaluates progress. The patient is actively engaged in all of these processes, but the therapist is responsible for leading them through the processes. The experiments are designed to facilitate full awareness of the emotion itself as well as its implications and genesis. FEP assumes that there are no ªgoodº or ªbadº emotions, per force, but rather that emotions exist in all human beings. Why an individual chooses to react in a dysfunctional or enhancing way to a stressful event is reliant on how accessible they are to emotional and sensory experience and the internalized rules that govern their behavior. The influence of early experiences in childhood cannot be overlooked in the formation of emotional development and the way in which an individual will react in emotionally laden situations. If a child is unable to complete an emotional cycle, then the expression of this emotion (most notably, anger) will become frozen and part of the individual's ªunfinished business.º In contrast to most forms of psychotherapy, FEP was designed to exert specific effects for individuals who tend to constrain and inhibit emotional expression, regardless of the specific symptoms manifest. Individuals who can identify the hurtful relationships and experiences that may have caused the inhibition of emotion

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and who can identify past and present relationships in which they are unable to express important desires are considered to be good candidates for this type of therapy. Process-experiential therapy (Greenberg, 1994) represents a similar model to FEP, but places more emphasis on the integration of broadly-based nondirective (client-centered) relationship strategies with Gestalt therapy methods, and less emphasis on the role of enduring patient traits. In this approach, there is also an effort to integrate the interventions within a theory of cognitive±emotion relationships. This theory blends cognitive and experiential theory (Greenberg & Safran, 1987). It assumes that the barriers to healthy functioning result from (i) difficulties in finding words or images to symbolize experiences, and (ii) dysfunctional emotional schemes through which to interpret experiences. Accordingly, the goal of therapy is to enable client's to access dysfunctional schemas within a therapeutic environment in order to facilitate relevant schematic change (Greenberg et al., 1993). In process-experiential therapy, the client and therapist interact on two different levels. The first level concerns the moment-by-moment effects that each of the therapist responses has following a client response. Accurate and empathetic understanding of the client's words and messages provide the client with a feeling of being understood and received by the therapist. It is anticipated that these therapeutic responses will allow the client to initiate work on increasingly more difficult and painful issues. The second level on which the client and therapist interact is viewed as more ªmolarº than the first. In this level, the therapist attempts to enable the client to resolve the larger affective problems that present themselves as in-session therapeutic tasks. This requires emotional experiencing, which is facilitated by attending to the emotions and senses in-the-moment, under the assumption that so doing activates emotional meanings that are then subject to inspection and change. Process-experiential therapy is considered to be most appropriate for use among ambulatory outpatients who are experiencing moderate clinical distress and symptomatology. It is not suited for clients with major thought disorder or schizophrenia, impulse control or antisocial personality patterns, or for those who may be in need of immediate crisis intervention or case management (e.g., acutely suicidal persons) (Elliott & Greenberg, 1995). It is not recommended for those who are unable to be selfreflective and those who find the therapist's nondirective stance of not advising or interpreting to be unacceptable.

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6.07.3.3 Research and the Status of Experiential Therapies The suspicion with which experiential therapies have traditionally regarded both diagnosis and empirical research has given way to produce an emerging body of scientific evidence. Led by the efforts to blend Gestalt therapy with clientcentered and cognitive therapy, research has included both naturalistic studies, randomized clinical trials of patients in clearly defined diagnostic groups, and meta-analyses of contributors to efficacy. Findings from all of these research areas have generally supported the value of these approaches. A prominent characteristic in the evolution of this research is the increasing focus on differentiating the client characteristics and problems for which experiential treatments are likely to be effective. Specific focus has been on clinical disorders such as anxiety disorders, major depression, and personality disorders. Some research has looked at broader dimensions than those identified by diagnosis, particularly focusing on the differential response of patients with different coping styles (internalizing and externalizing), levels of resistance, and those with physical symptoms. Greenberg et al. (1994) summarized the results of studies conducted since 1978, using meta-analytic techniques. They compared preto postchanges on symptom measures and, where possible, compared treatment effect sizes to those observed among patients who were assigned to control or alternative treatments. They found moderate to strong effect sizes for experiential therapies, which compared favorably both with those observed among other therapies and demonstrated that these treatments were more effective than no-treatment and placebo-treatment groups. Naturalistic and quasi-experimental studies have been used both to assess the relative efficacy of experiential therapy relative to alternative treatments (e.g., Beutler & Mitchell, 1981) and to assess the contributors to effective outcome within different types of psychotherapy (e.g., Burgoon et al., 1993; Greenberg & Foerster, 1996; Hill, Beutler, & Daldrup, 1989; Watson, 1996). Findings from these studies have suggested both that experiential therapies may be at least as effective as alternative treatments and that the level of arousal and experiencing induced by experiential methods facilitate the resolution of interpersonal conflict and reduce emotional distress. Randomized clinical trial research designs have also incorporated various experiential therapies among the treatment comparisons. Especially promising results have been found in

the treatment of those with depression using these controlled comparison procedures (e.g., Paivio & Greenberg, 1995). In a well-controlled investigation, Watson and Greenberg (1996) compared a Gestalt-based experiential therapy with a client-centered intervention, observing that while initial results were equivalent, longterm effects favored the more active experiential approach. FEP (Beutler et al., 1987) has also been used successfully in the treatment of individuals who present with chronic organic pain. This domain of study is based on the theoretical connection between chronic pain and depression. Beutler, et al. (1987) undertook the task of testing the hypothesis that the intensity of pain correlates with the degree to which a person has persistent difficulty expressing anger and controlling intense emotions (e.g., Beutler, Engle, Oro'Beutler, Daldrup, & Meredith, 1986). Using a multiple baseline design with six patients who had rheumatoid arthritis, Beutler et al. (1987) found that FEP substantially activated betaendorphin discharge and correspondingly reduced depressive symptoms. This was particularly true in the early and late phases of treatment. However, the beta-endorphin response was not correlated with alterations of pain, suggesting that they functioned as stress markers more than as anesthetics of pain. The evidence that certain ªtypesº of patients are particularly responsive to experiential therapy has been the area in which the largest body of research has accumulated. Identifying clients by coping styles is another way of identifying a ªtypeº of client who may benefit from experiential therapy. Whether a client is an externalizer vs. an internalizer may interact with the type of treatment that the client will receive. Beutler et al. (1991) found that those who coped with internalizing styles may profit more than externally-oriented clients in client-centered or nondirective therapies than from either cognitive therapy or Gestalt-based therapy (FEP). This has also been supported in several other studies that have used different approaches to identify or measure internalization. For example, Tscheulin (1990) reported that self-oriented clients (internalizers) did better with a nonconfrontational therapist than with a confrontational therapist. Several studies (see Greenberg et al., 1994) have also concluded that high levels of client resistance is a contraindicator to the directiveness that is inherent in many experiential treatments, particularly those based on Gestalt/ humanistic (e.g., FEP, process-experiential therapy) models. Specifically, highly resistant (high dominance, low submissiveness) patients do better in client-centered or nondirective

Conclusions therapies (Beutler et al., 1991, 1993) than in various directive, experiential therapies. In contrast, clients with low levels of resistance do better in these directive alternatives than they do in nondirective ones (Beutler et al., 1991). Although more research is needed on this general theme, the findings suggest that clients with good interpersonal interests and skills may be the ones who are most receptive to experiential therapies.

6.07.4 CONCLUSIONS Experiential therapies comprise a heterogeneous collection of theoretically diverse interventions. They share certain assumptions about the nature of existence, the most reliable avenue to knowledge, and the mechanisms of symptom development and change. Humanistic, existential, and phenomenological traditions have had a long history within the fields of psychotherapy. Existential views emphasize the importance of personal meaning and choice in facilitating adaptation and survival in times of crisis; phenomenological approaches have emphasized the role of subjective experience, safety, and therapist-offered conditions as the avenues to understanding and change; and humanistic models have emphasized the role of active therapist interventions and the provision of structure in facilitating change. Though deriving from different traditions, these models of behavior have merged over time, both in their theoretical development and in their methods of intervention. Central to these emerging, amalgamated theories is a common reliance on the concept of self as an organizing principle of personality, and on selfactualization as a foundation motivational principle. Experiential models of behavior have historically observed that the ªselfº has been defined in Western cultures indirectly. Thus, one identifies him or herself through either occupational role (e.g., ªI am a bus driverº) or through some other external attribute or possession (e.g., ªI am richº). Experiential therapies pose the thesis that such definitions relegate self-definitions to the status of superficial attributes that can be threatened or destroyed by external change. The result is an identity that lacks stability and that is changeable and uncertain. The resulting construct of ªselfº comes to serve only the most tenuous of functions, and in this process projects a social image that is not authentic. Such reliance on superficial structures provides some limited protection from external threat but does not provide protection from the most basic of fears, the fear of nonexistence. Indeed,

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its presence makes one vulnerable to related fears of being irrelevant, ignored, and nonessential when these defining roles and possessions are no longer present. Experiential therapies concentrate on redefining self-views, a process that is generally thought to be natural and orderly when environments are conducive. Thus, the specific therapy models that constitute the experiential tradition all seek to remove obstructions to these normal processes. By providing a permissive atmosphere, they attempt to facilitate and enhance normal movement toward differentiation of self, foster creativity, and stabilize personal identity. Specific theories of psychotherapy vary in the degree of directiveness exercised by the therapist (Perls vs. Rogers), in the roles they assign to spiritual and teleological drives (e.g., Frankl vs. Rogers), and to the acknowledgment of other motives (e.g., Maslow vs. Perls). However, they have in common efforts to focus patient attention on the moment, to encourage attendance to present sensory and perceptual impressions, and to expand therapist awareness of patient experience. While there is not now nor has there ever been absolute concordance among experiential models and therapists' theories, most have embraced this foundation principle. Modern developments of experiential therapies have blended theories, often including principles and practices of cognitive and behavior therapies, as well as various components from humanistic, existential, and phenomenological viewpoints. There has also been a significant movement to reconceptualize human experience within a developmental perspective. In this conceptualization, emphasis is placed on growth as an immediately ontological experience, the person is a consciously and developing ªbeing.º These modern experiential therapies urge patients to focus both on immediate experience and on the progressive change and evolution of that experience as a way of obtaining self-knowledge. This view contrasts with both a static description of personal meanings and with models of behavior that emphasize either the effects of historical experience in their own right, the roles of unconscious drives, or the influence of biologically determined behaviors. Traditionally, research has not been widely accepted in the experiential traditions. This is with the exception of Carl Rogers, whose clientcentered therapy introduced the scientific method to the study of psychotherapy process and outcome. Led by active movements from client-centered and Gestalt traditions, however, there has been a proliferation of research. This research has sought both to specify and

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operationalize the application of experiential therapy so that they can studied objectively. The resulting manualized therapies have then applied these methodologies to the study of various clinical conditions. The resulting studies have found that experiential therapies produce modest and reasonably strong effects when compared either to patients' pretreatment status, control conditions, or comparison treatments. Research also confirms that experiential treatments can be adapted to treat specific client disorders (e.g., depression, chronic pain, anxiety) as well as to a variety of client parameters. Research has been particularly fruitful in applying different aspects or tasks of treatments to different clients and situations. Therapists should be sensitive to the possibility that clients who are high in autonomy or reactance may react negatively to the effects of the more process-directive experiential therapies (e.g., Gestalt), whereas more dependent or externally oriented clients may react negatively to nondirective therapies. Likewise, experiential and nonexperiential traditions may be differentially effective for patients who vary in coping style. Experiential therapies may be most appropriate to those who are self-reflective, have organized cognitive processes, and who are capable of establishing stable interpersonal relationships. Clearly more research is needed to study the effectiveness of experiential treatments. Research is especially needed that assesses treatment outcomes among specific populations and disorders. However, it is also important to direct research attentions to studies of the transfer of treatment to alternative settings, including research on methods of training, procedures to ensure the retention of therapeutic effects, and applications to populations that are generally unresponsive to other treatments. 6.07.5 REFERENCES Bergin, A. E., & Garfield, S. L. (Eds) (1994). Handbook of psychotherapy and behavior change (4th ed.). New York: Wiley. Beutler, L. E., Bongar, B., & Shurkin, J. (in press). Am I crazy or is my shrink? New York: Oxford University Press. Beutler, L. E., Daldrup, R. J., Engle, D., Oro'-Beutler, M. E., Meredith, K., & Boyer, J. T. (1987). Effects of therapeutically induced affect arousal on depressive symptoms, pain and beta-endorphins among rheumatoid arthritis patients. Pain, 29, 325±334. Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., Bergan, J., Meredith, K., & Merry, W. (1991). Predictors of differential responses to cognitive, experiential, and self-directed psychotherapeutic procedures. Journal of Counsulting and Clinical Psychology, 59, 333±340. Beutler, L. E., Engle, D., Oro'-Beutler, M. E., Daldrup, R. J., & Meredith, K. (1986). Inability to express intense

affect: A common link between depression and pain? Journal of Counsulting and Clinical Psychology, 54(6), 752±759. Beutler, L. E., Machado, P.P.P., & Neufeldt, S. A. (1994). Therapist variables. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 229±269). New York: Wiley. Beutler, L. E., & Mitchell, R. (1981). Psychotherapy outcome in depressed and impulsive patients as a function of analytic and experiential treatment procedures. Psychiatry, 44, 297±306. Bugental, J. F. T. (1976). The search for existential identity. San Francisco: Jossey-Bass. Bugental, J. F. T. (1987). The art of the psychotherapist. New York: Norton. Bugental, J. F. T., & McBeath, B. (1995). Depth existential therapy: Evolution since World War II. In B. Bongar & L. E. Beutler (Eds.), Comprehensive textbook of psychotherapy: Theory and practice (pp. 111±122). New York: Oxford University Press. Burgoon, J. K., Beutler, L. E., LePoire, B. A., Engle, D., Bergan, J., Salvio, M., & Mohr, D. (1993). Nonverbal indicies of arousal in group psychotherapy. Psychotherapy, 30(4), 635±645. Corsini, R. J., & Wedding. D. (Eds.) (1989). Current psychotherapies (4th ed.). Itaska, IL: Peacock Publishers. Daldrup, R., Beutler L., Greenberg, L., & Engle, D. (1988). Focused expressive therapy: A treatment for constricted affect. New York: Guildford Press. Elliott, R., & Greenberg, L. S. (1995). Experiential therapy in practice: The process experiential approach. In B. Bongar & L. E. Beutler (Eds.), Comprehensive textbook of psychotherapy (pp. 123±139). New York: Oxford University Press. Engle, D., Beutler, L. E., & Daldrup, R. J. (1991). Focused expressive psychotherapy: Treating blocked emotions. In J. D. Safran & L. S. Greenberg (Eds.), Emotion psychotherapy & change. New York: Guilford Press. Feshbach, S., Weiner, B., & Bohart, A. (1996). Personality (4th ed.). Lexington, MS: D. C. Heath. Freedheim, D. K. (Ed.) (1992). History of psychotherapy: A century of change. Washington, DC: American Psychological Association. Frankl, V. E. (1961). Logotherapy and the challenge of suffering. Review of Existential Psychology and Psychiatry, 1, 3±7. Frankl, V. E. (1963). Man's search for meaning (Rev. ed.). New York: Washington Square Press. Gendlin, E. T. (1969). Focusing. Psychotherapy: Theory, Research, and Practice, 6, 4±15 Gendlin, E. (1981). Focusing (2nd ed.). New York: Bantam Books. Greenberg, L. S., Elliott, R. K., & Lietaer, G. (1994). Research on experiential psychotherapies. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 509±539). New York: Wiley. Greenberg, L. S., & Foerster, F. S. (1996). Task analysis exemplified: The process of resolving unfinished business. Journal of Consulting and Clinical Psychology, 64, 438±446. Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused therapy for couples. New York: Guilford Press. Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy, affect, cognition, and the process of change. New York: Guilford Press. Hart, J. T., & Tomlinson, T. M. (Eds.) (1970) New directions in client-centered therapy. Boston: Houghton Mifflin. Hatcher, C., & Himmelstein, P. (Eds.) (1976). The handbook of Gestalt therapy. New York: Aronson. Hill, D., Beutler, L. E., & Daldrup, R. J. (1989). The relationship of process to outcome in brief experiential

References psychotherapy for chronic pain. Journal of Clinical Psychology, 45(6), 951±957. Kelly G. A. (1955). The psychology of personal constructs (Vols. 1±2). New York: Norton. Kirschenbaum, H., & Henderson, V. L. ((Ed.) (1989). Carl Rogers: dialogues. Boston: Houghton Mifflin. Lambert, M. J. (1991). Introduction to psychotherapy research. In L. E. Beutler & M. Crago (Eds.), Psychotherapy research: An international review of programmatic studies (pp. 1±11). Washington, DC: American Psychological Association. Mahoney, M. J. (1993). Introduction to special section: Theoretical developments in the cognitive psychotherapies. Journal of Consulting and Clinical Psychology, 61, 187±193. Mahrer, A. R. (1983). Experiential psychotherapy: Basic practices. New York: Brunner/Mazel. Mahrer, A. R. (1986). Therapeutic experiencing: The process of change. New York: Norton. Mahrer, A. R. (1989). How to do experiential psychotherapy: A manual for practitioners. Ottawa: University of Ottawa Press. Mahrer, A. R. (1996). The complete guide to experiential psychotherapy. New York: Wiley. Maslow, A. H. (1968). Toward a psychology of being (2nd ed.). New York: Van Nostrand Reinhold. Maslow, A. H. (1971). The further reaches of human nature. New York: Viking Press. May, R. (Ed.) (1961). Existential psychology. New York: Random House. May, R. (1977). The meaning of anxiety (2nd ed.). New York: Norton. May, R., Angel, E., & Ellenberger, H. F. (Eds.) (1958). Existence: A new dimension in psychiatry and psychology. New York: Basic Books. May, R., & Yalom, I. (1984). Existential therapy. In R. J. Corsini (Ed.), Current psychotherapies (3rd ed., pp. 354±391). Itaska, IL: Peacock. Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy: Noch Einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 270±376). New York: Wiley. Paivio, S. C., & Greenberg, L. S. (1995). Resolving unfinished business efficacy of experiential therapy using

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empty-chair dialogue. Journal of Consulting and Clinical Psychology, 63(3), 419±425. Patterson, C. H., & Watkins, C. E., Jr. (1996). Theories of psychotherapy (5th ed.). New York: Harper Collins. Perls, F. S. (1947). Ego, hunger and aggression: The beginning of Gestalt therapy. New York: Random House. Perls, F. S. (1969). In and out of the garbage pail. Lafayette, CA: Real People Press. Rice, L. N. (1974). The evocative function of the therapist. In D. A. Wexler & L. N. Rice (Eds.), Innovations in client-centered therapy (pp. 282±302). New York: Wiley. Rice, L. N., & Greenberg, L. S. (1992). Humanistic approaches to psychotherapy. In D. K. Freedheim (Ed.), History of psychotherapy (pp. 197±224). Washington, DC: American Psychological Association Press. Rogers, C. R. (1951). Client-centered thereapy. Boston: Houghton-Mifflin. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95±103. Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships as developed in the clientcentered framework. In S. Koch (Ed.), Psychology: A study of science (Vol. 3, pp. 184±256). New York: McGraw-Hill. Rogers, C. R. (1961). On becoming a person. Boston: Houghton-Miflin. Tageson, W. C. (1982). Humanistic psychology: A synthesis. Homewood, IL: Dorsey Press. Tscheulin, D. (1990). Confrontation and non-confrontation as differential techniques in differential clientcentered therapy. In G. Lietaer, J. Rombauts, & R. Van Balen (Eds.), Client-centered and experiential psychotherapy in the nineties. Leuven, Belgium: Leuven University Press. Watson, J. C. (1996). The relationship between vivid description, emotional arousal, an in-session resolution of problematic reactions. Journal of Counsulting and clincial Psychology, 64 (3), 1±6. Watson, J. C., & Greenberg, L. S. (1996). Pathways to change in the psychotherapy of depression: Relating process to session change and outcome: Psychotherapy, 33, 262±274. Wexler, D. A., & Rice, L. N. (1974). Innovations in clientcentered therapy. New York: Wiley.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.08 Social Skills Training and Problem Solving KIM T. MUESER New Hampshire±Dartmouth Psychiatric Research Center, Concord, NH, USA 6.08.1 INTRODUCTION

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6.08.2 THEORETICAL MODELS

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6.08.2.1 The Stress±Vulnerability±Coping Skills Model 6.08.2.2 The Social Skills Model 6.08.3 ASSESSMENT 6.08.3.1 6.08.3.2 6.08.3.3 6.08.3.4

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Components of Social and Problem Solving Skills Assessment Strategies Nonskill Factors which can Affect Social Competence Integration of Assessment and Treatment

6.08.4 TRAINING TECHNIQUES 6.08.4.1 6.08.4.2 6.08.4.3 6.08.4.4 6.08.4.5

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Motor Skills Model The Problem Solving Model Common Learning Principles Basic Skills Training Techniques Problem Solving Training

6.08.5 FORMAT OF SOCIAL SKILLS AND PROBLEM SOLVING TRAINING

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6.08.5.1 Group Skills Training 6.08.5.2 Individual Format 6.08.5.3 Family Format 6.08.6 CLINICAL APPLICATIONS AND RESEARCH

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6.08.6.1 Utility of Social and Problem Solving Skills Training

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6.08.7 SUMMARY AND CONCLUSIONS

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6.08.8 REFERENCES

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Hollin & Trower, 1986; Kleinmuntz, 1966; L'Abate & Milan, 1985; Nezu & Nezu, 1989; O'Donohue & Krasner, 1995b). Although various definitions of social skills have been given by different clinical researchers, Bellack and Hersen offer one of the most comprehensive descriptions of social skills as the:

6.08.1 INTRODUCTION Over the past several decades, social skills training and problem solving training have become some of the most widely practiced techniques in clinical psychology, with applications spanning a broad range of adult disorders, and numerous books published on their theoretical foundations, clinical applications, and research (e.g., Bellack & Hersen, 1979;

ability to express both positive and negative feelings in the interpersonal context without

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suffering consequent loss of reinforcement. Such skill is demonstrated in a large variety of interpersonal contexts and involves the coordinated delivery of appropriate verbal and nonverbal responses. In addition, the socially skilled individual is attuned to the realities of the situation and is aware when he is likely to be reinforced for his efforts. (1979, p. 512)

Problem solving can be defined as the ability to recognize problems or formulate goals, and to develop strategies to successfully reduce or eliminate the problem or to make progress towards achieving a goal. Training in social skills and problem solving generally refers to the systematic application of principles of social learning to the teaching of requisite skills hypothesized to underlie dysfunctions in interpersonal relationships, mood, and functional capacity (Davis & Butcher, 1985; Goldstein, 1982; Larson, 1984). Skills training has a long history, and no single individual can be given sole credit for developing the method. However, several contributors to the development of social skills training should be noted. In the 1940s, Salter (1949) engaged individuals in role-plays in order to facilitate selfexpression and to help them overcome symptoms such as depression and anxiety. In the 1950s, Wolpe incorporated role-playing into his approach to psychotherapy based on reciprocal inhibition. Wolpe (1958) theorized that assertive interpersonal behavior would be experienced as incompatible with feelings of anxiety, leading to the extinction of anxiety in certain social situations. Role-playing was used to help clients develop more assertive interpersonal skills. In the 1960s, Bandura's (1969) work on observational learning led to the formal inclusion of role modeling as a critical ingredient in social skills training. Also around this time, Lazarus (1966) introduced the use of repeated role-plays paired with instructions to facilitate the behaviorshaping approach employed in social skills training. In their review of the history of psychological skills training, O'Donohue and Krasner (1995a) note several other key influences on the development of skills training which have played a prominent role in the emergence of behavior therapy as a system of psychotherapy. These influences include the concepts of behaviorism, instrumental and classical conditioning, social role learning, and finally social learning theory, which posited that deviant or maladaptive behavior could be learned, rather than being the product of a disease, leading to interventions designed to unlearn such behaviors or, as in the case of social skills and problem solving training, to teach more adap-

tive behavior. By the 1970s, the critical ingredients of social skills and problem solving training had begun to be packaged, and research was underway evaluating the effects of skills training on clinical populations. Since the ªpackagingº of skills training procedures into standardized approaches, social skills training and training in problem solving have become some of the most widely practiced clinical techniques in individual, group, and family psychotherapy. Indeed, aside from clinical applications, the methods employed in skills training are widely applied with nonclinical populations as well, such as in work with maritally distressed couples (Gottman & Rushe, 1995), training parenting skills (Forehand & McMahon, 1981), and teaching employment skills (Berg, Wacker, & Flynn, 1990). Thus, although the focus of this chapter is on the application of skills training procedures with clinical populations, the principles of training can be used to teach skills to any desired audience. This chapter begins with a review of theoretical models which serve as heuristics in understanding the impact of social and problem solving skills on interpersonal competence, and the effect of skills on the course of psychiatric disorders. Next, the fundamentals of assessing social and problem solving skills are described, followed by a review of the basic procedures for training skills. Different formats for training skills are then considered, including group, individual, and family-based approaches. Following this, different clinical applications of skills training are discussed, and research supporting the effects of training social and problem solving skills is reviewed. The chapter concludes with a brief summary of social skills and problem solving training for clinical populations.

6.08.2 THEORETICAL MODELS Two different models have been proposed for understanding the impact of social and problem solving skills on adaptive functioning and the course of psychiatric disorders: the stress± vulnerability±coping skills model and the social skills model. These two models are compatible with one another, but each addresses a somewhat different domain of functioning. The stress±vulnerability±coping model addresses the relationship between social and problem solving skills, and the severity and the course of severe psychiatric disorders such as schizophrenia and bipolar disorder. The social skills model, on the other hand, addresses the relationship between social and problem solving

Theoretical Models skills, and functional capacity, including the ability to achieve desired goals. Both of these models are described below.

6.08.2.1 The Stress±Vulnerability±Coping Skills Model This model provides a general framework for understanding the interactions between psychobiological vulnerability, psychosocial stress, and coping skills in determining the severity and course of psychiatric illnesses (Liberman et al., 1986; Nuechterlein & Dawson, 1984; Zubin & Spring, 1977). According to the model, psychobiological vulnerability is necessary for the development of a psychiatric illness. It is determined relatively early in life by factors such as genetic loading and early environmental contributions (e.g., insults to the fetus such as in utero exposure to the influenza virus or obstetric complications). Stress is defined as any environmental change or set of contingencies that requires adaptation to minimize noxious effects (e.g., the loss of support from a significant other, living in a stressful home environment, stressful life events). Stress interacts with psychobiological vulnerability, increasing the chances of either developing a psychiatric disorder, precipitating the occurrence of previously dormant symptoms in an individual who already has a psychiatric illness, or worsening symptoms in a currently symptomatic individual. Coping skills are those abilities that enable an individual to buffer the negative effects of stress on psychobiological vulnerability. Coping skills operate by either eliminating the source of stress (e.g., solving a pressing problem) or by decreasing the unpleasant effects of stress (e.g., talking about feelings with friends after the death of a loved one) (Lazarus & Folkman, 1984). Social skills and problem solving skills are examples of coping skills. The stress±vulnerability model of psychiatric disorders has important implications for treatment. Although psychobiological vulnerability is assumed to be present at a relatively early age, it can be decreased by encouraging adherence to prescribed psychotropic medications and minimizing the abuse of substances which may exacerbate psychiatric conditions (e.g., alcohol, cannabis, cocaine; Drake & Brunette, in press). The negative effects of stress on vulnerability can be minimized in three ways. First, clients' exposure to stress can be reduced by modifying the environment in which they live (e.g., decreasing negative affect in the family environment; Dixon & Lehman, 1995). Second, clients can be taught skills for minimizing the noxious effects of stress (e.g., stress manage-

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ment skills; Meichenbaum, 1985). Third, clients can be taught social and problem solving skills to enable them to decrease stressors that impinge upon them (Liberman, DeRisi, & Mueser, 1989). Thus, social skills and problem solving training offer the promise of decreasing symptom severity and the course of psychiatric illness by enhancing the ability of individuals to manage stress effectively.

6.08.2.2 The Social Skills Model This model addresses the relationship between social and problem solving skills on the one hand and social competence and social adjustment on the other (Bellack, Mueser, Gingerich, & Agresta, 1997). Social competence is defined as the ability to achieve desired goals. Social adjustment refers to an individual's actual attainment of those goals, including the ability to function in different social roles (e.g., worker, parent, spouse, student), to enjoy leisure and recreational activities, and to care for oneself (Mueser, Bellack, Morrison, & Wixted, 1990). The social skills model postulates four assumptions about the relationships between social skills and problem solving skills and social functioning: (i) social competence requires the integration of a set of component behaviors; (ii) impairments in component skills contribute to poor social competence; (iii) social skills are learned or are learnable; (iv) deficits in social and problem solving skills can be rectified by skills training. As noted by Bellack et al. (1997) and discussed further in Section 6.8.3, social skills are not the only determinent of social functioning; a wide range of other factors may also influence social adjustment, such as psychotic symptoms, environmental conditions, and mood. However, skills are postulated to be critical ingredients for interpersonal success, and deficits in these skills can be rectified through skills training techniques. While the stress±vulnerability model addresses the interface between skills and psychiatric illness, the social skills model is aimed at explaining the relationships between skills, social functioning, and goal attainment. It is beyond the scope of this chapter to review the wealth of evidence supporting the stress± vulnerability±coping skills model and the social skills model (e.g., Trower, 1995; Yank, Bentley, & Hargrove, 1993). The practical importance of these models is that they have served as heuristics for clinicians and researchers in understanding the roles of social and problem solving skills in social functioning, and the

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interaction between these skills and the course of psychiatric illnesses. Furthermore, these models have resulted in testable predictions about the effects of social skills and problem solving training on social adjustment in psychiatric disorders, predictions which have been empirically supported by research reviewed later in this chapter. 6.08.3 ASSESSMENT This section discusses: (i) the components of social and problem solving skills; (ii) the range of strategies for assessing skills; (iii) nonskill factors which can influence social competence; and (iv) strategies for integrating assessment into treatment. 6.08.3.1 Components of Social and Problem Solving Skills Prior to the late 1970s, social skills were broadly conceptualized strictly in terms of specific behaviors such as eye contact, voice tone, and the verbal content of what is said. However, in the late 1970s and 1980s, a number of different clinical research teams independently proposed a tripartite typology of social skills, which included social perception, cognitive (or problem solving) skills, and behavioral skills (McFall, 1982; Morrison & Bellack, 1981; Trower, Bryant, & Argyle, 1978; Wallace et al., 1980). Based on this broader conceptualization of social skills, social competence is conceptualized as requiring three different types of skills. First, in order to be effective in a social situation, the person must be able to accurately perceive relevant situational parameters, such as their relationship to the other person, whether the setting is public or private, and the other person's affective response (i.e., social perception skills). Recognition of these situational features is crucial, as they may constrain the appropriateness of social behaviors. There is ample evidence showing that social perception skills, such as the inability to accurately perceive the facial expressions of others or recognize interpersonal problems, are correlated with poorer role performance in clinical populations (e.g., Bellack et al., 1994; Hellewell & Whittaker, 1998; Mueser et al., 1996). Second, after the relevant social information has been extracted from a situation, the individual must be able to formulate a goal, generate possible response alternatives for achieving the goal, weigh the benefits and disadvantages of each possible solution, and choose the best solution. Although these cognitive skills may occur implicitly, they have an important bearing on the success of any plan,

and hence are of direct relevance to an individual's social competence. In addition to the cognitive skills generally subsumed under the rubric of ªproblem solving skills,º other cognitive skills can also influence social competence. Abstract thinking can be crucial for an individual to grasp a concept related to solving a particular problem or achieving a desired goal. Memory impairment may interfere with social competence by rendering it more difficult for individuals to learn from past mistakes or recall critical features of situations. Cognitive functioning has been found to be a robust predictor of psychosocial adjustment, with research suggesting that the ability to cognitively process socially-oriented information (i.e., social cognition) is especially critical to success in interpersonal spheres (Penn, Corrigan, Bentall, Racenstein, & Newman, 1997). Third, after social perception and cognitive skills have been used to appraise a situation and formulate a plan of action, behavioral skills are required to carry out the plan. Behavioral skills refer to the actual behaviors emitted in interpersonal situations that are necessary to achieve a particular goal. Broadly speaking, behavioral skills can be divided into four different areas, including nonverbal components, paralinguistic skills, verbal content, and interactive balance. Nonverbal components are behaviors such as eye contact and use of gestures that convey meaning or affect during an interaction. Paralinguistic skills correspond to the vocal characteristics of speech, such as voice tone, loudness, and inflection. Like nonverbal components, paralinguistic skills often communicate vital information during an interaction, such as the speaker's mood or underlying motives. Verbal content refers to what is actually said, regardless of the manner in which it is said. If the verbal content is difficult to understand, bizarre, or socially offensive, it will interfere with social competence. However, in most day-to-day interactions, nonverbal and paralinguistic skills are as important or more important than verbal content in determining a person's social effectiveness. Interactive balance concerns the reciprocity between two individuals in a social interaction. For example, the amount of time each person spends speaking, and the amount of reinforcement each speaker provides to the other when the other person is speaking, can influence whether a person experiences an interaction as rewarding. Thus, the interactive balance between two persons may partly determine whether either person desires similar interactions with the other in the future. Numerous studies have documented that the social behaviors emitted in interpersonal encounters, including paralinguistic features,

Assessment nonverbal skills, verbal content, and interactive balance, are less effective in clinical populations such as schizophrenia than in nonclinical populations, and are correlated with social functioning (e.g., Bellack, Morrison, Mueser, Wade, & Sayers, 1990; Bellack, Morrison, Wixted, & Mueser, 1990). Table 1 provides a summary of the different components of social skills. 6.08.3.2 Assessment Strategies A number of different strategies can be used to assess social and problem solving skills, including self-report, reports by significant others, naturalistic observations, and role-play tests (Liberman, 1982). Each of these strategies has advantages and disadvantages, and a combination of strategies is preferable (Curran, 1979; Wallace, 1986). It is usually best in clinical practice to combine at least two or more assessment strategies for identifying specific deficits in social and problem solving skills that will be the focus of subsequent training. Different assessment strategies are briefly described below, including the advantages and disadvantages of each approach. Self-report measures of social and problem solving skills (e.g., Connor, Dann, & Twentyman, 1982; Rathus, 1973), based on either questionnaires or interviews, have the advantage of being easy to administer and score. In addition, assessments are helpful because they

Table 1 Components of social skills. Nonverbal behaviors Eye contact Facial expression Posture Use of gestures Body orientation Interpersonal distance Paralinguistic skills Loudness Tone Pitch Affect Rate of speech Clarity of speech Duration of utterance Verbal content Verbal message Choice of wording Appropriateness of self disclosure Interactive balance Smoothness of turn-taking Use of social reinforcers (e.g., reflective listening skills) Balance of time-talking

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provide therapists with valuable insights into clients' perceptions of their own needs. Because of these distinct advantages, the assessment of skills usually includes at least some information from the client's point of view. Although selfreport information is easily obtained, it often has limited validity, especially in clients with severe mental illnesses such as schizophrenia and bipolar disorder. An additional problem is that self-reports often lack the behavioral specificity necessary to target specific situations and behaviors for skills training. For these reasons, self-reports are of limited utility in the assessment of social and problem solving skills, although they are frequently obtained as an adjunctive measure. Reports by significant others offer a number of advantages over self-reports of social and problem solving skills. Significant others often directly experience the consequences of poor skills in clients, and may be able to pinpoint specific situations in which these skills are most prominent. For individuals with psychotic disorders, reports by significant others also have the advantage of not being susceptible to the cognitive distortions and denials often present in persons with these illnesses. Despite these advantages, there are a number of limitations of these reports. Significant others are privy to only certain types of social interactions, and are thus unable to inform about clients' skills in many other situations. In addition, although significant others can often identify situations in which clients experience difficulty, their reports typically lack the level of behavioral specificity necessary to target skills for training. Therefore, reports by significant others are often useful for identifying problem areas and specific situations in which clients experience difficulties, which can then be the focus of more fine-grained behavioral analysis. After self-reports and reports by significant others have identified problematic social situations, detailed assessments of specific situations can be conducted through the use of naturalistic observations and role-play tests. Naturalistic observations can be important sources of information for several reasons. First, by their very nature such observations have a high generalizability to the social environment which clients face. Second, naturalistic observations can be easily performed in certain settings in which clinical staff have regular contact with clients. Third, direct behavioral observations provide information at a level of specificity necessary for targeting behaviors in skills training. Of course, there are also limits to the value of naturalistic observations (Foster, Bell-Dolan, & Burge, 1988). Only certain social situations can

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be readily observed by others, and some important situations are almost always unobservable (e.g., intimate communications, offers to use drugs or alcohol). A related problem is that the behavior of some clients may be reactive to the presence of an observer, rendering the observation less naturalistic than intended. Despite these limitations, naturalistic observations provide important information about the social behavior of clients in ªreal worldº settings. A final assessment method is the use of roleplay tests for the assessment of social skills. Role-play tests involve the engagement of clients in a simulated interaction which may be recorded and later rated on different dimensions of social and problem solving skills. There are several advantages of role-play tests over other assessment methods. Because roleplays can be scripted to address specific problem situations, they can be used to assess behavior across a wide range of situations, including situations in which naturalistic behavior cannot ordinarily be observed. Because of the contrived nature of role-play tests, the responses of confederates can be scripted, permitting the comparison of a client's performance both with other clients as well as over time. A final advantage of role-play tests is that there is extensive research supporting both their reliability and validity. For example, role-play tests tend to be stable over time in the absence of social skills training, and are correlated with independent measures of more naturalistically observed social behavior as well as social role performance (e.g., Bellack et al., 1990; Mueser, Bellack, Douglas, & Morrison, 1991). Probably the most significant limitation of role-play tests is the time and effort required to administer them properly. Additional persons need to be trained and on hand to participate as confederates in role-play tests or the therapist must be able to serve as the partner. Depending on the rigor necessary for the rating of social skills, extensive training may be necessary to obtain reliable ratings of skill in role-play tests. Aside from the effort involved in conducting role-play tests, another limitation is the fact that role-plays tend to provide information about whether a client is capable of performing a requisite skill, but not necessarily whether he or she will perform that skill when an appropriate situation arises. These limitations notwithstanding, role-play tests have been shown to be useful for assessing social skills across numerous studies, and are sufficiently sensitive to the effects of social skills training to show improvements consistent with predictions (Bellack, 1979, 1983). In summary, each of the different strategies for assessing social skills has both advantages

and disadvantages, and a combination of methods is optimal in most cases. Assessment usually begins with identifying general areas of dysfunction based on interviews with clients and significant others. Information gleaned from these interviews can then be used to specify situations for more specialized assessment, employing naturalistic observations and/or role-play tests to better characterize the nature of any behavioral deficits or excesses. 6.08.3.3 Nonskill Factors which can Affect Social Competence Although social and problem solving skills are hypothesized to be important determinants of social competence and social functioning, not all impairments in social adjustment are the result of deficits in these skills. The recognition of other factors which can also affect social functioning is critical, since successful intervention may require attention to these factors in addition to, or instead of, social skills. These factors fall under the general categories of medication side effects, mood, other psychiatric symptoms, environmental factors, and cultural mores. A number of medication side effects can interfere with social functioning (Kane & Lieberman, 1992). For example, akinesia is a side effect of antipsychotic medications, characterized by a diminution of facial expressiveness and use of gestures. Another common side effect of antipsychotic medications is akathisia, reflected by an inability to sit still and a need to pace. Both of these medication side effects can interfere with social functioning because they may either make it difficult for the client to be sufficiently expressive (akinesia) or have a distracting influence on social interactions (akathisia). Problems with mood, such as depression, may result in clients not using social and problem solving skills that are in their behavioral repertoire. For example, positive affect has been experimentally demonstrated to facilitate creative problem solving (Isen, Daubman, & Nowicki, 1987). Depression, reflected by a sense of futility and hopelessness, may cause a person not to use critical social or problem solving skills during an interaction, or to give up pursuing interpersonal goals altogether (Marx, Williams, & Claridge, 1992). Anxiety can interfere with a person's ability to use skills that he or she is ordinarily capable of, or may result in the avoidance of situations relevant to achieving interpersonal goals. Similarly, intense feelings of anger or hostility may impede the ability of a client to use effective social and problem solving skills.

Training Techniques Other psychiatric problems may also contribute to poor social competence independent of social skill. One group of symptoms that can have a negative effect on social functioning is the negative symptoms of schizophrenia, such as blunted affect, anhedonia, asociality, and paucity of speech (Andreasen, 1982). For example, clients with a diminished capacity to experience pleasure (anhedonia) may fail to initiate interactions or use relevant skills because they lack the motivation to pursue personal goals (Blanchard, Bellack, & Mueser, 1994). Another group of symptoms that can interfere with social functioning are positive symptoms such as hallucinations, delusions, and bizarre behavior. Clients with prominent positive symptoms often experience difficulties in their interpersonal relationships because their tenuous contact with reality interferes with establishing a common ground of understanding, a necessary precondition for much human communication (Chadwick, Birchwood, & Trower, 1996; Fowler, Garety, & Kuipers, 1995). Environmental factors can have a profound impact on the likelihood that clients will use skills that are in their behavioral repertoires. Similarly, environmental factors can also interfere with the acquisition of skills during social skills training, by either limiting the opportunity clients have to use particular skills, or by not providing sufficient reinforcement for using the skills in appropriate situations. For example, in some state hospital settings, clients are reinforced by staff for assuming the ªsick roleº (i.e., extremely passive behavior), and attempts to break out of this mold by more goal-directed behavior may be actively discouraged (Goffman, 1961; Wing & Brown, 1970). For another example, a depressed client who lives with a domineering spouse may be actively discouraged from becoming more assertive unless that spouse is involved in, understands, and accepts the treatment plan. Finally, cultural mores can influence both social skill and social competence. Cultures may vary in the established norms for behavior based on factors such as gender, age, and relationship to others. Behavior deemed to be ªunassertiveº in one culture may be viewed as ªnormalº and desirable in another (Sue & Sue, 1990). Awareness of the cultural norms of the groups to which clients belong is critical in order to understand cultural factors contributing to what appear to be problems in social functioning. 6.08.3.4 Integration of Assessment and Treatment Although the assessment of social and problem solving skills serves as the cornerstone

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for selecting target behaviors for intervention, ongoing assessment over the course of treatment is critical for evaluating the success of intervention. Improvements in the specific social and problem solving skills targeted for treatment can be evaluated through the use of role-play tests and naturalistic observations in some settings. The larger question of whether improved social and problem solving skills translate into better role functioning is best addressed through interviews with clients and significant others. More objective information may be obtained through the selected use of standardized instruments for evaluating social functioning. 6.08.4 TRAINING TECHNIQUES There are two basic models which are commonly used to train social skills: the motor skills model and the problem solving model (Bellack, Morrison, & Mueser, 1989). 6.08.4.1 Motor Skills Model The primary focus of the motor skills model is on training the specific component skills necessary for successful interactions through repetition and programming the generalization of skills to a variety of real-life situations (e.g., Bellack et al., 1997). The fundamental assumption underlying the motor skills model is that overlearning specific behavioral skills through practice in both simulated (role play) and real social situations will result in these skills becoming automatic in relevant situations. Improved social competence, according to the motor skills model, develops in a fashion similar to the way in which expert performance develops over the course of extensive practice, resulting in complex skills that can be performed without contemplating the necessary steps in advance (Ericsson & Charness, 1994). 6.08.4.2 The Problem Solving Model The problem solving model also places emphasis on the importance of repetition for acquiring necessary social skills. However, according to this model, the generalization of social skills to novel situations requires cognitive or problem solving skills to be maximally effective (e.g., Liberman et al., 1989). Real-life situations provide a multitude of different challenges, not all of which can be anticipated and prepared for in advance. The basic thesis of the problem solving model is that if clients are able to systematically apply problem solving skills in order to formulate goals and deal with obstacles or problems in social situations, their

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social competence will be improved. Thus, in addition to training motor skills, this model incorporates problem solving training in order to improve the generalization of social skills to novel situations, to enable clients to overcome potential obstacles to achieving goals, and to develop alternative strategies when initial ones fail. 6.08.4.3 Common Learning Principles Both the motor skills and problem solving models employ a common set of learning principles, based mainly on instrumental (or operant) and observational (or social) learning theories (Bandura, 1969; Skinner, 1938), to train new social skills. Modeling (demonstrating a skill in a role-play) is frequently employed to familiarize clients with the basic steps of targeted skills. Verbal reinforcement is generously used to encourage effort and to draw attention to particular component skills that were performed well in a role-play situation. Shaping refers to the reinforcement of successive approximations to a goal. Social skills require the complex integration of a number of component skills. Typically, these skills are learned gradually over many role-plays and with much practice outside of the sessions. Therefore, in order to encourage clients to keep trying, and to recognize their progress in acquiring targeted component skills, behavior needs to be shaped gradually over time by providing ample reinforcement along the way. Generalization is the ability to transfer a skill learned in one setting to another situation. In order for social skills training to improve social functioning, clients must be able to use the skills acquired in training sessions in real-life settings. Therefore, programming the generalization of skills to client's natural living environments is an integral part of social skills training. Some of the strategies employed to facilitate generalization include community trips for clients to practice skills on their own, homework assignments, and teaching significant others (e.g., family members, staff members) to prompt clients to use skills in appropriate situations. 6.08.4.4 Basic Skills Training Techniques The basic techniques of social skills training are outlined in Table 2 and are summarized briefly here. More information about techniques for training social skills are available in a variety of books, including McFall (1976), Trower et al. (1978), Goldstein (1982), Kelly (1982), Hargie and McCartan (1986), Liberman et al. (1989), and Bellack et al. (1997). The table describes social skills training in a group format,

although the basic techniques are the same when working with individuals. In order to teach a new social skill, a rationale must first be established for the importance of learning this skill. A combination of strategies can be used to develop the rationale, including asking questions in the Socratic style (e.g., ªWhy might it be helpful to express a positive feeling to someone who has just done something for you?º), providing additional reasons for the importance of a skill, and exploring the relevance of the skill to clients' personal goals and circumstances. The therapist's most immediate goal is to harness clients' motivation to learn the new skill. After the importance of a skill has been established, the therapist discusses the specific component steps of the skill. For example, the skill of ªexpressing negative feelingsº can be broken down into the following five component behaviors: (i) look at the person; (ii) speak in a firm voice tone; (iii) tell the person what they did to upset you; (iv) tell them how it made you feel; (v) suggest how this can be prevented from happening again in the future. The importance of each component step of the skill is discussed (e.g., it is important to look at the person so that you can be sure that you have their attention when you speak to them). After discussing the different steps of the skill, the therapist demonstrates the skill in a role-play. Role-plays are planned in advance, are usually quite brief, and are based on situations that are both highly plausible and likely to be encountered by clients. Immediately following the role-play, the therapist obtains feedback from clients about which component steps of the skill were observed and the overall effectiveness of the therapist in the role-play. When clients have had an opportunity to observe the therapist model the skill, one client is engaged in a role-play of the same skill, usually based on the same situation. The advantage of using the same role-play situation at this point of the training is that it minimizes the amount of work the client must do in order to achieve a successful performance. Immediately following the role-play, the therapist provides positive feedback to the client about which specific steps of the skill were performed well. A critical feature of social skill training is that the therapist always provides immediate, positive, and specific feedback following each role-play. This feedback serves to encourage clients' efforts for trying to perform the skill as well as specific reinforcement for behaviors that were done especially well. After positive feedback has been provided, the therapist provides the client with corrective feedback, conveyed in a helpful, upbeat manner.

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Table 2 Steps of social skills training. 1. Establish rationale for the skill . Elicit reasons for learning the skill from group participants . Acknowledge all contributions . Provide additional reasons not mentioned by group members 2. Discuss the steps of the skill . Break the skill down into three or four steps . Write the steps on a board or poster . Discuss the reason for each step . Check for understanding of each step 3. Model the skill in a role-play . Explain that you will demonstrate the skill in a role-play . Plan out the role-play in advance . Use two leaders to model the skill . Keep the role-play simple 4. Review the role-play with the participants . Discuss whether each step of the skill was used in the role-play . Ask group members to evaluate the effectiveness of the role model . Keep the review brief and to the point 5. Engage a client in a role-play of the same situation . Request the client to try the skill in a role-play with one of the leaders . Ask the client questions to make sure he or she understands their goal . Instruct members to observe the client . Start with a client who is more skilled or is likely to be compliant 6. Provide positive feedback . Elicit positive feedback from group members about the client's skills . Encourage feedback that is specific . Cut off any negative feedback . Praise effort and provide hints to group members about good performance 7. Provide corrective feedback . Elicit suggestions for how client could do the skill better next time . Limit the feedback to one or two suggestions . Strive to communicate the suggestions in a positive, upbeat manner 8. Engage the client in another role-play of the same situation . Request that the client change one behavior in the role play . Check by asking questions to make sure the client understands the suggestion . Try to work on behaviors that are salient and changeable 9. Provide additional feedback . Focus first on the behavior that the client was requested to change . Engage client in two to four role-plays with feedback after each one . Use other behavior shaping strategies to improve skills such as coaching, prompting, and supplemental modeling . Be generous but specific when providing positive feedback 10. Assign homework . Give an assignment to practice the skill . Ask group members to identify situations in which they could use the skill . When possible, tailor the assignment to each client's level of skill

Rather than providing negative feedback about component skills that were performed poorly, one or two suggestions are made for how the client could improve his or her performance in another role-play. In addition to giving verbal suggestions for how to improve performance in the next role-play, the therapist can also model the skill again, drawing the client's attention to specific component behaviors that are targeted for change.

When corrective feedback has been provided, the client is engaged in a second role-play with specific instructions to modify particular component behaviors. The same role-play situation is used as in the first role-play. The second roleplay is followed by the same sequence of positive specific reinforcement, with initial emphasis on the component skills targeted for change, followed by corrective feedback. Typically, a client can be engaged in two to five role-plays of a

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skill, depending on his or her motivation and improvement over the role-plays. If verbal instructions and praise alone are insufficient to bring about behavior change in the role-plays, the therapist may use a variety of other teaching techniques such as supplemental modeling by the therapist, coaching (i.e., whispering verbal prompts to the client during a role-play), prompting (i.e., providing the client with nonverbal cues, such as hand signals, to modify his or her behavior during a role-play) (Bellack et al., 1997), or, for severely impaired clients, attention focused training (i.e., combining verbal cues for response with primary reinforcers such as food) (Massel et al., 1991). The most critical concern when engaging a client in a series of role-plays is that he or she demonstrates some improvement in the targeted skill from the first to the last behavioral rehearsal. This is the essence of the shaping process, in which role-plays provide learning opportunities to improve performance over multiple trials. After sufficient progress has occurred over the role-plays (and other clients have had the opportunity to practice the skill in similar roleplays), the therapist develops a homework assignment for clients to practice the skill on their own. The rationale for practicing the skill outside of the session may need to be reviewed with the client. Homework assignments are most effective when a specific situation to practice the skill can be identified by the client and therapist in advance. Possible obstacles to completing the assignment should be anticipated. When possible, significant others should be informed of the homework assignment so they may remind or prompt the client to practice the skill in appropriate situations. The preceding sequence describes the introduction of new skills in social skills training. Usually several sessions are spent teaching one specific skill before moving onto another skill. Following the introduction to a skill, subsequent sessions begin with a review of homework, including the identification of situations where the client has unsuccessfully tried to use the skill or could have used the skill but did not. Instead of getting a description from the client of what happened, the therapist engages him or her in setting up the role-play of that situation. Following the role-play, positive and corrective feedback are provided using the principles previously described. Role-plays from more than one situation can be practiced, as well as situations that the client expects to encounter or hypothetical situations. Practicing the targeted skill across a variety of role-play situations, as well as trying the skill in real-life situations, serves as a form of generalization training. When the client has demonstrated an ability to

perform the skill spontaneously in real-life situations, additional skills are introduced and trained. 6.08.4.5 Problem Solving Training As in social skills training, training in problem solving skills involves following a specific sequence of steps (D'Zurilla & Goldfried, 1971). These steps are designed to allow consideration of as many solutions as possible and to consider what is needed in order to put a chosen plan into action. While social skills training focuses on teaching specific component behaviors necessary for effective interactions, problem solving training aims to teach a process for approaching problems and achieving goals. The process of problem solving has been likened to the scientific method (Kuhn, 1970; Popper, 1979), in which the essential task is to educate clients how to think and approach psychological problems in a more systematic, rational, and empirically based manner (Beck, 1976; Ellis, 1962). Thus, while social skills training tends to be content-oriented, training in problem solving is oriented towards teaching a set of processing skills designed to maximize goal attainment. The basic steps of problem solving are outlined in Table 3 and are briefly described here. Further information about problem solving training can be found in a variety of books and book chapters, including Falloon, Boyd, and McGill (1984), D'Zurilla (1986), Hawton and Kirk (1989), Nezu, Nezu, and Perri (1989), and Mueser and Glynn (1995). The same steps of problem solving listed in the table are followed when teaching in an individual, group, couple, or family format. Prior to the initiation of problem solving training, the therapist endeavors to develop in clients a problem solving ªorientationº in which problems are viewed as obstacles which can be overcome or improved upon by systematically exploring and trying different response options. Similarly, achieving short- and long-term goals is construed as requiring individuals to overcome a series of obstacles which are ordered in logical sequence. The development of a problem solving orientation can be facilitated by providing examples of problems and their solutions, and reviewing the steps of problem solving. However, in the long-run, clients learn to adopt a problem solving orientation through repeated prompting, practicing the steps of problem solving on personally relevant problems, and experiencing the natural consequences of implementing effective solutions to their problems. Problem solving begins with the identification of a problem or goal that the client wishes to resolve or achieve. As the definition of the

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Table 3 Steps of problem solving. Step . . .

1: Define the problem Get different opinions about the nature of the problem Define the problem or goal in behaviorally specific terms If the problem is shared by more than one person, make sure each one agrees on the definition

Step . . .

2: Generate possible solutions to the problem Brainstorm as many different solutions as possible Do not evaluate any solutions at this time Be creative and include ªwild and crazyº ideas

Step . . .

3: Evaluate the solutions Consider the advantages and disadvantages of each solution for solving the problem Systematically evaluate one solution at a time Avoid settling on one ªbestº solution before reviewing all solutions

Step . . .

4: Select the best solution(s) Select the solution that seems most likely to be effective Consider how difficult the solution will be to implement Choose more than one solution if they can be easily combined

Step . . . .

5: Plan on how to implement the solution(s) Consider what resources are needed to implement the solution (e.g., money, skills, information) Anticipate possible obstacles to implementing the solution Establish a time frame for implementing the solution(s) If more than one person is involved, establish specific tasks for each person

Step . . .

6: Review problem solving plan at a later time Plan a time to evaluate whether the problem solving plan was successful Do additional problem solving and modify the plan if the desired goal has not been obtained Praise all efforts at solving the problem, even if the problem is not entirely resolved

problem is crucial to the solutions that will be generated and likely success of solving it, the problem should be discussed in detail, and questions should be posed such as ªWhy is it a problem?,º ªFor whom is it a problem?,º and ªHow have you tried to solve this problem in the past and what happened?º If problem solving is conducted with others who may be invested in the problem and its solution (e.g., family members), then multiple perspectives on the problem are sought to ensure each person's involvement. When the nature of the problem or goal has been considered, the client must arrive at a specific definition of the problem. In general, the more behaviorally specific the definition, and the more circumscribed the problem, the greater the chance of solving the problem. Large, complex problems and ambitious goals are best approached by breaking them into smaller, more manageable chunks, each of which is the focus of problem solving. For couple- and family-based problem solving, all involved persons must agree on the definition of the problem in order for them to be involved in its resolution (Falloon et al., 1984). When a problem or goal has been articulated, multiple solutions are identified for solving the problem or achieving the goal. Clients are urged to be as creative as possible at this point of problem solving, and to avoid editing, censur-

ing, or evaluating any of the solutions that come to mind. Instead, all solutions are acknowledged, with the expectation that suggesting even bad or inappropriate solutions may lead to the identification of novel and innovative strategies. Clients who tend to be overly self-critical and punitive may require extra practice at not immediately rejecting solutions as soon as they are generated. After a variety of possible solutions have been identified, each one is systematically evaluated in terms of its perceived effectiveness for solving the problem. This evaluation can be standardized by routinely assessing the advantages and disadvantages of each solution. Following the evaluation of solutions, the best solution or combination of solutions is selected. Often, the best solution is quite evident after the advantages and disadvantages of each solution have been considered. Sometimes no one solution is obviously best, more than one solution appears equally effective, or, when more than one person has a stake in the problem, there is disagreement as to the ªbestº solution. In such cases, the best solution is determined by combining different solutions, selecting more than one solution to implement, and determining which one should be tried first, or creating a new solution drawn from the previously discussed ones.

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Solutions to problems can only be effective if they are implemented. Furthermore, a variety of obstacles can conspire to interfere with the implementation of a potentially effective solution to a problem. Therefore, planning on how to implement the solution is critical to successful resolution. Several factors are useful to consider when determining a plan for solving the problem. First, if more than one person is involved in solving the problem, roles for implementing the solution need to be agreed upon. Second, the resources needed to implement the solution must be evaluated, such as money, expertise, information, or skills. Roleplays may be useful at this stage to help clients develop or practice the requisite skills for enacting a solution. Third, possible obstacles to effective implementation should be explored and, if realistic obstacles are identified, tentative plans for dealing with them should be determined. Finally, a time-frame should be established for putting the different steps of the solution into action. This time-frame should include a follow-up time during which the success (or lack thereof) of the problem solving plan can be reviewed. Although some problems are solved after a single attempt at problem solving, many are not, and it is common for repeated efforts to be required to make sufficient progress at resolving a problem or achieving a goal. An important part of developing in clients a problem solving orientation is conveying the idea that problem solving is often an iterative process that requires multiple efforts in order to secure success. In order to ensure that problem solving continues to be applied to problems that remain unsolved, it is helpful to establish follow-up times to evaluate the status of the problem or goal. If the problem has been successfully resolved, then a new problem or goal can be targeted. On the other hand, if the problem remains, the therapist teaches the client how to systematically ªdebugº the problem solving plan. Finding the problem in a problem solving plan is accomplished by going through the steps of the plan in reverse order until a problem with the plan is identified, at which point the problem in the plan is corrected, and any necessary changes in the following steps are determined (Mueser & Glynn, 1995). Thus, the first step in debugging a problem solving plan is to determine if the solution was implemented as intended. If it was not, then the implementation plan needs to be altered in order to determine whether the selected solution will work. If the solution was implemented, but it did not work and the problem remains, then the second step is to reevaluate the other possible solutions, and choose a different solution (or combination of

solutions) for solving the problem. When a different solution has been selected, a new implementation plan must be made. If every solution has been tried and implemented, but the problem remains, the third step is to generate additional solutions for resolving the problem or achieving the goal, to then evaluate these new solutions, select the best one, and plan on how to implement it. Finally, if repeated attempts at solving a problem are unsuccessful and all viable solutions have been exhausted, a fourth and last step is to define the problem differently in order to increase the probability that the new problem will be more solvable than the old one. 6.08.5 FORMAT OF SOCIAL SKILLS AND PROBLEM SOLVING TRAINING Social and problem solving skills can be taught in a variety of formats, ranging from individual psychotherapy, to group therapy, to couples or family therapy. 6.08.5.1 Group Skills Training The group format is one of the most common formats for teaching social and problem solving skills. Skills training in groups generally follows a preplanned curriculum, which is provided over a limited time period, ranging from several months to over a year. Clients usually begin participating in the group at its initiation, and continue until the targeted skills have been acquired. Groups are often led by two therapists and comprise clients with deficits in similar areas. There are several advantages to teaching social skills and problem solving in a group format. First, there is the obvious advantage of economy, considering that one or two therapists can work with five to eight clients simultaneously in a group setting. Second, group-based skills training provides clients with a variety of different role models, which may facilitate their acquisition of targeted skills. Third, feedback from other clients can be obtained in a group format, providing additional reinforcement for clients to practice the requisite skills. Fourth, group-based skills training can provide the opportunity for role-playing with a variety of different partners (i.e., different clients), a task which is much more difficult to accomplish when conducting individual psychotherapy. Fifth, clients often appreciate the opportunity of working with others who share similar difficulties and goals. For example, group-based social skills training can be conducted with individuals with severe mental illnesses (e.g.,

Clinical Applications and Research schizophrenia), social phobia, or poor assertiveness skills. Problem solving training in a group format offers the same advantages. Clients often enjoy being able to help each other make progress towards desired goals and appreciate knowing that they are not alone in the problems or obstacles they face. In addition, since most problems or goals that clients have are not unique, more than one client may benefit from progress made on problem solving about a particular goal. 6.08.5.2 Individual Format Although the group format for skills training has a number of advantages, it is often not practical, especially for clinicians working in private practice. Social skills and problem solving training in an individual format follows the same basic principles as when working with groups. There are several advantages to individual-based work. By its very nature, it is easier to tailor treatment sessions to the specific needs presented by the client. There is also more time for training skills because of the exclusive focus on one client. Finally, skills training can be conducted on an ad hoc basis, rather than following a structured curriculum, which may be more beneficial for some clients participating in other types of psychotherapy, such as cognitive restructuring or relaxation training. 6.08.5.3

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dures used in the group format for teaching social skills, and are then given homework assignments to practice these skills on their own. Role-plays are used to assess family members' acquisition of targeted skills. When family members have demonstrated improvements in basic communication skills, they are then taught problem solving skills. Initially, the therapist leads the family to demonstrate the steps of problem solving. Subsequent to this, family members elect their own ªchairmanº to lead the problem solving discussion and ªsecretaryº to record the family's problem solving efforts. The members are encouraged to have weekly meetings to practice their problem solving skills. Over time, as the family members' skills improve, increasingly more difficult problems are tackled, including problems that may be the source of major conflict between family members. It is also possible to combine the group and family formats into a multiple family group format. For example, McFarlane (1990) has developed a model of multiple family group intervention for persons with schizophrenia and their relatives. In groups that are held every two weeks, problem solving is taught and regularly practiced in order to identify effective solutions to common problems, thereby reducing the risk of relapse and rehospitalization (McFarlane et al., 1995).

Family Format

Social skills and problem solving training can be conducted in the context of family or couples intervention. For example, behavioral marital therapy typically incorporates both training in basic communication skills for couples and problem solving skills as a strategy for minimizing conflict and increasing positive interactions (e.g., Bornstein & Bornstein, 1986; Jacobson & Margolin, 1979; Liberman, Wheeler, deVisser, Kuehnel, & Kuehnel, 1980). These interventions are based on the assumption that most of the difficulties maritally distressed couples experience are due to deficits in communication rather than fundamental differences in values and preferences. Similarly, behavioral family therapy involves teaching basic communication skills and problem solving skills to family members (Mueser & Glynn, 1995). For example, Falloon, Boyd, and McGill (1984) developed a model in which families are taught four basic communication skills (active listening, expressing positive feelings, making positive requests, expressing negative feelings), followed by the six steps of problem solving. Families are taught communication skills following the same basic proce-

6.08.6 CLINICAL APPLICATIONS AND RESEARCH Social skills and problem solving training have been applied to very wide range of psychiatric disorders and interpersonal difficulties. In fact, there are few areas of psychopathology or interpersonal dysfunction for which skills training approaches have not been developed. For example, skills training approaches have been developed to help people with problems such as anger management, interpersonal shyness and dating anxiety, poor assertiveness, conflict resolution, difficulties with interpersonal relationships on the job, marital discord, and dealing with social situations involving substance abuse. Although social and problem solving skill interventions generally focus on improving interpersonal competence in specific domains of functioning, programs are often targeted at groups of clients with specific diagnoses, including major depression, schizophrenia, borderline personality disorder, and social phobia, as well as individuals with developmental disabilities. Table 4 summarizes clinical applications of social and problem solving skills training to

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different problem areas and populations. Many of the programs described in this table have been empirically validated in controlled studies. The research literature supporting the efficacy of social and problem solving training has grown rapidly over the last two decades, and these approaches now enjoy some of the best empirical support of all psychological interventions. It is beyond the scope of this chapter to critically review research on the effects of social skills training and problem solving training. However, numerous books and review articles are available that critically evaluate these different training programs, including Bedell and Lennox (1996), O'Donahue and Krasner (1995a), Dilk and Bond (1996), Benton and Schroeder (1990), Nezu and Nezu (1989), and Smith, Bellack, and Liberman (1996).

6.08.6.1 Utility of Social and Problem Solving Skills Training From a treatment planning perspective, it is important to consider when skills training is a treatment on its own and when it best serves as an adjunct to other approaches to therapy. To some extent, the answer to this question depends on whether skills training is used to treat a complex constellation of behaviors and symptoms (e.g., a psychiatric disorder) or a more specific and narrower class of situations and behaviors. There have been numerous controlled studies of skills training for schizophrenia, with some evidence documenting benefits in the areas of social functioning, symptom severity, and relapses and rehospitalizations (e.g., Bellack, Turner, Hersen & Luber, 1984; Hogarty et al., 1991; Marder et al., 1996). Schizophrenia is a complex illness involving impairments across multiple domains, including social adjustment, cognitive functioning, and symptomatology. When skills training is conducted with persons with schizophrenia, it is provided in the context of a comprehensive treatment program (Bellack & Mueser, 1993), which may include a veriety of other interventions such as medication and symptom monitoring, case management, family psychoeducation, and vocational rehabilitation. With respect to major depression, both social skills training and problem solving training have been shown to be effective in reducing severity of depression without the use of other interventions (Bellack, Hersen, & Himmelhoch, 1983; Nezu & Perri, 1989). However, in contrast to schizophrenia, where relatively few psychological interventions have been established to be clinically effective, a wide variety of therapeutic approaches appear to result in improvements in depression comparable to those produced by

social and problem solving skills training, such as cognitive therapy and scheduling pleasant events (Dobson, 1989; Zeiss, et al., 1979). Therefore, skills training can be used as a primary treatment approach for depression, although its effects can be expected to be similar to those of other psychological interventions. In clincal practice, skills training is most often provided as an adjunctive intervention for some clients, in combination with cognitive or interpersonal therapy, rather than as the sole intervention. Similar in some respects to its use in major depression, social skills training is frequently employed as an adjunctive strategy in the treatment of social phobia. For example, in a program for social phobia developed by Heimberg et al. (1990), cognitive therapy and exposure are combined with social skills training (role playing) in order to provide clients with feedback about their behavior, to challenge their distorted perceptions about their own social behavior, and to encourage them not to avoid feared social situations. Although some research suggests that cognitive therapy may not reduce social anxiety above and beyond that provided by the combination of social skills training and exposure (Hope, Heimberg, & Bruch, 1996; Stravynski & Shahar, 1983), other research indicates that cognitive therapy alone may be effective (Emmelkamp, Mersch, Vissia, & van der Helm 1985). However, in practice no single treatment approach is usually provided for social phobia; rather, most treatment programs involve a combination of strategies, including social skills training, exposure, and cognitive therapy (e.g., Heimberg et al., 1990; Turner, Beidel, & Cooley, 1994). Social and problem solving skills training can be effective as treatments on their own (or in combination with training in other self-regulatory skills, such as stress inoculation, relaxation, cognitive restructuring) when they are provided to address a specific problem (or class of problems), often within a specific population (e.g., clients with developmental disabilities, psychiatric disorders). There are numerous studies in the research literature (some included in Table 4) of skills training interventions demonstrating superior outcomes compared with other treatment or waitlist (no treatment) comparison groups. For example, skills training has been found to be useful in decreasing problems related to anger (Benson, Rice, & Miranti, 1986; Deffenbacher, 1988), improving social anxiety, loneliness, and dating skills (e.g., Fox, McMorrow, Storey, & Rogers, 1984; MacDonald, Lindquist, Kramer, McGrath, & Rhyne, 1975), improving assertiveness (Gambrill, 1995), enhancing job-related skills, such as

Table 4 Examples of clinical applications of social and problem solving skills training. Program developers

Target population

Training format

Focus of traininga

Alberti and Emmons (1990)

Unassertive persons

Group

Becker, Heimberg, and Bellack (1987) Benson (1991) Falloon et al. (1984) Miklowitz and Goldstein (1997) Mueser and Glynn (1995) Fisher and Carstensen (1990) Heimberg et al. (1990) Jacobson and Margolin (1979) Kelly (1995)

Persons with depression Mentally retarded adults Families of persons with severe psychiatric disorders

Individual Group Family

Elderly nursing home residents Socially anxious clients Maritally distressed couples Persons with high HIV risk behavior Agoraphobics Clients with schizophrenia

Group Group Couples Group

SST to improve conversational and other social skills in elderly persons Exposure to social situations, cognitive restructuring, and SST for peer intentions SST for communication skills and PS to address problem areas SST to reduce HIV risk behaviors PS and exposure to feared situations SST for communication skills, resolving conflicts, making friends, dealing with care providers, recreational and leisure activities

Borderline personality disorder clients Domestically violent men Alcoholics

Individual Group (can be adapted for individuals) Group and individual Group Group

Kleiner, Marshall, and Spevack (1987) Liberman et al. (1989) Bellack et al. (1997) Linehan (1993) Maiuro (1991) Monti et al. (1989)

SST for skills to help people ªstand up for their rightsº and express feelings directly SST for interpersonal skills SST and PS to teach strategies for managing anger and interpersonal conflict SST for basic communication skills and PS to help families solve problems and achieve goals

SST and PS to address interpersonal skills, emotion regulation, and distress tolerance PS to reduce domestic violence SST for conversational skills, expressing feelings, dealing with alcohol-related situations PS to address anxiety and depression problems interfering with functioning

Mynors-Wallis, Davies, Gray, Barbour, and Gatz (1997) Nezu, Nezu, and Perri (1989) Novaco(1975)

Primary care clients

Individual

Persons with major depression Persons with anger problems

Individual Individual

Salkovskis, Atha, and Storer (1990)

Suicidal persons

Individual

Valenti-Hein and Mueser (1990)

Mentally retarded adults

Group

Waldo, Roath, Levine, and Freedman (1987) Wong and Woolsey (1989)

Mothers with schizophrenia

Group

PS to address interpersonal problems and goals related to depression Stress management skills, PS to identify suitable alternatives in conflict situations, SST for dealing with provoking situations PS to identify problems and arrive at solutions that are alternatives to selfinjurious behaviors SST and PS to develop dating skills (e.g., conversational skills, asking for a date, resisting persuasion) SST to teach parenting skills

Chronic psychotic inpatients

Individual

SST to re-establish conversational skills in severely impaired clients

a

SST = social skills training; PS = Problem solving training.

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interviewing, managing interactions with supervisors, and peer relationships (e.g., Hughes & Rusch, 1989; Mueser, Foy, & Carter, 1986), and dealing with social situations involving alcohol and drug abuse (e.g., Hawkins, Catalano, Gillmore, & Wells, 1989). Thus, social and problem solving skills training are most often combined with other therapeutic modalities when used in the treatment of psychiatric syndromes or disorders, whereas skills training can be used on its own when the goals are to improve specific areas of functioning related to specific types of social situations. 6.08.7 SUMMARY AND CONCLUSIONS Over the past several decades, social skills and problem solving training have become some of the most widely practiced interventions for the treatment of psychological disorders in adults. Therapies designed to improve social and problem solving skills are based on the assumptions that clients are capable of learning more adaptive interpersonal and self-management skills, and that these skills are most effectively taught in a systematic fashion, employing the principles of social learning theory. Training in social and problem solving skills can be conducted in a variety of different formats, such as with individuals, groups, couples, or families. Skills training approaches have enjoyed success across a broad range of clinical problems, including depression, poor social functioning in schizophrenia, social anxiety, anger, marital distress, and families coping with severe psychiatric disorders. Expertise in teaching social and problem solving skills is an important tool for clinical psychologists' armamentarium of treatment techniques. 6.08.8 REFERENCES Alberti, R. E., & Emmons, M. L. (1970). Your perfect right. San Luis Obispo, CA: Impact Press. Andreasen, N. C. (1982). Negative symptoms in schizophrenia: Definition and reliability. Archives of General Psychiatry, 39, 784±788. Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart and Winston. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Becker, R. E., Heimberg, R. G., & Bellack, A. S. (1987). Social skills training treatment for depression. New York: Pergamon. Bedell, J. R., & Lennox, S. S. (1996). Handbook for communication and problem-solving skills training. New York: Wiley. Bellack, A. S. (1979). A critical appraisal of strategies for assessing social skill. Behavior Assessment, 1, 157±176. Bellack, A. S. (1983). Recurrent problems in the behavioral assessment of social skill. Behaviour Research and Therapy, 21, 29±42. Bellack, A. S., & Hersen, M. (Eds.) (1979). Research and

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Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press. MacDonald, M. L., Lindquist, C. U., Kramer, J. A., McGrath, R. A., & Rhyne, L. D. (1975). Social skills training: Behavioral rehearsal in groups and dating skills. Journal of Counseling Psychology, 22, 224±230. Maiuro, R. (1991). The evolution and treatment of anger and hostility in domestically violent men. Revista Intercontinental de Psicologia y Educacion, 4, 165±189. Marder, S. R., Wirshing, W. C., Mintz, J., McKenzie, J., Johnston, K., Eckman, T. A., & Johnston-Cronk, K. (1996). Two-year outcome of social skills training and group psychotherapy for outpatients with schizophrenia. American Journal of Psychiatry, 153, 1585±1592. Marx, E. M., Williams, J. M. G., & Claridge, G. C. (1992). Depression and social problem solving. Journal of Abnormal Psychology, 101, 78±86. Massel, H. K., Corrigan, P. W., Liberman, R. P., & Milan, M. A. (1991). Conversational skills training of thoughtdisordered schizophrenic patients through attention focusing. Psychiatry Research, 38, 51±61. McFall, R. M. (1976). Behavioral training: A skill-acquisition approach to clinical problems. Morristown, NJ: General Learning Press. McFall, R. M. (1982). A review and reformulation of the concept of social skills. Behavioral Assessment, 4, 1±33. McFarlane, W. R. (1990). Multiple family groups and the treatment of schizophrenia. In M. I. Herz, S. J. Keith, & J. P. Docherty (Eds.), Handbook of schizophrenia (Vol. 4): Psychosocial treatment of schizophrenia (pp. 167±189). Amsterdam: Elsevier. McFarlane, W. R., Lukens, E., Link, B., Dushay, R., Deakins, S. A., Newmark, M., Dunne, E. J., Horen, B., & Toran, J. (1995). Multiple-family groups and psychoeducation in the treatment of schizophrenia. Archives of General Psychiatry, 52, 679±687. Meichenbaum, D. (1985). Stress innoculation training. New York: Pergamon. Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: A family focused treatment approach. New York: Guilford Press. Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989). Treating alcohol dependence. New York: Guilford Press. Morrison, R. L., & Bellack, A. S. (1981). The role of social perception in social skill. Behavior Therapy, 12, 69±79. Mueser, K. T., Bellack, A. S., Douglas, M. S., & Morrison, R. L. (1991). Prevalence and stability of social skill deficits in schizophrenia. Schizophrenia Research, 5, 167±176. Mueser, K. T., Bellack, A. S., Morrison, R. L., & Wixted, J. T. (1990). Social competence in schizophrenia: Premorbid adjustment, social skill, and domains of functioning. Journal of Psychiatric Research, 24, 51±63. Mueser, K. T., Doonan, R., Penn, D. L., Blanchard, J. J., Bellack, A. S., Nishith, P. & deLeon, J. (1996). Emotion recognition and social competence in chronic schizophrenia. Journal of Abnormal Psychology, 105, 271±275. Mueser, K. T., Foy, D. W., & Carter, M. J. (1986). Social skills training for job maintenance in a psychiatric patient. Journal of Counseling Psychology, 33, 360±362. Mueser, K. T., & Glynn, S. M. (1995). Behavioral family therapy for psychiatric disorders. Needham Heights, MA: Allyn & Bacon. Mynors-Wallis, L., Davies, I., Gray, A., Barbour, F., & Gath, D. (1997). A randomized controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. British Journal of Psychiatry, 170, 113±119. Nezu, A. M. & Nezu, L. M. (Eds.) (1989). Clinical decision making in behavior therapy: A problem solving perspective. Champaign, IL: Research Press.

Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problemsolving therapy for depression: Theory, research, and clinical guidelines. New York: Wiley. Nezu, A. M., & Perri, M. G. (1989). Social problem-solving therapy for unipolar depression: An initial dismantling investigation. Journal of Consulting and Clinical Psychology, 57, 408±413. Nuechterlein, K. H., & Dawson, M. E. (1984). A heuristic vulnerability/stress model of schizophrenic episodes. Schizophrenia Bulletin, 10, 300±312. Novaco, R. W. (1975). Anger control: The development and evaluation of an experimental treatment. Lexington, MA: D. C. Heath. O'Donohue, W., & Krasner, L. (1995a). Psychological skills training. In W. O'Donohue & L. Krasner (Eds.), Handbook of psychological skills training: Clinical techniques and applications (pp. 1±19). Boston: Allyn & Bacon. O'Donohue, W., & Krasner, L. (Eds.) (1995b). Handbook of psychological skills training: Clinical techniques and applications. Boston: Allyn & Bacon. Penn, D. L., Corrigan, P. W., Bentall, R. P., Racenstein, J. M., & Newman, L. (1997). Social cognition in schizophrenia. Psychological Bulletin, 121, 114±132. Popper, K. R. (1979). Objective knowledge. Oxford, UK: Oxford University Press. Rathus, S. A. (1973). A 30-item schedule for assessing assertive behavior. Behavior Therapy, 4, 398±406. Salkovskis, P. M., Atha, C., & Storer, D. (1990). Cognitivebehavioural problem solving in the treatment of patients who repeatedly attempt suicide: A controlled trial. British Journal of Psychiatry, 157, 871±876. Salter, A. (1949). Conditioned reflex therapy. New York: Farrar, Strauss. Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. New York: Appleton-CenturyCrofts. Smith, T. E., Bellack, A. S., & Liberman, R. P. (1996). Social skills training for schizophrenia: Review and future directions. Clinical Psychology Review, 16, 599±617. Stravynski, A., & Shahar, A. (1983). The treatment of social dysfunction in nonpsychotic psychiatric outpatients: A review. Journal of Nervous and Mental Disease, 171, 721±728. Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Theory and practice (2nd ed.). New York: Wiley. Trower, P. (1995). Adult social skills: State of the art and future directions. In W. O'Donohue & L. Krasner (Eds.), Handbook of psychological skills training: Clinical techniques and applications (pp. 54±80). Boston: Allyn & Bacon. Trower, P., Bryant, B. M., & Argyle, M. (1978). Social skills and mental health. London: Methuen. Turner, S. M., Beidel, D. C., & Cooley, M. R. (1994). Social effectiveness therapy: A program for overcoming social anxiety and phobia. Mount Pleasant, SC: Turndel. Valenti-Hein, D., & Mueser, K. T. (1990). The dating skills program: Teaching social±sexual skills to adults with mental retardation. Orland Park, IL: International Diagnostic Systems. Waldo, M. C., Roath, M., Levine, W., & Freedman, R. (1987). A model program to teach parenting skills to schizophrenic mothers. Hospital and Community Psychiatry, 38, 1110±1112. Wallace, C. J. (1986). Functional assessment in rehabilitation. Schizophrenia Bulletin, 12, 604±630. Wallace, C. J., Nelson, C. J., Liberman, R. P., Aitchison, R. A., Lukoff, D., Elder, J. P., & Ferris, C. (1980). A review and critique of social skills training with schizophrenic patients. Schizophrenia Bulletin, 6, 42±63. Wing, J. K., & Brown, G. W. (1970). Institutionalism and

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.09 Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis GRAHAM C. H. TURPIN and MICHAEL HEAP University of Sheffield, UK 6.09.1 INTRODUCTION

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6.09.2 A THEORETICAL OVERVIEW OF AROUSAL DYSFUNCTION AND AROUSAL MODIFICATION INTERVENTIONS

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6.09.2.1 6.09.2.2 6.09.2.3 6.09.2.4

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Arousal as a Hypothetical Construct Arousal Dysfunction and Health Theoretical Basis of Arousal Modification Methods Summary

6.09.3 AROUSAL REDUCTION METHODS: GENERAL PROCEDURES AND SPECIFIC TECHNIQUES 6.09.3.1 General Procedural Issues 6.09.3.1.1 Assessment 6.09.3.1.2 Therapeutic rationale 6.09.3.1.3 Practical considerations 6.09.3.1.4 Presentation of the technique 6.09.3.1.5 Evaluation of procedural factors 6.09.3.2 Specific Techniques 6.09.3.2.1 Relaxation-based methods 6.09.3.2.2 Biofeedback 6.09.3.2.3 Meditation 6.09.3.2.4 Hypnosis 6.09.3.3 Indications, Side Effects, and Contraindications 6.09.3.3.1 Client selection 6.09.3.3.2 Side effects and adverse reactions 6.09.3.3.3 Contraindications and procedural modifications 6.09.4 COMPARATIVE OUTCOMES AND THERAPEUTIC MECHANISMS

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6.09.4.1 Overview of Outcomes 6.09.4.2 Therapeutic Mechanisms 6.09.5 CONCLUSION

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6.09.6 REFERENCES

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and are also frequently associated with more serious mental health problems such as panic, obsessional disorders, and psychosis. It is not surprising, therefore, that some of the earliest proposed psychological treatments (e.g.,

6.09.1 INTRODUCTION Heightened arousal, elevated somatic tension, increases in anxiety and worry, are common consequences of many everyday life experiences, 203

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Jacobson, 1938), have targeted arousal reduction. Indeed, many of these techniques (e.g., meditation, hypnosis) have their origins in nonscientific or religious practices and customs. Because of this, relaxation, biofeedback, meditation, and hypnosis are frequently regarded, particularly within the USA, as alternative or complementary therapies within medicine and are provided by specialist practitioners such as stress counsellors, hypnotherapists, and biofeedback practitioners. A recent review of ªunconventional medicineº practised within the USA (Eisenberg et al., 1993) revealed, by means of a telephone survey of 1539 adults, that one in three respondents reported using at least one unconventional therapy in the past year, and a third of these had engaged in an average of 19 visits to a practitioner. Extrapolating from this pattern of contact to the entire population, the authors concluded that the extent of usage of unconventional therapies exceeded the number of primary care consultations and the economic cost ($13.7 billion) was comparable to out-ofpocket expenditure for all hospitalizations within the USA. Relaxation (13%), chiropracty (10%), and massage (7%) accounted for the most frequently used therapies, and back problems (36%), anxiety (28%), headaches (27%), chronic pain (26%), and cancer (24%) represented the most common health problems for which people had sought unconventional therapies. Although reliance on a telephone survey may have overestimated the prevalence of these techniques, Eisenberg et al. (1993, p. 251) conclude that these therapies have ªan enormous presence in the US health care system.º They further concluded that they represent a sizeable expenditure in healthcare, are used largely as adjuncts to conventional medical interventions, and are commonly undertaken independently of consultation with the medical practitioner responsible for conventional treatment of the presenting problem. The above review included a wide range of treatments unrelated to the focus of this particular chapter. Nevertheless, relaxation (13%), imagery (4%), biofeedback (1%), and hypnosis (1%) were reported as being widely used within a 12-month period for a range of psychological problems (e.g. anxiety, depression, insomnia, and headache) which are frequently referred to a clinical or health psychologist, and this raises a number of intriguing questions. For example, what is the efficacy of these techniques, how severe are the problems for which these therapies are commonly employed, how effectively are these therapies delivered, what training and levels of competence are associated with the practitioners responsible for delivery of these thera-

pies, and what proportion of therapists identified within Eisenberg et al.'s survey are clinical psychologists? Many of these questions go far beyond the scope of this chapter, since it is our intention to focus only on those specific therapies that are delivered as part of a formally constructed and scientifically evaluated package of psychological treatment. Nevertheless, clinical psychologists have to be aware of a wider context, whereby clients and their referral sources already have access to and are familiar with these treatments, and which goes far beyond that formally delivered within a clinic setting. It is likely, therefore, that such experiences may well influence how the efficacy and appropriateness of many of these therapies are judged, irrespective of any formal scientific evaluation of their effectiveness. The major aims of this chapter, therefore, are to overview therapeutic techniques directed at modifying arousal and inducing relaxation. The therapeutic rationales underlying these techniques will be critically examined, together with an evaluation of their efficacy. The review will restrict itself primarily to adults and to problems broadly conceived as being associated with mental health. Some reference, however, will be made to physical health and behavioral medicine when reviewing more contemporary applications. We will conclude by attempting to appraise whether any common process or mechanism might underlie change brought about by the application of these diverse psychological treatments. 6.09.2 A THEORETICAL OVERVIEW OF AROUSAL DYSFUNCTION AND AROUSAL MODIFICATION INTERVENTIONS A fundamental assumption that underlies this chapter is that elevated ªarousalº is associated with a variety of mental and physical health problems, and that treatment methods targeted at ªarousalº reduction will alleviate the severity of these conditions. Before we review these proposed treatments, it is important that this assumption is examined further. The critical questions are: what is arousal, what associations exist between elevated arousal and physical and mental health problems, what techniques exist to modulate arousal, and what are the mechanisms that mediate therapeutic change? 6.09.2.1 Arousal as a Hypothetical Construct The construct of arousal has been revisited extensively within the literature, with respect to psychophysiology (Andreassi, 1989; Cacioppo

Theoretical Overview of Arousal Dysfunction and Arousal Modification Interventions & Tassinary, 1990; Gale & Eysenck, 1992), emotion (Tucker, Vannatta, & Rothlind, 1990; Wagner, 1988), and clinical applications (Cacioppo, Berntson, & Anderson, 1991; Lader, 1975; Turpin, 1989, 1990; Wieisse, Davidson, & Baum, 1989). A variety of different arousal constructs can be identified, including arousal as central nervous system activation underlying an ªarousal±sleepº continuum (e.g. Duffy, 1951), arousal as a general drive system affecting behavior as characterized by the inverted U model (e.g. Andrew, 1974; Claridge, 1987), and arousal as a psychophysiological construct identified by peripheral physiological response patterning (e.g., Lacey, 1967). Despite the almost ubiquitous presence of the ªarousal constructº within psychophysiology, its current usage has markedly declined. Its demise can be traced to Lacey's classic critique (Lacey, 1967) wherein the unitary nature of a physiologically mediated arousal drive, as advocated by Duffy (1951), was discarded because different autonomic response measures, behaviors, and situational factors were found to be dissociable. More recent psychophysiological studies have also failed to demonstrate a unitary arousal construct and largely support Lacey's original position (Venables, 1984). Peripheral autonomic measures of arousal, therefore, fail to demonstrate high intercorrelations, and instead display response patterns specifically determined by either individual differences or situational factors. More recent arousal theories have also discarded the notion of ªarousalº as an unitary construct, but instead have stressed the complexities of stimulusÐ response relationships, different arousal systems, motivational systems, and neurophysiological or neurochemical substrates (Turpin, 1989). Given the paucity of evidence to support a unitary arousal construct, it is perhaps paradoxical that the construct of arousal continues to receive widespread support as an explanatory construct within clinical psychology. This is, perhaps, best characterized by Gale and Eysenck's (1992) quote from Claridge (1987, p. 134): ªI have often felt that as an explanatory concept in psychology ªarousalº has many of the qualities of a difficult but persuasive lover, whom reason tells one to abandon yet who continues to satisfy an inescapable need.º The question arises, therefore, as to why, particularly within the clinical arena, this irrational infatuation should continue. One answer is that ªarousalº is best viewed as a hypothetical construct and, as such, it is difficult to define precisely or to operationalize. However, clinical psychology deals with many such similar constructs including, for example, ªaffect,º

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ªemotion,º and ªanxiety,º and would be severely limited without the explanatory power that such constructs bestow on clinical formulations and conditions. Indeed, we suggest that arousal has important clinical utility and that its use can be progressed by treating it in a similar fashion to other clinical constructs such as anxiety. Just as anxiety is best conceptualized according to Lang's three-system model (Lang, 1968; Turpin, 1991), arousal might be broken down into three component systems: physiological, cognitive, and behavioral (Schilling & Poppen, 1983). Physiological arousal components will include both central activation and autonomic responding; cognitive components might refer to both subjective experience and verbal report, together with attentional consequences in terms of vigilance and selective attention; and behavioral components would account for levels of activity, together with the integration and coordination of motor responding. It is suggested that these three systems are loosely coupled in a fashion similar to that described by OÈhman (1987) for emotion (Figure 1). The failure to observe perfect coupling by measures either within or between component systems is essentially similar to the de synchrony concept commonly entertained for anxiety (Rachman & Hodgson, 1974; Turpin, 1991) and frequently encountered elsewhere within psychophysiology (Cacioppo & Tassinary, 1990; OÈhman, 1992). Several implications for therapy emerge if arousal is treated according to the systems identified in Figure 1. First, a comprehensive assessment of arousal will involve attempts to measure all three systems. Indeed, Poppen (1988) has written extensively about the multimodal assessment of arousal and the outcome of relaxation training. He suggests the use of selfreport relaxation and symptom scales, specific physiological measures (e.g., electrodermal, cardiovascular, electromyogram [EMG], skin temperature, and electroencephalogram [EEG] changes), and direct behavioral observations (e.g., Behavioral Relaxation Scale). Second, it becomes evident how overarousal might lead to dysfunction and the expression of a variety of symptoms including subjective distress, hypervigiliance and heightened attention, selective appraisal, hyperactivity, disorganized behavior, and autonomic and somatic overreactivity. The presence of such symptoms within a fear situation is consistent with the constructs of anxiety or panic. Finally, the three-system approach suggests a diversity of potential interventions that might moderate the expression of hyperarousal. The choice between a unitary model of arousal reduction and relaxation, on the one hand, and a multicomponent

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SITUATION

Cognitive system Subjective experience Verbal report Attention and vigilance Proprioception Appraisal

AROUSAL

Physiological system Cortical activation Autonomic responses Somatic tension Neurohumoral

Figure 1

Behavioral system Level of activity and observed wakefulness Organization of activity Speed Clonic movements and tics

The inferential basis of arousal (based on OÈhman's (1992) construct of emotion). (Ð) Observables and relationships between observables; (± ± ± ±) inferred constructs.

model with a variety of specific treatment effects, on the other, is discussed later in this section. 6.09.2.2 Arousal Dysfunction and Health Despite the difficulties described earlier in defining and measuring arousal, the construct has been used widely in association with etiologic theories of both physical and mental illness. Perhaps the most ubiquitous approach concerns diathesis±stress models of psychophysiological disorders (Gatchel, 1993). In particular, Sternbach (1966) postulated that situationally specific patterns of psychophysiological responding, if not adequately modulated by individual homeo-

static mechanisms, would lead to dysfunctional patterns of physiological activation characteristic of so-called ªpsychosomatic disorders.º Indeed, a diversity of theoretical models has been postulated in which elevated physiological arousal is included as a component of ªstressº and is linked to both predisposition and the subsequent expression of a variety of physical health problems including headache, gastrointestinal disorders, hypertension, and asthma (McEwen & Stellar,1993; Steptoe, 1991; Weiner, 1977; Wiebe & Williams, 1992). Such models either incorporate physiological arousal as a component of an undifferentiated stress response (Seyle, 1950), or identify specific pathways associated with autonomic hyperreactivity

Theoretical Overview of Arousal Dysfunction and Arousal Modification Interventions and end-organ dysfunction, as exemplified by Freedman's hypothesized adrenergic mechanism implicated in Raynaud's disorder (Freedman, 1989). Although psychosomatic disorders are covered elsewhere, they represent a major area of study that relies on ªstress±arousalº explanations of disease, and hence provide explicit therapeutic rationales for arousal reduction interventions (Lehrer, Carr, Sargunaraj, & Woolfolk, 1993). Nevertheless, as with arousal, many have argued that the concept of ªstressº is too ill-defined and lacks specificity when defining individual mechanisms underlying disease or dysfunction (Steptoe, 1980). A similar approach has been taken with regard to mental health, whereby stress is seen as a potential threat to mental well-being, and physiological stress or arousal is seen as a frequent consequence of psychosocial stressors and is manifested in a variety of psychological problems (Turpin & Lader, 1986). Such models underpin stress management approaches to mental health and the promotion of more adaptive life-styles, together with the development of more appropriate coping and adaptive responses to challenging stresses and life strain. Generic stress management approaches (Meichenbaum, 1993) are widely used for both physical and mental health problems, and are frequently employed within occupational and vocational settings (Reynolds & Shapiro, 1991). Within the area of mental health, several specific rationales can be identified that link elevated arousal manifested across physiological, cognitive, and behavioral response modes with psychological dysfunction. Several psychological disorders are defined with particular reference to elevated levels of physiological arousal, which are situationally inappropriate and are frequently present in association with other aspects of overarousal, such as heightened attention and vigilance, somatic tension, and behavioral hyperactivity. Generally, arousal is treated nonspecifically and, for example, can be considered as a component of anxiety or even sleep dysfunction in the form of insomnia. With reference to anxiety, the three-system conceptualization of anxiety (Lang, 1968; Kozak & Miller, 1982; Turpin, 1991) is still the prevalent conceptual model, particularly when used as the basis for the evaluation of cognitive behavioral therapies. Physiological, behavioral, and cognitive components of anxiety and their manifestations can easily incorporate the arousal construct, and may even be reformulated whereby arousal is seen as an energetic or drive component of situational fear or anxiety. Similarly, insomnia is frequently (Borkovec, 1979; Nicassio & Buchanan, 1981) conceptualized as arising from both elevated physiological

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arousal and cognitive activation such as preoccupation. We will return in more detail to the three-system analysis of anxiety and arousal when specific therapeutic processes are discussed in later sections of this chapter. Specific arousal components can also be identified for other psychological problems. For example, many sexual disorders are associated with specific patterns of arousal responding in the form of nonspecific physiological arousal, together with abnormal sexual dysfunction. Conditions such as vagismus, erectile dysfunction, and paraphelia might all be considered as involving a specific sexual arousal dysfunction. Similarly, heightened arousal is an important component of the expression of aggression and hostility, and may be specifically associated with particular patterns of cardiovascular and neuroendocrine response. Accordingly, it is frequently the focus of treatments aimed at anger management. Another disorder that might also be considered to include a specific arousal component concerns post-traumatic stress disorder, in which heightened anxiety, tension, hypervigiliance, and exaggerated startle responses are symptomatic features. Finally, the construct of arousal has been used as a mediational variable for several other psychological disorders. Although physiological arousal may not necessarily be an essential component of the expression of the disorder, it is hypothesized that an underlying arousal dysfunction is instrumental in the expression of the disorder. For example, the consequences of arousal on the habituation and conditioning of fear responses has been implicated both in theories of phobic fear (Lader & Mathews, 1970) and in treatment through desensitization (Wolpe, 1982). Habituation is also suggested as an essential component of anxiety reduction within in vivo exposure treatments of anxiety disorders (Foa & Kozak, 1986) and also in the response prevention treatment of obsessivecompulsive disorder (Mills & Salkovskis, 1988). Elevated physiological arousal has also been suggested as a substrate underlying suggested psychomotor disorders such as torticollis (Meares, 1973), tics (Corbett & Turpin, 1985), and writer's cramp (Cottraux, Juenet, & Collet, 1983). More recently, arousal dysfunction has been implicated in relapse for psychosis, whereby arousal is seen as a mediating pathway in the stress±vulnerability model of schizophrenia (Nuetcherlein & Dawson, 1984; Tarrier and Turpin, 1992). Therapeutic approaches that have sought to modify the stress±vulnerability relationship, such as coping enhancement strategies (Barrowclough & Tarrier, 1992), frequently include arousal modulation techniques and rationales.

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In summary, a variety of theoretical models exist that relate arousal dysfunction to the expression of physical and mental health problems. These frameworks, therefore, provide therapeutic rationales for arousal modification methods, assuming that such methods exist and can be shown to be efficacious. It is worth noting the wide range of problems that have been associated with an arousal dysfunction, and this perhaps lends greater credence to Eisenberg et al.'s survey that indicated widespread use of ªunconventionalº therapies for a wide range of conditions. In the next section the theoretical rationale underlying the treatment methods claimed to reduce arousal is reviewed.

6.09.2.3 Theoretical Basis of Arousal Modification Methods Various psychological interventions have been suggested to reduce the level of elevated arousal (Lehrer & Woolfolk, 1993). The rationale for their use depends on how elevated arousal and the mechanisms underlying it are conceptualized. As seen in the previous section, arousal can be defined in a variety of waysÐ physiological, behavioral, and cognitiveÐand each mode can be measured and assessed independently. Moreover, it is likely that elevated arousal is the product of several distinct processes that may or may not be interrelated (see Figure 1). Accordingly, different arousal modification methods might be targeted at different components and rely on different mediational processes. For example, a cognitive arousal component consisting of hypervigilance and appraisal of threat might be ameliorated either by cognitive therapy directed at the beliefs maintaining the negative appraisal or by the reduction and substitution of the prevalence of negative thoughts or worries per se using a cognitive distraction technique, perhaps involving meditation or imagery. A further reduction in a cognitive arousal component might also arise as a consequence of applied relaxation training directed at reducing physiological arousal, thereby eliminating a cue associated with interoceptive sensations of overarousal. Conversely, elevated somatic arousal, as induced by, for example, increased muscle tension and accompanying headache, might be reduced specifically by EMG biofeedback and training directed at the muscle group concerned. An emphasis on different arousal components, therefore, gives rise to what Poppen (1988) describes as multimodal theories of relaxation induction. Such theories originated from dualistic accounts of arousal reduction, which

emphasized both cognitive and somatic relaxation (Davidson & Schwartz, 1976; Heide & Borkovec, 1983; Lehrer, Woolfolk, Rooney, McCann, & Carrington, 1983). The implications of these approaches are that the arousal requires assessing across a range of different domains, and that different aspects of arousal reduction methods might target different sources of arousal. The above approach can be contrasted with unitary theories of arousal and relaxation induction, as exemplified by Benson's (1975) relaxation response. Many arousal reduction techniques are designed to induce a state of relaxation, which is conceived of as being antithetical to either arousal or stress and is typified as subjective calmness, lowered muscle tension, and lowered levels of physiological arousal. Indeed, many authors refer to the relaxation response in a similar, but opposite, fashion, to Selye's (1950) stress response. Moreover, several theoretical models have even implicated specific physiological mechanisms, particularly those related to autonomic balance, as mediating the relaxation state (Gellhorn, 1958). The rationale for some arousal reduction methods, therefore, is to lower arousal by the induction of an opposite and incompatible state of relaxation. This distinction between theories of arousal modulation, which rely on specific pathways, as opposed to a unitary model of relaxation induction is important when evaluating the differential efficacy of these techniques. If relaxation provides a common pathway, it may be that all arousal reduction interventions are equivalent in terms of process, and lead to identical outcomes, albeit with differing degrees of effectiveness in how easily achievable these outcomes are. Alternatively, if arousal reduction or relaxation induction is conceived of as a variety of specific components, different techniques might have differing degrees of efficacy expressed in different modalities for different individuals and disorders. Indeed, the issue of specificity concerning a variety of relaxation methods has been emphasized by Lehrer and colleagues (Lehrer, 1996; Lehrer, Carr, Sargunaraj, & Woolfolk, 1994; Lehrer & Woolfolk, 1993). In contrast to Benson's (1975) unitary relaxation response, they propose an extension of Davidson and Schwartz's (1976) model, in which relaxation is viewed as a multicomponent process (of up to 12 separate components), and that specific techniques give rise to specific effects. For example, they suggest that cognitive changes might be expected from cognitive oriented methods such as meditation; somatic tension changes would be brought about by muscle-oriented methods, such as Jacobson's (1938) progressive muscle

Theoretical Overview of Arousal Dysfunction and Arousal Modification Interventions relaxation (PMR) or EMG biofeedback; and autonomic changes would be brought about by either electrodermal/thermal biofeedback or autogenic training. It should also be acknowledged, however, that specific effects may actually overlie a more generalized induction of a relaxation response, and hence these two approaches are not necessarily seen as mutually incompatible. Moreover, it is by no means conclusive as to how different interventions should be classified using multicomponent models. Autogenic training, for example, can be said to be directed at both autonomic and cognitive components. Similarly, hypnosis can also be considered as multimodal. Lehrer and Woolfolk have tried to resolve the question of unitary vs. multicomponent models of relaxation by comparing the effects of different relaxation procedures on a range of outcome measures chosen to reflect the component processes described by Davidson and Schwartz (1976). This has been attempted either using a comparative treatment approach reviewing the results from different outcome studies (e.g. Lehrer et al., 1994) or by performing essentially analogue laboratory studies in which the effects of these different relaxation techniques on a battery of psychological and physiological measures are contrasted (Lehrer et al., 1983). Generally, these studies are consistent with the view that the effects of different relaxation techniques are mediated by specific changes in somatic and cognitive arousal. Reviews, principally by Lehrer and Woolfolk (Lehrer 1996; Lehrer et al., 1994; Lehrer & Woolfolk, 1993; Lehrer et al., 1983), concerning the specific effects of relaxation techniques on physiological activity support the contention that muscle relaxation training, either in its original form as PMR (Jacobson, 1938) or in its modified form as abbreviated progressive relaxation (APR) (Bernstein & Carlson, 1993), produces significant decreases in muscle tension as measured by EMG. Similarly, EMG biofeedback, either delivered alone or in conjunction with modified PMR, has been shown to produce significant decreases in target EMG levels. However, whether the effects produced by EMG biofeedback delivered to a single muscle site can be generalized to other EMG sites is debatable (Alexander, 1975). Similarly, the data remain equivocal as to the comparative effectiveness of PMR, APR and EMG biofeedback on reducing EMG levels (Lehrer et al., 1994; Lehrer & Woolfolk, 1993) although, EMG biofeedback is probably superior to APR with regard to EMG reduction (Lehrer et al., 1994). Nevertheless, the therapeutic rationale for muscle relaxation training does not restrict itself

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solely to reductions in muscle tension and EMG. Jacobson and his followers (see McGuigan, 1993) stressed that proprioceptive feedback from the musculature directly affects peripheral autonomic activity via the sympathetic and parasympathetic nervous system. This mechanism is based on Gellhorn's theories linking emotional experience to the skeletal musculature (Gellhorn, 1958; Gellhorn & Kiely, 1972). Accordingly, studies of relaxation training that include autonomic measures have generally demonstrated additional effects of, for example, lowered heart rate and electrodermal levels (Lehrer et al., 1994). Indeed, several studies have attempted to assess relaxation effects on the adrenergic system (see Freedman, 1994), and have included measures of peripheral muscle sympathetic nerve activity, blood norepinephrine levels (Hjemdahl et al., 1989), and platelet monoamine oxidase activity (Mathew et al., 1981). Other studies have also suggested effects on the immune system in the form of, for example, changes in killer cell activity and lymphocyte density (Gruber et al., 1993). Other arousal reduction methods have also been demonstrated to yield specific physiological effects. For example, breathing regulation techniques have been shown to lower physiological arousal and to normalize the EEG (Fried, 1993; Lehrer & Woolfolk, 1993). The physiological effects of more cognitively mediated procedures such as autogenics and meditation have also been reviewed by Lehrer and colleagues (Lehrer et al., 1994; Lehrer & Woolfolk, 1993). Although the specific effects model of Davidson and Schwartz would predict greater cognitive than physiological effects for interventions such as meditation, Lehrer et al. conclude that the differential effects of meditation vs. relaxation training are equivocal. With respect to autogenic training, Linden (1990) cites a collection of studies demonstrating physiological effects of autogenic training, which support the relationship between subjective somatic sensations and physiological change, particularly in relation to changes in breathing and peripheral skin temperature. Although the above studies generally substantiate the fact that the intended effects of relaxation on the levels of physiological activity are observed within treatment sessions, findings regarding the longer term effects of relaxation on physiological functioning are few. Indeed, a recent appraisal of the area which has been most thoroughly examined, that is, stress management and hypertension, reveals that a cautious approach to extrapolating from short-term effects to long-term outcomes might be warranted. Although relaxation-based stress management protocols revealed significant falls in

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blood pressure within hypertensive subjects (Patel et al., 1985), recent meta-analyses of studies within this area have produced lesspromising findings (Jacob, Chesney, William, Ding, & Shapiro, 1991; Johnston, 1994; but see also Linden & Chambers, 1994; Linden, Stossel, & Maurice, 1996). Some of the factors responsible for these disparate findings probably include pre-existing levels of hypertension, subject selection and entry to the study, habituation and initial testing effects on blood pressure measurement, and failure of blood pressure reductions to generalize to everyday life situations (Jacob et al., 1991). It remains to be seen, therefore, whether the long-term effects of relaxation on elevated physiological arousal can be demonstrated, particularly if the methodological rigors adopted within hypertension research were to be more generally applied. Most of the evidence reviewed in this section was derived from short-term treatment or laboratory analogue studies, and as such emphasizes process-related changes in relaxation measures. Whether these changes are also directly related to stable therapeutic outcomes with regard to reduction in symptoms and increased functioning remains to be demonstrated. Moreover, this assumes that the fundamental process underlying therapeutic change is physiological arousal reduction. However, this assumption has recently been challenged by Smith (1988, 1989), who has proposed that the therapeutic changes brought about by relaxation techniques are best explained by cognitive-behavioral formulations, as opposed to changes in physiological functioning. Hence changes in attitudes towards relaxation and stress, together with specific changes in personal cognitive schema, underlie therapeutic improvement, which may or may not be accompanied by a lowering of physiological arousal. The issue of specificity of effect will be examined in greater detail in the final section of this chapter. 6.09.2.4 Summary In summary, arousal reduction methods are based on a variety of different explanatory therapeutic models. Indeed, the construct of arousal has been difficult to define and cannot be satisfactorily operationalized. Nevertheless, despite the construct being less frequently employed within experimental psychology, its use as an explanatory factor in clinical psychology continues to be prevalent. Many physical and mental disorders can be considered to involve an element of arousal dysfunction, either resulting directly in the expression of symptoms or indirectly as a result of some

mediational role of arousal in triggering specific symptoms. Accordingly, a variety of therapeutic techniques targeted at arousal reduction have been devised in order to alleviate the effects of overarousal. A variety of mechanisms have been proposed to underlie these techniques, ranging from the unitary induction of a relaxation response through to specific processes responsible for therapeutic change across different arousal components. It would appear that the majority of relaxation techniques produce some measurable effects on a variety of cognitive, somatic, autonomic, and central measures. However, the effects produced by different techniques do not appear to be equivalent, as might be predicted by a unitary theory such as Benson's. Nevertheless, there would appear to be evidence of some more generalized physiological effects of relaxation on autonomic, neurohumoral, and immune system functioning that underlie specific treatment-induced changes. Moreover, it should be acknowledged that some specific predictions of the multicomponent models have not been supported.

6.09.3 AROUSAL REDUCTION METHODS: GENERAL PROCEDURES AND SPECIFIC TECHNIQUES In this section we systematically review clinical interventions derived in order to reduce arousal and facilitate positive functioning and therapeutic change. Only those techniques that are supported by a clear therapeutic rationale and that have been scientifically evaluated in terms of their efficacy are included. In addition, the review focuses primarily on mental health problems prevalent in adults. However, where appropriate, procedural modifications for child and elderly populations are noted. Physical conditions such as hypertension, headache, or pain control will not be systematically covered as these are reviewed elsewhere, but will be referred to if the studies are able to expand on some general procedural issues surrounding the implementation of these therapeutic techniques. The main techniques reviewed are relaxation methods, autogenic training, breathing modification, biofeedback, meditation, and hypnosis. However, many of these techniques have been advocated for use in a variety of different clinical problems based on a diverse range of therapeutic rationales. Hypnosis, for example, is claimed to be therapeutically beneficial in inducing a relaxation state, accessing ªinaccessible memories and feelings,º and promoting cognitive restructuring. Accordingly, we will restrict

Arousal Reduction Methods ourselves to covering only specific applications of these techniques where the therapeutic rationale upon which their use is based concerns the reduction or modification of arousal. Before reviewing each technique in turn, we briefly describe and evaluate some general procedural factors. Contraindications and modification of the technique for specific problems or client groups will also be reviewed. The comparative efficacy of different techniques and their use for specific conditions are dealt with in the final section of this chapter, together with a discussion of the therapeutic mechanisms that might underlie their efficacy. 6.09.3.1 General Procedural Issues The limited scope of this chapter prevents a detailed account of the clinical protocols used to deliver these methods. Instead, we aim to deal with some general procedural issues common to most relaxation or arousal reduction techniques, followed by a brief description of the essential features of each technique. Several excellent practical guides and training manuals have been published (Howell & Whitehead, 1989; Payne, 1995; Whitehead & Adams, 1991) and these should be consulted by the novice practitioner alongside this chapter. 6.09.3.1.1 Assessment The successful application of relaxation techniques will depend on sound assessment and formulation of the clinical problem, leading to an appropriate rationale for their use. Assessment should focus on identifying the clinical problems amenable to relaxation techniques (Lehrer & Woolfolk, 1993; Poppen, 1988), together with establishing the presence of elevated physiological arousal, and self-reports or inferred observations of tension, anxiety, or worry (Crist, Rickard, Prentice-Dunn, & Barker, 1989; Poppen, 1988; Smith, 1989). As discussed in Section 6.09.2.2, specific health problems said to be associated with elevations in arousal are generally identified as anxiety disorders (e.g., generalized anxiety disorder, panic disorder, and specific phobias), psychosomatic complaints (e.g., hypertension, tension headache, migraine, and asthma), elevated tension or somatic arousal (e.g., chronic pain, insomnia, and skeletomuscular disorders), and palliative problems and applications (e.g., side effects of chemotherapy). The purpose of assessment, therefore, is to substantiate the presence of any of these clinical indications, and to provide sufficient information to arrive at an individual formulation of the

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presenting problems. Such a formulation should address the rationale for the adoption of a relaxation-based intervention and should also rule out other more appropriate treatment approaches. The latter might concern the use of physically based medical treatments or more psychotherapeutically based interventions. Not that these treatments are necessarily mutually exclusive; in the case of psychological interventions in particular, relaxation techniques may well be used in conjunction with other cognitive and behavioral approaches. A final purpose of assessment should be to identify contraindications of applying relaxation-based therapies (see Section 6.09.3.2.1). In order to formulate the presence of an arousal-related health problem that might be amenable to relaxation, it is important to verify the presence of elevated arousal either directly through physiological measurement or by inference from observation or self-report. Indeed, given the multidimensional nature of the arousal construct (see Figure 1), it is likely that individual measures will not be interchangeable and that a multicomponent approach to assessment will be required. Physiological measures of arousal will require sophisticated equipment and expertise, which is unlikely to be available in most clinical settings, but may well be available if biofeedback techniques are also on offer within the clinic. Simple assessments of elevated EMG or heart rate may also be accomplished using inexpensive commercially available monitors. Further advice and information on psychophysiological assessment procedures are available elsewhere (e.g., Cacioppo & Tassinary, 1990; Turpin, 1989). An alternative to direct measurement is the use of either therapist observational checklists or client self-report instruments. The most widely used observational scale is the behavioral relaxation scale (BRS) (Schilling & Poppen, 1983), which is discussed in great detail in Poppen's instructional text (Poppen, 1988). A wide range of self-report scales is available to assess, for example, anxiety and worry, somatic arousal, stress and tension, state of relaxation and calmness. The use of these scales has been reviewed by Smith (1989). 6.09.3.1.2 Therapeutic rationale Assuming that assessment has revealed a need for relaxation training, and the most appropriate method has been chosen for the individual, a common feature of most methods is to present a clear therapeutic rationale to the client (Bernstein & Carlson, 1993). This will usually involve an explanation or reformulation of the

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client's problem in terms of anxiety or an inability to relax, the provision of basic information on stress and anxiety, and an explanation of how relaxation can be induced and its potential benefits to the client. The latter will usually stress the importance of regular practice and emphasize that the client must take responsibility for his or her own therapy. It is important that at the beginning of therapy the client has an accurate expectation of the nature of the therapeutic intervention and his or her own commitment to the therapy. The adoption of a clear therapeutic rationale, therefore, together with agreed therapeutic goals between therapist and client cannot be overstated. At the very least it provides the therapeutic framework within which relaxation techniques can be learnt and practised. Indeed, some would argue (e.g., Smith, 1989) that the therapeutic benefits of relaxation are dependent on the client's reframing of the clinical problem cognitively, and arise as much from changes in cognitive schema and appraisal processes as they do from any accompanying changes in physiological arousal. 6.09.3.1.3 Practical considerations In addition to introducing to the client an appropriate rationale, it is also important that the client is provided with instructions concerning environmental considerations for relaxation training. Important requirements are a comfortable chair and the adoption of a reclining position, avoiding extraneous noises or interruptions, subdued lighting and a comfortable ambient room temperature, and the wearing of loose clothing that does not restrict body movement. These factors apply both to clinic sessions and homework practice. Finally, the adoption by the therapist of a smooth, quiet, and almost monotonous voice for the presentation of instructions is also an important consideration. 6.09.3.1.4 Presentation of the technique Different techniques clearly have to be delivered to the client by the therapist in many different ways. Nevertheless, certain choices regarding the mode of training have to be made. For example, what amount of information is provided prior to training (booklets, audiocassettes, videos, etc.)? The role of the therapist in providing within-session modeling of the techniques for the client, and the opportunity for the client to rehearse techniques before the therapist and to receive feedback are examples of procedural questions that have to be resolved. Similarly, the therapist has to decide between the use of individual sequences of exercises, whereby

individual progression is based on mastering each stage and the strict adherence to a standardized and, possibly, inflexible protocol. The majority of published studies of relaxation training relate to individualized, one-to-one therapy as opposed to group delivery methods. However, in practice, many practical relaxation training programs are directed at group approaches (Howell & Whitehead, 1989; Whitehead & Adams, 1991). Other considerations include the number of sessions, homework practice, compliance, and follow-up and booster sessions. The overall impact of these factors on treatment efficacy are now reviewed. 6.09.3.1.5 Evaluation of procedural factors Several of the above general procedural factors commonly found in most forms of relaxation training have been investigated in order to determine their influence on therapeutic outcomes. These have included taped vs. live instruction, the use of homework practice sessions, and brief vs. extended practice, and they have been the subject of several reviews (Bernstein & Carlson, 1993; Borkovec & Sides, 1979; Blanchard et al., 1991; Hillenberg & Collins, 1982; Lehrer & Woolfolk, 1993). Although none of these reviews yield unequivocal conclusions, several consistent recommendations emerge. First, live instructions, whereby the client is able to control the progress of training by moving systematically from one muscle group to the next, with access to appropriate observation of and feedback from the therapist, appears superior to the sole use of standard taped instructions. Second, most clinical trials have included home practice sessions, perhaps supplemented by taped instructions and measures of homework compliance. Some data exist to support the additional benefits of prolonged and regular homework practice, although some studies (Borkovec et al., 1987; Nelson & Borkovec, 1989) have failed to support such an effect. Compliance and overreporting of homework practice sessions might explain some of the inconsistencies in these studies (Bernstein & Carlson, 1993). Third, it would appear that the greater exposure to relaxation training, either through extended clinic sessions or through continued application outside of the clinic, is more likely to be associated with maintenance of therapeutic change. The continued application of brief relaxation procedures, as opposed to more extended periods of relaxation training, has been argued by Lake and Pingel (1988) to be an important determinant of outcome for headache patients. It should be emphasized, however, that the above recommendations are

Arousal Reduction Methods largely based on clinical guidelines rather than extensive outcome studies. Moreover, specific procedural recommendations for different techniques or subject groups have yet to be evolved. 6.09.3.2 Specific Techniques The purpose of this section is to provide the reader with a brief account of the essential components of each technique. More detailed clinical protocols are available elsewhere (Lehrer & Woolfolk, 1993). As relaxation-based techniques have been the focus of this chapter so far, greater emphasis will be placed in this section on detailing the background to other techniques, such as biofeedback, meditation, and hypnosis, which have also been commonly employed as arousal reduction methods. 6.09.3.2.1 Relaxation-based methods (i) Jacobson progressive muscle relaxation The development and application of Jacobson's ideas have been reviewed extensively by McGuigan (1993). Jacobson's method was devised in 1938 and seeks to train subjects in the ability to perceive muscle tension accurately, to control and hence reduce tension, and to relax their muscles differentially. The training involves detailed familiarization with the majority of muscle groups and an emphasis on enhancing awareness of muscle tension. Discrimination training is brought about by the method of ªdiminishing tensions,º whereby the client learns to effect and detect the smallest possible muscle contraction in a variety of different muscle groups. Once the skill of discrimination in muscle tension has been acquired, the client can then bring about ªdifferential relaxationº of his or her muscles, which entails only contracting those specific muscles that are functionally required for action, and relaxing all other muscles unassociated with the ongoing physically active group. The distinctive feature of Jacobson's approach is its specific emphasis on muscle tension and control, and the absence of any cognitive or suggestive components directed at the induction of a subjective feeling of relaxation.

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tension-release cycle, and greater emphasis on subjective and cognitive approaches. Many of these changes were incorporated into a highly influential treatment manual produced by Bernstein and Borkovec (1973). The specific instructions underlying the technique involve the client performing a series of tension-release cycles in a systematic manner across 16 muscle groups, beginning with the hand and forearm, moving through the forehead, face and neck, down to the abdomen, and finishing with the feet. Each tension-release cycle involves the client contracting the specified muscle according to a cue ªtenseº or ªnow,º holding and sensing the contraction for 5±7 seconds, and relaxing the muscle on the command ªrelax,º followed by a period of 30±40 seconds during which the client focuses on the sensations of relaxation. A detailed account of these procedures is provided by Bernstein and Carlson (1993). Various modifications have also been proposed to the standard Abbreviated Progressive Relaxation Training (ABRT) protocol, including the establishment of relaxation cues in the form of cue-controlled relaxation (Grimm, 1980) and attempts to generalize the relaxation response into everyday settings, such as in applied relaxation training (Ost, 1987). (iii) Breathing training A variety of techniques exist to induce relaxation through the modification of breathing. Specific instructions to entrain diaphragmatic breathing have commonly been used as adjuncts to APR (Bacon & Poppen, 1985; Poppen, 1988) and have also been the focus of cue-controlled relaxation procedures (Grimm, 1980). For disorders such as panic, whereby sensations arising from hyperventilation have been implicated, controlled breathing exercises have been used effectively (Clark, Salkovskis, & Chalkley, 1985). More specific techniques involving respiratory feedback and slowly paced breathing have also been developed (Fried, 1993; Montgomery, 1994). Finally, breathing regulation is also a common component of yoga (Patel, 1993) and other meditationbased techniques (Carrington, 1993), and these are discussed later.

(ii) Abbreviated progressive muscle relaxation

(iv) Autogenic training

Jacobson's techniques were adapted, notably by Wolpe (1958) and Paul (1966), and modified in the 1960s to form part of the basis for several behavioral treatments, including systematic desensitization. The major changes were a shift from actual to subjective tension, an abbreviated and standardized protocol, use of the

Instead of focusing directly on muscle tension as a means to induce relaxation, autogenic training (AT) involves a set of exercises targeted at various physiological end-organs whereby a state of relaxation might be induced. These techniques have been described in detail by Linden (1990, 1993) and are based on the work

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of Schultz and further developed by Luther. ªAutogenicsº, as a term, essentially means ªselfexerciseº or ªself-inductionº therapy and relies on a theoretical rationale whereby the client gains psychophysiological self-control of autonomic functioning and is able to achieve relaxation. Control is said to be gained by the client focusing on body sensations in a passive manner. This is achieved by the client subvocally repeating six standard formulas that are designed to induce physiological change: these include the ªheaviness formulaº directed at the muscles, the ªwarmth formulaº aimed at peripheral blood flow, the ªheart formulaº associated with the heart rate, and the ªbreathing formulaº targeted at a natural breathing rhythm. Like many other relaxation techniques, AT has been modified and used in combination with other methods, particularly thermal biofeedback (Norris & Fahrion, 1993). Indeed, AT techniques and imagery are commonly employed to assist relaxation induction within a range of different procedures. However, it should be emphasized that the classical use of AT also implies a therapeutic rationale whereby the techniques facilitate cathartic experiences in the form of ªautogenic discharges.º

6.09.3.2.2 Biofeedback Biofeedback is the regulation of autonomic nervous system functions, such as blood pressure, heart rate, and sweating, by the subject continually monitoring that function and being rewarded (usually simply by the knowledge of his or her success) for changing that activity in a desired direction. Feedback is usually conveyed either auditorily by the pitch of a continuous tone or by using a visual display. The idea that a person, with training, can selectively influence the activity of a particular autonomic function, notably in the direction of diminished arousal, has been in existence for a long time and is traditionally associated with Eastern practices such as meditation and yoga. It has been claimed that practitioners of these forms of meditation have the ability to attenuate their vital functions (e.g. heart rate) to an extraordinary degree. In contrast, Western scientific interest in autonomic control has been a recent development and was stimulated by the work of Miller and his colleagues on the operant conditioning of autonomic responses in animals, particularly the curarized rat. This research was significant from a theoretical standpoint because the findings suggested that autonomic and visceral responses, hitherto held only to be amenable to alteration by classical conditioning, could be modified by positive

reinforcement within an instrumental or operant-conditioning paradigm. Around that time also, interest had been shown (Kamiya, 1969) in the operant conditioning of the alpha EEG rhythm (as a means of achieving altered states of consciousness) and of changes in skin conductance (Shapiro, Crider, & Tursky, 1964) and heart rate (Engel & Hansen, 1966). However, these studies on humans were criticized by Katkin and Murray (1968) for their lack of controls for mediating responses such as breathing. Despite the many problems encountered in replicating some of the above animal laboratory work, it proved very influential and a wide range of clinical applications have been investigated since then and have focused mainly on two types of problem. First, anxiety and stress disorders, where the aim of biofeedback is to reduce general arousal levels; and, second, disorders presenting as somatic problems (e.g., pain, tension headaches, and irritable bowel syndrome), which may be triggered or exacerbated by overarousal and where again the biofeedback is either aimed at general relaxation or is targeted more specifically to the affected organ or function in order to achieve self-regulation. Biofeedback techniques associated with generalized arousal reduction have included from the outset alpha rhythm EEG feedback (Budzynski & Stoyva, 1973) and other methods such as electrodermal (skin conductance) feedback (usually from the hand) and surface EMG feedback, for example, from the frontalis muscle, or in combination. The latter techniques are now more commonly used and may also be employed to augment systematic in vitro or in vivo desensitization by enabling closer monitoring of the return-to-relaxation phase, and thereby assisting patients to achieve this (Stoyva & Budzynski, 1993). Procedurally, treatment by biofeedback begins with an assessment of the patient's presenting problem and an explanation of the rationale of biofeedback. Initial training sessions with the therapist enable the patient to become more attuned to cognitions and bodily events that are associated with increase in arousal. This training has been reported to be productive in establishing anxiety-evoking cognitions in the case of generalized anxiety (Budzynski & Stoyva, 1973). This stage is followed by daily practice at home (multiple short sessions) until mastery of the target response has been achieved and the patient can be weaned off the biofeedback device. Again, it should be noted that biofeedback is often combined in treatment with other selfrelaxation methods, such as autogenic training or progressive relaxation (Lehrer et al., 1993).

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6.09.3.2.3 Meditation

6.09.3.2.4 Hypnosis

Shapiro (1982) defines meditation as referring to ªa family of techniques which have in common a conscious attempt to focus attention in a non-analytical way and an attempt not to dwell on discursive, ruminating thoughtº (p. 268). However, he points out that this definition covers a wide variety of methods of meditation. Moreover, the methods may involve either a state of mental relaxation, or excitement and arousal; either physical restfulness or, as in the case of the whirling dervish or tai chi, physical activity; and different prescriptions as regards the distribution of attention (focus on awareness generally, focus on a specific thought, or a shifting form one to the other). In general, however, it is not the contents of awareness that are significant but the process of attending to the objects of one's awareness. Such a definition of meditation presupposes no adherence to any cultic philosophy or beliefs, a point made by Carrington (1993) in her overview, citing transcendental meditation as the most widely known and extensively studied of the Western methods. Carrington goes on to distinguish two methods that have been used in clinical settings, namely clinically standardized meditation and the respiratory one method. In the former, the meditator selects a mantra (usually not a real word) which he or she initially repeats aloud with the instructor in the training phase. Later, the mantra becomes the focus for silent meditation, twice-daily for 20 minutes being recommended, although many meditators reduce the frequency of sessions to one per day or less after training (Carrington, 1993). Training is facilitated by written instructions and a cassette tape. The respiratory one method (Benson, 1975) requires the meditator to repeat silently the mantra (which may simply be the number one), pacing this with the outward breath. It is thus more structured, and is presumed to be more ªeffortfulº than the above method (Carrington, 1993). Meditation is recommended as an activity for everyday living, one which reduces the stress of daily life, encourages a calmer outlook, promotes greater self-awareness and inner contentment, and so on. However, it has also been used clinically in the case of anxiety (Kabat-Zinn et al., 1992; Kirsch & Henry, 1979; Thomas & Abbas, 1978), insomnia (Woolfolk, Carr-Kaffeshan, & McNulty, 1976), hypertension (Surut, Shapiro & Good, 1978), psoriasis (Gaston, 1988±1989), asthma (Honsberger & Wilson, 1973), and alcohol and drug abuse (Benson & Wallace, 1971; Parker, Gilbert, & Thoreson, 1978; Taub, Steiner, Weingarten, & Walton, 1994).

The origins of hypnosis may be traced back to the ideas and practices of the Austrian physician Franz Anton Mesmer (1734±1815). However, so great has been the transformation since that time that mesmerism, on the one hand, and modern hypnosis, on the other, bear little resemblance to one another. Hypnosis as it is now practised may be operationally defined as an interaction between two people (or one person and a group) in which one of them, the hypnotist, by means of verbal communication, encourages the other, the subject or subjects, to disattend to their immediate realities and concerns and to focus their awareness on inner experiences such as thoughts, feelings and imagery. The hypnotist further attempts to create changes in the way subjects are feeling, thinking and behaving by directing them to imagine various events or situations which, were they to occur in reality, would evoke the intended changes in the subjects. (Heap, 1995, p. 649)

The state of inner focus (which is almost invariably, though not always, associated with feelings of calmness and physical relaxation) is what nowadays most practitioners appear to mean by a ªtrance.º As such it is continuous with everyday experiences that are popularly given that label (e.g., absorption in a daydream). It is generally achieved by the hypnotist's use of suggestions and imagery, which denote feelings of calmness, heaviness, tiredness, sleepiness, and so on, a procedure known as ªhypnotic induction.º Whichever method is used, it may be learned by the patient and practised regularly at home, either by himself or herself or with the aid of a recorded tape. At its simplest then, ªself-hypnosisº resembles meditation and other self-directed relaxation procedures such as progressive muscular relaxation and autogenic relaxation, and the general aims are similar (Sanders, 1993). In the ªheterohypnoticº context, having performed an induction procedure, the hypnotist proceeds to give suggestions to the patient that are intended to elicit the desired therapeutic changes. It is useful, however, to bear in mind that rather than a therapy in itself, hypnosis is best regarded as an adjunct to therapy (Gibson & Heap, 1991), and the range of problems to which it is applied almost matches that seen in any mental health context. Thus it may be used to augment a cognitive-behavioral approach to, say, anxiety management by the use of suggestions of calmness and symptom control in mentally rehearsed, anxiety-provoking situations, and posthypnotic suggestions (i.e. suggestions to take effect after the hypnotic session) of

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the immediate and effective use of self-control techniques in such situations. These procedures, which may be targeted at any of the autonomic, cognitive, or behavioral levels, may be augmented by the use of cues or ªanchors.º For example, a positive feeling may be coupled with a simple gesture such as the clenching of a fist (Stein, 1963); this technique may be rehearsed repeatedly in imagination, and the posthypnotic suggestion be given that this feeling may be reevoked by the same action as and when required. Another very common routine is that of ªego strengtheningº; this consists of suggestions, usually delivered towards the end of a session of hypnosis, which are intended to promote selfconfidence and more positive self-esteem. Use is often made in this procedure of symbolic and metaphorical imagery and guided fantasy (Stanton, 1990, 1991). Hypnotic procedures are often used as an adjunct to dynamic psychotherapy, notably by the use of what are termed ªexploratoryº and ªuncoveringº techniques. These include age regression and various guided imagery techniques (Gibson & Heap, 1991; Karle, 1988), and are generally based on the notion that unconscious processes lie at the root of the patient's presenting problem. Nevertheless, these techniques may be put to good use by the eclectically minded cognitive or behavior therapist (Gibson & Heap, 1991; Heap, 1991). One difference between hypnosis and other methods of arousal control is that the capacity to respond to hypnotic suggestions varies (around a central tendency) among the population, and is a relatively stable trait (Hilgard, 1991). Standard scales exist for measuring hypnotic susceptibility (or, as some would prefer, suggestibility) and these have good psychometric properties (for a useful overview see Fellows, 1988). However, because so many factors contribute to the outcome of therapy and because hypnosis tends to be used in an adjunctive manner, the relationship of hypnotic susceptibility to therapeutic outcome is highly variable and tends to be of modest proportions (Spinhoven, 1987; Wadden & Anderton, 1982). 6.09.3.3 Indications, Side Effects, and Contraindications 6.09.3.3.1 Client selection The self-regulation methods presented here have the advantage that their immediate aim is to create pleasant experiences purely from something the patient does for him- or herself, and ultimately, at any time, control of treatment is in the hands of the patient, and may be

instigated, directed and terminated at his or her own initiative. Consequently, patients require a certain level of autonomy and ability to manage their own daily activities, and perhaps a more ªinternalº locus of control (see the review by Lehrer & Woolfolk, 1993). Adherence to a prescribed program of selfdirected relaxation has been noted to be a problem by a number of authors (Bernstein & Carlson, 1993; Carrington 1977; Linden, 1993) and some studies have indicated overreporting of home-based practice by patients (Hoelscher, Lichtenstein, & Rosenthal, 1986). A problem that is more serious than simple lack of discipline on the patient's part (or inadequate instruction or direction on the therapist's part) may be that training in self-regulation does not satisfactorily address the patient's problems. There may also be issues relating to secondary gain or marital and family relationships, or unacknowledged or undisclosed areas of difficulty and anxiety that need to be the focus of a more extensive cognitive behavioral or psychodynamic intervention. Another characteristic of potential relevance to patient selection is absorption, the tendency of an individual to become deeply immersed in the object of his or her attention (e.g., a book, some music, or a daydream). This quality may be measured using a standardized questionnaire (Tellegen & Atkinson, 1974). There is a modest relationship between absorption and measured hypnotic susceptibility (Council, Kirsch, & Hafner, 1986), and there is some evidence of a tendency for good meditators to be high on absorption (Davidson & Goleman, 1977). Hypnotic susceptibility is itself related to outcome in several of these self-regulation methods, although only modestly so, and not at all in the case of biofeedback (Lehrer & Woolfolk, 1993; Sigman & Phillips, 1985). Whereas, as was stated earlier, practitioners may make use of self-regulation procedures in combination, biofeedback and hypnosis do not appear to complement one another in this way, and the net effect may be less positive than either technique used alone (Edmonds, 1979; Sigman, 1988). Dumas (1980) has suggested that different attentional processes may be involved in these two methods. There is a case for favoring high susceptibility subjects as candidates for hypnotic self-regulation in, for example, an anxiety-management training program that relies heavily on suggestions of automatic responding (Spinhoven, 1987). There is also a case for offering hypnosis, and even simply explicitly calling the procedures ªhypnosis,º when it is the treatment requested by the patient, and not doing so when the patient has a negative attitude to hypnosis (Kirsch,

Arousal Reduction Methods 1996). Perhaps equivalent recommendations may be made in the case of the other methods. 6.09.3.3.2 Side effects and adverse reactions Notwithstanding the relatively benign nature of the procedures under discussion, adverse effects have been noted in the literature, and precautions and contraindications have been detailed by various authors (e.g. Shapiro, 1982, for meditation; Bernstein & Borkovec, 1973, for progressive relaxation; Linden, 1993, for autogenic training; and Crawford, Hilgard, & Macdonald, 1982, for hypnosis). Reported effects, which are generally transient, include unwelcome and intrusive imagery, anxiety, panic, dizziness, confusion, restlessness, and headache. For example, Edinger and Jacobsen (1982) surveyed 116 clinicians who reported on the effects of relaxation training on 17 542 clients. The following prevalence of problems was reported: intrusive thoughts (15%), fear of losing control (9%), disturbed sensory experiences (4%), muscle cramps and spasms (4%), inappropriate sexual arousal (2%), and dissociation (0.4%). Other problems less frequently reported included laughing, coughing, and falling asleep. Indeed, the presence of such side effects has led to the awareness of a particular problematic response known as ªrelaxation-induced anxiety (or panic),º which appears to represent a cumulative build-up of arousal during the relaxation procedure itself. Explanations have included fear of losing control, fear of the sensations of relaxation itself, ªinteroceptive conditioningº and brief bursts of hyperventilation (Adler, Craske, & Barlow, 1987; Bernstein & Borkovec, 1973; Borkovec, 1987; Braith, McCullough, & Bush, 1988; Ley, 1980). These effects do not in themselves contraindicate the use of relaxation procedures in the individual so affected; exploration of the reasons for their occurrence, and adjustments to the procedure may be required. For example, within the pretreatment rationale it may be useful to acknowledge the existence of side effects, while emphasizing that their occurrence is usually infrequent. When side effects do occur, this is confirmation of the prior information provided and less likely to be interpreted in a catastrophic manner. The client should be assured that side effects are probably of a transitory nature and that, from a positive and constructive perspective, they indicate that the training is clearly having some effect. In this way the client is also engaged with the treatment. Adaptive strategies may include focusing on breathing in order to reduce the likelihood of hyperventilation, and the use of mantras such as

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ªcalmº and ªrelax.º In the case of fear of loss of control, the use of a more individualized approach, self-paced by the client, should be considered. If problems persist, the therapist should consider adopting a different technique, preferably based on some formulation as to why the side effects are being experienced with the current relaxation method employed. Finally, it should be recognized that the possible presence of unreported side effects might account for treatment noncompliance and rates of uptake and dropout within therapy. As will be discussed in greater detail in Section 6.09.4.2, relaxation-based treatments have compared favorably with more recently evolved cognitive-behavioral techniques, sometimes rather unexpectedly since they have frequently been included in therapy outcome studies as a control condition. However, there are strong indications that they may be less acceptable to clients, resulting in lower uptake and higher dropout rates in therapy. Such effects may be due to a variety of factors, such as treatment credibility and client expectations; however, negative side effects might also account for possible reduced acceptability. 6.09.3.3.3 Contraindications and procedural modifications There is a limited literature regarding the suitability of arousal reduction techniques for specific clinical problems or client groups. Where contraindications have been recommended they tend to have been founded on clinical observation rather than on outcome data, and it is often uncertain whether specific warnings of adverse effects can be generalized across all methods. A brief overview of these issues is provided here, together with some possible procedural modifications for specific client groups that might result in making these techniques more appropriate. The presence of clinical depression is an important factor to consider. Shapiro (1982), for example, suggests that meditation may not be appropriate for chronically depressed individuals, for whom a low level of arousal is more characteristic. Neither, the same author argues, is it pertinent to the needs of the socially withdrawn individual. Depression has also traditionally been said to contraindicate hypnosis (Burrows, 1980), one argument being that it can have mood-elevating properties that may provide the suicidally depressed patient with the impetus to take his or her own life. There is not, however, a great deal of evidence for this, and in recent years hypnosis has been used to augment cognitive-behavioral therapy of depression (Alladin & Heap, 1991). Lehrer et al. (1993)

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have also reviewed whether stress management techniques in general, but particularly those involving relaxation training, should be directed at depression, since received clinical wisdom would counsel against such an approach. Again, they report that stress management is associated with improvements in depression, particularly when it is combined with other therapeutic approaches. Nevertheless, they only cautiously suggest the possible inclusion of stress management in programs for the treatment of depression in view of the problems of motivating clients to comply with an active homeworkbased therapeutic intervention, and the need to ensure that the most effective treatments are employed in the case of potentially suicidal clients. We may conclude that self-regulation may be used with the clinically depressed patient with due care, and as one component of a broader therapeutic program. One adverse consequence of the methods in question seems to be, as in the case of depression, the amplification of an existing negative internal state. Individuals who lack well-developed reality-testing processes, such as psychotic and borderline patients, and indeed who may hallucinate, may be unsuitable candidates for selfregulation methods, at least without close supervision (Carrington, 1977; Gibson & Heap, 1991), and there is some evidence that prolonged meditation may precipitate psychotic episodes in some highly vulnerable individuals (Lazarus, 1976). Similarly, Adler and Morrisey-Adler (1983) have reported the possibility of increased hallucinations with biofeedback training. Nevertheless, Lehrer et al. (1993) have reviewed several studies purporting to report beneficial effects of stress management within psychosis. Given the contemporary interest in psychological management techniques for psychotic symptoms, it is perhaps time to reassess the application of these techniques to schizophrenia. Moreover, many of these recent approaches to the psychological management of psychotic symptoms are based on the stress±vulnerability model (Clements & Turpin, 1992; Tarrier & Turpin, 1992), which identifies increases in arousal as an underlying mechanism in the production of psychotic states. Further support for such an approach may also be derived from studies of clients' own self-control strategies for psychotic phenomena, which commonly include arousal reduction methods. Indeed, these have been capitalized on by Tarrier and Barrowclough's therapeutic approach known as selfcontrol enhancement therapy. It remains to be seen, however, if these techniques are useful in both relieving psychotic symptoms as well as reducing excessive levels of anxiety in these clients.

There are some other conditions the presence of which warrants special consideration by the therapist. For example, Carrington (1993) advises careful monitoring of patients' medication requirements (antihypertensive and anxiolytic drugs), as these may alter during treatment. Stoyva and Budzynski (1993) give a similar warning for patients with insulin-dependent diabetes. Clearly, patients should not deny themselves their essential medication in the belief that otherwise they are failing in their selfregulation procedure (Gibson & Heap, 1991). In addition to specific clinical problems that might mitigate against the use of arousal reduction techniques, the applicability of these techniques in general to certain client groups has been questioned. Essentially, there are two major considerations: do clients possess sufficient cognitive functions to benefit from such an approach, and are there any physical barriers that might prevent the implementation of relaxation or other related exercises? Client groups that might be considered unresponsive to a stress reduction approach because of cognitive or developmental limitations might include children, people with a learning disability, or individuals with acquired brain damage. Poppen (1988) specifically reviews the application of behavioral relaxation training with these populations, and provides examples of successful interventions. Similarly, Lehrer et al. (1993) have reviewed applications of stress management techniques specifically for children, and report positive findings in relation to hyperactivity and academically related anxiety problems. Physical restrictions such as arthritis or neuromuscular dysfunction can give rise to serious obstacles to using muscle relaxation based methods with either brain-injured or elderly populations. Two different approaches might be used to overcome this problem. First, a variant of PMR has been designed that is based not on muscle contraction but on muscle stretch. It is argued by Kay and Carlson (1992) that this approach might be more acceptable to older adults. Second, it could be argued that more cognitively focused interventions might be of greater benefit to older adults who experience either restricted movement or arthritic pain. For example, Scogin, Richard, Keith, Wilson, and McElreath (1992) have demonstrated that imagination-based relaxation procedures were as effective as APR for an elderly population. Deberry, Davies, and Reinhard (1989) have also reported that a meditation based relaxation approach was more effective than a purely cognitive approach in dealing with emotional problems in an elderly group of clients.

Comparative Outcomes and Therapeutic Mechanisms 6.09.4 COMPARATIVE OUTCOMES AND THERAPEUTIC MECHANISMS In this final section we briefly address the issue of comparative outcomes for a variety of adult mental health problems, focusing particularly on anxiety disorders. In doing so, we draw attention to relationships between various techniques of arousal reduction and differential therapeutic responses across a range of outcome measures. We also speculate about possible therapeutic processes that might underlie these different relationships. 6.09.4.1 Overview of Outcomes In Section 6.09.2.3 we discussed the evidence supporting the notion of treatment specificity across a range of arousal reduction methods. However, the majority of these studies focused on within-session changes and relied on either experimental or analog designs as opposed to clinical outcome studies employing patient samples. Moreover, the question that was addressed concerned the effectiveness of individual techniques in modifying various measures of arousal or stress. For example, if EMG biofeedback is compared to PMR, which method gives rise to the greatest change in arousal as measured by muscle tension, autonomic activity, and self-reported calmness? Although such studies lend credence to the validity of the proposed therapeutic mechanisms said to underlie these techniques, and although they support, to some degree, the treatment specificity hypothesis (see Lehrer & Woolfolk, 1984), they do not address the question of clinical efficacy for individual disorders. To achieve this, it is essential that studies include clinical samples that fulfil specified diagnostic criteria, that therapeutic change is assessed with respect to specific measures of psychological distress and functioning and not just arousal dysfunction, that suitable designs are employed to assess the contribution of nonspecific treatment effects, and that long-term follow-up assessments are also included. Many reviews exist that focus on clinically relevant studies as described above. Some of these were discussed in Section 6.09.3.1 in relation to the effectiveness of different procedural components of relaxation techniques, such as homework compliance and taped instructions. Others have compared the general effectiveness of arousal reduction techniques in modifying psychological distress in patient samples. An early review by Glaister (1982) concluded that relaxation training leads to decreases in autonomic arousal both within and across sessions, and that these changes were

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associated with reductions in behavioral avoidance and distress. However, he suggested that the use of only relaxation is probably inferior to exposure treatments. Using a meta-analysis approach, Eppley, Abrams, and Shear (1989) compared the effects of different relaxation techniques on measures of trait anxiety. They concluded that transcendental meditation was superior to other techniques, and suggested that this might be related to the emphasis given to ªeffortless relaxation,º the concentration of training sessions within the first few weeks, and the regularity and duration of practice. Expectancies and demand characteristics were said not to influence effect size. However, these conclusions should be treated cautiously, especially when generalizing to adult mental health populations, since studies involving psychiatric patients were excluded from these analyses, mainly because of the lack of application of transcendental meditation to this subject population. Similar narrative reviews have been published by Lehrer et al. (1994) and provide useful overviews of the comparative efficacy of relaxation techniques in relation to, for example, psychosomatic disorders, insomnia, anger management, and substance abuse. Instead of focusing solely on arousal reduction techniques, more recent outcome studies have tended to address the comparative efficacy of a range of cognitive-behavioral interventions for specific disorders. This reflects the growth of psychotherapy outcome research for anxiety disorders and the continued inclusion of relaxation-based therapy components within these studies. However, it should be recognized that the rationale for the inclusion of arousal reduction methods has differed across individual studies. Some researchers, probably influenced by Mark's (1976) negative critique of the importance of relaxation in exposure treatment (but also see Wolpe, 1989), have included relaxation based techniques as control conditions in order to assess the additional beneficial effects of behavioral or cognitive treatment modalities. Other researchers (Borkovec & Costello, 1993; Ost, 1987) have employed relaxation protocols as treatments in their own right. We will focus mainly on panic disorder, agoraphobia, and generalized anxiety disorder. Before reviewing work in these areas, however, the issue of whether relaxation training leads to any additional beneficial effects on fear reduction in simple phobias when compared to exposure alone needs to be addressed. McGlynn, Moore, Rose, and Lazarte (1995), in a study of clinically anxious snake-phobic students, reported that group abbreviated PMR training, in association with in vivo exposure, led

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to less behavioral avoidance, reduced autonomic activity, and lower levels of subjective distress compared to exposure alone. It would appear, therefore, that Marks had prematurely dismissed the potency of relaxation techniques in fear reduction. The relationship between relaxation and exposure has been a focus of outcome research in both agoraphobia and panic disorder. Michelson, Mavissakalian, and Marchione (1988) compared paradoxical intention, therapist-assisted exposure, and relaxation on a range of outcome measures. Overall, the three treatments were equally efficacious and demonstrated significant improvements post-treatment and at a three-month follow-up. It should be noted that all groups underwent a general induction program that stressed the importance of self-directed exposure. In a later analysis, Michelson et al. (1990) examined differences in the three treatment modalities on psychophysiological processes and outcomes. Relaxation produced greater reductions in physiological arousal than did graded exposure, whereas paradoxical intention had no effect. However, despite earlier research indicating that patterns of synchrony± desynchrony might predict differential outcomes for these treatments (Turpin, 1990), no reliable relationships were obtained. In a review of the treatment of panic disorder, Craske (1991) reports the superiority of a cognitive exposure group to relaxation alone on decreasing panic-attack frequency. However, relaxation was more effective at reducing general somatic symptoms and daily anxiety ratings during the course of therapy. Unfortunately, at 6- and 24-month follow-up, the relaxation group showed deterioration, while the exposure and combined exposure and relaxation groups demonstrated maintenance of therapeutic gains. Moreover, the relaxation alone group experienced higher attrition rates from therapy. In contrast, more positive results have been obtained by Ost and colleagues (Ost & Westling, 1995; Ost, Westling, & Hellstrom, 1993) using applied relaxation training (Ost, 1987). The first of these studies suggested that relaxation, exposure, and cognitive therapy were equally efficacious in the treatment of agoraphobia, if used in combination with selfexposure instructions. The more recent study attempted to replicate Clark et al.'s (1994) findings that cognitive-behavior therapy was superior to applied relaxation. Instead, Ost and Westling (1995) again reported generally equivalent outcomes for the two therapies. However, in agreement with the cognitive model of panic proposed by Clark (1986), the present study demonstrated that measures of cognitive

beliefs predicted therapy outcomes, and this was equally true for both treatments. We discuss this finding further in the final section of this chapter. Given the relative success of cognitivebehavioral treatments for agoraphobia and panic, psychosocial interventions have also been advocated for generalized anxiety disorder. Barlow, Rapee, and Brown (1992) compared relaxation, cognitive therapy, and their combination to a waiting-list control group. All three treatments were superior to the control condition on measures of worry and anxiolytic medication usage, and these gains were maintained at two-year follow-up. However, no differences emerged between treatment groups and following treatment most patients were left with significant residual symptoms. Moreover, the dropout rate was high among the active treatment groups. Similar results were obtained by Borkovec and Costello (1993), and indicated that cognitive-behavioral therapy (CBT) and applied relaxation were superior to a nondirective therapy control group. Some between-treatment differences did, however, suggest themselves. Applied relaxation appeared to favor greater reductions in daily anxiety ratings and diary measures, whereas CBT seemed more effective for worry and depression. At a 12-month follow-up, CBT showed greater maintenance of therapeutic gain (58% vs. 38% high end-state functioning) than applied relaxation. Following a review of existing outcome studies for generalized anxiety disorder, Borkovec and Whisman (1996) come to similar conclusions, and recommend a combination package of CBT and relaxation training, targeting both somatic and cognitive features of anxiety. Finally, some mention should be made of outcome studies that have used nonrelaxationbased arousal reduction methods. Rice, Blanchard, and Purcell (1993) compared different biofeedback treatments (EMG and alpha EEG) with two control treatment conditions (EEG and pseudomeditation), and a waiting-list group. All four treatment groups, including the control treatment conditions groups, showed some improvement compared to the waiting-list control group. However, small sample sizes and a restricted number of treatment sessions limit the conclusions that can be drawn from this study. The utility of ªmindfulness meditationº used in conjunction with a stress-management program for patients diagnosed with a variety of anxiety disorders (panic, agoraphobia, generalized anxiety disorder, etc.) is reported by Kabat-Zinn et al. (1992). In discussing the success of their program, the authors reflect on the potential

Comparative Outcomes and Therapeutic Mechanisms benefits of ªmindfulness meditation,º and draw attention to the ability of clients to experience their thoughts directly as ªjust thoughtsº in a nonreactive way, which leads to a decatastrophizing of the situation. It may be that this is a similar process identified by Borkovec and Roemer (1994) as ªletting goº within applied relaxation, or the ªeffortless relaxationº discussed by Eppley et al. (1989) in relation to transcendental meditation. 6.09.4.2 Therapeutic Mechanisms We wish to conclude this chapter by addressing the question of whether different therapeutic pathways can be identified, albeit rather speculatively, that share some commonality both within different arousal reduction methods and across cognitive-behavioral approaches in general. Starting with Lehrer and Woolfolk's treatment specificity position, which was derived from Davidson and Schwartz's specific effects model, we can classify a range of arousal reduction methods according to their putative therapeutic effects. Hence, progressive relaxation and biofeedback are essentially considered as somatic or physiologically oriented techniques, whereas meditation and cognitive stress management approaches are regarded as cognitive techniques. The logic of this model, therefore, is to match the therapeutic method to the presenting problem. Hence, it is suggested that somatically based treatments might benefit problems characterized by excessive autonomic and muscular arousal. Implicit in this approach is a rather simplistic opponent process model of therapy, whereby presenting problems are ameliorated by the addition of an opposing therapeutic component. However, recent outcome studies appear not to support such a simple relationship. If panic disorder is considered, the specific effects model would specify that relaxation ought to target more somatic change, whereas cognitive therapy should give rise to greater attitudinal shifts, etc. Although there has been some support for this suggestion (Craske, 1991), in as much as relaxation was reported to bring about greater reduction in daily symptomatic ratings whereas cognitive approaches brought about a greater decrease in overall panic frequency, the majority of outcome studies have yielded more equivocal results. For example, Ost and Westling have reported that both applied relaxation and cognitive therapy yield roughly equivalent positive outcomes for agoraphobia. However, the major predictor of overall therapeutic outcome across both treatments were measures of cognitive beliefs (Ost & Westling, 1995; Westling & Ost, 1995). This

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would suggest that a common pathway involving cognitive beliefs mediated therapeutic change for both these interventions, as predicted by Clark's (1986) cognitive model of panic. The question arises, therefore, of how the specific effects model can accommodate findings such as the above. The answer is probably to be found in more recent models of therapeutic change, which involve concepts such as emotional processing (Borkovec, 1994; Foa & Kozak, 1986; Rachman, 1980) and give rise to more dynamic explanations of change that involve an interplay between a variety of more discrete psychological processes such as physiological arousal, preattentive biases, affective response, associative networks, imagery, cognitive avoidance, worry, and extinction. The exact nature of the interplay depends on the therapeutic technique considered, together with the nature of the clinical problem. Within this context, we would argue that arousal reduction techniques might yield more subtle therapeutic gains through a variety of possible pathways. To illustrate this, we provide here some speculative examples of how relaxation techniques might yield the suitable conditions that bring about enhanced emotional processing and therapeutic change. Before we can discuss the link between arousal reduction and emotional processing, we need to outline what is meant by the latter. According to Foa and Kozak (1986), emotional processing occurs when maladaptive fear structures are accessed in memory repeatedly, and fully processed, resulting in affective and physiological responding. In addition, this processing results in changes to the structure of the associative network responsible for representing the meaning of the fear object. With repeated exposure, together with full processing, extinction of the fear cues and their associations is brought about. Factors that are said to influence this process are level of arousal, early detection of threat cues, cognitive engagement and avoidance, depth of affective processing and emotional responding, worry, and distraction, together with overarching changes in attitude associated with mastery, coping, safety, and other metacognitive structures. We would argue, therefore, that in the case of emotional disorder, arousal reduction techniques yield a variety of therapeutic effects through their ability to enhance emotional processing. We further speculate that these techniques provide several quite discrete mechanisms through which such facilitation might be achieved. These influences of arousal reduction techniques on emotional processing and consequent therapeutic change are outlined in Table 1. First, we suggest that the consequences

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of gaining competence in any arousal reduction/ relaxation induction technique can be considered with respect to three general areas of functioning. These are direct changes in physiological activity, changes in ongoing attention and other associative processes (e.g., access to associative networks), and longer term cognitive, attitudinal, and behavioral changes. Clearly, many relaxation techniques are said to result in altered physiological functioning, such as greater cortical deactivation, increased parasympathetic activity, decreased sympathetic activity, and lowered muscle tension. These changes may well be intrinsically therapeutic, since they represent direct therapeutic targets in their own right (i.e., reduced muscle tension, lowered blood pressure, etc.) and may also be associated with longer term physiological benefits with respect to neuroendocrine and immune functioning. We would argue, moreover, that these changes in physiological arousal may also lead to therapeutic changes within a second area of functioning known as ªemotional processing.º Several authors (Borkovec, Lyonfields, Wiser, & Deihl, 1993; Foa & Kozak, 1986; Shapiro, 1995; Turpin, 1991) have

Table 1 Targets for potential therapeutic change arising from the implementation of arousal reduction techniques. Physiological Alteration of autonomic and endocrine functioning: Central deactivation Increased parasympathetic activity Decreased sympathetic activity Reduced muscle tension Altered breathing Endocrine changes Immune function changes Emotional processing Changes in fear structures and memory: Preattentive biases and early cue-detection of threat Associative networks consisting of stimulus and responses propositions Accessibility to network and imagery Changes in associative strengths and meaning Cognitive avoidance and worry Cognitive change Changes in sensation, attributions, and beliefs: Altered subjective experience of tension and calmness Redistribution of focused attention Reattributions of anxiety and panic cues/situations Reduction in worry and metacognitions Enhanced mastery and coping Commitment to approach and direct exposure of feared object/situation

suggested that the depth of processing might be enhanced by relaxation. An associated observation from Borkovec's research is the observation that generalized anxiety disorder and worry are associated with autonomic inflexibility, and that therapeutic improvement is associated with an increase in parasympathetic activity. It is too early, however, to speculate about the direction of this relationship. Finally, the association with decreased arousal and extinction of fear has been fundamental to many accounts of desensitization (Lader & Mathews, 1970) and is still relevant to more contemporary models of fear conditioning (Davey & Matchett, 1996) and other therapeutic procedures such as eye-movement desensitization and post-traumatic stress disorder (MacCulloch & Feldman, 1996; Shapiro, 1995). Changes in physiological activity may also be represented indirectly as altered interoreceptive feedback within a third general area involving cognitive change. Since it has been argued (Clark, 1986) that nonspecific bodily sensations might provide a cue for catastrophic attributions within panic disorder, any modification of these sensations, either due to relaxation or even medication, might have beneficial effects. This approach has been specifically developed further by Borkovec and Roemer (1994), whereby applied relaxation is combined with early cue detection and self-control desensitization. It would be expected that decreases in subjective bodily sensations and tension would also be accompanied by increases in subjective calmness, etc. Finally, a word of caution is warranted, since it has also been argued that a potential therapeutic strategy is to train clients to disattend to interoreceptive sensations (Wells, 1990). Somatically based relaxation techniques might contradict such an approach, and this may be apposite when clients occasionally experience relaxation-induced panic. The extent to which interoceptive feedback or any other anxiety-related cues, such as distressing imagery or worrisome thoughts, are detected and attended to might also be affected by arousal reduction techniques. In particular, techniques that focus on cognitive strategies as a means of controlling, for example, worry, troublesome imagery, and unpleasant thoughts, such as guided imagery, autogenics, meditation, and hypnotic relaxation procedures, might also have an important role in emotional processing. Although these techniques may not necessarily have a direct facilitative role, they may be expected to have therapeutic benefits by counteracting other maladaptive cognitive phenomena such as worry and disturbing imagery which, according to Borkovec (1994), inhibit emotional processing. Worry is said to lead to

References cognitive avoidance, suppression of affective responding to imagery, delayed habituation, and the preservation of intrusive thoughts and images. The degree to which various cognitively directed relaxation strategies can result in a client gaining control of these negative cognitive strategies requires further confirmation and research. Interestingly, as discussed in Section 6.09.4.1, there are several different observations that have independently stressed the importance of decontextualizing negative thoughts or images by such techniques as ªletting go,º ªeffortless relaxation,º ªjust thoughts,º or ªmindfulness meditation.º Moreover, the therapeutic rationale provided with various relaxation techniques, together with the nature of the therapeutic relationship and the experience of therapy, should contribute to positive attitudinal change in relation to selfcoping and efficacy, re-attributions of anxiety and panic, and overall changes in life-style and outlook. Indeed, Smith (1988) has emphasized the importance generally of the cognitive components of relaxation training and cognitive restructuring. 6.09.5 CONCLUSION In this chapter we have attempted to provide a theoretical context within which different arousal reduction techniques might be evaluated. We have briefly reviewed the practical applications of these techniques and attempted some discussion of their relative efficacy, together with a review of the relevant outcome data. From this review, we would suggest that relaxation techniques have been shown to be beneficial for a variety of physical and mental health problems, particularly in the short term and during the course of ongoing therapy. Although other techniques involving more cognitively oriented approaches have tended to eclipse relaxation-based therapies, we would argue that therapists continue to give these methods serious consideration, particularly when used in conjunction with other cognitivebehavioral methods. This recommendation is based on evidence from outcome studies that have demonstrated a degree of efficacy, even for relaxation applied alone, and also from consideration of potential factors that might, albeit rather speculatively, affect the depth and efficiency of emotional processing. 6.09.6 REFERENCES Adler, C. M., Craske, M. G., & Barlow, D. H. (1987). Relaxation-induced panic (RIP): When resting isn't peaceful. Integrative Psychiatry, 5, 94±112. Adler, C. S., & Morrisey-Adler, S. (1983). Stategies in

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Arousal and activation systems and primitive adaptive controls and cognitive priming. In N. L. Stein, B. Leventhal, & T. Trabasso (Eds.), Psychological and biological approaches to emotion (pp. 145±166). Hillsdale, NJ: Erlbaum. Turpin, G. (1989). An overview of clinical psychophysiological techniques: Tools or theories. In G. Turpin (Ed.), Handbook of clinical psychophysiology. Chichester, UK: Wiley. Turpin, G. (1990). Psychophysiology and behavioral assessment: Is there scope for theoretical frameworks? In P. Martin (Ed.), Handbook of behavior therapy and psychological science: An integrative approach (pp. 348±382). New York: Pergamon. Turpin, G. (1991). The psychophysiological assessment of anxiety disorders: Three-systems measurement and beyond. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 366±375. Turpin, G., & Lader, M. (1986). Life events and mental disorder: Biological theories of their mode of action. In H. Katschnig (Ed.), Life events and psychiatric disorders: Controversial issues. Cambridge, UK: Cambridge University Press. Venables, P. H. (1984). Arousal: An examination of its status as a concept. In G. H. Coles,, J. R. Jennings, & J. A. Stern (Eds.), Psychophysiological perspectives: Festschrift for Beatrice and John Lacey. New York: Van Nostrand Reinhold. Wadden, T. A., & Anderton, C. H. (1982). The clinical use of hypnosis. Psychological Bulletin, 91, 215±43. Wagner, H. L. (1988). Social psychophysiology and emotion theory and clinical applications. Chichester, UK: Wiley. Weiner, H. (1977). Psychobiology and human disease. New York: Elsevier. Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273±80. Westling, B. E. & Ost, L. G. (1995). Cognitive bias in panic disorder patients and changes after cognitive-behavioral treatments. Behavior Research and Therapy, 33, 585±588. Whitehead, C., & Adams, L. (1991). Relaxation techniques. Cambridge UK: Daniels Publishing Winslow Press. Wiebe, D. J., & Williams, P. G. (1992). Hardiness and health: A social psychophysiological perspective on stress and adaptation. Journal of Social and Clinical Psychology, 11, 238±262. Wiesse, C. S., Davidson, L. M., & Baum, A. (1989). Arousal theory and stress. In H. Wagner & A. Manstead (Eds.), Handbook of social psychophysiology (pp. 283±302). Chichester, UK: Wiley. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Wolpe, J. (1982). The practice of behavior therapy. New York: Pergamon. Wolpe, J. (1989). The derailment of behavior therapy: A tale of conceptual misdirection. Journal of Behavior Therapy and Experimental Psychiatry, 20, 3±15. Woolfolk, R., Carr-Kaffeshan, L., & McNulty, T. F. (1976). Meditation training as a treatment for insomnia. Behavior Therapy, 7, 359±365.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.10 The Therapeutic Relationship FRANK M. DATTILIO University of Pennsylvania School of Medicine, Philadelphia, PA, USA and ARTHUR FREEMAN and JOHN BLUE Philadelphia College of Osteopathic Medicine, PA, USA 6.10.1 INTRODUCTION

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6.10.2 THE EXISTENTIAL PERSPECTIVE

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6.10.3 THE PSYCHOANALYTIC PERSPECTIVE

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6.10.4 THE HUMANISTIC PERSPECTIVE

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6.10.5 THE BEHAVIORAL APPROACH

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6.10.6 THE COGNITIVE-BEHAVIORAL PERSPECTIVE

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6.10.7 IMPEDIMENTS TO THERAPY

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6.10.7.1 Definitions of Resistance 6.10.7.2 Client Factors 6.10.7.3 Therapist Factors 6.10.7.4 Problem/Pathology Factors 6.10.7.5 Client Factors 6.10.7.5.1 Lack of client skill 6.10.7.5.2 Client cognitions regarding previous therapy failure 6.10.7.5.3 Client cognitions regarding consequences to others change 6.10.7.5.4 Secondary gain 6.10.7.5.5 Fear of changing 6.10.7.5.6 Lack of client motivation 6.10.7.5.7 Negative set 6.10.7.5.8 Lack of limited motivation 6.10.7.5.9 Limited or poor self-monitoring 6.10.7.5.10 Limited or poor monitoring of others 6.10.7.5.11 Narcissistic style 6.10.7.5.12 Client frustrated with lack of therapy progress 6.10.7.5.13 Client perception of lowered status in therapy 6.10.7.6 Therapist Factors 6.10.7.6.1 Lack of therapist skill 6.10.7.6.2 Client and therapist distortions are congruent 6.10.7.6.3 Poor socialization to the treatment model 6.10.7.6.4 Lack of collaboration/alliance 6.10.7.6.5 Lack of data 6.10.7.6.6 Therapeutic narcissism 6.10.7.6.7 Poor timing of interventions 6.10.7.6.8 Lack of experience 6.10.7.6.9 Therapy goals are unstated, unrealistic, or vague 6.10.7.6.10 Lack of agreement with therapy goals

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6.10.7.7 Problem/Pathology Factors 6.10.7.7.1 Client rigidity foils compliance 6.10.7.7.2 Medical/physiological problems 6.10.7.7.3 Difficulty in establishing trust and cooperation 6.10.7.7.4 Press of autonomy 6.10.7.7.5 Impulsivity 6.10.7.7.6 Confusion 6.10.7.7.7 Limited cognitive ability 6.10.7.7.8 Symptom profusion 6.10.7.7.9 Dependence 6.10.7.7.10 Self-devaluation 6.10.7.7.11 Limited energy 6.10.7.7.12 Substance use

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6.10.8 ABUSES OF THE THERAPEUTIC RELATIONSHIP

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6.10.9 GENERAL GUIDELINES

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6.10.10 APA CODE

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6.10.11 REFERENCES

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The meeting of two personalities is like the contact of two chemical substances: if there is a reaction, both are transformed. (C.G. Jung, 1933)

6.10.1 INTRODUCTION Few would argue that the therapeutic relationship between client and therapist is the cornerstone of any psychotherapeutic modality. Whether one practices classical psychoanalysis or radical behaviorism, the practice of psychotherapy involves a relationship, an interaction, and an emotional exchange between two or more individuals. Regardless of whether or not the goal is in sight or is directed behavioral change, one cannot ignore the essential ingredient of the bidirectional influence of one party to the other within the therapeutic collaboration. With each client, the therapist must start from the beginning and build a relationship from the ground up. While the process of relationship building can become well developed over years of clinical practice, the therapist learns that each and every client requires the same regime. That is, to identify the needs of the client, discern the pathways to best relate to the client, and then use those pathways to establish and maintain the therapeutic relationship. The therapeutic relationship has been addressed in the professional literature in a number of different manners (Alexander & Luborsky, 1986; Horvath & Greenberg, 1986; Safran & Wallner, 1991; Suh, Strupp, & O'Malley, 1986; Sullivan, 1954; Wright & Davis, 1994). The therapeutic relationship typically involves factors of confession, atonement and absolution, encouragement, positive and negative reinforcement, aversive procedures, behavioral modeling, promotion of values, and cheer leading (Frank, 1985). What makes the therapeutic relationship different from a long talk

with a close friend can be summed up in Frank's definition of psychotherapy. He states: Psychotherapy is a planned, emotionally charged, confiding interaction between a trained, socially sanctioned healer and a sufferer. During this interaction the healer seeks to relieve the sufferer's distress and disability through symbolic communications, primarily words but also sometimes bodily activities. The healer may or may not involve the client's relatives and others in the healing rituals. Psychotherapy also often includes helping the client to accept and endure suffering as an inevitable aspect of life that can be used as an opportunity for personal growth. (Frank, 1985, p. 50)

The relationship is not the reason that therapy can have a helping effect for an individual, but rather the vehicle and context that makes the probability of relief more likely. This chapter will address four issues of the therapeutic relationship. The first focus will be to define and compare the view of the therapeutic relationship from different theoretical perspectives, including the Psychodynamic, Existential, Humanistic, and Cognitive-behavioral domains. The second area of focus will be to relate some of the empirical data on the therapeutic relationship and highlight the correlation between relationship factors and therapeutic efficacy. The third focus will be to identify and describe issues and circumstances that negatively impact on the therapeutic relationship, broadly termed resistance. Finally, we will address abuses of the therapeutic relationship and the impact that these abuses have on the therapeutic process. A final summary will attempt to integrate the factors discussed as well as review some general guidelines for the therapeutic relationship and the American Psychological Association's code for ethical behavior.

The Existential Perspective Early psychoanalytic work identified three relational components of the therapy process that had to be addressed in the therapy. The meaning, value, and importance of these factors has been the subject of debate for more than 100 years. Nevertheless, we can use them as a broad framework upon which to stretch the fabric of our discussion of the relationship in psychotherapy. These issues were termed transference, countertransference, and resistance. Broadly, they capsule the client's expectations, beliefs, reactions, and responses to the therapist and to the therapeutic environment (transference), the therapist's reactions and responses to the client's transference or, alternatively, the therapist's reaction to the client generally (countertransference), and the client's difficulty in therapy or avoidance of issues and areas of concern (resistance). These factors may be overtly expressed or more covertly expressed either subtly or symbolically depending on the particular client and the situation.

6.10.2 THE EXISTENTIAL PERSPECTIVE Within the context of Existential Therapy the therapeutic relationship is one characterized by mutual respect, individual uniqueness, authenticity, and pursuit of meaning. According to Seguin (1965), `It is through total acceptance, that the client comes to value his or her own uniqueness, becomes free to exert choice, to make commitments, and to find meaning in life.º According to Bugental and Sterling (1995), it is necessary to develop what they term a `meaningful realistic therapeutic contract.º This suggests an agreement or arrangement (contract) between the parties and that the individuals involved both contribute and hope to gain from the arrangement. The therapeutic contract facilitates understanding between the client and therapist, rendering it meaningful and realistic. Bugental and Sterling (1995) further identify the existence of other therapeutic functions characterizing the therapeutic course. Besides developing a meaningful, realistic therapeutic contract, they propose the importance of `Fostering the growth of a resilient alliance, working through the situational resistances, working through some of the character resistances, exploring client±therapist collusion (transference±countertransference issues), working with residual transferential elements and preparing for terminationº (p. 240). The therapeutic contract is viewed as providing a foundation for therapy with the therapeutic alliance being conceptualized as a container that will hold the struggles, emotions, and relationships necessary to a major life

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undertaking. According to May and Yalom (1989), existentially oriented therapists strive toward honest, mutually open relationships with their clients. The therapist and client address one another equally, generally both on a first-name basis, with the therapist striving toward demystification of the therapy process, answering questions fully and openly, as opposed to remaining impassive in an effort to evoke transferential distortions. The canon of humanistic existentialism is that the human element must be the focus of the therapeutic endeavor. No theory of the person, of therapy, or of pathogenesis can take precedence over the personhood and human elements. Further, those subscribing to a ªscientific materialistic modalityº as thinking about client's productions in atomistic terms such as units of energy, drives, impulses, needs, instincts, stimulus response links, or in transformation-of-energy terms lose the essence of the human element. For example, Ofman (1985) suggests that proponents of psychoanalysis will be guided by theory rather than by an attention to the person. He explains that the client should be seen in that (theoretical) light; taught that way of thinking (by the analyst); and the client's predictions will be traded in on the ªquotidianº view because it is difficult for behavioral scientists to proceed otherwise. In Ofman's view, ªHumanistic existentialism translated that position to dealings with clients, but not in counter transference terms. In such a translation there is not subject±object split, but there is a mutual processº (p. 12). Within the context of the therapeutic contract/alliance, the existential therapeutic task is the fostering of explicit awareness. The goals are for the person to utter, clarify, and identify projects, and their personal myth; to assume ownership and responsibility for one's projects; to validate and embrace both the inevitable positive and negative aspects of relationships and of acts, so that the divided, unattended parts of the personality become integrated. The attainment of such goals leads to greater autonomy, responsibility, and an attendant equality in relationships. Progress toward these goals is sought by means of acceptance, affirmation, and authentic relating between therapist and client (Ofman, 1985). The authenticity can occur only when the therapist sees that the client has freely chosen to do and to be what they are, and to make choices for the best of all possible reasons, personal growth. May (1969) states, ªIntentionality presupposes an intimate relationship with the world that we would not be able to go on existing in except if we could block the world out at times. This should not be called simply by the

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condemnatory term `resistance.' I do not doubt the reality of resistance, as Freud and other's elucidated it, but I am emphasizing here a broader, structural phenomenon. That is `every intention is an attention, and attention is I-can,' as Merleau-Ponty puts it. We are, therefore, unable to give attention to something until we are able in some way to experience an `I-can' with regard to itº(p. 36). In essence, the Existential view places a major importance on the development of the relationship as central to the therapy. The relationship is famed in terms such as ªrealº or ªauthentic,º with the realness of the therapist serving as both a model and guide for the client to emulate.

6.10.3 THE PSYCHOANALYTIC PERSPECTIVE Munroe (1955) capsules Karen Horney's position by conveying that she believed that man was born a potentially harmonious organism, capable of expanding his own capacities normally, in happy relationships within his surroundings. Conflict, Horney believed, occurred only as a consequence of social mishandling which instituted exaggerated impulses and fears in contradictory directions. Normally, a child is confident of help from his parents, because he has experienced it regularly. The neurotic child believes he must fight for everything he wants in a hostile world, because he has experienced deprivation. Yet open aggression in a creature as helpless as the human infant brings swift and overwhelming counteraggression. Thus, aggression and the fear of being aggressive both develop to an exaggerated degree. One important area addressed by Horney in the therapeutic relationship was her new perspective on the psychology of women. Tasman, Kay, and Lieberman (1997) identify very clearly that it was actually Horney who ªargued that Freud's model of feminine development was phallocentric, a masculine fantasy that protected men from their unconscious fear of women. Horney's arguments have been of central importance in feminist critiques of Freud and ultimately in the reworking of views of feminine psychology within the mainstream of psychoanalysisº (p. 16). Horney's therapeutic and theoretical approach was holistic and placed an emphasis upon the notion of self-realization as well as phenomenological and existential influences noted in her earlier works. Such a position is characterized by Horney (1945) in the following excerpt: ªFreud's pessimism as regards neuroses and their treatment arose from the depths of his

disbelief in human goodness and human growth. Man, he postulated, is doomed to suffer or to destroy. The instincts which drive him can only be controlled, or at best `sublimated.' My own belief is that man has the capacity as well as the desire to develop his potentialities and become a decent human being, and that these deteriorate if his relationship to others and hence to himself is, and continues to be, disturbed. I believe that man can change and go on changing as long as he livesº (p. 72). Rejecting Freud's instinctual approach Horney stressed a stronger contextual stance as influential on the individual's development. Tasman et al. (1997) make several cogent points that are important in understanding the therapeutic relationship: (i) ªHorney believed that humans were not the tragic figures that Freud depicted, driven by biological endowment to seek sexual and aggressive satisfaction and inevitably meeting conflict.º (ii) ªNormal development was not inherently conflictual. The neurotic child sacrificed the pursuit of pleasure and the fulfillment of his or her unique potential which Horney termed the real self, to ensure safety in an environment that the child perceived as hostile and dangerous.º (iii) ªUltimately, neuroses was the result of the environment; the neurotic child responded to the parents' failure to love her or him as she or he was; and neurotic symptoms were importantly determined by cultural norms.º (iv) ªHer emphasis on the current context of analysis has been absorbed into mainstream psychoanalysis; her concepts of the real self and human potential have contributed to the broader expanse of dynamic psychotherapiesº (p. 96). In the matter of issues directly involving the role of the analyst in the context of the therapeutic relationship, Horney (1939) writes: ªWhen I feel uncertain about a suggestion made to the client I point out its tentative character. If then my suggestion is not to the point, the fact that the client feels that I too am searching for a solution may elicit his active collaboration in correcting or qualifying my suggestion.º In effect, Horney takes the active position that the analyst should exercise a more deliberate influence not only on the direction of the client's associations but also on those psychic forces which cause the neuroses but also on those forces that may help him eventually overcome the neuroses. She further states that the work a client has to accomplish is most strenuous and most painful. It implies no less than relinquishing or greatly modifying all the strivings for safety and satisfaction which have hitherto prevailed. It implies relinquishing illusions about himself which in his eyes have made

The Psychoanalytic Perspective him significant. It also advocates placing his entire relations to others and to himself on a different basis. What drives the client to do this hard work? Clients come for analytical help because of different motivations and with different expectations. Most frequently they want to get rid of manifest neurotic disturbances. Sometimes they wish to be better able to cope with certain situations. Sometimes they feel arrested in their development and wish to overcome a dead point. Very rarely do they come with the outright hope for more happiness. The strength and constructive value of these motivations vary in each client, but all of them can be actively used in effecting a cure. Tasman et al. (1997) state, ªThe analyst should focus on the here and now, interpreting current wishes and defensive structures so the client's unconflicted potential could emergeº (p. 36). Concerning Horney's views on the therapist's and client's direction in therapy, the following excerpt best illuminates Horney's position, ªThe aim of therapy is then not to help the client to gain mastery over his instincts but to lessen his anxiety to such an extent that he can dispense with his `neurotic trends.' Beyond this aim there looms an entirely new therapeutic goal, which is to restore the individual to himself, to help him regain his spontaneity and find his center of gravity in himselfº (Horney, 1939). In an examination of issues of transference, Tasman et al. (1997) explain, ªAlthough childhood influences shaped character, current defensive needs rather than infantile wishes were the chief determinants of current behavior and of the client's transference.º Horney (1937) states, ªIn relationships in which one person becomes dependent on the other there is invariably a great deal of resentment. The dependent person resents being enslaved; he resents having to comply, but continues to do so out of fear of losing the other. When the fear is very great they may seek to protect themselves against this dependence by not attaching themselves to anyone. These processes are evident also in a client's attitude during analysisº (p. 24). In a more traditional sense, ªResistance often uses the mechanism of transference as its weapon to interfere with the progress of analysis. In this, the client unconsciously strives to avoid the insight which the cure demands. The transfer of unconscious infantile wishes to the person of the doctor facilitates their admission into consciousnessº (Eidelberg, 1968). According to Ferenczi and Rank (1925), the transference is an immediate goal of analysis; the replacement of the manifest neurosis by a transference neurosis. According to Horney (1937), ªTransference (in the traditional sense) should refer to

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the sum total of all the client's irrational reactions toward the analyst, not only the emotional dependence. The problem here is not so much why this dependence takes place in analysis, because persons in need of such protection will cling to any physician, social worker, friend, member of the family, but why it is particularly strong and why it occurs with such frequency. The answer is comparatively simple: analyzing means, among other things, tackling defenses built up against anxiety, and thereby stirring up the anxiety lurking behind the protecting walls. It is this increase of anxiety that causes the client to cling to the analyst in one way or another.º This view is emphasized in the following comment by Horney (1937). ªSexual desires concerning the analyst are usually interpreted as repetitions of a sexual fixation on the father or the mother, but often they are not genuine sexual wishes at all, but a reaching out for some reassuring contact to allay anxiety. The client, to be sure, often relates associations or dreamsÐexpressing, for example, a wish to lie at the mother's breast, or to return to the wombÐwhich suggest a father or mother transference. We must not forget, however, that such an apparent transference may be only the form in which a present wish for affection or shelter is expressedº (p. 48). In a discussion of issues of transference infatuation, Horney (1937) points out that the analyst becomes cognizant of the impersonal character of the infatuation and attributes this indiscrimination to the client's tendency to repeat old patterns. The client feels relieved because he/she recognizes that there is something compulsory, something not genuine in his/ her feelings of love. As a result, the actual infatuation diminishes, dependent on the analyst's strengths. The client's view may hold that his security and satisfaction may depend upon fastening himself to others or, more accurately, merging with them. Consequently, giving and hopefully obtaining affection is for him, a means of reassurance and thereby safety. It would seem inconceivable that a therapy could begin or proceed without some level of anxiety being raised for the client. Anxiety may reflect the need to discuss personal issues and problems. It may also involve the need, expectation, or requirement that the client relate to the therapist. Whenever anxiety emerges, the client's need to hang on to the analyst intensifies. Therefore, whenever the client displays a more than usual attachment or transference reaction to the analyst, the analyst should connect and reflect the attachment back to the client as an indication of anxiety or insecurity. The effect of this interpretation would be to open the gate toward a greater recognition on

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the client's part, and eventually to lead to an understanding of the underlying structure responsible for his/her anxiety reaction. As it is mainly the client's anxiety, according to the Horneyan view, which makes him dependent on the analyst, interpretations of this kind counteract from the beginning the danger of dependency. On matters of resistance, Horney (1939) contends that when the client is analyzed, he/ she will realize the futility of their efforts, though with some reluctance. He may politely and intellectually follow the analyst's suggestions that the irritations are only ªbubblesº surfacing. But as soon as the analyst identifies one of the deeper disturbances, the client will react with a mixture of concealed irritation and diffuse anxiety, and soon will argue most cleverly that the analyst is wrong, that at least he is exaggerating his reaction. Resistance for Horney (1939) involves the energy with which an individual protects repressed feelings or thoughts against their integration into conscious awareness. This concept is based on our knowledge that the client has good reasons for not acknowledging certain drives and will seek to avoid them. Regarding notions of countertransference and transference, Horney (1939) believes that when a therapist reacts with inner irritation to a client's tendency to defeat his/her efforts, he/she may be identifying the client with his/her own father, and thus repeating an infantile situation in which they felt defeated by the father. If, however, the therapist's emotional reactions are understood in the light of his/her own character structure as it is affected by the client's actual behavior, then it will be viewed as the therapist's need to cure every case. Failure to do so may be viewed as a personal humiliation. In summary, Horney's view states that neuroses are ultimately the expression of disturbances in human relationships. The analytical relationship is a very unique form of human interaction. The therapy then becomes a microcosm of the client's relational life. Relationships and existing disturbances are bound to appear in the therapy as they appear elsewhere. The particular controlled and contained conditions under which an analysis is conducted render it possible to study these relationship disturbances more accurately than elsewhere. Finally, the relationship problems in the analysis can serve to convince the client of their existence and of the role they play in forming and maintaining the problems. At the bottom is the question which is essential to the goals of therapy. Do we intend to put out a finished product with all problems solved for good and all? In fact, do we believe it

to be desirable? Or do we think of life as a process of development which does not end and should not end until the very last day of existence? The work of Harry Stack Sullivan is, by definition, based on the interaction between people. His work termed ªInterpersonal Psychiatryº is representative of the Neo-Freudian factions of his time that espoused a collection of ideas that could be found operative within the context of the therapeutic relationship. Sullivan held the belief that human beings possess an actualizing tendency, that is to say, an innate predisposition for fulfillment of one's human potential. According to Mullahy (1970), Sullivan believed that there was a built-in tendency of the self to maintain its current organization and functional activity. Furthermore, by our very nature we would rather be healthy than to suffer from the pains of mental illness. Sullivan clearly recognized the importance of creativity, purposefulness, and in stressing a holistic approach in the treatment of his clients. May and Yalom (1989) state that in the interpersonal model of personality an individual is not instinctually guided and preprogrammed, but is instead almost entirely shaped by his cultural and interpersonal environment. Hall and Lindzey (1970) regard personality as a hypothetical entity which is unable to be isolated from interpersonal situations and interpersonal behavior. It is all that can be observed as personality. In a sense, it is vacuous according to Sullivan to speak of the individual as the object of study because the individual does not and cannot exist apart from his relations with other people. Although Sullivan does not deny the importance of heredity and maturation in forming and shaping the organism, he contended that, that which is distinctly human is the product of social interactions. Some believe that Sullivan's interpersonal psychiatry emphasized psychopathology as a personal method for coping with terrifying relationships. He believed that the therapist as a participant-observer offered a new mutative quality of relatedness to the therapeutic relationship (Greenberg & Cheselka, 1995). Sullivan believed in experience and cognitive processes as represented by three modalities: the prototaxic, parataxic, and syntaxic modes. According to Kaplan, Sadock, and Grebb (1994), the prototaxic mode is undifferentiated thought that is unable to separate the whole into the parts or to use symbols. This is something Kaplan, Sadock, and Grebb believe occurs normally in infancy and is also seen in schizophrenia. Within the context of the therapeutic relationship we find that the process is a collaborative

The Psychoanalytic Perspective and active one. According to Kaplan et al. (1994), ªThe therapy process requires the active participation of the therapist, who is known as a `participant-observer' º (p. 236). Modes of experience, particularly the parataxic, need to be clarified and new patterns of behavior need to be implemented. In his critical analysis of Sullivan's works, Mullahy (1970) states that the therapeutic relationship is a performance of two people, a transaction, in which the client's behavior and what he says and does are adjusted, in accordance with the best of his information and ability, to what he guesses or surmises about the therapist. In addition, the rationale of the interview is based on a progressively unfolding expert client (therapist± client) relationship for the purpose of discovering the client's characteristic patterns of living. The therapist seeks to discover those (frequently obscure) patterns of living of the client that he experiences as particularly troublesome as well as those he experiences as particularly valuable. Within the scope of the therapeutic techniques, interrogation and interpretation warrant brief definition at this point. It was Sullivan's position to avoid direct interrogation. Sullivan viewed a direct question in a psychiatric interview as not likely to provoke the most informative answer. Rather, Sullivan would have the client test out hypotheses that would either support or disconfirm his/her existing thoughts on a subject which is more reflective of an indirect approach. Direct interrogative questioning was only to be used if there was a very justifiable reason and purpose. Mullahy (1970) writes, ªThe interrogation proceeds from a given point in a direction that is easy for a client to followº (p. 16). Regarding the use of interpretations, they must be timely and accurate as well as and constructive. Further interpretation as a therapeutic strategy if used inappropriately might serve to fuel anxiety. According to Mullahy (1970), one must usually avoid questions and interpretations that arouse anxiety since, among other things, it provokes aspects that interfere with growth of the client's information and insight. Clearly if an untimely inappropriate interpretation is made and results in an unnecessary escalation of the client's anxiety, the therapeutic relationship could fall into serious jeopardy. Sullivan was aware that at times anxiety could serve a constructive function when it helped to mobilize a client. In general, however, he viewed it as a ªformidable enemyº (Mullahy, 1970). In reading Sullivan's works, one can see that his methodology represents an honest attempt at scientific inquiry. It is clear that his psychiatric interview is an attempt at the collection of relevant data. The results or

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accomplishments of the interview are to ensue partly from interpretation of clearly documented facts, from the building of inferential bridges that carry one from particular concrete instances to a generalized formulation, and partly from considering alternative hypotheses regarding situations in which the client has preferred misleading formulations. It was Sullivan's contentions that psychiatrists, particularly some psychoanalysts, were prone to interpretation of the material expressed by their clients and that the abundance of interpretations was greatly in excess of the need for them. The therapist, within the context of the therapeutic relationship, seeks to facilitate identification and awareness of parataxic distortions and the development of insight into that process. The notion of resistances were renamed ªsecurity operationsº by Sullivan (1953). He felt that the discovery of a parataxic distortion brought about a sharp fall in one's level of security, causing one to become intensely anxious. This was viewed as injurious to the relationship, and ultimately to the therapy because, ªthe client's self-esteem, his interpersonal security, is often fragile or at least infirm, then, the disturbing consciousness of the `mistake' tends to arouse essentially disintegrative, distance-producing security operationsº (p. 34). The therapist must first be aware of the tendency for this to occur, be skilled in dealing with it, and to then intervene and counter the disintegrative operation. For Sullivan, counter transference (in the classical Freudian sense) was the result of inadequate skill or some personal inadequacy (Mullahy, 1970). Sullivan did not believe a therapist should become seriously ego-involved with a client, and would, in fact, consider any personal involvement with his client therapeutically dangerous and part of what he termed ªsocial hokum.º For Sullivan, the key to the effectiveness of therapy was the interpersonal relationship. He saw the therapist as an expert in the problems that ªailº the client but did not recommend that the therapist become intimate with any of them. Sullivan expanded upon and reformulated the notion of transference in terms of parataxic ªme±youº patterns. He interpreted transference as a one-way process that showed the direct interaction of personalities. ªBy transference the client manifests interpersonal processes that open the gates of memory sealed by dissociations, reorients his experience, and facilitates the development of arrested or distorted systems of motives so that he moves forward toward the conditions of adult personality organizationº (Sullivan, 1962, p. 87).

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In the initial stages of the therapeutic relationship the therapist has the responsibility when the client presents a problem, especially in the early stages of therapy, to not arouse so much anxiety that the client feels threatened. This would occur before a client learned how to withstand a good deal of anxiety when experiencing any perceived attack on their self-esteem. In the initial stages of the therapeutic relationship, the therapist must ensure within the structure of the therapeutic situations that both the therapist and client can arrive at an agreement on the overall goal, end, or inclusive ªpurposeº of the therapy, so that there is collaboration. Mullahy (1970) identifies that ªSullivan held that in the course of identifying all the more parataxically `surviving,' unresolved situations of the client's past and their consequent dissolutions, there progressively occurs an expanding of the self to the extent that the client as known to himself is much of the same person as the client behaving with others. This was, for Sullivan, the therapeutic cure. Ideally, the client would achieve social cure (though not always the outcome) that might bring about a more abundant life in the community.º

6.10.4 THE HUMANISTIC PERSPECTIVE A discussion of the therapeutic relationship would not be complete without addressing Carl Rogers and his person-centered approach. Rogers was a major spokesman for the humanistic movement in psychology and led a personal life that reflected the ideas that he developed and used in his psychotherapeutic approach. He displayed a questioning stance and a deep openness to change which spiraled personcentered therapy to a height of becoming a major force in psychology. The goals of person-centered therapy differ from those of traditional approaches. The person-centered approach aims toward a greater degree of independence and integration of the individual in treatment. Its focus is on the person, not on the person's presenting problem. Rogers (1977) contends that his aim of therapy is not merely to solve problems, but to assist clients in their growth process so that they can better cope with problems they are currently facing as well as deal with future issues. The specific role of the person-centered therapist is rooted in their ways of being and attitudes, not techniques designed to get the client to do something to change. Research on person-centered therapy indicates that the attitudes of therapists, rather than their knowledge, theories, or techniques, facilitate person-

ality change in a client. Basically, the therapist uses himself/herself within the relationship as an instrument of change. Hence, encountering the client on a person-to-person level, their role as a therapist is actually to be ªwithout a role.º The main function then is to establish a therapeutic climate that helps the client grow in an individual way. The therapist's role becomes essential in the person-centered modality in that it creates a helping relationship in which clients experience the necessary freedom to explore areas of their life that are now either denied awareness or distorted. A genuine aspect of the therapist's role involves the willingness to be real in the relationship wih a client instead of viewing him/ her in a preconceived diagnostic fashion. In essence, the relationship then meets the client on a moment-to-moment experiential basis in an attempt to help them divulge their world. It is through the therapist's relationship of genuine caring, respect, acceptance, and understanding that they are able to help the client loosen their defense mechanisms and rigid perceptions in order to evolve into a level of personal functioning. In his early work, Rogers (1961) wrote ªIf I can provide a certain type of relationship, the other person will discover within himself or herself the capacity to use that relationship for growth and change, and personal development will occurº (p. 33). It was Rogers' contention that the significant positive personality change of an individual occurs only as a result of the relationship between therapist and client. The characteristics of the therapeutic relationship that are conducive to creating a suitable psychological climate involve creating an atmosphere in which the client will experience the necessity to initiate personalty change. Rogers believed that the following six conditions were necessary and sufficient for personality changes to occur: (i) Two persons are in psychological contact. (ii) The first, whom we shall term the client, is experiencing incongruency. (iii) The second person, whom we shall term the therapist, is congruent or integrated in the relationship (iv) The therapist experiences unconditional positive regard or real caring and acceptance for the client. (v) The therapist experiences an empathic understanding of the client's internal frame of reference and endeavors to communicate this experience to the client. (vi) The communication to the client or the therapist's empathic understanding and unconditional positive regard is to a minimal degree achieved (Rogers, 1987, pp. 39±41).

The Cognitive-behavioral Perspective

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Rogers hypothesized that no other conditions were necessary to facilitate change in the therapeutic relationship. He believed that if the aforementioned six conditions occurred over a given period of time, constructive personality change would occur. In addition, three personal characteristics, or attitudes, of the therapist form the central part of the therapeutic relationship. These include congruence, or genuineness, unconditional positive regard and acceptance, and accurate empathic understanding. One final important aspect of Rogers' work was that he believed that the therapist and the person of the therapist were the same individual. He believed that therapists should live their lives in accordance with theory which is used in the course of psychotherapy. Rogers believed this to be paramount in the therapeutic relationship.

clients, the therapeutic relationship is important. Behavior therapists tend to be more active and directive and can function as consultants in helping the client solve problems as opposed to allowing the relationship in and of itself to facilitate the change. Since behavior therapists use a coping model in initiating behavioral change in the clients natural environment, it is important that they be personally supportive to them. However, once again the actual process of change comes from the implementation of techniques as opposed to a byproduct of the actual relationship. At the very least, behavior tharapists view the relationship as being an important supportive aspect, yet not necessarily essential to change.

6.10.5 THE BEHAVIORAL APPROACH

Despite criticism by some in the field, cognitive-behavior therapy places an important emphasis on the therapeutic relationship as an integral part of the effectiveness in the treatment process. Constructs from cognitive-behavioral therapy can be used to understand variability in client behavior, and cognitive-behavioral formulations can be used to guide individuals in dealing with difficult problems in the therapeutic relationship. What is more, vicissitudes in the therapeutic relationship can provide individuals with an opportunity to work directly with clients' most significant maladaptive schemas which are an essential part of the therapeutic relationship. Schemas are defined as cognitive structures that may be at the core of an individual's particular dysfunction. It is a maladaptive, cognitive±interpersonal cycle that clients' perceptions of the therapist's behavior provide a phenomonological link to the dysfunctional interpersonal schemas and associated patterns of behavior (Safran, 1990; Safran & Segal, 1990). The notion of an individual's maladaptive beliefs or schema was first proported by Beck, Rush, Shaw, and Emery (1979). Schemas, which are cognitive distortions at the individual's deepest level, consist of concepts that the client habitually uses in viewing reality. These biases direct their focus in the retrieval of information. Typical negative schemas include rejection, abandonment, control, uniqueness, and unrelenting standardsÐprime aspects that are found in any therapeutic relationship. Therefore, a client who may maintain a negative schema of rejection will tend to focus on any sign that he or she is being rejected by the therapist. The same goes for their concept of abandonment and consists of what may be

Clinical and research evidence suggests that a therapeutic relationship, even in the context of a behavioral orientation, can contribute significantly to the process of behavior change (Granvold & Wodarski, 1994). A good therapeutic relationship increases the chances that the client will be receptive to therapy. Not only is it important for the client to cooperate with the therapeutic procedures, but the client's positive expectations about the effectiveness of therapy may often contribute to successful outcomes as well. The behavior therapist is one who can conceptualize problems behaviorally and make use of the client/therapist relationship in facilitating change. As opposed to some of the other modalities of treatment, behavioral practitioners do not assign an all important role to relationship variables. Instead, they typically contend that factors such as warmth, empathy, authenticity, permissiveness, and acceptance are considered necessary, however, not sufficient for behavioral change to occur (Bandura, 1977). It is not a matter of the importance of the relationship per se, but rather the role of the relationship as a foundation on which therapeutic strategies are built to help clients change in the direction that they desire. Lazarus (1989) maintains that unless clients respect their therapist it will be difficult to develop the trust necessary for them to engage in significant self-disclosure. At the same time therapists need an array of clinical skills and techniques to employ once an effective client/therapist relationship has been established. Since behavior therapy demands such a high level of skills and sensitivity as well as the ability to form a working relationship with

6.10.6 THE COGNITIVE-BEHAVIORAL PERSPECTIVE

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defined by the specific bias of their content. These schemas are usually formed during early childhood and selectively focus on information processing. In his cognitive model, Beck, Freeman and associates (1990) used personality as a combination of core beliefs and a characteristic set of basic strategies for interacting with others. Inter-related beliefs and action plans are organized within a generic knowledge structure referred to in the cognitive literature as schema. These schemas guide and actively participate in the processing of information and actions so that we see recurring patterns of thoughts, feelings, and behaviors. When deeply held beliefs and well-ingrained behavioral patterns are repeated in the therapeutic relationship and interfere with the effective use of what cognitive therapists refer to as collaborative empiricism, this creates a threat in the therapeutic process. The clients' expectations and perceptions of the therapist are typically distorted to remain consistent with his/her underlying beliefs. Behavior also remains consistent with dysfunctional beliefs. Cognitive-behavior therapists state that ªcognitive transference develops when the aforementioned patterns are repeated in the therapeutic process (Wright & Davis, 1994). Cognitive-behavior therapists typically use certain procedures to identify and modify maladaptive beliefs and dysfunctional behavior when cognitive transference occurs. When an individual has a serious personality disorder, this process may require longer-term therapy than is usually the case with a major depressive or anxiety disorder. The examination of beliefs, related behavioral strategies, and patterns in the therapeutic relationship can help therapists recognize and manage each client's unique expectations within the therapeutic process. It is extremely important that this be done and addressed forthright since any schema level analysis that is ignored may contribute to the clients' resistance and noncompliance and thwart the progress in therapy. In addition, excessive dependency or stagnation in the treatment process may also occur. It is therefore that cognitive-behavior therapists emphasize the intense supervision on relationship issues in training programs (Michenbaum & Turk, 1987). In fact, it has been suggested that this element of the therapeutic process should require as much attention as learning how to implement specific cognitive and behavioral techniques (Wright & Davis, 1994). The degree of importance of the therapeutic relationship depends not only on the approach,

but in accordance with the complexity or the problem itself. The more specific and simple the problem, the more the therapeutic relation shall be of less importance. Results from a series of investigations give evidence to the importance that the therapeutic relation has gained as an instrument of social change. Sloan (1975) found that consultants who solved their problems satisfactorily through behavioral therapy considered the relation with their therapist as the most important factor in their recovery. Alexander (1976) reports that the therapeutic relationship contributed significantly to the behavioral treatment of delinquents and their families. Mathews et al. (1976) found that a group of agoraphobics considered that the support, enthusiasm, and sympathy received from their therapist helped them to overcome their fears more than the actual practice of exposure exercises. Researchers Orlinsky and Howard carried out a revision in 1986 about research undertaken in order to study the predictive capacity for diverse factors in psychotherapy with regard to their efficiency. They were surprised by the great predictive capacity shown by patients' feelings about the empathy shown by the therapist. This prediction went far beyond what could be done based on the empathy displayed by the therapist. In general, these results suggest that the interpretation which the client has on the actions of the therapist during treatment is a significant factor in the effectiveness of the respective treatment. The therapeutic relationship may therefore be used as a process facilitator of social influence of different forms. In summary, the therapeutic relationship is an essential, interactive component of the process of cognitive-behavior therapy. Cognitive-behavior therapists need to remain sensitive to both the general and idiosyncratic expectations of their clients, without compromising the necessary limits or boundaries of the relationship. It is attention to these principles that will aid in building productive therapeutic relationships.

6.10.7 IMPEDIMENTS TO THERAPY It is tempting (and simplistic) to blame treatment difficulty or lack of progress in therapy on the client's noncompliance or ªresistance.º Therapists may assume that when progress lags it is because the client does not want to change or ªget well,º for either conscious or unconscious reasons. However, there are many different problems which can slow or block progress in therapy and few of them are due to the client's desire to retain his or her problems. To illustrate this point, one might

Impediments to Therapy consider a ªself-helpº or ªself-improvementº task such as losing weight, exercising regularly, or completing unfinished paperwork which one has been slow to complete. Is the lack of followthrough due to a secret desire to remain overweight, out of shape, or behind in paperwork, and to what extent might it be due to a number of more mundane factors such as personal comfort, time limitations, and so on. Might it be viable to assume that sometimes it is a combination of the two?

6.10.7.1 Definitions of Resistance Common themes of client resistance in therapy involves distrust of the therapist, personal shame, grievances against others, depreciation, or fear of rejection. Typically, resistance may be manifested directly (e.g., tardiness or missing of appointments) or more subtly through omissions in the material reported in the sessions. A number of publications have addressed this important issue (Ellis, 1985; Shelton & Levy, 1981; Stark, 1994; Wachtel, 1982). There are, however, many reasons for noncompliance other than the client not wanting to change or the lack of compliance indicating a pitched battle between intrapsychic structures. Clinically, we can identify several reasons for noncompliance. They can appear in any combination or permutation, and the relative strength of any noncompliant action may change with the client's life circumstance, progress in therapy, relationship with the therapist, and so on. We can divide these impediments to therapy into four broad categories. The first are problems emanating from the client. The second category include those problems stemming directly from the therapist. The third category pertains to those attributes involving the type, severity, and nature of the client's problem(s) or diagnosis. The final factors are those related to the client's life situation, personal context, and significant others. For each problem discussed, we will describe therapeutic interventions for reducing or ameliorating these obstacles and impediments to therapeutic change. Resistance or noncompliance may take many forms. Some would appear more directly negative, for example, verbal evasion, verbal or physical aggression, or threats against the therapist or agency. Other forms of resistance may be more subtle, for example, lateness for appointments, missing appointments, extended silence in sessions, forgetting homework, or failing to pay the therapist's bill. And yet, others may appear positive, but still have the effect of

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resistance, for example, trying to win the therapist over with praise, gifts, or devotion. Resistance may be conscious, for example, withholding information and details to appear healthier, smarter, and so on. On the other hand, the same material might not be reported because of ªforgetting,º a process that might be more unconscious. A starting point for understanding resistance is to conceptualize it as a normal and adaptive response to any type of perceived threat. Whether the resistant behavior is viewed as an ego defense or as a response to unfamiliar demands, it is unreasonable to accept that an individual will move directly to change without some level of discomfort. In point of fact, an individual who moves too quickly to change may be seen as impulsive or labile. An extreme to this would be the client with a borderline personality disorder who moves quickly from overidealization to complete devaluation. Normally, there is initially some hesitation with this process. Such resistance needs to be identified and addressed directly within the therapy process. Resistance is a predictable and therefore expected and at times even welcome part of the therapy. It can become an arena for the practice of a range of therapeutic interventions and in some cases adds to the change process. Many of our clients have been involved in therapy prior to submitting to their present course of treatment. If the previous therapeutic experience has not been successful, it might be essential for the therapist to first assess what occurred in the previous therapy in terms of the focus, direction, content, timing, cadence, and style of treatment. With this information in hand, the therapist can then work to alter any and all of the factors emblematic of the previous therapy so that the present therapy is experienced as different, and not more of the same old pattern. For example, if the previous therapy was unstructured, structure would offer a different therapeutic experience and possibly draw forth new or different material. If the content revolved around a particular issue shifting to a variant of that issue, or even a different issue may be in order. The use of different examples would be useful in this regard. The short-term treatment approach is often enough of a different focus to make the therapy a new experience and opportunity for change. If the previous therapy was unstructured, structure would be helpful. If the previous therapy was a short-term treatment approach, the therapist must be even more creative in finding new directions or foci. Use of the broad umbrella term of resistance may do more to limit therapy than to encourage

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or support it. Several reasons for noncompliance with a given therapeutic regimen may be isolated. It would be impossible to totally isolate each one as a separate and completely distinct entity from all others. There will, of necessity, be similarity and overlap. To make it easier to identify and deal with each, we have divided them into three categories, client factors, therapist factors, and problem or pathology factors. 6.10.7.2 Client Factors (i) Lack of client skill (ii) Client cognitions regarding previous therapy failure (iii) Client cognitions regarding consequences to others of change (iv) Secondary gain (v) Fear of changing (vi) Lack of client motivation (vii) Negative set (viii) Limited or poor self-monitoring (ix) Limited or poor monitoring of others (x) Narcissistic style (xi) Client frustrated with lack of therapy progress (xii) Patent perception of lowered status in therapy. 6.10.7.3 Therapist Factors (i) Lack of therapist skill (ii) Client and therapist distortions are congruent (iii) Poor socialization to the model (iv) Lack of collaboration/alliance (v) Lack of data (vi) Therapeutic narcissism (vii) Poor timing of interventions (viii) Lack of experience (ix) Therapy goals are unstated, unrealistic, or vague (x) Lack of agreement with therapy goals. 6.10.7.4 Problem/Pathology Factors (i) Client rigidity foils compliance (ii) Medical/physiological problems (iii) Difficulty in establishing trust (iv) Autonomy press (v) Impulsivity (vi) Confusion (vii) Limited cognitive ability (viii) Symptom profusion (ix) Dependence (x) Self-devaluation (xi) Limited energy (xii) Dissociation.

6.10.7.5 Client Factors 6.10.7.5.1 Lack of client skill Therapists cannot make the assumption that every client has developed the skills to effectively perform a particular behavior or sequence of behaviors. For many clients their difficulty in therapy will parallel their inability to cope with life stressors. Both may be based on inadequately developed skills. These skills may be broad, that is, social skills, or more discrete, that is, making eye contact while speaking to another person. For many individuals, their skills may be adequate for ªgetting byº in familiar and highly structured areas of life experience, when their skills are tested in novel situations they have far more difficulty and may withdraw, or fail. If however, they are overtly successful at coping, they experience such a high level of discomfort that they will avoid future encounters. Given that the client may never have developed skills, or not developed them to the level necessary for adequate functioning, the therapist may need to teach particular skills to help the client move along in therapy and thereby in life. 6.10.7.5.2 Client cognitions regarding previous therapy failure When the client has cognitions of failing to be able to successfully make changes in thought or behavior, the therapist needs to help the client to carefully examine their cognitions. Examining the cognitions, the underlying assumptions/ schema and learning to respond in an adaptive manner to these negative and self-deprecatory thoughts, is a major goal of the therapy work. One aspect of ªfailureº which inhibits many clients is their anticipation regarding the therapist's reaction if homework assignments are not done ªright.º If the client anticipates receiving harsh criticism, anger, expressions of disappointment, or other aversive responses from the therapist when the homework is discussed, this can easily result in his or her avoiding the homework and coming up with excuses for not having done it. Obviously, it is important for the therapist to respond to noncompliance without being punitive or authoritarian and instead to work with the client to understand what blocked compliance. However, it is also important for the therapist to be alert for negative anticipation based on the client's previous experience with parents and teachers and to address these explicitly if they impede therapy. In particular, perfectionistic clients often anticipate extreme reactions if the homework is not done perfectly, and it can be quite useful to address these anticipations early in therapy.

Impediments to Therapy Usually it is possible to honestly present the client's task as a ªno-loseº situation by pointing out to the client that incidents of noncompliance or unexpected results provide opportunities for making valuable discoveries. For example, the therapist might follow the first homework assignment with, ªOne of the nice things about this sort of approach is that whatever happens, we come out ahead. If you go ahead and do [the assignment] and it goes the way we expect, great! We're making progress towards your goals. If you unexpectedly cannot get yourself to do it or if it does not work out the way we expect, then we have an opportunity to look at what happened and at your thoughts and feelings to discover more about what blocks you from your goals. If it goes smoothly we're making progress and if it doesn't, we're making a discovery.º For many clients this greatly reduces the fear of failure. 6.10.7.5.3 Client cognitions regarding consequences to others change Another set of cognitions involves the client having catastrophic ideas relative to the result of their attempting to change on others. The client often catastrophizes the result or consequences of their changing and needs to not only decatastrophize the potential, but to examine whether there are still advantages to changing. 6.10.7.5.4 Secondary gain There may be situations where the client may not change because of the gain that accrues from continuing their dysfunctional suicidal thinking and/or behavior. In the case of suicidal behavior or ideation, this may force family members to treat the client with ªkid gloves,º not put any pressure on the client, avoid confrontation, and generally allow the client to do whatever they wished, rather than increase the suicidal potential. This gain may be obtained from family, friends, employers, or other individuals with whom the client has interaction. This client needs to look at the ªprimary lossº that goes into achieving their secondary gain. The client needs to be helped to achieve their gain in other ways. 6.10.7.5.5 Fear of changing For some clients, changing means relinquishing ideas, beliefs, or behaviors that they see as inimical to their survival. While this may appear paradoxical in that their thinking makes them suicidal, these clients fear change as an unknown. They often choose the familiarity of their pain to the uncertainty of a new mode of thinking or behaving.

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6.10.7.5.6 Lack of client motivation Clients may arrive for therapy under protest. Therapy may be mandated as part of a legal penalty, that is, ªgo to therapy or go to jail.º For other clients, therapy is coerced by family members, that is, ªIf you don't get help, I'm leaving you.º For child and adolescent clients, the referral will come from the school or parents, that is, ªYou are in trouble and must change what you are doing, now.º In these circumstances, clients come to therapy with the message that the therapist is an agent of the referring (or coercive) individual, whether that individual is parent, spouse, judge, probation officer, guidance counselor, or teacher. This may facilitate an adversarial situation prior to the first therapy session, setting the stage for possible failure. 6.10.7.5.7 Negative set Often a client is seen to have a ªbad attitude,º or ªa very negative view.º What is labeled as negative or attitudinal is often an issue of negative set. The negative set might be manifested directly as ªYes-butº behavior quickly disqualifying whatever the therapist says, or as directly arguing with the therapist on issues both large and small. 6.10.7.5.8 Lack of limited motivation The reason for referral, the reasons offered for the client to change, the client's comfort or limited discomfort with behaving and feeling the way that they do, the level of dysfunction, and the press of demands of significant others all may work to reduce motivation. Often, the client may see small parts of the problems, but perceives them as ªpart of them,º or as too small to bother with in therapy. The demands of therapy, cost, time, money and effort all further contribute to the limiting of motivation. 6.10.7.5.9 Limited or poor self-monitoring Individuals may see the flaws and foibles of others, but remain blind to their own. Difficulty or inability to self-monitor will often be a major stumbling block to therapy. Being either unaware or unable to self-monitor and to then self-evaluate will lead to depressive affect and behavior. The client will often not self-monitor but will self-devaluate by developing and maintaining negative ideas about themselves. 6.10.7.5.10 Limited or poor monitoring of others For some clients, the monitoring of others is a problem. They tend to look at others, but see

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very little. Their response to others would more likely be based on the client's images and distortions of others rather than a databased assessment. They will often see others as brighter, more attractive, more skilled, and so on. They will view all other relationships as more rewarding than any they have or might have, and do not seem to open their eyes to collect the needed data regarding others. 6.10.7.5.11 Narcissistic style A narcissistic style needs to be differentiated from a diagnosis of clinical narcissism. The narcissistic style causes the client to be so selfinvolved that any attempt to have them look at others or at themselves is met with resistance. The reaction is typically framed as, ªIt can't be me,º or ªWhy would you (or anyone) expect so much from me.º 6.10.7.5.12 Client frustrated with lack of therapy progress

therapist, no matter what their training. If the therapist's skills are poorly developed to effectively cope with a problem, transfer to another therapist is the ethical requirement. 6.10.7.6.2 Client and therapist distortions are congruent This therapist blind-spot may be very destructive to the therapeutic process in that it would generally incline the therapist to accept the client's dysfunctional beliefs. If client and therapist share a particular dysfunctional idea, for example, ªeverything is hopeless and cannot change,º it will bode poorly for the therapy. This sharing of an idea or belief can result in the therapist ªbuying intoº the client's hopeless ideas and beliefs, not testing these beliefs, or even encouraging them. 6.10.7.6.3 Poor socialization to the treatment model

For some individuals, being a client is a mark of lowered status. For many, being in therapy is the mark of being ªsick,º ªdisturbed,º ªweird,º or ªcrazy.º Given that belief, it would follow that leaving or avoiding therapy makes one less of all of the above.

The client who does not understand what is expected of them will have difficulty complying with the therapeutic regimen. It is essential that the therapist assess the level of understanding of the model throughout the therapy work, especially with the suicidal client. Often their ability to listen and understand may be impaired by their hopelessness. The therapist cannot assume that having read books about therapy guarantees adequate socialization to therapy. Further, there may be proactive interference because of previous therapy. Clients who have been in therapy have, ideally, been socialized to that previous therapy model. They will continue to use the same strategies and approach to therapy and to life in general unless and until they are taught differently.

6.10.7.6 Therapist Factors

6.10.7.6.4 Lack of collaboration/alliance

Clients may have unrealistic expectations of therapy and possible therapy progress. When the expectations are not met, the client may blame self or therapist for the lack of therapy progress and withdraw or withhold from the therapeutic collaboration. 6.10.7.5.13 Client perception of lowered status in therapy

6.10.7.6.1 Lack of therapist skill Just as clients come into therapy with a particular set of skills, so too do therapists. Because of limited experience with a particular client problem or population, the therapist may not be best equipped to work with a particular client. The therapist working within the context of an agency or hospital setting may be able to call in colleagues for consultation on the case or to seek supervision on the particular case/ problem. It would be incumbent upon therapists to constantly develop, enhance, and upgrade their skills through additional training. Postgraduate courses, continuing education programs, seminars, workshops, or institutes would be part of the professional growth of the

Collaboration is an essential ingredient for all psychotherapy. This is crucial in working with the suicidal client. If the client and therapist do not have a good working alliance, it would seem to follow that the client may be less motivated to work with the therapist, do homework, follow the therapist's direction, or generally work towards making changes. The lack of collaboration, if not based on socialization difficulty or the skill of the therapist, may be due to the client's cognitions relative to cooperation or collaboration. Certain clients may actively work to thwart the therapist. This type of passive± aggressive behavior may be motivated by any of a variety of client cognitions, that is, issues of control, fear, competition, or displaced anger may all serve to cause difficulty in the therapy.

Impediments to Therapy This client may be directly challenging or more covertly avoidant as in the classic ªyes, BUTº response. For example, a therapist in training asked for advice in handling a client's noncompliance with behavioral experiments designed to reduce the client's perfectionism. The client's goals for therapy were to resolve some relatively minor marital problems, but the therapist saw the client's perfectionism and the stress and job dissatisfaction which resulted from it as more significant problems. Rather than discussing this issue with the client and reaching an agreement on the goals of therapy, the therapist had unilaterally begun working on perfectionism and this led to the noncompliance. Collaboration involves both the therapist and the client and either of them can disrupt it. If the client feels that he or she has no voice in how therapy proceeds, either because this is indeed the case or because of his or her beliefs and expectations, this is likely to interfere with collaboration and produce problems with compliance. It is important for the therapist to actively solicit and value the client's input in setting agendas, determining the focus of therapy, and developing homework assignments, particularly with clients who tend to be unassertive. It is also important to be alert for any cognitions on the part of the client which could block collaboration. 6.10.7.6.5 Lack of data The basis for treatment is the assessment and general collection of data. The therapeutic conceptualization and the resultant treatment plan is then databased. If the therapy is focused on theory without data, the therapy will suffer. The therapist may then make major conceptual leaps without a solid footing upon which to base the therapy. 6.10.7.6.6 Therapeutic narcissism An issue that can be a major impediment to therapy is what we term ªtherapeutic narcissism.º This results from the therapist being so taken with themselves that they are blinded by the need for greater humanity and empathy. The therapeutic narcissism may take the form of telling rather than asking the client how they feel. It may take the form of deciding what the client needs without consulting the client. 6.10.7.6.7 Poor timing of interventions Interventions that are untimely can have the effect of the client not seeing the importance or relevance of the therapeutic work, and thereby

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appearing to be noncompliant. If the therapist, because of his or her anxiety, tries to push or rush the client, the result may be the loss of collaboration, the missing of sessions, a misunderstanding of the therapeutic issues, or a premature termination of therapy, a possibly fatal issue with a hopeless client. The timing and pacing of interventions can be quite important. If the therapist tries to push or rush the client, the result may be the loss of collaboration, poor compliance, poor attendance, or premature termination of therapy.

6.10.7.6.8 Lack of experience Inexperience is something that all therapists face at the advent of their careers. This impediment is unintentional and a standard part of the mental health training system. Frontline therapists working with the most disturbed and problematic clients may be therapists in practicum, internship, or residency settings.

6.10.7.6.9 Therapy goals are unstated, unrealistic, or vague When the goals of therapy are unstated, unrealistic, or vague, the client may be in the position of unknowingly resisting the treatment. This issue also raises problems with informed consent. The client must be part of the treatment planning process and informed as to the goals, strategies, and interventions of the therapy so that they can best comply rather than being noncompliant out of ignorance.

6.10.7.6.10 Lack of agreement with therapy goals Obviously, the client who does not understand and agree to what is expected of him or her will have difficulty complying with the therapeutic regimen. However, it is easy for therapists to overlook the possibility that their instructions and explanations may not be understood and accepted by the client. It is important for the therapist to repeatedly solicit feedback from the client and to encourage the client to raise any concerns and objections, so that therapist and client can develop a shared understanding of the client's problems which forms a basis for collaboration and so that it is clear that the client understands and accepts the homework assignments. Generally this proves to be sufficient, but when the client holds strong preconceptions about therapy, the therapist may need to compromise to some extent in order to facilitate collaboration.

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6.10.7.7 Problem/Pathology Factors

6.10.7.7.6 Confusion

6.10.7.7.1 Client rigidity foils compliance

Clients who are confused because of schizophrenia, bipolar illness, or neurological injury or deficit will have difficulty making use of therapy. They may have memory problems, difficulty in follow-through, difficulty with homework, and problems dealing with any abstractions.

With some clients, their personality rigidity foils their ability to actively comply with therapy. This is particularly true with clients who are obsessive-compulsive, paranoid, among others, in which their disorder may preclude their compliance. They may question the therapist's motives or goals. They may be unable to break out of the rigid position that they see themselves as having to maintain. 6.10.7.7.2 Medical/physiological problems It is essential for every client coming for therapy to have a complete medical evaluation, with blood work as part of a comprehensive assessment and treatment plan. It is unethical and dangerous for the therapist to be treating what may appear to be psychological disorders but have a medical etiology, for example, a client with hypothyroidism may appear depressed because of the slowed action and thinking. Conversely, hyperthyroidism might be confused with anxiety disorders. 6.10.7.7.3 Difficulty in establishing trust and cooperation Trust is a central issue in therapy. The trust must be bidirectional where the client trusts the therapist and the therapist can trust the client. For clients where problems of trust are a diagnostic part of the disorder will have problems in therapy. 6.10.7.7.4 Press of autonomy The autonomous individual will be reluctant to come for therapy. Their view is that if they cannot help themselves, how can anyone else help them. The idea of coming to someone's office at a time set by someone else's schedule, to talk about themselves is, at best, uncomfortable. Their avoidance of therapy is seen as one way of maintaining their autonomy. 6.10.7.7.5 Impulsivity Clients who are impulsive, and this includes most children and adolescents, see therapy as restrictive and limiting. At best it is out of line with how they generally respond, at worst the therapy is seen as an onerous and problematic requirement that they cannot meet. Their standard and accustomed manner of response is to act without thinking and self-monitoring rather than to self-monitor and to think about actions.

6.10.7.7.7 Limited cognitive ability Clients may have limited cognitive ability that is a result of limited intellectual ability or neurological deficit. Their processing will be limited by the lowered level of cognitive integration. 6.10.7.7.8 Symptom profusion Anxious clients will often overwhelm the therapist with graphic, elaborate, and detailed descriptions of their symptoms. Their idea is that if anything is left out they run the risk that the omitted piece will be the essential piece that makes it impossible for them to be helped. If part of their symptom picture is gastrointestinal distress, they will regale the therapist with images of their distress. The therapist will quickly learn more about the clients gastrointestinal tract than is necessary. They will often avoid therapy by speaking quickly to get it all in. 6.10.7.7.9 Dependence The client who is dependent will often work to insure that the therapist is totally and completely on their side. They may overwhelm the therapist with data, bring the therapist gifts, or praise the therapist for the wit, insight, sensitivity, and perspicacity. The goal is closeness. Without the closeness, they believe that they will be injured or even destroyed. They are often frightened by short term therapy in that it means that in a relatively short time they will be without their helper. 6.10.7.7.10 Self-devaluation Often termed low self-esteem or poor selfimage, this involves devaluing everything that one does, or the concomitant overvaluing of what everyone else does (and therefore by comparison devaluing self). This often leads to ªyes-butº behavior and to devaluing both the therapy and the therapist. This devaluation can be summed up by paraphrasing Groucho Marx's comment, ªI would never join any club that would have me as a member.º The therapist and the therapy are, by extension of working with the client, tainted.

Abuses of the Therapeutic Relationship 6.10.7.7.11 Limited energy Depression is a major contributor to this impediment. Individuals who are depressed will often have vegetative signs that include lowered energy. It then becomes difficult to cooperate in therapy given that the major goal is to avoid any activity that requires action or energy. Levels of energy both within the session, for homework, or for interpersonal relationships is minimal. 6.10.7.7.12 Substance use If substance abusing clients come to therapy drunk or stoned, they cannot make use of the therapy. What may occur is state-dependent learning whereby they can only act in certain ways when under the influence of the substance. Clients who are semiaware or semirelated to the therapist will make little use of the therapy. When sober they either will not remember what was said or done or will have distorted it due to the filter of the drugs. 6.10.8 ABUSES OF THE THERAPEUTIC RELATIONSHIP Smith (1988) writes, ªThe practice of psychotherapy involves much more than the mere application of psychological theory and techniquesº (p. 59). The therapist±client relationship is a unique establishment of a working partnership with respect, trust, and confidentiality as its fundamental principles. This interactional process is the mechanism by which the effects of treatment are created and realized (Smith, 1988). As with most interpersonal relationships, the psychotherapeutic process has a frame or structure that delineates and identifies the purpose and meaning of the relationship. This frame consists of socially dictated components which serve as guidelines to how the therapeutic process should occur (Epstein, 1994). Trust is an element of psychotherapy which is of primary importance. Clients expect that within reason, their needs are the focal concern of the therapeutic relationship, and that the therapist's responses and interactions have the intention of promoting effective treatment gains (Galletly, 1993). The ethical dictum is that the therapist must act so as to avoid injury or harm to the client. The client has been encouraged to suspend their usual defenses, reveal deeply personal thoughts and feelings, and ultimately become somewhat dependent upon the clinician. The client enters treatment with the expectation of being helped. In addition, the client experiences the development of intense feelings toward the therapist as a manifestation of the transference.

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In this way, the therapist is in the position of power. The client becomes dependent, and depending on the presenting problems, possibly needy. The client is vulnerable to abuse. This abuse may take many forms from the more subtle (i.e., the therapist starting therapy sessions later than scheduled) through more moderate abuse (canceling therapy sessions) to the severe abuse of physical or sexual aggression. Sexual contact between a client and therapist will invariably cause situations that manifest themselves as the client experiencing greater difficulties with trust, self-esteem, and problems expressing anger (Simon, 1989). The clients usually feel exploited, used, and confused (Blackshaw & Patterson, 1992). Despite the documented harmful effects of sexual involvement with clients, 7±12% of therapists admit to having had sexual contact with a client (Gartrell, Herman, Olarte, Feldstein, & Localio, 1986). The gender breakdown of the therapists was approximately 10% of male therapists and 2±3% of female therapists having engaged in sexual activity with a client. Pope, Sonne, and Holroyd (1993) report that although the sexual exploitation of a client is the most explicitly defined ethical principle, it continues to be a problem within the mental health discipline. Other areas of potential problems occur in regard to fees and financial arrangements. The Ethics Code for Psychology states that the psychologist as early as possible define and make an agreement as to how the fee schedule is arranged. Fees are consistent with laws, and are not misrepresented. Psychologists are permitted to use collection agencies (Canter, Bennett, Jones, & Nagy, 1994). With regard to therapy itself, psychologists are required to advise the client as early as possible the structure and outline of therapy, confidentiality and its limits, and the proposed treatment plan. The psychologist is to provide coverage in the event of their absence, and terminate the professional relationship in a collaborative stance when it becomes evident that the client no longer requires the service or is not benefiting from continued treatment (Canter et al., 1994). In conclusion, therapists are bound by clinical, ethical, and legal standards to maintain the integrity of the psychotherapeutic process. Epstein (1994) writes, ªIdeally, the therapist will be able to fine-tune the frame into an empathic dynamic structure that is sensitive to the client's changing needsº (p. l7). The therapist is required to be not only competent in their chosen profession, but respectful, conscious of, and adhere to ethical standards espoused by their colleagues, licensing boards, legal mandates, and society as a whole in order to protect those

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vulnerable to potential harm. Gorton and Samuel (1996) propose that comprehensive training and mandatory education on the topic of sexual and ethical issues be included as a national requirement for graduate program accreditation. The therapeutic work must take place within a working partnership with respect, trust, and confidentiality as its fundamental principles. This interactional process is the mechanism by which the effects of treatment are created and realized (Smith, 1988). Like every interpersonal relationship, the psychotherapeutic process has a frame or structure that delineates and identifies the purpose and meaning of the relationship. This frame consists of socially dictated components which serve as guidelines to how the therapeutic process should occur (Epstein, 1994). Trust is an element of psychotherapy which is of primary importance. Clients expect that within reason, their needs are the focal concern of the therapeutic relationship, and that the therapist's responses and interactions have the intention of promoting effective treatment gains (Galletly, 1993). The ethical dictum is that the therapist must act so as to avoid injury or harm to the client. The client has been encouraged to suspend their usual defenses, reveal deeply personal thoughts and feelings, and ultimately become somewhat dependent upon the clinician. The client enters treatment with the expectation of being helped. In addition, the development of intense feelings toward the therapist as a manifestation of transference occurs. In this way, the therapist, doctor, or psychologist is in the position of power, while the client assumes a more vulnerable position (Blackshaw & Patterson, 1992). In addition, legal duties mandated by courts and statutes have further defined the psychotherapy relationship and the relevant and appropriate boundaries between the therapist and client. In sum, therapists are therefore accountable to professional, ethical, and legal standards (Simon, 1992). The process of transference provides an avenue for either beneficial treatment to become actualized or noxious to the client by the therapist exploiting the established trust. In addition, countertransference, or feelings toward a client a therapist may have also become a mode of either positive or negative influence to the therapeutic process (Smith, 1988). The therapeutic relationship is described as fiduciary in nature (Simon, 1992). A fiduciary relationship exists when the client's compliance requires trust and vulnerability while the therapist's position renders a clearly influential role upon the

relationship. The client relies on the therapist to provide treatment resulting in an asymmetrical or fiduciary relationship (Epstein, 1994). 6.10.9 GENERAL GUIDELINES Sigmund Freud provided specific guidelines defining the ideal psychotherapeutic structure. Cited in Epstein (1994), Freud stated that his guidelines were imperative for creating and maintaining trust between therapist and client, and provided self-protection for the therapist. Freud advised that the client should receive informed consent explaining the nature of treatment. The therapist should practice abstinence and the nonexploitation of a client which included not confusing transference for real or true feelings or expressions toward the therapist (Lakin, 1991). The therapist should maintain a neutral stance including not advocating any one position or stance over another. The therapist should avoid dual agency or becoming involved with a client already personally known to the therapist. The therapist should practice relative anonymity and keep personal disclosures to a minimum. Finally the therapist should collect coherent and rational fees at regular intervals (cited in Epstein, 1994). Recently, Simon (1992) conceptualized treatment boundaries or frames necessary to maintain the integrity of treatment. These guidelines and principles mirror the ethical standards espoused by the American Psychological Association (APA). The most recent published set of APA guidelines are the 1992 version (Canter et al., 1994). Simon advises that the therapist must follow the guidelines below in order to create an effective ethical treatment process (Simon, 1992). (i) Maintain therapist neutrality (ii) Encourage psychological separateness between client and therapist (iii) Maintain confidentiality (iv) Secure informed consent for treatment (v) Encourage verbal interaction with client (vi) Ensure that no current or future personal relationship occurs with the client (vii) Minimize or avoid physical contact (viii) Preserve anonymity of the therapist (ix) Establish and maintain a consistent fee policy (x) Provide a safe, consistent, and private treatment setting (xi) Provide clear definition of time and length of treatment sessions. 6.10.10 APA CODE The 1992 Ethics Code of the APA clearly identifies general principles and ethical standards for all areas of psychological treatment.

APA Code The creation of the first formal APA Ethics Code was the result of the increasing professional activity of psychologists, both industrial and in mental health settings. As activity increased, regulations and guidelines were needed to ensure the integrity of treatment and the protection of all clients. The first Code was formulated from a critical incident method in 1948 which involved psychologists describing what they felt was an ethical situation or dilemma. The Ethics Committee of the APA then created a draft and final version of guidelines and standards in response to the previously identified situations from the empirical data obtained from the critical incidents listed and defined by psychologists. The first version was published in 1953, with subsequent revisions in 1958, 1962, 1965, 1972, 1977, 1979, 1981, 1989, and 1992 (Canter et al., 1994). Following the outline of General Standards espoused by the APA Ethics Code, psychologists are expected to provide services for which they are competent based on their education and training. Continued training and education is required for the psychologist to remain in touch with current and updated treatment methods and research outcomes. The psychologist should speak with the client in a language understood by the client to ensure that informed consent has occurred. In this way, the client is aware and cognizant of the proposed treatment plan, procedures, or research (Canter et al., 1994). Psychologists need to be aware of how human differences such as age, gender, race, sexual orientation, and disabilities can affect their work and recognize when they may or may not be qualified to treat any one particular individual. If this occurs, the expectation exists that the therapist will provide an appropriate referral to a competent therapist with the relevant expertise. Psychologists should always respect the rights of others to hold values, beliefs, or opinions different from their own. Psychologists do not degrade those of differing religious values, cultural or ethnic backgrounds, or politics. In this way, they are nondiscriminative (Canter et al., 1994). Psychologists are prohibited from engaging in any form of sexual harassment, defined by sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature that occurs in the therapeutic encounter. If a client has complained of being sexually harassed, the psychologist does not make prejudicial decisions in response to the client being a complainant, for example, denying admission to a graduate program. Additionally, psychologists are prohibited from harassing or demeaning clients in any form (Canter et al., 1994).

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Psychologists must take reasonable steps and precautions to avoid harming their clients, and to minimize harm when it is foreseeable and unavoidable. In this way, psychologists must be able to recognize when their own personal problems or conflicts may interfere with their effectiveness as a treating clinician. If a psychologist is aware that their personal problems may be interfering with treatment, they are obliged to seek assistance and determine if they need to suspend or terminate treatment. A psychologist must also not misuse their influence upon a client, especially as the relationship between the therapist and client is asymmetrical with the position of power lying with the therapist (Canter et al., 1994). The 1992 Ethics Code specifically prohibits the psychologist and client engaging in any type of multiple relationship. A psychologist must refrain from beginning a personal, scientific, professional, financial, or other relationship with a client as it may involve future harm or exploitation of the client. The Code does, however, recognize that in some rural areas of the country, situations in which clinicians who know the client before treatment begins may not always be avoided due to lack of resources. Psychologists are also advised not to barter with a client which means refraining from accepting goods or services as a way of paying for psychological services. The psychologist may, however, participate in bartering providing it does not cause the client harm, and does not involve any exploitation of the client (Canter et al., 1994). Exploitation of the client is strictly forbidden in the Ethics Code. This includes not engaging in any sexual or personal relationship with students, supervisees, and clients (Canter et al., 1994). Clear evidence exists that clients are harmed. In conclusion, therapists are bound by clinical, ethical, and legal standards to maintain the integrity of the psychotherapeutic process. Epstein (1994) writes, ªIdeally, the therapist will be able to fine-tune the frame into an empathic dynamic structure that is sensitive to the client's changing needsº (p. l7). This is essential, particularly since the therapeutic relationship plays such an important part as an agent in the change process.

ACKNOWLEDGMENT The authors wish to acknowledge Gina Fusco, a doctoral student in clinical psychology at the Philadelphia College of Osteopathic Medicine, for her assistance with this chapter.

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6.10.11 REFERENCES Alexander, J. F. (1976). Social reinforcement in the modification of agoraphobia. Archives of General Psychiatry, 19, 423±427. Alexander, L. B., & Luborsky, L. (1986). The Penn helping alliance scales. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 35±366). New York: Guilford Press. Bandura, A. (1977). Social learning theory. Hillsdale, NJ: Prentice-Hall. Beck, A. T., Freeman, A. and associates (1990). Cognitive therapy of personality disorders. New York: Guilford Press. Beck, A. T., Rush, J. A., Shaw, B., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press. Blackshaw, R., & Patterson, P. (1992). The prevention of sexual exploitation of clients: Educational issues. Canadian Journal of Psychiatry, 37, 350±353. Bugental, J. F. T., & Sterling, M. M. (1995). Existential± humanistic psychotherapy: new perspectives. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theories and practice (pp. 226±260). New York: Guilford Press. Canter, M., Bennett, B., Jones, S., & Nagy, T (1994). Ethics for psychologists a commentary on the APA ethics code. Washington, DC: American Psychological Association. Eidelberg, L. (1968). Encyclopedia of psychoanalysis. New York: The Free Press. Ellis, A. (1985). Overcoming resistance: Rational-emotive therapy with difficult clients. New York: Springer. Epstein, R. (1994). Keeping boundaries maintaining safety and integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Press. Ferenczi, S., & Rank, O. (1925). The development of psychoanalysis. NMDP. Frank, J. (1985). Therapeutic components shared by all psychotherapies. In M. Mahoney & A. Freeman (Eds.), Cognition and psychotherapy (pp. 49±79). New York: Plenum. Galletly, C. (1993). Psychiatrist±client sexual relationships: The ethical dilemmas. Australian and New Zealand Journal of Psychiatry, 27, 133±139. Gartrell, N., Herman, J., Olarte, S., Feldstein, M., & Localio, R. (1986). Psychiatrist±client sexual contact: Results of a national survey. American Journal of Psychiatry, 143, 112±131. Greenberg, J., & Cheselka, O. (1995). Relational approaches to psychoanalytic psychotherapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies theory and practice (p. 56). New York: Guilford Press. Gorton, G., & Samuel, S. (1996). A national survey of training directors about education for prevention of psychiatrist-client sexual exploitation. Academic Psychiatry, 20(2), 92±98. Granvold, D. K., & Wodarski, J. S. (1994). Cognitive and behavioral treatment: Clinical issues, transfer of trauma, and relapse prevention. In D. K. Granvold (Ed.), Cognition and behavioral treatment: Method and applications (pp. 353±375). Pacific Grove, CA: Brooks/Cole. Hall, C. S., & Lindzey, G. (1970). Theories of personality. New York: Wiley. Horney, K. (1937). The neurotic personality of our time. New York: W. W. Norton. Horney K. (1939). New ways in psychoanalysis. New York: W. W. Norton. Horney, K. (1945). Our inner conflicts. New York: W. W. Norton. Horvath, A., & Greenberg, L. S. (1986). The development of the working alliance inventory. In L. S. Greenberg & W. S. Pinsof (Eds.), The psychotherapeutic process: A

research handbook (pp. 529±556). New York: Guilford Press. Kaplan, H. I., Sadock, B. J., & Grebb, J. A. (1994). Kaplan and Sadock's' synopsis of psychiatry: Behavioral sciences clinical psychiatry (7th ed.). Baltimore: Williams & Wilkins. Lakin, M. (1991). Coping with ethical dilemmas in psychotherapy. New York: Pergamon. Lazarus, A. (1989). The practice for multimodal therapy. Baltimore: Johns Hopkins University Press. Mathews, A. M., Johnston, D. W., Lancashire, M., Munby, M., Shaw, P. N., & Gelder, M. G. (1976). Imaginal floofing and exposure to read phobic situations: Treatment outcome with agoraphobic patients. British Journal of Psychiatry, 129, 362±371. May, R. (1969). Love and will. New York: W. W. Norton. May, R., & Yalom, 1. (1989). Existential psychotherapy. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies, (4th ed., pp. 363±402). Ithaca, IL: F. E. Peacock Publishers Inc. Meichenbaum, D., & Turk, D. C. (1987). Facilitating treatment: A practitioners guidebook. New York: Plenum. Mullahy, P. (1970). Psychoanalysis and interpersonal psychiatry. New York: Science House, Inc. Munroe, R. (1955). Schools of psychoanalytic thought. New York: Dryden. Ofman, W. V. (1985). Existential psychotherapy. In H. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry/IV (4th ed., Vol. 2 ). Baltimore: Williams & Wilkins. Orlinsky, D. E., & Howard, R. I. (1986). The relation of process to outcome in psychotherapy. In S. L. Garfield & A. E. Berguin (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley. Pope, K., Sonne, J., & Holroyd, J. (1993). Sexual feelings in psychotherapy. Washington, DC: American Psychological Association. Rogers, C. (1961). On becoming a person. Boston: Houghton Mifflin. Rogers, C. (1977). Carl Rogers on personal power: Inner strength an its revolutionary impact. New York: Delacorte Press. Rogers, C. R. (1987). The underlying theory: Drawn from experiences with individuals and groups. Counseling and Values, 32(1), 38±45. Safran, J. D. (1990). Towards a refinement of cognitive therapy in light of interpersonal theory. I: Theory. Clinical Psychology Review, 10, 87±105. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books. Safran, J. D., & Wallner, L. (1991). The relative predictive validity of two therapeutic alliance measures in cognitive therapy. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 188±195. Seguin, C. A. (1965). Love and psychotherapy. New York: Libra Publishers. Shelton, J. L., & Levy, R. I. (1981). Behavioral assignments and treatment compliance: A handbook of clinical strategies. Champaign, IL: Research Press. Simon, R. (1989). Sexual exploitation of clients: How it begins before it happens. Psychiatric Annals, 19(2), 104±112. Simon, R. (1992). Treatment boundary violations: Clinical, ethical, and legal considerations. Bulletin of the American Academy of Psychiatry & Law, 20(3), 269±288. Sloan, R. B. (1975). Psychotherapy versus behavior therapy. Cambridge, MA: Harvard University Press. Smith, J. (1988). Therapist±client sex: Exploitation of the therapeutic process. Psychiatric Annals, 18(1), 59-63. Stark, M. (1994). Working with resistance. Northvale, NJ: Jason Aronson, Inc. Suh, C., Strupp, H., & O'Malley, S. (1986). The Vanderbilt process measures: The Psychotherapy Process Scale

References (VPPS) and the Negative Indicators Scale (VNIS). In L. Greenberg & W. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 285±323). New York: Guilford Press. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W. W. Norton. Sullivan, H. S. (1954). The psychiatric interview. New York: W. W. Norton. Sullivan, H. S. (1962). Schizophrenia as a human process.

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New York: W. W. Norton. Tasman, A., Kay, J., & Lieberman, J. A. (1997). Psychiatry (Vol. 1). Philadelphia: W. B. Saunders. Wachtel, P. L. (1982). Resistance: Psychodynamic and behavioral approaches. New York: Plenum. Wright, J. H., & Davis, D. (1994). The therapeutic relationship in cognitive-behavior therapy: Patient perceptions and therapists responses. Cognitive and Behavioral Practice, 1, 25±45.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.11 Treatment Maintenance and Relapse Prevention JOHN W. LUDGATE Bristol Regional Medical Center, Bristol, TN, USA 6.11.1 OVERVIEW

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6.11.2 DEFINITIONS OF RELAPSE AND RECURRENCE

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6.11.3 REVIEW OF RELAPSE RATES AND PREDICTORS OF RELAPSE

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6.11.3.1 6.11.3.2 6.11.3.3 6.11.3.4 6.11.3.5 6.11.3.6 6.11.3.7

Depression Anxiety Disorders Substance Abuse Eating Disorders Overall Review of the Extent of the Problem of Relapse Review of the Predictors of Relapse Treatment Implications that Follow from Research on Predictors of Relapse

6.11.4 MODELS OF RELAPSE

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6.11.4.1 The Medical Biological Model 6.11.4.2 Cognitive Behavioral Models 6.11.4.2.1 Marlatt and Gordon's model 6.11.4.2.2 Shiffman's model 6.11.4.2.3 Teasdale et al.'s model 6.11.5 CLINICAL STRATEGIES TO REDUCE RELAPSE RISK 6.11.5.1 General Overview of Relapse Prevention Strategies 6.11.5.2 Application of Specific Relapse Prevention Procedures at Different Points in Therapy 6.11.5.2.1 Assessing the risk of relapse 6.11.5.2.2 Early therapy activities 6.11.5.2.3 Throughout therapy strategies 6.11.5.2.4 Pretermination procedures 6.11.5.2.5 Follow-up and aftercare activities 6.11.5.3 Working with the Patient who has Relapsed

258 258 259 259 259 259 260 260 261

6.11.6 CURRENT STATUS AND FUTURE DIRECTIONS FOR RELAPSE PREVENTION

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6.11.7 REFERENCES

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1970s there has been an upsurge of interest in the long-term effects of psychological treatments and how treatment effects can be maximized and maintained. As will be demonstrated in this chapter there is still a considerable relapse rate associated with all treatments of psychological disorders including psychotherapy and pharmacotherapy. Cognitive therapy (Beck, Rush,

6.11.1 OVERVIEW In the psychotherapy literature the main source of attrition in psychotherapy has been seen as dropouts during the acute phase of therapy. Rather less attention has been given to the problem of relapse and recurrence following sucessful treatment. However, since the late 251

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Shaw, & Emery, 1979), behavior therapy (Wolpe & Lazurus, 1966) and interpersonal psycotherapy (Klerman, Weissman, Rounsaville, & Chevron, 1984) have all demonstrated some degree of efficacy in the acute treatment phase and also seem to have some preliminary promise in reducing relapse in certain clinical populations. However, the task of further reducing the still high relapse rates found in several disorders such as depression (Belsher & Costello, 1988) and substance abuse (Hunt, Barnett, & Branch, 1971) needs to be given serious attention by clinicians and researchers. In this chapter the relapse rates and predictors of relapse in a number of disorders will be reviewed, and the implications of this research for clinical practice will be outlined. A number of models of relapse that can guide reseach and clinical practice will be described. Attention will be given to the assessment of relapse risk and to planning treatment in a manner designed to reduce the risk of relapse. Relapse prevention and maintenance facilitating strategies will be outlined. Some concluding comments on the present status of maintenance and relapse prevention therapy procedures will be offered and future directions for research and clinical practice in this area will be suggested.

6.11.2 DEFINITIONS OF RELAPSE AND RECURRENCE It is important to clearly define the terms ªrelapseº and ªrecurrenceº as these are often used interchangeably. In the field of depression, Klerman (1978) has suggested that clinicians and researchers adopt the convention that the term ªrelapseº be used to refer to a return of symptoms within six to nine months after the onset of the index episode and that the term ªrecurrenceº be used to denote a return of symptoms after a period of six or twelve months of remaining symptom-free. Klerman suggests that relapse may refer to continuity or reemergence of symptoms of the original episode, while recurrence would be considered a new episode. Despite these guidelines there is still considerable confusion regarding this distinction in the literature. Distinguishing between a chronic continuity of symptoms or behavior and a relapse following recovery or remission has been problematic in this field and made it difficult to establish accurate figures on relapse and recurrence. Designating patients as relapsed presupposes that they have experienced a recovery or remission from the original index episode. Recovery can be defined in a number of different ways. In the field of depression, for example,

recovery is said to occur when the number and severity of symptoms falls below the threshold used for defining onset for a specified period of time (Keller, Shapiro, Lavori, & Wolfe, 1982). Defining relapse can also be problematic. Brownell, Marlatt, Lichenstein, and Wilson (1986) have noted two different dictionary definitions of the term ªrelapse.º The first refers to an outcome and defines relapse as ªthe recurrence of symptoms of disease after a period of improvement,º and the second refers to a process, namely, ªthe act of backsliding, worsening, or subsiding.º The outcome definition, often associated with biological or medical models, has very different implications from the process definition, which suggests that relapse involves a number of stages and is not a single event (Marlatt & Gordon, 1985). Studies on long-term outcome in treatment often do not clearly specify the criteria used to define relapse. Also, since different studies do not utilize standardized criteria for recovery, relapse, and recurrence, comparing studies is difficult. Wilson (1992a) points out that there are many problems inherent in attempting to draw conclusions about relapse in psychological disorders due to the difficulty in drawing distinctions between lapse, relapse, and recurrence and clarifying the usage and measurement of these concepts in different disorders. Other methodological problems with the studies conducted in this field include inadequate cell size, differential attrition, failure to include control or comparison groups, and insufficient duration of follow-up. 6.11.3 REVIEW OF RELAPSE RATES AND PREDICTORS OF RELAPSE 6.11.3.1 Depression A great deal of research has been conducted into the long-term outcome of depressive disorders (see also Chapters 3 and 16, this volume). The NIMH consensus panel (NIMH, 1985) concluded that as many as 50% of patients with recurrent unipolar depressive disorder who recover from an episode of depression will have a recurrence within two years. Other reviewers in this field (Belsher & Costello, 1988; Lavori, Keller, & Klerman, 1984) confirm these findings and additionally report a 20% relapse rate within two months and a 40% rate within a year. Approximately 70% of unipolar depressed patients respond to antidepressant medication in the short term but there is a considerable relapse rate with short-term pharmacotherapy (Ludgate, 1991). There is now an emerging body of evidence demonstrating that the use of maintenance medication (antidepressants or

Review of Relapse Rates and Predictors of Relapse lithium) reduces the probability of relapse. Prien and Kupfer (1986) concluded in a review of this field that the risk of relapse was approximately 20% in patients continuing to take lithium or antidepressant medication compared to 50% who were switched to a placebo. Thase (1990) suggests that maintenance pharmacotherapy reduces the risk of recurrence over a two to three year period from 80% to 50%. Behavioral approaches have shown some promise in producing positive long-term outcome and reducing relapse in depressed patients (Gonzales, Lewinsohn, & Clarke, 1985; Thompson & Gallagher, 1984). Social skills training has been found to be superior to both psychotherapy and tricyclic maintenance medication at six month follow-up (Hersen, Bellack, Himmelhoch, & Thase, 1984). Behavioral therapy was found to have a better course than pharmacotherapy, relaxation therapy, and nondirective therapy in a two and a half year follow-up of depressed outpatients (McLean & Hakistian, 1990). Encouraging results have also been found using interpersonal psychotherapy with depressed patients (Weissman, 1994). Weisman, Klerman, Pruscoff, Shalomskas, and Padian (1981) found no difference between interpersonal psychotherapy and antidepressant medication at one year follow-up. Frank et al. (1990) used continuation interpersonal psychotherapy (on a monthly basis for 20 weeks) and antidepressant medication as a continuation treatment for unipolar depressed patients initially successfully treated with either interpersonal psychotherapy or medication. They found that maintenance medication had significant prophylactic effects and interpersonal psychotherapy had modest effects in reducing relapse risk. A number of reviews (Hollon, Shelton, & Loosen, 1991; Ludgate, 1995; Wilson, 1992) have concluded that cognitive behavioral therapy has a prophylactic effect in the treatment of depression. It appears that patients treated with short-term antidepressant medication have roughly twice the relapse risk compared to patients receiving cognitive behavioral therapy (22±38% vs. 65±78%). In the NIMH study (Shea et al., 1992), cognitive therapy, interpersonal psychotherapy, and short-term Imipramine were compared. Relapse rates at 18-month follow-up were: 36% for cognitive therapy, 33% for interpersonal psychotherapy, 50% for Imipramine, and 33% for placebo. Return to treatment was significantly lower in the cognitive therapy group than in the other groups. In the only studies that compared cognitive therapy to maintenance antidepressant medication (Blackburn, Eunson, & Bishop,

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1986; Evans et al, 1992), cognitive therapy still fared better in terms of relapse rates although the use of maintenance medication also resulted in relatively low rates of relapse. Wilson (1992b) concludes that cognitive therapy is at least as effective as maintenance medication properly maintained for one year. In all of the studies carried out on the long-term outcome of cognitive therapy for depression, no explicit relapse prevention or maintenance procedures are described. The therapy administered follows that described by Beck et al. (1979) and focuses on providing cognitive and behavioral strategies that aim to alleviate depressive symptomatology with the addition in some studies of booster sessions and some additional therapy (Blackburn et al., 1986). Only one study (Berlin, 1985) used an explicit relapse prevention focus and attempted to determine its effects. Self-critical patients were randomly assigned to standard cognitive behavior therapy or to a specifically designed relapse prevention program. Both treatments were equivalent in their effects on maintenance of treatment effects (reduced depression and increased self-esteem) at sixmonth follow-up. Despite lower relapse rates in depressed patients treated with maintenance pharmacotherapy, cognitive therapy and interpersonal psychotherapy compared to other treatment methods, relapse is still a significant problem in this area. Wilson (1992b) suggests that the following variables appear to put depressed individuals at greatest risk for relapse: chronicity, number of previous episodes, being in an environment of high expressed emotion or where a high number of critical comments are made by a spouse (Hooley & Teasdale, 1989), adverse life events, residual depression after treatment, posttherapy dysfunctional cognitive style (including the presence of dysfunctional attitudes and a negative attributional style), low self-efficacy concerning control over negative thoughts, dissatisfaction with major life areas, and coexisting medical problems. Other predictors for which there is at least some empirical support include endogenous subtype, duration of index episode, the presence of an Axis II disorder, higher levels of hopelessness at discharge, absence of social support, and persistent neuroendocrine dysregulation after recover (Belsher & Costello, 1988; Lavori et al., 1984; Ludgate, 1994).

6.11.3.2 Anxiety Disorders While there has been a good deal of research carried out on the short-term effects of a number

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of therapies for anxiety disorders (see Chapters 17±22, this volume), there are few studies that provide outcome data on patients with anxiety disorders followed up for any significant period of time. Rappee (1991), reviewing research on generalized anxiety disorders, concludes that the positive effects of psychological treatments tend to endure over 6±12 month follow-up periods. In a three-year follow-up of generalized anxiety disorder patients receiving short-term stress innoculation training (Meichenbaum, 1977), Holcomb (1986) found that these patients required fewer hospital readmissions compared to patients receiving pharmacological treatment. In agoraphobia, Telch, Tearnan, and Taylor (1983) found relapse rates of 27±50% in patients treated with Imipramine alone. Zitrin, Klein, and Woerner (1980) found that active psychotherapy methods such as exposure, when used in conjunction with Imipramine in the treatment of agoraphobia, reduces the relapse rate to 19% vs. 31% with Impipramine alone over a two-year follow-up. Encouragingly, Emmelkamp and Kuipers (1979) found that 60±70% of agoraphobic patients who responded to cognitive behavior therapy maintained their improvement at four-year follow-up. In treating panic disorder, medications such as Alprozolam and Imipramine have been found to be very effective at eliminating panic attacks in the short term but relapse rates of 70±90% following discontinuation have been found with Alprozolam and 35±40% with Imipramine (Brown & Barlow, 1992). A series of studies on cognitive therapy with panic disorder patients (Beck, Sokol, Clark, Berchick, & Wright, 1992; Clark et al., 1994; Craske, Brown, & Barlow, 1991; Ost & Westling, 1995) show impressively low relapse rates ranging from 0 to 19% in patients treated with cognitive behavior therapy whose panic attacks resumed in the follow-up period. In a review of behavioral treatments of agoraphobia, simple phobia and obsessive compulsive disorder with a follow-up period of at least one year, Ost (1989) reports relapse rates of 24% for agoraphobia, 4% for simple phobia, and 15% for obsessive compulsive disorder. Ost concludes that: further improvement after treatment is moderate in agoraphobia and obsessive compulsive disorder and nonexistent in simple phobia, overall about one-fifth of these patients relapse, and a large proportion seek further treatment. Ost (1989) describes a cost-effective maintenance program for anxiety disorders following initial behavioral treatment which is introduced in the last session of treatment when a contract to implement maintenance activities is signed by the patient. Over a six-week period following termination, the patient and therapist have 1.5±2 hours of telephone contact. Main-

tenance activities include: reviewing changes achieved and skills acquired during therapy, continued practicing of skills, distinguishing a setback from a relapse, identifying high-risk situations for relapse, and coping with setbacks. Results from three studies where agoraphobic panic and simple phobia patients completing this maintenance program were evaluated at 6±15 months, follow-up showed that overall, only 7% of patients relapsed and 10% needed further treatment, which compares favorably with the means of previously reported studies where 14% relapsed and 25% needed further treatment. A number of longer-term follow-up studies have been conducted in obsessive compulsive disorder treated with cognitive behavior therapy. Rates of relapse reported are consistently in the 20±25% range in follow-up periods ranging from seven months to three years (Foa et al., 1983). Similarly, relapse rates of 20±30% have been reported over follow-up periods of up to six years following treatment by exposure therapy with this population (Emmelkamp & Kuipers, 1979). While follow-up studies examining relapse and maintenance of treatment effects in patients with anxiety disorders are somewhat limited, the literature suggests that patients treated with cognitive behavior therapy have a lower risk of relapse compared to other treatment methods. However, as in the case of depression, a significant proportion of patients do not maintain treatment gains and experience a recurrence. There are few well-controlled studies that investigate predictors of maintenance and relapse following treatment for anxiety disorders. However, certain clinical characteristics have been implicated in poorer longerterm outcome. These include a comorbid diagnosis of a personality disorder (Turner, 1987), concurrent depression (Brown & Barlow, 1992), negative life events (Munroe & Wade, 1988), and interpersonal stressors and health problems (Tearnan, Telch, & Keefe, 1984) Rappee (1991) has hypothesized that information processing deficits are implicated in the long-term maintenance of generalized anxiety disorder. In the case of panic disorder, a cognitive factor, that is, misinterpretation of body sensations, is hypothesized to be involved in the etiology and maintenance of panic attacks (Clark et al., 1988), and this hypothesis has been given support in two studies which showed that higher scores on the Body Sensations Interpretation Questionnaire (Clark et al. 1988), an instrument which measures the tendency to misattribute sensations, were predictive of relapse at 15-month follow-up in panic patients who were panic-free at termination (Clark et al.,

Review of Relapse Rates and Predictors of Relapse 1988; Westling & Ost, 1995). In the area of obsessive compulsive disorder, Emmelkamp and colleagues (Emmelkamp, Kloek, & Blaauw 1992) have empirically demonstrated that life events, inadequate coping style, and high expressed emotion environments are predictive of relapse. In conclusion, though little systematic research has been done in this area, the following factors appear to increase the risk of relapse in anxiety disorders: comorbid depression or personality disorder, adverse life events, dysfunctional cognitive style after treatment, deficient coping skills, and a high expressed emotion environment.

6.11.3.3 Substance Abuse The treatment of substance abuse has become increasingly more research-driven in recent years (see Chapter 25, this volume). Stimulated by the seminal work of Marlatt and colleague (Marlatt & Gordon, 1985), a good deal of research on relapse in addictive behaviors has been carried out. In this field, rates of relapse are disturbingly high across the spectrum of addictive behaviors (Marlatt & Gordon, 1985). Additionally, the temporal course of the relapse process is remarkably consistent across the various disorders. In a comprehensive review of a large number of treatment studies that followed successfully treated addictive behavior patients over a 12month follow-up, Hunt et al. (1971) plotted survival rates for a number of addictive disorders and concluded that: the vast majority (65±75%) of treatment successes relapse within 12 months, two out of three relapses occur within three months, relapse rates seem to stabilize and plateau over time (after six months), and relapse rates and time to relapse are simular for heroin, nicotine, and alcohol addictions. Marlatt and Gordon (1985) confirm the finding that approximately two-thirds of all relapses across addictive disorders occur within 90 days of initiation of a treatment program or attempts at cessation. The high rate of relapse in addictive disorders is exemplified by research on smoking where as many as 88% of treated patients will relapse over a two-year period with the majority of relapses occurring within seven months with some stabilization of rates after 15 months (Brandon, Tiffany, Obremski, & Baker, 1990). Marlatt and his colleagues (Marlatt & Gordon, 1985) have carried out extensive research into the predictors of relapse in addictive disorders. Based on an analysis of 311 relapse episodes obtained from patients with problems in the areas of smoking, drinking,

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gambling, and overeating, it was found that the following three factors accounted for over 70% of relapses: negative emotional states (e.g. frustration, anger, anxiety, depression, and boredom): social pressure; and interpersonal conflict (Cummings, Gordon, & Marlatt, 1980). In reviewing this area, Marlatt and Gordon (1985) note that there has been condiderable consistency found in studies examining predictors of relapse across various addictive behaviors. They further state that these three factors (negative emotional states, social pressure, and interpersonal conflict) appear to be the most frequently found high-risk situations for relapse in addictive disorders with urges and temptations, negative physical states, testing personal control, and positive emotional states being implicated in a somewhat smaller number of relapse situations.

6.11.3.4 Eating Disorders Psychological treatments for eating disorders have grown in range and sophistication in recent years (see Chapter 29, this volume). A good deal of attention is now being given to long-term outcome in eating disorders although, as Orimoto and Vitousek (1992) note, these studies often track the status of diagnosed individuals over various time periods following diverse and often poorly specified forms of treatment, which makes comparison of findings across studies difficult. A review of the literature on anorexia nervosa suggests that a good long-term outcome is attained by roughly 40%, with 11±33% in an intermediate category and 14±42% judged to be doing poorly (Orimoto & Vitousek, 1992). Relapse rates following treatment are hard to estimate since a great number of anorexic patients do not attain recovery or remission after treatment and cannot thus be candidates for relapse by definition. Orimoto and Vitousek conclude that only roughly 50% of anorexics will eventually attain normal weight and menstruation and a significant subgroup will experience a relapse in the future, with the exact percentage of actual relapses being hard to ascertain. Bulimia nervosa is a relatively recent diagnosis and the long-term course of the disorder is still being investigated. However, some tentative conclusions can be drawn from the literature. Approximately 53% of patients improve over 12±15 months without formal therapy (Mitchell, Davis, & Goff, 1985). However, only onethird of a large sample of treated and untreated patients remained abstinent from bulimic behavior over a one-year period (Mitchell, Davis, Goff, & Pyle, 1986). In addition Mitchell

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et al. (1986) found that as many as one-third of relapses take place within one month of treatment. Keller, Herzog, Lavori, and Bradburn (1992) found that one-third of bulimics remained in the index episode three years later and there was a cumulative probability of relapse of 63% over a follow-up of 35±42 months. Orimoto and Vitousek (1992) summarize the cognitive behavior therapy outcome studies carried out in this area and show a median figure for abstinence from binging and from purging of 61% and 45.5%, respectively, at follow-ups of three months and longer. They also suggest, based on some preliminary findings, that interpersonal psychotherapy may show some promise in preventing relapse and maintaining treatment gains. Few studies using cognitive behavioral methods have used treatment formats that use explicit relapse prevention procedures, and this is an area for further investigation following the promise of initial studies in this area (Fairburn, Kirk, O'Connor, & Cooper, 1986; Wilson, Rossiter, Kleifield, & Lindholm, 1986). In the field of eating disorder, there are few systematic studies of predictors of long-term outcome following treatment. Keller et al. (1992) found that maintenance of recovery in bulimia nervosa could be predicted by less disturbed eating behaviors, more positive selfbody image at intake, and having good friends. Mitchell et al. (1985) found that the antecedent conditions for relapse included coping with stressful situations (80%), feeling anxious or nervous (23%), and feeling depressed (23%). Root (1990) showed that triggers to relapse in bulimic patients were found to include inability to cope with feelings, attitudes that give rise to negative affect, and stressful events. Freeman, Beach, Davis, and Solyom (1985) found that body image dissatisfaction at the end of therapy was found to be the most powerful predictor of subsequent relapse. Cognitive states such as guilt and the tendency to make internal, global, and uncontrollable causal attributions for an initial binging have been found to be predictors of subsequent binge behavior (Grillo & Shiffman, 1994).

6.11.3.5 Overall Review of the Extent of the Problem of Relapse Relapse rates following treatment have been well-established for depression. The incidence of relapse in depression has been shown to be reduced by the use of maintenance medication and psychosocial treatments such as cognitive behavior therapy and interpersonal therapy. Nevertheless, relapse still remains a significant

problem (up to 50% over two years) in depression. High rates of relapse (of the order of 60±80%) and a short survival time (the majority of relapses occurring within three months) are consistently found in addictive disorders. Rather less is known about long-term outcome in the fields of anxiety and eating disorders, and so no firm conclusions can be drawn. However, clinical experience would suggest that relapse and recurrence are significant problems in these disorders too. There is a considerable economic cost involved in the still high rate of recurrence in psychological disorders. The human cost is also very high in terms of distress and demoralization for the relapsing patients, their families, and for the clinicians who treat them. 6.11.3.6 Review of the Predictors of Relapse The prediction of relapse has a number of important consequences. First, it assists in our understanding of the fundamental processes responsible for change during and after treatment and on the nature of relapse. At a more practical level this work can help to identify individuals likely to show a poorer long-term response to treatment. This can help in treatment planning. Insofar as the predictors established are potentially modifiable (e.g., personal variables, such as dysfunctional beliefs or a poor sense of self-efficacy), these can become the focus of therapy in an attempt to prevent relapse. Across the disorders reviewed there appear to be some common factors that put individuals at risk for relapse. These include negative life events, inability to cope with stress or negative affect, persistence of certain cognitive patterns or dysfunctional beliefs, and a low sense of selfefficacy. It could be postulated that the above risk factors may also predispose patients to relapse in other psychological disorders that are beyond the scope of this review. 6.11.3.7 Treatment Implications that Follow from Research on Predictors of Relapse Research and clinical experience on relapse and its prediction suggest a number of rules of clinical practice, which if observed may lower the risk of relapse in patients with psychological disorders (Ludgate, 1995). The following strategies may be expected to facilitate maintenance and prevent relapse: (i) cognitive distortions, dysfunctional assumptions, and other personal variables that can create a vulnerability to relapse should be dealt with prior to termination of therapy;

Models of Relapse (ii) residual symptoms of emotional disorder, even those at mild or subclinical levels, should be targeted therapeutically prior to discharge; (iii) patients who evidence high symptom levels and a maladaptive cognitive style posttreatment should be kept in treatment longer and maintenance therapy provided; (iv) comorbid Axis I or Axis II disorders should also be addressed in treatment; (v) general problem-solving and selfmanagement skills with wide application should be practiced regularly during therapy, and a sense of self-efficacy should be fostered; (vi) future life stressors should be anticipated and planned for where possible; (vii) significant others should be involved in treatment, and therapy should focus on lifestyle modification, both of which may help to reinforce changes made in treatment. 6.11.4 MODELS OF RELAPSE The importance of deriving treatment and relapse prevention methods from a coherent model has been stressed in several reviews in this field (Ludgate, 1995, Teasdale, Segal & Williams, 1995; Wilson, 1992a). A conceptualization of relapse benefits not only theoretical and research developments in this field but, most importantly, can guide clinical practice and assist in the development of rationally derived relapse prevention procedures. Finally, a coherent explanation of relapse can assist relapsed patients in making sense of this often baffling and mysterious process and, as a result, help generate both hope and a sense of control. 6.11.4.1 The Medical Biological Model Until recently the predominant model of relapse was the medical biological view which stressed physiological or biochemical events that led to a return of symptoms or behaviors characteristic of the syndrome. This is seen in the definition of relapse as ªthe recurrence of a disease after a period of improvement.º In the extreme version of this model (the disease model), a relapse into addictive behavior or into depression is an event over which the individual has little control as it is assumed that it is precipitated by physiological or biochemical changes that lead invariably to symptom reemergence or behavioral loss of control. This model has been criticized on a number of grounds including the charge that it ignores known psychological factors in relapse and induces a sense of hopelessness and helplessness in relapsed patients, stemming from the belief

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that they have no control over the relapse process, which may result in a further downward spiral of negative cognition, helplessness, and symptom recurrence (Marlatt & Gordon, 1985; Wilson, 1992). 6.11.4.2 Cognitive Behavioral Models 6.11.4.2.1 Marlatt and Gordon's model Marlatt and Gordon's (1985) model of the relapse process in addictive disorders has had a major impact in the field of relapse prevention since the late 1980s. Marlatt and Gordon postulate that newly abstinent patients experience a sense of perceived control up to the point at which they encounter a high-risk situation, which most commonly entails a negative emotional state, an interpersonal conflict, or an experience of social pressure. If individuals cope effectively in the high-risk situation, perceived control and self-efficacy increase, which in turn makes the probability of relapse decrease. Conversely, the hypothesized result of a failure to cope with a high-risk situation is a decrease in a sense of self-efficacy, which in turn increases the probability of relapse. Each experience of successful or unsuccessful coping with a highrisk situation builds up a greater or lesser sense of self-efficacy, which determines the future risk of relapse in similar circumstances. Marlatt and Gordon (1985) contend that individuals' reactions to the initial slip and their attributions regarding the cause of the slip are the determining factors in the escalation of a lapse or setback into a full-blown relapse. The transition from slip or lapse to relapse involves the ªabstinence violation effect,º which results from a state of cognitive dissonance regarding the nonabstinent behavior and the individual's image of being abstinent. This dissonance can be reduced by either changing the behavior or changing the image, and characteristically in this population is resolved by the latter. Internal and stable attributes for the slip also lead to further lapse behavior. This model has received a good deal of empirical support and has the merit of dismantling the process of relapse and exploring subjective and cognitive variables in a manner that has important treatment implications. Marlatt and Gordon (1985) argue that relapse prevention and maintenance should focus on teaching individuals who are trying to change their behavior how to anticipate and cope with the problem of relapse. Relapse prevention therapy should include: identification and preparation for high-risk situations; coping with negative emotional states, interpersonal conflict, and social pressure; training in general coping or self-management skills; slip

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recovery and relapse-crisis debriefing; programmed relapse and relapse rehearsal; lifestyle interventions; and education about the disorder and relapse. The use of Marlatt and Gordon's model in disorders outside the area of addictions has been advocated. Wilson (1992b) examines the possible role of this model in efforts to deal with depressive relapse. In particular he stresses the need to enhance depressed patients' sense of self-efficacy, and suggests strategies to foster this. Emmelkamp et al. (1992) have adapted this model in arriving at a cognitive behavioral model of relapse in obsessive compulsive disorder. Ludgate (1994) describes how many of the strategies described by Marlatt and Gordon are also applicable at various stages in the therapy of emotionally distressed patients. 6.11.4.2.2 Shiffman's model Shiffman (1989) argues that the risk of relapse is related to the operation of three mechanisms: enduring personal characteristics (e.g., coping style and individual vulnerability factors such as low self-esteem); background variables (e.g., life events, relationship issues, mood, motivation); and precipitants (e.g., thoughts, feelings, and events that can lead to a relapse). Background and precipitating factors can both be viewed as high-risk situations. Background factors serve to ªset the stageº for relapse and may reach a threshold level where relapse becomes more likely. How individuals react to these high-risk situations will influence where their level of relapse proneness crosses the threshold for relapse. The individuals' reactions to these situations will be determined by their coping skills, their sense of self-efficacy, and their expectancies regarding outcome and the effect of using their problem-solving skills. This model is useful in introducing the valuable concept of relapse proneness and the notion of factors from different domains mutually interacting, with a threshold for relapse being established by background variables. The treatment implications of this model are: first, background factors need to be identified, monitored, and modified in order to keep relapse proneness below a threshold level; second, enduring personal characteristics need to be worked on to reduce vulnerability to relapse; and third, precipitants need to be anticipated and planned for where possible. 6.11.4.2.3 Teasdale et al.'s model Teasdale and colleagues (1995) have proposed a model of depressive relapse which attempts to explain the process of relapse in

depression and also the mechanisms by which cognitive therapy achieves its prophylactic effects in the treatment of depression. This model involves an information-processing analysis of depressive relapse. It hypothesizes that following recovery, mild states of depression can reactivate depressogenic cycles of cognitive processing similar to those found during a major depressive episode. Teasdale et al. suggest that preventive interventions such as cognitive therapy operate by changing the patterns of cognitive processing that become active in states of mild negative affect preceding a full relapse into major depression. They suggest that the redeployment of attention utilized in stressreduction procedures based on the techniques of mindfulness meditation (Kabat-Zinn, 1990) can be integrated with cognitive therapy procedures into a system of attentional control training. This approach would be applicable to recovered depressed patients and would serve as a means of preventing relapse. Teasdale and colleagues provide a description of this training which teaches generic psychological, self-control skills and can be used on a continuing basis to maintain skills after initial training. While no data on the effectiveness of this approach in preventing relapse exist to date, this appears to be a useful and stimulating conceptualization of relapse and relapse prevention that deserves further attention.

6.11.5 CLINICAL STRATEGIES TO REDUCE RELAPSE RISK 6.11.5.1 General Overview of Relapse Prevention Strategies Maintenance and relapse prevention depend on the nature and natural course of the specific disorder involved, and the specific procedures selected to target relapse prevention and maintenance in therapy also need to be linked to a detailed case conceptualization for each patient (Persons, 1989). However, there are a number of strategies which might be expected to facilitate maintenance and prevent relapse across the various psychological disorders (Greenwald, 1988; Krantz, Hill, FosterRawlings, & Zeeve 1984; Ludgate, 1995; Marlatt & Gordon 1985; Miller, 1984; Shiffman, 1989). These strategies include: (i) increasing patient responsibility within sessions and ensuring more between-session activities as therapy proceeds; (ii) promoting internal attributions of change; (iii) getting the patient to practice beyond a criterion (overlearning);

Clinical Strategies to Reduce Relapse Risk (iv) working on a variety of targets and providing training in general problem-solving or self-management skills; (v) developing a self-therapy program for use after formal therapy ends; (vi) helping patients anticipate high-risk situations and develop an emergency plan to deal with setbacks; (vii) education regarding relapse, developing realistic expectations, and working on cognitions regarding possible lapses or setbacks; (viii) assisting patients in recognizing early warning signs of possible relapse and intervening quickly and appropriately when these occur; (ix) fading the frequency of sessions later in therapy; (x) using booster or refresher sessions after acute therapy ends; (xi) modifying the patient's lifestyle or environment to ensure reinforcement of changes made; (xii) involving significant others in treatment. 6.11.5.2 Application of Specific Relapse Prevention Procedures at Different Points in Therapy 6.11.5.2.1 Assessing the risk of relapse During the assessment phase and in the early stages of therapy, data should be collected to allow a comprehensive individual conceptualization which guides treatment planning (Persons, 1989). As a part of an overall comprehensive case conceptualization, a risk analysis can be carried out for each patient. This will include: an analysis of enduring personal characteristics (e.g., coping style, dysfunctional beliefs); background variables (e.g., life events, stressors); and possible precipitants to relapse based on the patient's history (i.e., events, thoughts, and feelings that could lead to a recurrence). In addition, the patient's sense of self-efficacy and their perception of their resources or skills to deal with life problems can be assessed at different points in therapy as new information becomes available. In the case of depression, a risk-analysis might be based on the following factors: number of prior episodes, duration of episode, comorbidity (especially Axis II disorders), coexisting medical conditions, post-treatment symptom levels, vulnerability factors (poor self-esteem, dependency), dissatisfaction with life areas, post-treatment cognitive characteristics (dysfunctional attitudes, attributional style), sense of self-efficacy after treatment, social support, and life stressors. Individual patients can then be characterized as a result of this case analysis as high risk (if a significant number of these factors exist),

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moderate risk (where several of these factors are in evidence), or low risk (where none of these factors are in evidence). The focus of therapy and the choice of treatment strategies can then be devised in the light of the assessment of relapse risk. This risk analysis also allows the therapist to make decisions regarding aftercare. Patients at high risk can be offered continuation therapy and, if possible, engage in active therapy even after symptom remission to work on relapse prevention and maintenance. Patients at moderate risk may be offered booster sessions while patients at low risk may have their last several therapy sessions spaced out before discharge and be invited back for occasional refresher sessions (Ludgate, 1992). 6.11.5.2.2 Early therapy activities In the early part of therapy the ªmental setº necessary for eventual maintenance and relapse prevention activities can be facilitated by stressing that therapy will be time-limited and that the goal is to provide methods that patients can subsequently use to ªbecome their own therapist.º Eventual termination should be discussed and the therapist should emphasize the importance of the maintenance and underscore the notion that therapy involves learning self-control methods which patients can use on their own after therapy ends. The therapist should also stress the importance of patients being active in the therapy process, practicing new skills, and setting agendas. This will help facilitate the shift later in therapy to patients working on maintenance and relapse prevention on their own. 6.11.5.2.3 Throughout therapy strategies As an attempt to maximize the gains made in therapy, it is recommended (Ludgate, 1995) that throughout therapy attention be paid to the following: (i) reviews of skills at regular intervals; (ii) self-monitoring of progress; (iii) overpractice of skills (overlearning); (iv) teaching skills with wide application; (v) generalizing skills or tools; (vi) working at the schema or belief level and dealing with Axis II issues and comorbid diagnoses, where necessary; (vii) dealing with vulnerabilty issues; (viii) ensuring that the patient become more and more active in therapy; (ix) increasing the emphasis on betweensession behavior; (x) fostering internal attributions for change; and (xi) working on reactions to setbacks.

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6.11.5.2.4 Pretermination procedures In the later stages of therapy it is often beneficial to gradually taper off or space therapy sessions. There are three important therapeutic tasks to be accomplished prior to termination which may help reduce the risk of relapse. These are: first, developing a selftherapy or maintenance plan; second, reviewing skills learned in therapy and rehearsing the application of these to future high-risk situations; and third, learning to identify early warning signals of lapses or slips and developing an ªemergency planº to cope with these setbacks. A good rationale for maintenance activities needs to be given and thoughts and feelings related to continued self-therapy should be identified and restructured if necessary at this time. A list of possible helpful maintenance activities can then be drawn up collaboratively with the patient. To introduce the procedure of self-monitoring of early warning signals of relapse, the patient first needs to be socialized to the concept of relapse or recurrence as a process, not an event, and hence to the importance of early detection and intervention in the sequence. Using the patient's past history and the pattern of events in the most recent episode, it may be possible to come up with some key prodromal symptoms or behaviors that signal the beginning of the relapse process. A regular monitoring system carried out by patients themselves or by the therapist can then be set up to determine the presence of any of these early warning signs. Finally, a specific ªemergency planº can be generated before therapy ends, which should contain steps that can be taken in the event of symptoms or maladaptive behaviors reaching certain levels. It is also helpful at this point to discuss the criteria that will be used in making a decision to return to therapy or seek hospitalization. 6.11.5.2.5 Follow-up and aftercare activities There are a number of options for the therapist in terms of aftercare activities. These include formal maintenance or continuation therapy, booster sessions, and refresher sessions. These decisions should follow from an analysis of the potential for relapse in each particular case. Maintenance or continuation therapy (Thase, 1990) is clearly the most intensive in terms of therapist time and effort and would usually be reserved for patients who are symptomatically recovered but at high risk for relapse. The essential difference between continuation therapy and booster sessions lies in the frequency and duration of sessions and also

in the content of these sessions. Continuation therapy involves working actively on areas of vulnerability, anticipating high-risk situations, and continuing to practice and overlearn skills. Booster sessions are focused more on reviewing progress and dealing with any residual problems or current difficulties experienced by the patient. Although reviews of the effectiveness of booster sessions have shown that the addition of these follow-up sessions are only moderately successful in maintaining behavior change (Whisman, 1990), there are some obvious advantages clinically to using booster sessions after the initial treatment has ended. Booster sessions encourage patients to take more responsibility in solving problems or managing their dysfunctional behaviors or mood states with the therapist's role becoming more that of a consultant or adviser. They also allow continuing monitoring of symptoms and appropriate intervention if necessary. Patients are more likely to be accountable in terms of maintenance activities if they know they will be reporting back on their progress in booster sessions. Whisman (1990) recommends that the natural relapse rate for the problem being treated be first determined, and maintenance sessions be scheduled during this high-risk period rather than arbitrarily scheduled. He suggests that the effectiveness of booster sessions can be improved by including the following components: a review of skills covered in therapy and problem-solving difficulties encountered in their implementation; teaching new or familiar skills to deal with problems arising during the follow-up period; reinforcing the individual's accomplishments and positive achievements as well as anticipating and planning for future stressors; encouraging individuals to involve themselves in self-help or community social support systems; and promoting lifestyle changes that are incompatible with relapse. Group refresher sessions may be an alternative to individual booster therapy sessions for patients who are doing well and have a somewhat lower risk of relapse. As described by Ludgate (1992), this is a cost-effective way to promote maintenance in former patients who are invited to attend group refresher workshops that review general strategies for solving problems, managing moods and stress, and changing behaviors. The emphasis is on skills rather than specific patient issues and these workshops focus on education and skill consolidation rather than therapy per se. In addition to being cost-effective in terms of the therapist's time, these workshops allow monitoring of former patients' progress, which can facilitate decisionmaking regarding the need for further aftercare interventions.

Current Status and Future Directions for Relapse Prevention 6.11.5.3 Working with the Patient who has Relapsed The tasks facing the therapist in this situation are: to conceptualize and help the patient understand the relapse process, to re-instill a sense of self-efficacy, and to collaborate with the patient in generating a plan to recover from the lapse or setback. The extent and duration of the recurrence should be carefully explored in order to help distinguish a lapse from a full relapse. The task of the therapist and patient is to interupt the relapse process. It is important to explore patients' expectations regarding recovery, relapse, and the course of their disorder. If these are unrealistic, the therapist may help patients to substitute more realistic expectations. The therapist should help the patient ªmake senseº of what happened in this relapse episode, which will help to demystify the recurrence, give a greater sense of control, and encourage hope that the situation can be improved. The therapist should help foster external, unstable, and specific attributions regarding the relapse. The therapist can review with the patient strategies used during this episode and what impact they had. By a process of guided discovery the patient can identify skills learned in therapy that could be applied to this situation. A list of options can be drawn up to deal with the setback. It is important that the patient be as active as possible in the task of generating the remedial plan as this offsets hopelessness and increases the sense of selfcontrol. Finally, patients can be encouraged to consider what has been learned from this experience and what they would do differently if faced with a similar situation in the future.

6.11.6 CURRENT STATUS AND FUTURE DIRECTIONS FOR RELAPSE PREVENTION Since the late 1980s considerable progress has been made in the area of predicting relapse and in relapse prevention. While there have been appreciable advances in producing models of relapse and therapeutic methods to prevent relapse in addictions (Gossup, 1989; Marlatt & Gordon, 1985; Shiffman, 1989) and sexual deviancy (Laws, 1989), there is a need for clinical guidelines for relapse prevention in other fields such as depression, anxiety, and eating disorders. Some practical suggestions have been offered in the literature (Greenwald, 1988; Ludgate, 1994; Miller, 1984), but there are few specific guidelines for working with individuals with these disorders to promote maintenance and reduce the risk of relapse.

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Studies are needed across all areas of psychological disorders that will employ more standardized utilization of relapse prevention strategies during and after therapy. The development of treatment protocols for the continuation phase of therapy for patients at high risk is also a priority in this field. Research into factors involved in the maintenance of treatment effects and in the prevention of relapse is an important goal for both researchers and clinicians. There are a number of research questions that need to be answered by wellcontrolled studies. Wilson (1992a) argues that studies with long-term follow-up periods (e.g., three years or more) are needed, as few currently exist and most studies are confined to periods of 12 months or less. Research is also needed into the mechanisms responsible for relapse, or conversely for maintenance of initial remission. Clear predictions about conditions for relapse arising out of well-formulated theoretical models need to be made and empirically tested. Increasing our ability to predict the occurrence of relapse in particular disorders can be considered a high-priority task as it has obvious clinical implications in terms of treatment planning for at-risk individuals. Research into the development of valid and reliable measures of relapse risk is also an important research and clinical task at this time. Long-term outcome needs to be investigated in well-controlled studies which include clearly defined relapse prevention strategies applied in either the acute phase of treatment or during a continuation or maintenance phase of therapy following initial recovery. More research into the efficacy of booster sessions is needed and, in particular, into the optimal timing of booster sessions after treatment. Knowledge of survival time for a particular disorder may help to identify particular points in time for certain disorders when relapse is most likely and when booster sessions could usefully be scheduled. Wilson (1992a) advocates that several different types of relapse prevention procedures such as maintenance strategies integrated into the initial treatment program, boosters sessions and post-therapy, and minimal-contact procedures (self-help groups, telephone contact, bibliotherapy) be compared in terms of efficacy. To date, the shotgun or ªmore is betterº approach appears to be the norm and research is needed on the contribution made by the different components of relapse prevention programs (e.g., anticipation and planning for high-risk situations, early detection of warning signals of relapse, programmed relapse, relapse rehearsal, self-efficacy training, lifestyle modification, and interventions for vulnerability issues). Studies that investigate predictors of relapse and sustained

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improvement, particularly therapy and patient factors that are amenable to change, are needed to inform clinical practice. Pursuing some of the suggestions outlined above would serve to further expand some of the recent exciting developments in this crucially important field of maintenance of treatment effects and prevention of relapse. 6.11.7 REFERENCES Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press. Beck, A. T., Sokol, L., Clark, D. A., Berchick, R., & Wright, F. (1992). Focused cognitive therapy of panic disorder: A cross-over design and one year follow-up. American Journal of Psychiatry, 147, 778±783. Belsher, G., & Costello, C. G. (1988). Relapse after recovery from unipolar depression: A critical review. Psychological Bulletin, 104, 84±96. Berlin, S. (1985). Maintaining reduced levels of selfcriticism through relapse prevention treatment. Social Work Research and Abstracts, 21(1), 21±33. Blackburn, I. M., Eunson, K. M., & Bishop, S. (1986). A two year naturalistic follow up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. Journal of Affective Disorders, 10, 67±75. Brandon, T. H., Tiffany, S. T., Obremski, K. M., & Baker, T. B. (1990). Postcessation cigarette use: The process of relapse. Addictive Behaviors, 15, 105±114. Brown, T. A., & Barlow, D. H. (1992). Panic disorder with agoraphobia. In P. H. Wilson (Ed.), Principles and practice of relapse prevention (pp. 191±213). New York: Guilford Press. Brownell, K. D., Marlatt, G. A., Lichenstein, E., & Wilson, G. T. (1986). Understanding and preventing relapse. American Psychologist, 4, 765±782. Clark, D. M., Salkovskis, P. M., Gelder, M., Koehler, K., Martin, M., Anastasiades, P., Hackman, A., Middleton, H., & Jeavons, A. (1988). Tests of a cognitive theory of panic. In I. Hand & H. U. Wittchen (Eds.), Panic and phobias II (pp. 149±158). Berlin: Springer. Clark, D. M., Salkovskis, P. M., Hackman, A., Middleton, H., Anastasiades, P., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and Imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759±769. Craske, M. G., Brown, T. A., & Barlow, D. H. (1991). Behavioral treatment of panic disorder: A two year follow-up. Behavior Therapy, 22, 289±304. Cummings, C., Gordon, J. R., & Marlatt, G. A. (1980). Relapse: Strategies of prevention and prediction. In W. R. Miller (Ed.), The addictive behaviors: treatment of alcoholism, drug abuse, smoking and obesity (pp. 291±321). Oxford, UK: Pergamon. Emmelkamp, P. M., Kloek, J., & Blaauw, E. (1992). Obsessive-compulsive disorders. In P. H. Wilson (Ed.), Principles and practice of relapse prevention (pp. 213±235). New York: Guilford Press. Emmelkamp, P. M. J., & Kuipers, A. C. M. (1979). Agoraphobia: A follow-up study four years after treatment. British Journal of Psychiatry, 128, 86±89. Evans, M. D., Hollon, S. D., De Rubeis, R. J., Piasecki, J. M., Grove, W. M., Garvey, M. J., & Tuason, V. B. (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry, 49, 802±808. Fairburn, C. G., Kirk, J., O'Connor, M., & Cooper, P. J. (1986). A comparison of two psychological treatments

for bulimia nervosa. Behaviour Research and Therapy, 24, 629±643. Foa, E. B., Grayson, J. B., Steketee, G., Doppelt, H. C., Turner, R. M., & Lattimer, P. L. (1983). Success and failure in the behavioral treatment of obsessive-compulsives. Journal of Consulting and Clinical Psychology, 15, 287±297. Frank, E., Kupfer, D. J., Perrel, J. M., Cornes, C., Jarrett, D. B., Mallinger, A. G., Thase, M., McEachran, A. B., & Grochocinski, V. J. (1990). Three year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 47, 1093±1099. Freeman, R. J., Beach, B., Davis, R., & Solyom, L. (1985). The prediction of relapse in bulimia nervosa. Journal of Psychiatric Research, 19, 349±353. Gonzales, L. R., Lewinsohn, P. M., & Clarke, G. N. (1985). A longitudinal follow up of unipolar depressives: An investigation of predictors of relapse. Journal of Consulting and Clinical Psychology, 53, 461±469. Gossup, M. (Ed.) (1989). Relapse and addictive behavior. New York: Tavistock/Routledge. Greenwald, M. A. (1988). Programming treatment generalization. In L. Michelson & M. Asher (Eds.), Handbook of anxiety and stress disorders (pp. 583±616). New York: Plenum. Grillo, C. M., & Shiffman, S. (1994). Longitudinal investigation of the abstinence violation effect in binge eaters. Journal of Consulting and Clinical Psychology, 62(3), 611±619. Hersen, M., Bellack, A. S., Himmelhoch, J. M., & Thase, M. E. (1984). Effects of social skills training, amitriptyline and psychotherapy in unipolar depressed women. Behavior Therapy, 15, 21±40. Holcomb, W. R. (1986). Stress innoculation therapy with anxiety and stress disorders of acute psychiatric inpatients. Journal of Clinical Psychology, 42, 864±872. Hollon, S. D., Shelton, R. C., & Loosen, P. T. (1991). Cognitive therapy and pharmacotherapy for depression. Journal of Consulting and Clinical Psychology, 59, 88±89. Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depression: Expressed emotion, marital distress and perceived criticism. Journal of Abnormal Psychology, 1, 14±26. Hunt, W. A., Barnett, L. W., & Branch, L. G. (1971). Relapse rates in addiction programs. Journal of Clinical Psychology, 27, 455±456. Kabat-Zinn, J. (1990). Full catastrophe living: The program of the stress reduction clinic at the University of Massachusetts Medical Center. New York: Dell. Keller, M. B., Herzog, D. B., Lavori, P. H., & Bradburn, I. S. (1992). The naturalistic history of bulimia nervosa: Extraordinarily high rates of chronicity, relapse, recurrence and psychosocial morbidity. International Journal of Eating Disorders, 12, 1±9. Keller, M. B., Shapiro, R. W., Lavori, P. M., & Wolfe, N. (1982). Relapse in major depressive disorder: Analysis of the life table. Archives of General Psychiatry, 39, 911±915. Klerman, G. L. (1978). Long-term maintenance of affective disorders. In C. Lipton, A. Dismascio, & K. Killam (Eds.), Psychopharmacology: A generation of progress (pp. 1303±1311). New York: Raven Press. Klerman, G. L., Weismann, M. M., Rounsaville, B. J., & Chevron, E. (1984). Interpersonal psychotherapy of depression. New York: Basic Books. Krantz, S. E., Hill, R. D., Foster-Rawlings S., & Zeeve, C. (1984). Therapist's use of and perceptions of strategies for maintenance and generalization. The Cognitive Behaviorist, 6, 19±22. Lavori, P. W., Keller, M. B., & Klerman, G. L. (1984). Relapse in affective disorders: A re-analysis of the literature using life table methods. Journal of Psychiatric Research, 18(1), 13±25.

References Laws, D. R. (Ed.) (1989). Relapse prevention with sex offenders. New York: Guilford Press. Ludgate, J. W. (1991). The long-term effectiveness of cognitive therapy in the treatment of depression: A five year follow-up study of treated patients. Unpublished doctoral dissertation, University of Dublin, Ireland. Ludgate, J. W. (1992). Relapse prevention groups for former cognitive therapy patients. International Cognitive Therapy Newsletter, 6, 10±12. Ludgate, J. W. (1994). Cognitive behavior therapy and depressive relapse. Justified optimism or unwarranted complacency? Behavioural and Cognitive Psychotherapy, 22(1), 1±12. Ludgate, J. W. (1995). Maximizing psychotherapeutic gains and preventing relapse in emotionally distressed clients. Sarasota, FL: Professional Resource Press. Marlatt, G. A., & Gordon, J. R. (Eds.) (1985). Relapse prevention: maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press. McLean, P. D., & Hakistian, A. R. (1990). Relative endurance of unipolar depression treatment effects: Longitudinal follow-up. Journal of Consulting and Clinical Psychology, 58, 482±488. Meichenbaum, D. (1977). Stress innoculation. New York: Pergamon. Miller, I. W. (1984). Strategies for maintenance of treatment gains for depressed patients. The Cognitive Behaviorist, 6, 10±13. Mitchell, J. E., Davis, L., Goff, G. (1985). Relapse in patients with bulimia. International Journal of Eating Disorders, 4, 457±463. Mitchell, J. E., Davis, L., Goff, G., & Pyle, R. L. (1986). A follow up study of patients with bulimia. International Journal of Eating Disorders, 5, 441±450. Munroe, S. M., & Wade, S. L. (1988). Life events. In C. G. Last & M. Hersen (Eds.), Handbook of anxiety disorders (pp. 293±305). New York: Pergamon. National Institute of Mental Health National Institute of Health, Consensus Development Conference Statement (1985). Mood disorders: Pharmacological prevention of recurrences. American Journal of Psychiatry, 142, 469±476. Orimoto, L., & Vitousek, K. B. (1992). Anorexia nervosa and bulimia nervosa. In P. H. Wilson (Ed.), Principles and practice of relapse prevention (pp. 85±128). New York: Guilford Press. Ost, L. G. (1989). A maintenance group for behavioral treatment of anxiety disorders. Behaviour Research and Therapy, 27, 123±130. Ost, L. G., & Westling, B. E. (1995). Applied relaxation versus cognitive behavior therapy in the treatment of panic disorder. Behaviour Research and Therapy, 33(2), 145±158. Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: W. W. Norton. Prien, R. F., & Kupfer, D. J. (1986). Continuation drug therapy for major depressive episodes: How long should it be maintained? American Journal of Psychiatry, 143, 18±23. Rappee, R. M. (1991). Generalized anxiety disorder: A review of clinical features and theoretical concepts. Clinical Psychology Review, 111, 4019±440. Root, M. P. P. (1990). Recovery and relapse in former bulimics. Psychotherapy, 27, 397±403. Shea, T. M., Elkin, I., Imber, S. D., Sotsky, S. M.,

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Watkins, J. T., Collins, J. F., Pilkonis, P. A., Leber, W. R., Krupnick, J., Dolan, R. T., & Parloff, M. B. (1992). Course of depressive symptoms over follow-up. Findings from the National Institute of Mental Health Treatment of depression collaborative research program. Archives of General Psychiatry, 49, 782±789. Shiffman, S. (1989). Conceptual issues in the study of relapse. In M. Gossup (Ed.), Relapse and addictive behavior (pp. 149±179). New York: Tavistock/Routledge. Tearnan, B. H., Telch, M. J., & Keefe, P. (1984). Etiology and onset of agoraphobia: a critical review. Comprehensive Psychiatry, 25, 511±562. Teasdale, J. D., Segal, Z., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfullness) training help? Behaviour Research and Therapy, 33, 25±39. Telch, M. J., Tearnan, B. H., & Taylor, C. B. (1983). Antidepressant medication in the treatment of agoraphobia: A critical review. Behavior Research and Therapy, 21, 505±527. Thase, M. E. (1990). Relapse and recovery in unipolar depression: short-term and long-term approaches. Journal of Clinical Psychiatry, 6, 51±57. Thompson, L. W., & Gallagher, D. (1984). Efficacy of psychotherapy in the treatment of late life depression. Behaviour Research and Therapy, 6, 127±139. Turner, R. M. (1987). The effects of personality disorder on the outcome of social anxiety reduction. Journal of Personality Disorders, 1, 136±146. Weissman, M. M. (1994). Psychotherapy in the maintenance treatment of depression. British Journal of Psychiatry, 165(26), 42±50. Weissman, M. M., Klerman, G. L., Pruscoff, B. A., Shalomskas, D., & Padian, N., (1981). Depressed outpatients: Results one year after treatment with drugs and or interpersonal psychotherapy. Archives of General Psychiatry, 38, 51±55. Westling, B. E., & Ost, L. G. (1995). Cognitive bias in panic disorder patients and changes after cognitive behavioral treatments. Behaviour Research and Therapy, 33, 585±588. Whisman, M. A. (1990). The efficacy of booster maintenance sessions in behavior therapy: Review and methodological critique. Clinical Psychology Review, 10, 155±170. Wilson, P. H. (1992a). Relapse prevention: conceptual and methodological issues. In P. H. Wilson (Ed.), Principles and practice of relapse prevention (pp. 1±22). New York: Guilford Press. Wilson, P. H. (1992b). Depression. In P. H. Wilson (Ed.), Principles and practice of relapse prevention (pp. 128±156). New York: Guilford Press. Wilson, G. T., Rossiter, E., Kleifield, E. I., & Lindholm, L. (1986). Cognitive behavioral treatment of bulimia nervosa: A controlled evaluation. Behaviour Research and Therapy, 24, 277±288. Wolpe, J., & Lazurus, A. A. (1966). Behavior therapy techniques. New York: Pergamon. Zitrin, C. M., Klein, D. F., & Woerner, M. G. (1980). Treatment of agoraphobia with group exposure in vivo and Imipramine. Archives of General Psychiatry, 37, 63±72.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.12 Use of Self-help Books in the Practice of Clinical Psychology MICHAEL V. PANTALON Yale University School of Medicine, New Haven, CT, USA 6.12.1 INTRODUCTION

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6.12.2 CATEGORIZATION OF SELF-HELP BOOKS

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6.12.2.1 6.12.2.2 6.12.2.3 6.12.2.4 6.12.2.5 6.12.2.6 6.12.2.7

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Standardized Therapy Manuals General Self-help Books Problem-focused Self-help Books Technique-focused Self-help Books Internet Self-help Books Educational Self-help Books Other Self-help Books

6.12.3 OVERALL EFFECTIVENESS OF SELF-HELP BOOKS

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6.12.4 EFFECTIVENESS OF EACH TYPE OF SELF-HELP BOOK

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6.12.4.1 6.12.4.2 6.12.4.3 6.12.4.4

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General Self-help Books Problem-focused Self-help Books Technique-focused Self-help Books Internet Self-help Books

6.12.5 RECOMMENDATIONS FOR FUTURE RESEARCH

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6.12.6 INTEGRATING SELF-HELP BOOKS INTO THE PROCESS OF PSYCHOTHERAPY

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6.12.6.1 6.12.6.2 6.12.6.3 6.12.6.4

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Selection When to Use Self-help Books Introducing and Assigning Self-help Books Addressing Nonadherence

6.12.7 HOW SELF-HELP BOOKS CAN IMPROVE PSYCHOTHERAPY OUTCOMES

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6.12.8 POTENTIAL RISKS AND LIMITATIONS OF SELF-HELP BOOKS

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6.12.9 SUMMARY AND CONCLUSIONS

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6.12.10 REFERENCES

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Stephens, & Calhoun, 1990; Starker, 1986; 1988; 1990). In this chapter, SHBs will be broadly defined as the use of bibliotherapy and other written, psychotherapeutic materials that are usually read independent of a health professional. It seems likely that this effectiveness is due to the great appeal and availability of SHBs to the general public, including those who read

6.12.1 INTRODUCTION Review articles and meta-analytic studies have suggested that the use of self-help books (SHBs) is an effective adjunctive treatment in the practice of clinical psychology (Gould & Clum, 1993; Marrs, 1995; Pantalon, Lubetkin, & Fishman, 1995; Pardeck, 1990; Scogin, Bynum, 265

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them as study participantsÐmore than 2000 SHBs are published annually (American Psychological Association, 1989)Ðas well as the study of SHBs which are based on empirically supported psychological interventions (see Gould & Clum, 1993). Whether based on their great appeal, effectiveness, or other reasons, SHBs are widely prescribed by psychotherapists to their patients. One estimate of the number of therapists who have ever assigned a SHB to a client is 60% (Starker, 1988), and the number of therapists who prescribe SHBs on a regular basis ranges from 55% to 88% (Marx, Gyorky, Royalty, & Stern, 1991; Starker, 1986, respectively). In addition, favorable therapist and client ratings of the helpfulness of a variety of SHBs has been documented (Starker, 1986, 1988). Though the popularity of SHBs may have given rise to the empirical evaluations of their effectiveness, relatively few studies have been published on the critical factors which bear on their selection and appropriate use. Because information on these factors is unavailable, it is unclear whether the general public or the relatively large number of therapists who are assigning SHBs to their clients are selecting the most appropriate and/or effective SHBs. Another question regarding SHBs is whether their use is closely monitored by the prescribing therapist or whether they are merely suggested to clients, and not integrated into the course of therapy. Despite these and other unanswered questions, this author believes that SHBs have the potential to provide effective treatments, as well as to increase client involvement in the process of therapy and perhaps, improve its outcomes. These ideas are timely given the continued popularity of SHBs and the increase in managed care which sometimes severely limits the availability of psychotherapy sessions to its consumers. This author believes research on SHBs could be undertaken in a more systematic manner if the various types of SHBs available to the public were better defined and categorized, and if the degree to which readers follow the recommendations given in SHBs is assessed. Such improvements would allow empirical investigations of each type of book separately and comparisons among different SHBs, as well as information regarding the best way to use SHBs. This chapter will address these and other issues regarding the use of SHBs in the practice of clinical psychology. There has been a long-standing controversy surrounding the use of SHBs. Rosen (1987) stated that SHBs ªcommercializeº (p. 46) psychotherapy by making overgeneralized statements about psychological problems and their causes, and by promising unrealistic results. He

conjectured that this commercialization is mainly due to the market pressures to sell such books. Rosen believes that an SHB simply cannot present psychotherapeutic techniques in an adequate manner, and therefore unlikely to be sufficiently effective. Further, because SHBs may not accurately diagnose and because readers usually do not adequately comply with the recommendations therein, Rosen states that SHBs should not be used as a substitute for psychotherapy (Rosen, 1987). Although there have not been calls to have SHBs replace psychotherapy, this author agrees that the high degree of enthusiasm over some SHBs may have led to an overstatement of their effectiveness. Other authors disagree with Rosen's claims and suggest that an individual's ability to profit from a wide variety of SHBs is great (Mahoney, 1988; Starker, 1988). This author agrees with the statement that SHBs can be very helpful, but identifying the various conditions under which this can occur, and for whom, is crucial to advancing our knowledge in this area. This chapter will also attempt to address such issues. In the following sections, this author will first categorize the various types of SHBs available today. Second, the available empirical studies on the effectiveness of SHBs, when used alone and with therapist contact, will be reviewed. Third, the great appeal of SHBs will be discussed along with the manner in which this appeal can be used to increase the understanding of and adherence to psychotherapeutic interventions, and can therefore enhance clinical results. Finally, this chapter will include a description of an approach for integrating SHBs into the course of psychotherapy, which could be applied to various forms of psychotherapy. Specific recommendations for selecting, assigning, and using SHBs in the context of a clinical practice will be offered, along with identifying both the client and therapist variables that appear to be crucial in the effective use of SHBs.

6.12.2 CATEGORIZATION OF SELF-HELP BOOKS 6.12.2.1 Standardized Therapy Manuals Standard therapy manuals (STMs) describe a standardized treatment protocol to be used in conjunction with psychotherapy. They are therapist-directed and usually in an outline format. Both therapist and client versions are usually available. In essence, they are used as therapy guides. They are more technical than easy-reading, which differs from what one might generally find in a local bookstore in the self-help section. Marsha Linehan's (1993) treatment

Categorization of Self-help Books

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manual for borderline personality disorder is an example of an STM. Each chapter of Linehan's manual for dialectical behavior therapy illustrates in great detail the goals, methods, and objectives which will be used in treatment, similarly to what one would find in therapy sessions. It is considered a type of SHB because the client manual specifies tasks that clients can do on their own (e.g., homework). Other examples of STMs are Mastery of your anxiety and panic (Barlow & Craske, 1989) and Problem drinkers: Guided self-change treatment (Sobell & Sobell, 1993).

6.12.2.4 Technique-focused Self-help Books

6.12.2.2 General Self-help Books

6.12.2.5 Internet Self-help Books

These do not address specific disorders, but rather general emotional, relationship, or life development issues without delineating specific techniques and homework exercises within a structured protocol. They are usually selfadministered, but can also be therapist-assisted. Examples of such SHBs are The road less traveled (Peck, 1978) and Notes to myself (Prather, 1970). General SHBs can be used by therapists from a wide variety of orientations because they do not espouse any particular brand of therapy over another. Instead, they can be used to motivate clients to address problems which they may have avoided for some time or they can help clarify the goals and objectives of psychotherapy.

These are defined as any of the preceding SHBs that are found on the Internet. This category challenges the traditional notion of the genre that self-help is an individual helping himor herself with the use of materials written by another or several individuals. Once this material is formatted for the Internet, however, the opinions, advice, and counsel of potentially thousands of other, mostly lay, but some professional, people can be accessed via chatrooms, message boards, and e-mail. The advice obtained from such sources can be quite personalized, because of the Internet user's ability to e-mail or post very specific questions about their condition and/or treatment. However, for the purposes of this chapter, it shall be considered self-help as long as individuals are not seeking direct consultation with a psychotherapist. Some of the examples of SHBs listed above are actually on the Internet (albeit in severely condensed form), but many Internet SHBs are not in the form of a book per se, but are rather in the form of a homepage with a myriad of options for further information or directions to other resources depending upon a reader's specific interests. These ªbooksº are usually self-administered or with the assistance of ªonline therapists.º The reader is referred to Dow, Kearns, & Thornton (1996) for a list selfhelp sites.

6.12.2.3 Problem-focused Self-help Books These address a particular disorder (some actually assist the reader in diagnosing him- or herself) and delineate specific techniques and homework exercises within a structured protocol. They are usually self-administered, but can also be therapist-assisted. Examples of this type of SHB are Stop obsessing (Foa & Wilson, 1991), Control your depression (Lewinsohn, Munoz, Youngren, & Zeiss, 1992), Coping with depression (Blackburn, 1987), and The feeling good handbook (Burns, 1989). Although these are all examples of cognitive-behavior therapy (CBT) books, problem-focused SHBs are also written from a psychodynamic perspective (Bass & Davis, 1997). Problem-focused SHBs can be used by therapists with a wide variety of therapeutic orientations (e.g., behavioral, psychodynamic, interpersonal) for a wide variety of problems. However, it is advisable that they be used by therapists and clients who are prepared to systematically apply problem-solving and other techniques to a specific problem or symptom.

These are similar to problem-focused SHBs, but instead focus on a specific technique, rather than a disorder, that could be used for several or many problems. Unlike the previous SHBs, these are usually therapist-assisted, because therapists are usually the ones to recommend these books to their clients. However, they can also be self-administered. Examples of SHBs are The anxiety and phobia workbook (Bourne, 1990) and The relaxation response (Benson, 1975). As above, these books can be used by therapists from a wide variety of orientations.

6.12.2.6 Educational Self-help Books These attempt to help the patient, spouse, family member, or significant other learn more about the problems the identified patient is experiencing, and their prevalence, treatment, and course, as well as ways in which to effectively cope with the patient. This type of book is often helpful because it can shorten the educational process, allow patients and their families to become collaborators rather than passive recipients of treatment, and enhance

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adherence to treatment recommendations (Mueser, 1994). A number of such books have been written for many of the psychotic, affective, and anxiety disorders, such as Surviving mental illness: Stress, coping, and adaptation (Hatfield & Lefley, 1993) which pertains largely to schizophrenia, When once is not enough: Help for obsessive-compulsives (Steketee & White, 1990), or Panic disorder: The facts (Rachman & de Silva, 1996). A lengthier list of other organizations, SHBs, and resources for educating both patients and their families about psychological disorders has been prepared by Mueser (1994). 6.12.2.7 Other Self-help Books Finally, there are some SHBs which do not fall into one of the above categories. These are books that are not explicitly intended as selfhelp, but rather are books (e.g., novels, biographies) which, for example, chronicle a well-known individual's life or attempts to cope with a particular problem which is in some way instructive, such as Darkness visible by William Styron (1990), Pulitzer prize-winning fiction writer. Most of these SHBs are self-administered, but when they are used with the assistance of a therapist, it is usually within the framework of psychodynamic psychotherapy (Pardeck, 1991). However, their use in other types of psychotherapy, as with general SHBs, is not contraindicated, because they usually serve to motivate efforts to change and give clients a lexicon with which to better describe their complaints. Unfortunately, there are no controlled studies, known to this author, testing the efficacy of this type of SHB. In the next section, the effectiveness of SHBs in general is reviewed, followed by a summary of the research on each of the above SHB categories. 6.12.3 OVERALL EFFECTIVENESS OF SELF-HELP BOOKS Although the treatments found in many SHBs are usually not empirically supported, there are some significant exceptions and the number is increasing (Blackburn, 1987; Burns, 1989; Clum, 1990; Ellis & Tafrate, 1997; Foa & Wilson, 1991; Lewinsohn et al., 1992). However, even though there are some books which are based on empirically validated treatments, many of the SHBs themselves are not evaluated directly, though once again there are notable exceptions (e.g., Burns, 1989; Clum, 1990; Lewinsohn et al., 1992). For example, Foa & Wilson's (1991) book is based on a good deal of methodologically sound research study demon-

strating the effectiveness of the techniques therein (e.g., graduated exposure with response prevention). However, the book itself (i.e., how the treatment works when a client reads about it and decides on his or her own to what degree he or she adheres to the recommendations) has not been empirically tested in controlled trials. However, others have been empirically tested in this manner, such as Burns (1989). Because an SHB presents psychotherapeutic techniques in a unique manner, it can have a very different impact on a client as compared with the impact of seeing a therapist, even if the therapist and the author of the SHB are presenting the very same techniques. This is true, in part, because rationales for the use of therapeutic interventions may differ significantly from those presented in an SHB, and because different rationales can lead to very different perceptions about treatment and outcome (Newman, 1994). For some individuals, the therapist could be more motivating because he or she represents another human being expressing understanding of the client's problems, but for others an SHB could be more effective because it is less personally threatening. Gould and Clum's (1993) meta-analysis of 40 self-help studies resulted in a measurable overall effect size for self-help interventions of 0.76 at post-treatment and 0.53 at follow-up, which is comparable to those reported for psychotherapy (Stiles, Shapiro, & Elliot, 1986). This effect was strongest when SHBs were compared to no treatment conditions (e.g., wait-list and delayed-treatment controls) and when behavioral observations were used as the dependent measure (e.g., behavioral avoidance test). The lowest effect sizes were found when SHBs were compared to placebos (e.g., attention control conditions) and when physiological instruments (e.g., heart rate) were used as the dependent measure. Another meta-analysis, conducted by Marrs (1995), found a positive, though somewhat smaller effect size for SHBs (0.57), but no significant differences between SHBs and therapist-assisted treatments. In both of these more recent meta-analyses, SHBs for assertion training, anxiety, and sexual dysfunction were more effective than those for weight loss, impulse control, and studying problems. Additionally, Gould and Clum found that the mean effect size for pure self-help conditions (with no therapist contact at all) was greater than that of the minimal therapist contact conditions (where therapists periodically helped patients with the materials). However, the mean effect size for self-help conditions was less than that of the therapist-assisted conditions. The mean effect size for self-help conditions (SHB assigned with no therapist contact) was also less

Effectiveness of Each Type of Self-help Book than that of the combination of self-help and therapy (assignment of an SHB plus periodic therapist supervision). An important difference is that SHB plus therapy was a more intensive integration of therapy and self-help regimens than the minimal contact conditions. Obviously there is a need for more research in this area so that a definitive statement about usefulness of SHBs and their combination with psychotherapy can be made. Interestingly, in the Marrs (1995) study, the amount of contact the therapist made with participants in SHB-only conditions was not significantly correlated with outcome. However, it appeared that participants whose primary goal was weight loss or anxiety reduction improved significantly more with increased therapist contact. Thus, it appears that there are mixed results when comparing self-help vs. therapist-assisted conditions. One hypothesis, put forward by Gould and Clum (1993) is that the therapistassisted conditions may not adequately resemble how a therapist would actually assist a client with an SHB in therapy and therefore may not have enhanced the SHBs effectiveness; it may have even diminished it to some degree. One factor that may have influenced these results is the fact that only 15 of the 40 studies analyzed by Gould and Clum utilized a clinical sample and it is unclear whether SHBs would be as effective with patients who consistently met specific diagnostic criteria. Although Marrs (1995), based on a sample of nine studies, found that there was no significant difference between SHBs and therapist-directed treatments, a definitive statement about whether SHBs are more or less effective than therapy cannot be made because of the small number of studies that compare active treatment without an SHB to (i) self-help in general (only nine were included in Marrs' study), and (ii) pure self-help conditions (no therapist contact). 6.12.4 EFFECTIVENESS OF EACH TYPE OF SELF-HELP BOOK 6.12.4.1 General Self-help Books Although general SHBs sometimes focus on a particular area of an individual's life, the exact nature of the problem is ill-defined (e.g., low self-esteem, failed relationship), and they do not assist a reader in ascertaining a proper diagnosis. Such books also do not offer specific techniques and homework exercises within a structured protocol. For these reasons, these books are simply more difficult to assess in terms of effectiveness. They are often based on the clinical intuition and nonempirically based

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theories of the author. Another reason why they are difficult to investigate in research is that the advice described within them often appears to be overgeneralized and superficial. Despite the above shortcomings of general SHBs, their popularity is staggering. However, this popularity has not prompted much empirical investigation, and thus, very little data are available regarding the impact of these books (Starker, 1990). Therefore, it would be difficult at this stage to even recommend how they could be integrated into the context of psychotherapy or for what problems. However, it appears that such books (e.g., Peck, 1978) could be effective in helping a patient clarify exactly what thoughts, feelings, and/or behaviors are most distressing. They could also assist the therapist and client in setting goals and objectives at the outset of therapy, especially if the client is unclear about how he or she hopes to benefit from the experience. Such books have been described as being helpful in treating physically and/or sexually abused or neglected children (Pardeck, 1991), though only one controlled trial has been conducted (Ogles, Lambert, & Craig, 1991), which demonstrated that a general SHB worked equally well as behaviorally and stage theory-based SHB for coping with divorce. General SHBs seem to be utilized mostly by therapists who are experientially, Gestalt, or psychodynamically oriented therapists (Pardeck, 1991). This may be because these SHBs focus on events (current and/or historical) which are thought to be the cause of the problem behaviors, rather than on specific procedures to ameliorate them.

6.12.4.2 Problem-focused Self-help Books There are a number of other studies that demonstrate the effectiveness of problemfocused SHBs for particular disorders. Regarding depression, it appears that reading a cognitive or behavioral SHB is more effective than delayed-treatment groups (Scogin et al., 1990; Scogin, Jamison, & Gochneaur, 1989; Smith, Floyd, Scogin, & Jamison, 1997; Wollersheim & Wilson, 1991), equally effective as group CBT (Wollersheim & Wilson, 1991), and that cognitive and behavioral books were also equally effective (Scogin et al., 1989). Treatment gains have reported to be maintained or enhanced as long as three years beyond the end of self-help treatment (Smith et al., 1997). Additionally, Mahalik & Kivlighan (1988) reported that participants who are high on measures of independence, need for structure, internal locus of control, and self-efficacy, had responded better to a self-help approach to

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depression, than those who were low on these attributes. Regarding panic disorder, Ghosh and Marks (1987) found that self-exposure instructions worked equally well to reduce anxiety when given by a psychiatrist, SHB (Coping with panic [Clum, 1990]), or computer program, and that each resulted in substantial improvement up to six-month follow-up. Gould, Clum, and Shapiro (1993) similarly found that the effectiveness of an SHB was not significantly different from that of individual guided imaginal coping. Both treatments were significantly more effective than a wait-list control group. In a follow-up to the above study, Gould and Clum (1995) concluded that the SHB Coping with panic (Clum, 1990) was significantly more effective than a wait-list control group at post-treatment and at two-month follow-up. Lidren et al. (1994) also report that Coping with panic is as effective as group therapy based on the same book, which was required reading, and more effective than a wait-list control. Ogles et al. (1991) report findings from one of the few studies to compare problem-focused books based on different therapeutic orientations, namely behavior therapy and stage theory for the treatment of reactions to divorce. These books were also compared to a general SHB, which focused broadly on coping with life events (not only divorce). It was found that all three were effective in reducing a variety of symptoms associated with loss, but that they all worked equally well. In addition, those who reported high expectations of being helped fared better than those who did not, as evidenced by greater reductions in symptom scores, and attributed the change largely to their reading of the books. Other behaviors, such as problematic drinking (Heather, Robertson, MacPherson, Allsop, & Fulton, 1987; Hester & Delaney, 1997; Miller & Taylor, 1980; Sobell & Sobell, 1993) and smoking cessation (Glasgow, Schafer, & O'Neill, 1981) have also been shown to be modifiable with the use of SHBs. Heather et al. (1987), in particular, demonstrated that a problem-focused book on controlled drinking was more effective than an educational book regarding alcohol problems. In addition, many of these studies report maintenance of gains at six months, and one, two, and three years. Hester and Delaney (1997) and Gould and Clum (1995) have also demonstrated that computerized SHBs are also effective. In summary, the SHBs in this category which have some level of empirical support have been based predominantly on CBT. Thus, more research is required in other areas, as metaanalytic studies inform us that overall, most psychotherapies are equally effective (Stiles

et al., 1986). SHBs, based on other models of psychotherapy, could thus prove as helpful as those above. However, the books that take up the most space in the self-improvement section of a local bookstore (e.g., SHBs on dieting, relationships, parenting, hypnosis), or have been found to sell the best (Starker, 1990) are not the ones that have been empirically validated directly, nor are they based on treatments shown to be effective in research studies (Marrs, 1995). Conversely, some SHBs that are based on empirical data do not sell nearly as well as those that are not based on such information, perhaps because claims regarding change and its maintenance are more realistic in the former (Mahoney, 1988). However, as consumers of health care become more sophisticated in their knowledge of available treatments, which this author believes to be a byproduct of managed care, the demands to publish SHBs with some empirical support vs. the need to make such books appealing to the general public may become less competing. 6.12.4.3 Technique-focused Self-help Books A number of very clearly written workbooks on specific techniques for coping with various problems (e.g. tension headaches, depression, anxiety) have been written. Some popular examples are The anxiety and phobia workbook (Bourne, 1990) and The relaxation response (Benson, 1975), and Mind over mood (Greenberger & Padesky, 1995). Although some of the techniques therein have been empirically demonstrated to be effective, especially those in Benson (1975), the use of the books by clients on their own or with minimal therapist contact has not. Perhaps this is partially due to the fact that such books seem most appropriate for use as a supplement to the training of clients in various techniques (e.g., progressive muscle relaxation). Oftentimes, they do not offer an entire treatment plan for addressing all the various aspects of a problem (e.g., behavioral, cognitive, interpersonal), as does a problem-focused book, and may therefore be difficult to assign and test for a particular disorder. However, it is conceivable that their effectiveness in reducing some circumscribed aspect of a disorder (general anxiety or feelings of hopelessness), or in treating subclinical samples, could be empirically tested. 6.12.4.4 Internet Self-help Books At the time of writing, there are no controlled trials on Internet SHBs. As described earlier, Internet SHBs could greatly expand the number

Integrating Self-help Books into the Process of Psychotherapy and type of SHBs to be tested. The Internet also adds a new medium to test. For example, the difference between the effectiveness of an SHB that is read in the traditional manner vs. one that is read on the World Wide Web could be illuminating. Internet books have the potential to make SHBs significantly more personalized via their potential to cross-reference a greater amount of information than a traditional SHB (see Dow et al., 1996).

6.12.5 RECOMMENDATIONS FOR FUTURE RESEARCH It is recommended that statements regarding the effectiveness of SHBs should be made based on a careful investigation of specific types of books separately with more attention paid to the characteristics of individuals who can benefit from them and the experimenters/ therapists who utilize them. More controlled trials comparing the effectiveness of the various types of SHBs, especially those in the general, technique, Internet, and other categories would be helpful toward this end. Research on the characteristics of participants, such as reading and grade level, expectations of change, and motivation, should be addressed (Marrs, 1995). The issue of subject selection is also important. Perhaps individuals who typically read SHBs differ substantially from those who do so merely to be in a study for which they will receive some evaluation and/or financial remuneration. Investigations of the difference in outcomes between individuals who are permitted to read and apply the precepts of the book on their own vs. those who have periodic reviews with the experimenter, could be illuminating. Perhaps the use of diary recordings of progress and issues during reading would obviate the need for such frequent contacts with the experimenter. Such frequent contacts may contaminate the findings of self-help research in two important ways: (i) the contact with the therapist, rather than with the SHB, may account for some, if not all, of the improvement noted; and (ii) similarly demand characteristics, rather than the SHB, may elicit some portion of the improvement noted. However, research which compares the effectiveness of psychotherapy, with and without SHBs is not available at this time. Therapist characteristics which bear on the effectiveness of SHBs, which pertain mostly to the manner in which they are utilized and monitored in treatment (e.g., prescribed vs. suggested, monitored closely or informally), should also be addressed in future research so that practitioners may have guidance on how to make good use of such books. In addition,

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investigating what aspects of SHBs (e.g., instillation of hope via case examples vs. techniques) account for the most change in clients' behavior, would also be helpful. Both of these issues will be discussed in a later section of this chapter. In summary, although a carefully selected and closely read SHB, without any assistance from a therapist, may be good enough for some, the available data do not speak to the characteristics of such individuals. Thus, a more conservative approach, one consisting of an SHB plus therapy, may be warranted at this stage, given that the data are not conclusive and the fact that only a small number of SHBs have been empirically validated for use alone. Another reason why this approach might be more advantageous is that readers/clients would have guidance in how to select an SHB and how to adequately adhere to its recommendations. Poor selection and nonadherence are among the most deleterious results of an unstructured approach to self-help (Rosen, 1987). Therefore, because of the tentative nature of the research on SHBs, this author believes that psychotherapy, supplemented by judicious use of SHBs, is a safe and useful alternative to the pure self-help approach. Perhaps future research will explicate further under what conditions this may be the case and under what conditions a pure self-help approach may be indicated. Despite the fact that the prescription of self-help books and other materials is widespread, little research regarding various methods for assigning SHBs to clients or incorporating them into the course of therapy has not been undertaken. Future research should address this and the aforementioned questions as it suggests the possibility of using SHBs to enhance psychotherapy outcomes. It is hoped that the following guidelines for integrating SHBs in the practice of clinical psychology, which have been helpful in this author's work with clients, could facilitate such research.

6.12.6 INTEGRATING SELF-HELP BOOKS INTO THE PROCESS OF PSYCHOTHERAPY Many studies testing the effectiveness of SHBs do not clearly state how the books are to be used. Some authors, however, have addressed related issues, such as the prescription of SHB (Pardeck, 1990; Starker, 1990); which clients benefit most from a self-help approach (Mahalik & Kivlighan, 1988); and bibliographies of SHBs (Quackenbush, 1991). However, only Pantalon et al. (1995) and Pardeck (1991) have detailed a model of fully

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integrating SHBs into the course of psychotherapy. A brief overview of the former approach is given below.

mended, as it can help clients, and therapists of any orientation develop realistic expectations for behavior change.

6.12.6.1 Selection

6.12.6.2 When to Use Self-help Books

Before a therapist can adequately help select the SHB that will be best for a client, it is helpful for him or her to be aware of the most frequently cited positive characteristics of such books. These are: (i) optimistic frame, (ii) encouragement, (iii) advice to seek professional help, (iv) general self-understanding, and (v) understanding about specific problems (Halliday, 1991). This author believes that, in addition to the above, one of the most valued aspects of SHBs is the social validation offered through their suggestion that problems are understandable given life experiences, and that the readers are not to blame. Hence, fear of embarrassment or evaluation by a therapist are nonexistent. Also, instead of a complex diagnosis, the reader is given simple, easy-to-understand explanations for why they are the way they are, via accounts of cases which often mirror their own personal experiences. They also raise motivation to change through examples of others who have succeeded. They typically offer an optimistic outlook on problems and a multitude of suggestions for better coping. In addition, they are perceived by readers to be more efficient than therapy, especially in terms of time, cost, and effort (Starker, 1986). This author believes that SHBs will be able to offer all of the above, if they are goal-directed and written in a clear and user-friendly format (e.g., tables, figures, charts). They should also offer the reader a multitude of therapeutic exercises with rationales and encouragement, and descriptions of methods to measure noticeable changes (e.g., charts, checklists). In an effort to promote self-acceptance, it should prepare readers for setbacks or failure. In this author's opinion, however, the two most important things an SHB should offer a reader are research-based information and a plethora of case examples of those treated successfully, so that readers can identify with the case examples in a book and be convinced that they have selected an SHB that is appropriate to their needs. Both have also been demonstrated in research to significantly impact on expectancies for therapeutic change (Kazdin & Kranse, 1983). The reader is referred to Pantalon et al. (1995) and Santrock, Minnett, and Campbell (1994) for bibliographies of SHBs recommended for use in the practice of clinical psychology. Seligman's (1994) What you can change and what you can't is strongly recom-

The second step in integrating SHBs into the course of therapy involves deciding when and why to use them. When clients are experiencing difficulty understanding the nature of the problems they are facing, when the direction therapy should take is somewhat unclear, when clients either resist or have difficulty prioritizing goals, are only some examples of when SHBs can be used. A general rule of thumb, however, is that the use of SHBs could be effective at a point when either or all of these three situations arise: (i) the client is asking many questions about his or her symptoms or the process of therapy (ªHow is this going to help me?º or ªHow do you know this is right for me?º); (ii) the client is resistant in some way and/or does not adhere to therapeutic exercises (e.g., ªI can't understand why you want me to do this homework?º); or (iii) the client appears to be of the belief that he or she is the only person that is attempting to cope with such problems, which may accompany a sense of helplessness (e.g., ªNo one else has such major problems; I just can't do anything about itº). In these situations, an SHB could bolster the therapist's explanation of a problem, clarify the process of treatment, offer motivation and rationales for doing therapeutic exercises, normalize symptoms, and give hope. How ready a client is to engage in actual strategies to change behavior may affect how effectively he or she utilizes the advice in a particular type of SHB. For example, if a client is still thinking about whether or not he or she has a problem in the first place or whether he or she believes anything can be done about it, or whether the costs of change are too great, he or she may not be motivated to read a book which offers specific advice regarding how to change behavior directly. Instead they may profit from a book or a section of a book that discusses the pros and cons of their behavior first (e.g., general SHB or the ªdiagnosisº section of a problem-focused book). This then impacts on what type of book the theorist should assign to the client. One way to assess this is by using one of the various stages of change assessments available which have been shown to correlate with actual attempts to change and which are useful in planning clinical strategies (Prochaska, DiClemente, & Norcross, 1992).

Integrating Self-help Books into the Process of Psychotherapy 6.12.6.3 Introducing and Assigning Self-help Books The rationale for asking a client to use an SHB in conjunction with therapy should be planned after the therapist has (i) decided on the target problem; (ii) conceptualized his or her reason for seeking additional materials (e.g., client is asking many questions about the process of therapy); (iii) formulated his or her criteria for selecting an SHB; and (iv) selected an SHB, as well as, the introductory selections he would like the client to read. It may be best not to suggest exercises other than reading for the first two sessions after introducing an SHB, even if the client has already practiced such exercises prior to adding the book. Once all four conditions have been met the therapist can introduce the SHB he or she has selected following the suggestions found in the next several sections. When introducing the idea of using an SHB to a client, begin with a review of what gains the client has made thus far and how. It is then explained that if these efforts were extended, during nontherapy days and with new exercises, such as with the help of an SHB, greater improvements could be achieved. The client is then asked for his or her thoughts on this. Subsequently, the author shares some of his book selection criteria with the clients and points out the ways that the SHBs generally used by this author are different from other titles (e.g., research-based), many of which their friends may adore. If a client appears motivated to integrate an SHB into the work of therapy, then this author informs the client about the appropriate and reasonable expectations for what can be gained from reading an SHB. The degrees of behavior change and change as a process is emphasized. The client is told that the learning does not necessarily end by the time he or she finishes reading the book, but that it continues and the SHB becomes a reference, which the reader can go back to time and time again. This author then goes through the table of contents of the book with the client, remarking on how each of the sections (preselected by the therapist) is relevant to the client's particular problems and treatment. This exercise is sometimes quite illuminating because it makes it clear how therapist and client conceptualizations of the primary problems or methods of addressing them differ. Therefore, the therapist must be flexible at this early stage and willing to compromise on certain selections or exercises that the client may or may not see as relevant at first. This process of introducing and assigning an SHB also usually helps clients develop their own criteria for future self-help selections made on their own.

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This author believes that it is almost always better to prescribe an SHB rather than give the patient a choice of reading it or not. The more confident, directive, and positive a therapist is when assigning an SHB, the better the chance the SHB has of making a therapeutic impact on the client. Therapists should also display high regard for the selected SHB. Therefore, SHBs, and the exercises therein, are almost always assigned as homework, which is monitored by the therapist on a regular basis.

6.12.6.4 Addressing Nonadherence We have found that it is usually more effective to integrate SHBs into the context of therapy rather than to simply assign them. If they are not an integral part of the therapy, the patients may devalue such books, behavioral homework assignments, and even the therapy itself. If they are not good or relevant enough to use systematically, their use should be seriously questioned. This is true even if a therapist is only using one section of a particular book. However, some patients simply will not comply with such prescriptions as described above and will require more in the way of motivation to actively change problematic behaviors (e.g., a change in type of SHB). Readers of SHBs can mistakenly believe that reading a book, but failing to follow through on specific assignments, constitutes being actively engaged in the changing behavior. Due to the above, the following suggestions are made for dealing with nonadherence when using an SHB: (i) self-monitoring, which allows clients to become more aware of their resistant behavior, because a lack of such awareness may be stopping a client from acknowledging the severity of their problem; (ii) shaping of behavior, which involves positively reinforcing (e.g., giving praise, feedback, or acknowledgment for) each incremental effort toward more compliant behavior; (iii) agreeing on relevant sections. Frequent reevaluation of therapy goals and objectives facilitates this, and allows for a pace that is comfortable for both; (iv) assessing therapist demands regarding change. If a therapist is vigilant about monitoring his or her irrational expectations, then the chances of making unrealistic demands of the client, and hence of noncompliance, can be minimized; (v) anticipating nonadherence, which gives the therapist an early opportunity to plan strategies for addressing this issue. However, it also allows the therapist to view such resistant

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behavior as part of the process of change, rather than as an annoyance or interference. With this attitude, the therapist can respond to nonadherence in a nondefensive, reflective manner, which can be critical in motivating resistant clients; and (vi) traditional CBT techniques (e.g., desensitization, cognitive restructuring). 6.12.7 HOW SELF-HELP BOOKS CAN IMPROVE PSYCHOTHERAPY OUTCOMES Therapists may be able to enhance their effectiveness by adding SHBs to their armamentarium. In general, the manner in which SHBs could do this is by offering to therapists a new medium through which they can motivate behavior change. Specifically, SHBs can: (i) increase the number and variety of rationales given for treatment interventions, via case examples and interesting anecdotes in understandable language; (ii) increase opportunities to self-monitor problem behaviors as well as to rehearse adaptive ones, through the many therapeutic exercises they offer; (iii) enhance adherence to homework by offering the client motivational accounts of other clients and breaking down complex tasks into their component parts; (iv) increase self-efficacy via a heightened sense that they themselves (rather than the therapist) are solving their problems; and (v) improve generalization to other settings, because their suggestions are read and implemented in a wide variety of situations outside of the therapy office. 6.12.8 POTENTIAL RISKS AND LIMITATIONS OF SELF-HELP BOOKS Rosen (1987) suggests that the potential risks associated with the use of SHBs are associated mainly with the misdiagnosis of problems, lack of adherence with procedures, overgeneralized advice, and overstatement of the effects of SHBs. However, this author believes that these risks are associated with the misuse of SHBs, rather than by the books themselves. Specifically, SHBs may not help produce positive behavior change when the following conditions exist: (i) when expectations of change are unrealistic; (ii) when specific directions are not followed; (iii) when an irrelevant or inappropriate book is selected (e.g., due to a misunderstanding of the various types of books available);

(iv) when the book selected is not written in terms the reader can understand; or (v) when it does not match the goals of the reader. Since the psychotherapy plus SHB approach, described above, addresses each of these conditions, it should help the therapist avoid the potential risks associated with SHBs. Unfortunately, diligent attempts on the part of the therapist to ensure that each of these conditions is met does not always guarantee good outcome with an SHB. One of the most important aspects of using an SHB, as with any problem-focused therapy, is to achieve a good balance between efforts toward change and efforts toward acceptance (Hayes, Jacobson, Follette, & Dougher, 1994; Linehan, 1993). Thus, therapists attempting to integrate an SHB into the course of therapy should remember that at certain points he or she should either put the SHB (e.g., change effort) aside (with the mutual agreement that this is only a temporary change) or change the type of SHB that is being used (e.g., change from a problem-focused to a general SHB, which promotes more self-understanding or acceptance). One of the fundamental limitations of psychotherapy manuals in general, and SHBs in particular, is the assumption that the same disorder manifested by different people, with different learning histories and contingencies that maintain the symptoms, are to be treated in the same manner. Fishman (1981) refers to this as mistaking ªtopographical equivalenceº for ªfunctional equivalenceº (p. 244). In order to treat an individual effectively, the therapist may need to functionally assess each of the client's problematic behaviors so as to fully understand the reinforcement contingencies and how they relate to each problem area. Assuming that the same behavior exhibited by two individuals, compulsions related to unwanted, intrusive thoughts (i.e., topographical equivalence) serves the same function in both (i.e., functional equivalence), such as avoidance of intimate relationships vs. a desire to always be in control of one's thoughts, may lead the therapist to implement minimally helpful interventions. Thus, when using an SHB in therapy, it would be advisable for the therapist to individualize its procedures, either by timing or choosing the interventions or target behaviors in such a way that they are reasonable given the client's entire clinical picture (e.g., symptoms, motivation, social support, family life, occupational functioning, strengths and weaknesses). For example, an empirically validated SHB for generalized anxiety disorder may begin the course of treatment with progressive muscle relaxation, which for some may be anxietyprovoking, rather than relaxing. For such cases,

References reframing, or more assessment may be indicated. Without a functional analysis of each of this client's problem areas, the therapist might have incorrectly assumed relaxation training to be the best intervention with which to start. In fact, many of the issues that impinge on the use and effectiveness of manualized treatments in therapy also affect the effectiveness of SHBs. For example, the degree to which therapists individualize such manuals affects clinical outcome, and there is great controversy regarding whether modifications based on clinical intuition or actuarial judgment leads to greater efficacy of the treatment (Wilson, 1997). How a therapist individualizes an SHB for use by a particular client with a unique learning history may impact on its effectiveness in the same way that it does with treatment manuals. However, if future research attempts to experimentally control for differences in administration or individualization, more could be learned about the most productive way to do this. One of the more basic questions would involve a comparison of individualization vs. no individualization, or individualization with and without formal rules, as has been done with standardized treatment manuals. The results of such studies are mixed, but appear to favor actuarial judgment, which would suggest less individualization of standardized books. However, it appears that even those who favor the actuarial side of this debate, suggest that tailoring a treatment manual to reduce disruptive behaviors, and enhance adherence and regard for the interventions (much in the way described above), is both appropriate and improves the effectiveness of the treatment (Eifert, Schulte, Zvolensky, Lejuez, & Lau, 1997; Linehan 1993). A final purpose SHBs could serve is to further researchers efforts at wide dissemination of research findings regarding empirically supported psychotherapeutiic techniques (Persons, 1997). If SHBs based on empirically validated treatments became as popular to the general public as other books, clinicians who would otherwise be unaware of such treatments might have an incentive to learn and use them (i.e., if individuals in therapy were aware of such approaches, it is conceivable that they would seek such treatment from their therapist).

6.12.9 SUMMARY AND CONCLUSIONS This chapter reviewed (i) the various types of SHBs available today; (ii) the available empirical studies on the effectiveness of SHBs; (iii) the possible reasons for the appeal of SHBs to the general public and, more recently, to researchers; (iv) an approach for integrating SHBs into

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the course of psychotherapy, with specific recommendations for selecting, assigning, and using SHBs in the context of a clinical practice; (v) the manner in which SHBs could enhance (a) clinical results, especially via a better understanding of and adherence to psychotherapeutic interventions, generalization, and increased efficiency, as well as (b) dissemination of empirically supported treatments to practitioners and clients alike; and finally (vi) the potential hazards associated with the misuse of SHBs. It was proposed that if therapists used SHBs in the manner outlined, SHBs could be an effective adjunctive treatment in psychotherapy. It is the belief of this author that, with the above issues clarified, future research into the effectiveness of SHBs, including its potential positive impact on psychotherapy outcome, may be more systematically addressed. ACKNOWLEDGMENT The author wishes to express his gratitude to Wendy Bobadilla and Beatrice Martineau for their assistance in the preparation of this chapter. 6.12.10 REFERENCES American Psychological Association (1989). First annual golden fleece awards for do-it-yourself therapies. Presentation at the annual meeting of the American Psychological Association, New Orleans, LA. Barlow, D. H., & Craske, M. G. (1989). Mastery of your anxiety and panic. Albany, NY: Graywind. Bass, E., & Davis, L. (1997). Courage to heal: A guide for women survivors of childhood sexual abuse. New York: Harper Perennial. Benson, H. (1975). The relaxation response. New York: Avon. Blackburn, I. M. (1987). Coping with depression. Edinburgh, UK: Chambers. Bourne, E. J. (1990). The anxiety and phobia workbook. Oakland, CA: New Harbinger. Burns, D. D. (1989). The feeling good handbook. New York: William Morrow. Clum, G. A. (1990). Coping with panic. Pacific Grove, CA: Brooks/Cole. Dow, M. G., Kearns, W., & Thornton, D. H. (1996). The Internet II: Future effects on cognitive behavioral practice. Cognitive & Behavioral Practice, 3, 137±157. Eifert, G. H., Schulte, D., Zvolensky, M. J., Lejuez, C. W., & Lau, A. W. (1997). Manualized behavior therapy: Merits and challenges. Behavior Therapy, 28, 499±509. Ellis, A. E., & Tafrate, R. C. (1997). How to control anger before it controls you. Secaucus, NJ: Carol Publishing Group. Fishman, S. T. (1981). Narrowing the generalization gap in clinical research. Behavioral Assessment, 3, 243±248. Foa, E., & Wilson, R. (1991). Stop obsessing: How to overcome your obsessions and compulsions. New York: Bantam. Ghosh, A., & Marks, I. M. (1987). Self-treatment of agoraphobia by exposure. Behavior Therapy, 18, 3±16. Glasgow, R. E., Schafer, L., & O'Neill, H. K. (1981). Selfhelp books and amount of therapist contact in smoking

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cessation programs. Journal of Consulting & Clinical Psychology, 49, 659±667. Gould, R. A., & Clum, G. A. (1993). A meta-analysis of self-help treatment approaches. Clinical Psychology Review, 13, 169±186. Gould, R. A., & Clum, G. A. (1995). Self-help plus minimal therapist contact in the treatment of panic disorder: A replication and extension. Behavior Therapy, 26, 533±546. Gould, R. A., Clum, G. A., & Shapiro, D. (1993). The use of bibliotherapy in the treatment of panic: A preliminary investigation. Behavior Therapy, 24, 241±252. Greenberger, D., & Padesky, C. A. (1995). Mind over mood: Change how you feel by changing the way you think. New York: Guilford. Halliday, G. (1991). Psychological self-help books: How dangerous are they? Psychotherapy, 28, 678±680. Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental illness: Stress, coping, and adaptation. New York: Guilford. Hayes, S. C., Jacobson, N. S., Follette, V. M., & Dougher, M. J. (Eds.) (1994). Acceptance and change: Content and context in psychotherapy. Reno, NV: Context Press. Heather, N., Robertson, I., MacPherson, B., Allsop, S., & Fulton, A. (1987). Effectiveness of a controlled drinking self-help manual: One-year follow-up results. British Journal of Clinical Psychology, 26, 279±287. Hester, R. K., & Delaney, H. D. (1997). Behavioral selfcontrol program for windows: Results of a controlled clinical trial. Journal of Consulting & Clinical Psychology, 65, 686±693. Kazdin, A. E., & Krause, R. (1983). The impact of variations in treatment rationales on expectancies for therapeutic change. Behavior Therapy, 14, 657±671. Lewinsohn, P. M., Munoz, R. F., Youngren, M. A., & Zeiss, A. (1992). Control your depression. New York: Simon & Schuster. Lidren, D. M., Watkins, P. L., Gould, R. A., Clum, G. A., Asterino, M. & Tulloch, H. L. (1994). A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting & Clinical Psychology, 62, 865±869. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford. Mahalik, J. R., & Kivlighan, Jr., D. M. (1988). Self-help treatment for depression: Who succeeeds? Journal of Counseling Psychology, 35, 237±242. Mahoney, M. (1988). Beyond the self-help polemics. American Psychologist, 43, 598±599. Marrs, R. W. (1995). A meta-analysis of bibliotherapy studies. American Journal of Community Psychology, 23, 843±870. Marx, J. A., Gyorky, Z. K., Royalty, G. M., & Stern, T. E. (1991). Use of self-help books in psychotherapy. Professional Psychology: Research and Practice, 23, 300±305. Miller, W. R., & Taylor, C. A. (1980). Relative effectiveness of bibliotherapy, individual and group self-control training in the treatment of problem drinkers. Addictive Behaviors, 5, 13±24. Mueser, K. T., & Glynn, S. M. (1995). Behavioral family therapy for psychiatric disorders. Boston: Allyn & Bacon. Newman, F. (1994). Understanding client resistance: Methods for enhancing motivation to change. Cognitive & Behavioral Practice, 1, 47±70. Ogles, B. M., Lambert, M. J., & Craig, D. E. (1991). Comparison of self-help books for coping with loss: Expectations and attributions. Journal of Counseling Psychology, 38, 387±393. Pantalon, M. V., Lubetkin, B. S., & Fishman, S. T. (1995). Use and effectiveness of self-help books in the practice of

cognitive and behavioral therapy. Cognitive & Behavioral Practice, 2, 213±228. Pardeck, J. T. (1991). Using books in clinical practice. Psychotherapy in Private Practice, 9, 105±115. Peck, M. S. (1978). The road less traveled. New York: Simon & Schuster. Persons, J. B. (1997). Dissemination of effective methods: Behavior therapy's next challenge. Behavior Therapy, 28, 465±471. Prather, H. (1970). Notes to myself: My struggle to become a person. Moab, UT: Real People Press. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102±1114. Quakenbush, R. L. (1991). The prescription of self-help books by psychologists: A bibliography of selected bibliotherapy resources. Psychotherapy, 28, 671±677. Rachman, S., & de Silva, P. (1996). Panic disorder: The facts. Oxford, UK: Oxford University Press. Rosen, G. M. (1987). Self-help treatment books and the commercialization of psychotherapy. American Psychologist, 42, 46±51. Santrock, J. W., Minnett, A. M., & Campbell, B. D. (1994). The authoritative guide to self-help books. New York: Guilford. Scogin, F., Bynum, J., Stephens, G., & Calhoun, S. (1990). Efficacy of self-administered treatment programs: Metaanalytic review. Professional Psychology, 21, 42±47. Scogin, F., Jamison, C., & Davis, N. (1990). A two-year follow-up of the effects of bibliotherapy for depressed older adults: Journal of Consulting & Clinical Psychology, 58, 665±667. Scogin, F., Jamison, C., & Gochneaur, K. (1989). Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. Journal of Consulting & Clinical Psychology, 57, 403±407. Seligman, M. E. P. (1994). What you can change and what you can't: The complete guide to successful self-improvement. New York: Alfred A. Knopf. Smith, N. M., Floyd, M. R., Scogin, F., & Jamison, C. S. (1997). Three-year followup of bibliotherapy for depression. Journal of Consulting & Clinical Psychology, 65, 324±327. Sobell, M. B., & Sobell, L. C. (1993). Problem drinkers: Guided self-change treatment. New York: Guilford. Starker, S. (1986). Promises and prescriptions: Self-help books in mental health and medicine. American Journal of Health Promotion, 1, 19±24, 68. Starker, S. (1988). Do-it-yourself therapy: The prescription of self-help books by psychologists. Psychotherapy, 25, 142±146. Starker, S. (1990). Self-help books: Ubiquitous agents of health care. Medical Psychotherapy, 3, 187±194. Steketee, G., & White, K. (1990). When once is not enough: Help for obsessive-compulsives. Oakland, CA: New Harbinger. Stiles, W. B., Shapiro, D. A., & Elliot, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 165±180. Styron, W. (1990). Darkness visible: A memoir of madness. New York: Random House. Wilson, G. T. (1997). Treatment manuals in clinical practice. Behavior Research & Therapy, 35, 205±210. Wollersheim, J. P., & Wilson, G. L. (1991). Group treatment of unipolar depression: A comparison of coping, supportive, bibliotherapy, and delayed treatment groups. Professional Psychology: Research and Practice, 22, 496±502.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.13 Preventive Goals and Indirect/ Consultation Strategies: Meeting Current Needs Through a Recommitment to Underused Means and Ends RAYMOND P. LORION Ohio University, Athens, OH, USA 6.13.1 INTRODUCTION

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6.13.2 ANTECEDENTS TO PREVENTIVE CONSULTATION/INDIRECT STRATEGIES

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6.13.3 BEFORE THE BEGINNING; RETRACING PAST STEPS

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6.13.4 THE COMMUNITY MENTAL HEALTH MOVEMENT: A LOST OPPORTUNITY

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6.13.4.1 Shifting One's Conceptual Frame 6.13.4.2 Shifting Emphasis from Inside to Outside 6.13.5 EXTERNALIZING THE STUDY OF BEHAVIOR

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6.13.6 ENVIRONMENTAL MODELS OF BEHAVIOR

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6.13.7 TRANSACTIONAL MODELS OF BEHAVIOR

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6.13.7.1 Linking Inside and Outside 6.13.8 SHIFTING TO A PREVENTION FOCUS

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6.13.9 MERGING INDIRECT/CONSULTATION STRATEGIES WITH PREVENTION GOALS

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6.13.10 FINAL COMMENT

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6.13.11 REFERENCES

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related assumptions. First, information will increase the acceptance and delivery of the proposed alternative. Second, existing resistance to application of these services reflects a lack of information. Third, information about these has been developed in spite of resistance. Fourth, information developed for strategies

6.13.1 INTRODUCTION Chapters encouraging the adoption of alternative approaches to service delivery typically combine an overview of intervention strategies with a critical review of evidence for or against each strategy. Such an approach reflects several 277

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which have typically been limited to highly controlled use will be accepted as relevant to the decision to incorporate these approaches into existing service delivery strategies. Finally, with sufficient evidence, the existing service delivery strategies may be replaced by the alternative approaches. An alternative perspective is that understanding resistance to changing current services and professional definitions is an essential first step to achieving such changes. The transition of mental health from direct to indirect services and from a clinical treatment model to a public health prevention model has been understandably slow and difficult. This chapter reflects the belief that such transitions are necessarily and appropriately slow and that professional resistance is best understood as natural and well-intended rather than as selfish and meanspirited. Rather than look for enemies to progress, one must understand its impediments and plan accordingly. Such is the focus of this chapter which reviews the history, conceptual, and practical obstacles to the widespread acceptance, development, and implementation of indirect/consultation and preventive approaches by the mental health professions generally and clinical psychology specifically. Rather than attempt to present a compendium of strategies of questionable scientific merit and pragmatically uncertain dissemination, I will examine the circumstances under which progress had developed thus far and propose avenues for accelerating the pace at which further development occurs. Admittedly, the chapter focuses on the development of these strategies in the US. Systematic descriptions of how these strategies have evolved internationally (e.g., in South America, Australia, and Europe) are being prepared for publication in 1999 and 2000 in the Journal of Community Psychology. In his book, The creation of settings and the future societies, Sarason (1972) posits that to understand a human service one must examine the circumstances under which it is developed and delivered. One must particularly appreciate those pre-existing conditions which Sarason (1972, p. 24) labeled as occurring during the period ªbefore the beginning.º Change as reflected in an ªinnovativeº service, for example, does not arise without antecedents! Rather, it represents a sequence of events (some of which can be identified and some of which cannot) leading to recognition of the need for change and of the form(s) which that change must take to be accepted and incorporated within the surrounding service structure. As explained in this chapter, such is the case for the growing recognition of preventive interventions as

necessary components of a comprehensive mental health and health care strategy. Seemingly, such was also the case for the unfortunate de-emphasis of indirect/consultation strategies following their most recent introduction. At the same time, currently existing and expected conditions are likely to alter the perceived importance of these very strategies. Originally focused solely on ªindirect/consultation strategies,º the chapter took an unexpected and fortuitous turn. The invitation to prepare the chapter for this set of volumes came as somewhat of a surprise to the author. Although involved with the development, implementation, and evaluation of communitybased mental health interventions for nearly a quarter century, I had not associated my work on the prevention of emotional and behavioral disorders with ªindirect/consultative approaches.º On reflection, the link is as obvious as it is appropriate. Preventive interventions, by definition, focus on antecedents and concomitants of dysfunction rather than on dysfunction itself. As such, they both represent and rely heavily on indirect means of responding to mental health needs. Conceptually, their influence depends on understanding the nature and dynamic processes among individual and situational factors which are salient to pathogenesis (Lorion, Price, & Eaton, 1989). Pragmatically, the intervention's target is not the pathology but its antecedents, that is, enabling circumstances and related individual diatheses. A second reason for the surprise was that contemporary interest in consultation and indirect strategies was quite unexpected given the nation's seeming abandonment of both the goals and means of the community mental health movement born in the 1960s. The few remaining vestiges of what was to be a ªbold new approachº for responding to the nation's mental health needs seemed doomed in the current environment of managed care, welfare reform, and the search for the origins of emotional and behavioral impairment through neuroscience, genetic mapping, and research on biopsychosocial models of development (e.g., Bronfenbrenner, 1979). Four decades after beginning with lofty goals and expectations, the community mental health center system appears but a skeleton of its former self. Whether even the skeleton will remain in the next decade seems uncertain. Ironically, what may remain of the ªbold new approachº is the seemingly least emphasized and least valued of the five original mandatory services, that is, consultation and education. Again, on reflection, the timeliness of these approaches is understandable. If emotional and

Introduction behavioral problems are to be economically and efficiently addressed, they must be confronted early and on as many fronts as possible. Consultation and indirect strategies provide potentially cost-effective avenues for encircling situational and systemic elements of dysfunction and thereby the potential for accelerating its amelioration. Less recognized, however, is that these strategies might also contribute to a most timely goal, that is, the actual avoidance of dysfunction. In effect, these strategies represent routes to the prevention of mental disorder and to the promotion of optimal development and improved quality of life. The latter point highlights a link which has heretofore been largely ignored but which is particularly salient to this chapter. The importance of indirect/consultation approaches was acknowledged nearly four decades ago in President Kennedy's landmark message to the nation calling for a ªbold new approachº for responding to mental disorders: . . . We must seek out the causes of mental illness and mental retardation and eradicate them. Here, more than in any other area, ªan ounce of prevention is worth more than a pound or cure.º For prevention is far more desirable for all concerned. It is far more economical and far more likely to be successful. Prevention will require both selected specific programs directed especially at known causes, and the general strengthening of our fundamental community, social welfare, and educational programs which can do much to eliminate or correct the harsh environmental conditions which often are associated with mental retardation and mental illness. (Kennedy, 1963, reported in Bloom, 1977, p. 264)

To pursue this goal, ªconsultation services to other community agencies and mental health information and educationº (Bloom, 1977, p. 267) were included as mandatory components of community mental health services. The link between indirect/consultation strategies and preventive interventions was reaffirmed when the editors of this work extended the chapter's focus to include all three strategies. Confronting the responsibility for designing and delivering a new array of services (i.e., partial hospitalization, emergency, consultation, and education) to heretofore underserved segments (e.g., rural, low-income, or minority) of the population in unfamiliar settings (e.g., in sparsely populated villages, inner-city ghettoes, or working-class neighborhoods), community mental health service providers initially focused on established and evident need rather than incipient or potential disorder (Bloom, 1975; Cowen, 1973). As clinicians they were trained to recognize and treat disorder. Interest in doing

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these very activities, as professionals, determined, in part at least, their original career choice. Understandably, therefore, their initial forays into consultation and education efforts reflected contemporary assumptions about the nature of disorder and established intervention practices arising from such assumptions. The implementation of the remaining and predominant mandatory elements of the community mental health movement (i.e., outpatient and inpatient services) focused primarily on pathology as figure and the expert/therapist/ provider-serving-the-learner/client/recipient-exchange as ground. Within this framework, consultation and indirect/educational services were designed substantively and procedurally to maximize the recognition of disorder, the efficiency and timeliness of referral for treatment, and the appropriate utilization of community-based resources for supporting the effects of intervention. As explained below, social legislation of the 1960s and 1970s presented significant opportunities for the mental health system and mental health professions to change their conceptions of problems and solutions. Few (e.g., Levine & Perkins, 1997; Mrazek & Haggerty, 1994; Sarason, 1981) believe that the opportunities were taken or their potential fulfilled. Current and anticipated revisions of health and mental health care policies present another chance for substantive change. Whether the outcome will differ remains, for now, uncertain. What is certain, however, is that prior efforts at change were sincere but insufficiently cognizant of how established practices, perspectives, and assumptions about the nature of problems and solutions shaped the likelihood of true innovation. As we enter yet another era in which change is seemingly pursued, we must reflect on how current stances will necessarily shape our future. What seems quite certain is that the potential for change which arose in the 1960s remains unfulfilled! ªCommunityº in the community mental health movement, for example, referred primarily to the recipient and the location of services rather than to the rationale for and procedures of those services (Bloom, 1984). For this and other reasons, the heuristic and programmatic importance of the link between prevention as goal and consultation/indirect strategies as means lost its immediacy. Also clouded was appreciation of the vast array of alternatives which would have become available had the focus been on health and its maintenance rather than on pathology and its treatment or control. Ideally, this chapter will focus attention on the potential of those links and result in a broadening of perspectives as contemporary health and mental health service

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providers design intervention systems for the future. Toward that goal, it is important to note that the community mental health movement represented a return to rather than discovery of the value of indirect/consultation strategies. That recognition occurred decades before! In fact, the link between indirect strategies and prevention was unquestioned in the early twentieth century! 6.13.2 ANTECEDENTS TO PREVENTIVE CONSULTATION/INDIRECT STRATEGIES Legislative initiatives have understandably been assigned as much if not more of the credit than scientific findings and professional interest for moving to center stage the mental health disciplines' recognition of and involvement with prevention and indirect/consultation strategies. Attention to indirect/consultation strategies, for example, is assumed to have resulted from passage of the Community Mental Health Center Act (Public Law 88-164) of 1963. Legislative antecedents to that Act included the National Mental Health Act (Public Law 79487) of 1946. This law was written to facilitate the incorporation of public health principles into the design and delivery of mental health services. It also authorized the establishment of the National Institute of Mental Health which included the prevention of mental disorder among its stated purposes. More than a decade would pass, however, before that goal was publically acknowledged. Nearly two more decades would pass before substantive action was taken to achieve this goal (Goldston, 1986). Nearly 50 years after passage of Public Law 79487, preventive intervention research remains in the early stages of development and the products of its efforts, although increasing in number and documented value, account for a very small portion of the nation's mental health service effort (Durlak & Wells, 1997; Mrazek & Haggerty, 1994). Further legislative actions fueled the potential for momentum in establishing and disseminating indirect/consultation strategies. The Mental Health Study Act (Public Law 84-182) of 1955 created the Joint Commission on Mental Illness and Health charged with conducting a thorough and objective study of the human and economic costs of the nation's mental health needs, services, and service delivery systems. The Joint Commission took this assignment seriously. Over five years, it conducted comprehensive studies of topics ranging from the adequacy of staffing resources (Albee, 1959) to public attitudes toward mental health needs and services (Gurin, Veroff, & Feld, 1960) to

epidemiological analyses of mental illnesses. In addition to publication of numerous monographs reporting the results of individual studies, the Joint Commission (1961) submitted an integrative summary of its findings and recommendations in its final report entitled Action for mental health. That report provided the substantive foundation for the Community Mental Health Centers Act of 1963. The Joint Commission's report was supported by two significant epidemiological studies (Hollingshead & Redlich, 1958; Srole, Langner, Michael, Opler, & Rennie, 1962) published during that period. Whether measured in terms of need or demand for services, a serious imbalance was evident between the availability of mental health services and the prevalence of mental disorder in adults. A subsequent epidemiological study confirmed the existence of at least an equivalent imbalance between children's needs and available services (Glidewell & Swallow, 1969). These and related studies provided what appeared to be convincing support of ªAlbee's (1959) pessimistic assessment that sufficient mental health staffing resources would never be available to treat those in need within the dominant individual service delivery models. Other sources of personnel (e.g., paraprofessionals, Durlak, 1979, and ªnatural care givers,º Cowen, 1982) and other models of service (e.g., empowerment strategies, Rappaport, 1977) if developed and supported offered routes to redressing these imbalances. The founders of the emerging field of community psychology and their followers devoted considerable effort to pursuing such alternatives (Cowen, Gardner, & Zax, 1967; Iscoe, Bloom, & Spielberger, 1977). Although overlapping in terms of their goals and objectives, community psychology (e.g., Heller, Price, Reinharz, Riger, & Wandersman, 1984; Rappaport, 1977) and community mental health (Bloom, 1984) took somewhat differing routes to finding alternative solutions to resolving the needs/services imbalance. Each, however, emphasized the development and dissemination of preventive interventions and indirect/consultation strategies as outcomes to be achieved. Each spoke of the value of expanding definitions of providers of service, of the timing of services, and of the nature of services (Riessman, 1965). Both community psychology and community mental health, however, retained a strong identification with clinical psychology. With notably few exceptions (Iscoe et al., 1977; Phares & Trull, 1997), doctoral programs in these emerging fields devoted far more time to training in traditional theories of pathology and traditional methods of diagnosis and treatment than in those uniquely distinct theories and methods

Antecedents to Preventive Consultation/Indirect Strategies focused on communities. Understandably, professional identification was more likely to default to clinical than community psychology. Simultaneously, prevention's advocates reminded policymakers of the public health maxim that no disease or disorder had ever been controlled by treatment but only by prevention. As early as 1962, the American Public Health Association identified six categories of mental disorder which, because their etiology was known, were preventable (Bloom, 1984). These categories included diseases caused by: (i) poisons (e.g., brain syndromes following exposure to solvents); (ii) infections (e.g., rubella); (iii) genetic disorders (e.g., TAYSACHS disease); (iv) nutritional deficiencies (e.g., pellagra); (v) injuries (e.g., traumatic head injuries); and (vi) general systemic disease (e.g., prematurity). It is important, however, to note that early in the development of the community mental health movement, prevention represented not simply an idea but also an attainable goal. Moreover, guidelines for shifting to alternative approaches were provided by Caplan in his influential works, Principles of preventive psychiatry (1964) and The theory and practice of mental health consultation (1970). Riessman (1965) among others (e.g., Fairweather, Sanders, Maynard, & Cressler, 1969) described innovative ways in which self-help and environmental change, alone or in combination, offered relief which could precede and potentially avoid dysfunction and exacerbation of existing problems. These efforts did not depend on professional resources to operate and, under appropriate circumstances, may have become self-sustaining. Yet the solution to a problem is determined in large part by how it is defined and how it is presumed to have arisen. As noted, the movement toward community-based service delivery occurred at a time that conceptions of health and especially pathology were focused primarily on internal individual states (Sarason, 1981). Changes in the individual's affective response to stress, behavioral response to external stimuli, and the capacity to alter those responses were assumed to occur through interventions targeted to individuals. From that perspective, a reasonable response to Albee's (1959) prediction of chronic shortages in mental health professionals capable of delivering individual services was to resolve that shortage by increasing the nation's capacity to train such professionals. Concurrent with legislation to incorporate public health concepts into mental health theory and practice and to establish the community mental health movement, Congress funded programs to train substantial numbers of mental health professionals to provide

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traditional diagnostic and therapeutic services (Phares & Trull, 1997). The inclusion of reimbursement for mental health services in health care policies and the growing public acceptance of outpatient mental health services led, in psychology, to a proliferation of university and nonuniversity-based programs for health service providers (Phares & Trull, 1997). The shortages in mental health professionals capable of serving individual needs predicted by Albee (1959) appears to have been substantially resolved, if not replaced by a surplus (Routh, 1998). The surplus becomes undeniable if subdoctoral providers in psychology, counselor education, marital and family practice, counselor education, nursing, and social work are included in service delivery resources. Ignored in this solution were the alternatives suggested by Albee (1959) and echoed in the Community Mental Centers Act, that is, to expand the range of personnel available to provide services and to expand the range and nature of those services. Indirect/consultation efforts targeted at other than the detection of those in need of referral for treatment or the enhancement of nonmental health service providers (e.g., teachers, social service case workers) to support mental health interventions could not be justified within the prevailing understandings of pathogenesis, dysfunction, and treatment. Similarly, efforts to establish the feasibility of responding to mental health needs using providers who were indigenous to the communities in which the problems arose (e.g., Sobey, 1970) may have demonstrated their effectiveness (e.g., Dawes, 1994; Durlak, 1979) but the weight of evidence was insufficient to topple the individual focus and internal emphases dominant at the time. Being from the neighborhood, for example, could only be of advantage to a service provider if characteristics of the neighborhood were assumed to contribute to the etiology, maintenance, and resolution of emotional and behavioral dysfunction. If one assumed otherwise, one would reasonably question the therapeutic benefit of attracting and retaining heretofore untreated segments of the population if the insights needed for symptom removal could not be achieved in the presence of an ªunqualified therapist.º Those who challenged the innovativeness of the community movement pointed to its seeming lack of theory and focus. Levine and Perkins (1997) describe reactions to the community mental health movement as follows: The new thrust went off in all directions at once, with little coherence and little conceptual clarity.

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Critics committed to traditional medical model practice looked askance at social activism. Those committed to ªintrapsychic supremacy º (Levine, 1969)Ðthe belief that problems in living result from people's internal psychological structures, which in turn dictate perceptions, feelings, and actions in everyday situationsÐviewed the activists as misguided romantics who had foolishly strayed from proper professional roles and activities. Community-oriented critics of traditional practice were equally firm in their convictions but had little to offer by way of alternate conceptualizations. (pp. 59±60)

Alternative perspectives had yet another chance to establish themselves as a viable element of federal health care policies. Shortly after his election, President Carter created the President's Commission on Mental Health to review the state of the nation's needs and response capacity. In essence, the Commission's numerous task forces and panels revisited the issues raised by President Kennedy's group and recommended continued and vigorous pursuit of many of its most innovative elements. The Commission's findings were translated into the Mental Health Systems Act (Public Law 96398). Included within this legislation was the requirement that the National Institute of Mental Health establish an administrative unit focused on funding, evaluating, and disseminating preventive interventions. The prevention of emotional and behavioral disorders was to become a central and adequately supported element of the nation's mental health policy (Bloom, 1984). Significant changes in service and training priorities were expected along with consequent shifts in the balance of direct and indirect approaches to serving the nation's mental health needs. Just as suddenly, the Mental Health Systems Act was repealed! Newly elected President Reagan's initial budget shifted to the states responsibility for deciding which services to provide with the federal government's newly designed block-grant funding approach to underwriting the costs of such services. If they were to be funded, the preventive and indirect services needed to compete for limited funds which were primarily used to support the provision of direct services to those with established diagnosed needs. Unfortunately, the promises of benefits to be gained from support for preventive interventions significantly exceeded the evidence of such benefits (Lorion et al., 1989; Mrazek & Haggerty, 1994) and left the field open to significant challenge (Albee, 1986). Ironically, an appreciation of the history of mental health strategies would have revealed that justification for these alternative services could be found in the efforts of mental health providers decades earlier.

6.13.3 BEFORE THE BEGINNING; RETRACING PAST STEPS Examination of the scientific and legislative accomplishments reviewed thus far might lead one to conclude erroneously that prevention and indirect/consultation strategies were neither recognized nor attempted before the latter half of the twentieth century. The legislative initiatives and epidemiological studies just described, however, were not mental health's initial foray into indirect/consultation and preventive strategies. Human services generally and the mental health services specifically have not only applied such strategies throughout the twentieth century but periodically such strategies represented a dominant and explicit objective. Considered in their entirety, it appears quite possible that indirect/consultative approaches and even preventive interventions may have both a longer and a more successful history than interventions which provide direct services to individuals. In their analysis of the history of consultation, for example, Mannino and Shore (1986) report that clinical psychology has been associated with such interventions since its inception. Long identified as a defining milestone of clinical psychology's formation as a profession, the establishment of Lightner Witmer's psychological services clinic at the University of Pennsylvania in 1896 is also quite relevant to this chapter. Reportedly, this clinic's services documented early professional appreciation of the value of indirect services and of both the desirability and feasibility of balancing attention to referred needs with creation of ways to avoid such needs (Mannino & Shore, 1986). Little known is the fact that Witmer's clinic relied on consultative interventions to deliver a substantial portion of its services. Comprehensive assessments of the nature and origins of children's cognitive, behavioral, and impulse control problems were, for example, as likely to result in interventions with the child's family or school as with the child. Frequently, analysis of the needs of a referred child included diagnostic assessments of instructional procedures. In turn, the intervention often involved prescriptive changes in school curriculum and detailed suggestions to teachers for handling disruptive behavior within the classroom setting. Established during the initial decade of the twentieth century to respond to the needs of immigrants and low-income families, the Settlement House Movement hired teachers to visit the schools enrolling the children of families served by the Movement. These itinerant teachers would observe classroom procedures and recommend changes in curriculum, classroom organization, and instructional methods to

The Community Mental Health Movement: A Lost Opportunity improve children's educational performance. Such visits were intended both to reduce the needs of identified children and to enhance the overall effectiveness of the classroom. Without being labeled as such, these visits represent very early attempts to prevent emotional and behavioral problems and to promote optimal development and adaptive functioning. In the 1920s, similar goals were pursued by the Child Guidance Movement. Healy's Juvenile Psychopathic Institute in Chicago, for example, developed and implemented programs to assist troubled youth by enhancing the capacity of relevant community agencies, including the schools, to serve the needs of referred and nonreferred youth. Healy's staff also worked to increase public understanding of mental health principles and public acceptance of emotional problems. The recipients of these educational programs were the communities in which the youth lived and the public agencies which served them. Child Guidance staff in other cities established service priorities for a community based on systematic assessments of local needs and resources. Findings from this planning step identified gaps in services and achievable objectives. Problem solutions often included programs to educate staff from relevant agencies about mental health principles and strategies. Child Guidance staff also worked to improve a community's readiness to develop its own child guidance capacity. As described by Mannino and Shore (1986), such capacity development activities included the aforementioned local assessments as well as field services which carried out site visits, assisted existing service organizations to recognize the contributions of other human services, and identified ways for these organizations to network and collaborate. Through their activities, child guidance workers sought to make explicit the close relationship between the child and family as case and the community in which services were provided. Aware of the futility of attempting to respond individually to each case, child guidance workers often chose instead to alter the settings (e.g., home, school) in which the child lived and learned by influencing the decisions made by teachers, parents, and other caretakers. To effect such changes, caretakers were provided information about human development and child care methods. Child guidance workers explained these principles and provided direct models of alternative parenting or teaching behaviors. Child guidance workers recognized that their consultative and educational services should not be designed to make their recipients into mental health workers but rather to improve their functioning as parents or teachers. When the recipient was a service

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organization, the goal was not to change it into a mental health agency but to improve the developmental sensitivity, efficiency, and effectiveness of its intended services. Reflecting on these approaches, it becomes apparent that attention to indirect/consultation strategies preceded by several decades the community mental health movement. Lessons reflected in these services included appreciation of the need to understand, value, and respect the perspectives and skills of a variety of service organizations. Movements developed at the turn of the twentieth century (e.g., Child Guidance, Settlement Houses, Mental Hygiene) appreciated the significant problems in adjustment confronting families attempting to cope with immigration, emigration, and poverty. Neither the families nor the organizations associated with these movements had adequate resources; both confronted challenging and unforgiving circumstances. Early on, the movements recognized that attempting to solve problems individually could not succeed. With their limited financial and staff resources, they focused on reducing the demanding quality of the environment, on enhancing the responsiveness of existing organizations, and the benefits of interorganizational collaboration and (long before the term was popular) on empowering parents, teachers, and citizens to respond to needs confronting them.

6.13.4 THE COMMUNITY MENTAL HEALTH MOVEMENT: A LOST OPPORTUNITY As noted, following an intensive study of the nation's mental health needs and resources, the Joint Commission on Mental Health and Illness concluded that a ªbold new approachº was needed if services were to respond to need (Joint Commission on Mental Health and Illness, 1961). The Joint Commission's report urged the nation to pursue alternatives to a mental health delivery system which was recognized as unavailable, inaccessible, and unacceptable to significant portions of the population (Joint Commission on Mental Health and Illness, 1961). Then as now, the need for responsiveness and relevance mandated the development of strategies which fit the actual circumstances within which people lived, learned, worked, and recreated. Then as now, the need to respond early rather than later was perceived as both economically responsible and humane. Then as now, responsibility for the emotional and behavioral health of individuals extended beyond the mental health professions. As reported by Gurin et al. (1960), physicians and the clergy

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were considerably more likely than psychologists, psychiatrists, or social workers to be approached for help with emotional problems. Subsequently, Cowen (1982) noted that hairdressers, bartenders, retired persons, and many others in the community served or could serve as valuable resources for those experiencing emotional discomfort. What in the past may have been defined as ªsimply being a good neighborº has the potential of being organized into a pervasive network of support for those suffering distress which can be tapped naturally without risking the personal and public stigma of mental health diagnosis and treatment. Many forms of indirect/consultation approaches are, in fact, designed to sensitize others to the responsibility and ease of ªsimply being a good neighborº and to facilitate their capacity to fulfill it. Regrettably, these approaches received far too little attention to flourish during and since the 1960s. In fact, few ªbold new approachesº were developed which redefined the timing and nature of mental health interventions. The question presented in this chapter is: ªwill the potential of indirect/ consultation be recognized and exploited now and in the decades to come?º One by one, whether labeled client, patient, or consultee, those presenting emotional and behavioral dysfunction have been approached by growing legions of mental health service providers. The sincere and somewhat effective efforts of these providers have not, however, stemmed the tide. As reported in Rouse (1995), the proportion of the nation's citizens suffering from emotional and behavioral (including substance abuse) disorders remains unacceptably high. Nor is there any basis for anticipating this tide to abate in the foreseeable future. Whatever their modality, direct approaches are limited in this regard by their focus on the individual and by the requirement that pathology must be present or imminent before intervention can take place. In his pointedly titled book, The absurd healer, Dumont (1968) foresaw this outcome as the community mental health movement was just beginning. A decade later, I experienced Dumont's insightful moment as I entered the waiting room of a public clinic. I was then part of a team of mental health professionals excited by the opportunity to develop a short-term therapy program for indigent clients. We seemed to be a success! Clients were referred in substantial numbers; most cooperated with treatment protocols and participated in the 8±10 session program. We gloated to colleagues when an attempted comparison with long-term protocols could not be completed because few of the long-term clients attended the minimum of

four sessions required for inclusion in the study. For a moment after I entered on this day, the waiting room full of therapy clients confirmed my certainty that our protocol represented a solution to the unacceptable levels of measured pathology in low-income populations (Lorion, 1973, 1974). Suddenly, I realized that however successful we were, the room would never empty! Clients would come and go; their improvement ranging from considerable to none. Yet, without a substantive change in the system of care, others would always take the place of those who left. This prediction appeared valid whether long- or short-term interventions were provided and whether the recipients were individuals, groups, or families. To empty the waiting room, I and my colleagues would have to change our sense of when, where, and how we intervened. We would also have to shift our definition of the problem and of our responsibility for its solution from the waiting room to the circumstances and conditions which led to its need. We would, in effect, have to shift our existing theories of how problems arose and our theories of their solutions. Such shifts presented enormous challenges to a system seemingly committed to change. As noted, our profession has yet to commit wholeheartedly to confronting those challenges!

6.13.4.1 Shifting One's Conceptual Frame With hindsight, it seems difficult to understand the mental health fields' reluctance to adopt wholeheartedly the flexibility and potential breadth of effect associated with applying indirect/consultation strategies in the pursuit of preventing mental illness and responding to emotional disorders. Passage of the Community Mental Health Center's Act provided the political support and financial backing seemingly necessary for shifting from an emphasis on treatment to understanding and ultimately controlling factors relevant to the development and maintenance of disorder. Bloom's (1977) analysis of this ªbold new approachº makes evident that talented, dedicated, and hard working individuals were committed to its development. Soon after passage of this landmark legislation, the Swampscott Conference laid the foundation for the field of community psychology (Bennett et al., 1966). Subsequent organizational meetings of this group (e.g., Iscoe et al., 1977) gave evidence that this emerging field had momentum as reflected in budding programs of research, the development of programs at the master's and doctoral levels, and a growing corps of adherents anxious to

The Community Mental Health Movement: A Lost Opportunity enlist in this movement. Voicing a commitment to the integration of science and practice, this emerging field's established leaders led the way for successive generations to establish a critical mass of providers of indirect/consultation and preventive interventions (Iscoe et al., 1977). Within a decade of its inception, community psychology appeared to have the commitment, momentum, and tools to move mental health toward acceptance of conceptions of etiology that extended beyond the individual and conceptions of intervention that redefined service delivery in partnership (Tyler, Pargament, & Gatz, 1983) rather than caretaker roles (e.g., Heller & Monahan, 1977; Levine & Perkins, 1997; Rappaport, 1977). After a decade of building a foundation for a national program of prevention work (Klein & Goldston, 1977), this perspective shift appeared to have taken root and become ready to blossom. For the next decade, leading advocates of prevention science, policy, and practice met regularly at the Vermont Conference on the Primary Prevention of Psychopathology (Kessler & Goldston, 1986). Funding for research on the prevention of emotional and addictive disorders began to rise with passage of the Community Mental Health Centers Act in 1963, a trend which has generally continued to the present (Mrazek & Haggerty, 1994). Yet, three decades after passage of the Community Mental Health Centers Act and five decades after formation of the National Institute of Mental Health with its mandate to bring public health principles to mental health care, the mental health fields remain at best ambivalent toward and distant from prevention as a goal and indirect/consultation strategies as means to that goal. Proposing recommitment to that goal or attempting to convince readers that recent scientific findings argue convincingly that it lies within reach seem quite unlikely to have other than limited success. Rather, it seems important to examine the mental health field's seeming resistance to what all agree is a desirable outcome, that is, the avoidance of disorder and the promotion of positive mental health. Levine and Perkins (1997) raise a plausible explanation, that is, those proposing the shift from treatment to prevention and from direct to indirect/consultation services ªhad little to offer by way of alternate theoretical conceptualizationsº (p. 60). Other explanations seem rather less easily supported. Resistance to changing mental health's goals and methods must be considered historically. As reported in Mannino and Shore's (1986) review and echoed in Sarason's autobiography (1988), we have been there before! Attempts to develop and disseminate

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indirect strategies early in the twentieth century make evident that their limited survival cannot be attributed to a lack of talent in its advocates, a lack of social support for the resulting programs, or even a lack of evidence of their contribution to the welfare of those served. It is seemingly not about the creativity of those who design interventions, the importance of the research questions raised, the social problems addressed, or the explanatory power of the methods used to find answers (Sarason, 1996). Having devoted much of his career to understanding the intractability of educational methods to genuine change, Sarason (1990, 1993) warns against attempts to understand the intransigence of existing approaches by finding and blaming those who oppose change. He notes: Our task would be incomparably easier if such villains existed. Being imprisoned in tradition, being resistant to and fearful of anything other than superficial change and window dressing, puzzled by the failure of past efforts, allergic to fads and fashions, disenchanted with quick fixesÐ such attitudes and reactions are not those of villains. (Sarason, 1993, p.13)

Subsequent comments about impediments to educational change seem equally applicable to understanding the pace at which indirect/consultation and preventive approaches have been adopted by the mental health fields: If everyone is in agreement that we are faced with a set of problems that we have to do something about, and if in the post-World War II era serious people have committed themselves to valiant efforts at reform, why have the results been either so modest, minuscule, or nonexistent? That was the question the book (Sarason, 1990) tried to illuminate. It was not about what to do; it was about how we have been thinking, what axioms we have unreflectively accepted as right, natural, and proper, and alternative ways we should begin think. (Sarason, 1993, p. 13)

Sarason explains that existing conceptions of how emotional and behavior disorder developed and needed to be remedied were reflected in priorities for research and interventions. Assuming that the seeds of pathology lay within the individual leads to the conclusion that changes in the individual are necessary to correct disorder. That perspective was dominant before, during, and after earlier attempts to shift from direct to indirect approaches and was reinforced by clinical psychology's acceptance of psychiatry and medicine as the definers of the nature of problems and solutions (Phares & Trull, 1997; Sarason, 1981, 1985).

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Reluctance to shift to the public health perspective are understandable. Public health practitioners traditionally have viewed disease and disorder as the consequence of complex relationships between individual vulnerabilities (i.e., diatheses) and situational factors (i.e., stress) and of interventions (especially those seeking to prevent disorder) as requiring an understanding and alteration of aspects of the host (i.e., the individual presenting the disorder), the agent (i.e., the cause of the disorder), or of the environment (i.e., of the circumstances which bring the host in contact with the agent) (Lilienfeld & Lilienfeld, 1980). Ideally, at least a portion of the contributions of each element of this classic public health triad (i.e., host, agent, environment) will be understood in planning the preventive intervention. That understanding will identify those points along the etiological chain vulnerable to intervention and thus opportunities for avoiding or interrupting the pathogenic process. The public health perspective challenges many core elements of clinical psychology's most influential theories, research methods, and concerns (e.g., to understand, predict, and control individual differences). Not surprisingly, clinicians tend to focus their research and services at the individual level. By contrast, public health interventions target populations or segments thereof and measure their impacts at the population rather than individual level. Of concern to proponents of indirect/consultation and preventive approaches is the seeming reluctance of psychology's community-oriented fields to emphasize public health rather than traditional clinical orientations. This individual orientation is confirmed in examinations of the content and methods of published community psychology research in its initial decades (Lounsbury, Cook, Leader, & Mears, 1985) and thereafter (Heller, 1989; Levine & Perkins, 1997). Community psychology's endorsement of the prevention of disorder and the development and adoption of interventions to change social policies and resolve social inequities as defining goals are slowly translating into substantial research and programmatic activity beyond the individual level of analysis or impact. Echoing Sarason (1993), I would assert that the villains who are obstructing our pursuit of innovation and appreciation of indirect/consultation and preventive approaches are not ªthemº; contrary to Pogo, nor are they us! The impediment is the difficulty of leaving the traditions and methods of clinical training when such training is valued both within an existing professional culture and within the larger society. Sarason (1993) argues that ªif we have learned anything with near certainty, both from

the organizational and psychotherapeutic literature, it is that those who seek to change find themselves at some point resisting changeº (p. 28). His perceptions about the difficulty of creating new forms of service settings seem to apply equally to the creation of alternative services. Resistance to change must be recognized and expected as part of the process of change which must be thoughtfully and sensitively countered rather than simply regretted or condemned. Regarding the introduction of innovative settings, Sarason appreciated that ªif there was anything about which we were truly secure on the basis of past experience, it was that we were embarking on a venture that was very complicated, guaranteed to arouse anxiety and doubt, and, in all respects a venture that could bring out the best and worst in usº (Sarason, Zitnay, & Grossman, 1970, p. 71). Reflecting on the fate of indirect/consultation and preventive approaches thus far, one might apply the same lesson. Moving from an individual-clinical to a public health perspective required abandoning what was known and valued by the profession and, admittedly, reimbursed by society. As noted, the design, development, and delivery of public health interventions ran (and continues to run) counter to many aspects of clinical training. Many indirect/consultation and preventive interventions are intended to preclude either the need for clinical intervention or for professional intervention. In either case, clinical involvement in mental health service delivery would be reduced. The fact that, once established, the majority of public health interventions would not even belong to us raises yet another impediment to shifting from clinical to public health perspectives. Few professionals readily accede to such generosity! More likely we are influenced by ªprofessional preciousness,º that is, the tendency of . . . professionals to view their technical skills in very precious kinds of ways, that is, to overestimate the differences in skills among the professions and to underestimate the communalities . . . . Each field does have a core of distinctiveness, and thus should be both recognized and treasured. It is one thing, however, to say that each field has a distinctive core of skills and it is quite another thing to say that everything a particular profession does is either distinctive or not, in part at least, learnable by the other professions in the settings in which they work together. (Sarason, Levine, Goldenberg, Cherlin, & Bennett, 1966, p. 587)

If this applies to our dealings with other professions, one can only assume it is not diminished when those with whom we are to

The Community Mental Health Movement: A Lost Opportunity share, if not turn over entirely, our clinical and intervention skills are nonprofessionals. Consultants, after all, teach elements of their expertise to others so that those others can apply the elements. Health promotion and disease/ disorder prevention involves us with segments of the population to which we cannot lay claim based on our expertise in the diagnosis and treatment of psychopathology. Without an accepted taxonomy of health, we cannot use a specialized lexicon to stake out that claim. Indirect strategies which require entry into the realm of public policy, system analysis, and institutional change frequently requires that we do so without a recognized credential which asserts prima facie that such involvement is both our right and responsibility. Indirect/consultation and prevention strategies demand that we operate within alien territory in which generic knowledge and skills are the currency for goal attainment. Encouraging people in need to take advantage of self-help groups, enabling those without such experience to recognize and assert their right to influence the allocation of resources, and applying our science and profession to make teachers, parents and social service providers better at what they do seem quite discordant with established definitions of professional functioning. In the sole course on consultation I encountered in graduate school nearly three decades ago (during community psychology's presumed take-off phase), I was both impressed and frightened to learn that effective consultation is documented by evidence that the service is no longer needed by its recipient. It seemed that the task required providing recipients of the services with possession of critical elements of what I offered to be shaped in whatever form they deemed useful. My job, in effect, was to make my job unnecessary! Providing prevention and indirect/consultation services seemed to require literal acceptance of Miller's (1969) mandate that we ªgive psychology away.º It simultaneously challenged the content of most of my didactic and clinical courses! It turned around basic assumptions about professional responsibility, and about the patient's capacity to change their problem behaviors and feelings. Most importantly, perhaps, it required significant revision in the very understanding I was developing of why people behave and feel as they do. 6.13.4.2 Shifting Emphasis from Inside to Outside Suppose that the emotions and behaviors which concern mental health professionals reflect not only internal processes but also the

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circumstances under which they are displayed? Were this the case, to what should one attend . . . the people or the circumstances? Three decades ago, as the Community Mental Health Movement was getting underway, Barker (1968) and his colleagues proposed that behavior settings have greater influence on the expression of certain behaviors than the people who inhabit those settings. In other words, one might predict what will happen if one knows where it is expected to happen more so than if one knows who will be present. If generalizable, this assumption implies that understanding the conditions under which social services are provided, classroom instruction is given, play is attempted, or employment opportunities arise may predict expressed emotion and behavior better than (or if combined with) information about the individual's early childhood experiences, measured intelligence, or personality profile. It also implies that structuring those conditions might influence predictably the experience and expression of emotions and behaviors. Such a perspective would provide a theoretical rationale for program, setting, or system consultation focusing on the conditions under which people lived, worked, played, and learned. Although given little attention, a substantial theoretical and empirical basis for responding to individual emotional and behavioral needs through indirect/consultation approaches has been developing for decades. It should be noted that attributions to factors external to the individual have a long and respected history in public health. The classic ªhost±agent±environmentº model for understanding the occurrence of disease has successfully informed efforts to prevent and control threats to physical health. It worked because it looked both within and outside the individual to understand vulnerability and resistance to disease. Consideration of individual and environmental factors allows for the design and implementation of interventions whose health promotion or disease/disorder prevention effects can be delivered unobtrusively. To be effective, it is not necessary that the recipients of these interventions be either identified or participate actively. Rather, not unlike fluoride in the water or guard rails along the highway, the environment can be changed in ways which are preventive and health promotive. Many of these interventions operate without professional involvement and independent of either the cooperation or knowledge of the vulnerable individual. By contrast, the application and ultimate success of treatment generally depend on multiple patient variables including acknowledging the need for, having access to, being able to pay for (in terms of money and

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time), and complying with a treatment protocol. Interventions which have their effects independent of such factors and, ideally, which preclude the need for treatment would clearly be logistically and humanly advantageous. To consider those as viable, however, one must believe that factors external to the individual are salient to health and illness. In the early eighteenth century before germ theory accounted for contagion, the spread of disease among the poor was attributed to ªmiasmaº (i.e., bad air). As Bloom explained (1977): Miasma theory held that soil polluted with waste products of any kind gave off a ªmiasmaº into the air, which caused many major infectious diseases of the day. People living near swamps, and thus particularly vulnerable to marsh gases, were thought to develop fever from these gasesÐa fever that came to be known as malaria (bad air). The miasmist felt that the way to prevent disease was to modify the environmentÐto remove the sources of the miasma. (p. 71)

Given confirmation that a different external factor,ªgermsº (i.e., viruses and bacteria) explained most infectious disorders, miasma theory had limited influence on public health policy and practice. Its major tenet, however, informs concepts of vulnerability and resistance to emotional and behavioral disorders. Miasma theory posits that nonspecific characteristics of an environment are pathogenic. This position echoes widespread beliefs among mental health epidemiologists (e.g., Dohrenwend, B. P. & Dohrenwend, B.S., 1981; Dohrenwend, B. S. & Dohrenwend, B. P., 1981; Dohrenwend et al., 1987) that elements of the environment linked to experienced stress are significant pathogens. Analogously, it echoes explanations of delinquency based on social learning and modeling processes (Berkowitz, 1993; Goldstein & Keller, 1987) and links observed among neighborhood disorganization, deterioration (e.g., the presence of broken windows and littered vacant lots), and antisocial acts (Gold, 1987; Levine & Rosich, 1996). Continuing the analogy, indirect/consultation strategies could be thought of as avenues to ªmodify the environmentÐto remove the sources of the miasmaº (Bloom, 1977, p. 71). 6.13.5 EXTERNALIZING THE STUDY OF BEHAVIOR Albeit outdated and dismissed, miasma theory is offered to focus readers' attention on nonspecific characteristics of settings and situations in which disease and dysfunction

disproportionately occur. Alternatives to miasma were sought because of the variability of its effects, that is, not all exposed became ill. Not understood at the time were how individual characteristics enhanced resistance or raised vulnerability. Such distinctions are central to contemporary diathesis-stress models of illness (Lilienfeld & Lilienfeld, 1980). The complexity of understanding how nonspecific setting factors mix with individual variability raises questions about the processes by which each influences the other. More than six decades ago, Lewin (1935) asserted the importance of contextual factors in his widely cited formula: B = f(P, E) This formula reflects Lewin's (1944) concept of ªpsychological ecology,º that is, consideration of setting characteristics and opportunities and individual characteristics and constraints into predictions of human behavior. Lewin's perspective has been studied along the lines of research emphasizing, respectively, transactional (i.e., the person in environment) and environmental contributions to behavioral and developmental processes. The distinction between the two lines of inquiry is one of relative rather than absolute emphases of the contributions of individual and situational factors in determining behavior. Both lines provide important scientific and clinical bases for the design and evaluation of indirect/consultation strategies and offer avenues for altering pathogenic processes toward preventive goals. The qualifier,ªtransactional,º represents an important element of Lewin's conceptualization of behavioral dynamics. A transaction refers to the inter-relational processes between individual and situational factors in which each reciprocally influences the other. The distinction between a ªtransactionº and an ªinteractionº lies in the former's bidirectional nature, that is, each component in the transaction influences the successive states of the other. Dewey and Bentley (1949) described transactional processes as a basis for epistemological analysis. Based on the models of thought articulated in that work, the study of human behavior requires consideration of the actor (i.e., the knower), that which is acted upon (i.e., the known), and the circumstances under which the action occurred (i.e., the situation in which the knower confronts the known). It is within that entirety that the meaning of an action or event must be understood. As explained by Allport (1955): Perceptual order and stability can be regarded not merely as a matter of the appraisal of cues, but also as a more dynamic relationship between the organism and the environment. When percepts

Environmental Models of Behavior are attained their attainment is likely to involve direct participation in some process of overt adjustment. Perception and action can be seen to have a close functional relationship (emphasis added). (pp. 271±272)

From a transactional perspective, violent acts occurring in a school, for example, would be understood in terms of when, how, and where they occur, who is present at the time, and how each person present interprets the events and the options available to respond to those events. The coalescence of those elements gives meaning to the violence and determines how its occurrence influences subsequent events. Among those events are the responses of others to the violence, the likelihood of its continuation by its perpetrator(s), and of its adoption by others (Lorion, Brodsky, & Cooley-Quille, 1998). As used in this chapter,ªenvironmentalº research refers to studies which examine the contributions of setting characteristics to behavior. As explained by Schoggen (1989), environmental studies are exemplified by analyses of the physical or built environment on behavior (e.g., the design of playgrounds on student interactions or of classrooms on reading) and of physical qualities of a setting on functioning (e.g., noise and lighting levels on classroom ontask behavior). Such studies may, however, focus on the ªthe ecological environment (which) includes also the objectively observable standing patterns of behavior of peopleÐthat is, specific sequences of people's behavior that regularly occur within particular settingsº (Schoggen, 1989, p.2). This subset of environmental studies must, themselves, be distinguished from work on the ªpsychological environment,º that is,ªthe subjective representation of the objective environment by a given person at a particular timeº (Schoggen, 1989, p. 3). 6.13.6 ENVIRONMENTAL MODELS OF BEHAVIOR As noted, Lewin's (1935, 1944) assertion that behavior is a function of person and environment stimulated inquiry into the contribution of setting characteristics in shaping behavior. Barker, a colleague of Lewin, developed this line of research. In Barker's (1968; updated in Schoggen, 1989) view, the distinction between Lewin's concept of ªlife-spaceº or the psychological environment (i.e., the world as an individual perceives and is affected by it) and the ecological environment (i.e., the objective characteristics of real-life settings) makes evident the need to understand how the physical properties of settings, including the objects

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within them and the shared rules for relating to them, influence behavior. Support for the importance of attending to the ecological environment was provided in the findings of a series of early studies (summarized in Barker, 1968) on children's behavior across school settings. Barker and his colleagues determined that knowledge of situational characteristics of such settings resulted in better prediction of children's behavior than knowledge of the characteristics of individual children. Across a number of settings, children acted more like each other within a given setting than like themselves across settings. To the researchers, measurable properties of settings appeared to constrain the range of alternative responses and opportunities for behavior within each setting. Barker and his colleagues used the concept of ªbehavior settingsº to describe such personsetting linkages. As explained by Barker: A behavior setting has both structural and dynamic attributes. On the structural side, a behavior setting consists of one or more standing patterns of behavior-and-milieu, with the milieu circumjacent and synomorphic to the behavior. On the dynamic side, the behavior-milieu parts of a behavior setting, the synomorphs, have a specified degree of interdependence among themselves that is greater than their interdependence with parts of other behavior settings. (1968, p. 18)

In effect, a behavior setting refers to a pattern of behavior which appears regularly under specific setting-defined circumstances. As explained by Schoggen (1989): ªFrom this viewpoint, the environment is seen to consist of highly structured, improbable arrangements of objects and events that coerce behavior in accordance with their own dynamic patterningº (p. 4). Such patterns of behavior appear regularly and predictably; their occurrence is independent of the specific individuals present. These patterns of behavior are linked both in place (i.e., are circumjacent) and form (i.e., are synomorphic) to characteristics of the setting but not to the presence of specific individuals as much as to the presence of categories (e.g., students and teachers; players and coaches) of individuals. Within a behavior setting, the behavior and setting are ªinterdependentº to the extent that the former is unlikely to occur outside of the latter and that qualitative aspects of the behavior are shaped by characteristics of the setting. Examples of behavior settings include the fit between the organization and structure of a classroom and the behaviors expected of, and displayed by, students and teachers; the distinct

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activities of students within a gym, in a library, or on a playground's basketball court or hopscotch grid. The physical setting and its associated rules make some behaviors highly likely and other behaviors highly unlikely. Schoggen (1989) explains that neither the physical nor social aspects of settings preclude all but a single behavior; rather, these settings aspects make ªactions of some kinds easier than othersº (p. 43). Wicker (1979) explains this process as follows: Behavior settings are self-regulating, active systems. They impose their program of activities on the persons and objects within them. Essential persons and materials are drawn into settings, and disruptive components are modified or ejected. It's as if behavior settings were living systems intent on remaining alive and healthy, even at the expense of their individual components. . . . . . . to summarize some of the essential features of behavior settings. Most of them can be presented in a single sentence: A behavior setting is a bounded, self-regulated and ordered system composed of replaceable human and nonhuman components that interact in a synchronized fashion to carry out an ordered sequence of events called the setting program. (p. 12)

Although the heuristic potential of Barker's work on setting characteristics has yet to be aggressively mined (readers are encouraged to review Levine & Perkins, 1987; Moos & Insel, 1974; and Wandersman & Hess, 1985 for illustrations of the potential richness of this vein), Barker and other environmental psychologists offer a heuristic avenue for understanding and responding to external contributors to health and pathology. That the concept of behavior settings may help unravel interpersonal processes within educational settings is strongly suggested in findings reported by Barker and his colleagues (e.g., Barker, 1968; Barker & Gump, 1964; Barker & Schoggen, 1973; Barker & Wright, 1951; Schoggen, 1989). Extrapolating from that work, it seems reasonable to assume that aspects of the environments in which people live, learn, play, and work can be shaped such that they can contribute to optimal adjustment to developmental demands and reduced potential for emotional and behavioral dysfunction. 6.13.7 TRANSACTIONAL MODELS OF BEHAVIOR In his biopsychosocial theory of behavior, Bronfenbrenner (1977, 1979) focused attention on the synergistic relationship between the individual (e.g., IQ, temperament) and setting (e.g., parental responsiveness) in the processes of human development. Extending that theory,

Sameroff (Sameroff & Chandler, 1975; Sameroff & Fiese, 1989) proposed a transactionalecological model for understanding variation in the outcomes associated with presumably established risk factors for developmental disabilities. Unique to this model is a hypothesized ªtransactionº between individual and contextual factors. For Sameroff, emotional and behavioral development is the product of an ongoing synergistic series of: (i) responses by an individual to situational circumstances and demands; (ii) alterations of those situational circumstances and demands as a function of the individual's responses; and (iii) responses by an individual to that altered situation. Individual and setting characteristics, however, differ in their malleability and range of variation. Consequently, it should not be assumed that each transaction represents equivalent changes in individual and setting characteristics. Nevertheless, within Sameroff's model, individuals and settings evolve continually (albeit generally gradually rather than dramatically) over time. This element of the theory augments substantially the complexity of understanding and controlling behavioral development. It also suggests that behavior can be shaped through controlled changes in the individual, the context, or both. Sameroff's model mirrors the continuing occurrence and adaptation to events which characterize the ongoing flow of daily life. It also offers a basis for contextualizing variations in behavior across situations. In effect, unyielding settings would constrain behaviors within circumscribed parameters. In the most recent version of the model, Sameroff and Fiese (1989) make explicit that societal (and, presumably, subgroup) expectations have regulatory influence on definitions of behavioral roles and thereby set contextual limitations on developmental outcomes. Insofar as such expectations and setting demands are fixed, the behavioral responses of those within a setting may be more restricted than assumed or desired. Kellam's (Kellam, Branch, Agrawal, & Ensminger, 1975) Life Course-Social Field model offers further enhancement of Lewin's and Bronfenbrenner's theories. Kellam's approach integrates elements of the biopsychosocial perspective with Erikson's (1963) recognition that development involves confronting and resolving a series of social tasks across the life span. Thus, Life Course-Social Field theory defines development in terms of movement over the life span across diverse settings (i.e., social fields), each presenting its own demands and adaptive challenges. The success with which the unique and common tasks associated within and across social fields are resolved is assessed both by

Transactional Models of Behavior oneself and by significant others in those settings. Kellam labels the substance of assessments of one's own psychological state as ªpsychological well-being.º Examples include one's sense of self-efficacy, anxiety, self-esteem, depression, disappointment, inadequacy, etc. By contrast,ªsocial-adaptational statusº refers to the assessments which others make of the adequacy of an individual's response to these developmental tasks across the multiple contexts (labeled ªSocial Fieldsº in Kellam's model) in which we live, play, or work, for example. Unique to Kellam's model is his emphasis on the fact that the individuals (i.e.,ªnatural ratersº) who make such assessments vary across tasks and social fields. In that sense, social fields are social, that is, they involve exchanges among the players in settings who have setting-related roles and expectations. Depending on their responses, these raters influence for better or worse the individual's resolution of task demands. The salience of particular social fields and of their respective natural raters changes over time and across developmental demands. Thus, the school for example, has particular salience during childhood and adolescence but much less so during the adult years. Similarly, as peers grow in importance, the family becomes less salient during adolescence and early adulthood and more so thereafter. 6.13.7.1 Linking Inside and Outside As noted, Levine and Perkins (1997) suggested that an important obstacle to the widespread adoption of alternative perspectives of emotional and behavioral problems (i.e., as adaptations to setting conditions rather than as reflections of endogenous psychopathology) and their resolution (e.g., indirect/consultation and preventive approaches rather than psychotherapy) was the absence of ªalternate theoretical conceptualizationsº (p. 60). Such an alternative is now available in the growing body of work linking internal processes and external conditions. Environmental analyses reviewed thus far (e.g., Barker, 1968) provide evidence supporting the impact of external factors on emotional and behavioral functioning. Developmental theorists such as Sameroff (e.g., Sameroff & Fiese, 1989), Kellam (e.g., Kellam et al., 1975), Bronfenbrenner (1979), and Rutter (e.g., Rutter et al., 1997) extend our understanding of the programmatic significance of this impact by clarifying the transactional processes by which external and internal events influence each other. Acceptance of such insights is heuristically important for multiple reasons. Orford (1992) notes that ªone of the consequences of complex,

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transactional influence is that outcome is difficult to predictº (p. 33). Rather than a limitation for intervention design and application, this consequence argues for use of indirect/ consultation approaches, particularly in the pursuit of preventive goals. As explained by Sroufe (1997) and Rutter et al. (1997), conceptualizing psychopathology as a developmental phenomenon shifts the focus from the individual to the individual±environment dynamic. Particularly important is recognition of such phenomena as reflecting adaptations to environmental demands rather than as the inevitable result of individual failings, unresolved early experience, biological determinism, or other endogenous factors. Within this framework, adaptive states represent points along developmental pathways. Rather than reflecting linear and deterministic processes whose outcomes are fixed from the outset (e.g., based on inherited characteristics) or soon thereafter (e.g., based on early traumatic experiences), such pathways evolve over time branching this way and that depending on specific mixes of adaptive resources, coping demands, and as yet unknown determinants of salience at the moment (e.g., Bell, 1986). Outcome becomes difficult to predict if one requires that knowledge of beginnings implies knowledge of endings or vice versa. By contrast, emotional and behavioral states become manageable if understood in terms of antecedent processes and likely subsequent presentations (some of which may be mutually exclusive but most of which may overlap or co-occur). Such a view of pathogenesis has multiple implications (Sroufe, 1997): (i) adaptation and maladaptation represent evolving rather than established conditions determined by what has occurred in the past, what is currently happening and the range of options allowed by cultural, setting and individual circumstances. This temporal quality of functional states links what has been with what is and the likelihood, but not certainty of subsequent states. Kandell's ( ) ªgateway theoryº of drug involvement exemplifies this principle. Use of alcohol or tobacco, for instance, is associated with an increased probability of marijuana use just as the latter is associated with an increased probability of use of cocaine or heroin. Any individual may, however, not go beyond a particular gate; hence the discontinuity between antecedents and outcomes (Kandel, Single, & Kessler, 1976); (ii) because many characteristics of experience and environment are shared across individuals (e.g., who live in a given neighborhood or are raised within a common culture), diverse pathways may lead to a common outcome.

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General systems theorists and developmental psychologists refer to this pattern as ªequifinalityº (Cicchetti & Rogosh, 1996; Orford, 1992). Highly diverse economic, familial, educational and occupational antecedents, for example, have been associated with drug involvement; (iii) similarly, although individuals may share common antecedents (e.g., poverty, being reared in a single parent household; a history of physical or sexual abuse) differences in circumstances subsequent to those antecedents give rise to a variety of outcomes (e.g., depression, alcoholism, conduct disorder). General systems theorists and developmental psychologists refer to this pattern as ªmultifinalityº (Cicchetti & Rogosh, 1996; Orford, 1992); (iv) by combining a, b and c, one appreciates that developmental pathways offer multiple opportunities for changing direction and hence influencing outcome. Branching off may reflect the occurrence of positive or negative events (e.g., an increase in family income, parental death or divorce), the addition of individual or circumstantial resources which enhance or reduce adaptive capacity (e.g., acquisition of interpersonal problem-solving skills or access to a caring teacher) or a change in the environment (e.g., moving to a more or less violent neighborhood). Whatever the case, a seemingly normative or pathogenic process may be interrupted and its direction changed for good or ill; (v) recognition that developmental trajectories can be altered must be tempered with appreciation of the limitations of that assertion. It appears that the further along a path one has gone and the longer the pathogenic process has been underway, the less likely it is that the path's direction can be altered. This seems to be the case because the capacity to recognize, access and use additional resources in the environment to adapt to health compromising situations depend on prior experiences, verbal abilities, interpersonal skills etc. In effect, the further along a path one has traveled, the more likely one is to reach its end point. ªMore likely,º however, refers to probability rather than inevitability! The conceptual option presented links exogenous and endogenous processes in a way that enriches comprehension of etiological processes and expands the avenues for interventions to influence those processes. Developmentally, emotional and behavioral patterns reflect adaptations to situational demands based on individual and environmental resources and the adaptive history of both the individual and the setting. (Mal)adaptation may proceed linearly or circuitously, winding like a river or branching out like the roots of a tree. Depending on the resistance encountered as well as what has come before, one among many alternative paths will

be followed. Understanding that path will likely require understanding the history of the resistance encountered. Some of it may reflect the prior experiences of a specific individual; some may instead represent a community's, a neighborhood's, or a family's post-hoc response to the behavior or needs of others. Some paths will proceed in a relatively linear fashion; antecedents are followed by clinically defined emotional or behavioral problems. Removing, neutralizing, or interrupting antecedents prevents the undesired outcome. Unfortunately, few mental health conditions can be linearly modeled. More typical is Sroufe's (1997) portrayal of emotional and behavioral development as the branches of a tree or the meanderings of its roots. Within this perspective, growth and survival requires maximizing one's access to necessary resources regardless of the impediments encountered in the environment. At any point in time, emotional and behavioral status reflects the cumulative effects of its antecedents. The further back one traces a branch the more completely one can understand what has been and will be encountered. With such information, the better one can predict the probability of the branch's likely direction. Where the branch connects to the trunk is but one element to be considered in predicting its various termini. That beginning is likely to be common across many outcomes (i.e., the principle of multifinality). Equally likely is that termini in close proximity may have begun at different points along the trunk (i.e., the principle of equifinality). Adding to the complexity is that some branches will end close to where they began, whereas others continue on toward other terminating points. Presumed antecedents (e.g., alcohol or tobacco use) for some conditions (e.g., substance dependence or addiction) may, for many, represent an endpoint (i.e., substance use is limited, controlled, or even ended). In other cases, however, the process continues toward dependence and addiction. Common antecedents leading to diverse outcomes; diverse antecedents leading to common outcomes; the co-occurrence of multiple outcomesÐmay be perceived as too complex and misunderstood an etiological model to inform intervention design, especially preventive interventions (Lamb & Zusman, 1981). Presumably, one should wait until the die is cast, the nature of the pathology is clear, and treatment can be selected and applied. Public health practitioners might accept this approach were the costs of delay (health related and financial) minimal, the effectiveness of treatment certain, and the secondary consequences of the disorder acceptable. The common cold and the 24 hour flu fit within these parameters.

Shifting to a Prevention Focus Most emotional and behavioral disorders, however, do not. Alternatively, the aforementioned complexity may be recognized as allowing for, indeed requiring, nonspecific interventions focusing on common etiological factors, be they individual, environmental, or transactional. Targeting common risks factors or pathways which are epidemiologically linked with undesirable outcomes has the potential for impacting simultaneously multiple outcomes. Simply stated, interventions targeting common antecedents may impact on multiple pathways and thereby serve as a stone which kills (or at least weakens) multiple birds! By aggregating the measured preventive effects across those outcomes sharing common risks, the true impact of such interventions may finally be documented (Lorion et al., 1989). Applying the principle of multifinality to intervention design leads to targeting a limited number of shared risk factors and assessing their impact across alternative pathogenic expressions. Similarly, the principle of equifinality requires that interventions intended to reduce the occurrence of a specific outcome must target the various pathways and risks associated with that outcome. In both instances, basic elements of developmental theory supported by epidemiological findings argue against the likelihood of documenting substantial evidence of preventive outcomes if only a limited number of risks factors are targeted with the intent of impacting a single form of disorder or dysfunction. As noted below, neither prevention theory nor the traditional intervention taxonomy made that point clearly. 6.13.8 SHIFTING TO A PREVENTION FOCUS Initial forays by the mental health sciences and professions into preventive efforts were led by Caplan (1964) who recognized that the mental health disciplines had to move beyond sole reliance on treatment if they were to serve public needs. To organize initial efforts in this direction, Caplan urged mental health to adopt the goals of and the classification system for prevention extant in public health at the time (Commission on Chronic Illness, 1957). This system was centered around the epidemiological concept of ªcaseness,º that is, confirmation that the diagnostic criteria defining a syndrome were met. Intervention categories were differentiated within this system in terms of their proximity to the targeted condition's fulfillment of diagnostic criteria, that is, meeting the symptomatic definition of a syndrome. Preventive interventions were designed to reduce the prevalence of a targeted disease or disorder.

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Within this framework, primary prevention interventions are implemented prior to caseness. Successful interventions reduce prevalence (i.e., overall presence of cases of a target disorder in the population) by reducing incidence (i.e., the occurrence of new cases). Potential recipients of such interventions range from the population at large, to asymptomatic subgroups targeted on the basis of epidemiologically-defined risk, to subgroups presenting prodromal signs antecedent to diagnostic status. By contrast, secondary interventions seek to lower prevalence by reducing the duration of caseness, that is, through the application of effective treatment. Combinations of sensitive screening procedures which identify cases early and involve them in treatment exemplify this category. Secondary approaches seek both a return to premorbid status and avoidance of subsequent episodes. Finally, tertiary interventions reduce the longterm disabilities and sequella consequent to caseness. Rehabilitation strategies and support services exemplify tertiary approaches. Insofar as they enable a person with schizophrenia to live independently, tertiary goals are achieved. If recurrence of disabling symptoms is avoided, secondary goals are achieved. Ideally, primary prevention interventions are preferable. This assumes, of course, the availability of necessary etiological information, access to the population at risk, and effective intervention strategies. It also assumes that the intervention's effects are, at worse, neutral. This is a particularly important point given that the diseases and disorders of most interest to mental health are relatively low-frequency events. Hence, unless substantial risk information is available and targeting is very precise, it is most likely that the majority of those receiving the intervention are unlikely to manifest the disease or disorder in the absence of the intervention. If the intervention has iatrogenic consequences, then these individuals may be at greater risk for those consequences than to the etiological outcome to be avoided. Dismissal of this concern notwithstanding (Albee, 1986), evidence for caution has been reported (e.g., Lorion, 1987; Sameroff & Fiese, 1989) although the frequency of negative consequences appears to be low (Durlak & Wells, 1997). Secondary and tertiary prevention efforts, by contrast, are targeted only to those meeting diagnostic criteria and hence having confirmed need for the intervention. As noted earlier (Lorion, 1983), the classic public health triad of approaches applied to the disorders (e.g., infectious diseases) and etiological processes of primary concern to public health practitioners. The applicability of its underlying causal assumptions, however, to emotional and behavioral disorders has been

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challenged from the outset (e.g., Albee, 1982; Lamb & Zusman, 1979). As reflected in the work of Brofenbrenner (1979), Rutter (1989), and Sameroff and Fiese (1989), there is an emerging appreciation of the etiological complexity of emotional and behavioral problems involving biological, psychological, social, and environmental parameters. This complexity obscures determination of the onset of pathogenic processes, the presence of disorder, and thereby designation of ªcasenessº (Lorion et al., 1989). Unresolved, these challenges produce disagreements in the categorization of primary and secondary interventions and obstacles to empirical verification of their efficacy. In either case, they allow little room for consideration of the principles of equifinality and multifinality in intervention design or evaluation. Gordon (1983, 1987) has proposed an alternative taxonomy for organizing preventive efforts which allows for consideration of these most important developmental principles. Given the low base rate at which emotional and behavioral disorders occur in the general population, Gordon's system also allows for consideration of both the financial costs and the iatrogenic potential of the interventions. Weighting expected intervention risks with target selection, Gordon (1983) proposed that ªuniversal,º ªselective,º and ªindicatedº interventions should be designed for and targeted to ªpersons not motivated by current sufferingº (p. 108) and neither currently seeking nor in need of treatment. Universal interventions are applied to the population at large and combine low costs per contact with limited likelihood of iatrogenic consequences. Examples of such approaches include public service announcements advocating seat-belt use and physical exercise or discouraging tobacco use and the consumption of alcohol during pregnancy. In the mental health realm, universal interventions include the ªFriends can be good medicineº program implemented in California to enhance use of social support resources and emerging strategies to teach parenting skills to adolescents. Perhaps the designator ªuniversalº may also be applied to the generic nature of the risk factors targeted by such interventions. If so, the difficulty of measuring their impacts becomes understandable given the multiplicity of outcomes which may be affected at undefined points in the future. Selective interventions are targeted to segments of the population for which there is an epidemiologically established risk. Selection may be based on identified links between gender, ethnicity, economic status, or family history, for example, and the presence of emotional or behavioral disorders. Targeted subgroups have a higher likelihood of disorder

and hence a more focused (and potentially more iatrogenic) intervention can be justified. Examples include programs targeted to families considering marital separation or divorce (Wolchik et al., 1993) or the recently widowed (Silverman, 1988). Indicated interventions target individuals (rather than subgroups) who present risk factors or prodromal signs indicating substantial individual risk for subsequent disorder. Examples of these approaches include programs for women presenting early indices of depression (e.g., Vega, Valle, Kolody, & Hough, 1987) and adolescents referred to juvenile court for status offenses (Lochman, 1992). It also includes Olds' substantially validated approach to assisting high-risk adolescent mothers (Olds & Korfmacher, 1997, 1998a, 1998b). Gordon's proposal was intended to stimulate development of preventive efforts and to make explicit how they were clearly distinct from treatment of symptoms and syndromes. In an important sense, Gordon (1983) proposal offers a conceptual expansion of the original ªPrimary preventionº category. His approach highlights the breadth of opportunity available to influence prevalence by intervening along that functional continuum ranging from health through various prodromal stages prior to meeting diagnostic criteria. The richness of this alternative system lies in its clarification of concepts of ªriskº and ªvulnerabilityº as applied to individuals, situations, and their combinations. It also lies in its clear distinction between the end-state conditions to be avoided (e.g., substance abuse or depression) and susceptible individuals. Sameroff (1977) made a similar plea in his early warning to prevention scientists that their efforts must not compromise respect for the humanity of the recipients of those efforts. In his advocacy for health promotion efforts, Cowen (1996) similarly urged program developers to recognize that removal or reduction of risks and vulnerabilities could leave individuals both empowered and likely to reach their potential. In their metaanalytic study of primary prevention programs, Durlak and Wells (1997) report clear evidence of the value of skill-building and competency enhancement as a means of avoiding dysfunction as well as improving quality of life for at-risk youth. 6.13.9 MERGING INDIRECT/ CONSULTATION STRATEGIES WITH PREVENTION GOALS Whatever classificatory scheme is adopted, epidemiology and developmental psychopathology provide important conceptual and methodological foundations for meaningful

Merging Indirect/Consultation Strategies with Prevention Goals advances in prevention (Mrazek & Haggerty, 1994). Application of case±control methodology, for example, enables epidemiologists to discern potential risk and protective factors associated with symptomatic and syndromal expression. Developmental psychopathology's longitudinal methods offer insights into the pathogenic processes defining vulnerability and allow for modeling the sequence of states and events which define the trajectory from health to dysfunction, to distress, and potentially (but not necessarily) to pathology. As noted, examination of developmental processes from a system's perspective brings to the forefront the importance of the principles of equifinality and multifinality. In turn, the application of these principles argue for the design and implementation of preventive interventions which target multiple risk factors linked to one or more negative emotional and behavioral outcomes. This view is supported by Mrazek and Hall (1997) who question Durlak and Well's (1997) decision to exclude programs which sought to improve academic achievement and reduce substance use from their meta-analysis of preventive interventions: Even though this is a legitimate way to narrow the huge task they faced, it also represents one of the main problems in prevention science today, that is, the categorical approach to mental, social, educational, behavioral and legal problems. Many of these problems have common risk factors that interact in complex causal chains. Addressing clusters of risk and protective factors increases the chances of preventing multiple problems in many areas of functioning. It is the accumulation of multiple proximal outcomes across various domains of functioning, such as educational status, social adjustment, and behavioral and emotional well-being that will be the most convincing arguments for the effectiveness of prevention. (Mrazek & Hall, 1997, p. 223)

Impacting on such a diversity of targets requires in my view the application of indirect and consultation strategies to maximize achievement of desired outcomes. As noted earlier in this chapter, such approaches characterized early twentieth century attempts to respond to the needs of children and families at risk for emotional and behavioral problems. Across multiple settings and a diversity of goals relating to improving the status of those in need, such early efforts at consultation applied expertise in developmental processes and mental health to enhancing the effectiveness with which parents, teachers, and other members of a community met their responsibilities. Consultants observed behavior, examined policies, and procedures, identified and examined the as-

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sumptive bases of definitions of problems and solutions, and thereby opened new perspectives and alternatives to those whom they served. The recipients of their services, in turn, impacted on the lives of the children and families deemed to be at risk. Reviews of mental health consultation (e.g., Bloom, 1984; Gallessich, 1986; Mannino & Shore, 1986) reveal both the promise and limitations of attempts to extend these early efforts to meeting the mandates of the Community Mental Health Centers Act. Whether focused on the needs of a client being provided mental health services, of the provider delivering those services or of the agency in which those services, were delivered, consultation was generally targeted to responding to the needs of those with identified dysfunction or incipient forms of disorder. The delivery system itself was not altered nor were the conditions for providing its services. What seems necessary at this time is the application of indirect/consultation strategies which redefine service delivery systems and thereby impact on the common risk factors seemingly essential to the etiology of diverse emotional and behavioral problems. Durlak and Wells' (1997) meta-analysis of prevention programs for children and adolescents makes evident the promise of such interventions. Similar optimism is supported by the findings of the recent Institute of Medicine review of the state of preventive science (Mrazek & Haggerty, 1994). What both reviews underline is the importance of focusing on building skills in the individual at risk or in those who surround the individual. Preventive interventions with the most promise appear to strengthen basic academic skills, interpersonal resources, and the responsiveness of the social systems which can influence developmental outcomes (Durlak & Wells, 1997; Lorion, 1990; Mrazek & Haggerty, 1994). The best of such work is theory-based, systematic and, most importantly, incremental (Price, 1997; Price & Lorion, 1989). Like the pieces of a puzzle whose image gradually emerges, program development proceeds through the sequence depicted by Price (1983) as the ªfour domains of prevention scienceº (p. 291). These domains include: (i) problem analysis (i.e., epidemiological and etiological studies); (ii) innovation design (i.e., program development); (iii) field trial (i.e., efficacy research); and (iv) innovation diffusion (i.e., effectiveness research). A most important element of Price's model for the development of preventive intervention was the interconnectedness of these domains. In effect, Price recognized how progress through these stages modifies one's initial understanding

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of the originating problem and hence catalyzes the refinement of each subsequent stage. Earlier, Cowen (1980) had differentiated the initial two domains as ªgenerativeº and the latter two as ªexecutiveº components of prevention science. Generative studies have scientific importance beyond their capacity to inform the design and implementation of interventions for they inform us ªabout the very processes whereby functional and dysfunctional states develop and are maintained. Preventive research can increase our understanding of the environmental parameters which engender, maintain, and modify human behaviorº (Lorion, 1983, p. 264). The continuing heuristic value of Cowen's distinction between generative and executive studies and Price's four domains is reflected in the Institute of Medicine's analysis of the state of prevention science. To catalyze the field, the report advocates that the field adopt the ªpreventive intervention research cycleº as its map for the systematic accumulation of information (Mrazek & Haggerty, 1994). Optimistically, they conclude: If the research standards and methodology outlined here are systematically and rigorously applied within the preventive intervention research cycle and the guidelines on cultural, ethical, and economic issues are carefully considered at each step, prevention research will yield progressively more powerful results over the next decade. The ensuing development of prevention into a science will provide a firm base of knowledge for policymakers. This knowledge will inform their decisions on the allocation of available resources toward the ultimate goal of realizing the opportunities presented by the science for the alleviation of the personal and societal suffering and burdens associated with mental disorders. (pp. 408±409)

The validity of this assertion is clearly represented by the Home Visitation Program developed by Olds and colleagues and described in detail in two special issues of the Journal of Community Psychology (Olds & Korfmacher, 1997, 1998a, 1998b). Built slowly and methodically over more than two decades, this program exemplifies the challenges and potential payoffs of the systematic pursuit of preventive goals. Of direct relevance to this chapter is that the program relies on a mixture of direct and indirect intervention components to accomplish its goals. These components derive from recognizing the complementary aspects of self-efficacy, human attachment, and human ecology theory. Recipients of the program's direct intervention are primiparous ( 75% of contacts in community) Team initiates all admissions to hospital (and discharges) ªTeamº approach to sharing difficult clients (as opposed to strict ªindividualº case management) Service not restricted to Mon.±Fri./9±5 pm Regular (i.e., daily). team meetings Clear operational management Easy access to inpatient beds (preferably same RMO as community) Source: Teague et al. (1995).

priorities. They need to feel some sense of control and ªownershipº of their own care, even ifÐin extreme circumstancesÐthis has to be taken away. So, what would mental health services look like if they were designed by service users, instead of clinicians and managers? Finding out what users really think about services is not easy. First, there are problems with sampling and representativeness and care has to be taken to ensure that the group of users consulted does reflect the broad range of user opinion and is not simply constructed from those who are currently attending the service, or who are already active in local user groups. They are, by definition, biased groups and, although the views of ªactivistsº are obviously important, they may not be representative of the ªsilent majorityº of those who are not active (and possibly not very engaged) in the services they receive. The method chosen to measure users' views may also significantly influence the results. For example, some qualitative approaches (e.g., focus groups) may give very different answers compared with paper-and-pencil questionnaires. Again, this is often attributable to the dynamics of small groups which favor those who are more assertive (and generally more ªradicalº). On the other hand, standardized, quantitative measures may be more easily replicable, but may lack the depth and ªrichnessº of more qualitative approaches (and therefore have limited validity). A mixture of quantitative and qualitative methods is therefore preferable (see Mechanic, 1989). With careful sampling and multiple methods, it is therefore possible to survey users' and carers' views and then compare these with professionals' views. The results can then sometimes be quite surprising. For example, Shepherd et al. (1995) asked over 400 patients, relatives, and professionals

what they thought was most important for the care of people with schizophrenia in the community. The data were collected across six different districts, with a mixture of rural and urban settings. The patient and carer samples included some people who were contacted through mental health professionals (including a number who were not well engaged with current services) and others who were active in local user or carer groups. A mixture of quantitative (e.g., structured questionnaires) and qualitative methods (e.g., focus groups) were used. The results showed a reasonably good consensus between the three groups regarding what should be provided (housing, day care, symptomatic control, crisis planning, etc.) but significant differences between them regarding the relative importance attached to each element. Users emphasized the importance of practical helpÐhousing, money, physical health careÐwhile the professionals tended to rate professional interventionsÐtreatment, support, symptom control, etc.Ðas being most important. There were also some interesting differences between those users consulted through mental health professionals and those contacted through the local user groups. Both rated the provision of information about their individual disorders (diagnosis, treatment, outcome, etc.) and about services in general (availability of day care, accommodation options, etc.) as important; both also noted the difficulties of accessing professionals (or any other mental health services) outside normal working hours (Monday±Friday/9.00±5.00). However, as might be expected, the users who were active in user groups were much more radical in their views and more rejecting of services aimed at providing information about medication and ªillness.º They clearly did not wish to accept their status as ªpsychiatric patientº and there-

Developing a ªUser-ledº Service fore did not see the relevance of further information. In this respect, they were different from the majority of users and carers. Findings such as these suggest that users do have different priorities from those of professionals or managers. If they were designing mental health services they would probably begin by addressing their basic needsÐ somewhere to live, something to do, and a decent level of financial support. They would then build clinical (ªillnessº) services in around this framework. Given all the difficulties discussed earlier about the development of community services and the problems of interagency cooperation, even this seemingly simple prescription is not easy to meet. The results also highlight the heterogenous nature of ªuser views.º Just like nurses, doctors, or psychologists, there is no one, simple version of users' views. They differ depending on who is consulted and what methods are used. The involvement of users in service planning must therefore proceed on the assumption that there is no magic solution to the problem of user consultation. A variety of methods must be used, with a variety of groups, repeatedly over time. Perhaps most importantly, users must be given the opportunity to speak directly to professionals and be regularly involved in training and education programs. Only by regular, face-to-face contact, in a setting that allows users time to speak and professionals time to listen, can one be confident that the users' agenda will be kept in the foreground. As indicated, one area in which the majority of users agree is regarding the importance of information about their disorders (causes, treatments, outcomes, etc.). By giving information the user is empowered to take a more active role in managing their own care just as in the management of a long-term physical health condition like heart disease, diabetes, or asthma. The aim is to provide information and support so that those affected can manage their own disorder as much as possible and prevent the accumulation of secondary disabilities. Of course, this approach will not work with everyone (it does not work with all those suffering from diabetes or coronary heart disease) but it does imply a fundamental shift in attitude (and power) away from the professional and towards the patient and his/her family or other carers. The role of the professional is then to be ªon tap, not on topº providing expert knowledge and support, but not taking away from the individual their ultimate responsibility for their own health care and its management. If professionals are going to be able to function in this new kind of role, then they will

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have to be prepared to share information and knowledge in a much more open way than has been common in mental health services up to now. For far too long mental health professionals have been overly secretive about what they do and why. They have felt uncomfortable about trying to answer straight questions like ªWhy did I get ill? Will I get better? What do I have to do to prevent another breakdown? Sometimes this is because they simply do not know, not surprisingly, since these are very difficult questions. Sometimes they may feel that their credibility will be undermined if they reveal a degree of ignorance (despite the fact that most patients would prefer an honest answer to defensive interpretation). But sometimes they may rationalize their silence by appeals to confidentiality and professional values. In effect, whether consciously or unconsciously, they are then using their access to information to maintain their position of power and authority. A psychoeducational approach fundamentally challenges this position. Except in very special circumstances, a psychoeducational model assumes that patients have a right to know what professionals think they know about them and why they intend to treat or manage them in particular waysÐ whether they agree with this or not. An educational model is thus very different from a therapeutic model: good teachers aim to empower their students by sharing their knowledge and skills, not disempower them by concealment and manipulation. To date, the evidence in favor of the effectiveness of psychoeducational approaches is mixed. There do seem to be some measurable gains in knowledge resulting from the provision of simple, clear information to both users and carers, but the increases tend to be small and are heavily influenced by the receiver's preconceived ideas (Sidley, Smith, & Howells, 1991; Smith & Birchwood, 1987; Smith, Birchwood, & Haddrell, 1992). Psychoeducation thus seems to work best when integrated with a comprehensive psychosocial ªpackage,º including problem-solving, skills training, etc. (e.g., Hogarty et al., 1991). At the heart of psychoeducational packages is an attempt to help the personÐand their immediate carersÐrecognize the early warning signs of possible relapse and intervene accordingly (Birchwood et al., 1989). It has been recognized for some time that many patients do not relapse suddenly into a psychotic state. Most go through a ªprodromalº (i.e., prepsychotic) period, often characterized by an increase in neurotic symptoms (agitation, sleeplessness, poor concentration) before clear psychotic symptoms appear. Around two-thirds of people with relapsing

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psychosis can accurately report these early warning signs and over three-quarters of relatives and other carers (Herz & Melville, 1980). Furthermore, the particular pattern of symptomatic changes is often highly specific to each individual patient: they might therefore be said to possess a kind of personalized relapse ªsignatureº (Birchwood, Macmillan, & Smith, 1992). The potential importance of identifying such relapse signatures is obvious. Close monitoring of prepsychotic symptoms may enable patients and clinicians to work together much more effectively and thereby manage with significantly lower overall doses of medication. Since the prevalence of drug side effects is very much related to the size of the dose, and since for many patients it is the severity of side effects which most significantly influences their decision to continue (or not) with medication, these approaches hold out considerable promise in improving medication compliance and delivering the maximum positive benefits from pharmacological interventions while minimizing their adverse side effects. Other psychological approaches to improving compliance by involving users more fully in their own treatment and management plans have now also been developed (e.g., Corrigan, Liberman, & Engel, 1990; Eckman, Liberman, Phipps, & Blair, 1990; Eckman et al., 1992). One of the most interesting is the application of a technique known as ªmotivational interviewing.º This was originally formulated to assist people with tackling problems of drug or alcohol abuse and is based on the assumption that most important behavioral choices contain some element of conflict (e.g., ªHow do I weigh up the immediate benefits of alcohol or other drug consumption against its longer-term ill effects ?º). In the case of medication compliance in schizophrenia, the question is, ªHow do I weigh up the degree of symptom relief associated with taking my medication, as opposed to the clear disadvantages in terms of side effectsÐlethargy, tiredness, weight gain, loss of libido, etc.?º The motivational interviewing intervention is built around a structured exploration of these conflicted beliefs and an effort is made to encourage maximum personal commitment to whatever final decision is reached (Miller & Rollnick, 1991). Results from a random controlled trial using this approach suggest that such interventions cannot only improve compliance and enhance symptomatic outcomes, they can also increase community tenure up to 18 months postdischarge (Kemp, Hayward, Applewhaite, Everitt, & David, 1996). Such results are very encouraging and one would hope to see more of these new approaches aimed at addressing some of the

psychological issues around medication compliance. The effectiveness of medication in the treatment and management of severe mental illness is, after all, as much determined by the psychological decisions surrounding the decisions to take it (or not) as it is about its pharmacological action. A psychoeducational format therefore involve users in their own care in a way that is quite different from the traditional patient± therapist relationship. The therapist talks openly about symptoms, he/she acknowledges that these experiences are not uncommon, and that it isn't therefore just a personal nightmare. The individual is thus helped to develop a new ªrelationshipº with their disorder. Instead of being, ªa schizophrenic,º they become, ªa person who is trying to manage their schizophrenia,º not a schizophrenic. There is a parallel here with people with anxiety or depressive symptoms who develop a different relationship with their symptoms as a result of successful treatment. They start to see the possibility of exerting some degree of control over these painful and distressing experiences, rather than being controlled by them. This can be the basis for a more positive adjustment to their condition. 6.23.10 STAFF TRAINING All this implies some very fundamental changes in the way that mental health professionals are currently trained and supported. What do we need to make staff more effective in working with people with severe and enduring mental health problems? First, we need to ensure that they are able to deliver the range of psychosocial treatments of known effectiveness. We have emphasized throughout this chapter that rehabilitation must proceed from a basis of effective treatment, yet it is still rare to find staff who are well enough trained to deliver the full range of psychosocial interventions that have been demonstrated to be effective with this client group. For example, despite the familiar problems of lack of generalization and maintenance, traditional skills training models clearly have some value in promoting the acquisition of social and other skills (Corrigan, 1991). The effectiveness of skills training models are also likely to be enhanced if they are combined with suitable medication regimes, behavioral family management programs, and psychoeducational approaches (Hogarty et al., 1991). Similarly, the evidence for the effectiveness of EE-based family interventions in preventingÐor at least postponingÐrelapse in schizophrenia is now very strong (Barrowclough & Tarrier, 1998; Mari & Streiner, 1994), again

Staff Training particularly in combination with medication and psychological interventions. Finally, CBT has produced some promising evidence for its effectiveness in terms of reducing symptom severity and alleviating some of the subjective distress associated with residual psychotic symptoms in outpatient samples (Kuipers et al., 1997) and, as indicated earlier, there are some very interesting reports of CBT applied in inpatient settings resulting in significantly more rapid symptomatic recovery and reduced overall lengths of admission (Drury et al., 1996a, 1996b). There is thus a very strong evidence base for the effectiveness of a number of psychological approaches and a considerable task to be done in terms of training and supporting staff to implement such interventions. Staff must also be prepared to deliver care which is sensitively tuned to the ªuser agenda.º As indicated earlier, this means that services have to be delivered much more on the user's terms and much less according to a ªprofessional viewº of what is most important. This can be difficult for those staff with a strong desire to show off their therapeutic skills, but there is a kind of ªhigher professionalismº which recognizes that sometimes sorting out someone's housing benefits and finding them meaningful work is more importantÐand makes a better starting pointÐfor a therapeutic relationship than delivering ªstate-of-the-artº cognitivebehavioral intervention for residual psychotic symptoms, or detailed assessments of cognitive functioning, self-care skills, etc. Staff must also be credible. What makes staff credible will be different for different users: some may prefer younger workers, some may prefer older, some may prefer the same gender, same ethnic group, etc. Whatever their background, users must feel that the worker has a real understanding of their situation and is able to offer something constructive to help. Teams therefore require a mixture of ages, backgrounds, experience, etc. Some users may even prefer staff who themselves have direct experience of receiving mental health services and there are some interesting examples from the US of service users receiving training and then acting as case managers (e.g., Mowbray et al., 1996; Solomon & Draine, 1995). But it is not sufficient that staff simply have an intellectual understanding of users' problems, they must be able to empathize with their situation and convey this effectively. Users should also feel that staff like them (at least most of the time!). Sensitivity, humor, honesty, warmth may all sound like cliches, but they are central to forming effective working relationships in this, as in any other, form of therapeutic activity. Users may need to be seen in their own

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homes, in the street, in shops, the park, the pub, and the cafe. Staff need to be prepared to work outside normal offices and formal facilities; they must be prepared to work alongside the user in a variety of apparently mundane activities and recognize that these are all vital opportunities for assessment and treatment. They must be creative in their ability to exploit these contacts and to extract the maximum therapeutic benefit from what may often be unconventional encounters. Staff must also be very clear about the limits of their own competence (whatever their specific areas of expertise) and be prepared to enlist the help of colleagues from the same or other agencies (e.g., in housing, employment agencies, etc.) who also have expert knowledge in their own fields. This openness to working with others and clear recognition of one's own limitations are key ingredients for effective staff working with this client group. Can we say anything more about the kind of personality that we should be looking for? As indicated earlier, the concept of low EE has recently been extended to staff and other informal carers (Ball et al., 1992; Moore et al., 1992) and this forms a useful framework for thinking about staff characteristics. It is a common clinical observation that staff often make the same ªblame attributionsº for negative symptoms which seem to underlie the responses of high EE relatives (Brewin, MacCarthy, Duda, & Vaughn, 1991). It is therefore possible that the same kinds of educational and skills-based programs that have been developed for families (e.g., psychoeducation, problem-solving, communication training, etc.) may be equally relevant for staff (Ranz, Horen, McFarlane, & Zito, 1991). Low EE staff will not get too irritated or frustrated in the face of repeated failure and avoid blaming the patient for his or her difficulties. This does seem to be related to a particular kind of personality type, but may also be facilitated by having clear and realistic expectations for change, which in turn is based on good support and supervision. Effective leadership, organization, and management of staff are therefore also crucial. Leaders can be from any discipline, but they need both good analytic skills (to break down problems, set priorities, assign tasks, etc.) and good socio-emotional skills (to involve and support others, develop a strong sense of common ownership, commit them to carrying out agreed actions, etc.). There is a strong consensus now regarding the importance of team case management systems, as opposed to individually-based case managers (Stein, 1992; Test, 1979). Obviously, there have to be clear individual accountabilities, but this does not remove the necessity for good teamwork and

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sharing of responsibilitiesÐand, to a certain extent, clientsÐwithin the team. This is necessary to cover for staff when they are absent or unavailable. Effective teamwork is really the only way in which good continuity of care can be maintained. In the UK, the management of community teams has been identified as an important area of weakness (Onyett, Pillinger, & Muijen, 1994). This has been partly attributed to a lack of managerial authority on the part of team leaders, related to the continuing tension between professional and operational management. The outcome of this confusion is a lack of clarity regarding the roles and accountabilities of individual staff and this is associated with feelings of dissatisfaction and emotional exhaustion (burnout). Onyett et al. argue that in order to counteract this, team leaders should have clear managerial authority over operational matters (i.e., day-to-day running of the team) even if this means weakening professional line management. This may be controversial in some countries, but seems necessary if teams are to function effectively. In the end, teams are delicate and complex structures. They require good training, good leadership, good organization and management, and good support. None of these components can be ignored if they are going to function to their maximum effect. 6.23.11 CONCLUSIONS This chapter has covered a considerable range of topics. The effective treatment and management of people with severe and enduring mental health problems raises issues at all levels of servicesÐindividual, team, facility, subcultureÐand these are played out differently in different countries with differing social conditions, welfare systems, levels of unemployment, etc. In my view, this is what makes rehabilitation such a rich and intellectually challenging field and there is much that clinical psychology has contributed to the analysis and solution of these problems. But clinical psychology will never be enough on its own. Psychologists have to learn to work with other professionalsÐdoctors, nurses, social workers, occupational and vocational therapistsÐand a range of social scientistsÐmedical researchers, sociologists, economistsÐto produce integrated strategies to address these complex problems. At their heart remain the experiences of patients, staff, and families. People with severe and enduring mental health problems the world over are still waiting to see services emerge which will effectively address their very basicÐ and seemingly very simpleÐneeds. Somewhere

to live, something to do, and a decent level of financial support. These do not seem unreasonable, or unrealistic, demands, but it is still rare to find them completely met. Similarly, staff need to be trained in effective interventions and then organized and supported in such a way that these can be delivered in the most efficient way possible. Again such conditions are rarely met. Finally, there are families and other carers. Families provide more health care than any formal system of professional care ever does, or ever will do, and severe and enduring mental illness is no exception. Yet families are still often ignored, seldom consulted, and sometimes even blamed for being the cause of the problem. It is not surprising that many are frustrated to the point of bitterness, asking ªHow long will it be before we are treated as genuine partners in care?º As professionals we have a responsibility to respond to this question and to ensure that families are included in the process of care and not simply exploited as a convenient (and cheap) resource. So, there is much to be done. But, nevertheless I am optimistic. I believe that systems of care for people with severe and enduring mental illness have generally improved over the last 40 years and there are some outstanding examples, in several countries, of truly comprehensive, community-based services which do address peoples' housing, vocational, social, and clinical needs. Our task is to make these the norm rather than the exception. To achieve this, we must combine what the Italian philosopher Gramsci referred to as, ªThe optimism of will, tempered with the pessimism of reason.º This is surely the task for the next millenium. 6.23.12 REFERENCES Abrahamson, D., Swatton, J., & Wills, W. (1989). Do longstay patients want to leave hospital? Health Trends, 21, 16±21. Audit Commission (1994). Finding a place. London: HMSO. Bachrach, L. L. (1976). Deinstitutionalisation: An analytical review and sociological perspective. Maryland: US Department of Health, Education and Welfare. Bachrach, L. L. (1988). Defining chronic mental ilness: A concept paper. Hospital and Community Psychiatry, 39, 383±388. Bachrach, L. L. (1992). What we know about homelessness among mentally ill persons: An analytical review and commentary. Hospital and Community Psychiatry, 45, 453±464. Bachrach, L. L. (1997). Lessons from the American experience in providing community-based services. In J. Leff (Ed.), Care in the communityÐillusion or reality? (pp. 21±36). Chichester, UK: Wiley. Ball, R., Moore, E., & Kuipers, L. (1992). Expressed emotion in community care staff. Social Psychiatry and Psychiatric Epidemiology, 27, 35±39. Barrowclough, C., & Tarrier, N. (1998). Social functioning and family interventions. In K. T. Meuser & N. Tarrier

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drugs in the aftercare of schizophrenic patients. Archives of General Psychiatry, 36, 1055±1066. Linszen, D., Dingeman, P., Van Der Does, J. M., Nugter, A., Scholte, P., Lenoir, R., & Goldstein, M. (1996). Treatment, expressed emotion and relapse in recent onset schizophrenia disorders. Psychological Medicine, 26, 565±578. Mann, S., & Cree, W. (1976). ªNewº long stay psychiatric patients: A national sample survey of fifteen mental hospitals in England and Wales 1972/73. Psychological Medicine, 6, 603±616. Mari, J. J., & Streiner, D. (1994). An overview of family interventions and relapse in schizophrenia: Meta-analysis of research findings. Psychological Medicine, 24, 565±578. Marks, I. M., Connolly, J., Muijen, M., Audini, B., McNamee, G., & Lawrence, R. E. (1994). Home-based versus hospital-based care for people with serious mental illness. British Journal of Psychiatry, 165, 179±194. McRae, J., Higgins, M., Lycan, C. & Sherman, W. (1990). What happens to patients after five years of intensive case management stops? Hospital and Community Psychiatry, 41, 175±179. McCrum, B. W., Burnside, L. K., & Duffy, T. L. (1997). Organising for work: A job clinic for people with mental health needs. Journal of Mental Health, 6, 503±513. Mechanic, D. (1989). Medical sociology: Some tensions among theory, method, and substance. Journal of Health and Social Behaviour, 30, 147±160. Mechanic, D., & Aiken, L. (1987). Improving the care of patients with chronic mental illness. New England Journal of Medicine, 317, 1634±1638. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change. New York: Guilford Press. Mitchell, S., & Birley, J. L. T. (1983). The use of ward support by psychiatric patients in the community. British Journal of Psychiatry, 142, 9±15. Moore, E., Kuipers, E., & Ball, R. (1992). Staff±patient relationships in the care of the long-term mentally ill. Social Psychiatry and Psychiatric Epidemiology, 27, 28±34. Morrisey, J. P., Calloway, M., Bartico, W. T., Ridgely, M. S., Goldman, H. H., & Paulson, R. (1994). Local Mental Health Authorities and service system change: Evidence from the Robert Wood Johnson Foundation Program on chronic mental illness. Millbank Quarterly, 72, 49±80. Mowbray, C. T., Moxley, D. P., Thrasher, S., Bybee, D., McCrohan, N., Harris, S., & Clover, G. (1996). Consumers as community support providers: Issues created by role innovation. Community Mental Health Journal, 32, 47±67. Muijen, M., Marks, M., Connolly, B., Andini, B., & McNamee, G. (1992). The Daily Living Programme. Preliminary comparison of community versus hospitalbased treatment for the seriously mentally ill facing emergency admission. British Journal of Psychiatry, 160, 379±384. Nehring, J., Hill, R. G., & Poole, L. (1993). Work, empowerment and community: Opportunities for people with long-term mental health problems. London: RDP. NHS Executive (1996). 24 hour nursed care for people with severe and enduring mental illness. Leeds, UK: NHS Executive. Perkins, R., Buckfield, R., & Choy, D. (1997). Access to employment: A supported employment project to enable mental health service users to obtain jobs within mental health teams. Journal of Mental Health, 6, 307±318. Powell, R., & Slade, M. (1996). Defining severe mental illness. In G. Thornicroft & G. Strathdee (Eds.), Commissioning mental health services (pp. 13±27). London: HMSO. Pozner, A., Ng, M. L., Hammond, J., & Shepherd, G. (1996). Working it outÐcreating work opportunities for

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.24 Somatoform Disorders GEORG H. EIFERT and CARL W. LEJUEZ West Virginia University, Morgantown, WV, USA and THEO K. BOUMAN University of Groningen, The Netherlands 6.24.1 CLINICAL PICTURE

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6.24.1.1 DSM-IV Classification 6.24.1.2 Disease, Illness, and Somatization

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6.24.2 HISTORICAL PERSPECTIVES AND DIAGNOSTIC CHANGES 6.24.2.1 6.24.2.2 6.24.2.3 6.24.2.4 6.24.2.5

6.24.3 PREVALENCE, COURSE, AND DEVELOPMENT 6.24.3.1 6.24.3.2 6.24.3.3 6.24.3.4 6.24.3.5

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Somatization Disorder Hypochondriasis Pain Disorder Conversion Disorder Body Dysmorphic Disorder

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Somatization Disorder Hypochondriasis Pain Disorder Conversion Disorder Body Dysmorphic Disorder

6.24.4 PROBLEMS OF DIFFERENTIAL DIAGNOSIS AND COMORBIDITY 6.24.4.1 Somatoform Disorders vs. General Medical Conditions 6.24.4.2 Differentiating Somatoform Disorders 6.24.4.2.1 Somatization disorder vs. hypochondriasis 6.24.4.2.2 Somatization disorder vs. pain disorder 6.24.4.2.3 Somatization disorder vs. conversion disorder 6.24.4.2.4 Hypochondriasis vs. body dysmorphic disorder 6.24.4.3 Relation Between Somatoform Disorders and Depression 6.24.4.4 From Differential Diagnosis to Dimensional Classification 6.24.4.4.1 Hypochondriasis and disease fear: a dimensional perspective 6.24.4.4.2 Relation between hypochondriasis and anxiety disorders

549 549 550 550 550 550 550 551 551 551 552

6.24.5 CONTEMPORARY THEORETICAL PERSPECTIVES

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6.24.5.1 Dysfunctional Processes in the Somatoform Disorders 6.24.5.1.1 Abnormal illness behavior 6.24.5.1.2 Perception and attention 6.24.5.1.3 Deficits in emotion processing (alexithymia) 6.24.5.2 Disorder-specific Theoretical Models 6.24.5.2.1 Hypochondriasis 6.24.5.2.2 Pain 6.24.5.3 Future Challenge: Integrative Biobehavioral Theories

553 553 553 554 554 554 555 556

6.24.6 TREATMENT OF SOMATOFORM DISORDERS

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6.24.6.1 Somatization Disorder

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544 6.24.6.2 6.24.6.3 6.24.6.4 6.24.6.5

Somatoform Disorders 559 559 560 560

Hypochondriasis Pain Disorder Conversion Disorder Body Dysmorphic Disorder

6.24.7 CONCLUSIONS

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6.24.8 REFERENCES

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6.24.1 CLINICAL PICTURE Many individuals present to medical practitioners with physical complaints for which no medical explanation can be found. For instance, a European study (van Hemert, Hengeveld, Bolk, Rooijmans, & Vandenbroucke, 1993) found that among 191 new referrals to a general medical outpatient clinic, 52% of patients had symptoms that ultimately remained unexplained. An earlier Australian study reported that of 95 patients visiting a general practitioner and presenting with somatic complaints, 41% had no demonstrable somatic pathology (Pilowsky, Smith, & Katsikitis, 1987). Comparable percentages have been reported in other studies from different countries investigating unexplained symptoms of patients with abdominal pain (Harvey, Salih, & Read, 1983) and chest pain (Eifert, 1992; Mayou, Bryant, Forbar, & Clark, 1994). Although many of these patients will be satisfied with negative medical examination results, and some reassurance to that effect, a significant subgroup will anxiously continue to ruminate about the possibility of suffering from a yet-undiagnosed physical disease. They are likely to continue to seek help for the same or different physical symptoms, demand more physical examinations and specialist referrals, undergo costly laboratory tests, and, in some cases, even end up on an operating table (Warwick & Salkovskis, 1990). Despite the high prevalence of ambiguous and unexplained physical problems, somatoform disorders have received only minimal research attention and are poorly understood. A major reason for this relative lack of knowledge is that persons with such problems are typically reluctant to see a psychologist and prefer to remain within the medical service system. As a result, they have literally evaded the attention of clinical psychologists. We have organized our discussion in this chapter around the categories and classification put forward in the Diagnostic and statistical manual of mental disorders (4th ed., DSM-IV; American Psychiatric Association [APA], 1994). There is considerable overlap between somatoform disorders and several of the anxiety disorders. We will therefore make an attempt to

move beyond DSM categories toward a more function-based dimensional perspective of the problems of persons who present with either unexplained somatic symptoms or excessive concerns over physical symptoms. We believe that such an approach is clinically more beneficial because it provides information that is directly useful for the design of clinical interventions.

6.24.1.1 DSM-IV Classification The present classification of somatoform disorders stems from the DSM-III taskforce decision to eliminate the concept of neurosis because of its etiological connotations. This change resulted in disorders previously classified in one category as neuroses (anxiety neurosis, neurotic depression, hypochondriasis, and hysteria) to be redefined and reclassified in four separate DSM categories: anxiety disorders, mood disorders, somatoform disorders, and dissociative disorders (Murphy, 1990). According to DSM-IV (APA, 1994), the common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition (hence, the term somatoform) but are not fully explained by a general medical condition, the direct effects of substance, or by another mental disorder. Physical symptoms result in substantial personal, social, and occupational impairment, and are not feigned or voluntarily produced, as in malingering or factitious disorder. DSM-IV distinguishes between six somatoform disorders: somatization disorder, undifferentiated somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. These disorders can be categorized under two larger headings of the classical ªhysterical disordersº and ªpreoccupation disorders.º Hysterical disorders involve actual loss or alteration in bodily functions as in the case of somatization disorder, conversion, and pain disorder. Reports of suffering often exceed symptom reports of patients with known medical illnesses. Patients with hysterical disorders typically experience no anxiety, whereas persons with preoccupation disorders are excessively concerned that there is something

Clinical Picture physically wrong with their body either in terms of disease (hypochondriasis) or in terms of the shape and size (body dysmorphic disorder). The general features of each of these disorders will be outlined below. Somatization disorder is characterized by multiple physical complaints without clear or known physical causes. The condition may last for many years and, in some cases, extend over the entire adult life-span. To make the diagnosis, an individual needs to present with a history of pain related to at least four different sites or functions (e.g., head, back, abdomen, joints), two gastrointestinal symptoms (e.g., diarrhea, food intolerance), one sexual symptom (e.g., irregular menses, indifference to sex), and one pseudoneurological symptom (e.g., poor balance, numbness, paralysis). These symptoms lead to frequent and multiple medical consultations, complex medical history, and to alterations of the person's lifestyle. Physical and laboratory findings cannot detect a plausible medical condition to be the cause of the symptoms, and if a cause exists, the patient's reaction seems to be in excess of what would be expected. Hypochondriasis is characterized by unjustified fears, suspicions, or convictions that one has a serious and often fatal illness such as heart disease, cancer, or acquired immune deficiency syndrome (AIDS). Patients frequently seek reassurance, check their bodies, and avoid illness-related situations. Merely informing patients of the absence of a disease process, or explaining the benign nature of the symptoms, only results in temporary reassurance which is followed by renewed worry over symptoms and continuing overuse of medical services (Salkovskis & Warwick, 1986). Pain disorder is characterized by severe acute or chronic pain in one or more body parts. The pain is not easily understood, or cannot be fully accounted for, by a known medical condition. Pain is ipso facto a subjective phenomenon and psychological factors such as mood, anxiety, and attention may be involved in the onset, maintenance, or exacerbation of pain and complicate differential diagnosis. Pain is considered acute when it exists for less than six months and chronic when it persists beyond six months. Chronic pain, in particular, is often associated with major changes in behavior such as decreased activity and somatic preoccupation (Pilowsky, Chapman, & Bonica, 1977). Conversion disorder is characterized by symptoms suggesting a neurological disorder, although appropriate medical investigations fail to identify a neurological or general medical disorder. At times, symptoms may even be inconsistent with general neurological knowl-

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edge. DSM-IV describes four subtypes with (i) motor symptoms or deficits (e.g., paralysis), (ii) seizures of convulsions, (iii) sensory symptoms or deficits (e.g, blindness, anesthesia, and aphonia), and (iv) a mixed presentation. Some patients show an indifference or lack of worry about their symptoms (la belle indifference). An important requirement for the diagnosis is the temporal relation between conversion symptoms and a psychological stressor such as acute grief or victimization. Patients are typically unaware of the psychological basis for their symptoms and report being unable to control them. Body dysmorphic disorder (BDD) is characterized by a preoccupation with an imagined or exaggerated body disfigurement or an excessive concern that there is something wrong with the shape or appearance of one's own body parts. The perceived defect or abnormality is generally not or hardly noticeable to others. Objects of concern typically refer to the face (nose, mouth, eyes, teeth), head (hair thinning), sexual characteristics (size of penis, breasts), or general body appearance (too long or too short, ugliness). Other concerns may involve scars, wrinkles, or body odor. Cognitive features are excessive preoccupation, intrusive thoughts, and sometimes ideas of reference. On a behavioral level, features include avoidance (e.g., of body exposure, direct social contact, talking about the problem, looking in the mirror), camouflaging or concealing of imagined deformities (wearing a hat or glasses), excessive grooming and checking, and reassurance seeking.

6.24.1.2 Disease, Illness, and Somatization Disease is often described as the presence of objective biological abnormalities in the structure and/or function of bodily organs and systems. Illness refers to the subjective perception of being unwell, and may be unrelated to the presence of an objectifiable disease. The sick role is a sociological construct initially put forward by the American sociologist Talcot Parsons pertaining to a role granted to an individual by society with accompanying privileges (e.g., staying home from work) and obligations (complying with medical regimens). Pivotal to the somatoform disorders is the phenomenon of somatization, defined by Lipowsky (1988, p. 275) as ªa tendency to experience and express psychological distress in the form of somatic symptoms which the individual misinterprets as significantly serious physical illness and seeks medical help for them.º Rather than referring to a discrete group of disorders, this definition reflects the current

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Somatoform Disorders

opinion of somatization as a complex psychopathological process that may be involved in a variety of clinical problems (cf. Kellner, 1986). Psychosomatic disorders have traditionally been regarded as medical conditions in which psychological factors play a role. The concept of psychosomatic disorders is misleading, however, because it presupposes a special class of somatic disorders of psychogenic etiology (Lipowsky, 1988). A conceptually more neutral concept is that of ªfunctional somatic symptoms,º which Kellner (1986) defined as somatic symptoms that are not attributed to organic pathology demonstrable by physical examination or routine laboratory testsÐalthough transient physiological changes may be found in some of the disorders or can be detected by special techniques such as measurement of bowel contractions or of changes in striated muscle tension. Conceptual proliferation and confusion dominate the field of somatization and somatoform disorders. Many concepts are used interchangeably or remain ill-defined in research and clinical practice. Despite considerable comorbidity, and even phenomenological overlap between psychological and somatic disorders, Cartesian dualism is still implicitly or explicitly influential in clinical practice. This may, in part, be due to the traditional division of labor between medical and psychological disciplines, each claiming (or hoping) to answer some of the questions in the mind±body realm. Such reductionist models, however, are a serious obstacle to a more comprehensive understanding of somatoform disorders.

6.24.2 HISTORICAL PERSPECTIVES AND DIAGNOSTIC CHANGES Early views of somatoform disorders assumed that these disorders have common roots and are somehow related to the female reproductive system. The French neurologist Charcot (1825±1893) demonstrated that ªhysterical conversions,º involving symptoms such as convulsions and paralysis, could be induced by hypnotic techniques. He assumed that conversions originate from mental rather than physical processes. Physical symptoms were regarded as a defense mechanism against unacceptable unconscious conflicts where massive repression forces psychic energy to be transformed into bodily symptoms. Although specific psychodynamic notions have been eliminated from the current DSM-IV, conflict is still believed to be involved in some of the somatoform disorders. For instance, in the case of conversion disorders ªpsychological factors

are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressorsº (APA, 1994, p. 457). 6.24.2.1 Somatization Disorder Somatization disorder is the current term for what is arguably the oldest mental health diagnosis, ªhysteria.º More than 2000 years ago, the ancient Greeks believed that multiple somatic symptoms were caused by the uterus wandering through the female body. In the middle of the nineteenth century, the French physician Briquet described a polysymptomatic somatic condition (ªBriquet's syndromeº), which was redefined in the 1950s as somatization disorder (cf. Bass & Murphy, 1990) and became the basis for the current diagnostic entity. 6.24.2.2 Hypochondriasis Hypochondriasis is a Greek word meaning ªbelow the cartilage.º The ancient Greeks derived the concept of hypochondriasis from humoral theories of disease and considered it a special form of melancholia resulting from an excess of black bile. In the seventeenth century, Thomas Sydenham, an English physician, argued that hypochondriasis occurred only in men and was equivalent to hysteria occurring in females. Also around this period, Descartes proposed that the mind and body were separate entities, and there could be no causal relation between the two. Subsequent psychodynamic views suggested that hypochondriacal patients direct their libido inwards, whereas healthy persons typically direct their libido at external objects. Eventually, internally directed libido would build up and result in physical symptoms (Freud, 1956). 6.24.2.3 Pain Disorder Throughout history, there has been considerable speculation concerning the nature and cause of pain. For instance, Aristotle viewed pain as an emotion as opposed to a sensation, Descartes viewed it as a result of physical stimuli impinging upon the body, Epictetus viewed it as the result of cognitive activity, and religious leaders viewed it as a test of faith imposed by god or punishment for sins (Turk, Meichenbaum, & Genest, 1983). A commonality of these early theories was a unidimensional view of pain. Theories were based either upon organic or psychological causes, and few attempted to integrate the two. It was not until the twentieth

Prevalence, Course, and Development century that Cartesian dualism was seriously questioned and multidimensional theories of pain began to develop. 6.24.2.4 Conversion Disorder The origin of the contemporary concept of conversion disorder can be traced back to the Middle Ages when ªconversioº referred to diseases caused by a ªsuffocation of the womb.º Freud considered conversion a form of defense in which the resulting symptoms were fixations of physical patterns relating to events at the time of a patient's (sexual) trauma (Mace, 1992). Primary gain was seen as the warding off of these forbidden impulses, whereas secondary gain was the attention and privileges patients received. The loss of bodily functions in conversion disorder was thought either to be the direct effect of the trauma or to symbolize the unconscious conflict. 6.24.2.5 Body Dysmorphic Disorder The term ªdysmorphophobiaº was coined in the late nineteenth century by the Italian psychiatrist Enrico Morselli (cf. Berrios & Kan, 1996). Based upon his clinical observations, Morselli described a condition in which there is a sudden onset and subsequent persistence of an idea that the body is (or might become) deformed. Morselli stressed the obsessive nature of this condition and the strong desire to check the perceived body abnormality. Although Morselli described his patients as being fearful about their deformities, more recent investigations (e.g., Fava, 1992a) could not substantiate the presence of phobic anxiety in this condition. As a result, the term dysmorphophobia was abandoned in DSMIV and replaced with the diagnosis of body dysmorphic disorder (cf. Bass & Murphy, 1995). 6.24.3 PREVALENCE, COURSE, AND DEVELOPMENT There is a preponderance of studies showing that the presentation of symptoms for which no demonstrable organic pathology can be found is a common occurrence in a variety of medical settings (Pilowsky et al., 1987; van Hemert et al., 1993). Yet the exact prevalence of somatoform disorder is still unclear. This is largely due to the fact that studies frequently did not adequately differentiate between somatoform and related disorders (e.g., anxiety, depression), and epidemiological studies have used various diagnostic criteria and different samples (cf. Kellner, 1986). Although systematic knowledge is lack-

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ing, factors such as parental rearing and childhood development, stressful life events, high negative affect, and aspects of the relationship and communication between patients and doctors have been related to the development of somatoform disorders (e.g., Bass & Murphy, 1990; Craig, Boardman, Mills, Daly-Jones, & Drake, 1993). 6.24.3.1 Somatization Disorder Somatization disorder is a relatively rare phenomenon with recent community studies citing prevalence rates between 0.4% and 0.7% (cf. Bass & Murphy, 1990). Its onset is in early adulthood, course is often chronic, and prognosis is generally regarded as poor. Somatization is associated with frequent absences from work or school, overuse of medical care, and excessive use of drugs and alcohol (APA, 1994). In recent years sexual abuse and traumatization have been cited as a precursor of somatization disorder (Salmon & Calderbank, 1996). For instance, female psychiatric patients with somatization disorder have reported more sexual and physical abuse than patients with other disorders (Pribor, Yutzy, Dean, & Wetzel, 1993). 6.24.3.2 Hypochondriasis Most prevalence research related to hypochondriasis has been conducted in some type of medical or psychiatric setting and results have been inconclusive (cf. Iezzi & Adams, 1993). Research has been impeded by the use of different definitions of hypochondriasis. For example, Kenyon (1976) used a strict definition and determined that 3±14% of patients in a medical setting were hypochondriacal. With regard to illness fears, Agras, Sylvester, and Oliveau (1969) interviewed 325 randomly selected subjects from the general population and found that 16% had fears of illness and 3.1% qualified as having an illness phobia. Moreover, individuals with frequent exposure to medical settings (e.g., medical students) appear to have increased health concerns (Hunter, Lohrenz, & Schwartzman, 1964; Jacob & Turner, 1984). The onset of hypochondriasis is frequently in early adulthood. Although symptoms may wax and wane, the course is typically chronic and the condition frequently takes a dominant role in the person's life and relationships. In children, somatic complaints and attention to physical symptoms have been shown to be influenced by attention received from parents (Mechanic, 1964). In addition, adult patients who rate themselves as having high

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hypochondriacal concerns describe their parents as more caring and overprotective than patients with other psychiatric disorders (Parker & Libscombe, 1980). Studies also found that somatic symptoms of child and adult hypochondriacal patients resemble those of their parents (Apley, 1958). An individual's perception of and exposure to physical symptoms and disease in the family, in combination with parental attitudes towards illness influencing the development of hypochondriacal concerns in children (Eifert, 1992; Flor, Birbaumer, & Turk, 1990; Kellner, 1985). These concerns are likely to continue into adulthood, particularly when persons experience symptoms that they cannot easily explain or understand. For instance, Eifert and Forsyth (1996) found that exposure to heart disease in parents may make observing children more vulnerable to developing fears of heart disease. Furthermore, the death or terminal illness of a relative or friend has also been shown to precipitate hypochondriacal fears and behaviors with developing symptoms often resembling the deceased relative's symptoms (Eifert, Hodson, Tracey, Seville, & Gunawardane, 1996; Parkes, 1972). Finally, sexual trauma has also been linked to the development of excessive health anxiety. Barsky, Brener, Coeytaux, and Cleary (1995) found that hypochondriacal hospital outpatients recalled more childhood trauma (parental upheaval, sexual trauma, and beatings) before the age of 17 years than a patient control group. 6.24.3.3 Pain Disorder The exact prevalence of pain disorder is unknown, but it appears to be relatively common and may occur in adults of all ages. For example, pain is the most common complaint of individuals presenting to a physician (Ford, 1995). The proliferation of special pain clinics could be seen as another indication of the high number of pain patients seeking professional help. According to DSMIV (APA, 1994) estimates, in any given year, 10±15% of adults in the United States have some form of work disability due to back pain alone. A study of internal medicine private practice patients found that 13% of patients suffered from chronic pain (Margolis, Zimny, & Miller, 1984). Using a sample of HMO enrollees, von Korff, Dworkin, and LeResche (1990) observed that 45% of individuals reported persistent or recurrent pain with 8% reporting severe pain and 2.7% reporting severe pain that limited their normal activity. Although research aimed at determining the prototypical pain patient continues (cf. Gamsa, 1994), there is no compelling evidence that

shows pain patients as a homogeneous and separate group from individuals without pain (Love & Peck, 1987; Turk & Flor, 1984; Turk & Salovey, 1984). Consequently, in the place of uniformity, many researchers have begun to look for subgroups with different psychological profiles (Armentrout, Moore, Parker, Hewett, & Feltz, 1982; Jensen, Turner, Romano, & Karoly, 1991). Apart from a high frequency of prior physical abuse, sexual abuse, and other trauma, occupational factors play an important role. For instance, overuse of a body part has been shown to lead to specific pain syndromes (Newmark & Hochberg, 1987; Schuldt, Eckholm, Harms-Ringdahl, Aborelius, & Nemeth, 1987). 6.24.3.4 Conversion Disorder Isolated conversion symptoms are believed to be fairly common and symptoms often disappear after a relatively brief period. In contrast, the diagnosis of conversion disorder is rare and difficult to establish with estimates ranging between 0.001% and 0.3% (APA, 1994). One reason is that symptoms seemingly indicative of conversion disorder are later discovered to be linked to a gradually developing, physical (neurological) disease such as a brain tumor or multiple sclerosis (cf. Fishbain & Goldberg, 1991). Although this condition may occur at any age, onset is typically in late childhood or early adulthood. Onset is often sudden and in response to conflicts or stressful situations such as unresolved grief and sexual trauma. Emotional stress was found to be present before the onset of conversion in 87% of the 53 outpatients in an Indian study by Sharma and Chaturvedi (1995). According to DSM-IV (APA, 1994), conversion is five times more common in women than in men and more common in persons of lower socioeconomic status with limited medical or psychological knowledge. 6.24.3.5 Body Dysmorphic Disorder The prevalence of BDD is largely unknown, but preoccupation with body image and dissatisfaction with some aspect of one's appearance are believed to be widespread in the general population. In fact, according to DSM-IV (APA, 1994), BDD may be more common than was previously thought and under-recognized in settings where cosmetic procedures are performed. In terms of a diagnosable condition, Rosen (1995) found that about 1% of a community sample met criteria for BDD with virtually no gender differences in prevalence. Onset of BDD may be gradual or sudden, and its course is generally continuous and chronic,

Problems of Differential Diagnosis and Comorbidity though fluctuating in intensity. At present, we have only fragmentary and anecdotal reports on etiological factors, and no prospective longitudinal study of BDD has been undertaken (Rosen, 1995). Nevertheless, BDD is thought to start in adolescence when preoccupation with physical appearance is very common. Sociocultural factors influencing people's attitudes towards and dissatisfaction with their bodies seem to play a role in determining the extent to which a real or imagined physical abnormality becomes a cause for concern and preoccupation. Perfectionistic features seem to be related to BDD (Frost, Williams, & Jenter, 1995).

6.24.4 PROBLEMS OF DIFFERENTIAL DIAGNOSIS AND COMORBIDITY The diagnostic validity of the somatoform disorders has been questioned repeatedly and for good reason. Even the authors of the DSMIV concede that the grouping of these disorders in a single section is based on clinical utility rather than on assumptions regarding shared etiology or mechanisms (APA, 1994). Murphy (1990) indicated that the disorders are not qualitatively distinct but rather merge into each other, making distinctions between individual somatoform disorders hard to define. As an example, pain may occur in any of the somatoform disorders. Ambiguous normative criteria such as ªthe person's concern is markedly excessive,º ªgrossly in excess of what would be expected,º and ªslight physical abnormalityº create further problems. The distinction between BDD and normal concerns about appearances are as difficult to make as the distinction between BDD and delusional disorder (somatic subtype). The relation and distinction between somatoform disorders and personality disorders have also recently been questioned (Bass & Murphy, 1995; Tyrer, 1995). On the other hand, DSM criteria are very selective and will only allow diagnosing patients with a particular symptom profile (Fink, 1996). In view of all these problems, Fava (1992b) suggests that the concept of abnormal illness behavior should probably replace the somatoform disorders rubric because it provides a more useful conceptual framework for disorders that would otherwise be scattered and unrelated in the DSM or that would not find a place at all. Fink (1996) makes a similar point arguing that researchers have been preoccupied with physical symptoms in search for reliable and valid diagnostic criteria for somatization, but have neglected the psychopathology, behavior, and other aspects of the problem. A simplistic reliance upon physical symptoms is question-

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able for diagnosing somatoform disorders and useless for the purpose of designing treatments. Symptom-focused diagnoses may be artifacts biased by patient suggestibility and a clinician's preoccupation for some disease. Rather than the presence of a specific set of physical symptoms, it is the way a patient interprets, experiences, and responds to a symptom that constitutes psychopathology (Fink). In particular, a somatic attributional style (Robbins & Kirmayer, 1991) may contribute to the translation of personal and social problems into physical symptoms, and prompt patients to present with somatic distress and request somatic treatments. In sum, the diagnostic validity of somatoform disorders in relation to each other as well as to other clinical syndromes is problematic. The problem even extends to the distinction between the somatoform disorders and general medical conditions. Using a categorical classification system, diagnostic distinctions cannot be made to a satisfactory degree. What is needed is a multidimensional classification system incorporating psychological, somatic, and social dimensions (cf. Mayou, Bass, & Sharpe, 1995). Nonetheless, in the present diagnostic criteria the origin of somatic complaints assumes an important role for differential diagnosis. DSM-IV distinguishes symptoms as part of a ªreal diseaseº (general medical condition) from symptoms that are under a patient's voluntary control or intentionally produced. We will therefore briefly discuss attempts to distinguish somatoform disorders from each other and from a general medical condition. The interesting relation between somatoform and anxiety disorders will then be discussed to show how a classification system that focuses on the functions of maladaptive health-related behaviors, and defines problems in a dimensional rather than categorical manner, may be more beneficial for clinicians, researchers, and patients alike. Such an approach avoids the pitfalls of putting people into distinct categories and provides information that is directly useful for the design of clinical interventions. 6.24.4.1 Somatoform Disorders vs. General Medical Conditions The presence of a general medical condition that could account for the presenting symptoms must be carefully examined and considered in every case where physical problems are the focus of a patient's complaints. Symptoms such as pain or fatigue may be related to a wide array of problems ranging from normal sensations to fatal diseases. Health professionals are very

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much aware of the danger of misdiagnosing a somatoform disorder and of missing the presence of actual physical problemsÐparticularly diseases with a slow or diffuse onset such as multiple sclerosis, brain tumors, or systemic lupus. Some patients diagnosed with somatoform disorders or ªfunctional problemsº are ultimately diagnosed with a demonstrable medical condition and must be regarded as initial false-positives (for a particularly poignant example, see Fishbain & Goldberg, 1991). On the other hand, advances in medical diagnostic procedures (e.g., PET and magnetic resonance imaging (MRI) scans) have resulted in more accurate diagnostic decisions and reduced the number of false-positive diagnoses of somatization disorder (Kent, Tomasson, & Coryell, 1995). Any diagnosis of somatoform disorders should be made with caution and only after careful physical examination. This recommendation is also supported by the fact that it is occasionally difficult for physicians and psychologists alike to determine the ªtrueº nature of somatic complaints. In a study of 200 successive patients undergoing cardiac catheterization, it was found that neither standard medical tests before catheterization nor standard psychological questionnaires alone were able to discriminate reliably chest pain patients with coronary artery disease from patients without heart disease. Diagnostic accuracy only improved when cardiac catheterization was considered along with results from psychological assessments (Eifert, Edwards, Thompson, Haddad, & Frazer, 1997). In addition, there is at times a reciprocal relationship between health anxiety and somatic symptoms. For instance, Salkovskis (1996) describes how the very safety-seeking behaviors designed to reduce anxiety frequently increase the symptoms that are the focus of anxiety. He cites the example of patients who palpate or rub lumps until they swell and cause pain. Several authors also point to potential pathophysiological mechanisms that may underlie unexplained physical symptoms. Sharpe and Bass (1992) describe various pathophysiological mechanisms in abdominal pain, chest pain, chronic fatigue, breathlessness, and irritable bowel syndrome that can be detected by routine or advanced medical evaluation. For instance, symptoms can be due to excessive physiological activity (e.g., smooth-muscle contraction, striated-muscle contraction, changes in endocrine secretion and in blood flow) that may be accentuated by stress and intense emotions. Both in fairness to the patient, and to design the most appropriate intervention, we should be careful in the use of such terms as unexplained

physical symptoms and functional defects. Terms such as ªnonorganic . . .º should be avoided completely. 6.24.4.2 Differentiating Somatoform Disorders Differentiating the various somatoform disorders using DSM-IV criteria is difficult because criteria are vague and there is considerable overlap of symptoms, Nonetheless, several distinctions can be made and are briefly discussed below. 6.24.4.2.1 Somatization disorder vs. hypochondriasis In somatization disorder the patient's attention is directed at the somatic symptoms themselves, whereas in hypochondriasis symptoms are generally less elaborate and the patient is concerned about a possible underlying illness (Murphy, 1990). As a result, hypochondriacal patients experience higher levels of anxiety, whereas patients with somatization disorder experience lower levels of anxiety or no anxiety at all. 6.24.4.2.2 Somatization disorder vs. pain disorder Although pain symptoms are included in the diagnostic criteria for somatization disorder, symptoms other than pain must be present before a diagnosis can be assigned. In contrast, pain is the predominant (and frequently exclusive) focus of the clinical presentation of a person with pain disorder. 6.24.4.2.3 Somatization disorder vs. conversion disorder A key difference is the sheer number of symptoms. A person with somatization disorder, by definition, must report at least eight symptoms of four different types, whereas a person with conversion disorder typically manifests only one symptom. 6.24.4.2.4 Hypochondriasis vs. body dysmorphic disorder Although hypochondriasis and BDD share some features (e.g., bodily preoccupation, repetitious body checking, reassurance seeking, and medical consultations), individuals engage in these behaviors for different reasons. Persons with hypochondriasis are afraid of serious illness, whereas persons with BDD are concerned about the physical appearance of their body.

Problems of Differential Diagnosis and Comorbidity 6.24.4.3 Relation Between Somatoform Disorders and Depression There is a high comorbidity of all somatoform disorders with depression and to a lesser extent with dysthymic disorder. For instance, in a prospective study of 30 psychosomatic clinic inpatients, Rief, Hiller, Geissner, and Fichter (1995) found high lifetime comorbidity between various somatoform disorders and both depression (86%) and anxiety (43%). Remission rates were higher when somatoform disorders were not accompanied by other psychiatric disorders (e.g., anxiety, depression, or addiction) than in cases with comorbidity. In addition, the presence of somatoform disorders increased the risk for other psychiatric conditions (Rief et al.). Several studies found a striking relation between pain and major depression or dysthymic disorder but the specifics of that relation remain elusive (Chaturvedi & Michael, 1986; France, Krishnan, Houpt, & Maltbie, 1984; Turk, Okifuji, & Scharff, 1995). 6.24.4.4 From Differential Diagnosis to Dimensional Classification Despite considerable degree of overlap in the symptoms of persons with hypochondriasis, disease phobia, and panic disorder, also reflected in reports of high comorbidity rates (Warwick & Salkovskis, 1990), our understanding of the relation between somatoform and anxiety disorders is poor (Barlow, 1988; Forsyth & Eifert, 1998). In the following discussion, we will adopt a dimensional approach to understanding illness-related concerns that might be useful for both assessment and treatment purposes. Delineating points of overlap and differences is also an important first step toward designing more thorough empirical investigations of the subject. 6.24.4.4.1 Hypochondriasis and disease fear: a dimensional perspective According to Pilowsky's (1967) classic study, hypochondriasis has three dimensions: disease phobia, disease conviction, and bodily preoccupation. These dimensions are still the basis for the current DSM criteria for hypochondriasis. Unfortunately, the DSM definition fails to distinguish hypochondriasis as a fear of disease from a conviction of having a disease. This failure could, at least in part, account for the ambiguity in the use of the diagnostic label of hypochondriasis (cf. Eifert, 1992). Fear of having a physical disease has quite different theoretical, diagnostic, and therapeutic implications from a conviction of being seriously ill,

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regardless of whether the conviction is accompanied by fear or not. A clear separation of the different dimensions of hypochondriasis may contribute to a better understanding of such problems and result in more appropriate treatments. We view hypochondriasis as a syndrome where persons present with problems that fall on a continuum along four dimensions. (i) Preoccupation with the body and its functioning. Excessive awareness of and interest in bodily sensations and functioning, with or without physical complaints, constitutes what Starcevic (1988) aptly called ªthe hypochondriacal core.º Such bodily preoccupation, especially when coupled with somatic complaints, may produce a state of somatic uncertainty and form the basis for the other three dimensions of the disorder. (ii) Disease suspicion or conviction. The person has the suspicion or is convinced of having a serious physical disease; suspicion and conviction are on a continuum of strength, and in rare cases the conviction may reach delusional intensity. (iii) Disease fear. The person fears having a serious physical disease. (iv) Safety-seeking behaviors. The function of behavior such as repeated requests for medical examinations and tests, bodily checking, verbal complaints, and seeking reassurance is to reduce worry and anxiety over physical illness (Eifert, 1992; Salkovskis, 1996; Warwick & Salkovskis, 1990). Although a person could score highly on any one or all four dimensions, bodily preoccupation and disease suspicion/conviction are most central to hypochondriasis. As indicated, disease suspicion/conviction may or may not be accompanied by fear of the suspected disease. Clinically, this feature is most apparent in patient's resistance to medical reassurance. For instance, Fava and Grandi (1991) indicated that patients may continue to be extremely worried about their health even though their fear of suffering from a specific disease may be eliminated by a satisfactory medical examination. In other words, a patient's morbid preoccupation with disease may continue in the absence of any specific disease phobia maintaining and prolonging a person's suffering and keeping them from consulting a psychologist. Disease phobia is a persistent unfounded fear of suffering from or contracting a disease (Bianchi, 1973, Eifert, 1992) and may occur in the absence of a conviction or suspicion of having a disease. For example, a person may be afraid of having a heart attack or contracting cancer without being convinced or suspicious of having heart disease or cancer. According to

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Fava and Grandi (1991), there are two main clinical characteristics of disease phobia that distinguish it from more general hypochondriasis. One feature is the specificity and temporal stability of symptoms. For instance, it was found that most cardiophobic patients were only afraid of having a heart disease but not of other diseases (Eifert et al., 1996). Even over time, these patients are unlikely to develop fears focused on other organ systems. This specificity led Marks (1987) to view disease phobias as a subtype of hypochondriasis focused on a specific illness. The second feature of disease fears is that they manifest themselves in cue-controlled attacks of shorter durations. For example, a cardiophobic person's fear of having a heart attack becomes salient and particularly strong only in response to the acute experience of chest pain and heart palpitations (Eifert 1992; Eifert et al. 1996). This feature of disease phobias is in contrast to the morbid preoccupations of persons with primary hypochondriasis who constantly worry and ruminate about their health. 6.24.4.4.2 Relation between hypochondriasis and anxiety disorders A discussion of the dimensions of excessive health anxiety raises several questions regarding the relation of this type of anxiety to other anxiety-related problems, which will be discussed next. (i) Comorbidity of disease phobias and hypochondriasis with panic disorder Warwick and Salkovskis (1990) report that 59% of hypochondriacal patients seen in their clinic also met DSM-III-R criteria for panic disorder. Other studies (Beitman et al., 1987; Eifert et al., 1996) found that between 25% and 50% of cardiology persons with heart-focused anxiety also suffer from panic disorder. Panic patients with agoraphobia have been shown to score as high as hypochondriacal patients in areas such as somatic preoccupation, disease phobia, and illness conviction (Noyes, Reich, Clancy, & O'Gorman, 1986). Following treatment, significant reductions in hypochondriasis scores occurred in those panic patients who improved with treatment. Fava, Kellner, Zielezny, and Gurand (1988) also found that before treatment, patients with panic disorder and agoraphobia scored significantly higher on several illness fear and behavior measures than a group of healthy controls. Following the successful treatment of panic, however, these group differences had disappeared.

(ii) Modulation and timing of anxiety Fava and Grandi (1991) describe the relation of disease phobia to hypochondriasis as similar to that of panic disorder to generalized anxiety. This perspective is based on a difference in the modulation and timing of anxiety in disease phobia and panic compared to hypochondriasis and generalized anxiety disorder. As in panic disorder, which is characterized by a sudden surge of aversive sensations and fear that tends to subside within 30±45 minutes, persons with disease phobias tend to experience anxiety attacks of a relatively short duration when exposed to feared cues. In contrast, persons with primary hypochondriasis experience more constant and chronic levels of worry about body sensations and illness, similar to the chronic levels of worry found in generalized anxiety disorderÐ although in both disorders worries and fears may occasionally escalate into a ªcrescendo of panicº (Salkovskis & Clarke, 1993; Warwick & Salkovskis, 1990). In addition, these authors point out that persons with hypochondriasis typically judge the danger they fear to occur at some distant time in the future, whereas panic patients fear an imminent catastrophe. (iii) Misinterpreted symptoms and focus of fear In panic disorder as well as disease phobia, individuals misinterpret autonomic symptoms that are involved in acute anxiety attacks. Persons with disease fears, however, tend to report fewer and less severe panic symptoms (Beck, Berisford, Taegtmeyer, & Bennett, 1990) and their fear is more specific and focused on one organ or organ system (Eifert, 1992; Eifert et al., 1996). Such individuals do not fear the symptoms themselves but what they seem to indicate (i.e., serious disease). On the other hand, persons with panic disorder tend to fear generalized uncontrollable aversive autonomic body sensations, that is, they fear the actual bodily sensations (see Chambless & Graceley, 1989). They also have fewer and less pronounced illness behaviors and beliefs than persons with either disease phobias or hypochondriasis (Eifert, Seville, Antony, Brown, & Barlow, 1992). Hypochondriacal patients are more likely to misinterpret symptoms which are not subject to direct amplification such as lumps, skin rashes, and blemishes (Salkovskis & Clark, 1993), and their fear is focused on these health/disease issues. (iv) Behavioral avoidance Individuals with disease phobia typically cannot avoid the stimuli they fear (pain and

Contemporary Theoretical Perspectives palpitations) and therefore attempt to avoid activities which they believe bring on the dreaded physical symptoms (Eifert et al., 1996). They may also engage in a number of behaviors that are designed to protect their body or a specific organ that they are afraid of damaging. Warwick and Salkovskis (1990) have identified another important difference between hypochondriacal and panic patients in patterns of escape and avoidance related to illness. Hypochondriacal patients have more time to prevent the anticipated disaster by seeking medical attention because the anticipated harm is perceived as much less imminent. In contrast, panic patients are likely to be overwhelmed by the sudden surge of arousal and fear during a panic attack and perceive leaving the situation and their future avoidance as their only option (Salkovskis, 1996). In conclusion, we believe that a dimensional classification system could help overcome the pitfalls of pigeon-holing individuals into existing diagnostic categories. Identifying dimensions that allow a classification of illness behavior based on the function that such behavior serves, rather than its topography, might lead to a better understanding and improved treatments of persons with somatoform problems. Apart from the number and type of physical complaints, some of these dimensions include the presence and extent of preoccupation with body and health, symptom misinterpretation, disease suspicion or conviction, disease fear, safety-seeking approach and avoidance behavior, focus and modulation of worry and fear, and pathophysiological processes. Barlow (1988) noted that classification of any disorder, whether dimensional or categorical, should reliably describe subgroups of symptoms or behaviors that are readily identifiable by independent observers on the basis of operational definitions. There should also be some clinical usefulness or value in identifying these subgroups or dimensions such as predicting specific response to treatment, course of the disorder, and tailoring treatment (Eifert, 1996; Eifert, Evans, & McKendrick, 1990). We hope that a dimensional analysis of somatoform disorders will move us closer toward reaching that goal.

6.24.5 CONTEMPORARY THEORETICAL PERSPECTIVES Although some theoretical models have been advanced in relation to the process of somatization (cf. Kellner, 1991), somatoform disorders are understudied and poorly understood (Barlow, 1988; Hitchcock & Mathews, 1992). As

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cognitive-behavioral concepts predominate contemporary perspectives on somatoform disorders, we will briefly discuss some of these concepts. In terms of specific disorders, we will concentrate on hypochondriasis and pain since much of recent research has focused on these problems. 6.24.5.1 Dysfunctional Processes in the Somatoform Disorders 6.24.5.1.1 Abnormal illness behavior Pilowsky (1993, p. 62) defined abnormal illness behavior as the ªpersistence of a maladaptive mode of experiencing, perceiving, evaluating, and responding to one's own health status, despite the fact that a doctor has provided a lucid and accurate appraisal of the situation and management to be followed (if any), with opportunities for discussion, negotiation and clarification, based on adequate assessment of all relevant biological, psychological, social and cultural factors.º Abnormal illness behavior is not a diagnosis as such, but refers to the disagreement between the doctor and patient about the sick role to which the patient feels entitled (Pilowsky, 1993). Sharpe, Mayou, and Bass (1995) argued that the concept of abnormal illness behavior is not only valuable for understanding patients with functional somatic symptoms but for understanding the behavioral aspects of all illness. 6.24.5.1.2 Perception and attention Cognitive processing of medical information as well as attention to and attribution of symptoms are believed to be central features in all somatoform disorders. Pennebaker (1982) conducted various studies on the role of attention in symptom perception and concluded that the more salient a somatic symptom (and the lower the amount of external distraction), the more likely and more intense the original symptom is perceived. An implication of this finding is that deficient external stimulation may pave the way for an increased attention to somatic symptoms Pennebaker also demonstrated that simply directing a person's attention to bodily sensations increases reports of symptoms. Selective attention to internal stimuli could thus augment somatic concerns. Although attentional bias has been well documented in individuals with anxiety disorders showing that attention is biased towards threat-related stimuli (cf. MacLeod & Mathews, 1991), empirical evidence for this type of bias in somatoform disorders is mixed. Most studies have examined hypochondriacal patients

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(Barsky et al., 1995; Tyrer, Lee, & Alexander, 1980) or normal subjects with high scores on a hypochondriasis scale (Hanback & Revelle, 1978; Hitchcock & Mathews, 1992). In a series of experiments, Hitchcock and Mathews were able to demonstrate enhanced registration and availability of illness information. They also found that hypochondriacal subjects interpreted ambiguous information as threatening, although this bias was applied equally to illness and social ambiguity. By contrast, subjects did not show a bias for making rapid automatic inferences about bodily sensations implying illness. Hitchcock and Mathews rightly caution, however, that it is unclear whether enhanced perceptual sensitivity to illness cues is a cause or consequence of hypochondriacal anxiety. A particular perceptual disturbance in body image has been demonstrated in persons with BDD although the specific processes involved have not been studied in detail. Rosen (1995) proposed an integrative formulation of BDD linking processes such as thinking about the presumed abnormality in appearance with behavioral features such as avoidance of social situations, camouflaging, checking, and undertaking beauty remedies. Preoccupation with the imagined defect is especially salient in social situations and may take on delusional or obsessional qualities.

6.24.5.1.3 Deficits in emotion processing (alexithymia) Alexithymia literally means ªno words for feelings.º The concept refers to a hypothesized communicative function of somatic symptoms. Its key features are a relative constriction of emotional functioning, poverty of fantasy life, and inability to find appropriate words to describe one's emotions (Taylor, Bagby, & Parker, 1991). Alexithymic individuals seem to be vulnerable to mounting tension from undifferentiated states of unpleasant emotional arousal. This vulnerability is presumably caused by a disturbance in the processing of emotional awareness that is believed to interfere with the subject's ability to experience and express emotions. For example, in a sample of normal volunteers, Vingerhoets, Van Heck, Grim, and Bermond (1995) found strong negative correlations between alexithymia and the expression of emotions, daydreams, and fantasies, and planful and rational actions. Bach and Bach (1995) found high alexithymia scores to be predictive of persistent somatization. More recently, the concept of alexithymia has also been discussed in relation to a variety of psychological traumata (Salminen, SaarijaÈvi, & AÈaÈrelaÈ, 1995).

6.24.5.2 Disorder-specific Theoretical Models As indicated, cognitive-behavioral perspectives and research have been helpful in providing a fledgling basis for a better understanding and treatment of persons with somatic problems. Below we will focus on cognitivebehavioral perspectives of hypochondriasis and pain as most recent research has dealt with these problems. 6.24.5.2.1 Hypochondriasis Behavioral theories of excessive health anxiety stipulate that internal cues which have been associated with threat and bodily harm (unconditioned stimuli) can serve as conditioned stimuli (Forsyth, Eifert, & Thompson, 1996; Miller, 1977). In the presence of these stimuli, individuals will begin to exhibit conditioned responses such as anxious behavior and physiological changes. Classically conditioned instances of hypochondriacal behavior can be maintained through operant reinforcement. Somatic complaints may lead to attention, sympathy, and escape from or avoidance of undesirable tasks or situations. Such consequences may reinforce symptom reporting and other hypochondriacal behavior (Kellner, 1985). If somatic complaints are ignored in the patient's home, hypochondriacal behavior in the presence of family and friends may be extinguished, but it may also lead the patient to increase medical assistance-seeking in the hope of receiving attention from a physician instead. These are examples of contingency-shaped behavior, but observers may also learn to exhibit hypochondriacal behaviors through the process of modeling (Craig, 1986) or rulegoverned behavior (Hayes & Wilson, 1994). According to Kellner (1985), hypochondriacal behavior worsens as the conditioning process repeats. As can be seen in Figure 1, cognitive theories of health anxiety emphasize the role of misinterpretations of innocuous bodily changes or of information provided by doctors, friends, or the media. Patients focus on essentially harmless physical sensations, which they consistently misrepresent and misinterpret as indications of physical illness (Barsky & Klerman, 1983; Warwick & Salkovskis, 1990). As a result, symptoms and medical information tend to be perceived as more dangerous than they really are and a particular illness is believed to be more probable than it really is (Salkovskis, 1996). According to Salkovskis, the onset and maintenance of health anxiety involves the complex interaction of several factors. Previous experiences and perception of illness in self and

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POTENTIALLY THREATENING STIMULI bodily variations, medical information

PAST LEARNING past experiences, consequences, and perceptions of illness in self and others; medical (mis)management

APPRAISAL OF THREAT AND COPING SKILLS/ BELIEFS ABOUT BEING ILL probability, outcome, cost-benefits, coping resources

SAFETY-SEEKING BEHAVIOR reassurance seeking, body checking, activity avoidance, self-imposed restrictions

INCREASED AROUSAL/ PHYSIOLOGICAL CHANGES

MOOD CHANGES anxiety, depression

Figure 1 Cognitive-behavioral model of maladaptive illness-related behavior (adapted from Warwick & Salkovskis, 1990, and Salkovskis, 1996; cf. Eifert, 1992).

others (`whenever I had physical symptoms as a child I was taken to the doctorº) are often the root of future hypochondriacal behavior and may result in the formation of dysfunctional beliefs (`bodily symptoms are always a sign that something is wrongº). As a result, harmless incidents or physical symptoms activate these negative assumptions and other catastrophic thoughts (`this is going to get worseº), which in turn lead to behavior changes such as increased safety-seeking and avoidance as well as heightened physiological arousal, anxiety, and depression. Repeated cycles of this kind may lead to an exacerbation of hypochondriacal symptoms and perceptions of oneself as a sick and incapable individual (Salkovskis, 1996).

6.24.5.2.2 Pain According to the behavioral theory of pain developed by Fordyce (1976), pain behavior is often acquired through respondent conditioning (ªsensory painº) and maintained through operant conditioning (ªpsychological painº). Initially, pain is considered to be an overt reflexive response to an antecedent noxious stimulus such as an injury. Following onset,

future pain behavior is subject to selection by consequences. Verbal reports and nonverbal expressions of pain are maintained because of the associated delivery of positive and negative reinforcers. As indicated, pain behavior may be positively reinforced through tangible benefits, attention, or stimulation (i.e., concern or sympathy). Pain behavior may also be negatively reinforced when it results in the avoidance of or escape from undesirable activities or stimulation such as work or unwanted sexual encounters. In the absence of direct exposure to the environmental contingencies, these behaviors may be acquired or taught through modeling (Craig, 1986). Respondent and operant conditioning may interact in the onset and maintenance of pain behavior (Rachlin, 1985). For instance, the avoidance of physical activity can lead to muscle fibers shortening and losing elasticity. This can be quite painful and, as a consequence, persons tend to avoid or escape from physical activity. Such avoidance and escape are negatively reinforced when they lead to a short-term decrease of pain, but avoidance and escape may also result in long-term cost by exacerbating the physical condition of the individual and lead to a vicious circle (Flor et al., 1990). A number of studies have shown

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that pain behavior is susceptible to social reinforcement. For example, Cairns and Pasino (1977) reported that exercise behavior increased when praise was delivered contingently and decreased soon after praise delivery was discontinued. Moreover, pain patients who perceived their wives as solicitous exhibited more pain behavior in the presence of their wives than patients who perceived their wives as nonsolicitous (Flor, Kerns, & Turk, 1987). Although pain is a subjective phenomenon and difficult to quantify, behavioral researchers have attempted to quantify pain behavior. In a choice situation, the relative frequency of responding (either the number of responses or the amount of time responding) allocated to a particular alternative closely approximates the relative frequency of obtained reinforcement for that alternative. This relation is called the matching law (Baum, 1974; Herrnstein, 1970). Applied to pain, the matching law suggests that the frequency of an individual's adaptive behavior (e.g., pain coping without complaining), compared to maladaptive pain behavior (e.g., verbal complaints, facial contortions), will match the relative frequency of reinforcement obtained for each type of behavior. In other words, if maladaptive pain behavior is reinforced more than adaptive behavior, the likelihood of future maladaptive behavior will increase, whereas adaptive pain coping behavior becomes less likely. Conversely, if a patient's maladaptive behavior is reinforced less than adaptive pain behavior, preference will shift to adaptive pain behavior. The matching law is clinically useful because it allows us to quantify how much reinforcement will be necessary to sustain a particular level of a given behavior. Fernandez and McDowell (1995) found the matching law to provide accurate descriptions of pain behavior. Although there are no other studies applying the matching law to pain, the clinical utility of the matching law has been demonstrated in the study of self-injurious behavior (McDowell, 1981, 1982), social behavior (Conger & Killeen, 1974), and disruptive behavior of mentally retarded children (Martens & Houk, 1989). The matching law could provide a promising, more objective approach to quantifying pain behavior. Cognitive-behavioral perspectives emphasize that maladaptive pain behavior is due to negative or unrealistically high expectations about experiencing pain as well as low levels of perceived competence to deal with pain (Schermelleh-Engel, Eifert, Moosbrugger, & Frank, 1997). Apart from the physical characteristics of the pain stimulus, or the amount of tissue damage, differences in coping style are particularly important for the perception of

pain and associated mood states (Turk et al., 1995). Our own research specifically supports the importance of perceived competence for coping with chronic pain, indicating that perceived competence determines how intense persons experience pain, how much they are disturbed by it, and whether they engage in adaptive or maladaptive coping behavior (Schermelleh-Engel et al.). Although the coping process is not systematically affected by the characteristics of the pain stimulus, a person's type of coping behavior affects the impact of the pain stimulus (cf. Asmundson & Norton, 1995). Using path analytic structural equation modeling, we found that coping behavior is directly influenced by a person's perceived level of competence and only indirectly affected by pain intensity and pain-related anxiety and depression. Decreasing competence appears to lead to increasing pain intensity and increasing pain emotions, which, in turn, increase maladaptive behavior. Conversely, individuals who trust in their abilities to cope adequately with pain are more likely to engage in adaptive behavior, irrespective of how anxious they are; such persons also do not suffer as much as individuals with low perceived competence.

6.24.5.3 Future Challenge: Integrative Biobehavioral Theories Throughout this chapter we have alluded to the significant degree of overlap between somatization, hypochondriasis, and pain. Comprehensive theoretical accounts are just beginning to emerge for these problems, but they are impeded by a relative lack of agreement on what precisely somatization refers to. For instance, do persons diagnosed with ªunexplained physical symptomsº (e.g., Speckens et al., 1996) suffer from somatization disorder, hypochondriasis, or are they a mix between the two? Moreover, presenting with unexplained physical symptoms does not imply that there is no medical or other explanation for the symptoms. In some (although certainly not all) cases, an explanation might be found if more sophisticated tests such as MRI or PET scans were conducted. Moreover, there is a significant ªgray areaº that medical colleagues often refer to when they speak of persons who do have some degree of demonstrable pathophysiology. Yet patient symptom reports, or their response to symptoms, seem to be ªexaggeratedº in view of the degree of actual tissue damage or other physical changes. Since neither physicians nor psychologists can adequately pinpoint or understand the symptoms and behavior of such patients from their respective perspective alone,

Treatment of Somatoform Disorders these patients should be approached from a multidisciplinary perspective. Unfortunately, theories that attempt to integrate biological/ medical with psychological knowledge are rare. A notable exception is the psychobiological account of chronic pain, which we will briefly summarize as an example of what more adequate theories for persons with somatic problems might look like in the future. The early physiological views of pain regarded pain simply as a sensation resulting from patterns of stimulation from free nerve endings; pain intensity was believed to be directly proportional to the amount of peripheral nociceptive input related to tissue damage (Dallenbach, 1939). Proposed by Melzack and Wall (1965), the gate control theory (GCT) was one of the first psychophysiological theories to challenge this assertion. According to the GCT, pain is due to the complex interplay of receptors, afferent and efferent processes, and spinal and supraspinal processes. More recent theories (cf. Cailliet, 1993) have expanded the basic concepts of the GCT to relate current information on physiological processes (e.g., the role of acid metabolites and opiate receptors) to psychological factors. An integrative psychobiological theory of chronic pain proposed by Flor et al. (1990) relates concepts and findings from areas such operant, respondent, observational, and cognitive learning and relates them to biological concepts and physiological findings. Flor et al. (1990) propose that pain is a complex response that comprises subjectivepsychological, motor-behavioral, and physiological-organic components. Stress may precipitate and facilitate a particular pain disorder to which the individual is already predisposed on an unlearned or learned basis. The learned aspect of this predisposition consists of a reduced threshold for nociceptive activation due to previous trauma or social learning experiences resulting in a physiological response stereotypy of a specific body system or group of muscles. Stress and pain episodes may trigger a host of autonomic and muscular reactions, particularly sympathetic activation and elevated muscle tension levels. If stress or pain-related muscular contractions occur repeatedly, a number of muscular and sympathetic reflexes lead to increases in muscle tension and to sympathetically mediated vasoconstriction. If the muscular contractions are of sufficient intensity, frequency, and duration, there will not be sufficient blood and oxygen in the affected muscles and algogenic (paininducing) substances will be released. The ensuing pain experience increases muscular and sympathetic hyperactivity and may thus lead to a vicious circle. As these processes also

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increase the sensitivity of chemo-nociceptors, the likelihood of future pain also increases. This feedback circle, in particular, nicely illustrates the interplay between physiological and psychological processes and helps us understand how both physiological changes and the person's response to such changes may interact to create the problems that persons with chronic pain struggle with.

6.24.6 TREATMENT OF SOMATOFORM DISORDERS Psychologically distressed medical patients who present with unexplained somatic symptoms are high users of care and their doctors regard them as frustrating and difficult to treat (Mayou & Sharpe, 1995). There is often a mismatch between the expectations of these patients and their doctors' abilities and communication skills. For instance, Eifert (1992) pointed out that diagnoses such as functional heart problem, nervous heart, atypical chest pain, and pseudoangina can be easily misinterpreted by a cardiophobic patient who is determined to believe that some significant cardiac disease is being described. As a result, healthcare providers often feel frustrated and emotionally drained because these patients are obviously in need of psychological support but resent being referred to a psychologist or psychiatrist. Owing to the overlapping psychological processes involved in the various somatoform disorders, we will first outline treatment recommendations that are applicable to most individuals with any of the somatoform disorders. This discussion will be followed by some specific recommendations and outcome data for individual disorders. Patients often perceive the use of diagnostic labels such as hypochondriasis as an insult because these labels are seen to imply that patient problems are not real and are ªjust in their head.º Accepting and understanding the symptoms rather than refuting or arguing with the patient is therefore the most important condition for engaging the patient in a therapeutic working relationship (cf. Bass & Benjamin, 1993). In the engagement stage of treatment, patients are helped to see that there may be an alternative explanation for the difficulties they are experiencing (Salkovskis, 1996). For instance, although chest pain can be due to coronary artery disease, it can also be caused by hyperventilation-induced chest wall muscle tension (Eifert, 1992). The general treatment strategy is to test such alternative nonmedical or benign medical explanations for symptoms and to conduct therapy in the context

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of an experiment that provides an opportunity for testing alternative hypotheses (Salkovskis, 1996). Rather than merely telling patients there is no ªorganicº reason for their chest pain, an explanation of symptoms that overcomes the nonorganic±organic dualism provides the patient with a more acceptable rationale and reassurance. For instance, to provide a patient with a credible explanation of how anxiety and chest wall muscle tension can result in chest pain, patients may be given a chest-focused relaxation with EMG feedback that literally shows them how they can change their chest tension levels (Eifert, 1996). Salkovskis and Warwick (1986) found that reassurance which only informs the patients that there is nothing organically wrong with their body will actually increase future reassurance-seeking rather than decrease it. On the other hand, appropriate reassurance and feedback that provides the patient with new and alternative explanations is the key to successful treatment, and in some cases, may help prevent the development of chronic somatization problems in the first place. It is therefore important that medical professionals are trained to deal with patients in this manner. For example, Goldberg, Gask, and O'Dowd (1989) developed a training program for primary care physicians that included making patients feel understood by carefully listening to their complaints and symptoms, changing the agenda of the actions to be undertaken from a somato-medical focus on bodily symptoms to a psychological perspective focusing on emotional distress. Physicians were also taught how to help patients reattribute bodily symptoms by linking them to psychological factors. Another important treatment strategy is withholding unnecessary medication and medical examinations (response prevention for safety-seeking behaviors). A symptom diary is used to get a prospective, rather than retrospective, view of the symptoms' course, intensity, and relation to life stresses. Rief (1996) suggests starting off with a symptom-oriented treatment and, in the second phase of therapy, shifting towards more general goals, such as occupational problem-solving, social skills training, and quality of life enhancement.

6.24.6.1 Somatization Disorder Most articles refer to the management rather than to the treatment of patients with persistent somatic problems (e.g., Bass & Benjamin, 1993). Early diagnosis and the prevention of unnecessary medical and surgical investigation are

deemed to be of primary importance. Most somatization patients have distinct expectations regarding treatment goals and procedures and try to persuade their doctors to follow their wishes for further medical investigations and treatments. Bass and Murphy (1990) state that treatment often involves long-term supportive psychotherapy and must be directed toward controlling the demands on medical care as well as the treatment of symptoms and social disability. These authors recommend the following five steps: (i) establish a diagnosis by collecting appropriate medical and psychosocial information; (ii) encourage a long-term supportive relationship with only one understanding primary care physician to prevent doctorshopping and to coordinate all actions; (iii) see patients on regular appointments rather than on demand to prevent reinforcement of illness behavior; (iv) regard the patient's physical complaints as a form of communication rather than as evidence of disease; and (v) minimize the use of psychotropic drugs and/or analgesic medication. In general, adaptive behavior is encouraged and promoted, whereas sick role behavior is ignored as much as possible. A study by Smith, Monson, and Ray (1986) found that such a treatment program did not lead to improvements on any of the measures of mental, physical, or social health, but patient healthcare was less costly. In contrast, Krasner, Rost, Cohen, Anderson, and Smith (1995) demonstrated that eight sessions of brief group therapy improved physical and mental health at one year followup. Treatment focused on coping with the nature and consequences of the physical symptoms, general problem-solving, and helping patients take more control of their lives. A randomized controlled trial examining a comprehensive cognitive-behavioral approach for medically unexplained physical symptoms was conducted by Speckens et al. (1996). This team compared a cognitive-behavioral intervention group of 39 general medical outpatients with a control group of 40 patients receiving optimized medical care. The 6±16 sessions of cognitive-behavioral therapy included (i) imaginary exposure and distraction techniques to break the vicious circles of cognitive avoidance and preoccupation; (ii) activity scheduling, exposure in vivo, and response prevention to decrease avoidance behavior; (iii) relaxation training, breathing exercises, and physical exercises; and (iv) problem-solving or social skills training to overcome any problems in interpersonal relationships. At both 6 and 12 month follow-ups, compared to the control group, the intervention group reported lower intensity and frequency of symptoms, reduced

Treatment of Somatoform Disorders illness behavior, less sleep impairment, and fewer limitations in social and leisure activities.

6.24.6.2 Hypochondriasis Traditionally, individuals with hypochondriasis were considered difficult to treat and their prognosis was regarded as poor. For instance, early studies assessing the effectiveness of a variety of psychological interventions available at that time (e.g., Kenyon, 1964) found 40% of patients with primary hypochondriasis to be unchanged or worse following treatment. Although patients with unexplained physical symptoms and/or health anxiety still pose a considerable challenge for therapists, cognitive-behavioral interventions have yielded encouraging results. The first comprehensive cognitive-behavioral treatment formulations were provided by Warwick and Salkovskis (1990). Patients are instructed to self-monitor during hypochondriacal episodes, paying careful attention to environmental events, physical symptoms, associated cognitions, and their resulting hypochondriacal behavior. As indicated, their treatment is directed at evaluating alternative, nonthreatening explanations of body-related observations that patients misinterpret as signs of serious disease. Two possible explanations for the patient's problem are considered alongside each other rather than as mutually exclusive alternatives (Salkovskis, 1996). Patients are then asked to engage in a variety of behavioral experiments to test these new explanations and therapy proceeds as an evaluation of the relative merits of the alternative views. Salkovskis emphasizes that inappropriate safety-seeking prevents individuals from discovering that their fears are groundless. Hence, the key function of exposure exercises and response prevention is to allow patients to repeatedly experience feared bodily sensations to disconfirm fears. Thereby patients learn that the things they are afraid of do not actually happen or that consequences are not as bad as they expected. A system of differential reinforcement may need to be added for individuals who gain sympathy or interest for physical complaints but may receive little attention otherwise. In those cases, family members and other individuals the patient has contact with (including the therapist) should reinforce patient initiation of conversation on any topic other than symptoms (healthy conversation). This reinforcement could consist of praise or increased attention. As the patient engages in more healthy conversation, the natural contingencies (e.g., reduced medical bills, more pleasant interac-

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tions with others) should begin to maintain behavior and the frequency and magnitude of artificial reinforcement can be slowly reduced. Salkovskis and Warwick (1986) reported two successfully treated single cases of primary hypochondriasis using cognitive-behavioral methods. In another study, Visser and Bouman (1992) found that four of six hypochondriacal patients improved significantly following in vivo exposure, response suppression, and cognitive therapy. Interestingly, in this small study, exposure and response suppression (behavioral components) appeared to have accounted for more of the improvement than the cognitive component they used. The positive results of these series of single case studies were supported in a first controlled trial that showed cognitivebehavioral therapy to be superior to a wait-list control condition (Warwick, Clark, Cobb, & Salkovskis, 1996). For patients whose main hypochondriacal concerns involve disease or illness phobia without significant conviction of having the illness, a more focused program of tension reduction (e.g., through relaxation), exposure to the feared stimuli, and prevention of checking and safety-seeking can be sufficient (Eifert, 1992, 1996). A representative example of this type of program was implemented by Warwick and Marks (1988). Their treatment employed exposure to feared stimuli, paradox (deliberate attempts to induce a panic attack), and response prevention such as banning reassurance-seeking and physician visits. There was a significant decrease in illness fear and increase in work and social adjustment for the group of 17 patients who were treated. Overall, cognitive-behavioral treatments are very promising and prognosis for patients treated with such interventions seems more favorable than previously thought. More extensive and controlled studies are needed to examine what the most crucial treatment components are and to determine the mechanisms for their success.

6.24.6.3 Pain Disorder Although there have been suggestions that treatment of pain based on psychodynamic principles may be effective (Adler, Zlot, Hurny, & Minder, 1989), empirical evidence has been scarce and not very compelling (Gamsa, 1994; Turk et al., 1983). Biofeedback (e.g., Budzynski, Stoyva, Adler, & Mullaney, 1973) and hypnosis (Sacerdote, 1970) used to be popular treatments for pain, in the 1970s in particular. These approaches, however, have been harshly criticized on a number of grounds (for a review, see

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Turk et al.). Most importantly, critics claim that these techniques are ineffective when used alone, and any treatment effects are due to the unwitting inclusion of behavioral and cognitive treatment components (Turk et al.) We will therefore focus on cognitive-behavioral approaches to the management of pain. According to operant principles, pain behavior is not an expression or side effect of a pain problem, instead it is the problem (Rachlin, 1985). Therefore, the goal of treatment is to extinguish maladaptive pain behavior and to teach and encourage the use of more adaptive pain coping strategies (Nicholas, Wilson, & Goyen, 1991). Treatment begins with a thorough functional analysis of current pain behavior and the environmental contingencies associated with that behavior. Once the consequences maintaining the maladaptive pain behavior are determined, attempts are made to reduce reinforcement for that behavior and to increase reinforcement for adaptive pain-coping behavior (cf. Fordyce, Roberts, & Sternbach, 1985). In addition to changing a patient's maladaptive pain behavior, cognitive-behavioral therapy also attempts to alter associated thought patterns and the patient's perceived competence to deal with pain (Schermelleh-Engel et al., 1997). Pain management programs typically include: (i) decreasing demoralization through problem reconceptualization; (ii) enhancing outcome efficacy by motivating active patient participation; (iii) fostering a patient's real and perceived competence to deal with pain; (iv) breaking maladaptive behavior and thought patterns; (v) teaching skills and adaptive responses to problems; (vi) teaching selfattribution for change and success; and (vi) planning maintenance. Cognitive methods involving imagery and distraction have often been added to pain management programs (Turk et al., 1983). Based on the assumption that pain is mediated by thoughts and images, patients are encouraged to create and focus on those thoughts and images that alleviate pain, while ignoring those that exacerbate pain. Particularly for patients who engage in few activities, behavioral distraction may be beneficial in more than one way. This technique involves the introduction of overt activities that require attention in order to be performed (i.e., hobbies). As clients continue with these activities, they frequently recognize the value of the activities beyond their role as distractors. Although the cognitive-behavioral approach to pain management has been identified as an empirically validated treatment by the Task Force on Promotion and Dissemination of

Psychological Procedures (Chambless, 1995), it is unclear which specific methods are most effective. In a review of the experimental literature, Turk et al. (1983) concluded that patients successfully use cognitive strategies, but the data ªdo not convincingly establish the efficacy of any cognitive coping strategy relative to the strategies that subjects bring to experiments, nor is there sufficient evidence to support the use of any one strategy compared to any one otherº (p. 96). Others have raised more fundamental criticisms and argued that the effects attributed to direct cognitive manipulations could be due to associated environmental manipulations (Rachlin, 1985). 6.24.6.4 Conversion Disorder An important first step in the treatment of conversion symptoms is their early recognition in which a physical examination plays a crucial role. In many cases, a positive diagnosis can be made on the basis of the rather atypical or bizarre symptoms. Since conversion symptoms vary widely across patients, treatment needs to be individualized. Identifying precipitating stressors is an important treatment strategy so that patients can be taught more adaptive ways of coping with these stressors. Occasionally, manipulation of the patient's social environmental is necessary to reduce the influence of secondary gain. Partners and significant others may have to learn how to reinforce the patient's nonsymptomatic behavior. Favorable prognosis seems to be related to acute onset, massive stressor, and a good premorbid psychological and medical condition (Kent et al., 1995). 6.24.6.5 Body Dysmorphic Disorder Behavioral interventions for BDD aim at changing avoidance behaviors, reassuranceseeking, checking, and excessive grooming. Exposure in vivo is used to counter avoidance of social situations (meeting people, having a conversation, being in the spotlight), body image situations (wearing camouflaging clothing such as baggy pants, long hair, sunglasses). Patients are encouraged to expose themselves to social situations, rather than avoiding them and to observe the reactions of other people to their imagined deformity. Rosen (1995) suggests exposure assignments such as wearing trendy clothes, using make-up to accentuate features, standing closer to people, undressing in front of one's spouse. Response prevention may involve stopping looking in the mirror for excessive periods of time and refraining from

Conclusions the use of make-up and from inspecting skin blemishes. There are few controlled treatment outcome studies for BDD, but several case studies and uncontrolled trials have been reported that have used systematic desensitization (e.g., Munjack, 1978), exposure and response prevention (Neziroglu & Yaryura-Tobias, 1993), and social skills training (Braddock, 1982). Schmidt and Harrington (1995) describe a successful cognitive-behavioral therapy in a 24-year-old male who was preoccupied with having small hands. Nine one-hour sessions with behavioral experiments aimed at challenging beliefs about size of his own hands and other people's attention to his hands. Treatment resulted in a decrease of BDD-related cognitions, distress and avoidance behaviors, as well as a decrease in Beck Depression and Beck Anxiety Inventory scores. Recently, a first controlled study (Rosen, Reiter, & Orosan, 1995) compared the effectiveness of cognitive-behavioral therapy with a wait-list control condition in 54 female BDD patients. Treatment was conducted in small groups and encompassed eight two-hour sessions. Therapy was aimed at modifying dysfunctional thoughts about the patients' body image, the reduction of appearancechecking, and exposure to avoided situations. Results at post-test and four month follow-up indicated improvement in the active treatment condition on several measures of body image, whereas no such changes occurred in the control condition. Although the results of this study are promising, more controlled studies are needed to corroborate existing data and to examine the role of the various treatment components.

6.24.7 CONCLUSIONS Unexplained and unexplainable somatic symptoms are very common in the general population. These problems are costly to the individuals concerned in terms of distress and financial expense as well as to society in terms of lost productivity and healthcare costs. Compared with other common psychological dysfunctions (e.g., anxiety and depression), our present conceptual understanding of the somatoform disorders is poor and satisfactory comprehensive models are still lacking. Moreover, for most of these disorders we do not have basic and reliable information on issues such as prevalence, gender differences, etiology, and treatment outcome. One factor that has impeded a better understanding of the somatoform disorders is

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the unsatisfactory and somewhat arbitrary current DSM classification. We have noted a considerable degree of phenomenological and functional overlap in the problems of persons diagnosed with somatization disorder, hypochondriasis, and chronic pain disorder as well as overlap between somatoform and anxiety disorders. In fact, comorbidity of somatoform disorders with an anxiety disorder, depression, and general medical conditions are the rule rather than the exception. In view of the existing conceptual and diagnostic confusion, vagueness, and imprecision, we question not only the utility of the current criteria for and distinctions between somatoform disorders but also the wisdom of keeping hypochondriasis in particular in a section separate from the anxiety disorders. Difficulty in relating the physical and psychological aspects of somatoform disorders has led to further confusion. Although we caution against an over-reliance upon medical diagnostic procedures and the explanatory power of current medical theory, diagnoses of the somatoform disorders are based upon the sophistication and accuracy of medical diagnostic procedures. Research and service delivery for patients would benefit from a more balanced approach that is not just focused on finding or excluding somatic abnormalities but one that combines current medical knowledge and assessment techniques with assessments of a patient's behavior, cognitive processes, and social relationships (cf. Fink, 1996). In our work with cardiac patients (Eifert et al., 1997) we observed how a simple reliance on one source of information (medical or psychological) was inadequate for many patients. Instead, it was the combination of sophisticated medical tests and psychological information that yielded the type of knowledge that was useful for recommending and designing the most appropriate treatment for the individual patient. Hence, one of the most compelling conclusions arising from this chapter is that somatoform disorders cannot be adequately understood, assessed, and treated from a single perspective. Both the DSM classification system as well as research in the area could be improved by adopting a multidisciplinary approach and an integrated biopsychosocial perspective. For example, Mayou, Bass, and Sharpe (1995) propose a multidimensional classification of patients with functional somatic symptoms along five dimensions: (i) number and type of somatic symptoms, (ii) mental state (mood and psychiatric disorder), (iii) cognitions (e.g., symptom misinterpretations, disease conviction), (iv) behavioral and functional impairment (illness behavior, avoidance, use of health

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services), and (v) pathophysiological disturbance (organic diseases, physiological mechanisms such as hyperventilation). As indicated in the section on health anxiety, individuals may be assigned different positions on all of these dimensions across the various types of somatoform disorders. Rather than attempting to find the ªcorrect diagnosis,º we recommend assessing patients along the crucial dimensions involved in the regulation of maladaptive illness behavior and devising treatment programs based on such functional dimensional assessments. Beyond the number and type of physical complaints, some of these dimensions include the presence and extent of preoccupation with body and health, symptom misinterpretation, disease suspicion or conviction, disease fear, safety-seeking approach and avoidance behavior, focus and modulation of worry and fear, and pathophysiological processes. Based on a multicausal and multidisciplinary perspective, there are several potentially fruitful lines for future psychological research into somatoform disorders such as an increased focus on information processing behavior (attribution, attention, and memory) and environmental contingencies for illness behavior (e.g., social, occupational, medical). Psychoneuro-immunological studies may help clarify particular aspects of the nature of the interface between pathophysiological changes, and individual responses to such changes as exemplified in some chronic pain research (cf. Flor et al., 1990). Although the past emphasis on the problems of patients with no demonstrable physical pathology was worthwhile and deserves continued attention, the gray area of persons with some organic pathology, bodily symptoms, and psychological distress deserves greater recognition and needs to be investigated more carefully. Treatment programs and outcomes are likely to be enhanced further by an improved understanding of these problems from a multidisciplinary perspective. The need for an improved understanding and better treatments is even more pressing for those somatoform problems that have been particularly neglected in the past, such as somatization disorder, BDD, and conversion problems. The relative success of recent cognitive-behavioral treatment programs for persons with unexplained physical symptoms, health anxiety, or chronic pain is promising. These treatment successes may help change the common perception of healthcare providers that people with such problems are just a ªpain in the neckº and invariably difficult, or maybe even impossible, to treat and may provide more hope for patients as well.

6.24.8 REFERENCES Adler, R. H., Zlot, S., Hurny, C., & Minder, C. (1989). Engel's psychogenic pain and the pain-prone patient: A retrospective controlled clinical study. Psychosomatic Medicine, 51, 87±101. Agras, S., Sylvester, D., & Oliveau, D. (1969). The epidemiology of common fears and phobias. Comprehensive Psychiatry, 10, 151±156. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Apley, T. (1958). Common denominators in the recurrent pains of childhood. Procedural Research and Sociological Medicine, 51, 1023±1027. Armentrout, D. P., Moore, J. E., Parker, J. C., Hewett, J. E., & Feltz, C. (1982). Pain patient MMPI subgroups: The psychological dimensions of pain. Journal of Behavioral Medicine, 5, 201±211. Asmundson, G. J., & Norton, G. R. (1995). Anxiety sensitivity in patients with physically unexplained chronic back pain. Behaviour Research and Therapy, 33, 771±777. Bach, M., & Bach, D. (1995). Predictive value of alexithymia: A prospective study in somatizing patients. Psychotherapy and Psychosomatics, 64, 43±48. Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press. Barsky, A. J., Brener, J., Coeytaux, R. R., & Cleary, P. D. (1995). Accurate awareness of heartbeat in hypochondriacal and non-hypochondriacal patients. Journal of Psychosomatic Research, 39, 489±497. Barsky, A. J., & Klerman, G. L. (1983). Overview: Hypochondriasis, bodily complaints, and somatic styles. American Journal of Psychiatry, 140, 273±283. Bass, C. M., & Benjamin, S. (1993). The management of the chronic somatizer. British Journal of Psychiatry, 162, 472±480. Bass, C. M., & Murphy, M. R. (1990). Somatization disorder: Critique of the concept and suggestions for future research. In C. M. Bass (Ed.), Somatization. Phys ic al s ym ptom s a nd p sy ch olo gic al ill ne ss (pp. 301±332). Oxford: Blackwell. Bass, C. M., & Murphy, M. R. (1995). Somatoform and personality disorders: Syndromal comorbidity and overlapping developmental pathways. Journal of Psychosomatic Research, 39, 403±427. Baum, W. M. (1974). On two types of deviations from the matching law: Bias and undermatching. Journal of the Experimental Analysis of Behavior, 22, 231±242. Beck, J. G., Berisford, M. A., Taegtmeyer, H., & Bennett, A. (1990). Panic symptoms in chest pain without coronary artery disease: A comparison with panic disorder. Behavior Therapy, 21, 241±252. Beitman, B. D., Basha, I., Flaker, G., DeRosear, L., Mukerji, I. V., Trombka, L. and Katon, W. (1987). Atypical or non-anginal chest pain: Panic disorder or coronary artery disease? Archives of Internal Medicine, 147, 1548±1552. Berrios, G. E., & Kan C. S. (1996). A conceptual and quantitative analysis of 178 historical cases of dysmorphophobia. Acta Psychiatrica Scandinavica, 94, 1±7. Bianchi, G. N. (1973). Patterns of hypochondriasis: A principal components analysis. British Journal of Psychiatry, 122, 541±548. Braddock, L. E. (1982). Dysmorphophobia in adolescence: A case report. British Journal of Psychiatry, 140, 199±201. Budzynski, T. H., Stoyva, J. M., Adler, C. S., & Mullaney, D. J. (1973). EMG biofeedback and tension headache: A controlled outcome study. Psychosomatic Medicine, 35, 484±496.

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Applicability of Hernstein's law. Behaviour Research and Therapy, 33, 855±863. Fink, P. (1996). SomatizationÐBeyond symptom count. Journal of Psychosomatic Research, 40, 7±10. Fishbain, D. A., & Goldberg, M. (1991). The misdiagnosis of conversion disorder in a psychiatric emergency service. General Hospital Psychiatry, 13, 177±181. Flor, F., Birbaumer, N., & Turk, D. C. (1990). The psychobiology of chronic pain. Advances in Behaviour Research and Therapy, 12, 47±84. Flor, F., Kerns, R. D., & Turk, D. C. (1987). The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients. Journal of Psychosomatic Research, 31, 251±259. Ford, C. V. (1995). Dimensions of somatization and hypochondriasis. Neurologic Clinics, 13, 241±253. Fordyce, W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis, MO: Mosby. Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioural management of chronic pain: A response to critics. Pain, 22, 113±125. Forsyth, J. P., & Eifert, G. H. (1998) . Anxiety disorders. In J. J. Plaud & G. H. Eifert (Eds.), From behavior theory to behavior therapy (pp. 38±67). Needham Heights, MA: Allyn & Bacon. Forsyth, J. P., Eifert, G. H., & Thompson, R. N. (1996). Systemic alarms in fear conditiningÐII: An experimental methodology using 20% CO2 inhalation as a UCS. Behavior Therapy, 27, 391±415. France, R. D., Krishnan, K. R. R., Houpt, J. L., & Maltbie, A. A. (1984). Differentiation of depression from chronic pain with the dexamethason suppression test and DSM-III. American Journal of Psychiatry, 141, 1577±1579. Freud, S. (1956). Collected papers. London: Hogarth. Frost, R. O., Williams, N., & Jenter, C. (1995). Perfectionism and body dysmorphic disorder. Paper presented at the World Congress of Behavioral and Cognitive Therapies, Copenhagen, Denmark. Gamsa, A. (1994). The role of psychological factors in chronic pain. I. A half century of study. Pain, 57, 5±15. Goldberg, D., Gask, L., & O'Dowd, T. (1989). The treatment of somatization: Teaching techniques of reattribution. Journal of Psychosomatic Research, 33, 689±695. Hanback, J. W., & Revelle, W. (1978). Arousal and perceptual sensitivity in hypochondriasis. Journal of Abnormal Psychology, 87, 523±530. Harvey, R. F., Salih, W. Y., & Read, A. E. (1983). Organic and functional disorders in 2000 gastroenterology outpatients. Lancet, i, 632±634. Hayes, S. C., & Wilson, K. G. (1994). Acceptance and committment therapy: Altering the verbal support for experiential avoidance. Behavior Analyst, 17, 289±303. Herrnstein, R. J. (1970). On the law of effect. Journal of the Experimental Analysis of Behavior, 13, 243±266. Hitchcock, P., & Mathews, A. (1992). Interpretation of bodily symptoms in hypochondriasis. Behaviour Research and Therapy, 30, 223±234. Hunter, R. C. A., Lohrenz, J. G., & Schwartzman, A. E. (1964). Nosophobia and hypochondriasis in medical students. Journal of Nervous and Mental Disorders, 139, 147±152. Iezzi, A., & Adams, H. E. (1993). Somatoform and factitious disorders. In P. B. Sutker & H. E. Adams (Eds.), Comprehensive handbook of psychopathology (2nd ed., pp. 167±201). New York: Plenum. Jacob, R. G., & Turner, S. M. (1984). Somatoform disorders. In S. M. Turner & M. Hersen (Eds.), Adult psychopathology and diagnosis (pp. 304±328). New York: Wiley. Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of the

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literature. Pain, 47, 249±283. Kellner, R. (1985). Functional somatic symptoms and hypochondriasis: A survey of empirical studies. Archives of General Psychiatry, 42, 821±833. Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger. Kellner, R. (1991). Psychosomatic syndromes and somatic symptoms. Washington, DC: American Psychiatric Press. Kent, D. A., Tomasson, K., & Coryell, W. (1995). Course and outcome of conversion and somatization disorders. Psychosomatics, 36, 138±144. Kenyon, F. E. (1964). Hypochondriasis: A clinical study. British Journal of Psychiatry, 110, 478±488. Kenyon, F. E. (1976). Hypochondriacal states. British Journal of Psychiatry, 129, 1±14. Krasner, T. M., Rost, K., Cohen, B., Anderson, M., & Smith, G. R. (1995). Enhancing the health of somatization disorder patients. Effectiveness of short-term group therapy. Psychosomatics, 36, 462±470. Lipowsky, Z. J. (1988). Somatization: The concept and its clinical applicability. American Journal of Psychiatry, 145, 1358±1368. Love, A. W., & Peck, C. L. (1987). The MMPI and psychological factors in chronic low back pain: A review. Pain, 28, 1±12. Mace, C. J. (1992). Hysterical conversion. I: A history. British Journal of Psychiatry, 161, 369±377. MacLeod, C., & Mathews, A. (1991). Cognitive± experimental approaches to the emotional disorders. In P. R. Martin (Ed.), Handbook of behavior therapy and psychological science: An integrative approach (pp. 116±150). New York: Pergamon. Margolis, R. B., Zimny, G. H., & Miller, D. (1984). Internists and the chronic pain patient. Pain, 20, 151±156. Marks, I. M. (1987). Fears, phobias, and rituals. New York: Oxford University Press. Martens, B. K., & Houk, J. L. (1989). The application of Herrnstein's law of effect to disruptive and on-task behavior of a retarded adolescent girl. Journal of the Experimental Analysis of Behavior, 51, 17±27. Mayou, R., Bass, C. M., & Sharpe, M. (Eds.) (1995). Treatment of functional somatic symptoms. Oxford, UK: Oxford University Press. Mayou, R., Bryant, B., Forbar, C., & Clark, D. (1994). Non-cardiac chest pain and benign palpitations in the cardiac clinic. British Heart Journal, 72, 548±553. Mayou, R., & Sharpe, M. (1995). Patients whom doctors find difficult to help. Psychosomatics, 36, 323±325. McDowell, J. J. (1981). On the validity and utility of Herrnstein's hyperbola in applied behavior analysis. In C. M. Bradshaw, E. Szabadi, & C. F. Lowe (Eds.), Quantification of steady-state operant behaviour (pp. 311±324). Amsterdam: Elsevier. McDowell, J. J. (1982). The importance of Herrnstein's mathematical statement of the law of effect for behavior therapy. American Psychologist, 37, 771±779. Mechanic, D. (1964). The influence of mothers on their children's health attitudes and behavior. Pediatrics, 33, 444±453. Melzack, R., & Wall, P. (1965). Pain mechanisms: A new theory. Science, 50, 971±979. Miller, N. E. (1977). The effects of learning on visceral functions. New England Journal of Medicine, 296, 1274±1278. Munjak, D. J. (1978). The behavioural treatment of dysmorphophobia. Journal of Behavioural Therapy and Experimental Psychiatry, 9, 53±56. Murphy, M. R. (1990). Classification of the somatoform disorders. In C. M. Bass (Ed.), Somatization. Physical symptoms and psychological illness (pp. 10±39). Oxford, UK: Blackwell. Newmark, J., & Hochberg, F. H. (1987). ªDoctor, it hurts

when I playº: Painful disorders among instrumental musicians. Medical Problems of Performing Arts, 22, 93±97. Neziroglu, F. A., & Yaryura-Tobias, J. A. (1993). Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy, 24, 431±438. Nicholas, M. K., Wilson, P. H., & Goyen, J. (1991). Operant±behavioural and cognitive±behavioural treatment of chronic low back pain. Behaviour Research and Therapy, 29, 225±238. Noyes, R., Reich, J., Clancy, J., & O'Gorman, T. W. (1986). Reduction in hypochondriasis with treatment of panic disorder. British Journal of Psychiatry, 149, 631±635. Parker, G., & Lipscombe, P. (1980). The relevance of early parental experiences to adult dependency, hypochondriasis, and utilization of primary physicians. British Journal of Medical Psychology, 53, 355±363. Parkes, C. M. (1972). Bereavement: Studies of grief in adult life. New York: International Universities Press. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer. Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal of Medical Psychology, 113, 89±93. Pilowsky, I. (1993). Aspects of abnormal illness behaviour. Psychotherapy and Psychosomatics, 60, 62±74. Pilowsky, I., Chapman, C. R., & Bonica, J. J. (1977). Pain, depression, and illness behavior in a pain clinic population. Pain, 4, 183±192. Pilowsky, I., Smith, Q. P., Katsikitis, M. (1987). Illness behavior and general practice utilisation: A prospective study. Psychosomatic Research, 31, 177±183. Pribor, E. F., Yutzy, S. H., Dean, J. D., & Wetzel, R. D. (1993). Briquet's syndrome, dissociation, and abuse. American Journal of Psychiatry, 150, 1507±1511. Rachlin, H. C. (1985). Pain and behavior. Behavioral and Brain Sciences, 8, 43±83. Rief, W. (1996). Die somatoformen StoÈrungenÐGrosses unbekantes Land zwischen Psychologie und Medizin. Zeitschrift fuÈr Klinische Psychologie, 25, 173±189. Rief, W., Hiller, W., Geissner, E., & Fichter, M. M. (1995). A two-year follow-up study of patients with somatoform disorders. Psychosomatics, 36, 376±386. Robbins, J. M., & Kirmayer, L. J. (1991). Attributions of common somatic symptoms. Psychological Medicine, 21, 1029±1045. Rosen, J. C. (1995). The nature of body dysmorphic disorder and treatment with cognitive behavior therapy. Cognitive and Behavioral Practice, 2, 143±166. Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitive behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63, 263±269. Sacerdote, P. (1970). Theory and practice of pain control in malignancy and other protracted or recurring painful illness. International Journal of Clinical and Experimental Hypnosis, 18, 160±180. Salkovskis, P. M. (1996). The cognitive approach to anxiety: Threat beliefs, safety-seeking behavior, and the special case of health anxiety and obsessions. In P. M. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 49±74). New York: Guilford Press. Salkovskis, P. M., & Clark, D. M. (1993). Panic and hypochondriasis. Advances in Behaviour Research and Therapy, 15, 23±48. Salkovskis, P. M., & Warwick, H. M. C. (1986). Morbid preoccupations, health anxiety and reassurance: A cognitive±behavioural approach to hypochondriasis. Behaviour Research and Therapy, 24, 597±602. Salminen, J. K., SaarijaÈvi, S., & AÈaÈrelaÈ, E. (1995). Two decades of alexithymia. Journal of Psychosomatic Research, 39, 803±807.

References Salmon, P., & Calderbank, S. (1996). The relationship of childhood physical and sexual abuse to adult illness behavior. Journal of Psychosomatic Research, 40, 329±336. Schermelleh-Engel, K., Eifert, G. H., Moosbrugger, H., & Frank, D. (1997). Perceived competence and anxiety as determinants of maladaptive and adaptive coping strategies of chronic pain patients. Personality and Individual Differences, 22, 1±10. Schmidt, N. B., & Harrington, P. (1995). Cognitive behavioral treatment of body dysmorphic disorder: A case report. Journal of Behaviour Therapy and Experimental Psychitry, 26, 161±167. Schuldt, K., Ekholm, J., Harms-Ringdahl, K., Aborelius, U., & Nemeth, G. (1987). Influence of sitting postures on neck and shoulder EMG during arm±hand work movements. Clinical Biomechanics, 2, 126±139. Sharma, P., & Chaturvedi, S. K. (1995). Conversion disorder revisited. Acta Psychiatria Scandinavica, 92, 301±304. Sharpe, M., & Bass, C. M. (1992). Pathophysiological mechanisms in somatization. International Review of Psychiatry, 4, 81±97. Sharpe, M., Mayou, R., & Bass, C. M. (1995). Concepts, theories, and terminology. In R. Mayou, C. M. Bass, & M. Sharpe (Eds.), Treatment of functional somatic symptoms (pp. 3±16). Oxford, UK: Oxford University Press. Smith, G. R., Monson, R. A., & Ray, D. C. (1986). Psychiatric consultation in somatization disorder. A randomized controlled study. New England Journal of Medicine, 314, 1407±1413. Speckens, A. E. M., van Hemert, A. M., Spinhoven, P., Hawton, K. E., Bolk, J. H., & Rooijimans, H. G. M. (1996). Cognitive behavioral therapy for medically unexplained physical symptoms: A randomised controlled trial. British Medical Journal, 311, 1328±1332. Starcevic, V. (1988). Diagnosis of hypochondriasis: A promenade through the psychiatric nosology. American Journal of Psychotherapy, 42, 197±211. Taylor, G. J., Bagby, R. M., & Parker, J. D. A. (1991). The alexithymia construct. A potential paradigm for psychosomatic medicine. Psychosomatics, 32, 153±164. Turk, D. C., & Flor, H. (1984). Etiological theories and

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.25 The Treatment of Substance Abuse and Dependence ROBIN J. DAVIDSON Belvoir Park Hospital, Belfast, UK 6.25.1 INTRODUCTION

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6.25.1.1 Scope of the Problem 6.25.1.2 A Longitudinal Perspective 6.25.1.3 Assessment 6.25.2 THE STAGES OF CHANGE

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6.25.3 PSYCHOLOGICALLY BASED TREATMENT METHODS

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6.25.3.1 6.25.3.2 6.25.3.3 6.25.3.4

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Motivational Interviewing Behavioral Interventions Relapse Prevention Psychosocial Interventions

6.25.4 ISSUES IN TREATMENT

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forming one axis, the other being alcoholrelated consequences or disabilities. The elements first proposed for the alcohol dependence syndrome provide a framework for the description of psycho-active substance dependence in both major diagnostic systems. Dependence was seen by Edwards and Goss as a cluster of behavioral, cognitive, and physiological phenomena which develop after repeated use of alcohol. The elements were persistent use in the light of harmful circumstances, increasing salience of alcohol-seeking behavior, narrowing of drinking repertoire, difficulties in controlling intake, relief use, and neuroadaptive changes producing tolerance and withdrawal symptomatology. The ICD-10 criteria for substance dependence are outlined in Table 1. Most of the

6.25.1 INTRODUCTION The use of substances that alter mood, behavior, or cognitions has been a part of human life across numerous social contexts throughout history. Invariably, there are some individuals whose use of such substances may lead to abuse and eventual psychological, social, or physical harm. The fourth edition of the Diagnostic and statistical manual of mental disorders (DSM-IV; American Psychiatric Association, 1994) and the 10th edition of the International classification of diseases (ICD-10, World Health Organization, 1992) criteria for substance dependence owe much to the original description of the alcohol dependence syndrome (Edwards & Goss, 1976). These authors proposed a biaxial concept with dependence 567

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components of dependence in ICD-10 are to be found in DSM-IV and Hasin, Li, McCloud, and Endicott (1996) report excellent agreement between the two systems. One problem, however, with any diagnosis of psychoactive substance dependence is that it gives the impression of an all or none classification. This is not the case as there is continuous variation within all the elements, and so dependence should be seen as a continuum ranging from mild to severe. Mild dependence on alcohol could, for example, be regarded as a statistically normal condition. Nonetheless, the dependence syndromes as defined in the two major diagnostic classifications are robust and there is a body of factor analytic evidence that indicates that the elements form a single dimension, thus emphasizing the homogeneity of the syndrome (Davidson, Bunting, & Raistrick, 1989; Feingold & Rounsaville, 1995). This latter study also confirms that the dependence syndrome, as measured by DSM-IV diagnostic criteria, is factorially distinct from measures of the consequences of substance abuse in all drug groups. In other words, some people use drugs safely. Others, who may or may not develop symptoms of dependence, abuse drugs and encounter problems. Thus drug abuse and its debilitating sequelae are not necessarily synonymous with dependence. Abuse has been defined by the Royal College of Psychiatrists (1979) as the use of a substance that ªharms or threatens to harm the physical or mental health or social well-being of an individual.º Harmful consequences can arise from prolonged and excessive drug use, but can equally occur as a result of acute intoxication in an occasional user, or indeed can be associated with the mode of administration of the drug. For example the recreational use of ecstasy at a Saturday night dance can have fatal consequences, and HIV infection is not restricted to severely dependent, long-term abusers. This chapter will focus primarily on the treatment of addictive behavior itself, rather than the harmful consequences associated with drug and alcohol abuse.

6.25.1.1 Scope of the Problem The extent and demography of substance use is constantly changing. However, Babor (1994) draws a few broad conclusions about current trends. Use tends to be concentrated among the young and, with the exception of nicotine, the more addictive the substance, the more socially marginalized the user. The gender differential is diminishing and while the overall use of illicit drugs has increased in developed countries since

1985, alcohol sales have declined slightly (Anderson, 1997). Since 1973 alcohol consumption in Europe has decreased from a pure alcohol equivalent, annual, per capita intake of 14 litres to 10.4 litres (Gual & Colom, 1997). Consumption has since stabilized and alcohol abuse continues to be a significant drain on economic resources. For example, it has recently been estimated that the total cost of the alcohol problem to the US economy is $70 billion per annum. For every $1 collected in taxes about $7 are spent on problems arising from alcohol abuse. Alcohol continues to be the major drug of abuse within the USA, where there are 18 million alcoholics compared with five million addicted to all other drugs combined (Asbury, 1995). Gelder, Gath, Mayou, and Cowen (1996) outline the results of two major US surveys which suggest a one year prevalence rate for alcohol abuse and dependence of 7±10% with a lifetime risk of around 14±20%. Ramsey and Percy (1997) summarize the UK prevalence literature on drug use rather than abuse or dependence among the 16±29 year age group. In summary, about one-half of this group report using a prohibited drug ever, around one quarter in the last year, and 14% in the last month. In the surveys, it was estimated that 1% of respondents used heroin at some point in their lives. More direct approaches suggest that opiate use among the general, inner city population in London is around 2%. The Natural Comorbidity Survey in the USA (Kessler, McGonagle, & Zhao, 1994) found that one year prevalence for drug dependence for all adults was 3.6% while lifetime prevalence was 11.9%. Just under 40% in the US sample report using at least one illicit drug in their lifetime. It must be acknowledged that there is a range of prevalence estimation methodologies, which can render rather different estimates and which have been critically evaluated by Sutton and Maynard (1992). Rather than detail the extent and pattern of use for each substance for different groups of people, some of the problems faced by epidemiologists in this field will be outlined using cocaine by way of illustration. One can measure population use of a drug in terms of quantity and frequency, or the extent of drug dependence or alternatively drug-related problems, such as physical illness, accidents, or emergency admissions. It is important to note that each of these indices can present different distributions and demographic correlates in the population. For example, most of a sample of 100 Canadian cocaine users described it as an infrequent, selflimiting behavior (Erickson & Weber, 1994). This finding was mirrored in a group of Dutch

Introduction Table 1

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ICD-10 criteria for substance dependence.

Diagnostic guidelines A definite diagnosis of dependence should usually be made only if three or more of the following have been experienced or exhibited at some time during the previous year: (i) A strong desire or sense of compulsion to take the substance. (ii) Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use. (iii) A physiological withdrawal state . . . when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms. (iv) Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses. (v) Progressive neglect of alternative pleasures or interests because of psychoactive subtance use, increased amount of time necessary to obtain or take the substance or to recover from its effects. (vi) Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm. Source: World Health Organization (1992).

nondeviant cocaine users (Cohen, 1994), in which only one in five proceeded to high use, while sustained problematic use was very much the exception. This distinction between use and dependence would seem to be manifest when samples are not drawn from biased sources, like the treatment or criminal justice systems. At its peak in the mid 1980s, 25 million Americans reported having used cocaine, while three million of these were considered to be dependent on the drug (Kleber, 1988). Reinarman, Murphy, and Waldorf (1994) conclude that dependent, harmful use of cocaine is more contingent on the social circumstances of users and the conditions under which the drug is taken rather than its pharmacological action on human physiology. It is important then to acknowledge the differing prevalence of use, dependence, and problems across sociodemographic groups. The demographic profile of a drug can also change according to fluctuating availability, price, dependence potential of different forms of the drug, mode of administration, or public attitude. This has been elegantly illustrated by Pickering and Stimpson (1994) in their analysis of two centuries of cocaine use in the developed world. They trace the drug's changing demographic profile from the nineteenth century, when it was mainly taken in the USA by middle class women. Cocaine lost its nineteenth century status as a ªtonicº and became a ªsocial problemº when its use by soldiers could

have affected the First World War effort. By the early 1960s, users of the drug came largely from the middle-aged, male, bohemian classes. When different routes of administration such as smoking and injecting as well as sniffing became available, the drug began to appeal to a wider group of users. As noted above, the widespread use peaked in 1985, but later the advent of crack cocaine meant that the profile of the typical user became more homogeneous; notably inner-city, socially marginalized young people. This change was mediated by a combination of lower price, more adverse public attitudes and greater dependence-forming potential. The evolving demographic profile of cocaine illustrates the problem of changing fashions in drug use. Babor (1994) notes that while drugs that have abuse potential seem to become a public health problem as a function of the variables outlined above, the decline of drug epidemics is related to many of the same variables.

6.25.1.2 A Longitudinal Perspective In order to interpret treatment studies it is important to take account of the natural progression of dependence over time, although there have been surprisingly few studies that chart a typical drug-using career. This is a psychosocial construct, which takes account of

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various environmental influences and developmental changes that shape drug or alcohol use and must be understood in terms of the culture in which the individual lives. Treatment can be defined as a ªset of facilitative events which may have the effect of edging an individual into a less destructive long-term career path.º Edwards (1989) has similarly noted that treatment should be conceived of being, at best, a timely nudge or whisper in a long-term life course. Most people who successfully work through an addiction problem do so on their own without recourse to treatment. Indeed Prochaska, Di Clemente, and Norcross (1992) found that so-called selfchangers often spontaneously employ strategies described in formal therapeutic systems. Klingemann (1994) encapsulated the importance of assessing treatment effects within the context of the natural history of a drug using career in his succinct definition of treatment as ªassisted spontaneous remission.º Vaillant (1996) summarizes the long-term relationship between developmental changes and the onset, maintenance, and possible resolution of drug and alcohol abuse. When discussing resolution in particular, he concludes his review of longitudinal studies by arguing that variables such as maturation, treatment, a stable premorbid personality, or even social adjustment may be important in the short term but play a relatively limited role in eventual recovery. Rather, positive long-term outcome depends more on the eventual severity of dependence and ªthe individual encountering the right kind of naturalistic healing experience.º There are very few established psychosocial predictors that can distinguish between those alcohol and drug users who achieve stable outcomes and those who do not. However, there seems to be a slowly emerging consensus in the literature that the key naturalistic factors that contribute to stable outcome include acquisition of an alternative behavior that acts as an addiction substitute, the discovery of new sources of hope and self-esteem and the development of new, stable, supportive relationships. The effects of treatment then must be understood against the backdrop of naturally occurring influences on the process of recovery. Vaillant (1983) outlines a useful set of ground rules for the ideal evaluation of the natural history of any treatment intervention. These include a follow-up period of more than five years, outcome assessment at multiple different times, the inclusion of multiple indicators of social functioning, minimal attrition, and controlling for post-treatment, environmental variables. Unfortunately, many treatment outcome studies reported in the literature fall short of this ideal.

6.25.1.3 Assessment Before embarking on a treatment program, a sound assessment is required that will inform the choice of treatment goal and content. Information should be attained on the evolution of drug/alcohol intake, family history, patterns of current use, degree of dependence, the extent of drug- and alcohol-related problems, reinforcement parameters maintaining the behavior, and the opportunities within the client's environment for developing more adaptive responses. It is also important to assess the extent of any co-existing psychopathology. There are numerous scales that have been developed for the assessment of various aspects of drug and alcohol abuse. Normally these instruments are very general and assess a composite of variables from a number of conceptually distinct areas; for example, dependence on the drug, craving, reasons for drug use, attitudes towards self and others, outcome and efficacy expectations, personal, occupational, and social consequences of heavy drug use, drug-taking history, and behavior when intoxicated. The most widely used screening questionnaire for alcohol abuse is the four-item CAGE (Mayfield, McLeod, & Hall, 1974). Other common screening instruments include the Michigan Alcohol Screening Test (Selzer, 1971), the Alcohol Use Disorders Identification Test (Saunders, Aasland, Babor, De La Fuente, & Grant, 1992) and the Drug Abuse Screening Questionnaire (Skinner, 1982). Various semistructured interviews have also been developed to assist in the evaluation of a variety of drug and alcohol abuse variables. Examples include the Halikas±Crosby drug impairment rating scale for cocaine (Halikas & Crosby, 1991) or the Addiction Severity Index which assesses the severity of problems arising as a result of addiction to one or multiple substances (McClellan et al., 1992). As noted above these are examples of instruments that measure a broad range of variables and can be used for general screening or assessment purposes. However, they do not provide the clinician with a pure measure of degree of dependence. This is an important predictor of eventual outcome and a number of scales have been developed that are specifically based on the alcohol and drug dependence syndromes. For alcohol, the most commonly applied dependence questionnaires are the Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell, Murphy, & Hodgson, 1983) and the Short Alcohol Dependence Data (SADD) (Davidson & Raistrick, 1986) in which there are 15 items that enquire about most of the elements of the alcohol dependence syndrome.

The Stages of Change The severity of opiate dependence questionnaire SODQ was designed specifically, as the name suggests, to assess opiate dependence (Sutherland, Edwards, Taylor, Phillips, & Gossop, 1988). This instrument primarily focuses on the assessment of withdrawal symptoms and withdrawal relief behavior. As a result it may be difficult to adapt the SODQ to the measurement of dependence on drugs that do not produce a clearly defined withdrawal syndrome. The severity of dependence scale (SDS) is a fiveitem questionnaire designed to assess the degree of dependence experienced by users of different types of drugs (Gossop et al., 1995). It was devised to provide a short, easily administered scale and the five items are concerned with the psychological components of the drug dependence syndrome. The time frame of inquiry is the past year and the items are as follows: (i) Do you think your use of (named drug) is out of control? (ii) Does the prospect of missing a fix (or dose) or not chasing make you anxious or worried? (iii) Do you worry about your use of (named drug)? (iv) Do you wish you could stop? (v) How difficult do you find it to stop or go without (named drug)? The SDS would seem to be a promising research instrument which can provide an assessment of the degree of dependence experienced by users of a variety of psychotropic drugs, although as yet it is too early to evaluate its usefulness in clinical settings. The assessment process will assist the therapist in tailoring a treatment program to the needs of the individual as well as elucidating on the most appropriate treatment goal. Gossop (1996) has provided examples of treatment goals which might include the following: (i) Reduction of psychosocial or physical problems either directly or indirectly related to the drug problem. (ii) Reduction of risky behavior associated with the use of the drug. (iii) Attainment of controlled or nondependent use. (iv) Attainment of abstinence from the problem drug. (v) Attainment of abstinence from all drugs. The issue of controlled use rather than abstinence has been debated at length within the alcohol field for many years and is perhaps symbolic of the difference between the more traditional disease approach and explanations of alcohol abuse generated from social learning theory. For this reason the debate was at times conducted at a more personal and anecdotal level than is normally the case in scientific

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discourse. The question is not ªcan some alcoholics drink normally?º since the literature is replete with examples to show that they can (Heather & Robertson, 1985), but rather which client will benefit most from abstinence and who would best be suited to a controlled drinking goal. More recently the term ªharm reductionº has referred to interventions for drug abusers which involve controlled use rather than abstinence. A good example is the resurgence of interest in the methadone maintenance for opiate abusers and the reported associated benefits (Ball & Ross, 1991). Whatever the treatment goal, a key issue is the client's commitment to implementing real and permanent change in his or her pattern of drug or alcohol use. The following section will review some models that assist in our understanding of the stages in this decision-making process.

6.25.2 THE STAGES OF CHANGE Psychotherapists have long been interested in the process of change. Pentony (1981) noted that most therapeutically induced change in cognition, affect, or behavior involves an initial destructuring with resistance being a central feature, an intermediate stage of conversion, and a final stage of restructuring. Janis and Mann (1977) analyzed how all sorts of permanent life decisions are made and they note that such change progresses through a number of stages notably reappraisal, considering the options, evaluation, action, and consolidation. Within the addictions literature the idea of transitional stages or dispositional states has been developed by various authors. Tuchfeld (1976) interviewed a large sample of individuals who had recovered from alcohol dependence without recourse to formal treatment regimes, and on the basis of these interviews he proposed a two-stage model of change. The first is when defensive avoidance becomes untenable and a commitment to change is made. The second stage is one of maintenance of a new behavioral repertoire, which is characterized by personal vigilance and during which time the individual develops coping strategies to attenuate the possibility of relapse. Kanfer and Grimm (1980) also suggest a number of critical transition points as an individual begins to recognize the need for change, prepares for change, and eventually works towards maintaining change and minimizing the risk of relapse. Arguably, the most influential model of change within the addictions field has been

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the so-called transtheoretical model of Prochaska and Di Clemente (1984) and Prochaska et al. (1992). The stages of change circle is now probably as familiar to addiction workers as Glatts' U-shaped curve. Orford (1992) likened the development of the transtheoretical model to a Kuhnian paradigm shift and suggested that it has helped rationalize the diversity of psychological interventions and place them in the context of the evolution of personal change. He argued that it allows us to see things from a fresh perspective and casts the process of change in an entirely new mold. The model is summarized in Figure 1. The transtheoretical model was originally developed after detailed interviews of almost 1000 successful exsmokers, with success being defined as a period of abstinence of four or more years. Essentially during precontemplation individuals do not feel impelled to do anything about their behavior, perhaps as a result of ambivalence, denial, or selective exposure to information. As they become aware a problem exists, they enter the contemplation stage which is characterized by conflict and dissonance. Preparation is defined as a time when the individual drug user formulates action plans and is serious about his or her intention to alter behavior. Action is a period when overt changes

are made, after which successful individuals enter the maintenance stage when new behaviors are strengthened and consolidated. The individual who does not relapse during this stage eventually exits the change system to termination, or in other words favorable long-term outcome. The authors concede that a linear progression through the stages could be a simplification and acknowledge that on occasions a more cyclical pattern may be in evidence. People may move back from action to contemplation and precontemplation before eventually achieving long-term resolution of the problem. A number of questionnaires have been developed to assess the stage of change for drug abusers, including the eponymous Stages of Change Questionnaire (Prochaska et al., 1992) and the 12-item Readiness to Change scale (Rollnick, Heather, Gould, & Hall, 1992). Essentially these scales yield a score corresponding to the primary stage of change, which is indicated by the person's self-perceived intentions and behavior. Heather (1992) argues that the stages of change can now be reliably assessed and have considerable predictive validity. The key heuristic value of the model is that various categories of intervention are said to be differentially effective at each stage.

Exit termination Action

Maintenance Preparation

Relapse

Exit precontemplation

Contemplation

Precontemplation

Figure 1 Stages of individual change. Source: adapted from Prochaska, DiClemente, and Norcross (1992).

Psychologically Based Treatment Methods Perhaps as a result of its intuitive appeal to practitioners and researchers alike the model escaped any considered criticism in the addictions literature for almost a decade. However, more recently a number of authors have questioned its validity and theoretical cohesiveness. Davidson (1992, 1998) commented that it is derivative and noted a number of empirical and conceptual weaknesses. Sutton (1996) felt that it was arbitrary to divide a behavioral/ cognitive continuum into five mutually exclusive and exhaustive categories. He also reanalyzed some data on which the model is based and found that individuals did not necessarily progress through the stages of change in the sequence predicted by the model. Few subjects in fact showed a stable progression through three or more stages and, indeed, almost onethird of the sample remained in the same stage throughout the two year time frame. Budd and Rollnick (1996) applied a broadly similar analysis to scores on the Readiness to Change questionnaire, which revealed a continuum of readiness to change. These authors noted that while a stage model has greater intuitive appeal, a continuum model provides a better representation of the available data. In a stinging criticism of the transtheoretical model, Bandura (1997) announced that stage theories are undergoing a dignified burial in psychology. He argued that this oversimplified stage view substituted a categorical approach for what is essentially a process model of human change. He suggested that people do not recycle through discrete stages but fluctuate in their struggle to exercise control over their health behavior. The stages of precontemplation and contemplation are simply differences in degree of intention while the subsequent stages are gradations of the very behavior that the model seeks to explain. For example, he noted that the action and maintenance stages are simply arbitrary subdivisions of the duration of the new abstinent behavior rather than differences in kind. In other words, this is simply a quantitative rather than a qualitative distinction. Less than six months abstinence from alcohol or drug use is said to define the action stage, while longer than six months defines the maintenance stage. While all of these criticisms may be regarded as legitimate, the model continues to wield considerable influence in the addictions field and it is quite wrong for Bandura to argue that the stage models are undergoing a dignified burial. Terms such as contemplation and maintenance have become entrenched in addictions parlance and scarcely an article is written on treatment in addictions without reference to the stage of change model. Despite its short-

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comings, the model of change does provide a structure to help us match different interventions with the albeit arbitrarily defined stages (Davidson, Rollnick, & MacEwan, 1991). Miller (1983) suggested that motivational interviewing is most useful for individuals in the contemplation stage, although it can prove beneficial for individuals in all stages of change. Behavioral and cognitive interventions can be optimally applied in the preparation and maintenance stages. In summary, despite the criticisms, this model remains a useful guide to assist practitioners in their choice of appropriate interventions. 6.25.3 PSYCHOLOGICALLY BASED TREATMENT METHODS 6.25.3.1 Motivational Interviewing Motivational interviewing was described by Stockwell (1992) as the most important and influential therapeutic development within the field of addiction over the past decade. In his original account of motivational interviewing, Miller (1983) saw motivational problems as a result of the therapist/client dialogue, with the behavior of the therapist influencing the expectations, attributions, and behavior of the client. Denial was said to be a product of the more traditional, confrontational, therapeutic interaction. During motivational interviewing the individual is encouraged to reach his or her own decision about change, while the role of the therapist is simply to facilitate this process through clarification, advice when appropriate, accurate feedback, and empathy. The aim of therapy is to increase cognitive dissonance until a critical mass of motivation has been achieved and the individual is ready to move from precontemplation to eventual action. At this point commitment to real behavioral change is a likely outcome. Motivational interviewers operationally define motivation as the probability that a person will enter into, continue, and adhere to a specific change strategy and there is a strong emphasis on ambivalence resolution and the decisional balance. Essentially the client begins to present his or her own argument for change rather than being directed by a coercive therapist, while it is the therapist's role to set in place the optimum conditions for change. Specific motivational interviewing strategies and the treatment rationale have been detailed elsewhere (Miller & Rollnick, 1991). Motivational interviewing is something of a misnomer in as much as it has little to do with contemporary cognitive theories of motivation. Rather it seems to be an example of the phenomenological approach to change and

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adapts the psychology of self-actualization to the promotion of personal change among alcohol and drug abusers. Miller and Rollnick (1991) contrast motivational interviewing with client-centered counseling by arguing, for example, that empathic reflection is invariably and noncontingently employed in client-centered counseling but used only selectively in motivational interviewing. Furthermore, they say that the good motivational interviewer is not afraid to proffer advice and will actively attempt to create discomfort and discrepancy rather than passively follow the client. Davidson (1996) suggests that this analysis is based on something of a caricature of the Rogerian position and that neo-Rogerian client-centered approaches are more active and task-focused than was hitherto the case. While the distinction between motivational interviewing and contemporary clientcentered counseling may be little more than semantic, this is no bad thing. Motivational interviewing is an excellent example of a therapeutic system, squarely based on psychological principles, tailored to individual change in addictive behavior. Rollnick, Heather, and Bell (1992) described a brief form of motivational interviewing that is beginning to be used to good effect in primary care settings. Miller and Baca (1993) found some evidence of better long-term outcome in a small group of patients who received a brief motivational interview over those who experienced a more directive, traditional style of interview. Baker, Kochan, Dixon, Heather, and Wodak (1994), however, could demonstrate no significant difference in HIV risk-taking behavior between a brief motivational interview and a nonintervention control condition. Kuchipudi, Hobein, Fleckinger, and Iber (1990) found brief motivational interviewing to be unsuccessful in reducing future drinking. Saunders, Wilkinson, and Phillips (1995) present a controlled trial of a brief motivational intervention with 122 drug abusers attending a methadone clinic. Subjects were randomly assigned to a motivational condition or a control, educational procedure. After six months, the motivational subjects showed significantly greater commitment to abstinence, reported more positive outcome expectancies and relapsed less quickly than the control group. The authors concluded that motivational interventions can be a useful adjunct to a methadone program. Heather, Rollnick, Bell, and Richmond (1996) reported a comparison between brief motivational interviewing, skill-based counseling, and a nonintervention control condition in a sample of heavy drinkers. While there were no significant differences between the intervention conditions in terms of a quantity/frequency

measure at six months, clients who were evaluated at baseline as ªnot ready to changeº responded better to motivational interviewing. This is interpreted as providing support for the view that motivational interviewing is most appropriate for those in the contemplation stage. Noonan and Moyers (1997) conducted a review of 11 trials that compared motivational interviewing with a range of other treatments. It seemed that motivational interviewing was uniquely effective if it succeeded in eliciting positive motivational responses without evoking resistance. It was, however, not particularly effective in the more severely dependent drinkers. Nonetheless the authors concluded that motivational interviewing was essential for all groups in the assessment interview as it reduced attrition rates. The enormous popularity of motivational interviewing is in contrast to relative paucity of positive outcome studies. However, on balance it would seem that motivational interviewing strategies act in some way to resolve ambivalence and promote greater commitment to change.

6.25.3.2 Behavioral Interventions Within the addictions literature the popularity of behavioral interventions has waxed and waned over the years. During the 1980s, there was a move away from such treatments, which were said to be reductionistic, mechanistic, and deterministic, and they were replaced by much more cognitively based multimodal packages of care. However, there has been a renewed interest in once-popular interventions such as cueexposure and aversive conditioning which lend themselves to parsimonious explanation in the language of conditioning. Cue-exposure is based on the idea that a compulsion (a response to externally conditioned stimulus cues) will be reduced if the urge, which Marlatt (1978) defined as intention to carry out the behavior, is restricted. Cue-exposure can be understood in terms of both classical and operant conditioning. Drug responses, which can include withdrawal symptoms, antagonistic, compensatory, or agonostic effects, can become associated with the internal or external environment. Environmental cues are the conditioned stimuli which when presented in the absence of the unconditioned stimulus can produce this variety of responses. After classical conditioning, instrumental conditioning will occur if the conditioned responses become discriminative stimuli. Cue-exposure should in theory extinguish the conditioned response and so alter future behavior. In practice the client is exposed to

Psychologically Based Treatment Methods cues which would usually trigger an episode of alcohol or drug use but if responses are prevented or controlled, this weakens the stimulus±response relationship. Drummond, Cooper, and Glautier (1990) reviewed 20 years of cue-exposure research within addictions and concluded, rather disappointingly, that its efficacy must be questioned as there were so few methodologically sound studies that demonstrate its effectiveness in producing good quality, long-term change in the behavior of alcohol and drug users. More recently it has been suggested (Davidson, 1996) that this may be due to the possibility that treatment conditions employed by practitioners have not in fact taken account of the necessary contingencies required to promote maximum change in drug-using behavior. He suggests that there should be greater emphasis on individual differences in cue reactivity, only stimuli relevant to the individual should be included if generalization is to occur in the natural environment, and individuals should be instructed to focus on the most salient aspects of the stimulus. Finally there must be withinsession habituation. In practice this means that there should be individually tailored cues of different duration with the termination of each session determined by clear evidence of habituation of the induced responses. Studies with opiate addicts (Powell, Bradley, & Gray, 1993), which have adhered to a theoretically driven treatment design, have produced promising results. Drummond and Glautier (1994) compared cue-exposure with a relaxation control treatment in a randomized control trial involving a sample of 35 severely dependent alcoholics. The cue-exposure clients had a total of 400 minutes of exposure to the sight and smell of preferred drinks over a 10 day period and showed significantly greater improvement on a range of consumption variables at six month follow-up. These recent positive results have tempered the rather pessimistic earlier conclusions of Drummond et al. Cue-exposure is an example of a treatment for which conditioning models neatly predict the optimum conditions for change, without recourse higher order cognitive explanations. The second example of a treatment based explicitly on conditioning models is aversive conditioning, which was graphically described by Wilson (1991) as a strategy to decrease the appetitive allure of alcohol and drugs. The general criticism, that aversive procedures are inhumane and pejorative, is well known. However, in the context of the present discussion the importance of these interventions are that the conditions of maximum change can be theoretically specified. Cannon and Baker

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(1981) demonstrated the superiority of emetic therapy or chemical aversion over aversion produced to an electric shock and Elkins (1991) produced an elegant theoretical rationale for the consistent superiority of chemical aversion over electrical aversion for alcohol and drug abusers. Nevertheless, there have been surprisingly few well-controlled outcome studies that demonstrate the long-term efficacy of emetic therapy. It is possible that most trials to date may not necessarily have adhered to the conditions that should promote maximum change. Of central importance is the temporal continuity between the conditioned and unconditioned response and it may be that some of the failures of emetic therapy are due to the fact that exposure to alcohol or drugs is introduced after the initial peak of nausea. Arguably, there is only one study in the addictions literature to date that is theoretically and methodological flawless (Cannon, Baker, & Wehl, 1981). In this study there was random assessment of clients to chemical aversion and nonaversion treatment conditions. Optimum contingency intervals were employed and a significant superiority of aversive conditioning was demonstrated at one year followup. Parloff, London, and Wolf (1986) found that for some alcohol abusers, aversive procedures were consistently better than more cognitively based interventions. Hester and Miller (1989) have outlined a treatment protocol for covert sensitization (verbal aversion). While this offers many practical advances, Elkins (1980) suggested that alcohol misusers who experience real, rather than suggested, nausea after the taste or smell of alcohol remain abstinent for longer than those who do not. However, it is probably fair to conclude, at the time of writing, that the use of aversive procedures for alcohol or drug misusers is relatively rare. Heather and Stallard (1989) suggest that, generally, contemporary models of relapse perhaps underestimate the importance of classically conditioned craving in the relapse process. It is likely, therefore, that behavioural interventions, particularly cue-exposure, will become more important components of treatment programs for alcohol and drug abusers than they have been hitherto.

6.25.3.3 Relapse Prevention Substance abuse has long been seen as a chronic, relapsing condition. A sound understanding of relapse management is perhaps the most fundamental issue in a discussion of the nature of treatment for addictive behavior. Relapse prevention is a generic term for a

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variety of approaches to the treatment of drug and alcohol abuse, primarily aimed at those in the maintenance stage of change. Edwards (1994) points out that it is important to remember that relapse prevention ªdoes not imply a single theory of just one intervention technique but the deployment of a range of methods derived from a variety of behavioural and cognitive postulatesº (p. 252). The term relapse has been afforded a number of meanings by various authors. A lapse is seen by Gossop (1996) as being part of a transitional process which may ultimately lead to favorable long-term outcome, while a relapse is a return to the original pattern of drug intake. Relapse is not necessarily a discrete event that occurs at one moment in time, but rather it is the end point of the process of returning to former patterns of abuse. The process of relapse transcends the actual preferred substance of abuse. This was demonstrated in a seminal paper by Hunt, Barnett, and Branch (1971) who showed similar post-treatment, relapse/survival curves for alcohol, opiate, and nicotine abusers. Indeed, relapse prevention models have subsequently been applied to a range of behaviors about which an individual has made a commitment to behavioral control and has formulated a set of rules to govern this control. It was not until the 1970s that addiction researchers began systematically to examine the nature of the processes involved in relapse. Since then a number of leading models have emerged to guide our thinking and these have been reviewed by Connors, Maisto, and Donovan (1996). Gloria Litman and her colleagues (e.g., Litman, Eiser, Rawson, & Oppenheim, 1977, 1979) saw relapse as a person±situation interaction. Of primary importance was the high-risk situation and the effectiveness and appropriateness of the individual's coping skills for dealing with it. Relapse was more likely in individuals who had few coping resources and who encountered a relatively large number of risk situations. Sanchez-Craig (1987) placed more emphasis on the individual's perception and appraisal of the risk situation rather than the situation itself. Relapse has also been systematically approached from what has been called a psychobiological perspective. Central to these models is the idea that relapse is precipitated by craving, which results in loss of control. Craving can be seen as a cognitive interpretation of the feelings of arousal associated with drug-related stimuli. Solomon's (1980) opponent process model defines craving as the interplay between positive and negative emotional states, induced by the substance. Tiffany (1990) formulated a model of drug use and relapse which highlighted the importance of automatic and nonautomatic

cognitive processing. Automatic processes are characterized by speed, autonomy, effortlessness, and lack of conscious awareness. Examples are the urges and cravings generated by drug withdrawal or the reinforcing effects of drugs. Nonautomatic processes require conscious effort, the choice of competing strategies, the execution of preferred strategies, and the modulation of the strategy to take account of environmental changes. In order to deal with what Tiffany calls automatically induced urges and cravings, the individual must mobilize nonautomatic cognitive processes which require effort, attention, and intention and which can lead to overt behavioral and cognitive coping strategies. Most relapse prevention programs therefore emphasize the importance of a broad range of cognitive and behavioral strategies which will attenuate the possibility of relapse. Arguably, the most influential model developed with the addictions field has been Marlatt's taxonomy of relapse precipitants. Marlatt and Gordon (1985) presented relapse prevention as a set of principles broadly based on social learning theory. In a sample of over 300 individuals who used a variety of drugs, they were able to clarify the key relapse precipitants into two broad categories. The first includes intrapersonal precipitants such as negative and indeed positive physical and emotional states. For over one-third of alcohol and nicotine abusers and about one-fifth of heroine abusers the main relapse precipitant was a negative emotional state. The second category is interpersonal precipitants of relapse including relationship conflict and indirect or direct social pressure. As part of a relapse prevention program, Marlatt and his colleagues suggest that individuals are taught to recognize the possibility of relapse. Essentially the client constructs a personal behavioral analysis and receives training in specific coping strategies. These can include broad-based skills training (behavioral rehearsal, assertiveness training), cognitive reframing (coping imaginary, reframing reactions to lapse), and lifestyle interventions (relaxation and exercise enhancement). All of these have been found to contribute to the effectiveness of a relapse prevention program. Clients are taught to recognize early warning signals and made aware of apparently irrelevant decisions that can increase the possibility of relapse. Emphasis is placed on the modification of cognitive distortions and the challenging of faulty beliefs or dysfunctional assumptions. For example, the abstinence violation effect is a distorted redefinition of lapse as relapse, so undermining the effectiveness of future coping

Psychologically Based Treatment Methods behaviour. The Marlatt and Gordon relapse prevention program is therefore a combination of skills training, self-management, and cognitive interventions and the client is encouraged to practice these strategies using rehearsal, roleplay, and homework tasks. Carroll (1996) carried out a detailed review of 24 controlled trials that have evaluated the effectiveness of relapse prevention across a range of addictive behaviors including nicotine, alcohol, marijuana, opioid, and cocaine abuse. In the review, she included only those trials that specifically employed the relapse prevention model of Marlatt and Gordon (1985) and that were, in her opinion, methodologically sound. The outcome variables were primarily posttreatment patterns of substance use, rather than behavioral and cognitive indicators such as coping skills, self-efficacy enhancement, or social adjustment. The review concluded that there was some evidence of effectiveness of this type of relapse prevention approach across a range of substances, particularly smoking cessation, when compared with no treatment controls. However, its superiority over other active treatments and discussion control conditions was less consistent. The specific benefits over other treatments were in reducing the severity of relapses if they occurred and the approach seemed to be of most value for clients with more severe dependence or higher levels of psychopathology. The Relapse, Replication and Extension Project (RREP) was a major multicenter trial established to investigate the validity and reliability of Marlatt's taxonomy of relapse precipitants (Lowman, Allen, & Stout, 1996). Essentially the study confirmed the predictive validity of a modified version of Marlatt's taxonomy, although it did raise some questions about differences between proximal variables associated with time-limited relapse and variables that predict outcome in the longer term. The relapse prevention model of Annis and Davis (1989) draws more explicitly on selfefficacy theory. The emphasis of this approach is on performance-based methods, notably the exposure to increasingly high-risk situations with continuing self-monitoring of efficacy expectations. In guiding the client through risk situations, Bandura's (1985) four factors that engender strong efficacy expectations are taken into account. First, the situation is challenging; second, to succeed in mastering the situation a moderate degree of effort is needed; third, the client is responsible and external help is kept to a minimum; and fourth, the success is described as part of a pattern of improved performance. The Inventory of Drink Situations helps identify the client's areas of high risk of relapse and the

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Situational Confidence Questionnaire measures perceived ability to cope effectively with a variety of drug-related risk situations. More recently Moser and Annis (1995) have emphasized the role of coping strategies in their cognitive behavioral model of relapse. They demonstrate that the survival of a relapse is strongly related to the number and type of coping strategies employed. Avoidance strategies are less effective in preventing relapse than active strategies, such as carrying out alternative activities, seeking support from others, positive self-talk, and cognitive problem-solving. The relapse prevention models described above have been developed specifically within the addictions field, but their use has extended to a range of other clinical contexts, for example, anxiety management, eating disorders, and impulse control. However, there is also a series of models primarily used to inform research on health behavior decision making that emphasize the importance of cognitive processes as crucial determinants, not only in the abstention from risky behavior, but also the adoption of health beneficial behavior. These models have recently been employed within the addictions field. One of the first and most influential was the Health Belief Model (Becker, 1974) which expressed the likelihood of positive health decision-making in terms of a cost±benefit analysis. This was superseded by the theory of reasoned action (Ajzen & Fishbein, 1980) and then came the theory of planned behavior (Ajzen, 1988). This latter model specified a number of variables that predict intention and behavior, namely control beliefs, subjective norms, and attitudes (a form of outcome expectations). These health belief models have been refined and developed by Ralph Schwarzer in his Health Action Process Approach (HAPA). This idea is now widely applied to the understanding of the fluctuating relapse/ survival process of addictive behavior. Schwarzer (1992) comments that traditional relapse prevention approaches, such as that of Marlatt and Gordon (1985), have focused on the maintenance stage and have not promoted understanding of change strategies in the motivational and action phases of change. Essentially, within the motivation phase the individual forms an intention to adopt precautionary measures for changing risk behavior in favor of other behaviors. The action phase is an attempt to explain the relationship between intention and subsequent behavior, with emphasis being placed on action control and action plans. Estimates of the relative proportion of outcome variance explained by predictors of intention and behavior have been gleaned from

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a variety of sources. For example, outcome expectations and the perception of subjective norms contributed to about half of the variance in intention to stop smoking, but rather disappointingly stated intention to stop smoking accounts for only about 20±25% of the variance in actual observed long-term smoking abstention. However, when beliefs about personal efficacy are added to the model, its explanatory power increases substantially. Schwarzer concludes that self-efficacy expectation, or the belief that addictive behavior can be changed by mobilizing personal resources, is the most powerful predictor of intention and subsequent behavioral control. This view was supported by Kok, De Vries, Muddle, and Strecher (1990), who demonstrated that efficacy expectations alone could account for over two-thirds of the outcome variance of intention to stop and subsequent smoking abstinence. The total predictive effect of self-efficacy on the maintenance of health behavior exceeds the effect of any combination of other cognitive variables. Bandura (1997) agrees, and concludes his review of models of health behavior by noting that outcome expectations have variable effects, normative influences have little effect but efficacy expectations are constantly predictive. In summary, the work of Annis, Schwarzer, Bandura, and others indicates that self-efficacy is emerging as the most powerful predictor of relapse/survival across a variety of addictive behaviours. Allsop, Saunders, Philips, and Cann (1997) suggest that training in coping skills is not enough, people must use the skills at the right time for them to be effective. The practice of coping skills improves self-efficacy so that the skills can be deployed in real-life risk situations. Furthermore, in recent years there has been much cross-fertilization of ideas between relapse prevention models developed primarily for substance abusers and more general models of health decision-making behavior.

6.25.3.4 Psychosocial Interventions The prototypical, community self-group is Alcoholics Anonymous (AA) which was founded in 1935 by a serendipitous meeting between two American alcoholics, Bill W and Dr. Bob. Advice to attend AA remains part of many contemporary multimodal treatment packages for alcohol abuse. The principles of change espoused by AA are based on the Oxford group, a religious organization in the evangelical Protestant tradition (Bill W., 1957), which emphasized self-examination, the public

admission of character deficits, restitution, pledge taking, and bible reading. Bill W. used this as a metaphor for the organizing principles of AA. At an AA meeting open sharing is encouraged and members admit their powerlessness over alcohol. The AA belief system is articulated in the 12 steps, which include the requirement of a searching personal inventory, commitment to a greater power, making amends to other people, and carrying the message to other alcoholics. Essentially, the AA model of addiction is one of an illness which can only be arrested by complete and life-long abstinence from alcohol; an illness that is said to be arrested but never cured. All attenders, no matter how long they have been alcohol-free, remain designated as recovering alcoholics. An analysis of AA-mediated processes of recovery suggests that motivation can be bolstered by the use of proximal goals (a day at a time) for everyone from the first attender to the 20 year abstainer. Emphasis is placed on role modeling, with constant recourse to a pay-off matrix in which the profit of staying sober is compared to the loss of being drunk. AA also offers, in the best relapse management tradition, alternative activity and new social networks. Much AA folk wisdom, such as not getting angry, tired, or bored; monitoring thinking tricks, and selfjustifying statements, is the stuff of social learning theory. This prompted Edwards (1996) to compare an AA meeting to a cognitive behavioral workshop. In a small sample of AA attenders, Edwards et al. (1987) found that the most valued AA activity was hearing other people's stories and the least valued was the quasi-spiritual element. Tonigan, Ashcroft, and Miller (1995) examined three AA groups in terms of perceived social dynamics and the relative emphasis on the 12 steps. The groups significantly differed in terms of cohesiveness, independence, and expressed aggression and it was found that 12 step discussion was lowest in the groups with the highest aggressiveness. In the light of these results it was suggested that AA need not be regarded as a homogeneous entity and a clear understanding of the variation among AA groups needs to be gained before we can make definitive statements about its effectiveness. Davies (1992), in his attributional analysis of what he called the ªmyth of addition,º argued that step one, which is an admission of powerlessness over alcohol, can absolve the individual of personal responsibility for his drinking. It minimizes the importance of a functional explanation of drinking behavior and Davies would say that it does not bode well for dealing with relapses should they occur. Ogbourne (1993) observed that we know little about the

Issues in Treatment real long-term effectiveness of AA because as a matter of principle the organization keeps no records of the success and failures of its members. Furthermore as noted above, AA is less homogeneous than many people think. There is no doubt that AA, with its rigid explanations and emphasis on abstinence, does not suit most alcohol abusers and so attrition rate is high (Miller & McCrady, 1993). Edwards (1996) cautions ªthe evidence that AA works is suggestive and rests on the evidence of its popularity and seeming ability to meet need, rather than being a matter of proven factº (p. 235). Nonetheless, for some people it is the belief that they are personally powerless over alcohol which can inspire faith and promote change (Keene & Raynor, 1993), and it is indisputable that the profound and international influence of AA belies its humble beginnings. Narcotics Anonymous (NA) was established in 1953. Christo and Franey (1995), in a six month follow-up of over 100 graduates from a residential program, found that NA attendance was inversely related to continued drug use and that spiritual beliefs or beliefs in the disease concept were not prerequisites for NA attendance. The 12-step approach has been the basis of many community residential groups for alcohol and drug abusers. The 12 steps have been intermeshed with Maxwell Jones's (1956) pioneering models of therapeutic communities to produce concept houses, such as the original Phoenix House in New York, which provided long-term residential programs for addicts. Most of the emergent therapeutic communities in the North America and the UK can trace their roots back to the Phoenix House program. Contemporary Minnesota Model programs vary from group to group, but they are generally based on the first half of the 12 steps and include group work, lectures, and individual assignments, all of which can be preceded by detoxification. When appropriate there is family involvement, which will typically draw on the principles of Al Anon. DeLeon (1995) noted that not all residential drug abuse treatment programs are therapeutic communities and not all programs calling themselves therapeutic communities employ the same psychosocial models of treatment. However, the core themes of the drug and alcohol therapeutic communities are those identified over 30 years ago by Rapoport (1960), namely democratization, communalism, and reality confrontation. More recently, Norton (1996) has usefully reviewed the change process inherent in therapeutic communities and noted that it is difficult to specify the components of programs that best predict positive outcome.

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Smart (1976) reviewed outcome studies on community graduates and suggested that when recovery is defined solely in terms of patterns of drug use, outcome is fairly good. However when other outcome indices are employed, for example future employment, the results are less encouraging. Thorley (1981) reviewed a number of UK studies and concluded that therapeutic communities for drug abusers can greatly benefit some individuals but can actively harm others. It is also difficult to specify the optimum duration of care within such communities. For example, McCusker et al. (1995) compared a six month with a 12 month therapeutic community program for a mixed group of drug abusers and found no difference on a whole range of psychosocial variables and pattern of drug use at six month follow-up. While therapeutic communities may arguably be an effective rehabilitation system, they are relatively few in number and normally have quite strict entrance criteria, thus rendering them genuinely unavailable to all but a small minority of alcohol and drug abusers. One final addendum to the AA story is the remarkable growth of the 12-step model within the USA for the ªtreatmentº of a whole range of so-called appetitive disorders. Almost any potential problem from shopping to sex has a 12-step residential program for individuals prone to excess. This raises fundamental questions about choice, compulsion, and volition in our understanding of human behavior. Stanton Peele (1989) in his best-selling book, Diseasing of America, argues that there is now more ªtreatmentº for everything and this inevitably undermines an individual's personal perception of control over his or her behavioral outcomes. Self-efficacy, so important in the treatment of any addictive behavior, is being diluted by what Peele calls the ªtherapeutic colonisation of our lives.º One can only speculate how Bill W. and Dr. Bob would have reacted to the widespread use, perhaps abuse, of their simple approach. Maybe it has gone one step too far.

6.25.4 ISSUES IN TREATMENT There are two key issues relating to the provision of treatment within addictions that have been the subject of much debate in recent years. The first relates to treatment intensity and the emergence of a plethora of so-called brief interventions for substance abusers. The second is the long-held assumption by most workers in the field that treatment should be tailored to the needs of the individual. In other words, which intervention for which client by which therapist

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is the most efficacious? Most of the ideas on parameters of treatment have been developed in studies of alcohol abuse and it is this literature that will primarily be covered in the following review. 6.25.4.1 Treatment Intensity There have been over a dozen randomized controlled trials comparing the dose±response relationship in populations seeking psychological treatment for alcohol problems. In this context brief intervention is defined as one to three sessions of specialist treatment. A distinction should be drawn between minimal intervention or advice in a primary care setting and brief intervention within a specialist context. The seminal study on brief intervention was reported by Edwards et al. (1977), who followed up a sample of 100 male alcoholics, all of whom had a three hour initial assessment. Half of the men then received a single session of direct advice and the other half were offered the standard intensive treatment package of the time which included medical interventions, introduction to AA, and hospital admission when appropriate. This study is well documented elsewhere but the key conclusion, which has influenced thinking on delivery of care to alcoholics, is that even after a 10 year followup there was no significant difference between the groups on a host of outcome measures. Subsequent, similar trials have more or less confirmed this finding. Bien, Miller, and Torigan (1993) reviewed this body of work and concluded that there are remarkably few differences between brief and extended interventions for treatment-seeking alcoholics. Wellplanned, brief interventions produced similar outcomes when compared with more extended psychosocial interventions, with only two studies reporting a slight advantage for the latter. The dose±response literature should, however, be interpreted with some caution. These studies are notoriously difficult to design and most of the controlled trails comparing brief with extended treatments have been subject to some criticism. Indeed Orford (1980) would concede that the Edwards' trial was by no means methodologically flawless. Heather (1995) has recently produced a useful evaluation of the literature. He argues that brief interventions tend to be seen as a homogeneous category and researchers, as well as practitioners, have paid insignificant regard to heterogeneity of this type of intervention. Furthermore, there are important differences between treatment-seeking populations as distinct from those that are selected as a result of opportunistic screenings.

Heather also highlights the possibility of type two error, in that this family of studies is essentially proving the null hypothesis. It is an inferential error to conclude on the basis of a lack of significant difference between intensive and brief intervention that they are equally effective. Even with a large sample and sufficient statistical power, which is not the case in most of the trials, one can only conclude that there is no evidence of difference in effectiveness. Heather concludes his methodological critique by suggesting that it is at best premature, and at worst cavalier, to argue that highly dependent, treatment-seeking alcohol abusers gain as much from brief interventions as they would from more extended intervention. There is, however, some merit in investigating the so-called active ingredients of brief interventions which seem to be, at least, relatively successful. Miller and Sanchez (1993) reviewed the protocols of a large number of brief interventions and isolated some critical conditions or key elements that facilitate change in addictive behavior. These can be summarized by the acronym FRAMES, representing feedback, responsibility, advice, menu, empathy, and selfefficacy. Essentially their findings would suggest that for brief interventions to be successful the client should be given realistic and accurate feedback about any drug-related impairment, emphasis should be placed on personal control and efficacy with corresponding attention to feelings of helplessness and powerlessness, good advice should be proffered, and the client should be given a choice of preferred change options. Finally, and arguably most important, therapeutic styles should be empathic rather than confrontational. While acknowledging Heather's caveats, the brief intervention literature does offer hope that for some drug and alcohol abusers, treatments that are structured along these lines could offer potential long-term benefits. 6.25.4.2 Treatment Matching Almost invariably, any review of the treatment of addictive behavior concludes with a comment that intervention should be matched to the needs of the client. For example, Gossop (1996) notes that ªfor all types of drug problems that require treatment the intervention offered should be tailored to the needs and circumstances of the individualº (p. 159). Raistrick and Davidson (1985) say that ªtherapy should be tailored to the individual. What is useful for one person may be singularly inappropriate for anotherº (p. 154). Miller and Herster (1986) say that ªclients should be matched to optimal interventionsº (p. 27), and so it goes on.

Conclusion However, these apparently obvious and laudable matching sentiments have recently been the subject of some scrutiny in the alcohol literature. Edwards and Taylor (1994) report a study that explored the interaction among treatment intensity, client characteristics, and 12 month outcome. There were no interactive effects and the authors conclude that the matching hypothesis was not confirmed. These data suggest that individual characteristics such as degree of dependence on alcohol or socioeconomic class, rather than client/treatment matching, may best predict outcome. Edwards and Taylor draw the tentative conclusion that relatively weak matching differentials are masked by developmental or environmental influences on the process of recovery. Of particular interest in this regard is Project MATCH which Heather (1996) describes as the largest treatment trial ever mounted in the alcohol field. It was funded by the National Institute on Alcohol Abuse and Alcoholism and involved over 1600 clients tracked over a 15 month period. Meticulous attention was paid to all aspects of the trial design which essentially tested the relative merits of a variety of client/ treatment combinations. Clients were randomly assigned to one of the three treatment modalities namely 12-step facilitation (TSF), cognitive behavioral coping skills (CB), and what was called motivational enhancement therapy (MET). TSF was based on the methods of Alcoholics Anonymous, but as it was only conducted for 12 sessions, did not include regular and life-long AA attendance as part of the treatment condition. CB was limited to 12 sessions of coping skills training, and MET was a four session program based on the principles of brief motivational counseling as outlined above. A variety of client characteristics were assessed, including motivational status, selfefficacy, degree of alcohol dependence, extent of social support, the number of alcohol-related problems, psychiatric morbidity, and cognitive impairment. Obviously the interactions between client characteristics and intervention were as important as any potential main effect between treatment conditions. The primary objective of the study was to determine which of various subgroups of alcohol-dependent clients would differentially respond to the three broad interventions. Additionally, the interaction of treatment location (inpatient vs. outpatient) with client characteristics and mode of intervention was examined. In summary, the results indicated significant and sustained improvement on a range of outcome variables across the three main treatment conditions (Project MATCH, Research Group, 1997). In other words all three types of

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interventions were equally effective. With the exception of psychiatric morbidity, matching client characteristics with treatment did not enhance outcome. This one ªmatchº seemed to indicate that outpatients with greater psychiatric morbidity responded better to CB than TSF. However, the overall conclusion of the study was that the general lack of robust matching effects means that practitioners need not take these individual characteristics into account when triaging clients to one or other of the three treatment interventions, despite their different philosophies. This is a counterintuitive and radical finding which will undoubtedly resonate in the alcohol treatment field for decades to come. Despite the methodological rigor, it may be argued that the 12-week protocol for CB and TSF and the four-session MET intervention do not reflect the range or richness of available interventions, particularly those based on social learning theory. The length of follow-up was only 15 months in this first Project MATCH publication and it could be that matching effects become manifest much later. Furthermore, it is unclear about the validity of cross-cultural application of these results. For example in the UK, Woodhouse and Davidson (1996) matched broadly similar interventions with motivational stage and while there was no significant difference in a quantity/ frequency measure at one year, they found a small but significant matching effect at two years. Essentially contemplators responded relatively better to motivational interviewing, while those in the action stage were best suited to relapse prevention strategies. While this latter finding may not be clinically significant, it may add some weight to the possible criticisms of the Project MATCH trial regarding cross-cultural generalizability of the findings and the relatively short follow-up period.

6.25.5 CONCLUSION A number of conclusions can be drawn from this review of cognitive and behavioral approaches to the treatment of addictive behavior. Most of the interventions described in the chapter have been offered to users of a range of substances. There has been a tendency to assume, not unreasonably, that the important component of any intervention is the cognitive and behavioral changes that accrue irrespective of the preferred drug of abuse. While this is intuitively appealing, it would seem that it is not always the full story. For example, at the risk of oversimplification, relapse prevention procedures are clearly useful for smokers, moderately effective for alcohol abusers, and have some

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variable effect, according to the available literature, as a treatment for cocaine abuse. There has, as yet, been no demonstrable significant improvement against a control condition for the relapse prevention treatment of marijuana use (Stephens, Roffman, & Simpson, 1994). Klingemann (1994) has speculated about possible reasons for these substance specific effects. He particularly notes that good quality, extensive social support may become progressively less accessible as the substance changes from cigarettes to alcohol to illicit drugs. While it is obviously important to elucidate on the general principles of change, there may be some merit in clarifying the possible value of substance specific interventions. In answer to the question ªDo psychologically based treatments of addictive behavior work?º most reviewers interpret the literature slightly differently. In the past there has been an overwhelming sense of what people termed therapeutic nihilism, based on the weak relationship between any type of intervention and eventual outcome. There is now, however, increasingly good evidence on the effectiveness of psychological approaches for addictive behavior. Moos, Finney, and Crankite (1990) in their studious review, concluded that treatment leads to substantial improvements in drinking behavior while acknowledging the importance of individual and social factors in the determination of outcome. The treatment outcome prospective study (TOPS) was a systematic evaluation of a heterogeneous group of treatment programs for a range of drug abusers. The TOPS study reported a general overall reduction in drug use over a three to five year period, as well as improvement in other psychosocial variables (Hubbard, Marsden, & Rachal, 1989). While treatments based on psychological theory have been shown to be effective, no specific treatment approach has emerged as being consistently superior to the others. One problem with conventional, randomized controlled trials, particularly pertinent in the field of substance use disorder, is that the preference of an individual for one particular type of intervention over another is not taken into account in random allocation. A potential, future methodological advance may be greater use of designs like the partially randomized, patient-preference design advocated by Brewin and Bradley (1989) for the investigation of relative treatment effectiveness. Finally, work on the interaction between treatment intensity and outcome in both inpatient and outpatient settings has been summarized above. Unfortunately at times this debate is conducted against a background of

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for treatment and lifestyle change. In G. Howard (Ed.), Issues in alcohol use and misuse by young adults. Paris: University of Notre Dame Press. Moos, R., Finney, J. & Crankite, R. (1990). Alcoholism treatment: Contact, process and outcome. New York: Oxford University Press. Moser, A., & Annis, H. (1995). The role of coping in relapse crisis outcome: A prospective study of treated alcoholics. Addiction, 91, 1101±1114. Noonan, W., & Moyers, T. (1997). Motivational interviewing. Journal of Substance Misuse, 2, 8±16. Norton, K. (1996). How therapeutic communities work. In G. Edwards & C. Dare (Eds.), Psychotherapy, psychological treatments and the addictions (pp. 240±256). Cambridge, UK: Cambridge University Press. Ogbourne, A. (1993). Assessing the effectiveness of AA: Meeting the challenges. In B. McCrady & W. R. Miller (Eds.), Research on Alcoholics Anonymous: Opportunities and alternatives (pp. 76±85). New Brunwick, NJ: Rutgers Center of Alcohol Studies. Oxford, J. (1980). Understanding treatment: Controlled trials and other strategies. In G. Edwards & M. Grant (Eds.), Alcoholism treatment in transition (pp. 71±92). London: Groomhelm. Orford, J. (1992). Davidson's dilemma. British Journal of Addiction, 27, 832±833. Parloff, M., London, P., & Wolf, B. (1986). Individual psychotherapy and behaviour change. Annual Review of Psychology, 37, 321±349. Peele, S. (1989). Diseasing of America: Addiction treatment out of control. Lexington, MA: Lexington Books. Pentony, P. (1981). Models of influence in psychotherapy. New York: Free Press. Pickering, H., & Stimpson, G. (1994). Prevalence and demographic factors of stimulant use. Addiction, 89(11), 1385±1390. Powell, T., Bradley, B., & Gray, J. (1993). Subjective craving for opiates: Evaluation of a cue exposure protocol for use with detoxified opiate addicts. British Journal of Clinical Psychology, 32, 39±53. Prochaska, J. O., & Di Clemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. New York: Dow-Jones Irwin. Prochaska, J. O., Di Clemente, C. C., & Norcross, J. (1992). In search of how people change: Applications to addictive behaviors. Americian Psychologist, 7, 1102±1114. Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH post-treatment drinking outcomes. Journal of Studies in Alcohol, 58, 7±29. Raistrick, D., & Davidson, R. (1985). Alcoholism and drug addiction. London: Churchill Livingstone. Ramsay, M., & Percy, A. (1997). A national household survey of drug misuse in Britain: A decade of development. Addiction, 92(8), 931±938. Rapoport, R. (1960). The community as a doctor. London: Tavistock. Reinarman, C., Murphy, S., & Waldorf, D. (1994). Pharmacology is not destiny: The contingent character of cocaine abuse and addiction. Addiction Research, 2(1), 21±36. Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25±37. Rollnick, S., Heather, N., Gould, R., & Hall, W. (1992). Development of a short ªreadiness to changeº questionnaire for use in brief opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 743±754. Room, R. (1980). New curves on the course a comment on Polich, Armor and Braiker, ªThe Course of Alcohol-

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586 Hester, R. K. Miller, W. R. Edwards, G. Lader, M. Suls, J. Dare, C. Heather, N. Marlatt, G. A. Gordon, J. R. Gossop, M. Nathan, P. Loberg, T. McCrady, B. Howard, G. Grant, M. Schwarzer, R. Busch,

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6.26 Cognitive Approach to Understanding and Treating Pathological Gambling ROBERT LADOUCEUR Universite Laval, QueÂbec, PQ, Canada and MICHAEL WALKER University of Sydney, NSW, Australia 6.26.1 INTRODUCTION

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6.26.2 MOTIVATION TO GAMBLE

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6.26.3 DEPARTURES FROM NORMATIVE DECISION MAKING IN GAMES OF SKILL AND GAMES OF CHANCE

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6.26.4 DEVELOPMENT OF GAMBLING PROBLEMS

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6.26.5 DEFINITION AND ASSESSMENT OF PATHOLOGICAL GAMBLING

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6.26.6 PREVALENCE OF PATHOLOGICAL GAMBLING

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6.26.7 PSYCHOLOGICAL TREATMENT OF PATHOLOGICAL GAMBLERS

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6.26.7.1 6.26.7.2 6.26.7.3 6.26.7.4

Changing Erroneous Beliefs Concerning Randomness Problem Solving Training Social Skills Training Relapse Prevention

6.26.8 EFFICACY OF A COGNITIVE/BEHAVIORAL TREATMENT FOR PATHOLOGICAL GAMBLERS 6.26.8.1 Case History 6.26.8.1.1 Identification and correction of faulty cognitions toward gambling 6.26.8.1.2 Problem solving and social skills training 6.26.8.1.3 Relapse prevention

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6.26.10 COMMON DIFFICULTIES IN THE TREATMENT OF PATHOLOGICAL GAMBLERS

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6.26.11 CONCLUDING REMARKS

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6.26.1 INTRODUCTION The twentieth century has been described as the ªhinge of history.º This description follows from the wide range of indications of social, economic, and environmental measures showing catastrophic change. One of these indications is the general public's level of involvement in gambling activities. Rowntree (1941) compared the standard of living of the residents of New York City in 1899 and 1936. In his analysis of leisure in everyday life, he reached the conclusion that gambling had grown enormously over that period of time. It is well-documented that, since 1936, gambling has continued its rapid growth not only in the USA, but throughout the world (Frey & Eadington, 1984; McMillen, 1996). In explaining the upsurge in gambling, the British Royal Commission on Lotteries and Betting (1933, p. 60) stated that, ªOne of the main causes, perhaps the most potent in the growth of gambling, has been the increased facilities for organized gambling.º Similar views have repeatedly been expressed by contemporary observers of gambling (Connor, 1983; Cornish, 1978; Dickerson, 1984: Orford, 1985). However, the claim that the rapid growth in gambling is attributable to the legalization and the accessibility of gambling outlets may be considered false, or at least incomplete. Betting shops, gambling machines, lotteries, and casinos would be useless if ordinary people did not want to gamble. Even in societies where gambling has been prohibited, gambling games have nevertheless flourished (Dixon, 1996). Prior to discussing why people want to gamble, it is important to specify what we are referring to when using the word ªgambling.º Research on gambling does not incorporate all risk-taking behavior, but only a limited range of such behavior. The essential nature of gambling is that money (or its equivalent) is risked on the uncertain outcome of an event, subject to certain conditions: (i) gambling occurs in a group context whereby after costs, taxes, and profits, the money wagered by the losers is redistributed to the winners; (ii) the redistribution of money is independent of any other commercial enterprise related to the gambling event. This definition excludes insurance such as life or property insurance. This definition of gambling is similar to those put forth elsewhere (Perkins, 1950). It should be noted that all definitions of gambling appear to differ with respect to what is included or excluded. This problem can be overcome if the activities to be included are listed explicitly. In this context, three broad categories of gambling have been identified: betting, gaming, and lotteries. Betting refers to staking money on the outcome of an uncertain

or future event; gaming refers to playing for money in a game of chance; and lotteries refers to the distribution of prizes by drawing lots. Although these three kinds of gambling have much in common at the structural level, they are completely different sociologically. Claiming that people want to gamble does not advance our knowledge of gambling to any great extent, but immediately raises the question as to why people want to gamble. Understanding the motivation to gamble would appear to be central to understanding why people may gamble excessively, and can be expected to have an important bearing on how gambling-related suffering may be alleviated, diminished, or avoided. This chapter argues that the motivation to gamble is seen as the acquisition of wealth and that the real problems in explaining gambling concern why it is that gamblers believe that money can be won. Because the belief of gambers that money can be won is erroneous, it follows that therapeutic methods which change the false beliefs of the gambler are more likely to be effective. This proposition is examined in detail. 6.26.2 MOTIVATION TO GAMBLE Gambling explicitly involves the attempt to win money by staking money on an uncertain event. As a starting point in the attempt to understand the motivation to gamble, the acquisition of wealth can be assumed to be the prime motivation. The problem with this assumption is that all legalized forms of gambling are constructed so that the expected return is less than the sum wagered. For example, a roulette wheel with one zero takes in, on average, 1/37 of the money staked. Totalizators typically take in approximately 20% of the money wagered in racing (Ladouceur, Giroux, & Jacques, 1998) and lotteries typically take in approximately 40% of the revenue from ticket sales. These percentages vary from place to place and according to the structure of the distribution of prizes or returns, but in all cases the expected return on money invested constitutes a loss for the gambler. Thus, if the acquisition of wealth is the individual's goal, rational economic considerations would lead people to avoid gambling. This is the principal paradox of gambling: people, in attempting to gain wealth, engage in an activity which is expected to decrease wealth. The gambling paradox can be resolved in two different ways: (i) accepting that the acquisition of wealth is the motivation, but the gambler misjudges the chance of winning; or (ii) rejecting the acquisition of wealth as the sole or central motivation involved.

Motivation to Gamble The majority of theories of gambling behavior reject the acquisition of wealth as being the fundamental motivation for gambling behavior. However, cognitive theories of gambling assume that the acquisition of wealth is the primary motivation involved, and that people do not behave as they normally would with respect to that motivation. According to cognitive theories, gamblers hope to win money or believe that they will win money. Why people should hope to win or expect to win in the face of the adverse odds involved is the central concern of such theories. By contrast, other theories of gambling assume that winning money is not the principal motivation for gambling. One cluster of such theories assumes that it is the amusement and excitement (the change in arousal level) that motivates gambling behavior. In the behaviorist form of these theories, the changes in arousal reinforce the gambling behavior (Dickerson & Adcock; 1987; McConaghy, 1980), whereas in more purposive theories, gambling has the function of changing mood (Brown, 1996) as when the excitement of gambling overcomes boredom. In some cognitive behavioral explanations, arousal retains a dominant role but must be coupled with appropriate cognitions (Sharpe & Tarrier, 1993). A second cluster of theories places more emphasis on personality dimensions and, more specifically, on impulsiveness (Blaszczynski & McConaghy, 1994). It is assumed that risk-oriented individuals are attracted to gambling and that problems arising from excessive gambling can be attributed to impulsiveness. Yet other explanations see the gambling as largely irrelevant: gambling is simply one possible means of escaping or avoiding stresses and associated anxiety elsewhere in the individual's life. All such theories assume that the principal reward for gambling is something other than money. Some support for this view comes from the gambling industry which regards gambling as a leisure activity in which the money expended by the gambler buys the gambling product. The product is understood to be the amusement and excitement of the gambling venture. Thus, gambling is viewed as a desirable activity in itself, similar to eating in a restaurant or playing a round of golf. The money spent by the gambler pays for the enjoyment received. It might seem that these alternative explanations for gambling have a certain face validity. If, after all, it is unreasonable to expect to win money by gambling, then surely some other factor must be involved. When gamblers are questioned about why they gamble, the majority of answers concern amusement, excitement, and relief of boredom. By contrast, only a minority of individuals involved in betting and gaming

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state that they gamble in order to win money. The important question is whether or not the opinions of gamblers as to why they gamble should be accepted indiscriminately. A certain amount of validation of the data derived from other sources is a minimum requirement. Consider, for example, the claim that gambling is exciting and that the rewarding value of the excitement is the main reason why most people gamble. If this claim is true, then several implications follow: (i) Behavioural observation should support the self-report data. Gamblers should appear to be excited when gambling. Excitement should be apparent on faces (laughing and smiling), in exclamations of delight, and in the general bodily tension and alertness. (ii) Physiological measures should support the self-report data. Gamblers should exhibit raised levels of heart rate, blood pressure, and palmar sweating. Neurophysiological measures should also suggest general arousal. (iii) Indications of excitement should not be highly correlated with winning. If excitement always accompanies winning and no other events within the gambling cycle, then it is not possible to know whether it is the winning or the excitement which maintains the behavior. (iv) If an explanation of gambling in terms of the reward value of excitement is to be generalized, then the indicators of excitement should be present for all forms of gambling. Surprisingly, there is very little evidence supporting any of these specific implications. Here, we briefly review the evidence. Excitement is most easily observed in certain forms of betting and gaming, and among the winners of lottery prizes. Thus, the noise of the crowd at a race track reaches a crescendo as the leading horses reach the winning post. Similarly, certain casino games, such as craps and two-up, have been described as suitable for the extrovert in view of the manifest excitement of the players (Allcock & Dickerson, 1986). However, such observable excitement is not sufficient evidence. Observable excitement is less in offcourse betting shops and may be largely absent among home gamblers with phone accounts. Furthermore, certain casino games, such as blackjack and pai gow, are traditionally played with a minimum display of emotion. In poker, the ideal involves an absence of genuine emotion. Thus, there are many examples of gambling situations in which no excitement is expressed. Different measures of physiological arousal may be used in gambling research. Increases in heart rate have been reported for blackjack (Anderson & Brown, 1984) and changes in skin conductivity for slot machines (Sharpe, Tarrier, Schotte, & Spence, 1995) when players begin a

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session. It is likely that arousal increases at the beginning of all gambling sessions. However, excitement prior to gambling cannot be a reward for gambling. More importantly, arousal must be demonstrated to correlate with events within the gambling session. In a detailed study of slot machine gambling through time, Dickerson (1993) did not find any correlation between player arousal and the events within a session. Although variations in arousal have been demonstrated for certain gambling-related events, the failure by Dickerson to show that arousal is correlated with machine events in slot machines is an important obstacle for an excitement-based explanation of gambling. Furthermore, the low numbers of positive reports of arousal in relation to the wide range of gambling, casts doubt on the ability of excitement-based theories to have wide explanatory power. However, as discussed in detail later, arousal has been found to be associated with erroneous perceptions that create an illusion of control and result in the overestimation of the probabilities of winning. Interestingly, arousal decreased when erroneous perceptions were corrected (Giroux, Ladouceur, & Jacques, 1998). By contrast with arousal and personality theories, cognitive theories of gambling assume that the acquisition of wealth is the primary motivation involved, and that people do not behave as they normally would with respect to that motivation. According to cognitive theories, gamblers hope to win money or believe that they will win money. Why people should hope to win or expect to win in the face of the adverse odds involved is the central concern of such theories.

6.26.3 DEPARTURES FROM NORMATIVE DECISION MAKING IN GAMES OF SKILL AND GAMES OF CHANCE Some gambling games allow the players a range of decisions which can affect the outcomes. In such games, players may depart from optimal play by choosing alternatives with lower expected values. Skill then refers to the extent to which a player's strategy of choices approaches the optimal strategy. Gambling games involving skill include blackjack, poker, and sports betting. In all of these games, systematic departures from optimal play have been reported. In blackjack, with optimal play, the expected value of casino blackjack is approximately 70.7% with variations from that figure depending on the specific rules of play that apply. Nevertheless, most players do not approach this

figure in their play (Griffin, 1987; Wagenaar, 1988; Walker, Sturevska, & Turpie, 1995). Analysis of the errors in play shows that in general the players adopt strategies which are too conservative. Players tend to sit when they should hit, avoid splitting pairs when it is desirable, and take out insurance when it is unnecessary (Wagenaar, 1988; Walker, 1995). Interestingly, the departures from normative play in poker tend towards risk rather than avoidance of risk. For example, players in five card stud tend to stay in the pot with a small pair when they should fold (Yardley, 1957). In draw poker, players will draw to hands with very small probabilities of success, and professional poker players prefer games in which the action is loose, that is, risky (Hayano, 1977; Yardley, 1959). There are many systems for betting on horse races and, as the variations between the systems are great (Allcock, 1987; Beyer, 1993; Drapkin & Forsyth, 1987; Scott, 1982) and no more than one can be accurate, it follows that the majority of systems yield less than optimal decisions. More generally, betting patterns have been observed to vary across a race meeting with betting on the last race at the meeting being more risk oriented than betting on earlier races (Bird & McCrae, 1985). Recently, Ladouceur, Giroux and Jacques (1998) showed that regular punters, defining themselves as experts in horse races, could not provide a better rate of return than a random selection of horses. In games of chance all alternatives have equal expectations, and thus there is no optimal method of play. Well known games of chance include lotteries, roulette, and slot machines. Since no optimal strategy exists for games of chance, players would be expected to expend no effort in trying to choose the best actionÐthe most likely winning ticket in lotteries, the most likely winning number in roulette, or the machine most likely to pay out in slot machines. Nevertheless, players can be observed expending considerable effort in making these decisions (Griffiths, 1994; Wagenaar, 1988; Walker, 1992). To the extent that players believe that some alternatives are more likely than others in games of chance, their approach to betting can be regarded as not normative.

6.26.4 DEVELOPMENT OF GAMBLING PROBLEMS Although a wide range of gambling-related problems have been documented (Walker, 1992), the classification of such problems has not been adequately developed. Classification of gambling problems can proceed from different perspectives and be based on different

Development of Gambling Problems criteria. Most commonly, gambling-related problems are classified by the area in the gambler's life that is affected. Thus, Dickerson et al. (1995) divided gambling problems into those associated with the individual, the family, financial status, employment, and criminal activity. Lorenz and Shuttleworth (1983) divided the problems into personal, relationship, and financial. Similarly, Custer and Milt (1985) divided the problems into gambling, alienation, marital problems, boredom, legal problems, indebtedness, needs, and goalessness. Categorization of problems in this way has value at the level of assessment, but does not clarify the nature or source of the problems. Although overlaps must exist, it remains possible for a new researcher to divide the gambling-related problems differently into another, possibly equally useful, set based on areas affected. An alternative approach, which places more emphasis on the genesis of the problems, assumes that the main cause of the problems is persistence with gambling despite the losses. Cognitive theories seek to explain why the gambler may persist with gambling until the losses become excessive. The next step in understanding problem gambling, which ultimately becomes labeled ªpathological,º involves analyzing the consequences of extreme persistence in the face of large losses. The central consequence, and possibly the core factor in causing gambling problems, is the financial loss. Although it may seem obvious that financial loss is a fundamental aspect of gambling problems, this perspective is sometimes not given the emphasis that would seem appropriate. For example, only four of the 10 criteria defining pathological gambling in the Diagnostic and statistical manual of mental disorders (4th. ed.; DSM-IV; American Psychiatric Association [APA], 1994) explicitly refer to the loss of money and the problems caused thereby. If the financial cost of gambling is emphasized, then many of the criteria for identifying pathological gambling can be understood as consequences of this common cause. Walker (1992), in his description of a sociocognitive theory of gambling, shows how the false beliefs of gamblers can lead to chasing losses, changes in mood, withdrawal and secretiveness, deceitfulness, irritation and anger, and foolish financial transactions. These changes at the individual level, coupled with the large loss in income, would be expected to impact on the family life, employment, and social life of the gambler. Persistence with gambling causes not only financial loss, but also absorbs large amounts of the gambler's time. The time away can be expected to impact heavily on the family and on

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employment. Thus, to the group of spouses that includes ªgolfing widowsº and ªfishing widows,º should be added ªgambling widows.º The impact on the family of excessive involvement in leisure activities or employment is common across activities and may be a cause of family argument and distress. However, it is likely that time away is for most gamblers and their families a minor factor compared to the financial losses suffered by the persistent gambler. Apart from the loss of time and money, there is one further area of loss that is more difficult to quantify. Gambling can be characterized as a background of failure broken only by occasional success. According to cognitive accounts of persistence with gambling, the gambler holds a set of erroneous beliefs about the nature of gambling and the role of the gambler in relation to the gambling. Persistence with gambling increases the likelihood of overall loss. Thus the gambler is continually engaged in searching for explanations that maintain the core beliefs. The mass of evidence suggesting that the gambler's beliefs are erroneous is a continuing stress that can be expected to cause loss of self-esteem and, ultimately, depression. It would not be surprising to find that some gamblers show evidence of this stress in aspects of their physiology and biology (Blaszczynski, Winter, & McConaghy, 1986; Carlton & Manowitz, 1987; Sharpe et al., 1995). One problem that general theories of gambling must confront involves specifying why only a minority of regular gamblers suffer problems to the extent that they ultimately seek counseling and treatment. Individual differences in persistence with gambling have been explained in terms of personality differences (Zuckerman, 1979), biological differences (Jacobs, 1986), and learning differences (Dickerson, 1984). However, perhaps the most valuable insights concerning individual differences in gambling have been provided by Orford (1985) and Oldman (1978). Orford asked the important question as to why not all gamblers continue gambling until their money is exhausted. If gambling is intrinsically rewarding, progression to gambling problems and pathology would be expected. Yet the majority of gamblers control their gambling sufficiently to avoid the potential problems. Thus, inability to exercise control over the desire to gamble is an important aspect of the genesis of gambling problems. Orford suggests that gambling problems may involve the conjunction of excessive appetites, incomplete socialization of control over appetites, and the availability of opportunities to gamble. Evidence for such a view of gamblers comes from observational studies of

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regular gamblers that show that most are able to modify their approaches to gambling when demanded by changed financial circumstances (Rosecrance, 1986). Oldman (1978) took the argument one step further by pointing out that gambling problems were a natural consequence of persistence with gambling. The label ªpathological gamblingº may thus be a means by which society negotiates the counseling and treatment of gamblers who are sufficiently unlucky that they lose too much (Oldman, 1978; Walker, 1995).

6.26.5 DEFINITION AND ASSESSMENT OF PATHOLOGICAL GAMBLING Pathological gambling was officially recognized in 1980 with the publication of DSM-III (APA, 1980), and was classified as an impulse control disorder. The DSM-IV (APA, 1994) defined 10 criteria reflecting different aspects of pathological gambling. To assign the diagnostic of pathological gambling, the individual must meet at least five of these criteria. As mentioned above, if most individuals gamble without it being a problem, some will eventually become overwhelmed by the desire to gamble, will gamble more than they planned, and will eventually spend more money than they can afford to lose. Pathological gambling is characterized by a loss of control over gambling, lies about the extent of involvement with gambling, family and job disruption, stealing money, and continuous chasing of losses. From a clinical perspective, two elements are the most representative of a pathological gambler: continuous or obsessional chasing of losses; and family, job, and social disruption caused by gambling. In our clinic (R. L.), we have recently adopted a multistep evaluation procedure. When an individual calls for help for a gambling problem, we return the call within 24 hours. During this first call, we ask the gambler to describe his main complaints and then administer the South Oaks Gambling Screen (SOGS). The SOGS is a 20 item instrument used in many prevalence studies around the world to identify the number of pathological or problem gamblers in the general population. It has been translated into many languages including French, Chinese, German, and Spanish. If preliminary data collected during the phone call suggests that the individual is a pathological gambler, a formal semistructured interview is immediately scheduled in order to identify the nature and history of the problem. Before starting this interview, the individual will be asked to complete questionnaires evaluating the following areas: depression, anxiety beliefs about gambling

(Ladouceur, Arsenault, DubeÂ, Jacques, & Freeston, 1997), superstitous behavior (Ladouceur, Giroux, & Jacques, 1988), and problem solving abilities. The interview is divided into two sections and covers the following aspects: history of the gambling activities; motivation for the consultation; first contact with gambling; first problems with gambling; familial, professional, and marital problems; money lost and criteria of pathological gambling. The last step in our evaluation is the second administration of the DSM-IV in order for the therapist to confirm the diagnostic of pathological gambling. If the individual is diagnosed as a pathological gambler, treatment is offered and usually starts the next session after the evaluation procedure. This procedure has many advantages. First, the gambler is contacted within the 24 hours after his call. Second, the telephone interview focuses on the gambling problem (description of the main complaints and the administration of the SOGS), thus setting the purpose of the consultation and the subject matter of further treatment, if necessary. Third, this assessment procedure provides relevant information about the different aspects of the gambler's life problems (family, job, social, legal, financial, etc.). Fourth, this procedure will provide useful data for the validation of various instruments, and on the characteristics of the patients who refuse or drop out of treatment. As will be discussed later, adherence to treatment is a major concern for professionals working with pathological gamblers. We need to identify the characteristics and the reasons of individuals who refuse treatment, drop out, or simply do not show up for the first session.

6.26.6 PREVALENCE OF PATHOLOGICAL GAMBLING The prevalence of pathological gambling is the percentage of the members of a society at a given point in time whose gambling is pathological according to some agreed criterion. Nearly all studies of the prevalence of pathological gambling have used one or other of the two measures described: the DSM-IV criteria and the SOGS. Most of the research has been conducted in the USA by Rachael Volberg on a state by state basis (Volberg, 1996), although substantial numbers of studies have been conducted outside the USA, such as in Canada (Ladouceur, 1996), Spain (Becona, 1996), Australia (Dickerson, Baron, Hong, & Cottrell, 1996), and New Zealand (Abbott & Volberg, 1996). Comparison of the data from the studies reviewed by the authors listed above is made

Psychological Treatment of Pathological Gamblers difficult by the fact that the details of the designs varied considerably across research groups. Volberg and Ladouceur used telephone surveys, whereas the surveys in Spain, Australia, and New Zealand used door knock surveys. Becona used DSM-III-R criteria whereas other researchers based their conclusion on the SOGS. Although most research has adopted a cut-off of five on the SOGS for the identification of pathological gamblers, Dickerson has argued that the cut-off should be higher. Finally, the SOGS itself may not be a sufficiently accurate indicator of pathological gambling for use in the prevalence research (Walker & Dickerson, 1996). Thus, current estimates of the prevalence of pathological gambling must be treated with a degree of caution. Nevertheless, the available evidence suggests that the occurrence of pathological gambling varies from country to country. Walker and Dickerson note that the prevalence figures for pathological gambling are correlated with the average expenditure on gambling across countries. Thus, in countries in which a higher percentage of personally expendable income is spent on gambling, there is a higher reported prevalence of pathological gambling (Table 1). Evidence of this kind strengthens the argument that gambling-related problems are primarily associated with the loss of excessive amounts of money. Theories of pathological gambling must explain why the gambler persists in gambling despite such losses. Cognitive theories assume that it is erroneous beliefs and inferences about gambling and the likelihood of favorable outcomes which maintains the behavior in the face of serious monetary losses. It follows that a cognitive approach to therapy is the one that will attempt to correct the erroneous thinking involved. 6.26.7 PSYCHOLOGICAL TREATMENT OF PATHOLOGICAL GAMBLERS The central assumption of cognitive approaches to treatment is that the pathological gambler continues to gamble because they

maintain an unrealistic hope that they will recover their losses if they persevere with the gambling. It is assumed that their erroneous beliefs about gambling, about the nature of predictability, and about their own special skills and knowledge in relation to predicting gambling events, conspire to maintain the gambling far beyond any reasonable limits. It follows that any correction of erroneous perceptions weakens the belief that losses can be recouped. However, alternative approaches to the treatment of pathological gambling are not based on these assumptions. There are in fact two main alternatives to the erroneous thinking approach: (i) the behaviorist orientation, based on the use of extinction processes; and (ii) the problem solving approach where the gambler is counseled in methods appropriate to solving problems causing the gambling. Both orientations assume that the central motivation is not avarice, but some other factor altogether. These two approaches differ in the level at which they assume the relevant processes are operating: molecular and below awareness for the behavioristic approach; conscious planned processes in the problem solving approach. The behavioral approach assumes that gambling-based arousal is the central factor in the reinforcement process. It is assumed that the increase in arousal associated with gambling is positively reinforcing. With repeated gambling a whole range of associated stimuli become conditioned reinforcers. Approach to, and participation in, gambling in regular gamblers are triggered by a wide range of environmental features: the sight of the newspaper, driving the car, leaving work, the sight of money in the wallet, and so on. The wide range of factors associated with gambling is often referred to, at the macro level, as preoccupation with gambling. Treatment makes use of established learning theory principles involving extinction of the association between arousal and central conditioned elicitors. The most effective specific treatment program using the behavioral approach appears to be imaginal desensitization (McConaghy,

Table 1 SOGS scores and gambling expenditure across countries. Country

SOGS scores (% scoring 5+)

Expenditure on gambling (% of personal consumption)c

Australia New Zealand Spain Canada

7.1 2.7 1.5a 1.2b

1.6 0.9 0.7 0.5

a

b

Means of estimates provided by Becona.

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Ladouceur's data only. cHaig (1985).

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Cognitive Approach to Understanding and Treating Pathological Gambling

Armstrong, Blaszczynski, & Allcock, 1983; Blaszczynski, McConaghy, & Frankova, 1991). Imaginal desensitization involves creating a list of specific gambling triggers for the individual. The gambler is taught standard muscle relaxation techniques. Finally, the gambler is asked to imagine the trigger situations one by one, each time accompanied by the relaxation procedure. In this way, the association of arousal with each of the triggers is extinguished. McConaghy, Blaszczynski and co-workers treated 60 pathological gamblers with the imaginal desensitization procedure, and a further 60 pathological gamblers by a range of other techniques (aversion therapy, relaxation therapy, and cue exposure). Of the 60 pathological gamblers treated by imaginal desensitization, only 33 could be followed up two or more years later. However, of these 33, 26 (79%) were gambling in a controlled way or not at all. In the control group, only 16 (53%) of the 30 followed up had achieved control or abstinence. The problem solving approach refers to a general orientation towards treatment rather than a coherent orientation towards the causes of pathological gambling. The actual causes of the gambling are assumed to be a variety of factors determined primarily according to the implicit theories of the counselor. According to addiction counselors, the gambler is driven by intense urges to gamble repetitively and in a maladaptive way. Thus the problem solving approach is oriented to increasing the gamblers ability to cope with the urges and to provide action alternatives that can be used to redirect the energies involved into alternative less hazardous directions. Many counselors believe that the gambling is an escape from crises and dilemmas which cause the individual great anxiety. Thus the problem solving approach is oriented to dealing with these other issues for which the gambling is an escape. There is a considerable body of research suggesting that counseling approaches yield improvement within a before-and-after design (Walker, 1992), little research has been done in which alternative therapies are compared or control groups used. The evidence available suggests that significant improvement may occur in a group of untreated pathological gamblers in a six month period (Echeburua, Baez, & Fernandez-Montalvo, 1996). Thus the necessity for controlled trials with longer-term follow ups (two years or more, ideally) is apparent. The cognitive approach to the treatment of gambling is based on experimental work demonstrating a wide range of cognitive errors made by gamblers in relation to gambling (Ladouceur & Walker, 1996). The research of

Ladouceur and his colleagues in Canada suggests that the core cognitive error lies in the gambler's notions concerning randomness. The illusion of control and belief in the predictability of events that depend on the misconception of randomness are assumed to lead ultimately to the bizarre beliefs documented by Coventry (1997), Walker (1992), and others. Gamblers try to control and predict outcomes of games that are objectively uncontrollable. The illusion of control motivates them to elaborate strategies to win more money. However, all gambling is based on the inherent unpredictability of gambling events either through inadequate information, as in sports betting, or through the incorporation of randomness as in slot machines, casino games, and lotteries. It follows that if the erroneous perceptions and understanding of randomness in the gambler can be corrected, then the motivation to gamble should decrease dramatically. Our treatment programs have focused on erroneous cognitions concerning randomness as the most important targets for change. The whole range of erroneous cognitions, sometimes labeled ªirrational thinkingº and which constitute the illusion of control, are also important targets for change. Since persistent gambling induces a range of other problems these are also treated. The loss of money is associated with many of these problems. Training in problem solving techniques appears to be appropriate and necessary in some cases. Also, many gamblers often lie and isolate themselves in order to gamble, and so social skills training may be necessary to help the client to reestablish adequate social relationships. In order to evaluate the effectiveness of cognitive theory for pathological gambling, a controlled study has been undertaken at Laval University. Four components were included in the therapy: (i) cognitive correction; (ii) problem solving training; (iii) social skills training; and (iv) relapse prevention. These components are now described and are followed by a case study which illustrates how these elements have been integrated in the treatment of a pathological gambler. Treatment is administered on an individual basis with one 60±90 minute session per week, over a period of 12 weeks.

6.26.7.1 Changing Erroneous Beliefs Concerning Randomness Correction of the misunderstanding of randomness is the first goal of the treatment. Different approaches to this task are possible according to the characteristics of the individual. However, only the general guidelines will be

Psychological Treatment of Pathological Gamblers described here. First of all, most gamblers are not aware of their erroneous perceptions of randomness. They spontaneously deny that they maintain such false conceptions. Increasing awareness of the actual way in which gambling events occur is a first step in enabling gamblers to recognize their misconceptions concerning the predictability of the game (Ladouceur & DubeÂ, 1997; Ladouceur, Paquet, Lachance, & DubeÂ, 1996). The patient will be asked to describe the evolution of their gambling habits, how they were betting at first, the changes in their betting as they became more familiar with the games, and to what extent they feel they have some potential control over certain games. By asking about the way to get an edge in the particular form of gambling involved, the gambler is invited to expose some of their errors in thinking. Inevitably, the gambler will describe strategies of play which assume that there is more predictability present than is in fact the case (Ladouceur, Paquet, & DubeÂ, 1996). The therapist will ask the client to describe what they are saying to themselves when they gamble. In doing so, the therapist may ask the patient to answer the following questions: Why did you place one particular bet instead of another? How did you determine this bet? Are you trying to control the game by avoiding certain bets? Would you agree to switch poker machines in the middle of a session when the machine you are playing has not paid out for a long time? Would you agree to bet on any number at the roulette table? How did you pick the numbers that you did on the lottery ticket you bought this week? The main goal of these questions is to clarify the fact that the gambler is using some sort of information to predict an event which is independent of all other events and essentially unpredictable beyond its chance probability. The therapist makes a distinction between gambling that involves events that are inherently unpredictable because of inadequate information (such as horse racing) and events which are random (such as lotteries or slot machines). The therapist then shows that inherently unpredictable events are essentially the same as random events. Then, explanation of the concept of randomness follows, focusing on the most crucial element: each turn is an independent event (Gaboury & Ladouceur, 1989; Walker, 1992). Since each event is independent, there can be no influence from one event to the next and no predictability across events. Furthermore, as the events cannot be influenced legally, there can be no strategies to control the outcomes of the game. The therapist will focus on the strategies used by the gambler in their preferred game, and draw

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attention to the specific strategies that imply a sequential relationship between outcomes or that the probabilities of specific outcomes can be altered. The therapist should focus attention on any verbalizations made by the gambler that suggest the existence of links between the outcomes of the games. We often tape record these sessions in order to capture and analyze all of the patient's verbalizations suggesting links between the outcomes of the games. This recorded material is used to increase the patient's awareness, and later on to correct faulty perceptions. Another useful way to illustrate the erroneous links inferred between events is by tossing a coin with the patient. First the patient is asked to predict whether the next event will be ªheadsº or ªtailsº and to explain and justify his choice (Ladouceur & DubeÂ, 1997). Most patients will say that their choice is based on a 50/50 probability of each possible outcome, which is indeed correct. This exercise is carried out a few times in order to demonstrate that predicting heads or tails is such a simple game, and that all of the outcomes of the toss are independent. Gamblers will generally agree with the therapist. Then, in order to demonstrate the presence of erroneous cognitions during a gambling session, a simple test is performed. The therapist writes down six consecutive outcomes of heads and covers them with a piece of paper. Once again, the patient is asked to predict the outcome of the next toss. After their choice has been made, the six previous outcomes are revealed and the patient is asked if they would like to change their prediction before the coin is tossed again. Whether they change their prediction or not, patients will examine this series of outcomes. The therapist then points out the fact, that although the gambler knew that every outcome of a coin toss is independent, they spontaneously examined past outcomes even though these are completely irrelevant. This simple behavioral exercise has proven to be very helpful for demonstrating to the patient how this tendency to link irrelevant events is very powerful. (Ladouceur & Walker, 1996, give an extensive discussion of this phenomenon.) The notion of randomness is then explained in detail, illustrated by examples of the games played by the patient. The fundamental error is in believing that information may be used to establish links between outcomes and then used to place winning bets. Gamblers will erroneously perceive some elements of skill that, if used appropriately, enhance their probability of winning. This illusion of control explains why people bet more money as they become more familiar with a game, firmly believing that they

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Cognitive Approach to Understanding and Treating Pathological Gambling

have developed some skills that can be used profitably. During this first stage of treatment, it is brought to the patient's attention that in many studies, conducted with different games in different countries, more than 75% of the players' verbalizations are erroneous (Ladouceur & Walker, 1996). Literature detailing the frequent misconceptions of gamblers is also provided to the client. The pathological gambler is then asked to identify their own erroneous perceptions. This is achieved through a variety of methods such as: asking the patients to describe what they are saying to themselves when gambling (see example below); simulating a game and having the gambler describe how they proceed in choosing their bets; and asking the patient to imagine a gambling session and describe out loud what they are thinking, using the ªthinking out loud methodº (Gaboury & Ladouceur, 1989). These sessions are also usually recorded. Some examples of erroneous cognition are: ªIf I lose four times in a row, I will win the next time,º or, after one or two wins, ªI am really getting better at this game, I know how to bet.º We will often start by replaying the tape obtained within an earlier treatment session, to demonstrate to the clients their false beliefs about the notion of randomness. The clients will also be asked to listen to the tape at home and identify every erroneous perception, or irrational statement. It is important to note that the basic cognitive error involves the linking of independent events. Finally, the last phase involves the correction of inadequate verbalizations and faulty beliefs. Patients will monitor their own verbalizations when they are thinking about gambling, when they have the urge to gamble, or when they are gambling if they have not yet stopped. The patients will (i) identify erroneous perceptions, (ii) evaluate and challenge the adequacy of these perceptions, (iii) replace these inadequate cognitions by adequate verbalizations, and (iv) assess the strength of their belief in the new cognitions. The recording of their own verbalizations made during a simulated gambling session may be used during this corrective phase by asking the patient to reformulate erroneous perceptions by an adequate verbalization. The success of this phase is normally required before addressing further issues. Our clinical experience and empirical data (see below) support the fact that other therapeutic components are likely to be unsuccessful unless the gamblers have developed an adequate conception of the notion of randomness and can apply this notion to their own behavior. If the illusion of predictability in gambling events is allowed to remain, relapse is likely to occur.

6.26.7.2 Problem Solving Training Problem solving training is a second therapeutic intervention, used if the gambler shows poor problem solving skills when coping with excessive gambling activities. Problem solving training becomes an integral aspect of the treatment of the pathological gambler if the therapist and the patient identify that additional skills are needed to solve the actual problems related to excessive gambling. The therapist will introduce a problem solving technique (Goldfried & Davison, 1976) that involves the following five steps: (i) defining the problem, (ii) collecting information about the problem, (iii) generating different solutions, (iv) listing advantages and disadvantages for each solution, and (v) implementing and evaluating the solution. The patient learns how to cope with the difficulties related to gambling. For example, in order to have better control over spending, they may decide to pay their bills immediately after they are issued, create a budget, and carry only the amount of money they need. 6.26.7.3 Social Skills Training If necessary, gamblers are also given social skills training in order to improve their social competence. The potential link between poor social skills and gambling activities is discussed with the patients. It is important to recognize that pathological gamblers may need more than usual social skills to deal with their relationship conflicts. For example, some gamblers needed assertiveness training in order to increase their ability to refuse invitations to gamble with friends. Role playing can be used to improve communication skills. This training focuses on the negative consequences of gambling and how the lack of good social skills is a contributing factor. 6.26.7.4 Relapse Prevention Relapse prevention is based on and adapted from the relapse prevention model developed by Marlatt (1985) for alcoholics. The possibility of relapsing is always discussed with the participants. They learn to become aware of high risk situations (present or past) and the reasons why people return to gambling. Patients will describe their relapses, identify high-risk situations, and develop specific ways to deal with the situations. For example, carrying cash (as on pay days), stress, loneliness, and lack of social activities are common high-risk situations. Each situation is discussed in terms of the erroneous perceptions associated with gambling. Specific attention is

Efficacy of a Cognitive/Behavioral Treatment for Pathological Gamblers drawn to the debt and to the likelihood that the debt will be increased if gambling is resumed.

6.26.8 EFFICACY OF A COGNITIVE/ BEHAVIORAL TREATMENT FOR PATHOLOGICAL GAMBLERS Single case experimental studies have been conducted over several years to evaluate the cognitive/behavioral approach to treatment for adults and adolescents suffering from pathological gambling. The results were quite encouraging (Bujold, Ladouceur, Sylvain, & Boisvert, 1994; Ladouceur, Boisvert, & Dumont, 1994). The following control group comparison study was conducted to further assess the treatment's efficacy (Sylvain, Ladouceur, & Boisvert, 1997). Twenty-nine pathological gamblers participated in the study. The majority of gamblers were video poker players, whereas others gambled on horse races or casino games. Subjects were randomly assigned to a treatment or a waiting list control group. The following dependent variables were used: (i) DSM-III-R; (ii) SOGS; (iii) perception of control over the gambling problem rated on a scale of 0±10; (iv) desire to gamble indicated on a 0±10 scale; (v) self-efficacy perception evaluating their belief that they could refrain from gambling in high risk situations; (vi) frequency of gambling in terms of the number of gambling sessions, the number of hours spent gambling, and the total amount of money spent on gambling during the previous week. Results showed that treated subjects improved significantly compared to the control group. Treated individuals met fewer diagnostic criteria, reported less desire to gamble, and had a lower SOGS score. They also reported a significantly higher perception of control and self-efficacy. In order to provide clinically relevant results, the percentage of change and end state functioning (comparing post-test scores to a criterion score) were calculated. Among the treatment group, 12 of the 14 participants improved by 50% or more on three dependent variables, and on the end state functioning criteria, in comparison to one of the 15 participants in the control group (85% success rate). Finally, six and 12 month followup measures indicated that the therapeutic gains were still present, confirming the long-term effects of this therapeutic program. The following case study illustrates the procedure described above.

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6.26.8.1 Case History Peter is 43 years old, married, and the father of two adolescents. He is currently working as a civil servant. He has been playing video poker for four years. At the time of his consultation, he was playing three times a week on average, which resulted in monetary losses of $350±500 per week (Canadian). Peter started gambling when two of his colleagues invited him for a drink after work. As soon as they entered the bar, the two colleagues, both video poker players, showed Peter how to play the game. After an initial bet of $10, Peter won $125. During the following weeks, he developed an interest for video poker and played often. He occasionally made significant wins, and started believing that video poker was a good way to make money. After six months, his gambling became so intense that he had to use his personal credit and borrow money to cover his losses. He progressively became obsessed with gambling. He accumulated increasing debts and was constantly preoccupied by the need to recover his money. He neglected his wife and children more and more each day. He lost his motivation to work, he often arrived late after having spent the lunch hour gambling or, he left early in the afternoon in order to play. His spouse did not know about her husband's gambling habits. She began to worry about his repeated lateness in the evening and his incapacity to pay the bills before the due date. She questioned and doubted Peter's justifications for his prolonged absences. Tension and conflicts became commonplace within their relationship. Peter's urge to play increased with his need to recover the lost money so that he could pay his bills, and in order to escape the climate of tension reproaches in his relationship with his wife. After four years of excessive gambling, the losses were enormous. His absences from home became no longer justifiable and lying was frequent. One day, his boss, worried about Peter's diminished productivity, asked him the reasons for this change. Confronted with the possibility of losing his job, Peter had no choice but to admit that he had a gambling problem. He also decided to tell everything to his wife. Finally, he decided to seek treatment. A diagnostic of pathological gambling was made by the therapist and confirmed by a second experienced therapist who listened to a tape of the first session. The goal of the first intervention was to evaluate his motivation to change. Peter listed the advantages of stopping gambling and the negative consequences the game has had on his life. Monetary losses, professional and

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marital problems, and stress were examples of the negative consequences. Also, the return to a normal financial situation, general well-being, and better relationships with the people around him were the main advantages formulated by Peter to stop gambling. 6.26.8.1.1 Identification and correction of faulty cognitions toward gambling Considering that one of Peter's motivations to gamble was to make money rapidly, it was important to provide him with factual information concerning gambling, and to identify his erroneous cognitions. The therapist asked him to imagine his last gambling session and try to identify his thoughts and the triggering events. Peter reported the following sequence. He left the office and drove toward his usual gambling place instead of going home as he had initially planned. He reported having this reaction instantly, without thinking, as if someone had told him what to do. The therapist had Peter focus his attention on the sequence of events that took place immediately before leaving his office. He was asked to remember what was going on and what he was thinking at that specific moment. Peter remembered putting his documents in order and, by accident, seeing the bills for his credit card that were overdue. The therapist inquired about the thoughts associated with finding unpaid bills. Peter answered that he suddenly felt panic and became very tense. When thinking back on the feeling of panic, he identified the links between this feeling and his unpaid bills. Peter panicked because he did not have the money to pay his bills. This made him so uncomfortable that he wanted to get money to pay them as fast as he could. The therapist finally asked him what he said to himself following this discomfort, and how was he going to solve his problem of obtaining money? At that moment, Peter became aware that he strongly believed that the best way to get a lot of money in a short period of time was by gambling. He realized that this was his motivation to gamble on this last occasion. The therapist discussed the probabilities of winning, and the negative monetary expectancies of the games which would inevitably result in losses in the long run. The therapist explained that no strategies could be used by the player to win, and that the urge to recover the lost money was, in fact, just an illusion that leads to a vicious circle which can only end in loss. By questioning and confronting Peter's erroneous cognitions over several sessions, he started to realize that thinking he will win money is not realistic. Peter learnt to replace erroneous cognitions with appropriate ones, and to

question his gambling habits (e.g., ªWhy do I feel like playing?º ªI want to make money . . . is this realistic?º ªWhat could happen to me if I play? I risk further loss.º ªAnd if I lose, what will happen? I want to recover my money.º ªCan I really win?º ªEven if I win tonight, it will never be enough to compensate for all the money I have lost.º ªThe longer I try to win, the more likely I am to lose.º). 6.26.8.1.2 Problem solving and social skills training This component was used to modify behaviors related to excessive gambling. Peter mentioned going to the bank machine to check how much money he had left in his banking account. This compulsive checking triggered cognitions related to his lack of money, and the need to win more and gamble. Peter became aware of the sequence of these behaviors and realized the links between this checking behavior and his gambling activities. He resolved to stop checking his banking account. Peter also had to modify other relevant behaviors that stimulated gambling such as keeping less cash money with him, not carrying his banking and credit cards, and avoiding bars with video poker machines. Finally, the involvement with new activities, such as sports and family activities, helped Peter to reorganize his timetable and to replace the time spent gambling with less financially damaging activities. 6.26.8.1.3 Relapse prevention By learning to identify situations with a high risk of triggering a relapse, and by analyzing situations which led him to gamble, Peter developed cognitive and behavioral strategies needed to refrain from gambling. 6.26.9 EVALUATION OF A COGNITIVE TREATMENT FOR PATHOLOGICAL GAMBLING Following the positive results obtained through this controlled study, it was decided to evaluate the specific role of correcting the fundamental cognitive error about the notion of randomness. From a theoretical and clinical perspective, it was believed that this component was the crucial variable in the maintenance of excessive gambling. The efficacy of a cognitive treatment for pathological gamblers was assessed based on the correction of erroneous cognitions concerning the notion of randomness and, more specifically, through the modification of the gambler's tendency to link independent events when gambling.

Concluding Remarks Five pathological gamblers from the population described above participated in this study (Ladouceur, Sylvain, Letarte, Giroux, & Jacques, in press). A single case experimental design across subjects was used to assess the efficacy of the treatment. Cognitive correction included four components: (i) Understanding the concept of randomnessÐthe therapist explains the concept of randomness, independence among events, the impossibility to control the game. (ii) Understanding the gamblers' erroneous cognitions, mainly the difficulty to apply the principle of independence among events. The therapist explains how the illusion of control contributes to the maintenance of gambling habits. (iii) Awareness of inaccurate perceptions. (iv) Cognitive correction of erroneous perceptions. The dependent variables were the same measures used in the study described previously. Results indicated that all subjects, except one, increased their perception of control and reduced their urge to gamble, thus supporting the prediction that a cognitive treatment, based on the correction of erroneous perception about the notion of randomness, decreases pathological gambling. The treatment outcome of this intervention provided positive results equivalent to those obtained by a multicomponent intervention. Therefore, cognitive correction of erroneous perceptions toward the notion of randomness is likely to be the key element in the treatment of pathological gambling. We are now replicating this study with a greater number of subjects, using a controlled group comparison design. In conclusion, these therapeutic interventions, with an 85% success rate, open new avenues for the treatment of pathological gambling.

6.26.10 COMMON DIFFICULTIES IN THE TREATMENT OF PATHOLOGICAL GAMBLERS Clinicians who have treated pathological gamblers have been confronted with a number of difficulties. We will briefly mention the most common and difficult ones encountered over the years in our clinic where approximately 200 pathological gamblers have been interviewed. The first and most important issue is treatment compliance. Very often, individuals will ask for an appointment but, without canceling, will not show up. They frequently drop out after one or two sessions, or will simply decide to terminate treatment after a few weeks of abstinence, thinking that their problem has been solved.

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There are no obvious solutions to these matters. Our clinical experience has led to the development of a series of procedures used to improve treatment compliance. First of all, when an individual contacts us, we return the call within 24 hours, conduct a brief telephone interview, and administer the SOGS. If the individual appears to be a pathological gambler, an appointment is scheduled within a week at which point we conduct a structured interview and administer a series of questionnaires. If therapy is undertaken, the therapist will inform the patient that compliance is a major difficulty for pathological gambling and explore ways to overcome this problem. Furthermore, the patient will sign a contract indicating that they agree to participate for at least 10 sessions, and that if they are unable to attend, they will call ahead of time to cancel the session, that they will pay one session in advance, and that after two nonmotivated absences, treatment will be terminated. A second difficult issue is determining whether the goal of the treatment should be controlling the gambling or abstinence. Many pathological gamblers ask that the goal of treatment be controlled gambling. Some will be very convincing and will put forth appropriate and rational arguments. We have often caught ourselves spending many sessions discussing this difficult subject without finding a solution. Gamblers suggest that controlled gambling is the main goal, simply because they cannot see themselves abstaining from this activity, or simply because they are not ready to stop gambling. Our approach on this matter is to consider abstinence as the main goal, and then once it is achieved, the matter can be reconsidered. In a few cases, instead of losing the patient, we have accepted controlled gambling as the main goal of treatment. However, this solution should never be accepted except as a last option. The third difficulty is identifying erroneous perceptions towards the notion of randomness as discussed above. Often, pathological gamblers will simply deny that they have these misconceptions. The best way to pursue this matter is to design some behavioral experiment to facilitate the identification of erroneous perceptions. Gamblers deny these perceptions because they are not aware of them.

6.26.11 CONCLUDING REMARKS This account of pathological gambling takes a cognitive perspective. It is assumed that pathological gambling occurs when the gambler persists in gambling, despite the losses involved,

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believing that ultimately the losses will be recovered and money will be won. These false beliefs of the gambler are maintained by the inadequate knowledge of the probabilities of success and the erroneous interpretation of the notion of randomness. If this account of the motivation to gamble is correct, then it follows that pathological gambling can be treated effectively by correcting erroneous beliefs of the patients. This chapter presents data supporting this theoretical position.

6.26.12 REFERENCES American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorder (3rd ed.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorder (4th ed.). Washington, DC: Author. Abbott, M., & Volberg, R. (1996). The New Zealand national survey of problem and pathogical gambling. Journal of Gambling Studies, 12, 143±160. Allcock, C. C. (1987). An analysis of a successful racing system. In M. B. Walker (Ed.), Faces of gambling. Sydney, Australia: National Association for Gambling Studies. Allcock, C. C., & Dickerson, M. G. (1986). The guide to good gambling. Australia: Social Sciences Press. Anderson, G., & Brown, R. I. F. (1984). Real and laboratory gambling, sensation-seeking and arousal. British Journal of Psychology, 75, 401±410. Becona, E. (1996). Prevalence surveys of problem and pathological gambling in Europe: The of Germany, Holland and Spain. Journal of Gambling Studies, 12, 179±192. Beyer, A. (1993). Beyer on speed: New strategies for racetrack betting. Boston: Houghton Mifflin. Bird, R., & McCrae, M. (1985). Gambling markets: A survey of empirical evidence. In G. T. Caldwell, M. G. Dickerson, B. Haig, & L. Sylvan (Eds.), Gambling in Australia. Sydney, Australia: Croom Helm. Blaszczynski, A., & McConaghy, N. (1994). Antisocial personality disorder and pathological gambling. Journal of Gambling Studies, 10, 129±146. Blaszczynski, A., McConaghy, N., & Frankova, A. (1991). Control versus abstinence in the treatment of pathological gambling: A two to nine year follow-up. British Journal of Addiction, 86, 299±306. Blaszczynski, A. P., Winter, S. W., & McConaghy, N. (1986). Plasma endorphin levels in pathological gambling. Journal of Gambling Behavior, 2, 3±14. Brown, R. I. F. (1996). Arousal and sensation-seeking components in the general explanation of gambling and gambling addictions. International Journal of the Addictions, 21, 1001±1016. Bujold, A., Ladouceur, R., Sylvain, C., & Boisvert, J.-M. (1994). Cognitive behavioral treatment of pathological gamblers. Journal of Behavior Therapy and Experimental Psychiatry, 25, 275±282. Carlton, P. L., & Manowitz, P. (1987). Physiological factors as determinants of pathological gambling. Journal of Gambling Behavior, 3, 274±285. Connor, X. (1983). Report of the inquiry into a casino for Victoria. Melbourne, Australia: Victorian Government Printer. Cornish, D. B. (1978). Gambling: A review of the literature and its implication for policy and research. London: HMSO.

Coventry, K. R. (1997). Rationality and decision making: The case of gambling and the development of gambling addiction. The proceedings of the Ninth International Conference on Gambling and Risk Taking, Las Vegas, NE, 1994. Custer, R. L., & Milt, H. (1985). When luck runs out. New York: Facts on File Publications. Dickerson, M. G. (1984). Compulsive gamblers. London: Longman. Dickerson, M. G. (1993). Internal and external determinants of persistent gambling: Problems in generalizing from one form to another. In W. R. Eadington & J. A. Cornelius, (Eds.), Gambling behavior and problem gambling. Reno, NV: Institute for the study of gambling and commercial gaming. Dickerson, M. G., & Adcock, S. (1987). Mood, arousal and cognitions in persistent gambling: Preliminary investigation of a theoretical model. Journal of Gambling Behavior, 3, 3±15. Dickerson, M. G., Allcock, C., Blaszczynski, A., Nicholls, B., Williams, J., & Maddern, R. (1995). An examination of the socio-economic effects of gambling on individuals, families and the community, including research into the costs of problem gambling in New South Wales. Sydney, Australia: Report to the Casino Community Benefit Fund Trustees in New South Wales. Dixon, D. (1996). Illegal betting in Britain and Australia: Contrasts in control strategies and cultures. In J. McMillen (Ed.), Gambling cultures: Studies in history and interpretation (pp. 86±100). London: Routledge. Drapkin, T., & Forsyth, R. (1987). The punter's revenge. London: Chapman and Hall. Echeburua, E., Baez, C., & Fernandez-Montalvo, J. (1996). Comparative effectiveness of three therapeutic modalities in the psychological treatment of pathological gambling: Long-term outcome. behavioral and Cognitive Psychotherapy, 24, 51±72. Frey, J. H., & Eadington, W. R. (1984). Gambling: Views from the social sciences. The Annals of the American Academy of Political and Social Science, 474 (Special Issue). Gaboury, A., & Ladouceur, R. (1989). Erroneous perceptions and gambling. Journal of Social Behavior and Personality, 4, 411±420. Giroux, I., Ladouceur R., & Jacques, C. (1998). Correction of erroneous perceptions and arousal. Manuscript submitted for publication. Griffin, P. A. (1987, August). Mathematical expectation for the public's play in casino blackjack. Paper presented at the Seventh International Conference on Gambling and Risk Taking, University of Nevada, Reno, NV. Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. New York: Holt Rinehart and Winston. Griffiths, M. D. (1994). The role of cognitive bias and skill in fruit machine gambling. British Journal of Psychology, 85, 351±369. Haig, J. (1985). Gambling expenditure. In G. Caldwell, M. Dickerson, J. Haig, & M. Sylvain (Eds.), Gambling in Australia (pp. 76±85). Sydney, Australia: Croom Helm. Hayano, D. M. (1977). The professional poker player: Career identification and the problem of respectability. Social Problems, 24, 556±564. Jacobs, D. F. (1986). A general theory of addictions: A new theoretical model. Journal of Gambling Behavior, 2, 15±31. Ladouceur, R. (1996). Prevalence of pathological gamblers in Canada and related issue. Journal of Gambling Studies, 12, 129±142. Ladouceur, R., Arsenault, C., DubeÂ, D., Jacques, C., & Freeston, M. H. (1997). Pathological gamblers among volunteers in experiments on gambling. Journal of Gambling Studies, 13, 69±84.

References Ladouceur, R., Boisvert, J.-M., & Dumont, J. (1994). Cognitive behavioral treatment of adolescent pathological gamblers. Behavior Modification, 18, 230±242. Ladouceur, R., & DubeÂ, D. (1997). Erroneous perceptions in generating random sequences: Identification and strength a basic misconception. Swiss Journal of Psychology, 56, 256±259. Ladouceur, R., Giroux, I., & Jacques, C. (1998). Winning on the horses: How much strategy and knowledge is needed? Journal of Psychology, 132, 133±142. Ladouceur, R., Paquet, C., & DubeÂ, D. (1996). Erroneous perceptions in generating sequences of random events. Journal of Applied Social Psychology, 26, 2157±2166. Ladouceur, R., Paquet, C., Lachance, N., & DubeÂ, D. (1996). MeÂcanismes psychologiques de la perception du hasard. International Journal of Psychology, 31, 93±99. Ladouceur, R., Sylvain, C., Letarte, H., Giroux, I., & Jacques, C. (in press). Cognitive treatment of pathological gamblers. Behavior Research and Therapy. Ladouceur, R., & Walker, M. (1996). Cognitive perspective on gambling. In P. M. Salkovskis (Ed.), Trends in cognitive therapy (pp. 89±120). Chichester, UK: Wiley. Lorenz, V. C., & Shuttleworth, D. E. (1983). The impact of pathological gambling on the spouse of the gambler. Journal of Community Psychology, 11, 67±76. Marlatt, G. A. (1985). Relapse prevention: General overview. In G. A. Marlatt & J. R. Gordon, (Eds.). Relapse prevention. Maintenance strategies in the treatment of addictive behaviors (pp. 33±44). New York: Guilford. McConaghy, N. (1980). Behavior completion mechanisms rather than primary drives maintain behavioral patterns. Activita Nervosa Supplement, 22, 138±151. McConaghy, N., Armstrong, M. S., Blaszczynski, A., & Allcock, C. (1983). Controlled comparison of aversive therapy and imaginal desensitisation in compulsive gambling. British Journal of Psychiatry, 142, 366±372. McMillen, J. (1996). Gambling cultures. London: Routledge. Oldman, D. (1978). Compulsive gamblers. Sociological Review, 26, 349±371. Orford, J. (1985). Excessive appetites: A psychological view of addictions. Chichester, UK: Wiley. Perkins, E. B. (1950). Gambling in English life. London: Epworth Press. Rosecrance, J. (1986). Why regular gamblers don't quit: A

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sociological perspective. Sociological Perspectives, 29, 357±378. Rowntree, B. S. (1941). Poverty and progress; a second social survey of York, London, and New York. London: Longmans and Green. Royal Commission (1933). Royal Commission on Lotteries and Betting, 1932±33: Findings. London: Her Majesty's Stationary Office. Scott, D. (1982). The winning way. Sydney, Australia: Puntwin. Sharpe, L., & Tarrier, N. (1993). Towards a cognitivebehavioral theory of problem gambling. British Journal of Psychiatry, 162, 407±412. Sharpe, L., Tarrier, N., Schotte, D., & Spence, S. H. (1995). The role of autonomic arousal in problem gambling. Addiction, 90, 1529±1540. Sylvain, C., Ladouceur, R., & Boisvert, J.-M. (1997). Cognitive and behavioral treatment of pathological gambling: A controlled study. Journal of Consulting and Clinical Psychology, 65, 727±732. Volberg, R. (1996). Prevalence of pathological gambling in the United States. Journal of Gambling Studies, 12, 111±128. Wagenaar, W. A. (1988). Paradoxes of gambling behavior. London: Erlbaum. Walker, M. B. (1992). A sociocognitive theory of gambling involvement. In W. R., Eadington & J. A. Cornelius (Eds.), Gambling and commercial gaming: Essays in business, economics, philosophy and science (pp. 371±398). Reno, NV: University of Nevada. Walker, M. B. (1995). Pathological gambling: The fundamental error. In J. O'Connor (Ed.), High stakes in the nineties (pp. 97±98). Fremantle, Australia: National Association for Gambling Studies. Walker, M. B., & Dickerson, M. G. (1996). The prevalence of problem and pathological gambling: A critical analysis. Journal of Gambling Studies, 12, 233±249. Walker, M. B., Sturevska, S., & Turpie, D. (1995). The quality of blackjack play in Australian casinos. In J. O'Connor (Ed.), High stakes in the nineties (pp. 173±182). Fremantle, Australia: National Association for Gambling Studies. Yardley, H. O. (1957). The education of a poker player. Glasgow, UK: Fontana/Collins. Zuckerman, M. (1979). Sensation seeking: Beyond the optimal level of arousal. Hillsdale, NJ: Erlbaum.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.27 Sexual Problems: Dysfunction W. P. DE SILVA Institute of Psychiatry, University of London, UK 6.27.1 SEXUAL DYSFUNCTION

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6.27.2 CLASSIFICATION AND DIAGNOSTIC ISSUES

604 605 605 605 605 605 605 605 605 605 605 605 605 605

6.27.2.1 Sexual Desire Disorders 6.27.2.1.1 Hypoactive sexual desire disorder 6.27.2.1.2 Sexual aversion disorder 6.27.2.2 Sexual Arousal Disorders 6.27.2.2.1 Female sexual arousal disorder 6.27.2.2.2 Male erectile disorder 6.27.2.3 Orgasmic Disorders 6.27.2.3.1 Female orgasmic disorder 6.27.2.3.2 Male orgasmic disorder 6.27.2.3.3 Premature ejaculation 6.27.2.4 Sexual Pain Disorders 6.27.2.4.1 Dyspareunia 6.27.2.4.2 Vaginismus 6.27.3 ETIOLOGICAL FACTORS

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6.27.4 ASSESSMENT OF SEXUAL DYSFUNCTION

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6.27.4.1 Aims of Assessment 6.27.4.2 The Interview 6.27.4.2.1 Special problems 6.27.4.2.2 Areas to enquire about 6.27.4.2.3 Individual and couple interviews 6.27.4.2.4 Motivation and selection 6.27.4.2.5 Physical examination and investigations 6.27.4.2.6 Questionnaires and inventories 6.27.4.2.7 Subjective ratings 6.27.4.2.8 Physiological measures

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6.27.5 FORMULATION

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6.27.6 TREATMENT OF SEXUAL DYSFUNCTION

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6.27.6.1 Behavioral Sex Therapy 6.27.6.1.1 The behavioral approach 6.27.6.1.2 Present-day conjoint cognitive-behavioral sex therapy 6.27.6.1.3 Some general considerations on therapy 6.27.6.2 Some Practical Issues 6.27.6.3 Therapy for Those Without Partners 6.27.6.4 Group Therapy 6.27.6.5 Efficacy of Therapy 6.27.6.6 A Note on Physical Treatments 6.27.6.7 Scope of Cognitive-behavioral Sex Therapy

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6.27.7 TREATMENT ISSUES WITH SPECIAL POPULATIONS

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6.27.7.1 The Elderly 6.27.7.2 Those with Physical Handicaps and Chronic Illnesses 6.27.7.3 Gay Clients

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6.27.7.4 Women with Eating Disorders 6.27.8 SUMMARY AND COMMENTS ON FUTURE DEVELOPMENTS

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6.27.9 REFERENCES

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6.27.1 SEXUAL DYSFUNCTION The term ªsexual dysfunctionº refers to a disturbance or impairment in sexual functioning. Sexual dysfunctions are usually contrasted with sexual deviations, or called ªparaphilias.º The latter are seen as a disturbance in the direction of one's sexual interest or desire, rather than of functioning. Thus paraphilias include paedophilia (sexual interest in children), fetishism (sexual interest in inanimate objects), and so on. Dysfunctions, on the other hand, are failures or problems in the actual sexual functioning, for example, difficulty in obtaining an erection, or failure to reach an orgasm. It must be noted, however, that there can be overlap and interdependence between sexual dysfunctions and paraphilias. A man complaining of erectile difficulties in coital activity with adult partners may get strong erections in paedophiliac acts. Equally, a man presenting with, say, fetishistic desires for rubber or leather may also have erectile difficulty when he is not in contact with rubber or leather garments (de Silva, 1995). This overlap between these two types of sexual problems is important to recognize and take into account in clinical settings. A further consideration is the link between sexual dysfunction and marital or relationship problems. Both clinical and research data show that the two areas are often related. Rust, Golombok and Collier (1988) reported that sexual dissatisfaction in the male partner strongly correlated with a poor marital relationship as perceived by both partners. The relationship between the two areas is not an invariant one, nor is there any clear evidence of the direction of causation when there is a link. The prevalence of sexual dysfunction is hard to establish, as epidemiological studies are scarce. Masters and Johnson (1970) estimated that half of all couples in the USA have a sexual dysfunction. Spector and Carey (1990), who undertook a full review of the sexuality, psychopathology, and epidemiology literature, concluded that sexual dysfunctions may be very common. A major problem is that the presence of a sexual dysfunction is not always distressing to, or seen as a problem by, couples or individuals. The much-cited study of Frank, Anderson and Rubinstein (1978) provides some interesting data. Well over half the women and nearly half the men in this survey of 100 happily

married American couples reported sexual difficulties, yet most were satisfied with their sexual life. Similar findings have been reported in a Swedish study (Nettelbladt & Uddenberg, 1979) and a British investigation (Reading & Wiest, 1984). This highlights another key issue. Sexual dysfunction is not an all-or-none affair; there are varying degrees of difficulties. The way they are perceived varies; occasional erectile failure may be seen as a perfectly acceptable situation by some men and their partners, while it may bring other men to a clinic seeking help. There are also major differences in sexual functioning in relation to age. Inability to obtain an erection increases progressively with age (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994; Weizman & Hart, 1987). In the Kinsey survey (Kinsey, Pomeroy, & Martin, 1948), it was found that less than 1% of males had erectile dysfunction before the age of 19, increasing to 25% by the age of 75.

6.27.2 CLASSIFICATION AND DIAGNOSTIC ISSUES Sexual dysfunctions have been classified in different ways by different authors in the past (e.g., Bancroft, 1989; Hawton, 1985), but in the 1990s a consensus has been emerging. The current classification offered in the Diagnostic and statistical manual of mental disorders (4th ed., DSM-IV) (American Psychiatric Association [APA], 1994) links dysfunctions to the phases of the sexual response cycle: (i) desire (this phase includes desire to have sexual activity and sexual fantasies); (ii) excitement (this phase consists of a subjectively felt sense of sexual pleasure and related physiological changes, for example, penile erections and vaginal lubrication); (iii) orgasm (this phase consists of the climax or peaking of sexual pleasure, with release of sexual tension and the rhythmic contraction of the perineal muscles and reproductive organs; in the male there is also ejaculation of seminal fluid, and in the female contraction of the wall of the outer third of the vagina); and (iv) resolution (this phase consists of a sense of muscular relaxation and general well-being, in the male this also includes a physiologically refractory period in which further erection and orgasm do not take place). The dysfunctions, linked to the first three of these phases, are classified below.

Etiological Factors

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6.27.2.1 Sexual Desire Disorders

6.27.2.3.3 Premature ejaculation

6.27.2.1.1 Hypoactive sexual desire disorder

Here, the essential feature is the persistent onset of orgasm with minimal sexual stimulation. Men with this problem reach an orgasm prior to, or just after, penetration, thus making any meaningful coital activity impossible. Attempts to define premature ejaculation by linking it to partner's orgasm (cf. Masters & Johnson, 1970) is problematic.

Here, there is an absence or deficiency of sexual fantasies and desire for sexual activity. The terms ªlow libidoº and ªreduced libidoº are also commonly used to refer to this. 6.27.2.1.2 Sexual aversion disorder In this disorder, there is an aversion to, and avoidance of, genital sexual contact with a sexual partner. Often the aversion is focused on a particular aspect of sexual experience. There may also be anxiety, fear, or disgust.

6.27.2.4 Sexual Pain Disorders In addition the DSM-IV includes the following: 6.27.2.4.1 Dyspareunia

6.27.2.2 Sexual Arousal Disorders 6.27.2.2.1 Female sexual arousal disorder Here, there is a persistent inability to attain or maintain adequate vaginal lubrication and vaginal expansion in response to sexual excitement. 6.27.2.2.2 Male erectile disorder In this condition, the main feature is the persistent or recurrent inability to attain or sustain an adequate penile erection. There is much variability in this. Some attain very strong erections without being able to sustain them, some have sustainable erections which are not strong enough for penetration. Loss of erection during thrusting is also reported by some. 6.27.2.3 Orgasmic Disorders 6.27.2.3.1 Female orgasmic disorder This is also referred to as ªinhibited female orgasm,º ªanorgasmia,º and more rarely, ªinorgasmia.º The essential feature is the persistent delay in, or absence of, orgasm following a normal sexual excitement phase. 6.27.2.3.2 Male orgasmic disorder Here, the male has difficulty in reaching orgasm following a normal sexual excitement phase, despite adequate stimulation. This condition has also been called ªinhibited male orgasm.º An earlier term, ªretarded ejaculationº is problematic, as it focuses on ejaculation rather than orgasm. In some conditions a male can reach an orgasm without discharging any semen. The new term refers specifically to the orgasmic experience.

Here, there is genital pain associated with sexual intercourse. This is most commonly experienced during coitus, but it can also occur before or after coitus. It can happen in both men and women, but it appears from clinical settings that it is much more common in the latter (Bancroft, 1989; Renshaw, 1988). 6.27.2.4.2 Vaginismus This consists of the persistent involuntary contraction of the muscles surrounding the outer third of the vagina when penetration is attempted. When severe, it makes penetration impossible. Each of the above dysfunctions can be either lifelong or acquired. A lifelong dysfunction is said to exist when the problem has been present since the beginning of sexual functioning, for example, a man who has never had an erection as an adult. In the acquired type, the dysfunction develops only after a period of normal functioning. Sexual dysfunctions are also categorized into generalized and situational types. In the former, the dysfunction occurs in all situations, and is not linked to certain types of partners, situations, or stimulation. In the latter, the dysfunction is limited to certain types of stimulation, situations, or partners. For example, a man may have an erectile difficulty when attempting sex with a partner, but not when masturbating. It is also important to note that there can be comorbidity in sexual dysfunctions. The cooccurrence of erectile dysfunction and premature ejaculation is not uncommonly seen in clinics. 6.27.3 ETIOLOGICAL FACTORS Sexual dysfunctions may be due to a variety of etiological factors, and clinicians usually look

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for organic and psychological factors. The state of knowledge with regard to organic factors is not easy to summarize, as different dysfunctions can have different etiologies. The most work has been done on male erectile disorder. Endocrine, vascular, and neurological systems have been seen as crucial for erectile functioning (Bancroft, 1997). Alcohol and other drugs of abuse, and certain prescribed medications, can also have a role to play. For female dysfunctions, hormonal factors are sometimes strongly implicated, as in sexual arousal disorder where decreases in estrogen can cause vaginal dryness. Such changes are not uncommon following menopause or ovariectomy. Local infections, presence of pelvic tumor, and pelvic inflammatory disease are among the factors that can be associated with dyspareunia. Psychological factors in the etiology of sexual dysfunctions have been extensively written about (e.g., Bancroft, 1989; de Silva, 1994a; Wincze & Carey, 1991). The role of anxiety, including ªperformance anxiety,º is commonly found to be linked to erectile disorder, and indeed some other dysfunctions. Stresses of various kinds, depressed affect, anger, and relationship factors have been implicated. In women, lack of learning to relinquish control has been considered by some authors as an important variable (McConaghy, 1993). Cognitive factors, including attitudes and beliefs, both individual and cultural, are also seen as relevant (e.g., Baker, 1993; Bhugra & de Silva, 1993; Spence, 1991). The overall picture from many studies with inconsistent results clearly points in the direction of multifactoral etiology for sexual dysfunctions. Biological factors, and cultural and psychological factors in the individual and relationship domains, seem to determine the origins of sexual dysfunctions, as indeed they determine and influence sexual functioning in general. These issues are well reviewed in McConaghy (1993) and Wincze & Carey (1991) among others.

6.27.4 ASSESSMENT OF SEXUAL DYSFUNCTION Assessment of sexual dysfunctions should be comprehensive, and cover in detail the presenting problem(s) and the relevant associated factors. While the principles of clinical assessment of sexual dysfunctions is in theory no different from the clinical assessment of other problems, in practice it is often a more challenging task. Since sex is a very private aspect of one's life, detailed and open discussion of it, however relevant clinically, can be difficult for the patient and the inexperienced therapist.

Further, some of the usual methods of clinical assessment, such as direct observation by therapist and reports from independent observers, are not possible for obvious reasons. Some of these matters, and other general issues in the assessment of sexual dysfunction, are discussed in detail in the literature (e.g., Bancroft, 1989; Hawton, 1985; Wincze & Carey, 1991). 6.27.4.1 Aims of Assessment The purpose of assessment is to obtain as clear a picture as possible of the problem(s) and factors that may be related to it, so that a good formulation can be arrived at. From the perspective of psychological therapy, one would want to gain information about the dysfunction in behavioral terms, also including relevant cognitive aspects. What happens in the actual sexual situation needs to be enquired about, and this is usually facilitated by focusing on the most recent attempt. Information about the behavior of both partners will be elicited, including their antecedents and consequences. Relevant past experiences, past partners, traumatic events, and so forth are part of the picture. A full behavioral analysis (e.g., Kanfer & Saslow, 1969) should be aimed for. 6.27.4.2 The Interview 6.27.4.2.1 Special problems The main source of information in assessment is the clinical interview. In the case of sexual dysfunction assessment, there are special problems associated with it (cf. de Silva, 1994a; Wincze & Carey, 1991). These include the following: (i) There may be embarrassment on the part of the patient. The therapist needs to be sensitive to the difficulties the patient may have in talking about intimate matters. Starting with more general questions may help build rapport. Acknowledging that talking about sexual matters could be difficult can also help. (ii) The language must be simple and easy to understand. The jargon that comes easily to a professional is often unfamiliar to the patient. Every effort must be made to ensure that the patient understands the questions. (iii) Precise details need to be obtained about the problem presenting, going beyond general descriptions such as ªI don't seem to want it any moreº or ªI have lost interest.º The therapist, however, needs to be patient in enquiring about details. Careful probing is often needed. (iv) There should be an attitude of nonjudgmental acceptance with regard to the patient's

Assessment of Sexual Dysfunction behavior, likes, and dislikes. Even unintended display of disapproval or surprise may discourage the patient from giving relevant details. (v) It is possible that patients may not be able to disclose some information in the initial assessment interview. This may be due to embarrassment, or due to the therapist being still unfamiliar to them. It is important to allow patients to give more information in later sessions. 6.27.4.2.2 Areas to enquire about The areas to be covered in the interview include the following: (i) The nature of the problem in as much detail as required to obtain a full picture of the difficulty and all its associated factors, including anxiety and situational variations; in men with impotence, particular enquiry should be made about whether early morning erections are present or not, as their presence usually helps to rule out the possibility that the problem is organic. (ii) The history of the problem, its beginnings and course, and present sexual activities including masturbation. (iii) The partner's reactions to the problem, both in the sexual situation and in general. (iv) The patient's sexual knowledge, beliefs, and attitudes, including those determined by religion, culture, and subculture. (v) The patient's sexual likes, dislikes, preferences, and fantasies. (vi) Past sexual history including relevant early experiences, first experience of intercourse, and so on. (vii) Psychiatric and medical factors, including drugs, alcohol, and so forth; current depression is particularly important to assess. (viii) Menstrual history and relation of problem to the menstrual cycle. (ix) Contraception and past pregnancies, and attitude to the possibility of conception. (x) General relationship factors. (xi) Background factors, such as job, income, accommodation, extended family and so on, which can be sources of stress. (xii) Previous treatment, if any. More details may be needed on some of the areas than on others in a given case, and this is a matter of clinical judgment as the interview proceeds. Needless to say, therapists must be prepared to vary their enquiry to suit each patient, as needed. Most clinicians rely on a history schedule or a general checklist of topics to enquire about as a matter of routine. Examples of such checklists are available in, among others, de Silva (1994a), Hawton (1985), and Spence (1991). In practice, while such

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detailed checklists are indeed useful, flexibility is needed in their use; such a list or schedule should serve as a general guide rather than as something to be rigidly adhered to. 6.27.4.2.3 Individual and couple interviews One major issue in interviewing patients with sexual dysfunction is whether the partnersÐ when a couple present themselves for helpÐ should be interviewed together or not. Different viewpoints have been expressed about this (e.g., Bancroft, 1989; Masters & Johnston 1970; Wincze & Carey, 1991). In general, a good arrangement is to see the couple jointly to start with, and then to conduct assessment interviews separately. If two therapists are available, this may be done in parallel sessions; if not, more time should be spent with the partner with the presenting problem, followed by a briefer interview with the other partner. It is important that individual interview sessions are undertaken in all cases. This provides an opportunity for each partner to give his or her version of the problem, and to discuss with the therapist relevant matters, including feelings about the partner, without inhibition. It also gives an opportunity for individuals to divulge information that might have been kept away from the partner, such as an extramarital relationship, or a particular aspect of the individual's past history. 6.27.4.2.4 Motivation and selection Assessment of the motivation of the patient/ couple for therapy is an important aspect of the interview, although this may not prove easy in a single interview except perhaps to identify those who are clearly unwilling to accept the treatment offered. As for suitability for therapy, an assessment comprising two interviews at most is usually sufficient to identify those who are clearly not likely to benefit from the therapy that can be offered. For example, presence of clear psychiatric illness will often require appropriate treatment of that condition first; serious marital difficulties may require referral to a specialist clinic, unless therapists feel competent to deal with this themselves; and, when physical factors are probably involved, investigations of these, and a physical examination, will need to be arranged prior to acceptance for therapy. 6.27.4.2.5 Physical examination and investigations An important issue for the clinician dealing with sexual dysfunctions is that of whether or

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not a physical examination and/or investigations should be asked for. Nonmedical clinicians cannot always assume that the clients referred to them have been adequately screened for possible organic factors. Some clinicians take the view that all patients presenting with sexual dysfunction should routinely be examined physically (e.g., Kolodny, Masters, & Johnson, 1979; Spence, 1991). This is unnecessary, but it is essential to have the facilities to get this and relevant investigations done if required in a given case. Bancroft (1989) has given an extremely useful set of indications for physical examination. These are: (i) complaints of pain or discomfort during sex; (ii) recent history of ill-health or physical symptoms other than the sexual problem; (iii) recent onset of loss of sex drive with no apparent cause; (iv) when the patient believes that a physical cause is most likely, or is concerned about the genitalia (e.g., a man complaining that his penis is too small or bent, or a woman suspecting that there is something abnormal about her sexual organs); (v) history of abnormal puberty or other endocrine disorder; (vi) in men, being aged over 50; and (vii) in women, being in the pre- or postmenopausal age group or having a history of marked menstrual irregularities or infertility. Where appropriate, the medical practitioner carrying out the physical examination will also carry out, or arrange for, relevant laboratory investigations. Details of the common investigations may be found in several sources including Bancroft (1989), Hawton (1985), and Wincze & Carey (1991). 6.27.4.2.6 Questionnaires and inventories Data obtained from the interview can profitably be supplemented by the use of questionnaires and inventories. These help to cover some important areas quickly, but more importantly they provide quantitative data that are particularly useful in assessing differences between before and after treatment. Several useful instruments are available for the measurement of sexual experiences, attitudes, dysfunctions, and other related matters. Hoon, Wincze, and Hoon (1976a) provide an inventory (Sexual Arousability Index) for the assessment of female sexual arousal. Lo Piccolo and Steger (1974) have developed an inventory (Sexual Interaction Inventory) to assess sexual interaction and satisfaction of a couple. Lief and Reed (1972) provide a questionnaire to assess both sexual knowledge and sexual attitudes,

while Wilson (1978) has produced a useful fantasy questionnaire, which measures fantasies, desires, and actual behaviours. The Derogatis Sexual Functioning Index (Derogatis & Melisaratos, 1979) is a wide-ranging scale of sexual functioning covering 10 domains (e.g., information, desire, attitudes). While its comprehensiveness is no doubt an asset, its prohibitive length (245 items) makes it somewhat unwieldy for routine clinical use. A brief measure for assessing erectile functioning, developed recently, is the International Index of Erectile Function (Rosen et al., 1997). A relatively recent British development is the Golombok±Rust Inventory of Sexual Satisfaction (GRISS; Rust & Golombok, 1986). This 28-item questionnaire, intended for use with heterosexual couples or individuals with a current heterosexual relationship, yields an overall score, for men and women separately, of the quality of sexual functioning. In addition, the following subscores can also be obtained: erectile dysfunction, premature ejaculation, anorgasmia, vaginismus, infrequency, poor communication, dissatisfaction, nonsensuality, and avoidance. This instrument has good reliability, and is easy to use. In view of the multiplicity of scores it yields, the GRISS is an economical instrument that can be used routinely. A parallel, and equally economical, instrument for the assessment of the quality of the overall relationship is the Golombok±Rust Inventory of Marital State (GRIMS; Rust, Bennun, Crowe, & Golombok, 1988). Other established marital questionnaires include the Locke±Wallace Marital Adjustment Scale (Locke & Wallace, 1959) and the Dyadic Adjustment Scale (Spanier, 1976). The recently developed Marriage and Relationship Questionnaire (Russell & Wells, 1993) is another useful instrument to be considered. When depression is a relevant factor needing to be assessed, a standard depression inventory may be used for this purpose. The same applies to anxiety. 6.27.4.2.7 Subjective ratings Self-rating scales may be used as part of an assessment of the major variables in question for a given patient. For example, anxiety in sex, desire, and sexual arousal may each be rated by the patient on a 0 to 100 scale indicating subjective estimates (cf. de Silva, 1994a). Patients usually find these simple scales easy to use. Equally simple are frequency charts, recording the frequency of target behaviors on a daily basis. A predesigned diary provided by the assessor/therapist, specifying the targets to be

Treatment of Sexual Dysfunction recorded, is an effective way of obtaining baseline data as well as of monitoring change. Conte (1986) and Spence (1991), among others, provide discussions of these. 6.27.4.2.8 Physiological measures Physiological techniques have been used in the assessment of sexual function for many years, receiving impetus from the work of Masters and Johnson (1966, 1970). Measuring techniques are available for both male and female arousal. Penile plethysmography for the assessment of erection is widely used in research and can be used in clinical practice where needed and practicable (e.g., Wagner & Green, 1981; Wincze et al., 1988). The measure may be of either penile volume or penile circumference changes. Penile plethysmography has also been used to assess nocturnal erections in an attempt to distinguish psychogenic from organically caused impotence (Karacan, 1978). The injection of a chemical vasodilator, such as papaverine, into one of the corpora cavernosa of the penis, is also used in the assessment of erectile disorder. If the patient develops a full erection following the injection, severe vascular insufficiency can be excluded as a cause of the problems (Brindley, 1983; Wagner, 1993). As for female arousal, the best established method is the photoplethysmography technique (Hoon, Wincze, & Hoon, 1976b), in which vasocongestion in the vaginal walls is measured with the help of a probe. Detailed discussions of these, and other laboratory techniques, for the assessment of sexual problems are provided by Bancroft (1989), Meisler and Carey (1990), McConaghy (1993), and Schiavi (1992). In a clinical setting, however, the use of physiological methods for routine assessment is not feasible. Also, the interpretation of their results in the clinical context is not always clearcut (Bancroft, 1989; Conte, 1986). 6.27.5 FORMULATION All the information gained from the different aspects of assessment need to be carefully integrated. This should lead to a case formulation, the equivalent of a working hypothesis (Carey, Flasher, Maisto, & Turkat, 1984; Hawton, 1985). A good formulation will include the following: (i) a detailed description of the problem; (ii) predisposing factors (e.g., cultural beliefs, history of diabetes, strict upbringing, childhood traumatic events); (iii) precipitating or triggering factors (e.g., childbirth, physical illness, redundancy, be-

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reavement, discovery of partner's adultery, failure while attempting sex in insecure circumstances); (iv) perpetuating factors (e.g., anxiety about possible failure, ongoing marital conflict, continuing stress at work); and (v) prognostic factors (e.g., good overall relationship and commitment of both to the marriage as good prognostic factors). The formulation will provide a tentative explanation of the problem, and also establish a basis for treatment. The formulation is fed back to the patient or couple, and discussed. Revision of the formulation may follow this discussion.

6.27.6 TREATMENT OF SEXUAL DYSFUNCTION 6.27.6.1 Behavioral Sex Therapy 6.27.6.1.1 The behavioral approach Historically, there have been several psychological approaches to sexual problems (de Silva, 1994b). However, the major approach since the 1960s has been the behavioral one. Behavioral sex therapy became established as the treatment of choice for these problems in the 1970s, and began to be practiced widely in various parts of the world (Gillan, 1987). In the modern folklore of sex therapy, it is widely held that the basic techniques of behavioral sex therapy derive from the work of William Masters and Virginia Johnson (Masters & Johnson, 1970). It is certainly true that Masters and Johnson developed, established, and popularized a treatment package that has had a major impact. However, the roots of behavioral sex therapy can be traced to the work of Joseph Wolpe in South Africa. Wolpe is regarded as the pioneer of modern behavior therapy, his work from the late 1940s on the application of learning principles to the analysis and modification of behavioral problems culminating in his book Psychotherapy by reciprocal inhibition (Wolpe, 1958). While much of the work reported in this book related to phobias and other anxiety disorders, Wolpe also reported behavioral work on sexual dysfunctions. He recognized the crucial role of anxiety in sexual problems, and used anxiety reduction as a key element in the treatment of these problems. The principle of the couple undertaking cooperative therapy, the need to remove pressure to perform, and the use of a graded series of activities eventually leading up to the resumption of sexual intercourse, which are seen as three major elements of present-day sex therapy, were key aspects of Wolpe's approach.

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Wolpe (1958) cites cases of both erectile dysfunction and premature ejaculation with whom he had successfully used this approach. It is perhaps worth quoting a passage that summarizes Wolpe's approach: The patient is told to inform his sexual partner (quoting the therapist if necessary) that his sexual difficulties are due to absurd but automatic fears in the sexual situation, and that he will overcome them if she will help him, i.e. if she will participate on a few occasions in situations of great sexual closeness without expecting intercourse or exerting pressure toward it. He is to ask her to be patient and affectionate and not to criticize. Assured of her cooperation, he is to lie in bed with her in the nude in a perfectly easy, relaxed way, and thereafter to do just what he really feels like doing and no more. He has no duty at any stage to reach any criterion of performance. It is found that from one love session to the next there is a decrease in anxiety and an increase in sexual excitation and therefore in the extent of the caresses to which the patient feels impelled. He has increasingly strong erections, and usually after a few sessions coitus is accomplished and then gradually improves. (Wolpe, 1958, p. 131)

6.27.6.1.2 Present-day conjoint cognitivebehavioral sex therapy While the work of Wolpe (1958) represents the early use of standard behavior therapy techniques for sexual dysfunctions (see also Lazarus, 1963), it is profitable to consider these and other behavioral techniques as elements that may be incorporated into a wider treatment package. The obvious reason for this is that sexual problems are often multifaceted so that to deal with them effectively one needs several methods. The general package most widely used in this way is the conjoint therapy of Masters and Johnson (1970), modified and further developed by subsequent writers (e.g. Bancroft, 1989; Gillan, 1987; Hawton, 1985; Spence, 1991; Wincze & Carey, 1991). One major new development is the incorporation of cognitive principles and techniques (e.g. Baker, 1993; Spence, 1991). This approach may be termed ªconjoint cognitive-behavioral sex therapy.º In the Masters and Johnson conjoint therapy approach, the presenting partner and spouse are seen as a couple for therapy. In the original program, each couple was seen by a male and female cotherapist team. Therapy was carried out on an intensive basis: daily sessions over a two-week period (Masters & Johnson, 1970). Other clinicians and researchers found that the involvement of a second therapist added little to the program and that sessions did not need to be so closely massed together (Arentewicz &

Schmidt, 1983; Bancroft, 1989; Crowe, Gillan, & Golombok, 1982). The main elements of the conjoint cognitivebehavioral sex therapy approach may be summarized as follows: (i) Treating the dysfunction as a joint problem. This helps to reduce worry and guilt in the presenting partner and also emphasizes that the need is to learn, or relearn, how to have satisfactory sex jointly. (ii) Reduction of anxiety. This is achieved by several strategies, including banning any attempt at intercourse. This removes the pressure to perform. Relaxation training may also be used as an extra help. Graded steps are recommended, so that progress is achieved without a resurgence of anxiety. (iii) Setting sexual tasks or assignments to be carried out at home. They are specific behavioral tasks and involve touching, caressing, and so on. The two main stages of this are ªnongenital sensate focus,º where the touching excludes genitals and breasts, and ªgenital sensate focusº where these are included. These basic tasks aim to help the couple to learn giving and receiving pleasure by touch, with no pressure for performance, moving from less sexual to more intimate interactions. (iv) Work on eliciting and changing negative or problematic cognitions. (v) Educating the couple in sexual knowledge, for example, anatomy, physiology, coital positions. (vi) Helping the couple to develop sexual and other communication skills. (vii) Using specific additional techniques for specific dysfunctions. While (i) to (vi) above are common to all, there are specific interventions designed to deal with specific presenting problems. The timing of their introduction is flexible; they are usually introduced after some progress has been made in the common stages. This program is a cognitive-behavioral package in that there is no attempt to interpret the presenting symptoms in terms of psychodynamic constructs, and that behavioral tasks and cognitive work are a major part of the package. The degree to which an approach geared towards unraveling conflicts and problems in the overall relationship is incorporated into this, varies from therapist to therapist and from case to case (Beck, 1992; Crowe & Ridley, 1990; Woody, 1992). Anxiety reduction is a key part of this package. The prohibition of attempts at intercourse helps to achieve this, as immediately the performance anxiety in the male and fears of pain and so on in the female are removed. Other techniques of anxiety reduction may be added as required. McCarthy (1977, 1992), for example,

Treatment of Sexual Dysfunction has listed a number of ways, both general and specific, in which anxiety can be reduced in sexual problems. The sensate focus assignments help a couple to learn to relax in each other's company and enjoy physical contact and interaction without worries of failure. In this relaxed, mutually pleasuring stage, they can acquire the confidence to move towards more intimate interactions. It is perhaps worth noting here that the progression from nongenital to genital sensate focus, and from there to more specific and more explicitly sexual acts, is similar in many ways to an in vivo desensitization program (Wolpe, 1958). Self-exploration may also be incorporated into the program where required. Communication, both verbal and nonverbal, on matters of pleasure, sensations, and sexual responses is encouraged and taught (e.g., how to indicate to the partner where and how to touch and how to express pleasure at what the partner is doing). The verbal aspects of this kind of simple, but to many couples new, interaction may be role-played and rehearsed during therapy sessions. The meetings with the therapist are crucial in discussing progress or otherwise of the homework assignments, and difficulties and problems are discussed fully. Not infrequently in these feedback discussions relevant new material about the relationship emerges for the first time (Bancroft, 1989; Hawton, 1985). Cognitive therapy principles have a key part to play. The elicitation and modification of cognitions related to the dysfunction are the main feature of this, and individual work along these lines is often a key part of therapy. Where maladaptive cognitions have a role in the genesis and/or maintenance of a problem, these need to be challenged and changed. Common myths, attitudes, and idiosyncratic beliefs, and so forth, often contribute to sexual difficulties (Baker & de Silva, 1988; Bishay, 1988; de Silva & Dissanayake, 1989). Spence (1991) has provided a useful discussion of the use of cognitive strategies in the treatment of sexual difficulties. She includes fantasy training and attention-focusing skills as possible aspects of therapy. The major cognitive interventions, however, consist of identifying and restructuring the relevant cognitions. Maladaptive or negative thoughts need to be identified and changed as needed (Zilbergeld, 1978, 1992). This approach is well represented in the work of Baker (1993). She highlights the role of the individual's core assumptions about gender role and accompanying expected behaviors. Such assumptions are reflected in automatic thoughts, commonly reported by patients in sex therapy, such as: ªMy partner will leave me

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if I continue to lose my erectionsº or ªI can't be very masculine if I don't last long with a partner.º Baker (1993) argues that these negative thoughts play a crucial role in maintaining, and in some cases even causing, sexual dysfunctions. The cognitive approach she uses aims to challenge and modify these dysfunctional cognitions, and to break the vicious circle of negative thoughts that contribute to difficulties. The role of cognitive work has also been emphasized by Bancroft (1997) and Wincze and Carey (1991). The need to focus on the partner's cognitions as well as those of the presenting patient has also to be emphasized. Typical partner cognitions include: ªI am no longer exciting to him,º ªHe is just not trying,º and ªShe must be having an affair with someoneº (cf. Wincze & Carey, 1991). Specific techniques are incorporated into this general program in the treatment of specific disorders. Comments on the treatment of some specific dysfunctions are made below. (i) Hypoactive sexual desire disorder Low interest usually begins to respond to the general treatment package if nothing more serious is underlying. Additional techniques are self-focusing, self-stimulation, use of vibrators, and stimulation with erotic material such as pictures, videos, and audiotapes. (Gillan, 1979, 1987). It is important, however, that the kind of erotic material recommended or provided is not distasteful to the patients, and so the choice is best left to them. Fantasy training is a related technique, sometimes useful for those whose fantasies are minimal (Spence, 1991). To encourage fantasies, published fantasy materials may be used, such as the volumes of fantasies published by Nancy Friday (1976, 1991). Masturbation training, usually with fantasy, may also be considered. The use of agreed timetables for sex are also found to be useful (e.g., Crowe & Ridley, 1990). The therapist would negotiate with the couple a timetable for sex; for example, intercourse will take place only on certain days of the week, or sex will be initiated by each partner on certain days only. This approach is often quite effective in cases where the partner with the low level of desire finds the demands made by the spouse too much, thus making the problem worse. The timetable helps to establish an acceptable pattern or schedule, within which further progress can be made. (ii) Male erectile disorder In the genital sensate focus stage, ªteasingº is introduced, that is, periods of penile stimulation

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alternating with absence of stimulation. While erections may spontaneously occur, these are not considered the aim of therapy at this stage and the couple are encouraged to let the erection subside before restimulating. This helps in training them not to rush to intercourse once an erection is there, and also demonstrates that erections, when lost, can reappear. The next stage is vaginal entry, in the female superior position but with no movement. In the following stage the female makes slow movements, eventually leading to the male participating in and/or initiating movement, and using different positions. Cognitive work has a particularly valuable role to play in the treatment of this disorder. Positive sexual thoughts should be identified and encouraged. The patient needs to be helped to refocus his thinking onto more positive cognitions. One way of doing this is to encourage recall of the thought content during past satisfactory sexual experiences. The therapist can also help the patient to develop positive thoughts by prompting ªtypicalº helpful thoughts (Wincze & Carey, 1991). There is also a need to appraise and reappraise the meaning of specific types of sexual acts. Negative meanings or appraisals that inhibit the sexual functioning need to be altered (cf. Bancroft, 1997). Some cognitive work may also be needed with the partner. Partners of men with erectile disorder not uncommonly develop negative cognitions, and they need to be dealt with. (iii) Female orgasmic disorder For females with orgasmic dysfunction the main additional element in the therapy package is a good deal of self-focusing and selfstimulation (Barbach, 1980; Gillan, 1987; Heiman & Lo Piccolo, 1988; Lo Piccolo & Stock, 1986). This helps the patient to learn to enjoy the sexual sensations in a relaxed manner. These self-sessions, including stimulation until orgasm is achieved, can be built into the basic program as parallel assignments. It has been shown that the use of vibrators can help these women to achieve orgasm; this may be done by the patient herself first, and the partner may help her to achieve orgasm with the vibrator in later stages. The use of fantasy and erotic materials may also be used as an adjunct (Gillan, 1979, 1987; Spence, 1991). Exercises to achieve control over the pubococcygeal muscle and to strengthen its tone, commonly referred to as ªKegel exercisesº (Kegel, 1952), have also been recommended as an aid to achieving orgasm. For females who are unable to achieve orgasm with the partner but have no problem in masturbation, other

elements may need to be added to the program. For example, orgasmic reconditioning may be attempted, in which the patient is taught to pair the positive pleasurable aspects of self-stimulation or other sexual situations with images of the partner in a fantasy-based graded program (Asirdas & Beech, 1975; Gillan, 1987). In some, perhaps many, instances a woman's inability or difficulty in reaching an orgasm is linked to her inability to relinquish control (McConaghy, 1993, 1996). Some help specifically directed towards this, involving education, counseling and practice exercises, is necessary in such cases. (iv) Male orgasmic disorder The aim is to work towards intravaginal ejaculation, in a series of steps gradually approaching this goal. Again the instructions are introduced at the genital touching stage. For those males who do not reach an orgasm easily in any situation, vigorous stimulation (ªsuperstimulationº) with the aid of a lubricant is recommended. The use of a vibrator may also be considered. Once orgasm can be achieved in this way, vaginal entry, after some initial manual stimulation, may be attempted. In those men whose problem is that they cannot reach orgasm in the vagina but can do so with manual stimulation, a graded program in which orgasm is achieved by manual stimulation, with the penis increasingly close to the vagina, is recommended. In the next stage vaginal entry is achieved, after stimulation by hand close to orgasm. Even then, some manual stimulation may be needed to achieve orgasm once the penis is in the vagina. Suitable coital positions that facilitate these steps need to be recommended. Subsequently, vaginal stimulation alone will be sufficient for orgasm (Kaplan, 1987). (v) Premature ejaculation There are two, closely similar, techniques used for premature ejaculation. Masters and Johnson (1970) recommend what is called the ªsqueezeº technique. The couple are asked to practice this in the genital touching state. The female stimulates the penis of her partner with her hand, and when the man feels he is about to reach a climax, he indicates this to her with a prearranged signal. She then squeezes the penis hard for two or three seconds. For squeezing, the penis is held with the thumb on the frenulum and the first and second fingers on the opposite surface, one on each side of the coronal ridge. The squeeze makes the man lose his urge to ejaculate, and also perhaps some of the erection. This process of stimulation and squeeze is

Treatment of Sexual Dysfunction repeated several times in a session. Several sessions of this leads to gradual increase in ejaculatory control, and the couple is then asked to effect vaginal entry, in the woman-above position. At first, entry is not followed by movement. If the man feels he is about to ejaculate during vaginal containment, he communicates this to his partner who then lifts herself off him lightly and applies the squeeze. Kolodny et al. (1979) recommend a basilar squeeze technique at this stage so that the penis does not have to be completely disengaged. The penis is held at the base, anterior to posterior, and the pressure applied. The couple may eventually revert to preferred positions. The squeeze technique is, in fact, a variant of the start±stop method described in 1956 by Semans, which is used by many therapists (e.g. Kaplan, 1974). This consists of stimulating the penis and stopping at the point of near-climax, and repeating the process several times. Initially, the stimulation is with a dry hand; later a lubricant is used to increase sensitivity and make the sensations more like the experience of vaginal entry (Gillan, 1987). The rest of the program consists of vaginal containment without movement, followed by movement in the woman-above position. (vi) Vaginismus This is treated by helping the patient, as a first step, to learn to relax and to explore her own genitals. Following this, a graded series of steps involving penetration using own fingers, and dilators (or trainers) of increasing sizes, is undertaken (Gillan, 1987; Scholl, 1988). The use of a vaginal lubricant may be advised. After the initial stages, the partner may be included in the procedure. This is done, however, with the patient retaining control. In many cases, this graduated dilation training leads to quick improvement. 6.27.6.1.3 Some general considerations on therapy Some general points about this treatment approach need to be made. (i) The therapy package The package in its basic form is for use with all sexual dysfunctions, with the specific elements added to suit specific difficulties. There are, however, many instances where there is no need to apply the whole package, where perhaps sexual counseling and basic education are all that is needed (Bancroft, 1989; Hawton, 1985; Kaplan, 1987). The therapist needs to

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have a flexible approach in applying the therapy package or parts of it. (ii) Psychogenic and organic problems The program is intended mainly for psychogenic problems, as patients with clearly organic problems may need different forms of therapy. On the other hand, there is no reason why some aspects of the program should not be used even with those whose problems are not psychogenic, as a way of helping them to relax in their sexual activity and enhance their sexual experience, thus facilitating whatever physical treatment may be used. For example, in elderly men with erectile dysfunction who, due to aging and other physical causes, may not be able to have erectile function restored, much can still be achieved by a program aimed at enhancing their enjoyment of sexual activity, enabling them to accept that sex need not always mean vaginal intercourse (Gibson, 1992). It is also important to remember that the psychogenic±organic distinction is not always clear cut, and there are often multiple causal factors (Bhugra & Crowe, 1995). A problem caused, or triggered, by a physical condition, may often be aggravated or maintained by psychological factors, such as anxiety, invalidism, and diminished self-esteem. In many cases, substantial psychological help is needed in addition to a physical intervention. (iii) Flexibility The program is meant to be applied flexibly. The needs of each couple determine what changes to aim for, and the therapist must be prepared to change the direction of a program as and when required; for example, a couple presenting with a premature ejaculation problem may turn out to be one where the basic problem is lack of responsiveness in the female. Some couples require a good deal of direct education; shy patients may not be able to participate fully in therapy sessions until their embarrassment is overcome, and will need considerable time and effort to reach the point where therapy can proceed. The need for flexibility is very well illustrated by Lobitz, Lo Piccolo, Lobitz, and Brockway (1976) and Wincze and Carey (1991). (iv) Resistance to the program The program can sometimes meet with resistance. A couple may not carry out homework assignments, or do them only infrequently or cursorily. Their difficulties will need to be fully explored. Previously unacknowledged marital or relationship problems may come to

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the surface at this stage, in which case efforts should be directed towards resolving these (Bancroft, 1989; Crowe & Ridley, 1990). (v) Additions to the program Additions to the basic program need not be confined to the specific techniques mentioned above. Any suitable cognitive and/or behavioral technique for aspects of the problem may be incorporated as required. For example, when a strong phobic element is present, an intervention to deal with the phobia may be used; for a man whose dysfunction is bound up with paraphiliac desires, a parallel program aimed at dealing with these may be required (de Silva, 1995). (vi) Functional analysis The notion of functional analysis (Kanfer & Saslow, 1969) is extremely useful in devising individualized treatment programs. When the assessment shows clearly identifiable factors related to the problem behavior, the systematic manipulation of these can achieve impressive results, usually as part of the program, but sometimes also as the main intervention (Lobitz et al. 1976). 6.27.6.2 Some Practical Issues As noted earlier, Masters and Johnson (1970) used male and female teams of cotherapists in their program, but others have shown that a second therapist adds little to the program effectiveness (e.g., Crowe et al., 1982). On the other hand, in certain cases an additional therapist of the opposite sex to the main therapist can be an advantage, for example, by making it easier for both of the partners to communicate about the problem and their feelings about it. The individuals should be given an opportunity to report to the therapist separately, that is, in the absence of the partner, at least in some of the sessions. This enables the therapist to gain a balanced account of the progress and related matters. Giving written instructions, with illustrations, is a valuable addition to the therapy program. They should be used as a supplement to verbal instructions. Equally useful is to recommend a well-written basic book on sex. There are many good books that may be recommended, for example, Barnes and Rodwell (1992), Delvin (1974) and Yaffe and Fenwick (1986a, 1986b). Films, videos, and slides may also be used (Gillan, 1987).

6.27.6.3 Therapy for Those Without Partners When a patient comes for therapy without a partner, what help can be offered? If the patient has a steady partner who, though unwilling to come to the clinic, will co-operate with a therapy program, a ªremote controlº approach may be used, with the presenting partner also acting as communicator of instructions. The use of written material will be particularly useful in such cases. Clinical experience shows that this is a less than ideal substitute for conjoint therapy, but should be considered in the right circumstances. If the refusal of the partner to attend the clinic reflects a poor relationship, and/or an attitude that it is all the other's problem, then clearly the chances of joint work being successfully carried out are slim. A somewhat different problem arises when the patient has no partner available. Many young men with erectile or ejaculatory problems not only do not have a steady partner but also avoid developing relationships, through fear of failure and rejection. Individual therapy is the only option available in such cases, unless group therapy is considered and facilities are available for it (see below). The basic principles of individual sex therapy are largely the same as those for couples. Education, counseling, anxiety reduction in various ways including relaxation, self-focusing and self-stimulation, and fantasy training are all possible and useful elements in such programs. Cognitive principles have a key role. As for specific techniques, premature ejaculators will find the start-stop technique easier to use than the squeeze. Imaginal desensitization may be used for fear or anxiety, while role play and social skills training can be useful where required (McCarthy, 1992). The sexual reeducation program of Zilbergeld considers it important to dispel some widespread male ªmythsº about sex (such as that sex always means intercourse, that the male must always take the active role, and so on) in helping these persons, and explorationÐand correctionÐof the individual's misconceptions about sex will be a useful element in an individual sex therapy program (Zilbergeld, 1978, 1992). For females, masturbatory exercises, Kegel exercises, fantasy training, vibrator use, and other such techniques that are possible for the individual to use without a partner, may be used as needed. The treatment of individuals without partners presenting with sexual problems is discussed by, among others, Anson (1995) and Catalan, Hawton, and Day (1991). The use of surrogate partners in the treatment of patients who come without partners has been reported and recommended by some therapists.

Treatment of Sexual Dysfunction Several sex therapists in the USA use surrogate therapy (Dauw, 1988; Sommers, 1980), while in the UK Cole (1988) has described such therapy with 425 patients, 390 men and the rest women. Of these, 316 (74.4%) completed therapy; unfortunately, the follow-up was possible in only 13.3% of these. There are serious problems with the use of surrogate therapy, including obvious legal and ethical issues. For example, in the Cole sample, the spouse in many cases was not aware that the patient had come for therapy. A serious clinical question is whether patients who have been treated with a surrogate partner will be able to generalize their gains to other situations. In view of these reservations, it is difficult to recommend surrogate therapy as an option in the management of sexual dysfunction. 6.27.6.4 Group Therapy In recent years, an increasing number of therapists have treated patients with sexual dysfunction in groups. There are reports in the literature of male groups, female groups, couple groups, and mixed-single groups; and there have been groups for patients with similar problems and groups for heterogeneous problems (e.g., Barbach & Flaherty, 1980; Kayata & Szydlo, 1988; O'Gorman, 1978; Spence, 1985; Zilbergeld, 1975). The groups have used a variety of techniques, including education, tasksetting, relaxation, desensitization, instructions to use masturbation and vibrators, and open discussion of problems. Particularly for young and sexually diffident persons, the experience of well-conducted group therapy can be of much benefit (Bancroft, 1989).

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and failures, and so on (Beck, 1992). Within these limitations, the available data are encouraging. There are no reliable comparative outcome data, but on the whole 50±60% of couples who enter treatment show satisfactory outcome. Marked differences in outcome exist for specific sexual dysfunctions. For example, excellent results are obtained for vaginismus (e.g., Hawton & Catalan, 1990), whereas the treatment of hypoactive sexual desire appears to be less effective, especially in the long term (e.g., Hawton, Catalan, & Fagg, 1991). While the conjoint cognitive-behavioral therapy approach is the best option when it is feasible, it is up to clinicians to use their ingenuity and judgment in choosing, for each case, those elements of therapy that are particularly suitable for the problems they are called upon to deal with. A related issue is that of the mechanisms of change. Even when various techniques and strategies achieve clinical success, the mechanisms through which change has been achieved is not always clear. Bancroft (1997) has recently highlighted this issue and offered a valuable, if brief, discussion. The relative lack of understanding of mechanisms of change also reflects the uncertainty about the etiological factors in these dysfunctions. The outcome literature also points to factors associated with prognosis. Good prognostic factors include the quality of the overall relationship. Motivation for therapy also appears to be a key factor. There is also some evidence that the attractiveness of the partners to each other predicts satisfactory outcome. Current psychiatric illness is a predictor of poor outcome. These issues have been reviewed by Hawton (1992).

6.27.6.5 Efficacy of Therapy

6.27.6.6 A Note on Physical Treatments

What about the efficacy of the therapeutic approaches and techniques that have been discussed above? The very high success rates reported by Masters and Johnson (1970; also Kolodny et al., 1979) have not been matched by later investigators but there is, generally, evidence that the conjoint cognitive-behavioral approach is beneficial to many patients (Arentewicz & Schmidt, 1983; Bancroft, 1989; Hawton, 1992; Hawton, Catalan, Martin, & Fagg, 1986; Spence, 1991). A thorough evaluation of sex therapy outcome is not easy to undertake because of various confounding factors: heterogeneity of samples, lack of uniformity in outcome measures, ambiguity of criteria of improvement, preponderance of single-case reports, poor description of patient characteristics, absence of data on drop-outs

A brief note is necessary about physical treatment. A variety of physical interventions are used in medical settings for sexual dysfunctions. It is beyond the scope of this chapter to review these. Hormonal therapy, surgery, vacuum devices, and penile prosthetic devices have been used, and certain drugs have also been claimed to be of value. Much of this work has been reviewed by Bancroft (1989), Bhugra and Crowe (1995), McConaghy (1996) and others. In recent years, many reports have appeared on the use of injections of smooth muscle relaxants such as papaverine and prostaglandin E into one of the corpora cavernosa of the penis to induce erections (e.g. Brindley, 1986; Linet & Ogring, 1996). The erections induced in this way may last from one to four hours and are usually adequate for

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satisfactory intercourse. The patient is taught to give these injections himself, and the partner may also be taught to play this role. The use of this method to help men with organically caused erectile problems, or those who have failed to respond to an adequate trial of psychological methods, is advocated by several authorities. There is, however, an urgent need for further research and the use of this approach needs caution (Althof & Turner, 1992; Bhughra & Crowe, 1995; Crowe & Qureshi, 1991). The procedure also has some side-effects, especially parapism (prolonged erection) in a small number of cases. An even more recent development is the intraurethral administration of prostaglandin E (e.g., Wolfson, Pickett, Scott, De Kernion, & Rajfer, 1993). When used appropriately after careful investigation, physical methods do have a useful role in the treatment of sexual dysfunctions. However, when the problem is largely psychologically determined, the use of physical treatments can be counterproductive. Even when there are physical causes of the presenting problem, and the main treatment is of a physical nature, additional psychological help along the lines discussed above is often useful and necessary (Wincze & Carey, 1991). The reliance on a physical treatment alone in the treatment of sexual dysfunction is not recommended (Bhugra & Crowe, 1995). 6.27.6.7 Scope of Cognitive-behavioral Sex Therapy It was noted above that success rates have declined in recent years when compared to the very high rates reported in early years. This may be due to changes in culture and to changes in the nature of referrals for specialist help. Lo Piccolo (1994) has argued that the behavioral approach of the 1970s and the 1980s needs to be augmented, and that a ªpostmodernº sex therapy is required. In this approach, while the behavioral outlook is still the primary feature, the role that sexual dysfunctions may play in maintaining a systemic homeostasis for the couple in crucial areas of their relationship (e.g., intimacy, trust, power) is recognized, and is appropriately dealt with. Second, it is recognized that a sexual problem may have individual psychodynamic significance. Third, it is recognized that a sexual dysfunction may be a mechanism for the patient to deal with unresolved family or origin issues, such as problems of closeness associated with an alcoholic father, or an aversive reaction associated with incestuous abuse. Finally, the operant reinforcing value of a sexual dysfunction for clients in their larger environment is

looked into; for example, ªthe financial success that comes to a man who works especially hard to compensate for his erectile failureº (Lo Piccolo, 1994, p. 6). It is clear that all but one of these aspects of sexual dysfunction highlighted by Lo Piccolo (1994) can be accommodated easily within the broad framework of the cognitive-behavioral approach. In fact this happens almost routinely in actual clinical practice. As noted above, relationship factors are always an important area to investigate and work on in sex therapy. A systemic approach may be of much value in this endeavor in some cases. Such an approach can be accommodated easily within a broad cognitive-behavioral framework, as demonstrated by Crowe and Ridley (1990). The reinforcing value of the sexual problem would naturally be investigated and dealt with in the cognitive-behavioral approach, as indeed it is done for all behavioral difficulties (Kanfer & Saslow, 1969). The historical aspects of a case need to be considered in any approach, and a good cognitive-behavioral formulation would necessarily include recognition of these. As for the psychodynamic value and significance of a symptom, this may appear at first sight to be an aspect that does not easily fit within a cognitive-behavioral framework. Kaplan (1974, 1987) has argued for the use of a psychodynamic approach if and when behavioral procedures produce no further change in a patient, in other words when there is resistance. However, it can be argued that a broadly conceived cognitive-behavioral approach, imaginatively applied, should be able to deal with these matters. It appears that what is needed in such cases is for the individual to be helped to reappraise the meanings of certain sexual acts or responses (Bancroft, 1997). Negative meanings acquired in childhood, persisting into adult life and inhibiting appropriate sexual responses, need to be reappraised. As Bancroft (1997) points out, there is no doubt that this endeavor ªlends itself particularly well to the cognitive-behavioral approachº (p. 247). What is required is for the therapist to lead the patient towards this necessary reappraisal with the skillful and sensitive use of cognitivebehavioral principles. 6.27.7 TREATMENT ISSUES WITH SPECIAL POPULATIONS Sexual dysfunctions occurring in various special populations need some consideration. The approach to treatment described in the above sections is a robust one, the principles of which are applicable to all groups. However, certain additional considerations are sometimes

Treatment Issues with Special Populations needed, and treatment needs to be adapted as required. A few commonly encountered special clinical populations are discussed below. 6.27.7.1 The Elderly Elderly couples and individuals increasingly attend services for sexual problems (Gibson, 1992; Spence, 1991). This is not because of any real increase of sexual dysfunctions in the group, but because of the awareness of the availability of services and also the increasing acceptance that sexual activity in later life is not something to be ashamed of (Gibson, 1992). Erectile disorder is one of the commonest presentations (Mulligan, 1989); male and female orgasmic disorder also present for help. While physiological influences have a clear role to play in some of these cases, problems of ill-health can also contribute to, and/or complicate, the difficulties. Changing life circumstances, including the nature of the overall relationship between a couple, are also relevant factors. Psychological factors, especially attitudinal ones, may also play a part. It is not uncommon for elderly people to take the view that sexual activity should no longer be part of their lives, and this can be a problem when the partner continues to desire an active sex life. In the treatment of elderly clients, all of the above need to be considered in the assessment, and should be part of the formulation. When needed, advice, information, and reassurance need to be given. The normality of continuing sex in later years may need to be emphasized. If there are fears or concerns about one's loss of attractiveness to the partner, some specific cognitive work on this will need to be undertaken. The therapy program needs to take into account the clients' preferences and longstanding habits and practices, and any instructions for new and adventurous sexual activity should be given only after careful consideration and discussion. Greater emphasis on the nongenital aspects of sexual activity may be needed, and many elderly couples can learn to find much sexual pleasure in this way. Specific practical advice may include the use of lubricants, when there is a female arousal disorder including lack of lubricationÐa very common presentationÐand on how vaginal penetration may be achieved even with a not fully erect penis (Gillan, 1987). Finally, there are instances when the presentation of a sexual dysfunction in this age group is linked to anxiety about not being able to perform as well as in previous years. This is particularly so with males who may get concerned about their declining erectile response. Part of the treatment would

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then be providing information about the common changes in sexual functioning with increasing age, thus allaying any undue anxiety. The variability of the effects of aging on sex needs to be emphasized. Further, increasing the need for direct physical stimulation of the partner's penis in order to obtain an erection has to be emphasized, and the instructions for touching and foreplay need to include this as a major part. 6.27.7.2 Those with Physical Handicaps and Chronic Illnesses Many clients with physical handicaps and chronic illnesses seek help for sexual problems. Cardiac problems, epilepsy, arthritis, cancer, and prostrate problems are among the difficulties that are commonly encountered. Assessment should include full details of the problems, including the study of medical reports about the client's difficulties. The medication the client may be on is also important to ascertain, as it may well have an effect on sexual functioning and the presenting dysfunction may even be just a secondary result of medication. A third area to pay attention to is how the physical illness or handicap has affected the person psychologically, mainly in the areas of self-image and role in relation to the partner. Chronic illness and handicaps often lead to invalidism, which affects the person's functioning including confidence and role in the area of sex. These issues need to be addressed in therapy, and it is best done using cognitive techniques with the individual and in joint counseling (cf. Malloy & Herold, 1986). When there is chronic handicap, the aim of therapy for sexual dysfunction should be to maximize pleasurable sexual activity that is possible within the limits imposed by the handicap. A couple may need to use only certain coital positions, and variations within these. Those who are paraplegic or quadraplegic, or who have a limited range of motion due to back problems or arthritis, need education and advice on comfortable positions (cf. Bullard, 1988). Sometimes the focus needs to be on noncoital sexual activities. Couples may need to be given carefully graded behavioral homework exercises, in which they can proceed at a slow pace and without fear of pain or risk of fatigue. Some of these issues are discussed in detail by Schover (1992), Schover and Jensen (1988), and Spence (1991). 6.27.7.3 Gay Clients Presentation of gay men for help in sexual dysfunction is common (Reece, 1988). The

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problems they present are varied, and cover the full spectrum that is seen in heterosexual men (Bhugra & Wright, 1995). Etiological factors often include fear of HIV/AIDS, uncertainty about sexual orientation, and feelings of being shunned or oppressed by society at large (cf. Bhugra, 1987; Dupras & Morriset, 1993). In the treatment of these clients, the general principles of cognitive-behavioral sex therapy are applied, with special focus on the issues noted above. Therapists need to be nonjudgmental in their attitude. When fear of sexually transmitted diseases are a part of the picture, clear advice on safe sex practices needs to be provided as part of the therapy package. In the treatment of gay clients without partners, a group approach may be considered (cf. Reece, 1985). This format provides an economical and effective way of dealing with issues of stigma, ambivalence about sexual orientation and so on, in addition to work on specific dysfunctions. Another issue that needs to be dealt with, in the treatment of gay men without partners, is how one might get over the fearÐand avoidanceÐof developing new relationships, out of embarrassment about the sexual dysfunction. Here, a behavioral rehearsal may be used to provide practice in disclosing the dysfunction to a new partner (cf. McCarthy, 1992).

6.27.7.4 Women with Eating Disorders Females with eating disorders, especially anorexia nervosa, present a special challenge to therapists. There is a very high incidence of sexual problems in women with anorexia nervosa (Beaumont, Abraham, & Simson, 1981; Bancroft, 1989; de Silva & Todd, 1998; Raboch & Faltus, 1991). The reasons for this are complex. Clearly, in severe anorexia nervosa endocrine factors are involved, and this affects sexual functioning. There is also evidence that many anorexic patients have anxieties about sexuality and womanhood (cf. Anderson, 1985). When they seek treatment, it is often for hypoactive female sexual disorder, or for arousal disorder. Anorgasmia is also found as a problem, and not uncommonly sexual aversion disorder (see de Silva & Todd, 1998). There are major issues in the treatment of these clients. While the basic cognitivebehavioral approach described in this chapter forms the basis of therapy for them, its application has to be cautious and carefully tailored to the individual. Often they come for treatment with some ambivalence; they may come either due to the need to please their partner if they are in a relationship, or in order

to ªbecome normal.º Any attempt to treat sexual dysfunction while the client is still at a very low body weight is a mistake. The pace of therapy should be determined by the client's readiness. Preliminary work on sex education and attitudes may be needed (Van Vreckem & Vandereycken, 1994). Individual work preceding joint work is often advisable. Specific cognitive work on the significance of sex and sexuality, the client's self-concept, and so on may also be needed. Essentially, the therapy with this group of clients takes a slower, more finely graded form than in general sexual dysfunction therapy. Examples of the treatment of females with anorexia nervosa along these lines are found, among others, in Guile, Horne, and Dunston (1978) and de Silva and Todd (1998).

6.27.8 SUMMARY AND COMMENTS ON FUTURE DEVELOPMENTS This chapter has reviewed the nature, diagnosis, etiology, assessment, and treatment of sexual dysfunction. The field has developed rapidly since the 1970s, with many practicing clinical psychologists getting actively involved in the clinical management of these problems, and in research aimed at elucidating them. Work in this area is now very much part of mainstream clinical psychology practice. The current picture is, in essence, a promising one. There is much in the literature to guide the practitioner in the clinical assessment and treatment of these difficulties. The outcome literature is relatively weak, due to a variety of factors. However, there is enough in the literature on the outcome of therapy for sexual dysfunction to enable practitioners confidently to undertake the treatment of those patients who seek help for sexual problems. As for the future, several developments can be predicted. Many therapists have begun to use and develop cognitive techniques more extensively in recent years, and this trend will continue to grow. The incorporation of the systemic approach into a broad cognitivebehavioral framework is another recent development that is likely to progress further. An integrated approach deriving concepts and strategies from the cognitive-behavioral and the systemic traditions may well emerge as the favored model in the near future. The other major area of development is likely to be in the physical treatments for sexual dysfunctions, mainly but not exclusively male erectile dysfunction. Extensive and ambitious research is currently taking place in this area, and the results of these investigations and trials are

References likely to have an impact on sexual dysfunction therapy. It is probable that more effective physical treatments will become available, but this is unlikely to reduce the need or demand for psychological treatments. First, the proportion of patients who will derive significant benefit from physical treatments is likely to be limited. Second, even when an effective physical treatment is used for a patient or couple, there will remain a clear need for additional psychological help. For these cases, it is likely that an integrated approach combining physical and psychological interventions will become the treatment of choice. 6.27.9 REFERENCES Althof, S. F., & Turner, L. A. (1992). Self-injection therapy and vacuum devices in the treatment of erectile dysfunction: Methods and outcome. In R. C. Rosen & S. R. Leiblum (Eds.), Erectile disorders: Assessment and treatment (pp. 283±309). New York: Guilford. Anderson, A. E. (1985). Practical comprehensive treatment of anorexia nervosa and bulimia. London: Edward Arnold. Anson, M. (1995). Non-couple therapy for sexual dysfunction. International Review of Psychiatry, 7, 205±216. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Arentewicz. G., & Schmidt, G. (1983). The treatment of sexual disorder: Concepts and techniques of couple therapy. New York: Basic Books. Asirdas, S., & Beech, H. R. (1975). The behavioural treatment of sexual inadequacy. Journal of Psychosomatic Research, 19, 345±353. Baker, C. D. (1993). A cognitive-behavioural model for the formulation and treatment of sexual dysfunction. In J. M. Ussher & C. D. Baker (Eds.), Psychological perspectives on sexual problems (pp. 110±128). London: Routledge. Baker, C. D., & de Silva, P. (1988). The relationship between male sexual dysfunction and belief in Zilbergeld's myths: An empirical investigation. Sexual and Marital Therapy, 3, 229±238. Bancroft, J. (1989). Human sexuality and its problems (2nd ed.). Edinburgh, UK: Churchill Livingstone. Bancroft, J. (1997). Sexual problems. In D. M. Clark & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 243±257). Oxford, UK: Oxford University Press. Barbach, L. (1980). Women discover orgasm. New York: Free Press. Barbach, L., & Flaherty, M. (1980). Group treatment of situationally anorgasmic women. Journal of Sex and Marital Therapy, 6, 19±29. Barnes, T., & Rodwell, L. (1992). A Woman's guide to loving sex. London: Boxtree. Beaumont, P. J. V., Abraham, S. F., & Simson, K. (1981). The psychosexual histories of adolescent girls and young women with anorexia nervosa. Psychological Medicine, 11, 131±140. Beck, J. G. (1992). Behavioural approaches to sexual dysfunction. In S. M. Turner, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of clinical behavior therapy (2nd ed.). New York: Wiley. Bhugra, D. (1987). Homophobia: A review of the literature. Sexual and Marital Therapy, 2, 169±177. Bhugra, D., & Crowe, M. J. (1995). Physical treatments of

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erectile disorders. International Review of Psychiatry, 7, 217±223. Bhugra, D., & de Silva, P. (1993). Sexual dysfunction across cultures. International Review of Psychiatry, 5, 243±252. Bhugra, D., & Wright, P. (1995). Sexual dysfunction and gay men: Diagnosis and management. International Review of Psychiatry, 7, 247±252. Bishay, N. R. (1988). Cognitive therapy for sexual dysfunction: A preliminary report. Sexual and Marital Therapy, 3, 83±90. Brindley, G. S. (1983). Cavernosal alpha-blockade: A new technique for investigating and treating erectile impotence. British Journal of Psychiatry, 143, 332±337. Brindley, G. S. (1986). Maintenance treatment of erectile impotence by cavernosal unstriated muscle relaxant injection. British Journal of Psychiatry, 149, 210±215. Bullard, D. G. (1988). The treatment of desire disorders in the medically ill and physically disabled. In S. Leiblum & R. Rosen (Eds.), Sexual desire disorders (pp. 109±120). New York: Guilford. Carey, M. P., Flasher, L. V., Maisto, S. A., & Turkat, I. D. (1984). The apriori approach to psychological assessment. Professional Psychology: Research and Practice, 15, 515±527. Catalan, J., Hawton, K., & Day, A. (1991). Individuals presenting without partners at a sexual dysfunction clinic: Psychological and physical morbidity and treatment offered. Sexual and Marital Therapy, 6, 15±23. Cole, M. (1988). Sex therapy for individuals. In M. Cole & W. Dryden (Eds.), Sex therapy in Britain (pp. 272±299). Milton Keynes, UK: Open University Press. Conte, H. R. (1986). Multivariate assessment of sexual dysfunction. Journal of Consulting and Clinical Psychology, 54, 149±157. Crowe, M. J., Gillan, P., & Golombok, S. (1982). Form and content in the conjoint treatment of sexual dysfunction: A controlled study. Behaviour Research and Therapy, 19, 47±54. Crowe, M. J., & Qureshi, M. J. H. (1991). Pharmacologically induced penile erections (PIPE) as a maintenance treatment of erectile impotence: A report of 41 cases. Sexual and Marital Therapy, 6, 273±285. Crowe, M. J., & Ridley, J. (1990). Therapy with couples. Oxford, UK: Blackwell. Dauw, D. C. (1988). Evaluating the effectiveness of the SECS surrogate-assisted sex therapy model. Journal of Sex Research, 24, 269±275. Delvin, D. C. (1974). The book of love. London: New English Library. Derogatis, L. R., & Melisaratos, N. (1979). The DFSI: A multidimensional measure of sexual functioning. Journal of Sex and Marital Therapy 5, 244±281. de Silva, P. (1994a). Sexual dysfunction: Investigation. In S. J. E. Lindsay & G. E. Powell (Eds.), The handbook of clinical adult psychology (2nd ed., pp. 199±212). London: Routledge. de Silva, P. (1994b). Sexual dysfunction: Treatment. In S. J. E. Lindsay & G. E. Powell (Eds.), The handbook of clinical adult psychology (2nd ed., pp. 213±228) London: Routledge. de Silva, P. (1995). Paraphilias and sexual dysfunction. International Review of Psychiatry, 7, 225±229. de Silva, P., & Dissanayake, S. A. W. (1989). The loss of semen syndrome in Sri Lanka: A clinical study. Sexual and Marital Therapy, 4, 195±204. de Silva, P., & Todd, G. (1998). Sexual dysfunction in women with anorexia nervosa: Nature and treatment. Sexual and Marital Therapy, 13, 21±36. Dupras, A., & Morriset, R. (1993). Sexual dysfunction among HIV positive gay males. Sexual and Marital Therapy, 8, 37±46. Feldman, H. A., Goldstein, I., Hatzichristou, D. G.,

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Krane, R. J., & McKinlay, J. B. (1994). Impotence and its medical and psychosexual correlates: Results of the Massachusetts Male Aging Study. Journal of Urology, 151, 54±61. Frank, E., Anderson, C., & Rubinstein, D. (1978). Frequency of sexual dysfunction in normal couples. New England Journal of Medicine, 299, 111±115. Friday, N. (1976). My secret garden: Women's sexual fantasies. London: Quartet. Friday, N. (1991). Women on top. London: Hutchinson. Gibson, N. B. (1992). Love, sex and power in later life. London: Freedom Press. Gillan, P. (1979). Stimulation therapy for sexual dysfunction. British Journal of Sexual Medicine, 6, 13±14. Gillan, P. (1987). Sex therapy manual. Oxford, UK: Blackwell. Guile, L., Horne, M., & Dunston, E. (1978). Anorexia nervosa: Sexual behaviour modification as an adjunct to an integrated treatment programme. Australian and New Zealand Journal of Psychiatry, 12, 165±167. Hawton, K. (1985). Sex therapy: A practical guide. Oxford, UK: Oxford University Press. Hawton, K. (1992). Sex therapy: For whom is it likely to be effective? In K. Hawton & P. Cowen (Eds.) Practical problems in clinical psychiatry (pp. 93±104). Oxford, UK: Oxford University Press. Hawton, K., & Catalan, J. (1990). Sex therapy for vaginismus: Characteristics of couples and treatment outcome. Sexual and Marital Therapy, 5, 39±48. Hawton, K., Catalan, J., & Fagg, J. (1991). Low sexual desire: Sex therapy results and prognostic factors. Behaviour Research and Therapy, 29, 217±224. Hawton, K., Catalan, J., Martin, P., & Fagg, J. (1986). Long-term outcome of sex therapy. Behaviour Research and Therapy, 24, 377±385 Heiman, J. R., & Lo Piccolo, J. (1988). Becoming orgasmic. Englewood Cliffs, NJ: Prentice-Hall. Hoon, E., Wincze, J., & Hoon, P. (1976a). The SAI: An inventory for the measurement of female sexual arousal. Archives of Sexual Behavior, 5, 291±300. Hoon, E., Wincze, J., & Hoon, P. (1976b). Psychological assessment of sexual arousal in women. Psychophysiology 13, 196±208. Kanfer, F. H., & Saslow, G. (1969). Behavioral diagnosis. In C. M. Franks (Ed.), Behavior therapy: Status and appraisal (pp. 417±444). New York: McGraw-Hill. Kaplan, H. S. (1974). The new sex therapy. London: BallieÁre Tindall. Kaplan, H. S. (1987). The illustrated manual of sex therapy (2nd ed.) New York: Brunner/Mazel. Karacan, I. (1978). Advances in the psychophysiological evaluation of male erectile impotence. In L. Lo Piccolo & J. Lo Piccolo (Eds.), Handbook of sex therapy (pp. 137±145). New York: Plenum. Kayata, L., & Szydlo, D. (1988). Sex therapy in groups. In M. Cole & W. Dryden (Eds.), Sex therapy in Britain (pp. 184±203). Milton Keynes, UK: Open University Press. Kegel, A. (1952). Sexual functions of the pubococcygeus muscle. Western Journal of Surgery, Obstetrics and Gynaecology, 60, 521±524. Kinsey, A. C., Pomeroy, W. B., & Martin, C G. (1948). Sexual behavior in the human male. Philadelphia: Saunders. Kolodny, R. C., Masters, W. H., & Johnson, V. E. (1979). A textbook of sexual medicine. Boston: Little Brown. Lazarus, A. A. (1963). The treatment of chronic frigidity by systematic desensitization. Journal of Nervous and Mental Disease, 136, 272±278. Lief, H. I., & Reed, D. M. (1972). Sexual knowledge and attitude test (SKAT) (2nd ed.). Centre for the Study of Sex Education in Medicine, University of Pennsylvania. Linet, O. I., & Ogring, F. G. (1996). Efficacy and safety of

intracavernosal alpostradil in men with erectile dysfunction. New England Journal of Medicine, 334, 873±877. Lobitz, W. C., Lo Piccolo, J., Lobitz, G. K., & Brockway, J. (1976). A closer look at simplistic behaviour therapy for sexual dysfunction: Two case studies. In H. J. Eysenck (Ed.), Case studies in behaviour therapy (pp. 237±271). London: Routledge and Kegan Paul. Locke H. J., & Wallace, K. M. (1959). Short marital adjustment and prediction tests: Their reliability and validity. Marriage and Family Living, 21, 251±255. Lo Piccolo, J. (1994). Leading comment: The evolution of sex therapy. Sexual and Marital Therapy, 9, 5±7. Lo Piccolo, J., & Steger, J. C. (1974). The Sexual Interaction Inventory: A new instrument for assessment of sexual dysfunction. Archives of Sexual Behavior 3, 585±595. Lo Piccolo, J., & Stock, W. (1986). Treatment of sexual dysfunction. Journal of Consulting Clinical Psychology, 54, 158±167. Malloy, G. L., & Herold, E. S. (1986). Factors related to sexual counselling of physically disabled adults. Journal of Sex Research, 24, 200±227. Masters, W. H., & Johnson, V. E. (1966). Human Sexual Response. Boston: Little Brown. Masters, W. H., & Johnson, V. E. (1970). Human Sexual Inadequacy. Boston: Little Brown. McCarthy, B. W. (1977). Strategies and technique for the reduction of sexual anxiety. Journal of Sex and Marital Therapy, 3, 243±248. McCarthy, B. W. (1992). Treatment of erectile dysfunction with single men. In R. C. Rosen & S. R. Leiblum (Eds.), Erectile disorders: assessment and treatment (pp. 313±348). New York: Guilford. McConaghy, N. (1993). Sexual behavior: Problems and management. New York: Plenum. McConaghy, N. (1996). Treatment of sexual dysfunctions. In V. B. Van Hessalt & M. Hersen (Eds.), Sourcebook of psychological treatment manuals for adult disorders (pp. 333±373). New York: Plenum. Meisler, A. W., & Carey, M. P. (1990). A critical reevaluation of nocturnal penile tumescence monitoring in the diagnosis of erectile dysfunctions. Journal of Nervous and Mental Disease, 178, 78±89. Mulligan, T. (1989). Impotence in the older man. Medical Aspects of Human Sexuality, 23 32±36. Nettelbladt, P., & Uddenberg, N. (1979). Sexual dysfunction and sexual satisfaction in 58 married Swedish men. Journal of Psychosomatic Medicine, 23, 141±147. O'Gorman, E. (1978). Treatment of frigidity: A comparative study of group and individual desensitization. British Journal of Psychiatry, 132, 580±584. Raboch, J., & Faltus, F. (1991). Sexuality in women with anorexia nervosa. Acta Psychiatrica Scandinavica, 84, 9±11. Reading, A. E., & Weist, W. M. (1984). An analysis of selfreported sexual behavior in a sample of normal males. Archives of Sexual Behavior, 13, 69±83. Reece, R. (1985). Group treatment of sexual dysfunction in gay men. In J. C. Gonsianek (Ed.), A guide to psychotherapy with gay and lesbian clients (pp. 113±129). New York: Haworth. Reece, R. (1988). Causes and treatment of sexual desire discrepancies in male couples. In E. Coleman (Ed.), Psychotherapy with homosexual men and women (pp. 157±172). New York: Haworth. Renshaw, D. C. (1988). Profile of 2376 patients treated at Loyola Sex Clinic between 1972 and 1987. Sexual and Marital Therapy, 3, 117. Rosen, R. C., Riley, H., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997). The International Index of Erectile Function (IIEF): A multidimensional scale for the assessment of erectile dysfunction. Urology, 49, 822±830.

References Russell, R. J. H., & Wells, P. A. (1993). Marriage and Relationship Questionnaire. London: Hodder & Stoughton. Rust, J., Bennun, I., Crowe, M. J., & Golombok, S. (1988). The Golombok±Rust Inventory of Marital State. Windsor, UK: NFER-Nelson. Rust, J., & Golombok, S. (1986). The Golombok±Rust Inventory of Sexual Satisfaction. Windsor, UK: NFERNelson. Rust, J., Golombok, S., & Collier, J. (1988). Marital problems and sexual dysfunctions: Are they related? British Journal of Psychiatry, 152, 629±631. Schiavi, R. C. (1992). Laboratory methods for evaluating erectile dysfunction. In R. C. Rosen & S. R. Leiblum (Eds.), Erectile disorders: Assessment and treatment (pp. 141±170). New York: Guilford. Scholl, G. M. (1988). Prognostic variables in treating vaginismus. Obstetrics and Gynaecology, 72, 353±358. Schover, L. R. (1992). Erectile failure and chronic illness. In R. C. Rosen & S. R. Leiblum (Eds.), Erectile disorders (pp. 341±367). New York: Guilford. Schover, L. R., & Jensen, S. B. (1988). Sexuality and chronic illness: A comprehensive approach. New York: Guilford. Semans, J. H. (1956). Premature ejaculation: A new approach. Southern Medical Journal, 49, 353±358. Sommers, F. G. (1980). Treatment of male sexual dysfunction in psychiatric practice integrating the sexual therapy practitioner (surrogates). In R. Farleo & W. P. Asini (Eds.), Medical sexology (pp. 261±270). Amsterdam: Elsevier. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15±23. Spector, I. P., & Carey, M. P. (1980). Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Archives of Sexual Behavior, 19, 389±408. Spence, S. H. (1985). Group versus individual treatment of primary and secondary orgasmic dysfunction. Behaviour Research and Therapy, 23, 539±548. Spence, S. H. (1991). Psychosexual therapy: A cognitivebehavioural approach. London: Chapman and Hall. Van Vreckem, E., & Vanderycken, W. (1994). A sexual education programme for women with eating disorders.

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In B. Dolan & J. Gitzinger (Eds.), Why women? Gender issues and eating disorders (pp. 110±116). London: Athlose Press. Wagner, G. (1993). Injection therapy for impotence. In G. Wagner & H. S. Kaplan (Eds.), The new injection treatment for impotence (pp. 75±93). New York: Brunner Mazel. Wagner, G., & Green, R. (1981). Impotence: Physiological, psychological, surgical diagnosis and treatment. New York: Plenum. Weizman, R., & Hart, J. (1987). Sexual behavior in healthy married American men. Archives of Sexual Behavior, 16, 39±44. Wilson, G. D. (1978). The secrets of sexual fantasy London: Dent. Wincze, J. P., Bansal, S., Malhotra, C., Balko, A., Susset, J. G., & Malamud, M. (1988). A comparison of nocturnal penile tumescence and penile response to erotic stimulation during working states in comprehensively diagnosed groups of males experiencing erectile difficulties. Archives of Sexual Behavior, 17, 333±348. Wincze, J. P., & Carey, M. P. (1991). Sexual dysfunction: A guide for assessment and treatment. New York: Guilford. Wolfson, B., Pickett, S., Scott, N. E., DeKernion, J. B., & Rajfer, R. (1993). Intraurethral prostaglandin E-2 creams: A possible alternative treatment for erectile dysfunction. Urology, 42, 73±75. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition Stanford, CA: Stanford University Press. Woody, J. D. (1992). Treating sexual distress. Newbury Park, CA: Sage Publications. Yaffe, M., & Fenwick, E. (1986a). Sexual happiness for men. London: Dorling Kindersley. Yaffe, M., & Fenwick, E. (1986b). Sexual happiness for women. London: Dorling Kindersley. Zilbergeld, B. (1975). Group treatment of sexual dysfunction in men without partners. Journal of Sex and Marital Therapy, 1, 204±214. Zilbergeld, B. (1978). Men and sex. Boston: Little Brown. Zilbergeld B. (1992). The man behind the broken penis: Social and psychological determinants of erectile failure. In R. C. Rosen & S. R. Leiblum (Eds.), Erectile disorders: Assessment and treatment (pp. 27±51). New York: Guilford.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.28 Relationship Problems W. KIM HALFORD Griffith University, Brisbane, Qld, Australia HOWARD J. MARKMAN University of Denver, CO, USA and PETER FRAENKEL New York University, NY, USA 6.28.1 INTRODUCTION

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6.28.2 NATURE AND SIGNIFICANCE OF MARITAL DISTRESS

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6.28.2.1 Prevalence of Marital Problems 6.28.2.2 Effects of Relationship Problems 6.28.3 NATURE AND ETIOLOGY OF RELATIONSHIP PROBLEMS

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6.28.4 BEHAVIORAL, COGNITIVE, AND AFFECTIVE COMPONENTS OF RELATIONSHIP PROBLEMS

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6.28.4.1 The Etiology of Relationship Distress 6.28.5 COUPLES THERAPY 6.28.5.1 6.28.5.2 6.28.5.3 6.28.5.4 6.28.5.5

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The Different Approaches to Couples Therapy Assessment of Relationship Problems and the Process of Couples Therapy Cognitive-behavioral Couples Therapy The Effectiveness of Cognitive-behavioral Couples Therapy Couples Therapy and Psychological Disorder

6.28.6 PREVENTION OF RELATIONSHIP PROBLEMS

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6.28.6.1 Prevention and Early Intervention 6.28.6.2 Content of Prevention Programs 6.28.7 CONCLUSIONS

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6.28.8 REFERENCES

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Marriage is one of the most nearly universal of human institutions. No other touches so intimately the life of practically every member of the earth's population. (Terman, 1938, p.1)

ships at some point in their lives. In Western countries over 90% of the population marry by age 50 years (DeGuilbert-Lantione & Monnier, 1992; McDonald, 1995). Even among those who choose not to marry, the vast majority engage in ªmarriage-likeº relationships by living together in committed, couple relationships (McDonald, 1995). Expectations of couple relationships are high. In Western cultures the vast majority of

6.28.1 INTRODUCTION An overwhelming percentage of people become involved in intimate couple relation623

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adults perceive their marital relationship as their primary source of support and affection (Levinger & Huston, 1990). Most young unmarried adults expect to marry at some point in their lives, for that marriage to be lifelong, and expect their partners to show sexual monogamy, honesty, expressions of affection, intimacy, and support (Millard, 1990). Almost all couples that marry report high levels of relationship satisfaction early in their relationship (Markman & Hahlweg, 1993). Many couples sustain a mutually satisfying relationship, and seem to derive many benefits from that relationship. Relative to other people, those in satisfying marriages have lower rates of psychological distress, higher rated life happiness, and greater resistance to the detrimental effects of negative life events (Glenn & Weaver, 1981; Gore, 1978; Gove, Hughes, & Style, 1983; Halford, Kelly, & Markman, 1997). Unfortunately, for many other couples their relationship quality and satisfaction erodes over time. Relationship problems spill over to negatively affect partners' ability to cope with parenting and work outside the home, and this has major detrimental effects on them and their children (Halford & Markman, 1996; Sanders, Nicholson, & Floyd, 1997). Seeking help about relationship problems is very common. Relationship preparation and enhancement programs are widely becoming accepted and attended by increasing proportions of the population entering marriage (Bradbury & Fincham, 1990; Stanley, Markman, Leber, & St. Peters, 1995; Simons, Harris, & Willis, 1994). In fact, relationship preparation programs are more widely attended than just about any other form of psychoeducational program (Simons et al., 1994). Couple relationship problems are one of the most common presenting problem of adults seeking psychological assistance (Veroff, Kulka, & Douvan, 1981), and couples often seek divorce mediation when their relationships end (Emery & Wyer, 1987; Walsh, Jacob, & Simons, 1995). In this chapter we analyze the nature and significance of relationship problems, assessment of couple relationships, the conduct of couples therapy, and prevention of relationship problems.

6.28.2 NATURE AND SIGNIFICANCE OF MARITAL DISTRESS 6.28.2.1 Prevalence of Marital Problems The most statistically reliable index of marital distress is divorce rates, and divorce has reached epidemic proportions in most Western societies. About 45% of Australian marriages, 55% of

American, 42% of UK, and 37% of German end in divorce (De Gulbert-Lantoine & Monnier, 1992; McDonald, 1995). As painful as the experience of divorce is for many people, most divorcees still aspire to be in a committed relationship. In the US about 75% of divorced people remarry within five years of the end of their first marriage (Glick, 1989; Martin & Bumpass, 1989). The divorce rates of second marriages are even higher than for first marriages (Glick, 1989). Divorce rates represent only a portion of couples experiencing relationship problems. Many couples have significant relationship distress, but opt to stay together for various reasons such as the financial implications of divorce, and personal and cultural expectations about marriage (Gottman, 1993, 1994). Surveys of representative samples of married adults show that between 80% and 85% report they are very satisfied with their current relationship (Beach, Arias, & O'Leary, 1986; Eddy, Heyman, & Weiss, 1991, Gallup, 1989; Reynolds, Rizzo, Gallagher, & Speedy, 1979; Stanley & Markman, 1996). However, satisfied partners tend to make unrealistically positive comments and predictions about their relationship functioning (Fowers, Lyons, & Montel, 1996). For example, the majority of maritally satisfied partners believe there is zero probability that they will ever divorce, despite the well-publicized evidence of how common divorce is (Fowers et al., 1996) Furthermore, of the married people who report high relationship satisfaction, 40% also report having seriously considered leaving their current partners at some point (Gallup Poll, 1989), and over 50% are characterized by interaction patterns that erode satisfaction and predict future divorce (Stanley & Markman, 1996). Thus, even those couples who report that they are very satisfied in their relationship at any point in time are at risk for future problems and divorce. All these figures converge on the point that significant relationship problems are common in most Western societies.

6.28.2.2 Effects of Relationship Problems Given the central importance placed upon couple relationships, it is not surprising to find that relationship distress and dissolution are experienced as extremely stressful events. In fact, after a death in the immediate family, marital distress and divorce are rated as the most severe of commonly occurring stresses experienced by adults (Bloom, Asher, & White, 1978). Relationship distress is associated with increased risk for development of a range of

Nature and Significance of Marital Distress individual psychological disorders including depression, particularly in women (Bebbington, 1987; Coyne, Kahn, & Gotlib, 1987; Hooley, Orleay, & Teasdale, 1986), alcohol abuse, particularly in men (O'Farrell, 1989), and anxiety disorders (Craske & Zoellner, 1995), and sexual dysfunction in both sexes (Zimmer, 1983). Marital conflict is also associated with increased behavior problems and poorer psychological adjustment in the couples' children (Emery, 1982; Emery, Joyce, & Fincham, 1987; Grych & Fincham, 1990). The causal connections between marital distress and individual psychological disorder are complex. Long-standing, psychological disorders reduce the chance of having a satisfactory marriage. For example, patients diagnosed with schizophrenia or severe personality disorders are much less likely than the rest of the population to get married, and are much more likely to get divorced if they do marry (Lange, Schaap, & van Widenfelt, 1993; Reich & Thompson, 1985). However, the association between marital problems and psychiatric disorder is not simply psychological disorder causing marital problems. For example, in cases of coexisting marital problems and depression, the marital problems often antedate the onset of depression (Birchnall & Kennard, 1983). Even when treatment produces an improvement in depressed mood there is limited effect on marital distress (Dobson, 1987; Klerman & Weissman, 1982; O'Leary & Beach, 1990), and the ongoing marital problems are associated with poor prognosis for the depression (Rousanville, Weissman, Prusoff, & Herceg-Baron, 1979). Similarly, marital problems stimulate excessive drinking (Davis, Berenson, Steinglass, & Davis, 1974), precipitate relapse by people with high alcohol dependence who have been abstinent from alcohol consumption (Maisto, O'Farrell, Connors, McKay, & Pelcovits, 1988), and are predictive of poor prognosis in alcohol treatment programs (Billings & Moos, 1983; Vannicelli, Gingereich, & Ryback, 1983). Thus, a simple unidirectional model of causality is inadequate. Marital distress and psychological disorder reciprocally influence each other. In addition to the psychological maladjustment associated with relationship problems, relationship problems are also correlated with poorer physical health. Individuals in satisfying and supportive marriages are less likely to have major illness, and they recover better when they do become ill than individuals in distressed relationships (Burman & Margolin, 1992; Schmaling & Sher, 1997). The mechanisms linking poor physical health to relationship problems are complex and only partially understood. Relationship distress has some indirect

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effects mediated through health-related behaviors, such as low adherence to medical treatment regimens by those in distressed relationships (Schmaling & Sher, 1997). Inadvertent reinforcement of illness behavior in distressed marriages and inadequate support of coping in chronic illness can have a negative impact upon partners' health (Schmaling & Sher, 1997). There are also some direct effects of relationship distress on physiological processes which impact upon health. For example, relationship conflict is associated with immunosuppression (Kiecolt-Glaser et al., 1993), elevated stress hormone levels (Keicolt-Glaser et al., 1996), elevated blood pressure in people with essential hypertension (Ewart, Taylor, Kraemer, & Agras, 1991), and possibly atherosclerosis (Gottman, 1990; Medalie & Goldbourt, 1976). Each of these physiological effects are likely to increase risk for serious health problems. Relationship problems at home spill over to work. More specifically, for men relationship conflict at home is associated with days lost at work and poor work performance (Thompson, 1997). The economic cost of the effects of relationship problems are extensive. Relationship violence has a major effect on the health and well-being of many partners in committed relationships. About 25% of all marriages have at least one episode of interspousal physical aggression at some point (O'Leary et al., 1989; Strauss, Gelles, & Steinmetz, 1980), and this violence almost always is associated with relationship distress. Over half of maritally distressed couples presenting for therapy report having experienced interpartner violence in the previous year (O'Leary & Vivian, 1990). Whilst men and women are equally likely to engage in aggressive acts such as hitting, pushing, or slapping (Strauss & Gelles, 1986; O'Leary et al., 1989), men are much more likely to engage in severe violence, and women are at particular risk for being injured or even killed by their partner (Koop, 1985; Stets & Strauss, 1990). Even when physical injuries are less severe, violence can have severe negative consequences for female victims. Women repeatedly assaulted by their partners are at high risk of developing depression, alcohol abuse, psychosomatic disorders, and are high users of the healthcare system (Cascardi, Langhinrichsen, & Vivian, 1992; Jaffee, Wolfe, Wilson, & Zak, 1986; Stets & Strauss, 1990). Relationship aggression is also linked to child abuse (Grych & Fincham, 1990), development of antisocial behavior in male offspring (Grych & Fincham, 1990), and increased risk of children entering a violent relationship as an adult (Widom, 1989).

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6.28.3 NATURE AND ETIOLOGY OF RELATIONSHIP PROBLEMS The common element to clinical presentations of relationship problems is almost always dissatisfaction by at least one partner with the relationship. Attempts to define and measure relationship problems have taken relationship (marital) satisfaction, as assessed by self-report inventories, as the ultimate criterion (Weiss & Heyman, 1997). The most widely used selfreport inventories are the Locke±Wallace Marital Adjustment Test (Locke & Wallace, 1959), and an expanded revision known as the Dyadic Adjustment Scale (Spanier, 1976). These two scales, and many similar scales, have been subjected to repeated criticism (e.g., Heyman, Sayers, & Bellack, 1994) for confounding relationship satisfaction, measured by items such as ªoverall how would you rate your marital happiness,º with adjustment processes alleged to influence satisfaction, measured by items such as ªhow often do you and your partner disagree about finances?º While the collapsing of the constructs of relationship satisfaction and adjustment seems conceptually unsound, factor analyses of measures of marital adjustment and dissatisfaction consistently show that partners make unidimensional, global evaluations of their relationship problems (Eddy, Heyman, & Weiss, 1991; Heyman et al., 1994). In essence, partners who are dissatisfied with their relationships tend to report that just about anything that could be negative about their relationship is negative. The finding that reported relationship distress seems to reflect an overriding global evaluation of negative aspects of the relationship does not mean that relationship quality is unidimensional. In the late 1990s work shows that couples distinguish between dissatisfaction about negative aspects of the relationship (e.g., the level of distress associated with conflict) and satisfaction with positive aspects of the relationship (e.g., the sense of satisfaction with expressions of love) (Fincham, Beach, & Kemp-Fincham, 1997). Some couples present with severe relationship distress and little positive feeling about their partner or the relationship, while other couples are distressed by the negative aspects of the relationship associated with dissatisfaction but still retain some positive feelings about the partner. The latter group of couples seem to benefit more from couples therapy (Hahlweg, Schindler, Revenstorf, & Brengelman, 1984). In either group of couples their initial focus often is on reducing negative behaviors associated with dissatisfaction, but successful therapy also needs to prompt couples to attend to developing positive aspects of the relationship.

Active consideration of separation is common in couples with relationship problems, (Weiss & Cerreto, 1980). However, the association of relationship problems, consideration of separation, and divorce is not straightforward. Most couples who eventually divorce go through a protracted process which proceeds from worsening relationship problems, through active consideration of separation, to actual separation, and eventually to divorce (Gottman, 1990, 1993). Often in couple presentations one or both partners are ambivalent about the relationship and its future. Ambivalence can be a major challenge to the partners. They risk neither proceeding with separation nor working to improve a distressed relationship, and by default the distress of the status quo is maintained. The systematic assessment of relationship problem areas and strengths, combined with conjoint goal setting, often serves to overcome this inertia (Halford, Osgarby, & Kelly, 1996; Weiss & Halford, 1995). We will say more on this in the section on relationship assessment (Section 6.28.5.2).

6.28.4 BEHAVIORAL, COGNITIVE, AND AFFECTIVE COMPONENTS OF RELATIONSHIP PROBLEMS Problems in communication are the most frequently cited specific complaint by couples seeking therapy, with up to 90% of distressed couples citing these difficulties as a major issue in the relationship (Bornstein & Bornstein, 1986). Both independent observers and spouses report communication deficiencies are associated with relationship distress (Weiss & Heyman, 1997). When discussing problem issues, distressed partners are often hostile, and criticise and demand change of each other (Christensen & Shenk, 1991; Gottman & Krokoff, 1989; Gottman, 1994; Halford, Hahlweg, & Dunne, 1990; Heavey, Christensen, & Malmuth, 1995; Notarius & Markman, 1993). Distressed couples also do not actively listen to their partner when discussing problems (Halford et al., 1990; Jacobson, McDonald, Follette, & Berley, 1985; Weiss & Heyman, 1990), and tend to withdraw from problem discussions (Christensen & Shenk, 1991; Gottman, 1994; Gottman & Krokoff, 1989; Halford, Gravestock, Lowe, & Scheldt, 1992; Heavey, Christensen, & Malmuth, 1995). Contentious relationship issues are less likely to be resolved by discussion in distressed couples than nondistressed couples (Halford et al., 1992). Distressed couples are highly reactive at an emotional level to their partners' behavior, and show significantly higher rates of negative

Behavioral, Cognitive, and Affective Components of Relationship Problems reciprocity during interaction than nondistressed couples (e.g., Gottman, Notarius, & Markman, 1977; Schaap, 1984). In observational studies of communication, the conditional probabilities of distressed partners responding negatively to their partner's negativity is much higher than the conditional probabilities for nondistressed partners (e.g., Halford et al., 1990). In addition to this negative reciprocity, relationship distress is also associated with high levels of psychophysiological arousal during interaction (e.g., Gottman & Levenson, 1988). This arousal is aversive, which may explain the higher rates of withdrawal during problem-focused discussions by maritally distressed partners (Christensen & Shenk, 1991; Gottman & Krokoff, 1989). In any case, both the extent of arousal and the frequency of withdrawal prospectively predict deterioration in marital satisfaction (Gottman, 1993; Gottman & Krokoff, 1989; Heavey, Layne, & Christensen, 1993; Heavey et al., 1995). Another common complaint of couples seeking relationship therapy is the negativity of their day-to-day interactions (Halford, in press). Using behavioral checklists in which partners monitor their spouses' behavior there is a well-replicated finding that monitored daily behaviors correlate with relationship satisfaction (Birchler, Weiss, & Vincent, 1975; Halford & Sanders, 1988; Jacobson, Follette, & McDonald, 1982; Johnson & O'Leary, 1996). More specifically, relative to maritally satisfied couples, distressed couples report higher rates of negative, displeasing behaviors by their spouse and fewer positive, pleasing behaviors (Birchler et al., 1975; Halford & Sanders, 1988; Jacobson et al., 1982; Johnson & O'Leary, 1996). Furthermore, distressed couples tend to reciprocate on a quid pro quo basis the behaviors of their spouse. In other words, in a distressed relationship partners tend only to be positive if their partner recently has been positive, and if one partner behaves negatively the other often responds negatively immediately (Birchler et al., 1975; Jacobson et al., 1982). In contrast, satisfied couples' behavior is less contingent on the preceding partners' behaviors; satisfied couples tend to be positive irrespective of their partners' prior actions. There also is evidence that distressed couples' perceptions of their partners' behavior are negatively biased. Distressed couples disagree to a greater extent with both objective observers (Robinson & Price, 1980) and with each other (Christensen & Nies, 1980; Jacobson & Moore, 1981) regarding the occurrence of particular behaviors in their relationship. More specifically, they tend to overestimate the frequency of negative partner behaviors. The nature of

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relationship distress cannot be understood simply in terms of the behaviors occurring during marital interaction, but also requires attention to the cognitive appraisal by partners of that interaction. Distressed couple have a number of characteristic cognitions about their relationships (Beaucom, Epstein, Sayers, & Sher, 1989). Maritally distressed couples selectively attend to their partner's negative behavior (Eidelson & Epstein, 1982; Floyd & Markman, 1983; Jacobson & Moore, 1981), and selectively recall such negative behavior (Halford & Osgarby, 1996). In contrast, maritally, satisfied partners tend to overlook negative behaviors by their spouses (Gottman et al., 1977; Notarius, Benson, Sloane, Vanzetti, & Horyak, 1989), to have an unrealistically positive view of their partners and relationships (Fowers, Applegate, Olson, & Pomerantz, 1994), and to selectively recall positive aspects of relationship interaction (Halford & Osgarby, 1996). Another characteristic of distressed couples in the cognitive domain is holding unrealistic beliefs about relationships and partners. More specifically, relative to happy couples, distressed couples are more likely to believe that any form of disagreement is destructive, that change by partners is not possible, and that rigid adherence to traditional gender roles is desirable (Baucom & Epstein, 1990; Eidelson & Epstein, 1982). Distressed couples also report that their relationships often violate standards about how they think their relationship should be (Baucon et al., 1996). For example, distressed women report that their partners do not share power within the relationship in the manner the women believe they should, and men believe their partners should invest more time and energy in the relationship than they do (Baucom et al., 1996). Distressed couples attribute the causes of relationship problems to stable, internal, negative, and blameworthy characteristics of the partners (Bradbury & Fincham, 1990; Fincham & Bradbury, 1992). For example, a partner arriving home late from work may be perceived as ªa generally selfish person who doesn't care about the familyº by a maritally distressed partner. The same behavior may be attributed by a maritally satisfied partner as the spouse ªstruggling to keep up with a heavy load at work, and being subject to lots of pressure from the boss.º The process of attributing much or all of the relationship problems to their partners leaves most people with relationship distress feeling powerless to improve their relationship (Vanzetti, Notarius, & NeeSmith, 1992). A key element of couples therapy is to enhance each partners' sense of relational efficacy or capacity

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to improve their relationship through their own actions (Halford, Sanders, & Behrens, 1994). One additional cognitive characteristic of a distressed couple is that they expect negative outcomes from interaction with their partners. Distressed couples report that prior to a discussion they expect not to be able to resolve problem issues in their relationships (Vanzetti et al., 1992). In anticipation of a problemsolving discussion, maritally distressed partners show high physiological arousal (Gottman, 1994), negative affect, and become primed to access negative evaluative judgements about their partner and the relationship (Fincham, Garnier, Gano-Phillips, & Osborne, 1995). The cognitive characteristics of distressed couples mediate their subsequent behavior toward their partners. For example, the occurrence of negative attributions is associated with subsequent behavioral negativity (Bradbury & Fincham, 1992). In unhappy couples, negative thoughts about the partner predict future negative behaviors better than predictions from previous behavior (Halford & Sanders, 1990), suggesting these cognitions are more than just the consequences of negative marital behavior. In other words, relationally distressed partners seem to respond to their subjective perceptions and memories of relationship interactions, and these perceptions and memories are negatively biased. 6.28.4.1 The Etiology of Relationship Distress There are over 100 published studies assessing the longitudinal course of couple relationship satisfaction and stability (Karney & Bradbury, 1995). This comprehensive literature can be usefully summarized in terms of three broad classes of variables which impact upon the etiology of relationship problems: adaptive processes within the couple system, stressful events impinging upon the couple system, and enduring individual vulnerabilities of the partners (Bradbury, 1995). Adaptive processes refer to the cognitive, behavioral, and affective processes that occur during couple interaction. Certain deficits in these adaptive processes seem to predispose couples to relationship problems. More specifically, deficits in communication and management of negative affect and conflict observed in engaged couples prospectively predict divorce and relationship dissatisfaction over the first 10 years of marriage (Markman & Hahlweg, 1993). Dysfunctional communication and negative affect regulation in engaged couples also predicts the development of relationship verbal and physical aggression in the first few years of marriage (Murphy & O'Leary, 1989; O'Leary

et al., 1989), at least for mild to moderate severity aggression. Relationship aggression is often established early in the relationship, and usually continues and escalates once established (Murphy & O'Leary, 1989; O'Leary et al., 1989). It is noteworthy that the communication and conflict management deficits observed in some engaged couples do not correlate with their reported relationship satisfaction or commitment at the time (Markman & Hahlweg, 1993; Sanders, Halford, & Behrens, 1996). It seems that these communication difficulties do not stop couples from forming committed relationships, but the difficulties do predispose couples to develop relationship problems later. In couples who have been married for some time, these same communication difficulties predict deterioration in relationship satisfaction and decreased relationship stability (Gottman, 1993, 1994) The beliefs and expectations individuals have when entering into relationships and marriage predict the risk of divorce in the first few years of marriage (Olson & Fowers, 1986; Olson & Larsen, 1989). Couples characterized by unrealistic expectations and beliefs in areas such as importance of communication, appropriate methods of conflict resolution, importance of family and friends, and gender roles, have higher rates of erosion in relationship satisfaction than couples not so characterized. Negative attributional patterns in which partners attribute blame for relationship problems to stable, negative characteristics of their spouse also prospectively predict deterioration in relationship satisfaction (Fincham & Bradbury, 1990). Thus, certain communication and cognitive characteristics of the couple's adaptive processes predate, and prospectively predict, relationship problems. Stressful events refer to the developmental transitions and acute and chronic circumstances which impinge upon the couple or individual partners. Relationship problems are more likely to develop during periods of high rates of change and stressful events (Karney & Bradbury, 1995). For example, the early stages of marriage, including transition to parenthood, is often associated with decline in couple relationship satisfaction (Cowen & Cowen, 1992), as is an increase in work demands (Thompson, 1997). Retirement is another major transition for couples which can be associated with relationship distress (Dickson, 1997). One partner developing a major health problem also puts couples at increased risk for relationship and sexual problems (Schmaling & Sher, 1997). A common stressful transition worthy of special mention is entering a second marriage. Second marriages in which there are dependant

Couples Therapy children from an earlier relationship break down at very high rates (Booth & Edwards, 1992; Martin & Bumpass, 1989). Negotiating parenting roles in step-families is a common source of interpartner conflict, and unresolved differences in this area are the most common stated reason for relationship breakdown in step-families (Lawson & Sanders, 1994). Moreover remarital partners tend to repeat the same patterns of negative interactions with their new partners despite efforts to the contrary (Prado & Markman, in press). In general, couples with less robust adaptive processes are believed to be particularly vulnerable to the negative effects of a range of stressful events (Markman, Halford, & Cordova, 1997). In particular, couples who lack communication skills, or who have inflexible or unrealistic expectations of relationships, find it hard negotiate the changes required to adapt to major life transitions (Markman, Stanley, & Blumberg, 1994). For example, one of us (WKH) is studying couples where the women were recently diagnosed with breast or gynecological cancer. In couples with good communication and effective mutual support the adversity of cancer diagnosis and treatment seems to bring the couples closer together and reinforce the relationship bonds. In contrast, couples with poor adaptive processes show deterioration in their relationships and poor individual coping with the cancer. Enduring vulnerabilities refer to the stable historical, personal, and experiential factors which each partner brings to a relationship (Bradbury, 1995). Family of origin experiences have been widely studied as historical factors which correlate with risk of relationship problems. For example, the adult offspring of divorce are more likely than the rest of the population to divorce (Glenn & Kramer, 1987), and interparental aggression is associated with increased risk for having an aggressive relationship as an adult (Widom, 1989). The mechanisms by which exposure to parental divorce or aggression may impact upon subsequent adult relationships is becoming clearer. Exposure to parental divorce is associated with more negative expectations of marriage (Black & Sprenkle; 1991; Gibardi & Rosen, 1991; Van Widenfelt, Schaap, & Hosman, 1996), and with observable deficits in communication and conflict management in couples prior to marriage (Halford et al., 1994). Adult offpsring of parents who were aggressive also show deficits in communication, and conflict management skills in dating and marital relationships (Sanders, Halford, & Behrens, 1998; Skuja & Halford, 1998). Negative expectations and communication deficits may well be learned from the parents' relationships

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and subsequently these learned behaviors impact negatively upon the adult relationships of the offspring. The argument that communication difficulties may be acquired through observation and interaction with parents is supported by a finding from Howes and Markman (1991). They found couple communication style assessed premaritally predicted subsequent communication style when the partners become parents and were interacting with their children (Howes & Markman, 1991). The association between personality variables and relationship problems has been widely studied. Normal personality variations do not seem to contribute much variance to relationship satisfaction (Gottman, 1994; Karney & Bradbury, 1995; Notarius & Markman, 1993). One exception is that low ability to regulate negative affect (high neuroticism) consistently has been found to predict higher risk for relationship problems and divorce (Karney & Bradbury, 1995). How this personality characteristic may impact upon relationship problems is not yet understood. Another major risk indicator for relationship distress and divorce is past or present history of psychological disorder. Higher rates of relationship problems and divorce consistently have been reported in populations with severe psychiatric disorder (Halford, 1995), and in people with depression, alcohol abuse, and some anxiety disorders (Emmelkamp, De Haan, & Hoogduin, 1990; Halford, Kelly, Bouma, & Young, in press; Halford & Osgarby, 1993; O'Farrell & Birchler, 1987; Reich & Thompson, 1985; Ruscher & Gotlib, 1988; Weissman, 1987). As described earlier in this chapter, relationship problems and individual problems can both exacerbate each other (Halford et al., in press). In addition, certain personal vulnerabilties may dispose people to both psychological disorders and relationship problems. For example, deficits in interpersonal communication and negative affect regulation are risk factors that predict the onset of both alcohol abuse (Block, Block, & Keyes, 1988) and relationship problems (Markman & Hahlweg, 1993). This common risk factor might be part of the explanation for the common co-occurrence of relationship and alcohol problems.

6.28.5 COUPLES THERAPY Intervention with relationship problems can potentially target couples' adaptive processes, stressful events, or enduring vulnerabilities, as each of these classes of variables influence relationship problems. The focus of all interventions evaluated in research has been on

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modifying couples' adaptive processes, either through conjoint therapy for couples with existing relationship problems (e.g., Baucom & Epstein, 1990; Halford, in press), or through brief programs to prevent the development of relationship problems (Halford & Behrens, 1996; Markman & Hahlweg, 1993). Often interventions are adapted to take account of the enduring vulnerabilities of the partners. For example, there has been considerable research on therapy with couples in which one partner has depression (Beach, Sandeen, & O'Leary, 1992) or alcohol abuse (O'Farrell & Rotunda, 1997). In the 1990s some work has focused on developing couples' adaptive processes to manage particular life transitions and stressful events, such as being in a step-family (Lawton & Sanders, 1994). In the rest of this chapter we focus on interventions targeting change in couple adaptive processes.

6.28.5.1 The Different Approaches to Couples Therapy A number of different approaches to couples therapy, including behavioral, cognitive, cognitive-behavioral, emotion-focused, and insight-oriented couples therapy, have been demonstrated to improve the relationship satisfaction of the majority of couples who present for therapy (Baucom & Epstein, 1990; Greenberg & Johnson, 1988; Hahlweg & Markman, 1988; Halford, Sanders, & Behrens, 1993; Shadish et al., 1993; Snyder, Wills, & GradyFletcher, 1991a). All these approaches share the characteristics of the use of systematic assessment and goal setting at the beginning of therapy, and a focus on conjoint therapy targeting changes in the couples' adaptive processes. The different theoretical approaches to couples therapy which have empirically validated efficacy have placed different emphases on the processes alleged to produce change in couples' adaptive processes. In insight-oriented and emotion-focused couples therapy emphasis was placed on changing partners' subjective experience of relationship interactions, usually through insights gained into the subjective significance of particular relationship events (Greenberg & Johnson, 1988; Snyder, Wills, & Grady-Fletcher, 1991b). In contrast, in behavioral approaches to couples therapy the original emphasis was on changing relationship interaction through procedures such as behavioral contracting and skills training in areas such as communication and problem-solving (Jacobson & Margolin, 1979). Cognitive behavioral couples therapy combined attempts to change the subjective experience of relationship

interactions through cognitive change procedures and attempts to change relationship interactions with behavioral procedures (e.g., Baucom & Epstein, 1990; Halford et al., 1993). The distinctions between these different empirically validated approaches to couples therapy are becoming somewhat blurred. Treatment manuals written for insight-oriented couples therapy (Snyder & Wills, 1989) include considerable use of behaviour change procedures that seem identical to those used in cognitive-behavioral couples therapy (Jacobson, 1991; Markman, 1991). Treatment manuals published by cognitive-behavioral couples therapists (Christensen, Jacobson, & Babcock, 1995; Weiss & Halford, 1995) describe the limitations of relying on changing relationship interactions and incorporate procedures acknowledged as very similar to those advocated by emotion-focused therapists to change the subjective experience of relationship interactions. While there is some blurring of the distinctions between different theoretical approaches to couples therapy, there are still some important differences in such approaches. The most widely used approaches to couples therapy in clinical practice are systemic and strategic approaches (Boughner, Hayes, Bubenezer, & West, 1994), and there are a diversity of procedures used within these approaches (Fraenkel, 1997). There is little evidence by which to judge how useful these procedures are. In contrast, relatively few practitioners use the most extensively researched approach to couples therapy: cognitive-behavioral couples therapy (CBCT) (Markman, Halford, & Cordova, 1997; Shadish et al. 1993). As we believe in practice being guided by research, the couplestherapy approach outlined in this chapter is based on the CBCT approach, which has developed from the research foundation we reviewed earlier in this chapter.

6.28.5.2 Assessment of Relationship Problems and the Process of Couples Therapy Clinical descriptions of cognitive-behavioral couples therapy emphasize the importance of developing therapeutic alliances with each partner, developing a shared understanding of relationship problems and goals which promotes adaptive change, and explicit negotiation with couples about their roles in therapy (e.g., Beach, Sandeen, & O'Leary, 1990; Baucom & Epstein, 1990; Christensen et al., 1995; Weiss & Halford, 1995). Assessment is crucial in achievement of these process outcomes in couples therapy. In essence, the therapist seeks

Couples Therapy through assessment both to establish an empathic understanding of each partner's experience of the relationship and to promote a shared conceptualization of problems in terms of relationship interactions. The shared conceptualization is the basis for the participants to negotiate the goals of therapy and to determine how those goals are to be achieved. Establishing a shared conceptualization of relationship problems sometimes is a difficult therapeutic task. Therapists tend to see relationship problems in terms of the adaptive processes occurring between the partners. In contrast, couples often enter therapy conceptualizing their relationship problems as due to stable, global negative characteristics of their partners (Fincham & Bradbury, 1990), and believe there is little they can do individually to improve their relationship. To achieve a shared, productive relationship focus in couples therapy the therapist initially assesses the presenting concerns from the perspective of each partner. Often these initial descriptions by clients are critical and blaming of the partner (e.g., ªhe does not communicate,º ªshe is too demandingº). The therapist then uses a variety of strategies to promote a relationship focus. For example, strategic use of questioning can promote attention to relationship interaction (e.g., ªHow do you two resolve conflict?º ªAs a couple how do you ensure you have quality time together?º). Particular assessment tasks also prompt attention to relationship interaction. For example, undertaking certain communication tasks can be used to identify strengths and weaknesses in communication. Reframing summaries also can foster a relationship focus. For example, suppose a couple argue about parenting. One partner may present this issue as ªhe is too soft on the children when they misbehave.º The spouse might describe the issue as ªshe is too harsh in her discipline of the children.º The therapist may summarize this as: ªas a couple you struggle to agree on the best ways to manage your children's behavior.º The therapist's summary reframes the issue as a relationship challenge the couple can work on together. In CBCT there is a strategic separation of assessment and therapy. At the completion of assessment the therapist provides the couple with structured feedback on the results of the assessment. This feedback summarizes and integrates the assessment information and focuses the results on how the problems can be conceptualized within a relationship framework. The process typically involves the therapist presenting the results of the assessment to the couple, one assessment instrument at a time. The therapist continually checks that

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the descriptions and conclusions being reached are accurate according to each partner. After presenting all the key findings the therapist summarizes the results and discusses with the couple possible goals for therapy. The most commonly identified goals are improving communication, controlling conflict, enhancing quality time together, and renegotiating key relationship responsibilities. Other common goals include working together to improve parenting difficulties, enhancing support for each other, and enhancing the expression of intimacy and closeness. After developing a shared relationship focus, the next step in couples therapy is to have each partner define what she or he can do to change problematic interactions. This emphasis on selfchange (also known as self-regulation) focuses therapy on that which each client has the most direct control over, namely their own behavior (Halford, Sanders, & Behrens, 1994). This is not to say that changes in the partner are unimportant, but rather that the most productive method of achieving change is for each partner to focus on their own opportunities to change. For some couples the process of assessment, plus one or two sessions focused on self-directed goal setting and change, can be sufficient to improve a distressed relationship (Halford et al., 1996). For other couples, assessment is just the beginning of a more extensive therapeutic process, but serves the crucial function of determining the directions for therapy. Assessment provides two kinds of information: content and process. Content information refers to the reports of the concerns of the partners, such as the specific content of conflicts, or their current thinking or actions about separation. Process information samples how the couple respond to the various probes or tasks the therapist initiates. For example, if the couple are asked to discuss an issue of relevance to the relationship, the therapist may be particularly interested in either the process of interchange between the partners (e.g., the degree of effective listening to each other's perspective) or the actual content of the discussion. Many therapists rely exclusively on conjoint interviews with the couple to assess the content of relationship problems (Boughner, Hayes, Bubenezer, & West, 1994). This is a mistake. Content information obtained from conjoint interviews is less reliable than information derived from either individual interviews or self-report inventories (Haynes, Jensen, Wise, & Sherman, 1981). For example, physical abuse is dramatically under-reported in conjoint interviews relative to either self-report inventories or individual interviews (O'Leary, Vivian, & Malone, 1992). Furthermore, encouraging couples

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to recount lengthy lists of complaints about their partners in the presence of the partner rarely promotes a collaborative set to move therapy forward. Consequently, we recommend that a combination of self-report inventories and individual interviews be used to assess content information, and that conjoint interviews be focused on assessment of process. A structure for an initial interview which illustrates the combination of process and content assessment is outlined in Table 1. The session begins with a brief conjoint interview in which the agenda for the session is negotiated. At the beginning the therapist should ask the couple an open-ended question about the reasons they are seeking assistance. When posing the question it is often helpful for the therapist to get eye contact with both partners, and then look at a point midway between the partners as the question is finished. The goal at this point is to establish if the couple can collaborate and conjointly tell a coherent story about their relationship problems. If each partner allows the other to speak, and there is mutual respect, then a conjoint intake interview may be possible. More commonly, in couples with relationship problems, the response to this initial probe is escalating conflict in the session, with each partner being blaming and negative toward the other. The therapist should intervene promptly to stop such escalation. The therapist also needs to note that the couple need to develop a mutually acceptable way of talking about their problems if therapy is to proceed successfully. Table 1 Structure of couples initial interview. Initial orientation (10 minutes) Introduction Present structure of session Ask for a brief/joint statement of problem Individual interviews (30 minutes each) Current status of relationship Sources of difficulty Specific areas: behavior changes for self/partner communication time use sex external stressors individual problems domestic violence separation commitment Joint session (20 minutes) Review individual material Describe behavioral couples therapy approach Review suitability of behavioral couples therapy Logistics of therapy

The second phase of the intake interview is then done with each individual partner, covering the key areas identified in Table 1. The goal in this phase is to identify key areas of concern, and to establish an empathic relationship with each partner. The third phase brings the couple back together again. In the third phase the therapist summarizes the key concerns identified by each partner. These summaries need to express the concerns in a manner consistent with the experience of each partner, and in a manner that allows mutual agreement that particular areas need attention. For example, the therapist might describe areas of disagreement as identified areas requiring further negotiation. Both partners can agree these are issues that they need to resolve. Table 2 is a summary of key areas of relationship problems which need assessment, and some useful assessment instruments for each of those areas. The process of assessment typically involves each partner completing the various self-report inventories and behavioral monitoring tasks between therapy sessions. The therapist reviews and discusses the information each partner provides. In addition, the therapist often sets the couple particular tasks within sessions. A common assessment procedure is to have couples undertake one or more communication tasks, such as discussing a source of disagreement within the relationship. This is best done with the therapist outside the room observing via one-way screen or videorecording where available. The goal is to assess how the couple communicate and manage conflict. Further detail on these assessment tasks are available in O'Leary (1977), Baucom and Epstein (1990), and Halford (in press). The assessment process is more than just passive collection of information. In the process of assessment the therapist is working with the partners to develop an agreed on concept of the relationship problems which facilitates change. The completion of assessment tasks often prompts each partner to consider aspects of their relationship in new ways. For example, as noted earlier, many partners in distressed relationships attribute the causes of their relationship problems to their partner, and feel powerless to change the things that distress them. In a version of the Areas of Change Questionnaire (Weiss & Halford, 1995), each partner is asked to identify behaviors they personally need to change to enhance their relationship. Just posing the question of selfchange in a structured way can help the person to generate change ideas. Similarly, the experience of a communication assessment task can prompt partners to identify aspects of their own communication behavior they wish to change.

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Couples Therapy Table 2 Key areas of assessment for couples therapy. Area

Example measure

Explanation

Relationship satisfaction

Dyadic Adjustment Scale (Spanier, 1976): 31-item selfreport inventory

Level of distress, global evaluations of relationship

Divorce potential

Marital Status Inventory (Weiss & Ceretto, 1980); a 14-item rating scale

Steps toward separation, high steps predict poor prognosis

Behavior exchange

Areas of Change Questionnaire (Weiss & Perry, 1983); 34 items rating extent of requested behavior change by a partner

Current patterns of daily interaction, identify behavior change preferences of each client

Communication and conflict management

The most common presenting concern, and a key area requiring attention in much couples therapy

Aggression and violence

Conflict Tactics Scale (Strauss, 1979)

Verbal, psychological, and physical aggression between partners

Relationship standards and beliefs

Baucom et al. (1996)

The expectations partners have of each other and relationships. Often unrealistic beliefs can be a source of relationship problems

The assessment process needs to move couples stuck in a partner-blaming focus for distress to a relationship focused view of the problems. Ultimately the goal is to have each partner take responsibility for self-directing personal change to enhance the relationship (Halford et al., 1994).

6.28.5.3 Cognitive-behavioral Couples Therapy Based upon the premise that a relationship is defined by the exchange of behaviors between partners, CBCT began as the application of behavioral contracting to the treatment of relationship problems. Couples were trained to monitor their partners' behavior and, based on such assessments, contingency contracts were developed to reduce displeasing and increase pleasing behaviors within the relationship (e.g., Azrin, Naster, & Jones, 1973; Stuart, 1969; Weiss, Hops, & Patterson, 1973). Such contracting initially stressed tightly structured quid pro quo agreements, in which spouses were taught systematically and immediately to reward desired behavior from the partner (Azrin et al., 1973; Stuart, 1969). This was later replaced by unilateral ªgood faithº contracts in which partners were asked to undertake positive change for the good of the relationship (e.g., Gottman, Notarius, Markman, & Gonso, 1976; Weiss, Birchler, & Vincent, 1974). Subsequently, emphasis has been placed on each partner actively seeking out information in

order to self-select and implement self-change goals to enhance the relationship (Halford et al., 1994; Weiss & Halford, 1995). Although the details of the procedures have been refined, an emphasis on changing relationship behaviors remains an important element of how CBCT attempts to alter couples' adaptive processes. In Table 3 some of the key behaviors identified as promoting long-term satisfying relationships are identified. In couples therapy partners are helped to self-identify behaviors that they wish to change within these different domains to enhance their intimacy with their partner. There are several ways of doing this. For example, partners can be asked to self-monitor behaviors within a given class and then to identify behaviors they wish to increase in that domain. A second example is the Caring Days Exercise (Weiss & Halford, 1995). In this procedure each person is encouraged to identify some small specific behaviors which they can do which demonstrate caring for their partner. To enhance their ability to self-select appropriate caring behaviors, partners can be assisted to be more creative in generating ideas. For example, to enhance creativity people can brainstorm ideas, they can ask their partner what would demonstrate caring effectively to them, they can ask friends about caring behaviors that they engage in within their relationships, they can observe others demonstrating caring in their normal day-to-day lives, or they can read through checklists of ideas and suggestions provided by the therapist. The self-regulatory

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focus encourages each person to take individual responsibility for being creative in identifying behaviors that they will engage in and to set themselves tasks of implementing behavioral changes. A second element of CBCT is communication and problem-solving skills training. These skills are conceptualized as providing couples with the means to enhance intimate communication and resolve their current and future sources of conflict (Jacobson & Margolin, 1979; Notarius & Markman, 1994). In most applications of CBCT the communication skills targeted in training have been identified by the therapist based upon contrasting the couple's current communication with a model of adaptive marital communication. The models of adaptive marital communication were derived, in large part, from research contrasting the communication behaviors of maritally distressed and nondistressed couples in problem-solving interactions within research laboratories (see Weiss & Heyman, 1990, 1997, for reviews of this literature). Often CBCT would teach couples a relatively fixed curriculum of skills (e.g., paraphrasing, asking open-ended questions, behavioral pin-pointing), based on the assumption that each of these skills were adaptive as communication skills. Research shows that there is no clear relationship between the use of particular, specific communication behaviors (e.g, para-

phrasing, minimal encouragers) and relationship problems (Halford et al., 1990, 1993). Rather, it seems that there are a few broad classes of adaptive relationship communication behaviors, such as validation (active, positive listening to partner) and positive engagement, and use of any of a wide variety of behaviors within these broad classes is associated with improvements in relationship problems (Sayers, Baucom, Sher, Weiss, & Heyman, 1991). The specific behaviors within the broad classes which are functional vary across relationships, time and settings (Halford, Gravestock, Lowe, & Scheldt, 1991). In other words, different communication styles suit different relationships and circumstances, but we can be reasonably confident that an adaptive communication style will need to involve validation and positive engagement. Furthermore, successful couples do not always use these skills after intervention, but do so when needed (Hahlweg & Markman, 1996). A crucial skill in couple interaction is management of negative affect. In successful long-term relationships, partners must both be able to manage their own negative feelings and respond constructively to their partner's negative feelings (Markman, Stanley, & Blumberg, 1944). One negative interaction erodes the effect of 5±10 previous positive interactions (Notarius & Markman, 1994), so preventing destructive negativity is crucial.

Table 3 Classes of behavior most strongly related to marital satisfaction. Class of behavior

Examples

Affection

Saying ªI love youº Giving a hug or kiss Enjoying a shared laugh or joke Saying they enjoy partner's company

Respect

Listening to the partner's opinion Telling partner of admiration/respect Showing confidence in partner's abilities Introducing partner to others with pride

Support

Doing errands for partner Making self available to do work for partner Asking partner about their day Doing something to save partner time/energy

Communication of ideas

Telling partner about their day Discussing topical events Giving an opinion Talking about mutual interest(s)

Shared quality time

Spending an hour or more just talking Work together on a project Take a drive or walk Go out together, just the two of you Discuss personal feelings

Couples Therapy Applying the self-regulation approach to communication skills, each partner is assisted to self-select goals for changing his or her own communication, and to self-evaluate his or her own communication. For example, clients review their own couples discussions (e.g., an audiotape of a conversation at home on a difficult topic) with the therapist in sessions, with partners each focusing on their own communication. This maintains the therapeutic focus on what the client can change (i.e., his or her own behavior). Based on the assumption that adaptive marital communication is defined by its functional impact within the relationship, self-directed attempts at changes in communication are seen as behavioral experiments. Consequently, when a partner makes a change in communication that produces a negative outcome (e.g., making an assertive rather than aggressive request for change by the partner when discussing a particular issue elicits verbal abuse from the spouse), this shows that assertion was not adaptive in this context, and a different approach is needed. A third element of CBCT is altering subjective experience of relationship interaction. Although CBCT always included recognition of the importance of internal mediators of external experience (Weiss, 1984), more recent developments have placed greater emphasis on cognitive and affective change strategies. Many of these strategies apply standard cognitive therapy procedures to relationship problems. For example, self-instructional strategies are used to modify negative attributions (Baucom & Lester, 1986) or control anger (Schindler & Vollmer, 1984), and guided discovery, Socratic dialogue and behavioral experiments are used to challenge irrational relationship beliefs (Baucom & Epstein, 1990; Halford, in press). The greater emphasis on changing subjective experience in CBCT is particularly evident in recent changes in managing destructive conflict within distressed couples. Earlier versions of CBCT emphasized teaching communication and problem-solving skills to reduce conflict. More recently, emphasis has been placed on exploring with each partner the attributions, meaning, and significance attached to the issues which are sources of conflict (e.g., Christensen et al., 1995; Weiss & Halford, 1995). While there are variations in the details of the therapeutic process used by different authors, the common emphasis is on altering how partners respond to behaviors of their spouses which they dislike. Christensen et al. (1995) describe the goal of this process as promoting acceptance, which they define behaviorally as the reduction of attempts to get the other person to change. In essence, there is an attempt to balance a combination of

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behavior change to alter relationship interaction and change in the subjective experience of existing relationship interactions. The CBCT approach to relationship dissatisfaction usefully can be summarized within an extension of the self-regulation framework proposed by Halford et al. (1994). Subjective dissatisfaction with your relationship can be responded to in one of five ways. First, you can alter the ways in which you attempt to persuade your partner to change, so that you get change. Second, you can alter your own behavior to enhance relationship functioning. These first two options were the focus of traditional behavioral couples therapy, producing behavior change through procedures such as behavioral contracting and negotiation. Third, you can alter your own subjective response to negative aspects of relationship interactions so that those aspects are less stressful and you feel no pressing need for change. This is what Christensen et al. (1995) call acceptance. Fourth, you can decide that particular existing behaviors are unacceptable, intolerable, and unchangeable, and that you will therefore leave the relationship. Finally, you can do nothing, and maintain the status quo. In our experience few clients have explored all these options for individual action.

6.28.5.4 The Effectiveness of Cognitivebehavioral Couples Therapy CBCT consistently has been shown to be superior to no treatment or therapist contact control conditions in reducing marital distress (Hahlweg & Markman, 1988; Markman & Hahlweg, 1993). More specifically, CBCT improves couples' communication skills, reduces destructive conflict, enhances positivity of day-to-day interactions, and increases the positivity of couples' cognitions about their partners and their relationships (Hahlweg & Markman, 1988; Halford et al., 1993). In other words, CBCT is effective in changing the key identified risk factors for marital distress. Among couples who present for couples therapy, the negative effects of relationship distress usually are already evident (Bloom, 1985). For example, alcohol abuse and depression are common in partners seeking marital therapy, as are behavior problems in the couples' children (Halford, Kelly, & Markman, 1997). These individual problems often result from the prolonged effects of marital distress, and make marital therapy less effective (Halford & Bouma, 1997). Furthermore, patterns of dysfunctional marital interaction typically become entrenched over time and resistant to change (Markman, Floyd, Stanley, & Storaasli,

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1988; Raush, Barry, Hertel, & Swain, 1974). Eventually there is erosion of any positive affect toward the spouse, which is predictive of very poor response to couples therapy (Hahlweg, Schindler, Revenstorf, & Brengelmann, 1984). Approximately 25±30% of couples show no measurable improvement with CBCT, and as many as a further 30% improve somewhat from therapy but still remain significantly maritally distressed after treatment (Bray & Jouriles, 1995; Halford et al., 1993; Jacobson, 1989; Jacobson et al., 1984). Even among those couples who initially respond well to CBCT, there is substantial relapse toward marital distress over the next few years (Jacobson, Schmaling, & Holtzworth-Munroe, 1987; Snyder, Mangrum, & Wills, 1993; Snyder et al., 1991a). The consistent finding is that the longer couples have been maritally distressed, and the more severe their relationship dissatisfaction, the poorer their response to marital therapy (Whisman & Snyder, 1997). The effectiveness of CBCT relative to other approaches to couples therapy is unclear. There are relatively few studies which compare approaches to couples therapy (Snyder et al., 1991a). One study compared insight-oriented and behavioral marital therapies. The findings were that each treatment was effective, with few significant differences in effects of the treatments in the short term (Snyder & Wills, 1989). At four-year follow-up the insight-oriented therapy was associated with lower rates of divorce and higher rated marital satisfaction than the behavioral marital therapy (Snyder et al., 1991a). However, this study has been the source of considerable controversy (Jacobson, 1991; Snyder et al., 1991b). A major criticism of the study was that the so-called insight-oriented therapy was not really psychodynamic in approach, but rather represented state of the art CBCT (Jacobson, 1991). An important index of the value of couples therapy is the satisfaction of clients with the service they receive in that therapy. The magazine Consumer Reports, which is very widely read in the US, has its readers complete a survey every year. In one survey they asked about satisfaction with psychotherapy, including couples therapy. The results were very positive in terms of the effects of psychotherapy from the consumers' point of view. However, consumers expressed less satisfaction with couples' counseling than any other form of therapy. From one perspective, this makes the field of couples' counseling look ineffective. However, when one thinks about the goals of couples therapy, it actually makes sense that there will be less satisfaction from the consumers' point of view. Often one or sometimes

both partners in couples therapy are using the therapy as a way of exiting the relationshipÐ leaving the hurt spouse on the therapist's doorstep. Some marital therapists describe how a spouse who is interested in leaving the relationship often brings in the other spouse with the hope that the therapist will help wean the more committed spouse from the marriage and ease the break-up of the relationship. In a survey of therapists conducted with practitioners in Colorado in the US (Stanley, Lobitz, & Markman, 1989), couples' therapists were asked to indicate the percentage of couples who were significantly improved or not improved, how many of the couples seen in the practice were still together, and how many decided to end their relationship. The results indicated that about 33% of the relationships ended in separation or divorce. Interestingly, the therapists rated 80% of these relationships that ended in divorce as a successful outcome. The Consumer Reports survey suggests that this 80% probably did not rate the therapy as a success from their own perspective (Seligman, 1995). Consumer satisfaction with couples therapy may be low because people unrealistically expect therapy to persuade their partners to stay with them.

6.28.5.5 Couples Therapy and Psychological Disorder Couples therapy can be useful in the treatment of individual psychological disorders, either as the entire treatment or as an adjunct to individual treatment. More specifically, there have been a number of studies evaluating couples therapy and its effects on depression and alcohol abuse. In this section we evaluate this evidence. As noted previously, people with co-existing marital problems and depression often do not respond well to traditional individual therapies for depression. Beach and O'Leary (1986) and Jacobson, Dabson, Fruzetti, Schmaling, and Salusky (1991) showed that CBCT was effective in reducing both marital distress and depression where wives were depressed and the couples were maritally distressed. Individual cognitive therapy also was somewhat effective with these clients, but not as effective as CBCT (Beach & O'Leary, 1986; Jacobson et al., 1991). Of particular interest was Jacobson's finding that, while both CBCT and cognitive therapy were helpful, adding cognitive therapy to CBCT did not enhance outcome. In Jacobson's study the treatment conditions were matched for total hours of therapy contact. As a consequence the combined condition got less CBCT than the

Couples Therapy CBCT alone condition, and this may explain why the combined treatment condition did not do as well. The Jacobson et al. (1991) study highlights that couples therapy should not be used for all presentation for depression by married clients. For depressed clients where there was no marital distress, individual cognitive therapy was superior to couples therapy in its effect on depression. Even when relationship problems and depression coexist there is a need to make careful judgments as to when couples therapy is most helpful. In couples where the individual depression is severe, the marital problems postdated the onset of depression, and neither partner attributes the cause of the depression to the marital problems, then marital therapy seems less effective than individual therapy (Jacobson et al., 1991). On the other hand, where the marital problems antedate the depression, the marital problems are severe, and the source of the depression is attributed by at least one of the partners to the marital problems, then marital therapy seems to be the treatment of choice (Jacobson et al., 1991). There is a large body of literature attesting to the value of various forms of couples therapy in the treatment of alcohol problems. The best established approach is the use of CBCT to complement individual therapy in the treatment of alcohol abuse. In the case of people with heavy dependence on alcohol, there has been successful use of conjoint contracting to promote use of antebuse (an oral drug which induces severe illness if alcohol is consumed) to establish abstinence (O'Farrell & Bayog, 1986). Once sobriety is established, conjoint couples therapy when used in combination with ongoing use of antabuse promotes both improvements in relationship satisfaction and enhanced maintenance of drinking control (O'Farrell, Cutter, Choquette, Floyd, & Bayog, 1992; O'Farrell, Cutter, & Floyd, 1985). When CBCT is combined with relapse prevention training, there is even better maintenance of reduced alcohol consumption (O'Farrell, Choquette, Cutter, Brown, & McCourt, 1993). Furthermore, there is also a substantial reduction in the prevalence of marital violence after CBCT, at least in those couples with mild to moderate severity of violence (O'Farrell & Murphy, 1995). There are two significant limitations on the evidence of the impact of couples treatments for problem drinking. First, all successful trials have used antabuse, and the effectiveness of CBCT without antabuse is unclear. Second, up to 50% of men in alcohol treatment refuse offers of couples-based treatment (O'Farrell, Kleinke, Thompson, & Cutter, 1986). This may be associated with more general reluctance of

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many people who abuse alcohol to accept treatment. Partners of male problem drinkers often present to treatment agencies reporting that their partners refuse to seek treatment (Halford & Osgarby, 1993). The frequent unwillingness of the person abusing alcohol to accept help, with consequent strains on the relationship and individual distress, have prompted the development of therapies to assist the spouses of heavy drinkers. For example, Sisson and Azrin (1986) and Thomas and Ager (1993) both developed therapies aiming to help clients reduce the negative impacts of their partner's drinking. Both these programs were aimed at teaching women to manage stress associated with their husbands' drinking and to encourage the men to seek individual therapy (Sisson & Azrin, 1986; Thomas & Ager, 1993). These programs do assist the women to reduce their individual distress, and there is some evidence that these approaches can increase the chance of the male drinker presenting for individual treatment (Halford, Price, Bouma, Kelly, & Young, 1998; Sisson & Azrin, 1986; Thomas & Ager, 1993). Some programs for the wives of male problem drinkers were also aimed at helping the women to influence the men to reduce drinking. For example, Sisson and Azrin (1986) described helping women to identify high-risk settings for problem drinking, and suggested that wives schedule activities incompatible with drinking for high-risk times. Partners have also been encouraged to praise sobriety, and not to inadvertently reduce the negative consequences of drinking (e.g., by refusing to ring your partner's supervisor to say your partner is sick when he really has a hangover). Similar strategies were used by Halford et al. (1998). The only systematic evaluation of this approach was in the Halford study, which found that these strategies had little impact upon the drinker's alcohol consumption. The degree to which women actually implemented the suggested strategies was not evaluated, so it is unclear if women were unconvinced to implement the suggestions or if women changing these behaviors had little effect on the men's drinking. In summary, CBCT is a well-established treatment for relationship problems which has demonstrated efficacy. CBCT is also very useful in the treatment of depression and alcohol problems of adults in committed relationships. However, common to all applications of CBCT and other approaches to couples therapy is a substantial input of time from therapists and couples. As described in the research and clinical literature, couples therapy typically involves anything from 12 to 30 sessions of conjoint therapy (e.g., Baucom & Epstein, 1990;

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Greenberg & Johnson, 1988; Snyder et al., 1991a; Weiss & Halford, 1995). The time commitment and costs involved in all these approaches probably are a major disincentive to couples to seek assistance; only a small minority of distressed couples ever seek out therapy (Sanders, 1995; Wolcott & Glazer, 1989). Thus, even if CBCT were optimally effective for those who present for therapy, it would have modest impact on the community prevalence of relationship problems. This has led to attempts to prevent relationship problems. 6.28.6 PREVENTION OF RELATIONSHIP PROBLEMS 6.28.6.1 Prevention and Early Intervention Programs to prevent relationship problems vary greatly along several dimensions, including the phase of the relationship at which they are targeted, the settings in which they are offered, the number and duration of sessions, the level of training of the service providers, the extent to which didactic vs. experiential forms of learning are emphasized, and the amount of group vs. dyadic interaction that occurs (Guerney, Guerney, & Cooney, 1985; Levant, 1986; Van Widenfelt, Markman, Guerney, Behrens, & Hosman, 1997). Existing programs can be usefully classified into two broad categories: (i) counseling and educational programs (e.g., Mace & Mace, 1976; Rutledge, 1968), and (ii) skill acquisition and cognitive restructuring programs (e.g., Guerney, 1977; Markman, 1984; Markman, Floyd, Stanley, & Lewis, 1986). Programs are based on a wide range of theoretical perspectives including social learning theory, Rogerian theory, and systems theory (Bradbury & Fincham, 1990). Regardless of theoretical orientation, all programs include efforts aimed at improving communication and problem-solving, negotiation of roles and responsibilities, clarification of values and expectations, sexuality and intimacy, developmental changes and transitions (e.g., parenting), and awareness of relationship dynamics. The rationale for skills-based prevention of relationship problems is that acquisition of crucial relationship competencies are presumed to prevent problems. As noted earlier, research has identified these crucial competencies to include constructive communication and problem-solving skills, management of negative affect and conflict, realistic relationship beliefs and expectations, and promotion of positive behavior exchange (Markman, 1984; Notarius & Vanzetti, 1984). Programs designed to improve couples' abilities in these areas have been conducted both with couples planning

marriage (e.g., Markman, 1981; Halford et al., 1994) and with married couples not experiencing relationship distress (e.g., Guerney, 1977; Miller et al., 1975). Skills training prevention programs do increase couples' communication and problemsolving skills (Hahlweg & Markman, 1988; Markman et al., 1988; Miller, Nunnally, & Wackman, 1975). In their meta-analysis of controlled trials of such interventions, Hahlweg and Markman (1988) found an effect size of 1.51 on communication skills. Given that an effect size of 0.8 is generally considered a large effect size, this is a very impressive result. Couples in prevention trials are, by definition, currently satisfied with their relationships. Consequently, it is unlikely that prevention programs could produce large, immediate increases in relationship satisfaction above the pre-existing high levels. Consistent with this interpretation, Hahlweg and Markman (1988) report a mean effect size across seven premarital programs of 0.51 on relationship satisfaction, which is still a moderate size effect. Over time many couples show declines in relationship satisfaction (Markman & Hahlweg, 1993), and the real test of prevention programs' effectiveness is whether the onset of relationship problems can be prevented. A significant methodological problem associated with evaluating prevention programs is devising appropriate comparison conditions for longterm controlled trials. If couples are randomly assigned to a no-intervention control when they desire intervention, they may seek intervention outside the study. On the other hand, failure to randomly assign to conditions can make interpretation of results difficult. Perhaps because of these difficulties few studies have assessed long-term outcome. A survey of 85 couple and family prevention and enrichment studies found that only 40% included follow-up measures at some point after post-test (mean follow-up was 12 weeks), with the longest follow-up assessment occurring at 12 months (Giblin, Sprenkle, & Sheehan, 1985). Only Markman and co-workers (e.g., Markman et al., 1988; Markman, Renick, Floyd, Stanley, & Clements, 1993) have reported follow-up data beyond two years. Markman and co-workers found that skillsbased marital distress prevention programs reduce marital violence (Markman et al., 1993), and the prevalence of marital separation and divorce over the first 5±10 years of marriage (Markman et al., 1993). However, these series of studies have a methodological problem. Subjects initially were recruited for a long-term follow-up study of marriage, and subsequently randomly assigned subjects to matched groups

Prevention of Relationship Problems to be offered, or not offered, an intervention. Sixty percent of couples offered the relationship preparation program declined to participate. The two treatment conditions consist of those who accepted the program and their matched controls. As the treatment group were selfselected for agreeing to participate in the program, and the matched controls were not offered the program, there is confound between the conditions of self-selection. Despite the limitations of the existing research, it is clear that skills-based prevention programs do modify aspects of couples' adaptive processes which are identified risk factors for relationship problems. The long-term maintenance of these behavioral changes needs further investigation, as do the long-term effects of these interventions on relationship problems, but preliminary results are encouraging. 6.28.6.2 Content of Prevention Programs The content covered in skills-based prevention programs can be usefully considered as falling into six modules: (i) behavior exchange and positive intimacy enhancement, (ii) communication skills enhancement, (iii) management of conflict and negative affect, (iv) sexual enrichment, (v) gender role flexibility, and (vi) adaption to life transitions and maintenance of relationship satisfaction. We will consider each of these in turn. Behavior exchange and positive intimacy enhancement procedures have been adapted from those used in couples therapy. As for therapy, the emphasis is on each partner selfselecting behavior change goals which enhance relationship functioning. In prevention programs this is often much easier to achieve than in therapy. In therapy, couple's negative feelings toward each other and possible ambivalence about the relationship often inhibit partners from making relationship enhancing efforts. Prevention program couples, by definition, have positive feelings about their partner and relationship. Communication skills training involves individuals self-selecting goals for enhancing their own communication from an array of available skills and self-evaluating their own communication. This can be done by asking the couple to have a discussion. Immediately after the discussion both partners are asked to self-assess their communication using a checklist of potentially helpful communication behaviors set out on the form in Table 4. After completing the form, partners self-identify specific communication behaviors that each would like to increase in their repertoire in order to enhance their communication. This does not mean that

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the leader avoids responsibility for helping the partners to determine goals. Rather, the role of the leader is to help both partners to accurately self-evaluate their current communication and to develop specific, self-selected goals for enhancing communication. Another exercise often used in communication skills training is to ask the couple to have a discussion at home which they audiotape. At the end of the discussion both partners self-evaluate their communication skills, formulate selfchange goals, and then repeat the conversation building on the selected communication skills. Each partner then evaluates the impact of changing communication skills on the communication process. This procedure allows the partners to directly test the hypothesis that changing their communication behaviors in a particular way will enhance the relationship communication process. It also has the partners practice active self-correction of ineffective communication attempts. Communication tasks that we recommend in relationship enhancement initially focus on nonconflictual topics. For example, we emphasize to couples the importance of discussing dayto-day occurrences on a regular basis, so as to keep informed and interested in the experiences of your partner. Consequently, we usually ask couples to have a series of discussions about what each does during the time they are apart. We also ask the couple to address ways in which they can support and show interest in each other's interests. This support might be in work, parenting, household chores, or in particular interests or hobbies. The relevant communication task is for one partner to initiate a conversation with their spouse about the spouse's interests and needs. Both partners are asked to identify ways in which they might be more supportive. Conflict management is another important element of prevention programs. Once couples have a reasonable level of communication skills, they can then use these communication skills to handle difficult conflictual issues. In discussion of conflict management we describe the different settings in which conflictual topics may be discussed, and the fact that there are some settings in which it is easier to have a productive discussion than others. Couples are asked to consider the times, places, and circumstances in which they could most productively talk about topics which are difficult. Also couples are educated about the common maladaptive patterns in interaction around conflictual topics, such as the demand-withdraw and mutual avoidance patterns. Couples self-select goals which will help them to avoid those unhelpful patterns of interaction.

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Relationship Problems Table 4

Communication skills self-evaluation form.

Name:

Date:

The aim of this form is for you to identify your strengths and weaknesses in communication and to specify goals for improvement. Rate each of the skills below using this code: 0 Ð 1 Ð 2 Ð 3 Ð N/A Ð

Skill

Very poor use of skill Unsatisfactory use of skill Satisfactory use of skill, but room for improvement Good use of skill Not applicable

0

1

2

3

N/A

Specific descriptors Self-disclosure Clear expression of positives Assertive expression of negatives Attending to partner Minimal encouragers Reserving judgement Asking questions Summarizing content Paraphrasing feelings

Self-identified strengths in communication:

Self-identified weaknesses in communication:

Another useful notion in relationship preparation programs is the idea of relationship rules for managing conflict. Relationship rules refer to the implicit assumptions and processes which couples develop for handling conflict. For exmple, some couples may believe that either partner should be able to raise any issue

that is troubling them at any time. Other couples may feel that there is some responsibility to raise difficult issues at times and in places which maximize the chance of productive discussion. Table 5 lists some common relationship rules that couples may apply to managing conflict. Through discussion and negotiation couples

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Prevention of Relationship Problems can be asked to agree on relationship rules that increase their chance of managing conflict effectively. Sexual enrichment is also an important element of many prevention programs. We make use of the widely available video tape The lovers guide. We would play this to couples, ask them to talk about their general reactions as a group, and then have the couples talk together in privacy about any goals they may wish to set in order to enhance their sexual experience. The video that we show is very sexually explicit, demonstrating ways in which one can enhance sensual and sexual pleasure, and identifies and describes some common sexual difficulties. We find that showing this tape is useful in helping couples to talk intimately about their desires to enhance their sexual relationship. Gender role flexibility is another element of some prevention programs. Gender role flexibility refers to each partner taking some responsibility for a wide range of relationship maintaining activities, and transcending very rigid or traditional gender-based definitions of responsibilities. The notion of gender role flexibility can be introduced by asking both partners to identify which of a range of different behaviors, which potentially can be stereotyped as belonging to a woman or a man, they take responsibility for within the relationship. The potential value of being flexible in gender roles is in helping the couple adapt to changing life circumstances. For example, if both partners are able to earn an income, then the couple can adapt better if one person has difficulty obtaining work. Partners can be helped to self-identify

specific behavior changes they wish to make in order to become more gender role flexible. For example, males may set themselves the target of learning to cook better, and women to learn how to maintain a car. An additional rationale for this process is that often the domestic responsibilities in families fall primarily on women, and this is a major source of relationship dissatisfaction for women. We point out to our male participants that women initiate approximately three-quarter of all divorce proceedings (Wolcott & Glezer, 1989). If men want to remain in happy relationships, then they need to ensure that they are domestically competent to contribute to the household. In relationship preparation and enhancement programs it is important that couples prepare themselves for future changes in their relationship likely to result from major life transitions (Hahlweg & Markman, 1993). In one such exercise couples complete an adapted form of the life change event scale and are asked to rate the likelihood of these events occurring in the next one or two years and the probability that if those events occur they might have a negative effect on their relationship. For example, couples are asked to identify the ways in which events such as birth of a child, loss of a job, or a change of work circumstances might impact on their relationship. Partners are asked to selfselect goals that they believe would help them adapt in a relationship-maintaining way to these life transitions. For example, a number of couples have identified that they may have reduced opportunities for having time together as a couple once they have children. They have

Table 5 Suggested ground rules for handling conflict. 1.

We can bring up issues at any time, but the ªlistenerº can say ªthis is not a good timeº If listener does not want to talk at that time, he or she takes responsibility for setting up a time to talk in the near future (you need to decide on how ªthe near futureº is defined)

Yes

No

When conflict is escalating we will call a ªstop actionº and (i) try it again, using the speaker/listener technique, (ii) agree to talk later at a specified time about the issue, using the speaker/listener technique

Yes

No

When we are having trouble communicating we will ªengagerº the speaker/listener technique

Yes

No

When using the speaker/listener technique, we will completely separate problem-discussion from problem-solution

Yes

No

5.

We will have weekly ªcouple meetingsº (you should set up a time now)

Yes

No

6.

We will state when we have a problem, if we want to negotiate a relationship, or just solve the immediate problem

Yes

No

2.

3. 4.

Source: Markman, Stanley, and Blumberg (1995).

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then set individual goals, such as ensuring child minding is available or that they cultivate activities they can do at home, which increase the chance of having mutual shared enjoyable activities when they have young children. In Table 6 we have set out the typical content of each of five 2 hour group sessions of a relationship preparation program. This is not a rigid schedule that must be followed, but rather a schematic representation about how a group might work. Sessions can be combined and homework resequenced to cover the same content in a full day, with one or two followup sessions.

6.28.7 CONCLUSIONS Relationship difficulties are very common, and have a huge impact on adults and their offspring. The most common relationship problems are lack of relationship satisfaction, ambivalence about the future of the relationship, and problems in the adaptive interactional processes between partners. In the domain of the adaptive processes between the partners the most important factors contributing to relationship problems are poor communication, poor management of negative affect and conflict, unrealistic beliefs and expectations, and lack of

positive shared experiences. Other important contributors to relationship problems are enduring vulnerabilities of the partners, such as individual psychological disorders and stressful life events. Couples lacking robust adaptive couple processes are likely to develop relationship problems when challenged by major life transitions and stressful events. Cognitive-behavioral couples therapy is a well-established and effective means of helping many couples with relationship problems. Effective couples therapy uses the assessment process to help partners build a shared and constructive model of their relationship problems, and to define individual action that can improve the relationship. Therapy itself assists partners to self-direct a change process focused on enhancing positive exchange between partners, improving communication, and controlling destructive conflict. Adaptions of these procedures have been used successfully to teach currently satisfied couples to enhance their relationship and to prevent future relationship problems.

ACKNOWLEDGMENTS Preparation of this chapter was supported by an Australian Research Council Grant on

Table 6 Overview of typical content in a five session premarital skills training program. Session

Detail of content

1

Introduction to group members; explain rationale for self-directed, skills training focused group program; identification of key behavioral domains promoting relationship intimacy; self-directed intimacy enhancement through self-directed goal setting and definition of homework task of behavior change; identification and modeling of key communication skills to enhance intimacy

2

Review of intimacy enhancement behavioral homework tasks; self-directed selection of further behavior change goals; review of key communication skills; guided self-evaluation of current communication skills; self-directed selection of communication enhancement goals and practice of implementation of those skills; self-directed goal setting and definition of homework task to enhance communication

3

Review of communication homework tasks, and self-directed further goals selection and definition of further homework task; introduction to the concept of the patterns of conflict and effective conflict management; negotiation with partner about relationship rules for managing conflict; self-directed goal setting for effective management of conflict; introduction to the concept of flexible gender roles, couple review of current gender roles, self-directed goal setting for future gender role flexibility

4

Review of communication homework task; review of the role of sexuality in relationship intimacy; couple discussion and goal setting to enhance sexual intimacy; introduction to the concept of partner support, self-directed goal setting to enhance partner support; self-directed definition of homework tasks to implement selected goals in areas of sexuality or partner support

5

Review of homework tasks; self-directed selection of any further goals to enhance relationship functioning; introduction of issue of maintenance of relationship functioning; self-directed identification of future life events impacting upon relationship; planning to promote relationship adaptation to predictable life events Closure

References ªPrediction and prevention of marital distressº to the first author. Thank you to Rhoda Richardson, Kathy Eadie, and Amanda Thomas for help with manuscript preparation.

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Contractual models for negotiation training in marital dyads. Journal of Marriage and the Family, 36, 321±330. Weiss, R. L., & Cerreto, M. S. (1980). The Marital Status Inventory: Development of a measure of dissolution potential. American Journal of Family Therapy, 8, 80±85. Weiss, R. L., & Halford, W. K. (1995). Managing couples therapy. In V. Van Hasselt & M. Hersen (Eds.), Sourcebook of psychological treatment manuals for adult disorders (pp. 312±341). New York: Plenum. Weiss, R. L., & Heyman, R. (1990). Marital distress and therapy. In A. S. Bellack, M. Hersen, & A. Kazdin (Eds.), International handbook of behavior modification (2nd ed., pp. 475±502). New York: Plenum. Weiss, R. L., & Heyman, R. (1997). A clinical-research overview of couples' interactions. In W. K. Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples therapy (pp. 13±42). Chichester, UK: Wiley. Weiss, R. L., Hops, H., & Patterson, G. R. (1973). A framework for conceptualizing marital conflict: A technology for altering it, some data for evaluating it. In L. A. Hamerlynck, L. C. Handy, & E. J. Marsh (Eds.), Behavior change: Methodology, concepts, and

practice (pp. 309±342). Champaign, IL: Research Press. Weiss, R. L., & Perry, B. A. (1983). The spouse observation checklist. In E. E. Filsinger (Ed.), A source book of marriage and family assessment. Beverly Hills, CA: Sage. Weissman, M. M. (1987). Advances in psychiatric epidemiology: Rate and risks for major depression. American Journal of Public Health, 77, 445±451. Whisman, M. A., & Snyder, D. (1997). Evaluating and improving the efficacy of conjoint couple therapy. In W. K. Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples interventions (pp. 679±694). Chichester, UK: Wiley. Widom, C. S. (1989). Does violence beget violence? A critical examination of the literature. Psychological Bulletin, 106, 3±28. Wolcott, I., & Glazer, H. (1989). Marriage counselling in Australia: An evaluation. Melbourne, Australian: Australian Institute of Family Studies. Zimmer, D. (1983). Interaction patterns and communication skills in sexually distressed, maritally distressed, and normal couples: Two experimental studies. Journal of Sex and Marital Therapy, 9, 251±266.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.29 Eating Disorders ANITA JANSEN Universiteit Maastricht, The Netherlands 6.29.1 INTRODUCTION

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6.29.2 ANOREXIA NERVOSA

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6.29.3 BULIMIA NERVOSA

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6.29.4 OBESITY AND BINGE EATING DISORDER

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6.29.5 ATYPICAL EATING DISORDERS

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6.29.6 DIFFERENTIAL DIAGNOSES AND COMORBIDITY 6.29.6.1 Differential Diagnoses 6.29.6.2 Comorbidity 6.29.7 PREVALENCE AND PROGRESS

653 653 654 654

6.29.8 ETIOLOGY 6.29.8.1 Genetics 6.29.8.2 Childhood Sexual Abuse 6.29.8.3 Dieting for the Perfect Figure 6.29.8.4 Serotonin Depletion 6.29.8.5 The Learned Nature of Binge Eating 6.29.8.6 Dysfunctional Cognitions 6.29.9 TREATMENT 6.29.9.1 Anorexia Nervosa 6.29.9.2 Bulimia Nervosa 6.29.9.3 Obesity and Binge Eating Disorder 6.29.9.4 Predictors of Treatment Outcome 6.29.10 IN CONCLUSION

655 655 656 656 657 659 659 661 661 662 663 663 663

6.29.11 REFERENCES

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This chapter discusses eating disorders. Eating disorders differ from the problems mentioned above in the frequency and seriousness of the symptoms and the extent to which they interfere with the individual's functioning. With an eating disorder, the symptoms are much more serious and frequent than with an eating problem. Unlike an eating problem, an eating disorder is often dysfunctional: the patient suffers from it to an extent that it is virtually impossible to function normally. This is not always evident to others; the eating disorder bulimia nervosa, for

6.29.1 INTRODUCTION Nowadays, more than half of all women diet because they believe they are too fat (e.g., Agras, 1990). In the late 1970s, one in every five of a sample of British women binged once a month, and 10% of these women regurgitated after bingeing in order to get the quantity of food eaten out of the system as quickly as possible (Wardle, 1980). Eating behaviors of this type can be problematic, but they are seen so frequently that they can no longer justifiably be categorized as ªabnormal.º 649

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example, can be concealed by sufferers for many years. The eating disorders anorexia nervosa and bulimia nervosa, as well as atypical variations of these disorders and the recently identified binge eating disorder, are discussed in the present chapter. Because eating disorders are primarily seen among women, patients will be referred to as women. After a clinical description of the eating disorders, the diagnostic features, differential diagnoses, comorbidity and prevalence are discussed. Next, empirically validated theories of the origin and maintenance of eating disorders are considered. A final section discusses the effectiveness of the various treatments currently available.

6.29.2 ANOREXIA NERVOSA The characteristic of a patient with anorexia nervosa is that she continually assumes that she is too fat. This conviction fuels an intense drive to be thinner, sometimes referred to as a relentless pursuit of thinness. The fervent desire to lose weight continually dominates the patient's thoughts, feelings, and behavior (Garfinkel, 1995). She eats only low-calorie food and exerts an enormous amount of physical effort, resulting in a loss of weight. Sleeping problems and depression can result from malnutrition. It is striking that neither the idea of being too fat nor the fear of gaining weight disappear as the weight loss continues. On the contrary, as weight decreases, the fear of becoming fat intensifies. Another striking aspect is that the patient usually denies the seriousness of the loss of weight. Incessant attempts to lose an extreme amount of weight, and the belief among these underweight patients that they are still too fat, resulted in recent decades in the suspicion by numerous specialists and researchers that a distorted perception of the body is characteristic of patients with anorexia nervosa. Patients with anorexia nervosa were presumed to overestimate the size of their body. However, this clinical impression could not be irrefutably confirmed. Researchers asked patients, for example, if they could estimate the size of their body while viewing themselves on a video monitor. By turning knobs they could show on the screen how big they thought they were. It was learned that some patients with anorexia nervosa overestimate the size of their body more than others, while other patients with anorexia nervosa did not. Moreover, it was determined that people without an eating disorder also often overestimate their size (Garfinkel, 1995; Smeets, Smit, Panhuysen, & Ingleby, 1997).

The group of anorexia nervosa patients can be divided into two subgroups: the binge/ purging type and the restricting type (American Psychiatric Association [APA] 1994). Purging refers to behavior oriented towards getting the food out of the body as quickly as possible: selfinduced vomiting and the use of laxatives and diuretics (substances that stimulate the excretion of fluids: ªpee pillsº). Dieting, fasting, and sports activities are not considered purging behavior. An average of nine months after anorexia nervosa commences, about half of the patients start to suffer from uncontrollable bingeing and purging behavior (Polivy & Herman, 1985; Wardle & Beinart, 1981). Purgers often stimulate the vomiting reflex by sticking a finger, toothbrush, or other oblong object into the desired position in the throat. After some time, some patients can stimulate this reflex simply by exerting a small amount of pressure on the stomach under the ribs. Vomiting is then more or less ªautomatic.º Some chronic vomiters have a hard spot or callus on the back of the hand or under the ribs. This callus results from the hand rubbing along the teeth or from exerting pressure on the stomach. The use of laxatives is not as effective as the patient often believes. Laxatives rinse food through the intestines at an accelerated speed. This rapid journey through the digestive track can prevent complete absorption of the nutrients, as a result of which somewhat less energy (kilocalories) is absorbed. The weight loss achieved in this manner, however, is small and short-lived because the laxatives primarily stimulate the excretion of fluids. The weight lost is regained after drinking a few glasses of fluids. A paradoxical effect of the long-term use of laxatives is that constipation occurs because of the reduced or complete loss of activity of the intestines. Patients of the other, restricting type do not suffer from binges. These patients continually restrict their intake of food and therefore do not turn as easily to the purging measures explained above. Which factors determine when and why a patient changes from a restricting type to a purging type with binges is unknown. The two groups do, however, differ in a number of other ways: on average, the bingeing/purging type has a higher weight before the anorexia nervosa started and suffers more often from disorders involving controlling impulses, excessive use of alcohol or drugs, mood disorders, and personality disorders (Garfinkel, 1995). Malnutrition and purging behavior have medical consequences. The menstrual cycle is usually interrupted, and when underweight becomes extreme the menses cease. The extremities (fingers, toes) are cold and turn purple-blue (this

Bulimia Nervosa is referred to as cyanosis), the body temperature is low (hypothermia), which can result in a downy layer of hair growing on the body (lanugo), the blood pressure is low (hypotension), and the heartbeat is slow (often lower than 60 beats per minute: in medical terms bradycardia). The metabolism is also often slow. The physical consequences of malnutrition often disappear once the eating pattern and weight have returned, but this can take some time. The diagnostic criteria for anorexia nervosa according to the Diagnostic and statistical manual of mental disorders (4th edn., DSMIV) are listed in Table 1.

6.29.3 BULIMIA NERVOSA A chaotic eating pattern, weight-control measures, and irrational ideas about one's figure, appearance, and weight are characteristic of the eating disorder bulimia nervosa (APA, 1994). Normally, periods of sparse eating alternate with binge eating episodes (bulimia literally means ªas hungry as an oxº). During a binge, in an uninterrupted period of time an amount of food is consumed that is considerably larger than most people would normally eat in the same period of time. Typical is the subjective feeling of loss of control over eating: during the binge, the patient feels as if she can no longer stop or control what or how much she eats (Fairburn & Wilson, 1993). The binge can be induced by a variety of stimuli: fluctuating moods (e.g., depression, fear, euphoria), the breaking of idiosyncratic diet rules, for example, by eating ªforbiddenº food (i.e., food rich in calories), and a craving for food stimulated by the smell of palatable food (Jansen & van den Hout, 1991). Some patients describe a type of dissociative amnesia: they experience their binge

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as a dream and cannot remember the details. After bingeing, in the very short term, the binge improves affect, but very soon thereafter (often even before the end of the binge) the subject feels guilty and self-disgusted. The patient is afraid of gaining weight and seeks refuge in the compensational behavior described above: purging and dieting. The chaotic eating pattern (alternating between much and little) results from extreme worry about the figure, appearance, and weight. Like patients with anorexia nervosa, despite the fact that their weight is often normal, patients with bulimia nervosa believe they are heavy, slow, and fat (Phelan, 1987). These irrational ideas about their figure and weight determine to a significant degree their self-esteem, which is often low. Patients with bulimia nervosa also have irrational cognitions about things other than their body shape and weight. Their ideas about food and eating are also dysfunctional (Dritschel, Williams, & Cooper, 1991). Everything that is edible is either ªgoodº or ªbad.º Good food is food that has a low amount of kilocalories (e.g., skimmed yogurt, bouillon, and lettuce); bad food is food with a high amount of calories, and is ªforbiddenº (e.g., chocolate, pizza, and fried meat). Eating a bit of forbidden food is ªcompletelyº bad. This dichotomous (black-and-white) thinking style is an invitation to failure: the stricter the rules they apply to themselves, the more likely the rules are to be broken. Bulimia nervosa, like anorexia nervosa, is often accompanied by medical complaints that result from the binges, vomiting, fasting, and use of laxatives and diuretics. Most of these complaints are reversible and disappear as soon as the eating behavior has normalized. Some, however, are life threatening. When vomiting

Table 1 DSM-IV diagnostic criteria for 307.1 anorexia nervosa. A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) B. Intense fear of gaining weight or becoming fat, even though underweight C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles (a woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration) Specify type: Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in bingeeating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge-eating/purging type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

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and using laxatives and diuretics, the patient loses a significant amount of fluids. This dehydration may result in thirst, dry skin, dizziness when rising from a sitting or horizontal position, light-headedness, and fainting. Chronic purging can also result in serious disorders of the electrolyte balance. Electrolytes (the most important of which are sodium, potassium, and chloride) are called just that because they are responsible for the transmission of electrical signals between the cells in our body. They play an important role in metabolic processes and ensure that the nerve and muscle cells function properly. As a result of purging, a considerable quantity of electrolytes, in particular sodium and potassium, are excreted. Serious shortages can be life threatening because the heart muscle is weakened and receives insufficient impulses to compress and then relax. A simple blood test can indicate whether the electrolyte levels are abnormal. The DSM-IV criteria for bulimia nervosa are listed in Table 2. 6.29.4 OBESITY AND BINGE EATING DISORDER Obesity refers to an excess of body fat. Because body weight and body fat are highly correlated, overweight is often used as a proxy for obesity (Brownell, 1995; Wardle, 1995). To determine whether someone's weight is in or outside the normal range, the body mass index (BMI) is generally used. The BMI refers to the ratio of height and weight; it is calculated by dividing body weight (in kilograms) by height2 (in meters). For example, the BMI of a subject weighing 63 kg and 1.68 m tall is: 63/

(1.68)2 = 22.3. A BMI between 20 and 25 shows a healthy weight. The more a BMI drops below 20, the more severe the underweight is, and, vice versa, the more the BMI rises above 25, the more severe the overweight (see Table 3). Levels of BMI greater than 30 are usually taken to indicate obesity. In most cases, obesity develops in the absence of any medical disease (Foster, 1992), but it is a risk factor for a range of major health hazards, including cardiovascular diseases, hypertension, diabetes, stroke, hypercholesterolemia, gallbladder diseases, and osteoarthritis (Wardle, 1995; Willett & Manson, 1995). Statistics from life insurance companies show a significant increase of morbidity and mortality when the BMI rises above 30. The health consequences are more serious for the obese with fat around the waist (the ªappleº) than for obese subjects with fat around the hips and thighs (the ªpearº). Stigmatization, prejudice, and discrimination of the obese, for example, in relation to acceptance for a job, makes obesity a psychological problem as well. Obesity is considered unattractive in Western cultures, leading to negative self-images and even self-hate in obese persons, especially women (Foster, 1992; Stunkard & Wadden, 1992). Children as young as six years of age describe silhouettes of obese children as ªlazy, dirty, stupid, ugly, cheats, and lies,º and they rate children with a variety of disabilities as more attractive than the obese children (Rodin, Silberstein, & Striegel-Moore, 1984). Low self-esteem, feelings of anxiety, depression, and guilt are frequently seen in the seriously obese (Stunkard & Wadden, 1992). Following the definitions of DSM-IV, obesity is not defined as an eating disorder or even as a

Table 2 DSM diagnostic criteria for 307.51 bulimia nervosa. A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months D. Self-evaluation is unduly influenced by body shape and weight E. The disturbance does not occur exclusively during episodes of anorexia nervosa Specify type: Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in selfinduced vomiting or the misuse of laxatives, diuretics, or enemas

Differential Diagnoses and Comorbidity Table 3 Body Mass Index. BMI

Weight category

518 18±20 20±25 25±27 27±30 430 30±35 35±40 440

Severe underweight Underweight Normal weight Slightly overweight Overweight Obesity Mild obesity Moderate obesity Morbid or severe obesity

Body Mass Index (BMI) = weight/height2; kg/m2.

mental disorder. Until recently, obesity has generally been studied by doctors and biologists, whereas eating disorders have always been within the scope of psychologists and psychiatrists. However, in the last few years, interest in obesity among psychologists and psychiatrists has been growing. One of the main reasons for this renewed interest is the recognition of increased psychopathology in some obese people. This subgroup of the obese population frequently overeat in a way which could be described as bingeing. Some of these obese binge eaters meet the diagnostic criteria of bulimia nervosa, but most of them do not. Those who do not meet the criteria binge regularly but do not engage in the characteristic compensatory purging behaviors of bulimia nervosa, that is, self-induced vomiting or use of laxatives. DSM-IV considered this a possible eating disorder and called it the Binge Eating Disorder. In the diagnostic handbook, binge eating disorder is included in an appendix listing clinical presentations which must be studied in detail before they can be definitely included in a diagnostic category in the handbook. In Table 4 the preliminary DSM-IV criteria for binge eating disorder are listed. Obese subjects who meet the criteria for the binge eating disorder differ on several characteristics from obese persons who do not meet the binge eating disorder criteria (Brody, Walsh, & Devlin, 1994; Castonguay, Eldredge, & Agras, 1995; Fichter, Quadflieg, & Brandl, 1993; Lowe & Caputo, 1991; Spitzer et al., 1993). Obese binge eaters in general have a higher body mass index, report more weight fluctuations, show an earlier onset of obesity, spend more time dieting, are more restrained in their eating patterns, drop out of treatment more frequently, have poorer treatment outcomes, and show more psychopathology than the obese nonbingers. Observed links between obesity and psychopathology (see Section 6.29.6.2) are mostly

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accounted for by binge eating; it is the severity of binge eating and not the severity of obesity which is correlated with the indices of psychopathology (Castonguay et al., 1995). Note, however, that the obese nonpurging binge eaters show less psychopathology than the purging bingers, i.e. subjects with bulimia nervosa.

6.29.5 ATYPICAL EATING DISORDERS About one-third of the patients who presented in England for the treatment of an eating disorder failed to meet the diagnostic criteria for anorexia or bulimia nervosa (Fairburn & Walsh, 1995). They normally have an atypical eating disorder or, in DSM-IV terms, an eating disorder ªnot otherwise specifiedº (APA, 1994). These are people who, for example, meet all of the criteria for anorexia nervosa except that they still have a regular menstrual cycle, or they have lost a considerable amount of weight, but the weight is not low enough. A patient may also meet all of the criteria for bulimia nervosa except that the binges do not occur frequently enough.

6.29.6 DIFFERENTIAL DIAGNOSES AND COMORBIDITY 6.29.6.1 Differential Diagnoses Considerable weight loss can occur as a result of certain physical illnesses (e.g., cancer, intestinal disorders, and AIDS), depression, schizophrenia, and others. Weight loss of this type must be distinguished from anorexia nervosa if the patient fails to meet the other diagnostic criteria for the eating disorder, such as an extreme fear of being fat and the desire to continue to lose weight. Binges can occur as a result of schizophrenia, depression, a borderline personality disorder, and certain neurological disorders such as the Kleine±Levy syndrome. If these patients do not show compensation behavior and do not appear extremely overly concerned with their figure, they do not meet the criteria for bulimia nervosa. If patients with an eating disorder handle food compulsively or are afraid of eating in social situations, they do not necessarily suffer from an obsessive-compulsive disorder or from social anxiety. It must first be determined whether the patient also meets the other criteria for these disorders and whether, for example, they also suffer from obsessions, compulsions, or social fears that are not related to food or the figure.

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Eating Disorders Table 4 DSM-IV research criteria for Binge Eating Disorder.

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. The binge eating episodes are associated with three (or more) of the following: (1) eating much more rapidly than normal (2) eating until feeling uncomfortably full (3) eating large amounts of food when not feeling physically hungry (4) eating alone because of being embarrassed by how much one is eating (5) feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present D. The binge eating occurs, on average, at least 2 days a week for 6 months Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa

6.29.6.2 Comorbidity Obese bingers more often than obese nonbingers are characterized by depression, anxiety, personality disorders, low self-esteem, impulsivity, body perception disturbances, neuroticism, and overall distress. Obese binge eaters significantly more often meet criteria for a psychiatric disorder than obese nonbinge eaters (60% vs. 28%; Castonguay et al., 1995). Some authors consider depression a risk factor for the occurrence of binges among people who are overweight (Marcus, 1995). Nearly half of women suffering from anorexia nervosa and bulimia nervosa are depressive, whereas others show obsessions and compulsions or other anxiety disorders. Their first-degree relatives suffer from mood disorders more often than could be expected by chance (Cooper, 1995a). In particular, patients who regularly purge are clearly more depressed and show more anxiety than those who do not regularly purge (Garner, 1993). This is why from time immemorial there have been experts who believe that eating disorders are a variation of mood and/or anxiety disorders (Garfinkel, 1995), but the symptoms of anxiety disorders and depression occurring during the eating disorder are virtually always secondary to the eating disorder. When the eating disorder disappears, the depressive and/or phobic characteristics often disappear as well (Fairburn & Cooper, 1989). Recently, Welch and Fairburn (1996b) found that deliberate self-harm by repeated cutting was much more common among a community sample of bulimia nervosa subjects (19%) than among a psychiatric (3%) and a normal (1%) control group. Although it is a general clinical

impression that subjects with eating disorders show a high incidence of psychoactive substance abuse, controlled epidemiological studies do not confirm this (Welch & Fairburn, 1996b; Wilson, 1991). Also, a borderline personality disorder is considered to be much more prevalent among subjects with eating disorders, in particular bulimia nervosa, than among other psychiatric populations. Rates have ranged from 2% to 47% (Wonderlich, 1995). However, methodologically sound studies are rare; the main problems in these studies are the absence of (psychiatric) control groups and the diagnostic problems related to the definition of the borderline personality disorder. There is considerable overlap between the diagnostic criteria for eating disorders and the diagnostic criteria for the borderline personality disorder. The latter includes, for example, binge eating, mood fluctuations, unstable self-image, suicidal or self-mutilating behavior, feelings of boredom and emptiness. Because of the overlap in criteria, there is a risk of overdiagnosing the borderline personality disorder among (depressed) subjects with eating disorders. This idea is supported by data that indicate a decrease in the rate of borderline personality disorders with short-term, symptom-focused interventions (Wonderlich, 1995). 6.29.7 PREVALENCE AND PROGRESS Anorexia and bulimia nervosa are seen significantly more often among women than men. About 10% of the patients are male (APA, 1994). Epidemiological research into the prevalence of the two eating disorders suggests that about 0.5±1% of girls and young adult women

Etiology (18±30 years) suffer from anorexia nervosa, while bulimia nervosa is seen in 1±3% of this group (APA, 1994; Fairburn & Beglin, 1990). Atypical eating disorders are considered to be much more common (APA, 1994; Fairburn & Walsh, 1995), but how common is currently unknown. It is difficult to collect exact data concerning the prevalence of eating disorders. In addition to the fact that women with anorexia nervosa often deny that they have an eating disorder and women with bulimia nervosa often keep their problem hidden because they are ashamed, research of this type requires precise, unambiguous application of the diagnostic criteria. Some researchers believe that the prevalence of the two eating disorders has increased in recent decades (APA, 1994). Epidemiological studies, however, do not show an upward trend in rates (Fombonne, 1996). The alleged increase could be a result of the increased publicity about and familiarity with eating disorders, as a result of which cases are identified more quickly. Patients or relatives turn to their family physician or another expert more readily, and the diagnostic process and the available assistance have improved, so that an eating disorder is more readily recognized by all concerned. Obesity is much more common than the eating disorders anorexia and bulimia nervosa. In the USA 12% of adult men and 15% of adult women are obese, in the UK 8% and 12%, respectively (Wardle, 1995). Binge eating disorder is primarily seen in overweight people and one and a half times more often in females than in males (APA, 1994; Marcus, 1995). About 2±5% of overweight nonpatient community subjects meet criteria for the binge eating disorder, compared with one-third of overweight people who present for treatment. The higher the BMI, the greater the likelihood of binge eating. Obesity is more prevalent in lower than in higher socioeconomic groups (Foster, 1992), whereas anorexia and bulimia nervosa occur to about the same extent in all social classes (Fairburn & Beglin, 1990; Gard & Freeman, 1996; Rogers, Resnick, Mitchell, & Blum, 1997) and appear to be more common in industrialized countries, where there is an excess of food and the ªperfect figureº culture prevails, than in undeveloped countries. However, we do not know this for certain, because systematic studies of the prevalence in other cultures are seldom made. Women in certain professions run a higher risk than other women: anorexia nervosa is seen relatively more frequently among ballet dancers, models, and athletes (professions in which a low body weight is an advantage), but it is not clear whether these professions stimulate

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the eating disorder or people with (a predisposition for) an eating disorder choose these professions. Anorexia and bulimia nervosa usually start prior to the age of 18. In 10% of the cases in which hospitalization is required, anorexia nervosa results in death (APA, 1994). The progress of the two eating disorders is highly variable. Some people are cured after a short episode of anorexia nervosa, while some regularly relapse and others suffer chronically from the disorder. The younger anorexia nervosa starts and the shorter the time between onset and presentation for treatment, the better the prognosis. The progress of bulimia nervosa varies: 20% of the treated cases suffer chronically from the eating disorder and 30% relapse now and then, in which cases periods of bulimia nervosa alternate with periods of normal eating behavior (Hsu, 1995). Fifty per cent of bulimics remain completely free of symptoms up to 10 years after cognitive-behavior therapy (Hsu, 1995). Figures for untreated cases are not available. 6.29.8 ETIOLOGY A number of influential theories concerning the origin and maintenance of eating disorders are discussed in this section. Their empirical validity is also examined. 6.29.8.1 Genetics The fact that first-degree relatives of anorexia and bulimia nervosa patients suffer from an eating disorder more often than could be expected by chance is often presented as proof that eating disorders are genetically determined. This conclusion is not justified: a higher prevalence of eating disorders among relatives does not establish the genetic nature of the disorders. Such evidence can only be supplied by disentangling the influence of inherited factors from environmentally transmitted factors, for example, through studies of twins or adopted children. By studying concordance rates of eating disorders among monozygotic (MZ) and dizygotic (DZ) twins, Treasure and Holland (1995) found significantly more MZ pairs concordant for anorexia nervosa than DZ pairs. This was not the case for bulimia nervosa, suggesting that genetic factors play a significant role in the development of anorexia nervosa, whereas this may not be true for bulimia nervosa. Thus, both eating disorders tend to run in families, but, for the origin of bulimia nervosa, environmental factors also appear to be important. Genetic influences may be more

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important in the development of anorexia nervosa. The nature of inherited factors in anorexia and bulimia nervosa needs to be examined more closely. The cause of obesity is still poorly understood. It is clear that obesity is always caused by a greater energy intake over output, but the cause of the energy imbalance is unknown. Obesity runs in families. Whether this results from genetic factors or family eating patterns or maybe both is yet unknown. Adoption studies point to a heredity factor for body weight: they show that adopted children have weights more closely related to their biological than to their adoptive parents, and monozygotic twins resemble each other more than dizygotic twins, whether they have grown with each other or not (Foster, 1992). According to some experts, the heritability factor is not a gene for excess body weight, but a vulnerability to obesity that is expressed under suitable environmental circumstances (Drewnowski, 1996; Wilson, 1994). There are also some indications that the obese are characterized by inherited metabolic efficiency which enables them to gain or maintain weight easily. For example, obese children tend to have obese parents, and research has shown that the energy expenditure of normal weight offspring of obese parents was only about 80% of that found in normal-weight children of nonobese parents (Foster, 1992). However, there is also evidence for distorted eating patterns in the obese. In general, obese persons are found to eat more than their lean counterparts, and there are indications that childhood obesity is triggered by overeating (Foster, 1992). Moreover, the obese show a preference for fat, and their diet indeed is richer in fat than diets of lean persons. Children's preferences for fat food were not only influenced by their own body fatness, but also by the fatness of their mother, which led Drewnowski (1996) to hypothesize that the genetic vulnerability is an increased appetite for energy-dense fat-containing foods. 6.29.8.2 Childhood Sexual Abuse The fact that a large proportion of patients with eating disorders and people who have suffered from sexual abuse have low self-esteem and tend to feel shame about their body led some authors to relate childhood sexual abuse to the development of eating disorders (e.g., Andrews, 1997). Some recent large-scale and well-controlled studies show that self-reported childhood sexual abuse is present in about 25±35% of the eating-disordered subjects (Vize & Cooper, 1995; Welch & Fairburn, 1994; 1996a). Welch and Fairburn (1994) found a rate of 26% for sexual abuse in a community sample

of subjects with bulimia nervosa. This was significantly more than the rate of sexual abuse in a normal control group (10%) but no different from the rate of sexual abuse in community controls with other psychiatric disorders (24%), like affective disorders or anxiety disorders. Thus, childhood sexual abuse is not directly relevant to most cases of eating disorders, and the data suggest that childhood sexual abuse is a nonspecific risk factor for the development of psychopathology in general and not for the development of eating disorders in particular. However, self-report data have serious limitations: over-reporting, under-reporting, and retrospective distortion may play parts in skewing the data, suggesting that care is needed in their interpretation (Esman, 1994), especially when the influence of neuroticism and depression is not controlled for. 6.29.8.3 Dieting for the Perfect Figure It has been found in many studies that physically attractive people are considered to be overendowed with favorable qualities. Beautiful people are considered more interesting, stronger, friendlier, more intelligent, and more sexually exciting than less beautiful people; appearance is unrelated to these qualities. As a result of the wonderful qualities attributed to attractive people, their lives become even better than they would otherwise be: they are more likely to receive assistance during conflicts, are more likely to get the job they apply for, and are less likely to be found guilty in a court of law (Feingold, 1992). It has therefore been suggested that the media systematically present distorted information about the ideal figure and the perfect body, dictating weight standards that are unobtainable for women or only obtainable by considerable effort; being beautiful makes life much more pleasant while being fat is generally not considered attractive; therefore many women use extreme measures to lose weight and consequently develop an eating disorder. A number of facts appear to support this train of thought. Eating disorders are seen much more often among women and girls than among men and boys. Eating disorders are also reported to be more common in the Western, industrialized countries where women compare themselves to extremely skinny models than in non-Western cultures where this type of figure is not considered to be as ideal. Women with a typically female distribution of fat (broad hips, buttocks, and upper legs) suffer more often from eating disorders than women with a figure that is more male (narrow hips, buttocks, and legs). Lesbians suffer less often from eating disorders than

Etiology heterosexual women, while homosexual men are more likely to develop eating disorders than heterosexual men (it is assumed that homosexual women are less influenced by the ideal female figure, while outward appearance is more important to homosexual men than to heterosexual men) (Brand, Rothblum, & Solomon, 1992). In our culture, a slim figure is appreciated and striving to lose weight causes a lot of women eating problems, simply because they inherited a figure whichÐaccording to our cultural standardsÐis not ideal. The idea that our culture overvalues the ªperfect figureº and therefore causes eating disorders is, nevertheless, an oversimplification of the facts. The perfect-figure culture is something that is applicable to all women in Western society. If the perfect-figure culture did in fact cause eating disorders, there would be epidemics of these disorders. This is not the case. It would appear more likely that the ªperfectfigure cultureº stimulates women to diet to lose weight, thereby increasing the risk of an eating disorder. Why? Binges go hand in hand with the intention to limit the intake of food (Polivy & Herman, 1985); retrospectively, it was found that about 80% of patients with bulimia nervosa tried to lose weight by strict dieting prior to the onset of binge eating (Rossiter, Wilson, & Goldstein, 1989); about 50% of anorexia nervosa patients develop binge eating episodes about 9±18 months after the onset of strict dieting (Polivy & Herman, 1985); and nonclinical dieters report significantly more binge eating than nondieters (Wardle, 1980). The set-point theory explains the relationship between dieting and binge eating. According to that theory, every organism has a certain amount of fat that has been predetermined for life. The idea is that the amount of fat present in an organism is continuously registered. A homeostatic mechanism is responsible for keeping the amount of fat balanced. If, in comparison with the predetermined amount of fat, a shortage of fat is identified, processes are activated that bring the quantity of fat up to the set-point level. If too much fat is identified, processes are activated that bring the quantity of fat back down to the set-point level (Keesey, 1995). According to this theory, people with a low set-point weight in our ªperfect-figureº culture are just plain lucky. The people with bad luckÐa high set-point weightÐare condemned to being ªoverweightº for their entire lives. When these peopleÐfor instance, when influenced by the concept of a ªperfect-figure'Ðstart to diet and lose weight, their weight drops below their own set-point weight. Then the body responds with mechanisms designed to regain weight: bingeing and a slower metabolism can

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be triggered. According to the set-point theory, patients with bingeing urges have dropped below their set-point weight. The theory is elegant, but there are a few anomalies. In the first place, patients with anorexia nervosa are the perfect example of malnourished dieters. Nevertheless, only half of these patients report suffering from bingeing urges. Second, there are dieters who never overeat; they are called ªsuccessfulº dieters. A German study indicated that about one-half of every one thousand women diet without any problems (Westenhoefer, Pudel & Maus, 1990); in England and the USA, documented studies indicate that ªonlyº 8±9% of dieting women and girls suffer from bingeing urges or develop an eating disorder (Agras, 1990; Patton, JohnsonSabine, Wood, Mahn, & Wakeling, 1990). The set-point mechanism is therefore not nearly as dominant as suggested. Apparently, many people can diet and lose weight to below the set-point level without any problems. Furthermore, it does not appear likely that dieters with bingeing urges are below their set-point weight: a number of studies have indicated that dieters have a higher BMI and eat the same amount or even more kilocalories (and retain that energy) than nondieters (see, e.g., Jansen, 1996). Of course, one might put forward the untestable and circular argument that the bingeing dieters have a higher set-point than the normal eaters; advocates of the set-point theory still have the formidable task of discovering how a person's set-point weight can be determined. Studies of the relationship between dieting and bingeing are usually retrospective or correlative and they thus do not render any certainties with reference to causality. It therefore cannot be proven that dieting is not a consequence of a tendency to regularly overeat or that there is not a third factor involved; an underlying mechanism that explains both the dieting and the bingeing. Briefly summarized: the ªperfect-figureº culture prescribes a female figure that most women will never be able to achieve. This is why many women diet. In about 9% of the cases, dieting results in an eating disorder. This makes it improbable that the ªperfect-figureº culture and dieting are the key determinants of eating disorders; if this were the case, a considerably larger number of women would suffer from eating disorders. 6.29.8.4 Serotonin Depletion First-degree relatives of patients with an eating disorder not only have eating disorders more often, but mood disorders are also more common than would be expected. Nearly half of

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patients with eating disorders are also diagnosed as suffering from depression (Laessle, 1990). The association of the two disorders within families and individuals led to the hypothesis that eating disorders are in fact a type of biological mood disorder. This will be discussed further below. Various studies identified a relationship between eating carbohydrates and mood. Eating a proportionately large amount of carbohydrates results in a better mood (Fichter & Pirke, 1995; Jansen, van den Hout, & Griez, 1989; Wurtman & Wurtman, 1984). This mood improvement is assumed to be mediated by the neurotransmitter serotonin: by eating relatively large amounts of carbohydrates and little protein, serotonin production in the brain increases. The increased serotonergic activity results in mood improvement. A shortage of carbohydrates, by contrast, results in a decrease in the amount of serotonin in the brain. In turn, this results in a lowering of mood. The amount of serotonin in the brain determines not only mood state but also the craving for carbohydrates. As the amount of active serotonin decreases, an increased craving for carbohydrates is observed. It can therefore be hypothesized that the production of serotonin in the brain is in part dependent on the amount of carbohydrates consumed. Eating a larger amount of carbohydrates results in more serotonin being produced in the brain. As a result, mood improves and the craving for carbohydrates diminishes. If, however, too few carbohydrates are consumed, less serotonin is produced, mood declines, and the craving for carbohydrates increases. Animal experiments have shown that deprivation of carbohydrates seriously disrupts the carbohydrate regulation as described above. After rats were deprived of carbohydrates for a short period, cerebral sertonin level decreased as predicted. It was striking that serotonin did not reach the normal level again until after an excessive amount of carbohydrates was consumed (Wurtman & Wurtman, 1984). These and other findings resulted in the following hypothesis concerning the origin of binges among patients with bulimia nervosa (see also Figure 1): for a variety of reasons, for example the desire to fulfill the cultural ideal of the female figure, some women subject themselves to a rigid eating regime. If this eating regime results in too few carbohydrates being consumed, successfully following the strict regime will result in disruption of the serotonergic system on the cerebral level. By depriving themselves of carbohydrates for longer periods of time, consumption of carbohydrates later will not immediately result in the required increase

in serotonin. This increase will not be achieved unless excessive amounts of carbohydrates are consumed during a binge. A binge could, therefore, be considered a type of ªselfmedication.º Indeed it was found, analogous to the finding from the animal experiment of the Wurtmans (Wurtman & Wurtman, 1984), that the consumption of a standard quantity of carbohydrates by patients with bulimia nervosa did not result in the expected increase in the tryptophan ratio. Tryptophan is a large neutral amino acid, and its ratio to other large amino acids determines the amount of tryptophan entering the brain. A larger ratio means more tryptophan entering the brain, resulting in increased serotonin levels in the brain. What's more, eating carbohydrates did not stop until the tryptophan ratio in the blood plasma reached a normal level (see Pirke, 1995). Others found a lower concentration of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) of severe bulimic patients (Jimerson, Lesem, Kaye, & Brewerton, 1992). The quantity of 5-HIAA in the CSF reflects the amount of serotonin active in the brain; the data thus point to a low turnover of 5hydroxytryptophan (5-HT) in subjects with severe bulimic symptoms. However, a study with weight-restored anorexics indicates that abnormalities in central serotonin function follow from weight loss and malnutrition and are not related primarily to the disorder itself (Odwyer, Lucey, & Russell, 1996). Caution is also advised when the findings are presented as evidence supporting the theory that binges serve to increase the quantity of serotonin in the brain. In the above-mentioned studies, it is assumed that the food patients consume during binges is rich in carbohydrates, whereas this is not the case. It has repeatedly been found that patients with bulimia nervosa eat as much carbohydrates during the binges as they do in between binges (Jansen, van den Hout, & Griez, 1989; Walsh, 1993). Moreover, in both periods they consume the same amount of carbohydrates as a normal control group. However, it should also be noted that a recent study among healthy female subjects shows that even moderate dieting on a diet with a normal macronutrient composition (1000 kcal, 31% protein, 44% carbohydrate, 25% fat) causes increased sensitivity of 5-HT receptors in the brain (Cowen, Clifford, Walsh, Williams, & Fairburn, 1996), suggesting that the overall decrease in the neurotransmission of serotonin during dieting does not require a relative carbohydrate depletion. The serotonin hypothesis concerning the origin of bingeing is important, but it must as

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Etiology

5 HT (serotonin)

mood

binge

5 HT (serotonin) Figure 1 The serotonin model of binge eating.

yet be proven that the bingeing truly serves to increase the serotonin level in the brain. Findings suggesting that other psychiatric disorders may be characterized by low serotonin levels in the brain also generate the question of why these patients do not suffer from bingeing as a type of self-medication. 6.29.8.5 The Learned Nature of Binge Eating Recent studies in the area of addiction suggest that the urge to consume a substance is a classically conditioned response (Drummond, Tiffany, Glautier, & Remington, 1995; Siegel, 1983). Addicts normally use a substance in the presence of certain stimuli, for example, their favorite pub, drinking or shooting buddies, the bottle, the syringe, the spoon and the silver foil. In a long series of experiments, it was shown that stimuli the nature of their exclusive presence eventually predict the use of a substance resulting in the addict having preparatory physiological reactions. Even before any substance is swallowed, injected, or inhaled, changes occur in the body. These anticipative physical changes are said to be experienced as a virtually uncontrollable urge to consume the substance, and striking is the fact that the occurrence of physical reactions after successful withdrawal accurately predicts a relapse (Drummond et al., 1995). Patients with bulimia nervosa show some striking similarities with addicts. Both are preoccupied with the substance that they use excessively, both experience an urge to consume the substance, and both are characterized by loss of control during consumption. The

analogy between bulimia nervosa and addiction may teach us something about the origin of binges. Excessive consumption of food during a binge is often related to a configuration of specific stimuli. Think in this respect of seeing, smelling, and tasting rich food, emotional confusion (a somber mood, fear, boredom, or loneliness), certain disinhibiting thoughts, and the time of the day. When repeatedly and exclusively combined with the bingeing, these stimuli become excellent predictors for a binge. Impressive data from experiments with animals indicate that eating behavior can be induced by stimuli that are repeatedly associated with the intake of food (Wardle, 1990; Woods, 1991). According to this theory, the stimuli that predict the binge continually induce preparatory physiological responses in the eater (see Jansen, 1994, in press). The model predicts that the physiological responses are experienced as a virtually irresistible urge to consume food and therefore increase the chance of a binge. It remains, however, to be seen whether this model for the origin of binges will be confirmed by empirical studies. 6.29.8.6 Dysfunctional Cognitions Excessive worry about the figure, appearance, and weight, as already indicated, is characteristic for patients with an eating disorder. The extreme worries about appearance and weight probably represent the core of the eating disorders. Thinness is idealized, and the feeling of being fat fuels the drive to lose weight. Eating-disordered subjects continually evaluate themselves in terms of outward

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appearance and weight. They tend to judge selfworth almost exclusively in terms of body shape and weight and, therefore, often show longstanding negative self-evaluation (Fairburn, 1997a). Being fat is associated with being worthless, unlikable, disgusting, and so on; being skinny means being attractive, successful, intelligent, happy, and so on (Vitousek & Hollon, 1990). This method of self-evaluation is remarkable because in all cases of anorexia nervosa and in most cases of bulimia nervosa, patients are not objectively overweight at all. Of course, the evaluation of a person is dependent on much more than his outward appearance alone. It is more usual to judge self-worth on the basis of performance in a variety of domains, like work, sports, friendships, relationships, and so on (Fairburn, 1997a). According to the cognitive view on the maintenance of anorexia nervosa and bulimia nervosa (Fairburn, 1997a), the overvalued ideas about the significance of body shape and weight are at the heart of the eating disorders. Self-evaluation is unduly influenced by how the subject perceives her body shape and weight. The preoccupation with food, eating, dieting, and weight control methods are supposed to be secondary to this overconcern. The model states that binge eating follows from a particular type of dieting: intense and rigid dieting. It is postulated that eatingdisordered subjects are characterized by perfectionism and black-and-white (all-or-nothing) thinking, which also becomes manifest in their way of dieting. The idea is that breaking one of their diet rules, even after a minor dietary transgression, results in the view that their diet is ªtotally broken,º which ends up in a total loss of control and thus a binge (Fairburn, 1997a; Herman & Polivy, 1984). This is said to be accompanied by typical, disinhibiting automatic thoughts along the lines of ªmy day is already ruined, I might as well continue to eatº and ªI'm trying not to eat. If I eat anyway, I might just as well continue to eat,º reflecting their perfectionism (Garner, 1986). Thus, if eating-disordered subjects feel as if they have eaten too much, they consider their diet a failure for that day and eat too much the rest of the day. Disinhibiting, all-or-nothing thoughts are therefore supposed to be responsible for the onset of the binge. The cognitive view on the maintenance of anorexia nervosa and bulimia nervosa is at the moment the most widely accepted model of eating disorders. Strikingly, considering the popularity and plausibility of the cognitive view on the maintenance of eating disorders, there is little direct empirical evidence for most of the hypotheses flowing from the model. Among

other things, the model predicts that (i) subjects with eating disorders are characterized by negative self-evaluation or low levels of selfesteem, (ii) low self-esteem is closely related to the extreme concerns about body shape and weight, and (iii) long-term treatment success is related to a reduction of the overconcern about body shape and weight. Furthermore, it is predicted that (iv) a binge is caused by disinhibitive thoughts such as ªmy day is ruined now, I might as well continue to eat.º Let us review the evidence. The first hypothesis (subjects with eating disorders are characterized by low levels of selfesteem) has indeed been supported in diverse questionnaire and interview studies (see, e.g., Mizes & Christiano, 1995). Also a prospective study on the development of eating disorders showed that 11- and 12-year-old dieting girls with low self-esteem were at significantly greater risk of developing eating disorders at the age of 15±16 than dieting girls with normal and high self-esteem (Button, Sonagu-Barke, Davies, & Thompson, 1996). Considering hypothesis (ii) (the low self-esteem is closely related to the overconcern about body shape and weight), questionnaire studies indicate that subjects with eating disorders perceive weight and eating as the basis of approval from others, whereas control subjects do not (Mizes & Christiano, 1995). However, self-report data on the assumed link between mental concepts have serious limitations. There is little experimental research investigating the direct link between low self-esteem and overconcern with body shape and weight. In an analog study with restrained eaters, Eldredge, Wilson, and Whaley (1990) hypothesized that highly restrained eaters experiencing failure in an achievement task would react more negatively towards their own bodies than restrained eaters who experienced success. They found that the highly restrained eaters experiencing failure did not feel worse about their bodies than the highly restrained eaters experiencing success. Others, however, did find evidence for the link between self-evaluation and body concern. It was found that activation of thoughts about eating, weight, and shape led to an increase in negative self-statements (Cooper, Clark, & Fairburn, 1993) and, the other way around, presentation of negative events involving the self led to weight and shape explanations in eatingdisordered subjects (Cooper, 1997). Furthermore, a recent study from our lab (Meijboom, Jansen, Kampman, & Schouten, in press) showed that priming low self-esteem in highly restrained subjects facilitated the accessibility of subliminally presented body shape and weight words. The latter three findings support the idea

Treatment that concern with body shape and weight is linked to self-esteem in eating-disordered subjects. However, much more experimental research is needed before any definite conclusions about the link, and its causal relationship, between self-esteem and overconcern with body shape and weight can be drawn. It might, for example, be an interesting enterprise to test whether priming body shape and weight words will lead to higher accessibility of (low) selfesteem stimuli. Furthermore, it is necessary to test experimentally whether reducing the overconcern about body shape and weight will increase self-esteem, whereas an activation of the overconcern about body shape and weight in normal dieters will decrease their self-esteem. There is some evidence for hypothesis (iii) (long-term treatment success is related to a reduction of the overconcern about body shape and weight). Fairburn, Peveler, Jones, Hope, and Doll (1993) showed that the severity of concerns about shape and weight at the end of treatment were directly related to the likelihood of relapse: 9% of the subjects with the least concerns relapsed vs. 19% of those with a moderate level of concern and 75% of those with the greatest level of concern. Considering hypothesis (iv), clinical notes indeed indicate that a binge is caused by disinhibiting thoughts such as ªmy day is ruined now, I might as well continue to eat.º However, such clinical impressions have received little empirical support. In our laboratory, the prediction was studied in bogus taste experiments, but it could not be demonstrated that disinhibiting thoughts play a significant role in the onset of overeating (Jansen, Merckelbach, Oosterlaan, Tuiten, & van den Hout, 1988; Jansen & van den Hout, 1991). There is, however, some circumstantial evidence consistent with the idea that the activation of disinhibiting thoughts in normal dieters can elicit bingeing. In a laboratory study with high and low restrained eaters, Spencer and Fremouw (1979) manipulated their subjects' beliefs concerning the caloric content of a preload and demonstrated that the restrained eaters overate after the preload when they only thought they had overeaten during the preload. It was not clear, however, whether the overeaters were characterized by more disinhibitive thoughts. Whether a straightforward activation of disinhibitive thoughts elicits a binge has never been tested. A final prediction following from the hypothesis is that a reduction of disinhibitive thoughts prevents a binge. There is an experimental finding which counters this prediction. Dieters were led into temptation to eat by smelling very palatable food. Because they merely smelled the food (their diet was not

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broken), it was assumed that the manipulation prevented the occurrence of disinhibitive thoughts. Contrary to what the cognitive model predicts, it was found that dieters who were merely exposed to, and intensively smelled the food, but whose diets were not actually broken or threatened, overate (Jansen & van den Hout, 1991). Contrary to hypothesis (iv), the absence of disinhibiting thoughts did not prevent dieters overeating. All in all, there is evidence that subjects with eating disorders are characterized by low selfesteem, and there is some support for the hypothesis that low self-esteem is linked to extreme concerns about body shape and weight. However, much more experimental research on the precise link between self-esteem and body shape evaluation is needed before firm conclusions can be drawn. Furthermore, there is hardly any empirical evidence for the idea that disinhibiting thoughts cause binge eating. There have been more studies on the cognitions of subjects with eating disorders than the studies cited above (for an overview see Vitousek & Hollon, 1990). Remarkably, however, the goal of most of those studies was to verify that eatingdisordered subjects show cognitive distortions concerning food, eating behavior, body shape, and weight. For example, in the modified Stroop test, it has repeatedly been found that subjects with eating disorders selectively process stimuli related to food, eating, body shape, and weight. It has also been found that they show a memory bias for fatness words (Sebastian, Williamson, & Blouin, 1996). This kind of research may be based on circular reasoning; subjects are selected for their abnormal cognitive processes concerning body shape, weight, food, and eating, and it is concluded that they are characterized by an abnormal processing of body shape, weight, food, and eating information. 6.29.9 TREATMENT 6.29.9.1 Anorexia Nervosa Traditionally, anorexia nervosa is treated on an inpatient basis with a program to increase weight, loosely based on operant conditioning. The patients are admitted to the clinic and it is agreed that they will gain a predetermined amount of weight each week. They are prescribed lots of bed rest (so that they will burn less energy), and a number of pleasant pastimes (receiving visitors and watching television, for example) are forbidden. They can gradually earn back these pleasant pastimes by gaining the desired amount of weight. The effectiveness of treatments of this type has never been established; the clinical impression is that

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patients gain weight during the treatment but quickly relapse after leaving the clinic. Perhaps this is caused by the overemphasis on the sole goal of gaining weight. Anorexia nervosa consists of more than simply being considerably underweight. Its core psychopathology consists of cognitive distortions concerning body shape and weight, which probably do not change during a treatment that is solely oriented towards gaining weight. For this reason, today many (but not all) inpatient treatment programs are much more versatile. In addition to focusing on gaining weight, the patients learn to accept their body, for example, by video confrontation, and talk about emotions. They are often given nutritional counseling and family therapy. Focus is also placed on increasing self-esteem and improving social skills (Fichter, 1995). The effectiveness of treatments of this type, however, has not been empirically confirmed. As long as the patient's physical condition makes it possible, outpatient treatment is preferred above intramural treatment. Recently, it has been argued that patients with anorexia nervosa would, like subjects with bulimia nervosa, benefit from outpatient cognitive behavior therapy, a treatment which is focused on changing maladaptive thoughts, feelings, and behavior (Fairburn, Marcus & Wilson, 1993; Vitousek, 1995). Again, however, the effectiveness of cognitive-behavior therapy in the treatment of anorexia nervosa also remains to be established. Antidepressants are the most commonly prescribed medications for anorexia nervosa; however, in the long run they do not appear to be effective. The reason for this ineffectiveness may be that antidepressants do not affect the morbid attitudes, beliefs, and associated behaviors which constitute the central features of the illness (Wakeling, 1995). 6.29.9.2 Bulimia Nervosa The effectiveness of treatments for bulimia nervosa have been studied in numerous controlled studies. Cognitive-behavior therapy, based on the cognitive model of eating disorders (see Section 6.29.8.6), has been shown to be the most effective therapy. For the present, it must be the treatment of choice for bulimia nervosa. A detailed manual was developed by Chris Fairburn (see, e.g., Fairburn, 1997a) focusing on disrupted eating behavior, the cognitive distortions concerning body shape and weight, and the long-standing negative self-evaluations of subjects with eating disorders. In about twenty 50-minute sessions over 20 weeks, the patient learns to eat and think more normally.

After the therapy, a reduction in binge and purge frequency of about 80% has been observed and about 55% of the patients stopped bingeing altogether (Fairburn, 1995; Wilson, 1996a). The patients also show more normal attitudes towards their body shape and weight. In one study, patients were followed for a period of six years. The long-term results are also favorable: after six years there is virtually no relapse (Fairburn et al., 1995). Cognitive-behavior therapy for eating disorders in fact is a multicomponent treatment package including, among others, self-control techniques, self-monitoring, education, diet management, cognitive restructuring, problemsolving training, interpersonal training, and relapse prevention. A relevant question of course is: which of these treatment components are necessary to effect positive response? For researchers on eating disorders, the time is here, now to identify the effective parts of cognitivebehavior therapy as well as to identify the mechanisms of action, that is, the mechanisms by which the effective treatment parts achieve changes. There has been one treatment that may be as effective as cognitive-behavior therapy: interpersonal psychotherapy (Fairburn, 1997b). During this short-term focal psychotherapy, little attention is paid to the eating disorder symptoms, instead the treatment focuses on the identification and modification of current interpersonal problems. In the long run, interpersonal therapy proved to be as effective as cognitive-behavior therapy. The idea is that the treatment is successful because it improves interpersonal functioning and thereby selfworth, meaning that self-evaluation is less dependent on body shape and weight, which makes dieting less necessary and so the eating disorder gradually erodes (Fairburn, 1997b). However, the assumed mechanism by which the treatment brings about change still has to be studied, and more controlled trials are needed before any firm conclusions about the robustness of the effects can be drawn. A rather new and promising approach is the cognitive-behavioral body image therapy (Rosen, Reiter, & Orosan, 1995). Considering the fact that the severity of concerns about shape and weight at the end of treatment are related to the likelihood of relapse (Fairburn et al., 1993), it is argued that maintenance of recovery without significant body image changes will be a continuous struggle (Rosen, 1995). The body image therapy is divided into two parts: (i) cognitive restructuring, and (ii) exposure. During the cognitive part, subjects keep a body image diary in which they record situations that provoke concerns about appearance, body

In Conclusion

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image beliefs, and the effect of both on mood and behavior. Irrational, dysfunctional thoughts about the body and damaging beliefs concerning self-worth are challenged and restructured. Furthermore, the patient gradually exposes herself to a hierarchy of distressing aspects of appearance, and during the exposure the goal is to change negative self-talk in nonjudgmental self-descriptions (Rosen, 1995). A further goal is to reduce or prevent body-checking behavior. Body image therapy has been shown to be effective (Rosen, 1995), but it is surprisingly infrequently applied. Medication for bulimia nervosa has mainly focused on the use of antidepressant drugs. Considering binge frequency, the drugs establish a reduction in binge frequency of about 60% with an abstinence rate of 22% (percentage of subjects that stopped binge eating completely). However, the effects are only maintained when subjects remain on the drugs. When medication is stopped, recurrence of binge eating is frequently seen, so the maintenance of change is poor (Fairburn, Agras, & Wilson, 1992). Furthermore, it seems that the drugs do not influence attempts to diet, cognitive distortions concerning body shape and weight, nor the longstanding negative self-evaluations of subjects with bulimia nervosa. Moreover, comparative trials show that cognitive-behavior therapy is superior to medication, and a combination of medication and cognitive-behavior therapy is not convincingly more effective than cognitivebehavior therapy alone (Wilson, 1996a).

fulfilling (Smith, Marcus, & Kaye, 1992; Wilson, 1994). Binge eaters may also benefit from cognitive-behavioral self-help treatment manuals (Cooper, 1995b; Fairburn, 1995a). In a couple of studies they have proved to be an effective treatment method to combat binge eating. They can be used independently by sufferers on their own, or with guidance from a nonspecialist therapist (Fairburn, 1997a; Fairburn & Carter, 1997). Finally, there are preliminary data pointing to cue exposure as a successful method for the treatment of binge eating (Jansen, in press; Jansen, Broekmate, & Heymans, 1992). In vivo exposure with response prevention is a therapy which has been successfully applied for many years in the treatment of anxiety disorders. Subjects are repeatedly exposed to the stimuli they are afraid of, and during the exposure their anxiety gradually extinguishes. From the learning model on binge eating (see Section 6.29.8.5), it follows that the urge to binge will also be extinguished during exposure to the cues which predict a binge. By repeatedly exposing patients for long periods to the stimuli that predict a binge with response prevention (eating is not allowed), the stimuli eventually lose their predictiveness. Once the stimuli are no longer predictors for a binge, there is no point in preparing the body for consumption. The preparatory physical reactions no longer occur and the urge to binge has disappeared. The data from five, largely uncontrolled and small-scale studies are promising (see Jansen, 1998).

6.29.9.3 Obesity and Binge Eating Disorder

6.29.9.4 Predictors of Treatment Outcome

Obesity has, so far, proved to be refractory to most treatment methods (Wilson, 1994). The behavioral weight loss programs, which are focused on dieting and self-control strategies, produce short-term weight loss but are ineffective in the long run. Recently, Wilson (1996b) has argued that the narrow focus on weight loss only may no longer prove acceptable, and he proposes a change of treatment goals. He argues that treatment of the obese should focus on the enhancement of self-acceptance, predicting that increased self-acceptance of the obese might lead to more lasting changes in eating and exercise behavior. Treatment of the binge eating disorder has been studied only minimally. Cognitive-behavior therapy appears to be partly effective for patients suffering from a binge eating disorder. Loss of weight is not achieved, but no more weight is gained, binge frequency decreases, mood improves, dissatisfaction with the body decreases, self-esteem increases, interpersonal skills improve, and marriages become more

An important clinical issue is whether it can be predicted who will respond to treatment. However, reliable predictors of treatment outcome have not yet been identified. In some but not all studies, weight, premorbid and paternal obesity, self-esteem, personality disorders, and binge eating have been identified as predictor variables (Wilson, 1996a). These studies show that the worst outcome is found in subjects with lower weight, higher premorbid and paternal weight, lower self-esteem at the start of the treatment, comorbid borderline personality disorders, an early onset of binge eating, and more severe binge eating. However, the data on these negative prognostic factors are not conclusive; more and better research is needed. 6.29.10 IN CONCLUSION The eating disorders anorexia nervosa and bulimia nervosa are characterized by: (i) abnormal eating behavior, (ii) the use of unusual methods to control weight, and (iii)

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irrational and dysfunctional ideas about the patient's own body and weight, leading to negative self-evaluation. Because the patients feel fat and are afraid to gain weight, they continually strive to lose weight. In the case of anorexia nervosa, this results in a decrease in weight of at least 15% compared with the person's normal weight. People with bulimia nervosa usually have a normal weight, often because of binges that regularly disrupt attempts to lose weight. During binges, considerable quantities of food are consumed, and after the binge the patient vomits, uses laxatives, or starts extreme dieting. Weight control measures of this type are partly effective: the patient gains virtually no weight. However, they do not prevent some of the food from being absorbed by the body, as a result of which the patient does not lose an extreme amount of weight. Obesity is not an eating disorder as presently defined, but a subgroup of the obese is found to fulfill the criteria of the binge eating disorder. Like subjects with bulimia nervosa, they are characterized by objective binges during which they eat a large amount of food and lose control over intake. However, contrary to subjects with bulimia nervosa, they do not engage in the characteristic compensatory purging behaviors of bulima nervosa. It is (as yet) unknown how the eating disorders originate. A number of influential theories have been discussed here. There is evidence for a genetic component in anorexia nervosa and obesity, but not in bulimia nervosa. However, what exactly is inherited is still unknown. The ªperfect-figureº culture appears to be more of an explanation for the common dieting among women. This does not explain the origin of eating disorders because ªonlyº a fraction of the dieters (9%) develop an eating disorder. Dieting is related to binge eating; however, their cause and effect relationship is unclear. Empirical data show that dieting is not necessarily required for binge eating to occur, and it is also clear that dieting is not sufficient for eating disorders, including binge eating, to occur. The serotonin hypothesis offers an explanation for the isolated act of bingeing and for the coherence between eating disorders and depression. Too little serotonin in the brain is said to result in a virtually uncontrollable craving for carbohydrates and low mood. Eating an excessive amount of carbohydrate is said to restore the serotonin level in the brain and, as a type of ªself-medication,º to improve mood. Empirical findings suggest that patients with bulimia nervosa do in fact have a brain serotonin deficit. However, other psychological

disorders may also be accompanied by a lack of serotonin. Moreover, it has been repeatedly shown that the food patients with bulimia nervosa consume during a binge does not contain more carbohydrates than either the food they consume between binges or the food consumed by a normal control group, findings which do not support the self-medication hypothesis. Various experimental findings suggest that overeating is a learned behavior. Predictors or cues of excessive eating trigger a craving for food for as long as they continue to predict a binge, meaning as long as they are systematically followed by excessive food consumption. They will always trigger a physical preparatory response which is experienced as craving or an urge to eat. The model is confirmed post hoc by a variety of findings, but there is no direct empirical evidence that supports this theory on the origin of binges. Irrational cognitions concerning one's body shape, weight, eating, and food are characteristic for patients with anorexia and bulimia nervosa. The precise role they play in the etiology and maintenance of the eating disorders is, however, as yet unknown. In terms of the proposed cognitive origin of binge eating, it appears at this time that binges do not automatically follow irrational disinhibiting thoughts, for example, ªmy day is ruined anyway, I may as well continue to eat.º Despite the fact that little is known about the exact causes of eating disorders, bulimia nervosa can be effectively treated. Cognitive behavioral therapies are the most successful methods. They have a behavioral and a cognitive component; the focus is on both learning to eat normally and changing irrational thinking (about body shape and weight as well as food intake). New cognitive-behavioral approaches such as the exposure to binge provoking cues as well as the exposure to appearance, are promising and need to be studied further. The treatment of obesity is disappointing; most treatment methods are ineffective in the long run. Obese binge eaters may benefit from cognitive-behavior therapy; although weight loss is not achieved, weight gain is prevented, binge frequency decreases, and well-being improves. Finally, less is known about the effectiveness of treatments for anorexia nervosa: unfortunately, to date, virtually no properly controlled studies have been performed. 6.29.11 REFERENCES Agras, W. S. (1990). Is restraint the culprit? Commentary. Appetite, 14, 111±112.

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