Evidence-based Interventions in Social Work: A Practitioner's Manual 9780398078539, 9780398078546

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EVIDENCE-BASED INTERVENTIONS IN SOCIAL WORK

EVIDENCE-BASED INTERVENTIONS IN SOCIAL WORK A Practitioner’s Manual By

JOHN S. WODARSKI, PH.D. Professor College of Social Work The University of Tennessee and

MARVIN D. FEIT, PH.D. Professor and Dean Ethelyn R. Strong School of Social Work Norfolk State University

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CHARLES C THOMAS • PUBLISHER, LTD. 2600 South First Street Springfield, Illinois 62704

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© 2009 by CHARLES C THOMAS • PUBLISHER, LTD. ISBN 978-0-398-07853-9 (hard) ISBN 978-0-398-07854-6 (paper) Library of Congress Catalog Card Number: 2008042414

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Library of Congress Cataloging-in-Publication Data Wodarski, John S. Social work: a practitioner’s manual / by John S. Wodarski and Marvin Feit. p. cm. Includes bibliographical references and index. ISBN 978-0-398-07853-9 (hard) -- ISBN 978-0-398-07854-6 (pbk.) 1. Psychiatric social work. 2 Evidence-based social work. 3 Social service-Psychological aspects. Feit, Marvin D. II. Title HV689.W627 2009 362.2’04251--dc22 2008042414

CONTENTS Chapter

Page I. CHILDREN AND ADOLESCENTS

1. Evidence-Based Interventions in Social Work: A Practitioner’s Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Developmental Disabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3. Conduct Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4. Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . . . 33 5. Oppositional Defiant Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 6. Enuresis and Encopresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 7. Separation Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 8. Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 9. Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 II. ADULTS 10. Generalized Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 11. Alcohol Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 12. Polysubstance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 13. Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 14. Major Depressive Disorder and Dysthymic Disorder. . . . . . . . . . . . 157 15. Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 16. Panic Disorder with Agoraphobia . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 17. Specific and Social Phobias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 18. Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 19. Post-traumatic Stress Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 20. Borderline Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

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III. BRIEF CASES 21. Teen Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 22. Opiate Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 23. Polysubstance Abuse in Teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 24. Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 25. Teen Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 26. Teenage Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 27. Oppositional Defiant Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 28. Antisocial Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 29. Physical Disability 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 30. Physical Disability 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 31. Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

EVIDENCE-BASED INTERVENTIONS IN SOCIAL WORK

I. CHILDREN AND ADOLESCENTS

Chapter 1 EVIDENCE-BASED INTERVENTIONS IN SOCIAL WORK: A PRACTITIONER’S MANUAL

E

vidence-Based Interventions in Social Work: A Practitioner’s Manual centers on the factorial complexity of planning interventions with major client groups. Monumental economic and political forces are reshaping the way medical, mental health, and social services are delivered in the United States. Our roles as social workers in the evolving systems of care must address the critical questions that have been generated by the empirical practice research. These questions are: Who should deliver the intervention to whom, what intervention is the most effective with which clients, where and at what level should the intervention take place, when should the intervention occur, how long should the intervention continue; and how is behavior change maintained (relapse prevention, medication)? Short-term goals, long-term interventions, and short-term outcomes are detailed, as are long-term goals, long-term interventions, and long-term outcomes, and the interaction between these variables and medication (Long, Homesley & Wodarski, 2007). WHO SHOULD DELIVER THE INTERVENTION AND TO WHOM?

Empirical research indicates a number of worker variables, such as social class, race, ethnicity, religion, age, sex, and verbal skills, related 5

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to therapeutic outcome (see Beutler, Machado & Neufeldt, 1994). One practice generalization taken from the literature is that differences between clients and workers should be minimal, and therefore matching client and worker demographic variables enhances effectiveness (Harrison, Wodarski & Thyer, 1992; Thyer, Meyers, Wodarski & Harrison, in press). Beutler and colleagues (1994) suggested that future research must concentrate on more complex worker variables, such as cultural attitudes, coping patterns, therapeutic style, and directiveness. In addition, advanced client variables such as client expectations and attitude toward therapy, must be delineated (Garfield, 1994). What type of worker intervenes most effectively with which type of client and with which type of problem presents a challenge to researchers and therefore to practitioners. Also of importance is what level of training is necessary to deliver which interventions (e.g. paraprofessional, or a bachelor’s or master’s degree in social work) (Wodarski, in press). WHAT INTERVENTION IS THE MOST EFFECTIVE WITH WHICH CLIENTS?

Perhaps not for every client with a particular difficulty and perhaps not the point of complete resolution or cure, but for many problems we are now in a position to offer effective professional social work services. The American Psychiatric Association (APA), the American Psychological Association, and the National Association of Social Workers (NASW) are busy at work developing practice guidelines that contain guidance as to what treatments are indicated first for particular problems. The American Psychological Association is carefully compiling psychosocial interventions that work for particular disorders (see Sanderson & Woody, 1995), and this information will have an increasing influence on the conduct of practice. Contrary to Witkin’s (1991) nihilistic view that virtually any intervention can be justified on the grounds that it has as much support as alternative methods have (p. 158), numerous outcome studies comparing various forms of psychosocial treatment regularly find that certain types of interventions work better than others do for particular problems. (Consult any recent issues of Research on Social Work Practice, the Journal of Consulting and Clinical Psychology, the Journal of Evidence-

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Based Social Work, or the Archives of General Psychiatry for evidence of this contention.) Yet, the interventions in the studies cited are not effective with all clients. Clients are heterogeneous, even when they have the same disorders, ethnicities, or religious backgrounds. Consequently, the advanced research question would be to examine treatment effectiveness within groups and among groups, asking questions such as whether cognitive-behavioral treatments work as effectively with a white woman who has obsessive-compulsive disorder as they do with a black man with the same disorder? WHERE SHOULD THE INTERVENTION TAKE PLACE AND AT WHAT LEVEL?

Few empirical studies have delineated the parameters or criteria for determining whether interventions are more effective in particular settings or at particular levels. Interventions can be delivered in multiple settings (i.e. inpatient hospital, outpatient clinic, criminal justice setting, home, etc.). Does the setting have an impact on the intervention? Do some interventions become more effective or weaker in certain locations. Even fewer studies have concentrated on the level of practice appropriate for intervention delivery. Is individual, family, group, or community-level treatment best for achieving change in a given situation? Should a combination of levels be utilized? Criteria need to be developed concerning who can benefit from what level of treatment in which locale. Such knowledge will only be forthcoming when adequately designed research projects are executed in which clients are randomly assigned to varying levels of treatment to control for confounding factors, such as type of behavior, age, gender, ethnicity, academic, and intellectual and social abilities. WHEN SHOULD THE INTERVENTION OCCUR?

Intervention timing is a particularly relevant question for the complex problems clients present to practitioners. Comorbidity, which has been identified as the rule rather than the exception (Bierderman, Faranone, Mick & Lelon, 1995; Clarkin & Kendall, 1992), compounds the delivery of effective interventions. Should depression be treated

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before conduct disorder and alcohol abuse after anxiety, or should they be addressed simultaneously? Empirical research needs to ascertain the most effective timing for interventions and how timing may vary for different clients. HOW LONG SHOULD THERAPY CONTINUE AND HOW DO WE ADDRESS MAINTENANCE OF CHANGE?

A substantial number of evaluative studies have been produced in the last three decades that have had a profound impact on traditional therapeutic practice. In the past, therapy was considered to be a long and involved process. Current trends, however, indicate that the optimal number of outpatient service visits is between eight and sixteen, with the maximum being twenty. Inpatient services should consist of ten, twenty-one, or thirty days. Current research indicates that brief directive interventions have a consistent outcome advantage in the treatment of a multitude of disorders (Giles, Prial & Neims, 1993). However, since disorders differ, research studies need to continue to identify how long interventions need to continue to provide substantial improvement in clients. Once treatment has concluded, how are gains perpetuated? Will booster sessions be utilized? If so, how often and when? Considerable study is needed to delineate those variables that facilitate the generalization and maintenance of behavior change. Such procedures will be employed in future sophisticated and effective social service delivery systems. Each chapter includes a case study for illustration purposes. We begin by choosing a short-term goal for the client. Research indicates that picking one appropriate, attainable goal will help ensure the participation of the client. Short-term client interventions should be selected based on empirical data and evaluated appropriately. For example, if the goal is to obtain employment, the intervention might be Azrin’s classic Job-Club Program (Azrin, 1977) with the outcome being to secure employment. If managed-care companies will provide support, short-term and long-term goals can be developed, long-term interventions can be implemented, and long-term outcomes can be evaluated. For example, if a client is suffering from a phobia, relaxation and systematic desensitization provide the interventions, and the outcome is the reduction of the phobia.

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An evidence-based approach to social work practice is not only economically demanded in this day of managed care but also ethically imperative. We endorse this approach and provide our readers the latest of practice research findings. Each chapter is geared toward enabling social work practitioners to incorporate these findings to provide competent and timely evidence-based services. REFERENCES Azrin, N.H. (1977). Job-finding club: A group-assisted program for obtaining employment. Rehabilitation Counseling Bulletin, 21, 130–139. Beutler, L.E., Machado, P.P., and Neufeldt, S.A. (1994). Therapist variables. In A. E. Bergin and S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change (pp. 229–269). New York: John Wiley & Sons. Bierderman, J., Faranone, S., Mick, E., and Lelon, E. (1995). Psychiatric comorbidity among referred juveniles with major depression: Fact or artifact? Journal of the American Academy of Child and Adolescent Psychiatry, 24, 579–590. Clarkin, J., and Kendall, P. (1992). Comorbidity and treatment planning: Summary and future directions. Journal of Consulting and Clinical Psychiatry, 60, 904–908. Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin and S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change (pp. 190–228). New York: John Wiley & Sons. Giles, T. R., Prial, E. M., and Neims, D. M. (1993). Evaluating psychotherapies: A comparison of effectiveness. Special series: Evaluation in treatment methods in psychiatry: 3. International Journal of Mental Health, 22, 43–65. Harrison, D. F., Wodarski, J. S., and Thyer, B. A. (1992). Cultural diversity and social work practice. Springfield, IL: Charles C Thomas. Long, K., Homesley, L., and Wodarski, J. S. (2007). The role for social workers in the managed health care system: A model for empirically based psycho-social intervention. In B. A. Thyer and J. S. Wodarski (Eds.), Social Work in Mental Health: An Evidenced-Based Approach. Hoboken, NJ: John Wiley & Sons. Sanderson, W. C., and Woody, S. (1995). Manual for empirically validated treatments: A project of the Task Force on Psychological Intervention, Division of Clinical Psychology, American Psychological Association. The Clinical Psychologist, 48, 7–11. Thyer, B. A., Meyers, L., Wodarski, J. S. and Harrison, D. F. (in press). Cultural diversity and social work practice, 3rd ed. Springfield, IL: Charles C Thomas. Thyer, B. A., and Wodarski, J. S. (1998). Handbook of Empirical Social Work Practice, Vol. 1: Mental Disorders. New York: John Wiley & Sons. Witkin, S. L. (1991). Empirical clinical practice: A critical analysis. Social Work, 36, 158–163. Wodarski, J.S. (in press). Behavioral Medicine for Social Work Practice. New York: Taylor & Francis.

Chapter 2 DEVELOPMENTAL DISABILITIES

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ental retardation is a syndrome that embodies a final universal pathway produced by a variety of factors that injure the brain and affect its normal development (Andreasen & Black, 2006). Mental retardation (MR) is defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR) (APA, 1994), as having three major characteristics. The first characteristic is a significant deficit in intellectual or cognitive functioning. The second characteristic is having a significant deficit in adaptive behavior, and the third is that these deficits must be present during the developmental period of the individual’s life prior to the age of eighteen. The DSMIV-TR requires all three criteria to be present in order for an individual to be diagnosed with MR (Gerdtz & Bregman, 1998). There has been considerable discussion of the appropriateness and future use of the term “mental retardation.” Advocates and others (see the summary in Thyer & Wodarski, 2007, p. 49) argue that the term is both obsolete and degrading. Alternative terminology, such as intellectual disabilities and cognitive disabilities, has been proposed, and in many other countries (e.g. the United Kingdom, Australia, New Zealand) mental retardation is not accepted as appropriate terminology, and intellectual or cognitive disabilities is the accepted term. In August 2006, members of the American Association on Mental Retardation (AAMR) voted to change the name of the organization to the American Association on Intellectual and Developmental Disabilities (AAIDD). Note: Case study by Heather Daniels and Christy Swansbrough.

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According to the APA and the DSM-IV-TR, the most common tool utilized to test an individual for the first criteria (i.e. deficit in intellectual or cognitive functioning) is a standardized intelligence test, otherwise known as an intelligence quotient (IQ) test such as the Wechsler Intelligence Scales for Children (3rd ed.), the Stanford-Binet (4th ed.), or the Kaufman Assessment Battery for Children (APA, 2000). The DSM-IV-TR (APA, 2000) defines MR as being two standard deviations below the mean score for IQ, which usually is an IQ of 70 or below. It should be pointed out that the standard effort for IQ tests is approximately 5 points, which may vary from instrument to instrument (APA, 2000). Therefore, it is possible to diagnose MR in an individual with an IQ of 70 to 75 if the individual meets the second criterion (Andreasen & Black, 2006). The second criterion, deficits in adaptive behavior, must also be met in order to properly diagnose an individual with MR. Adaptive behaviors are defined as the skills needed to cope with everyday demands of life that are common to the individual’s age group (Beirne-Smith, Ittenbach & Patton, 2002). Some examples of adaptive behaviors include tying shoes, potty training, and feeding oneself. Standardized testing is used to determine adaptive deficits along with information regarding the individual’s birth and, medical, developmental, and educational histories, which are gathered from family members, teachers, and physicians (Gerdtz & Bregman, 1998). Once an individual is diagnosed with MR, a level of severity is identified that typically determines the functionality of the individual and the future quality of life (Beirne-Smith et al., 2002). The most common level of severity is Mild Mental Retardation which accounts for around 85 percent of individuals with MR and is classified as having an IQ range from 50 or 55 to 70. Moderate mental retardation accounts for around 10 percent of individuals with MR and is classified as having an IQ range of 35 or 40 to 50 or 55. Severe mental retardation, accounts for around 3 to 4 percent of individuals with MR and is classified with an IQ range of 20 or 25 to 35 or 40. Profound mental retardation accounts for around 1 to 2 percent of individuals with MR and is classified as having an IQ range below 25 or 20. The last level of MR is, severity unspecified; this diagnosis is given to the individual when there is a good reason to presume a diagnosis of MR, but the individual cannot be assessed using the standardized testing methods (Gerdtz & Bregman, 1998).

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The causes of MR are many, and, regardless of the assessment tools utilized, the etiology is never known in 30 to 40 percent of diagnosed individuals. In those individuals with clear etiologies, the most common cause of MR is environmental factors, which include nutritional deficits and the absence of physical, social, language, and educational stimulation. Other causes of MR include genetic conditions such as Down syndrome and fragile X syndrome; genetic defects account for around 5 percent of individuals with MR. Alcohol consumption and substance use during pregnancy are also known causes for MR and account for around 30 percent of individuals with MR. Trauma, infection, and other difficulties in pregnancy have also been identified as causes of MR, accounting for around 10 percent. Lastly, medical problems during infancy and early childhood, such as exposure to toxins or injuries, account for around 5 percent of individuals with MR. Overall, the prevalence rate for individuals with MR is less than 3 percent of the population of those accounted for in the school systems (Smith, 2004). The differential diagnoses for MR are complex due to the frequent comorbidity of childhood disorders; the differential diagnoses include attention deficit/hyperactivity disorder (ADHD), learning disorders, autism, and childhood psychoses (Andreasen & Black, 2006). Children and adolescents with MR have been found to be at a higher risk of psychiatric comorbid disorders such as ADHD and depression (Filho et al., 2005). For many children and adolescents with MR periodic intellectual evaluations will be beneficial in determining educational needs and placements. Studies are inconclusive regarding whether or not students with MR benefit more from placement in regular school programs (mainstreaming) or in special settings tailored to meet their specific intellectual needs. Mainstreaming, however is the current trend (Andreasen & Black, 2006). When referring to a person with a disability it is considered appropriate to place the person before the disorder, for example, “an individual with MD or with ADHD” versus the “mentally retarded person” (Kauffman, 2001).

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CASE STUDY

The Client Cathy is a fifteen-year-old white female who was diagnosed in kindergarten as having mild MR with an IQ of 68. Cathy lives with both of her parents and two siblings in a midsize metropolitan area. Cathy’s older brother Thomas is seventeen years old, and her sister Kate is twelve years old. Cathy’s parents have a healthy marriage and are very supportive and involved in their children’s lives. Cathy is a sophomore in high school. She attends some regular classes and is involved in the special education program. Cathy enjoys drawing and painting and is in the Art Club, which meets once per week and enters its work into local art contests. Cathy is high functioning and plans on getting a job at Wal-Mart when she turns sixteen next year. Cathy has several close friends at school and is well-liked by her peers. She has recently been dating a senior student, Cody, who is also in special education. Since her parents do not allow her to go on dates with Cody, Cathy has been sneaking out at night to see him. Cathy and Cody are sexually active but have not told anyone. Cathy’s parents noticed that she has not been eating normally and has been feeling nauseous in the mornings. They took her to her pediatrician for a physical exam because of their concern with her declining health. After questioning Cathy without her mother in the room, Cathy disclosed her sexual activity to the doctor. The pediatrician then ordered a pregnancy test, which came back positive. Cathy’s parents were made aware of the situation and are being supportive. After the news of the pregnancy, Cathy began to show other changes that are not typical for a woman who is pregnant. She was referred to the school social worker by her resource teacher and principal for changes in her behavior over the previous two weeks. Cathy appears sad, cries in the bathroom, and wanders off during lunchtime. Her resource teacher has also noticed that Cathy has not been able to concentrate as usual and seems to lack any energy to participate in class. Cathy does not want to go to the Art Club and has no interest in any leisure activities. She has also been more agitated with her siblings and parents and has reported some sleep disturbances.

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The Worker The worker has achieved a bachelor’s or master’s-level degree in social work, both of which should have included clinical experience working with individuals with developmental disabilities, and should be familiar with the adolescent population. The school social worker will participate in individual and group therapy with Cathy in addition to home visits. A male or female could work with the client, but a female would be preferable for Cathy because of her gender and pregnancy. Other professionals working with Cathy will consist of teachers, doctors, nurses, and community agencies. Assessment Cathy’s treatment will initiate with the assessment process. Cathy has been diagnosed with mild MR, so an assessment to determine diagnosis and eligible services is not needed. The assessments implemented will be used to plan clinical interventions for Cathy and her family. After receiving the referral from the resource teacher and principal, the school social worker will do a thorough intake assessment on Cathy, which will include basic demographic information, living arrangements, employment, previous treatments and hospitalizations, and medications. Feelings of depression, anxiety, anger, and thoughts of suicide are rated on a scale. The presenting problem is identified from the client’s and significant others’ perspectives. Social and family supports, leisure information, parental relationship information, and legal issues are also included. The Beck Youth Inventories for Children and Adolescents will be given to Cathy to assess her situation and her perceived level of family support. This inventory consists of the regular inventory tailored for adolescents and children. A complete assessment would include the family functioning, so the Beck Depression Inventory is administered in conjunction with the Home Observation for the Measurement of Environments (HOME) scale (Gerdtz & Bregman, 1998). The Beck Depression Inventory is administered to Cathy’s parents during a home visit to assess the family situation and support. The HOME observational scale is helpful for assessing the home environment of the child with developmental disabilities (Gerdtz & Bregman, 1998). The assessment process gives the therapist a basis to begin Cathy’s treatment plan.

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Behavior Definition Developmental disability is a diagnosed condition that needs attention and has an impact on daily living. Cathy was diagnosed with mild MR in kindergarten. Cathy lives with both of her parents and two siblings in a medium-size metropolitan area. She is a sophomore in the city high school and also involved in special education classes. Cathy’s pregnancy is from a short-term relationship with her boyfriend Cody. The relationship with the father of the baby is ongoing and supportive. Cathy has a desire to complete the pregnancy but with feelings of confusion and anxiety regarding the future. There is some denial regarding the implications the pregnancy brings to current and future life. Cathy’s parents are very involved and supportive. She is currently experiencing six symptoms of depression: lack of concentration, loss of energy, loss of interest, depressed mood, agitation, and sleep disturbances. TREATMENT PLAN

Intervention The treatment plan is based on information from Wodarski, Wodarski, and Dulmus (2003) and from Wodarski, Rapp-Paglicci, Dulmus, and Jongsma (2001) and will be implemented over the duration of therapy. Therapy for Cathy will be a holistic approach consisting of individual therapy, group therapy, and home visits. Cathy will receive individual therapy two times a month for one hour. The individual therapy will take place at the high school where she is enrolled. The most common respondent conditioning technique implemented for persons with developmental disabilities is relaxation (Gendtz & Bregman, 1998). Therapy will utilize poetry and drawing activities. The social worker’s office will be private, familiar, and easy to access. The individual therapy will continue as needed after the birth of Cathy’s child. Cathy will also be required to attend a Teen Able group that meets once a week at school. The group is mandatory for teen mothers and pregnant teens enrolled at her school. Although the group is mandatory it will be a great opportunity for peer support and psychoeducation. As students get older, the odds of a friendship between nondis-

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abled students and students with developmental disabilities diminishes, so the group will provide for Cathy’s interaction with other students (Smith, 2004). The group will meet in a conference room affording privacy, space and available supplies. The cotherapists will be the school social worker, with whom Cathy will be very familiar, and a social worker from a local mental health community agency. The outside cotherapist will provide information about community resources and pregnancy. The client will attend the group until eighteen months after her delivery and will then receive the option to either continue or not. In addition to individual therapy and group therapy, the school social worker will do a home visit once a month. The home visit will allow the school social worker a systems perspective and the opportunity to speak with Cathy’s family. All of the services provided to Cathy through the school will be free of charge since she is a student at the high school. Long-Term Goals To obtain access to medical and psychological care from available community resources. 1. To learn effective coping skills 2. To obtain prenatal care consistently until delivery 3. To remain in school during her pregnancy 4. To continue the education programs provided through the school and community during pregnancy 5. To learn effective parenting skills through modeling and plenty of learning trials 6. To use birth control upon completion of pregnancy Long-Term Interventions 1. To partner with Cathy’s parents in setting up prenatal care 2. To train parents in reinforcement and operant techniques 3. To provide services for a developmental disability 4. To arrange services through local community mental health and employment services 5. To partner with parents, teachers, and school administration to continue Cathy’s education

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Short-Term Goals 1. Identify Cathy’s feelings about pregnancy 2. Involve Cathy’s parents in the decision-making and counseling process 3. List options and expected consequences for each response 4. Attend individual and group counseling sessions to help cope with the stress 5. Attend home visits with school social worker and family 6. Access medical and prenatal care on a consistent basis 7. Verbalize realistic expectations for life after delivery 8. Alleviate depression and anxiety through medications and therapy Short-Term Interventions 1. Explore more of the facts and Cathy’s feelings related to her becoming pregnant 2. Explore the future with the father and Cathy’s family 3. Provide Cathy with a range of options regarding her pregnancy (i.e. adoption, keeping the baby, abortion) 4. Teach Cathy problem-solving techniques 5. Discuss advantages of counseling with Cathy: refer to individual, group, and home visits 6. Refer Cathy for prenatal and medical care 7. Provide parenting education for Cathy and her parents if she decides to keep the baby 8. Assist Cathy in setting realistic post-pregnancy goals considering her condition 9. Review with Cathy the options and resources for emotional and child care support 10. Refer Cathy to psychiatrist for prescribing and monitoring of medications Medications Several medications can be given to individuals suffering from depression: tricyclics and other related compounds; monamine oxidase inhibitors (MAOIs); selective serotonin reuptake inhibitors (SSRIs) and structurally unrelated drugs, such as bupropion hydro-

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chloride (Wellbutrin®) and mirtazapine (Remeron®). These medications operate by “altering levels of various neurotransmitters at crucial nerve terminals in the central nervous system” (Andreasen & Black, 2006). These medications are largely similar in their effectiveness and from 65 to 70 percent of individuals who take antidepressants will show marked improvement (Andreasen & Black, 2006). However, there is much controversy surrounding the use of antidepressants on children and adolescents. According to Waters (2000), none of the adult antidepressants that are routinely prescribed have been approved by the FDA as safe and effective for depressed children. However, 72 percent of pediatricians and family doctors admit to prescribing antidepressants to children or adolescents, although only eighty-five of those surveyed believed that they were adequately trained in the management of childhood depression. Managed care may play a part in the prescribing of antidepressants to children and adolescents because some managed care companies demand that medication be prescribed within twenty-four hours upon admission to a hospital or they may deny psychotherapy for children and adolescents suffering from depression (Waters, 2000). Cathy has not been on any medications for MR because there are no medications specifically designated for mild MR. She has been identified as having depression, but due to the risks associated with adolescents and antidepressants and also the risks with her pregnancy, medication will not be administered at this time. If therapy is not adequate to alleviate her symptoms, Cathy will be seen by a psychiatrist to prescribe an appropriate medication. Bupropion has been found to be one of the safer antidepressants for treatment of depression in women who are pregnant and may be an option for her (WebMD, 2006). Relapse Prevention Cathy was born with a developmental disability. Although there are no preventive measures for her disability, there are measures to prevent Cathy from becoming pregnant again. Educating Cathy and her family will help them care for Cathy and provide positive support. Cathy will attend abstinence-plus education seminars at a local community agency. The abstinence-plus program teaches not only about abstinence but also effective contraceptive methods. The school social

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worker will train Cathy in problem solving and decision making so she will be able to make choices and understand the consequences of those choices. Cathy may not need to see the school social worker twice a month after the birth, but therapy will be continued once a month to discuss stressors and problems. After Cathy’s delivery, she will use proper birth control methods to prevent an unwanted pregnancy. She will also remain involved with the local community recreation program for social activities with other individuals with developmental disabilities. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Andreasen, N.C., and Black, D.W. (2006). Introductory Textbook of Psychiatry (4th ed.). Washington, DC: American Psychiatric Publishing. Beirne-Smith, M., Ittenbach, R.F., and Patton, J.R. (2002). Mental Retardation (6th ed.). Columbus, OH: Merrill Prentice Hall. Filho, A.G.C., Bodanese, R., Silva, T.L., Alvares, J.P., Aman, M., and Rohde, L.A. (2005). Comparison of risperidone and methylphenidate for reducing ADHD systems in children and adolescents with moderate mental retardation. Journal of American Academy for Children and Adolescent Psychiatry, 44, 748–755. Gerdtz, J. and Bregman, J. (1998). Mental retardation. In B.A. Thyer and J.S. Wodarski (Eds.), Handbook of Social Work Practice. Hoboken, NJ: John Wiley & Sons. Kauffman, J.M. (2001). Characteristics of Emotional and Behavioral Disorders of Children and Youth (7th ed.). Boston, MA: Pearson Education. Smith, D.D. (2004). Introduction to Special Education: Teaching in an Age of Opportunity (5th ed.). Boston, MA: Pearson Education. Thyer, B.A., and Wodarski, J.S. (Eds.) (2007). Social Work in Mental Health: An Evidence-Based Approach. Hoboken, NJ: John Wiley & Sons. Waters, R. (2000). Generation RX. Family Therapy Networker, 35–45. WebMD. (2006). Structurally unrelated drugs [Online]. Retrieved on December 6, 2006. Available: http://www.webmd.com/content/Article/87/99353.htm?/page=5. Wodarski, J.S., Rapp-Paglicci, L.A., Dulmus, C.N., and Jongsma, A.E. (2001). The Social Work and Human Services Treatment Planner. New York: John Wiley & Sons, Inc. Wodarski, J.S., Wodarski, L.A., and Dulmus, C.N. (2003). Adolescent Depression and Suicide: A Comprehensive Empirical Intervention for Prevention and Treatment. Springfield, IL: Charles C Thomas.

Chapter 3 CONDUCT DISORDER

A

ccording to the DSM-IV-TR (APA, 2000), general population studies report that the prevalence of conduct disorder ranges from less than 1 percent to more than 10 percent. Conduct disorder is one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children (APA, 2000). The prevalence of conduct disorder is higher among males than it is in females, but the rate in females may be increasing (Andreasen & Black, 2006). Conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. There are four major domains of relevant behavior, including aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. Conduct disorder has three codes based on the age of the individual at onset and also specifies the severity of the behaviors: Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of conduct disorder prior to age ten years. Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of conduct disorder prior to age ten years. Conduct Disorder, Unspecified Onset: age at onset is not known.

There are three levels of severity according to DSM-IV-TR (2000): Mild: few if any conduct problems in excess of those required to make the diagnosis, and conduct problems cause only minor harm to others. Note: Case study by Jason Miner, Katie Rash, and Marcy Sturgill.

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Moderate: number of conduct problems and effect on others intermediate between “mild” and “severe.” Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others. All categories are defined as a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the criteria in the past twelve months, with at least one criterion in the past six months (APA, 2000). Aggression to People and Animals 1. often bullies, threatens, or intimidates others 2. often initiates physical fights 3. has used a weapon that can cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife, gun) 4. has been physically cruel to people 5. has been physically cruel to animals 6. has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery) 7. has forced someone into sexual activity Destruction of Property 8. has deliberately engaged in fire setting with the intention of causing serious damage 9. has deliberately destroyed others' property (other than by fire setting) Deceitfulness or Theft 10. has broken into someone else's house, building, or car 11. often lies to obtain goods or favors or to avoid obligations (i.e. “cons” others) 12. has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering; forgery) Serious Violations of Rules 13. often stays out at night despite parental prohibitions, beginning before age thirteen years

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14. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) 15. is often truant from school, beginning before age thirteen years The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning and, if the individual is age eighteen years or older, criteria are not met for antisocial personality disorder. Conduct disorders have considerable comorbidity with other childhood disorders such as learning disorders, ADHD, and mood disorders. At least 10 percent of the children with conduct disorder have specific learning disorders. From 20 to 30 percent of the children who present with ADHD also meet the criteria for conduct disorder (Thyer & Wodarski, 2007). CASE STUDY

The Client Robert is a fifteen-year-old white male from a middle-class family. He had been attending a local public high school, until it became evident that his behavior was too disruptive to continue on in that environment. As a result, Robert has been suspended from school for the remainder of the semester. For the past eight months, Robert has constantly been in fights, bullied other children, stolen from other kids’ lockers, been rude to his classmates and teachers, been disobedient in class, set fires in the parking lot, and destroyed other children’s property. Robert has very few friends, and he has little disregard for the feelings of others. He seems to have only moderate trouble at home, including disobedience, fire setting, and some destruction of property. Most of his issues tend to stem from problems with peers and teachers. Robert’s actions are not excessive in number or severity, but they are persistent. For these reasons Robert has been diagnosed as having conduct disorder, adolescent-onset type, moderate unsocialized (APA, 2000). The Worker The worker is a second-year master’s-level student in clinical social work. The worker has experience working with adolescents in several

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settings, including intensive outpatient for alcohol and drug treatment, school social work, the oncology department of a children’s hospital, and legal settings within the realm of social work. The worker has taken classes on individual, as well as group counseling and has knowledge and experience with regard to many different theories within the practice of social work. This particular worker believes that, in particular, the systems theory, strengths-based perspective, motivational interviewing, behavioral modification, family therapy, and, in some cases, a dose of reality therapy tend to be best when working with adolescents. The worker also believes that pharmacotherapy can be a good mode of treatment for adolescents when necessary and when there is evidence that it works and has no harmful side effects. In the case of conduct disorder, it has been shown that behavior modification, family therapy, and pharmacotherapy are effective in treating individuals with the disorder (Searight, Rottnek & Abby, 2001). TREATMENT PLAN

The goals and interventions for Robert must address each aspect of the behavior definition. Conduct disorder has an etiology rooted in three prominent areas of the individual’s life: familial factors, psychosocial factors, and biological factors (Searight et al., 2001). If not looked at from all angles in regard to treatment, conduct disorder may eventually progress into the far more serious disorder of antisocial personality disorder. The interventions, goals, and outcomes defined for Robert were derived from a mix of behavioral modification, family therapy, pharmacotherapy, and reality-based therapy. Several of the interventions, goals, and outcomes were gathered from, or are modifications of, interventions, goals, and outcomes listed in The Social Work and Human Services Treatment Planner (Wodarski, Rapp-Pagglicci, Dulmus & Jongsma, 2001). Long-Term Goals The long-term goals set for Robert are necessarily broad and cover the full spectrum of what is hoped to be accomplished with him. 1. Terminate all illegal and antisocial behaviors. (This is the most troubling area and is thus the biggest goal in treating Robert. This

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would include all of his illegal behaviors, particularly fire setting and theft, which it is hoped will be eliminated completely.) 2. Demonstrate increased compliance with rules, sensitivity to the feelings and rights of others, control over impulses, and acceptance of responsibility for behavior. (Because Robert has had trouble adhering to rules, we hope that he will begin to understand and follow laws as wells as rules at home and in school. Through the interventions we hope that Robert will have increased his level of empathy and understanding of the needs and feelings of others. We also hope that he will cut down significantly on his impulsive behavior and accept the consequences of his behavior when he is acting out.) 3. Learn anger management skills and terminate assaultive behavior. (Since Robert has had issues in dealing with his anger, this is an area where we hope to see a large improvement.) 4. Return to school and show respect for the rules and authority figures. (Having Robert behave well enough to return to school and continue to stay enrolled in school was a primary goal for Robert and his parents. Being able to show respect for teachers and authority figures in general goes along with this as Robert had problems with teachers and other authority figures.) 5. Help parents develop appropriate expectations about adolescent behavior and learn appropriate methods to nurture, guide, and discipline children. (Robert is still learning behaviors from his parents, and it is important that his parents are modeling and upholding the right behaviors. It is therefore highly important that his parents develop the skills and behaviors through the classes and groups they attend to help Robert create positive and upstanding behaviors.) 6. Help ensure that Robert continues to take his medication regularly if it was deemed an appropriate method of helping Robert with his conduct disorder. (If the medication is successful in helping suppress his anger and antisocial behaviors, it is imperative that Robert continues to take the medication on a regular basis.) Long-Term Interventions 1. Emphasize the reality of increasingly negative consequences if Robert’s misconduct continues. (Robert could benefit from a dose

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of reality therapy. Therapy would begin first by talking to him about what could happen if he continues to act up in school and is expelled permanently; then taking him down to a juvenile detention center to show him what it would be like if he ended up there; and finally taking him to the federal penitentiary to show him how he will end up spending the rest of his life if he continues along the destructive path he is on.) 2. Confront Robert’s lack of sensitivity to the needs and feelings of others. (Show Robert what he is doing to his relationships and how that is affecting not only his life, but also the lives of several others. Explain to him that it is a vicious cycle that is perpetuated by his lack of caring for and respecting the needs and feelings of others.) 3. Develop a plan with Robert whereby he provides restitution to those who have suffered from his behavior and monitor his follow-through with the plan. (It is very important that Robert begins to realize that he faces consequences for his actions, and that every time he harms another person in some way he is going to have to pay a price for that. Having him provide restitution for his deeds is also a practice in empathy building because he may begin to understand what he has done to other people and how that has affected them.) 4. Point out instances of his uncontrolled, aggressive, impulsive, disrespectful expressions of anger and have him list the negative impact on him and others as a result. (Realization of the consequences of Roberts’ behavior on himself and others ties in with intervention three in that it makes him realize how many things he has done and how many people he has affected. It also requires making a physical inventory of the actual types of acts he has committed, thus making him realize how his anger is out of control and how impulsive and disrespectful his actions are.) 5. Educate Robert on the dangers of fire setting and engage him with behavioral modification techniques to try to stop his fire setting. (It is important for Robert to understand how dangerous the behavior is and what behaviors such as fire setting can lead to in adulthood.) 6. Develop a plan to track Robert’s behavior at school, once he returns, and monitor his progress. (Keeping track of his behavior and understanding how and when the behaviors occur can great-

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ly help determine what the best interventions may be to help Robert stop the behavior.) 7. Role-play situations that have prompted uncontrolled anger expressions and substitute anger management techniques at critical times in the interaction (e.g. deep breathing, relaxation, and positive self-talk). (Teaching Robert coping and relaxation techniques that he can use in the situations that trigger the behavior can help reduce the number of instances of the behavior.) 8. Refer the parents to classes on behavior modification and anger management techniques. (It is important that the parents know healthy parenting, behavioral modification, and anger management techniques. If the parents are using faulty techniques or do not understand what a healthy family situation or child behaviors look like, these classes tend to be of great help.) 9. Engage Robert and his family in family therapy to work on communication, conflict resolution, boundary establishment, and anger management techniques. (Communication, conflict resolution, establishment of boundaries, and anger management are necessary to cover all the bases of Robert’s disorder. Family therapy and anger management, in particular, play a major part in the treatment of conduct disorder.) 10. Engage Robert in individual therapy to cover all of the issues that he is facing in his life and to help him understand his mindset and the reasoning behind his actions. (Time taken to analyze Robert’s leisure skills is well-spent because it is possible that Robert lacks healthy leisure skills and may need to acquire some. The use of motivational therapy, and the strengths-based perspective may help to empower Robert to want to change his behavior. Looking at Robert and his environment using the systems theory may also help to understand what triggers the behaviors and what may perpetuate those behaviors.) 11. If it is found that Robert would be a good candidate for pharmacotherapy, suggest the appropriate medication prescription decided upon in his assessment. Short-Term Goals and Interventions In order to build up to the long-term goals, it is necessary to begin with smaller goals and interventions that set the process in motion. A

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broad range of short-term goals are selected that address each of the areas in which Robert is struggling. Short-Term Goals 1. Admit to all illegal behavior, actions that have harmed others, and disobedient behaviors. 2. Verbalize an understanding of the legal consequences for his antisocial behavior. 3. List the negative consequences for the antisocial behavior exhibited. 4. Agree to make restitution to those individuals harmed by his actions. 5. Describe alternative constructive ways to manage anger. 6. Get the family members involved in the process by having them attend counseling to learn conflict resolution, communication, and boundary establishment techniques. 7. Have the parents implement positive and negative reinforcement, punishment, shaping, and stimulus control to influence his behavior. 8. Include assessment of medications, such as haloperidol (Haldol®) or lithium carbonate, which might be appropriate in Robert’s case. Short-Term Interventions 1. The first step in dealing with Robert’s behaviors is to have him admit to the behavior. Acceptance for the actions of the behaviors and paying restitution for those behaviors can only come after first admitting to the actions themselves. 2. Having Robert verbalize the consequences at least makes it known that he understands why he has been penalized in the way that he has and how he will be penalized in the future if he continues to perpetuate his behavior. 3. This exercise is another one in which Robert can visualize and verbalize the extent of the consequences he has faced and those that he will face if he continues to behave this way. 4. Having accepted responsibility for his actions, the next step is to have Robert agree to pay restitution for his actions. Knowing that he does not have to perform those actions immediately will give

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him time to build empathy and greater understanding of the effects of his actions. 5. Once Robert has begun anger management, and even prior to doing so, it is important that he be able to list and later follow through with the use of anger management techniques. 6. Starting the process of getting Robert and his family involved in these programs is a big step in creating stronger relationships and understanding how to better communicate, understand boundaries, manage anger, and resolve conflicts. 7. If Robert’s parents are modeling the correct behaviors and implementing a strong, positive, and consistent mode of reinforcement and punishment, Robert is much more likely to follow those behaviors at home and in other environments as well. 8. Medication can be very helpful to individuals with conduct disorder, but, as with therapy, each case will differ and must be determined on an individual basis. Medications Children and adolescents who have been diagnosed with conduct disorder are typically not treated with pharmaceuticals. Exceptions to this rule occur when a child has been simultaneously diagnosed with another condition, especially ADHD or a seizure disorder and must be medicated for those symptoms. In addition, some medications have been recommended in cases in which the aggressive behaviors often associated with conduct disorder, such as stealing, fire setting, and temper tantrums, are severe and cognitive behavioral or other psychotherapeutic interventions have proved to be ineffective. Haloperidol was initially considered one of the superior pharmacological treatments, until serious side effects, especially the propensity for developing tardive dyskinesia, were discovered (Rapp & Wodarski, 1998). Soon after, studies indicated that lithium was just as promising a solution but with fewer side effects. Lithium carbonate, psychostimulants, and both traditional and second-generation antipsychotics are all effective in curbing aggressive symptoms (Andreasen & Black, 2006). Use of medications should still be closely monitored as other, although perhaps not as debilitating, side effects may still occur. Because not all children and adolescents diagnosed with conduct disorder exhibit typically aggressive behaviors, more research on the

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treatment of other possible symptoms is necessary. The limited available literature on this topic indicates a need for more empirical studies to determine other pharmacotherapy treatments for patients who may not respond to psychosocial interventions. One recent study measured the impact of divalproex sodium on seventy-eight male adolescents diagnosed with conduct disorder. The results obtained from selfreport instruments implied an improvement in symptoms associated with depression and impulse control and a greater sense of responsibility, while there were no significant changes regarding anger, anxiety, and self-esteem (Khanzode, Saxena, Kraemer, Chang & Steiner, 2006). That said, there were also few side effects associated with the medication, and those mentioned were mostly mild and included isolated incidents of gastrointestinal difficulties that improved with length of treatment, clearing up almost entirely after three or four weeks (Khanzode et al., 2006). Researchers are also discussing the possible implications of low levels of cortisol in the saliva of adolescents diagnosed with conduct disorder, as well as impaired hypothalamic-pituitary-adrenal (HPA) axis functioning, especially in patients with a diagnosis of early-onset conduct disorder (prior to age ten) (van Goozen & Fairchild, 2006). Potential Outcomes Although it is important to recognize potential serious risk factors for developing conduct disorder, such as cognitive deficits, academic failure (specifically the preceding deficits in verbal intelligence and the resulting punitive reactions from adults), poor parental discipline, overall family dysfunction, poverty, minority status, and the child’s own temperament) the clinical worker should also recognize the plethora of possible protective factors. After all, not all children or adolescents at risk for conduct disorder actually develop the condition, and in order to evaluate possible outcomes and relapse prevention models, the worker must understand why some do. Some protective factors are social and may include being the first born, having high self-esteem and IQ levels, and possessing a strong internal locus of control (Thyer & Wodarski, 1998). Furthermore, social skills, friends, and academic success may insulate and distract children from opportunities to misbehave, because they have positive outlets and self-imposed goals to help them achieve a bright future. A strong ethnic or religious identity may also instill important values,

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identity, and purpose in individuals who may otherwise be tempted by opportunities to engage in destructive behaviors. As is usually the case, these protective factors, as well as the aforementioned risk factors, will vary in their impact on certain individuals depending on demographic variables such as age, gender, and race or ethnicity. There is no guarantee that the presence of these protective factors will prevent the onset of, or improve the outcome of, conduct disorder, but the greater the number of protective factors and the fewer the number of risk factors, generally speaking, the more likely a patient is to avoid some of the more serious and damaging effects of this behavior disorder. However, if conduct disorder goes undetected or untreated, or if treatment modalities are unsuccessful, the child or adolescent’s involvement in irresponsible or criminal behavior could result in incarceration, either in a juvenile detention facility or in a jail or prison, depending on the young person’s age at the time and the severity of the infraction. Furthermore, many (approximately 40% of boys and 25% of girls) who are diagnosed with conduct disorder will develop antisocial personality disorder as adults (Andreasen & Black, 2006). The outcome of children diagnosed with the socialized type of conduct disorder is usually more optimistic, because these patients are almost always able to form relationships and display some empathy and compassion, if only for the peers who engage in disruptive and aggressive behaviors with them. These adolescents are those most likely to form or join gangs as an outlet for their deviant symptoms and are indeed sometimes reassured by the realization that there are others with similar behavioral and emotional patterns. Adolescents diagnosed with the unsocialized form of conduct disorder may face a more dismal outcome because they are unable to form bonds and will likely rebuff offers of support and therapeutic intervention when offered and are nearly incapable of understanding the emotional reactions of their peers or possible victims. Relapse Prevention Whether or not a child will be able to manage aggressive impulses and other symptoms of conduct disorder long term depends a great deal on the family environment. Research has illustrated that having even only one adult who can serve as a positive role model and pro-

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vide support, guidelines, and discipline can drastically improve the long-term outcome of children with disordered behavior and prevent potential relapses. Unfortunately, many children with conduct problems were raised in families plagued by chronic substance abuse, mood disorders, learning disorders, antisocial personality disorder, and/or criminal activity. There are clearly genetic as well as environmental links to the onset of conduct disorder in specific individuals. If the family is not willing to support the patient by bringing him or her to therapy sessions or filling prescriptions, then the child is likely to relapse. Sometimes the family environment is so dysfunctional, often due to the behaviors of both the member with conduct disorder and other relatives, the patient may eventually experience treatment as more beneficial if he or she is removed to a specially trained foster or group home, at least temporarily until symptoms are better managed and the patient’s behaviors have stabilized. For a patient whose family is involved and supportive, family therapy is often indicated. If the family, especially the parents, can learn more constructive ways to react to such symptoms as temper tantrums, truancy, and violence, new behavior patterns can be established that will discourage misconduct and reward appropriate actions. The most promising intervention along this line of treatment is parent management training (PMT). Studies show immediate improvements in both the child’s behavior and the parents’ attitudes and reactions towards the child (Rapp, Thyer & Wodarski, 1998). Siblings are also often positively affected by the parents’ new or improved techniques, even when they are not the primary target or are not suffering from an oppositional or conduct disorder. In this training, parents are responsible for learning to identify inappropriate behaviors and to demonstrate proper intervention techniques. These techniques are said to include reinforcement, planned ignoring, mild punishments, negotiation, and contracting (Rapp & Wodarski, 1998). The authors go on to suggest an increase in manuals on PMT so concerned families can be made aware of these highly viable methods and hopefully prevent a relapse, or at least decrease the frequency and severity of conductrelated symptoms.

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Evidence-Based Interventions in Social Work CONCLUSION

Conduct disorder is a complicated disorder with a multitude of possible subsets of symptoms and often presents as comorbid with other disorders and syndromes, further complicating the diagnosis. However, with a careful analysis of criteria required by the DSM-IV-TR, social workers should be able to identify and assess clients, as well as assist them with establishing short- and long-term treatment plans, desired outcomes, and realistic goals. They can also design case-specific interventions that can include cognitive behavioral therapy, family therapy, and possibly pharmacotherapy if the previous methods are unsuccessful or if the disorder is especially severe. Relapse prevention can be established, primarily through familial involvement and support. REFERENCES American Psychiatric Association. (2000). The Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revised). Washington, DC: Andreasen, N.C., and Black, D.W. (2006). Introductory Textbook of Psychiatry (4th ed.) Washington, DC: American Psychiatric Publishing. Khanzode, L., Saxena, K., Kraemer, H., Chang, K., and Steiner, H. (2006). Efficacy profiles of psychopharmacology: divalproex sodium in conduct disorder. Child Psychiatry and Human Development, 37, 55–64. Rapp, L.A., and Wodarski, J. (1998). Conduct disorder. In B. Thyer and J. Wodarski (Eds.), Handbook of Empirical Social Work Practice. Hoboken, NJ: John Wiley & Sons. Searight, H.R., Rottnek, F., and Abby, S.L. (2001). Conduct disorder: Diagnosis and treatment in primary care. American Family Physician, 63, 1579–1588. Thyer, B., and Wodarski, J. (1998). Handbook of Empirical Social Work Practice. Hoboken, NJ: John Wiley & Sons. Thyer, B. A., and Wodarski, J. S. (2007). Social work in mental health: An evidence based approach. Hoboken, NJ: John Wiley & Sons. Van Goozen, S., and Fairchild, G. (2006). Neuroendocrine and neurotransmitter correlates in children with antisocial behavior. Hormones and Behavior, 50, 647–654. Wodarski, J.S., Rapp-Pagglicci, L.A., Dulmus, C.N., and Jongsma, A.E, Jr. (2001). The Social Work and Human Services Treatment Planner. New York: John Wiley & Sons.

Chapter 4 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER CASE STUDY

Behavior Definition According to the DSM-IV-TR (APA, 2000) attention-deficit/hyperactivity disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development. The prevalence of ADHD is 3 to 7 percent in school-age children and is more common in boys than in girls. The Client Peggy is a ten-year-old white female who has recently been adopted into a single-parent low-income household. Currently, she is in the fourth grade at a rural elementary school. For the past few months, Peggy has been having trouble concentrating on her school work and sitting still in class and is constantly talking and disrupting the classroom. Her grades have been slipping as well because she is not turning in assignments and not following the teacher’s directions. Peggy’s adoptive mother brought her in for treatment after being referred by the school’s guidance counselor.

Note: Case study by Marcy Sturgill.

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The Worker A master’s-level student in clinical social work receiving weekly supervision at her agency is the treatment provider. She is knowledgeable about the behavioral symptoms of ADHD and of the intervention techniques used to treat this disorder. The student’s career was focused on early childhood development; therefore, she is familiar with the developmental stages of children. Assessment On their first visit to the agency, the client and her mother were asked to fill out a psychosocial history, including background information, symptom checklist, and individual and family medical histories. The first few therapy sessions will consist of questions for the adoptive mother and ten-year-old client. The clinical interview is helpful for gathering information to complete the assessment and evaluation. Equally important is the utilization of behavioral observation, especially for potential ADHD clients. The combined clinical interviews, psychosocial history forms, and behavioral observations allow for the most complete and accurate assessment of the client and the family members (Markward, 1998). In addition to the number of assessment tools mentioned by Markward (1998), another important tool is the Test of Variables of Attention (T.O.V.A.TM), which is an objective neurophysiological measure of attention formatted like a computer game. Because she is an intern, the student therapist is not licensed or trained to administer this test; the supervisor joins one of the sessions and administers the test. The T.O.V.A. is 95 percent accurate in testing and diagnosing ADHD among children (Dupper & Musick, 2007). TREATMENT PLAN

Long-Term Goals A long-term goal for Peggy is to reduce the number of her ADHD symptoms by half. Peggy’s grades should be improved and maintained, with help of the development of organizational skills. Having Peggy write her assignments and tasks in a daily planner will be help-

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ful. Another long-term goal is for Peggy to maximize attending skills by employing self-monitoring strategies, external cues, prompts, physical reminders, and reinforcements. Long-Term Interventions The student worker will continue to work with Peggy’s adoptive mother and elementary school teacher and help ensure that the behavioral management techniques are still being used and are productive. Peggy’s mother and teacher need to continue to minimize environmental distractions that might subvert task-directed behavior. Another long-term intervention for Peggy is for her teacher and mother to continue structuring tasks in small steps with immediate reinforcements for performance. Peggy will continue in therapy with the student for at least ten months, until the student feels that Peggy’s behavioral symptoms have improved to the point where she no longer needs help. The psychiatrists will continue with medication and will meet with her once every other month, or as needed. Short-Term Goals Administering the T.O.V.A. is high on the list of priorities and shortterm goals. Proper diagnosis precedes and helps ensure appropriate interventions. Scheduling an appointment with the agency’s psychiatrist to see if medications will be helpful for treating Peggy’s ADHD is another goal. Seventy percent of children respond to ADHD medications; therefore, therapy combined with medications usually produces more successful outcomes. Meeting with Peggy’s teacher and discussing ways they can work together is essential. Another important component of treating the client’s ADHD is to work closely with the adoptive mother. Parent training and support is crucial in treating children with ADHD. Having the support of her teacher and her adoptive mother will be extremely helpful and most productive. The most important short-term goal is for Peggy to decrease her inattentiveness and hyperactivity. Short-Term Interventions Several interventions will work in tandem for this client. First, closely working with Peggy’s adoptive mother will help her learn the basic

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techniques of behavioral management, such as the value of positive reinforcement and firm, nonpunitive limit setting (Andreasen & Black, 2006). Peggy needs her adoptive mother to provide structure with consistency and value. The therapist will also be working with the teacher to ensure Peggy has limited stimulation in the classroom, which diminishes distractibility and inattentiveness. Peggy’s teacher and adoptive mother need to work with Peggy in completing tasks and homework in small increments best suited for her, mastering one task before going on to the next. Medications Utilizing the agency’s psychiatrist to evaluate Peggy for an ADHD medication is a valuable asset. Peggy will most likely be prescribed methylphenidate (10–60 mg/d) followed by dextroamphetamine (5–40 mg/d). These are psychostimulants that have proved to be effective in treating ADHD in children. If these medications are unsuccessful, the psychiatrist can move on to antidepressants, which have effects that tend to last longer. REFERENCES American Psychiatric Association. (2000). The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revised). Washington, DC: author. Andreasen, N.C., and Black, D.W. (2006). Introductory Textbook of Psychiatry (4th ed.). Washington, DC: American Psychiatric Publishing. Dupper, D.R., and Musick, J. (2007). Attention-deficit/hyperactivity disorder. In B.A. Thyer and J.S. Wodarski (Eds.), Social Work in Mental Health: An EvidencedBased Approach (pp. 75–96). Hoboken, NJ: John Wiley & Sons, Inc. Markward, M.J. (1998). Attention deficit hyperactivity disorder. In B.A. Thyer and J. S. Wodarski (Eds.), Handbook of Empirical Social Work: Vol. 1. Mental Disorder (pp. 55–74). Hoboken, NJ: John Wiley & Sons.

Chapter 5 OPPOSITIONAL DEFIANT DISORDER

O

ppositional defiant disorder (ODD) is a collection of behavior problems that persist and exceed the intensity or severity of similar behaviors in children of the same age. These behaviors must last at least six months and cause impairment in academic and social functioning. The impairment cannot occur during a psychotic episode or mood disorder. The DSM-IV-TR (APA, 2000) recognizes that ODD is similar to conduct disorder and specifies that a diagnosis of conduct disorder be given when both ODD and conduct disorder are present. When conduct disorder occurs with ADHD, a dual diagnosis is appropriate. ODD is part of the disruptive behaviors category within the DSM-IVTR. This category includes ODD, conduct disorder, and ADHD. The behavioral features of the disorder include frequent loss of temper and describe someone who often (1) argues with adults, (2) actively defies or refuses to comply with adults’ requests or rules, (3) deliberately annoys people, (4) blames others for his or her mistakes or misbehavior, (5) is touchy or easily annoyed by others, (6) is angry and resentful, and (7) is spiteful and vindictive. ODD is classified as one of two types: • aggressive/versatile onset • late onset

Note: Case study by Carla Kimble and Teresa Nolen Pratt.

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Aggressive/versatile-onset ODD occurs when the behavioral features of the disorder are noticed as early as preschool. Because of the earlier onset, the prognosis of the disorder is generally poorer. Late-onset ODD is usually diagnosed in adolescence and has a better prognosis than the aggressive/versatile type. Symptoms of ODD appear to be stable over time and to have a developmental profile and sex distribution different from those of conduct disorder. The reliability of the diagnosis is low. There is some support for ODD as a category that reflects an oppositional-aggressive psychological dimension, which is different from a delinquent dimension. There is little evidence for making ODD a part of the construct of conduct disorder and for making “lying” a criterion for it. Considerable impairment should be required for the diagnosis. A more detailed description of symptoms, including a threshold for considering them present, may increase reliability of the diagnosis. Hyperactive children are at risk for both juvenile and adult criminality. The risk for becoming an adult offender is associated with conduct problems in childhood and serious antisocial behavior (repeat offending) in adolescence. Hyperactive children who do not have conduct problems are not at increased risk for later criminality. Risk Factors The main risk factor areas for the development of ODD include features related to the child, parents, and family. Risk factors related to the child include a difficult temperament, problems with impulsivity and inattention, and aggressive behaviors. Low verbal IQs have also been found to be relevant to delinquent behavior (Quay, 1987). Often the parents of children with ODD have trouble applying consistent consequences in discipline (Patterson & Stouthamer-Loeber, 1984; Snyder & Patterson, 1987), ineffective monitoring of the child’s activities, and lack of positive reinforcement and affect. There is a large body of evidence at this point that correlates “family warmth and cohesion” with youth delinquency (e.g. Blaske, Borduin, Henggeler & Mann, 1989; Hanson, Henggeler, Haefele & Rodick, 1984; Tolan, 1988). Parent criminality also has been associated with youth delinquency (Loeber & Dishion, 1983). The families of these children are also troubled and are often plagued with parental conflict, substance abuse, parental psychopath-

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ology, and significant life stressors such as poverty, unemployment, crowded living conditions, and illness. It is thought that the interplay among all of these factors as well as the system in which they are embedded creates the underpinnings of the disorder’s development, as well as its maintenance (Henggeler & Borduin, 1990). Prevalence ODD is a very common disorder, with the category of disruptive disorders accounting for 50 percent of all child mental health referrals. Seven to 25 percent of these referrals have the characteristics of conduct disorder or ODD. If ODD is not treated, it may develop into conduct disorder or even antisocial personality disorder. Gender studies have been inconclusive. CASE STUDY

The Client Mary, a thirteen-year-old white female entered a local therapist’s office with her mother. Her mother reported to the therapist that Mary has “out of control behavior.” The mother described the teen’s behavior as talking back to her parents and fighting with her eleven-year-old sister (punching and slapping). The teen slipped out of the house without permission, took the family four-wheeler, and drove it down the hill. The four-wheeler ran out of gas, and the teen hitchhiked back to their home. The teen began to curse her mother and revealed to them the person that gave her a ride home. The mother is not sure what to do with her teenage daughter at this point. She reported that nothing seems to get her daughter’s attention and is not sure what is going on. Mary was placed on state juvenile probation and charged with possession of tetrahydrocannabinol (THC; marijuana), hydrocodone, and cigarettes at school. The teen has been to court twice since being placed on probation within the last six months. She was charged as a delinquent for testing positive for THC and fighting at the Alternative school. Mary reported she has been using THC since age twelve. Mom claims she does not know what is going on. Later in the session she reported that Mary’s biological mother died of a drug over-

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dose when Mary was six years old and her biological father remarried when she was eight years old. The Worker The worker is a master’s-level student in clinical social work who received weekly supervision at her fieldwork placement agency. The Assessment No single treatment philosophy exists to diagnose ODD and very few methods have been appropriately evaluated (Kazdin, 1987, 1994). Even so, most models take into account intraorganismic factors, such as genetics, temperament, physiology, and neurology, and developmental pathways and relational and environmental elements, such as parenting practices, parental psychopathology, socioeconomic status, and substance abuse. Some methods of assessment include conducting direct interviews with the child and family, conducting direct observation of child behaviors and family interaction behaviors, self-report pencil and paper testing, and parent and family functioning measures. Interventional methods used most often include parent training, child training, family training, and working through the school and community. Specific treatments delivered through community-based settings include behavioral parent training, multicomponent behavioral treatments, and family therapies. Behavioral parent training is one of the most widely researched methods for children with ODD and conduct disorder (Forehand & Kotchick, 1996). Many social service, mental health, and juvenile justice agencies either offer or require behavioral parent training for ODD cases (Serketich & Dumas, 1996). Multicomponent behavioral therapies include videotape modeling programs and are a cost-efficient way to teach families new communication and methods of interaction (Webster-Stratton & Herbert, 1994). One such program is BASIC, a three-prong approach including videotape education, group discussion, and therapist intervention for parent support (Webster-Stratton & Herbert, 1993, 1994). Additional programs such as ADVANCE offer additional training beyond the BASIC program and include marital communication, self-control and

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self-care, development of social networks, and problem-solving skills (Webster-Stratton, 1994). PARTNERS was also developed and expanded communication and problem-solving skill so parents could learn to interact effectively with schools and community resources in order to assist their children (Webster-Stratton & Spitzer, 1996). Combined parent-management training and problem-solving skills training are other programs with similar characteristics, including utilizing the parents as change agents, role-playing, homework, and monitoring (Kazdin, 1994). Family therapies include functional family therapy, one of the first to combine social learning and family systems interventions to target delinquent youth (Alexander & Parsons, 1982); multidimensional family therapy, originally developed to treat substance abuse (Liddle & Dakof, 1995; Liddle, Dakof & Diamond, 1991); structural family therapy, which has been successful in tailoring treatment to different cultures (Kurtines & Szapocznik, 1996); and multisystemic therapy, a three- to five-month treatment intervention based on an social-ecological perspective and “pragmatic systems models of behavior” (Henggeler & Borduin, 1990; Henggeler, Schoenwald, Borduin, Rowland & Cunningham, 1998). TREATMENT PLAN

Intervention Specific treatment for children with ODD is determined by the child’s (adolescent’s) physician based on: • the child’s (adolescent’s) age, overall health, and medical history • extent of the child’s (adolescent’s) symptoms • the child’s (adolescent’s) tolerance for specific medications, proce-

dures, or therapies • expectations for the course of the condition • the guardian’s opinion or preference Treatment may include: • individual psychotherapy: Individual psychotherapy for ODD

often uses cognitive-behavioral approaches to improve problem solving skills, communication skills, impulse control, and anger management skills.

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Evidence-Based Interventions in Social Work • family therapy: Family therapy is often focused on making changes

within the family system, such as improving communication skills and family interactions. Parenting children with ODD can be very difficult and trying for parents. Parents need support and understanding as well as developing more effective parenting approaches. • peer group therapy: Peer group therapy is often focused on developing social skills and interpersonal skills. • medication: Although not considered effective in treating ODD, medication may be used if other symptoms or disorders are present and responsive to medication. Behavior Definition • Refuses to follow adult directives and is disrespectful to authority

figures • Engages in unlawful behavior that has led to arrests • Threatens others or has engaged in assaultive behavior • Does not respect the rights, feelings, or needs of others • Lies and projects blame for her misbehavior onto others • Lacks motivation to succeed academically • Abuses illegal drugs • Runs away from home overnight (at least twice) • Has been arrested and adjudicated as being in need of supervision • Parents enforce rules inconsistently Long-Term Goals • Terminate all illegal and antisocial behaviors • Demonstrate increased honesty, compliance with rules, sensitivity

to the feelings and rights of others, control over impulses, and acceptance of responsibility for behavior • Demonstrate empathy, concern, and sensitivity for the thoughts, feelings, and needs of others; learn anger-management skills and terminate assaultive behavior • Show respect for the rules and authority figures and complete homework assignments • Accept responsibility for her actions, including apologizing for hurts and not blaming others; come to the understanding and ac-

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ceptance of the need for limits and boundaries on behavior; parents develop appropriate expectations about adolescent behavior • Parents learn appropriate methods to nurture, guide, and discipline children Short-Term Goals • Admit to illegal or maladaptive behavior that has violated the law

or the rights and feelings of others • Verbalize an understanding of the legal consequences of her beha-

vior • List the negative consequences that have resulted from poor anger

management • Describe alternative, constructive ways to manage anger • Complete all homework assignments and seek tutorial assistance

when she falls below a grade of C academically • Parents verbalize an understanding of typical adolescent behavior • Parents define reasonable rules that will be consistently enforced • Parents implement positive and negative reinforcement, punishment, shaping, time-out, and stimulus control to influence Mary’s behavior • Family members attend counseling to learn conflict resolution, communication, and boundary-establishment techniques Therapeutic Interventions • Gather a history of Mary’s delinquent behavior from the Depart-

ment of Children Services • Emphasize the reality of increasingly negative consequences ordered by Juvenile Court if Mary continues to have delinquent occurrences • Confront Mary’s lack of owning responsibility for her behavior in individual therapy • Confront lack of sensitivity to the needs and feelings of others in both individual and group therapy • Explain to Mary the legal consequences of behavior, such as, court cost, extended probation time, weekends spent in the Juvenile Detention Center, and possible commitment in state’s custody, all of which can be recommended by her probation officer and ordered by the Juvenile Judge or Referee.

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Evidence-Based Interventions in Social Work • Point out instances of Mary’s uncontrolled aggressive, impulsive,

disrespectful expressions of anger: slapping her sister or fighting with her when she does not agree with Mary, stealing the family’s four-wheeler and leaving it when it ran out of gas, and cursing her parents when she becomes angry. The negative consequences of this behavior will be listed for herself and others. When Mary fights with her sister she will receive a consequence if she starts the fight or argument. The consequence can range from losing her telephone privileges to losing allowance for the week. Mary can be violated by her probation office for stealing the family four-wheeler. When Mary curses at her parents she strains the trust and relationship between them. • Role-play situations that have prompted uncontrolled anger expression by the client. While Mary is in individual therapy, situations that have made her angry will be enacted. This will teach Mary appropriate techniques to use in the home that will minimize future arguments or disrespectful behaviors. Substitute anger management techniques including deep breathing techniques, relaxation techniques, journaling, positive self-talk and removing herself (take a walk, time-out, etc.) from a situation that she know will get her into trouble. • Mary will participate in individual and group therapy as recommended by her therapist. Mary will also participate in an anger regression class. • Will monitor Mary’s progress in completing the court-ordered request of sixty community service hours for second drug offense • Written progress notes from each class will be sent home every Friday; this will give the parents an opportunity to monitor Mary’s academic progress • Contract agreement with Mary pertaining to completing her school assignments • Parents will participate in a parenting class to understand and gain information on principles of behavior modification as used in shaping behaviors, time-out, positive reinforcement, negative reinforcement, and punishment. They will also be provided with information regarding the use of consequences and rewards to manage the client’s behavior. • Parents will participate in family therapy as recommended by the therapist.

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Prevention of ODD in Childhood Some experts believe that a developmental sequence of experiences occurs in the development of ODD. This sequence may start with ineffective parenting practices, followed by difficulty with other authority figures and poor peer interactions. These experiences compound and continue; oppositional and defiant behaviors develop into a pattern of many behaviors. Early detection and intervention into negative family and social experiences may be helpful in disrupting the sequence of experiences leading to more oppositional and defiant behaviors. Early detection and intervention with more effective communication skills, parenting skills, conflict resolution skills, and anger management skills can disrupt the pattern of negative behaviors and decrease the interference of oppositional and defiant behaviors in interpersonal relationships with adults and peers, and school and social adjustment. The goal of early intervention is to enhance the child’s normal growth and developmental process, and improve the quality of life experienced by children or adolescents with ODD. Medication There have been some recent studies that have examined the effects of certain medications on ODD. All the research is preliminary and only suggests that certain treatments may help. One study examined the use of methylphenidate hydrochloride (RitalinTM) to treat children with both ADHD and ODD. This study found that 90 percent of the children treated with Ritalin no longer had the ODD by the end of the study. The researchers skewed the results a bit because a number of children were dropped from the study when they would not comply with the treatment regimen. Still, if these children are included as treatment failures the study still showed a 75 percent success rate. There have been two studies examining the effect of atomoxetine hydrochloride (Strattera®) on children with both ADHD and ODD. One study showed that Strattera helped with ODD; one study showed it did not help. REFERENCES Alexander, J.F., and Parsons, V.V. (1982). Functional Family Therapy. Monterey, CA: Brooks/Cole.

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American Psychiatric Association. (2000). The Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revised). Washington, DC: American Psychiatric Press. Blaske, D.M., Borduin, C.M., Henggeler, S. W., and Mann, B.J. (1989). Individual, family, and peer characteristics of adolescent sex offenders and assaultive offenders. Developmental Psychology, 25, 846–855. Forehand, R., and Kotchick, B.A. (1996). Cultural diversity: A walk-up call for parent training. Behavior Therapy, 27, 187–206. Hanson, C.L., Henggeler, S.W., Haefele, W.F., and Rodick, J.D. (1984). Demographic, individual, and family relationship correlates of serious and repeated crime among adolescents and their siblings. Journal of Consulting and Clinical Psychology, 52, 528–538. Henggeler. S.W., and Borduin, C.M. (1990). Family Therapy and Beyond: A Multisystemic Approach to Treating the Behavior Problems of Children and Adolescents. Pacific Grove, CA: Brooks/Cole. Henggeler, S.W., Schoenwald, S.K., Borduin, C.M., Rowland, M.D., and Cunningham, P.B. (1998). Multisystemic Treatment for Antisocial Behavior in Children and Adolescents. New York: Guilford. Kazdin, A.E. (1987). Treatment of antisocial behavior in children: Current status and future directions. Psychological Bulletin, 102, 187–203. Kazdin, A.E. (1994). Psychotherapy for children and adolescents. In A.E. Bergin & S.L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change (pp. 543–594). New York: Wiley. Kurtines, W.M., and Szapocznik, J. (1996). Family interaction patterns: Structural family therapy within contexts of cultural diversity. In E.D. Hibbs and P.S. Jensen (Eds.) Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Stra-tegies for Clinical Practice (pp. 671–697). Washington, DC: American Psychological Association. Liddle, H.A., and Dakof, G.A. (1995). Efficacy of family therapy for drug abuse: Promising but not definitive. Journal of Marital and Family Therapy, 21, 511–543. Liddle, H.A., Dakof, G., and Diamond, G. (1991). Adolescent substance abuse: Multidimensional family therapy in action. In E. Kaufman and P. Kaufman (Eds.), Family Therapy with Drug and Alcohol Abuse (pp. 120–171). Boston, MA: Allyn & Bacon. Loeber, R., and Dishion, T. (1983). Early predictors of male delinquency: A review. Psychological Bulletin, 94, 68–99. Patterson, G.R., and Stouthamer-Loeber, M. (1984) The correlation of family management practices and delinquency. Child Development, 55, 1299–1307. Quay, H.C. (1987). Patterns of delinquent behavior. In H.C. Quay (Ed.), Handbook of Juvenile Delinquency (pp. 118–138). New York: John Wiley & Sons. Serketich, W.J., and Dumas, J.E. (1996). The effectiveness of behavioral parent training to modify antisocial behavior of children: A meta-analysis. Behavioral Therapy, 27, 171–186. Snyder, J., and Patterson, G. (1987). Family interaction and delinquent behavior. In H.C. Quay (Ed.), Handbook of Juvenile Delinquency. New York: John Wiley & Sons.

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Tolan, P.H. (1988). Socioeconomic, family and social stress correlates of adolescents' antisocial and delinquent behavior. Journal of Abnormal Child Psychology, 16, 317–332. Webster-Stratton, C. (1994). Advancing videotape parent training: A comparison study. Journal of Consulting and Clinical Psychology, 62, 583–593. Webster-Stratton, C., and Herbert, M. (1994). Troubled families — problem children: Working with parents: A collaborative process. Chichester, England: John Wiley & Sons. Webster-Stratton, C., and Spitzer, A. (1996). Parenting a young child with conduct problems: New insights using qualitative methods. Advances in Clinical Child Psychology, 18, 1–62.

Chapter 6 ENURESIS AND ENCOPRESIS BEHAVIOR DEFINITION

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hildren with elimination disorders may suffer embarrassment, low self-esteem, and negative reactions such as anger punishment and rejection from caretakers. Impairment in social functioning may be characterized by avoidance of overnight activities, teasing, and ostracism from peers (Samuels & Sikorsky, 1998). For these reasons, it is important for enuresis and encopresis to be treated in a clinical setting. Enuresis and encopresis are considered “family disorders” and therefore treatment should include both the child and the family (Butler & Campise, 1998). According to the DSM-IV-TR (APA, 2000), there are several criteria that must be met for the diagnosis of an elimination disorder. For the diagnosis of enuresis, the child must urinate either involuntary or intentionally into clothing or bedding twice a week for at least three months, and must have reached age five chronically or developmentally, and the symptoms cannot be due to medication or a general medical condition. There are two types of enuresis: primary, in which the child has never been continent, and secondary, in which the enuresis develops after a period of continence. For the diagnosis of encopresis, the child must either voluntarily or involuntarily pass feces into inappropriate places at least once a month for three months. The child must be at the age of four chronically or developmentally, and the behavior cannot be due to medication or a general medical condition. Note: Case study by Rebecca Hamrick.

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There are two types of encopresis: encopresis with constipation and overflow incontinence, and encopresis without constipation and overflow incontinence. These two types can be further differentiated by the subtypes of primary or secondary encopresis. CASE STUDY

The Client The client in this case study is a five-year-old white female named Carla who is seen regularly at the field agency. She was referred to the agency by the Department of Child and Family Services and was brought in by her father and his girlfriend. Carla’s father stated that she frequently urinates on herself, sometimes as much as five times per day. He stated that she sometimes wets the bed but her problem wetting is usually during the day. Carla’s father explained that she was potty trained when she was three years old but then she began urinating on herself about a year ago. Her father was unable to identify any antecedents that could possibly trigger the behavior, and he stated that the consequences for Carla’s behavior are usually just to change her clothes. He stated that the problem had gotten out of hand and had negatively affected not only Carla but also the family. The Worker Carla will be treated by either a master’s-level intern or a licensed clinical social worker. It is preferable that the worker have some experience in working with children and prior experience in treating enuresis and encopresis. Carla will be treated in individual psychotherapy once per week. In order for Carla’s treatment to be as effective as possible, it is preferable that her family also be involved in her treatment. Assessment There are three areas that are suggested for assessment according to Butler and Campise (1998): medical evaluation, the clinical interview, and some type of baseline recording. Therefore, the first step is to have Carla evaluated by a physician to determine if her behavior can be better explained by a general medical condition. The clinical inter-

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view should address six important areas: the history of the problem, family and medical history, parental attitudes, behavior problems, family circumstances, and obtaining a baseline of wetting behavior prior to treatment (Thyer & Wodarski, 1998). TREATMENT PLAN

Behavior Definition The behavioral definitions for enuresis that apply to Carla should be noted prior to developing a treatment plan. Enuresis is defined as the repeated pattern of voluntary or involuntary voiding of urine into bed or clothes during the day or at night after age five. Feelings of shame may be associated with enuresis that cause avoidance of situations that might lead to further embarrassment. The child may make frequent attempts to hide the soiled clothing because of shame or fear of further ridicule, criticism, or punishment. Finally, the child may have poor impulse control, which contributes to a lack of responsibility with toilet-training practices ( Jongsma, Peterson & McInnis, 2006). Intervention According to Butler and Campise (1998), there are several interventions that have been found to be effective in treating enuresis. One such intervention is dry bed training (DBT), which could be effective in helping Carla when she urinates in her sleep. DBT involves four components: a urine alarm, a nightly hourly waking schedule, overcorrection in the form of positive practice after accidents and prior to bedtime, and cleanliness training. Long-Term Goals and Intervention The worker and client will develop several long-term goals for Carla’s treatment. First she would eliminate all diurnal and nocturnal episodes of enuresis. Carla’s parents will eliminate any rigid or coercive toilet-training practices. Carla’s self-esteem should be increased, and she would successfully work through feelings of shame or humiliation associated with past enuresis ( Jongsma et al., 2006). These longterm goals will be treated with the use of behavior therapy.

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Short-Term Goals and Intervention There are several short-term objectives and corresponding interventions that must be completed in order to reach the long-term goals. First, Carla’s family should comply with a physician’s orders for a medical evaluation. It should also be determined if Carla should be prescribed any medication. Carla’s parents should comply with behavior modification procedures and should be educated on the procedures, including DBT. The frequency of Carla’s enuretic behavior should be reduced by designing and counseling the parents on the use of positive reinforcement to increase her bladder control. Carla’s role in implementing the toilet-training practices and interventions should be increased. Finally, the worker should assist Carla in identifying and listing her positive characteristics to help decrease feelings of shame and embarrassment and reinforce her positive self-statements. Medications The use of both medical and behavioral components in the treatment of enuresis have been found to be very successful (Butler & Campise, 1998). As has been stated, it is critical that the child have a medical exam completed to rule out a medical condition as the cause for enuresis. Children can be prescribed psychotropic medication to help treat enuresis. Tricyclics can be prescribed as well as desmopressin, which has been found to be effective when combined with behavior treatment. Relapse Prevention There is little in the literature on relapse prevention for enuresis. Butler and Campise (1998) state that there is a high relapse rate when using the urine alarm alone, but when combined with DBT and full spectrum home training (FSHT), the rate of relapse decreases. According to the DSM-IV-TR (APA, 2000), the rate and prevalence of enuresis and encopresis decrease with age.

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Evidence-Based Interventions in Social Work REFERENCES

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revised ). Washington, DC: Author. Butler J.F., and Campise, R.L. (1998). Enuresis and encopresis. In B. Thyer and J. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders. Hoboken, NJ: John Wiley & Sons. Jongsma, A., Jr., Peterson, M., and McInnis, W. (2006). The Child Psychotherapy Treatment Planner (4th ed.). Hoboken, NJ: John Wiley & Sons. Samuels, S., and Sikorsky, S. (1998). Clinical Evaluations of School-Aged Children: A Structured Approach to the Diagnosis of Child and Adolescent Mental Disorders (2nd ed.). Sarasota, FL: Professional Resource Press. Thyer, B.A., and Wodarski, J.S. (Eds.) (2007). Social Work in Mental Health: An Evidenced-Based Approach. Hoboken, NJ: John Wiley & Sons.

Chapter 7 SEPARATION ANXIETY DISORDER

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eparation anxiety disorder (SAD) represents a more severe and disabling form of a maturational experience that all children normally have (Andreasen & Black, 2006). The fundamental feature of SAD is excessive anxiety about separation from an attachment figure or from home. Children and youth with this disorder typically become socially withdrawn and display apathy, sadness, or difficulty in concentration and attention to work or play when separated from the parent or other figure (Sowers-Hoag & DiDona, 1998). At least three of eight characteristic symptoms must be present for four weeks and include three types of distress or worry, three types of behaviors, and two physiological symptoms. The types of distress or worry include distress at being separated from home, worry that some harm will come to the parents, and worry that the child will be lost or somehow separated from them. The types of behaviors include school refusal, sleep refusal, and clinging, and the physiological symptoms include nightmares and physical complaints such as headache or nausea. At times, the high degree of distress may resemble a panic attack (Samuels & Sikorsky, 1998). Approximately four percent of children and young adolescents present with SAD. SAD decreases in prevalence from childhood through adolescence. It may develop after some sort of life stressor, for example the death of a relative or pet, a change in schools, or an illness experienced by the child or a relative. Children and adolescents with chronic illnesses may be at higher risk for SAD; specifically, those with

Note: Case study by Rebecca Hamrick and Cameron Koucheki.

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end-stage renal disease, in particular, have been found to have a significantly higher incidence than do matched healthy controls (SowersHoag & DiDona, 1998). Onset may be as early as preschool age and may occur at any time before the age of eighteen years. However, onset in late adolescence is uncommon. Some literature has stated that SAD is more common in girls than in boys; however, in clinical samples, the disorder is apparently equally common in males and in females. The DSM-IV-TR (APA, 1994) lists five criteria for SAD. Criterion A: There is developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached. Criterion B: The duration of the disturbance is at least four weeks. Criterion C: The onset is before age eighteen years. Criterion D: The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. Criterion E: The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescence and in adults, is not better accounted for by panic disorder, agoraphobia. It should be specified if there is early onset, which means that onset occurs before six years. Differential Diagnosis and Comorbidity The differential diagnosis for SAD is relatively easy to make due to the specificity of the anxiety-evoking stimuli that are centered around separation from major attachment figures (Sowers-Hoag & DiDona, 1998). However, some common differential diagnoses include, but are not limited to, panic disorder, mood disorders, generalized anxiety disorder (GAD), and social phobia. Depressed mood is typically concurrent and may intensify over time, usually precipitating an additional concurrent diagnosis of dysthymic disorder or major depressive disorder (Sowers-Hoag & DiDona, 1998). SAD is often found to be comorbid with school phobia. School phobia is a significant anxiety disorder in which children develop a fear of going to school. The child may begin to develop methods for staying home. Often associated with school refusal, there is evidence to suggest that SAD may be present in as many as 80 percent of all cases of school phobia (SowersHoag & DiDona, 1998). For younger children, school phobia may stem from a fear that something will happen to them or their caregiv-

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er while they are away at school. For older children, school phobia usually has its roots in academic problems, social challenges, or bullying (Mayes & Cohen, 2002). CASE STUDY

Client Kayla is a seven-year-old white female. She lives with her mother, maternal grandmother, and maternal great-grandparents in a mediumsize metropolitan area. Kayla’s parents became pregnant with her as teenagers, and she is an only child. Her parents have been twice married to each other and divorced. She was referred for mental health treatment due to anxiety when being separated from a caregiver. Recently Kayla and her mother had to move in with her grandparents due to financial instability. Since they have moved, Kayla’s mother has passed much of her parental responsibilities onto the grandmother. She goes out and parties with her friends several nights a week, leaving Kayla with her grandparents. Kayla also refuses to sleep alone and often sleeps with her mother or grandmother. Kayla’s grandmother and mother report that Kayla becomes extremely angry, irritable, and obstinate when she feels threatened that her mother is going to leave. Her grandmother described a most recent incident in which Kayla’s mother decided to go out with some friends for the night. She stated that Kayla threw a tantrum and told everyone that she hated them, and she refused to calm down. Kayla’s grandmother tried to put her to bed and Kayla cried and said she was too angry to go to sleep. Her grandmother put on some soft music, and Kayla crawled in the bed next to her and eventually fell asleep. Kayla’s mother and grandmother report that Kayla says that she hates school and has been refusing to attend. When she does attend school she often fakes an illness to be allowed to go home for the day. She does not seem to have many close friends at school or in the neighborhood in which she lives. Along with school refusal, she also refuses to participate in any social activities, such as the children's choir at her church. When Kayla arrived for her initial assessment, her grandmother stated that Kayla did not want to come to the session and cried on the way to the appointment. When the worker attempted to separate her

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from her grandmother in order to assess her, Kayla became very upset and clung to her grandmother. When the worker was finally able to assess the client, she stated that she did not like leaving her grandmother or mom because she was worried about something happening to them or her being left alone. Kayla’s grandmother reported that Kayla has been having trouble with separating from attachment figures since they moved two months ago. Her grandmother also described Kayla’s irritability and anger as lifelong but her fear of separation began more recently, since the move. Kayla previously received mental health treatment when she was five years old due to issues surrounding her parent’s first divorce. She has never had much positive interaction with other children her age, and she is currently obsessed with her seven-year-old boyfriend, Les. She also gets anxious when she is threatened with time away from her boyfriend. Kayla is close to the family members in her home but is estranged from her other family members. Kayla’s grandmother reports no history of substance abuse within the family. Kayla also has no known medical condition that may contribute to her symptoms. On the other hand, her grandmother reports several psychiatric illnesses that run within the family, such as bipolar disorder, major depression, schizophrenia, dysthymic disorder and GAD. The Worker Kayla and her family will be working with a master’s-level social worker or a licensed clinical social worker (LSW). The worker must have adequate knowledge of play therapy in order to work effectively with Kayla and to interact more on her level. It will also give Kayla a therapeutic medium to complete therapy. The worker must also have the sufficient knowledge and skills to assess the situation effectively and must be trained to do a person-in-environment assessment. Assessment According to Sowers-Hoag and DiDona (1998), SAD is less difficult to diagnose than other disorders are, and can be assessed by three different methods: a structured clinical interview, self-report methods, and observational methods. Two interviews that can assess for symptoms of SAD and lead to an accurate diagnosis are the Diagnostic

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Interview for Children and Adolescents (DICA) and the Child Assessment Schedule (CAS). The Anxiety Disorders Interview Schedule for Children (ADIS-C) is useful also because it is specific to the assessment of anxiety disorders. Self-report methods use several multidimensional scales that include a measure or subscale of separation anxiety. Some of these scales include the Ontario Child Health Study (revised) (OCHS), the KiddieInfant Descriptive Instruments for Emotional States (KIDIES), the Visual Analog Scale for Anxiety (VASA), the Interpersonal Sensitivity Measure (IPSM), and the Fear Survey Schedule for Children (FSSC). The most preferred scale is the Children’s Separation Rating Scale (CSRS). This scale is preferred because it is short and easy to administer and score. The CSRS also has good internal consistency and validity. Two scales that are not recommended for the assessment of SAD due to poor or unknown psychometric properties are the Separation Anxiety Test (SAT) and the Children’s Manifest Anxiety Scale. Observational methods include the use of diagnostic peer groups that involve a small number of children of equal age and development. The purpose of the diagnostic peer groups is to allow the worker to observe separation and reunion behaviors, peer interactions, social skills, and overall development. These observations should provide a point of reference for the worker and are useful for diagnosis. The choice of assessment for Kayla will be a structured clinical interview as well as a self-report method. The structured clinical interview will be conducted using the CAS. The CAS has been found to be a reliable measure with good reliability for diagnosis and treatment. The self-report method used will be the CSRS, which is the preferred self-report scale. Behavior Definition The behavioral definition of SAD specifies excessive emotional distress and repeated complaints when anticipating separation from home or close attachment figures. They usually present with crying, regressive behaviors, pleading with parents to stay, and temper tantrums to name a few. Children and youth with SAD often have low self-esteem and lack self-confidence which contributes to the fear of being alone or participating in social activities, for example, Kayla’s

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school refusal and unwillingness to participate in church activities. Children and youth with SAD also have persistent and unrealistic worry about possible harm occurring close to attachment figures or excessive fear that these figures will leave and not return. There are also repeated complaints and heightened distress (e.g. pleading to go home, demanding to see or call a parent) after separation from home or an attachment figure has occurred. Jongsma, Peterson, and McInnis (2006) include other behavioral definitions, including frequent reluctance or refusal to go to sleep without being near a close attachment figure, refusal to sleep away from home, and persistent fear or avoidance of being alone as manifested by excessive clinging and shadowing of a close attachment figure. Long-Term Goals The first of Kayla’s long-term goals will be to eliminate the anxiety and expression of fears when a separation is anticipated or occurs. Another long-term goal is to help her tolerate separation from attachment figures without exhibiting heightened emotional distress, regressive behaviors, temper outbursts, or pleading. Kayla should be able to manage nighttime fears effectively as evidenced by remaining calm, sleeping in her own bed, and not attempting to go into the attachment figure’s room at night. The worker should aid Kayla in resolving the core conflicts or traumas contributing to the emergence of the separation anxiety. Another goal is that Kayla will be able to participate in extracurricular or peer group activities and spend time in independent play on a regular, consistent basis. Kayla’s parents and caregivers should establish and maintain appropriate parent-child boundaries and set firm, consistent limits when she exhibits temper outbursts or manipulative behaviors around separation points ( Jongsma et al., 2006). Short-Term Goals Short-term goals for Kayla are derived from The Child Psychotherapy Treatment Planner ( Jongsma et al., 2006). The short-term goals are as follows: (1) Describe the history and nature of the phobia(s), complete with impact on functioning and attempt to overcome it; (2) cooperate with an evaluation by a physician for psychotropic medication; (3) learn and implement calming skills to reduce and manage anxiety

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symptoms; (4) identify and challenge fearful self-talk with positive and realistic self-talk; (5) participate in gradual repeated exposure to feared or avoided separation situations; (6) demonstrate support of Kayla by family members as she tolerates more exposure to the separation; (7) reduce the frequency and severity of crying, clinging, temper tantrums, and verbalized fears when separated from attachment figures; (8) increase the frequency and duration of time spent in independent play away from major attachment figures; (9) implement relapse prevention strategies for managing possible future anxiety symptoms; and (10) express feelings and fears in play therapy, mutual storytelling, and art. Intervention SAD is generally treated through individual therapy with a variety of models of intervention. Sowers-Hoag and DiDona (1998) identify these models as psychodynamic models, play therapy models, cognitive-behavioral treatments, exposure-based procedures, contingency management procedures, and real-life exposure techniques. There has been little support for the use of psychodynamic therapy to treat SAD. In fact, behavioral literature suggests that school phobia and SAD can be treated successfully without the use of psychodynamic therapy. Play therapy should be considered a possible treatment for SAD considering that the disorder occurs more frequently in children than in adolescents. However, research in this area has demonstrated that play therapy is not effective in reducing the anxiety symptoms associated with SAD. There is mixed evidence supporting the cognitive-behavioral treatment for SAD, but it has been effective in some cases described by Sowers-Hoag and DiDona (1998). Most literature supports behaviorally based interventions for the treatment of SAD, such as systematic desensitization, flooding, contingency management, or some combination of these. Exposure-based procedures such as desensitization with emotive imagery, self-control desensitization, and in vivo desensitization have all been documented to be effective in the treatment of SAD. Contingency management procedures have also been found to be effective in the treatment of SAD. However, the intervention that has been found to be the most successful in treating SAD is real-life exposure techniques. Kayla will be attending an individual therapy session biweekly. She will also be attending group therapy for children with SAD once a

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week. This will help her to develop some social skills and may also help her to develop skills to cope with SAD. In order for Kayla’s treatment to be effective as possible, her family must be involved. They will be attending family therapy biweekly. It is important for them to be educated on SAD so that they can help Kayla cope with it as well as learn some skills to help themselves cope with the disorder. The worker will use several intervention models such as play therapy, CBT, exposure therapy, and behavior therapy to treat Kayla’s symptoms of SAD. The first intervention that the worker should implement is to build a level of trust with Kayla that will promote the open showing of thoughts and feelings. The worker should assess Kayla’s fear and avoidance. The worker should discuss how separation fears are common and natural, but unfounded, and are not a sign of weakness but cause unnecessary distress and disability. The storytelling technique should be used to help Kayla identify her fears, their origins, and their resolution. The worker should teach Kayla anxiety management skills to address anxiety symptoms that may emerge during encounters with phobic objects or situations. Kayla’s schema and self-talk should be explored that mediates her fear response, challenge her biases, and assist her in replacing distorted messages with realitybased, positive self-talk. The worker will implement behavior therapy by using behavioral techniques to train Kayla in positive self-talk that prepares her to endure anxiety symptoms without serious consequences. Also, the worker and Kayla will work together to design a reward system or establish a contingency contract that reinforces Kayla for being able to manage separation from her parents or caregivers without displaying excessive emotional distress. The worker will direct and assist Kayla in construction of a hierarchy of separation anxiety-producing situations. The worker will implement exposure therapy by conducting practice exposures in session with Kayla and attachment figures using graduated tasks, modeling, and reinforcement of the client’s success. The worker should assess whether Kayla's anxiety and fears are associated with a separation, loss, abuse, trauma, or unrealistic danger. The worker will use childcentered play therapy principles to promote greater awareness of self and increase motivation to overcome fears about separation. Ideally, Kayla’s family should also be involved in the treatment process. Therefore, the worker should conduct family anxiety man-

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agement sessions and assist the family in overcoming the tendency to reinforce the separation anxiety. The worker should teach the family members problem-solving and communication skills to enhance Kayla’s progress through therapy. The worker will counsel the parents and caregivers about setting firm, consistent limits on Kayla’s temper tantrums and excessive clinging or whining. Medications When evaluating whether or not medication is necessary for clients, it is important to refer them to an appropriate physician. Medication generally is not used or needed for SAD. The medication should be limited to children who do not respond to less intrusive, nonpharmacological interventions. In drug trials wherein medication was provided concurrently with supportive counseling and implicit or explicit behavioral strategies, it was not possible to determine the relative role of medication alone (Sowers-Hoag & DiDona, 1998). Imipramine is a tricylic antidepressant that has been found to be helpful. In some cases, the use of a mild tranquilizer may be helpful, and several different forms of tranquilizers may also be beneficial, as may some other medications (Sowers-Hoag & DiDona, 1998). Relapse Prevention It is important that social skills as well as self-esteem skills be learned and implemented so that the client is able to manage her feelings. It is also important that clients identify and rehearse with the worker the management of future situations or circumstances in which lapses could occur. The worker also should instruct the client to routinely use strategies learned in therapy (e.g. cognitive restructuring, exposure) and build them into her life as much as possible. REFERENCES American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Andreasen, N., and Black, D. (2006). Introductory Textbook of Psychiatry (4th ed.). Washington, DC: American Psychiatric Publishing. Jongsma, A., Jr., Peterson, M., and McInnis, W. (2006). The Child Psychotherapy Treatment Planner (4th ed.). Hoboken, NJ: John Wiley & Sons.

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Mayes, L., and Cohen, D. (2002). The Yale Child Study Center Guide to Understanding Your Child: Healthy Development from Birth to Adolescence. New York: Little, Brown and Company. Samuels, S., and Sikorsky, S. (1998). Clinical Evaluations of School-Aged Children: A Structured Approach to the Diagnosis of Child and Adolescent Mental Disorders (2nd ed.). Sarasota, FL: Professional Resource Press. Sowers-Hoag, K.P., and DiDona, T.M. (1998). Separation anxiety disorder. In B. A. Thyer and J. S. Wodarski (Eds.). Handbook of Empirical Social Work Practice: Vol. l Mental Disorders. (pp. 157–178). Hoboken, NJ: John Wiley & Sons.

Chapter 8 BULIMIA NERVOSA

B

ulimia nervosa (BN) is an eating disorder identifiable by episodes of overeating followed by unhealthy practices to lose weight. Selfinduced vomiting, abuse of laxatives, and excessive amounts of exercise are all methods used by persons with BN to rid the body of calories (Myers, 1996). According to the DSM-IV (APA, 2000), BN is characterized by the following: recurrent episodes of binge eating, recurrent compensatory behavior to prevent weight gain, self-evaluation that is unduly influenced by body shape and weight, and the occurrence of the disturbance that does not occur exclusively during episodes of anorexia. Persons with BN experience recurrent episodes of binging and purging. Binging includes eating an amount of food within a two-hour period that is larger than most people would eat within the same time frame and under similar circumstances. During the binge episode, the individual also experiences a sense that he or she is not in control of how much food is being eaten at the time (APA, 2000). Following episodes of binge eating, an individual with BN purges to rid the body of calories. Purging is defined as “inappropriate compensatory behavior in order to prevent weight gain” (APA, 2000). In between episodes of binging and purging, individuals with BN typically eat small amounts of food and often skip meals altogether (Mayo Clinic, 2006). According to CQ Researcher (2006), eating disorders such as BN occur mainly during the adolescent years. BN affects approximately 1 to 3 percent of adolescent girls and young women and between 0.1 perNote: Case study by Katie Parsell and Rebecca Haas.

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cent and 0.3 percent of adolescent males and young men (Myers, 1998). These statistics indicate that BN is an eating disorder that is more common in females than in males. Researchers have speculated that the onset of the disorder may begin in girls as their bodies begin to develop during puberty. Both girls and boys may become concerned about gaining weight in new places. In an attempt to gain control over body changes, the adolescent may react by taking total control of what they eat, thus developing unhealthy eating patterns (CQ Researcher, 2006). CQ Researcher (2006) states that many Americans place the blame for eating disorders on the nation’s obsession with appearance; however, there is evidence to support the idea that genetics and brain chemistry also play a role in developing eating disorders. According to the National Institutes of Mental Health (NIMH, 2001), research is being conducted to determine the causation of BN. Because some studies suggest that heritability plays a role in the development of BN, researchers are searching for specific genes that may be involved in susceptibility. There is speculation that there are multiple genes that could interact with environmental factors to increase a person’s risk of developing BN. Other studies are also investigating the neurobiological, social, and emotional aspects of the disorder. Scientists have concluded that neuropeptides play a role in BN. Energy expenditure and appetite are regulated by neuropeptides, thus making them a target for research (NIMH, 2001). CASE STUDY

The Client Janet is a fifteen-year-old white female who comes from a middleclass background. She is currently a sophomore in a metropolitan high school. Janet and three of her closest friends have begun binging and purging together. Recently, Janet tried out for gymnastics and did not make the team. She attributes her rejection to the fact that other girls who tried out and made the team appeared much smaller than she is. Janet first attempted binging and purging during a slumber party with the previously mentioned friends. Whereas her friends only binge and purge on occasion, Janet has begun purging after every meal and has

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had a slight weight loss. Janet’s mother questioned her after hearing Janet purging in the bathroom after dinner one night. Janet denies having a problem but acknowledges having several symptoms of BN. Janet’s mother has brought her in for treatment at the local hospital. Janet’s symptomatic presentation corresponds with the eating disorder symptom cluster. Her predominant symptoms are weight loss, binging and purging behaviors, low self-esteem, and self-evaluation that is unduly influenced by body shape and weight. Psychiatric comorbidity is common for many patients. Clients suffering with BN are at high risk for substance use disorders (Andreasen & Black, 2006). Persons suffering with bulimia may also be negatively affected by major depressive disorder, anxiety disorders, or even a personality disorder. Sometimes it is unclear which disorder is preexisting. It is clear, however, that the intersection of disorders compounds symptomatology (Andreasen & Black, 2006). In Janet’s case, major depressive disorder and obsessive compulsive disorder are differential diagnoses that should be considered (Andreasen & Black, 2006). However, these disorders are unlikely in this case due to Janet’s distorted body image. Poor appetite and weight loss are indicative of major depression. In most cases of major depressive disorder, however, weight loss is unwanted and is not associated with body image distortion. Ritualistic eating behaviors may be associated with obsessive compulsive disorder (OCD). However, persons suffering with OCD do not typically experience a distorted body image or fear of gaining weight (Andreasen & Black, 2006). Medical illnesses should also be ruled out before concluding that a client’s symptoms can all be explained by BN. Andreasen and Black (2006) identify gastrointestinal disorders, such as malabsorption syndrome, and endocrine disorders, such as hyperthyroidism, as conditions associated with severe weight loss. They acknowledge, however, that the presence of a morbid fear of fatness makes a medical cause highly unlikely. The Worker The social worker most appropriate to treating Bulimia Nervosa would be a master’s-level student or LCSW. The worker must be educated regarding eating disorders and appropriate treatment techniques and will be familiar with various developmental stages throughout the life course. The worker will need to be especially familiar with ado-

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lescent and young adult development because eating disorders often have an onset during adolescence or young adulthood (Andreasen & Black, 2006). The worker will also need to be familiar with or have experience in treating eating disorders. Finally, the worker will need to be experienced in administering cognitive behavioral therapy (CBT) because it is considered the most efficacious means of treating an eating disorder (Thyer & Wodarski, 1998). The primary components of CBT used while treating BN are self-monitoring, examining environmental cues, meal planning, problem-solving, relaxation training, psychoeducation, and cognitive restructuring (Fairburn, 1988). It is important that the worker be thoroughly familiar with the aforementioned fundamentals when administering CBT. Assessment There are several fundamental assessments clinicians can use to assess both the existence and severity of BN. The Coping Scale for Bulimia Nervosa is a variation of the Coping Scale by Hall, Havassy, and Wasserman used in substance abuse treatment research (Binford et al., 2005). The severity of BN can be assessed using daily self-monitoring reported by the client. The Eating Behavior-IV helps patients record meals and snacks, binge eating episodes, and compensatory behaviors (Bailer et al., 2004). The Eating Disorder Questionnaire is another example of a self-rating instrument (Bailer et al., 2004). Myers (1998) suggests the Eating Disorder Examination, a structured interview, and the Bulimia Test, a self-report instrument, as effective modes of assessment. The Eating Disorders Inventory (EDI) accurately assesses eating disorder-related psychopathology (Bailer et al., 2004; Myers, 1998). Depressive symptomatology often accompanies BN (Andreasen & Black, 2006). The Beck Depression Inventory effectively measures the existence and severity of depression coexisting with BN (Bailer et al., 2004; Binford et al., 2005). Observation methods are also important sources of information used to inform the clinician treating an eating disorder. Myers (1998) acknowledges the significance of assessing a client’s body image distortion, observing a client’s eating and compensatory behaviors, and measuring the amount and type of food involved in compensatory behaviors. A complete medical examination is crucial when evaluating and treating BN. Height, weight, vital signs, and body mass index should be measured initially

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and throughout the course of treatment (Andreasen & Black, 2006; Bailer et al., 2004; Myers, 1998). Specific testing should also be considered to measure electrolyte disturbances, potassium levels, tooth decay, and blood count (Andreasen & Black, 2006; Myers, 1998). Assessments help clinicians formulate treatment plans by highlighting a patient’s distorted beliefs and feelings related to his or her eating (Wiseman et al., 2002). Assessments can be performed at baseline, mid treatment, and end of treatment to determine the potential course and outcome of BN for each individual patient (Bailer et al., 2004). Accurate assessments, especially self-report measurements, help patients closely examine their eating habits and the circumstances under which behavioral manifestations of the disorder arise (Wiseman, Sunday, Klapper, Klein & Halmi, 2002). Accurate assessments ensure that clinicians make appropriate decisions regarding a patient’s need for medical and nutritional management (Andreasen & Black, 2006). In sum, accurate assessment can help ensure effective treatment. As mentioned earlier, an integral part of assessment and diagnosis of BN includes an extensive medical examination. Janet’s physician should pay extra attention to her vital signs, weight, skin, and cardiovascular system. Janet’s weight and height should be measured and recorded. Her weight and height or body mass index will be compared to the standard weight and height for a female of Janet’s age to help guide medical and nutritional management (Andreasen & Black, 2006). After all other explanations for Janet’s symptoms have been ruled out, she will participate in a structured interview with the social worker. As part of the assessment process, the social worker will administer the Eating Disorder Examination. This assessment tool is designed to provide more detail and accuracy than the standard self-report questionnaires do. The social worker who administers this test will have been thoroughly trained in interviewing skills and the scoring procedures of this instrument (Thyer & Wodarksi, 1998). Along with the structured interview Janet will also complete a number of self-report instruments as part of her assessment. She will be asked to complete the Motivational Stages of Change for Adolescents Recovering from an Eating Disorder (MSCARED), the Perceived Body Image Scale (PBIS), and the EDI. Janet will be asked to complete these instruments before and after treatment (Gusella, Butler, Nichols & Bird, 2002). Janet will be asked to take the Bulimia Test, a

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twenty-eight-item test designed to help the social worker measure the symptoms of bulimia, as outlined in the DSM-IV (APA, 2000). This test will help the social worker measure the severity of Janet’s symptoms and get a more accurate picture of her outcome (Myers, 1998). Behavior Definition According to the Mayo Clinic (2006), persons with BN often live in a very secretive world surrounded by self-disgust and shame. BN is an eating disorder in which people are preoccupied or obsessed with their weight and the shape of their bodies. People with BN often judge themselves very harshly. The binging and purging episodes that are characteristic of BN are behaviors that are often embarrassing and socially unacceptable. Like individuals with anorexia nervosa, people with BN may fear gaining weight, want to lose weight, and feel largely dissatisfied with their bodies. Because of compensatory behaviors to lose weight after a binging episode, people with BN may weigh within the normal range for their weight and height. Although it is stated that those with BN feel ashamed and guilty after binging, they often feel relieved following an episode of purging (NIMH, 2001). People with BN often feel out of control when it comes to eating. During a binge eating episode the individual is unable to restrain from eating copious amounts of food. Shortly after eating, the individual feels the strong need to purge, thus reinforcing the feeling of being out of control (NIMH, 2006). Along with the behavioral manifestations of BN, there are also physical consequences to the disorder. According to Andreasen and Black (2006), people with bulimia may develop calluses on their hands from placing their fingers down their throats to induce vomiting. Also, as a result of frequent vomiting, dental erosion is likely to occur. In some rare cases, an individual may suffer from esophageal erosion or tears. Other medical conditions that may be caused by bulimic behaviors include hypocalcemia (seen in individuals who engage in self-induced vomiting or abuse laxatives or diuretics), electrolyte imbalances that result in feeling weak or lethargic, electrocardiographic changes (such as depressed T waves), elevated serum transaminases (a reflection of fatty degeneration of the liver), elevated serum cholesterol and carotenemia (a reflection of poor nutrition), and parotid gland enlargement.

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As one can see, BN can pose severe consequences to one’s body. Statistics show that only 25 to 40 percent of people with eating disorders will be able to eat normally (Andreasen & Black, 2006, pp. 333–334). Research confirms that a team approach is the most effective means of treatment. Stewart and Williamson (2004) acknowledge the importance of a multidisciplinary team and a hospital-based program. They contend that the treating team should comprise one or more of the following: psychiatrist or medical director, clinical psychologist, nursing staff, social worker or family therapist, dietitian, activity therapist, eating disorder therapist, and mental health technician. Binging and purging behaviors must be specifically addressed when treating patients with BN. As mentioned earlier, CBT is considered to be the most effective means of addressing behavioral symptomatology. Treatment content should also include nutrition therapy, pharmacotherapy, group therapy, and family therapy (Thyer & Wodarski, 1998). Fairburn (1988) describes three important stages of CBT. The first stage in the content of therapy includes establishing a therapeutic relationship, educating the patient about the need for behavior and cognitive change and body weight regulation, reduction in frequency of undesirable behaviors, and mobilizing social supports. The second stage focuses on replacing unhealthy eating habits with more stable patterns of eating. The focus is more generalized in regard to education about dieting, body image, and basic cognitive distortions. The third stage focuses on maintenance of change following treatment. At this time, a relapse plan is generated, and patients are encouraged to process the rationale for setbacks (Fairburn, 1988). Fairburn’s (1988) three stages of CBT take approximately twenty weeks to administer. Other researchers advocate a popular twelveweek program that uses Healthy Eating Meal Planning System by Boutacoff, Zollman, and Mitchell and Bulimia Nervosa Group Treatment Manual by the Eating Disorders Research Program (Binford, Mussell, Crosby, Peterson, Crow & Mitchell, 2005). Other researchers promote programs ranging in duration from eighteen weekly sessions to twenty individual outpatient sessions over a four-month period (Bailer et al., 2004; Wiseman et al., 2002).

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Short-Term Treatment Because she admits to recent bouts of depression and anxiety, after an in-depth physical examination at the hospital, Janet’s primary care physician decides that Janet would benefit from taking an antidepressant. According to NIMH (2001), many persons with BN benefit from taking an antidepressant. This is especially true in situations in which the patient also suffers from depression and anxiety. After leaving the hospital, Janet is referred to a day treatment program that specializes in treating eating disorders. Upon entering treatment Janet participates in an in-depth assessment process that includes a structured interview, administration and completion of selfreport measurement instruments, an assessment of body image distortion, observational methods used by the interviewer, and a complete physical examination (Thyer & Wodarski, 2007). The assessment process is just the beginning of treatment for Janet. She must also attend individual psychotherapy in which a cognitive behavioral approach is utilized. As mentioned earlier, CBT has been shown to be effective in treating people with bulimia (Loeb et al., 2005). CBT targets the core features of the disorder. In the beginning sessions, the goals of treatment will focus on the therapist’s building rapport with Janet, educating her about using CBT to treat bulimia and about weight regulation, along with addressing the physiological effects that bulimia has on her body. During the first few sessions, the therapist will also help Janet to establish a regular eating pattern and an appropriate weight monitoring plan. Individual therapy is important for Janet since it addresses all the psychological components of the eating disorder and serves as the binding factor across therapeutic modalities (Stewart & Williamson, 2004). Individual therapy will make Janet accountable and responsible for behavior change and her ultimate recovery. Aside from receiving individual counseling, Janet will also be encouraged to participate in a support group for girls her age who are also suffering from BN. According to Riess (2002), group therapy for the bulimic population has been shown to be effective. The group setting provides individuals such as Janet with added social support, decreased isolation, and group interactions that foster changes in behaviors and attitudes.

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The fact that Janet has BN affects not only her, but also her family. As part of her treatment she and her family will begin attending family therapy once a week. According to Thyer and Wodarksi (2001), research has suggested that for younger clients such as Janet, family therapy may be more effective than individual techniques are in some circumstances. Janet and her parents will begin family therapy with an assessment of both Janet and her parents. The assessment will cover such topics as family structure; the family life cycle; family functioning; individual functioning; the presence of any individual psychopathology; and the meaning of the eating disorder on behavioral, experiential, and cognitive levels. Along with psychotherapies, nutritional therapy is also an integral part of Janet’s treatment since it is an important component to CBT models. During nutritional therapy, Janet will be provided with basic information regarding good nutrition. The nutritionist will also help her to integrate what she has learned about good nutrition. Janet and her nutritionist will work together in formulating healthy and adequate patterns of food intake. Long-Term Treatment Long-term goals will ensure that Janet remains motivated and focused in regard to her treatment plan. It is important for the clinician to facilitate the construction of a complete and accurate treatment plan and to obtain a signature of commitment every time the treatment plan is revised (Stewart & Williamson, 2004). It is also important for the treatment plan to be individualized to address a patient’s specific needs (Andreasen & Black, 2006). The most important long-term goal is to restore the patient’s nutritional state and ensure that her metabolic balance has been achieved. In this case, Janet will demonstrate stability by maintaining proper nutritional balance, maintaining a healthy body weight and body mass index, and demonstrating a marked diminishment in distorted eating behaviors. Changes in cognitions must also be long term. Janet will demonstrate that she has learned techniques to control binging, purging, and other compensatory behaviors. She will also exhibit a change in her distorted and erroneous beliefs about the benefits of weight loss. Long-term interventions must be utilized to achieve and maintain long-term goals. Long-term interventions should focus on harnessing

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social support, modifying undesirable behaviors, and promoting medical and therapeutic treatment compliance. A patient also needs to be able to create a self-dialogue, such as a journal, in order to cognitively process thoughts and feelings regarding recovery. The journal can be used to assess how Janet is adjusting to the various courses of treatment and can also be used in conjunction with CBT to address persisting cognitive distortions. Fairburn (1988) acknowledges the importance of creating and mobilizing additional social supports. Janet’s peer group will be closely evaluated, especially since the onset of BN was triggered by social interaction with her close friends. The clinician will also explore the possibility of utilizing a mentorship program for Janet in which a person in good physical health serves as a role model. Janet and her mentor can engage in appropriate exercise and can practice appropriate eating habits together. Once sufficient rapport is established, Janet’s mentor can fortify her cognitive restructuring by means of reality testing while processing media items such as television commercials or magazines. Finally, Janet’s family support will be strengthened as family members become better educated about her illness. Family therapy with Janet and her family will provide opportunities to improve interpersonal functioning by addressing communication and problemsolving techniques (Stewart & Williamson, 2004). Specific behaviors will need to be targeted for correction. Since BN often develops due to low self-esteem and social pressures to be thin, low self-esteem and related problems (such as compensatory behaviors to prevent weight gain) are the target behaviors for change (Bailer et al., 2004). It is important for persons with BN to establish healthy eating patterns, modify habits of physical activity, resolve psychological disturbance, modify body image disturbance, and correct medical complications (Stewart & Williamson, 2004). The clinician will help Janet modify undesirable behaviors by helping her develop mindfulness, increased insight and understanding, enhanced motivation for change and recovery, autonomy, identity and purpose for living, acceptance of self, and a sense of overall empowerment (Stewart & Williamson, 2004). Psychoeducation will help Janet attend to the medical and social consequences of her eating disorder (Wiseman et al., 2002). She and her clinician will address common short-term medical consequences, such as difficulty concentrating, dizziness, electrolyte problems, and

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menstrual abnormalities. Janet also will be educated regarding the long-term consequences of BN, such as osteoporosis, cardiac abnormalities, and tooth decay. Janet will be prompted to discuss the medical complications she has already experienced. Finally, Janet will discuss the social implications of her eating disorder by assessing her current relationships with friends, families, authority figures, and peers. Janet will benefit greatly from nutritional education. Researchers suggest that patients be educated about the food pyramid and how each of the food groups plays an essential role in bodily functions (Wiseman et al., 2002). Nutritional education will help Janet decrease her dietary restraint and will help her improve her body image and accompanying attitudes about shape and weight (Binford et al., 2005). Janet will demonstrate her learning by broadening her food choices. Finally, she will be educated about the processes that maintain her disorder such as preoccupation with or obsessive thoughts about eating and weight (Bailer et al., 2004). Medications Researchers are finding that psychotropic medications, which affect emotions, can help in treating BN (Thyer & Wodarski, 2001). Before Janet is started on medications, however, she will have to gain some weight. According to CQ Researcher (2006), it is very difficult, if not impossible to work with a starving brain; therefore, the first step in treatment would be for Janet to begin to put on some weight. After an intensive assessment, the social worker working with Janet has decided that she would benefit from pharmacotherapy. During sessions with her social worker Janet mentioned being depressed at times and talked about how she would have episodes of anxiety on occasion. Janet reported that sometimes she would get anxious about just leaving the house because she was too self-conscious about the way she looked. The social worker decided to make the proper referral for Janet to be evaluated by a psychiatrist or medical doctor who can prescribe appropriate medications. According to Thyer and Wodarksi (2001), the social worker is not directly responsible for the medication aspect of treatment; however, he/she would want to be familiar with medications used to treat BN in order to best serve the client. Janet’s social worker has experience in working with adolescents with BN and feels certain that Janet would benefit from antidepressant medication.

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According to NIMH (2001), antidepressants such as SSRIs, have been found to be helpful in treating BN, especially when the client presents with symptoms of depression and anxiety. According to CQ Researcher (2006), there are several new medications that hold promise in treating persons with BN. Topiramate, a drug that is often used to control seizures, may actually reduce the frequency of binging and purging episodes in persons with BN. A separate treatment, vagus nerve stimulation, which is currently being used to treat depression and epilepsy, may also be beneficial in treating BN. This treatment may help bulimics stop vomiting, because the vagus nerve initiates in the brain and continues down the neck and affects the vocal cords and the acid content of the stomach and other organs. Relapse Prevention Relapse prevention is important with any mental health diagnosis; however, it is especially important with eating disorders. Relapse literature indicates that only one fourth of individuals with BN who complete treatment remain symptom free six months after treatment completion (Binford et al., 2005). Unfortunately, it seems as if therapeutic gains are not well-maintained for most of the population. Thus, it is imperative that relapse prevention be developed in order to avert future crises. Stewart and Williamson (2004) promote participation in goal-setting and discharge planning groups. These groups are conducted at least twice weekly. The groups focus on short- and long-term goal setting, with the overall goal being full recovery and eventual discharge from therapy. The group educates and trains patients and their parents separately to ensure treatment gains are maintained. Group therapy can be a significant companion to discharge planning. Group therapy will help Janet learn the distinction between lapses and relapses (Stewart & Williamson, 2004). Janet will also learn plans to manage high-risk situations. Relapse prevention focuses on preparing patients for vulnerability to relapse during high-risk times. Janet will be provided tools to avert relapse, such as learning how to recognize patterns of thinking, personal triggers, and destructive behaviors that increase her propensity to relapse (Stewart & Williamson, 2004).

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Alumni groups can be significant sources of social support. The alumni group functions as a type of aftercare group for patients who have graduated from a hospital-based eating disorders program (Stewart & Williamson, 2004). The group is grounded in enhancing skills to help patients learn positive lessons from difficult life events and stress. In this group, mindfulness is enforced as a basic tool for maintaining recovery, preventing relapse, and enhancing the general quality of life. Follow-up assessments are also a fundamental component of relapse prevention. The Setting Conditions for Anorexia Nervosa Scale (SCANS) can help clinicians detect how likely a patient is to develop or to continue anorexic or bulimic behaviors (Myers, 1998). The Bulimia Test-Revised will help the clinician predict Janet’s course of illness and assess her potential treatment outcome (Myers, 1998). The clinician can also admit Janet to an accountability program, in which her behavior during and after meals is observed. This type of program is selected based on clinical discretion and is often used in the beginning stages of relapse prevention. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) Washington, DC: Author. Andreasen, N., and Black, D. (2006). Introductory Textbook of Psychiatry. Washington, DC: American Psychiatric Publishing. Bailer, U., de Zwaan, M., Leisch, F., Strnad, A., Lennkh-Wolfsberg, C., El-Giamal, N., et al. (2004). Guided self-help versus cognitive-behavioral group therapy in the treatment of bulimia nervosa. International Journal of Eating Disorders, 35, 522–537. Binford, R.B., Mussell, M.P., Crosby, R.D., Peterson, C.B., Crow, S.J., and Mitchell, J.E.(2005). Coping strategies in bulimia nervosa treatment: Impact on outcome in group cognitive behavioral therapy. Journal of Consulting and Clinical Psychology, 73, 1089–1096. Fairburn, C.G. (1988). The current status of the psychological treatments for bulimia nervosa. Journal of Psychosomatic Research, 32, 635–645. Gusella, J., Butler, G., Nichols, L., and Bird, D. (2002). A brief questionnaire to assess readiness to change in adolescents with eating disorders: Its applications to group therapy. European Eating Disorders Review, 11, 58–71. Loeb, K.L., Wilson, G.T., Labouvie, E., Pratt, E.M., Hayaki, J., Walsh, B.T., et al. (2005). Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: A study of process outcome. Journal of Counseling and Clinical Psychology, 73, 1097–1107.

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Mayo Clinic. (2006). Bulimia nervosa: Overview [Online]. Retrieved November 14, 2006. Available: http://www.mayoclinic.com Myers, L.L. (1996). Bulimia nervosa: What social workers need to know. Journal of Applied Social Sciences, 20, 63–75. Myers, L.L. (1998). Bulimia nervosa. In B. Thyer and J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice (pp. 439–450). Hoboken, NJ: John Wiley & Sons. National Institute of Mental Health. (2001). Eating disorders: Facts about eating disorders and the search for solutions [Online]. Retrieved November 14, 2006. Available: http://www.nimh.gov Riess, H. (2002). Integrative time-limited group therapy for bulimia nervosa. International Journal of Group Psychotherapy, 52, 1–26. Stewart, T.M., and Williamson, D.A. (2004). Multidisciplinary treatment of eating disorders. Part 2. Primary goals and content of treatment. Behavior Modification, 28, 831–853. Thyer, B.A., and Wodarski, J.S. (Eds.) (2007). Social Work in Mental Health: An Evidenced-Based Approach. Hoboken, NJ: John Wiley & Sons. Thyer, B.A., and Wodarski, J.S. (Eds.) (1998). Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders. Hoboken, NJ: John Wiley & Sons. Wiseman, C.V., Sunday, S.R., Klapper, F., Klein, M., and Halmi, K.A. (2002). Shortterm group CBT versus psycho-education on an inpatient eating disorder unit. Eating Disorders, 10, 313–320.

Chapter 9 ANOREXIA NERVOSA

A

norexia nervosa (AN) is a serious eating disorder that comprises disturbed eating patterns and intense obsessions regarding weight or body shape. Symptom criteria according to the DSM-IV-TR (APA, 2000) often include a refusal to maintain a minimally normal weight for age and height, intense fear of gaining weight, disturbance in the way in which one’s body weight or shape is experienced, and, in women, amenorrhea, or the absence of at least three consecutive menstrual cycles. CASE STUDY

Client Allison is a sixteen-year-old female with a six-month history of abnormal eating behaviors. Her family environment is somewhat dysfunctional. Although her parents are wealthy and can provide for her financially and materially, they are both distant and perhaps overly involved in their careers. When Allison was fourteen years old she attempted suicide, which led to a psychiatric hospitalization. Before she was released, her parents voluntarily relinquished custodial rights and the state assumed care for her, placing her with foster parents. She sees her biological parents irregularly. Not long after, Allison became increasingly preoccupied with her weight. She complained to her social worker and foster parents that she believed she was overweight, Note: Case study by Katie Rash.

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although she had always been in the normal, healthy weight distribution for girls of her height and age. Her social worker became concerned that there were underlying problems and that Allison might be targeting an issue that she knew she could control, primarily her size and overall appearance but was really unhappy with her family situation and parental neglect, a situation that would be far more difficult for her to correct. Allison’s foster parents complain that she regularly skips meals and refuses food, despite their urgings and attempts to entice her by buying what were previously her favorite foods and offering to take her out to her favorite restaurants for meals. Allison’s teachers have also noticed that she rarely eats anything at school, although she acknowledges that her foster parents provide her with lunch money and have offered to help her pack a lunch if she does not like the food that the school serves. Allison’s biological parents state that she was always a “picky” eater, but even they are perplexed by her dramatic weight loss and skeletal appearance. She has lost nearly 40 pounds since her disordered eating habits began and is now 5 feet 3 inches and weighs approximately 80 pounds. Treatment Plan AN is a serious condition that can devastate the lives of its victims, but with an appropriate diagnosis based on the information presented in the case study, realistic long-term goals and short-term therapeutic interventions, including medical and dietary, the client can progress and hopefully even avoid relapse if all facets, including underlying psychological distress, are actively addressed. The immediate concern is Allison’s eating habits, although her foster care maladjustment should also eventually be addressed. In Allison’s case, the cause of her suicide attempt (i.e. a depressive or other mood disorder) was sufficiently addressed during her psychiatric inpatient hospitalization, although in similar cases that would obviously be an area to investigate further. Long-Term Goals Long-term goals for treating Allison’s eating disorder would include 1. attaining and maintaining a healthy weight 2. avoiding another inpatient hospitalization to gain weight

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3. finding a more appropriate outlet for lack of control or need to express feelings, if relevant 4. achieving an understanding of healthy nutrition and a realistic view of her body Short-Term Goals Short-term objectives for treating Allison’s eating disorder would likely include 1. contracting with her social worker, foster parents, and other concerned adults regarding a healthy eating plan, which may consist of a menu or list of food items that she agrees to consume every day 2. weighing in with the social worker and/or her foster parents every week to demonstrate weight gain 3. agreeing to seek medical support or hospitalization if she cannot begin to gain weight on her own 4. researching and reporting back to worker on the possible dangerous effects of anorexia, including health problems and possible death 5. exploring and gaining understanding regarding the underlying psychological issues causing or contribution to her disorder Therapeutic interventions will likely include individual counseling with the social worker, ideally using CBT to address the distorted beliefs and resulting behaviors of living with a disease such as AN. Family therapy could also be conducted with her biological and/or foster parents to explore relevant issues that may be exacerbating Allison’s problems. She could also possibly attend a psychoeducational support group for other teenage girls recovering from AN. Medical intervention will likely be necessary if she refuses or is unable to maintain weight on her own, and nutritional counseling would also be helpful at this stage. Medications Medications for Allison would be determined by a physician or psychiatrist if her symptoms became too severe to be managed by the clinical social worker alone. Although medication is not sufficient to cure her, because her attitudes and behaviors about eating are the pri-

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mary targets of intervention, medication may be necessary to treat some accompanying symptoms, such as anxiety or depression, which may be an interrelated component of her disturbed eating behaviors. A physician or psychiatrist could prescribe antidepressants for the symptoms of depression or anxiety that accompany her anorexia. Furthermore, if she is unable to gain weight independently with the assistance of outpatient counseling, a physician would likely mandate another inpatient hospitalization, where she can be monitored constantly and placed on a feeding tube temporarily if necessary. Relapse Prevention A necessary step in relapse prevention is to encourage Allison to avoid dieting and instead stick to a healthy meal plan that meets all of her nutritional needs and does not consist of many unnecessary calories, which she will likely be uncomfortable with on a long-term basis. Exercise should also be limited to thirty to sixty minutes, three to five times a week. When she feels overwhelmed or begins to imagine that she is fat she should ask herself what she thinks she would gain by being thinner that she does not have now. If her answers are typical, she may say self-esteem, more friends, acceptance, confidence, and control. She must then remind herself of the reality of life when she becomes too thin, when medical intervention is necessary and she therefore loses control, self-esteem, positive attention from friends, and society’s acceptance. Allison should also accept that the shape of her body is due in part to genetics and may not ever take on the appearance that she would ideally like, at least not while maintaining a healthy weight. Finally, if she finds herself slipping and considering former eating habits, she should contact her social worker or another therapist or professional to schedule an appointment in order to reevaluate her progress and perhaps revise her treatment plans. Foster Care Maladjustment In regard to Allison’s possible maladjustment to her foster care setting, demonstrated by the behavioral definition of eating too little, she must have a long-term goal of demonstrating appropriate eating habits. She should continue to attend visitation with her biological family as well as demonstrating appropriate expressions of anger, sadness, and frustration with her current life experiences. A treatment

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plan should be initiated for Allison concerning whether additional individual or group therapy is necessary and to determine whether there is sufficient evidence to consider the possible diagnosis of an adjustment disorder. The social worker can monitor her visits with her biological parents, at least to some extent, and can also encourage her social involvement with friends and peers, since Allison had to switch schools after her hospitalization and during her foster care placement, which is often a stressor for adolescents. Allison’s academic and behavioral reports from school should also be carefully monitored during and following treatment for the AN, in case her negative behaviors that currently manifested through eating are transferred to other areas of her life. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revision). Washington, DC: Author.

II. ADULTS

Chapter 10 GENERALIZED ANXIETY DISORDER H UGHLETT O. P OWELL, P H.D.

“I always thought I was just a worrier; I’d feel keyed up and unable to relax. At times it would come and go, and at times, it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party or what would be a great present for somebody. I just couldn’t let something go.” “When my problems were at their worst, I’d miss work and feel terrible about it. Then I worried that I'd lose my job. My life was miserable until I got treatment.” “I’d have terrible sleeping problems. There were times I’d wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My heart would race or pound, and that would make me worry more. I was always imagining things were worse than they really were. When I got a stomachache, I’d think it was an ulcer.” National Institutes of Mental Health (2005)

G

eneralized anxiety disorder (GAD) is an Axis I disorder that is diagnosed when a person worries excessively about a variety of everyday problems for at least six months (APA, 2000). The disorder comes on gradually and can begin across the life cycle, although the risk is highest between childhood and middle age (Huppert & Rynn, 2004; Roemer, Orsillo & Barlow, 2002). People with GAD do not seem to be able to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They constantly have difficulty relaxing, they are startled quite easily, 85

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and they have difficulty concentrating on any specific topic or subject. People with GAD often go through the entire day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Often, the thought of getting through the day produces anxiety (Brouette & Goddard, 2002). In the DSM-II (APA, 1968), panic disorder and GAD fell under the broad category of anxiety neurosis. With the release of DSM-III (APA, 1980), GAD and panic disorder became distinct diagnoses; however, GAD remained poorly defined and required only one month of symptoms for the diagnosis. The duration of symptoms was increased to six months with DSM-III-R (APA, 1987). A duration of six months is still required for the diagnosis of GAD, but DSM-IV (APA, 1994) decreased the number of associated symptoms down from eighteen to six. According to the DSM-IV, patients are required to experience at least three of these six associated symptoms, compared with six out of eighteen symptoms that were required in the previous edition of the DSM. GAD is the most common of the anxiety disorders (Huppert & Rynn, 2004). It is characterized by unrealistic or excessive anxiety and worry about two or more life circumstances for at least six months. It has a combination of cognitive and physical symptoms. GAD affects about 6.8 million adult Americans and about twice as many women as men. Over the past two and a half decades, GAD has undergone more changes than any other anxiety disorder. As noted earlier, it was not until DSM-III that GAD first appeared as a diagnostic category (APA, 1980). Despite its appearance in the DSM-III for the first time as a diagnostic category, real diagnostic clarity in its definition did not appear until several revisions later in the DSM-III-R (APA, 1987). The final set of revisions of the criteria for GAD occurred in the DSM-IV (APA, 1994). The DSM-IV differential guidelines for GAD specify that the disorder should not be assigned if its features are better accounted for by another mental or medical disorder (for example, worry about negative evaluation by others in social phobia should be not counted toward the diagnosis of GAD). In addition, although most of the diagnostic hierarchy rules that were prominent in earlier editions of the DSM have been removed, such a rule still exists for GAD. Specifical-

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ly, the DSM-IV definition of GAD states that the disorder should not be assigned if its features occur exclusively during the course of a mood disorder. Although the DSM-IV definition of GAD reaffirmed the major change that was introduced in the DSM-III-R, which established excessive worry as the key feature of the disorder, several revisions were made to the criteria in order to make them more fitting and to underscore the pathological features of worry. For instance, whereas the worry criterion in DSM-III-R required the presence of two or more spheres of worry, DSM-IV deemphasizes the specific number of worry areas but specifies that the worry must be excessive (that is, the intensity, duration, and frequency of the worry is out of proportion to the likelihood or impact of the feared event), pervasive (that is, worry occurs about a number of events or activities on more days than not for at least six months), and uncontrollable (that is, the person finds it difficult to control the worry) (APA, 1994). In addition, whereas the associated symptom criterion for DSM-III-R comprised eighteen symptoms forming three clusters (motor tension, vigilance and scanning, and autonomic hyperactivity), this criterion now consists of only six symptoms in DSM-IV. Specifically, many of the symptoms from the DSM-III-R motor tension and vigilance and scanning clusters were retained in the DSM-IV associated symptom criterion, but all of the symptoms from the autonomic hyperactivity cluster were eliminated (i.e. sweating and accelerated heart rate) (APA, 1994). There were no changes to the criteria for the diagnosis of GAD in the DSM-IV-TR (APA, 2000), the most recent edition of the DSM; here GAD is clearly defined as referring to chronic and excessive worry about many different life events, such as finances, health, and the wellbeing of others. Most significant are the excessiveness of the worry and the inability of the patient to control or stop it. In an attempt to provide additional clarity and to distinguish between the everyday worry (ego-syntonic) and the ego-dystonic worry that is characteristic of GAD, Rygh and Sanderson (2004) explained the difference between pathological worry and nonpathological worry. Pathological worry, according to these authors, is distinguished from nonpathological worry because of the frequency, intensity, and duration of the worry; the individual’s ability to control the worry and whether the worry significantly interferes with functioning. Additionally, nonpathologial worry is less likely to be accompanied by physiological symptoms that are present with pathological worry.

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Typical symptoms of GAD include difficulty controlling the tendency to worry, muscle tension, fatigue, irritability, restlessness, difficulty sleeping and concentrating, and apprehension. GAD is characterized by at least six months of persistent and excessive anxiety and worry (APA, 1994). Unlike other anxiety disorders, GAD can arouse anxiety in almost any situation without a specific trigger. In fact, many people suffering from this disorder are anxious all the time and the focus of their concerns shifts frequently. Both psychological and physical symptoms are generally associated with GAD. Some typical psychological symptoms are chronic worry about events that are unlikely to occur; inability to shut off constant anxious thoughts; feelings of dread, restlessness, and inability to relax; trouble falling asleep or staying asleep; trouble concentrating; irritability; easy to startle; and procrastination. Some physical symptoms typical of GAD are lack of energy, twitching or trembling, muscular tension, aches or soreness, stomach problems (nausea or diarrhea), headaches, chest pains, grinding of teeth, dry mouth, and dizziness or lightheadedness. DSM-IV-TR DIAGNOSTIC CRITERIA FOR GAD

A. Excessive anxiety and worry (anxious expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past six months). Note: only one item is required in children. 1. restlessness or feeling keyed up or on edge 2. being easily fatigued 3. difficulty concentrating or mind going blank 4. irritability 5. muscle tension 6. sleep disturbance (difficulty falling or staying asleep or restless unsatisfying sleep)

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D. The focus of the anxiety and worry is not confined to features of an Axis I disorder; for example, the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in OCD), being away from home or close relatives (as in SAD), gaining weight (as in AN), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g. drug abuse, or a medication) or a general medical condition (e.g. hyperthyroidism) and does not occur exclusively during a mood disorder a psychotic disorder or a pervasive developmental disorder (APA, 2000). As suggested in items D and F of the DSM-IV-TR diagnostic criteria, some medical conditions and other organic factors can present as symptoms of GAD. Underlying physical pathologies, such as disorders of the endocrine system or brain tumors, can present with symptoms similar to GAD. In addition, stimulant intoxication from caffeine, cocaine, or amphetamines; exposure to a toxin; or withdrawal from sedatives or alcohol can also present symptoms of an anxiety syndrome (Rygh & Sanderson, 2004). EPIDEMIOLOGY

Because of the changes in the definition and its recency as a distinct disorder, prevalence data based on DSM-IV criteria for GAD are limited (Papp & Kleber, 2002). However, over the last several years, large amounts of data on DSM-III and DSM-III-R criteria for GAD have become available. Studies of the lifetime prevalence for GAD in the general population have provided estimates ranging from 1.9 to 5.4 percent (Kessler, Walter & Wittchen, 2004). The most recent prevalence data for GAD have come from the National Comorbidity Survey (NCS), in which more than 8,000 persons in the community (ages fifteen to fifty-four years) were evaluated with structured interviews.

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This study obtained prevalence estimates of 1.6 and 5.1 percent for current and lifetime GAD, respectively, as defined by DSM-III-R criteria (Blazer, Hughes, George, Swartz & Boyer, 1991). Consistently, community surveys indicate a 2:1 female to male preponderance of GAD (Blazer et al., 1991; Kessler, DuPont, Berglund & Wittchen, 1999; Papp & Kleber, 2002). In the NCS, race, religion, education level, and income were not associated with risk for GAD. Multivariate logistic regression analysis, however, indicated that being older than twenty-four years, having had a previous marriage (that is, being separated, divorced, or widowed), being unemployed, and being a homemaker were significant correlates of the disorder (Papp & Kleber, 2002). Although conclusive data on the epidemiology of GAD in older populations are needed, initial evidence suggests that GAD may be one of the more common disorders in the elderly (Papp & Kleber, 2002). According to Roemer and associaates (2002), GAD is significantly more common in primary care settings, with current and lifetime prevalence rates ranging from 3.5 to 14.55 percent among primarily low-income, black females to 22 to 40 percent among high users of medical care. Roemer and colleagues (2002) also reported findings where GAD appeared to be about twice as high among women as among men in both community and clinical samples. These authors noted that this finding might be culturally specific after examining an epidemiological study that was conducted in South Africa that found higher prevalence rates of GAD among men. Carter, Wittchen, Pfister, and Kessler (2001) found that the likelihood of being diagnosed with GAD increased significantly with age. Citing the results of a number of epidemiological surveys, Kessler and associates (2004) also reported that the lifetime prevalence of GAD is more common among women than men, among unmarried than married people, among racial/ethnic minorities than majority groups, and among respondents with low socioeconomic status (SES) than middle or high SES respondents. However, prospective analysis shows that none of these sociodemographic variables is a significant predictor of the course of GAD (Yonker, Dyck, Warshaw & Keller, 2000). According to Rygh and Sanderson (2004), individuals with GAD often report a long history of symptoms dating back to childhood, with a large portion unable to report a clear age of onset. Although early ages of onset are most common, the syndrome of GAD may first

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emerge later in life. Some people with GAD report an onset in adulthood that is usually in response to some form of life stress (Blazer et al., 1991; Kessler et al., 1999). In an epidemiological survey of the DSM-III disorders, a bimodal distribution in the age of onset of GAD was observed, possibly reflective of two separate pathways to the causes of this disorder (Blazer et al., 1991). For instance, it has been suggested that when compared with early-onset GAD, stressful life events may play a stronger role in onsets of GAD occurring later in life. The findings of Blazer and colleagues (1991), who noted that the occurrence of one or more negative life events increase by threefold the risk of developing GAD in the following year, support this suggestion. DEVELOPMENT OF GENERALIZED ANXIETY DISORDER

Although there has been a recent influx of interest in GAD as a separate Axis I syndrome, most of the focus has been on its epidemiology, assessment, and treatment. Less attention has been given to its development andetiology (Hudson & Rapee, 2004). Increasingly, conceptual models of the origins of GAD involve the integration of biological and psychosocial factors. In most models, GAD is characterized as comprising an excess of features (that is, worry, negative affect) found in persons without mental disorders, with the key differences between pathological and nonpathological states being the frequency, intensity, and uncontrollability of these features (Borkovec, 1994; Roemer et al., 2002). In addition to asserting that the constituent features of GAD operate on a continuum, these models provide an explanation for why some individuals manifest these symptoms at pathological levels. For example, Barlow (1988, 2002) asserts that anxiety and depression share a common biological vulnerability that is best characterized as an overactive neurobiological response to life stress. In an attempt to address the void in the literature as it relates to the development and etiology of GAD, Hudson and Rapee (2004) presented yet another model that can be used as a guide for future etiological research. Beginning with a brief review of the literature, the authors conceded that the etiological research in anxiety disorders remains in its infancy. As indicated earlier, the frequent changes in the criteria for GAD across the editions of the DSM have contributed to the void in studies that examine GAD, in general, and its development

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and etiology in particular. Further emphasizing the variety of the pathway to anxiety disorders in general and GAD in particular, the model presented by Hudson and Rapee (2004) highlighted two possible pathways: genetic/biological factors and environmental factors. These pathways to the development and etiology of GAD are also supported in the research literature (Kessler et al., 1999; Papp & Kleber, 2002; Roemer et al., 2002; Rygh & Sanderson, 2004). Genetic/Biological Factors Several investigations have examined the genetics of GAD (Brouette & Goddard, 2002). Although some early studies failed to find a clear role of genetic factors in GAD DSM-III as described in (Andrews, Stewart, Allen & Henderson, 1990; Torgersen, 1983), more recent findings based on DSM-III-R criteria have indicated otherwise (Brouette & Goddard, 2002; Rygh & Sanderson, 2004). For example, in a study of 1,033 blindly assessed female twins, Kendler, Neale, Kessler, Heath, and Eaves (1992) concluded that GAD is a familial disorder, with a heritability estimated at around 30 percent. Further research in both all female (Kendler et al., 1992) and mixed-sex twin samples (Roy, Neale, Pedersen, Mathe & Kendler, 1995) has indicated that although a clear genetic influence exists in GAD, the genetic factors in the disorder are completely shared with major depression. Although GAD and major depression share the same genetic factors, their environmental determinants appear to be mostly distinct (Roemer et al., 2002). From their review of the literature, Rygh and Sanderson (2004) report that most studies on the genetic biological factor of GAD suggest a lack of specificity in the transmission of GAD. The evidence, these authors continued, suggests a more general heritability of traits such as anxiety, negative affect, and behavioral inhibition in those with anxiety, depression, and other related emotional disorders. The general consensus, the authors concluded, is that there is a common genetic basis for anxiety and related disorders, such as depression, but that specific differences among disorders are best accounted for by environmental factors.

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Environmental and Psychosocial Factors The review of the literature on genetic biological factors in the development of GAD underscored the significant role of environment in the development of anxiety disorders in general and GAD in particular (Hudson & Rapee, 2004). Results from adult twin studies indicate a fundamental role for nonshared environmental factors, such as experiences that are specific to the individual, in the development of anxiety disorders. Shared environmental factors, experiences common to siblings in a family, however, have been shown to play a minimal role ( Jardine, Martin & Henderson, 1984; Kendler et al., 1995). Pike and Plomin (1996) and Rowe (1997) assert that the family is only likely to be important in the development of psychopathology when it is part of a child’s nonshared environment. However, more recent studies of twin children affirm that shared environmental factors account for a significant amount of variance in both anxiety symptoms and disorders (Edelbrock, Rende, Plomin & Thompson, 1995; Eley, 1997; Thapar & McGuffin, 1995; Topolski et al., 1997). In addition to highlighting the role of shared environment in the development of anxiety, the studies also demonstrate that the overall results from child twin studies indicate a more important role for shared environment than in indicated by adult studies (Kessler et al., 2004). In additional exploration of the influence of familial environment on the development and etiology of GAD, Ben-Noun (1998) examined the relationship between persistent and prolonged family dysfunction and the rate of GAD in either parent. The results indicated that GAD developed in dysfunctional couples and mostly in the female partners. The researcher also found that the presence of GAD in either partner appeared to produce a negative influence on the disturbed relationship within the family. Others studies that have examined the familial environment and its influence in the development of GAD have looked at the incidence of enmeshed relationships and role reversal with primary caretakers, the incidence of past physical trauma (Borkovec, 1994), the relationship between amount of worry and parental criticism and expectation (Stober & Joorman, 2001), and the incidence of overcontrolling parents (Barlow, 2002; Chorpita & Barlow, 1998). Although these studies suggest some possible relationship or influence in the development of GAD, additional research is needed before any specific causal relationship can be concluded (Rygh & Sanderson, 2004).

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In addition to genetic biological and environmental influences, psychosocial factors are also considered in current conceptual models to be implicated in the origins of GAD. One such psychological vulnerability may stem from early experiences of uncontrollability (Barlow, 1988, 2002). Although the nature of these early experiences may be complex, Borkovec (1994) has asserted that childhood histories of psychosocial trauma, such as death of a parent or physical or sexual abuse, and insecure attachment to primary caregivers may be particularly salient to the origins of this psychological vulnerability. Finally, combined with a biological vulnerability and triggered by the stress of negative life events, this psychological vulnerability results in clinical anxiety (GAD) (Barlow, 2002). Differential Diagnosis and Comorbidity In spite of the recent revision and clarity of its definition, GAD continues to be one of the least researched anxiety disorders (Mennin, Heimberg & Turk, 2004). Papp and Kleber (2002) recognized the paucity of research on GAD and provided the following four specific reasons to explain this gap in the research. First, the authors noted, because the diagnostic category of GAD was first introduced in DSMIII in 1980 (APA, 1980), studies conducted before that date have limited relevance and questionable validity. Second, because treatment resistance in GAD in not uncommon, patients and therapists are reluctant to engage in the prolonged and frequently unsuccessful therapeutic process that could yield the much-needed information. Third, because the varied symptoms of GAD can mimic a series of medical conditions, these patients usually are seen by nonmental health specialists; psychiatric referral, if ever made, is frequently delayed. Fourth, because “pure” GAD without comorbid conditions is less common, the interpretation of studies with heterogeneious comorbid samples is difficult. Moreover, the significant level of comorbidity (the occurrence of at least two different disorders in the same individual) and diagnostic uncertainty increases the difficulties in the differential diagnosis of GAD (Huppert & Rynn, 2004: Papp & Kleber, 2002; Rygh & Sanderson, 2004). Other authors (Brown, Moras, Zinberg & Barlow, 1993; Mennin et al., 2004; Roemer et al., 2002) have highlighted the comorbidity that goes along with the clinical picture of GAD as a significant

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challenge in the diagnosis of this disorder. Mennin and associates (2004) reported that GAD has often been found to be comorbid, with approximately 60 to 90 percent of patients meeting criteria for another disorder. Brawman-Mintzer and Lydiard (1996) reported high rates of co-occurrence, ranging from 45 to 91 percent, of many other psychological disorders with GAD. Researchers (Bruce, Machan, Dyck & Keller, 2001) have also found that it is often rare to find “pure” presentations of GAD, especially when diagnoses are viewed longitudinally. Additionally, Rygh and Sanderson (2004) reported that the symtomatology of various medical conditions and other organic factors could be quite similar to those of GAD. More specifically, underlying physical pathologies, such as disorders of the endocrine system (e.g. hyperthyroidism) or brain tumors, can present with symptoms that are very similar to GAD (Rygh & Sanderson, 2004; Stein & Williams, 2002). According to Borkovec, Abel, and Newman (1995) and Wittchen, Zhao, Kessler, and Eaton (1994), the symptoms of GAD are present in most anxiety and mood disorders, but only about 20 percent of the patients with depression and 10 percent of those with another anxiety disorder meet the criteria for the full syndrome of GAD. Additionally, more than two-thirds of the patients with the principal diagnosis of GAD have an additional Axis I disorder with social phobia and dysthymia at the top of the list (Papp & Kleber, 2002). Mennin and collegues (2004) also found GAD to be the most common additional diagnosis among patients with social phobia, with rates as high as 33 percent and as low as 17 percent. Some researchers have begun to examine the occurrence of personality disorders in patients with anxiety disorders (Mennin et al., 2004). Reich and associates (1994) found GAD to have a stronger relationship with the Axis II disorders than panic disorder or agoraphobia, and this relationship tends to be stronger when major depression is also present. In another study, Sanderson, Beck, and McGinn (1994) found that 49 percent of patients with GAD met criteria for at least one comorbid personality disorder. Additionally, in a study in which thirty-two patients were diagnosed with GAD, avoidant personality disorder and dependent personality disorder were found to be the most common Axis II diagnoses.

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The assessment of GAD presents various challenges to the clinician. The phenomenon (worry) that makes up the main characteristics of this syndrome is also associated with both normal human functioning and other psychological disorders (Huppert & Rynn, 2004). Furthermore, as presented earlier, there is a high level of comorbidity among the anxiety disorders and GAD in particular which requires one to consider diagnosing multiple disorders as well as making a differential diagnosis. The primary distinction between GAD and other anxiety disorders is the focus of the patient’s concern (Barlow, 2002). Providing clarity to the distinction between the types of worry exhibited in patients with other anxiety disorders and those in GAD patients, Huppert and Rynn (2004) report that patients with GAD experience uncontrollable worry about a number of different areas in their life. In fact, these authors continued, GAD patients often worry about their worrying. In contrast, the focus of concern for patients with other anxiety disorders is specific to their respective disorder. Subsequently, to differentiate GAD from other disorders and to determine whether the patient’s symptoms meet the criteria for clinical diagnosis require a thorough assessment that is based on a comprehensive understanding of psychopathology. A comprehensive assessment of GAD combines information gathered from several sources, including clinical interviews, questionnaires, and self-monitoring records. In addition to determining the existence and nature of GAD, Rygh and Sanderson (2004) insisted that a thorough assessment of GAD is also crucial for planning appropriate treatment and evaluating treatment outcome. According to these authors, there are three types of assessments. One type establishes the existence and severity of the disorder through self-report measures. The second type of assessment uses both interviews and self-monitoring to show how the disorder is expressed within the client’s life. The third type serves also to assess important information that is used in the planning and execution of treatment (Rygh & Sanderson, 2004). A significant feature of these types of assessments is their capacity to provide necessary data that can be used to compare pre and post conditions of GAD. Rygh and Sanderson (2004) provided the following summarized listing of the possible methods of gathering these types of data:

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Overview of Possible GAD Assessment Methods Diagnostic Clinical Interviews Highly structured Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) Structured Clinical Interview for DSM-IV (SCID) Loosely structured Decision tree for differential diagnosis of GAD Decision tree for GAD diagnostic criteria Self-Report Measures for Diagnosis and Severity Beck Anxiety Intervention (BAI) Beck Depression Intervention-II (BDI-II) Penn State Worry Questionnaire (PSWQ) Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV) Assessing Idiosyncratic Aspects of GAD Life context interview Self-monitoring tools Worry Diary Worry Episode Log Assessing Problematic Patterns in Relationships Inventory of interpersonal problems circumplex scales (HP-C) Looking for patterns arrows client’s relationships Exploring one relationship in depth Using therapist’s emotional experiences with client to identify treatment targets Assessing Pleasurable Activity Pleasurable activity log As indicated earlier, the treatment of GAD falls into two main categories, psychological and pharmacological. Most clients with the disorder are treated with a combination of medication and psychotherapy. In their review of effective treatments for GAD, Sussman and Stein (2002) assert that clients should be encouraged to cope with low levels of anxiety without medication, reserving medication for when it is clearly needed. Thus, pharmacological treatment is usually recommended for clients whose anxiety is severe enough to interfere with their daily functioning. Tolerance level of GAD symptoms (severity) is generally measured on a case-by-case basis. For example, how much do the patient’s symptoms (preoccupation with/excessive worry) keep him/her from completing daily work assignments? How much do the

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symptoms interfere with social and interpersonal relationships? These are some of the questions that the patient and the treatment provider should discuss before medication is recommended. Medications B ENZODIAZEPINES. This group of tranquilizers does not decrease worry but does lower anxiety by decreasing muscle tension and hypervigilance. These medications are often prescribed for patients with double anxiety because they act very quickly. The benzodiazepines, however, have several disadvantages. They are unsuitable for long-term therapy because they can cause dependence, and GAD is a long-term-disorder They cannot be given to patients who abuse alcohol, and they cause short-term memory loss and difficulty in concentration. B USPIRONE (B U S PAR®). Buspirone appears to be as effective as benzodiazepines and antidepressants are in controlling anxiety symptoms. It is slower to take effect (about two to three weeks) but has fewer side effects. In addition, it treats the worry associated with GAD rather than the muscle tension. TRICYCLIC ANTIDEPRESSANTS. Imipramine (Tofranil®), nortriptyline (Pamelor®), and desipramine (Norpramin®) have been given to patients with GAD. They have, however, some problematic side effects. Imipramine has been associated with disturbances in heart rhythm, and the other tricyclics often cause drowsiness, dry mouth, constipation, and confusion. They increase the patient’s risk of falls and other accidents. S ELECTIVE S EROTONIN RE-UPTAKE I NHIBITORS (SSRI). Paroxetine (Paxil®), one of the SSRIs, was approved by the FDA in 2001 as a treatment for GAD. Venlafaxine (Effexor®) appears to be particularly beneficial to patients with a mixed anxiety/depression syndrome; it is the first drug to be labeled by the FDA as an antidepressant as well as an anxiolytic. Venlafaxine is also effective in treating patients with GAD whose symptoms are primarily somatic (manifesting as physical symptoms or bodily complaints) (Heimberg, Turk & Mennin, 2004; Rygh & Sanderson, 2004; Sussman & Stein, 2002). Based on their extensive review of the psychological and psy chopharmacological treatment of GAD, Rygh and Sanderson (2004) made the following recommendations:

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First, test the effectiveness of psychological intervention before the introduction of psychopharmacological treatment, except when the following conditions exist: when a client's functioning is significantly impaired by the disorder and an exclusive trial of psychological treatment creates undue hardship. When the level of anxiety is experienced as intolerable, medication as an adjunctive treatment may be necessary. However the authors also recommend the inclusion of a goal of becoming medication-free within treatment under such conditions. When the response to psychological intervention is present but has proven insufficient, the authors further recommend that medication be considered as an adjunctive treatment.

Exclusive psychopharmacological treatment of GAD should be reserved for cases that prove to be highly adverse to psychological treatments. Among the many forms of psychological treatments that have been applied to GAD are psychoanalytic, brief supportive-expressive psychodynamic, supportive-expressive, and client-centered therapies; eye movement desensitization and reprocessing (EMDR); electroencephalographic alpha and theta neurofeedback training; and CBT (Rygh & Sanderson, 2004). Of these treatments, CBT has been found to be the most effective in the treatment of GAD. In their review of GAD treatments, Rygh and Sanderson (2004) found CBT to be the only form of psychological treatment for GAD that has been repeatedly subjected to rigorous, well-controlled treatment outcome research. CBT In CBT, the therapist uses strategies and techniques designed to help clients correct their negative distorted views about themselves, the world, and the future, as well as the underlying maladaptive beliefs that gave rise to these cognitions (Beck, Rush, Shaw & Emrey, 1979). The client gradually learns to see situations and problems in a different perspective, and to recognize his/her faulty perceptions and learns the methods and techniques to use to alleviate and reduce the anxiety. Many researchers (Barlow, 2002; Borkovec, Newman, Pincus & Lyte, 2002; Leahy, 2004; Roemer et al., 2002) have supported the effectiveness of CBT as a primary treatment intervention for GAD. In addition, the Task Force of the Division of Clinical Psychology of the American Psychological Association, the organization that is involved with identifying empirically supported treatments, has reported that

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only techniques used in CBT meet the criteria to be included as empirically supported treatments for GAD (Chambless, Baker & Baucon, 1998; Woody & Sanderson, 1998). In his review of the treatment literature on GAD, Leahy (2004) underscored the effectiveness of CBT. He reported that, until recently, the treatment of GAD focused on the use of anxiety management techniques, such as relaxation, activity scheduling, and assertiveness training. Although these primarily behavioral approaches had some efficacy in reducing hyperarousal, which is the second most significant principal component that forms the target of a treatment intervention for GAD (Brown et al., 1993), the unconcentrated and general worry, which is the most significant principal component that characterizes GAD, was not adequately addressed (Leahy, 204). As with all treatment modalities, CBT has its limitations. For example, in their review of CBT treatment for GAD, Chambless and Gillis (1993) indicate that clinically significant change occurs in only about 50 percent of patients. Likewise, Durham and Allan (1993) and Fisher & Durham (1999) reported that although CBT appears to be the most effective intervention, only 50 percent of patients achieved high end-state functioning or recovery. In an attempt to address the limitations of CBT for GAD, Borkovec and colleagues (2002) suggested that some clients may need to receive more sessions of CBT to benefit fully from this intervention. To test this hypothesis, these researchers conducted a trial that subsequently increased client contact time. Despite almost twice as much contact time, the rate of high end-state functioning was not improved (Newman, Castonguay, Borkovec & Molnar, 2004). Another hypothesis is that CBT has failed to address important factors in the development and etiology and maintenance of GAD. As discussed previously, GAD is a chronic disorder with disturbances not only in the client’s cognition but also in his/her interpersonal and somatic domain (Borkovec et al., 2002). In the final analysis, the ultimate answer to the effective/comprehensive treatment of GAD may lie with a treatment package that can address all of its complex components. However, for now, as presented earlier and discussed throughout this chapter, CBT continues to be the most effective and empirically driven psychological treatment for this complex syndrome.

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CULTURAL CONSIDERATIONS

In its 2000 report, the United States Census Bureau (2000) asserted that the United States is becoming increasingly diverse. Whereas white Americans currently constitute 71 percent of the population, by the year 2050 nearly one in two Americans will be a person of color. The authors of the DSM have made significant changes in the manual that suggest their recognition of these demographic changes. Acknowledging the significance of culture in the diagnosis of psychopathology, they made special efforts in the preparation of DSM-IV to incorporate an awareness that the manual is used in culturally diverse populations in the United States and internationally. Clinicians are called on to evaluate individuals from numerous different ethnic groups and cultural backgrounds (including many who are recent immigrants). Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-IV classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual’s culture. The provision of a culture-specific section in the DSM-IV text, the inclusion of a glossary of culture-bound syndromes, and the provision of an outline for cultural formulation are designed to enhance the cross-cultural applicability of DSM-IV (APA, 1994). Friedman (1997) sees the guidelines for the cultural formulation in Appendix 1 as the most important addition to the manual. This author further asserts that the cultural formulation should become a routine part of the assessment in every case in which cultural difference is salient. In outline, a cultural formulation consists of (1) the cultural identity of the client, including reference groups(s), language, spiritual/religious affiliation, and multicultural identity; (2) cultural explanations of the illness (e.g. cultural influences on stressors, idioms of distress, explanatory models, experience with popular and professional sources of care); (3) cultural factors related to the psychosocial environment and functioning (e.g. cultural influences on stressors, social support, and stigmatization); (4) cultural aspect of the relationship between patient and clinician (e.g. attitudes toward clinical authority, dependency, influence on transference, and countertransference); and (5) an overall formulation, synthesizing the preceding information.

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Guarnaccia (1997) asserts that a key issue in the cross-cultural application of anxiety diagnostic criteria is whether the emotional symptoms of excessive worry and apprehension are necessarily the predominant symptoms. Additionally, this author questioned whether these emotional symptoms of excessive worry and apprehension should be given priority over the range of somatic symptoms and rich bodily idioms of anxiety that are often of concern in the cross-cultural literature to people experiencing these disorders. This author also affirms that across cultures there is a rich somatic vocabulary for the expression of anxiety that complements the expression of worry and apprehension. In applying generalized anxiety diagnostic criteria cross-culturally, attention needs to be given to the preponderance of concern with somatic symptoms and the expression of anxiety in bodily idioms and distress (Guarnaccia, 1997). Addressing the phenomenon of anxiety across cultures, Barlow (2002) asserts that it is certainly not easy to map the symptoms and features of anxiety as we know them in the west onto other cultures. The comorbid nature of GAD increases the challenge of identifying the disorder across cultures. Establishing the universality of other anxiety disorders would be far less challenging (Stein & Williams, 2002). Although it is believed that the GAD exists in most cultures, the particular overlaps of anxiety, depression, and somatic symptoms may differ substantially from culture to culture. IMPLICATIONS FOR SOCIAL WORK PRACTICE

Throughout this chapter, the author has presented extensive information on the DSM history of GAD as an Axis I syndrome, its development and etiology, and its diagnostic assessment and treatment along with the most current empirical findings, that support the effective assessment and treatment of this syndrome. As discussed before, having the highest degree of comorbidity among the anxiety disorders increases the diagnostic and treatment challenges of GAD. As noted, GAD untreated can be a very debilitating disorder. It is said to be one of the leading causes of workplace disability in the United States (Ballenger et al., 2001). Although the studies presented in this chapter suggest that the prevalence of GAD is quite evenly distributed in reference to race and ethnicity, when socioeconomic status is factored

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into the equation, we find that minority groups, especially women, are affected in much higher rates. This is most likely due to the fact that minority groups, in general, experience a poorer overall health status and lower levels of access to health care than the majority group does and therefore they experience a disproportionate burden of chronic illness. Moreover, a number of researchers (Dohrenwend, Levav, Shrout & Schwartz, 1992; Friedman, 1997; Yu & Williams, 1999) have presented evidence that supports an inverse and causal relationship between socioeconomic status and mental health. Reporting from a national comorbidity study, Kessler and colleagues (1994) noted that an anxiety disorder was 2.82 times more common in those who had not completed high school than in those with a college education or more (sixteen or more years) and was 2.12 times as common in those with a yearly income of less than $20,000 than in those with a yearly income of more than $70,000. Wittchen and colleagues (1994) found that, in addition to low socioeconomic status, being separated, widowed, divorced, unemployed, and a homemaker are correlates of GAD. These researchers also found depression to be a risk and a consequence of GAD. These risk factors and consequences of GAD (workplace disability; low socioeconomic status; poor overall health status and lower levels of access to health care; being separated, widowed, divorced, unemployed, and a homemaker) are also symptoms and consequences of larger social problems that social workers are trained to assist clients manage or alleviate. Social work interventions have focused on problems in living based on a person-in-environment (PIE) paradigm (Appleby, 2006). The historical mission of the profession places great emphasis on advocacy and caring for the disadvantaged, disenfranchised, and oppressed. From this paradigm, the interdependency of the individual and environment are emphasized along with the environment's influence on the individual and his/her ability to influence the environment (Appleby, 2006). This perspective supports approaches to the assessment of GAD that underscore larger cultural messages and their constraining influence on individual meaning. Although the holistic approach to assessment and treatment that the PIE paradigm promotes equips the social work practitioner with a solid foundation, additional or more advanced training is necessary to work successfully with the GAD client. First, a thorough understanding of the DSM is necessary to differentiate the symptoms of GAD

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from those of other anxiety disorders and other categories of psychopathology, given the high comorbidity of the disorder. In addition to gaining additional training in the overall use of the DSM, social workers who aspire to provide services to GAD clients would need to obtain extensive training in CBT and its various techniques, since this mode of treatment has been shown to be the most effective form of treatment for the disorder. Additional training would also provide knowledge of the various GAD assessment methods presented in this chapter. In addition to gaining a basic understanding of the principles of CBT, effective treatment requires that the social work practitioner be equipped with skills that are necessary for the development and maintenance of a therapeutic relationship. In such a relationship, the skills of the worker help to create a positive relationship. In turn, this relationship serves as the medium through which the worker influences the outcome of the intervention (Shulman, 2006). The relationship is the vehicle toward healing. Paramount to the relationship is a mutual feeling of trust and respect. A significant part of the worker’s job is to create the environment in which the client feels safe to be himself or herself — to let go — to relax or drop his/her defenses. These conditions require a great deal of mutual trust. The development of the aforementioned trust that creates the safe environment is a major part of the therapeutic work, without which the worker would be unable to apply the principles of CBT or any other psychotherapeutic treatment techniques effectively. Additionally, effective treatment of GAD requires the development of a treatment plan that has clear and measurable goals and objectives and a reasonable timeline. It is crucial that the client has an active role in the development of the plan. When the client feels that he/she has had a significant part of the plan’s design, he/she is be more likely to work sincerely toward accomplishing the goals and objectives of the plan. As indicated before, all goals and objectives and timeliness of treatment must be contextualized based on the client’s culture and socioeconomic position. Progress, too, must be considered and defined within the sociocultural context of the client, and it must be determined with significant input from the client. Finally, it is important to structure each session to forty-five to fifty minutes. Consistency with the structure of the sessions will inevitably increase the predictability, which should lead to an increase in the

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client’s sense of safety in the treatment environment. Rygh and Sanderson (2004) suggest the following session format: (1) develop an agenda for the session that includes specific treatment of goals, (2) review the main concepts from the prior session, (3) review the client's progress with assignments from the prior session, (4) complete the session’s goals, (5) assign self-help exercises to facilitate generalization of skills, and (6) conduct a session review. These authors also suggest that sixteen to twenty weekly sessions are adequate for standard CBT treatment. SAMPLES OF TREATMENT INSTRUMENTS

The following two clinical interviews are often utilized in the diagnostic assessment and treatment of GAD. The first interview (A) provides questions for ruling out other possible diagnoses and ensuring that a client’s symptoms meet criteria for GAD when anxiety is presented as the initial complaint. If the answers to the questions in A are no, then the therapist should assess for GAD by considering the questions in B. For a diagnosis of GAD, all of the questions in B must be answered in the affirmative. Partially affirmative responses may result in a diagnosis of anxiety disorder not otherwise specified (NOS) (Rygh & Sanderson, 2004): A. Decision Tree for Differential Diagnosis of GAD Is the anxiety related to embarrassment or humiliation in social situations? No Yes Assesses for social phobia Have there been any sudden rushes of anxiety for no apparent reason? No Yes Assesses for panic disorder and agoraphobia Is there a persistent fear of a specific object or situation? No Yes Assesses for specific phobia Has there been exposure to a traumatic event? No Yes Assesses for posttraumatic stress disorder or acute stress disorder Is the anxiety associated with recurrent and intrusive images that do not make sense to the client? No Yes Assesses the recurrent and intrusive images

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Does the client engage in repetitive behaviors or thoughts to lessen uncomfortable feelings? No Yes Assesses for OCD Is the anxiety restricted to loss of or separation from a significant other or from home and was the onset before eighteen years old? No Yes Assesses for SAD Is there persistent fear of serious disease or illness that has been medically evaluated and not supported? No Yes Assesses for hypochrondriasis Are there physical complaints (e.g. fatigue, gastrointestinal problems, or urinary problems) that cannot be fully explained by, or are in excess of, a known medical condition? No Yes Assesses for somatization disorder or undifferentiated somatoform disorder Is there persistent fear about gaining weight, accompanied by underweight appearance? No Yes Assesses for AN Is there preoccupation with perceived defect in appearance that is markedly excessive? No Yes Assesses for body dysmorphic disorder Did the symptoms occur within three months of the onset of an identifiable stressor, and is the stressor still present? No Yes Assesses for adjustment disorder with anxiety Is there a medical condition that could account for the anxiety? No Yes Assesses for anxiety disorder due to a general medical condition Can the anxiety be attributed to a drug, medication, or toxin? No Yes Assesses for substance-induced anxiety disorder Does the anxiety occur exclusively during the course of a mood disorder? No Yes Assesses for mood disorders Does the anxiety occur exclusively during the course of a psychotic disorder? No Yes Assesses for psychotic disorders B. Decision Tree for GAD Diagnostic Criteria Are the anxiety and worry about a number of events or activities? Are the anxiety and worry excessive? Is the worry difficult to control?

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Do the anxiety and worry occur more days than not? Have they been present for at least six months? Have three or more of the following symptoms been present to some degree over the last six months (one symptom, if the client is a child): Restless, keyed up, on edge Fatigues easily Difficulty concentrating or mind going blank Irritable Muscle tension Disturbed sleep Do the anxiety, worry, or physical symptoms cause clinically significant distress or interference with functioning (daily routine, social, or occupational)? (Rygh & Sanderson, 2004) SUMMARY AND DIRECTION FOR FUTURE RESEARCH

Extensive review of the literature shows that GAD is a common, persistent, debilitating disorder that often goes untreated. Both psychopharmacological and psychological, especially CBT, treatment have been shown to be effective in the alleviation of its debilitating symptoms. However, additional research is needed to maximize the benefits of both medication therapy and psychotherapy in the interest of further improving the quality of life and interpersonal functioning of those individuals afflicted with this disorder. As discussed in this chapter, much of the research on anxiety disorder in general and GAD in particular has shown a distinct overlapping with other forms of distress. Furthermore, there are many culture-specific symptoms that are associated with anxiety (Friedman, 1997). Clinicians unfamiliar with these symptoms may misinterpret them as evidence of physical illness, somatization, or even psychosis, leading to misdiagnosis and inappropriate treatment. Thus, cultural differences may increase the aforementioned overlap, making the identification of discrete anxiety disorder more difficult, if not misleading. Additional research from a cross-cultural perspective is needed to assist clinicians in differentiating between socially accepted idioms and authentic symptoms of GAD. This type of research can also assist clinicians in determining appropriate (best-fit) treatment modalities on a

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case-by-case basis. There is also a need for additional epidemiological studies that would canvas culture-specific symptoms in order to arrive at meaningful estimates of prevalence and adequate characterization of the problems in specific communities. Increase knowledge on crosscultural response to various treatment modalities can lead to more effective treatment outcomes. Finally, as noted elsewhere in this chapter, although CBT is heralded as the treatment of choice with the most empirical data to support its effectiveness in the treatment of GAD, researchers (Chambless & Gillis, 1993; Durham & Allan, 1993; Fisher & Durham, 1999) have found that clinically significant change occurred in only about 50 percent of patients treated with CBT, thus underscoring the need for additional rigorous clinical investigations that would build on the already established gains of CBT and explore beyond the cognitive elements of GAD to include both its interpersonal and somatic domains. REFERENCES American Psychiatric Association. (1968). Diagnostic and Statistical Manual of Mental Disorders (2nd ed.). Washington, DC: Author. American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author. Andrews, G., Stewart, S., Allen, R., and Henderson, A.S. (1990). The genetics of six neurotic disorders: A twin study. Journal of Affective Disorders, 19, 23–29. Appleby, G.A. (2006). Framework for practice with diverse and oppressed clients. In G.A. Appleby, E. Colon, and J. Hamilton (Eds.), Diversity, Oppression and Social Functioning: Person-In-Environment Assessment and Intervention (2nd ed.). Boston, MA: Pearson. Ballenger, J.C., Davidson, J.R.T., Lecrubier, Y., Nutt, D.J., Borkovec, T.D., and Rickels, K. (2001). Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 62, 53–58. Barlow, D.H. (1988). Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. New York: Guilford Press. Barlow, D.H. (2002). Anxiety and Its Disorders: The Nature and Treatment of Anxiety and

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Panic (2nd ed.). New York: Guilford Press. Beck, A., Rush, A., Shaw, B., and Emrey, G. (1979). Cognitive Theory of Depression. New York: Guilford Press. Ben-Noun, L. (1998). Generalized anxiety disorder in dysfunctional families. Journal of Behavioral Therapy and Experimental Psychiatry, 29, 115–122. Blazer, D.G., Hughes, D., George, L.K., Swartz, M., and Boyer, R. (1991). Generalized anxiety disorder. In L.N. Robins and D.A. Rogier (Eds.), Psychiatric Disorders in America. New York: Free Press. Borkovec, T.D. (1994). The nature, functions, and origins of worry. In G.C. Davey and L. Tallis (Eds.), Worrying: Perspectives on Theory, Assessment, and Treatment. Chichester, England: Wiley. Borkovec, T.D., Abel, J.L., and Newman, H. (1995). Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. Journal of Counseling and Clinical Psychology, 63, 479–483. Borkovec, T.D., Newman, M.G., Pincus, A.L., and Lyte, R. (2002). A component analysis of cognitive behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology, 70, 288–298. Brawman-Mintzer, O., and Lydiard, R.B. (1996). Biological basis of generalized anxiety disorder. Journal of Clinical Psychiatry, 58, 16–25. Brouette, T.E., and Goddard, A.W. (2002). Pathogenesis of generalized anxiety disorder. In D.J. Stein and E. Hollander (Eds.), Textbook of Anxiety Disorders. Washington, DC: American Psychiatric Publishing. Brown, T.A., Moras, K., Zinberg, R.E., and Barlow, D.H. (1993). Diagnostic and symptom distinguishability of generalized anxiety disorder and obsessive-compulsive disorder. Behavior Therapy, 24, 227–240. Bruce, S.E., Machan, J.T., Dyck, I., and Keller, M.B. (2001). Infrequency of pure generalized anxiety disorder: Impact of psychiatric comorbidity on clinical course. Depression and Anxiety, 14, 219–225. Carter, R.M., Wittchen, H.U., Pfister, H., and Kessler, R.C. (2001). One year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample. Depression and Anxiety, 13, 78–88. Chambless, D.L., Baker, M.J., and Baucon, D.H. (1998). Update on empirically validated therapies. The Clinical Psychologist, 51, 3–16. Chambless, D.L., and Gillis, M.M. (1993). Cognitive therapy of anxiety disorders. Journal of Counseling and Clinical Psychology, 61, 248–260. Chorpita B.F., and Barlow. D.H. (1998). The development of anxiety: The role of control in the early environment. Psychological Bulletin, 124, 3–21. Dohrenwend, B.P., Levav, I., Shrout, P.E., and Schwartz, S. (1992). Socioeconomic status and psychiatric disorders: The causation-selection issue. Science, 255, 946–952. Durham, R.C., and Allan, T. (1993). Psychological treatment of generalized anxiety disorder: A review of the clinical significance of results in the outcome studies since 1980. British Journal of Psychiatry, 163, 19–26. Edelbrock, C., Rende, R., Plomin, R., and Thompson, L.A. (1995). A twin study of competence and problem behavior in childhood and adolescence. Journal of Child

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Psychology and Psychiatry, 36, 775–785. Eley, T.C. (1997). General genes: A new theme in developmental psychopathology. Current Directions in Psychological Sciences, 6, 90–95. Fisher, P.L., and Durham, R.C. (1999). Recovery rates in generalized anxiety disorder following psychological therapy: An analysis of clinically significant change in the STAI-T across outcome studies since 1980. Psychological Medicine, 29, 1425–1434. Friedman S. (1997). Cultural Issues in the Treatment of Anxiety Disorders. New York: Guilford Press. Guarnaccia, P.J. (1997). A cross-cultural perspective on anxiety disorders. In S. Friedman (Ed.), Cultural Issues in the Treatment of Anxiety Disorders. New York: Guilford Press. Heimberg, R.G., Turk, C.L., and Mennin, D.S. (2004). Generalized Anxiety Disorder: Advances in Research and Practice. New York: Guilford Press. Hudson, J.L., and Rapee, R.M. (2004). From anxious temperament to disorder. In R.G., Heimbger, C.L. Turk, and D.S. Mennin (Eds.), Generalized Anxiety Disorder: Advances in Research and Practice. New York: Guilford Press. Huppert, J.D., and Rynn, M. (2004). Generalized anxiety disorder. In D.J. Stein (Ed.). Clinical Manual of Anxiety Disorders. Arlington, VA: American Psychiatric Publishing. Jardine, R., Martin, N.G., and Henderson. A.S. (1984). Genetic covariation between neuroticism and the symptoms of anxiety and depression. Genetic Epidemiology, 1, 89–107. Kendler, K.S., Neale M.C., Kessler, R.C., Heath, A.C., and Eaves. L.J. (1992). Generalized anxiety disorder in women: A population-based twin study. Archives of General Psychiatry, 49, 267–272. Kendler, K.S., Walter, E.E., Neale, M.C., Kessler, R.C., Heath, A.C., and Eaves. L.J. (1995). The structure of genetic and environmental risk factors for six major psychiatric disorders in women: Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and alcoholism. Archives of General Psychiatry, 52, 374–382. Kessler, R.C., DuPont, R.L., Berglund, P., and Wittchen, H.-U. (1999). Impairments in pure and comorbid generalized anxiety disorder and depression at 12 months in two national surveys. American Journal of Psychiatry, 156, 1915-–1923. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.-U., and Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the national comorbidity survey. Archives of General Psychiatry, 51, 8–19. Kessler, R.C., Walter, E.E., and Wittchen, H.-U. (2004). Epidemiology, In R.G. Heimberg, C.L. Turk, and D.S. Mennin (Eds.), Generalized Anxiety Disorder: Advances in Research and Practice. NY: Guilford Press. Leahy, R.L. (2004). Cognitive-behavioral therapy. In R.G. Heimberg, C.L. Turk, and D.S. Mennin (Eds.), Generalized Anxiety Disorder: Advances in Research and Prac-tice. New York: Guilford Press. Mennin, D.S., Heimberg, R.G., and Turk, C.L. (2004). Clinical presentation and diagnostic features. In R.G. Heimberg, C.L. Turk, and D.S. Mennin (Eds.), Generalized Aanxiety Disorder: Advances in Research and Practice. New York: Guilford Press.

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National Institutes of Health (NIH). National Institute of Mental Health (NIMH) (NIH-4677). (2005). Generalized Anxiety Disorder (GAD): A Real Illness. Author. Newman, M.G., Castonguay, L.G., Borkovec, T.D., and Molnar, C. (2004). Integrative psychotherapy. In R.G. Heimberg, C.L. Turk, and D.S. Mennin (Eds.), Generalized Anxiety Disorder: Advances in Research and Practice. New York: Guilford Press. Papp, L.A., and Kleber, M.S. (2002). Phenomenology of generalized anxiety disorder. In D.J. Stein and E. Hollander (Eds.), Textbook of Anxiety Disorders. Washington, DC: American Psychiatric Publishing. Pike, A., and Plomin, R. (1996). Importance of nonshared environmental factor for childhood and adolescent psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 560–570. Reich, J.H., Perry, J.C., Shera, D., Dyck, I., Vasile, R., Goisman, R.M., RodriguezVilla, F., Massion, A.O., and Keller, M. (1994). Comparison of personality disorders in different anxiety disorder diagnosis: Panic agoraphobia, generalized anxiety disorder, and social phobia. Annals of Clinical Psychiatry, 6, 125–134. Roemer, L., Orsillo, S.M., and Barlow, D.H. (2002). Generalized anxiety disorder. In D.H. Barlow (Ed.), Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (2nd ed.). New York: Guilford Press. Rowe, D.C. (1997). As the twig is bent? The myth of child-rearing influences on personality development. Journal of Counseling and Development, 68, 606–611. Roy, M.A., Neale, M.C., Pedersen, N.L., Mathe, A.A., and Kendler, K.S. (1995). A twin study of generalized anxiety disorder and major depression. Psychological Medicine, 25, 1037–1040. Rygh, J.L., and Sanderson, W.C. (2004). Treating Generalized Anxiety Disorder: Evidenced-Based Strategies, Tools, and Techniques. New York: Guilford Press. Sanderson, W.C., Beck. A.T., and McGinn, L.K. (1994). Cognitive therapy for generalized anxiety disorder: Significance of comorbid personality disorders. Journal of Cognitive Psychotherapy: An International Quarterly, 8, 13–18. Shulman, L. (2006). The Skills of Helping Individuals, Families, Groups, and Communities (5th ed.). Belmont, CA: Thomson. Stein, D.J., and Williams, D.R. (2002). Cultural and social aspects of anxiety disorders. In D.J. Stein and E. Hollander (Eds.), Textbook of Anxiety Disorders. Washington, DC: American Psychiatric Publishing. Stober, J., and Joorman, J. (2001). Worry, procrastination, and perfectionism: Differentiating amount of worry, psychological worry, anxiety, and depression. Cognitive Therapy and Research, 25, 49–60. Sussman, N., and Stein, D.J. (2002). Pharmacotherapy for generalized anxiety disorder. In D.J. Stein and E. Hollander (Eds.), Textbook of Anxiety Disorders. Washington, DC: American Psychiatric Publishing. Thapar, A., and McGuffin, P. (1995). Are anxiety symptoms in children heritable? Journal of Child Psychology and Psychiatry, 36, 439–447. Topolski, T.D., Hewitt, J.K., Eaves, L.J., Silberg, J.L., Meyer, J.M., Rutter, M., Pickles, A., and Simonoff, E. (1997). Genetic and environmental influences on child reports of manifest anxiety and overanxious disorders: A community-based twin study. Behavior Genetics, 27, 15–28.

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Torgersen, S. (1983). Genetic factors in anxiety disorders. Archives of General Psychiatry, 40, 1085–1089. U.S. Census Bureau. (2000). U.S. Census of Population. Washington, DC: U.S. Govern-ment Printing. Wittchen, H.-U., Zhao, S., Kessler, R., and Eaton, W.W. (1994). DSM-III-R generalized anxiety disorder in the national comorbidity survey. Archives of General Psychiatry, 51, 355–364. Woody, S.R., and Sanderson, W.C. (1998). Manuals for empirically supported treatments: 1998 update from the task force on psychological interventions. The Clinical Psychologist, 51, 17–21. Yonker, K.A., Dyck, I.R., Warshaw, M., and Keller, M.B. (2000). Factors predicting the clinical course of generalized anxiety disorder. British Journal of Psychiatry, 176, 544–549. Yu, Y., and Williams, D.R. (1999). Socioeconomic status and mental health. In C.S. Aneshensel and J. Phelan (Eds.), Handbook of the Sociology of Mental Health. New York: Plenum.

Chapter 11 ALCOHOL ABUSE

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lcohol is one of the most available and abused substances in our society today. According to Sarafino (2002), people’s use of alcohol has a very long history dating back before the eras of ancient Egypt, Rome, and Greece. The use of alcohol varies widely across cultures around the world. In the United States, there is a sharp contrast in the patterns of drinking in ethnic groups. According to Thyer and Wodarski (1998), men drink more than women do; whites have the highest rates of heavy drinking, followed by Hispanics, and blacks. Alcohol use and abuse play a significant role in problems that include a wide range of diseases, accidental injuries and deaths, attempted and completed suicides, homicides, criminal behavior, family violence (Redden, 2004; White, 2004), job productivity losses, and birth defects (Thyer & Wodarski, 1998). Alcohol, in regard to treatment admissions, was reported as the primary form of substance abuse in 1999, and the average age at admission for alcohol with a secondary drug problem was thirty compared with thirty-eight for alcohol-only admissions (Drug and Alcohol Services Information System [DASIS] Report, February 2002). Admissions for abuse of alcohol alone were for persons who were white (74%), male (77%), and whose average age at admission was thirty-eight years (DASIS Report, January 2002). Many people have the image of the “typical” alcoholic as an unemployed scruffy-looking derelict with no friends or family (Sarafino, 2002). On the contrary, although this may be true for a small number of people who abuse alcohol, most problem drinkers are married, em-

Note: Case study 1 by Martha S. McCallie and Amanda M. Gerth. Case study 2 by Marsha Foster.

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ployed, and/or living with their families. Large numbers of problem drinkers come from the higher socioeconomic classes and hold highstatus jobs. CASE STUDY 1

The Client Marty is a forty-nine-year-old white male with a history of continued alcohol and cocaine abuse despite experiencing persistent physical, legal, vocational, social, and relationship problems that are directly caused by the use of alcohol and cocaine (Wodarski, Rapp-Paglicci, Dulmus & Johnsma, 2001). He is divorced, homeless, and unemployed even though he has a BS degree in marketing. This client was referred from a metropolitan homeless shelter and intensive outpatient program. It is unclear if the client has the appropriate licensure for transport, but a vehicle is not accessible to him. Marty is on probation for theft of over $1,000. He was charged with driving while intoxicated at age nineteen. He rates his present legal problems as considerably serious, but the courts did not prompt his admission to the current treatment program. PAST TREATMENTS. The client has participated in the VA hospital inpatient treatment program on two other occasions. He is moderately bothered by the alcohol problems but is considerably bothered by the drug problems. It is extremely important to Marty that he get treatment for his drug and alcohol issues. M ENTAL H EALTH. Marty reports experiencing serious bouts of depression, sadness, hopelessness, loss of interest, and difficulty with daily functioning. He also reports experiencing anxiety and tension, which he defines as being uptight, unreasonably worried, and unable to relax. He reports emotional abuse in his lifetime, but he declines to elaborate on particular events or situations. He has been referred to a local mental health center to address the issues of depression and anxiety. FAMILY H ISTORY. Marty reports having good rapport with his brother and youngest sister, but he has lost communication with his oldest sister. He reported that his relationship with his mother has always been good. He reports in the Addiction Severity Index (ASI) assessment and the corresponding ASAH PP 2R that he has a close recip-

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rocal relationship with his parents, his children, his siblings, and his friends. According to his psychosocial assessment (the [CADAS] Psychosocial Behavioral Assessment), his relationship with his father is not good because of his father’s lack of knowledge about addiction. For the past three years Marty has lived alone and reports dissatisfaction with this situation. M ILITARY AND E MPLOYMENT H ISTORY. Marty reported being a Petty Officer in the Navy. He served for four years but did not experience combat. He received an honorable discharge. Marty has completed sixteen years of school and four years of technical training. He reported in the Addiction Severity Index (ASI) that he has a valid driver’s license, but in the application for admission to the local halfway house, he answered that he did not have a valid driver’s license. His longest full-time job was ten years in management and personnel. During the past three years he has held a few temporary jobs. He has not worked in his field in the past nine months. Marty first started regular work at age sixteen and worked part-time jobs throughout his high school career. He does not receive any income at this time from employment, unemployment compensation, welfare, pensions, social security benefits, or illegal sources. He does receive “pocket money” from family members. The Worker Appropriate workers for individuals with addictions have a wellrounded knowledge of the various substances of abuse. Good insight on transference and countertransference between worker and client is useful. Social workers with a bachelor in social work or a master of science in social work are qualified to work with this individual. The Alcohol and Drug Abuse Counselor’s License would also be a useful credential for working with this individual. Treatment Context The location of therapy will be determined by the environment of the social worker’s employment. It might be a private office setting, an alcohol and drug inpatient treatment program, a halfway house, or an intensive outpatient treatment program. The advantage to serving this client in an alcohol and drug-focused setting would be the availability

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of services at that facility. Serving this client in a private setting could require more referrals for services in the local community. Duration of Therapy The duration of therapy would be determined by the type of program providing the service to the client. The private office setting would probably be limited to eight or ten sessions. The alcohol and drug treatment setting would provide twenty-one to twenty-eight days of therapy. The intensive outpatient setting would provide for fifteen to eighteen sessions over a five- to six-week time frame, and the halfway house would provide one weekly therapy session for up to six months of residency (D. D. Brown, personal communication, October 14, 2005). ASSESSMENT

Marty was seventeen years old when he first used alcohol to intoxication. He has used alcohol thirty-one years of his life. The date of his last use was April 4, 2005. He began using cocaine at age twenty-three. He used cocaine for six years of his life and reported the method of use as smoking. The date of his last cocaine use was March 31, 2005. Diagnosis Axis I:

Cocaine Dependence: 304.20 Alcohol Dependence: 309.90 Axis II: Diagnosis Deferred on Axis II Axis III: None Noted Axis IV: Unemployed, Homeless, Financial, and Legal Concerns Axis V: GAF 50 Upon initial admission, a thorough intake assessment was completed using the CADAS Intake Information Assessment. The intake includes basic demographic information, living arrangements, employment, reason(s) seeking treatment, and precipitating incident. The agency’s Alcohol and Other Drugs Overview and checklist and a Substance Abuse History were completed and included general medical treatment information and a mental health history, including eating

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disorder information, psychological information, and medication information. In addition, it includes legal information, such as parole officer and attorney’s phone numbers and legal charges. It also included financial and insurance information on the client. The CADAS Psychosocial Behavioral Assessment Addendum was completed in the assigned level of care. It reviews areas such as childhood and family background, sexual and emotional history, physical pain, vocational and employment screening, and educational screening. Items in each section are broken down to provide a more in-depth review of the client’s life, such as current home and family environment, number of children, number of brothers and sisters, and so on, for the section of childhood and family background. The CADAS ASI was completed with the client. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2005), the ASI is a semistructured interview designed to address seven potential problem areas in substance-abusing patients: medical status, drug abuse, alcohol use, legal status, employment and support, family/social status, and psychiatric status. This information is gathered by a trained interviewer on recent and lifetime problems in all areas. It focuses on an overview of problems with substance abuse. There are various other assessment tools that can be utilized when looking at abuse, problems, or dependence on alcohol. O’Hare (2005) provides examples of two. The first is the Psychosocial Well-being Scale (PSWS), which rates the client’s well-being for the past thirty days. Several areas are scored based on a Likert-type scale ranging from poor to excellent. The areas that are rated are the emotional and cognitive mental status, coping skills, impulse control, extended and immediate social networks, living environment, recreational activities, health, use of alcohol and drugs, work satisfaction, and independent living skills. The second is the Substance Abuse Treatment Self-Efficacy Scale (SATSES). This scale looks at the degree of confidence in the client, employing the knowledge in areas such as assessment/treatment planning, case management, group and individual counseling, and ethics. This scale is a one to five Likert-type scale that begins at very low and goes to very high. According to Smyth (1998), there are several self-report methods that can be utilized and that can be conceptualized in three major categories: screening and diagnostic measures, measures of alcohol consumption, and measures of characteristics of drinking that can be help-

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ful in the treatment planning process. Some examples of screening and diagnostic measures are the Michigan Alcoholism Screening Test (MAST) and the CAGE Assessment. The MAST has several brief versions. The CAGE is the simplest of the screening tools and consists of asking the following four questions: Do you feel that you should cut down on your drinking? Have you ever been annoyed by others criticizing your drinking? Have you ever felt guilty about your drinking? Have you ever taken a drink to get rid of a hangover (eye opener)? These assessments are mainly utilized to determine if further assessments are needed rather than to determine a current drinking problem. Common ways to measure alcohol consumption include the Time Line Follow Back (TLFB) Method, the use of logs and diaries, and a range of quantity-frequency (QF) measures. All measures of alcohol consumption look at drinking in terms of the quantity of standard drinks. Diaries and logs are useful in looking at the current or prospective levels of drinking. QF measures look at the past average pattern of alcohol use. The TLFB uses a calendar to collect information about the drinking habits of an individual over a certain designated time period. There are many assessment instruments that can assist in providing useful information for designing a treatment plan. One example is the Readiness To Change Questionnaire (RTCQ). This instrument assesses a client according to the stages of change model developed by Prochaske and associates. The five stages of change that people go through are: precontemplation, contemplation, preparation for change, action, and maintenance. The beliefs and expectations of clients about alcohol use are of utmost importance as the insights of people with alcohol problems hold different alcohol expectancies than those of people without problems. Two other methods that can be used are observational and physiological. Although observational methods are not used as much in the assessment and treatment of alcohol abuse, they often play a role in clinical research. An example of an observational method is the Alcohol-Specific Role Play Test (ASRPT). This method is a ten-situational role play that is used to assess relapse risk in interpersonal and intrapersonal situations. Some examples of physiological measures are a blood or urine test and a BreathalyzerTM to determine the blood alcohol count (BAC) or blood alcohol level (BAL).

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TREATMENT PLAN

Behavioral Definitions 1. This client continued to use alcohol despite experiencing persistent physical, legal, vocational, social, and relationship problems. 2. He demonstrated an increased tolerance for alcohol and cocaine, needing more to attain the desired effect. 3. He suspended important social, recreational, and occupational activities because they interfered with his use. 4. He experienced poor health, low self-esteem, unemployment, broken relationships, and financial stress as a result of his alcohol and cocaine use. 5. He also experienced homelessness, depression, and social isolation. Long-Term Outcomes or Goals The long-term goals for alcohol and drug use for this client are: 1. to accept alcohol and chemical dependence and actively participate in a recovery program 2. to withdraw from drug and alcohol use, stabilize physically and emotionally, and then establish a supportive recovery plan 3. to improve quality of life by maintaining an ongoing abstinence from all mood-altering chemicals Due to the long-term history of drinking and the fact that this client is smoking cocaine, reducing and maintaining acceptable levels of consumption are not an option. The long-term objectives for employment status for this client are: 1. to obtain services to ensure financial assistance, emotional support, medical care, rehabilitation assistance, and so on during the initial period of stabilizing sobriety 2. to obtain employment reflective of interests and abilities 3. to achieve reasonable satisfaction with job or position, employer, and coworkers 4. to maintain employment in that position for longer than 180 days

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The long-term objectives for homeless status for this client are: 1. to gain access to emergency shelter and nutritional food 2. to access community-based social service program that provides financial support and fosters active participation in a recovery program while also fostering independence 3. to obtain permanent housing through employment and preparation for moving into the community Short-Term Outcomes or Goals The short-term objectives and interventions for therapy for alcohol and drug use for this client are as follows: Objectives 1. Describe the details regarding the nature, extent, and frequency of drug use and alcohol consumption.

2. Participate in medical examination to assess the consequences of past use of drugs and alcohol. 3. Describe the negative consequences of drug and alcohol abuse to self and loved ones.

4. Attend Alcoholics Anonymous (AA) or any support group the client would prefer to attend on a frequent and consistent basis

5. List sources of stress and pressure that provide the impetus for escape into drug or alcohol abuse

Interventions 1. Convey a warm, nonjudgmental approach when eliciting information from the client regarding his history of drug and alcohol abuse. 2. Obtain written confidentiality release from the client to allow for contract with the evaluating professional to share information regarding the abuse and obtain the results and recommendations of the evaluation. 1. Refer client to a physician for examination of the medical consequences of past use of drugs and alcohol. 1. Assist the client in listing the negative consequences of drug and alcohol abuse (e.g. vocational, legal, familial, medical, social, and financial). 2. Confront the client when he minimizes the use of drugs and alcohol or its negative impact. 1. Refer the client to AA or any support group the client prefers; contact a member of the group to accompany the client to a first-step meeting, if needed 2. Process the client’s experience at the group meeting and reinforce consistent attendance and participation 1. Assist the client in identifying the sources of pain and stress that foster escape into drug and alcohol abuse

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The short-term objectives and interventions for therapy for employment status for this client are as follows: Objectives 1. Express concern regarding current employment situation.

2. Decide the appropriate options for employment problem resolution and implement the options. 3. Obtain vocational rehabilitation services as a step toward reemployment.

Interventions 1. Explore the client’s current employment situation (e.g. what he likes or dislikes, working conditions, cause of unemployment, and assessment of abilities. 2. Explore the client’s history of unemployment and the factors contributing to it. Review with the client counseling options that offer training in stresscoping skills, assertiveness, anger control, vocational rehabilitation, and job skills. Refer the client to vocational rehabilitation counseling as a precursor to becoming employed.

The short-term objectives and interventions for therapy for homeless status for this client are as follows: Objectives 1. Stabilize current homelessness crisis.

2. Obtain funding for residence.

3. Implement a budget and banking routine to facilitate regular payment of rent or mortgage.

Interventions Refer the client to a local shelter for the homeless or facilitate placement of the client with a family member, friend, or peer. Encourage and assist the client in obtaining regular employment to increase income for housing costs. 1. Assist the client in developing a budget for the payment of rent or mortgage. 2. Assist the client in obtaining a lowinterest, no-fee banking account with a participating bank.

Additional goals should include dietary guidelines, exercise, stressreduction techniques, social skills training, expressive art therapy, and brief intervention (Dorsman, 1996). Evaluation of Goals Additionally, when the long-term goals can be demonstrated by the client, they will be considered successfully completed.

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Goal 1. Client is able to demonstrate compliance with the treatment plan.

2. Family members and client verbalize an understanding of alcohol and drug abuse treatment and each of their roles in treatment.

3. Client reports improved satisfaction with the job, steady employment, acquisition of services, and so on. 4. Client is able to complete short-term goals and interventions listed in the previous sections.

Successful Interventions 1. Monitor the client’s following through on linking with service providers. 2. Reinforce the importance of following through with linkages and treatment. 1. Client and family members identify individual roles and responsibilities in the treatment of client’s alcohol and drug abuse. 2. Regular, scheduled contact with the family members to review progress. Reevaluate the client’s goals, solutions, and strategies, and repeat steps when necessary.

TREATMENT AND MEDICATION

Medication cannot be separated from treatment for addictions. Medical detoxification is a common feature of addiction treatment programs and is currently being addressed in private practice ( Jungels, 2005). Buprenorphine hydrochloride/naloxone hydrochloride dihydrate (Suboxone®) is successful for opiate- and cocaine-dependent persons who have tried everything else ( Jungels, 2005). This drug is being used in private practice where physicians and social workers use the team approach to treatment and in treatment centers where the team approach is the accepted modality. Consideration must be made for the withdrawal from Suboxone. It is a new method of detoxification treatment, and further research must be considered. In addition to detoxification medications, patients must address the issues of mental health diagnoses while stabilizing sobriety. Many patients come into treatment for substance abuse with a preexisting mental health diagnosis; others are diagnosed while in treatment. Many patients cannot abstain from substance use without treating the mental health issues. This has led to the theory that many substance abusers are self-medicating. It is the experience of this writer that both must be considered for successful abstinence.

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CONCLUSION

There are many ways to assess and treat a client with alcohol issues. The overall outcomes depend on the client's readiness to change and that person’s willingness to work on the issues at hand. Professional social workers can only assist in planning for the outcomes that an individual is willing to work on. Another consideration is the holistic approach. For instance, in this scenario the client is homeless. If the client is not homeless by choice, then the immediate need for shelter, food, clothing, and so on must be taken care of prior to attempting to delve into deeper issues. It is our duty as social workers to empower clients and to work on what they want for themselves, rather than on what we feel they should want. CASE STUDY 2

The Client Jane is a seventeen-year-old white female with a history of alcohol abuse. Jane has been abusing alcohol for two years, but her alcohol use has increased a great deal over the past six months. She went from drinking a weekend or two a month to drinking every weekend and usually through the week as well. She realizes she drinks a lot but does not see it as a problem. She has said that she feels that she could stop if she wanted to and that she is just trying to have fun while she is young. She is willing to come to therapy but does not know if she is ready to give up her party life. A school counselor, who felt that Jane needed more help than the counselor could give her, referred Jane. She was also ordered by the court to receive help for her alcohol use. LEGAL I SSUES. Jane was arrested and expelled for bringing alcohol onto the school premises. She was ordered by juvenile court to attend therapy sessions, as well as AA meetings twice a week. She is on probation for one year, during which she must be seeking therapy, going to two meetings a week, have good behavior, and not test positive for any drugs or alcohol. PAST TREATMENTS. Jane received some therapy when she was younger, about age seven, when her parents got a divorce. The therapy only lasted a few months, and she has not received any prior treatment for her alcohol abuse.

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M ENTAL H EATLH. Jane reports feeling sad a lot and does not have the motivation to do many of the things she did before, such as play soccer. She has reported several symptoms of depression. She reports experiencing anxiety quite often. Jane will be evaluated more to determine levels of depression and anxiety. FAMILY H ISTORY AND S UPPORT SYSTEMS. Jane and her mother report that her father is a recovering alcoholic and has been sober for three years. Jane’s mother drinks occasionally. There are reports that her paternal grandfather and maternal aunt are alcoholics. Jane’s maternal aunt has also been diagnosed with bipolar disorder, and her maternal grandmother and mother have both been diagnosed with diabetes. Jane has an older brother age twenty-two, an older sister age twenty, and a younger half-sister age three. Jane feels close to both her brother and sister but does not get to see them very much anymore because they are away at college. She has stated that she loves her parents very much, but she feels they are overwhelming at times. She has become a lot closer with her father in the last few years due to his sobriety. Her mother is remarried, and Jane argues with her stepfather quite a bit. Her father is not remarried but does have a girlfriend whom Jane is not very fond of. ALCOHOL U SE. Jane has been using alcohol for two years. She started when she was fifteen. The first time she drank was with some older friends on the soccer team, and she had two beers. It progressed from there, and now she drinks every weekend to the point of being heavily intoxicated and/or passing out. She also drinks throughout the week, but not as heavily. The last time Jane drank any alcohol was two days ago, Saturday, December 2, 2006. The Worker The person who works with Jane should be experienced with drug and alcohol abuse, preferably a licensed drug and alcohol counselor. A worker with a master of science in social work with extensive knowledge in alcohol abuse or addictions would be a good match as well. The therapy sessions take place in the therapist’s office or a private room without disruptions. This is to help maintain Jane’s confidentiality. Jane will meet with her therapist once a week for one hour and will be reevaluated after a year and continued if needed.

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Assessment Tools Jane will be given the Teen ASI, (T-ASI), which, the therapist will administer if trained to do so; if not, someone who is trained will be the administrator. The T-ASI is an appropriate tool because it has seven subscales that test chemical use, school status, legal issues, and so forth appropriate to teens (Kaminer, Buckstein & Tarter, 1991). TREATMENT PLAN

The following are behavioral definitions that Jane has met: 1. She has consistent use of alcohol until high, intoxicated, or passed out. 2. She has the inability to stop or cut down use of alcohol once started, despite the verbalized desire to do so and the negative consequences it brings. 3. She denies that alcohol use is a problem despite direct feedback from friends and relatives. 4. She experiences the occurrence of amnesiac blackouts when abusing alcohol. 5. Her tolerance for alcohol has increased, because she needs to use more to become intoxicated or to attain the desired effect. 6. She has suspended important social or recreational activities because they interfere with consuming alcohol. 7. She has invested large amounts of time in activities to obtain alcohol, use it, or recover from its effects. 8. Her loved ones have expressed their worry that she is drinking excessively. 9. She has neglected family obligations due to alcohol abuse. Long-Term Goals and Interventions Jane will accept her dependence on alcohol as a problem and will actively participate in AA. Jane will reduce her alcohol consumption completely.

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Short-Term Goals and Interventions Jane will talk about the nature and extent of her alcohol use. She will see her family physician to determine if she has any medical problems. She will need to continue with any ongoing medical care, and that care will be coordinated with the intervention therapist. The therapist will educate Jane on the effects of alcohol on herself and her family and friends. Jane will attend AA meetings twice a week. She will list sources of stress and talk about how to reduce these stressors. Jane and the therapist will work together to find better coping mechanisms (Wodarski et al., 2001). CONCLUSION

Treatment of an alcoholic depends largely on where the client stands in regard to desire to change. Jane does not view her alcoholism as a problem; therefore, she will need to be educated on alcoholism and will need help figuring out why she escapes to alcohol. This will require the determination and implementation of more appropriate coping mechanisms. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revision). Washington, DC: Author. Drug and Alcohol Services Information System Report. (2002, January). Admissions to treatment for abuse of alcohol alone. Copy Editor, 1–4. Drug and Alcohol Services Information System Report. (2002, February). Treatment admissions for alcohol abuse alone and with a drug problem. Copy Editor, 1–4. Dorsman, J. (1996). Improving alcoholism treatment: An overview. Behavioral Health Management, 16, 26–29. Jungels, G. (2005). Maximizing use of medication in a counseling practice. Addiction Professional, 3, 14–20. Kaminer, Y., Buckstein, O., and Tarter, R. (1991). The Teen-Addiction Severity Index: Rationale and reliability. International Journal of Addiction, 26, 219–226. National Institute on Alcohol Abuse and Alcoholism. (2005). Project Match [Online]. Retrieved October 7, 2005. Available: http://pubs.niaaa.nih.gov/publications .match.htm O’Hare, T. (2005). Evidence-Based Practices for Social Workers: An Interdisciplinary Ap-

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proach. Chicago, IL: Lyceum Books, Inc. Redden, G. (2004). Substance use and violence: Understanding the nuances of the relationship. Addiction Professional, 2, 20–22. Sarafino, E.P. (2002). Health Psychology (4th ed). New York: John Wiley & Sons. Smyth, N. (1998). Alcohol abuse. In B.A. Thyer and J.S. Wodarkis (Eds.), Handbook of Empirical Social Work Practice: Mental Disorders: Vol. 1, (pp. 181–204). Hoboken, NJ: John Wiley & Sons. White, W.L. (2004). Substance use and violence: Understanding the nuances of the relationship. Addiction Professional, 2, 13–19. Wodarski, J.S., Rapp-Paglicci, L.A., Dulmus, C.N., and Jongsma, A.E., Jr. (2001). The Social Work and Human Services Treatment Planner. New York: John Wiley & Sons.

Chapter 12 POLYSUBSTANCE ABUSE

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ccording to the National Institute of Drug Abuse (NIDA, 2005), drug abuse, even polysubstance abuse, is treatable. Although treatment must be tailored to individual needs, patients can learn to take control of their condition and lead normal, productive lives. Like people with diabetes and other medical conditions, people in treatment for drug addiction learn to make behavioral changes and often take medications as part of their treatment regimen. The NIDA (2005) states that “drug abuse has a great economic impact on society; an estimated $67 billion per year. This figure includes costs related to crime medical care, drug abuse treatment, social welfare programs and time lost from work. Treatment of drug abuse can reduce those costs. Studies have shown that from $4 to 47 are saved for every dollar spent on treatment. It costs approximately $3,600 per month to leave a drug abuser untreated in the community and incarceration costs approximately $3,300 per month. In contrast methadone maintenance therapy costs about $290 per month.” Dozier and Johnson (1998) go on to state that more and more it is becoming less likely that a single drug user (including alcohol) will be treated. Instead, most of drug users are polydrug users and are treated for polydrug use. Behavioral therapies such as counseling and group and family therapies are all focused on one outcome: the success of the participants’ efforts in kicking their drug habits. In this case study, the polysubstance abuse of a particular client is explored in relation to his biopsyNote: Case study by Sarah Feist-Gardner, Jackie Levine, and Kimberly Long.

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chosocial history and the different treatment regimens that may be utilized for his success. WHAT IS POLYSUBSTANCE ABUSE?

Polysubstance abuse, according to Wodarski and Feit (1995) is “the simultaneous or sequential use of more than one psychoactive drug for non-medicinal purposes.” This is self-explanatory. This is what we, as mental health care providers, need to know. However, the DSM-IV (2000) has the definition and criterion that will be utilized in order to receive payment for services. The DSM-IV states that the definition for polysubstance dependence is given the code of 304.80, which states that (1) one’s behavior over a 12-month period in which one repeatedly uses at least three groups of substances not including caffeine and nicotine, (2) no single substance predominates, and (3) the criterion is met for a group but not a specific substance. Polysubstance abuse affects youth, young adults, middle-aged adults as well as older adults. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2002), in 2000, among full-time workers age eighteen to forty-nine in 2000, 8.1 percent reported past-month heavy alcohol use, and 7.8 percent reported past-month illicit drug use. In the past year, 7.4 percent of these workers were dependent on or abusing alcohol, and 1.9 percent were dependent on or abusing illicit drugs, much like our client. CASE STUDY

The Client Eric is a thirty-four-year-old divorced male who is being admitted into his first residential treatment center for polysubstance abuse and dependence. Eric has undergone chemical detoxification in the main facility and has just been transferred onto the adult residential unit where he will stay for the next twenty-eight to thirty-two days. The unit is not a locked unit; therefore, Eric could leave at any time. Eric claims that his drugs of choice (DOC) are cocaine (in the powder form), alcohol, and an occasional use of marijuana. He states that over the last two weeks, he was snorting around $500.00 worth of

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cocaine per day, but before that he probably went through the same amount of cocaine in about a week’s time. He also states that he was drinking a fifth of liquor and an average of twelve to fourteen beers per day over the last month, which is an increase from the twelve-pack of beer per day he was drinking every day for the last twelve years. Eric states that at the age of fifteen he began smoking marijuana. At the age of nineteen (during college) he began using cocaine and alcohol. Eric states that only recently has his substance use become a problem for him. E MPLOYMENT AND E DUCATION. Eric graduated from high school in 1990 at the top of his class. He states that he was well-liked in school and had many friends. He went to college as a business major, right out of high school on a tennis scholarship. He states that he played and competed until his junior year when he became involved with a group of friends who “like to party a lot.” Eric states that his grades did not suffer too much because the partying was mostly limited to breaks and weekends, but it did interfere with his tennis practice schedule, so he gave up the party life. Eric states that right after he graduated with his undergraduate degree in marketing, he was accepted into his university’s MBA program. He states that he lived in a “party house” the entire time and his drinking increased, but he still graduated at the top of his class. Eric was hired by the corporate real estate company with whom he completed his graduate internship and moved quickly up the corporate ladder. In fact, at one time he claims that he was the top sales person in the country. Eric claims that his employer is unaware of his treatment status and knows only that he is out on medical leave for at least the next month. He is currently at odds with his employer despite his past successes. His employer claims that Eric has been missing a lot of work and has come in with a hangover on more than one occasion. Eric states that recently (over the last six months) his “party spending” has become higher than his income, and he has begun to divert money from a corporate account to pay for his habit. This diversion has now cost him close to $100,000, which he made worse after investing some of the money poorly in the stock market, which brings us to Eric’s legal problems. LEGAL I SSUES. Eric was hesitant to discuss his legal problems but did finally open up to staff after a few days. He states that his misuse of

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funds at work could mean he is facing embezzlement charges when he gets out of treatment. Eric states that in addition to the potential legal problems he could be having at work, he has been struggling with some other bigger issues related to his social life. Eric states that he is currently being questioned by the police concerning the death of a woman (and girlfriend of sorts) who died of an overdose in his bed two weeks before he came to treatment. He also stated that his cocaine use increased in frequency during the two weeks after the woman’s death. M EDICAL H ISTORY. Eric states that he has not had any hospitalizations or surgeries in his lifetime. He states that he has no known food or drug allergies. He appears to be of average height and weight and has no digestive problems. He states that he does not take any prescribed medication and is not on any special diet for hypertension or diabetes. P SYCHOLOGICAL AND FAMILY S UBSTANCE ABUSE H ISTORY. Eric has never been treated for any psychological problems. He states that he does not know of any family history of mental health issues or suicide. Eric states that his maternal grandfather was an alcoholic, but his parents never used alcohol or drugs. He states that he has a maternal cousin who might have a drug problem and a paternal uncle who has been in recovery for forty years. At the time of this assessment, Eric states that he is not suicidal or homicidal. He states that he is not feeling depressed but feels he might be having some situational anxiety related to the stress he has been under due to his employment and legal problems. He states that he has been having trouble sleeping since he came into treatment. He does not report any loss of weight or appetite at this time. FAMILY, SOCIAL, AND LIVING S ITUATION. Eric states that he was married for three years just out of graduate school, but is now divorced. Eric’s mother reported in her family questionnaire that Eric’s drinking seemed to increase after his divorce, but Eric states that he could not blame his ex-wife for his drinking. He states that the divorce was ugly so he was glad that there were no children involved to make it even messier. Eric stated that he can now see that his partying may have had some negative effect on the loss of his marriage, but he feels that they “were just too different people and their work schedules kept them apart for the majority of the relationship.” Eric states that he currently lives alone in an affluent apartment complex. He reports that he has few “friends” at this time and most of

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them are using buddies or drug dealers. Eric states that he has not had any significant romantic relationships since his divorce 7 years ago, and that the woman who died in his bed was “just a friend with whom he partied with and had sex.” Eric’s mother stated that he grew up in an upper middle-class neighborhood and is the eldest of two boys. Eric states that his parents raised him in the Methodist church, but he has not gone in “many years.” He states that until he went off to college he had a fairly close family. He adds that he currently has a very distant and strained relationship with his younger brother who is married with two young children. Also, his sister-in-law is very stuffy and does not like his brother to hang around him too much. Eric reports that his mother and father are his main source of emotional support although he has neglected them over the past few months in the height of his drug and alcohol use. His mother stated that she and his father are pretty angry with him right now for attempting to con them out of several thousand dollars in an attempt to get himself out of trouble at work. Eric’s mother stated that she is, however, very proud of Eric for seeking treatment at this time, and she is willing to be a support for him when he comes home. STRENGTHS AND STRESSORS. Eric has several personal strengths and life stressors that come into play in his treatment at this time. Some of his strengths include • above average intelligence • family support • good health • good insurance to help pay for treatment • a sense of humor • great job skills and employability • willingness to seek treatment

These are all things that will be beneficial to Eric as he is working on getting his life together. Some of his stressors include • employment problems • legal problems • financial problems • family relationship strain

These are all areas on which he can work while he is in residential treatment and later when he transfers to outpatient.

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The Worker and Treatment Context The services will be rendered, in the beginning, in a for-profit inpatient facility specializing in drug and alcohol abuse. Eric will be guaranteed privacy during the detoxification process, and then he will share a double occupancy room with another patient. The room will be sparsely, but nicely, decorated and will have an adjacent bathroom. Eric will be allowed the use of the common room, where he can socialize with other patients, watch TV, or play board games. Eric will not wear his own clothes but will wear clothing given to him by the hospital. This will consist of pajamas, sweats, tee shirts, and, of course, underwear, socks, and shoes. Eric will meet with a psychiatrist upon entering the program for an initial assessment and prescription for medications, if needed, and then will meet with social workers (licensed clinical social worker [LCSW] or licensed Association of Alcoholism and Drug Abuse Counselor [LAADAC]) for individual and group therapy sessions. There is also a certified trainer for exercise on staff who will lead exercise sessions as a means of teaching new and better techniques for coping with stress. Upon leaving the treatment center, Eric will be going back into his old neighborhood and back to his old job. He will continue to see an LCSW or an LAADAC for individual therapy in either a private setting or a community agency setting. He will also attend group sessions independently (AA or Narcotics Anonymous [NA]) or group sessions led by the worker at the worker’s agency. In either case, group work will continue. TREATMENT PLAN

The treatment plan could consist of many different methods of treatment and assistance. However, this client is a private insurance payer and will not need many of the possible services that are offered. Eric checked himself into a treatment facility for help. His personal treatment plan is as follows: 1. Assessment: in order to determine the needs of the client and to

set treatment in motion. Give prescriptions for detox, craving control, and aversive therapy drugs if needed.

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2. Assign to a social worker in the treatment facility for individual

therapy. a. Build a contract with the client b. Go over rules c. Determine and set short-term and long-term goals d. Set group goals 3. Assign to a therapy support group in the treatment facility for group therapy. a. Contract with the client b. Go over group rules c. Restate the short-term and long-term individual goals d. Set group goals 4. Upon leaving the treatment center, assign a social worker for individual cognitive therapy. a. Assessment b. Continue with current individual goals or state new goals that will coincide with the old goals c. Contract with the group • Go over rules • Go over what is generally expected from group members. d. Utilize cognitive behavioral techniques e. Wean the client from individual therapy by increasing time between appointments until the meetings are finally ceased. This should be done according to the insurance carriers needs; therefore, be aware of time limits for specific therapies 5. Upon leaving the treatment center, assign to either an agency-run or community-operated therapy group a. Continue with current individual or group goals or state new goals that coincide with the old goals b. Contract with the group • Rules for attendance • Know what is generally expected form the participants c. Find a sponsor, if that is a requirement of the group

Assessment The assessment process is one of the most important aspects of treatment. Without a thorough and accurate assessment of the client’s

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problem, one cannot know how to help. When Eric came into treatment, the first assessment was completed in the form of an intake assessment. This assessment was completed by the nursing staff and provided a good description of Eric (who was still under the influence of alcohol) at the time of admission. After Eric had some time to sober up, he was given an assessment packet to begin working on while he was undergoing chemical detoxification. The packet includes a Minnesota Multiphasic Personality Inventory – 2 (MMPI–II), a Substance Abuse Subtle Screening Inventory (SASSI), a client self-report questionnaire, and other miscellaneous surveys that measure issues such as gambling and sexual addiction. The MMPI-II and the SASSI were reviewed and administrated by professionally trained staff, and the results were included in Eric’s chart. Eric’s self-report questionnaire was reviewed by counseling and therapy staff. After Eric completed the written part of his assessments, he participated in a series of interview-type assessments. First, he was given an ASI by a training staff member. The second interview was a clinical interview with the staff psychiatrist or one of the social workers. In addition to the information Eric provided, information was also collected from members of his family. On admission, Eric was required to sign a release of information form concerning which family member he felt comfortable with answering a series of questions in the form of a family questionnaire. This information was used to confirm patient information and provide additional information that Eric may not have been able to recall at the time of admission. This is the final stage of the formal assessment process. Methods of Treatment According to the NIDA (2005), there are several types of drug abuse treatment programs that may be appropriate for polysubstance abuse clients. Short-term methods last less than six months and include residential therapy, medication therapy, and drug-free outpatient therapy. Longer-term treatment may include, for example, methadone maintenance outpatient treatment for opiate addicts and residential therapeutic community treatment. In Eric’s case, a 30-day inpatient program was used in which he was to receive drug therapy to assist with the alcohol dependence and withdrawal, individual CBT,

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group therapy, and family therapy. Upon leaving the facility it will be recommended that Eric continue with a group therapy setting, such as AA or NA as well as biweekly (until otherwise specified) individual outpatient therapy. Individual Therapy Individual therapy should be used because of the nature of the problem. Polydrug dependence is a difficult illness to overcome. The type of individual therapy that will be utilized is CBT because of the significantly supportive data associated with this kind of mental health treatment. This form of treatment is goal oriented and fosters skills training through motivational change, teaches coping skills, changes reinforcement contingencies, fosters the management of painful affects, improves interpersonal functioning, and enhances social supports (Wodarski & Feit, 1995). I NPATIENT I NDIVIDUAL THERAPY. During the inpatient phase of Eric’s recovery, he will first meet with a psychiatrist who will determine and prescribe the medication that will be utilized during his detox and recovery. After Eric has been through the detoxifying stage, he will meet with and schedule appointments with a social worker who will utilize CBT, or change therapy with the client. CBT has become the preferred treatment for most emotional and behavioral problems (Bush, 2005) because it combines two effective types of therapy: cognitive therapy, which focuses on changing ill-effective or distorted thinking patterns, and behavioral therapy, which focuses on weakening the connections between troublesome situations and the habitual reactions to them. Therefore, by utilizing CBT, the client will change thinking patterns such as “I need a drink to cope” and behaviors like “it’s five o’clock, time to stop by the bar and drink.” Eric will focus on the present and future and not on the past. Although exploring the past can help to determine where certain behaviors come from, focusing on the past too much does not help the client to change. By focusing on the here and now and the future, the client can learn to cope with the stressors that are triggers for drinking as well as change the thoughts that enable him to drink. Eric, while in residential treatment, will meet with the worker for one hour each day for the first week after detox, and then every other

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day for the remainder of the time. During this time, the worker will help Eric to begin to establish new thought patterns and behaviors associated with them through a number of outlets such as keeping a journal, learning new coping strategies, and role playing. It will also be during this time that Eric will be placed in an appropriate group therapy setting to be attended in tandem with the individual CBT. OUTPATIENT I NDIVIDUAL THERAPY. Upon release from the residential treatment program, Eric will continue to see a worker for biweekly appointments, then monthly appointments, and finally, appointments every six months for maintenance. Of course if Eric needs or wants to see the worker more often or for other issues, it will be explored with him. P OSITIVE RESULTS OF CBT. According to Bush (2005), CBT is an effective (and efficient) treatment method for all forms of psychopathology and life problems. Extensive research over the last thirty years has shown that CBT works very well and saves patients’ time and money. No other forms of counseling or psychotherapy have been so thoroughly investigated nor have any had such significant and consistently positive results. Thus, CBT is favored by insurance companies and managed care organizations. Practitioners may expect to have fewer difficulties obtaining treatment authorizations when using CBT, and workers have the satisfaction of seeing their clients get better in less time and enjoy lasting results. Therefore, it is reasonable and ethically responsible to utilize CBT as the primary technique of individual therapy. Group Therapy A form of therapy important for an individual trying to overcome a problem in polysubstance abuse is group therapy. Group therapy consists of a combination of people with specific goals, all of whom have a desire to learn about their problems and work toward some recovery from it. “Group therapy is a powerful tool that is effective in treating substance abuse” (Living Sober, 2005). Group therapy can be practiced in either an inpatient or an outpatient setting with focus placed on each client. After all clients have had an opportunity to speak (if they have the desire to), the group will be able to discuss specific issues a client may have. The initial discussion that the group has will assist the group in becoming cohesive in a controlled setting. It is important to realize that, when working with

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groups, being goal directed is one of the most important concepts of therapy. I NPATIENT G ROUP THERAPY. When working with groups in an inpatient setting, it is important to focus the clients on working through their problems and the specific reason they are in treatment. An inpatient group in a treatment facility for polysubstance abuse will begin by setting specific group norms. These norms may include: not using the phone until you have proved you are stable enough to do so, speaking openly and honestly to the other group members and facilitators(s), being on time and coming regularly to the group, listening when others are speaking, and confidentiality, among many other norms or rules that can be set. Once the norms of the inpatient group are set, the facilitator may go on to discuss how the program will work. It is extremely important for the client to be involved in a group while in a controlled setting (treatment facility, hospital, etc.) because he will have the opportunity to express his opinions, goals for himself or the group, and his feelings in a safe place where he will not have the open ability to speak to outsiders about this experience. OUTPATIENT G ROUPS. AA and NA are two group programs that have been of great assistance to many people who need support when they are on their own. These programs can be found worldwide. AA began in the late 1940s and NA “sprang” from AA in the early 1950s (Narcotics Anonymous, World Services, 2005). AA and NA are based on twelve steps created to assist each group member with his or her addiction. These are both nonreligious organizations; however, members are encouraged to cultivate spiritual beliefs of their own. Some of the principles incorporated within the twelve-step programs are admitting there is a problem, seeking help, engaging in a thorough self-examination, confidential self-disclosure, making amends for harm done, and helping other drug addicts who want to recover (NA, 2005). These principles are important because they allow group members to become involved in the program at their own pace. The group member also has the opportunity to gain support and feel comfortable in a setting with people in situations similar to his or her own. AA and NA are voluntary groups, and members are given sponsors in order to have someone to talk to. The sponsor is someone who has already worked through the steps of these programs and has an effi-

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cient way of helping other people “stay the path” of the program. There are community agencies that will have groups that will address alcoholism and drug abuse as well. However, these are usually utilized by the clients of said agency and are generally unknown to the community at hand. FACTORS ASSOCIATED WITH G ROUP THERAPY. Working with clients in polysubstance abuse groups requires the understanding that some negative factors are associated with beginning a group. It is important to recognize these factors in order to assist the clients become more comfortable in the group as well as the group’s becoming more cohesive over time, when each individual begins to self-disclose. Some of these factors are depression, anxiety, isolation, denial and shame. Each of these factors “responds better to group therapy than to individual treatment” (Living Sober, 2005) this is because in group therapy, the members are able to bounce their ideas and problems off other group members. This helps the members work through what is going on in their lives by having the open opportunity to talk to people who are dealing with the same polysubstance abuse tribulations. P OSITIVE RESULTS OF G ROUP THERAPY. Group therapy also allows the members the opportunity to find themselves by working through group meetings. Members should gain higher self-esteem, which will let them realize they can make a difference in their own lives and that when helping others, they are also helping themselves. The members gain a more positive outlook on life; they have something they are interested in doing. They realize that they do want something out of their lives other than constantly using a plethora of substances. Hopefully, the groups can assist members in becoming more optimistic, rather than pessimistic, about their lives. Being in group therapy also allows each member to become acquainted with others in similar situations. Knowing they are not alone will allow the members to be more open with each other and their situations. Family Therapy Treatment centers across the United States have varying degrees of family involvement programs. The lower end of this range might not have any sort of family involvement at all and could even discourage visitation from family members. These types of programs are considered to focus solely on the individual. In more comprehensive programs, the treatment center might offer individual family sessions,

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family group sessions, support groups, and other family programs. Trepper, McCollum, Dankoski, Davis, and LaFazia (2000) found that treatment programs that have a family therapy-based approach have an average retention rate of 66 percent that is nearly twice that of individually focused treatment. There is little debate over the benefits of family participation in the treatment of drug and alcohol substance abuse patients. The literature states that chemical addiction should be considered a family disease that requires intervention into the family system to truly remediate the intertwining effects upon the individual and the family (Crnkovic & DelCampo, 1998). Although most of the research related to family therapy and the treatment of substance abuse patients has been done with spouses or parents of adolescents, it was believed that Eric can benefit from family therapy while in treatment. In deciding which family members to include in family sessions and family groups, it was found that, in Eric’s case, his biggest support system is within his family and social support network. Eric reported on admission that he was not married and had few friends who did not drink or use drugs to excess. He stated that his parents are his biggest source of positive emotional support. He also admitted that his relationship with them is damaged and that his parents are angry with him due to his treatment of them during his drinking and drug use. After discussing the benefits of family therapy with his parents, they agreed to participate in weekly (and later bi-weekly) family therapy sessions and have agreed to start going to Al-Anon meetings near their home. Eric claims that he is willing to work with his parents in family therapy to improve his relationship with them and begin to build a positive support network. Short-Term Goals and Interventions Goals Interventions 1. Become clean and sober Detoxification 2. Understand self, behaviors, and mo1. Begin individual therapy tivations for polysubstance abuse be2. Begin group therapy haviors 3. To help client and family to begin to Begin family therapy reach common ground and establish the family as a support system for the client

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Long-Term Goals and Interventions Goals 1. Maintain sobriety 2. Maintain changes in ways of thinking, coping and behaving 3. Learn relaxation skills 4. Learn relapse prevention strategies 5. maintain and increase positive familial interaction and support

Interventions Individual and group therapies

Family therapy

Relapse Prevention When working with an individual with a polysubstance abuse problem, it is important to understand relapse prevention. First and foremost, as therapists, we must understand that relapse is inevitable. No matter how much one works with an individual, it is out of the hands of the worker if the client feels he or she needs to go back to using the substances. STRATEGIES TO P REVENT RELAPSE. Five basic strategies to prevent relapse will be discussed here. First, individuals should get a job; with a job, the clients will not have too much time on their hands and will be focused on something other than their polysubstance abuse. Clients will be working too much and will hopefully spend the rest of the time getting their priorities straight. It will also be important for individuals to understand what triggers sent them into substance use. Triggers can be anything from thinking about the substance to seeing someone else use, which could essentially lead up to the individual using again. Another strategy could be joining a support group such as AA or NA. These groups have been established so that each member can help and support the other people in the group. Along with support groups, it is helpful for the members to find a sponsor, someone who has already worked through the program and can be of great assistance to the individuals they are sponsoring in order to give support. The fifth and final strategy discussed here is random drug screenings, which can be done if the individual is on probation, living in a halfway house, required to take them at work or even required by the therapist to submit to one weekly, monthly, or randomly. Random drug screens help the client to take individual responsibility, therefore controlling the substance use and avoiding relapse.

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Drug Therapy According to Bush (2005), there is no reason to use drugs with CBT unless the drugs are antipsychotics that will always be needed or are drugs that will be used temporarily to lessen symptoms that would interfere with treatment. With this in mind, Eric would be given certain drugs in order to help him successfully manage detoxification as well as to help maintain sobriety. The drugs that will be utilized are as follows: • Benzodiazepines will lessen withdrawal symptoms during detoxifi-

cation. • Naltrexone, which in oral form can be used with opiates or alcohol, will be used to reduce cravings. This drug is used in conjunction with a complete psychiatric treatment program. This drug is a DOC because it helps to reduce cravings felt by the client during the early stages of treatment by replacing the natural balance of certain brain chemicals. • Disulfiram (Antabuse®) will also be utilized during early and mid therapy time frames as a deterrent to alcohol use. Eric will be weaned off of Antabuse during the late-middle stage of treatment and will remain off unless he relapses. The use of alcohol while using Antabuse will cause the subject to become violently ill. FURTHER THOUGHTS

We have looked into the demands insurance companies tend to place on the different forms of treatment therapy in contrast to the demands real life places on people in the treatment programs. While searching for specific information regarding treatment sessions, it was discovered that it is difficult to find exact statistics. Although the information is provided, one must read between the lines, so to speak. Insurance Demands Insurance companies suggest that each therapy session be, at the minimum, 1.5 hours long. The companies do not really care, per se, how the therapy is achieved as long as the therapist does not go over the allotted amount of time or number of sessions. Fees for therapy

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vary drastically among insurance companies because the companies want to get the most, or least, for what they will allow someone to go through. Depending on the type of therapy an individual will need — be it individual, group, or family — the therapist selected is important. This person must be on the insurance company’s approved list of mental health care providers in order for insurance to pay. Insurance companies typically only pay for a limited number of therapy sessions. These can be five to ten group or family counseling sessions and four to twenty individual sessions, depending on the company. Any counseling sessions needed after the allotted number from the insurance company will have to be paid for by the individual seeking treatment. Real Life Demands In real life, it is important to acknowledge that not all treatment will be achieved within the set amount of time the insurance company demands. Clients tend to need more than “a few” sessions of counseling to begin opening up and self-disclosing to a therapist, the family, the group, and even to themselves. Clients who stay in treatment for more than three months tend to have a must better chance of success (staying clean, sober, and out of trouble) than do those who only do the few sessions insurance companies tell them they can do. Not all clients are prepared to leave when the insurance companies put a cap on their treatment. Around the time insurance says to stop treatment, clients are finally beginning to feel comfortable with the other people around and are getting to the point where they want to self-disclose. In real life, clients probably want to continue their specific therapy, and, unfortunately, the only way to do so is on their own, unless the therapist is capable of composing a justification for them to remain in therapy at the company’s expense. Finally, clients, whether they are in individual, group, or family therapy, need time to discuss what is occurring in their lives. Having only 1.5 hours for therapy a week may not be enough time for the client to express everything he needs to. A client in therapy needs the time to find his level of comfort in order to progress in a way most helpful to him.

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Bush, W. (2005). New York Institute for Cognitive Behavioral Therapies [Online]. Retrieved November 25, 2005. Available: www.cognitivetheapy.com Crnkovic, A., and DelCampo, R. (1998). A systems approach to the treatment of chemical addiction. Contemporary Family Therapy, 20, 25–35. Dozier, C., and Johnson, J. (1998). Opiate abuse. In B. Thyer and J. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders (pp. 235–236). Hoboken, NJ: John Wiley & Sons. Living Sober: A Guide to Living Your Recovery (2005). Groups and Substance Abuse Treatment [Online]. Retrieved October 30, 2005. Available: http://livingsober.com/substance-abuse-treatment Narcotics Anonymous, World Services. (2005). Information about NA (Online). Retrieved October 29, 2005. Available: http://www.na.org/basic.htm Substance Abuse and Mental Health Services Administration. (2002, September 6). NHSDA Report: Substance Use, Dependence or Abuse Among Full-Time Workers. Retrieved October 22, 2005. Available: http://www.drugabusestatistics.samhsa.gov/ 2k2/workers/ workers.cfm Trepper, T., McCollum, E., Dankoski, M., Davis, S., and LaFazia, M. (2000). Couples therapy for drug abusing women in an inpatient setting: A pilot study. Contemporary Family Therapy, 22, 201–221. Wodarski, J., and Feit, M. (1995). Adolescent Substance Abuse: An Empirically Based Group Preventive Health Paradigm. New York: Haworth Press.

Chapter 13 SCHIZOPHRENIA

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he term schizophrenia was coined by Eugen Bleuler, who chose this term to represent the schisms between thought, emotion, and behavior in patients with this disorder (Kaplan & Sadock, 1998). Bleuler also identified four primary symptoms of schizophrenia that included associational disturbances, affective disturbances, autism, and ambivalence. These became know as the “Four A’s” (Kaplan & Sadock, 1998). Symptoms of this disorder vary and often begin to present themselves in adolescence or early adulthood. Diagnostic criteria include six decisive factors. The first, Criterion A, includes positive symptoms such as delusions, hallucinations, disorganized speech and behavior, catatonic behavior, and negative symptoms such as alogia, avolition, and flat affect. Two or more of these symptoms must have persisted for a substantial amount of time during the last month. However, only one symptom is necessary for diagnosis if the person’s delusions are bizarre or if the person hears voices conversing with each other and/or keeping a running commentary on the person’s behaviors and thoughts. The second, Criterion B, states that key areas of functioning, such as education, employment, self-care, and interpersonal relationships, must be below the level attained prior to the onset of the disorder. Criterion C indicates that symptoms of disturbance must last for at least six months. During this time, the person must experience at least one month of active-phase symptoms (i.e. Criterion A) and may experience periods of residual or prodromal symptoms such as negaNote: Case study by Jill Howard, Brandi Johnson, and Sarah Turner.

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tive symptoms only or milder forms of positive symptoms such as odd beliefs. Criterion D states that other disorders, such as schizoaffective disorder and mood disorder with psychotic features, must be ruled out. The fourth criterion, E, indicates the symptoms of schizophrenia must not be substance induced or due to a general medical condition. The last criterion (F) states that if the individual has a previous diagnosis of autism or pervasive developmental disorder, prominent delusions and hallucinations must be present for a month in order for schizophrenia to be diagnosed (Maxmen & Ward, 1995). Schizophrenia is categorized into one of five subsets depending on the most prominent symptoms. The five subsets include paranoid type, disorganized type, catatonic type, undifferentiated type, and residual type (APA, 2000). Paranoid schizophrenics experience auditory hallucinations and a preoccupation with one or more delusional ideas. Disorganized schizophrenics exhibit disorganized speech and behavior patterns and a flat or inappropriate affect. They often present as incoherent and have severe social impairment. Catatonic schizophrenics exhibit marked motor abnormalities. They may present with motor immobility rigid posture (extreme negativism), excessive motor activity, or abnormalities in their voluntary movements. The third subset, undifferentiated type, is diagnosed when a person exhibits Criterion A symptoms but does not meet criteria for any of the other subsets. The last subset, residual type, is diagnosed when a person experiences negative symptoms, and/or a milder form of positive symptoms that do not include hallucinations, disorganized speech, or delusions. Instead, these people may experience odd thinking or abnormal perceptual experiences (Maxmen & Ward, 1995). CASE STUDY

The Client Art is a thirty-two-year-old white male. He has been married for five years. Art has a master’s degree in mathematics from a major Ivy League university. Art is extremely intelligent. He lives with his wife in a house in a suburban neighborhood of a large city. Art was raised by his mother and father in the Northeast. His parents were supportive and helped him financially through college. Art does not have a history of mental illness in his family.

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Art began having ego-syntonic hallucinations during graduate school. He began having visual hallucinations of a roommate named Charlie, with whom he formed a relationship. When he began seeing Charlie he also began having the hallucination of a little girl whom he believes is his niece. He also has visual hallucinations of a boss and Russian soldiers. Art has the delusion that he is working for the government cracking codes from the Russians. Art’s office is full of clutter and magazine cut outs all over the walls. Art placed his work for the government in a secret mailbox. He thinks his psychiatrist is a Russian spy. He has the delusion of an implant in his arm. Art has been selfmutilating and is easily agitated. He was diagnosed with paranoid schizophrenia during an inpatient hospitalization. Art has been experiencing racing thoughts and flight of ideas. He sees everything in codes and number patterns. Art’s affect is constricted and guarded. He experiences restlessness and decreased sleep. He also experiences ritualistic behaviors with his math obsession. Art’s wife is very supportive. Art is not compliant with treatment. His wife Alice gives him his medications but he does not take them. Art has a low sex drive, which has affected his marriage. He and Alice have one son together, and he has experienced avolition in caring for this child. The Worker The worker is a licensed master’s level social worker with clinical experience in working with psychotic and schizophrenic patients. She will participate in all types of therapy for Art — individual, group, and family — and will determine goals and an agenda for all therapy sessions. Other professionals who will work with the client include psychiatrists, nurses, mental health assistants, and intake specialists. TREATMENT AND CONTEXT

After a public psychotic episode, Art was admitted to an inpatient psychiatric hospital where he will remain until his psychotic symptoms are stabilized. The typical stay is five to seven days. After his psychotic symptoms are stabilized, Art will return to the partial program at the hospital. This program is five days a week for the first three weeks and

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then three days a week for the last three weeks. After the partial program, Art will continue to see the psychiatrist and therapist on a regular basis. Art will attend group therapy in the group room, a large room with Dry-Erase boards and comfortable chairs. He will receive individual therapy in the social worker’s office. The office is set up so Art and the social worker will talk facing each other. The chairs in the office are made of comfortable black leather. Assessment The first part of Art’s treatment will be the assessment process, an essential part of the treatment where the therapist will get a basis for planning the rest of Art’s treatment. The Present State Examination is a state-structured examination and was chosen for assessment. A tool for assessing the mental status of clients for interventions, it consists of 140 items that monitor changes. It provides scores of thirty-eight syndromes specific to psychotic behaviors. These assessments are based on clients’ reports as well as observations made by social workers during the interviews. It provides interview questions and probes. Each symptom is based on frequency and severity. The interview typically takes one hour. Limitations of this instrument include failure to address organic systems basis toward reported versus observed behaviors, lack of utility in assessing noncommunicative clients, and insensitivity to mild symptoms (Farmer, Walsh & Bentley, 1998). Another useful assessment scale is the Brief Psychiatric Rating Scale (BPRS). This rating scale provides practitioners with a clinical profile at a particular point in time. The version that will be used with Art consists of eighteen items, each rated on a seven-point scale. Twelve of the items are specific to schizophrenia, and six are related to depression. It is conducted for measuring schizophrenia symptoms but can also be a schizoaffective scale. This assessment is conducted by the social worker and should not last longer than thirty minutes. The scale is scored by four domains: thinking disturbance, withdrawal and retardation, hostility and suspicion, and anxiety and depression (Farmer, Walsh & Bentley, 1998). Another aspect of the assessment will be the administration of the Quality of Life Interview. This is a structured forty-five minute instrument for schizophrenia and serious mental illnesses. This instrument

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can provide quality of life information from a specific point in time or change in nine domains. These domains include living situation, family relations, social relations, leisure, work, finances, legal and safety concerns, physical health, and mental health. The first part consists of asking the client for demographic information and life satisfaction, followed by questions regarding the life domains (Farmer, Walsh & Bentley, 1998). The last type of assessment that will be used with Art is the Social Adjustment Scale for Schizophrenics. This instrument consists of fiftytwo items that measure interpersonal and instrumental performance in five areas, including work, relationships with household members, relationships with other relatives, performance of leisure and recreational activities, and personal well-being. These items are obtained during a forty-five to ninety-minute interview. The purpose of this scale is to access the client’s level of social functioning (Farmer, Walsh & Bentley, 1998). Treatment Plan Individual Therapy During Art’s hospital stay, he will participate in individual therapy once a day. The individual therapy will consist of psychosocial skills training, and cognitive and behavioral interventions. The therapy will be conducted between the therapist and the client. Art’s therapy will have three purposes: supportive therapy, social skills training, and cognitive and behavioral interventions. Supportive therapy generally includes “strengthening the therapeutic alliance; providing environmental interventions; offering education, advice and suggestion; offering encouragement and praise; setting limits and prohibitions; and emphasizing strengths and talents” (Farmer, Walsh & Bentley, 1998, p. 254). Art will be able to talk openly during the session. He will also be taught skills to help him better deal with his environment and family. During these sessions, Art will be able to set goals for himself and accomplish tasks that will help him when he leaves the hospital. The second part of individual therapy is to introduce social skills training. Art will be taught interpersonal skills that many schizophrenia patients lack. These individual therapy sessions will be more focused on education. Art will learn to function socially and overall

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this will improve his quality of life (Farmer, Walsh & Bentley, 1998). This will also assist him in becoming a better provider for his family and a better husband and father. The third part of individual therapy will be focused on cognitive and behavioral interventions. Cognitive and behavioral interventions focus on reducing the symptoms of the illness and their meaning to the individual (Farmer, Walsh & Bentley, 1998). Art will participate in this type of therapy with the hopes of reducing his hallucinations and delusions and helping him to distinguish reality from unreality. According to Farmer, Walsh, and Bentley (1998, p. 256), “cognitive interventions can influence hallucinations and delusions by decreasing their frequency and the subjective distress associated with them and by increasing the person’s belief that the voices are really thoughts.” Family Interventions The family intervention will include Art and his wife, Alice. They have been having some difficulty with communication, sexual intercourse, and accomplishing daily activities because of the schizophrenic behavior. Art and Alice live together along with their baby son. Family intervention is essential for relapse when dealing with mental health clients. The family sessions will be psycho-educational, and will consist of an informational learning time for the family as a whole. This will incorporate behavioral problem solving, family support, and crisis management (Farmer, Walsh & Bentley, 1998). Having a supportive family has shown to have great effects on clients dealing with schizophrenia. The family sessions will take place in the hospital and will be supervised by the therapist. There will be an outlined agenda with goals, but Art and Alice will be able to talk openly about their feelings. The family sessions will be limited, so progress will need to be made early. Social support has been shown to have high outcomes for those suffering from mental illness (Farmer, Walsh & Bentley, 1998). With Art’s family support, he has a good chance of recovering from this illness. Alice gets frustrated at times due to her inability to understand “why.” Educating Alice can help her to better cope with Art, thus allowing her to be a better support. Schizophrenia can be hard to deal with if the family has not been properly prepared. Art was diagnosed late in life. He started out life being the “all-American guy,” graduating with his master’s degree

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from a prestigious university. Alice had no idea what she was getting herself into. Art has had this disorder for several years, but his family has never been properly trained on how to handle situations. The main purpose of the family session is to help educate Alice regarding the importance of and the need to become an expert on crisis management. Involving the family will ensure a greater chance for Art’s success. The family will be able to cope better and develop a resiliency to the disorder. They will be able to treat him with the respect that he deserves and provide him with the help that he needs. With the help of his wife, Art will be more likely to get back on his medications and return to his environment. Group Therapy Group therapy is an important part of the treatment process. Since Art is actively psychotic, group therapy may not be very effective at this point. When his psychotic symptoms diminish he will be able to gain more from group interactions. Group therapy will be important in increasing his social skills and improving his reality testing. Interaction-oriented groups have proved to be more effective with schizophrenic patients than insight-oriented groups are. Participating in groups such as art therapy will help him increase emotional communication, free-time activities, and pleasurable experiences. Psychoeducation groups have proved to be more effective in multifamily groups and have also been found to extend the time until relapse (Farmer, Walsh & Bentley, 1998). Another type of group therapy is multimodal integrative cognitive stimulating therapy (MICST). According to Ahmed and Boisvert (2003), MICST is designed to stimulate clients’ cognitive and memory functioning, improve information processing, and enhance clients’ abilities to engage in reality-based conversations. This type of therapy consists of social skills and relaxation, with an emphasis on cognitive rehabilitation. Getting Art and his family involved in a multifamily psychoeducation group will be an important aspect of treatment. Relapse Prevention One of the most important aspects in prevention for Art is being compliant with treatment and taking medications as prescribed. Art

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has a history of not taking his medications and this is a large contributor to relapse. He needs to continue to see his psychiatrist on a regular basis and comply with treatment. Alice can also help Art manage his medications and take them appropriately. Along with seeing the psychiatrist regularly, Art should also see his therapist regularly. He may not need to see the therapist twice a week, but going to therapy consistently is a preventative measure. Art may get to a point where he only needs to see the therapist once a month, but it is still important that he continue therapy in order to discuss problems and stressors. Another important aspect in relapse prevention is staying in a stress-free environment as much as possible. Art will become more vulnerable to symptoms when he is exposed to stressors that exceed his coping abilities. Limiting activities and not taking on more than he can handle are vital components of staying healthy for Art. Schizophrenia has three types of prevention methods. For the therapist, only two types of preventions will be accomplished. The first, primary prevention, refers to the professional activities that result in preventing schizophrenia from developing in at-risk individuals (Farmer, Walsh & Bentley, 1998). Art is an at-risk individual. He is one of the one third of schizophrenics who have the disease and for whom it will never go away. He will live his life with this disorder forever. The next prevention that applies to Art is tertiary prevention. Tertiary prevention refers to rehabilitation activities that attempt to help clients return to their highest possible level of functioning after the disorder has become severe (Farmer, Walsh & Bentley, 1998). The purpose of the prevention is to diminish the possibilities that trigger the onset of the disorder. Schizophrenia is brought on by stressors with which the client is unable to cope. Teaching the client coping methods and assisting in dealing with the environment can be beneficial ways of preventing the disease from arising. During this prevention, Art will be given the vulnerability stress model. This will allow him to see where in his life he is vulnerable to stress. This will allow him to set goals for his future that will help prevent the psychotic episodes.

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Treatment Goals Short-Term Goals and Treatment Goals 1. Stabilize medications

2. Control behavior impulses

3. Education on medication and the importance of taking it properly

4. Learn the difference between reality and hallucinations

5. Maintain safety

1. 2. 3. 4. 5.

Treatment While Art is in the hospital all his medications will be monitored by a doctor and nurses. His vital signs will be taken twice a day, and he will be monitored at all times to make sure his medications are working sufficiently. This will be accomplished during group therapy. The behavior will be discussed and addressed through cognitive and behavioral interventions with the patient. Art will meet with a nurse three times a day to discuss his medicine. During these times, the nurse will educate Art about the importance and use of his medicine. This intervention will take place during the individual therapy. Art will go through intensive therapy during his hospitalization to teach him to recognize the difference between the two. Safety is an issue for Art and his family while he is off his medication and is in a psychotic episode. The hospital will remain a safe place for Art while he stabilizes. There will be staff on the unit at all times to maintain order and help meet the patient’s needs.

Long-Term Goals and Treatment Goals Treatment Maintain a stable job Social skills training Develop positive parenting skills Attend parenting class Be compliant with medication See psychiatrist and therapist regularly Participate in socialization and recreRecreational and group therapy ation activities Maintain a supportive family enviPsychoeducational family therapy ronment

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Medication Antipsychotic medications have revolutionized the treatment of schizophrenia. Antipsychotic medication includes two major categories: dopamine receptor antagonists (typical) and serotonin-dopamine antagonists (atypical). Typical antipsychotic agents, also known as firstgeneration antipsychotic agents, were introduced in Paris, France, in the 1950s. They can be broken down into three subgroups that include phenothiazines, nonphenothiazines, and Butyrophenones. Typical antipsychotic medications include chlorpromazine (Thorazine®) haloperidol (Haldol®), molindone hydrochloride (Moban®), thioridazine (Mellaril®), trifluoperazine hydrochloride (Stelazine®), fluphenazine (Prolixin®), thiothixene (Navane®), chlorprothixene (Tarac-tan®), and loxapine (Loxitane®). These drugs are all effective in treating the positive symptoms of schizophrenia, such as hallucinations and delusions. They work by blocking postsynaptic dopamine receptors in the mesolimbic system. They also are shown to increase dopamine turnover by blockade of the second dopamine receptor (D2). This relates to the theory that schizophrenia occurs because of excess amounts of dopamine in the brain. Typical antipsychotics, however, are associated with the risk of extrapyramidal effects (EPS). These effects include weight gain, abnormal lipids, Parkinsonian symptoms (apathy, social withdrawal, and flat affect), dystonia (acute muscle spasms), and tardive dyskinesia (hyperkinetic abnormal movements). Other side effects may include sexual dysfunction, abnormalities in temperature regulation, amenorrhea, galactorrhea, cardiac toxicity, and neuroleptic malignant syndrome (a lethal reaction caused by reduction in dopamine activity). There is evidence to show that most schizophrenic patients do not improve significantly while using typical antipsychotic mediation. Only a small portion of people recover enough to regain a sufficient amount of normal functioning (Kaplan & Sadock, 1998). Atypical antipsychotic medication is also referred to as second-generation antipsychotics. Their utilization began during the 1990s and proved more effective in treating a broader range of schizophrenic symptoms. For instance, they are exceptionally effective in treating the negative symptoms of schizophrenia. They are also just as effective as typical antipsychotic agents in treating the positive symptoms of schizophrenia. Unlike typical antipsychotic agents, these medicines have an impact on multiple neurotransmitters in various locations. These

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drugs include clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine fumarate (Seroquel®), ziprasidone hydrochloride (Geodon®), and aripiprazole (Abilify®). The most important benefit of atypical medication is that most are at low risk for serious side effects. An exception to this is Clozaril. It was the first atypical introduced and is the most effective antipsychotic agent. However, it is now only used to treat symptoms that are resistant to other medications because of its association with seizures and agranulocytosis (Kaplan & Sadock, 1998). It is crucial that the attending physician consider five major principles when prescribing antipsychotic agents for schizophrenia. These include defining the target symptoms, knowing what medication has been used in the past, and keeping the patient on it if it works, utilizing a minimum trial period of four to six weeks, using no more than one antipsychotic at a time (unless absolutely necessary), and using the lowest dosage possible (Kaplan & Sadock, 1998). Noncompliance with medication is one of the biggest causes of relapse for patients with schizophrenia; therefore, it is important to consider the individual’s needs when choosing a medication. Art is on one antipsychotic drug. This drug is taken daily and is used to reduce the symptoms of his disease. Schizophrenia is a difficult and complex disorder to treat; thus, there are many drugs and drug combinations that are used. Art is on Risperdal. This drug is used to treat all positive symptoms and assists in decreasing audio and visual hallucinations and in helping Art to better function in society. REFERENCES Ahmed, M., and Boisvert, C.M. (2003). Multimodal integrative cognitive stimulating group therapy: Moving beyond the reduction of psychopathology in schizophrenia [Online]. Professional Psychology: Research and Practice, 34, 644–-651. Retrieved November 22, 2005. Available PsychInfo database. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision) (Schizophrenia. pp. 298–317). Washington, DC: author. Farmer, R.L., Walsh, J., and Bentley, K.J. (1998). Schizophrenia. In B.A. Thyer and J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders (pp. 245–270). Hoboken, NJ: John Wiley & Sons.

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Kaplan, H.I., and Sadock, B.J. (1998). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (8th ed.) (pp. 456–491). Philadelphia, PA: Lippincott Williams & Wilkinson. Maxmen, J.S., and Ward, N.G. (1995). Essential Psychopathology and Its Treatment (2nd ed.) ( pp. 173–205). New York: W.W. Norton & Company.

Chapter 14 MAJOR DEPRESSIVE DISORDER AND DYSTHYMIC DISORDER

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ne of the most robust predictors of depression is the domain of stressful life events (Markowitz, 2003). Most individuals who experience a major depressive episode in both community and clinical samples report the prior occurrence of a severely stressful life event. Typically, the events that trigger depressive reactions are those that match a person’s area of vulnerability as defined by the importance of such experiences to self-worth and sense of competence. Most individuals who experience a stressful life event do not experience clinically severe depressive experiences; they either have transitory or relatively minor depression after a loss, disappointment, or major readjustment, or they have little emotional distress at all (Markowitz, 2003). According to the DSM-IV-TR (APA, 2000), the essential feature of major depressive disorder is a clinical course that is characterized by one or more major depressive episodes and possessing a depressed mood or loss of interest accompanied by at least four additional symptoms of depression for at least two weeks, without a history of manic, mixed, or hypomanic episodes. Depression is among the most common of all psychiatric disorders. It is estimated that between 8 percent and 18 percent of the general population will experience at least one clinically significant episode of depression during their lifetime; many people will experience several relapses ( Johnson, Hayes, Field, Schneiderman & McCabe, 2000). Note: Case Study 1, Adult Depression, by Lisa Bell and Beth Ross. Case Study 2, Adolescent Depression, by Heather Daniels.

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The Western cultures have recognized that depression can be a mental disorder, and “melancholia” occurs if fear and distress lasts for years (Akiskal & Cassano, 1997). The essential features of dysthymic disorder include a chronically depressed mood that occurs for most of the day, more days than not, for at least two years. Individuals with this disorder describe their mood as sad or “down in the dumps.” During periods of depressed mood, at least two of the following additional symptoms are present: insomnia or hypersomnia, poor appetite or overeating, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness (APA, 2000). Dysthymic disorder may be described as having a “low profile” in patients who are able to function at work and are unlikely to be hospitalized unless they develop an exacerbation of symptoms (Markowitz, 2003). CASE STUDY 1: ADULT DEPRESSION

The Client The client, Marcie, is a forty-three-year-old white female who is married. Marcie reports experiencing sexual, physical, and emotional abuse from her father throughout her childhood. Her mother died when she was a baby, and her father was an alcoholic. He died five years ago. Marcie’s mother suffered from depression, and there is a history of depression within her extended family. She has been married and divorced four times prior to the current marriage and describes the past marriages as abusive relationships. She has three children from her first marriage and no children from the other marriages. Marcie has been in the current marriage for four years and reports it as a happy and safe marriage. She receives a disability check from social security because she reports she cannot work. She depends on her husband financially and emotionally and suffers from abandonment issues. She does not want him to work because she hates being alone, but he needs to work in order to support them. Even though Marcie has positive support from her husband, her neighbors and neighborhood are negative factors, and she would like to relocate, but cannot afford to move. She expresses having a relationship with her

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children and siblings, in the past, but to her the relationships were always stressful, and currently she has no contact with any of them. Marcie has been hospitalized five times since August 2005. She is the youngest of six children, and all have suffered from depression. Marcie has been hospitalized twenty-six different times throughout her life due to her past and current problems. She also has a history of abusing medication and being noncompliant with her treatment plans. Marcie has been diagnosed on all five axes of the DSM-IV-TR (APA, 2000). On Axis I, she has major depressive disorder and posttraumatic stress disorder (PTSD). Her thoughts and perceptions have been documented as sometimes being delusional and disorganized. On Axis II she has Borderline Personality Disorder (BPD), and on Axis III, she has physical problems. The physical health problems consist of a seizure disorder, asthma, reflex sympathetic dystrophy, osteoarthritis, and migraine headaches. In addition, she experiences difficulty with her sleep patterns, averaging four hours per night. She is not receiving rapid eye movement (REM) sleep, which is where the deepest and greatest sleep occurs, which is probably contributing to her major depressive disorder. The social and work stressors are present on Axis IV, consisting of stress-related issues in her social support network and her unstructured environment, as well as having ineffective coping and problem-solving skills. Her spirituality and religious aspects are her protective factors. On Axis V her highest global assessment functioning (GAF) was fifty, which she has not met for months, and her lowest GAF was thirty. There is a fluctuation in the GAF score between the ranges of fifty and thirty, lately more on the lower end. A GAF score of fifty indicates serious impairments in occupational and social aspects, resulting with few to no friends and being unable to maintain employment. A GAF score of forty indicates major impairments in occupational and social aspects and being avoidant and neglectful to others, and a GAF score of thirty indicates the inability to perform in almost all areas of the person’s life, where they isolate from others and situation (APA, 2000). The Worker The worker earned a master’s degree in social work ten years ago and has been an LCSW for the past five years. She is well-trained and educated in mental health disorders. She is a patient, empathetic, and

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compassionate person who is also very confident in her abilities. The LCSW has been employed at the hospital on the psychiatric unit for eight years and has seen the client for a total of three years, because she has been readmitted many times. The LCSW is a white female who is thirty years old, which allows the client to relate more effectively to her therapist. The LCSW is very informed and comfortable using the chosen assessment methods. TREATMENT PLAN INTERVENTIONS

Once the social worker has completed the assessment and has diagnosed the patient, it is the social worker’s ethical responsibility to select effective interventions. Treatment goals will depend on Marcie’s mood, safety, and her overall well-being (Thyer & Wodarski, 1998). Most the techniques used will be from cognitive therapy and behavioral therapy, and some techniques will come from interpersonal psychotherapy. Marital therapy will be used periodically during the treatment with Marcie and her husband. Marcie will receive pharmacotherapy from her psychiatrist while at the hospital. Once discharged, Marci will see a therapist and psychiatrist regularly at a local community mental health center in her community. According to Dulmus and Wodarski (1998), the goal of cognitive therapy is to break down existing negative thoughts and to replace them with more positive and functionally adaptive ones (Dulmus & Wodarski, 1998). Another goal of cognitive therapy is “to alleviate depression and to prevent its recurrences by helping clients identify and test negative cognitions; develop alternative, flexible, and positive ways of thinking; and rehearse new cognitive and behavioral responses” (Dulmus & Wodarski, 1998). Cognitive therapy has proved to be effective for depression; therefore, the treatment plan will be beneficial. The hope in using this therapy with Marcie is that it will have a longer life-span range in decreasing her negative symptoms that are affecting her quality of life (Dulmus & Wodarski, 1998, p. 278). Behavioral therapy is used with Marcie to assist in functioning and in more effective interpersonal interactions to increase reinforcements. Behavioral therapy will provide her with social skills training and emphasize assertiveness and verbal skills, which she will then apply to her life. Behavioral therapy treatment “focuses on reducing the client’s

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exposure to aversive or punitive situations and on the development of coping skills and stress management techniques” (Dulmus & Wodarski, 1998, p. 279). The foundation of behavioral therapy is the concept of reinforcement; therefore, pleasant activities can serve as reinforcers in elevating the mood. Mood elevates with increases in pleasant activities, but depressed people often lack the social skills needed for pleasant activities. One main objective of behavioral therapy is to increase the rate of pleasant activities and interactions in order to elevate mood. Marcie’s treatment will include structured homework exercises to promote reinforcing experiences. “The behavioral view suggests that depression is a consequence of punitive or aversive experiences, not a cause. One’s environment is seen as causing concurrent dysphoric affect, depressive behaviors, and dysfunctional thoughts” (Dulmus & Wodarski, 1998, p. 279). The behavioral perspectives focus more on environmental manipulations to decrease stressors and promote a more reinforcing life. The combination of CBT and antidepressants has been reported as the most effective intervention for treating individuals suffering from depression. The first goal is to reduce depressive symptoms and reduce the frequency and intensity of depressive thinking. The social worker will also use interpersonal psychotherapy in her treatment plan to improve the quality of Marcie’s social and interpersonal functioning by teaching her positive coping skills and problem-solving skills, thus helping her deal with life stressors (Dulmus & Wodarski, 1998). The social worker further will use marital therapy with Marcie and her husband once a month. Marital therapy will help the therapist to receive Marcie’s husband’s perspective of what is happening at home and then compare it with Marcie’s perception. This will provide an indepth insight and, hopefully, will help to decrease marital conflict. According to Dulmus and Wodarski (1998), it has been reported that this style of therapy can be beneficial because some research suggests that a life event that occurred, most often prior to the onset of depression, was an increase in arguments with one’s spouse. Other research studies indicate that those with depression are more emotionally vulnerable to hostile comments by family members compared with people with other disorders. Additionally, research indicates a divorce rate among those who have experienced a depressive episode as being nine times higher than that of the general population. One study

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comparing antidepressant medication to marital/family therapy showed that clients improved sooner with antidepressants. However, the study also showed that marital therapy produced long-term improvements in depression, participation in family role tasks, and increased satisfaction with the marriage. Marcie’s treatment will consist of pharmacotherapy in addition to the different types of therapies. According to Wodarski, Wodarski, and Dulmus (2003), the use of specific pharmacotherapy approximately doubles the chance that the patient will recover in one month. Treatment Context The individual and marital treatment sessions will be located in the social worker’s office while Marcie is in the hospital. However, the location setting will be flexible as appropriate. Sometimes the individual sessions will be held in a meeting room, the social worker’s office, or the patient’s residential room. The group sessions are held in the group room with other psychiatric residents and Marcie, the LCSW, and the MSSW intern. The sessions are private; thus patients are ensured confidentiality. Length of Therapy Unfortunately, the length of the therapy process, many times depends on managed care, which determines the length of stay covered by insurance. Marcie’s managed care is constantly reviewed and evaluated by the insurance company. The insurance coordinator on the unit is required to call the managed care plan to ascertain that Marcie’s treatment in reimbursable. Marcie has been a client of the LCSW for three unsteady years because she is frequently readmitted. The one-hour group sessions are held four times per week. Individual sessions are held on a daily basis, and marital sessions weekly, both fortyfive minutes in duration. Assessment The psychosocial assessment history is focused on a theoretical framework based on the psychosocial model and empirically based therapeutic approaches that focus on the experiences and the effects of ideas that a person may not be aware of through his or her feelings and

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behaviors. This is derived from a person’s ability to function within his or her own mind. These techniques have been proven to be effective in treating individuals with mental disorders (Brabender, 2002). Marcie’s developmental history is complex, and the problems are considered to be pervasive, stemming from her past experiences. Marcie’s mother died when she was sixteen months old. She has older siblings: four brothers and three sisters. She and her siblings lived with their biological father, who never remarried. Growing up she had a close bond with her siblings, but currently they are not in touch because of an argument within the family. Marcie’s father was an alcoholic and was abusive to her verbally, physically, and sexually. Her father drank alcohol her entire life and would take her, as a young child, with him to bars while he drank. The family life was highly dysfunctional and stressful, and there was no positive support from extended family members or friends, except for Marcie’s maternal grandmother. This grandmother lived in Texas, whereas Marcie lived in Kentucky, so keeping in contact was difficult because neither family had money to spend on long distance phone calls or traveling. The therapist will utilize several assessment methods, including clinical interviewing, the DSM-IV, Rapid Assessment Instruments, empirically based scales, the Beck Depression Inventory, and the Hamilton Rating Scale for Depression (Dulmus & Wodarski, 1998). Short-term Outcomes, Interventions, and Goals OUTCOMES. Maintaining stabilization outside of the hospital is a primary outcome that is desired for Marcie, but one that she has had difficulty achieving. She has been hospitalized seven different times from August 2005 to November 2005. Marcie has poor coping skills and ineffective problem-solving skills. She needs to improve her skills and learn to utilize new skills that she has learned to meet her outcomes. Marcie will need to verbalize an understanding of available community and state-governmental medical services. She will also need to comply totally with her entire treatment plan. Marcie’s husband needs to verbalize an acceptance of her physical and mental limitations and demonstrate more support to her, and they will need to develop a healthier living environment and reduce stress together (Wodarski, Rapp-Paglicci, Dulmus & Jongsma, 2001). Marcie will be expected to cooperate with an assessment of current statuses and be compliant with antidepressants on a weekly basis. She, likewise, will need to

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accept her treatment as necessary in order to safely address her depression. She must accept professional care and verbalize feelings and emotions of suicide ideations and past attempts. Marcie will need to demonstrate improved problem-solving and relaxation skills and identify and verbalize reasons she has for living (Wodarski et al., 2001). I NTERVENTIONS. Marcie will attend therapeutic groups and activities daily, take medications appropriately, and she will need supervision over her medication. Therefore, it has been suggested in marital therapy sessions that her husband will evaluate her medication doses daily. Marcie's interventions will occur through individual, group, and family therapy. She needs to attend therapeutic groups that focus on improving positive coping and problem-solving skills. She also needs to become more involved within her community to increase her socialization skills. Hopefully, with the proper education, she will be able to successfully achieve her intervention goals. The psychiatrist, LCSW, and Marcie’s husband together will monitor her compliance to medication and redirect when appropriate. Marcie must make her therapy appointments and attend them regularly. The LCSW will reinforce the husband's support of Marcie’s follow-through with her treatment. The LCSW will explain Marcie’s conditions to her and her husband and will provide them with supportive steps. Marcie and her husband will be referred to community support groups that include others who are struggling with similar problems so she can experience universality (Wodarski et al., 2001). GOALS. Marcie’s primary short-term goal is to be functional outside the hospital setting in society. In order for her to achieve her goals, she must successfully complete her outcomes and interventions. Marcie will be provided with psychoeducation about her depression and antidepressants so that she can succeed in her recovery. She will be monitored according to her mental health treatment plan, medication compliance, and her effectiveness toward achieving a successful recovery. Through the interventions, the LCSW will teach Marcie positive problem-solving and coping skills in order for her to reach her goals. She will learn deep breathing, muscle relaxation, and positive imagery techniques for stress reduction.

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Long-term Outcomes, Interventions, and Goals OUTCOMES. Marcie needs to become an active member in her community and interact with society to become a functional member of society. She should develop positive ways to increase her social support network. One of the worst things Marcie can do is to isolate herself; therefore, she must learn to interact with people. The hope is that with the proper treatment, she will gain empowerment and positive self-esteem that will decrease her levels of depression. Through developing a sense of hope, her major depressive symptoms should decrease. I NTERVENTIONS. Marcie will attend support group meetings twice a week, and will meet regularly once a week with a therapist and monthly with her psychiatrist in order to remain compliant with medications. She needs to engage in positive activities inside and outside of the home, and she will need to increase her positive social support network. The LCSW will assist Marcie in identifying goals to reinforce positive success for her future. The therapeutic process will provide family therapy for Marcie and her husband in order to identify familial factors contributing to the suicide attempts (Wodarski et al., 2001). Educating Marcie and her husband about symptoms of depression, antidepressant side effects, warning signs of suicide, and providing emotional support in the treatment plan is critical to achieving a successfully recovery. Before discharge, Marcie will be linked to community support programs and will be assured that she has the resources to obtain assistance when she needs it. Marcie will develop a contract for no self-harm and will be provided with local twenty-four-hour hotline numbers and instructed on how the services operate. GOALS. Marcie’s primary long-term goal is to be able to be a functional member of society. In order for her to achieve the goal, she must engage in positive activities and requirements. She will need to follow through with the necessary medical and emotional treatment from her LCSW therapist, psychiatrist, primary care physician, and the community support groups. She must be compliant with her entire treatment plan and will need to access services and develop coping skills to compensate for cognitive deficits (Wodarski et al., 2001).

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Relapse Prevention Relapse prevention is critical for those who are suffering from mental disorders. It is important that after hospitalization clients follow up with a psychiatrist and a licensed therapist. According to Dulmus and Wodarski (1998), it has been indicated that CBT may well be more effective in relapse prevention than pharmacotherapy alone is. By informing the patient's family of the disorder through education, a better understanding should result to help family members better care for the patient and provide her with a positive and structured environment. Marital therapy has been reported to be an effective treatment option by “increasing marital satisfaction and decreasing negative marital communication, thereby decreasing the probability of relapse among patients with depression” (Dulmus & Wodarski, 1998, p. 281). Support groups have also been reported as good resources for improving coping skills for people in both informal and formal social networks. As a part of relapse prevention, once Marcie is released from the hospital, she can utilize an outpatient community mental health service. The service of choice is a local nonprofit community mental health center that specializes in serving individuals who either have no insurance or have managed care. Services provided by the center include medication management; individual, group, and family therapy; and case management. In the groups, Marcie will benefit from experiencing the universality concept by being around other people who are suffering with problems, as well as benefitting from peer interaction and community involvement. Marcie could benefit immensely from medication management, case management, and individual therapy. In case Marcie were to be disenrolled from care, the community mental health center does allow clients to pay for medication on a sliding fee scale. Marcie could benefit from case management because, as mentioned previously, she has expressed an interest in relocating to another neighborhood. A case manager could help her and her husband with locating housing, teaching everyday living skills, linking them to community resources, as well as providing a support system. Marcie has been noncompliant in the past with therapy and therefore is in contact with a therapist only when she is admitted to the hospital. The case management services may also help Marcie to remain compliant with therapy and medication.

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Medications Medication taken incorrectly can exacerbate Marcie’s problems; therefore, she needs to be more compliant with her medication intake. Marcie has been prescribed many different types of antidepressants to assist her with her pervasive problems leading to her depression. She has difficulty maintaining appropriate self-management of her medication. She is also faced with financial difficulties due to a cut in her health insurance, resulting in fewer resources and medication. Marcie and her husband are on a fixed income and do not have extra money to pay for medication the insurance does not cover. “The tricyclic anti-depressants (for example, imipramine, amitriptyline, desipramine, nortriptyline, and protriptyline) and related agents are commonly prescribed for patients with moderate to severe depression” (Wodarski et al., 2003). People suffering with moderate to severe depression are also prescribed bupropion and the SSRIs. SSRIs are safer, better tolerated, and the most effective psychotropic drug intervention. SSRIs are the most preferred pharmacotherapy intervention for depression because they mix well with other medication, have fewer side effects, and are more difficult to cause an overdose. According to recent practice guidelines on depression, it is suggested that SSRIs, desipramine, nortriptyline, buproprion, and venlafaxine are best suited for most patients (Tolman, 2001). Tricyclics and monamine oxidase inhibitors (MAOI) are not prescribed as often because of side effects such as weight gain, sedation, and an overall increase in other common side effects. Tricyclics and MAOIs are dangerous for individuals who are suicidal because an overdose results in a crisis that many times leads to death. The relapse rates for clients treated only with antidepressants are typically much higher than for clients who complete psychotherapy, especially CBT. Recent reviewers note that if patients discontinue taking antidepressant medications following recovery from depression, about 25 percent of the patients will relapse within the next two months. The relapse rates have led many clinicians to recommend that antidepressants be taken for six months to one year, continuing even after depressive symptoms have remitted to reduce the risk of relapse (Tolman, 2001). Suicide Risks Once Marcie has been discharged from the hospital and is referred

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to needed outside resources, there is still a risk that she may relapse back into severe depression or even engage in suicide attempts. The presence of depression significantly elevates the risk of suicide. In evaluating risks, the clinician needs to differentiate between attempts and completed suicides. This distinction is important because 85 to 90 percent of persons diagnosed with depression eventually do commit suicide. As many as 75 to 80 percent of all those who commit suicide provide some type of overt verbal clue to their intentions; therefore, clinicians must determine if patients are suicidal and if they have a plan (Tolman, 2001). Prior suicide attempts should dramatically raise the level of risk in the clinician’s mind. Older males often succeed on the first try due to the lethal method chosen. It is important to pay attention to the client’s family history of depression and suicide. A family history is a strong predictor of suicide actually being carried out. Thus, it is very important that the therapist be attentive to the client’s meaning and continually check to see if ideations are present. In conclusion, it is essential that Marcie understands her treatment plans and has a crisis plan developed before she is discharged. She must be aware of the risks of relapsing, and she needs to know the directions she must take when relapse occurs. It is important to educate clients and families about relapse prevention through psychoeducation to increase awareness of their behavior and feelings, as well as the manner in which they can safely and appropriately manage these feelings. Educating Marcie and her husband of the warning signs of a depressive episode and the signs of suicidal thoughts is important and could possibly save her life. CASE STUDY 2: ADOLESCENT DEPRESSION

The Client Sally is a fifteen-year-old female student at a local private high school who was referred for counseling by her mother, who stated that her daughter is having difficulty with peer relationships and a recent incident with the law. Sally lives at home with both of her parents and her two older sisters, one of whom is in high school and the other in college. The client occasionally drinks but does not use any other substances. Sally has never been sexually or physically abused and has no prior history of mental illness. Sally does well in school, typically mak-

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ing As and Bs, but recently her grades have been dropping, which her mother believes is due to her inability to concentrate. Sally is considered to be popular in school and, until this school year, has been very involved in clubs and sports teams. Sally also has a gym membership, that previously she used every day. Sally explains that she has a loss of energy and does not feel like exercising. Recently, she has been eating more, gaining weight, and not working out or participating in any school activities, including volleyball, which she used to love. Sally has also been having initial insomnia for which her mother has been giving her over-the-counter sleeping pills, which have been effective. However, Sally is now “addicted” to the pills and needs them to fall asleep. Not only has Sally lost interest in pleasurable activities and been experiencing insomnia, increased appetite, and weight gain, but also she has feelings of sadness almost every day. She also has decreased energy and the inability to concentrate. Sally does not admit to any thoughts of suicide or homicide. Assessment After initial intake and analysis of the Beck Adolescent Depression Scale, Sally was diagnosed as having a major depressive episode with the onset occurring four months previously. Sally explains that around four months ago, she was driving her friend’s car without a license or a permit and was involved in an accident. Since the accident, she has been placed on probation and has had to complete community service hours. Sally’s social life has also been a major stressor in that her love interest broke up with her after she refused to have sexual intercourse with him. He soon after started dating her best friend, and since then she has not had any close friends. Two weeks ago she went to a friend's house and drank five beers, resulting in intoxication and vomiting. The Worker, Content, and Duration Sally presented to the school counseling program, where she will be seen by a second-year clinical social work graduate student. Sally’s parents do not wish for her to be placed on any medications at this time, but at the suggestion of the worker, she will be seen by a medical doctor. Sally has agreed to see a counselor once a week for the next three months to reduce her symptoms of depression. The counselor has designed a treatment program based on the CBT model (Wodarski et al., 2001; Wodarski et al., 2003).

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Long-Term Goals Upon first meeting with Sally, the worker discussed several longterm goals for therapy. One goal is to overcome the mood disruption in her life and to be able to return to a state of joy, happiness, and peace. Another goal is for Sally to learn how to cope with the depression and to improve the way she feels. Sally added some other longterm goals, which are to interact with positive and appropriate peers, to be released from probation, and to obtain her driver's license when she turns sixteen. Long-Term Interventions The primary intervention for coping and overcoming the depression that Sally is suffering from is the use of CBT, in which she will learn to identify her thoughts, beliefs, and feelings and also identify which activities produce the negative emotions and which activities bring her the most happiness. Sally will be given the self-monitoring log, in which she will be encouraged to document the activities she participates in over the next few weeks and to record her mood after each day. In the next counseling session, Sally will review the activities with her counselor and discuss her overall mood each day. Another long-term intervention will focus on identifying the qualities of positive relationships and discussing how to choose appropriate peer relationships. Sally also agreed to abide by the terms of her probation and to complete her community service hours in order to receive her license on her sixteenth birthday. Short-Term Goals In addition to the long-term goals that Sally and the counselor have set, Sally also agrees to several short-term goals that include identifying and decreasing negative thoughts and beliefs, identifying feelings and being able to express them appropriately, and learning relaxation techniques such as deep breathing, progressive relaxation, and guided imagery. In regard to peer interactions, Sally will describe friends, their values, and the types of activities that they engage in together, will identify stress-related problems, generate solutions, and choose the best solution. In regard to the legal issue, Sally will verbalize an understanding of the process of removal from probation and commit to following through with the process.

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Short-Term Interventions The first short-term intervention that will be used with Sally involves explaining the cognitive component of depression and having her write down her thoughts and identify whether they are negative or positive. Once Sally is able to more easily identify her thoughts, the worker will encourage her to interrupt her negative thoughts and insert a positive, counteracting thought through priming, using clues, and noticing what she accomplishes throughout a normal day. In order for Sally to properly identify her feelings, the worker will read certain hypothetical situations and have Sally identify the feeling that would most likely follow the stimuli. The worker will also educate Sally on the action, belief, and consequence (ABC) model and explore feelings that follow certain self-statements. Sally will also be encouraged to practice expressing her feelings using “I” messages. Other interventions to be utilized with Sally involve relaxation techniques in which the worker explains the importance of relaxing and calming herself each day to alleviate the effects of stress. The worker will guide Sally through breathing awareness and deep breathing techniques. The worker will also guide her through progressive relaxation, alternating between a state of tension and complete relaxation of various muscles. The last relaxation technique utilized will be guided imagery, in which the worker educates Sally on how to use imagination to create relaxation. The worker will also encourage Sally to construct a sociogram of her social network and identify the closeness of each friend. Sally will also explore with the worker her values and priorities as well as her friends' values, and she will explore the leisure activities enjoyed by her peer group. Sally also will be encouraged to identify current problems that generate stress and conflict, and the worker will teach her the steps of effective problem solving. The worker will also explore Sally’s feelings toward her probation and any link between the incident and her depression, and she will review the process of removal from probation. The worker will also write up a contract for Sally to sign and keep as a reminder and accountability to abide by the terms of her probation.

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Outcomes Sally has been very motivated to participate in therapy and has shown a belief and desire for change. In just three months, her condition improved, and she reported feeling “normal” again. Sally’s grades have improved, and her parents have seen marked improvement in her sleeping and eating habits. Sally’s mood has improved according to self-report and a recent Beck Depression Inventory. Medications Sally did not have a need for antidepressants due to the effectiveness of counseling. However, Sally’s pediatrician recommended weaning her off of the sleeping medication. Sally’s parents accomplished this over a two-week period, and she has not suffered from insomnia in the past two months. Sally agreed to meet with the counselor once every two months for a follow-up to prevent relapse. REFERENCES Akiskal, H.S., and Cassano, G.B. (Eds.). (1997). Dysthymia and the Spectrum of Chronic Depressions. New York: The Guilford Press. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Brabender, V. (2002). Introduction to Group Therapy. New York: John Wiley & Sons. Dulmus, C., and Wodarski, J. (1998). Major depressive disorder and dysthymic disorder. In B. Thyer and J. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1, Mental Disorders, (pp. 273–285). New York: John Wiley & Sons. Johnson, S., Hayes, A., Field, T., Schneiderman, N., and McCabe, P. (Eds.) (2000). Stress, Coping, and Depression. Mahwah, NJ: Lawrence Erlbaum. Markowitz, J. (2003). Interpersonal psychotherapy for chronic depression. Journal of Clinical Psychology, 59, 847–858. Thyer, B., and Wodarski, J. (1998). Handbook of Empirical Social Work Practice: (Vol. 1). Mental Disorders. New York: John Wiley & Sons. Tolman, A. (2001). Depression in Adults: The Latest Assessment and Treatment Strategies (2nd ed.). Kansas City, MO: Dean Psych Press Corp. Wodarski, J.S., Rapp-Paglicci, L.A., Dulmus, C.N., and Jongsma, A.E. (2001). The Social Work and Human Services Treatment Planner. New York: John Wiley & Sons. Wodarski, J.S., Wodarski, L.A., and 0Dulmus, C.N. (2003). Adolescent Depression and Suicide: A Comprehensive Empirical Intervention for Prevention and Treatment. Springfield, IL: Charles C Thomas Publishers.

Chapter 15 BIPOLAR DISORDER DEFINITION OF BIPOLAR DISORDER

B

ipolar disorder, also known as manic depression, is a brain disorder that causes unusual shifts in an individuals mood, energy, and ability to function. Bipolar disorder is a lifelong illness and indicates a higher intensity of symptoms than the usual ups and downs of everyday life. According to the DSM-IV (APA, 1994), the essential feature of bipolar I disorder is a clinical course that is characterized by the occurrence of one or more manic episodes or mixed episodes, often accompanied by one or more major depressive episodes. However, it is important to note that an individual diagnosed with bipolar I disorder does not need to experience depression to qualify as bipolar I. It is important to distinguish bipolar I disorder from bipolar II disorder. The essential feature of bipolar II disorder is a clinical course that is characterized by the occurrence of one or more major depressive episodes accompanied by at least one hypomanic episode (DSMIV, APA, 1994). A diagnosis of bipolar I disorder is often accompanied by the following: bipolar I disorder, single manic episode; bipolar I disorder, most recent episode hypomanic; bipolar I disorder, most recent episode mixed; bipolar I disorder, most recent episode manic; bipolar I disorder, most recent episode depressed; bipolar I disorder, most recent episode unspecified. These categories help clinicians identify Note: Case study by Deisha Shah and Lindsay Homesley.

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and manage patients at different levels of bipolar I disorder (DSM-IV, APA, 1994). The symptoms of mania include inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences (APA, 1994). The symptoms for depression include lasting sad, anxious, or empty mood; feelings of hopelessness or pessimism; feelings of guilt worthlessness or helplessness; loss of interest or pleasure in activities once enjoyed, including sex; decreased energy, a feeling of fatigue or being slowed down; difficulty concentrating, remembering, making decisions, restlessness, or irritability; sleeping too much or inability to sleep; change in appetite and/or unintended weight loss or gain; chronic pain or persistent bodily symptoms that are not caused by physical illness or injury; and thoughts of death or suicide or suicide attempts (APA, 1994). Prevalence Bipolar Disorder is prevalent in more than two million American adults. In any given year, one percent of the American population age eighteen and older has bipolar disorder. It is equally prevalent in both sexes and typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life (NIMH, 2005). The Client Andrew is a thirty-year-old man living with bipolar I disorder, with the most recent episode accompanied by depression. Andrew had his first bipolar episode at the age of twenty-one and has since had many recurrent episodes of mania and depression. He has been hospitalized numerous times. Andrew recently moved from the United Kingdom to a large metropolitan area in the United States and currently lives with his brother, who noticed that Andrew had stopped taking his medication and was showing many of the symptoms of mania. Fearing another manic episode, especially due to the stress of the move,

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with new people and a new environment, Andrew’s brother took him to a hospital for evaluation and treatment. Andrew’s mother has battled depression off and on for years; his father died when Andrew was young; his stepfather was abusive in the past; and he has three brothers. Andrew is close with his youngest brother, who is also his roommate and is knowledgeable regarding symptoms and risks of bipolar disorder. Andrew is not married and has no children. The Workers The workers involved in Andrew’s treatment include a psychiatrist, an LCSW for individual outpatient therapy, an LCSW for group therapy, and a medical doctor. A medical doctor is important in the treatment of bipolar disorder in order to assess and clarify symptoms that are due to medical problems and those due to the actual disorder (Treatments, 2005). ASSESSMENT

Accurate assessment is vital in the diagnosis and treatment of all disorders. To successfully determine the most appropriate intervention plan for Andrew, several assessment techniques were utilized as recommended by Brotter, Clarkin, and Carpenter (1998). A clinical interview is a common way to gather information relating to bipolar disorder and its effects on the individual. An LCSW at a nearby hospital conducted the clinical interview as the initial step in the assessment process. One of the main functions of the clinical interview is to determine if Andrew met the DSM-IV criteria (APA, 1994) for bipolar disorder. Other functions of the clinical interview include determining if Andrew accepts his diagnosis and the need for treatment and his medication history, overall psychosocial functioning, early warning signs, current stressors, and amount of family and/or social support. The Structured Clinical Interview for DSM-IV The clinical interview provides valuable basic information, but, if possible, it is wise to obtain standardized measures as well. Therefore,

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the LCSW administered the Structured Clinical Interview for DSM-IV (SCID). This assessment is helpful when the diagnosis of the disorder is unclear or if other disorders need to be ruled out. Another advantage is the Axis II portion of the SCID. Bipolar clients often have Axis II personality disorders along with the Axis I bipolar disorder. This allows the LCSW a standardized means to determine if Andrew is suffering from an Axis II disorder as well. The Global Assessment Scale and The Social Adjustment Scale The Global Assessment Scale (GAS) is a rating system used to identify Andrew’s overall daily functioning and degree of symptom pathology. It is also used to support observations and/or expose errors made in the clinical interview. The Social Adjustment Scale (SAS) is a prepared interview to recognize areas of social functioning that have been harmed by his disorder. The SAS measures Andrew’s overall social functioning and focuses on six major areas of life including social activities, work, and extended family functioning, just to name a few. A benefit of this scale is Andrew’s functioning can be measured and compared over the course of his treatment to see if improvements are made. After the assessment tools have been administered and the results obtained, there was enough evidence to promote a diagnosis of bipolar I disorder. Although Andrew is diagnosed with the disorder, it is determined that he does not need to be hospitalized at the present time, but his treatment plan should begin immediately. Hospitalization is often mandatory for bipolar clients. For clients in a depressed state, some common symptoms that warrant hospitalization include a high risk of suicide or causing harm to others, low or no support systems, and lack of improvement from outpatient intervention (Treatments, 2005). Manic clients may require hospitalization if they present with psychotic symptoms, if they are at high risk of hurting themselves or others, or if they have lost all sense of reality and self-control (Treatments, 2005). Fortunately, Andrew’s level of pathology did not warrant such a decision by the LCSW at the hospital. Also, Andrew has a supportive roommate who has agreed to monitor his symptoms and to provide transportation to future medical and psychiatric appointments.

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INTERVENTION

Traditionally, medication was the only available source of treatment for individuals diagnosed with bipolar disorder. Current studies suggest that a psychological intervention in addition to medication is most effective in treating and preventing relapse of this crippling disorder (Hayward, Wong, Bright & Lam, 2002). There are a variety of psychological interventions that have been successful, including familyfocused therapy (FFT), interpersonal and social rhythm therapy (IPSRT), and CBT (Fountoulakis et al., 2005). It is important to note that “It is generally agreed that all bipolar patients should be maintained on a mood stabilizer,” and medication must be used during any psychological intervention in order for it to be successful (Tamminga et al., 2002, p. 591). Family-Focused Therapy The family plays an important and pivotal role in the course and treatment of bipolar disorder (Kim & Miklowitz, 2004). Many studies examine family members’ attitudes and emotional affect and the relationship those factors have on the bipolar individual (Tompson, Rea, Goldstein, Miklowitz & Weisman, 2000). Studies show that families that express themselves in a more critical, hostile, or overly involved manner can have detrimental effects on the client’s treatment outcome, and these studies predict higher relapse rates in the family member suffering from bipolar disorder (Tompson et al., 2000). Because family style and emotional affect can have such negative consequences on the client, family intervention is a valuable way to help deal with these issues (Tompson et al., 2000). Common themes in FFT are providing psychoeducation to family members about bipolar disorder, problem-solving skills, and communication techniques in a family perspective (Tompson et al., 2000). Kim and Miklowitz state that “psychosocial interventions that modify family relationships, especially as these evolve over time in concert with changes in the illness, are emerging as effective adjuncts to pharmacotherapy in the outpatient management of bipolar disorder” (2004, p. 351). Interpersonal and Social Rhythm Therapy IPSRT is an intervention plan designed specifically for bipolar cli-

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ents, and many studies have proved it is an effective treatment option (Frank, Swartz & Kupfer, 2000). IPSRT is very complex, but the main purpose is to regulate sleep patterns of bipolar individuals by identifying and controlling social factors and stressors that disrupt the individual’s sleep-wake cycle and circadian rhythms (Frank, Swartz & Kupfer, 2000). IPSRT treatment is “manual-based psychotherapy,” and it focuses on five components: connection between life events and mood, importance of maintaining stability in daily events, management and identification of triggers and stressors that disrupt sleep patterns, grieving the “lost healthy self,” and identifying and managing emotional symptoms (Frank et al., 2000). Medication compliance is another essential component of IPSRT (Otto, Reilly-Harrington & Sachs, 2003). Cognitive-Behavioral Therapy In a critical review of 224 articles and 27 papers concerning bipolar treatment guidelines, CBT is cited numerous times as a nonpharmacological treatment option for this disorder (Fountoulakis et al., 2005). It is well-known that CBT is effective in the treatment of unipolar depression, and the current research suggests that this style of therapy is helpful in the treatment of manic depression as well (Zaretsky, Segal & Gemar, 1999). The main components of CBT in the treatment of bipolar disorder focus on medication compliance, identifying early warning signs, stress management, treatment of comorbid factors, and the actual treatment of bipolar disorder (Otto, Reilly-Harrington, & Sachs, 2003). In the actual treatment of the disorder, standard CBT techniques, such as contracting, motivation interviewing, and cognitive restructuring, are modified specifically for special needs of the bipolar individual (Otto et al., 2003). Electroconvulsive Therapy Another form of treatment that can be used for treating a bipolar individual in an extreme depressed or manic state is electroconvulsive therapy (ECT). This is a very controversial method of treatment, but it is being used more often due to pressure from managed care to shorten the length of time individuals stay in the hospital (Tamminga et al., 2002). ECT is often a last resort method of treatment, but it can be successful in treating some bipolar individuals (Fountoulakis et al.,

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2005). ECT is used more often than not to help patients deal with and manage their depressive state. However, current data also supports findings that ECT helps calm patients during their manic phase (Fountoulakis et al., 2005). TREATMENT PLAN

After reviewing Andrew’s assessment results, the LCSW determined that the most appropriate intervention plan would be medication use, individual therapy using a cognitive-behavioral approach, and participation in support group therapy. Andrew is not married, has no children, and has little family contact, so participation in FFT is not recommended. In his treatment plan, there are various shortterm and long-term goals that can hopefully be achieved through his completion of the treatment. Andrew agreed to the proposed treatment plan. Short-Term Goals The first and foremost short-term goal of Andrew’s treatment is medication management and compliance. As stated earlier in this chapter, medication is vital in the management of bipolar disorder, and it must be taken during his individual and group treatments (Tamminga et al., 2002). The psychiatrist is responsible for prescribing and monitoring his medication use and will make appropriate changes as necessary. Other short-term goals in Andrew’s treatment are decreasing impulsive behaviors, achieving mood stability, and identifying “positively biased” thoughts associated with mania and “negatively biased” thoughts associated with depression (Brotter et al., 1998). These goals will be obtained through his completion of individual CBT over a sixmonth period (Otto et al., 2003). This treatment will provide Andrew with education about the disorder; problem-solving and communication training; along with the traditional cognitive-behavioral methods, such as homework assignments, cognitive-restructuring, and behavioral modification, to meet his treatment goals (Brotter et al., 1998). The individual therapy will be led by an LCSW at a nearby outpatient facility.

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The final short-term goals are identifying stressors and triggering symptoms, learning positive coping skills, gaining social support, reducing isolation and stigmatization, and improving self-esteem (Hayward et al., 2002). Research states that participation in a support group therapy format is an excellent way for bipolar clients to meet these goals (Hayward et al., 2002). Andrew will participate in an eightweek “stress management” group for bipolar individuals after his medication has been prescribed and his symptoms have stabilized. The group will be facilitated by an LCSW also. Another goal for Andrew is to be able to maintain independent living. He is not hospitalized at the present time and, hopefully, with his medication compliance and, individual and support group therapy, he will avoid hospitalization in the future. Long-Term Goals Bipolar disorder is a vicious and, in many cases, chronic disease (Brotter et al., 1998). To reduce the frequency of relapse and maintain mood stability, there are several long-term goals in Andrew’s treatment plan as well. Medication should be maintained for at least six to twelve months after a single bipolar episode. For individuals who have experienced repeated episodes or have a strong family history of the disorder, however, medication should be maintained throughout their lives (Fountoulakis et al., 2005). Andrew has had several bipolar episodes; therefore, lifelong medication compliance is necessary. Mood stabilization is another long-term goal, and the medication should help him achieve this objective. Another long-term goal is the ability to recognize early warning signs of episodes, seek early treatment, and avoid full-blown attacks (Perry, Tarrier, Morriss, McCarthy & Limb, 1999). Hopefully, Andrew’s participation in the “stress management” group will prepare him to be able to accomplish this lifelong goal. The maintenance of Andrew’s social and interpersonal functioning is another long-term goal. If his symptoms are maintained and his mood stabilized, Andrew should be able to have a full-time job and be able to support himself monetarily. In addition, the development and continuation of meaningful family, friend, and romantic relationships should occur. In the end, the medical and behavioral staff hopes

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Andrew will be able to live a positive and productive life and stabilize his bipolar disorder symptoms. RELAPSE PREVENTION

Current research studies suggest that the best form of therapy to reduce manic or depressive episodes is cognitive-behavioral therapy in conjunction with medication (Lam, McCrone, Wright & Kerr, 2005). As mentioned earlier, this therapy allows patients to understand the importance of medication compliance, identify early warning signs, and manage stress. Often patients suffering from bipolar disorder feel restrained taking medications, thus their natural instincts often urge them to stop medications. CBT allows individuals to recognize their harmful cognitions and respond appropriately. Many studies indicate that an episode of mania or depression may be the result of major stressors in life. Teaching bipolar disorder patients basic life skills can help manage stress. These life skills classes are important not just for the patients, but also for their families, so that they can help the patients identify and deal with everyday stressors. Weekly support groups are also available in many of the major cities, as well as online support organizations such as Depression and Bipolar Support Alliance, The Winds of Change Bipolar Disorder Online Support Group, Mood Disorder Support Group, and so forth. Because most bipolar patients are on more than one medication, it is important for them to have a clear understanding of how these medications work and the possible side effects that they may experience. Doctors and social workers may have to spend a good deal of time helping patients understand how their medications affect their body and how to identify warning signs of possible health problems. The Sorensen Therapy for Instability in Mood (STIM) is a new psychoeducational and cognitive therapy tool for bipolar disorder. It is an individualized biopsychosocial formulation that helps individuals understand bipolar-related experiences. “It involves education about the disorder, work with the therapist to understand the client’s particular triggers for manic or depressive periods, and the inclusion of the patient’s social network in attempts to stabilize mood” (Sorensen, 2005). Friends and family can be a part of the relapse prevention by being aware of possible symptoms of mania and depression. Monitoring symptoms can lead to the maintenance of an episode before it

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becomes full blown and harmful. Patients can educate themselves and encourage those they visit frequently to monitor their affect and behavior. Finally, it is essential that bipolar disorder patients continue their medications and stick to the treatment plan. A recent cost-effective research study showed that patients who maintained the treatment plan of medication and CBT spent significantly fewer days in bipolar episodes after the effects of medication compliance was controlled (Lam et al., 2005). Medications Medication is a vital component of any treatment plan for a patient suffering from bipolar disorder. Most individuals with this disorder usually take more than one medication and often go through many dosage changes before finding the right formula. Medication for the treatment of bipolar disorder is usually used for five reasons: to control mania, to stabilize mood, to control psychotic depression, to control anxiety, and to control insomnia (Brotter et al., 1998). Lithium Lithium is the first mood-stabilizing medication approved by the FDA for treatment of mania and has now been used for more than fifty years. It is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes. Lithium can help reduce severe symptoms of mania in about five to fourteen days, but to control the condition may take several weeks to months. However, since lithium is a type of salt, ingesting such a substance may result in many health problems. These health problems may include, but are not limited to, drowsiness, weakness, nausea, fatigue, hand tremor, increased thirst and urination, and possible weight gain. Regular blood tests are very important to maintain the lithium levels in the body and to ensure that it is effective and does not become detrimental for the patient’s physical health (NIMH, 2005). Anticonvulsant Medications Anticonvulsant drugs, such as valproate (Depacon®) or carbamazepine (Tegretol®) are used to stabilize mood and are often used to

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treat difficult bipolar episodes. The most popular anticonvulsant, valproate, was approved by the FDA in 1995 for treatment of mania. Anticonvulsants are often used with lithium to manage the condition until lithium is able to take full effect. Newer anticonvulsants are being studied to determine how well they work in stabilizing mood cycles, both manic and depressive. According to the NIMH, anticonvulsant medications are “as effective in non-rapid-cycling bipolar disorder as lithium and appear to be superior to lithium in rapid-cycling bipolar disorder.” Side effects from this medication include gastrointestinal complications, liver dysfunction, headaches, double vision, dizziness, anxiety, or confusion (NIMH, 2005). Atypical Antipsychotic Medications Atypical medications, such as clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), and ziprasidone (Geodon®), are usually used to treat patients who do not respond well to lithium or anticonvulsants. These medications are usually used as mood stabilizers for acute mania and psychotic depression. Atypical medications were introduced in the 1990s and clinical tests showed that they demonstrated fewer side effects than their counterparts, typical antipsychotics. However, atypical medications can result in a blood disorder called agranulocytosis; thus, a biweekly blood test is necessary for patients on such medication (NIMH, 2005). Antidepressant Medication Antidepressants, such as sertraline (Zoloft®), paroxetine (Paxil®), and other SSRI’s are usually used during a depressive episode. However, a patient does not have to be suffering from major depression to be able to benefit from antidepressants. These medications usually take six to eight weeks to take full effect. The side effects from these newer antidepressants may include sexual dysfunction, head-ache, nausea, nervousness, insomnia, and agitation. Patients should not discontinue these medications without consulting the doctor be-cause sudden neurotransmitter imbalance in the brain may escalate suicidal thoughts and urges (NIMH, 2005).

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Antianxiety Medications Antianxiety medications can help deal with various forms of anxiety and insomnia. The most popular class of antianxiety medications is the benzodiazepines, which may be helpful in promoting better sleep and a feeling of relaxation. However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Side effects from benzodiazepines include drowsiness and loss of coordination (most common). Fatigue and cognitive impairment can also occur; therefore patients using these medications should be advised to not drive or operate some machinery (NIMH, 2005). Bipolar disorder is a lifelong illness. Understanding the tools necessary to maintain remission and maintaining treatment are essential for relapse prevention. Setting appropriate, individualized goals and treatment options that take into account environmental, biological, social, and cognitive abilities are salient to the effectiveness of treatment. Andrew's intervention plan has illustrated such an ecological perspective, and thus his prognosis will be positive as long as he adheres to his treatment plan. REFERENCES American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th ed.) Washington, DC: Author. Brotter, B., Clarkin, F.J., and Carpenter, D. (1998). Bipolar disorder. In B.A. Thyer and J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders (pp. 287–308). Hoboken, NJ: John Wiley & Sons. Fountoulakis, N.K., Vieta, E., Sanchez-Moreno, J., Kaprinis, G.S., Goikolea, M.J., and Kaprinis, S.G. (2005). Treatment guidelines for bipolar disorder: A critical review. Journal of Affective Disorders, 86, 1–10. Frank, E., Swartz, A., and Kupfer, J.D. (2000). Interpersonal and social rhythm therapy: Managing the chaos of bipolar disorder. Society of Biological Psychiatry, 48, 593–604. Hayward, P., Wong, G., Bright, A.J., and Lam, D. (2002). Stigma and self-esteem in manic depression: An exploratory study. Journal of Affective Disorders, 69, 61–67. Kim, Y.E., and Miklowitz, J.D. (2004). Expressed emotion as a predictor of outcome among bipolar patients undergoing family therapy. Journal of Affective Disorders, 82, 343–352.

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Lam, D.H., McCrone, P., Wright, K., and Kerr, N. (2005). Cost-effectiveness of relapse-prevention cognitive therapy for bipolar disorder: 30 month study. British Journal of Psychiatry, 186, 500–506. National Institutes of Mental Health (NIMH). (2005). Medications [Online]. Retrieved June 17, 2008. Available: http://www.nimh.nih.gov/health/publications/ medications/complete-publication.shtml Otto, W.M., Reilly-Harrington, N., and Sachs, S.G. (2003). Psychoeducational and cognitive-behavioral strategies in the management of bipolar disorder. Journal of Affective Disorders, 73, 171–181. Perry, A., Tarrier, N., Morriss, R., McCarthy, E., and Limb, K. (1999). Randomized controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal, 318, 149–153. Sorensen, J. (2005). Relapse prevention in bipolar disorder [Online]. Retrieved June 17, 2008. Available http://perseus.herts.ac.uk/uhinfo/university-of-hertfordshirepress/psychology/relapse-prevention-in-bipolar-disorder.cfm Tamminga, A.C., Nemeroff, B.C., Blakely, D.R., Brady, L., Carter, S.C., Davis, L.K., et al. (2002). Developing novel treatments for mood disorders: Accelerating discovery. Society of Biological Psychiatry, 52, 589–609. Tompson, C.M., Rea, M.M., Goldstein, J.M., Miklowitz, J.D., and Weisman, G.A. (2000). Difficulty in implementing a family intervention for bipolar disorder: The predictive role of patient and family attributes. Family Process, 39, 105–200. Treatments. (2005). Treatment for bipolar affective disorder other than medication [Online]. Retrieved June 17, 2008. Available: http://www.bipolarworld.net/ Treatments/treatment.html. Zaretsky, E.A., Segal, V.Z., and Gemar, M. (1999). Cognitive therapy for bipolar depression: A pilot study. Canadian Journal of Psychiatry, 44, 491–494.

Chapter 16 PANIC DISORDER WITH AGORAPHOBIA

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anic disorder with or without agoraphobia is a common psychiatric problem “which presents predominately in primary care” (Sharp, Power & Swanson, 2004). The condition is present in approximately 1.5 percent of the general population (Himle & Fischer, 1998). Stafford states that on May 15, 1998, the population of the United States was 269,708,540. Therefore of that date, approximately 1.5 percent of the population, or 4,045,627, were suffering from a panic disorder. According to the DSM-IV-TR, the diagnostic criteria for panic disorder with agoraphobia are A. Both (1) and (2): (1) recurrent unexpected panic attacks (2) at least one of the attacks has been followed by one month (or more) of one (or more) of the following: a. persistent concerns about having additional attacks b. worry about the implications of the attack or its consequences (e.g. hyperthyroidism) c. a significant change in behavior related to the attacks B. The presence of agoraphobia. C. The panic attacks are not due to the direct physicological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism). D. The panic attacks are not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-comNote: Case study by Michelle Leigh Allen and Dawn Willis Bergstrom.

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pulsive disorder, posttraumatic stress disorder, or separation anxiety disorder (APA, 2000). Although panic attacks are associated with panic disorder, a panic attack itself is not a codable disorder. The criteria for a panic attack are described in the DSM-IV-TR as a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within ten minutes: (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)

palpations, pounding heart, or accelerated heart rate sweating trembling or shaking sensations of shortness of breath or smothering feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint derealization (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going crazy fear of dying paresthesias (numbness or tingling sensations) chills or hot flashes (APA, 2000, p. 432).

Like panic attacks, agoraphobia is not a codable disorder. Agoraphobia must be coded within the specific disorder in which it occurs. The criteria for agoraphobia are: A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing), or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic cluster of situations that include being outside the home alone. B. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion. C. The anxiety or phobia avoidance is not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder (APA, 2000, p. 433).

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Patients who present with panic disorders are highly sensitive to stressful events. Any disruption of routine can lead to a panic attack, even those situations that are considered mildly stressful by most standards (Cassano et al., 1999). “The average age of onset for Panic Disorder and agoraphobia has consistently ranged from the mid- to late20s,” with women being twice as likely to suffer from the illness (Hilme & Fischer, 1998, p. 312). For sufferers whose disorder is not treated, approximately one in five will attempt suicide. The main causes for panic disorder are genetics and stressful life events. When the two causes are coupled, the sufferer can actually bring on a panic attack (Henerson, 2000). First onset of panic attacks frequently occurs during “major life transitions that are potentially stressful, such as graduating from college, getting married, having a first child, extreme crisis, relationship problems, divorce, or abuse” (Henerson, 2000). CASE STUDY

The Client Alice is a fifty-one-year-old female who was recently released from a metropolitan hospital and was referred for follow-up outpatient treatment at the community mental health clinic. She was hospitalized on the psychiatric floor due to severe depression, suicidal ideations, and alcohol dependence. Upon admission to services at the mental health clinic, Alice was diagnosed with panic disorder with agoraphobia, bipolar disorder, alcohol dependence, and BPD. Alice was first hospitalized at nineteen and reports approximately fifty-five hospitalizations since then. Also, at nineteen, she began using alcohol regularly. Alice states that she began drinking heavily around twenty-seven while going through a difficult divorce from an abusive and jealous husband. She has four children and is currently living with her boyfriend, who is supportive. Approximately ten years ago, Alice received a violation for driving under the influence but has had no other legal issues. Alice was raised by different family members throughout her life. At three, her parents separated, and Alice lived with her maternal aunt for two years. She then lived with her biological father and stepmother until they divorced when she was eight. After the divorce Alice

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lived with her father who was sexually abusive to her. At fifteen, she spent one year living in a home for teenagers. She dropped out of school in the tenth grade and can barely read and write. She was married at sixteen for five years and had two children while in the marriage. Alice remarried at twenty-two and had two more children. She was divorced at twenty-seven. She now has two sons and two daughters ranging in age from twenty-nine to twenty-one. Her biological mother is still living; and her biological father passed away about one month ago. Alice has been with her current boyfriend for five years. Before coming to the mental health clinic for follow-up treatment, Alice had not left her home for three years except for when she was hospitalized. She is afraid of leaving her home and often has panic attacks when she thinks about having to go out of the house. She constantly worries and is consumed with thoughts of having panic attacks. The Worker Social workers from several different disciplines could potentially work with Alice. Depending on her financial status, she might be seen individually at a community health center or by a social worker in private practice. Panic disorder, with or without agoraphobia, “causes sufferers considerable distress leading to their making heavy use of primary care treatment services” (Sharp, Power & Swanson, 2004). CBT has been proven to be an effective treatment for the disorder, but there is a shortage of primary care providers who are trained in the techniques. Therefore, empirical studies are being designed to determine the efficacy of group CBT for treating the disorder (Sharp, Power & Swanson, 2004). Alice might be offered the opportunity to attend group CBT sessions. The group process will be helpful for her because she would see that other people suffer from the same illness she has. Her therapist may also recommend that she attend a support group of individuals who suffer from panic disorder with agoraphobia. This might take quite awhile to implement because of Alice’s mental state, but realizing that she is not alone in her situation will be helpful to her. Alice will also be referred to a psychiatrist for evaluation to determine whether or not medications would help control the panic attacks from which she suffers. Psychopharmacology is frequently combined with other therapies to maximize the help the client receives.

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Assessment The assessment instruments used in Alice’s case were the Panic Attack Record and Worksheets adapted from the “Panic Attack Cognitions Questionnaire” (Clum, 1990). Interventions The social worker will use CBT in working with Alice. CBT has been successful in eliminating panic in 80 percent of patients (GarciaPalacois et al., 2002). CBT is reputed to maintain its treatment gains over time. Many patients with panic disorder relapse on discontinuation of medications. Even a few weeks of cognitive behavioral therapy can produce favorable outcomes (Nadiga, Hensley & Uhlenhuth, 2003). Studies have shown that a reduction in panic symptoms occurs when the client has a relationship with the therapist and has spent some time with the therapist conducting the CBT (Power, Sharp, Swanson & Simpson, 2000). Guided imagery is the conscious use of imagination to create positive images in order to bring about healthful changes in the mind and the body. The belief that the power of the imagination can help people heal has ancient roots. Traditional folk healers used guided imagery to treat ailments. Guided imagery allows a client to communicate more openly with his or her unconscious mind, requesting that the body function in an optimal or healthy way. Practitioners say that guided imagery works because, in terms of brain activity, picturing something and actually experiencing it are equivalent. Brain scans have verified that this is the case. Stimulating the brain with imagery can have a direct effect on the nervous and endocrine systems and can ultimately affect the immune system as well. The brain’s visual cortex, which processes images, has a powerful connection with the autonomic nervous system, which controls involuntary activities such as pulse, breathing, and physical responses to stress. Soothing uplifting images can actually slow your pulse and breathing and lower your blood pressure as well as help trigger the release of hormones, such as endorphins, which make you feel good and nurture the body’s restorative powers. The practitioner will guide Alice through a visualization exercise, using all five senses and perhaps focusing on a special place

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where the client usually feels happy and peaceful. The practitioner may suggest some ideas but will leave most of the imagining up to the client. The best images are the ones that Alice conjures up because they have personal meaning to her. With practice, she will be able to bring up healing images quickly and at anytime. She, furthermore, will be able to use guided imagery to help relax during stressful moments or panic attacks. Progressive muscle relaxation is a systematic technique for achieving a deep state of relaxation. This technique is based on the premise that every muscle can be relaxed first by tensing it for a few seconds and then releasing it. Immediate effects include a decrease in heart rate, respiration rate, blood pressure, skeletal muscle tension, metabolic rate, and oxygen consumption. Long-term benefits of muscle relaxation include a decrease in generalized anxiety, a decrease in anticipatory anxiety related to phobias, a reduction in the frequency and the duration of panic attacks, improved concentration, an increased sense of control over moods, increased self-esteem, and increased spontaneity and creativity (Bourne, 2000). Short-Term Objectives and Therapeutic Interventions First, Alice will obtain a complete physical evaluation to rule out medical etiologies for her anxiety symptoms. Alice will schedule a physical with her primary care physician and follow up with any recommendations he or she makes. Next, Alice will identify a secondary gain that may be reinforcing her anxiety symptoms. In order to achieve this objective, the social worker will assist Alice in identifying a secondary gain that is achieved by the presence of the anxiety symptoms such as lowered expectations from others. Alice will also implement cognitive and behavioral coping techniques to reduce anxiety. To fulfill this objective, the social worker will train Alice in guided imagery techniques. The social worker will also teach Alice progressive muscle relaxation and deep breathing exercise to reduce anxiety symptoms. In addition, Alice will implement cognitive and behavioral techniques to decrease the intensity, duration, and frequency of panic attacks. The social worker and Alice will utilize role playing, modeling, and behavior rehearsal to encourage her to use breathing and muscle relaxation techniques to help work through a panic attack and to induce relaxation. Lastly, Alice will complete a psychiatric evaluation to determine whether or not she is appropriate for psychotropic

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medication. If so, she will take all medication as prescribed (Berghuis & Jongsma, 2000). Long-Term Interventions Long-term interventions are intended to help Alice become self-sufficient in managing her condition. Frequently, people who are having a panic attack think they are “going crazy” or having a heart attack. Cognitive restructuring can help the client “replace those [negative] thoughts with more realistic positive ways of viewing the attacks” (Ross, 2004). According to Himle and Fischer (1998, p. 317), “one source of information that can be used to assess the accuracy of a client’s thinking . . . is the client’s own history. . . . Most clients report catastrophic thinking of one sort or another (heart attack, stroke, death, or going crazy) during these attacks. . . . The social worker can gently question patients and help them to recount how often they have had panic attacks, erroneously predicted disaster, yet somehow escaped it.” They also recommend that the social worker educate the client by providing information about other clients who have panic disorder who have predicted disaster and have escaped (Himle & Fischer, 1998). Another intervention intended to help Alice manage her illness over the long term is cognitive therapy. Cognitive therapy helps the client identify possible triggers for panic attacks, “something like a thought, a situation, or something as subtle as a slight change in heartbeat” (Ross, 2004). Still another intervention that would help Alice manage her illness is interoceptive exposure. “This is similar to the systematic desensitization used to cure phobias, but what is focused on is exposure to the actual physical sensations that someone experiences during a panic attack. [It] can help them go thru (sic) the symptoms of an attack . . . in a controlled setting, teaching that these symptoms need not develop into a full-blown attack” (Ross, 2004). Long-Term Outcomes The purpose of the long-term intervention is to ensure that Alice’s treatment is successful for her in the long term. The goal of the interventions is to reduce the level of worry, anxiety, and panic that she feels in her daily life. Alice will practice all of the interventions until she is comfortable using them even without the guidance of her therapist.

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Once she has mastered the long-term interventions, Alice will be able to manage normal life stressors with minimal levels of anxiety. Those situations that would have induced a panic attack in the past will no longer have the same power over her. She will no longer be consumed with the fear of having a panic attack. Alice will be able to leave her house as necessary to perform the activities that she wants to perform. She will be able to have a more normal relationship with her mother and children. Regular attendance at a support group for people with panic disorder or agoraphobia will help her to practice and reinforce the skills she learned in individual or group therapy. Relapse Prevention Relapse is a major issue for any client who suffers from a mental illness. Motivation to get well and stay well is the main factor in relapse prevention. First, Alice will have to recognize her triggers for panic attacks. Initially, she will utilize all of the techniques she has been taught in order to calm herself and to avoid a full-blown attack. She will use guided imagery to bring about a more pleasant feeling about her life. Deep muscle relaxation will help her to consciously relax the muscle groups that are frequently affected by a panic attack. She will be able to slow her breathing, which will lead to a lessening of symptoms when she feels a panic attack coming on. By using cognitive restructuring and interoceptive exposure, Alice will be able to “relive” a panic attack, separating out the triggers from the physical reactions she has had to those triggers in the past. This will help her to stay in control, even when she finds herself in a situation that would have set off a panic attack prior to treatment. Alice will continue attending support groups for people with panic disorder and agoraphobia. The purpose of the support groups is to give her a network of people who understand what she is going through in her daily struggle to recuperate. She will have people she can call when her other coping skills do not appear to be helping. Alice can also utilize online support groups for people with panic disorder or agoraphobia. The online support groups offer education and support, which will be helpful to her when it is difficult for her to get out.

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Medications For panic attacks, the greatest benefit that medications can provide is to enhance the client’s motivation and accelerate progress toward facing panic and all of its repercussions. For a drug to help in this area, it must help in at least one of the two stages of panic. The first stage is anticipatory anxiety: all uncomfortable physical symptoms and negative thoughts that rise up as someone anticipates facing panic. The second stage is the symptoms of the panic attack itself. If a medication can specifically block the panic attack itself, many patients no longer anticipate events with such anxiety and can overcome their phobias more quickly (Bourin & Lambert, 2002). The primary medications used today for panic disorder are the benzodiazepines, several types of antidepressants, and the new SSRIs. The most common benzodiazepines for panic attacks are alprazolam and clonazepam. The quick-acting nature of alprazolam makes it an ideal medication to take as needed just before panic-provoking events. Clonazepam, on the other hand, lasts longer in the body than alprazolam does. This allows a client to take it twice a day for full twentyfour-hour coverage. Clonazepam is also used as needed before a panic-provoking situation. When a client is practicing facing his or her fears, he or she may notice the effects of a medication and may tend to attribute the success more to the medication than to his or her own efforts. Benzodiazepines are very useful in treating panic disorder, but due to Alice’s substance abuse history, using benzodiazepines for treatment may not be suitable (Bourin & Lambert, 2002). Of the antidepressants, the tricyclic antidepressant imipramine has the longest record for treatment of panic attacks. Patients have also reported improvement while taking other antidepressants such as desipramine, nortriptyline, and amitriptyline. MAOIs are another family of antidepressants that assist with managing panic. Phenelzine is the preferred MAOI. Some of the new SSRIs help and have fewer side effects than the tricyclic antidepressants have. These include fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, and escitalopram. The rate of improvement from panic symptoms when clients are taking SSRIs is equal to the improvement of clients placed on tricyclic antidepressants. At times a physician may recommend a combination of a benzodiazepine and an antidepressant. Once the primary effects of the antidepressant begin after four to eight weeks, the pa-

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tient then slowly tapers off the benzodiazepine (Bourin & Lambert, 2002). For obsessions and worries, medications can reduce the degree of intensity of the worries and their corresponding distress. Medications do not prevent obsessions from occurring. However, when the medication lessens the strength of the worries, the client can use self-help skills to control them. SSRIs are the most helpful in reducing worrying. Since Alice worries constantly, as well as experiences frequent panic attacks, SSRIs may be the best medication for her. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC: Author. Berghuis, D.J., and Jongsma, A.E. (2000). The Severe and Persistent Mental Illness Treatment Planner. NY: John Wiley & Sons. Bourin, M., and Lambert, O. (2002). Pharmacotherapy of anxious disorders. Human Psycho-pharmacology, 17, 383–400. Cassano, G.B., Frank, E., Maser, J.D., Shear, M.K., Rotondo, A., Maure, M., et al. (1999). The panic-agoraphobic spectrum. Human Psychopharmacology, 14, 38–44. Clum, G.A. (1990). Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks. Paci-fic Grove, CA: Brooks/Cole Publishing Company. Garcia-Palacios, A., Botella, C., Robert C., Banos, R., Perpina, C., Quero, S., et al. (2002). Clinical utility of cognitive-behavioral treatment for Panic Disorder. Results obtained in different settings: A research center and a public mental health care unit. Clinical Psychology and Psychotherapy, 9, 373–383. Henerson, E. (2000, May 14). Panic attacks haunt sufferers [Online]. Los Angeles Daily News. Retrieved November 12, 2005. Available: http://anxieties0.tripod.com/ anxieties101/id13 .html Himle, J.A., and Fischer, D.J. (1998). Panic disorder and agoraphobia. In B. Thyer and J. Wodarski (Eds.) Handbook of Empirical Social Work Practice, Vol. 1: Mental Disorders. NY: John Wiley & Sons. Nadiga, D.N., Hensley, P.L., and Uhlenhuth, E.H. (2003). Review of the long-term effectiveness of cognitive behavioral therapy compared to medications in panic disorder. Depression and Anxiety, 17, 58–-64. Power, K.G., Sharp, D.M., Swanson, V., and Simpson, R.J. (2000). Therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care. Clinical Psychology and Psychotherapy, 7, 37–46. Ross, J. (2004, January 20). How can panic disorder be treated [Online]? Retrieved November 12, 2005. Available: http://anxieties0.tripod.com/ anxieties101/id13.html Sharp, D.M., Power, K.G., and Swanson, V. (2004). A comparison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care. Clinical Psychology and Psychotherapy, 11, 73–82.

Chapter 17 SPECIFIC AND SOCIAL PHOBIAS

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pecific and social phobias fall under anxiety disorders in the DSMIV (APA, 2000). There is a difference between a specific phobia and a social phobia. A specific phobia is when a person has a “persistent fear of clearly discernible circumscribed objects or situations” (Plaud & Vavrovsky, p. 327). A social phobia is when a person has a “noticeable and persistent fear of social or performance situations in which embarrassment may occur, which provokes an immediate anxiety response that may take the form of a situationally bound or situationally predisposed panic attack” (Plaud & Vavrovsky, 1998, p. 328). According to the DSM-IV, both can be diagnosed only when the fear, avoidance, or anxiety interferes significantly with a person’s occupational functioning, social life and daily schedule. This interference in the person’s life must happen when she/he encounters the phobic stimulus; the person must be markedly distressed about the phobia (APA, 2000; Plaud & Vavrovsky, 1998). COMMON SUBTYPES

According to the DSM-IV there are five different types of specific phobias: animal, natural environment, blood-injection-injury, situational, and other (APA, 2000; Plaud & Vavrovsky, 1998). The animal type, which we will be focusing on in the case study that follows, occurs when animals or insects cue the fear. The blood-injection-injury type is when seeing blood or, receiving an injection or, an injury or Note: Case study by Alicia Hutchinson and Amy Williams.

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another invasive medical procedure cues the fear. The situational type is when a specific situation, such as traveling in elevators, flying, using public transportation, and being in an enclosed space cue the fear. The other type is when a person fears vomiting, choking, a “space” phobia, or contracting an illness (APA, 2000; Plaud & Vavrovsky, 1998). Specific Culture, Age, and Gender Features According to the DSM-IV the content of certain phobias varies depending on culture and ethnicity (APA, 2000). An example in some cultures would be a fear that magic and/or spirits are present and could be considered a phobia. Children do not recognize that their fears and phobias are excessive or unreasonable, therefore, they rarely report them. However, some of the subtypes of specific phobias, including animal, have a childhood onset. Women may have more role models for learning to fear animals; some examples would be movies, TV, and cartoons (Antony & McCabe, 2005). Antony and McCabe (2005) report that when it comes specifically to animal phobias, 70 to 80 percent are women. According to the DSM-IV the ratio of women to men with specific phobias is approximately 2:1 (APA, 2000). Fear of Animals Of all the types of phobia, the most frequently reported in the general population is animal fear (Antony & McCabe, 2005). The most commonly feared animals include most of the creepy crawly animals, such as spiders, snakes, bugs, and rodents. Some of the other feared animals are cats, dogs, bees, and birds. The client in this case example has a fear of spiders, or arachnophobia. According to Arrindell (2000), there may be several factors as to why certain animals are feared more than others. Some factors could be the perceived physical characteristics of the animal, such as visual appearance and environmental aspects, such as exposure, predictability, and cultural attitudes. There also might be some biases in the processing of information about threatening animals, such as their perceived dangerousness (Arrindell, 2000).

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The Client Betty is a biracial female who is twenty-eight years old. She is single but currently is involved with her boyfriend of two years and has no children. She lives alone in an apartment in a large suburban area that is ten minutes away from her parents. She is currently working as a receptionist at a law firm. Parenting Problem As a child, Betty had always feared spiders and other creepy crawly animals. She recently went on a camping trip with her boyfriend and had an anxiety attack when she woke up and found a spider crawling in her hair. Since the camping trip, Betty has anxiety attacks when she sees a spider, a picture of a spider, thinks of a spider, or sees a spider on TV. She also has frequent nightmares about spiders. Betty has a hard time leaving her apartment because she believes that spiders will attack her before she can get to her car. She also has missed a lot of days at work and avoids doing her daily chores (doing things outside the house). Betty calls on her parents around the clock. She wants them to come and sit with her or to go to the store. Her boyfriend Robert has really been supportive of Betty even though he does not understand why she cannot get over it. Betty recently told Robert about her childhood fear of spiders and that she has not been able to deal with it yet. Regardless, he does all he can for Betty. However, her parents feel that Betty is long overdue for help. The parents called the community health center hoping that they could be of help for Betty. History Betty never knew the onset of her fear, but she did remember going into her parent’s basement as a child and seeing a spider hanging down by some boxes. She stood there quietly watching its every move. Her heart was racing and her palms began to sweat. She finally backed away and took off running back upstairs. She remembered having nightmares about that spider coming down from over the boxes and attacking her. From that moment she would not go in the basement.

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She would hide out under her bed every time her mother asked her to get something from the basement. At first she was embarrassed and scared to tell her parents about her fear because she felt that they would think something was wrong with her or would lock her up in an institution. Her fear became so overwhelming that she began to fear all other creepy crawly bugs that can be seen everywhere (bugs, worms, roaches, etc.). Betty’s parents began to worry about her because she would refuse to go to school or go outside to play. She also barely ate anything because she feared that a spider would be in her food. She believed that all spiders and bugs were after her, and she could only escape them by not going outside the house. Her parents ended up taking her to the doctor to get checked and found that nothing was wrong physically. The doctor suggested that the parents try therapy, but Betty refused to go. After a month, Betty became her old self again, and she began attending school and participating in other activities. Betty dealt with her anxiety attacks off and on from childhood up to about age sixteen, which is when she finally decided to give therapy a try. She remembers during her first therapy session that she was sitting there pouring her heart out speaking of how her fear of spiders and other bugs had taken over her life and at that moment a bug appeared on the therapist’s desk. Betty began to freak out and she ran out of the therapist’s office. From that point on, Betty decided to handle her fears by herself. Betty somehow was able to manage her fears up until the incident on the camping trip. The Worker Betty has several options of workers who can assist her in addressing her fear of spiders. The main workers are an LCSW and a master’s-level social worker who can provide therapy and group services. Also, she will see a psychiatrist who will order medication to relieve her anxiety and panic attacks. Other workers who can work with this client include a licensed counselor or psychologist. TREATMENT PLAN

It was determined that systematic desensitization (SD), which is the most clinically effective treatment for phobias, would be appropriate

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for Betty (Plaud & Vavrovsky, 1998). This treatment includes three parts: relaxation exercise, constructing a fear hierarchy, and gradual exposure. Relaxation Exercise There are many different relaxation exercises that are appropriate for Betty, including breathing techniques and muscle relaxation techniques. With Betty, a breathing technique called diaphragmatic breathing was selected (Wehrenberg, 2005). In diaphragmatic breathing, a client does deep breathing; when they are breathing they need to be aware of the chest and abdomen and how it moves. The client breaths in for a four second count, holds it for a four second count, releases for a four second count, and then holds again for a four second count. According to Wehrenberg (2005), a client should practice the deep breathing for one minute at a time and anywhere from 10-15 times per day. Fear Hierarchy The next process using SD is constructing a fear hierarchy, which is a list of situations that you would typically avoid because of your phobia (Antony & McCabe, 2005). The client makes a list from one to ten of fear-provoking situations. Then she lists them in order from the least-provoking to the most-provoking situation. The hierarchy tool is important for the therapist to use when it comes to the next part of SD. Gradual Exposure Using the hierarchy, the therapist will set up certain situations for the client in which gradual exposure can be practiced (Antony & McCabe, 2005). This gradual exposure can include videos, stuffed animals, and the actual phobia. The therapist will only go as far as the client is willing to go. Context Betty’s therapy takes place at a group service facility that provides therapy and many types of group services. The therapy room consists

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of comfortable couches and pillows, blankets, dimmed lighting (lamps instead of using overhead light), and plenty of tissues. The setup of the room provides a relaxing environment. The Length of Therapy The focus of Betty’s therapy is using SD that includes relaxation exercise, developing a fear hierarchy, and gradual exposure. SD is known as a clinically efficacious treatment for phobias (Plaud & Vavrovsky, 1998). This approach to phobias contributes to both Pavlovian and Hullian learning theories and has been incorporated in multiple studies over the past thirty-five years. In the procedure of SD, “clients are first trained in progressive muscle relaxation exercises and are then gradually exposed imaginally or in real life to feared stimuli while simultaneously relaxing using the learned muscle relaxation techniques. Clients construct a fear hierarchy and usually start with the least feared item, then gradually move up the hierarchy to the most feared items” (Plaud & Vavrovsky, p. 337). The client is contracted to complete twelve sessions (meet at the center once a week for an hour and a half), which is within the range that has proven effective results. Stevens (2002) suggests the number of sessions necessary varies in accordance with many factors. For relatively simple problems, experience has shown that ten to twenty sessions is often sufficient, but occasionally fewer and sometimes many more are necessary. However, it is not wise to set a limit or expectations on the number of sessions you will need to desensitize your hierarchy (Stevens, 2002). Ost (1989) suggests that SD in a variety of forms has been commonly used to treat specific phobias and, in some cases, can be achieved in a single therapeutic session. Assessment In assessing the client, the following measures will be used, including the Anxiety Disorder Interview Schedule (ADIS-IV), the Fear Survey Schedule (FSS-III), the Spider Phobia Questionnaire, and the Behavioral Avoidance Tasks (BAT) (Koch, Spates & Himle, 2004). These measures will help identify more clearly the present symptoms that the client is experiencing.

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Diagnostic Interview The ADIS-IV is a “structured interview designed to assess for current episodes of anxiety disorders, and to permit differential diagnosis among the anxiety disorders according to the DSM-IV criteria” (Koch et al., 2004, p. 1485). In addition to the anxiety disorders, the ADISIV also assesses several other conditions: “current mood, somatoform, and substance use disorder are included because of their high comorbidity rate with anxiety disorder and because the presenting symtomatology of these disorders is often quite similar to that of the anxiety disorder” (Brown, DiNardo, & Barlow, 2004, p. 1). Self-Report The FSS-III “consists of 108 potential fears that are rated from 0 (not at all) to 4 (very much)” (Koch et al., 2004, p. 1485). There are six face-valid factors of the FSS-III, including “fear of animals, injury/illness, classical phobias (e.g., being alone), social stimuli, noises, and assorted other stimuli (e.g., falling, insects)” (Beck, Carmin & Henninger, 1998, p. 178). Also, the FSS-III contains four dimensions of feared stimuli including interpersonal (social events), blood death (injury stimuli), undesirable animals and insects and agoraphobic fears (Beck et al., 1998). The Spider Phobia Questionnaire contains forty-three yes-and-no questions assessing dimensions of vigilance, preoccupation, copingavoidance, and additional cognitive items (Koch et al., 2004). These three primary factors of the Spider Phobia Questionnaire demonstrated that “adequate internal reliability and criterion-related validity studies confirm the utility and external validity of this instrument” (Koch et al., 2004, p. 1486). Behavioral BAT generally measures self-reported affect and degree of avoidance in response to specific stimuli, which measures the contact time, proximity to the animal (distance), and overt responses (Woody, McLean & Kassen, 2005). The contact time is measured from 0 to 180 seconds, which also includes total time of physical contact with the animal (e.g. continuous and noncontinuous touching and holding) (Koch et al., 2004). The process of BAT includes thirty steps. The first

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fifteen steps primarily involve distance from the animal based on a large ruler placed on the floor. The last fifteen steps of the BAT include some interaction with the animal (e.g. placing hand in cage, touching animal, picking up animal, etc.) (Koch et al., 2004). In Woody and colleagues’ (2005) study of spiders, three different stimuli were used: a spider, a pen that had been contaminated by a spider, and a new clean pen. The spider (a large Honduran curly tarantula that was 12 cm long with legs outstretched) was used because it was “alarming in appearance (being both large and rather hairy) but not dangerous, and she moved relatively slowly” (Woody et al., 2005, p. 465). The participant would begin the task once he/she entered the door of the testing room. When the participant reaches the end or refuses to go any further the experimenter will obtain the ratings of anxiety peak and disgust during the task and guide the participant out of the testing room (Woody et al., 2005). The second stimulus, the contaminated pen, was effective because it gave the participant the opportunity to engage with the pen the spider had touched while allowing the experimenter to examine affect and avoidance with no threat value (Woody et al., 2005). The steps in the contaminated pen BAT include “touching the pen with one finger and then with both hands. If the participants wish to continue, they were asked to use the pen to write their name on the paper plate and then touch the pen to their head and close their lips and finally to eat a cracker after rolling the pen across it (Woody et al., 2005, p. 466). The third stimulus, the clean pen, was used because it is generally acceptable to participants if the spider had not touched the pen (Woody et al., 2005). This process is similar to the contaminated one except that there is no mention of the spider. The experimenter would remove a new pen from a box of pens and have the participant engage in the same steps for the contaminated pen BAT, including eating a cracker after rolling the pen across it (Woody et al., 2005). Other measures that have been used and proven effective are the Anxiety Sensitivity Index, Thought Checklist (TC), Cognitive-Somatic Anxiety Questionnaire (CSAQ) and the Distress Evaluation Scale for Treatment (DEVS-T). The Anxiety Sensitivity Index is a “16-item scale measuring danger beliefs and feared social and somatic consequences of anxiety symptoms” (Woody et al., 2005, p. 464). It also demonstrated good reliability and showed predictive validity for “development of subsequent

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panic attacks and anxiety disorders” (Woody et al., p. 464). The TC is used to measure “positive and negative thought related to the feared” (Koch et al., 2004, p. 1486). It has several items that specifically relate to animal phobia. The CSAQ contains “14 items with separate cognitive and somatic scales (seven items each)” (Koch et al., p. 1486). The symptoms are rated on a scale from 1 (none at all) to 9 (very distressed). This takes place during the “baseline session during treatment, and a few hours after treatment” (Koch et al., p. 1486). The remaining items assess level of treatment acceptability from 1 (not at all) to 9 (very acceptable) and whether the participant would recommend the treatment to others from 1 (not at all) to 9 (yes definitely) (Koch et al., 2004). Short-Term Goals and Interventions Goals 1. Client will reduce anxiety and panic attacks 2. Educate client on spiders and phobias

Interventions Client will use diaphragmatic breathing and psychotropic drugs Psychoeducational group therapy

In her short-term goal 1, the therapist will work with Betty to reduce her anxiety and panic attacks. Betty can accomplish this using the interventions of diaphragmatic breathing and psychotropic drugs. She will need to practice the diaphragmatic breathing daily (Wehrenberg, 2005). The best time for her to practice the breathing technique is when she is waiting for something, such as a doctor’s appointment, the water to boil, while she is in line at the bank or grocery store. This will help her to associate this deep breathing with her surroundings. So when Betty comes in contact with spiders and gets anxious she will remember to breathe (Wehrenberg, 2005). Psychotropic drugs are used only if the client is willing to use them. Later, we will discuss which kinds of drugs are available for specific phobias. In goal 2, Betty will be educated about spiders and phobias using psychoeducational group therapy. In group sessions, Betty will be made aware of what phobias are and how they are triggered. She will learn about other people’s phobias, which will help her realize that she is not alone. The group will also be given material on their specific phobias. Clients also receive websites that could be useful to them as well as any support groups that are available to them.

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Long-Term Goals and Interventions Goal 1. Client will be able to handle a spider 2. Client will rely on support network

Intervention Gradual exposure and fear hierarchy Educating support network about phobias (parents and boyfriend)

In her long-term goal 1, Betty will eventually hold a spider, if that is her desire; in actuality, the client may wish to go only as far as being across the room. Therapists must proceed at the client’s pace. In order to reach this goal, the client will use gradual exposure and the fear hierarchy, which have been discussed earlier. In goal 2, Betty will learn to rely on her support network, which includes her parents and boyfriend. Her close support network will be brought in to learn more about the phobia she has. They also will be taught how they can help her to progress towards normalcy in her life. Betty also will need to rely on any support groups she has found while being in the psychoeducational group. Medication If medication is indicated for a specific phobia, the anti-anxiety benzodiazepine agents such as alprazolam (Xanax®) or clonazepam (Klonopin®) would be the drugs of choice (Farr, 2003). Benzodiazepines are often used for anxiety or panic attacks. Because they are short acting, which means they work quickly to relieve anxiety, they do not have to build up in a person’s body over time to be effective, and they leave a person’s system quickly, so that the person does not have to deal with ongoing negative side effects of being on a continuous medication. It is important to use benzodiazepines carefully, however, because they are highly addictive physically and psychologically (Farr, 2003). Other than the two drugs suggested before there are other benzodiazepines that can be used for the treatment of panic attacks, include diazepam (Valium®), lorazepam (Ativan®), and temazepam (Restoril®) and many more. The benzodiazepines that we have listed only help for an anxiety or panic attack. It has been suggested that there are no medications that treat for specific phobias. However, if a person has GAD or a social phobia there are more psychotropic drugs that can be chosen, for example SSRIs, tricyclic antidepressants, and MAOIs.

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Relapse Prevention S UPPORT N ETWORKS. The family and boyfriend will continue to be a support system in Betty’s goal to a healthy recovery. Teaching the parents and boyfriend about spider phobia will help them better understand their loved one’s condition and how important it is for them to be there for her. It will be a struggle and overwhelming for all at first, but once the individual therapy sessions take place, Betty’s behavior can change (if she wishes to change). F OLLOW U P WITH THERAPIST. Betty will continue to follow up with the therapist after termination. The therapist will guide her through developing further coping skills for reducing anxiety and reinforcing the breathing technique. CONTINUE B REATHING TECHNIQUE. Betty will continue to do breathing exercises in order to reduce anxiety and panic attacks. She will be educated on the breathing exercise steps and will also receive information for use in emergencies. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision.). Washington, DC: Author. Antony, M., and McCabe, R. (2005). Overcoming Animal and Insect Phobias. Oakland, CA: New Harbinger Publications, Inc. Arrindell, W. (2000). Phobic dimensions: IV. The structure of animal fears. Behavior Research and Therapy, 38, 509–530. Beck, J., Carmine, C., and Henninger, N. (1998). The utility of the fear survey schedule-III: An extended replication. Journal of Anxiety Disorders, 12, 177–182. Brown, T., DiNardo, P., and Barlow, D. (2004). Anxiety Disorder Interview Schedule ADIS-IV and ADIS-IV-L Combination Specimen Set. New York: Oxford University Press, Inc. Farr, G. (2003). Psychoactive Medications. Memphis, TN: University of Tennessee College of Pharmacy. Koch, E., Spates, R., and Himle, J. (2004). Comparison of behavioral and cognitivebehavioral one session exposure treatment for small animal phobias. Behavior Research and Therapy, 42, 1483–1504. Ost, L. (1989). One-session treatment for specific phobias. Behavioral Research and Therapy, 27, 1–7. Plaud, J., and Vavrovsky, K. (1998). Specific and social phobias. In B.A.Thyer and J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice (pp. 327–341). Hoboken, NJ: John Wiley & Sons.

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Stevens, T. (2002). You Can Choose To Be Happy: “Rise Above” Anxiety, Anger, and Depression. Seal Beach, CA: Wheeler-Sutton Publishing Company. Wehrenberg, M. (2005). Anxiety-management techniques. Psychotherapy Networker, 47–59. Woody, S., McLean, C., and Klassen, T. (2005). Disgust as a motivator of avoidance of spiders. Journal of Anxiety Disorders, 19, 461–475.

Chapter 18 OBSESSIVE-COMPULSIVE DISORDER

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he DSM-IV-TR describes obsessions as “persistent ideas thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress” (APA, 2000, p. 457). For the obsessive-compulsive sufferer, obsessions are seen as ego-dystonic but are typically understood by the individual to be a product of his or her own mind (APA, 2000). The most common obsessions are “contamination, pathological doubt, somatic fears, need for symmetry, and aggressive and sexual impulses” (Cohen & Steketee, 1998, p. 343). These obsessions are unlikely to be related to reallife problems, and most individuals who have these obsessions attempt to ignore or suppress their thoughts or seek to reduce the anxiety associated with the obsession through some other thought or action (APA, 2000). Compulsions are “repetitive behaviors or mental acts the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification” (APA, p. 457). Compulsions are not realistic remedies to the obsessions they are intended to prevent and can often be excessive, which leads to only a temporary abatement of obsession fears and anxiety (APA, 2000). The most frequent obsessions are “checking, washing, counting, needing to ask or confess, ordering, and hoarding” (Cohen & Steketee 1998, p. 344). If the obsessive-compulsive individual attempts to resist the compulsion, he or she is usually confronted with a mounting tension often relieved only by giving in to the compulsion. As the disorder progresses, individuals often stop tryNote: Case study by Chris Smith and Pat Dodds.

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ing to resist the temptation to compulsively act and incorporate the compulsive behaviors into their everyday world (APA, 2000). The DSM-IV-TR allows an obsessive-compulsive diagnosis if the client’s recurrent obsessions or compulsions cause significant impairment or result in the individuals surrendering a significant amount of his/her day (more than one hour in a twenty-four-hour period) to complete ritualistic behaviors. While the DSM-IV-TR allows for the specifier “with poor insight,” most sufferers notice that their obsessive thoughts and compulsive behaviors are excessive and do not result in a true prevention of assumed maladies. The individual’s behavior cannot be explained by other medical conditions or restricted to another Axis I disorder (APA, 2000). Although there are many theories surrounding the etiology of the disorder, there is no known cause of its origin. From a behavioral perspective, obsessive-compulsive individuals may pair a normally neutral stimulus with an adverse event (Abramowitz, Brigidi & Roche, 2001). For example, an individual could see a trash can overflow its contents onto the floor and thereafter associate the floor with that anxiety-provoking event. With these obsessive thoughts in place, the individual may decide to cope with the anxiety by excessively cleaning the floor. Others believe that obsessive thoughts are, in themselves, a normal part of the human existence. Those that suffer from the disorder, however, have a strong belief that their obsessive thoughts are unacceptable and attempt to control them through compulsive behaviors (Abramowitz et al., 2001). Still others see biological roots to the disorder, pointing toward neurochemical and neuroanatomical causes of obsessive-compulsive symptomatology (Cohen & Steketee, 1998) For most, the course of the disorder is gradual. Most individuals who suffer from the disorder have a lifelong waxing and waning of symptoms, with obsessions and compulsions typically more severe during times of duress. In males, the mean age of onset is between six and fifteen years of age. For females, onset is typically between twenty and twenty-nine years of age. The disorder seems to affect individuals at the same rate in various cultures and geographical regions (APA, 2000).

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The Client Nathan is a successful, fifty-five-year-old romance novelist with an astounding sixty-two books under his belt. He works at home and derives a great deal of satisfaction from his ability to produce voluminous works without much effort. He claims to work “all the time” and says that he leaves his typewriter only when he has to. Nathan claims that his obsessive thoughts and compulsive behaviors began around the age of nine. Although his parents noticed that their child was behaving differently, they did not seek medical attention for his behaviors. His obsessions typically center on the fear of contamination (which leads to the compulsion to spend large portions of the day cleaning), pathological doubts (which lead to the compulsion to continually see if he has locked his doors, turned out the lights, etc.), and a need for symmetry. Nathan also refuses to step on pavement creases when he is walking outside on the city streets to prevent some unknown calamitous event. His obsessive-compulsive behavior, although beginning at a relatively young age, developed gradually and is generally worse during stressful or unusual circumstances. Nathan understands that his obsessions and subsequent compulsions are unreasonable, but previous attempts at resisting his compulsions have been met with incredible anxiety. To deal with his obsessions and compulsions, then, Nathan has chosen to live reclusively; he spends almost the entire day in the safe confines of his home. His only excursions out into the world are ritualistic in themselves: he goes to the same diner and sits at the same booth to eat lunch; he goes to the same store and buys the same foods to eat; he seeks the same modes of entertainment without variation; and so forth. Until recently, Nathan has been fine with his “real world” avoidance. Over the past several weeks, he has become attracted to the waitress at his diner. Understanding that his ritualistic behaviors would be detrimental to a romantic relationship, Nathan has decided to seek therapeutic attention to address his OCD. The Worker The social worker plays an important role and often inhabits the first line of intervention with the obsessive-compulsive client. The

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client often does not know that his or her obsessive thoughts or compulsive behaviors merit clinical attention, and too often medical doctors may not notice obsessive-compulsive symptoms as being produced by an anxiety disorder (Abramowitz et al., 2001). The social worker, as a staff member of a number of social service agencies, private practice settings, and other medical health centers, may be the first responder in the treatment of the disorder (Cohen & Steketee, 1998). It is important, then, that social workers in a variety of settings can identify and be able to treat the obsessive-compulsive client. The literature points to a number of important characteristics the therapist should possess to effectively deal with the obsessive-compulsive client. The client’s perception that his or her therapist is understanding, respectful, and encouraging has been linked to greater client involvement in the therapies for the disorder. Because the obsessive thoughts and the subsequent compulsions produce an abundance of stress for the obsessive-compulsive client, the therapist must be able to sufficiently explain the rationale behind the therapy and show how confronting feared situations will produce an abatement or reduction of either obsessive thoughts, compulsive actions, or both (Abramowitz et al., 2001). Although concepts such as therapist understanding, respect, and empathy toward the client seem relatively commonplace as therapeutic skills, regardless of the clientele, they may be even more important for the therapist to demonstrate when dealing with an obsessive-compulsive client confronting anxiety-provoking situations. Similarly, the literature suggests that having a support person may increase the efficacy of treatment and, therefore, therapy outcome. Having an individual who understands therapy and can help the obsessive-compulsive client extend his or her therapeutic accomplishments into the everyday setting may provide added incentive for the clients to confront their fears (Abramowitz et al., 2001). Psychoeducational programming, engagement in the inpatient or outpatient therapy sessions, and support groups may be effective tools in the successful involvement of the obsessive-compulsive support person (Cohen & Steketee, 1998). The treatment team for Nathan includes a social worker (the first responder and possibly an important person in providing the interpersonal contact essential for the effectiveness of therapy) and a psychiatrist, who will be properly qualified to use assessment tools and prescribe medications. Although Nathan has chosen a lifestyle in

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which he has very little contact with friends or family, the treatment team will also seek a support system to aid in treatment endeavors. TREATMENT PLAN

Intervention A large bulk of the treatment literature focuses on the effectiveness and use of Exposure and Response Prevention (ERP) in the treatment of the obsessive-compulsive client. ERP “involves exposing clients to overt and covert cues that provoke obsessive, coupled with blocking of the rituals in order to prevent them from prematurely reducing obsessive fears, thereby interfering with the habituation of the negative emotion generated by the obsession” (Cohen & Steketee, 1998, p. 349). Using ERP to treat a pathological doubter may include exposing the client to a feared stimulus (leaving the house without checking to make sure that the oven is off), and then preventing or reducing the compulsion to act on the obsession to temporarily reduce the anxiety associated with that obsessive thought (not allowing the client to go back to the house to check oven dials). The efficacy of ERP has been well-proven. In a meta-analysis review of twenty-four studies, it was found that obsessive-compulsive symptoms, depressive symptoms, and general anxiety were substantially decreased during ERP therapy. Moreover, therapeutic gains were maintained for four to five months following the cessation of therapy (Abramowitz et al., 2001). In another meta-analysis review of twelve outcome studies, it was found that 83 percent of 330 clients were immediate responders to ERP therapy, and 76 percent of those clients were still considered improved on an average of twenty-nine months after treatment (Abramowitz et al., 2001). Although ERP has proved to be an effective treatment for obsessive-compulsive clients, there is some contention concerning the methods of implementation within the literature. One question surrounds the importance of exposure versus that of response prevention. Can the therapist effectively deal with the obsessive-compulsive client through exposure and without response prevention or vice versa? One study suggests that exposure-only therapy reduces the fears associated with obsessions more than response prevention-only therapy. Response-prevention-only strategies, however, result in a greater reduc-

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tion of compulsive rituals as compared with the exposure-only approach (Abramowitz et al., 2001). It would seem, then, that by combining exposure and response prevention therapy the therapist might be able to better reduce both obsessive fears and compulsive rituals. Another focal point in research surrounding ERP therapy involves the comparison of therapist-guided exposure exposure conducted by the client. Studies suggest that, as discussed earlier, the therapist may be able to better help the client confront feared stimuli. Without the help of the therapist, the client may not, on his or her own, be able to overcome the fears associated with obsessive thoughts or compulsive behaviors (Abramowitz et al., 2001). A psychoeducational therapy helping the client understand the importance of exposure and ritual reduction may, therefore, not be enough to ensure treatment compliance or success. There is also a question concerning the amount and timing of exposure in ERP therapy. Traditionally, ERP involves creating a hierarchy of feared stimuli and measuring the level of distress evoked by the feared situation (Cohen & Steketee, 1998). Using a flooding technique, the therapist may choose to expose the client to those stimuli that evoke the most fear. The literature suggests that a more gradual exposure — exposing the client to those situations that cause the least amount of anxiety first — may provide the client with valuable experiences of success that will be needed as the therapy approaches more feared stimuli (Abramowitz et al., 2001). Likewise, there is contention involving the method of response prevention. Should rituals be stopped at the start of therapy, or should the client be allowed to more gradually decrease compulsive behaviors? Using gradual methods, the therapist may chose to delay the response of the compulsion (allowing the client to compulsively act on the obsession after a time delay), to reduce the amount the compulsion is done (reducing checking behaviors from thirty times a day to five times a day) or to have the client stop the ritualistic behaviors that have already been treated but allow those that have not (Cohen & Steketee, 1998). Much of the variations of ERP depend on the severity of the disorder or the intensity of obsessive thoughts and compulsive behaviors (Abramowitz et al., 2001). Although ERP strategies dominate the literature, there are other methods of treatment that the therapist can use to treat the obsessivecompulsive client. Cognitive therapy may be a powerful intervention

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strategy in linking faulty beliefs to obsessive-compulsive behaviors (Cohen & Steketee, 1998). Research applying cognitive therapy techniques to obsessive-compulsive clients has been limited. Abramowitz and coworkers (2001) point out that there has not been a large-scale, placebo-controlled application of cognitive therapy to an obsessivecompulsive clientele. When cognitive therapy techniques are compared with ERP therapy, results have shown that both are, at best, similar in efficacy in treating the obsessive-compulsive client. The trials that compare the two strategies have involved a variation of ERP in which exposure to feared stimuli has been conducted by the client and not with the help of the therapist. The studies, then, have not evaluated the most effective variation of ERP and may provide a skewed comparison of the two methods of treatment. Although a cognitive-behavioral approach to therapy for the obsessive-compulsive client has been shown to be the most effective mode of treatment, other innovative strategies are being attempted. Jones and Menzies (1998) used Danger Ideation Reduction Therapy (DIRT) on eleven subjects suffering from OCD. Pointing out that 20 to 30 percent of patients refuse to cooperate or drop out from behavioral treatment therapies, the authors suggest that a program like DIRT, which does not involve exposure to feared stimuli, requires few sessions for therapeutic effect, and is easy to administer, may provide the obsessive-compulsive client with a viable alternative to behavior therapies. Focusing primarily on a psychoeducational approach, DIRT uses films, structured reports, and exercises that allow the client to deal with his or her disorder without the discomfort of exposure. Unfortunately, the trial showed little effect in reducing the symptoms of those being treated ( Jones & Menzies, 1998). Although therapists and researchers may benefit those suffering from OCD by looking for therapeutic techniques that reduce the anxiety surrounding exposure and response prevention, those intervention strategies have not, to date, been as efficacious in reducing obsessive-compulsive symptoms. Although medications have proved to be effective for many suffering from OCD, reducing symptoms from 20 to 60 percent when they are used without other modes of therapy, they do not usually completely stop obsessive-compulsive symptoms (Cohen & Steketee, 1998). Moreover, many of the medications used to treat obsessivecompulsive clients today, as will be discussed in a later section, produce side effects and may require long-term use (Cohen & Steketee, 1998; Jones & Menzies, 1998).

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For Nathan, the treatment team decided to provide him with ERP therapy. Since Nathan has exhibited a number of adaptive strategies and obsessive-compulsive symptoms seem to be comfortably ingrained in his daily routine, a gradual exposure and response prevention method of ERP appeared to be most efficacious. It was hoped that ERD would decrease the initial anxiety of therapy and provide early successes important for future work with more stressful stimuli. The team also determined that Nathan may be a good candidate for medication and will attempt to administer these medications to reduce symptomatology before ERP begins. Treatment Context Nathan entered the outpatient treatment program at the Mayo Clinic. He will commute from home to the clinic because it is recommended that a normal environment be maintained during treatment, particularly when the patient’s fears are generated from home environment stimuli (Foa, Kozak, Steketee & McCarthy, 1992). This particular patient has unwanted distressing thoughts and compulsive rituals concerning contamination and symmetry. He engages in hand washing and checking rituals that primarily occur in the home. According to Foa and colleagues (1992), patients who are hospitalized for treatment may not experience their usual urges to check because they do not feel responsible for their surroundings. The patient is self-employed and works from home, which allows him flexibility in his schedule to participate in the intensive treatment program. Additionally, to ensure that the patient’s optimal gains from the treatment program are generalized at home, homework assignments are given. A home visit is scheduled for two days, four hours each session at the end of the treatment program. This provides the therapist and patient with the opportunity to discuss guidelines for normal behavior and to conduct additional exposures to obsessive stimuli around the patient’s home. For example, allowing the patient to lock the door and turn on the lights only once without checking (Foa et al., 1992). Also, the therapist may ask that the patient not exceed five hand washings per day and for only thirty seconds each time.

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Duration of Therapy As discussed earlier, research indicates that a specific application of CBT — ERP — is the most effective psychosocial intervention for OCD (O’Hare, 2005). However, an intensive treatment schedule is often not feasible in many settings (Abramowitz, Foa & Franklin, 2003). In a recent study, researchers examined whether a twice-weekly ERP program reduced the effectiveness of intensive ERP (Abramowitz, Foa, et al., 2003). Forty obsessive-compulsive patients received fifteen sessions of ERP. Twenty patients received daily treatment over three weeks and twenty received twice weekly therapy over eight weeks (Abramowitz, Foa, et al., 2003). Both programs were found to be effective according to the results. Although there is little empirical data on which to base this recommendation, patients with high emotional reactivity or difficulty comprehending treatment procedure rationale would be candidates for intensive treatment (Abramowitz, Foa, et al., 2003). Therapy duration for Nathan was determined to be sixteen sessions — twice weekly over eight weeks — each session lasting two hours. The first two sessions are for treatment planning and for gathering information about the patient’s obsessional fears and rituals as well as for developing an exposure hierarchy of anxiety-evoking situations and thoughts (Abramowitz, Foa, et al., 2003). Sessions three to fifteen will include periods of live and imaginal exposure. Exposures begin with moderately to less-distressing situations and gradually increase toward high anxiety-evoking situations. The patient is also assigned exposure homework over the eight-week period. During the exposure part of the therapy, the therapist points out the patient’s mistaken thoughts about the probability that something catastrophic will occur. Assessment Nathan’s initial interview lasted ninety minutes. Although the outside temperature was eighty degrees, he was wearing gloves and resisted an introductory handshake from staff. During the interview, Nathan reported that his life had become unmanageable as he described obsessive thoughts about contamination by germs and excessive orderliness. He also described his compulsive repetitive behaviors of checking, counting, and hand washing.

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Nathan stated that his obsessive thoughts about being contaminated by germs causes much anxiety and leads to his compulsive hand washing. He also stated that he washes his hands in scalding hot water and can only use a bar of soap one time. He stated that he uses two bars of soap each time he washes his hands. Nathan lives in a well-secured, high-rise condominium complex, and each time he arrives or leaves the residence he locks and unlocks the door five times. He also ritualistically turns on and off the lights five times consecutively. Additionally, Nathan has a daily regimen that includes eating at the same restaurant, dining at the same table, and insisting that the same server wait his table at the same time every day. Nathan stated that he carries several wrapped packages of plastic ware to the restaurant because of his fear of being contaminated by germs. He stated that he has no friends and his compulsions have caused him to be barred from eating at the restaurant because of his offensive behavior toward other patrons when they are sitting at his table. Nathan stated that when his preferred server quit her job to care for her sick child, he hired a medical doctor to care for her son and paid her medical expenses so that she could return to the restaurant to serve his meals. Nathan recognizes that his ritualized behavior does not prevent his imagined contamination from germs. In order to determine the severity of Nathan’s OCD, the YaleBrown Obsessive-Compulsive Scale (Y-BOCS) was administered. The Y-BOCS is a tool that is deemed valid for assessment and evaluation of treatment outcomes. It measures five parameters of both obsessions and compulsions: (1) duration/frequency, (2) interference in social and occupational functioning, (3) associated distress, (4) degree of resistance, and (5) perceived control over obsessions or compulsions (O’Hare, 2005). There is a checklist of more than sixty specific OCD symptoms that are organized into fifteen obsession and compulsion categories, and it is considered the “gold standard severity measure of OCD” (Abramowitz, Franklin, Furr & Schwartz, 2003, p. 1050). The Y-BOCS has limitations in that it does not adequately assess covert mental compulsive rituals (Abramowitz, Franklin, et al., 2003). Administering the Y-BOCS requires appropriate training as well as taking approximately one hour of patient time (Abramowitz, Tolin & Diefenbach, 2005). Consequently, an alternate assessment tool to the Y-BOCS is often used. This alternative, the Obsessive-Compulsive Inventory (OCI),

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was developed with three goals: (1) ability to be more comprehensive than existing instruments, (2) allowance for a wider range of severity scores, and (3) ease of administration to clinical and nonclinical populations (O’Hare, 2005). A cutoff score of twenty-one is the recommendation for identifying a patient to meet DSM-IV-TR criteria for OCD (O’Hare, 2005). If Nathan were in another clinical setting, this tool might have been used as a Y-BOCS substitute. The revised version of this assessment tool (OCI-R) has demonstrated “good test-retest reliability as well as convergent and discriminate validity with clinical and nonclinical samples” (Abramowitz et al., 2005, p. 319). Additionally, Nathan completed the Beck Depression Inventory (BDI) to assess depressive complaints. The BDI is a twenty-one-item, self-report scale that assesses affective, cognitive, motivational, vegetative, and psychomotor components of depression (Abramowitzet al., 2005). Short-Term and Long-Term Goals and Treatment (O’Hare, 2005) Short-Term Goals 1. Reduce anxiety regarding dysfunctional thinking 2. Improve ability to relate to neighbors and business contacts

Long-Term Goals 1. Eliminate obsessional thoughts and checking behaviors 2. Eliminate anxiety regarding dysfunctional thinking 3. Develop personal relationships

Short-Term Treatment Relationship building: create atmosphere of openness and trust so patient will commit to treatment plan Teach imaginal exposure and relaxation exercises; ERP; pharmacotherapy Long-Term Treatment Psychoeducation relative to OCD and how ERP works Daily 30-minute imaginal exposure practiced at home Attend support group for OCD

Relapse Prevention Regular maintenance sessions are scheduled to help the patient maintain therapeutic gains from the treatment. The maintenance sessions are in addition to assigning the patient’s continued self-exposure tasks. The maintenance sessions are implemented for planning additional exposures as well as to refine guidelines for normal behavior

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and to deal with issues that occur as the patient adjusts to life without OCD (Barlow, 1993). Evidence indicates that continued therapist contact benefits the patient by reducing the number of relapses (Barlow, 1993). The maintenance sessions in Nathan’s case consist of one week of daily cognitive-behavioral sessions followed by eight, 10-minute weekly telephone contacts (Barlow, 1993). Additionally, motivation is a key element for any change. At the beginning of treatment, the therapist should explain to the patient that he will experience high levels of distress and determine the patient’s level of motivation. Likewise, the therapist should explain that intensive therapy is not likely to eliminate all OCD symptoms but that the anxiety and urges to ritualize will decrease and become more manageable (Barlow, 1993). Support Groups Although Nathan has no friends or family, research indicates that support groups for family members of obsessive-compulsive individuals are beneficial because they provide education as well as mutual aid (Cooper, 1993). Nathan indicated that his disorder has prevented him from becoming romantically involved in his past, but he now has a potential partner who is interested in learning more about the disorder and in helping him with his therapy. Group goals for family members include (1) providing members with information about OCD and treatment alternatives and resources, (2) helping families express their feelings relative to the impact of the disorder on their daily lives, (3) enabling families to respond more effectively to the person with OCD, (4) teaching effective strategies for dealing with the person with the disorder by not participating in rituals and relieving stress, and (5) helping families rebuild their lives with pleasurable and meaningful activities whether the person with the disorder participates or not (Cooper, 1993). Medication A combination of behavioral therapy and antidepressants is generally recommended for OCD patients (Maxmen & Ward, 1995). However, the response to medication can take 10 to 12 weeks (Maxmen & Ward, 1995). SSRIs such as fluoxetine, sertraline, paroxetine, and fluvoxamine, as well as serotonergic tricyclic antidepressants, such as clo-

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mipramine are proven effective drugs for OCD (Maxmen & Ward, 1995). Typical doses are: 60 to 80 mg for fluoxetine (Prozac®), 150 to 200 mg for Sertraline (Zoloft®) 40 to 50 mg paroxetine (Paxil®). Clomipramine must be given in an eventual dose of 150 to 250 mg after gradual titration (Maxmen & Ward, 1995). Although high doses of SSRIs may be required, a recent study indicates that doses typically effective for depression are sufficient (Maxmen & Ward, 1995). However, recent research indicates that CBT appears to be helpful whether a patient receives pharmacotherapy or not (Franklin, Abramowitz, Bux, Zoellner & Feeny, 2002). There are questions that remain about long-term outcomes especially relative to whether patients receiving only CBT are more prone to relapse (Franklin et al., 2002). REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC: Author. Abramowitz, J.S., Brigidi, B.D., and Roche, K.R. (2001). Cognitive-behavioral therapy for obsessive-compulsive disorder: A review of the treatment literature. Research on Social Work Practice, 11, 357–372. Abramowitz, J.S., Foa, E.B., and Franklin, M.E. (2003). Exposure and ritual prevention for obsessive-compulsive disorder: Effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71, 394–398. Abramowitz, J.S., Franklin, M.E., Furr, J.M. & Schwartz, S.A. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 71, 1049–1057. Abramowitz, J.S., Tolin, D.F., and Diefenbach, G.J. (2005, December). Measuring change in OCD: sensitivity of the obsessive-compulsive inventory-revised. Journal of Psychopathology and Behavioral Assessment, 27, 317–324. Barlow, D.H. (1993). Clinical Hhandbook of Psychological Ddisorders: A Step-By-Step Treatment Manual (2nd ed.). New York: The Guilford Press. Cohen, I., and Steketee, G. (1998). Obsessive-compulsive disorder. In B.A. Thyer and J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders (pp. 343–363). Hoboken, NJ: John Wiley & Sons. Cooper, M. (1993, May). A group for families of obsessive-compulsive persons. Families in Society: The Journal of Contemporary Human Services, 301–307. Foa, E.B., Kozak, M.J., Steketee, G., and McCarthy, P.R. (1992). Treatment of depressive and obsessive-compulsive symptoms in OCD by imipramine and behavior therapy. British Journal of Clinical Psychology, 31, 279–292. Franklin, M.E., Abramowitz, J.S., Bux, D.A., Zoellner, L.A., and Feeny, N.C. (2002). Cognitive-behavioral therapy with and without medication in the treatment of obsessive-compulsive disorder. Professional Psychology: Research and Practice, 33, 162–168.

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Jones, M.K., and Menzies, R.G. (1998). Danger ideation reduction therapy (DIRT) for obsessive-compulsive washers: A controlled trial. Behaviour Research and Therapy, 36, 959–970. Maxmen, J.S., and Ward, N.G. (1995). Essential Psychopathology and Its Treatment (2nd ed.). New York: W.W. Norton & Company. O’Hare, T. (2005). Evidence-Based Practices for Social Workers: An Interdisciplinary Approach. Chicago, IL: Lyceum Books, Inc. Thyer, B.A., and Wodarski, J.S. (Eds.). (1998). Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders. Hoboken, NJ: John Wiley & Sons.

Chapter 19 POST-TRAUMATIC STRESS DISORDER

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ost-traumatic stress disorder (PTSD) describes an array of symptoms related to being exposed to traumatic or life-threatening event or events. According to Annitto and Mueller (2005), PTSD is the fourth most common psychiatric disorder, affecting more than one half of rape victims and 17 percent of American troops in Iraq and Afghanistan. Vonk and Yegidis (1998) elaborate on criteria required for a PTSD diagnosis in accordance with the DSM-IV-TR (APA, 2000). These criteria include exposure to the trauma-inducing event; some type of re-experiencing of the event, such as intrusive thoughts; and some type of functional impairment, among other criteria. It is not certain why some who experience a traumatic event develop PTSD later on and others do not. There is, however empirical evidence suggesting that once PTSD symptoms develop in an individual, he or she is more likely to react negatively to potential threats or additional traumatic events (Gray & Litz, 2005). Gray and Litz discuss how structured therapeutic interventions should not be used immediately after a traumatic event and should only begin when the individual feels ready to work on decreasing symptoms. They found that unstructured debriefing after an event is more appropriate, because not everyone exposed will develop PTSD, and it could be counterproductive to push an individual into reliving any part of the experience. Individuals who have either witnessed or been involved in a severely traumatic event may experience PTSD. According to Barlow (1993), the most common victims of PTSD are combat victims. HowNote: Case study 1 by Leslie Jenkins and LaTonya D. Lundy; Case Study 2 by Joel Cox; Case Study 3 by Katie J. Parsell.

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ever, people who experience PTSD often have survived disasters, such as abductions, natural floods, domestic violence, and rape to name a few. Important life events that would be excluded from being considered a traumatic event would be normal life events such as divorce, grief, and the diagnosis of a serious illness. Contrastingly, the “unexpected death of a loved one or a child’s serious illness would qualify as a traumatic event” (Morrison, 2001, p. 269). The previously mentioned traumatic events “are generally understood to be extreme psychological experiences” (O’Hare, 2005, p. 190). Many individuals are able to bounce back from these experiences simply because of their temperament, support from family and/or friends, and other protective factors that may be present within their environments. Unfortunately, other individuals may suffer for many years from the effects that were left behind from the event. The group of “anxiety-related symptoms and behaviors that include arousal, reexperiencing the traumatic event, and avoiding the stimuli that remind the person of the event is referred to as post-traumatic stress disorder (PTSD)” (O’Hare, 2005, p. 190). Many individuals diagnosed with PTSD “struggle with flashbacks, intrusive thoughts and feelings, or disturbing dreams that make them anxious and upset” (Goldstein, 1995, p. 282). Although working with this population of individuals can be challenging, this illness has shown to improve favorably with CBT that includes prolonged exposure to the thoughts or situations that provoke disabling anxiety. Three case studies are included here to illustrate effective intervention for clients suffering from PTSD as a result of sexual assaults, military combat, and spousal abuse. CASE STUDY 1

The Client Cindy has been living on the streets for the past month. She currently does not have an income or a place where she can live. Cindy reports that she relapsed with cocaine and alcohol two months ago. She believes the cause of her relapse was the death of her husband. She describes her husband as the only man she has felt safe with since “the rape.” She is voluntarily seeking inpatient treatment for her alcohol and drug dependence at a women’s shelter.

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Cindy is white and is thirty-four years old. Cindy describes her childhood as being “lonely.” She reports not having a close relationship with her mother and not knowing her father. Cindy has two sisters and a brother, and she describes their relationships as being distant. Her mother gave birth to her at the age of sixteen, and Cindy does not have any knowledge of what type of pregnancy her mother had or if there were any complications. She reports that she never knew her maternal grandparents. The dependencies or other personal problems of family members that she is aware of are alcoholism and cigarette use by her mother, two aunts, and an uncle. As stated earlier, Cindy does not have any information regarding her father or his side of the family. Her husband had a history of illegal drug and prescription dependence and of being a workaholic. Her two sisters and brother all share the same dependencies as Cindy. They suffer with alcoholism, illegal drug dependence, and prescription drug dependence, cigarette addiction and have been diagnosed with bipolar disorder. While discussing her siblings, Cindy became teary-eyed describing how one of her sisters had attempted suicide by overdosing on Valium. Cindy was widowed four months ago when her husband died suddenly of a heart attack. They were married for six years. When asked how she feels about becoming a widow, Cindy reported that she feels indifferent. Cindy has a fourteen-year-old daughter who is in foster care. Cindy does not know where her daughter’s father is. She also describes her living arrangements for the past five years as being unstable. Cindy spends most of her free time getting high with “friends.” She states, “I’d like to be doing something more productive with my time, I’m tired of hanging out.” Cindy reports that she only has one close friend. In addition, she feels like the relationships that she has with her mother, sisters, and brother are weak and not reciprocal. Cindy says that she would like to develop a close relationship with her daughter. She hopes that being in treatment will assist her in being able to gain her daughter’s trust again. Cindy grew up in a single-parent home and remained in the same home with her mother and siblings for fourteen years. At this time, she ran away and “lived from pillar to post,” she states. During this time, she also describes being brutally raped by a friend of the family, but she never reported the rape. Cindy mentions that drugs and alcohol have negatively affected all of her relationships throughout her lifetime.

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Cindy reports being emotionally abused by her mother, brother, sisters, and her husband. She defines emotional abuse as making her feel bad through harsh words. Her husband also abused her sexually by forcing her to perform sexual acts that she felt uncomfortable with. In addition, Cindy describes being sexually abused by her mother’s boyfriend when she was eleven years old. She describes the sexual abuse as being forced to have sex with him. She also reports not having any serious conflicts with her friends or family for the past thirty days. Cindy does not feel that she needs counseling for any of the abuse that she has endured. Cindy has been treated for psychological and emotional problems in an inpatient facility twice and once in an outpatient facility. She was first diagnosed with bipolar disorder when she was twenty-one. In addition, she was treated for the disorder the same year. She does not receive financial compensation for a psychiatric or emotional disability. She has experienced serious depression, anxiety, trouble concentrating, and thoughts of suicide that were not the direct result of drug or alcohol use. In addition, she has not experienced hallucinations or trouble controlling violent behavior. Cindy reports that she has attempted suicide (when her husband died) by taking an overdose of Depakote® (divalproex). Cindy talks about how she is significantly bothered by her emotional problems, and she feels that it is very important for her to receive counseling in order to better manage her emotional problems. Cindy has been hospitalized four times during her adult life. Her last hospitalization was eleven years ago when she had a hysterectomy. She has not visited a dentist during her adult life and is missing a few teeth in the front. She does not have any chronic medical problems that interfere with her daily functioning. The only chronic medical illness that she had as a child was asthma, which she developed at the age of five. Cindy is not pregnant and is not taking any prescribed medications at this time. She states that she has a Pap test each year and had a mammogram this year. She does not receive any type of financial compensation, such as a pension or compensation for a physical disability. She has not experienced any medical problems within the last thirty days. Cindy completed eleven years of school, and she has not participated in any type of training or technical education. She states that she

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does not have a profession, trade, or skill, but she also states “I wish I did.” Cindy says that she believes in God. Her religion is Christianity, and she has viewed herself as a Christian all of her life. She also mentioned that she would like to learn more about prayer and meditation. She states that she is not comfortable with her relationship with God and would like to begin working on it. Cindy is currently unemployed. She reports that she began working at the age of fourteen. She maintained employment for two years as a cashier and since then she has held jobs for no longer than six months. She reports always working as a cashier. At this time, Cindy does not receive unemployment compensation, welfare, pension, benefits, or social security, and she does not have anyone who contributes to her support in any way. When asked how many people depend on her for most of their food, shelter, and so on, Cindy responds by stating, “I wish I was able to take care of my daughter.” Cindy reports that she is moderately bothered by her employment history and is not sure how important counseling is for helping her to resolve these employment problems. Cindy has chosen to enter into the shelter’s inpatient facility, and her admission is not the result of being mandated by the criminal justice system. She states that she will be on probation for the next two years. She has been arrested and charged for the following: shoplifting, violation of probation, a drug charge, forgery, and driving while intoxicated (three times). Her arrest for the drug charge resulted in her being incarcerated for twelve months. Cindy was charged and convicted for possession of cocaine with the intent to resell. She is not presently awaiting charges, trial, or sentencing. Her first arrest occurred when she was twenty-one years old and was for driving while intoxicated. Cindy reports that she did not have a juvenile record and has not engaged in any illegal activities for the past thirty days. She also states that she does not have any present legal problems and does not require counseling in this area. Cindy reports that she first tried alcohol and drugs, including tobacco, at the age of sixteen. The first drug she tried was Tylox® (a combination of oxycodone and acetaminophen). She has used alcohol for ten years, and the last time she drank to become intoxicated was in July 2003. Cindy states that she first tried heroin at the age of thirtythree. Her last time using heroin was in August, 2003. In addition, she

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reports that she has not used methadone, barbiturates, sedatives, hypnotics, tranquilizers, amphetamines, hallucinogens, or inhalants. However, Cindy does mention that she began using cocaine at age twenty and continued using it for four years. She states also that she stopped smoking marijuana in July 2003. She also mentions that she has used more than one substance per day (including alcohol) since the age of sixteen and continued for seventeen years. She states that she has administered some of these drugs intravenously. She further reports that her drug of choice is cocaine. She also states that she relapsed four months ago. Cindy was a previous client at the shelter two years ago. She has not received either inpatient or outpatient treatment for the past thirty days and she states that she is “extremely” concerned that she receives immediate treatment for her drug abuse. Cindy has many activities that she enjoys. She likes swimming, listening to music, dancing, exercising, going to movies, playing arcade games, and cooking. She expresses that her values are being sober, being a parent, God, family, and contentment. The situations that cause Cindy to want to use alcohol and/or drugs are when she is around people who are using these substances and after she has a problem with a family member or friends. In addition, she may want to use drugs when she is faced with being alone. The moods that cause her to want to use are loneliness, depression, tiredness, boredom, self-pity, fear, and the loss of a loved one. Furthermore, when Cindy sees someone that she used to get high with or a place where she used to get high, it causes her to want to begin using again. At the time of this interview, Cindy does not appear to be depressed or withdrawn. She is a very warm and pleasant lady. Treatment Plan The Setting The PTSD therapy group takes place within a nonprofit Christian agency. The purpose of this group is to provide members who have shared a similar traumatic experience and have consequently been diagnosed with PTSD with an environment in which they have opportunities to engage, contribute, and support each other. Another feature of this group is that it addresses what has been viewed as possible impediments influencing the clients’ abilities to realize successful com-

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pletion of a drug and/or alcohol recovery program. Cindy’s expression of continued feelings of depression, thoughts of suicide, crying, shame, social anxiety, and recurrent mental images of being raped led the therapist to conclude that it would be especially beneficial for Cindy to be involved with a therapy group that would involve a combination of therapy techniques, including exposure therapy, imaginal exposure, and other stress-management techniques that will aid in reducing Cindy’s symptoms of PTSD. Cindy was involved in a homogeneous group, each of them was female, spoke English, had experienced being victimized by rape, and had a diagnosis of PTSD. There are no criteria to meet with regard to socioeconomic status, race, education or previous group experience. As noted in Yalom and Leszcz (2005), heterogeneous groups best maximize learning opportunities, thus every effort was made to further develop the group by including group members with more heterogeneous characteristics. The closed-ended PTSD group meets for twelve sessions, once a week for 1.5 hours. Ideally, the number of group participants ranges from five to eight members. In order to allow all members time to express their feelings and provide feedback for one another, the number of group members should not exceed ten. The setting is the shelter where most of the female clients reside. Both childcare and transportation are provided for group participants. The Worker The worker is a MSSW student supervised by an LCSW. There exists today an abundance of instruments to assess PTSD among rape victims, and the use of these assessment instruments has become the norm. A selection of these instruments is described later. There is considerable variability in the various measures used to assess PTSD; thus, it is important to conduct a structured interview and not rely exclusively on self-report measures. It is also important to use several standard measures when assessing PTSD. The assessment of trauma and PTSD is a complex process that unfolds in a rich interpersonal context. When properly conducted, it can be both educational and therapeutic for the traumatized individual being assessed. The goals of assessment of PTSD include looking beyond the diagnosis to understand the impact of the trauma on the individual’s life, identifying and

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prioritizing specific targets for change, and offering clear feedback to the client (Weathers & Keane, 1999). One of the most controversial issues in the field of traumatic stress is the “criterion A problem.” Initially, the criterion A problem centered on questions such as how to define a traumatic event and whether or not experiencing a traumatic event should be a requirement for a PTSD diagnosis (Weathers & Keane, 1999). Currently, there appears to be a growing consensus that traumatic events can be distinguished from ordinary stressors and that they serve a useful gatekeeping function that preserves the meaningfulness of the disorder as a distinct diagnostic entity and prevents trivialization of the suffering of survivors of overwhelming stressors. As a follow-up to the DSM-III-R, modest changes were made in the DSM-IV’s presentation of PTSD. These changes include an extensive reworking of criterion A, moving cued physiological reactivity from the hyperarousal cluster to the reexperiencing cluster, adding the requirement that symptoms must cause marked subjective distress or functional impairment, and rewording and clarifying some symptoms (Weathers & Keane, 1999). There are two common approaches used in the assessment of PTSD. The survey interview approach is based on the premise that people can reliably report their experience of specific psychiatric symptoms if the symptoms are briefly described to them in a survey interview setting. Survey interview approaches use fully structured interviews in which the interviewer simply reads the prescribed questions and records the responses, with no interpretations and no unstructured probing (Schlenger, Fairbank, Jordan & Caddell, 1997). The clinical interview approach shares the survey interview approach’s focus on specific symptoms but is conducted by an experienced clinician and is semistructured (Schlenger et al., 1997). It includes specific questions about all of the symptoms of interest, but the interviewer is encouraged to probe for more information when appropriate. The SCID for DSM-III-R is a comprehensive structured interview that assesses the client’s PTSD symptoms according to the DSM-III-R criteria. PTSD Symptom Scale (PSS-1) is a structured interview containing seventeen questions designed to assess the severity of PTSD symptoms. PTSD Interview (PTSD-1) is a structured interview consisting of twenty items that assesses the DSM-III-R criteria for PTSD. The clinically Administered PTSD Scale (CAPS-1) is a comprehensive

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structured interview for PTSD and is intended for use by experienced clinicians. It assesses the seventeen core symptoms of PTSD, as well as associated symptoms, response validity, overall symptom severity, and the impact of symptoms on social and occupational functioning. It also assesses the frequency and intensity of each symptom. The Impact of Events Scale (IES) was the first standardized measure of posttraumatic distress symptomatology to appear and is also one of the most widely used. It consists of fifteen items, including seven items assessing intrusive symptoms and eight items assessing avoidance. The Rape Aftermath Symptom Test (RAST) is a seventy-item self-report measure of psychological symptoms and fear-producing stimuli. The Sexual Experiences Survey is a ten-item self-report instrument that assesses types of coercion as well as sexual assault. The Ways of Coping questionnaire examines the coping strategies of rape victims. The revised ADIS (ADIS-R) is the most comprehensive instrument for differential diagnosis of anxiety and related disorders, and also for the assessment of depression, substance abuse, and psychosis. The State and Trait Anxiety Inventory and Beck’s Depression Inventory are often used with rape victims due to the high comorbidity rates of PTSD with anxiety or PTSD with depression. Assessment of traumatic exposure and PTSD diagnosis involves focusing the attention of clients on experiences and symptoms that are likely to have been, and may continue to be, painful. Although a few clients will experience an observable emotional reaction to the assessment and may experience some distress, the experience is not damaging in and of itself (Schlenger et al., 1997). Interviewers should inform all potential participants in advance of the possibility of experiencing distress during the assessment. A professional support network should also be made available for participants and interviewers. Short-Term Goals and Interventions Goals 1. Reduction of anxiety 2. Reduction of depression 3. Reduction of stress and increase in coping skills 4. Alleviation of symptoms 5. Educate client about PTSD and medication 6. Reduction of fear, anger, and somatic complaints

Intervention Exposure therapy CBT Stress inoculation training Psychotropic medication Psychoeducation Crisis-oriented support group

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Exposure therapy techniques involve confronting one’s fears. The techniques are derived from learning theory. This theory states that fear is acquired via classic conditioning, which occurs when a neutral stimulus is paired with an aversive stimulus (unconditioned stimulus). Afterwards, the neutral stimulus (conditioned stimulus) comes to elicit a conditioned fear response (conditioned response). This acquired fear is then maintained via operant conditioning, in which avoidance and escape are used to alleviate anxiety through negative reinforcement. Even when the unconditioned stimulus is terminated, the persistent avoidance of the conditioned stimulus prevents the realization that the conditioned stimulus no longer leads to negative consequences. The avoidance of the stimulus serves to maintain the fear and anxiety. Exposure techniques were developed as a way of intervening in this process, forcing the fearful individual to realize that the conditioned stimulus is no longer dangerous and avoidance is no longer necessary (Meadows & Foa, 1999). CBT helps clients modify dysfunctional cognitions. The basic assumption of this theory states that dysfunctional thoughts drive negative emotional states. Therefore, a given situation may lead to different emotions depending on the individual’s interpretation of the situation. Typically, cognitive restructuring (CR) aims to teach clients to identify dysfunctional thoughts, to evaluate their validity, to challenge erroneous or unhelpful thoughts, and to replace them with more beneficial ones (Meadows & Foa, 1999). Stress Inoculation Training (SIT) was the first treatment approach to be proposed for treating trauma-related symptoms (Resick, 2001). The goals of SIT are to help clients understand and manage their traumarelated fear reactions, resulting in decreased avoidance behavior. The reduction in avoidance of fear-producing stimuli is assumed to result in the extinction or habituation of these strong fear and anxiety reactions. The SIT protocol consists of an education phase, a skill-building phase, and an application phase (Resick, 2001). The number of sessions ranges from eight to twenty depending on the needs of the client. During the educational phase clients are given an explanation for their trauma symptoms, and they are taught to identify their different modes of response, including emotions, behaviors, physical reactions, and thoughts. During the skill-building phase, clients are taught progressive muscle relaxation and relaxing imagery. Clients are also taught coping skills designed to address the cognitive mode of re-

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sponse, including thought-stopping, covert rehearsal, problem solving, and guided self-dialogue. In the final phase of treatment, clients learn how to apply these coping skills step by step in daily situations that provoke anxiety. A crisis-oriented support group is a supportive therapy that helps clients develop appropriate coping skills to deal with the event at hand (Resick, 2001). Crisis theory presumes that the traumatic event upsets the person’s homeostasis (Resick, 2001). Because usual coping mechanisms and strategies are overwhelmed due to the severity of the event, the person will begin to develop maladaptive strategies. Crisis intervention emphasized brief group therapy that lasts for six to eight weeks. Crisis intervention is helpful in reducing or shortening trauma reactions. Members of crisis-oriented support groups may benefit psychologically, emotionally, and physically as a result of the group’s support for meaningful engagement (Yalom & Leszcz, 2005). Long-term Goals and Interventions Goal 1. Restore functioning level 2. Improve ability to establish satisfying relationships with members of the opposite sex 3. Improve self-esteem 4. Attempt to prevent future victimization 5. Restore family functioning and maximize the effectiveness of social support

Intervention 1. Cognitive processing therapy 2. Role-playing and covert modeling

3. Assertiveness training 4. Safety training 5. Family therapy

Cognitive processing therapy (CPT) was developed to treat the specific symptoms of PTSD in rape victims (Resick & Calhoun, 1998). A unique feature of CPT is that it combines the main ingredient of exposure-based therapies. The content of the cognitive portion of the therapy challenges specific cognitions that are most likely to have been disrupted as a result of the trauma (Resick & Calhoun, 1998). Established fear structures can be dismantled by activating the fear memory and providing new information that is incompatible with the current fear structure in order for a new memory to be formed. Activation can occur through information about the stimuli, responses, or meaning. Systematic exposure to the traumatic memory in a safe envi-

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ronment serves to alter the feared memory such that threat cues are reevaluated and habituated (Resick & Calhoun, 1998). This approach is more effective than exposure only is because memories of the event are elicited, and then conflicts and maladaptive beliefs are directly confronted. During a role-play, the client and therapist act out successful coping in anxiety-producing scenes with which the client expects to be confronted (Resick & Calhoun, 1998). The client may then be asked to role-play scenes with family members or friends. Covert modeling occurs when clients are taught to visualize a fear- or anxiety-provoking situation and to imagine themselves confronting it successfully (Resick & Calhoun, 1998). This skill is practiced until proficiency is obtained. The amount of time needed to master the skill is quite variable due to individual differences in ability level. This skill is useful in preparing for situations that a client knows will likely produce fear and anxiety reactions (Resick & Calhoun, 1998). Both role-plays and covert modeling teach clients how to communicate effectively and resolve problems using appropriate social skills (Resick, 2001). Presumably, the cognitive rehearsal will decrease the likelihood of avoidance responses. During assertiveness training, clients will learn how to communicate more effectively. They will learn how to use “I messages” to express themselves. They will learn problem-solving skills and tips for dealing with conflict. They will also learn tips to assist them in improving their self-concepts and safety tips in an attempt to prevent future victimization. Clients will learn how to decrease the chances of being attacked, what to do if attacked, and how to stay safe in public. Family therapy that consists of a systems-oriented approach may be an appropriate treatment method to address the needs of clients with PTSD, as well as those of their family members. According to this model, the purpose of using family treatment with these families is to facilitate normal family functioning, including maximizing the effectiveness of social support in five general phases (Vonk & Yegidis, 1998). Phase I involves developing a relationship with the family and securing a commitment to the goals of treatment. Phase II involves framing the problem, including an examination of the traumatic event that has disrupted the balance of the family system. Phase III is a reframing of the problem to help family members view the stress as a challenge to be conquered together. Phase IV involves the develop-

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ment of a healing theory, providing the family an opportunity to develop alternative ways of coping with future traumatic events. Finally, Phase V is the closure and preparedness phase, in which the successes of treatment are reviewed. Relapse Prevention The ways people interpret and cope with events and the ways others respond will affect the eventual outcome (Resick, 2001). How one interprets, or appraises, the causes of the event, the meaning and consequences of the event, or even the event itself will influence how the affected person will attempt to cope with the situation. Not only do the direct participants with the stressor play a role in interpreting and coping, but loved ones, friends, acquaintances, and even the community may play a role in cognitive appraisals. Cognitive appraisals may not only affect the person’s coping but also the amount and quality of social support he or she receives (Resick, 2001). Most people appear to need to understand why events happen in order to attempt to predict and control future events. People also appear to need to make meaning of events in order to put them into a larger context of understanding themselves and the world. Rape victims are likely to accept responsibility for the rape in order to maintain a sense of control over their lives and to maintain the belief that the world is just and orderly (Resick, 2001). This self-blame is associated with both negative shortterm and long-term effects. Knowing that one has supportive family and friends prior to a rape can affect whether someone even discloses that something happened, much less discussing how the event is affecting them (Resick, 2001). In times of great stress and trauma, the need for supportive others increases while the inadequacies of relationships become all too obvious and a distressing factor to contend with. It is also important for clients to complete their treatment and notify their therapist if future problems arise. Pharmacological Treatments Medication is frequently offered by primary care physicians and psychiatrists to deal with some of the symptoms that are problematic for trauma survivors. Although there is no medication that has been designed to treat the range of symptoms of PTSD, there are specific medications available for depression and anxiety. At this time, there

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have been fewer than a dozen controlled studies of pharmacotherapy for PTSD, and no one has studied how medications may best be combined for optimal effects (Resick, 2001). There are seven principal goals of medication in PTSD. First, the client will experience a reduction in the frequency or severity, or both of intrusive symptoms. Second, the client will experience a reduction in the tendency to interpret incoming stimuli as recurrences of the trauma. Third, the client will experience a reduction in conditioned hyperarousal to stimuli reminiscent of the trauma, as well as in generalized hyperarousal. Fourth, the client will experience a reduction in avoidance behavior. Fifth, the client will experience an improvement in depressed mood and numbing. Sixth, the client will experience a reduction in psychotic or dissociative symptoms. Finally, the client will experience a reduction of impulsive aggression against self and others. The adrenergic system has been implicated with PTSD, and there is a great deal of research to indicate that those with PTSD have excessive adrenergic activity. Two drugs, clonidine and propranolol, have been shown to reduce sympathetic arousal and adrenergic activity (Resick, 2001). These medications appear promising in reducing traumatic nightmares, intrusive recollections, hypervigilence insomnia, startle reactions, and angry outbursts. Serotonin abnormalities may also be present in clients with PTSD. In addition to the core symptoms of PTSD, serotonin has also been associated with symptoms that are frequently comorbid with PTSD, such as depression, suicidal ideation, impulsivity, substance abuse, and aggression (Resick, 2001). SSRIs such as fluoxetine, sertraline, and fluvoxamine reportedly reduce overall PTSD symptoms in all three categories of symptoms: intrusion, arousal, and avoidance (Resick, 2001). The SSRIs have been the only medications that have resulted in improvements for the symptoms other than depression. Two types of medication affect both the adrenergic and serotonergic systems: Tricyclic antidepressants and MAOIs. The tricyclic antidepressants most frequently studied are imipramine, amitriptyline, and desipramine; the MAOI usually studied has been phenelzine (Resick, 2001). These medications are effective for both depression and anxiety. Finally, benzodiazepines such as alprazolam and clonazepam are frequently prescribed (Resick, 2001). These antianxiety agents, called anxiolytic drugs, are associated with reductions in anxiety and fear. In the studies conducted, benzodiazepines have been found to reduce anxiety, insomnia, irritability, and hyperarousal.

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Medication may help to relieve the severity of symptoms and may allow the affected person to sleep and to function. However, medication should not be considered a cure for this disorder. If the trauma survivor is seeking the reduction in anxiety or depression to further avoid dealing with the trauma memory, it is likely that these symptoms will reemerge when the medication is discontinued (Resick, 2001). The greatest benefit of medication may be that it can assist a person to benefit from therapy without becoming overwhelmed. CASE STUDY 2

The Client The client is Jonah, a twenty-eight-year-old white male who recently returned from Iraq, where he was in a military combat unit. Jonah reported to a local mental health agency after a referral from a veterans’ hospital. He reports that he is having recurrent and intrusive thoughts in which he feels like he is reliving scenes from combat he experienced in Iraq. Jonah also reports that this is causing strain in his relationship with his family and problems with being able to hold down a job. His wife feels that there is a decrease in emotional and physical intimacy since Jonah returned. He reports that he has difficulty going to sleep at night and is abusing alcohol and opiates in order to deal with his symptoms. Jonah reported that when he first returned from Iraq, he started working at a local garage where he was an auto mechanic. One day a car backfired, and he suddenly felt as if he were back on a street in Iraq where his company came under ambush. He was very shaken by the incident and was unable to work the rest of the day. The following day he got into an argument with a customer who stared yelling at him, thinking that Jonah was trying to charge him too much for a car part. He suddenly lost control of himself and put the man in a choke hold. The police were called, but the man he choked decided to not press charges when he found out that Jonah was a combat veteran. However, Jonah was asked to leave his job. He became even more distant from his wife and started drinking heavily and abusing opiates. He entered treatment on his wife’s insistence.

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The Worker The therapist has recently obtained his master’s degree in clinical social work and is working toward licensure. He received weekly supervision on his cases and is able to consult with senior practitioners as needed. The therapist is trained in CBT and uses an empirically based treatment planner in making best practice decisions. The therapist is careful to convey interest and empathy when working with clients. He is well aware of the limitations of managed care practice and is careful to use the most effective and efficient treatment means available. The Setting The setting is an office at a local community health center. The center accepts most types of insurance, works with mental health referrals from the local veterans’ hospital, and is a provider for the state’s program for the uninsured. The office is private and quiet. It is painted with soothing colors and decorated in a way to make it seem comfortable and inviting without being too cluttered or informal. The furniture is modern and comfortable. Therapy sessions are weekly and last for fifty minutes. Most insurance providers allow for a maximum of eight sessions; however, veterans can receive additional sessions if they are determined to be needed. The Intervention The client meets the criteria for PTSD according to the DSM-IV-TR (APA, 2000). Through a structured interview during the initial assessment, the diagnosis is affirmed as PTSD. Several treatment methods have been shown to be useful in treating PTSD with no significant superiority of one method yet determined (Vonk & Yegidis, 1998). A client would be referred for medication management if necessary. In this case, the client’s substance abuse also needs to be addressed through assessing the discriminative stimuli and looking at the behavioral contingencies. Attending AA or other support groups would be helpful. CBT has been shown to be effective in treating PTSD and is an efficient means of treatment in the managed care era. The client needs to learn effective problem solving and behavioral management. Relaxation training would also be part of an effective intervention.

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When and if the client is ready, systematic desensitization would be used. The instillation of hope is also crucial in effectively treating PTSD (Vonk & Yegidis, 1998). Group interventions are effective in treating PTSD, and empirical evidence suggests that CBT beginning several days to weeks after an event is associated with the best outcomes (Gray & Litz, 2005). Several cognitive behavioral techniques are utilized in the treatment of PTSD. These are often used in some combination over the course of treatment. Jaycox, Zoellner, and Foa (2002) suggest a treatment protocol that uses four cognitive behavioral components: breathing training, an educational component about symptoms, imagined exposure situations, and CR. Current literature supports the use of these techniques and further suggests that PTSD can be effectively treated by combining pharmacological treatments with CBT (Vonk & Yegidis, 1998). Relapse Prevention Relapse prevention would include ongoing evaluation and use of medication. Continuing to attend support groups for substance abuse would also be part of a relapse prevention regimen. By learning emotional management, Jonah is less likely to decompensate in stressful situations. Vonk and Yegidis (1998) also suggest that family counseling could be effective in the treatment of PTSD. Family relationships are often strained and compromised in cases of PTSD. Since Jonah is experiencing difficulties with emotional intimacy with his wife, couples therapy would be useful. Perhaps his wife might also benefit from individual therapy. Medication with Treatment Several medications are shown to be effective in helping with PTSD symptoms. A medication referral would be made very early in the treatment process. Medication, along with therapy, should prove helpful for PTSD. There is empirical evidence that sibutramine hydrochloride (Meridia®) is effective for rapid treatment of PTSD (Annitto & Mueller, 2005). There are also empirical data supporting the use of 3, 4-methylenedioxymethamphetamine (MDMA) as a tool in conjunction with psychotherapy for individuals unresponsive to traditional treatments (Greer & Tolbert, 1998).

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CASE STUDY 3

The Client Anita is a thirty-seven-year-old Caucasian female who has presented at a local mental health facility. She is currently separated from her husband, whom she reports has been both emotionally and physically abusive for the past eleven years of their marriage. Anita has produced two children as a result of the marriage. However, her two children are currently in foster care due to reports of domestic abuse in the home. Anita presents with multiple bruises and a wrist fracture on her right hand. Throughout the initial interview, Anita appears hypervigilant and tearful. She eventually requests that the door be locked to ensure her safety. Anita is depressed, anxious, and fearful. She appears to have low-self esteem because her gaze is focused on either the floor or her feet. She also reports experiencing nightmares and states that she has hallucinations of her face bloodied and beaten while looking in the mirror after taking a shower. Anita has begun to isolate herself from family and friends and reports drinking on occasion to “numb the pain.” She describes her future as “bleak and hopeless.” The Worker Social workers serving PTSD victims should have some experience in working with PTSD as well as possessing a generally helpful attitude (Vonk & Yegidis, 1998). The practitioner should also be educated about typical reactions to trauma and PTSD. The social worker should be able to tolerate hearing graphic details of the trauma as relayed by the client (Vonk & Yegidis, 1998). Thus, a social worker should be able to tolerate strong emotional expression. It is also important for the social worker to effectively build rapport with a client in order to avert premature disclosure. A client should be encouraged only to share details as he or she feels is appropriate. Finally, the social worker should be knowledgeable regarding effective treatments of PTSD. Since CBT is a fundamental treatment option, the social worker should be skilled in administering this type of therapy. Since victims of PTSD are often highly symptomatic, LCSWs are the most appropriate type of workers for this case. It is assumed that LCSWs have greater experience, increased levels of skill, and greater knowledge of various clinical presentations than do nonlicensed social work professionals.

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It is important to accurately assess PTSD and its coexisting symptomatology, such as depression and anxiety, in order to provide effective treatment. According to a popular treatment planner, various behavioral definitions must be met to diagnose a client with PTSD (Wodarski, Rapp-Paglicci, Dulmus & Jongsma, 2001). Based on the aforementioned case, Anita is eligible for a PTSD diagnosis due to the following: she has a self-report of physical assault; she re-experiences the trauma through nightmares and intrusive thoughts; she presents with evidence of physical assault, including bruises and a bone fracture; she is tearful, depressed, anxious, and fearful; and she uses alcohol in an attempt to self-medicate. Other assessments should be considered along with a diagnosable clinical presentation. Structured interviews allow for in-depth exploration of the disorder, accompanying emotional responses, and the experience of the traumatic event itself. Examples of such interviews are the SCID for DSM-III, PTSD-1, and Clinician Administered PTSD Scale (Vonk & Yegidis, 1998). Objective measures such as the IES and the PTSD Symptom Scale are also informative assessment tools. Since PTSD victims often combat anxiety and depression, assessment tools should be used to measure these symptoms. The State and Trait Anxiety Inventory and the Beck Depression Scale are often utilized for cases of PTSD (Vonk & Yegidis, 1998). Treatment Plan Behavioral Definition Anita is vulnerable to PTSD because she has experienced a trauma involving actual and threatened serious injury along with threatened physical integrity. Anita is also experiencing the three major elements of PTSD: reexperiencing the trauma through nightmares and intrusive thoughts, detaching from others, and expressing symptoms of autonomic hyperarousal (Andreasen & Black, 2006). Anita also exudes typical emotional responses to trauma such as fear, anxiety, and depression (Vonk & Yegidis, 1998). Anita may be expressing decreased self-esteem as a direct result of the trauma. Some researchers purport that intense trauma violates a person’s sense of control, beliefs about safety, and self-esteem (Vonk & Yegidis, 1998).

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Effective Interventions The most efficacious means to clinically manage PTSD is through CBT and group and family therapy (Andreasen & Black, 2006). CBT is also an effective tool for treating the anxiety and depression that often accompany PTSD (Thyer & Wodarski, 1998). CBT may be used to help clients explore assumptions about themselves and the world that may have been disrupted by the trauma. CBT involves helping clients monitor distressing cognitions and cognitive distortions (Thyer & Wodarski, 1998). Clients are later challenged to replace disturbing thoughts with more adaptive thoughts. Family therapy would be especially helpful in Anita’s case. A systems-oriented family approach would facilitate normal family functioning and would effectively mobilize Anita’s social supports (Vonk & Yegidis, 1998). This is essential if Anita is to regain custody of her children. Treating the entire family is also important because PTSD victims typically express symptoms that affect the overall functioning of the family. Crisis-oriented supportive treatment can help improve symptoms of anxiety, fear, depression, anger, diminished self-esteem, and somatic complaints (Vonk & Yegidis, 1998). Group therapy is generally beneficial because members discover they are not alone in their experience of trauma and are reassured that their reactions to their trauma are normal given their circumstances (Vonk & Yegidis, 1998). Support groups can generate support, provide a mutual transfer of skills, and promote cathartic change. Anita could receive significant benefit from said therapies. Long-Term Treatment Goals Treatment goals should be comprehensive. The most relevant treatment goals in Anita’s case would be to increase her cognitive understanding of the trauma; improve her functioning in social roles, such as work and family; and increase her understanding of PTSD (Vonk & Yegidis, 1998). It is also important to strengthen her internal resources, such as her ability to manage anxiety, and help her develop a hopeful outlook on the future. Other long-term goals include at least four outcomes as prescribed by a popular treatment planner (Wodarski et al., 2001). The clinician will help Anita reduce the negative impact that the assault has had on the many aspects of her life. As a

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result, Anita will be able to return to her pretrauma level of functioning. Anita will also be able to implement effective coping skills in order to fulfill tasks of daily living and participate constructively in relationships. She will be able to terminate destructive behaviors and replace such behaviors with those that promote healing, acceptance of assault, and responsible living. Finally, Anita will be able to recall the assault without being overwhelmed by negative emotions (Wodarski et al., 2001). Short-Term Treatment Goals The most relevant short-term treatment goals in Anita’s case would be the reduction of her PTSD symptoms, including her nightmares, intrusive thoughts, and hallucinations; use of alcohol to self-medicate; and isolation from friends and family (Vonk & Yegidis, 1998). In addition, Anita and the clinician will work on reducing her feelings of guilt, improving social support systems, and increasing her cognitive understanding about the typical responses to trauma. Because Anita’s assault is a result of domestic abuse, the first task will be to work on issues of safety and protection from further abuse. Other potential short-term objectives for Anita include her eventual ability to express feelings experienced during times of the assault, contact legal authorities to seek protection for self, accept a referral for individual counseling, identify specific sources of support among family and friends, and accept a referral to a support group for assault victims (Wodarski et al., 2001). Since Anita admits to using alcohol as an ineffective means of coping, it will be useful for her to describe the amount, history, and frequency of alcohol used to cope with the trauma. Medication Medication is sometimes effective in treating symptoms of PTSD. However, other means of treatment should be considered first. When medication is appropriate, it is often most effective when used in conjunction with other modes of treatment such as individual therapy. Antidepressants have been found to be helpful in alleviating symptoms of chronic PTSD. However, the prescription for antidepressants should be based on the particular symptoms of each client (Vonk & Yegidis, 1998). Antidepressants may be especially helpful for Anita since she presents as fearful, anxious, and depressed during the clinical interview.

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In sum, Anita’s clinical presentation of PTSD can be effectively managed. A good prognosis and outcome are ensured when a licensed clinical professional carefully composes a treatment plan. In this case, Anita will be evaluated for medications while participating in individual, family and group therapies. CBT will be the primary treatment modality during Anita’s individual therapy. As a result of the aforementioned therapies, Anita should be able to consecutively meet both her long-term and short-term objectives. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC: Author. Andreasen, N., and Black, D. (2006). Introductory Textbook of Psychiatry. Washington, DC: American Psychiatric Publishing. Annitto, W., and Mueller, P.S. (2005). Rapid treatment of posttraumatic stress disorder with sibutramine. Epilepsy & Behavior, 7, 565–566. Barlow, D.H. (1993). Clinical Handbook of Psychological Disorders (2nd ed.). New York: Guilford Press. Goldstein, E.G. (1995). Ego Psychology and Social Work Practice (2nd ed.). New York: The Free Press. Gray, J.M., and Litz, B.T. (2005). Behavioral interventions for recent trauma. Behavior Modification, 29, 189–215. Greer, R.G., and Tolbert, R. (1998). A method of conducting therapeutic sessions with MDMA. Journal of Psychoactive Drugs, 30, 371–379. Jaycox, L.H., Zoellner, L., and Foa, E.B. (2002). Cognitive-behavior therapy for PTSD in rape survivors. Psychotherapy in Practice, 58, 981–906. Meadows, E.A., and Foa, E.B. (1999). Cognitive-behavioral treatment of traumatized adults. In P.A. Saigh and J.D. Bremner (Eds.), Posttraumatic Stress Disorder: A Comprehensive Text (pp. 376–390). Boston, MA: Allyn & Bacon. Morrison, J. (2001). DSM-IV Made Easy: The Clinician’s Guide to Diagnosis. New York: Guilford Press. O’Hare, T. (2005). Evidence-Based Practices for Social Workers: An Interdisciplinary Approach. Chicago, IL: Lyceum Book, Inc. Resick, P.A. (2001). Stress and Trauma. UK: Psychology Press Ltd. Resick, P.A., and Calhoun, K.S. (1998). PTSD. In D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders (2nd ed.) New York: Guilford Press. Schlenger, W.E., Fairbank, J.A., Jordan, B.K., and Caddell, J.M. (1997). Epidemiological methods for assessing trauma and posttraumatic stress disorder. In J.P. Wilson and T.M. Keane (Eds.), Assessing Psychological Trauma and PTSD (pp. 139–159). NY: Guilford Press. Thyer, B.A., and Wodarski, J.S. (1998). Post-traumatic stress disorder. In Handbook of Empirical Social Work Practice (pp. 365–-383). Hoboken, NJ: John Wiley & Sons.

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Vonk, M.E., and Yegidis, B.L. (1998). Post-traumatic stress disorder. In B.A. Thyer amd J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice (pp. 365–383). Hoboken, NJ: John Wiley & Sons. Weathers, F.W., and Keane, T.M. (1999). Psychological assessment of traumatized adults. In P.A. Saigh and J.D. Bremner (Eds.), Posttraumatic Stress Disorder: A Comprehensive Text (pp. 219–247). Boston, MA: Allyn & Bacon. Wodarski, J.S., Rapp-Paglicci, L.A., Dulmus, C.N., and Jongsma, A.E. (2001). The Social Work and Human Services Treatment Planner. NY: John Wiley & Sons. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). New York: Basic Books.

Chapter 20 BORDERLINE PERSONALITY DISORDER

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f asked to describe someone’s personality, one might respond by listing different emotional and behavioral characteristics. For example, one might describe Mr. Jones as outgoing, energetic, and funny. He may be referred to as stern, but fair, and always there to lend a helping hand. The New Webster’s Dictionary defines personality as “all the special qualities of a person which make him [or her] different from other people” (Bolander & Stodden, 1986). When do these distinguishing characteristics of a person then become labeled a disorder? When personality characteristics become so ingrained that they are inflexible and therefore interfere with the person’s ability to adapt to his or her environment in a functional and productive way, the person is said to have a personality disorder. Personality disorders are ego-syntonic, which means they are acceptable to the ego. For this reason, people with personality disorders will not likely view their behaviors as maladaptive or seek out treatment to alter their interpersonal relational patterns. People with borderline personality disorder (BPD) are considered by many clinicians to be some of the hardest clinical clientele to manage because the assessment, diagnosis, and treatment of this population are problematic. The DSM-IV defines BPD as “a pattern of instability in interpersonal relations, self-image, and affects, and marked impulsivity” (APA, 2000). As mentioned earlier, persons with BPD do not view their patterns of relating as problematic. They are more apt to seek treatment for a cooccurring mood disorder and/or suicidal behavior. Note: Case study by Lisa J. Randles and Ivan S. Deitch.

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Maxmen and Ward (1995) provide information about the essential features of BPD five of which must be present to meet the criteria for a diagnosis. Persons with this disorder are described as impulsive. They are said to experience a chronic feeling of emptiness and may exhibit self-harm and suicidal behavior more often because attempts to counter the empty feeling and/or to gain attention, which Paris (2002) pointed out, may actually reinforce the behavior. Splitting is a common defense mechanism used by people diagnosed with BPD, which explains their black or white, all good or all bad, or love or hate view of the world. To complicate matters, BPD may co-exist with several other personality disorders, as well as Axis I diagnoses (Landeckers, 1992; Murray, n.d.; Torgensen, Kringler & Cramer, 2001). As will be discussed later, BPD symptomatology may have roots related to childhood abuse and negative family dynamics, with possible underlying biological traits. BPD occurs twice as often in women as in men (Kaplan, Sadock, & Grebb, 1994), with some studies reporting a prevalence rate as high as 75 percent in women. The DSM-IV states that BPD is present in approximately 25 percent of the general population (APA, 2000). However, Torgensen and colleagues (2001) found a higher prevalence rate of 13.1 percent for personality disorders in general in their large community sample of 2,053 participants, but the rate of BPD in their study was .70 percent, which is lower than expected. People with BPD are noted for being high consumers of mental health services. Stone (as cited in Becker, 2000) determined ninety-three combinations of criteria for meeting a BPD diagnosis. In addition, Kraus and Reynolds (2001) argue that 90 percent of persons diagnosed with BPD also meet the criteria for a co-occurring personality disorder. Among mental health consumers, BPD clients are seen in 10 percent of outpatient population, and 20 percent of the inpatient populations (APA, 2000). SUICIDAL FACTORS

Paris (2002) states that one fourth of all suicide attempts are by persons with BPD. About 10 percent of people with this disorder will die from suicide. The rate of suicide among this population is said to be close to that of those with schizophrenia and major mood disorders, which historically have the highest suicide rates. Although Paris (2002)

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reports that men commit suicide more successfully with fewer attempts, women with BPD are more apt to die after repeated suicide attempts and when not actively in treatment. Paris (2002) suggests that suicidal behavior might increase after treatment has been unsuccessful. However, he addresses the possibility that some people with BPD die from suicide by accident, stating that the protection part of the suicide plan failed. Here he is referring to those who attempt suicide in the company of others or attempt suicide when they are expecting someone to arrive shortly. Ivanoff, Linehan, and Recknor (1998) also reported on the high rates of suicidal behavior among the BPD population. These authors describe the characteristics of persons with BPD with the same similarity as the descriptions cited by other authors, except they include the reference to intense negative emotions. According to these authors, 80 percent of their inpatient study contains histories of self-injurious behaviors, with more than half of the participants having seriously attempted suicide. Nonserious attempts, which were reported in 40 percent of the inpatients studied, could be hypothesized to support Paris’s (2002) statements that suicidal behavior can be, and often is, a manipulative characteristic of BPD. Still, caution is advised, given that around 10 percent of BPD clients die from suicide. Paris (2002) pointed out that understanding these suicidal behaviors as expressions of distress is important. Both he and Landeckers (1992) say that one must consider the consequences of these behaviors for the client when considering treatment. Paris (2002) further states that therapists should not extinguish the self-injurious behaviors until the client has gained other productive ways of coping with the distress. Landeckers (1992) further adds that hospitalizations, with all the social reinforcers, can actually strengthen the self-injurious behaviors that the outpatient therapists are trying to replace with more positive/productive coping skills. ETIOLOGY

Biological Factors Research has uncovered biological features in BPD. Numerous twin studies show similarities among identical twins, even when the twins have been reared apart, providing evidence for genetic factors (Kap-

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lan et al., 1994; Siever & Davis, 1991). Family studies also reveal statistically significant percentages of mood disorders in the relatives of persons with BPD (Kaplan et al., 1994). When discussing the impulsive/aggressive dimension of the dramatic cluster personality disorders, BPD in particular, Siever and Davis (1991) profess that studies involving genetics and family history show support for a biological and genetic link with BPD. This support for biological correlations can be seen in studies that make the case for the serotonergic system as controlling behavioral inhibition. Lesions in this serotonergic system cause less inhibited behavior in individuals. This reduction in inhibitions is possibly due to a diminished capacity to realize that the anticipation of impending punishment should translate into behaving appropriately, with some amount of inhibition. In other words, clients with BPD have a hard time learning from the consequences. Furthermore, a reduction of serotonergic functions seems to be linked with being less inhibited for impulsive and aggressive behaviors. Reductions in certain serotonin metabolites have been noted in patients with personality disorders who attempted suicide. Patients with BPD have a lower prolactin response to the serotonergic releasing agent fenfluramine. The noradrenergic system may also play a factor in the control of impulsive/aggressive behaviors. The noradrenergic system controls arousal and orientation to one’s environment. Higher levels of noradrenergic activity could result in increased other-directed aggression. Both of these physiological systems, the serotonergic system and the noradrenergic system, might be biological factors in determining impulsive and aggressive behaviors that are self and other-directed. Environmental Factors There is extensive research that links BPD to childhood abuse. Although causal inferences cannot be assumed, there is little doubt that childhood abuse is a contributing factor. According to Gallagher and Kibel (2000), 73 percent of clients with BPD have a history of abuse. Therapists should give careful consideration to the histories of BPD clients, while being cautious about clinical expectations. In gathering client histories, details surrounding the abuse are important because of the connection between severity of abuse and adult symptomatology. Several publications link abuse to the etiology of BPD

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(Becker, 2000; Comer, 2004; Gallagher & Kibel, 2000; Landeckers 1992; Maxmen & Ward, 1995; Murray, n.d.; Weaver & Klum, 1993). Gallagher and Kibel (2000) point to three abuse factors linked to the later emergence of BPD: (1) relationship of the perpetrator; (2) type of abuse; and (3) duration of abuse, said to be the most significant indicator. Even though Becker (2000) explains that not all persons with BPD have histories of childhood abuse research and clinical records reveal high percentages of abuse, especially sexual abuse in the histories of clients with BPD. Nevertheless, many clients do not connect their current difficulties with their past trauma. Although sexual trauma is cited in several research articles as the most significant indicator, BPD has also been linked to physical abuse and other negative family dynamics. What is more, when reviewing the history of these clients, details are important because severity of abuse was correlated with adult psychopathology. In addition to the three factors indicated earlier, other studies link age of onset to diagnosis, stating that a history of abuse before age twelve is common among the abuse histories of persons with BPD. There is some evidence that the earlier the abuse occurs, the more likely one is to be diagnosed with BPD. Again, researchers do caution about assuming causation because there are many intertwining variables, including perpetrator, age when abuse occurred, type of abuse, duration, family environment, social support, and early loss to name just a few (Landeckers 1992; Murray, n.d.; Becker, 2000; Comer, 2004; Gallagher & Kibel, 2000; Weaver & Clum, 1993). While testing their hypotheses about the positive correlation between the early traumatic experiences (sexual abuse, physical abuse, witnessed violence, early separation, and family characteristics) and the later diagnosis of BPD, Weaver and Clum (1993), concluded, just as other research has indicated, that when all other variables are controlled, sexual abuse is a significant predictor of BPD, and, as was emphasized in the Landeckers study, repeated and severe trauma (or severity of trauma) was correlated with BPD. Families with high levels of negative experiences were also correlated with BPD, but sexual abuse remained the most significant indicator. Understanding the etiology of BPD can offer a greater array of possible interventions.

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DIFFERENTIAL DIAGNOSES AND COMORBID DIAGNOSIS

Early trauma has been linked to other diagnoses as well. Some studies led researchers to hypothesize that age of abuse might be related to one of three diagnoses listed: BPD, PTSD, and multiple personality disorder (MPD)/dissociative identity disorder (DID). Murray (n.d.) reviewed the research to examine the relationship between childhood sexual abuse and BPD, PTSD, and MPD (currently called DID). Just as Gallagher and Kibel (2000), Weaver and Clum (1993), and Landeckers (1992) emphasized, Murray (n.d.) points to research that warrants attention when considering the impact of early sexual trauma on later psychiatric illness. Females are said to be victims of child sexual abuse at a rate ten times that of males, with the oldest daughter having the greatest risk. The long-term effects can include symptoms from various psychiatric disorders. One study revealed that when inpatients’ histories were recorded, those reporting sexual abuse had a diagnosis of BPD in 485 of the cases. Murray’s (n.d.) review of the research found similar correlations between sexual and physical abuse and long-term psychiatric consequences, including BPD, PTSD, and MPD/DID. Murray (n.d.) claims that variations in abuse, with abuses’ multiple factors, may contribute to different diagnoses. Becker (2000) examines the implications of encompassing clients formally diagnosed with BPD under the expanding umbrella of the PTSD diagnosis. In Landeckers’s (1992) review of the literature, the overlap between BPD and PTSD was considered, and the research covered pointed to a connection between childhood abuse and these diagnoses. Yet just as Miller (1994) observed in her qualitative study of patients’ perception of the BPD experience, Becker (2000) reminds the reader that not all persons diagnosed with BPD have histories of childhood abuse. According to Becker (2000) there are 175 different ways to reach a diagnosis of PTSD, and just as BPD has been referred to as the “wastebasket” diagnosis, PTSD is the “catchall” diagnosis. The PTSD diagnosis is viewed as being less blaming for the abuse survivor. The danger here is that the clients’ diagnoses and treatment approaches may be based more on clinicians’ perceptions, with hardto-manage clients being labeled BPD. She goes on to discuss the possibility that difficult clients might be labeled BPD, whereas the more likeable client will get the PTSD diagnosis. These labels could further affect the way that helping professionals interact with these clients.

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Those viewed as having character defects, namely BPD, will probably not be treated with the same patience and understanding as the PTSD clients. Murray (n.d.) examines the high percentages of childhood abuse in each of these disorders and speculates that biology, negative family dynamics, and developmental stage at the time of abuse, along with extraneous variables, play a part in the emergence of later psychiatric illness, if it was not already present, be it BPD, MPD/DID, or PTSD. Along with the complications of differentiating symptomatology and diagnosis among the three disorders mentioned before, clinicians have to assess for co-occurring personality disorders and other comorbid Axis I diagnoses. Mood disorders and substance use and abuse issues are the most common comorbid conditions (APA, 2000; Maxmen & Ward, 1995). TREATMENT

Cognitive Behavioral Therapy Wong, Wilder, Schock, and Clay (2004) document how CBT can be beneficial when working with clients with severe and persistent mental illness. Although they do not focus on BPD, they address how CBT can be used with “behavioral excesses,” specifically bizarre oppositional and stereotypic behaviors. They emphasize the importance of establishing a therapeutic relationship before these confrontation methods are introduced. Many of the techniques mentioned for addressing and modifying excessive behaviors could be used in the treatment of BPD clients. Learning theory is the theoretical base for these techniques, and the goal is to use reinforcement to change maladaptive ways of interacting in the environment. Kraus and Reynolds (2001) emphasize three core beliefs that are the impetus for maladaptive behaviors (1) the world is dangerous and malevolent; (2) I am powerless and vulnerable; and (3) I am inherently unacceptable. Group Therapy Yalom and Lesczc (2005) provide extensive writing on the dynamics of group work. They demonstrate through vignettes how interpersonal learning through group therapy can expose conflicts for many

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clients, including those with borderline characteristics. Clients with BPD are described as cognitively, emotionally, and interpersonally unstable. Group therapy can be beneficial to clients with BPD, but they may need concurrent individual therapy that can provide a supportive foundation. This concurrent individual therapy will help the client remain in the therapy group. Yalom and Lesczc (2005) do not go into the etiology of the BPD client but instead keep the focus on the forces that influence group members’ interpersonal interactions. Special consideration for the clinician working with BPD clients is noted, including how these clients’ fears of abandonment and intimacy, separation anxieties, and transference reactions can emerge and impede progress for both the client and, in the case of group therapy, the other members. Dialectical Behavior Therapy Dialectical behavior therapy is an empirically based treatment that has a standard duration of one year. Clients are treated in both 1-hour weekly individual psychotherapy sessions and 2.5 hour weekly skillstraining groups. In groups, clients gain skills in “emotion regulation, distress tolerance, interpersonal effectiveness and identity confusion and maladaptive cognitive reduction; each of these skill areas address one of the four primary problem areas of BPD clients, . . . which are difficulties in maintaining relationships, maladaptive behavior that interferes with maintaining employment, persistent depression and misery, and repeated acts of self-harm or suicide attempts” (Ivanoff et al., 1998, p. 461; Johnson, 1991). The individual treatment supports and strengthens the clients’ skillstraining while attending to the clients’ maladaptive behaviors. Research outcomes with dialectical behavior therapy demonstrated a decrease in suicidal behavior and client dropout rates. Clients receiving this treatment approach maintained higher GAS scores. Biosocial theory is the underlying theoretical base for this treatment approach to BPD. This theory holds that the maladaptive behavioral characteristics of BPD have both a biological basis and an environmental influence that intertwine to reinforce the clients’ behavior (Ivanoff et al., 1998; Johnson, 1991).

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Psychotropic Medications The following table describes psychotropic drugs and their use in the treatment of BPD (Ivanoff, Linehan, & Recknor, 1998; Kraus & Reynolds 2001; Siever & Davis, 1991; Maxmen & Ward, 1995). Psychotropic Medications Neuroleptics (antipsychotic drugs) Chlorpromazine (Thorazine®) Fluphenazine (Prolixin®) Haloperidol (Haldol®) Clozapine (Clozaril®) Risperidone (Risperidal®) MAOIs Tranylcypromine (Parnate) Isocarboxazid (Marplan) Phenelzine (Nardil)

SSRIs Fluoxetine (Prozac®) Sertralline (Zoloft®) Paroxetine (Paxil®)

Lithium

Benzodiazapines Alprazolam (Xanax®) Anticonvulsants Carbamazepine (Tegretol®)

Possible Uses in BPD 1. Most effective for treating the psychotic and schizotypal symptoms 2. To control anger, irritability, and brief psychotic episodes 3. Mood stabilization 1. Used for the affective symptoms 2. Used to treat impulsivity and aggression 3. Mood stabilization 4. Rejection sensitivity 5. Co-occurring depression 1. Used for the affective symptoms 2. Used to treat impulsivity and aggression 3. Mood stabilization 4. Rejection sensitivity 5. Used to improve global functioning 6. Co-occurring depression 1. Used to treat impulsivity and aggression 2. Mood stabilization 1. Used cautiously to treat anxiety 1. Used to improve global functioning 2. Decreasing impulsive self-destructive behavior

CASE STUDY

The Client Sandra is a fifty-four-year-old white female who was referred to an outpatient facility for follow-up and treatment after a suicide attempt. She has a long history of psychiatric hospitalizations with an Axis I diagnosis of major depressive disorder and an Axis II diagnosis of BPD. She has had several suicide attempts and other incidents of selfharm or self-sabotaging behaviors, including reckless driving and im-

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pulsive spending. She has been on several psychotropic medications, yet has a history of being noncompliant with her medications due to numerous stated side effects. Sandra reports drinking alcohol daily, stating that it calms her nerves, helps when she is angry, and relieves the boredom of her mundane life. Although she reports that she does not see her drinking as a problem, her responses to the CAGE assessment indicates possible alcohol abuse. Sandra has been married for thirty-five years, yet describes her relationship with her husband as distant and unsatisfying. Her fear of abandonment and dependency issues perpetuate the relationship. Sandra’s relationships with her three grown children are subject to her extreme shifts in mood. Frustration of expectations, separation, criticism, and sensitivity to other environmental cues often trigger rapid shifts in her affective states. The Worker The treatment plan that will be adopted for Sandra includes a multiintervention team approach. Initially, Sandra would be referred to the staff psychiatrist in order to assess her need for symptom stabilization with psychotropic drugs. Next, she would be directed to concurrent group and individual therapy, with the underlying rationale being that individual therapy is conducive to retention in group therapy and vice versa. An LCSW will implement the individual weekly treatment. Another social worker and a licensed practicing counselor will cofacilitate the weekly group. Yalom and Lesczc (1995) consider coleaders to be especially productive when working with the BPD client because of their use of the defense mechanism splitting. If the client begins to project negative aspects onto one leader, positive views of the other leader may decrease premature termination. In the dialectical behavioral model, duration of treatment averages twelve months. This time frame allows for the development of a trusting therapeutic alliance and takes into consideration the client’s capacity and motivation for change. This team approach to treatment will take place at the outpatient counseling center, which offers flexible treatment hours.

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Treatment Plan The treatment plan for Sandra would encompass treatments that address her behaviors that fit the impulsive/aggressive dimension of the dramatic cluster B personality disorders. This would be accomplished by providing the dialectical behavior therapy component of individual therapy that would aid in reaching short- and long-term treatment goals. CBT would also be used to counter the three previously mentioned core assumptions that clients with BPD adhere to. Sandra’s alcohol abuse would be targeted with dialectical behavior therapy, focusing on the area of urge control, with a contingency contract. Yalom and Lesczc (1995) suggest that group work can be used, with its interpersonal learning component, to teach the social skills the client needs in order to maintain stable relationships. Interpersonal learning is a desired outcome in the dialectical behavior therapy model. Throughout treatment, the client’s experience must be validated with validation strategies, which begin with empathy. Problem-solving strategies will also be used with an emphasis on contingency management and cognitive modification (Ivanoffet al., 1998). Relapse Prevention Short-Term Goals 1. Reduce behaviors that interfere with therapy

2. Reduce suicidal and parasuicidal behavior

3. Reduce alcohol consumption

Objectives Establish rules Appointment times End sessions on time Voice fee expectations Discuss consequences Contract agreement Suicide not an option Call crisis line Call before self-harm Use less harmful alternatives No accidental harm Daily monitoring Identify SDs Decrease consumption by one drink Urge control

Short-Term Outcomes Active participation in therapy

Reduction of suicidal and parasuicidal behavior achieved

Reduction of alcohol consumption achieved

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Long-Term Goals 1. Reduce self-doubt and increase self-trust 2. Increase social skills

Objectives Therapeutic validation 3 types 6 levels Mindfulness Reasonable mind Emotion mind Wise mind Distress tolerance Activity-oriented distraction Consider pros and cons Interpersonal effectiveness Express needs Set limits Emotion regulation Regulate physiological arousal Refocus attention Inhibit mood-dependent actions Regulate emotions Structure behavior around non-mooddependent goals

Long-Term Outcomes Decrease in maladaptive functioning Global functioning improved

When considering methods of relapse prevention, comorbid diagnoses must be addressed. People with BPD, comorbid major depression, and/or substance abuse are at high risk for relapse. Hooley and Teasdale (1989) suggest that persons with depression who rate their spouse or family as highly critical are at an increased risk for relapse. Quigley (2003) proposes that factors affecting relapse in the beforementioned comorbid conditions may be similar to those factors that contribute to relapse in BPD clients. He points out that BPD clients experience difficulties throughout their life spans and that returning for treatment is common. Yalom and Lesczc (1995) also state that treatment is not the all-encompassing “cure,” and it might be better viewed as a segment of treatment over one’s life. Quigley (2003) discovered that steady work or school status following remission served to protect against relapse. Bagge and associates (2004) stated that impairment in academic and occupational achievement might possibly be a target for

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intervention given its prevalence in negative outcomes for BPD clients. Relapse prevention would focus on maintaining therapy outcomes, such as improved social skills, through continued exposure to positive environmental opportunities, such as support groups, and follow-up maintenance visits, with frequency based on client need. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington DC: Author. Bagge, C., Nickell, A., Stepp, S., Durrett, C., Jackson, K., and Trull, T.J. (2004). Borderline personality disorder features predict negative outcomes two years later. Journal of Abnormal Psychology, 113, 279–288. Becker, D. (2000). When she was bad: Borderline personality disorder in a posttraumatic age [Online]. American Journal of Orthopsychiatry, 70, 422–432. Bolander, D.O., and Stodden, V.L. (Eds.) (1986). The New Webster’s Dictionary. New York: Lexicon Publications, Inc. Comer, R.J. (2004). Abnormal Psychology (5th ed.). New York: Worth Publishers. Davis, S. (1991). An overview: Are mentally ill people really more dangerous? [Online] Social Work, 36, 174–180. Gallagher, R.E., and Kibel, H.D. (2000). Group treatment of severe clinical disorders, personality disorders, and substance use problems. In R.H. Klein and V.L. Schermer (Eds.), Group Psychotherapy for Psychological Trauma, (pp. 326–354). New York: Guilford Press. Hooley, J.M., and Teasdale, J.D. (1989). Predictors of relapse in unipolar depressives: Expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology, 98, 229–235. Ivanoff, A., Linehan, M.M., and Recknor, K.L. (1998). Borderline personality disorder. In B.A. Thyer and J.S. Wodarski (Eds.), Handbook of Empirical Social Work Practice: Vol. 1. Mental Disorders, (pp. 453–472). New York: John Wiley & Sons. Johnson, H.C. (1991). Borderline clients: Practice implications of recent research. Social Work, 36, 166–173. Kaplan, H.I., Sadock, B.J., and Grebb, J.A. (1994). Kaplan and Sadock’s Synopsis of Psychiatry Behavioral Sciences Clinical Psychiatry (7th ed.). Baltimore, MD: Williams & Wilkins. Kraus, G., and Reynolds, D.J. (2001). The “A-B-C’s” of the cluster B’s: Identifying, understanding, and treating cluster B personality disorders. Clinical Psychology Review, 21, 345–373. Landeckers, H. (1992). The role of childhood sexual trauma in the etiology of borderline personality disorder: Considerations for diagnosis and treatment [Online]. Psychotherapy, 29, 234–242. Maxmen, J.S., and Ward, N.G. (1995). Essential psychopathology and its treatment (2nd ed.). New York: W.W. Norton & Company.

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Miller, S.G. (1994). Borderline personality disorder from the patient’s perspective [Online]. Hospital and Community Psychiatry, 45), 1215–1219. Murray, J.B. (n.d.). Relationship of childhood sexual abuse to borderline personality disorder, posttraumatic stress disorder, and multiple personality disorder [Online]. The Journal of Psychology, 127, 657–676. Paris, J. (2002). Chronic suicidality among patients with borderline personality disorder [Online]. Psychiatric Services, 53, 738–742. Quigley, B.D. (2003). Diagnostic relapse in borderline personality disorder: Risk and protective factors (Doctoral dissertation, Texas A & M University, 2003). Dissertation Abstracts International. Siever, L.J., and Davis, K.L. (1991). A psychobiological perspective on the personality disorders. American Journal of Psychiatry, 148), 1647–1991. Torgensen, S., Kringler E., and Cramer, V. (2001). The prevalence of personality disorders in a community sample [Online]. Archives of General Psychiatry, 58, 590–596. Weaver, T.L., and Clum, G.A. (1993). Early family environments and traumatic experiences associated with borderline personality disorder [Online]. Journal of Consulting and Clinical Psychology, 61, 1068–1075. Wong, S.E., Wilder, D.A., Schock, K., and Clay, C. (2004). Behavioral interventions for severe and persistent mental disorders. In H.E. Briggs and T.L. Rzepnicki (Eds.), Using Evidence in Social Work Practice Behavioral Perspectives (pp. 210–230). Chicago, IL: Lyceum Books, Inc. Yalom, I.D., and Lesczc, M. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). New York: Basic Books.

III. BRIEF CASES

Chapter 21 TEEN PREGNANCY THE CLIENT

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egan, age sixteen, was referred to a Catholic Charities Counseling Service by the school guidance counselor in whom Megan confided regarding her pregnancy. During the initial therapy session, a routine intake assessment was conducted in which Megan disclosed that her abusive boyfriend pressured her into having sex, resulting in her pregnancy. Megan had committed to wait until marriage to have sex, but her boyfriend told her that if she loved him, she would have sex with him. Not only was she embarrassed because she was pregnant, but also she was experiencing feelings of guilt and shame due to breaking the commitment she made to abstain. Megan has informed her parents of the pregnancy and, due to religious beliefs, has decided against abortion and against adoption. Her parents are divorced but are both reportedly supportive and involved in her life. Megan is concerned about the relationship with her boyfriend, worried about how she will continue school, and questions whether she can manage being a mother and a full-time student. She is also concerned about the stigma of being an adolescent parent, and she has revealed her pregnancy to only a few close friends and the youth minister at her church. She reports having mixed emotions: sadness, guilt, confusion, and fear of being a parent. After the initial assessment, a treatment plan was developed with Megan. Megan’s presenting problem is teen pregnancy. This is the problem that is most important to her and the one that will most affect her life. Note: Case study by Heather Daniels.

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In selecting behavioral definitions that describe Megan’s situation, the relationship with the father of the unborn child is non-supportive and terminated at this time, the pregnancy is the result of a short-term relationship, and she desires to complete the pregnancy but has feelings of confusion and anxiety regarding the future. Megan also has feelings of guilt and shame that need to be addressed in therapy. Some long-term goals for Megan will include obtaining prenatal care consistently throughout pregnancy, continuing her education program during the pregnancy, and coping with her feelings of self-blame and guilt. There are several short-term goals that Megan and her case worker agreed to work on throughout therapy. One short-term goal was to confirm the pregnancy and duration of the pregnancy and to access medical and prenatal care on a consistent basis. The worker spoke with Megan’s mother to ensure that she will make an appointment for Megan with an ob-gyn in the next week or two. Another short-term goal was for Megan to identify her feelings about the pregnancy. To accomplish this goal, the therapeutic interventions that will follow will include exploring the facts and her feelings related to the pregnancy; the future of her relationship with the father of the unborn child, especially safety issues due to past abuse; and family dynamics that may have contributed to her behavior. This goal was anticipated to be reached in the next four sessions. Another short-term goal was to attend counseling sessions to aid in coping with the stress of the life crisis. In addition to counseling services, one goal was for Megan to continue educational classes on a consistent basis. The therapeutic interventions used would be to stress the importance of her continuing her education, to reinforce her consistent school attendance, and to coordinate with her parents and school officials to ensure that Megan’s education continues whether at the regular high school or through home schooling services. Megan’s teachers and parents were challenged to encourage and assist her in pursuing her education throughout her pregnancy and post-pregnancy. Another integral goal is for Megan to attend parenting education classes whether through her couneling sessions or through a parenting center. Megan was provided with a list of local parenting centers, and plans were developed for discussing parenting issues through the therapeutic sessions. The final, and most important, goal for Katie was to verbalize realistic expectations for life after delivery. In addition to discussing par-

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enting in counseling sessions, the interventions would be to assist Megan in setting goals that take into account the responsibilities of caring for her infant and reviewing with her all the potential sources for emotional and childcare support after delivery. Megan was referred to a local support group for adolescent parents at the local community health center. Counseling will include discussions of her feelings of guilt and shame and work toward accepting her situation and adjusting to the new stage in her life. After discussing her treatment plan, Megan signed a contract and agreed for the worker to meet with her parents to discuss their participation in her treatment. Her parents approved of her treatment plan and agreed to initiate prenatal care with a doctor. Megan elected to continue counseling until she gives birth, at which time an evaluation will be made to determine if she wants and/or needs to continue with therapy.

Chapter 22 OPIATE ABUSE

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piates occur naturally (morphine, codeine, and opium), as semisynthetic compounds (heroin or hydromorphone [Dilaudid®]), and as synthetic compounds (methadone). Heroin is most frequently associated with abuse and addiction. Opiates are highly addictive drugs producing symptoms of drowsiness, slurred speech, mood changes, and analgesia, and users are often unaware of their surroundings. Physicians use small doses as pain killers and cough suppressants (high doses may lead to depression of the central nervous system). OPERATIONAL DEFINITIONS

Three terms are particularly relevant to opiate abuse. Addiction, defined by SAMHSA is a progressive, chronic, primary, relapsing disorder that generally involves compulsion, loss of control, and continued use of alcohol or drugs, despite adverse consequences (Landry, 1995). Chemical dependency is described as the harmful use of either alcohol or illicit psychoactive substances, and withdrawal is a symptom commonly associated with opiate dependence: dysphoric mood, nausea or vomiting, dilation of the pupils, diarrhea, fever, weeping, muscle aches, and insomnia (Dozier & Johnson, 1998).

Note: Case study by Melissa A. Chimenti.

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PREVALENCE AND SOCIAL COSTS OF OPIATE USE AND ABUSE

Reported numbers of abusers remain stable; however most believe this population is undersampled in studies. Injection remains the most common method of use, but there are increasing percentages of snorting and other unknown methods. Costs associated with opiate abuse include crime, criminal justice involvement, property loss, AIDS, depression, premature aging, significant risks to fetus, and so forth (Dozier & Johnson, 1998). RELEVANCE OF OPIATE TREATMENT TO SOCIAL WORK PRACTICE

Social workers should use the least intrusive methods of treatment (self-help groups, outpatient drug-free programs, detoxification, and inpatient treatment). Fiscal constrains apply pressure to practice in regard to client-treatment matching (Dozier & Johnson, 1998). ASSESSMENT

Admission for treatment at most centers requires a diagnosis of either opiate dependence (must exhibit three of seven symptoms in past twelve months) or opiate abuse (must have one of three symptoms) as defined in the DSM-IV (APA, 1994). Five goals of assessment process include (1a) determine formal diagnosis, (2) ascertain severity and impact of substance abuse on the patient and those around him or her, (3) establish a baseline of status for future use, (4) provide a guide to treatment planning and patient’s progress, and (5) evaluate the impact of environmental influences and appropriate preventative efforts (Dozier & Johnson, 1998). Self-Report Instruments The ASI is the most widely used instrument in the field for both client assessment and research purposes. It is composed of 161 items assessing the patient’s status in six treatment-related life-problem areas: drug and alcohol use, medical problems, psychological or psy-

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chiatric problems, legal or criminal justice involvement, family and social relations, and employment and financial support. The Drug Abuse Treatment for AIDS Risk Reduction (DATAR) and the Index of Drug Involvement (IDA) are also widely used. Self-rating versus observation of opiate withdrawal (to be given in conjunction with one another) are determined through the Subjective Opiate Withdrawal Scale (SOWS), a sixteen-item scale completed by client, and the Objective Opiate Withdrawal Scale (OOWS), completed by an observer. TREATMENT PLAN

Two primary types of interventions include one that leaves the addicted individual drug-free and the other that successfully maintains and monitors the addicted client on drug medication (Dozier & Johnson, 1998). Detoxification is defined as a clinical process aimed at the relief of symptoms associated with the opioid abstinence syndrome while eliminating physical dependence; it normally takes five to seven days. Methadone is often used to prevent withdrawal symptoms during the process in a medical facility. Inpatient rehabilitation treatment began in the 1920s, and in the 1960s long-term residential therapeutic communities emerged. Therapeutic communities consist of a residential setting where opiate addicts engage in “intensive social therapy that lasts for about 9-18 months.” The group-centered approach is preferred and includes firm behavioral norms; reality-oriented group and individual psychotherapy that extends to lengthy encounter sessions; a system of clearly specified rewards and punishments; a series of hierarchical responsibilities, privileges, and esteem achieved by working up a ladder of tasks; and some degree of potential mobility from client to staff status. For opiate addiction treatment to be effective, four areas of functioning must be addressed: physical and medical, psychological or emotional, social or family, and spiritual (Dozier & Johnson, 1998). Outpatient drug-free treatment consists of a nonresidential form of therapy that does not use methadone or any narcotic antagonists and that varies in length and intensity. Methadone maintenance treatment is the most commonly used pharmacotherapy for heroin addiction, as well as the most controversial. It is designed to be used with clients who have serious addictions to heroin. One issue related to methadone treatment is the client’s continued or newly developed use of

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other nonopiate drugs and alcohol. Naltrexone treatment is nonaddicting and less costly than methadone is. Also, this treatment has little impact on the treatment community and is the most widely discussed in academic and research settings. Frequently, opiate addicts are also alcoholics, thus treatment should be designed to address both, in other words, polyaddiction treatment. Dual diagnosis and the term mentally ill chemical abuser (MICA) were developed to identify those patients with psychopathology who are primarily treated in substance abuse programs. Self-medication with opiates is common with varying psychiatric conditions and must be addressed. Examples of natural recovery include Charles Winich’s “maturing out” hypothesis and Lee Robins’s study of Vietnam veterans addicted to opiates. Although more research is needed, one study suggests that treating people who have supportive families and do not want treatment may be less effective than no treatment at all. According to Dozier and Johnson (1998) there is little empirical support for self-help groups, but much clinical evidence exists for the benefit of self-help groups. Examples include the traditional twelve-step programs (AA, NA). CASE STUDY

The Client Al is a twenty-six-year-old, white, middle-class, single male who has been inhaling heroin for the last four months. While in college, he began drinking heavily four or five nights a week. He then started smoking marijuana and taking “pills,” such as hydrocodone (Vicodin®). Although extremely intelligent, he began struggling with his courses and had to stay for three extra semesters to earn his degree in business administration. Once graduated, Al had a hard time finding a full-time job. He continued drinking heavily and taking pills, which escalated from Vicodin to oxycodone (OxyContin®). Approximately four months ago, Al reported that he began inhaling heroin because “it was easier to get than OxyContin.” He is now seeking help because he feels he is incapable of “sobering up” on his own. His family is extremely supportive and is encouraging treatment.

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The Worker She is a master’s level clinical social worker and has experience with substance abuse patients. She has extensive knowledge in the area of drug abuse, with extensive knowledge in emotional illness. She also has an above-average understanding of the various treatment modalities and sensitivity to the individual’s specific needs. ASSESSMENT

The ASI, the IDA (to be repeated intermittently), the SOWS, and the OOWS are the selected assessment instruments. Behavioral Definitions A. Maladaptive pattern of substance use manifested by increased tolerance and withdrawal B. Inability to stop or cut down use of mood-altering drug despite the verbalized desire to do so and the negative consequences of continued use C. Continued substance use despite persistent physical, legal, financial, vocational, social, or relationship problems that are directly caused by the substance use D. Increased drug tolerance as increased substance use is required to become intoxicated or to recall the desired effect E. Physical withdrawal symptoms when going without the substance for any length of time F. Aggressive or abusive behavior toward others when under the influence of the drug Short-Term Goals A. Describe the amount, frequency, and history of substance abuse B. Client and family members recognize physical and behavioral signs of drug abuse C. Identify the negative consequences of drug and alcohol abuse D. Family members recognize that the client’s drug abuse is the cause of family, school, and work problems E. Client and family members consent to participate in a treatment program to reduce the client’s drug abuse

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F. Family members and Al attend NA meetings. Short-Term Interventions A. Gather a complete drug and alcohol history, including amount and pattern of use, signs and symptoms of use, and negative life consequences. B. Provide information to Al and family members regarding the signs of drug abuse. C. Ask Al to make a list of the ways substance abuse has negatively impacted his life and process it with social worker. D. Assist the family in identifying problems in the home, school, or workplace that are precipitated by Al’s drug abuse. E. Guide Al and his family in identifying the consequences to each member when drugs are abused. F. Provide Al and family with information regarding the diagnoses, treatment, and prognosis for drug abuse. G. Assist Al’s family in identifying individual roles and responsibilities in his treatment. H. Review Al’s prescribed medications and schedules with him and his family members. I. Assess the level of care necessary to most effectively treat Al’s drug dependence, considering his chronicity of drug use, degree of physiological dependence, available support system, and previous treatment. J. Refer Al and family members to the appropriate level of care for his drug abuse problem. K. Refer Al to NA and the family members to Al-Anon. Long-Term Goals A. Accept powerlessness over and inability to manage mood-altering substances and participate in a recovery-based program. B. Improve quality of life by maintaining abstinence from all moodaltering substances. C. Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan. D. Eliminate work, school, or family problems precipitated by drug abuse. Describe the amount, frequency, and history of substance abuse.

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E. Increase fulfillment of duties and obligations at home and work. Long-Term Interventions A. Refer client to NAs and the family members to Al-Anon. B. Explore Al’s evaluation of the effectiveness of the currently prescribed medication regimen. C. Facilitate and monitor Al’s and his family’s follow-through on acquiring counseling services. D. Schedule regular contact with the family members to review progress. Pharmacotherapy It was the decision of Al and his family to refrain from using methadone treatment. They do wish to use Buprenorphine to prevent withdrawal symptoms and to block the effects of heroin so using heroin will not provide the “high” that would normally be expected. Relapse Prevention Al will regularly attend NA. Regular contacts will be scheduled with the family members to review progress, to provide information to Al and family members regarding the signs of drug abuse, and to encourage open communication regarding these issues. Al will be encouraged to change his social network interaction patterns so that he has fewer contacts with opiate users and more links with positive, nondrug-using role models. REFERENCES American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Dozier, C.D., and Johnson, J.A. (1998). Opiate abuse. In B.A. Thyer and J.S. Wodarski (Eds.) Handbook of empirical social work practice: Vol. 1. Mental disorders, pp. 223–242. Hoboken, NJ: John Wiley & Sons. Landry, M.J. (1995). Overview of Addiction Treatment Effectiveness (DHHS Publication No. SMA 96-3081). Washington, DC: U.S. Government Printing Office.

Chapter 23 POLYSUBSTANCE ABUSE IN TEENAGERS

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he following behavioral definitions, goals, and objectives were written for a teen whose diagnosis was Axis I: 304.80 Polysubstance Abuse, 304.30 Cannabis Abuse, 304.40 Amphetamine Dependence. BEHAVIORAL DEFINITIONS

1. A maladaptive pattern of substance abuse by increased tolerance and withdrawal 2. Inability to cut down use of mood-altering drug despite the verbalized desire to do so and the negative consequences of continued use 3. Continued substance use despite persistent legal, financial, social, and relationship problems that are directly or indirectly caused by the substance use 4. Arrests for substance abuse-related offenses (minor in possession, theft under $4,500) 5. Suspension of important occupational activities as a result of the illegal substance abuse 6. Large time investments in activities to obtain the substance, use it, or recover from its effects 7. Ingestion of medicine in larger dose than prescribed 8. Abuse of nonprescription drugs Note: Case study components, modifications for teens by Jason Miner.

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9. Aggressive or abusive behavior toward others when under the influence of the drug 10. Neglect of obligations within school, with friends, with the family, and at work 11. An irrational belief that happiness is best achieved through substance abuse LONG-TERM GOALS

1. Accept powerlessness over and inability to manage mood-altering substances and participate in a recovery-based program 2. Improve quality of life by maintaining abstinence from all moodaltering chemicals 3. Withdraw from mood-altering substances, stabilize physically and emotionally, and then establish a supportive recovery plan 4. Eliminate the misuse of prescribed or over-the-counter drugs and medications 5. Eliminate work, school, relationship, family, and social problems precipitated by drug abuse 6. Eliminate aggressive, violent, or abusive behavior due to drug abuse 7. Increase fulfillment of duties or obligations at home, work, and/or school 8. Create a plan to live a happier and healthier life without the need for abusing substances SHORT-TERM OBJECTIVES

1. Describe the amount, frequency, and history of substance abuse 2. Client and family members recognize the behavioral signs of drug abuse 3. Identify the negative consequences of drug abuse 4. Family members and client recognize the role of drug abuse in the client’s life, and each other’s roles in the treatment process 5. Family members and the client participate in NA meetings 6. Report absence of drug abuse in home, school and work environments, as well as giving reasons behind what factors kept the

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client from abusing drugs in those situation to better understand what factors help keep the client clean THERAPEUTIC INTERVENTIONS

1. Gather a complete drug history, including amount and pattern of use, signs and symptoms of use, and negative life consequences (social, legal, familial, and occupational) 2. Provide information to the client and family members regarding the signs of drug abuse (e.g. abusive or aggressive behavior during drug episodes; behavioral and personality changes that are evident with drug abuse) 3. Ask the client to make a list of the ways substance abuse has negatively impacted his life and process it with the therapist 4. Assist the family in identifying problems in the home, school, or workplace that are precipitated by the client's drug use 5. Assist the family in identifying individual roles and responsibilities in the treatment of drug abuse 6. Urge the client to adhere strictly to prescribed dosages of medication and to report honestly to the physician regarding the effectiveness of the medication 7. Schedule regular contact with the family members to review progress 8. Have client continue to attend group to learn life skills, information about drug abuse, how to create positive healthy relationships, share with other clients with other drug addictions, and instill hope into the client that life can be great without the use of drugs

Chapter 24 CHILD SEXUAL ABUSE

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ethany is a six-year-old girl who was brought to treatment by her mother, Elizabeth, who reported that a neighbor sexually molested Bethany. Historically, the neighbor cared for Bethany on evenings when Elizabeth worked late. Elizabeth states that she has frequently relied on the neighbor for childcare due to the role strain she experiences as a single mother. Elizabeth stated that Bethany gave an account of the abuse after she questioned Bethany about her reluctance to bathe before going to bed. Elizabeth described Bethany’s perpetrator as a fifty-five-year-old married man whom Bethany calls JoeJoe. Bethany reported that Joe-Joe used to give her a bath while his wife cleaned up the dinner dishes in the kitchen. According to Bethany, she no longer goes to Joe-Joe’s house because he “touched her so much it hurt.” Elizabeth recently received reports from the school that Bethany is sexually acting out by touching herself in front of her peers as well as using sexually explicit language inappropriate for her age. BEHAVIORAL DEFINITIONS

1. Bethany reports that she “has been touched so much it hurts.” 2. Bethany’s mother reports that Bethany has disclosed details about the abuse to her. A report has been filed with the local police department. Note: Case study by Katie J. Parsell.

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3. The mother reports that Bethany often withdraws from various activities, such as bathing, that are associated with her abuse. 4. The school reports that Bethany is behaving in sexually inappropriate ways. Her behavior includes inappropriate sexual dialogue and touching her genitals in front of her peers. LONG-TERM GOALS

1. Obtain immediate protection from all further sexual victimization. 2. Family members provide emotional support to the sexually abused child. 3. Eliminate all inappropriate sexual behaviors. All of the aforementioned goals focus on the long-term outcome of returning Bethany to her status as a fully functional six-year-old child. SHORT-TERM OBJECTIVES

Therapeutic interventions are listed according to each short-term objective. 1. Move to a non-abusive living environment. a. Monitor and support the client’s move to a safe environment. Meet with client and client’s family to encourage and reassure them and to answer questions. b. Monitor the client’s ongoing safety for any incidents or threats of further abuse. 2. Verbalize understanding of the need to contact legal authorities for self-protection. Explain to client and family why it is necessary to contact legal authorities to obtain protection from further abuse. Collaborate with children’s protective services agency about client’s case. 3. Parents provide emotional support to the victimized child. Involve parents in the assessment process and encourage their emotional support for the child. 4. Parents attend classes that teach effective parenting techniques and establishment of proper boundaries.

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a. Insist on and teach the need for proper boundaries between an adult and a child. b. Refer the parents to an effective parenting class. c. Monitor the client and family members to ensure that linkages to recommended treatment resources are made. 5. Verbalize agreement that responsibility for the abuse falls on the perpetrator, not on self. Provide a more reality-based view of the circumstances of the abuse when the client tends to take on blame for the abuse or excuses the perpetrator's actions. 6. Accept a referral to counseling to heal the emotional scars resulting from the abuse. a. Refer the client for a psychological evaluation to assess emotional and cognitive consequences of the abuse. b. Coordinate the client’s obtaining ongoing treatment for psychological problems resulting from the abuse. Refer the client to an appropriate counseling provider. c. Monitor the parents’ follow-through on obtaining necessary counseling services for the client.

Chapter 25 TEEN PREGNANCY

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he treatment planner was applied to an individual case: Judy, a junior in high school, is very involved in school extracurricular activities, on the cheerleading squad, student council, and the Fellowship of Christian Athletes (FCA). She was very distraught after taking a home pregnancy test to find that she was pregnant. Her doctor confirmed her pregnancy. The father is Judy’s boyfriend Chad, whom she has been dating for a little over a year. He has been very supportive and concerned for her. Both Chad and Judy told their parents together, and neither set of parents understood. Judy’s parents were the worst, and they told her she would need to move out and that they no longer would support her. Judy was not surprised by her parent’s behavior, based on their strong religious beliefs. Chad’s parents were very upset but did not make any threats. Both Chad and Judy are concerned about how they will care for their baby, especially without the support of their families. Neither has an after-school job because they are too busy with school activities. They decided together that abortion is not an option but have not decided whether to raise their child or go through adoption. Judy is very nervous and anxious all the time, especially about the future. She just does not know what to do.

Note: Case study by Christy Swansbrough.

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1. Pregnancy resulting from a long-term relationship with boyfriend 2. Relationship with the father of the unborn child is ongoing and supportive 3. Desire to complete the pregnancy but with feelings of confusion and anxiety regarding the future 4. Severe conflict in Judy’s family due to the pregnancy LONG-TERM GOALS

1. Obtain consistent prenatal care 2. Decide whether to keep the infant or release it for adoption SHORT-TERM OBJECTIVES

1. Identify Judy’s feelings about the pregnancy 2. List options and expected consequences for each response 3. Attend counseling sessions to help Judy cope with the stress of this new situation 4. Access medical and prenatal care on a consistent basis 5. Verbalize realistic expectations for life after delivery THERAPEUTIC INTERVENTIONS

1. Explore more of the facts and Judy’s feelings related to her becoming pregnant 2. Explore the future of Judy’s relationship with Chad, the father of the unborn child 3. Explore family dynamics that may have contributed to Judy’s behavior 4. Provide the client with a range of options regarding her pregnancy (i.e. adoption, keeping the baby) 5. Teach Judy problem-solving techniques (e.g. brainstorming and analyzing pros and cons for each; finding outside resources) that she can apply to her crisis to improve her decision-making

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6. Discuss the advantages of counseling and refer Judy for psychological counseling to assist in managing the stress associated with pregnancy 7. Refer Judy for medical and prenatal care 8. Provide parenting education or refer Judy for it if she plans to keep the baby 9. Assist Judy in setting realistic postpregnancy goals that take into account all the responsibilities of parenthood and caring for a totally dependent infant 10. Review with Judy all the options and potential resources for emotional and child care support after the delivery

Chapter 26 TEENAGE SEXUAL ABUSE

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eannie is currently fourteen years old, and was severely sexually abused by her grandfather between the ages of six and twelve. She was abandoned by her mother at the age of twelve and is currently living in foster care and has few support systems. Jeannie is very depressed and has attempted suicide. She is resistant to treatment and avoids discussing the issue of being sexually abused. She is currently in a safe environment, and her perpetrator is deceased. BEHAVIORAL DEFINITIONS

1. Self-report of being sexually abused 2. Depressed affect, low energy, sleep disturbance, and tearful spells 3. Agitation and irritability LONG-TERM GOALS

1. Overcome mood disruption and return to a sense of joy, peace, and security. 2. Live in a safe environment without fear of reprisal.

Note: Case study by Rebecca Hamrick.

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SHORT-TERM OBJECTIVES AND THERAPEUTIC INTERVENTIONS

1. Describe the details regarding the nature, extent, frequency, and perpetrator of abuse (within two months) a. Build rapport with the client through consistent eye contact, unconditional positive regard, warm acceptance, soft voice, conversation about nonthreatening topics, and expressions of reassurance regarding the client’s safety b. Slowly explore the details of the client’s abuse without pressing the client beyond her level of trust or capacity to cope c. Change the subject to less-threatening topics before gently returning for more open probing of the facts of the abuse 2. Verbalize agreement that responsibility for the abuse falls on the perpetrator, not on self (within two months) a. Confront the client for excusing the perpetrator and reinforce all statements that place clear responsibility for the abuse on the perpetrator b. Provide more reality-based view of the circumstances of the abuse when the client tends to take on blame for the abuse or excuse the perpetrators actions 3. Verbalize feelings toward the perpetrator of the abuse (within two months); Explore the client’s emotional reaction to the abuse, allowing for a free expression of feelings in an accepting atmosphere of support 4. Cooperate with an assessment of current mental status and need for antidepressants (within one month) a. Conduct a current mental status exam of the client to determine the level of psychiatric care immediately needed b. Refer the client to a physician for assessment of her need for antidepressants and/or inpatient treatment c. Educate the client about depression 5. Verbalize feelings surrounding the suicide attempt (within two months) a. Assist the client in identifying reasons for the suicide attempt b. Slowly explore the client’s feelings that led to the suicide attempt

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6. Demonstrate improved problem-solving and relaxation skills (within three months) a. Teach the client problem-solving skills (e.g. brainstorming and evaluating alternative solutions, discussing issues with others, and developing an action plan with small steps toward the goal) to assist her in identifying alternatives to suicide b. Teach the client techniques of deep breathing, muscle relaxation, and positive imagery as stress-reduction mechanisms 7. Establish a prevention plan in case suicidal ideation should return (within three months) a. Assist the client in identifying a plan to access immediate support (e.g. phone numbers for crisis center, social worker family member, and emergency room) in case suicidal ideation should return b. Develop a contract with the client for no self-harm and for contract with support services if suicidal urges return c. Provide the client with a local 24-hour crisis number and instructions on how to use the service

Chapter 27 OPPOSITIONAL DEFIANT DISORDER

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DD is a common clinical diagnosis that has attracted little research interest. As doubts about its validity as a distinct category remain, the diagnosis has undergone substantial changes from the DSM-III to the DSM-IV. Traditionally, children with any psychiatric condition were diagnosed with ODD and received traditional mental health services. Symptoms of ODD appear to be stable over time and have a developmental profile and sex distribution different from those of conduct disorder. The reliability of the diagnosis, however, is low. There is some support for ODD as a category that reflects an oppositional-aggressive psychological dimension, which is different from a delinquent dimension. There is little evidence for making ODD a part of the construct of conduct disorder and for making “lying” a criterion for it. Considerable impairment should be required for the diagnosis. A more detailed description of symptoms, including a threshold for considering them present, may increase reliability of the diagnosis. Hyperactive children are at risk for both juvenile and adult criminality. The risk for becoming an adult offender is associated with conduct problems in childhood and serious antisocial behavior (repeat offending) in adolescence. Hyperactive children who do not have conduct problems are not at increased risk for later criminality. Specific treatment for children with ODD is determined by the child’s (adolescent’s) physician based on: • the child’s (adolescent’s) age, overall health, and medical history • extent of the child’s (adolescent’s) symptoms Note: Case study by Carla Kimble.

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• the child’s (adolescent’s) tolerance for specific medications, proce-

dures, or therapies • expectations for the course of the condition • parent’s or caretaker’s opinion or preferences Treatment may include the following: • Individual psychotherapy for ODD often uses cognitive-behav-

ioral approaches to improve problem-solving skills, communication skills, impulse control, and anger management skills. • Family therapy is often focused on making changes within the family system, such as improving communication skills and family interactions. Parenting children with ODD can be very difficult and trying for the parents. Parents need support and understanding as well as developing more effective parenting approaches. • Peer group therapy is often focused on developing social skills and interpersonal skills. • Medication, although not considered effective in treating ODD, may be used if other symptoms or disorders are present and responsive to medication. PREVENTION OF OPPOSITIONAL DEFIANT DISORDER IN CHILDHOOD

Some experts believe that a developmental sequence of experiences occurs in the development of ODD. This sequence may start with ineffective parenting practices, followed by difficulty with other authority figures and poor peer interactions. These experiences compound and continue, and oppositional and defiant behaviors develop into a pattern of many behaviors. Early detection and intervention into negative family and social experiences may be helpful in disrupting the sequence of experiences leading to more oppositional and defiant behaviors. Early detection and intervention with more effective communication skills, parenting skills, conflict resolution skills, and anger management skills can disrupt the pattern of negative behaviors and decrease the interference of oppositional and defiant behaviors in interpersonal relationships with adults and peers and school and social adjustment. The goal of early intervention is to enhance the child’s normal growth and developmental process and improve the quality of life experienced by children or adolescents with ODD.

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MEDICATION

There have been some recent studies that have examined the effects of certain medications on ODD. All the research is preliminary and merely suggests that certain treatments may help. One study examined the use of methylphenidate HCl (Ritalin®) to treat children with both ADHD and ODD. This study found that 90 percent of the children treated with Ritalin no longer had ODD by the end of the study. The researchers skewed the results a bit; a number of children were dropped from the study because they would not comply with the treatment regimen. Still, if these children are included as treatment failures, the study still showed a 75 percent success rate. There have been two studies examining the effect of atomoxetine (Strattera®) on children with both ADHD and ODD. One study showed that Strattera helped with ODD; one study showed it did not help. CASE STUDY

The Client Casey, an eleven-year-old black female entered therapy with her mother, Lynne, who reported to the therapist that her daughter had “out of control behavior.” Lynne described her daughter’s behavior as talking back to her and fighting with adults and classmates (punching and slapping). Casey had slipped out of the house without permission, took the family car, wrecked it, and left the scene of the crime. She then hitchhiked back to her home and for four hours refused to tell her parents what happened to the car. Casey cursed her mother and revealed to her parents that a stranger gave her a ride home. Lynne is not sure what to do with her daughter at this point. She reported nothing seems to get her daughter’s attention. Lynne is at a loss to understand what is going on. Casey was placed on state juvenile probation and charged with possession of drug paraphernalia (marijuana pipe) and cigarettes at school. She has been to court four times since being placed on probation within the last six months. She also was charged as a delinquent for carrying drug paraphernalia to school and fighting at the alternative school. Casey reported that she has been using THC since age nine.

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Lynne stated she is aware that her daughter uses drugs but cannot make her stop using “the stuff.” Casey’s father is rarely at home because he has been working third shift at the factory. Casey refuses to take her medication for the diagnosis of ODD. She reported to her mother that the medicine makes her “sleepy.” Diagnostic Suggestions Axis I 313.81 Oppositional Defiant Disorder 312.9 Disruptive Behavior NOS 292.9 Cannabis-Related Disorder NOS

Chapter 28 ANTISOCIAL PERSONALITY DISORDER The Client Howard is an eighteen-year-old white male from an economically wealthy family. He was adopted at a young age and has had attachment issues ever since. The most prevalent of his problems is his incessant drug use and his fairly severe antisocial personality disorder. The more prevalent of the two is definitely his antisocial personality disorder, which is likely a cause for his drug use, problems in the legal system, issues with family and relationships, and aggressive behavior. Howard was having issues at school until he was expelled for drinking on school grounds. BEHAVIORAL ASPECTS OF ANTISOCIAL PERSONALITY DISORDER

Legal Involvement Definition Components 1. 2. 3. 4. 5.

Being involved in a criminal proceeding Recently having been in jail Being on probation Being charged with multiple felonies Being ordered to an intensive outpatient alcohol and drug treatment program by the court

Note: Case study by Jason Miner.

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Assaultive Behavior 1. Episodes of loss of control of aggressive impulses out of proportion of the situation and resulting in assaultive acts and/or destruction of property 2. Use of verbally abusive language intended to berate, intimidate, or hurt others 3. Failure to conform to social norms with respect to the law, as shown by repeated performance of antisocial acts that may or may not result in arrests 4. Refusal to follow rules, with the attitude that they only apply to other people 5. History of arrests and current court involvement 6. Abuse of alcohol and/or drugs 7. Consistent, aggressive challenges of authority Relational Problems 1. Lack of conflict-resolution skills leads to frequent disparaging, arguing, and detachment 2. Serious disputes between the client and family members often go unresolved 3. The client constantly challenges his parents’ authority 4. Issues in romantic relationships as a result of abusive language, belittling, and narcissism 5. Threatening family members and/or romantic partners Substance Abuse 1. A maladaptive pattern of substance abuse by increased tolerance and withdrawal. 2. Continued substance use despite persistent legal, financial, social, and relationship problems that are directly or indirectly caused by the substance use 3. Arrests for substance abuse-related offenses 4. Aggressive or abusive behavior toward others when under the influence of the drug 5. Neglect of obligations within school, with friends, with the family, and at work

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6. Suspension of important occupational activities as a result of the illegal substance abuse 7. Use of illegal drugs in the presence of children 8. Neglect of obligations with the family when using drugs LONG-TERM GOALS

1. All legal issues are resolved, probation requirements are met, and the client continues to stay out of legal trouble 2. Client is able to handle his anger in a more appropriate and constructive matter 3. Client learns a healthier means of communication 4. Client gains a better understanding of laws, authority, and the need for such establishments 5. Client discontinues the use of illegal drugs and alcohol 6. Client has a better understanding of the components of a healthy relationship 7. Client continues to take medication if deemed appropriate for him SHORT-TERM GOALS

1. Client verbalizes an understanding of the legal issues he is facing currently, as well as the issues he will face if he continues to perpetuate his behavior 2. Have client assessed in depth to be sure there is not also a reactive attachment disorder present 3. Have client assessed to see if medication is appropriate for him. 4. Client verbalizes an understanding of the requirements to complete probation, and follows those requirements 5. Client verbalizes an understanding that he has an aggression/anger problem, talks about the side effects that have resulted in key instances, and shows a desire to change. Client will describe better means to handle anger 6. Have the client’s family and romantic partners be involved in the group process for the healthy relationships and communication group

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7. Client verbalizes an understanding of his communication issues with family, friends, and romantic partners as well as shows a desire to change 8. Client verbalizes an understanding of the side effects of the drugs he is abusing, as well as takes responsibility for his actions INTERVENTIONS

1. Gather a complete drug history including amount and pattern of use, signs and symptoms of use, and negative life consequences (social, legal, familial, and occupational) 2. Provide information to the client and family members regarding the signs of drug abuse (e.g. abusive or aggressive behavior during drug episodes; behavioral and personality changes that are evident with drug abuse) 3. Point out instances of his uncontrolled, aggressive, impulsive, disrespectful expressions of anger and have him list the negative impact on him and others as a result 4. Role-play situations that have prompted uncontrolled anger expressions and substitute anger management techniques at critical times in the interaction (e.g. deep breathing, relaxation, and positive self-talk) DIAGNOSES

Axis I:

Axis II: Axis III: Axis IV: Axis V:

304.80 Polysubstance Abuse 304.30 Cannabis Abuse 305.00 Alcohol Abuse 305.30 Hallucinogen Abuse 301.70 Antisocial Personality Disorder None Family, romantic relationships, school, legal problems GAF 31

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ADDITIONAL COMMENTS

In the case of Howard, it is possible that although he may be compliant with the treatment plan, he would likely only be doing the things necessary to be released from treatment. If this is the case, Howard likely will relapse into his old ways of doing things. It is unfortunate, but in many cases the only place a person with antisocial personality disorder can get “treatment” is in the prison system. It is important that therapists empower the client to change and hope for the best, but at this point in time there is little evidence that those with antisocial personality are helped by treatment.

Chapter 29 PHYSICAL DISABILITY 1

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aurice’s problems stem from the difficulty of living with a physical disability caused by his severe hemophilia A (factor VIII deficiency). The physical disability is due to the lack of treatment available when he was younger and continued deterioration from lack of treatment when needed. Today, patients with hemophilia can use prophylaxis treatment to avoid bleeding into the organs and joints, which causes deterioration over time. Maurice did not have this available to him and in fact, the “medicine” he was given — cryoprecipitate — complicated his situation because it was tainted and he acquired hepatitis C. The last two behavioral definitions listed were included to help with understanding some of the other presenting difficulties, such as the lack of follow through on medical treatment regimen due to Maurice’s feelings of betrayal by those whom he trusted with his care. BEHAVIORAL DEFINITIONS • A medical condition for which the client is under a physician’s care • Constant chronic pain that is debilitating and depressing • Physical disability that limits freedom of movement and choice of

activity • Lack of follow through on medical treatment regimen • Resentment/anger toward medical professionals for complications of treatment Note: Case study by Melissa A. Chimenti.

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LONG-TERM GOALS • Follow-through with necessary medical treatment for physical mal-

ady • Access medical or psychological care available from community resources Short-Term Objectives and Interventions Objects 1. Describe the history, nature, and treatment of the hemophilia and hepatitis C

2. Manage pain with a combination of pharmaceuticals and relaxation techniques

3. Cooperate fully with ongoing prescribed medical treatment regimen

4. Comply with doctor’s orders for tests, medications, limitation, and/or treatments

Therapeutic Interventions 1. Gather a history of the patient’s medical condition 2. Assess the urgency of the patient’s need for medical care and take immediate action to obtain access to medical services, if necessary 3. Encourage patient to discontinue any alcohol consumption due to effects on presenting disorders 1. Refer patient to hematologist for an evaluation of pain medication needs and factor replacement therapy 2. Attend patient’s appointment as needed 3. Educate patient in relaxation techniques such as deep breathing to help cope with pain 1. Help patient understand his medical problem and the need to cooperate with the doctor’s recommendations 2. Reinforce the family members’ support of the client’s follow-through with the treatment regimen 1. Monitor patient’s follow-through and success with obtaining necessary medical care; redirect when necessary 2. Facilitate the patient’s obtaining medical treatment by encouraging patient to schedule appointments from therapist’s office 3. Provide financial assistance for travel to and from hospital Continued on next page

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(Continued) 5. Apply for medical insurance or government-subsidized medical services

6. Identify sources of social and emotional support and increase the frequency of these contacts

1. Teach the patient and family about community and government supported medical insurance and services the client is eligible for such as the State Hemophilia Program and Patient Services, Inc 2. Refer the patient and family to the proper social services agency to apply for Medicare and TennCare 3. Explore treatment options with patient and refer to gastroenterologist for discussion of Interferon treatment 1. (Refer patient to support group for men with hepatitis C)

Incorporating Maurice’s input to the treatment plan will assist in the development of the therapeutic alliance and will help gain a higher level of commitment and likelihood of adherence. The treatment plan will serve as a tool to keep both the patient and the therapist on track to goal attainment. The stated objectives will help Maurice understand the need to adhere to treatment, provide resources for access to that treatment, alleviate pain using various approaches, and provide psychosocial support by meeting with others in similar situations to enhance coping skills. DIAGNOSIS DETERMINATION

Maurice was ignoring the issues surrounding his refusal to follow treatment guidelines. Many of the difficulties he was experiencing, such as chronic pain and the limits placed on his activities, could have been prevented through adherence to infusion of factor concentrate. His lack of knowledge caused him to be unaware of new treatment therapies available with absolutely no risk of vial transmission. For these reasons, the Diagnostic Code of 316: Maladaptive Health Behaviors Affecting General Medical Condition was selected.

Chapter 30 PHYSICAL DISABILITY 2

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erry is a seventeen-year-old white male who is currently undergoing treatment for leukemia. He was formally very physically active, but the chemotherapy has left him with severe pain in both legs so that he is temporarily confined to a wheelchair. He presented in the pediatric oncology clinic with scars on his arm and confided to the supervising social worker that they were the result of his injecting the morphine that the doctor had prescribed for him to take orally. His mother informed the social worker and other clinic staff that she was frustrated and was, in fact, so angry and overwhelmed by both his drug use and his general negative, confrontational attitude that she did not want to take him home and instead wished to voluntarily place him in the custody of the Department of Children’s Services (DCS). Terry stated that he also did not want to go home, although he was visibly very emotionally upset by the events. In designing a treatment plan for Terry, it was decided to begin by addressing the substance issue, since the morphine and the resulting behaviors were what seemed to be causing him and his family the most immediate physical and emotional harm. Terry is currently hospitalized to give social services ample time to find an appropriate foster care placement. Therefore, assessing his behavior was difficult, although many staff members believed that he will show symptoms of withdrawal if he has been using as frequently as he claims. (He stated to the on duty social worker that he once “shot up” fourteen times in a twenty-four-hour period.) Upon release from the hospital, his ability Note: Case study by Katie Rash.

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to stop using, both intravenously and in excessive doses, must occur. Terry reported that he realized that he has a problem and needs help, and that if he cannot discontinue the injections on his own, that will be proof of as much. Terry definitely presented with the ingestion of medicines in larger doses than prescribed, and his mother also reported aggressive and abusive behavior while under the influence. Although he had some anger management issues in the past, she had witnessed a dramatic increase in recent weeks, including name-calling and verbal threats. Terry also neglected some obligations, most importantly the ingestion of his oral chemotherapy, which his mother told the social worker that he had refused to take for the past four days. Short-term objectives and long-term goals were set to assist Terry in the process of overcoming his drug problem. Short-term objectives included obtaining an honest self-report on the amount and frequency of Terry’s drug use. He had already informed the social worker that the problem has existed for nearly a month. Terry and his family were assisted in identifying physical and behavioral symptoms of the abuse. His biological family has a history of substance abuse, so they may unfortunately be all too familiar with the symptoms. If he is placed in a foster home, social work staff at the hospital are hopeful that it will be a specialized placement, with people trained to recognize and manage children who sometimes engage in unlawful and otherwise deviant behaviors. Terry’s home environment would also need to be inspected, which will be a customary procedure if he is placed in foster care, and may explain many of his difficulties if he is not. Terry previously resided with his mother, two brothers, sister-in-law, and nephew in a small trailer. Their home was at one time, and possibly still is, infested with cockroaches, as hospital personnel realized when he brought a PlayStation game system to the hospital on a visit and his room was subsequently infested as well. Terry’s mother also has a history of medically neglecting him, often failing to bring him in for scheduled appointments and forgetting to monitor and regulate his medication schedule. This may interfere with her understanding and agreeing to consent to participating in his treatment, but should he be placed in foster care, this should hopefully be somewhat easier to accomplish. Whether working with Terry’s biological or foster family, supportive services will be necessary for the opportunity to discuss their trials and frustrations without Terry present to prevent their worrying about his further hurting himself or impeding his progress.

Physical Disability 2

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Long-term goals for Terry include such typical ideas as helping him to accept his powerlessness over his prescribed medication and participate in a recovery program such as NA. This should assist him in maintaining abstinence, therefore improving the quality of his relationships and experiences. His hospitalization and extremely close supervision in foster care may allow him to withdraw and recover physically and will also help to eliminate the misuse of his prescribed medications. His family problems and aggressive behavior may be alleviated by the removal of substance abuse but will likely require additional therapy since these behaviors were in place prior to the reported start date of his substance abuse. Terry’s medication schedule should be monitored carefully by his legal guardian or other responsible adult until he can prove that he is able to maintain this responsibility by himself and not endanger himself by allowing for the likely relapse of his leukemia. In order to fulfill these goals and objectives, several therapeutic interventions were employed. It will be necessary to obtain a complete drug and alcohol history, provide information to the family, and ascertain the physical safety of Terry and those in his environment. Terry will make a list of the various ways that the abuse of his morphine has negatively impacted him, such as his family problems, his hospitalization, his transfer of custody, physical symptoms, and any others that he wishes to list. Because he already acknowledges that his drug abuse is a problem and wishes to stop, convincing him logically should not be difficult, although physically the task may be very draining. Since the problem has been brought to the surface relatively early, there is reason for optimism. His medication schedule will be reviewed with him, and he will be questioned as to whether or not he believes the current medications and dosages are effective. His feelings will be discussed with his physician, and he will be encouraged. Afterwards his reactions to the physician’s response and other options for pain management will be discussed with him. Terry is currently in a safe environment, the hospital, where the staff will not allow him to sedate or otherwise treat himself with his medication. It is hoped that his impending foster placement will be equally effective since DCS is taking the time and energy to find a medically appropriate home.

Chapter 31 DOMESTIC VIOLENCE BEHAVIORAL DEFINITIONS • Hitting, punching, or kicking client’s partner • Shoving, pushing, or scratching client’s partner • Behaving in a manner that causes police to be called to the home

in response to domestic violence • Throwing objects at client’s partner GOALS • Eliminate verbal and physical abuse • Complete group counseling focused on anger management and

domestic violence Short-Term Objectives and Interventions Objectives 1. Describe the history and nature of abuse.

2. Client agrees to rules for safe interaction with the partner.

Note: Case study by Marcy Sturgill.

298

Therapeutic Interventions Interview both partners separately as to the nature and history of abuse (i.e. verbal and/or physical: specifically, frequency and intensity). 1. Assist the client in developing a decision matrix for remaining in the relationship (e.g. what boundaries must be maintained, what changes must be made to promote safety, and what

Domestic Violence

299

(Continued)

3. Identify the physically and verbally aggressive acts that have been exhibited over the past year. 4. Client lists the triggers that escalate violence.

legal sanctions will occur if violence erupts). 2. If it is determined that the partners can remain together, outline the rules for interaction (e.g., no threats, insults, physical assaults, hitting, or weapons); solicit the client’s clear agreement with these rules. Explore and document instances of the client’s aggressive behaviors

5. List alternative coping responses to triggers to abusive behavior.

6. List relationships that have been broken or damaged because of physical and verbal aggression or abuse.

1.

2.

7. Client accepts and follows through with group treatment focused on anger management and domestic violence.

1.

2.

8. List the external sources of stress that raise the tension level within the relationship.

1.

Teach the client to recognize and list the escalating triggers for verbal and physical abuse and violence. Teach the client cognitive and behavioral coping mechanisms for thoughts and feelings that have historically triggered physical abuse (e.g. time-out, deep breathing, physical exercise, escalation avoidance procedure, and so forth) Review relationships that have been broken or damaged due to the client’s attitudes and behaviors. Confront the client’s lack of sensitivity to the needs and feelings of others. Monitor and reinforce followthrough with recommendations regarding psychological and relationship treatment; process and eliminate any barriers to access to mental health services. Contact court authorities regarding making the client’s attendance at treatment a compulsory part of sentencing or probation. Assist the client in identifying the external stressors (e.g. lack of employment, indebtedness, extended family issues, illness, or disability).

Diagnosis: 312.34 Intermittent Explosive Disorder

INDEX A AA (see Alcoholics Anonymous) Abilify®, 155 Abuse (see Sexual abuse) Addiction Severity Index (ASI), 114-115, 117, 265 Teen (T-ASI), 125 ADHD (see Attention-deficit/hyperactivity disorder) ADIS (see Anxiety Disorders Interview Schedule) ADVANCE, 40 Aggression, 21 see also Conduct disorder; Violence Agoraphobia definition, 187 and panic disorder, 186–195 see also Panic disorder; Phobias Al-Anon, 140, 269–270 Alcohol abuse assessment, 116–118 case study, 114–116, 123–125 and developmental disabilities, 12 treatment, 119–122, 125–126 medications, 122 see also Polysubstance abuse Alcohol-Specific Role Play Test (ASRPT), 118 Alcoholics Anonymous (AA), 133, 138, 141 American Psychiatric Association (APA), 6 Amphetamines (see Polysubstance abuse) Animals aggression toward, 21 fear of, 197 spiders, 203 Anorexia nervosa (AN) case study, 77–81 treatment medications, 79–80

relapse prevention, 80 see also Bulimia nervosa Antabuse®, 142 Antisocial personality disorder, 287–291 see also Borderline personality disorder Anxiety Disorders Interview Schedule (ADIS), 201–202, 230 for Children (ADIS-C), 57 Anxiety Sensitivity Index, 203 APA (see American Psychiatric Association) ASI (see Addiction Severity Index) ASRPT (see Alcohol-Specific Role Play Test) Ativan®, 205 Attention-deficit/hyperactivity disorder (ADHD) case study, 33–36 comorbidities conduct disorder, 22 developmental disabilities, 12 oppositional defiant disorder, 38, 45 definition, 33 treatment, 34–36 medications, 36 B BASIC, 40 Beck Adolescent Depression Scale, 169 Beck Depression Inventory (BDI), 14, 66, 163, 218, 230, 240 Beck Youth Inventories for Children and Adolescents, 14 Behavioral Avoidance Tasks (BAT), 201–203 Benzodiazepines bipolar disorder, 184 borderline personality disorder (BPD), 253 generalized anxiety disorder (GAD), 98 panic disorder, 194

301

302

Evidence-Based Interventions in Social Work

phobias, 205 polysubstance abuse, 142 PTSD, 235 see also Medications Bipolar disorder assessment, 175–176 definition, 173–174 intervention, 177–179 prevalence, 174 treatment medications, 182–184 relapse prevention, 181–184 therapies CBT, 178 electroconvulsive, 178–179 family-focused, 177 IPSRT, 177–178 BN (see Bulimia nervosa) Borderline personality disorder (BPD) case study, 253–257 definition, 245–246 diagnosis, 250–251 factors biological, 247–248 environmental, 248–249 suicide risks, 246–247 treatment medications, 253 relapse prevention, 255–257 therapies CBT, 251 dialectical behavior, 252 group, 251–252 see also Antisocial personality disorder Breathalyzer™, 118 Brief Psychiatric Rating Scale (BPRS), 148 Bulimia nervosa (BN) case study, 64–69 definition, 63 treatment, 70–75 medications, 73–74 relapse prevention, 74–75 see also Anorexia nervosa Bupropion, 18 BuSpar®, 98 C CADAS (see Council for Alcohol and Drug

Abuse Services) CAGE Assessment, 118, 254 Cannabis (see Polysubstance abuse) CBT (see Therapy) Child Assessment Schedule (CAS), 57 Children's Manifest Anxiety Scale, 57 Children's Separation Rating Scale (CSRS), 57 Clinically Administered PTSD Scale (CAPS-1), 229 Clozaril®, 155, 183 Cocaine (see Polysubstance abuse) Cognitive behavioral/processing therapy (CBT/CPT) (see Therapy) Cognitive restructuring (see Therapy) Cognitive-Somatic Anxiety Questionnaire (CSAQ), 203–204 Comorbidity anxiety disorders generalized (GAD), 94–95 separation (SAD), 54 bulimia nervosa, 65 conduct disorders, 22 and interventions, 7 personality disorders (BPD), 250–251 Compulsions (see Obsessive-compulsive disorder) Conduct disorder aggression, 21 case study, 22–23 deceitfulness, 21 definition, 20 etiology, 23 serious violation of rule, 21–22 theft, 21 severity, 20–21 treatment, 23–31 medications, 28–29 relapse prevention, 30–31 types, 20 Coping Scale, 66 Council for Alcohol and Drug Abuse Services (CADAS), 116–117 CPT (see Therapy) Criminal behavior domestic violence, 298–299 theft, 21 see also Conduct disorder; Violence CSAQ (see Cognitive-Somatic Anxiety Questionnaire) CSRS (see Children's Separation Rating Scale)

303

Index D Danger Ideation Reduction Therapy (DIRT), 214 DATAR (see Drug Abuse Treatment for AIDS Risk Reduction) DBT (see Dry bed training) Deceitfulness, 21 see also Conduct disorder Depacon®, 182 Depression (see Major depressive disorder) Desensitization, systematic (SD), 199–200 Desipramine, 98 Developmental disabilities (see Disabilities, developmental) DEVS-T (see Distress Evaluation Scale for Treatment) Dextroamphetamine, 36 Diagnostic Interview for Children and Adolescents (DICA), 56–57 DICA (see Diagnostic Interview for Children and Adolescents) DID (see Dissociative personality disorder) Dilaudid®, 264 DIRT (see Danger Ideation Reduction Therapy) Disabilities, developmental case study, 13–15 definition, 10–11 terminology, 10 treatment, 15–19 medications, 17–18 relapse prevention, 18–19 Disabilities, physical definition, 292 diagnosis, 294 hemophilia, 292–294 leukemia, 295–297 Disorders ADHD, 33–36 anxiety generalized (GAD) assessment, 96–99 cultural considerations, 101–102 development, 91–95 diagnostic criteria, 88–89 epidemiology, 89–91 medications, 98–99 signs and symptoms, 88 and social work, 102–105 therapy (CBT), 99–100 treatment, 96–99, 105–107

separation (SAD) case study, 55–61 diagnosis, 54–55 medications, 61 relapse prevention, 61 bipolar assessment, 175–176 definition, 173–174 intervention, 177–179 prevalence, 174 treatment, 179–181 medications, 182–184 relapse prevention, 181–184 conduct case study, 22–23 treatment, 23–31 medications, 28–29 relapse prevention, 30–31 dysthymic, 157–172 elimination, 48–51 intermittent explosive, 298–299 major depressive adolescents, 168–172 adults, 157–172 assessment, 162–163, 169 case study, 158–160, 168–172 treatment, 160–168 medications, 167, 172 relapse prevention, 166, 172 obsessive-compulsive case study, 210–212 treatment, 212–220 medications, 219–220 relapse prevention, 218–219 support groups, 219 oppositional defiant (ODD) case study, 39–41, 285–286 prevalence, 39 prevention, 45 in children, 284 risk factors, 38–39 treatment, 41–45 medications, 45, 285 panic and agoraphobia, 186–195 case study, 188–189 treatment, 190–195 medications, 194–195 relapse prevention, 193

304

Evidence-Based Interventions in Social Work

personality antisocial, 287–291 borderline (BPD) case study, 253–257 diagnosis, 250–251 etiology, 247–249 medications, 253 relapse prevention, 255–257 suicide risks, 246–247 treatment, 251–253, 255–257 dissociative (DID), 250–251 multiple (MPD), 250–251 PTSD assessment, 240 case study, 223–236, 236–239, treatment, 227–236, 240–243 medications, 234–236, 238, 242 relapse prevention, 234, 238 see also disorders by name Dissociative personality disorder (DID), 250–251 Distress Evaluation Scale for Treatment (DEVS-T), 203 Divalproex sodium, 29 Domestic violence (see Aggression; Violence) Down syndrome, 12 Drug abuse (see Polysubstance abuse) Drug Abuse Treatment for AIDS Risk Reduction (DATAR), 266 Dry bed training (DBT), 50–51 DSM-IV-TR (2000) anorexia nervosa, 77 bulimia nervosa, 63 disorders ADHD, 33 anxiety generalized (GAD), 88–89 separation (SAD), 54 conduct, 20–21 elimination, 48 major depressive, 157 obsessive-compulsive (OCD), 208–209 oppositional defiant (ODD), 37 panic, 186–187 personality, borderline (BPD), 245 PTSD, 222 mental retardation, 10–11 phobias, 196 polysubstance abuse, 129 Dysthymic disorder, 157–172

see also Major depressive disorder E Eating Disorders Inventory (EDI), 66 Effexor®, 98 Electroconvulsive therapy (ECT) (see Therapy) Elimination disorders case study, 49–50 definition, 48–49 treatment dry bed training (DBT), 50–51 medications, 51 relapse prevention, 51 Enuresis and encopresis (see Elimination disorders) Exposure and Response Prevention (ERP), 212–216 F Family-focused therapy (FFT) (see Therapy) Fear Survey Schedule (FSS), 201–202 for Children (FSSC), 57 Foster care, 80–81 Fragile X syndrome, 12 Full spectrum home training (FSHT), 51 E GAS (see Global Assessment Scale) Generalized anxiety disorder (GAD) assessment, 96–99 cultural considerations, 101–102 definition, 85–87 development, 91–95 epidemiology, 89–91 factors environmental/psychosocial, 93–94 genetic/biological, 92 diagnosis, 88–89, 94–95 and social work, 102–105 treatment, 96–99, 105–107 therapy (CBT), 99–100 Geodon®, 155, 183 Global Assessment Scale (GAS), 176 H Haldol®, 27–28, 154 Hamilton Rating Scale for Depression, 163

Index Home Observation for the Measurement of Environments (HOME), 14 Hypothalamic-pituitary-adrenal (HPA) function, 29 I Imipramine, 61, 98 Impact of Events Scale (IES), 230, 240 Index of Drug Involvement (IDA), 266 Insurance, 142–143 Intelligence quotient (IQ), 11, 38 Intermittent explosive disorder, 298–299 see also Violence Interpersonal and social rhythm therapy (IPSRT) (see Therapy) Interpersonal Sensitivity Measure (IPSM), 57 Interventions delivering, 5–6 effectiveness, 6–7 family, 150–151 location, 7 timing, 7–8 see also Therapy IPSM (see Interpersonal Sensitivity Measure) IPSRT (see Therapy) J Job-Club Program (Azrin), 8 K Kaufman Assessment Battery for Children, 11 Kiddie-Infant Descriptive Instruments for Emotional States (KIDIES), 57 Klonopin®, 205 LAADAC (see Social work) LCSW (see Social work) Loxitane®, 154 M Major depressive disorder adolescents, 168–172 adults, 157–172 assessment, 162–163, 169 case study, 158–160, 168–172 definition, 157

305

treatment, 160–168 medications, 167, 172 relapse prevention, 166, 172 see also Dysthymic disorder Manic depression (see Bipolar disorder) MAOI (see Monamine oxidase inhibitors (MAOI)) Marijuana (see Polysubstance abuse) MAST (see Michigan Alcoholism Screening Test) MDMA (see 3, 4-methylenedioxymethamphetamine) Medications alcohol abuse, 122 antianxiety, 184, 235 anticonvulsants, 182–183, 253 antidepressants anorexia nervosa, 80 bipolar disorder, 183 developmental disabilities, 17–18 generalized anxiety disorder (GAD), 98 major depressive disorder, 167 PTSD, 242 tricyclic, 235 antipsychotics, 154, 253 atypical, 154, 183 benzodiazepines bipolar disorder, 184 borderline personality disorder (BPD), 253 generalized anxiety disorder (GAD), 98 panic disorder, 194 phobias, 205 polysubstance abuse, 142 PTSD, 235 brands Abilify®, 155 Antabuse®, 142 Ativan®, 205 BuSpar®, 98 Clozaril®, 155, 183 Depacon®, 182 Dilaudid®, 264 Effexor®, 98 Geodon®, 155, 183 Haldol®, 27–28, 154 Klonopin®, 205 Loxitane®, 154 Mellaril®, 154 Meridia®, 238 Moban®, 154

306

Evidence-Based Interventions in Social Work Navane®, 154 OxyContin®, 267 Paxil®, 98, 183, 220 Prolixin®, 154 Prozac®, 220 Remeron®, 18 Restoril®, 205 Risperdal®, 155, 183 Ritalin®, 45, 285 Seroquel®, 155, 183 Stelazine®, 154 Strattera®, 45 Suboxone®, 122 Taractan®, 154 Tegretol®, 182 Thorazine®, 154 Tylox®, 226 Valium®, 205 Wellbutrin®, 18 Xanax®, 205 Zoloft®, 183, 220 Zyprexa®, 155, 183 bupropion, 18 desipramine, 98 dextroamphetamine, 36 disabilities, developmental, 17–18 disorders ADHD, 36 anorexia nervosa, 79–80 anxiety generalized (GAD), 98–99 separation (SAD), 61 bipolar, 182–184 bulimia nervosa, 73–74 conduct, 28–29 elimination, 51 major depressive, 167, 172 obsessive-compulsive, 219–220 oppositional defiant, 45, 285 panic, 194–195 personality, borderline (BPD), 253 phobias, 205 PTSD, 234–236, 238, 242 schizophrenia, 154–155 divalproex sodium, 29 imipramine, 61, 98 lithium, 182, 253 lithium carbonate, 27–28 MAOIs, 17, 167, 194, 235, 253

MDMA, 238 methadone, 266 methylphenidate, 36 naltrexone, 142 nortriptyline, 98 opiate abuse, 270 polysubstance abuse, 142 psychostimulants, 36 psychotropics, 51, 73, 204, 253 SSRIs bipolar disorder, 183 borderline personality disorder (BPD), 253 bulimia nervosa, 74 generalized anxiety disorder (GAD), 98 major depressive disorder, 167 obsessive-compulsive disorder (OCD), 219–220 panic disorder, 194–195 PTSD, 235 topiramate, 74 tranquilizers, 61 see also medications by name Mellaril®, 154 Mental retardation (see Disabilities, developmental) Mentally ill chemical abuser (MICA), 267 see also Polysubstance abuse Meridia®, 238 Methadone, 266 Methylphenidate, 36 Michigan Alcoholism Screening Test (MAST), 118 Minnesota Multiphasic Personality Inventory II (MMPI-II), 135 Moban®, 154 Monamine oxidase inhibitors (MAOI), 17, 167, 194, 235, 253 Motivational Stages of Change for Adolescents Recovering from an Eating Disorder (MSCARED), 67 Multimodal integrative cognitive stimulating therapy (MICST) (see Therapy) Multiple personality disorder (MPD) (see Dissociative personality disorder) N Naltrexone, 142

307

Index Narcotics Anonymous (NA), 133, 138, 141, 269–270 National Association of Social Workers (NASW), 6 National Institute for Alcohol Abuse and Alcoholism (NIAAA), 117 National Institute of Drug Abuse (NIDA), 128 National Institutes of Mental Health (NIMH), 64 Navane®, 154 Nortriptyline, 98 O Objective Opiate Withdrawal Scale (OOWS), 266 Obsessive-compulsive disorder (OCD) case study, 210–212 definition, 208 etiology, 209 treatment, 212–220 medications, 219–220 relapse prevention, 218–219 support groups, 219 Obsessive-Compulsive Inventory (OCI), 217–218 ODD (see Oppositional defiant disorder) Ontario Child Health Study (OCHS), 57 OOWS (see Objective Opiate Withdrawal Scale) Opiate abuse assessment, 265–266, 268–270 case study, 267–268 definition, 264 prevalence, 265 and social work, 265 treatment, 266–267 medications, 270 relapse prevention, 270 see also Polysubstance abuse Oppositional defiant disorder (ODD) aggressive/versatile onset, 37–38 case study, 39–41, 285–286 definition, 37 late onset, 37–38 prevalence, 39 prevention, 45, 284 risk factors, 38–39 treatment, 41–45 medications, 45, 285 OxyContin®, 267

P Panic disorder and agoraphobia, 186–195 case study, 188–189 definition, 186 treatment, 190–195 medications, 194–195 relapse prevention, 193 see also Agoraphobia Parent management training (PMT), 31 PARTNERS, 41 Paxil®, 98, 183, 220 Perceived Body Image Scale (PBIS), 67 Person-in-environment (PIE) paradigm, 103 Personality disorders antisocial, 287–291 borderline (BPD), 245–257 dissociative (DID), 250–251 see also disorders by name Phobias animals, 197 case study, 198–199 social, 196–206 specific, 196–206 subtypes, 196–197 treatment, 199–206 medications, 205 relapse prevention, 206 see also Agoraphobia; Panic disorder PMT (see Parent management training) Polysubstance abuse alcohol, 113–126 assessment, 116–118 case study, 114–116, 123–125 treatment, 119–122, 125–126 medications, 122 assessment, 134–135 case study, 129–133 definition, 129 teenagers, 271–272 marijuana, 39, 129–130, 271 opiates, 264–270 assessment, 265–266, 268–270 case study, 267–268 definition, 264 prevalence, 265 and social work, 265 treatment, 266–267

308

Evidence-Based Interventions in Social Work

medications, 270 relapse prevention, 270 teenagers, 271–273 treatment, 133–142 medications, 142 relapse prevention, 141 see also Alcohol abuse; Opiate abuse Post-traumatic stress disorder (PTSD) assessment, 240 case study, 223–243 definition, 222–223 treatment, 227–236, 240–243 medications, 234–236, 238, 242 relapse prevention, 234, 238 Pregnancy and alcohol abuse, 12 teenagers, 261–263, 277–279 case study, 13–19 definition, 278 treatment, 278–279 Present State Examination, 148 Prolixin®, 154 Prozac®, 220 Psychosocial Well-Being Scale (PWS), 117 PTSD (see Post-traumatic stress disorder) PTSD Symptom Scale (PSS-1), 229 Q Quality of Life Interview, 148–149 R Rape Aftermath Symptom Test (RAST), 230 Readiness To Change Questionnaire (RTCQ), 118 Remeron®, 18 Restoril®, 205 Retardation, mental (see Disabilities, developmental) Risperdal®, 155, 183 Ritalin®, 45, 285 S SAD (see Separation anxiety disorder) SASSI (see Substance Abuse Subtle Screening Inventory) SAT (see Separation Anxiety Test) SATSES (see Substance Abuse Treatment SelfEfficacy Scale)

Scales, assessment children Anxiety Disorders Interview Schedule for Children (ADIS-C), 57 Beck Adolescent Depression Scale, 169 Beck Youth Inventories, 14 Child Assessment Schedule (CAS), 57 Children’s Manifest Anxiety Scale, 57 Children’s Separation Rating Scale (CSRS), 57 Diagnostic Interview for Children and Adolescents (DICA), 56–57 Fear Survey Schedule for Children (FSSC), 57 Kaufman Assessment Battery for Children, 11 Kiddie-Infant Descriptive Instruments for Emotional States (KIDIES), 57 Motivational Stages of Change for Adolescents Recovering from an Eating Disorder (MSCARED), 67 Ontario Child Health Study (OCHS), 57 Teen Addiction Severity Index (T-ASI), 125 Wechsler Intelligence Scales for Children, 11 disorders Anxiety Disorders Interview Schedule (ADIS), 201–202, 230 Anxiety Sensitivity Index, 203 Beck Depression Inventory (BDI), 14, 66, 163, 218, 230, 240 Behavioral Avoidance Tasks (BAT), 201–203 Brief Psychiatric Rating Scale (BPRS), 148 Clinically Administered PTSD Scale (CAPS-1), 229 Cognitive-Somatic Anxiety Questionnaire (CSAQ), 203–204 Coping Scale, 66 Distress Evaluation Scale for Treatment (DEVS-T), 203 Eating Disorders Inventory (EDI), 66 Fear Survey Schedule (FSS), 201–202 Global Assessment Scale (GAS), 176

Index Hamilton Rating Scale for Depression, 163 Impact of Events Scale (IES), 230, 240 Interpersonal Sensitivity Measure (IPSM), 57 Minnesota Multiphasic Personality Inventory II (MMPI-II), 135 Obsessive-Compulsive Inventory (OCI), 217–218 Perceived Body Image Scale (PBIS), 67 Present State Examination, 148 Psychosocial Well-Being Scale (PWS), 117 PTSD Symptom Scale (PSS-1), 229 Quality of Life Interview, 148–149 Rape Aftermath Symptom Test (RAST), 230 Readiness To Change Questionnaire (RTCQ), 118 Separation Anxiety Test (SAT), 57 Setting Conditions for Anorexia Nervosa Scale (SCANS), 75 Social Adjustment Scale (SAS), 176 for Schizophrenics, 149 Spider Phobia Questionnaire, 201–202 Stanford-Binet, 11 State and Trait Anxiety Inventory, 230, 240 Test of Variables of Attention (T.O.V.A.®), 34–35 Thought Checklist, 203–204 Visual Analog Scale for Anxiety (VASA), 57 Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), 217 polysubstance abuse Addiction Severity Index (ASI), 114–115, 117, 265 Alcohol-Specific Role Play Test (ASRPT), 118 CAGE Assessment, 118 Index of Drug Involvement (IDA), 266 Michigan Alcoholism Screening Test (MAST), 118 Objective Opiate Withdrawal Scale (OOWS), 266 Subjective Opiate Withdrawal Scale (SOWS), 266

309

Substance Abuse Subtle Screening Inventory (SASSI), 135 Substance Abuse Treatment SelfEfficacy Scale (SATSES), 117 see also scales by name SCANS (see Setting Conditions for Anorexia Nervosa Scale) Schizophrenia assessment, 148–149 case study, 146–147 definition, 145 subtypes, 146 treatment, 147–155 medications, 154–155 relapse prevention, 151–152 SD (see Desensitization, systematic) Selective serotonin reuptake inhibitors (SSRI) bipolar disorder, 183 borderline personality disorder (BPD), 253 bulimia nervosa, 74 developmental disabilities, 17 generalized anxiety disorder (GAD), 98 major depressive disorder, 167 obsessive-compulsive disorder (OCD), 219–220 panic disorder, 194–195 PTSD, 235 Separation anxiety disorder (SAD) case study, 55–61 definition, 53 diagnosis, 54–55 treatment medications, 61 relapse prevention, 61 Separation Anxiety Test (SAT), 57 Seroquel®, 155, 183 Setting Conditions for Anorexia Nervosa Scale (SCANS), 75 Sexual abuse definition, 274–275 teenagers, 280–282 definition, 280 treatment, 275–276 SIT (see Stress Inoculation Training) Social Adjustment Scale (SAS), 176 for Schizophrenics, 149 Social phobias (see Phobias) Social work

310

Evidence-Based Interventions in Social Work

and GAD, 102–105 licensed Association of Alcoholism and Drug Abuse counselor (LAADAC), 133 licensed clinical social worker (LCSW), 56, 65, 133, 159–160, 175 and opiate treatment, 265 Sorensen Therapy for Instability in Mood (STIM), 181 SOWS (see Subjective Opiate Withdrawal Scale) Spider Phobia Questionnaire, 201–202 Spiders, 203 see also Phobias SSRI (see Selective serotonin reuptake inhibitors) Stanford-Binet, 11 State and Trait Anxiety Inventory, 230, 240 Stelazine®, 154 Strattera®, 45 Stress Inoculation Training (SIT), 231 Subjective Opiate Withdrawal Scale (SOWS), 266 Suboxone®, 122 Substance abuse (see Alcohol abuse; Opiate abuse; Polysubstance abuse) Substance Abuse Subtle Screening Inventory (SASSI), 135 Substance Abuse Treatment Self-Efficacy Scale (SATSES), 117 Suicide and borderline personality disorder, 246–247 and major depressive disorder, 167–168 Systematic desensitization (SD) (see Desensitization, systematic) T Taractan®, 154 Teenagers polysubstance abuse, 271–273 Teen ASI (T-ASI), 125 pregnancy, 261–263, 277–279 sexual abuse, 280–282 Tegretol®, 182 Test of Variables of Attention (T.O.V.A.®), 34–35 THC (see Polysubstance abuse) Therapy children, 8–9

cognitive behavioral (CBT) bipolar disorder, 178 borderline personality disorder (BPD), 251 bulimia nervosa, 66, 69–70 generalized anxiety disorder (GAD), 99–100 major depressive disorder, 160–161 panic disorder, 190–191 polysubstance abuse, 136–137 PTSD, 241 cognitive processing (CPT), 232 cognitive restructuring, 231 Danger Ideation Reduction Therapy (DIRT), 214 dialectical behavioral, 252 electroconvulsive (ECT), 178–179 Exposure and Response Prevention (ERP), 212–216 family bipolar disorder, 177 oppositional defiant disorder (ODD), 41 polysubstance abuse, 139–141 group borderline personality disorder (BPD), 251–252 bulimia nervosa, 74 oppositional defiant disorder (ODD), 41 polysubstance abuse, 137–139 schizophrenia, 151 interpersonal and social rhythm (IPSRT), 177–178 marital, 160–161 multimodal integrative cognitive stimulating (MICST), 151 psychotherapy, 41 schizophrenia, 149–150 Sorensen Therapy for Instability in Mood (STIM), 181 Stress Inoculation Training (SIT), 231

Thorazine®, 154 3, 4-Methylenedioxymethamphetamine (MDMA), 238 Thought Checklist, 203–204 Topiramate, 74 T.O.V.A.® (see Test of Variables of Attention) Tylox®, 226

Index V Valium®, 205 Violence, domestic, 298–299 Visual Analog Scale for Anxiety (VASA), 57 W Wechsler Intelligence Scales for Children, 11 Wellbutrin®, 18 X Xanax®, 205 Y Yale-Brown Obsessive-Compulsive Scale (Y- BOCS), 217 Z Zoloft®, 183, 220 Zyprexa®, 155, 183

311