[William O'Donohue, Scott O. Lilienfeld] Case Stud

Case Studies in Clinical Psychological Science This page intentionally left blank Case Studies in Clinical Psychological Science BRIDGING THE GAP FROM SCIENCE TO PRACTICE Edited by William O’Donohue Scott O. Lilienfeld 1 3 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trademark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016 © Oxford University Press 2013 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Case studies in clinical psychological science : bridging the gap from science to practice / edited by William O’Donohue, Scott O. Lilienfeld. p. cm. Includes bibliographical references and index. ISBN 978–0–19–973366–8 1. Clinical psychology—Case studies. 2. Psychotherapy—Case studies. I. O’Donohue, William T. II. Lilienfeld, Scott O., 1960– RC467.C367 2013 616.89—dc23 2012024765 ISBN 978–0–19–973366–8 1 3 5 7 9 8 6 4 2 Printed in the United States of America on acid-free paper We would like to dedicate this book with love to our mothers, Margery O’Donohue and Thelma Farber Lilienfeld. This page intentionally left blank { CONTENTS } Preface Contributors Introduction: Case Formulation and Clinical Science xi xiii xv WILLIAM O’DONOHUE AND SCOTT O. LILIENFELD PART I Childhood Disorders 1. Tailoring Parent-Child Interaction Therapy for Oppositional Defiant Disorder in a Case of Child Maltreatment 3 AMANDA M. N’ZI AND SHEILA M. EYBERG Commentary 17 PATRICK C. FRIMAN AND STACY SHAW Response 22 AMANDA M. N’ZI AND SHEILA M. EYBERG 2. Attention Deficit/Hyperactivity Disorder (ADHD) 25 KEVIN M. ANTSHEL Commentary 43 RUSSELL A. BARKLEY Response 52 KEVIN M. ANTSHEL 3. Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism: The Case of Jorge 54 W. LARRY WILLIAMS, ASHLEY E. GREENWALD, AND HOLLY A. SENIUK Commentary 77 MICHAEL E. KELLEY Response 81 W. LARRY WILLIAMS, ASHLEY E. GREENWALD, AND HOLLY A. SENIUK PART II Mood Disorders 4. Treatment of Depression PATRICIA J. ROBINSON Commentary 102 OLGA V. OBRAZTSOVA AND LAUREN B. ALLOY Response 106 PATRICIA J. ROBINSON 85 Contents viii 5. Psychiatric Treatment of Bipolar Disorder: The Case of Janice 109 JEFFREY J. RAKOFSKY AND BOADIE W. DUNLOP Commentary 128 W. EDWARD CRAIGHEAD AND ANJANA MURALIDHARAN Response 133 JEFFREY J. RAKOFSKY AND BOADIE W. DUNLOP PART III Anxiety Disorders 6. Panic Disorder with Agoraphobia: A Case Illustration with Treatment Decisions Informed by Clinical Science 137 JULIA R. CRANER, GEOFFREY L. THORPE, K. LIRA YOON, AND SANDRA T. SIGMON Commentary 157 NATALIE CASTRIOTTA AND MICHELLE CRASKE Response 164 JULIA R. CRANER, GEOFFREY L. THORPE, K. LIRA YOON, AND SANDRA T. SIGMON 7. Treatment of Complex PTSD: The Case of a Torture Survivor 167 RICHARD A. BRYANT AND ANGELA NICKERSON Commentary 190 BARBARA O. ROTHBAUM Response 195 RICHARD A. BRYANT AND ANGELA NICKERSON 8. Treatment of Social Anxiety Disorder: A Case Complicated by Panic Disorder 198 MILENA STOYANOVA AND DEBRA A. HOPE Commentary 221 RICHARD M. MCFALL Response 223 DEBRA A. HOPE AND MILENA STOYANOVA 9. Psychological Treatment of Obsessive-Compulsive Disorder: The Case of Cassie 225 JONATHAN S. ABRAMOWITZ AND BRITTAIN MAHAFFEY Commentary 241 DEBORAH C. BEIDEL Response 246 JONATHAN S. ABRAMOWITZ AND BRITTAIN MAHAFFEY PART IV Psychotic Disorders and Organic Brain Syndromes 10. The Initial Evaluation and Treatment of Schizophrenia and Related Psychotic Disorders BELINDA MCINTOSH AND MICHAEL T. COMPTON 251 The Treatment of Dissociative Identity Disorder: Questions and Considerations 329 STEVEN JAY LYNN. LIAM CONDON. BELLACK Response 277 BELINDA MCINTOSH AND MICHAEL T. COMPTON 11. FISHER Commentary 293 ANN M. GEORGE Response 297 CHRISTINA GARRISON-DIEHN. AND GEP COLLETTI PART VI Other Adult Disorders 14. LIAM CONDON. CLAIR RUMMEL. CLAIR RUMMEL. FRUZZETTI Response 327 SHIREEN L. AND JANE E.Contents ix Commentary 272 ALAN S. FISHER Personality and Dissociative Disorders PART V 12. AND GEP COLLETTI Commentary 352 HARALD MERCKELBACH Response 356 STEVEN JAY LYNN. STEFFEN AND NIKA R. Borderline Personality Disorder 301 SHIREEN L. RIZVI AND KRISTALYN SALTERS-PEDNEAULT 13. A Contextual Approach to Dementia Care in Alzheimer’s Disease 279 CHRISTINA GARRISON-DIEHN. AND JANE E. RIZVI AND KRISTALYN SALTERS-PEDNEAULT Commentary 323 ALAN E. The Use of Family and Individual Cognitive Behavioral Therapy with a Patient with Anorexia Nervosa 361 BARBARA CUBIC Commentary 393 CAROL B. Chronic Pain 402 ROBERT GATCHEL AND ROB HAGGARD Commentary 419 MELANIE DUCKWORTH Response 424 ROBERT GATCHEL AND ROB HAGGARD . PETERSON Response 400 BARBARA CUBIC 15. STINSON AND JUDITH V. STINSON AND JUDITH V. BECKER Index 459 . BECKER Commentary 448 TONY WARD Response 456 JILL D. Pedophilia: A Case Study in Empirically Supported Treatment 425 JILL D.Contents x 16. as clinical psychologists ourselves.” The case studies in this book nicely illustrate what Temple University psychologist Philip Kendall has termed “flexibility within fidelity”—using evidence-based treatment protocols as rough blueprints to be modified as necessary. evidence-based practice is in no way akin to “following a cookbook. The question. In the psychotherapy outcome literature.” The cases that follow demonstrate that sophisticated clinicians implementing evidence-based treatments make numerous individual judgments. This canard is commonly expressed by the critiques of evidence-based interventions: “I don’t want to follow a boring manual. with great care and forethought—decisions that are nonetheless guided and constrained by scientific evidence. “Does therapy x work?” is all too often answered in the affi rmative. for a broad array of clinical presentations. As such. contingency management. Regrettably. too little is done by our professional organizations to call attention to this problem and to remediate it.{ PREFACE } We chose to edit this book because we believed that it would benefit readers in several ways. we hope to underscore the complexity and richness of clinical cases. solely by a case example (“Well. skills-building interventions. The stimulating chapters that follow depict exposure therapies. By illustrating how evidence-based approaches can be put into practice. Certain professional organizations in particular are complicit in this benign neglect. actual cases are typically presented without . This is not the purpose of the cases that follow. behavioral activation. and cognitive interventions. this treatment seemed to work for my client. so it must be effective in general”). among others. we hope that this book will increase the likelihood that current and future practitioners will deliver them. Third. First. prioritizing the interests of dues-paying members who wish to practice their favored interventions and administer their favored assessment instruments over the interests of clients. Nevertheless. I want to think and make judgments. “Following the evidence” is not a mechanical or cookie-cutter process. This error has been a common one in our field. We should be clear that we are not presenting these cases as further evidence to support the claims of specific therapies’ efficacy or effectiveness. we are deeply concerned about the large number of professional psychological services sold and delivered that are not evidence-based. as each case is unique and has its own complexities. Second. we want to highlight the wide variety of evidence-based assessments and interventions available to clinicians. This is a preventable tragedy that often harms the very people we ought to be helping. we believe that these cases can serve as exemplars for clinicians to learn from and apply to their own cases. Clinicians and students ought to fi nd this diversity both interesting and challenging to master. . and abnormal psychology at both the graduate and advanced undergraduate levels should fi nd this book to be a valuable supplement to their other texts. we hope. We would like to thank a number of individuals for their assistance with this book. and students in training in all mental health professions (clinical psychology. will ultimately help—future clients. guidance.xii Preface much detail and are described only in the most abstract fashion. psychiatric nursing) will benefit from the cases and the stimulating back-and-forth discussions of treatment and assessment approaches presented here. we thank the clients whose courageous struggles comprise these clinical cases. This book should be of interest to a number of audiences. they permit them to see leading psychotherapy researchers apply these techniques skillfully to their own areas of expertise. Practicing clinicians. We would like to thank Linda Goddard and Olga Cirlugea for their help in the preparation of the manuscript. psychotherapy. clinical researchers. psychiatry. we thank our editor Sarah Harrington at Oxford University Press for her expertise. social work. In addition. and patience with us during this project. and whose life stories here inform—and. counseling. In addition. The chapters that follow enable clinician and student alike to observe fi rsthand the meaty details of evidence-based treatments and assessment procedures. instructors in clinical psychology. In addition. Finally. Compton The George Washington University School of Medicine and Health Sciences Boadie W. Craner University of Maine Lauren B. Antshel SUNY—Upstate Medical University Barbara Cubic Eastern Virginia Medical School Russell A. Fruzzetti University of Nevada. Fisher University of Nevada. Becker University of Arizona Deborah C. Louis Liam Condon Binghamton University (SUNY) Ashley E. Barkley Medical University of South Carolina. Alloy Temple University Michelle Craske University of California Los Angeles (UCLA) Kevin M. Reno Judith V. George University of Missouri-St. Beidel University of Central Florida Alan S. Reno Christina Garrison-Diehn University of Nevada. Reno Patrick C. Edward Craighead Emory University Robbie Haggard University of Texas at Arlington . Charleston Melanie Duckworth University of Nevada. Reno Robert Gatchel The University of Texas at Arlington Nika R. Abramowitz University of North Carolina at Chapel Hill Julia R.{ CONTRIBUTORS } Jonathan S. Dunlop Emory University Sheila M. Eyberg University of Florida Jane E. Bryant University of New South Wales Natalie Castriotta University of California Los Angeles (UCLA) Gep Colletti Binghamton University (SUNY) Michael T. Reno W. Greenwald University of Nevada. Bellack University of Maryland School of Medicine Richard A. Friman Boys Town and the University of Nebraska School of Medicine Alan E. Kelley Univeristy of Nebraska’s Munroe-Meyer Institute Barbara O. Rakofsky Emory University Shireen L. Rothbaum Emory University School of Medicine Steven Jay Lynn Binghamton University (SUNY) Brittain Mahaffey University of North Carolina at Chapel Hill Richard M. Seniuk University of Nevada. Robinson Mountainview Consulting Group Michael E. Steffen University of Missouri-St. Reno K. Stinson Fulton State Hospital Milena Stoyanova University of Nebraska—Lincoln Geoffrey L.Contributors xiv Debra A. Larry Williams University of Nevada. Hope University of Nebraska —Lincoln Patricia J. Sigmon University of Maine Ann M. Rizvi Rutgers University Clair Rummel University of Nevada. Peterson University of Minnesota Medical School Jeffrey J. Reno Kristalyn Salters-Pedneault Eastern Connecticut State University Holly A. Reno Stacy Shaw Boys Town Sandra T. Louis Jill D. Lira Yoon University of Maine . Thorpe University of Maine Tony Ward Deakin University W. McFall Indiana University—Bloomington Belinda McIntosh Emory University School of Medicine Harald Merckelbach Maastricht University Anjana Muralidharan Emory University Angela Nickerson University of New South Wales Amanda M. N’zi University of Florida Olga V. Obraztsova Temple University Carol B. 2008) and these useful analyses have often adopted a cognitive behavioral orientation. they leave unanswered a host of questions about the fundamentals of scientific case formulations. Nezu. if any. not all case formulation is scientific. so that a case formulation can be a little bit scientifi c or a lot? Are there any legitimate competitors to a scientific case formulation? Can there be more than one sound scientific case formulation for a given case? In this introduction.g. Haynes O’Brien. 2011. 1965). Proper case formulation is crucial. as opposed to unscientific? What are the advantages and disadvantages. we address these and other often unasked questions about case formulations. Nezu.. 1991). made little or no effort to control for confi rmation bias and a host of related biases (Lazarus. dismiss. and . Popper. as case formulation provides the blueprint and foundation for the professional’s behavior.Introduction CASE FORMULATION AND CLINICAL SCIENCE William O’Donohue and Scott O. The essence of a scientific approach is the ceaseless effort to compensate for confirmation bias. which would seem at least prima facie scientific. Freud’s case studies. 2004. Of course. of a scientific case formulation? Can a scientific case formulation be a matter of degree. or distort evidence that is not (Lilienfeld. This behavior. it first must be formulated along scientific lines. and safely. To the contrary. although beautifully written and ingeniously interpreted. bears direct implications for whether the client’s problem will be correctly diagnosed. Many thoughtful scholars have written about case formulations (e. Although we believe that these authors offer many valuable insights and helpful practical suggestions. the ubiquitous tendency to seek out evidence consistent with our hypotheses and to deny. Lilienfeld For a case to be conducted within the paradigm of clinical science. Freud often worked hard to fi nd any evidence that might rescue his clinical hypotheses from refutation. effectively. Persons. & Kaholokula. 2010. & Lombardo. in turn. These core questions include the following: How do we defi ne the key dimensions of the problem of case formulation? What does it actually mean to formulate a clinical case along scientific lines? What makes a case formulation scientific. properly and efficiently understood. Maguth. important) items while ignoring (many. (p. displayed an attitude of benign neglect to the problem of errors in our formulations. 61) The clinician is in a similar epistemic situation. Shoe size ought to be observed if and only if research shows that it helps define a problem (i. carefully observe.e. as well as friends and loved ones. The key question becomes: Of all the possibilities that the clinician can observe. virtually any piece of clinical data—for example. There is no such thing as purely “bottom up”—that is. The Meta-Questions of Case Formulation The prominent philosopher of science. for example. or is relevant to . because practitioners inevitably harbor theoretical preconceptions that influence their interpretation of clinical data. . in preparation). many) others. In contrast. clients. He or she cannot simply observe and directly “see” a case formulation. Physical medicine has been relatively proactive about defi ning medical errors and taking systematic steps to reduce them (see. including that this behavior is rather insignificant. and write down what you have observed!” They asked. an interest. of course. Observation is always selective.e. the list can go on and on. it is relevant to diagnosis) or helps to understand the cause a problem (i. the client’s parents’ shoe sizes and history of shoe buying. 1965) are the best candidates for constructing this list. He or she needs a focus—a point of view. history of shoe size. to use Popper’s words. a defi nite task. Sir Karl Popper (1965) once asked his students to conduct the following exercise: Twenty-five years ago I tried to bring home this point to a group of physics students in Vienna by beginning a lecture with the following instructions: “Take a pencil and paper. a client’s yawning during a therapist’s interpretation of her phobia—can be interpreted in a multitude of ways. what is the list of legitimate candidates that the clinician ought to observe. a point of view. and incorrect assessment methods and less effective or safe treatment methods can be administered.. A properly executed case formulation performs this winnowing function to allow the clinician to acquire a certain cognitive economy: He or she can focus on certain (relevant.. 2009). Gawande. It needs a chosen object. In other words. history of shoe buying. to be charitable.Introduction xvi efficiently treated. a problem. For the clinician can ask about the client’s shoe size. which can lead to what may be called psychotherapy errors (O’Donohue & Heaton. incorrect treatment goals can be pursued. those of us in clinical psychology have. theory-free—observation in psychotherapy. what I wanted them to observe. . can experience needless suffering. it is relevant to psychopathology). Without a sound case formulation. Moreover. and how can they be organized to inform practical behaviors that the clinician ought to pursue? Scientific research and scientific theories that have been corroborated by research relative to their competitors (Popper. . Clearly the instruction “Observe!” is absurd . If these relevancies are not found in research. one can see myriad possibilities. O’Brien. Again. such as dreams. it is an important process or outcome variable in psychotherapy). we argue that: 1. 2011.Introduction xvii treatment (i. then this construct can be ignored. 2004. This point is s critical. The form of a scientific case formulation is that of a sound deductive logical argument. At the same time. Persons. & Lohr. or ability to act in a certain way in a psychodrama. or authenticity. We agree with Popper . “major depressive episode. toileting experiences. to hold sway over assessment and treatment methods that have more scientific support (Lilienfeld. Nezu. although it is missing from other explications of what scientific case formulations are. so a meta-question is a higher level question).” “dry drunk. a sound case formulation answers the following meta-questions (by meta-questions we mean questions about questions. We also use the term meta given that the problem is reflexive: Information is needed to determine what information is needed. the practitioner should be able to shift to a different—and more clinically useful—focus. & Kaholokula. & Lombardo. a scientific approach is self-correcting. 2008). 2003). Other accounts can help clinicians to select such clinical issues as details in one’s drawings of a house. one that is in the client’s best interests and in which the therapist’s epistemic duties. and how should I make them? What are the client’s problems? How are these best described (What kind of constructs should I use—e. and castration fears.” “loss of attachment figure”?)? What are the key dimensions of these problems (How long have they been in existence? How severe are they?)? What are possible causes of these problems? Are these causes interrelated or independent? What are effective ways to treat the client’s problems? What are effective ways to prevent relapse? How confident am I in my conclusions about the above and regarding the following questions? Contra others who have written on case formulation (Haynes. More specifically. Lynn. often untested or tested and found to be inferior to other alternatives.” “sadness. such as the knowledge of which treatment approaches yield the best outcomes. Nezu. 1999).e.. The thesis of this work is that a scientific approach allows clinicians to rationally winnow these possibilities into a viable focus. Perhaps the central mistake in case formulation is to allow favored beliefs. so that if the initial focus of the practitioner turns out to be misleading or incorrect. • • • • • • • What information ought to be gathered in this case? What decisions do I as a professional need to make in order to determine which courses of action to pursue with this client.. Theories can assist clinicians to select dimensions on which to focus. Maguth. slips in speech. are best honored (O’Donohue & Henderson.g. such as assuming that a client who is similar in some ways to previous clients with Disorder X necessarily has Disorder X). These arguments. . the latter of which stem from the uncritical use of mental shortcuts or rules of thumb (Ruscio. clinicians need to be on guard against well-known biases and heuristic errors. 3. and so on. provided that these researchers can be clear about what constructs they are measuring. Introduction (1965) that science is a subspecies of rationality—and that formal logical arguments are the currency of rationality. in turn. and three component deductive arguments: one covering goals. There are multiple arguments that need to be formed. But the APA has often implied that far more is understood about the role of culture and professional knowledge in influencing psychotherapy outcome than is actually the case. 5. and other variables as they may arise in treatment). descriptive claims. and together these premises entail certain conclusions and courses of action. In addition. The premises of the deductive arguments contain responses to key questions of case formulation (see below). personality.xviii 2. the advantage of such arguments is that they can be explicated. This is particularly the case with the American Psychological Association’s (APA’s) fetish with cultural sensitivity (O’Donohue & Benuto. although virtually all would agree that it is important for therapists to remain attuned to cultural factors in therapy (just as therapists should remain attentive to issues of gender. political views. such as illusory correlation (seeing statistical associations in their absence) and an overreliance on the representativeness heuristic (judging a book by its cover. Scientific case formulation is not a mechanical process. In both cases. despite the lack of evidence that these are indeed relevant.” both of which are used in the APA’s ethical code. one assessment methods. indicating that the clinician needs to focus on these variables. As such. summaries of research. are interrelated. but involves clinical judgment. At times. the APA has precipitously encoded this ideological commitment into its ethical code. the APA is right to imply that culture and professional knowledge need to be investigated by researchers. but these have no formal rational connection. In our account of case formulation. one treatment methods. covering ethical claims. age. religion. However. 2007). There is one major meta-argument. For example. Other explications of case formulation suggest a list of considerations. and the nature of these premises are varied. 2011) and other vague constructs such as “professional knowledge. 4. there is presently little systematic evidence that tailoring interventions to cultural backgrounds results in improved treatment outcomes. and explicit reasoning increases accountability. they are premises of a sound deductive argument. namely. ideology rather than science has influenced case formulation. the clinician’s formulation of the case. each has multiple premises. Scientific case formulation is complex. for a further explication of quality improvement in clinical psychology). built bridges spanning wide expanses. In a classic statement of behavior therapy. progress has been made: We have cured diseases. guessing. such as intuition. McFall (1991) also argued that quality improvement data should be gathered to understand how the clinician can improve (see O’Donohue & Fisher. 2009. we have also made progress in understanding basic behavioral principles (e. This is because no case formulation process is without error. Popper pointed out that our tests should be “severe. Increased accountability is a central component of health care reform efforts. and the advice of gurus have repeatedly been found to be inferior methods for producing knowledge. Clinical cases ought to be conducted such that the clinician and even the client (as part of informed consent) have an explicit understanding of the case formulation and its soundness. Ullmann (1977) argued that therapy ought to be data-based and data-generating. Quality improvement is data-generating—data such as fidelity to treatment manuals. thereby enhancing client care. for several key reasons: 1. 1991.g. When we have applied science to human behavior. Science is intimately involved in error correction.” By that. O’Donohue & Fisher. 2009). When humans have applied science to problems. for key classic readings regarding this important point). It is a more severe test of the belief “Frank does not swear” to . 2012. client satisfaction. learning principles) and in developing applied technologies for ameliorating clinical problems (see the subsequent chapters in this book). Clinicians. put people on the moon. can and in fact do have erroneous beliefs. and quality improvement seeks to minimize error in the current case as well as in future cases. we have made the most progress. Prayer. Historically. When science has been applied to problems. The last point emphasizes that explicating a case formulation is crucial to holding health care professionals accountable.Introduction xix 6. just like everyone else. the scientific method has by far worked the best (see Lilienfeld & O’Donohue. and gained a deeper understanding of the structure and behavior of the universe. he meant that we should attempt to falsify our beliefs so that if we are wrong we fi nd this out efficiently. processes designed to identify errors in practice and eliminate them. unsystematic case studies. Scientific case formulation should take place in the context of systematic quality improvement processes (McFall. It can be problematic if the clinician cannot explicate the case formulation or if the explication shows faults.. WHY SCIENCE? Science is widely believed to be superior to other ways of generating knowledge. and magnitude of clinical change can all be collected and compared with benchmarks. namely. Science minimizes confi rmation bias and our love of and attachment to our most cherished beliefs by putting them to the test. “I want to quit smoking” (and the therapist agrees this goal is acceptable).Introduction xx observe Frank after he hits his thumb with a hammer or on the golf course than to view him in the church pew on Sunday morning. for example. If we think Therapy y is the most efficient and effective intervention for alleviating our clients’ problems when it is not. If 1. we can come to false conclusions about our client. all fall woefully short when it comes to producing enduring knowledge. gurus. 3. Therefore S is an appropriate treatment goal. 5. 5. 6 and ceteris paribus (all else being equal). Science provides us with knowledge that no other method can or has. 6. 8. Yet. 9. 4. The Key Arguments in Case Formulation Following O’Donohue (1991). S is not inconsistent with any overriding states of affairs that C wants to.” We will now explicate the deductive arguments that ought to serve as key components of the clinician’s case forumulation.g. C is informed about alternatives and the costs and benefits associated with achieving S. “You are suffering from obsessive-compulsive disorder and you ought to try to change certain behaviors. who argued that there is no viable alternative to science. and interesting narratives may all be useful in some cases as a means of generating intriguing hypotheses that can later be pursued in systematic research. In behavioral health care. clinical experience. we can cause them needless suffering. depression) when it is not. or should. then S is an appropriate treatment goal. FORMULATING TREATMENT GOALS There are two major ways in which treatment goals are determined: (1) the client decides on these. Client C wants to achieve state of affairs S. compared with science. we suggest that there are three major questions in the typical psychotherapy case: (1) What will be the treatment goals? (2) What assessment methods will be used? and (3) What treatment methods will be used? These will defi ne the major dimensions of the case. S is a morally permissible state of affairs. as they defi ne the desired goals and process of the case. for example. 2. 3. we can do harm to our clients if we hold false beliefs. . S is a practically feasible state of affairs. If we think Test x is valid for measuring a construct (e. 7.. Argument 1A: Client-Driven Treatment Goals 1. 4. or (2) the clinicians decides on them. Finally. Intuition. we agree with McFall (1991). Ceteris paribus. Variables influencing S or S itself are psychological/behavioral entities. obtain. 2. An are the proper assessment methods to use in this case. .Introduction xxi Argument 1B: Other-Driven Treatment Goals 1. . 12. . . 9. . . Therefore S is an appropriate treatment goal. . . 3. . then S is an appropriate treatment goal. 10. and consents to the gathering of this information by the use of these methods. Assessment methods A1 . In is sufficiently complete and comprehensive information about the principal dimensions of the case. . . 7. Ceteris paribus. Treatment goal G entails the realization of states of affairs S1 . Argument 3: What treatment methods should be used in this case? 1. Sn . fn are cost-efficient methods to obtain S1 . 6. Gathering information I1 . . Assessment methods A 1 . Therapist T wants information I1 . 5. An are cost-effective methods for gathering information I1 . 6. Gathering information I1 . . parent. O is informed concerning alternatives and the costs and benefits associated with achieving S. In is practically feasible. 9. . . Sn.g. In. Variables influencing S or S itself are psychological/behavioral entities. guardian). 2. If 1–8. F1 . Significant other O wants Individual I to be in state of affairs S. 8. S is a morally permissible state of affairs. . 10. 7. An are reliable and valid methods for gathering information I1 . In 2. 4. . . . An are the proper assessment methods to use in this case. . 3. S is a practically feasible end state. . In is morally permissible 4. C is fully informed regarding alternatives to gathering this information and these assessment methods. .. . 11. In. 3. I does not want to be in S. 5. In has been shown in well-designed research studies to be potentially relevant to the treatment of client C. . Some factor overrides I’s desire not to be in S. . . . . If 1–9 and ceteris paribus. . 8. Sn. . O is in some legitimate position in relationship to S that allows O to determine treatment goals (e. Information I1 . F1 . Ceteris paribus. 2. Argument 2: What assessment methods will be used in this case? 1. . S is not inconsistent with any overriding state of affairs that I should obtain. Information I1 . . 11. then assessment methods A1 . and ceteris paribus. Therefore assessment methods A1 . Fn are all factors that are known through well-designed research to be causally relevant to S 1 . . Assessment methods A z . If 1–5 and ceteris paribus. Fn-m are the proper treatment methods to use in this case. 5. Fn-m. . if the case has been properly assessed. Premise 6). . . F1 . then F1 . Premise 3—an example of this is whether changing a homosexual orientation in a client who desires to do so is ethically permissible). Therefore F1 . in Argument 2. . Empirical information concerning specific facts. 2. Fn-m are the proper treatment methods to use in this case. Premise 5). Therefore the client’s situation should show improvement. Client C is fully informed concerning alternative methods and the costs and benefits of these methods and consents to the use of F1 . 5. 4. F n-m are the proper treatment methods to use in this case. 3. the clinician must decide whether a treatment goal is ethically permissible (Argument 1.Introduction xxii 4. 5. Costs of assessment methods and treatment methods and alternatives must be considered (for example. Ceteris paribus. The therapist needs to understand what are valid inferences and what are error terms in various alternative assessment devices (for example. . and ceteris paribus. Sn. . Financial information. 6. in Argument 3. The Meta-Argument: The Clinician’s Case Formulation 1. 3. For example. Comments on the Nature of Case Formulations These arguments show that there is a wide variety of different types of information needed to make a complete and sound case formulation: 1. Psychometric information. 4. Premise 2). . . . Causal information. Ceteris paribus. in Argument 3. the clinician must assess the goals of the client (Argument 1. 7. . . An are the proper assessment methods to use in this case. . If appropriate treatment goals have been chosen. The means to desired ends must be determined (for example. . then the client problems should show improvement. F1 . Premise 1). 2. 6. In addition. . For example. there is one meta-argument that collects these sub-arguments and concludes that all of these cohere into a sound case formulation. Fn-m are the least restrictive methods to obtain S 1 . S is an appropriate treatment goal. and if the proper treatment methods have been competently applied. Moral and ethical knowledge. 8. McFall (in Chapter 8 of this volume) nicely summarizes these limitations. in addition. 7. the cases in this book are often amalgams of several cases or are partially disguised features due to concerns regarding confidentiality. views about meaning (What constitutes a good life?. There are strong regularities regarding electricity. or what are often termed the nomothetic and the idiographic. changed resistance by x amount. Structure of the Book WHY CASE STUDIES? We are presenting case studies of over a dozen clinical problems not because we believe that they add to the evidence base supporting these assessment and treatment options. Moreover. in Argument 3. It is the scientific established regularity—Ohm’s law—that provides the warrant for the electrician’s . One of the practitioner’s major challenges is how to translate the results of group studies. Well-conceptualized case studies can demonstrate how to apply nomothetically derived knowledge to the idiographics of a specific individual. case studies can be similar to what Kuhn (1970) meant by a paradigm —a problem-solving exemplar that can serve as a model for solving similar problems. Lloyd. that given that there is a scientifically established regularity known as Ohm’s law. The case study by itself certainly is not sufficient to demonstrate causal inferences regarding clinical methods or problem resolution. For example. Concerns about the over-reading of case studies would be correct if the electrician used her wiring experience with the hot tub as the primary kind of evidence to support Ohm’s law or to justify her future behavior regarding wiring. and doing so. The therapist must determine what is practically possible when informing the client about alternatives (for example. they are often of unclear generalizability to other cases. and what is morally acceptable also influence case formulations. Pragmatic information. Rather. in preparation). case studies are markedly limited in inferring cause-and-effect relations.Introduction xxiii 6. but at its best it can help to illustrate how one takes a scientifically supported regularity and applies it to a specific clinical case. like some published case studies. O’Donohue. In this way. The clinician’s ontology (What exists?). She says. such as randomized controlled trials demonstrating a treatment’s efficacy. our purpose in asking authors to present case studies was to illustrate how clinicians can bridge the two great clinical realms of general and the specific. & Lavin. Let’s say that an electrician uses such regularities and publishes an article showing how she used them to wire a particularly complicated house. Let us illustrate with an example. in wiring this hot tub I needed to increase the width of the wire. so these cases may not always mirror clinical reality precisely. to the idiosyncrasies of the individual case. Premise 5). Metaphysical claims. in effect. We understand the epistemic limitations of case studies. What cultural factors did you consider. What were your strategies for dealing with therapy problems (missed appointments. such as base rates and comorbidity. we asked authors to address the following dimensions in their case description: 1. What are the key principles/core knowledge that you use in initially approaching this case? Explicate principles from basic science. for what reasons? 6. we invited authors who were prominent contributors to the process and outcome literature for a particular clinical problem. But if the electrician cites Ohm’s Law. and how was it (if at all) informed by scientific evidence? 13. What is the “art” of this case. regarding law model scientific explanation). What ethical considerations came into play? 10. lack of commitment. and how is it evidence-based? What diagnostic issues arose. 1965. The Content and Format of the Book In developing this book. How did you deal with relapse prevention and termination? 12. and also shows the instantiation of this law in the wiring of the hot tub. In addition. We recruited authors who were well acquainted with the relevant research literature and its gaps. distortions. First.). and how did these direct case formulation? What did you rule out and how? What is your view of the psychometric standards (validities) of the assessment strategies that you decided to use? 3. 2. if any. What epidemiological considerations. she may instruct other clinicians on how to behave successfully when faced with a practical problem (see Hempel. What common “mistakes” did you work to avoid in treatment? 11. she is on reasonable epistemic grounds. How did you develop an assessment strategy in this particular case? What were key questions that you needed answered. How did you develop an intervention model for this case? What other interventions did you consider and reject. How did you deal with nonspecifics in this case? 7. etc. why and how did you handle these? 5. What would you have done if therapy wasn’t working like you thought it would? 9. To ensure that the chapters addressed similar clinical questions that often arise in treatment. came to play in diagnosing or case formulation? 4. 8. and what difference did these make? (if relevant in this case) . as well as informed about real world complexities of implementing the assessments and treatments. What was your initial case formulation.Introduction xxiv behavior. we followed a consistent game plan. how did you come by it. New York: Springer. Boston. J.. O’Donohue (Eds. Chicago: University of Chicago Press. 7. & Henderson. New York: Picador. W. O’Donohue. The practitioner’s guide to evidence based treatment (pp. 444–447. assessment strategies. 10–19. Haynes. O. Lilienfeld. . This lively and thought-provoking three-way interchange. We will see that.. 281–288. Behavior Change. O. and research interventions. S... & Kaholokula. C. Such disputes. A. Nezu. H. (2009). The structure of scientific revolutions. 24–37. Practice. O. NJ: Wiley. Research. although there is often broad consensus on fundamentals. Epistemic and ethical duties in clinical decision making. S. (2004). New York: Springer. K. J. E. L. (2003) Complications: A surgeon’s notes on an imperfect science. (2003). & O’Donohue. 28. Lynn.. S. In J. (2011). The Clinical Psychologist. K. McFall.. M. W.. Training. (2010). such as following a treatment manual in a formulaic way.. (1999). We are convinced that this is a caricature and that the interchanges to follow show why. 44(6). M. Fisher and W. Lilienfeld. choice of treatment goals. we believe. Science and pseudoscience in clinical psychology. Cognitive-behavioral case formulation and treatment design: A problem-solving approach. & Lohr.Introduction xxv In addition.. Problems with the construct of cultural sensitivity. 49. reflect healthy differences of opinion. E. & Fisher. Hempel. A plague on Little Hans and Little Albert. Manifesto for a science of clinical psychology. References Gawande. (2011). T. Lilienfeld.. New York: The Free Press.. Nezu. Lazarus. R.. W. 16. Scientific Review of Mental Health Practice. illustrates the dynamism of the clinical science approach. W. Great readings in clinical science: Essential selections for mental health professionals. O’Donohue. A. & Lombardo. (2012). S. O’Donohue. D. Aspects of scientific explanation. N. A. In turn. we asked other leading researchers to review the case study and to provide a brief commentary. O’Brien. (1970). we also afforded the original author(s) the opportunity to rejoin to this commentary. Psychotherapy: Theory. Can psychology become a science? Personality and Individual Differences. M. which in turn are the lifeblood of scientific progress in clinical science. W. (1991). Some have falsely characterized clinical science as dry and mechanical. 75–88. there are interesting disputes—possible fodder for future research—regarding diagnoses. to show that case conceptualization is not a mechanical process. A. J. T. Maguth. Behavioral assessment and case formulation. The role of quality improvement. (1991).). (1965). Kuhn. & Benuto. MA: Pearson. but that there are legitimate options at several choice points (and that reasonable people could disagree). C. New York: Guilford. we contend. 1–32). M. S. Hoboken. (1977). Winett. ix–xxvii). 14.). The Behavior Therapist. Conjectures and refutations: The growth of scientific knowledge. & W. Ullmann. Implications. Davidson (Eds. O’Donohue (Eds.. J. MacDonald. (pp. R. S. K. Practitioners are subject to the same judgment errors as everyone else. L. In M. & Heaton. R. . J. The case formulation approach to cognitive behavior therapy. P. A. What is a psychological intervention error? Persons. L. W. (2007). New York: Harper. The great ideas of clinical science: 17 principles that every mental health professional should understand (pp. (1991). (1965). 29–48 ). O’Donohue. The clinician as subject. T. New York: Taylor and Francis.). Popper. New York: Guilford Press. Behavioral approaches to community psychology. M. In S. March. O. New York: Pergamon Press. Ruscio. (in preparation).xxvi Introduction O’Donohue. Nietzel. Normative models of treatment decisions. (2008). 70–72. W. J. opportunities and responsibilities. Lilienfeld and W. Behavioral community psychology. { PART I } Childhood Disorders . This page intentionally left blank . Children under the age of 6 in the welfare system are particularly vulnerable to negative outcomes associated with multiple placements. Eyberg It is a myth that treatments following a manual look the same for all cases. He had also witnessed frequent physical abuse of his 3-year-old sister. and adaptive functioning delays (Clausen. N’zi and Sheila M. Chadwick. she had been concerned because he spoke very little and played alone for extended periods of time. These children are at higher risk than children in community samples for developing internalizing and externalizing psychological disorders. Marcus. school problems. . 1998. & Litrownik. Alvin had been confi ned in a high chair during most of every day. & Pears. Landsverk. aggressive behavior. including developmental delay (Fisher. posttraumatic stress disorder.{1} Tailoring Parent-Child Interaction Therapy for Oppositional Defiant Disorder in a Case of Child Maltreatment Amanda M. 2006) if maltreatment occurs on multiple occasions. although he had not himself been physically abused. The caseworker had sent case notes detailing a history of severe neglect.. Until he was removed from his biological mother’s home. social skills deficits. This case study illustrates how an empirically supported treatment may be substantially tailored to the needs of the family while maintaining treatment fidelity. The case notes indicated that when Alvin was placed with his grandmother. Key Principles/Core Knowledge In our initial approach to this case. avoiding interactions with both his grandmother and his sister. we drew on the literature describing the characteristics of children with histories of maltreatment. Burraston. Alvin is a 4-year-old African American boy who was initially referred by his caseworker for assessment of possible intellectual delay and for treatment of his behavior problems. 1991). 2005) and attachment disruptions (Baer & Martinez. which provides a functional analysis of Alvin’s behaviors and the conditions that maintain them. We planned to select standardized caregiver report instruments based on interview and observation data to help confi rm initial diagnostic hypotheses. Alvin’s oppositional behavior escalated. Alvin’s grandmother also elaborated on Alvin’s refusal to do what she asked. Alvin began excitedly playing with the toys. In the waiting room. She described some continuing concern about his unresponsiveness to her. Ginn.4 Childhood Disorders Assessment Strategy Based on information from the case notes. Because of the sensitive nature of the interview information. At the time we met Alvin and his grandmother. and in particular his refusal to let her hug him or show affection. we planned to administer the Wechsler Preschooler and Primary Scale of Intelligence III (WPPSI-III. Bhuyian. Alvin had learned to use utensils appropriately when eating and had gone from barely speaking when he fi rst arrived to having become a “chatterbox. Despite the many different strategies that were employed to engage him in formal testing. and quick to anger. easily annoyed. and he began screaming and resisting her efforts as she physically led him to the playroom. but he refused to sit at the table. During the clinical interview with Alvin’s grandmother. Alvin was playing with toys on the floor by himself. often lasting for as long as an hour or until she withdrew her demand. Please don’t make me have to feel bad. 2002). in press). as well as extreme irritation and bossiness toward his sister whenever she tried to join in his play or touch his things. Wechsler. We planned to use the clinical interview to elaborate and clarify the presenting concerns. . His grandmother walked over to him and explained sweetly. and having frequent temper tantrums). which involved severe temper tantrums in response to her direction. and then he progressed to more aggressive behaviors. Alvin had been in her home for three months. Once in the playroom. we asked his grandmother if she would be comfortable with Alvin playing in this room while we talked in the adjoining observation room. we planned to use the Dyadic Parent-Child Interaction Coding System IV (DPICS-IV. she attempted to pick him up. we identified the assessment domains to include clinical interview. He initially ignored requests from his grandmother to come with us to the examination room. she proudly reported that since coming to live with her. However. He willingly followed the therapist to the testing room. Eyberg. and structured behavioral observations. multimethod diagnostic procedures. & Boggs. Our initial assessment strategy was based on well-researched. To explore Alvin’s behavior problems and his relationship with his grandmother. To address the first referral question concerning Alvin’s intellectual functioning. Nelson.” Our initial assessment plan was to evaluate Alvin’s intellectual functioning to rule out intellectual disability. “It’s time to go with the ladies now Alvin. standardized testing. He tested many limits by repeatedly crawling under and jumping up from under the table.” After a minute. she confirmed the information from the case notes detailing Alvin’s significant history of neglect and his symptoms of oppositional defiant disorder (being noncompliant. so that we could keep an eye on him and talk freely. with highest scores on subscales of aggression and conduct problems. The therapist told Alvin that she had to step out for a minute to check on his grandmother. without acknowledging the presence of his grandmother. they’re for the other lady. Internalizing behavior problems were rated in the average range. administering standardized questionnaire measures to evaluate both (a) Alvin’s broadband psychological functioning. we asked the grandmother to let Alvin lead the play in the low-demand. Abidin. We thought it might be necessary to treat Alvin’s behavior problems before adequate intellectual testing could be accomplished. the therapist played with Alvin and collected informal observations of his behavior. Version 2 (BASC-2.” In the second DPICS-IV situation. She asked Alvin if he would like to draw with the crayons. He then made eye contact and asked. When his grandmother asked if she could play with the cars. Alvin responded. at the 70th percentile on the Parent-Child Dysfunctional Interaction subscale. using the Behavior Assessment System for Children. too. we introduced the three DPICS-IV standard situations that we would use to observe the interactions between Alvin and his grandmother. including Alvin’s primary presentation of anger and defiance as well as his diminished interpersonal and adaptive functioning. including the subscales of adaptability and social skills. Alvin ran up to the therapist and hugged her legs. child-led play situation. Alvin sat at the opposite end of the play table from his grandmother and again played enthusiastically with the cars. We continued with the assessment. and subclinical elevations on activities of daily living. On the PSI-SF. Reynolds & Kamphaus. Alvin stood and approached the therapist and continued to repeat statements such as “When are you coming back?” and “Are you coming back?” Alvin’s grandmother had fi nished her questionnaires and returned with the therapist to the playroom. Short Form (PSI-SF. “Are you leaving me?” Despite reassurance. and then described his car game to her in an animated manner. While Alvin’s grandmother completed these questionnaires. After a break. 1995). The therapist joined him by the cars and described his play. he created stories about the cars and continued his stories enthusiastically in response to the therapist’s comments. The information from these instruments provided initial hypotheses for our diagnostic formulation. and he said. Alvin’s grandmother’s scores were at the 35th percentile on the Parent Distress subscale. and at the 85th percentile on the Difficult Child subscale. 2004) and (b) his grandmother’s parenting stress. When invited to play with cars. Although Alvin didn’t make eye contact with the examiner. using the Parenting Stress Index. called parent-led play. “I need to put the cars through the carwash first. For the fi rst 5-minute observation.” The . “No.Tailoring Parent-Child Interaction Therapy 5 throwing papers off the table and attempting to rip pages from the test booklet. When they entered. The testing information also reflected the grandmother’s distress over Alvin’s behaviors and the quality of their relationship. His grandmother asked him many questions about his play. Alvin was immediately excited and eagerly pulled them out of the toy box. we asked the grandmother to choose the play activity. Results from the BASC-2 indicated clinically significant externalizing behavior problems. but Alvin did not respond to her inquiries. Lahey. stated warmly. high-demand situation. “Would you like to . suggesting that her distress was limited to concerns about his behavior. “okay”). Her praise and positive attention occurred both when she approved and when she disapproved of Alvin’s behavior. ODD is a highly prevalent mental health diagnosis among young children and one of the most common reasons for referral to child mental health clinics (Loeber.g. . his grandmother began putting the toys away and asked him if he thought it would be fun to see who could clean up the fastest. “The cars have to get dry. Alvin started screaming and throwing the toys at the toy box across the room. In the fi nal. “good”).. Alvin’s grandmother was asked to have Alvin put the toys away by himself. acknowledgments (e.. and unlabeled praises (e. we were able to rule out a diagnosis of pervasive developmental disorder. .g. American Psychiatric Association [DSM-IV-TR]. ”). 2000). Then can we draw?” and Alvin said. it was evident that Alvin also engaged in excessive familiarity with relative strangers and was often unforthcoming with his grandmother. and suggested highly permissive parenting. but when she became more insistent.” He responded to most of her commands with countercommands during this 5-minute observation. On the PSI-SF. BASC-2. Each of these brief verbalizations was repeated very frequently. The DPICS-IV data indicated that the grandmother’s primary verbalizations in all three situations were questions (including indirect commands (e. that’s good.. Burke. combined with his history of normal speech and motor development and the absence of stereotyped behaviors. Epidemiological and Contextual Considerations for Case Formulation The results of the psychological evaluation showed consistent evidence of oppositional and defiant behaviors across interview. “Okay. He did not comply with any of his grandmother’s indirect commands. based on the BASC-2 results of Alvin’s adaptive behaviors and our observations of his current developmental skills. There are neither psychometrically sound studies examining . After asking him once if he would like to clean up the toys.g.6 Childhood Disorders grandmother responded. Winters. & Zera. and behavioral observations of Alvin’s response to high-demand situations. In our observations of Alvin’s responses to the therapist and his grandmother. Despite our inability to complete intellectual testing. Because Alvin demonstrated with the therapist the ability to engage in appropriate social conversation and to initiate eye contact. cleanup. She continued to suggest ideas that might get Alvin to help. it is necessary to rule out intellectual delay and pervasive developmental disorder. You draw it. his grandmother’s results were within the normal range except on the Difficult Child scale. To diagnose RAD. we felt comfortable ruling out intellectual disability at this time. His history of severe neglect and his developmentally inappropriate social interactions suggested difficulties beyond those expected in ODD and were consistent with a diagnosis of reactive attachment disorder of early childhood (RAD. 2000). suggesting a diagnosis of oppositional defiant disorder (ODD). 2000). 2006).. The APSAC guidelines further indicate that the interventions should be short-term. Selecting an Intervention Model The challenge of selecting an evidence-based intervention for Alvin and his grandmother was to select an intervention that would address his diagnosis of ODD while maintaining sensitivity to his difficult attachment behaviors. Nelson. Although there is no intervention that has been identified as empirically supported for treating RAD. and should focus on increasing parental sensitivity. The conceptual foundation of PCIT is based broadly in the developmental and behavioral . parent-child interaction therapy (PCIT) is an intervention also identified as a “best practice” for helping children recover from the impact of abusive experiences (Chadwick Center on Children and Families. We then discussed the contrasting responses that Alvin showed to his grandmother and the therapist and explained that within the context of his history of maltreatment. PCIT outcome studies evidence increases in positive parenting skills and decreases in disruptive child behavior (Zisser & Eyberg. & Boggs.Tailoring Parent-Child Interaction Therapy 7 the diagnostic accuracy of an attachment disorder among maltreated children nor any evidence-based assessment instruments for this diagnosis (Chaffi n et al. Alvin had perhaps learned that caregivers could be more unpredictable and inconsistent in meeting his needs than unfamiliar adults. there is little systematically gathered epidemiological information on the prevalence. In addition. 2006). These guidelines indicate that the treatment for attachment problems should be based in both behavioral and attachment theories and should be evidence-based for the primary presenting problem of the child. 2004. 2011).. 2008). which might lead him to be less comfortable with caregivers and more willing to trust unfamiliar adults with whom he has not experienced such an unpredictable history (Howe & Fearnley. For these reasons. Thomas & Zimmer-Gembeck 2011. should involve the primary caregiver. Hanson & Spratt. 2004). and for this reason it was considered for Alvin’s treatment.. Case Formulation At the conclusion of the evaluation.. PCIT meets the American Professional Society on the Abuse of Children (APSAC) task force guidelines for treating children with attachment problems (Chaffin et al. Among these treatments. 2003). we selected PCIT as the treatment we would use in this case (Eyberg & Funderburk. We first commented that it was good she came in to seek help for Alvin’s behavior and that the assessment results indicated that his oppositional and defiant behavior was more frequent than that seen in most children of his age. 2006. we provided brief feedback to Alvin’s grandmother. incidence. 2010) and physical reabuse rates (Chaffin et al. There are at least five evidence-based parent training interventions for disruptive behavior in preschool-age children (Eyberg. 2012). or natural course of RAD that could be used to confirm our diagnosis (Chaffi n et al. In PCIT parents learn authoritative parenting skills during two sequential phases of treatment. The following week. As a result. His grandmother expressed initial hesitancy about treatment with us because of difficulties with transportation to our center and her own discomfort with navigating the unfamiliar environment of the large health science center. At the same time. using the Eyberg Child Behavior Inventory (ECBI. parents learn to follow their child’s lead in play by providing attention to positive child behavior. we established the plan for Alvin’s treatment. & Eyberg. 1999). PCIT is based on Baumrind’s (1966. Newcomb. combined with active ignoring of negative child behavior. 1993. alone. it would be important to involve her in treatment to establish the primary attachment relationship with the anticipated permanent caregiver. In this session. & Funderburk. Eyberg & Pincus. and behavioral observation of the caregiver’s treatment skills. caregivers learn to avoid intrusive verbal behaviors such . Fussell. using the DPICS-IV. McNeil. good communication. N’zi. which holds that authoritative parenting—a combination of nurturance. We arranged to see Alvin in a satellite clinic at their community center for treatment. Alvin’s Treatment At the feedback session. nurturing parent-child interaction called the child-directed interaction (CDI). and to become more emotionally available. the CDI teaching session. called the parent-directed interaction (PDI). expressing approval and enjoyment of the child’s ideas. Because Alvin was in a temporary guardianship arrangement with his grandmother. In the first phase. to create an empathic. thus creating a more secure caregiver–child attachment and reducing parent stress (Eisenstadt.8 Childhood Disorders literature. 2012). are assessed at the beginning of each session. behaviors. 1991) developmental theory. The results of these measures are graphed weekly and are reviewed with the caregivers at the end of each session. Eyberg. The caregiver’s report of the child’s behavior. The grandmother informed us that Alvin’s long-term placement plan was adoption by his grandmother due to the unstable psychological condition of his biological mother. the decision was made to proceed with PCIT including only Alvin and his grandmother. During the second phase of PCIT. to respond with greater warmth. and activities by describing and praising the child’s positive play behaviors and by reflecting (paraphrasing) the child’s comments during play. caregivers learn to follow the child’s lead in play with positive attention. parents learn to direct their child’s behavior when necessary and to provide consistent consequences. If there were a possibility of reunification with his biological mother. By providing caregivers with the skills to attend selectively to child behavior. the caregiver also learns to be more sensitive to the child. Alvin’s grandmother attended the fi rst PCIT session. PCIT is a performance-based intervention in which the caregiver’s skills and the child’s behaviors are monitored weekly to guide progress through treatment and to determine when treatment ends. it was important to explore the stability of this placement. and behavioral regulation—produces optimal child mental health outcomes. which included building towers with food cans from the pantry. the grandmother mentioned that Alvin did not have many toys besides his tricycle and football. when reviewing the kinds of toys that work best when practicing the skills at home. The therapist then has the caregiver begin practicing the CDI with the child while the therapist codes the interaction from an observation room. and describes the emotional and behavioral effects of each skill on the child. By coding. The therapist described some ways to make toys out of household items. the frequency of the caregiver’s skills during a 5-minute observation.1). by moving toy animals across the room to play there with them. commenting positively on the parent’s use of the new skills. The coaching sessions begin with a 5. One of the most effective kinds of coaching statements is a short. Near the end of the session. In these sessions. 2011. During observation of the CDI interaction. which showed that Alvin’s grandmother had practiced all seven days since the teaching session. In the CDI teaching session. such as how to use pots and pans in play and how to create a giant block set out of old cereal and oatmeal boxes. role-plays the skills with the parents. the caregiver and child practice the CDI skills together in the playroom while the therapist observes and coaches the caregiver from an observation room.g. labeled praise. or tallying. commands. Coaching in CDI becomes slightly more directive after one or two coaching sessions. such as “Nice description!” or “Excellent behavior to praise. He remained distant from his grandmother. although she continued her indiscriminate use of unlabeled praise. All subsequent sessions in the CDI phase of treatment are called CDI coaching sessions. For example. we reviewed the PCIT homework sheet (Eyberg & Funderburk. the therapist can assess the progress made since the previous session and can determine which skills to focus on during coaching. many negative child behaviors drop away during the CDI. the therapist demonstrates the individual skills of the CDI. it can be tempting to give corrective feedback.” after the caregiver uses a CDI skill.Tailoring Parent-Child Interaction Therapy 9 as questions. though. the grandmother increased her use of labeled praises from zero at the pretreatment assessment to five and decreased her questions from 53 to 20. Through the behavioral mechanisms of modeling and differential social attention. and criticism.. “You could praise him for sharing with you”) to help caregivers notice cooperative behaviors. the therapist initially focuses on following the caregiver’s lead. Our . a therapist might suggest that the caregiver praise a particular behavior (e. and the parent-child play begins an upward cycle of mutually reinforcing and responsive interactions. see Figure 1. the therapist took time to discuss all of the comments that Alvin’s grandmother had written and to praise the good toy and activity choices she had come up with. To reinforce the importance of daily homework practice. but we maintained the focus on the grandmother’s positive use of the skills while ignoring mistakes. which can give attention to and increase negative child behaviors. At the first CDI coaching session. when caregivers are comfortable with the procedure. Alvin directed more of his play talk to his grandmother during this observation than at the pretreatment assessment. When coaching the CDI.to 10-minute check-in when the therapist and caregivers review the CDI homework and the child’s behavior during the previous week. just as the caregiver follows the child’s lead in the CDI. When coaching in this session. Alvin’s grandmother continued to practice homework daily. rather than commenting that she still asked many questions during the play. CDI Homework Sheet goals in this session were to increase the frequency of her CDI skills and to model the interaction skills that she was learning to use with her child.10 Childhood Disorders CDI Homework Sheet Mother ____ Father ____ Child's First Name ____________________ Did you spend 5 minutes in Special Time today? Date Yes Problems or questions in Special Time Activity No Monday ________________ Tuesday ________________ Wednesday ________________ Thursday ________________ Friday ________________ Saturday ________________ Sunday ________________ FIGURE 1. When reviewing the observation data with Alvin’s grandmother at the end of the session. When discussing homework for the next week. we emphasized her improvement in decreasing questions. and at the second CDI coaching session she described continued improvements in his behavior at home. She mentioned that Alvin had started talking to her more at home also.1. including fewer temper tantrums during the week. During the 5-minute . as well as our observation that Alvin spoke to her somewhat more this week. Alvin’s grandmother decided to focus on increasing her reflections of Alvin’s speech because he seemed to enjoy it during coaching. The therapist pointed out the connection between this change and the grandmother’s consistent homework practice and commented that her practice seemed to be reflected on her ECBI graph as well. Alvin’s grandmother dramatically increased her labeled praise of Alvin’s positive opposite behaviors. she demonstrated improvement in the frequency of her reflections.e. The therapist prompted his grandmother to praise him for playing with her at the table. the grandmother increasingly caught her own questions mid-stream or before.” After coaching for only a few minutes. The therapist also coached the grandmother to ignore Alvin’s bossy statements. and Alvin helped her move the toys. his grandmother was beaming. and his “directions” were stated more matter-of-factly than with anger. . restating them as CDI skills. “I went to bed fast!” with a big smile on his face. She asked if the grandmother would find it helpful or annoying if the therapist signaled her over the “bug” each time she heard the grandmother ask a question. Alvin continued to increase the frequency of comments he directed to his grandmother about the play.e. he sat closer to her. getting ready slowly) and that she had used one of the best kinds of praise to help Alvin change his behavior. Alvin’s grandmother was catching most of her questions.” after which the grandmother would attempt to restate the question as a statement. rather than “telling” her what to do. Notably he was “asking nicely” more often for his grandmother to join his play in a particular way. The therapist pointed out that the grandmother had used a “positive opposite praise” (i. and he did not move away. including comments he made that were bossy or that contradicted something she had done. During subsequent coaching. and Alvin said to the therapist. The therapist asked the grandmother what she thought had contributed to this change. During the DPICS-IV observation of their interaction. While in the room. like sharing. When Alvin and his grandmother came to the third CDI coaching session. The therapist gave the grandmother feedback about her use of the word “good” and said that today she was going to focus coaching on labeling her praises for behaviors that she wanted to see again.. and Alvin became increasingly engaged with his grandmother in play. The grandmother expressed enthusiasm. She reported that Alvin had gotten ready for bed without a temper tantrum for the last three days. Still.Tailoring Parent-Child Interaction Therapy 11 coding. The grandmother agreed. she shifted uncomfortably while sitting on the floor. to help the grandmother become more aware of them. but her questions remained high and she often did not seem aware of asking a question. the therapist entered the playroom to praise the grandmother for following Alvin’s lead by moving to the floor to play next to him and asked if she would be more comfortable if some of the toys were moved to the table. However. such as telling her to put a toy in a different place than she had. His grandmother joined Alvin to play on the floor. and the plan was made for the therapist to signal by saying “question. the therapist told the grandmother that reducing questions would be a focus of today’s coaching. and she had also increased her labeled praises to 5.. and the grandmother mentioned that she had been praising Alvin for getting ready quickly each time he did it. going to bed quickly) instead of focusing on the problem behavior (i. Before coaching began. and it seemed that her discomfort was affecting her ability to focus on the treatment skills. Even though Alvin continued to tell his grandmother what to do. she continued to use the unlabeled praise “good” indiscriminately in response to many of Alvin’s comments. often by praising her for staying quiet (“good ignoring”) before she had the chance to say “good. and she had almost achieved the CDI mastery criteria. Her improved mood at the end of the session may have helped her work more effectively with the social worker. Instead of using the session time to process the distressing event or attempting to help the grandmother problem-solve a solution. they were noticeably higher than they had been the week before. she also noted that Alvin’s behavior problems had increased. and his grandmother appeared distraught. who was able to obtain emergency funding. the therapist described this pattern to the grandmother and used motivational enhancement strategies to facilitate the grandmother’s commitment to resuming special time practice sessions each day. The warmth of the interaction was qualitatively improved as well—they laughed together in session. she described losing her social security check and began to elaborate on the consequences of losing this check. the therapist observed that Alvin’s grandmother had to ignore negative and bossy statements more often than in recent sessions. Alvin’s grandmother’s skills had greatly improved from previous weeks. The therapist responded empathically to her concerns and then told her that at the end of the session she would connect her with the social worker at the community center who arranges emergency funding services. and she expressed more confidence in her ability to manage his behavior by using the skills throughout the day as well as during their special time. and she reflected on his requests as both a positive sign and an indication that their one-on-one time was important for preventing their progress from backsliding. The therapist discussed the importance of thinking about her and Alvin’s progress towards meeting their treatment goals in order to re-evaluate their treatment plan during the next session. As the therapist had anticipated. and Alvin rested his head on his grandmother’s shoulder when she told him she was proud of how polite he was being. At the sixth CDI coaching session.” During coding and coaching. In the fifth CDI coaching session. during the seventh CDI coaching session. This pattern on the ECBI graph often reflects a decrease in homework practice. The grandmother’s ECBI score had reached the criterion level for treatment termination. She ignored his three bossy statements effectively and Alvin did not give his grandmother any direction for how to play during the second half of the session. Alvin did not pull away when she put her arm around him. The therapist pointed out that she was very close to mastery of the CDI skills and that her description of Alvin’s behavior on the ECBI placed his behavior well into the normal range at this point in treatment already. Alvin’s grandmother said that Alvin had asked to have special time a few times. The grandmother’s CDI skills had continued to improve during the previous week and during in-session coaching. When she scored the ECBI. the grandmother brought in a blank homework sheet and stated that she had practiced special time only twice in the past week because she was “just using the skills all day long. Her ECBI ratings of . During the review of the ECBI graph. and although they were still below the clinical range. During the check-in. the therapist found a way to refocus the grandmother on the session goals and avoid derailing the child’s progress.12 Childhood Disorders Alvin and his grandmother arrived 10 minutes late to the fourth CDI coaching session. This interaction illustrates another common trap that the therapist avoided. Alvin’s grandmother met mastery criteria for the CDI skills. Dealing with adherence issues was evidenced by the therapist’s response to homework noncompliance in the fi fth CDI coaching session.” The therapist discussed the importance of continuing daily special time and scheduled a follow-up call with the grandmother in one month to check on their continued progress. the therapist decided to recommend not moving into the PDI phase of PCIT. A concrete plan was established for maintaining gains. Because she was able to manage his behavior adequately with positive attention and active ignoring. . This case also illustrated ways in which the therapist was able to avoid common mistakes that can harm the therapeutic alliance or therapy progress. the therapist validated her concerns. The therapist also let the grandmother know that she could contact her before their scheduled follow-up call if she had any concerns about Alvin’s behavior. For example. in addition to praise for compliance. Ethical considerations were demonstrated when the therapist explored the long-term custody arrangements with the grandmother to ensure that treatment intervention established an attachment relationship with the caregiver most likely to be permanent. the time-out procedure is usually emotionally distressing initially. The therapist discussed these issues with Alvin’s grandmother. enhancing the grandmother’s motivation to complete homework consistently (see Figure 1. as shown by holding sessions at an easily accessible facility in the grandmother’s community to reduce fi nancial burden. but maintained focus on the established treatment goals. and she continued to report confidence in managing his few remaining behavior problems. still developing attachment relationship between Alvin and his grandmother. The therapist considered potential advantages and disadvantages of this second phase for Alvin and his grandmother.Tailoring Parent-Child Interaction Therapy 13 Alvin’s behavior at home continued to be within the average range for children his age. Highly important process issues arise when addressing treatment termination and relapse prevention. Consideration of cultural factors in this case were highlighted by the therapist’s sensitivity to the caregiver’s socioeconomic situation. in which caregivers learn to set fair but fi rm limits and to follow through on their rules with a timeout consequence for noncompliance. and a follow-up call was scheduled to monitor progress and prevent relapse. who agreed and added that she felt that she and Alvin had met their treatment goals and were “ready to graduate. With the recent. Review of General Therapy Process Many nonspecific issues common across all treatments were exemplified in the case of Alvin and his grandmother (Eyberg. the therapist critically evaluated with the grandmother the need for further treatment once the identified treatment goals were achieved. when the grandmother arrived at the fourth CDI coaching session in distress regarding her fi nances. The therapist pointed out the correspondence between practice and progress that can be seen weekly on the ECBI graph.2). In this case. in press). moving on to the PDI phase of treatment was not obligatory. For children with ODD who have not experienced consistent limit-setting and followthrough. These observations were supported by the additional standardized questionnaires completed by the primary caregiver. The child’s history of maltreatment and his diagnosis of ODD led us to select PCIT as an appropriate evidence-based treatment.2. One strategy used in coaching with this case was to increase the grandmother’s positive verbal attention to the child’s initially limited conversation. A diagnosis of ODD often occurs with comorbid disorders. & Kessler.14 Childhood Disorders ECBI Graph 80 75 ECBIT score 70 65 60 55 50 45 40 CDI Teach CDI 1 CDI 2 CDI 3 CDI 4 CDI 5 CDI 6 CDI 7 Session Graph of the Grandmother’s Weekly Ratings of Alvin’s Behavior Problems during Treatment on the Eyberg Child Behavior Inventory (ECBI) FIGURE 1. As mutual security in the relationship increased. which more effectively conveyed her approval while enhancing the child’s trust in her as a safe and nurturing caregiver. Hirpi. the child became less insistent on remaining in control of their interactions and gradually began accepting the grandmother’s . The Art of Tailoring PCIT in the Case of Alvin This case illustrates how the use of PCIT for a child with ODD and RAD can maintain fidelity to the treatment protocol while addressing the unique presentation of the individual family. Observational data provided key information on the child’s attachment behaviors and the grandmother’s permissive parenting style for the considerations in tailoring coaching during treatment. the pretreatment assessment is essential to the process of tailoring treatment effectively. 2007). In considering the relatively uncommon diagnosis of RAD. The recommendation that treatment be grounded in both behavioral and attachment theories also suggested that PCIT would be an appropriate fit. Kazdin. and complex contextual factors are present in many families of children with ODD (Knock. In all evidence-based treatments. A comprehensive multimethod assessment provided information on three important aspects of this case that guided our treatment selection and planning. A second coaching strategy was to increase the selectivity and specificity of the grandmother’s praise to the child. we sought guidance from the literature. 11. References Abidin. M. doi:10. and attachment problems. et al.1207/s15374424jccp2201_4 Eyberg. doi: 10.1177/0272431691111004 Chadwick Center on Children and Families.72. (1995). R. B. 887–907. B. (1991).1080/02646830600821231 Baumrind. Journal of Child and Family Studies. C. Greene. A. Journal of Clinical Child Psychology. J. Silovsky. S. Closing the quality chasm in child abuse treatment: Identifying and disseminating best practices. (2004). The grandmother became more open to coaching recommendations to ignore inappropriate behavior and. B. R.x Baumrind.1467-8624. DC: Author. (in press).. Eyberg.. W. Balachova.). Report of the APSAC task force on attachment therapy. (1998).. P. 22. Washington. Child maltreatment and insecure attachment: A meta-analysis. D. 24. T. (2000). Saunders. FL: Psychological Assessment Resources. D. V..1177/1077559505283699 Clausen. B. D. Treatment was completed when the grandmother’s CDI skills reached mastery level. Norcross. (2006)... McNeil. Principles of treatment with the behaviorally disordered child.Tailoring Parent-Child Interaction Therapy 15 suggestions for play. The decision to end treatment at this point was in consideration of the potential for mutually reinforcing positive interactions to continue improving child behavior problems (Hood & Eyberg. C. Parenting stress-manual (3rd ed. The influence of parenting style on adolescent competence and substance use. text revision). Baer. doi: 10.. 500–510. Nichols. C. & Litrownik. M. Ganger. J. J.1037/0022–006X. Psychologists’ desk reference (3rd ed. J.. 7. Barnett. Valle. M. 2003) and for the child’s newly formed attachment to his caregiver to be protected from unnecessary emotional distress when so little is known about treating children meeting diagnostic criteria for RAD.1966. Landsverk. Journal of Early Adolescence. CA: Author. 187–197. A. Bonner.. Parent-child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports.. (1993). doi: 10. Effects of authoritative parental control on child behavior. In G. Hanson..). (1966). . T.L. Odessa. E. Koocher. C. reactive attachment disorder. and Funderburk. Inc.. A. doi: 0.. .. J. setting in motion a positive reinforcement cycle. L. 11. Child Maltreatment. K. D..3. & Martinez . 76–89. F.. 283–296.. Child Development. she was able to use differential social attention effectively to manage her grandson’s behavior. 42–51. American Psychiatric Association.tb05416... Journal of Consulting and Clinical Psychology. T. Parentchild interaction therapy with behavior problem children: Relative effectiveness of two stages and overall treatment outcome. (2006). & B. as a result. enabling her to manage and maintain the child’s behavior within normal limits for disruptive behavior. Funderburk. Mental health problems of children in foster care. doi:10. M. Eisenstadt. Chadwick. E. . Newcomb. D. 37. Diagnostic and statistical manual of mental disorders (4th ed. 72. (2004).1111/j.. 56–95. Brestan.. San Diego. New York: Oxford University Press. S. Journal of Reproductive and Infant Psychology.500 Chaffi n. Chaffi n. . S. K. Clinical Child Psychology and Psychiatry. B. 37. Howe. Odessa.) (BASC-2). R. San Antonio. (2012).. (2000). Kazdin & J. & Zimmer-Gembeck. Social and General Psychology Monographs. Hirpi.2010. 365–394. Disorders of attachment in adopted and fostered children: Recognition and treatment. Reynolds. & Funderburk.. & Zera. & Spratt. A. R. Burke. 179–193). F. doi:10. 10. A. (1999). K. Journal of Clinical Child and Adolescent Psychology. S. E. N’zi. The Early Intervention Foster Care Program: Permanent placement outcomes from a randomized trial. doi:10.. M. Bhuyani. Parent-child interaction therapy protocol. 5.. E. P. Kazdin. J.. (2012).. FL: PCIT International. & Kessler. W. 253–266..C. of oppositional defiant disorder: Result from the National Comorbidity Survey Replication. M. J.. & Pincus. & Eyberg. doi:10. S. Weisz (Eds. (2010). Reactive attachment disorder: What we know about the disorder and implications for treatment. Parent–child interaction therapy: An evidence-based treatment for child maltreatment. M. D. (2004).. 61–71. R. Thomas. Circle Pines. E.1177/1077559500005002005 Hood. 213–235.. R.) Evidence-based psychotherapies for children and adolescents (2nd ed. doi: 10. S.. M. 419–429. A. (2008). R.. Hanson.. & Eyberg. R. 8. Child Maltreatment. M. and persistence. & Eyberg. (1991). N. Outcomes of parent-child interaction therapy: Mothers’ reports on maintenance three to six years after treatment. M. (2003). (2007). Genetic.). TX: Psychological Corporation. doi: 10.. B.1111/j.1177/1077559504271561 Fussell. (2005). S. C. Eyberg. M. part I. & Pears. (2011).x Loeber.01548. doi: 10. doi: 10. D. & Boggs. 17. & Kamphaus. K. The attachments of children in foster care. Evidence-based treatments for child and adolescent disruptive behavior disorders. R. 369–386. Nelson. Nelson. R. S. Child Development. M. correlated. (2002). Ginn. Oppositional defiant disorder: A review of the past 10 years.16 Childhood Disorders Eyberg. J. M. 1468–1484. S. MN: AGS Publishing. Emotional abuse and attachment: A Parent-Child Interaction Therapy Study. D. A. Burraston.1177/1359104503008003007 Knock. M. Eyberg child behavior inventory and SutterEyberg student behavior inventory: Professional manual. Journal of the American Academy of Child and Adolescent Psychiatry. E.. In A.. R. 117. pp. M. B. M. Lifetime prevalence.. Journal of Child Psychology and Psychiatry. & Fearnley... doi: 10. Journal of Clinical Child and Adolescent Psychology. Child Maltreatment. & Boggs.R. & Zimmer-Gembeck.1469–7610. F. Child Maltreatment. (2011). 177–192. 703–713.. Behavior assessment system for children (2nd ed. Manual for the dyadic parent -child interaction coding system (4th ed. Fisher. R. 39.. (in press).. A. Accumulating evidence for parent–child interaction therapy in the prevention of child maltreatment. .) (WPPSI-III ). (2003). N.1177/1077559512459555 Thomas.01733. M. A.2007.1080%2F15374410701820117 Eyberg. M. 137–145. Wechsler preschool and primary scale of intelligence (3rd ed.1111/j. G. Eyberg.1097%2F00004583-200012000-00007 Marcus.. Gainesville. S. 48. (2000). FL: Psychological Assessment Resources. 32. Treating oppositional behavior in children using parent-child interaction therapy.. B.x Wechsler. S. M. Manuscript in preparation... B. R. S. New York: Guilford. C..W. 82. Winters.1467–8624. Gainesville: PCIT International. Lahey. Zisser. D. Sheila Eyberg. Hanf. arguably. both are remarkable. Roberts. Dr. she formulated the fi rst two-stage parent training protocol. As a review of the relevant literature shows. My (Friman) initial contact was during my first year in graduate school (1980) when I was assigned a highly relevant reading (Peed.. We will discuss both of these aspects below.. 1969.. which remains the basis for many of the behavioral parent training protocols in existence today. Rex Forehand. but for different reasons. But there are two other sources that are worth mentioning here.g. & Bean. McMahon. Stacy Shaw’s initial contact also occurred during her fi rst year of graduate school (2005) when she was assigned the same reading for a clinical practicum led by one of its authors (Mark Roberts). . Hanf’s influence is rather remarkable given that her work was never published. Roberts. Hanf & Kling. where she had a tremendous impact on child clinical psychology. including PCIT. Constance Hanf. On the other hand. The fi rst is a now legendary woman whom we did not have the opportunity to meet. the paper reflects the remarkable potency and flexibility of PCIT. 1977). 1981. Her name appears on only one conference presentation and two unpublished manuscripts (Hanf. & Forehand. and ultimately disseminate her approach.g.g. although at dramatically different points in time. Cheryl McNeil. She was a professor at the Oregon Health Sciences University (OHSU). it reflects the clinical acumen and interpersonal dexterity of the clinicians who reported the case. 1973). 1970. Mark Roberts contributed significantly to the early empirically derived knowledge base that has contributed to PCIT (e. Roberts. Hatzenbueler. We both came into contact with PCIT-related material during graduate school. test. & Humphreys. her influence appears to be primarily derived through the interns and postdoctoral fellows whom she trained at the OHSU. Specifically. Forehand.COMMENTARY Patrick C. Carolyn Webster-Stratton) who went on to refi ne. Instead. Friman and Stacy Shaw There is much to admire in this report of an adaptation of parent-child interaction therapy (PCIT) used to treat a uniquely complex case involving comorbid reactive attachment and oppositional defiant disorders. One the one hand. Russell Barkley). the most widely used and empirically supported approach to disruptive behavior in young children in the history of child psychology. and it is they and their students (e. 1978). and PCIT is. Hanf’s students read like a “Who’s Who” of child clinical psychology (e. the most difficult in our experience has been generational difference.. Eyberg is one of several prominent psychologists who trained at the OHSU with Dr. This brings us to the target chapter by N’zi and Eyberg: it is the latest addition to the large body of literature that persuasively reveals the effectiveness and durability of PCIT. generative. They are: Helping the Noncompliant Child (Forehand & McMahon. Hanf. not wholly empirical. and the portion devoted to treatment is quite small. Reid. & Boggs. and creative lines of systematic replication in the field of applied child psychology (e. For these reasons. In addition to the aptness of the treatment selection. there were three potential barriers to success in this case—ethnicity. Nelson. .htm for a comprehensive list of PCIT literature). ufl. Dr. We could say more about the contributions of these two remarkable people but space forbids elaboration. Jones. 1975). 2004). 2003). N’zi and Eyberg note that there are four other parent training interventions that are considered evidencedbased and thus serve as additional treatment options for oppositional behavior. socioeconomic status (SES). Dr. 1980. Eyberg & Robinson. As noted above. The second involves the extent to which the authors adapted to a highly complex set of socioeconomic conditions.. Hanf appears to have introduced the concept. 1982). Of the three. but four are particularly noteworthy. Parent Management Training Oregon Model (Patterson. PCIT was aptly selected due to its classification as “best practice” for helping children to recover from the impact of abuse (Chadwick Center on Children and Families. The literature on reactive attachment disorder (RAD) is mostly descriptive. The fi rst involves the clinical presentation of the participating child. 2008. and Positive Parenting Program (Sanders. Eyberg has evolved it into the best-known empirically supported approach to child disruptive behavior in this country. 1999) (see Eyberg. Dr. & Conger. Dr. Eyberg et al. and generational difference—and all three were bridged successfully. we do agree that increasing mutually reinforcing and responsive interactions between caregiver and child and decreasing coercive/aversive interactions is most appropriate given the attachment concerns. there are several other virtues of the target chapter. perhaps in the world.phhp.g. Eyberg herself went on to produce one of the more rigorous. Although admittedly without an empirical basis. for a more detailed description of empirical support).18 Childhood Disorders The second name that deserves special attention here is the second author of the source document for these remarks. 2001. That is. This literature shows that PCIT is defi nitely among the most rigorously tested parent training protocols and perhaps the most empirically supported of them (the interested reader is referred to http://pcit.edu/Literature. it is at the top of the options that the many providers in our clinic select when they are preparing treatment plans for young children who exhibit clinically significant oppositional behavior. In the case described by N’zi and Eyberg. This paper provides clinicians with a practical conceptualization of RAD-associated treatment goals and a userfriendly guide for related treatment techniques. Specifically. The Incredible Years (Webster-Stratton & Reid. Eyberg & Matarazzo. 1981). Sheila Eyberg. the therapist successfully addressed the grandmother’s transportation and fi nancial needs without distracting from the pursuit of an effective therapeutic application. but we suspect that N’zi was significantly younger than her client. Thank you very much for inviting our opinion. the treatment goals had been reached. from the assessment of Alvin’s presenting problem and treatment progress to the assessment of Alvin’s grandmother’s skill acquisition. It is perhaps even more difficult when the therapist does not have a family of his or her own. We also speculate that for a child affl icted with RAD. and. Despite the potential difficulties posed by this barrier and the others we have mentioned. RAD). both emphasize objective data collection. but when working with a grandparent the difficulties multiply.Tailoring Parent-Child Interaction Therapy 19 establishing adherence to parent training treatment requirements is difficult enough when working with a parent. For all of those reasons. ethnic. In closing. is a testament to the compelling nature of PCIT. . Moreover. but even more important. And given the outcome. Specifically. neglect. Specifically. that appears to have been the case here. making the more invasive disciplinary procedures unnecessary. it was astutely determined by the therapist that the use of time-out may be harmful to the budding relationship between Alvin and his grandmother due to the often emotionally distressing nature of the procedures for both parent and child. which usually involves a version of time-out. it indicates that PCIT can be adapted to cross generational. A third virtue involves a strategic modification to the conventional form of PCIT. Dr. we both believe this is an excellent case report for the reasons mentioned above. particularly through behavioral observation techniques. which is almost certainly a testament to her skills as a therapist. The fourth virtue brings us back to Drs. Hanf seems to have introduced the concept and Dr. we have found that having good social worker and community agency referrals can be a session saver. Practical barriers such as transportation difficulty and serious fi nancial problems are also difficult and can waylay even the most experienced therapist. Hanf and Eyberg’s tremendous contributions to the treatment of childhood conduct problems from a social learning perspective. more specifically. In this case. And. Again. We cannot say enough about the value of objective data in clinical practice and appreciate the comments on its use. like the therapist in this case. which are a somewhat unique staple of parent training from a social learning perspective. Eyberg has cemented it as a standard of practice. and socioeconomic lines and can be modified to fit special diagnostic characteristics. Because of the special clinical presentation of the child involved (history of abuse. placing emphasis on the child empowerment version of the therapy may be just what the doctor ordered. so to speak. the therapist (we assume it was N’zi) obtained excellent compliance. This is especially true when the therapist is quite young. Whether this is the case with the fi rst author. Balancing in-session demands is often tricky. we cannot say. consequential detachment could function as a reinforcer. it is one more tribute to the power of PCIT. . Funderburk. C . 1. W. Oregon. & Hood. M. C. Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. R. University of Oregon Medical School. The effects of differential attention and time out on child noncompliance. S.. R. G. Portland. doi:10. 1–20. (1982).. (1970).. Parent-child interaction training: Effects on family functioning. & King. B. (2008). doi:10. Training parents as therapists: A comparison between individual parent-child interaction training and parent group didactic training.. (2001). 36.. (1973).. Shaping mothers to shape their children’s behavior. L. Child and Family Behavior Therapy. C.. & Boggs. R .. R. Parent-child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. (1980). T. Unpublished manuscript. M. doi: 10. doi:10. doi:10. & Robinson. 37. S. Evaluation of the effectiveness of a standardized parent training program in altering the interaction of mothers and their noncompliant children.. New York: Guilford Press.1023/A:1021843613840 . M.. B. M. (1977 ). R. & Humphreys. Behavior Modification. Querido. 9.. 93–99. & Matarazzo. Hanf. Journal of Clinical Child Psychology. Paper presented at the meeting of the Western Psychological Association. The effect of parental instruction-giving on child compliance. 2. Behavior Therapy. McNeil. J... Journal of Clinical Child and Adolescent Psychology. (1981).1300/J019v23n04_01 Eyberg.1080/15374410701820117 Eyberg..1080/15374418209533076 Forehand. Clinical Child and Family Psychology Review. R. 492–499. B. J. G. Unpublished manuscript. (2004). A. & MacMahon. J . (1969). L. C. M.20 Childhood Disorders References Chadwick Center on Children and Families. M. J . doi:10. M... doi:10. 23. (1999).1016/S0005-7894(78)80009-4 Roberts. M.. OR: Castalia. Journal of Clinical Psychology. E. E . Closing the quality chasm in child abuse treatment: Identifying and disseminating best practices. Eyberg. Eyberg. San Diego. R. CA: Author. S. 71–90. M. W. 12. Hembree-Kigin. K. (1978). S. McMahon. A two-stage program for modifying maternal controlling during motherchild (M-C) interaction. Vancouver. Hanf. Patterson. G. Oregon. Eugene. R. Nelson. Portland. R. M. Canada. Roberts.. Hanf. W . C . University of Oregon Medical School. (1981). L . 215–237. Forehand. Triple p-positive parenting program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. BC. W. & Bean. Reid. R. Behavior Therapy. Helping the noncompliant child: A clinician’s guide to parent training. Facilitating parent-child interaction: A two-stage training model. & Conger. S. 11. A social learning approach to family intervention: Families with aggressive children (Vol. J. Hatzenbuehler.1177/014544557713003 Roberts. Jones. L. 793–798.. 323–350. R. 1 ).1016/S0005-7894(81)80109-8 Sanders. R. & Forehand . (1975). 130–137. Peed .. S. 00475. & Reid.. (2003).14753588. Kazdin & J. Evidence-based psychotherapies for children and adolescents (pp. The incredible years parents. 224–240).). In A. doi:0. Weisz (Eds. teachers.Tailoring Parent-Child Interaction Therapy 21 Webster-Stratton. New York: Guilford.1111/j. C. E. and children training series: A multifaceted treatment approach for young children with conduct problems. R.2007. M.x . King. and Gerald Patterson (e. Cunningham. As Friman and Shaw suggest. Second. manualized treatment protocols for children. N’zi and Sheila M. young. 1975). and Alvin’s presentation was challenging. King moved to Georgia and published the fi rst studies of Hanf-influenced treatment with Forehand (Forehand & King. we wish to emphasize our clinical approach to the case of Alvin. Although I was not able to observe Hanf’s work due to her sabbatical the year that I was an intern (1971–1972). while tailoring standard elements to meet the unique needs of this family. As the commentators note. Hanf mentored several UAF interns and postdocs who subsequently developed treatments influenced by her mentorship (Barkley. Virginia Axline (1947). Eyberg In their assumptions that the first author of our case study is a graduate student. Patterson & Gullion.” We thank them for their comments on this case.RESPONSE Amanda M. Elizabeth King. In this response. the commentators are “4 for 4. This case study indeed demonstrates N’zi’s skill. 1974. Unfortunately. & Yoder. Eyberg & Matarazzo. I (Eyberg) wish fi rst to clarify a historical assumptions in the commentary. Forehand. Forehand). and talent. Along with the writings of Diana Baumrind (1967). I was a clinical psychology intern at the University of Oregon Medical School (UOMS) in the internship program directed by Arthur Wiens. Hanf’s work (1969) contributed importantly to the development of PCIT during my internship and residency at UOMS (see Funderburk & Eyberg. I was not a student of Constance Hanf. Alvin’s treatment followed the PCIT protocol with fidelity. A fourth-year graduate student at the time.g. Peed. I (Eyberg) also want to acknowledge N’zi’s clinical acumen. this case provides an illustration of the flexibility of the evidence-based.. 1975). 2010. and recently received the departmental award for psychotherapy skill. and Alvin’s therapist. I learned about it from my internship mentor. had treated over 20 PCIT cases before working with Alvin. not yet a parent. Hanf was on the faculty of the internship program at the University Affi liated Facility (UAF) directed by Ann Garner on the other side of campus. N’zi had completed her clinical coursework and practica. H. Since that time. 1968). Tailoring refers to changes in the delivery . experience. PCIT is a difficult treatment to conduct. generations of students have researched and refined the early treatments influenced by Hanf. S. Typically. (2005). Tailoring and adapting parent-child interaction therapy to new populations. such as greater acceptability in the new population (or greater effectiveness). however. 42–44. V.. In the case of Alvin. Play therapy. References Axline. Baumrind. We are indebted to the many researchers who over the years have dedicated their careers to the development and dissemination of ESTs for troubled young children. 2005). (1975). R. Her skillful application of contingent attention during the CDI was sufficient to manage the behavior problems that Alvin presented. H. 79–84. Sacramento. To adapt an empirically supported treatment (EST) requires well-conducted research showing that the adapted protocol works at least as well as the standard protocol and has some additional benefit. Eyberg. 28... R. Genetic Psychology Monographs.. that she had mastered the CDI skills. E. S. Forehand. Behavior Research and Therapy. Eyberg. treatment adaptations refer to changes in the core structure or content of the protocol for universal application to a specific population (often a specific diagnostic or cultural group. (1974). moving the toys to the table and focusing on attachment concerns during coaching are two examples of this approach. In contrast to tailoring treatments for the individual family. (1967). 2005). & Matarazzo. (1975. Pre-school children’s non-compliance: Effects of short-term behavior therapy. & Yoder. E. and it occurs with every family in treatment.. King. (1947). R. Eyberg. Forehand. Journal of Community Psychology. caregivers opt to continue on to PDI to learn ways to apply contingent attention in the discipline interaction. 2. The decision to end treatment after CDI is another example of tailoring. 75. In Alvin’s case. S. and we do not recommend such an adaptation at this time. Education and Treatment of Children. 43–88. Peed. Efficiency in teaching child management skills: Individual parent-child interaction training versus group didactic training. April). M. without altering the procedures themselves (Eyberg. the therapist and the grandmother decided that continuing to PDI was not the best course of action at this time. . Child care practices anteceding three patterns of preschool behavior.Tailoring Parent-Child Interaction Therapy 23 style of therapy elements and components to accommodate the individual sensibilities of each family. Decades of research have documented the effectiveness of ESTs. There is no evidence to suggest that a CDI-only protocol would be suitable for the entire RAD population. P. based on our knowledge that Alvin’s disruptive behavior was rated within normal limits by his grandmother. D. Boston: Houghton Miffl in. H. and it is important to maintain the integrity of these treatments for the best clinical outcomes. and that her skills markedly changed the quality of interaction between the two. 13. & King. Paper presented at the meeting of the Western Psychological Association. M. 197–201. Mother-child interactions: Comparison of a noncompliant clinic group and a non-clinic group. S. R. Norcross (Ed. Paper presented at the meeting of the Western Psychological Association. . DC: American Psychological Association.24 Childhood Disorders Funderburk. & Gullion. Patterson. Champaign. & Eyberg. IL: Research Press. 415–420). BC. G. (1968). A two-stage program for modifying maternal controlling during motherchild (M-C) interaction. (1969). Hanf. Washington. Vancouver. C.. Living with children: New methods for parents and teachers. Canada. In J.. M. E. (2010). B. W.. M. pp.). History of parent-child interaction therapy. History of Psychotherapy: Continuity and Change (2nd ed. Pat has had multiple legal infractions. Pat was diagnosed with attention deficit/hyperactivity disorder (ADHD) at age 7. Pat was living with his mother. he was described as “bossy” and could be “stubborn”. his father was less concerned . Pat: Childhood Pat was born full-term. nonetheless.{2} Attention Deficit/Hyperactivity Disorder (ADHD) Kevin M. At the request of his school. including several substancerelated charges. Since age 15. Pat’s teachers had concerns regarding his abilities to exert self-control and complete tasks. Antshel Pat (note that a pseudonym has been used to maintain confidentiality) is a 21-year-old Caucasian male who was court-ordered for evaluation/treatment. Pat could be oppositional and/or defiant. was employed part-time as a pizza delivery person. Negative peer exchanges. He attained his developmental milestones in an age-appropriate fashion. His parents were still married at the time of this evaluation. while his mother was concerned about his behaviors and difficulties with authority.) At the time of referral. The case of Pat represents a fairly typical case of a young adult who was diagnosed with ADHD in childhood. Pat was described as an “active” child who “had a great imagination.” With peers. (His most recent legal charge. often escalating to aggression. and was not currently enrolled in college. driving while impaired. he had a keen interest in social relations and was described as a “social butterfly. Pat was referred for a mental health evaluation. He was not engaged in any type of treatment at the time of referral. prompted the current referral.” At home. During early elementary school. As a toddler. the product of a planned pregnancy. This case may or may not be applicable to those individuals who were initially diagnosed with ADHD during adulthood. became more common in 2nd grade (age 7). but his mother reported that he responded very well to “point systems” and other strategies rooted in operant conditioning. He was having great difficulties managing the increased independence that was expected from a middle school student (e. Much of the confl ict between his parents was attributed to Pat and his difficulties. despite having made strong progress in elementary school. This transition brought with it new teachers and some new students. His parents did. and oppositional defiant disorder (ODD). Full Scale IQ = 119) with especially strong perceptual/ spatial skills (WISC-III Perceptual Organization Skills standard score = 130). While a combined psychosocial and pharmacological treatment plan was recommended by the mental health professional. As a function of Pat’s escalating disruptive behaviors and weaker school performance.) These new faces and the transition proved to be very difficult for Pat. after having completed K–4th grades at the same elementary school. Academically. His school was considering moving Pat . In fact.g. It was also at this time that his parents’ marriage dissolved and his mother fi led for divorce. Pat completed the social skills group with limited improvement. combined type.” Based upon the evaluation. planning for assignments). The school appropriately concluded that Pat’s difficulties at school were not a function of a learning disability. Pat and his parents also participated in family therapy aimed at improving family functioning. changing classes. the middle school was fed by several different elementary schools. Pat’s grades slipped considerably in middle school. Pat was not engaged in any type of ADHD or mental health treatment. While he continued to excel academically. In addition. Results from that evaluation documented that Pat had above average intellectual potential (Wechsler Intelligence Scales for Children III [WISC-III]. Pat’s parents were getting almost daily phone calls from his school regarding disruptive behaviors. Pat was diagnosed with ADHD. Pat was once again diagnosed with ADHD and ODD. (While Pat did not switch school districts. For the remainder of elementary school. his mother reported that Pat “learned new ways to be devious” by observing other children in the group.26 Childhood Disorders and believed that many of Pat’s difficulties were a function of a “poor childteacher match. as well as the stresses associated with the divorce. his mother sought to once again enroll Pat in some form of mental health treatment. Within the fi rst month of school. In addition to the standard psychiatric evaluation. the school district also completed a psychoeducational evaluation. enroll him in a social skills treatment group. Pat’s academic attainment was similarly described as above average for age. his behavior and peer relationships at school both continued to be impaired. family therapy was discontinued after several months due to increasing confl ict between Pat’s parents. seeking and being awarded uncontested sole custody of Pat. Pat’s parents did not wish to medicate their son. once again. a combined treatment program was recommended to his mother.. In addition. however. Pat: Early Adolescence Pat attended a new school for 5th grade. Nonetheless. In addition. new students. While the improvements in Pat’s functioning were exciting. although she also reported that he was somewhat more manageable than before. Pat was found to . then titrated to 10 mg BID). Pat was prescribed mixed amphetamine salts (5 mg BID. and unhappy with the continued side effects of the methylphenidate. This medication similarly helped Pat exert better self-control and had fewer side effects. As in his first year of middle school.” and so on. “focuses more on social activities than school work”. His mother was also learning more effective ways to manage Pat at home behaviorally. At the urging of Pat’s school psychologist. “disorganized”. In October of his 9th grade year. more adaptive methods to manage his anger. Pat continued to have difficulties in school. Pat’s cumulative averages were generally in the low 80s (“C”) with considerable between.and within-subject variability. his mother was concerned about his “mood swings” in the late afternoon when he was coming off his stimulant medication. 7th. largely as a function of simply completing and turning in all of his homework assignments. his mother’s improved parenting skills (as a function of completing her parenting class) and his continued biweekly therapy. and new expectations. His mother reported that Pat “instantly” responded to the medication and was “almost like a different boy. then titrated to 10 mg BID). Pat lost several pounds during the second half of his 5th grade year. his mother also participated in a parenting class offered at a local mental health clinic. Pat went from a “C” student to an “A” student. she implemented a point system with a response cost component. his mother was getting almost daily phone calls about his behavior at school. Pat did not do well with the transition. and his grades reflected their impressions. Pat was prescribed methylphenidate (initially 5 mg BID. At the urging of his pediatrician. At the beginning of 6th grade. Possibly frightened by this possibility. “late for class”. his mother was also increasingly concerned about his poor appetite and problems getting to sleep. Academically. his mother did not continue to give Pat his methylphenidate during the summer. His therapist reported that Pat was more vocal about his feelings toward his father and was learning new. Finally.Attention Deficit/Hyperactivity Disorder (ADHD) 27 to an alternative classroom that would be better suited to manage his disruptive behaviors. His mother reported that many of his disruptive behaviors returned during the summer. his pediatrician also recommended that Pat participate in therapy with a local psychologist. Pat’s mother discussed the use of medication with his pediatrician. Pat’s mother discussed alternative medication options with his pediatrician.” His teachers also noted the improvement. Pat: Late Adolescence High school again brought another change in school and with it new teachers. both academically and socially. even with the medication. “disrespectful to authority. and 8th grade report cards all shared the same trends: “bright boy who could be doing much better if he applied himself”. A review of his 6th. ” At the end of 10th grade. Pat reported that he dated his first girlfriend for approximately three months. he discontinued his atomoxetine. as it was felt that he “could do the work if he wanted to. and that the relationship ended when Pat “cheated” on her with another classmate. Pat also continued to be prescribed mixed amphetamine salts. Academically. No drug charges were recorded during these two years. then titrated up to 40 mg).. His mother.” with the occasional peer conflict resulting in aggression. English) between 11th and 12th grades. Pat had completely untreated ADHD. Thus. Thus. Along with a three-day suspension from school. There was also concern that Pat was diverting his stimulant medications to friends. a job that he seemed to enjoy more. “There were many days which I thought he would not do it. but he was reportedly inconsistent in his adherence. he looked for work and held several part-time jobs at local restaurants as a dishwasher.” To no one’s surprise. Pat and his mother both reported that he continued to use marijuana throughout high school. Concerns were raised about Pat “not being able to graduate” unless significant improvements occurred. He attended summer school for two subjects (History. Pat had his fi rst romantic relationship and sexual activity. Pat eventually began working as a pizza delivery person. He often grew dissatisfied with the job and either quit or was asked to leave within the fi rst few months. a decision was made in February of his 9th grade year to try atomoxetine (initially 10 mg. With his native intelligence. although Pat commented that he frequently attended school “high” from morning marijuana use. He also refused to take any ADHD medications. most often for “insubordination. Instead. Pat graduated 341st in a class of 404 students.g. for both 11th and 12th grades. . He had weekly disciplinary referrals. he insisted that the marijuana “helped [me] relax. His academic performance and behavior at school dropped appreciably. Pat continued to earn low “C” grades across all subjects. shoplifting.28 Childhood Disorders have marijuana in his school locker. “egging” houses. He did not receive any ancillary supports. Pat’s general trend was to wait until May to “turn it on” academically. There was a general consensus from all of his teachers that he was capable of much more. etc. however. While Pat was reported to have initially responded well to the atomextine. and concerns continued to be raised about his poor academic motivation. commenting. His coworkers were also regular marijuana users. Thus. Pat was able to “get by” and to eventually graduate high school. His mother was far more concerned about his marijuana use than Pat. was simply pleased to have her son graduate high school. at the end of his 9th grade year. Pat decided that he “no longer needed therapy” and discontinued his biweekly therapy sessions.). he and his mother were unsure if the medication was helping. over time. Pat also began to experiment more with alcohol during this time period. he was required to participate in a substance abuse education program administered through the county. Pat also reported having unprotected sex with both girls. Pat had no interest in attending college.” Pat’s friends were also regular marijuana users and were involved in other antisocial activities (e. In 10th grade. he made a seemingly impulsive decision (two weeks before classes started) to matriculate at the community college and to live on campus. the friend had sexual relations with Pat’s girlfriend. began to have more considerable discussions with him about “giving school another try.Attention Deficit/Hyperactivity Disorder (ADHD) 29 Pat’s uncle. & Slanetz. who was an instructor at a community college several hours away. 1998). Bezman. Pat was no longer attending classes and was “partying” quite often. Pat continued his lifestyle and had several girlfriends during this time period. In an attempt to improve their relationship. Several months before his 21st birthday. mandating Pat to enter ADHD-focused treatment. Pat still refers to his community college experience as the “best three months of my life. Pat left home for the fi rst time and moved into his dormitory room. Two days after his 19th birthday. Pat continued to use marijuana (almost daily) and was drinking alcohol excessively. Pat was found guilty of DWI and was court-ordered to substance abuse treatment. and resumed his job at the pizza restaurant. much research suggests that ADHD persists into . Pat became so enraged that he punched a brick fireplace. and validated childhood psychiatric disorders (Goldman. breaking several bones and requiring surgery to repair his hand. Pat was arrested for driving while impaired and possession of a narcotic. The judge (who reportedly has a daughter with ADHD) agreed. his mother refused to have him return for the spring semester. Pat left work at the pizza shop with friends and went to a local bar. yet when he attained a 0. and his friends were escorted home by the police. One of Pat’s friends had oxycontin pills on his person and hastily threw the pills into the car glove box. and marijuana. such that his mother began taking an antidepressant. Key Principles/Core Knowledge ADHD is one of the most prevalent (~5% of the childhood population [APA. and was asked to attend counseling. Pat had a roommate whom he did not know. Pat spent the night in jail. The relationship between Pat and his mother had soured considerably. After living with them for several months. sharing an interest in music. 2000]). This is around the time that I first meet Pat. his mother encouraged the substance abuse therapist to suggest to the judge that Pat be mandated to continue with “ADHD-focused treatment” (her words). yet the two quickly became fast friends. Pat left the bar and was stopped by a police officer on the drive home. Once the substance abuse therapy was completed. 1996). was placed on disciplinary probation. Once considered exclusively a childhood condition (Hill & Schoener.” Pat returned home. his mother allowed one of his friends to move into their home.” While Pat continued to express disinterest in school. Pat and his friends all had fake IDs and were able to order mixed drinks. Pat did well socially at community college. Genel. the friend refused to acknowledge that the pills were his possession. Pat was found to have marijuana in his dorm room. When the officer searched the car and found the pills.8 GPA. technology. Within two weeks. well–researched. lived with his mother. and motor vehicle operation realms is common in adult ADHD (Murphy & Barkley. Faraone. Barkley’s longitudinal research indicates that ADHD in adults is a more impairing disorder than many other disorders (e.. 2006.76. Monuteaux. 1983). 2005). & Cadogen.. Heiligenstein. 1993. 2007). Biederman et al. Murphy & Barkley. Significant functional impairment in educational. Approximately 70% of children with ADHD will demonstrate a therapeutic response to stimulant medications (for reviews. & Erkanli. G. Faraone et al. 1996. Hess. 1996. Malloy. The same holds true in adult ADHD. 2000. Faraone. Faraone. Costello. & Perlman. Asarnow. much higher than the 15 percent prevalence of ADHD among siblings of ADHD children. 1994).. and family domains are often functionally impaired by ADHD symptoms (MTA Collaborative Group. 2003). Biederman. anxiety. inattentive and/or overactive and impulsive symptoms have to impair the child’s functioning in two or more domains to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th edition. 2004). By defi nition.. occupational. Biederman et al. especially educational and occupational functioning. & Wheeler. see Biederman et al. Manshadi. 1999). & Milberger. 2004) are strikingly similar and suggest that the majority (74%) of adults with ADHD will demonstrate a therapeutic response to stimulant medications.. Biederman.30 Childhood Disorders adolescence and adulthood for roughly 60% of the population (Barkley. For example. & Sprich. Biederman. adult ADHD is also associated with comorbid mood.. 1995. ADHD TREATMENTS There are ample data in the pediatric ADHD literature to support the efficacy of stimulant medications (MTA Collaborative Group. Bober. 1991).. Borland & Heckman. Hechtman. Zaucha. The adult ADHD data (Biederman et al. interpersonal. Murphy. 1999. & Blackman. Newcorn. . etc. Bessler. Shekim. O’Daniel. and management of daily responsibilities (Barkley et al. Schubiner et al. 1990. & Fischer. & LaPadula. anxiety disorders. Mannuzza. Family studies of pediatric ADHD suggest that the parents of children with ADHD are more likely than parents of non-ADHD children to have ADHD themselves (Faraone. and disruptive behavioral disorders (Angold. marital. Likewise. Wilens & Dodson. Conyers. In children. ADHD is a highly heritable condition (average heritability index = . 2007. The same pharmacological agents that are efficacious in the pediatric ADHD literature have also been demonstrated to be effective in adults with ADHD. Weiss. & Mick. Klein. Pediatric ADHD commonly co-occurs with multiple psychiatric disorders.. Biederman. educational. & Miller.g. Lippmann.) across multiple domains of major life activities. offspring of parents with ADHD are more likely to have ADHD themselves (Biederman et al.. 1995. 1999). including mood. In fact. Milroy. (1995) found a 57 percent prevalence of ADHD among children of ADHD adults. social.. Thomson et al. 1976. 1993). anxiety. 2005). 1985. DSM-IV-TR). 2007. text revision. 1998. and substance use disorder diagnoses (Barkley et al. money management. Berns. mood disorders. 1996. Bupropion has demonstrated efficacy in open (Wender & Reimherr. 1991. stating. He was not engaged in any form of treatment and was quite opposed to any treatment.” Given that he was living with his mother. For example. Wolf. M.. 2005. and desipramine have also been described as efficacious for managing adult ADHD (Biederman et al. there is some evidence that CBT is efficacious for reducing functional impairments in patients also being treated with stimulants (Safren et al. Although CBT has not been demonstrated to be efficacious in children with ADHD. 2001). “I have been on just about every ADHD medication there is. Bloomquist. & Ostrander. Hirt. 1998). Pat was rather resistant to treatment and stated on several occasions that he was “only coming here because some judge said [I] have to be. Both the stimulants and atomoxetine improve core symptoms of hyperactivity. 2005) and may be used as second-line agents. 2006. Safren et al. Greenley. CBT is generally more effective in adolescents relative to preadolescents (Holmbeck. Reingold. Due to its limited efficacy with children.. meta-analyses of CBT for children with ADHD have typically reported the effect sizes to be less than one-third a standard deviation (Baer. 1985. and lisdexamfetamine are stimulants that are FDA approved.Attention Deficit/Hyperactivity Disorder (ADHD) 31 Methylphenidate. Atomoxetine is a non-stimulant that is FDA approved for managing ADHD. Morrill. amphetamines. 1996. While the stimulants and atomoxetine are more commonly prescribed for ADHD. psychosocial or pharmacological. & Schroeder. 2001. 1990) and controlled (Kuperman et al. August. 2005). Dush. 2010).” After a failed attempt at college... In addition to pharmacotherapy.. Spencer et al. in the adult ADHD literature. I structured the intake assessment so that I .. inattention. Wilens et al. 1997. Adults with ADHD are more likely to require poly-pharmacy than is the case for childhood ADHD (Adler. Wender. and similar to managing ADHD in children.. & Franks. Weiss & Hechtman. 2005. I asked both Pat and his mother to attend the intake assessment. and impulsivity (Adler et al. 1991. 2006. Wilens et al. DuPaul & Eckert. 1989).. Spencer et al. CBT was not included in the NIMH Multimodal Treatment Study of Children with ADHD (MTA) treatment protocols.. 2001). & Wasserstein. modafi nil. For example. & Wilens. a psychosocial treatment component is generally recommended (Dodson. there are reasons to be optimistic that CBT may be more efficacious in adults with ADHD. I hate them all.. Taylor & Russo. 2000. bupropion. Baer & Nietzel. Neither cognitive behavioral therapy (CBT) nor cognitive therapy has much research support in pediatric ADHD (Abikoff & Gittelman. 2003). 2005) studies and may be particularly efficacious in adults with ADHD who have comorbid mood disorders (Daviss et al. 1991). Similarly. Assessment Strategy At the time of referral. 2008. Pat had been living with his mother for several years and was employed part-time as a pizza delivery person. negative relationship). young adults with ADHD are rather poor historians. 1997).” She “pushes” him. After spending some time with Pat and his mother. Pat also met DSM-IV diagnostic criteria for ADHD. Rather.. At the time of referral. his mother was asked to go the waiting room to complete several behavioral rating scales commonly used by our clinic to gather collateral information. Our program also supplements the SCID with the ADHD module from the Schedule for Affective Disorders and Schizophrenia for School-Age Children. During the initial 45-minute interview. Given both of these facts (limited involvement. In addition. These scales include the Adult Behavior Checklist (Achenbach. Based upon the SCID. his mother perceived Pat as “lazy. (The K-SADS-PL is used because the SCID does not have an ADHD module. This entire interview took approximately 90 minutes. it became clear that Pat and his mother had a negative relationship. I attempt to gain collateral information from a parent. In my experience. 1997). Gibbon. While his mother was completing the rating scales. This is not to say that Pat’s mother was not appropriately concerned for her son nor to infer that Pat and his mother did not have a good emotional bond.” Conversely. not otherwise specified. if possible. These scales were chosen for adults with ADHD. & Williams. Present and Lifetime Version (K-SADS-PL. Kessler et al. Pat met formal DSM-IV diagnostic criteria for substance abuse (marijuana. Whenever working with a young adult such as Pat.. 2006). . Kaufman et al. First. combined type. most of which she attributed to Pat. 2007). Spitzer. His father continued to live near Pat and his mother yet did not have regular contact with either. During this initial 45-minute interview. alcohol) and a mood disorder.) Based upon his report.32 Childhood Disorders met with Pat and his mother together for approximately 45 minutes. different scales are employed for children and adolescents with ADHD. a feedback session was scheduled for the following week. it also became evident to me that Pat’s mother quite possibly also had ADHD. 2005) and Impairment Rating Scale (Fabiano et al. World Health Organization Adult ADHD Scale (ASRS. unmotivated and selfish. both past and present diagnoses. Meeting together allowed me to collect information regarding Pat’s history and also to observe the relationship between Pat and his mother. Pat perceived his mother as a “nag” who was “always on [my] back. Pat’s parents had divorced when he was 11 years old.. Pat’s mother had been prescribed an SSRI (selective serotonin reuptake inhibitor) for mood/anxiety concerns. the negative relationship can be better characterized as a “push-pull” relationship. neither Pat nor his mother had a positive relationship with Pat’s father. Pat was interviewed using the structured clinical interview for DSM-IV disorders (SCID. although she had not been diagnosed with the disorder. a decision was made not to invite Pat’s father to the intake assessment or involve him in treatment. At the conclusion of this two-hour appointment. Both Pat and his mother were encouraged to attend the feedback session. he “pulls” away. meeting weekly in the beginning of therapy (for roughly the fi rst three months) and then biweekly thereafter. diagnostic impressions were provided and a treatment plan was described. especially in light of the many . valid. and we collect a wide variety of data at the initial evaluation (see above). I also spoke privately to Pat’s mother via telephone to follow up with her about my own observation that she may indeed have ADHD herself. Pat is a rather prototypical young adult who was diagnosed with ADHD in childhood. Pat’s mother was referred to another local clinician who specializes in ADHD and was indeed diagnosed with ADHD herself.” After the feedback session. She was also counseled to keep the methylphenidate in a secure place. In addition to his ADHD diagnosis. We have had 34 sessions together. I referred her to another local clinician who specializes in ADHD for a diagnostic evaluation. not otherwise specified. I believe that my diagnoses were evidence based because they relied on structured. Our program is a research program. who prescribed extended release bupropion (100 mg initially. She was prescribed extended release methylphenidate by her primary care physician. Given that Pat had been “cleared” by his substance abuse program and was not deemed to need further services. alcohol) and a mood disorder. Epidemiological Considerations I have been working with Pat (and occasionally with Pat and his mother conjointly) for just over one year. Case Formulation My initial case formulation was that Pat had ADHD and comorbid substance abuse diagnoses and likely had many subthreshold dysthymic mood symptoms.” Given my therapeutic relationship with Pat. then titrated up to 200 mg). substance abuse. In my eyes. this was a relatively straightforward diagnosis. While his mother was very excited and hopeful about the proposed treatment plan. not otherwise specified.Attention Deficit/Hyperactivity Disorder (ADHD) 33 During the feedback session. lest Pat have any ideas about diverting / misusing his mother’s medication. In many ways. our treatment plan was to include both a pharmacological and psychosocial treatment component geared more toward his ADHD diagnosis. “What choice do I have? I don’t think any. Pat met also formal DSM-IV diagnostic criteria for substance abuse (marijuana. and reliable assessment instruments as well as collateral report. His mother reported that “all of [my] friends say the same thing. one did not need the vast amount of data to reliably conclude that Pat continues to meet criteria for ADHD. Nonetheless. Pat met formal DSM-IV diagnostic criteria for ADHD. Pat was less enthusiastic yet stated. Pat was referred to our team psychiatrist. and mood disorder. & Kaiser. Pelham. INITIAL SESSIONS While the Safren et al. Evangelista. & Milich. modified to account for an ADHD population. Hoza. etc.34 Childhood Disorders previous assessments that Pat has had. These modules included sessions focused on reducing procrastination. periodic conversations with Pat’s mother were also included. The second three-session core module focused on Pat learning skills to reduce distractibility. part of my job is convincing the young adult that there is a problem. as well as the clear chronic nature of his impairing symptoms. why would anything need to be changed? Thus. a common starting point for my work with young adults is increasing motivation. module begins with direct intervention aimed at improving organization and planning. Handouts describing the topics covered were provided to Pat at the conclusion of each session. more time was spent in the improving anger/frustration management modules than originally proposed by Safren et al. many authors have commented on the “positive illusory bias” (PIB). 2007. This module was our longest module and we spent far more sessions (11 sessions) in this module than in the original Safren et al. Again.g. Hoza. In fact. 2010). The third core module used cognitive restructuring strategies described by Beck (1995). improving active listening. manual.. 2005. While this may be a clinical reality for many mental health workers. The handouts were provided in an attempt to encourage generalizability of the strategies to the real-world. CBT model involves components of motivational interviewing. much of my initial work with Pat consisted of applying motivational interviewing . practice. Waschbusch. 2000. and repetition of learned skills and is composed of three core modules. This has patent connections to motivation (or lack thereof) for therapy: If you do not perceive that there is a problem. given Pat’s history. PSYCHOSOCIAL INTERVENTION: OVERVIEW The psychosocial intervention was the cognitive behavioral treatment for adult ADHD developed by Safren et al.. in addition to three optional modules. the individual with ADHD views things as better than they really are. The Safren et al. The fi rst four-session core module involved psychoeducation about ADHD as well as training in organization and planning skills.) and improving anger/frustration management. Stated another way. Safren et al.. which reflects an overestimation of perceived abilities relative to actual level of ability and competence (Canu & Carlson. In addition to relying on Pat for information regarding his functioning and application of the skills. Goldfi ne. The Safren et al. (2005) optional modules were also completed. improving communication skills (e. (Safren et al. Pat received all six modules (core plus optional modules). In other words. this is a very common phenomenon for those of us who work in the ADHD field. review. Molina. reducing interruptions. 2007). Owens. Other organizational strategies are covered. This style is present throughout my work with the individual with ADHD. consisting of 11 sessions. The concept of simple awareness of the automatic errors in thinking was covered first.e. we focus on describing ADHD from a biopsychosocial perspective. always charging your cell phone before you go to sleep at night. my goal is to have the young adult and I talk roughly the same amount (i. which. 2002). Pat talks for 50%. we began the Safren et al. The third module was our longest module to date. estimating how long a task will take and then assessing [his] estimate. his mother was consulted for her perspective on what she observes and/or hears from Pat. protocol focuses on psychoeducation about ADHD. In addition. After enhancing his awareness of his own self-talk. albeit in a slower fashion than I would have liked. The fi rst module in the Safren et al. We stress the importance of having a planner. we focused on “fighting back” against the thoughts using cognitive restructuring techniques.g. always putting your keys in the same place. These strategies were covered over the course of three sessions. in my experience. These real-world “gifts” became a means to enhance motivation.Attention Deficit/Hyperactivity Disorder (ADHD) 35 techniques and concepts in an attempt to move him toward sensing a need for change. CORE MODULES Once some motivation for change had been established. I talk for 50%). not only during the initial sessions. we covered errors in thinking using a structured sheet providing the most common errors in thinking based upon Beck’s work. and keeping a list in [his] front pocket to help him write down a task rather than interrupting [his] ongoing task. module focused on lessening distractions. using timers or alarms to help monitor time. This module with Pat accounted for four sessions.. In our program. In our program we make a great distinction between a planner (which tells us when we will do something) and a calendar (which tells us when something is due). The second Safren et al. It certainly helped when his girlfriend at the time broke up with him. Directing the session is a general practice in most forms of cognitive behavioral therapy (Blagys & Hilsenroth.. Considerable motivational interviewing continued to be a prominent focus of the sessions. We focused on breaking larger tasks down into smaller chunks. one-sided discussions. etc. Pat was asked to identify which errors he makes more regularly. We also focus a great deal on the functional impairment criterion in ADHD. in an attempt to lessen the relatively common viewpoint (in my opinion) that ADHD is a benign condition. As a general rule. The organizational and planning skills components include very concrete interventions such as having Pat purchase a planner. is fairly typical for young adults with ADHD. SAFREN ET AL. not a calendar. citing his “anger” and “jealousy” as primary reasons. including the importance of doing things in a routine fashion (e. core modules. yet working with individuals with attention lapses has taught me to nurture a great amount of conversational “give-and-take” rather than long.). . This was a challenge initially. Pat continues to struggle to effectively manage his anger. we walked through the hospital one day with the expectation that Pat would initiate and sustain conversations with strangers in the hospital. Moreover.g. recognizing when is or is not a good time to have an argument). “Pat did laundry last week. and so on. strategies for reducing procrastination.g. a decision was made by our program psychiatrist to start lisdexamphetamine (initially 30 mg. then titrated to 50 mg). Over the course of the fi rst 20 sessions (predominantly weekly). In addition to the core Safren et al. She reported that she and Pat were arguing far less often and that Pat was less emotionally impulsive and more responsible (e. tasks. and while not specific to ADHD..) were each covered in two sessions. as Pat had made progress such that his frustration level was less than it had been nine months prior. Thus. However. While we continued to role-play anger management strategies and focus on very concrete strategies (e. improving active listening. The improving communication skills module involved a great deal of role-playing various scenarios. to ourselves was included. The goal was to get Pat to become more aware of the power of “advertising” in helping him to either choose to complete the task or not. especially establishing a strong therapeutic alliance and promoting . a real-world change (another girlfriend breakup) helped bring the need for anger management back into focus. In my opinion.g.36 Childhood Disorders At this point. his mother was reporting far more optimistic progress. and we had held 20 sessions.) The final Safren et al. While Pat was able to very clearly describe how he should manage his anger. his poor anger management was not a knowledge deficit. once again. Pat had missed one appointment and had been late to two others. Having a young adult and parent (or spouse) disagree about the efficacy of treatment is not uncommon in my experience. Pat had gradually become more verbal and engaged in therapy. attention problems persisted (especially being easily distracted). Pat continued to have difficulties managing his anger. (He seemed to enjoy this task immensely. optional module focused on improving anger/frustration management. reducing interruptions. Pat’s poor anger management abilities are his most enduring symptom. but more of a performance deficit. Thus. Nonetheless. While Pat reported limited changes in his real-world functioning.”). OPTIONAL MODULES Reducing procrastination and improving communication skills (e. SAFREN ET AL.. the concept of how we “advertise” activities. sadly seeming recalcitrant to my best interventions. I did not even know that he knew how to do laundry.. I had been working with Pat in therapy for approximately four months. the direction of the difference is not consistent across cases. etc. NONSPECIFIC FACTORS A considerable amount of clinical attention was devoted to the nonspecific factors of therapy. He also appeared to be having a therapeutic response to the bupropion. In addition. 2006) as our standard metric for assessing clinical response. reporters are instructed to rate the severity of the young adult’s problems in each domain and the need for treatment using a 7-point Likert Scale (0 = no problem/defi nitely does not need treatment → 6 = extreme problem / defi nitely needs treatment). .0 on the assessed domains. providing feedback.) In both the Parent and Self versions. our program spends considerable time at the beginning of the treatment covering our attendance policy (after 3 missed appointments without calling 24 hours ahead to cancel. Thus. Fabiano et al. while Pat has not been arrested in the past year and has tested negative for marijuana at his five most recent drug tests (mandated through his courtordered treatment). relationship with parents. At this point in therapy. Providing optimism and hope for change manifested itself through our very detailed discussion of the CBT framework and how CBT may be more effective for adults than children. Pat’s mother rated him as having an average of 3. Pat’s mother rated him as having an average of 4. and providing choices. Pat is functioning better. a IRS rating of 3. I explicitly avoided arguments with Pat and attempted to “roll with resistance” rather than confronting him. At the beginning of treatment (34 sessions ago). As mentioned previously. influence on family functioning. Pat continues to have the same job (pizza delivery) and loses his temper quite frequently with coworkers.Attention Deficit/Hyperactivity Disorder (ADHD) 37 optimism and hope for change. One of my guiding influences in establishing therapeutic alliance was getting a sense of these previous therapies (what worked and what did not) and attempting to integrate features of previous therapies that had been somewhat successful.) Thus. self-esteem. (Pat’s ratings are 3. right from the start. Given that Pat was court-ordered to treatment. relying heavily on motivational interviewing techniques such as empathetic responding. Likewise.6 on the assessed domains (relationship with peers. occupational functioning. Thus. (We have modified the IRS to include a self-report version for adults. he was well aware that discharge would not be in his best interest. motivational interviewing techniques were heavily integrated into my treatment with Pat. However. Given that Pat did not really see a need for change.9. the person is automatically discharged).0 and 1.. and overall impairment). Pat has modestly improved his functioning. I once again relied heavily on motivational interviewing techniques to attempt to lessen Pat’s ambivalence toward therapy. Using the Impairment Rating Scales (IRS. from both perspectives.0 does not represent “normal” functioning. The fi rst several weeks of therapy were simply focused on establishing rapport with Pat and attempting to connect with him. respectively. Lack of commitment should be almost assumed in those that are court-ordered for treatment. POTENTIAL PROBLEMS Missed appointments and arriving late to appointments are very common in adults with ADHD. Pat was not especially pleased to be in therapy and had participated in many previous psychological therapies. etc. uncles. In many ways. enrolling at a local community college. Shanahan. I quickly shifted into motivational interviewing techniques. Pat has talked previously about moving out of his mother’s home. For example. this is a relative rarity.g. (In fact. not . 2000). girlfriend. attempting to get him to lessen his ambivalence toward his marijuana smoking. Thus. If the above mentioned data did not suggest that Pat was improving. Another common mistake that I attempted to avoid in treatment was passively reinforcing Pat’s marijuana use. At this point. I would take a step back and rely more heavily on motivational interviewing techniques. teachers). none of the above has come to fruition or. Ethical Considerations The issue of confidentiality/privacy need always be considered for young adults who are not functioning like young adults. Rather. and requesting a promotion at work. ADHD itself is often defi ned by inconsistencies in performance and functioning. frankly. Thus. I attempt to secure release of information in order to be in ongoing contact with parents or others who may function like parents (e. By having a very structured and intensive assessment process. these attributes and qualities are often very difficult for individuals like Pat who have been diagnosed with ADHD. Each time that Pat discussed his marijuana use. supervisors. yet in my work with young adults with ADHD. I certainly respect the wishes of those who do not wish to release information to parents. Having parents attend the first session and provide historical information generally improves the likelihood that the young adult will consent to having parents involved in the therapy.) in the context of therapy. it is usually the parents who refer the young adult for treatment in the fi rst place. 1994. The transition to adulthood is defined by young adults themselves as accepting responsibility for one’s self. we attempt to avoid “rubber stamping” diagnoses simply based on what childhood condition may have been diagnosed. at the beginning of treatment. setbacks along the way are almost a guarantee. I would not continue to press ahead with the Safren modules. has even begun to head in that direction. gaining autonomy and independence.38 Childhood Disorders The goal for Pat moving forward is to help him continue to navigate the transition to adulthood. Having this mind-set has helped me to “be curious. I would also attempt to engage more of Pat’s natural social supports (mother. Relapse prevention needs to be included in any treatment plan for a young adult with ADHD and comorbid substance abuse.) Common Mistakes to Avoid The most fundamental mistake that I attempted to avoid was assuming that Pat’s childhood diagnosis was still his adult diagnosis. and becoming fi nancially independent (Arnett & Taber.. (1999). I have become much more aware of the art that is involved in practicing competent CBT. 11. (2008). 953–961. T. J. the decision to present Pat was quite easy for me. Basic issues such as the pacing of the session. Reingold.. text revision. L. S. metaphors.. keeping a list. Levine. S.) has also helped to lessen relapses.. and digression from the manual by providing analogies. tone of voice. there are less impaired young adults with ADHD who do not require the level of intervention that Pat has received. and so on. H. Kelsey. Morrill. T. Adult behavior checklist for ages 18–59 (ABCL). In conclusion.. D. (2000). & Taber. L. & Gittelman. J. Knowing when to push forward. nonetheless. Tamura. & Erkanli.. E. (1985). J. 20. at the core of my CBT practice remains the science. as well as the clear need for treating this population. and digress from the manual are all learned with CBT experience. et al. However. R. 400–412. Arnett. A. DC: American Psychiatric Association. (2007). Adolescence terminable and interminable: When does adolescence end?. J. References Abikoff. L. step back. I wholeheartedly believe that there is much “art” to the practice of CBT. Current Psychiatry Reports. I view Pat as a rather prototypical young adult who was diagnosed with ADHD as a child. Certainly.Attention Deficit/Hyperactivity Disorder (ADHD) 39 furious” when the inevitable relapse occurs. In my opinion. A. Journal of Youth and Adolescence. all figure heavily into my CBT practice. Journal of Clinical Child Psychology. A. S. J. Adler. (1994). 720–727. Functional outcomes in the treatment of adults with ADHD. DSM-IV-TR). While this approach may be true for some CBT practitioners. Washington. I believe that Pat represents both the challenges of treating this population. over the years in which I have been practicing CBT. T. By no means do I consider myself a master clinician in CBT.. Baer.g. 42(10). Journal of Child Psychology and Psychiatry. R. Adler. Hyperactive children treated with stimulants: Is cognitive training a useful adjunct? Archives of General Psychiatry.. Nonetheless. Spencer. L. E. Diagnostic and statistical manual of mental disorders (4th ed. Costello. M. 409–415. VT: ASEBA.. Burlington. Comorbidity.. R. using planners..... Achenbach. R. 8(5). Cognitive and behavioral treatment of impulsivity in children: A meta-analytic review of the outcome literature. Continuing to reinforce previously learned skills (e.. Ramsey. etc. M. A. (1991). . & Nietzel. (2006). M. T.. 40(1). ADHD is not the relatively benign condition that the media often portrays. & Wilens. APA. 57–87. 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Groves. P. M. et al. T. E. N. & Morrison. Jones. J. Safren. L. Wilens. Whelan. Biederman. 211–220. Comprehensive Psychiatry. J. J. (2005). Milroy. & Perlman. T... J. 875–880. Prince. 175–186. Safren.. W.. 1998) and the substantial genetic and neurological contributions to psychopathy (Blair. at least to the patient’s loved ones. Mitchell. 2008. Given the strong contribution of psychopathic traits to persistence of antisocial behavior into and through adulthood (Fowler et al. Lynam. Clinicians also need to appreciate the high risk that such cases of ADHD/ antisocial behavior have for current and later drug use and abuse. Barkley Dr. clinicians need to be on the alert for its existence in cases such as Pat’s. Antshel describes an interesting and relatively typical case of a young adult referral in which ADHD has been previously diagnosed. As in this case. & Pine. & Homer. Whittinger. conduct disorder (CD. 2006). if not to the patient himself. Rice. Obradovic. Peschardt. Pat’s history of repetitive antisocial behavior and occasional contacts with the legal authorities is. antisocial behavior). there is a greater likelihood of psychopathy in teens and adults with ADHD than is the case in the general population. Swanson. Consequently.. especially if they had manifested symptoms of childhood conduct problems (Waschbusch & Willoughby. & Loeber. Murphy. 2009. and most cases of ADHD do not become adult psychopaths (Fowler. 2006). And while ADHD. My own longitudinal study of children with ADHD followed to age 21 suggests that while earlier conduct . including the use of medication while driving. relatively commonplace in children with ADHD followed to adulthood (Barkley. as it may bode for an even poorer outcome than would ADHD or CD alone. Thus it might have been useful in this case to screen for such traits using rating scales for this purpose. Crinella. starting in early adolescence. 2007). antisocial activities or contacts with legal authorities may be the basis for the referral for evaluation and often are the most impairing and distressing feature of the current presentation. where available research shows teens and adults with ADHD to be at high risk for a variety of adverse outcomes (Barkley & Cox. Budhani. 2008). clinicians must take care to advise not only patients with ADHD but parents as well about the driving risks of teens and young adults with ADHD under their care and the need to take appropriate steps to address those risks. sadly. 2007).COMMENTARY Russell A. This was clearly the case for Pat. Ross et al. and psychopathy are distinct yet interrelated disorders/constructs (Pardini. Faller.. Langley. Satterfield. Schell. & Fischer. It may also increase the risk of harm to family members and others attempting to intervene with the patient. This is particularly so for driving offenses. 2009). 43. Fletcher. sale. 2002).21 and at age 27 was just . ADHD was associated with later drug-related activities. and need for current treatment is a common occurrence. particularly when oppositional defiant disorder and conduct problems exist in the patient (Johnston & Mash. 2008). & Fletcher. Fischer. and use of illegal drugs and theft. our longitudinal research found that only 4% of cases we previously diagnosed with the disorder in childhood reported sufficient symptoms to meet DSM diagnostic criteria. Parental reports of symptoms were found to correlate more highly with impairment and with more domains of impairment than were self-reported symptoms at age 21.. Hence the need for substance use treatment programs is likely to be part of the treatment package recommended for such cases. in my experience—this was certainly the case with Pat’s father and removes one source of potential constructive influence from this situation.44 Childhood Disorders problems/disorders are clearly associated with later risks for predatory forms of antisocial behavior and with running away from home and teen prostitution by age 21. 2005). such as possession. Smallish. That Pat should show some affi nity for the use and abuse of marijuana is also not uncommon. even after controlling for earlier CD (Barkley. Antshel ably discusses. disengagement from the teen and even from the marriage may be likely.. as it was for Pat. those using marijuana are likely to be using tobacco and typically started with the latter drug fi rst (Barkley et al. 2008). The limited or nonexistent insight of Pat into his current problems. as Dr. Edwards. & Smallish. The significant level of distress and confl ict in the parent-offspring relationship so palpable between Pat and his mother is also typical of teens and young adults with ADHD. father absence is more common or. & Fuemmeler. And once drug use was initiated. We have found that adults who were diagnosed with ADHD as children and adult clinic-referred patients diagnosed with ADHD have higher rates of use of alcohol. As evidence of this fact. And while not mentioned in Pat’s case history. In such families. and marijuana than does the general population or control groups (Barkley et al. we found that the correlation between parent and patient report at age 21 was just . tobacco. In such cases. history of ADHD. the likelihood of ADHD in one or both parents is significant as a consequence of the striking heritability of the . despite the patient having been diagnosed as a child. 2001). McClerman.. the majority saw themselves as not having the disorder and grossly underreported their symptoms (Barkley et al. Barkley et al.. perhaps because the individual may fi nd some therapeutic benefit from the nicotine and thus may be self-medicating his or her ADHD (Kollins. Antshel of interviewing the parent (or other collateral who knows the patient well) in addition to the routine interview of the patient and has led to this practice being considered as important to the evaluation of adults with ADHD (McGough & Barkley. For instance. 2004). if a father is present within the family unit. This striking disparity between parental reports and self-reported information in someone not selfreferred for an evaluation of ADHD is commonplace. and thus parent reports were considered more valid (Barkley. 2001. 2008). Fischer. it interacted over time with antisocial behavior such that each exacerbated the other. It supports the commendable practice by Dr. 2004). Further evaluation of and treatment for the parent’s ADHD. Swanson. & Thompson. Should the patient’s demoralization have arisen as a consequence of his repeated failures and impairments in major life activities associated with his ADHD. from shared genetics between the disorders (Faraone & Biederman.. such as major depression. despite above average intelligence and absence of a specific learning disability. Such disorders occur with greater frequency in both children with ADHD followed to adulthood (age 27) and adults with ADHD who self-refer for clinical evaluations (Barkley et al. The linkage may arise. as was initiated in this case. it must be sustained through adolescence to young adulthood. is likely to prove beneficial not only for Pat’s mother but also for the treatment plan created for Pat as well. Also noteworthy in Pat’s history and current adjustment is his limited educational attainment. Clinicians should follow Dr. is also relatively typical in the small literature that has examined the issue (Barkley et al. Antshel’s lead in screening all parents of patients with ADHD in instances such as this one (and obviously in children and teens) in which the parent continues to play a substantial role in the life of the patient. as would be the case with any chronic medical condition such as diabetes. This is not likely to be the case for more serious mood disorders. This is not because treatments given in childhood do not have beneficial effects on children’s ADHD or domains of impairment—clearly they do. Daley. it may well respond to management with ADHD medications. as evident in Pat’s case. and clearly noticeable in his irritability with his mother and the examiner. His resistance to taking medication as an adolescent and his later begrudging acceptance of it as a young adult are also quite typical. CD. Numerous longitudinal studies. That is easier said than done with adolescents. for which separate treatments may be necessary. Arnold. The limited or nonexistent benefit of earlier treatments during childhood for ADHD on adolescent and young adult outcomes. such that by high school only a minority of ADHD cases who were previously treated continued on their medication or in a combined medication/psychosocial treatment program. as was clear in Pat’s case. 1997). 2002) for which the parent may have some direct or indirect responsibilities. & Erkanli. That a mild mood disorder. The lesson here seems to be that for treatment to improve adolescent and young adult outcomes. 2008. have repeatedly documented the adverse impact of ADHD on eventual educational . Molina. 2008). Adolescent noncompliance with ADHD medications thus makes intervening in these crucial adolescent years much more difficult than may be the case for children with ADHD or for the management of adult self-referrals who are diagnosed with the disorder and are more cooperative with such self-sought interventions. in my own experience. The parent’s ADHD may well interfere with not only the current adjustment of the patient but also with efforts to implement treatment programs (Sonuga-Barke. It is more likely due to the termination of these treatments over time. is likewise not surprising.Attention Deficit/Hyperactivity Disorder (ADHD) 45 ADHD trait(s). as well as the common comorbidity between ADHD.. and depression (Angold. Costello. Hinson. Vitiello et al. was evident in Pat’s case. 2009). such as demoralization or dysthymia. in part. 1999). as was seen in Pat’s case.. including my own. 30–40% of childhood cases do not complete high school. however.. I do not recommend that clinicians waste their time with such a time-consuming psychometric test battery approach in cases of adult ADHD. & Gordon. As a result. A few comments on the approach to assessment used by Dr. Barkley & Fischer. Conners. Fontanella. 2006. 2009). Problematic with the Children’s Impairment Scale. Lewandowski. that the latter scale may have the potential to over-identify EF deficits . Barkley. and ecologically valid is the use of rating scales of EF in daily life activities. & Curry. however. economical. Biederman. 2010). & Sparrow. 2011a. convenient. is essential for establishing that the patient has met these aspects of diagnostic criteria for ADHD (McGough & Barkley. with either ratings of EF in daily life activities or with measures of impairment in a variety of important domains of adult major life activities (Barkley. 2008.46 Childhood Disorders attainment. While this has been traditionally done using psychometric EF test batteries. Doyle et al. Barkley & Murphy. requiring that impairment be assessed separately and specifically in such cases. I also encourage clinicians to incorporate some assessment of these functions in the evaluation of adults with ADHD. if at all. have acceptable norms and are available for documenting DSM-IV symptoms of ADHD in adults (Barkley. 2011. Several rating scales. This will obviously carry forward to have a detrimental effect on the level of occupation that such individuals can obtain at entry into the workforce. 2004. Moreover. 2011b) that now would be a more appropriate alternative. Note. is the lack of validity and other psychometric information about the scale when used with adults and the lack of norms for an adult general population sample. Faraone. Erhardt. Symtom severity does not equate directly to related levels of impairment. 2006). Black. Given that adults with ADHD often have associated deficits in various domains of executive functioning (EF. Petty. 2011. Doyle et al. & Gioia. More useful. These problems have been addressed in a more recently published rating scale of impairment in adults that captures 15 major domains of life activities (Barkley.. Murphy & Gordon. such tests have low or no ecological validity. Barkley & Murphy. such as the Deficits in Executive Functioning Scale (Barkley. 2011c. Barkley et al. rather than just inferring such from the severity of the ADHD symptoms (Gordon. Antshel to broadly screen for potential impairment in major domains of life activities. Antshel. 2004). Fried. 2011.. This is to say that they correlate poorly. 2008. as was done here. Also noteworthy was the attempt by Dr. 2005). as well as on their upward advancement in their chosen occupation. 1998). Petty. Biederman. such tests often fail to detect the difficulties in EF associated with ADHD. 2008). Epstein. Fried. 2011d) or Behavior Rating Inventory of Executive Functioning. The use of adult ADHD rating scales for the initial screening for risk for disorder and especially to document the developmental inappropriateness of the symptoms. Lewandowski et al.. in this case adapting the child impairment scale initially developed by Fabiano. and perhaps just 5–10% complete a college degree program (Barkley et al. Isquith.. Antshel seem in order. besides the Adler scale used here. Lovett. Adult Version (Roth. Hervey. 2006). with just 25–50% falling in the impaired range on these tests (Barkley & Murphy. While annoying side effects certainly exist with these medications. Such scales indicate that 86–98% of adults with ADHD are impaired in one or more domains of EF in daily life. and self-regulation of emotions (Barkley. 2010). along with insomnia. 2006) and so returning Pat to medication was a wise choice in this case. amphetamine). From 10–25% of cases do not respond to the starting medication type or delivery system (pills. Dr. Several similar programs that also have an evidence base are available for conducting CBT with adults with ADHD (Ramsay & Rostain. All CBT programs focus on training adults in strategies to compensate for their deficits in executive functioning in daily life. . or pro-drug) and may require switching to alternative delivery systems or medications before a good therapeutic effect is obtained. OROS pump. empirically based treatment for child and especially adult ADHD (see Prince. 2010). self-management to time. clonidine XR [FDA approved only for children to date]) are utilized. such as difficulties with time management. or anti-hypertensives (guafacine XR. these being medication and cognitive behavioral treatment (CBT). About 3–5% of cases may not be able to tolerate any dose of these medications. which makes them more pertinent to assessing issues of EF deficits in clinical settings where understanding and predicting such impairments is a major purpose of such evaluations. but these have not been documented to continue into late adolescence or adulthood. Spencer. the safety profi le of these medications is unsurpassed in any other area of psychopharmacology for psychiatric disorders despite sensationalized media accounts to the contrary. organization. The CBT program by Safren and colleagues (Safren. & Biederman. to treat their comorbid disorders. self-discipline. Some modest temporary cessation of gains in growth in children may occur. 2005) implemented with Pat is a fi ne intervention for adult ADHD with an increasing evidence base (Knouse & Safren. 2008). Antshel commendably elected to use the most evidence-based interventions for Pat’s ADHD. time release pellets. Solanto. self-motivation. The most common side effects (30–50% or more of cases) for the stimulants are typically loss of appetite for midday meals primarily. & Otto. in my opinion. using the ADHD and impairment ratings. 2010).Attention Deficit/Hyperactivity Disorder (ADHD) 47 in view of its relatively super-normal and technologically. 2011c). psychiatrically. Another advantage to such EF rating scales and those noted earlier for adult ADHD and impairment is their convenience for monitoring response to interventions. whether to treat the ADHD or. such as self-organization and problem-solving.. both of which tend to be more problematic for child than adult cases of ADHD. nonstimulants (atomoxetine). Perlman. Perhaps 25% or fewer cases complain of stomachaches or headaches in conjunction with stimulant use. Sprich. as was done in Pat’s case. as often is the case in over 80% of adults with ADHD (Barkley et al. Medications will likely be required for the management of 70–80% or more of adult cases. Medications remain a mainstay. Rating scales have greater utility than tests in predicting impairment (Barkley & Fischer. and medically fi ltered normative sample. Barkley & Murphy. 2007. even if the patient complied grudgingly. 2011. and their side effect profi le clearly depends on whether stimulants (methlphenidate. Wilens. skin patch. ADHD medications. and management of the case is commendable. The Solanto program has been studied with patients being off medication and has had some success as well. Dr. P. Pera. Antshel has selected a fi ne case. Sarkis & Klein. . with both children and adults with ADHD. Putnam’s Sons. These impairments include not only the driving problems noted above. 2008). as noted above. Ramsay and Rostain strongly encourage a combined intervention as well. 2006. some commonsense advice can still be offered. 2010. & Smith. much of which may not be science-based. My remarks and caveats notwithstanding. emotional self-control. counseling.48 Childhood Disorders problem-solving. and increased health risks such as excess use of legal substances. 2009. Flory.. but it is not clear whether more improvement might have been evident had patients also been on an ADHD medication. 2010). 2006). Besides such feedback counseling about the disorder following the evaluation. and follow through on. 2010. There is no consensus yet in the field as to the sequence in which the medication and CBT treatments ought to be instituted for an adult with ADHD.. is in order concerning other major domains of increased risk in major life activities associated with ADHD at these ages. Fischer. as well as possible means to address the risks (Barkley & Benton. money management problems. Safren and colleagues require their patients to be on medication before enrolling in CBT as they believe that it makes them more likely to attend to. References Adler. Gnagy. While little or no research exists on the best treatments for various impairments. Ramsay. obesity. (2006). along with his or her parents or guardians. Barkley & Benton. empirically based. New York: G. given the plethora of such information in these sources. L. some counseling of the teen or young adult with ADHD. Given the initial fi ndings of the MTA study (and others) with children that combined treatment was typically more beneficial than either medications or psychosocial treatments alone. occupational difficulties. His approach to the evaluation. bulimia (in ADHD females). et al. Molina. when both are available—something not usually the case in rural areas of the United States. 2006. and the manual-based CBT interventions. It is also important to direct such patients and families to trusted sources of information on adult ADHD and its management in the trade media and on the Internet (see Adler. and an exemplar to other clinicians. and so on. 2010. but also the penchant for risky sexual behavior and adolescent pregnancy (Barkley. this would seem to be the best approach for now. representative of the typical referral that one is likely to encounter in seeing young adults for evaluation and management of ADHD. Pelham. psychosomatic symptoms. and cardiovascular disease (Barkley et al. Tuckman. 2007). Scattered minds: Hope and help for adults with attention deficit hyperactivity disorder. the treatment procedures than if they are off medication—a point with which I agree. Journal of Abnormal Psychology. 262–275. (2006).. (2007). (2011). New York: Guilford. V. 195–211. S. Peschardt.. ADHD in adults: What the sciences says. & Pine. R. Costello.. & Fletcher... 33. Developmental Neuropsychology. & Benton. 45. 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Journal of the American Academy of Child and Adolescent Psychiatry. However. ADHD in adulthood is very rarely diagnosed without a comorbid condition. Dr. in my estimation. my focus was more on the ADHD and associated impairments. these instruments were not available. I could not agree with Dr. Antshel I am grateful to Dr. Substance abuse is one common comorbid condition. Barkley clearly delineates. Dr. While not all individuals with ADHD have limited insight into their own functioning. I continued to frankly discuss Pat’s substance use and the associated impairments. He thought he was doing fi ne. While I would not say that his marijuana use was the primary focus of our treatment. at the time that I began working with Pat. his marijuana use was an almost weekly discussion. As one parent of a high school student with ADHD recently told me. It is a great honor to have someone so knowledgeable about ADHD comment on my clinical work. Barkley. Thus.” Although improved. The current move in ADHD pharmacological intervention studies is also in this direction.” That is. My experience with Pat regretfully suggests that even with random drug tests. I guess his teachers think otherwise. Barkley is a veritable ADHD encyclopedia—there is no one. “There is no one more surprised when he sees his report card than my son. While I am excited about the new instruments that have been recently developed (and our clinic will be switching to those instruments for assessing impairment). for this reason. and Pat was required to complete a substance abuse treatment program with continuing monitoring of his substance use. Barkley refers to the limited insight of those with ADHD. it is possible to continue to use marijuana yet pass drug tests. Barkley not only for his astute and insightful commentary but also to have the opportunity to respond. Barkley more when he asserts that the focus should move well beyond symptoms and focus far more on functioning. a sizable number of those with ADHD may demonstrate a “positive illusory bias. Pat continues to have a relative lack of insight into his functioning. Barkley also astutely points out the relatively limited number of instruments that currently exist to assess functional impairments in adults. individuals with ADHD may report that they are functioning better than they may actually be. who knows the ADHD literature better than Dr. As Dr. . Dr. ongoing contact with collaterals such as his mother have become part of my work with Pat.RESPONSE Kevin M. Anyone who has ever treated an individual with ADHD knows that ADHD is not the benign condition that it is often made out to be in the popular media. (Our clinic is currently in the process of moving away from these psychological tests as routine for our adult patients. yet remain functionally impaired in the real world by his or her poor planning and limited attention regulation skills.) Again. such as the Wisconsin Card Sorting Test or Stroop Color Word test. . In sum. Barkley for his insightful commentary and agree with all of his excellent observations and suggestions.Attention Deficit/Hyperactivity Disorder (ADHD) 53 Finally. Treating individuals with ADHD. Dr. Dr. can also be very rewarding. It is not uncommon for an adult with ADHD to score very well on psychological tests designed to measure executive functioning. I thank Dr. Barkley has suggested several self-report and collateral report measures that we are currently considering. while undeniably challenging. Barkley also correctly notes that adults with ADHD may be impaired in their application of executive functioning skills. Jorge would begin to whine and cry. diagnosed with autistic disorder (autism).e. Upon prompting. would not feed himself. and Holly A. an 8-year-old Hispanic male. When he needed assistance with something. “turn off the light”). Jorge would walk up to an adult. Upon subsequent home observations. and he did not interact with the behavior analysts.. Jorge had been referred for treatment by a service coordinator at one of the state’s regional centers.{3} Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism: The Case of Jorge W. If his needs were not adequately met. “Jorge” (note: a pseudonym is used here and some facts have been altered in this chapter to protect client confidentiality). Jorge was observed to have an excellent imitative repertoire (i. engaged in noncompliant and screaming behaviors. he could imitate simple words) and was able to follow simple instructions (i. limited communication. Larry Williams. and was not toilet trained. and use gestures to communicate his wants and needs. The family also reported that toilet training was of high priority given that his school was concerned for the health and safety of other students and staff. do you need help?” and Jorge would respond.e. Greenwald. presented with high rates of noncompliance and whining. when his mother would say. Jorge appeared to be very energetic and he enjoyed playing alone and preferably outdoors. For example. occasionally escalating into screaming. Jorge would imitate the exact words that were said. “Jorge. do you need help?” When any academic work was .. “Jorge. Seniuk Case History INITIAL REFERRAL AND INTAKE At his initial intake. Ashley E. Jorge’s family reported that the lack of self-feeding was very problematic given that Jorge was underweight and at risk for a diagnosis of failure to thrive. The referral indicated that Jorge was nonverbal. take him or her by the hand. along with music therapy using classical music piped through state-of-the-art headphones. Jorge was observed. Tarbox. When observed at mealtime. DiLavore. imitation and matching). his parents indicated that Jorge showed no interest in using the toilet although they had attempted to teach him many times. Jorge began speech therapy at age 5. 1999. Accardo.. At the time of his diagnosis. given their socioeconomic status and limited knowledge of the diagnosis. 1989). nor was another standard tool. his family was unfamiliar with the diagnosis and attempted to access services. was fluent in both Spanish and English. turn away from the work. is more currently understood to be a significant neurodevelopmental disorder (Filipek. and attempt to elope from the table. Jorge and his family were predominately Spanish-speaking. Kaplan. such as the Autism Diagnosis and Observation Scale (ADOS) (Lord.. Jorge’s parents reported that they bathed and clothed him. & Risi. Carmen. including basic learning skills (i. Vismara & Rogers. Jorge’s family was originally from Mexico and had strong familial relationships and valued hard work and success. Jorge lived with his two parents and 12-year-old sister. Jorge attended a strategies program at his local elementary school for skill acquisition and behavior management. Dixon. Activities of daily living were not a part of Jorge’s skill repertoire. The strategies program is designed specifically for children on the autism spectrum and follows a national curriculum model. Carmen. As described by Granpeesheh. 1995). BRIEF PERSONAL HISTORY Jorge was raised in a lower-middle class community in the northwestern United States. Jorge refused to eat most foods served to him and would only consume certain foods if he were being spoon-fed by one of his parents. daily.. first identified by Kanner (1943) as a social learning or psychiatric condition. 5 months. Baranek. Jorge’s family reported little to no academic or self-help gains since receiving his diagnosis. the Gilliam Autism Rating Scale (GARS) (Gilliam. students progress into more advanced interpersonal skills (i. 2000): . Cook. had not been administered. Epidemiological Considerations Autism spectrum disorder (ASD).Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 55 presented.e. & Wilke (2009) with reference to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association. however. or place his feet on the table and push his chair backward. With regard to toileting. although his older sister. Dawson. to independently drink juice. et al. they were unsure of what services Jorge needed. However. socialization and conversation). Jorge was spoken to in Spanish at home. It was reported that Jorge would void in his diaper and provide no indication of needing to be changed. At the time of treatment. Jorge received a diagnosis of autism at age 3 years. upon mastery of the basic skills. Jorge would laugh. Rutter.e. 2010). We noted that a common diagnostic instrument for autism. Thorndike and. including autistic disorder (299.g. fundamental to ABA is the process of operant behavior discovered by E. emotion. released by the Centers for Disease Control and Prevention based on 2002 data. B. Rett’s disorder (299. behavior analysts regularly conduct “preference assessments” in order to utilize events and activities that actually function as reinforcers. pp.g. medications starting to have effect) and are referred to as motivating establishing or abolishing operations (MEO. pervasive developmental disorder not otherwise specified (PDD NOS) (299. F.g. ASD is characterized by deficits in 2 or more areas of functioning. e.g. Asperger’s disorder (299. human performance is considered to be behavior. thereby increasing adaptive behaviors engaged in by the child.10). 2009. and generalization (Martin & Pear. 2011).. impaired social development. 1953) that the consequences of behavior either strengthen or weaken its future occurrence. with headache. stimulus control.00). These . including impaired language development.80). and childhood disintegrative disorder (299. L. Skinner (1938. For these reasons. home. motor. the addition of positive events or the removal of aversive events) will be strengthened. A basic tenet of behavior analysis is that all public (e.80). MAO. and all behavior. is approximately 1 in 150.g. ASD prevalence has been reported at one in 110 or even one in 70 children (Centers for Disease Control. self-talk. 163) More recently. consumatory.. playing) and unlearned (e. morning without breakfast. 1–20). Behavior that is followed by the occurrence of functional consequences (subjectively. language) and private (e. car. Michael. behavior that is followed by the presentation of aversive consequences or the removal of desirable consequences will be weakened (these are referred to as punishment). 2004). whether adaptive or maladaptive. (2009. The most recent estimate of the prevalence of autism among children in the United States. Behavioral Principles Relevant to Addressing Jorge’s Behaviors Fifty or so years of research in applied behavior analysis (ABA. These are the principles of reinforcement (positive and negative). Similarly.. and the presence of excessive and stereotyped repetitive behaviors or interests. later.80). is functional. Prevalence estimates of ASD have increased dramatically in recent years and may be due in part to an actual increase in the occurrence of this disorder as well as greater awareness of the disorder among clinicians. see Journal of the Experimental Analysis of Behavior. extinction.56 Childhood Disorders Autism spectrum disorder (ASD) has become the commonly used term for all diagnoses falling within the pervasive developmental disorders. In addition to the processes involved in neuro-reflexive or classical conditioning.. p. problem-solving). Journal of Applied Behavior Analysis) have been based on behavioral processes studied in the experimental psychology areas of learning and motivation. punishment. at school. These processes occur in constantly changing physiological and social contexts under external environmental and internal physiological conditions that can be learned (e.. cognition. Schreibman. chaining. 1973.e.. An important feature of the behavioral approach to autism is that its methods have been shown effective in reducing autistic performances and increasing adaptive learning repertoires in most children with which it has been used. Remington et al.) in the teaching of basic language and social skill repertoires and the reduction of selfstimulatory. & Wynn. Green.. the teaching methods (such as one-to-one repeated discrete trial instruction) became refined into packages of assessment and intervention that eventually were reported on a larger scale (Lovaas. 1987. the higher was the likelihood that a child would no longer engage in “autistic” behaviors. Specific antecedent events. & Stanislaw. approximately 50 percent of cases were indistinguishable from their typically developing peers. where a single component of a multiple-component event will gain control over a behavior.. Berberich. These and other behavior analysts also began to describe specific attention and discrimination phenomena related to a diagnosis of autism (e. The growing popularity of applied behavior analysis (ABA) treatment in autism is likely a direct effect of the correspondence of treatment to the diagnostic criteria of autism: behavioral excesses (i. 2000).. Smith. 2011. maximum effects have been observed when intervention can be started as early as possible. 2000). as opposed to many or all components in normal children). Thus. Over time. One lesson learned throughout this development was the somewhat obvious fact that the earlier intervention could be started (e. self-stimulatory behavior or aggression) and deficits (i. 1971). 2008. The predictable and functional occurrence of these events due to the learning history result in the eventual engagement of the adaptive behavior at the correct time. etc. 1966. Cohen. referred to as discriminative stimuli. & Schafer. 2005. and are described as appropriate or inappropriate stimulus control. Simmons. Perry et al. Lovaas. even at the age of 7. and oppositional behaviors in children diagnosed with autism. extinction. while early intervention is ideal. Sparkman.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 57 operations increase the functional value of the specific consequence and under certain conditions will evoke behavior. 1989) and more recently replicated by many others (Howard. discrimination training.e. fading. Early Childhood Behavioral Intervention Perhaps the hallmark of evidence-based intervention in autism was the early behavioral work of Lovaas and colleagues in the 1960s and 1970s (Lovaas. This evidence-based approach is in stark contrast to many reported interventions that claim treatment outcomes but are not described sufficiently . Koegel. & Rehm. These initial reports described the first applications of the behavioral principles outlined above (such as reinforcement. overselectivity..g.. Perloff. Koegel. However. 2–3 years old).g. Lovaas & Smith. Perry et al. shaping. & Long. cue or prompt us that a specific behavior will result in a specific outcome. Lovaas. self-injurious. 2007. it was not surprising to see large-scale behavioral changes in Jorge. communication and social skills) (DSM-IV-TR. Groen.. The above studies also showed that after early intensive treatment. it was reported that he did not use words to communicate his wants and needs and that his vocal repertoire consisted of imitating words that were spoken to him. Finally. Baseline data serve as a control against which the effects of specific independent variables are objectively evaluated (Cooper. Direct assessment Direct observation consisted of antecedent-behavior-consequence (ABC) recording (Bijou. It was reported that at times he would come out of his room and whine for no apparent reason. Given this information. 2005). the behaviors targeted for reduction would be whining (any instance of whining or crying). Foxx. and his current repertoire of adaptive living skills. nonresponsiveness. noncompliance (any instance of repetitive laughter.58 Childhood Disorders to be replicated or are shown to be erroneous by subsequent studies (Jacobson. & Mulick. and under what circumstances those behaviors were likely to occur. 2007). Cooper et al. & Ault. independent eating. Peterson. Jorge’s discrimination abilities. Assessment A variety of assessments were conducted to evaluate the potential function(s) of target problem behaviors. and an evaluation comparison measure of the effectiveness of later treatment procedures. as they allow for the verification and identification of current levels of behavior. Additionally. it was reported that during mealtime Jorge would often refuse to eat. it was determined that during mealtimes. appropriate toileting. Heron. Baseline data collection and analysis are a critical part of behavioral assessment and treatment procedures. Jorge’s parents reported that he did not engage in any severe problem behaviors except for the occasional whine. an interview was conducted with Jorge’s parents to identify problem behaviors in which he currently engaged. baseline data were collected on all behaviors targeted for both acquisition and reduction. During this assessment. 1968). Behaviors targeted for acquisition included communication in the form of manding (a verbal operant in which the speaker asks for what he or she wants. when Jorge should normally be relatively hungry. FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA) Indirect assessment First. and putting his feet on the table during task time). and compliance to reasonable instructions.. & Heward. the assessment of the functional causes of those behaviors. 2007). Parents also reported that Jorge would engage in behaviors such as repetitive laughter and putting his feet on the table when asked to perform a task. Additionally. and food refusal (any instance of Jorge not eating food when it was presented to him during mealtime). as identified by the parents. whining behavior . Jorge’s parents also reported that he was not currently toilet-trained and wore a diaper at all times. Hagopian. Owens. Bowman. prevocational. based on how many times he had selected the item. This laughter and putting his feet on the table would often last up to 5 minutes and was difficult to interrupt or redirect. These results indicated that whining was maintained by both escape from demand and access to preferred activities/items. The toys were then rank-ordered. An ABC analysis involves the recording of the events that precede a behavior. and Flora (1977) is a tool designed to assess the ease and difficulty with which individuals with intellectual disabilities perform three simple and two conditional discrimination tasks considered to be prerequisites for language development and a variety of educational. Yu. It consists of six levels that are hierarchically ordered by difficulty (Martin.e. 1992) was conducted with Jorge. as well as the conditions under which the behavior occurred and the specific consequences that followed each occurrence of behavior. & Slevin. Assessment of Basic Learning Abilities The Assessment of Basic Learning Abilities (ABLA) developed by Kerr. ABC contingency analysis determined that this behavior was likely maintained by escape from demand. This behavior also frequently occurred when Jorge was denied access to a preferred activity (i. & Heward. it was observed that Jorge enjoyed playing outdoors and with video games. SKILL ASSESSMENTS Preference assessment A formal paired-stimuli preference assessment (Fisher. play dough.. A formal preference assessment was not conducted using leisure activities. These items were then simultaneously presented two at a time (in random sequence such that each item is paired with every other) and Jorge was asked to choose one. The results of this assessment indicated that Jorge’s most highly preferred toys were a ball. The fi rst level is a simple motor task in which the individual is required to place a piece of foam into a container. However.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 59 was observed. 2007). Piazza. Items determined to be highly preferred were then used during teaching sessions to increase the probability that behaviors targeted for acquisition would occur more frequently. yielding an overall description of the patterns of occurrence and outcomes for that behavior (Cooper. Through this analysis it was determined that whining typically occurred when Jorge was asked to perform a task and was often followed by the parents allowing him to take a break from the task. The second level is a position discrimination in . 2004). Heron. and vocational skills. & Vause. his parents were asked which toys Jorge typically enjoyed playing with. and the events following the behavior. going outside). using toys to determine which toys would potentially function as reinforcers. defi ned as repetitive laughter and/or putting his feet on the table when presented with an academic task. and a toy airplane. the behavior itself. Direct observation also indicated that Jorge frequently engaged in noncompliance. Meyerson. For this assessment. drawn-out fashion. & Yu. and intraverbals (when a verbal stimulus evokes a verbal response that does not have point-to-point correspondence with the stimulus. completing most of the tasks in each section independently.60 Childhood Disorders which the individual is required to put a piece of foam into the container on the right. these results indicated that Jorge has the prerequisite skills to learn to communicate through the use of spoken language. motor imitation. and that establishing and maintaining the motivation to learn is a critical component of teaching an individual to acquire language. with the exception that the positions of the red box and yellow can rotate randomly between trials (Vause. Level four is a quasi-identity-match-to-sample task whereby when given a red cube the correct response is to put it into the red box. 2007). vocal imitation. This indicated that Jorge was able to perform auditory-visual conditional discriminations. the positions of the red box and yellow can are randomly rotated. requests. high-pitched tone. The results of this assessment provided the basis for the development of protocols to teach language skills not already in Jorge’s repertoire. and motor skills. Additionally. Martin. It was clear that Jorge had . 1957). However. Sundberg in 1998 and was revised in 2006 by Partington. The fi fth level is an auditoryvisual discrimination in which the individual is required to put the foam into the yellow can when the tester says “yellow can” in a long. Partington and Mark L. and spontaneous vocalizations. The positions of the red box and yellow can remain fi xed during this level. Level six is an auditory-visual conditional discrimination that is conducted in the same way as level five. Jorge was unable to perform most of the skills in each of these areas. he did not perform as well in the areas of visual performance. the behavior analysts found it imperative to focus on vocal language acquisition first. Case Formulation Given the results of the ABLA and ABLLS-R. which proposes that language consists of behavior influenced primarily through reinforcement. Level three is a visual discrimination whereby the correct response is to place the foam into a yellow can that rotates positions randomly with a red box between trials. The ABLLS-R (Partington. 2006) is based on Skinner’s 1957 book Verbal Behavior. Jorge was able to pass all levels of the ABLA. academic skills. The implications of these results were that Jorge had the prerequisite skills to respond to vocal instructions. Skinner. Assessment of Basic Learning and Language Skills The Assessment of Basic Learning and Language Skills (ABLLS-R) was originally developed by James W. self-help skills. and to put the foam in the red box when the tester says “red box” in a fast. labeling. Jorge performed well in the areas of cooperation and reinforcer effectiveness. receptive language. This assessment measures an individual’s ability to perform a variety of tasks in the domains of basic learner skills. and when given a yellow cylinder the correct response is to put it into the yellow can. Additionally. 1957) was the initial recommendation to the family. it was decided that functional communication training (FCT) would serve to increase communication as well as decrease whining and noncompliant laughter. it was concluded that Jorge would benefit from several academic interventions. FCT involves a differential reinforcement procedure in which an individual is taught an alternative response that results in the same reinforcement that previously maintained the problem behavior. after the ABLLS-R assessment results were completed. Hanley. and also from toilet training. The goals selected by the family were increasing communication. problem behavior is typically placed on extinction (Tiger. The behavior analysts then invited the family members to participate in selection of interventions that would ensue over the 6 months of treatment time that the behavior analyst would have with the child. FCT involves . Since the first two goals would be encompassed by the behavior analyst’s initial recommendations. It was therefore decided that appropriate communication would replace noncompliance and whining. The behavior analyst therefore provided the assessment results and several recommendations to the family if they were to receive any private tutoring. given concerns regarding malnutrition. The behavior analyst met with the family and explained the assessment results and the initial treatment recommendations. However. independent eating. 2008). During FCT. it was determined that avoidance of task demands was maintaining the noncompliant laughter. The behavior analysts approached the school to discuss some skill deficits and recommended areas to target for improvement. mand training. the notion of independence was discussed further and it was agreed upon that independence would come from increasing communication. & Bruzek. increasing independent eating. and independent eating protocols would begin immediately.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 61 very limited functional communication abilities. Additionally. The family and the behavior analysts therefore agreed that functional communication training. and independence. Intervention Planning COMMUNICATION Functional communication training Based on the results of the FBA. as they were the top priorities for the family and were found to be clinically necessary. the school was not receptive to the behavior analyst’s suggestions. and therefore mand training (Skinner. once progress was made with communication and eating. Finally. based on the results of the FBA. It was agreed upon that toilet training would be the third intervention attempted. given that they had a regimented autism curriculum in place that was approved by the school district. the behavior analysts determined that it was also highly important to focus efforts on increasing independent eating. The parents were asked to select three goals for their child during the 6-month intervention. say “ball. Once the response “break” was adequately conditioned.e.e. say “ball”) and wait for him to say the word. mand training was used to increase appropriate responses to obtain a number of preferred items and activities as well as the frequency of those requests.” Upon a correct response of “break. Mand training The results of the FBA also determined that whining was maintained by both escape from task demands and access to preferred tangible items or leisure activities. “ball. per parent request of independence. a ball. & Bruzek. Hanley. it was determined that a preferred movie would be used as a reinforcer for independent consumption of food. As soon as Jorge engaged in the correct response. “say ball. Using a prompting hierarchy. If Jorge repeated the words “say ball” he was immediately told “no” and the prompt was provided again.. The procedure used was outlined as follows: Jorge was asked to sit at a table to work on an academic task. while problem behavior is placed on extinction (Tiger. In accordance with FCT. The consultant would give Jorge a full verbal prompt (i. After about 10 seconds of access to the preferred item or activity. problem behavior was placed on extinction.. 2008). EATING INTERVENTION The goal of this intervention was to increase Jorge’s independent eating and reduce the need for parent spoon-feeding or prompting during mealtime. This teaching was done in a discrete trial format (Martin & Pear. the item was removed from Jorge. As with FCT.” Jorge was allowed to scoot away from the worktable for 10 seconds. pictures). but instead to allow him the opportunity to eat on his own. Upon engaging in noncompliance. “good job!” and a pat on the back)... The procedure used was outlined as follows: Jorge was given a preferred item to engage/play with (i.e. Additionally. ball”).” If Jorge continued to say. When time was up. Jorge was positioned at the dinner table such that he could see the television within his view. Jorge’s feet were immediately removed from the table and he was redirected to the academic task.62 Childhood Disorders a differential reinforcement procedure in which appropriate responses are taught and reinforced. 2011) in which Jorge was given multiple discrete opportunities to rehearse the new mand. . “say . Jorge was immediately prompted to ask for a “break. Based on the result of the preference assessment.” a longer pause was inserted between the two words in the prompt (i. Jorge was again asked to complete an academic task. . Jorge’s parents were given the remote control and . it was important to teach Jorge to use socially appropriate communication to request things that he wanted or needed. The family was instructed to not spoon-feed Jorge or provide him with any prompts to eat. The procedures implemented were as follows: Jorge was seated at the dinner table and his entire meal (consisting of foods he was more likely to eat) was placed in front of him. the behavior analyst granted fewer and fewer breaks until Jorge was completing a majority of the academic task while requesting no more than 2 breaks in a 10-minute session.e.” the ball was immediately given to him followed by praise (i. movie. If Jorge had an accident. . After consumption of food (defi ned as swallowing). and a weekend was selected in which all immediate family members would be home with the behavior analysts to help support the process. On the fi rst day of the intervention. To begin this intervention. a highly preferred toy was selected for toilet training and was stored out of Jorge’s sight until the intervention weekend began. the behavior analysts sat down with the family and explained the recommended procedures. fluid loading. The movie was turned on again as soon as Jorge put another bite of food or sip of juice to his lips. Jorge remained in pullups training pants overnight until he no longer was having overnight accidents. Digital timers were used to place toileting on a 15-minute schedule in which Jorge was required to say. which he helped select. Jorge’s family was instructed to give him a gestural prompt by pointing to his food. Given that the family had attempted toilet training several times in the past with no success. the behavior analysts decided that it was clinically necessary to use positive reinforcement. the family was asked to collect data on Jorge’s elimination schedule by conducting diaper checks every 30 minutes over the span of 5 days. The toileting schedule timings were slowly lengthened and fluid loading was discontinued. Jorge’s family purchased several pairs of underwear for Jorge. As per the results of the preference assessment. If 20 seconds of not consuming any food or drink elapsed. Jorge was given 5 seconds to consume another bite of food or sip of his juice. If he did not continue eating or drinking within that 5 seconds. after which Jorge was consistently eliminating in the toilet. Jorge was praised and provided with 5 minutes of access to his preferred toy identified for use during toilet training. These procedures continued for two days. This component was used to ensure that Jorge would need to urinate frequently. Heron. 2007). such that Jorge was independently toileting himself on his own schedule. Initially. given that the response effort for accidents is exaggerated to make the clean-up event exhaustive and slightly aversive (Cooper. The family agreed that they were comfortable with the procedures. an overcorrection procedure was used in which Jorge was provided with a statement of disapproval. and overcorrection procedures. & Heward. his favorite movie was momentarily turned on for him to watch. and change his own clothes.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 63 every time that Jorge took a bite of his food. 1974) was used to meet the clinical need of this case. the movie was paused.” and then sit on the toilet for 5 minutes or until elimination occurred. If any elimination occurred while on the potty. allowing for more opportunity for success and teaching. This procedure is called an overcorrection procedure. TOILET TRAINING A rapid method for toilet training (Azrin & Foxx. Jorge was given unlimited access to many preferred fluids and was prompted to take a sip every few minutes. Formally programmed positive reinforcement for appropriate toileting was discontinued after one week. made to clean up the area of his accident. a process called fluid loading. “potty. Potential Treatment Obstacles Many obstacles may arise in the treatment of any individual. Rapport building with the parents consisted of initial meetings in which the concerns of the parents were heard and realistic suggestions of how those concerns may be addressed were formulated. parents were consulted in the development of intervention protocols and were asked for their feedback on the extent to which they would realistically be able to implement the protocols. the behavior analysts avoided the use of technical terms and communicated with the parents at a level with which they were comfortable. “10% is knowing what to do. as well as his speech and language pathologist. It should be noted that the most effective behavioral treatment for autism has been early childhood intensive training. 1977). Furthermore. 1987). 230). Additionally. Given the lack of resources in the community in which the family lived. One of the most common difficulties faced by behavior analysts who conduct in-home consultation is inconsistency across family members. Therefore. . The behavior analysts in this case were fortunate that the family worked together as a unit. This may be attributable to the fact that all family members attended parent-training sessions (that the authors provided and which were the “backdrop” in recruiting this family) as well as consultation meetings. Carmen. the behavior analysts contacted other individuals in the community who were providing other forms of treatment for Jorge. Including Carmen in the process allowed for another individual to implement protocols. The purpose of the parent training was to provide parents with the skills necessary to implement the protocols developed by the behavior analysts. was also involved in the training sessions and attended all meetings with the behavior analysts. it was important that they trusted the behavior analysts and the programs that were developed. Given that the parents had previously experienced a lack of success with other treatment programs. including Jorge’s teachers at school. as well as the maintenance of consistency across all family members. 1967.64 Childhood Disorders Addressing Nonspecifics The model used for the treatment of this case was one of parent training and inhome consultation. Jorge’s sister. Foxx (1996) stated that in the case of successful behavioral intervention programs. 90% is getting people to do it” (p. Another important component of any treatment package is the acceptance and compliance of intervention protocols by all who have an influential role in the caretaking and education of the individual. This allows for consistency across environments to enhance the likelihood that the intervention will be successful and durable (Forehand & Atkeson. This approach allows for the early establishment of appropriate learning as a child develops and has been associated with an approximate 50% success rate in eliminating autistic behaviors (Lovaas. The first step in this process was building rapport with the family. intensive intervention was not available at the time of Jorge’s original diagnosis. Finally. and inconsistency across family members was minimal. Once he began to urinate. the behavior analysts decided to reexamine the effectiveness of the reinforcers being used.” . Limited reinforcers can cause problems for treatment. This limited the amount of items that could be used as reinforcers for Jorge. lack of success of an intervention may be due to other factors. inconsistency was addressed at meetings between family members and the behavior analysts. Foxx (1996) suggested that often a program will fail because its success depends on the consultant convincing people to carry out the program. In addition to collaboration and implementation barriers. 30). edible reinforcers were automatically excluded due to food refusal. other potential reinforcers were sought out. as strong reinforcers are a critical part of any intervention. there was difficulty in fi nding appropriate reinforcers. The difficulty was that Jorge was not urinating in the toilet and thus was not contacting reinforcement. so the behavior analysts met with the family to discuss modifications. Another barrier commonly faced when conducting behavioral consultation work is inconsistency or lack of collaboration among treatment providers for the individual. the behavior analysts and the family decided to use a more intensive intervention. In this case. Therefore. The original protocol was not effective at first. the behavior analysts observed each of the family members implementing each of the protocols and provided corrective feedback. 1996). This is not an uncommon scenario. The principle of reinforcement states that “when a type of behavior is followed by reinforcement there will be an increased future frequency of that type of behavior” (Michael. he was immediately placed on the toilet and allowed access to the video game.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 65 To address the issue of inconsistency. This modification proved to be highly effective. we were not successful in establishing a meeting. p. In this case. as is common in many behavior analytic interventions. The behavior analysts had Jorge remain in the bathroom until he began to urinate. The lack of effectiveness of the video game technology as a reinforcer was eliminated on the basis that Jorge would seek out the game. Therefore. following the prompt “Say. preferred items were identified through a preference assessment. For example. as education and human service professionals often feel threatened when they must learn a new set of skills and therefore engage in resistant behavior (Foxx. the behavior analysts in the case of Jorge faced challenges at the more basic level. The teacher was resistant to accepting academic suggestions because the school was following a model that had been approved by the school district. Once items have been shown to be effective reinforcers. Unfortunately.” For example. 2004. Additionally. after numerous attempts to meet with Jorge’s teacher. but when treatment was not initially successful. This was the case during toilet training. When Treatment Was Not Working PROBLEMS WITH COMMUNICATION One obstacle encountered during mand training was that Jorge would repeat arbitrary words such as “say. ball. The total mealtime was reduced from 45 minutes to 25 minutes. Additionally.e. in which the same protocol was used to reinforce independent eating with a preferred movie. a differential reinforcement procedure was used in which only the response “ball” was reinforced and not “say ball” or “say ball please. the behavior analysts modified the protocol and kept Jorge in the bathroom.” Additionally. and then Jorge and the behavior analyst watched movies in the bathroom during the time between sits on the toilet. scoop the food.e. instead of eating and pausing after swallowing bites. hot dog. and bring food to his lips. it was observed that Jorge would refuse to eat them. even though parental report indicated that he had previously eaten those foods. Jorge’s parents were prompting him to say “ball. as soon as Jorge began voiding in his underwear.. A portable DVD player was brought into the bathroom. A modification to the protocol was made to include spoon-only foods during certain meals. At that time. Jorge had still not had a successful elimination on the toilet during the fi rst 7 hours of the toilet training intervention. When provided with foods that required a spoon (i. Some additional teaching was required to get Jorge to hold the spoon. PROBLEMS WITH EATING After several successful meals in which Jorge ate independently. the behavior analysts had to meet with the family and request that only one-word mands (i.66 Childhood Disorders Jorge would repeat. Up to that point. the behavior analyst quickly escorted him onto the potty to fi nish his elimination in the toilet. During the intervention.. A second concern that arose during mealtime was the duration of time that it took Jorge to consume the foods. A prompt fading procedure was used in which the discriminative stimulus. “ball”) were taught initially and that arbitrary words such as “please” were left out. “ball. Jorge was praised and the successful elimination on . However. Jorge had traditionally spent an hour or more at the dinner table while his parents tried various strategies to feed him. Jorge spent about 45 minutes per meal while independently eating. chips).” as well as many other subsequent items and activities. he had 8 accidents and no successful eliminations on the toilet.e. Scheduled sits continued as usual. the behavior analysts were able to provide a variety of fi nger and spoon foods for Jorge at each meal. please. After several meals with spoon foods only.. “say ball. it was noted that Jorge was only eating fi nger foods (i. yogurt or applesauce).” After noting that Jorge would use the words “say ball please” to request the ball. until no prompts were needed.” This alternative procedure helped to break the inappropriate verbal chain of words and assisted in teaching Jorge his fi rst functional word. PROBLEMS WITH TOILET TRAINING Even with the 15-minute scheduled toilet time and overcorrection procedure for accidents. quesadillas. “say” was spoken softer and with a longer pause prior to the mand. At that point. The protocol was modified again to shape continuous eating during a meal. the only time that punishment was used was during the overcorrection procedure for accidents during toilet training. it was concluded that some support would be better than no support. model appropriate supports. including skill acquisition and behavioral reduction strategies. Jorge continued voiding in the toilet during the scheduled sit time. the behavior analyst approached the family and received consent to use the punishment procedure during toilet training. 2007). However. and provide technical assistance over a period of 4 months. Additionally. Ethical Considerations CONSULTATION MODEL: IS IT ETHICAL? A primary consideration in the consultation model implemented in Jorge’s case is whether or not it is ethical to provide limited service and recommendations for clinical treatment when there is no ongoing professional clinical service to follow through with the treatment recommendations. enough time to ensure that the family could implement the clinical recommendations with fidelity. the behavior analysts felt that it was necessary to use the procedure. However. Heron.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 67 the toilet was reinforced with the highly preferred toy item. In this case. as well as the health concerns of Jorge’s school. Ethical consideration was given prior to its use. Given these issues. given the short amount of time in which toilet training needed to occur and the several reported previous failed attempts of the family to teach appropriate toileting behavior. in this case. Following that initial elimination and contact with the reinforcer. Punishment has historically been a controversial topic in the science of behavior analysis. facilitate the implementation of plans. The procedure was carefully monitored. 2005). and was . USE OF PUNISHMENT Punishment is defi ned as a consequence that decreases the likelihood of the behavior occurring in the future (Cooper. the behavior analysts were able to work with the family to set obtainable goals. was implemented only by the behavior analysts. given the limited availability of services in the area and the limited financial resources that the family was able to contribute to ABA treatment. and remaining in the bathroom during breaks was no longer necessary. however. a sibling were trained in the basics of behavior support. or for a behavior in which other less intrusive interventions have been demonstrated to be ineffective (Baily & Burch. A referral to a community ABA resource was made at the end of treatment in hopes that the family would access continued clinical supports when they were fi nancially able to. & Heward. punishment is said to be an ethical treatment if it is deemed necessary by the behavior analyst to reduce a behavior that is dangerous to self or others. In the treatment of Jorge. the consultation model included a rigorous parent-training component in which both parents and. object.. 2000). A motivating operation is “an environmental variable that a) alters the reinforcing effectiveness of some stimulus. Therefore. However. on subsequent days it was discontinued. The momentary effectiveness of any stimulus change as reinforcement will depend on the existing level of motivation with respect to the stimulus change (Cooper et al. and b) alters the current frequency of all behaviors that have been reinforced by that stimulus. 2007). As mentioned previously. It should be noted that access to video game technology was also restricted to toilet-training sessions for the same reason. the items that were being used for mand training were a ball. Upon observing increases in behavior. object. 699). Reinforcer assessments are useful in this sort of a situation (Cooper et al. and pictures. The fi rst common mistake. it was established that the preferred item was in fact functioning as a reinforcer. it is important to systematically verify that the putative reinforcers are functioning as such. In the case of Jorge. or basing it on the incorrect function. In the case of Jorge. A common mistake in behavioral treatment is to assume that the intervention is not working.68 Childhood Disorders needed only during the fi rst day of toilet training. This is of importance in any intervention designed to promote acquisition of a behavior. An FBA will provide important information regarding both antecedents related to the problem behavior that. the behavior analysts assessed the effectiveness of potential reinforcers by using the identified preferred items during mand training and assessing the data. Family members were asked to restrict access to these items during times in which mand training was not being implemented. particularly in the case of teaching manding. Common Treatment Mistakes to Avoid Numerous common mistakes should be avoided when designing and implementing behavioral interventions. briefly mentioned above.. Another common mistake made by behavioral consultants is not basing an intervention on the function of the behavior. increasing the effectiveness of the protocol.. A related obstacle in terms of reinforcement is ensuring that appropriate motivating operations are in effect to increase the likelihood that reinforcers will function as such. a mand is a verbal operant that is under the functional control of a motivating operation. a movie. In this type of situation. is incorrectly assuming that the lack of success of an intervention is a result of the intervention and not due to the ineffectiveness of reinforcers. Functional behavior assessments (FBA) should be conducted prior to the development of any intervention. as well as information . or event” (p. by restricting Jorge’s access to these items it was more likely that a motivating operation would be in place during training sessions. or event. may reduce the motivating operation for problem behavior. reinforcers should be assessed systematically through a reinforcer assessment to ensure their effectiveness and to avoid mistakenly modifying a protocol. it is possible that the items chosen as reinforcers may not actually be functioning as such (Higbee et al. 2007). In such cases. if altered. functions of behavior are likely to change. it is important to reexamine the function of the behavior and make appropriate modifications. which can then be eliminated (Cooper et al. in such cases. usually in quantified form” (Johnston & Pennypacker. p. During parent training sessions. Moreover. and that his verbal language continued to increase. 1993. Data are “the results of measurement. Behavior analysts program interventions to prevent regression and relapse through the use of generalization and maintenance techniques. 2007). (1994) stated that an intervention may lose its effectiveness over time due to the function of the problem behavior changing. over the course of time. Follow-up was conducted 4 months following the closing session. It is important to monitor the data closely in order to detect changes that may be a result of changing environmental variables. The information gained from data provides necessary insight into the success or failure of an intervention. there are cases in which the function is difficult to identify or is incorrectly identified.. 2007). However. If an intervention is designed that does not match the function of the behavior. Lerman et al. Data analysis is arguably the most important part of behavioral interventions.. the programs are likely to fail. and settings. It is important that this process be considered one of importance and not something that just occurs (Stokes & Baer. A common mistake is to make programmatic changes without regard to the data. it is unlikely that it will be successful in reducing the behavior. Behavior analysts use a variety of methods to specifically program for generalization. Overcoming Regression/Relapse Regression and relapse are important considerations in any treatment regimen. behavior analysis is a field in which all decisions are based on data (Cooper et al. where decisions are not guided by data. such as introducing natural maintaining contingencies and using many exemplars. Other methods used to prevent relapse and regression in the case of Jorge were the use of parent training and referral to other services. The goal of any treatment program is to modify behavior in such a way that the observed changes will last over time and across situations. In such situations. Given that behavior is dynamic and behavior change is an ongoing process. Stokes and Baer (1977) argued that for a treatment to be effective it must occur over time. 1977). families were taught the basic principles of behavior analysis as well as the importance of data monitoring. The parent training was important. and the parents reported that Jorge had continued to eat independently and use the toilet independently. persons. as well as to use what they have learned to teach new skills. . Behavioral assessment and intervention are ongoing processes in which data analysis and monitoring are highlighted. as it provided the family with the basic skills to be able to respond appropriately to new problem behaviors that may arise. 365).Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 69 regarding the source of reinforcement for the behavior. this is called generalization. Behavioral consultation is designed to provide temporary treatment in which the effects will maintain once consultation is removed. 2).1. It was observed that the family was engaging in daily teaching interactions with Jorge. Anecdotally. Jorge had some words that were occasionally used functionally. It is common in low. who was once assumed to be un-teachable. Data and Conclusions 5/11/2005 4/11/2005 3/11/2005 60 55 50 45 40 35 30 25 20 15 10 2/11/2005 Number of words Within a four-month period. even on days when the behavior analyst was not in the home. By the end of the intervention.1). Jorge engaged in over 50 functional words. but were often used inappropriately to request items that he later refused. McLaurin. the family felt accomplished and empowered in learning new strategies to teach their son. This may result in the use of services that are not empirically supported and may ultimately be ineffective. or during echolalic responding. Each data point represents the number of words considered mastered at each of the dates. Daniels. By the end of treatment. all of which he was able to use appropriately to request items or talk about items and events in his environment (see Figure 3. Ellis.70 Childhood Disorders In addition to providing families with basic skills in behavior analysis through formal training. Jorge Date Functional Communication Training. & Morrisey. the family reported that they felt as if the behavior analysts had “awoken Jorge from autism. . FIGURE 3. Jorge’s family was trained on how to provide teaching and behavior support to their autistic son. Jorge was also taught to eat independently without spoon-feeding or continual prompting from his parents (see Figure 3. Jorge’s parents were provided with information regarding behavior analytic service providers in the community and were referred to a local behavior analyst who could provide ongoing services. At the beginning of treatment. it also provides them with the knowledge to be more informed consumers of autism services.” In other words.and middle-class communities that families often lack the necessary information regarding services offered for autism treatment and thus are less likely to receive services (Thomas. 2007). Prompts to use the 160 Cumulative Frequency 140 120 100 Prompts Urination BM Accident 80 60 40 20 0 -20 1 12 23 34 45 56 67 78 89 100 111 122 133 144 155 Sessions FIGURE 3. was able to eat a meal independently within 20 minutes.3). Jorge was engaging in successful urination eliminations on the toilet (see Figure 3. Jorge was taught to independently toilet himself using the toilet in his home. Accidents were seen during the fi rst three days but by the fourth day were no longer occurring. he was given a laxative and was successful in having bowel movements on the toilet after seven days. .3. Jorge held his bowels (often common during initial toilet training) during the fi rst five days. Cumulative Occurrence over The First Five Days of Training Sessions of Prompted and Independent Toilet Urinations and Accidents and BMs. By the end of the first day. using a spoon correctly.2.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 80 71 Baseline Intervention 70 Movie Turned Off Prompts 60 50 40 Verbal or Gesture Prompt 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Session FIGURE 3. as needed. upon consultation with the pediatrician. The open circle data stream indicates the number of verbal or gestural prompts that were necessary for Jorge to self-feed over training sessions. Independent Eating Treatment. Finally. The solid square data stream indicates the number of times the video had to be turned off due to Jorge’s cessation of eating. may be modified or removed. parents often look to the behavior analyst with hope of recovery from autism. to duration of time during meals. Wolf. must decide which responses to reinforce and which to extinguish. the diagnosis. While shaping involves using the empirically established scientific principles of reinforcement and extinction from the experimental analysis of behavior. often the behavior analyst must work with the parents just as much as the behavior analyst works with the individual child. Additionally. The Art of Behavior Analysis While applied behavior analysis is based on scientific principles (Baer. to successful approximations of speech during mand training. it must be made clear that the strength of behavior analysis is overcoming the behavioral excesses and deficits. the decision to stop reinforcement of a particular amount or strength of a behavior.” For example. the behavior analyst will work to reduce behavioral excesses and to increase skills to overcome behavior deficits associated with autism. defi ned by the occurrence of these behaviors. Speaking with and relating to parents of a child with a debilitating condition often takes a certain level of fi nesse and compassion. and to successful approximations to independent toileting. Behavior analysis is widely accepted as a treatment for autism.72 Childhood Disorders toilet were needed for just over two weeks. to await variations in the behavior. there is certainly an art to the delivery of services in behavior analysis. This can be a challenge for the behavior analyst to explain that there is no promise of “recovery” and that. however. instead. 2011) is also a procedure that may be considered as much an art as a science. in which Jorge later would independently request a trip to the potty in the community by saying “potty” or if he was in his own home. acting as the listener. Relating particularly to the treatment of childhood autism. In the treatment case of Jorge. specifically pertaining to the treatment of children with respect to how the parent . Shaping (Martin & Pear. 1968). and then to reinforce those new levels of the response in applied behavior analysis is often left up to the clinician’s “acumen. While there is an abundance of research on each of these topics. Once those behaviors are changed. would simply go himself. each case is individually treated and each behavior individually shaped such that shaping can be said to involve some talent or art on behalf of the behavior analyst. there is no written rule that dictates when the sound of a verbal operant is correct. Cultural Factors to Consider in Providing Treatment There are often cultural concerns that arise during the treatment of autism. but rather the behavior analyst. & Risley. especially in a consultation model. the art of shaping was used to reinforce successive approximations to spoon-feeding. many parents who were themselves raised in a disciplinary household do not understand why the standard disciplinary techniques do not always put an end to a problem behavior. music therapy. N. Often. Perhaps one of the most outstanding cultural factors to consider when providing treatment to autism is reframing the idea of child rearing for parents who were raised in a more restricted disciplinary household. DC: Author. it is important to come to an agreement as to which language is most important for the child with autism to speak such that initial functional communication can be taught efficiently and effectively without the additional confusion resulting from two separate languages. Mahwah. occupational therapy. 91–97.. escape-maintained problem behavior (behavior that is reinforced by the postponement or removal of requests to engage in a certain behavior. A fi nal identified cultural barrier is differences of opinion of alternative treatments of autism. M. & Burch. play therapy. Though applied behavior analysis is currently considered best practice in evidence-based treatment of autism (Vismara & Rogers. acupuncture. 1. (2005). R. NJ: Lawrence Erlbaum Associates. Toilet training in less than a day. or the removal of environmental cues that signal the introduction of less desirable activities) is actually strengthened by the time-out procedure. However.” Perhaps one of the more obvious cultural factors to consider is the language barrier that occasionally arises. J. 2010). many have not been. as was the case in the treatment of Jorge. T. M. sometimes there are barriers to its use as a treatment in certain communities. Diagnostic and statistical manual of mental disorders (4th ed. including speech therapy. “go to your room”). with regard to function of behavior.g. Although many of these therapies have been demonstrated to be helpful in the treatment of autism. (1968). H. D. Ethics for behavior analysts. & Foxx. In this case. Given that autism is classified in part by behavioral excesses (often aberrant behavior). S. W.. M. New York: Pocket. M. a common parenting strategy is to use time-out (removing the child to a relatively isolated place with little or no environmental stimulation) when a child does not behave as expected (e.. sensory integration therapy. when there are two languages being spoken in the household. For example. Additionally. (1974). and so on. but rather reinforces the problem behavior. There are many documented treatments in autism. what the parents consider to be punishment does not function as punishment at all. initially a translator was brought in to assist in communication between the behavior analysts and the family. Azrin. equine therapy.. Baily. physical therapy. Some current dimensions of applied behavior analysis. References American Psychiatric Association. while the parent is using what is thought to be “discipline..Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 73 was raised. R. chelation. . (2000). & Risley. R. Baer. Journal of Applied Behavior Analysis.. 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Yu. T. 20.. L. L. 6.. clearly show the difficulty in assessing and treating the core and associated deficits and excesses of autism. In a sense. convert a parent’s . it becomes exceedingly clear that diagnosing autism and subsequent assessment and treatment of the core and associated behavioral deficits and excesses of autism are an exceedingly difficult set of tasks. Some individuals may establish specific routines or repetitive behaviors that are difficult to compete with. Williams et al. Some individuals may develop significant food selectivity. and making objective. There are several other possible symptom clusters that might covary among individuals diagnosed with autism. and caregivers. one of the confusing aspects of autism is that several individuals diagnosed with autism may present with very different symptoms. while others will purposely avoid social interaction. and instruments that are specifically designed to provide the practitioner with information about the individual’s behavior. One of the most interesting features of this case description is that Jorge exhibited many of the types of behavioral excesses and deficits found in individuals diagnosed with autism. while others may not. They also clearly show (with their single-subject data collection) the power of behavioral techniques and procedures for collecting data. One of the strengths of the chapter is that a practitioner could practically use the section descriptors as a guideline for a clinical case of his or her own. generating function-based treatments. teachers. testing hypotheses. Some individuals may seek out some social interaction. rating scales. establishing hypotheses. some individuals may engage in vocal speech. at best. and Seniuk provide a systematic description of a case study involving one individual who exhibited symptoms consistent with a diagnosis of autism. and others may not. Simply considering the above potential symptom presentations. Kelley Willams. Greenwald. Jorge is a prototypical individual diagnosed with autism because he provides clear-cut examples of the excesses and deficits that are often described by parents. others may tolerate social interaction.g. data-based decisions about the adequacy of an assessment or treatment. For example. Those procedures may include interviews.. Specifically.COMMENTARY Michael E. On the other hand. The primary strength of the indirect procedures is to obtain historical information that helps the practitioner to develop operational defi nitions of problem behavior (e. functional behavioral assessment (FBA) typically begins with—and I emphasize begins with —some sort of indirect assessment procedures. Consider the example above. ABC recording does not provide information about the overall context in which the problem behaviors occurred. Pence. There is a growing literature on conditional probabilities that can help guide the practitioner in this area (e. First. If attention was only diverted 10 times. Woods. and it is likely that practitioners will find them reasonable to use and helpful during assessment and treatment. and to develop a plan for upcoming assessment. This might seem like fairly clear evidence that attention diversion is motivating and attention delivery is maintaining aggression. a one-to-one relationship would exist between aggression and attention.78 Childhood Disorders description of an “aggressive child” to specific instances of what does and does not count as “aggression”).g. & Ault. Specifically. Lerman & Iwata. 1968). ABC recording produces a permanent product that aids in generating hypotheses about the function of behavior. 2009. The primary difference between ABC recording and conditional probabilities is the exclusion or inclusion of the background context in which the behavior occurs. because preference assessment results typically guide the practitioners’ use of stimuli as potential reinforcers. and so on. There are several advantages to ABC recording. & Lesser. 1993. Roscoe. There are also some significant limitations to ABC recording. preference assessments help to select the best candidates for potential reinforcers. to develop hypotheses about the function of those behaviors. Borrero. Second. Borrero. the literature clearly supports several conclusions. Van Camp. McKerchar & Thompson. From a teacher’s perspective. that problem behavior is likely to occur when the mother’s attention is diverted). Vollmer. However. First. However. if attention was only available contingent on aggression. conducted skills assessments next. began with antecedent-behavior-consequence (ABC) recording (Bijou. and aggression did not occur on those occasions? We would be far less confident about the relationship between attention diversion and problem behavior. which is described so well in this chapter. including many aspects of family life. and all 10 instances were preceded by diverted attention and were followed by reprimands. The plan will be influenced by myriad variables. The next step in the process involves direct assessment. ABC recording provides details about the circumstances that preceded and followed the occurrences of target behavior.. there are several procedural variations to choose among. this line of research helps practitioners to collect and analyze data such that the likelihood of a contingent relationship between events can be judged. 2004. a one-to-one relationship would exist between the attention diversion and aggression. it might seem daunting to have to establish specific preferences for each individual. & Lalli. Finally. Williams et al. what if attention was actually diverted an additional five times. Wright. Masler.g. I thought it was interesting that the preference assessment was placed under skills assessment. Bourret. the use of tools like . 2010. that can only be obtained through indirect assessment. and aggression did not occur on those five occasions? What if attention was diverted 100 times. & Ahearn. Peterson. Borrero. Second. Williams et al.. 2001). ABC recording may help one to detect certain patterns in the environment (e. Let’s say that a child engaged in 10 instances of aggression. and (not mentioned by the authors) assessment of interobserver agreement. by negative reinforcement in the form of escape from or avoidance of eating. That is. or FCT. [1982]1994). Unfortunately.Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism 79 the Assessment of Basic Learning Abilities (ABLA. All of the procedures up to this point are designed to place a practitioner in the best possible position to develop an effective treatment. function-based treatments (Mace. based on the results of the FBA. Kerr. Slifer. Consider the data generated by Piazza et al. 1977) and the Assessment of Basic Learning and Language Skills (ABLLS-R) is critical. Williams et al. The development of functional analysis technology has helped to move treatment of problem behavior away from the arbitrary selection of reinforcement-and-punishm ent-based procedures and toward the use of specific. The other option available is to simply guess at a starting point. there are no studies showing that positive-reinforcement-based treatments are useful for escape-maintained problem behavior (including refusal) during mealtimes. 1994). In their study. describe problems with treatment. I suspect that this would true. the art of behavior analysis. In Jorge’s case. In Jorge’s case. Meyerson. with constitutes differential reinforcement of alternative behavior (DRA). Of those 10 functional analyses. relapse. because apparati such as these specifically guide skill development. 10 of the 15 functional analysis outcomes were interpretable. to date. Dorsey. it is critical to maintain clear and consistent operational defi nitions. The data must guide the practitioner for selection of preferred stimuli . Carr & Durand. I wondered if the treatments may have been more robust if they had been informed by the results of functional analyses. Bauman. it did not. particularly for Jorge’s eating behavior. an evaluation of their data. data collection procedures. An FBA may include a functional analysis. several studies have shown that using escape extinction (usually in the form of nonremoval of a bite of food) is often effective for increasing compliance with taking a bite. & Flora. Later in the chapter. Each of these discussion points provide excellent “rules of thumb” for practitioners to follow when developing treatment plans with clients. arranged access to preferred stimuli contingent on compliance. & Richman. Williams et al. and cultural considerations (to which the authors alluded earlier in the chapter). which is obviously a crude and inefficient way to establish a baseline from which to begin teaching. “Intervention Planning. 9 out of 10 (90%) suggested that inappropriate mealtime behavior was maintained. One procedure that readers may fi nd conspicuously absent is the use of functional analysis (Iwata. at least not when escape extinction is not a part of the treatment. The feeding intervention was also put in place without the information provided by a functional analysis. 1985) was implemented. These data were congruent with previous research on treatment of eating disorders with children with developmental disabilities. Williams et al.” discusses the integration of the previous assessments and their application to treatment development. treatment (functional communication training. From a scientific standpoint. address common mistakes to avoid. but in this case (as in many cases). at least in part. The next section of the chapter. and Jorge’s manding and eating behavior remained resistant to treatment. In the remainder of the chapter. (2003). W. Identifying possible contingencies during descriptive analyses of severe behavior disorders. G. H. 27.. The assessment of basic learning and language skills—revised. Journal of Applied Behavior Analysis. (1994).. M. Lerman. R. The measurement of motor. and auditory discrimination skills. 27. The significance and future of functional analysis methodologies. A. J. Descriptive and experimental analysis of variables maintaining self-injurious behavior... (1977). C. and Lalli. Masler.. & Ahearn.. 293–319.. (1968). M. Bourret. A descriptive analysis of potential reinforcement contingencies in the preschool classroom. 43. E. F. S. J. M. 26. C. J. 385–392. M. Toward a functional analysis of self-injury.. Journal of Applied Behavior Analysis.. (2003). A method to integrate descriptive and experimental field studies at the level of data and empirical concepts. & Richman. Katz . Piazza. Dorsey. Borrero. Roscoe. H. C. (2001). J. J. C. (2004). Relative contributions of three descriptive methods: Implications for behavioral assessment. M. R. 71–88. Journal of Applied Behavior Analysis. Brown. C. H. 37. Mace. Peterson. Rehabilitation Psychology. W. (2006). S. D. Journal of Applied Behavior Analysis. J. (2009). N. R. D. (1993). Meyerson. R. W. Iwata. A. Vollmer. W... visual. A. . Pence. W. 36. Borrero. M. Descriptive analyses of pediatric food refusal and acceptance. K. E. Journal of Applied Behavior Analysis. 18. M. 34. V. J.. P. T... N. Bauman. Kerr... A. J. C.. 425–446. 1. & Ault. & Thompson. R.. B.. G. Partington. E. (1994). C.. Reducing behavior problems through functional communication training. F. Carr. E. 24 (Monograph Issue). A. 95–112. 197–209.. W. Journal of Applied Behavior Analysis. S. Journal of Applied Behavior Analysis. Fisher. C. K. McKerchar.. A. & Iwata. & Lesser. A. K. S. Wright. B. C. B. 111–126. Shore.. M. S. Borrero. Gulotta.. L. Van Camp.. Functional analysis of inappropriate mealtime behaviors. 269–287. Slifer. Woods. & Flora.. F. 431–444.... Sevin. 187–204. A. C. Journal of Applied Behavior Analysis. B. Patel.. 175–191. C. Journal of Applied Behavior Analysis. 42. References Bijou. (2010). Behavior Analysts Inc. Journal of Applied Behavior Analysis. S. (1985). S. T. & Blakely-Smith.80 Childhood Disorders and to judge whether assessment and treatment procedures are producing the desired information and outcome. & Durand. RESPONSE W. Marcus. and therefore there was minimal risk in attempting an intervention prior to a direct empirical demonstration of function. Dorsey.g. the difficulty with the manding intervention as a result of echolalic behavior was easily resolved by fading the word “say. Had the intervention failed. In the case of Jorge. This escape-maintained behavior was not the case with Jorge. However. in the interest of time and resources. Vollmer. Slifer. and Holly A. Greenwald. and an intervention was immediately used to correct the inappropriate behavior. this echolalic behavior was not harmful to Jorge or to others. Although it may have been acceptable to conduct a functional analysis here.maintained behavior and the demonstrated use of escape extinction in the literature for feeding problems. Instead. it was assumed that the behavior was automatically maintained. Larry Williams. With regard to the eating intervention. We agree that the case of Jorge was a classic case of treatment of autism. & Roane. The use of differential . We commend the commenter for his analytical overview of our clinical interventions and appreciate his thorough explanation of the many behaviors that may be prominent with an autism diagnosis. We support Kelley’s argument that a functional analysis is considered best practice with regard to establishing a functional relationship between behavior and environmental contingencies. there are several limitations to the functional analysis (e. & Richman. 1995). [1982]1994). Additionally. Kelley makes a strong argument for escape. Bauman. The major criticism posed by Kelley was that of the absence of a functional analysis (Iwata. the most relevant to this case being the limitation of time commitment in conducting a functional analysis. but that he lacked motivation to feed himself. Ringdahl. Ashley E. a functional analysis would have been implemented to determine the maintaining variables before attempting another intervention. it was observed that Jorge would readily accept food when fed.” Given that no social contingencies were altered during instances of echolalia. the clinicians decided to forgo the analysis and implement an intervention. with many behavioral excesses and deficits present prior to treatment.. Seniuk Kelley raises some excellent points with regard to the overall treatment of autism. References Iwata. 197–209. Vollmer. (1994). & Roane. Kelley’s commentary reminds practitioners of the need for thorough justification for the use of empirically demonstrated interventions in the treatment of autism. S. .. E.82 Childhood Disorders reinforcement of alternative behavior (DRA) during Jorge’s mealtime proved to be an effective intervention to increase independent eating. Without the use of evidence-based treatment. G.. R. Dorsey. Progressing from brief assessments to extended experimental analysis in the evaluation of aberrant behavior. Journal of Applied Behavior Analysis. Toward a functional analysis of self-injury. Slifer. B. K. S. A. M. (1995). & Richman. T. 28. H. E. This data-based decision-making is a foundation of applied behavior analysis and lends to the strength of its success in the treatment of autism.. Marcus. J. K. A. time may be lost in the race against autism. Bauman.. J. and most important.. Kelley makes an excellent point when he notes that data must guide the practitioner in selecting interventions to produce desired outcomes. 561–576. parents are cautioned that resources may be wasted. There tends to be a trend for use of “treatment of the month” approaches as parents and clinicians struggle to fi nd a “cure” for autism... F. Ringdahl. B. Journal of Applied Behavior Analysis. 27. { PART II } Mood Disorders . This page intentionally left blank . Indeed. Specifically. when in fact it is more about becoming numb to emotions.. Results from research studies conducted independent of pharmaceutical companies’ influence suggest that depression is not a purely biological illness. the body responsible for defi ning and describing disease states. While most people experiencing symptoms of depression report some form of loss or personal setback. Additionally.{4} Treatment of Depression Patricia J. Robinson There a number of popular myths about depression. when permitted. Clinical research fi ndings indicate that one in ten people in America suffer from some sort of depression every year (Kessler et al. such as loss of a loved one or a job and economic hardship. and these myths have a substantial impact on the health care services that people with symptoms of depression receive. While the World Health Organization. 2006) and colleagues suggests that cognitive behavioral therapy is more effective than medicine in preventing future episodes of depression.” However. pharmaceutical companies promote this notion in marketing medications to health care providers and patients. in order for something to be abnormal it must occur rarely. 2005). there is growing evidence that cognitive and . Sadness is a part of our human birthright. and they are not trained to market their findings. many do not experience depression so severe as to warrant intensive treatment and instead fi nd a way to “keep calm and carry on. Researchers who are not sponsored by pharmaceutical companies have no readily available organized group to promote dissemination of their results to the lay and professional community. the work of Paykel (Paykel. First. much like our other basic emotions. does not currently recognize depression as a disease. A second myth concerns the inevitability of depression as a response to difficult life circumstances. and this is not the case with depression. it flows in and out of our awareness throughout the day. and. there are many things in life that should trigger sadness.” A third myth about depression is that it is associated with experiencing emotions. That depression is purely a biological illness is a fourth—and important— myth. therapists and patients alike may think that depression is abnormal or “out of the ordinary. who get trapped in their mind. Gifford. Hayes. 1989). 2011). Gould. Moitra. These clinical methods are derived in part from basic scientific research in the field of relational frame theory (RFT) (Blackledge. et al.. the therapist assists the patient with making gains in “psychological flexibility. Bissett. Piasecki. & Lillis. Treatment formulation is based on six core processes of psychological flexibility derived from acceptance and commitment therapy (ACT) theory (Hayes. Barnes-Holmes. In the case of depression. 2011) and found to be effective in clinical research studies (Bach & Hayes. Luoma. Depression is a common problem. Yeomans. The learning history of the subject of this case study resulted in her experience of this vulnerability. When we look closely at these myths and research findings. provide access to social reinforcement. When life circumstances overwhelm a person’s ability to cope. 1999. Hayes. 2001. 2008. Piasecki. rest. and memories are avoided) and “outside the skin” (behavioral avoidance. 2004. sensations. & Strosahl.” so to speak.86 Mood Disorders behavioral interventions may produce very rapid improvements in depression (Kelly. that response typically involves avoidance of sad and angry feelings. 2011. Forman. feelings. Antonuccio. In the recommended approach. Ruby had suffered several episodes of depression prior to the one described here. Yardi. it is important to understand not only the patient’s response to difficult life circumstances. Dahl. 2002. Callaghan. a period of withdrawal. We are more able to tease out the differences between patients who do and do not experience clinical depression and to help patients with symptoms of depression identify change targets that move them toward a meaningful life. 2006. and the avoidance may occur both “within the skin” (experiential avoidance. & Glenn-Lawson. The problem of depression occurs when the withdrawal becomes a new way of life and precludes active pursuit of new solutions and the development of new skills to deal with the life circumstances that overwhelmed the patient’s ability to cope in the first place. 2003. 2004. McCracken & Eccleston. Wilson. Kohlenberg. Strosahl & Wilson. & Wilson. 2007. This is the setting where most depressed patients seek help and where increasing numbers of behavioral health providers are working (Robinson. & Roche. Gifford. 2007). Treatment of Ruby is offered in a primary care clinic. 2000). we are more prepared to treat with intention and to understand the waters we are swimming in. Hayes. Hayes & Strosahl.. Hayes. Zettle & Rains. Hayes. & Ciesla.” the goal of ACT. It is also important to note that patients prefer cognitive behavioral treatments to medications (Mynors-Wallis et. Torneke. & Nilsson. but also “the patient’s response to that response. in which daily actions function to create a barrier between the patient and direct experiences that might provoke psychological distress but alternatively evoke positive emotion. Roberts. Masuda. This chapter offers therapists contextual behavior therapy strategies for use with people who are vulnerable to clinical depression. Gregg. 2004. Hayes. one in ten among us are prone to responding to hardships in life by using avoidance strategies and forgetting to reengage. Bond. et al. and moving . al. Robinson & Reiter. Strosahl. & Geller. and who struggle with struggling. Herbert. 2003. and request of support from others may be adaptive. Lundgren. Dahl. Wilson. 2007. in which psychologically distressing thoughts.. and shape new behaviors). 2004. 2005). As this case demonstrates. & Melin. Ruby gave birth to one child and adopted one child. Over the years. They argued about how soon their returns would be realized. While David had participated in methadone treatment. David. He had been married twice previously and had two children. David had struggled intermittently with polysubstance abuse and heroin addiction since his high school years. for intervention materials and protocols). and. He reasoned that he wouldn’t need to spend money on lodging. Ruby retired from her career as an office manager two years ago when she and her husband moved from a large city to a home in the country five miles outside a town of 700 people. Ruby went along with the plan reluctantly. They had met at work and pursued their relationship in a secretive fashion for years before “tying the knot. and they had married in their forties. and had worked for years at a time. Ruby was saddened by Albert’s decision. he reasoned that he could spend the workweek at his brother’s house.” and he believed that they could create and work in a home business for a 10-year period and then retire. and his salary would fund the cost of starting the barbecue business. Her daughter. The idea was to grow tomatoes and peppers and other ingredients to make a secret family recipe for barbecue sauce. and she anticipated the many details and hours of hard work needed to create and implement a business plan. her adopted son. as she had hoped for a more intimate relationship at this phase of their marriage. they both agreed to enter the new business. Albert. the birth child. as he lived near the company where Albert planned to work. more contemplative life in this pastoral setting.” Her husband. 2008. was the “author of plan B. he continued to have relapses into using street drugs. in the end. She and her husband had planned to pursue art-related hobbies and to lead a slower paced.Treatment of Depression 87 from the “depression trap” toward a vital life (see Strosahl & Robinson. to prepare the sauce in their home. explaining that . lived in another state and was happily married and working long hours at her job. She lives in a rural area with her dog and her husband of 18 years. Over the past month. Ruby had come to anticipate David’s relapses and to “brace” herself. had stable housing. Shortly after the launch. lived in the city where she and Albert had lived previously. Ruby Ruby is a 64-year-old married mother. but they had significant fi nancial problems during their fi rst year “on the farm” and had to pursue a “plan B.” In her fi rst marriage. and to sell it both locally and on the Internet. She had a strong business mind and worried that they would have to spend a lot on farming and processing equipment related to the business. reasoning that she “should be happy that Albert had a chance to bring in some money. While it entailed a 100-mile commute. She didn’t complain to Albert. Ruby had worked for many years as an office manager.” Albert was her second husband. Albert had an opportunity to take a job in the city where he and Ruby had lived for several decades prior to moving to their country home. David had asked Ruby for “a loan” several times. he would spend weekends with Ruby. and he assumed responsibility for her blood pressure and arthritis medications. take painting lessons. and learn yoga. Marks shortly after moving to the area. She was frustrated with not having had the time to “even unpack all the boxes” from their move. and supportive. Ruby had walked her at a brisk pace and found that it helped her to feel calm and optimistic. At night. the more she wanted to retreat to her bedroom with her dog and “just maintain. She always slept much worse when she worried about David. she reviews the frustrating and overwhelming activities of the day and anticipates an uncontrollable tomorrow. even though it required her to walk at a slower pace and for a shorter distance than she would have liked. Ruby and Albert often argued when he did come home. Given increasing fatigue in the morning and the lack of energy to persevere.” Ruby doesn’t hear that this message is often delivered in the voice of her long-deceased mother. After her divorce.” When she remembered her dreams about her retirement years. and she felt pangs of panic when she saw day after day that money was going out and not coming in. as well as completing all of the office tasks. Ruby enjoyed walking Fiesty. thoughtful. Ruby’s constant companion was her mixed-breed dog. as he was “fed up with David.” Ruby admittedly struggled with organizing the personal and office space areas of the home. At the point when she sought care.” She experienced benefit at times but with a decrease in sexual interest. she had experienced depression and sought help. and instead experiences it as mandate. and their seven-yearold son. Albert did not come home every weekend as planned. He was also the prescriber for her anti-depressant. she felt sad and told herself to “buck up” and “play the hand she’d been dealt. study Spanish. and she worried about him. Fiesty was 9 years old and suffered from arthritis in her back legs. and she rarely talked with Albert about her concerns. she was socially isolated and didn’t “even have time to visit with the neighbors.” After Albert started his new job. She had established care with Dr.” She was irritable with Albert. and then critical of herself for not being more organized. He was sometimes critical of Ruby for not being “a better housekeeper. as he was “exhausted at the end of the week. The less organized her home and workspace become. his wife.” During this challenging year.88 Mood Disorders he and his wife were “ a little short. While only a distant memory.” Ruby worried that this was a signal of his return to street drugs. Ruby worked to optimize production of the barbecue sauce. having restarted it “about a year ago” and as a pattern of intermittent use over the past “10 years or so. Ruby decided to ask her family physician for help. She was also responsible for managing their home fi nances. He also encouraged her to walk 30–45 minutes daily and to reduce salt in her diet. A psychiatrist had originally prescribed Prozac for Ruby. She’d hoped to find a reading group. She continues to take Prozac. Albert insisted that he needed time to rest and pursue his woodworking hobby when he was home and limited his work on the business to creating jar labels and further developing marketing plans. this involved managing personnel issues with their two full-time employees. Prior to Fiesty’s decline over the past two years. Ruby’s intention in moving to a rural area was to have time for painting and writing. She took the medicine and . I work as a (continued) . These scores range from 0 to 100. Behavioral Health Consultant Introduction Hello. there were no counselors in the smallest town near her home. she didn’t know if her current insurance coverage would cover counseling or psychiatric care. her consultation visit began with a description of her services (see Box 4. Peterson was a “behavioral health consultant” and often had good ideas about “how to work with stress. He reinforced the importance of daily walks and dietary adjustments and scheduled a follow-up visit to further discuss a possible change in her blood pressure medication. Marks also said he was concerned about Ruby’s blood pressure. She routinely completes the Duke at the beginning of initial and follow-up visits with patients 18 years of age or older and shares results with patients immediately. Use of the Duke is congruent with the strengths-based approach that Dr. It also orients the patient to the structure of the visit.1. Peterson was able to see Ruby for a 30-minute initial visit immediately after her visit with Dr. and he already knew something of her history of depression. The Duke Health Profi le is a 17-item measure of health-related quality of life.” To her knowledge. Mental Health. Peterson uses in primary care behavioral health visits. Marks to ask his advice about how to “get things under control. Marks. I am a behavioral health consultant and a psychologist.” Dr. and she knew that she could not afford the time to go 20 miles to the next largest city. These initial activities may be completed in 5 minutes or less (90 seconds for the introduction and 180–210 seconds for completion and scoring of the Duke). He said he would like to avoid increasing her anti-depressant and asked her to consult with a colleague who worked with him in the clinic.” She briefed him on her stresses. He explained that Dr. Peterson’s job description defines her work as consultative (rather than psychotherapeutic) and as a primary care service (rather than specialty mental health service). she reports scores on three Function Scale Scores: Physical Health. Ruby scheduled a visit with Dr. The normative sample was that of primary care patients. The doctors refer to me whenever there is a concern that stress is having a negative impact on health or when behavior changes might help a patient improve their health. In her chart notes and her feedback to the patient. higher scores indicate better functioning. Moreover. She was unclear about the cause of depression. Peterson. She had begun to feel better and had stopped the counseling.Treatment of Depression 89 went for a dozen or so visits to discuss her family of origin and the failure of her marriage. Assessment As was standard for Dr. I’d like to tell introduce myself and explain what I do here in the clinic. and Social Health. so that the patient is able to participate actively. Dr. BOX 4. Dr.1) and completion of the Duke Health Profi le. but felt it was probably a mix of “bad genes” and “a failure of character. Peterson focused her assessment on the referral problem identified by Dr.90 Mood Disorders BOX 4. Love • Where do you live? • With whom? • How long have you been there? • Are things okay at your home? Do you have loving relationships with your family or friends? 2. Play • What do you do for fun? For relaxation? • What do you do to connect with people in your neighborhood or community? 4. I’ll ask a lot of questions. Marks and to Ruby. Play. & Strosahl. I have the same reporting responsibilities concerning risk or danger as other providers in the clinic. then. are you looking for work? • If not working and not looking for a job. Peters obtained a “snapshot” of Ruby’s present life context in about five minutes by asking a series of questions. conversational manner. Work. alcohol. let’s start with having your respond to the Duke Health Profi le. Organized into four areas. how do your support yourself? 3. Marks and . The Life. Gould. Do you have any questions? If not. First. Health • Do you use tobacco products. After her introduction and completion of the Duke. trying to get a snapshot of your life right now and. Dr. and Health Tool (Robinson. we will begin to generate ideas about what you might be able to do to work on the problem and pursue a better quality of life. Dr.1 (Continued) consultant to you and to your doctor and I write my chart note in the medical chart. illegal drugs? • Do you exercise on a regular basis for your health? • Do you eat well? Sleep well? Consistent with her role as a consultant to Dr. Our visit today will take about 20–25 minutes. we will focus on the problem that you and your doctor have concerns about. Work • Do you work? Study? • If yes. 2011) is an interview aid that primary care providers (including primary care behavioral health providers) may use to obtain psychosocial and health information in a time-effective. these questions include: 1. what is your work? • Do you enjoy it? • If not working. which is usually experienced as supportive of relationship development by patients. it’s a measure of health-related quality of life. After about 15 minutes. Three T and Workability questions are organized into four areas and include a variety of questions in each area. Dr. Peterson completed a brief functional analysis. As can be seen in the Plan section of the chart note. ” exercise. so important to informing timely skill training and development of an engaging and meaningful behavior change plan. & Strosahl. from Ruby’s point of view. how long does it last? 2. and her organizational and planning skills. Peterson introduced the idea of setting goals in a value context. Dr. 1. Time When did this start? How often does it happen? Does it happen at a particular time of the day or in a particular situation? When you have this problem. Peterson’s efforts to help Ruby approach her life and all of its stresses with greater psychological flexibility built upon Ruby’s strengths: her history of a meditation practice. . . Peterson shifted the interview to behavior change planning. To help Ruby clarify her values and connect with them. Let’s say that you won the lottery. Box 4. Triggers What happens just before you have the problem? Is there anything or anyone that seems to set it off? What do you think causes the problem? Do you have a hypothesis or do you have a guess about why you have the problem? 3.” To obtain an understanding of the way in which these symptoms were functioning in Ruby’s life.Treatment of Depression 91 Ruby—symptoms of depression and. Dr. You are somewhere over the Pacific Ocean. even a little? Did it work in the short term? Did it work in the long term? Did what you tried to do to cope with the problem have unexpected costs or unintended negative consequences? Did it work in terms of what matters to you in life? After completing a 20-minute assessment designed to inform development of a meaningful intervention. Workability What have you done to cope with the problem? Did it work. “trying to get things under control. “Our plane is having . 2011) offers a structure that helps the behavioral health consultant strike a balance between thoroughness and brevity. Dr. and you have decided to go on the vacation of a lifetime. and your captain comes on the overhead PA to announce. Dr. The Three Ts and Workability Tool (Robinson. Gould.2 is the resulting chart note for the first visit. Peterson used the “You won the lottery and . In an effort to create a more powerful context for goal setting. Trajectory Is it here all the time or is it episodic—comes and goes? What’s the problem been like over time—sometimes better and sometimes worse? Has it been getting better or worse over time? How about recently—better or worse in the past month? 4. along with a current interest in meditation and yoga. Does not use tobacco products.” To solve current problems. Objective: Patient is alert and oriented.” Patient has had similar periods and started intermittent use of Prozac over 10 years ago. Support patient in above Patient to follow up with BHC in 1–2 weeks difficulties and we will be making a water landing. Walking the dog. her irritability. work responsibilities. Set up meditation area in bedroom and practice 5 minutes every morning 2. work) Completed the Duke Health Profi le (a measure of health-related quality of life) at today’s visit. ” You follow the instructions. 1 work. The island has things you can eat and you quickly fi nd a little cave to sleep in. Dr. Experiences little benefit from it at present but wants to continue “just in case I might feel worse if I stopped. higher scores indicate better functioning). Stresses include fi nances. Drinks 3–4 cups of green tea daily. patient has tried making lists and setting small goals (two skills encouraged by a previous therapist). Try yoga class Recommendations to PCP / Follow-up Plan 1. Results included three scores: Physical Health 40. and the husband works weekdays in a city 100 miles away. Social Health 40 (scores range 0–100. . family problems (increased confl ict with husband. Everyone is expected to survive. and your life jacket supports you in swimming to a deserted island. patient had wanted to learn Spanish and study yoga. we need for you to follow instructions carefully. talking with neighbors. Patient rates “trying to get control” of symptoms of depression as an 8 on a 1–10 scale where 10 is “a very big problem. family.” These symptoms have become increasingly problematic over the past 2–3 months. Use values statement generated in today’s visit to guide selection of 1 home organizing. Mood is dysthymic. Mental Health 50. and patient is most concerned about her difficulties with concentration. .2. and a “sense of dread about the next day. but fi nds little time for vigorous exercise or pleasurable activities (such as writing and painting). Has hypertension and arthritis. You realize that you will survive and that eventually someone . No SI / HI. No specific relaxation activities. Prior to onset of fi nancial problems.92 Mood Disorders BOX 4. She lives with her husband of 18 years in their home of two years. but has tried meditation in past. They have a home business. takes medicine as prescribed. social. and 2 social activities for the day during a morning planning activity 3. Peterson’s Chart Note of Initial Visit with Ruby Subjective: Ruby is a 64-year-old married mother of two adult children. . adopted son with history of drug problems). She enjoys short walks with her dog. and watching movies also helps sense of calm. Plan: Recommendations to patient 1. Drinks about 4 glasses of wine weekly. Assessment: Symptoms of depression in the context of multiple life stresses (fi nancial. Figure 4. I’m used to it”). “buck up.Treatment of Depression 93 will fi nd you. such as “be a good wife. and you will be happy”. fair and honest. I hope that my children would say I believed in them. Ruby was swimming in the “feel good” agenda that is pervasive in today’s society. and (3) ignoring life results. What is it that you hope your husband would say? What do you hope that your daughter would say? Your son. then something must be wrong with us.” (2) avoiding painful experiences.” The rules we seek to follow and the stories we tell ourselves to justify our success or lack of success in implementing these rule-based strategies for living life vary. They hope that you’ll be coming back.” Avoiding conflict and “trying to be a good soldier” were not moving Ruby toward her values and were in fact having the unintended side effects of increasing her sense of resentment and her withdrawal from productive. Implicit in the “feel good” agenda are rules that we should follow in order to be happy. three processes are at work when people get stuck in the “depression trap. Case Conceptualization From the acceptance and commitment therapy point of view. This agenda suggests that we should feel happy and that if we are not happy. And of course that I was a loving partner willing to be close even in tough times. Peterson and Ruby talked about the workability of the strategies she’d been using to “get control. In talking with Dr. Our rules about life and our stories about self are subtle. and we often don’t see them. “be a good mother. smile. that I was a good listener.” These include (1) trying to “feel good. What is consistent among humans is the fact that our learning histories predict our pursuit of rules and stories perfectly. proactive problem solving. as well as her disappointment with not pursuing . she readily dismissed her feelings about her marriage and her son’s ongoing health problems (“Oh. your loved ones back home come together to talk about your life. they take turns talking about who you were to them and what they thought you stood for. Peterson. and you will be appreciated and experience joy”. encouraged them to make the world a better place. Dr. able to call it as I saw it. and the world will smile with you. as you have a flare and will send it off when a plane comes near the island. I hope that my husband would say that I was a smart businesswoman. much as we might have trouble realizing that we are seeing through sunglasses if we wear sunglasses all the time for years. First. One by one. In debriefi ng this exercise. but they don’t know and they want to share their thoughts and memories about you. After a couple of weeks. David? This was Ruby’s response to the exercise. Ruby was also avoiding painful experiences.1 provides a brief summary of how Ruby’s coping efforts mapped to these three processes. limited. and. Overall. resigned to a life of quiet desperation. Further. emotions. victimized.94 Mood Disorders Ruby avoided experience of the frustration and sadness she felt about having interesting and enjoyable activities in her life. and resentment.” even while saying to Dr. FIGURE 4. Without the ability to experience more contact with the present moment. exhaustion. She also carefully avoided direct experience of her anger toward her husband and any interactions that would bring her into confl ict with him (“I just go outside or have a glass a wine. She avoided having conflict with her husband. Peterson that it didn’t seem to be helping her and actually seemed to diminish her interest in sex and in this way furthered the tensions between her and her husband. in fact. there’s no point in making trouble. to “not complain”. Ruby felt pushed around by life. above the water line. we talk about a “water line”. it’s impossible anyway”). Without guidance and support. she planned to follow the rule of “take the medicine and you’ll feel better.1. we swim in our rules and stories and don’t notice them.” her ability to learn from her direct experience with her life choices was limited. she might continue to live life according to unseen and unexamined . Ruby ignored the fact that her daily activities did not bring her a sense of vitality and purpose. we can see our private experiences for what they are—stories. below the water line. In ACT. Given Ruby’s difficulties with “swimming above the water line. and. sensations. be grateful. be a “good wife”. brought her sadness. and he isn’t going to change anyway”). She couldn’t make a connection between her lack of engagement in pleasurable and mastery activities and her sense of life satisfaction or between her behavior toward her husband and his response to her. in many ways. Avoid Painful Experiences Try to Feel “Good” Compression Depression Ignore Life Results The Depression Trap Ruby tried to be happy. Case Conceptualization Tool: The Depression Trap her planned life directions related to learning and creativity (“It doesn’t matter. she was unable to learn from her direct experience. overlap in many ways. patients often make gains in processes not targeted in an intervention. she anticipated that she would perhaps need to help Ruby with unexamined rules (concerning the expectation that if she could only not complain or persevere with taking the pills.Treatment of Depression 95 rules. Dr.2. Six Core Processes of Psychological Flexibility and Vitality . six core processes are important to psychologically flexible responding (see Figure 4. In follow-up visits. indeed. Peterson reasoned that she could best help Ruby to build some momentum by targeting development of daily exercises to (1) strengthen her ability to experience the present moment (process 1) and (2) engage in selection and execution of home. work. Peterson’s mental conceptualization of Ruby’s situation helped her to formulate ideas about what interventions might help Ruby develop greater psychological flexibility. Contact the Present Moment 2. Since patients typically have strengths in some areas. From the ACT perspective. Hold Your Self-Story Lightly & Become a Mind-Watcher FIGURE 4. Peterson saw Ruby’s previous experience with meditation (an activity that supports experience of the present moment. Learn to Let Go of Distressing Thoughts/Feelings and Name Unworkable Rules 3. In 1. and social activities consistent with her values (process 3). Make Commitments. Since the six core processes are not mutually exclusive. Dr. the therapist may use a patient’s strengths in one area to build strengths in other processes. Dr. along with active acceptance of difficult feelings) (process 1) as an area of strength that might help Ruby to tap into the ability to differentiate between what she could and could not change and to focus on changing what she could (process 6). Define Your Values 6. and. she would get back “in control”) (process 5) and limiting self-stories (concerning her “failure to help her son with his drug problems and perhaps how her “wants and needs didn’t matter”) (process 4). Keep Commitments 4. Accept What You Cannot Change and Focus on Action Psychological Flexibility & Vitality 5.2). Additionally. she saw Ruby’s ability to connect readily with her values in the initial visit as an area of strength (process 2) that would help her eventually strengthen her ability to clarify her commitments and sustain value-consistent action (process 3). She had also made additional changes that seemed to help her.96 Mood Disorders providing ACT-consistent interventions. Through their close collaboration. worsen. Dr. Wischman. Robinson. Peterson and Dr. 2009. Marks were able to amplify each other’s interventions. as Dr. Ruby’s Duke Health Profile Scores Visit 6 Visit 7 . 2007. She and her 100 90 80 70 60 50 40 30 20 10 0 Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Physical Health Mental Health Social Health FIGURE 4. Dr. Peterson provided him with information on ACT designed for primary care providers (see Robinson. 1996. Robinson. 2011. “workable” means that the solutions contribute to the patient’s sense of vitality (whether symptoms improve. therapists “dance” around the six core processes in an effort to help the patient more flexibly pursue workable solutions. Strosahl & Robinson. Intervention Development: Course of Treatment Ruby was seen for a total of seven visits over the course of a year.3 provides a graph of her Duke scores at all visits. 1996). Gould. Marks indicated an interest in ACT. for a guide to implementing the Primary Care Behavioral Health model). or stay the same). PHASE ONE Engagement Ruby returned for a second visit within two weeks and reported some success with the planned interventions. and.3. Peterson and Dr. and Figure 4. including restarting a diary-writing habit from the past. They had worked together for six years using the Primary Care Behavioral Health model to develop their collaborative program (see Robinson & Reiter. Marks can perhaps be best conceptualized in three phases. & Strosahl. & Del Vento. Her collaboration with Dr. and the puppy liked to walk at a brisk pace two or three times . she made a commitment to call him twice weekly and to focus on listening to him and to showing an interest in areas of his life other than “the problem ones. and so on. Ruby had three visits with Dr. Peterson was seven months after her initial visit. Marks. Marks to let Dr. Her work with Dr. Peterson focused on her identification and “naming” of unworkable rules. Dr. Peterson. Her dog had passed away. she was able to make contact with the psychological pain she felt concerning her son’s struggle and to examine her self-story about this. This empowered her to reduce her rate of engaging in behavioral attempts to control him or his problem and to focus instead on attending to his engagement in activities inconsistent with drug use. Ruby’s rule about disregarding her own feelings and needs and trying to “just get along” came to be known as the “Never Mind Me” rule. She dropped by after a medical visit with Dr. equipment. and each would cook one. Marks. Peterson know that she and her husband had decided to shut down the home business and that they were busy selling leftover product. PHASE TWO During months three through five. While he was continuing to work away from home. For example.” Ruby bought a book online about it and skimmed it. he had changed his schedule to allow for three days per week at home.Treatment of Depression 97 husband had agreed to have two special meals when he was home for a weekend. Peterson and one with Dr. PHASE THREE Ruby’s last contact with Dr. The work with Dr. he wanted to see if she could improve it further by working more intentionally on sleep quality. Marks supported Ruby’s work with Dr. While her blood pressure was under better control. He recommended that she complete an online cognitive behavioral program designed to improve sleep hygiene skills. Over the course of the following six weeks. and her husband had bought her a new dog. Peterson focused on Ruby’s ability to accept her sadness and frustration concerning her relationships with her husband and son and her approach to discriminating between what she could and could not change. She continued with her meditation practice and made some progress with unpacking some boxes left over from the move two years prior and in creating a profit-and-loss report for the home business. She learned to say “Hello” to it when it showed up in discussions with her husband about how the home business interfered with her ability to pursue important life directions. She had taken to walking several times a week with a neighbor she had met while walking her dog. She was taking a yoga class and had been looking on-line at senior volunteer opportunities.” When Dr. Through her journal. Peterson made a brief mention of “personal assertive statements. Ruby returned for three additional visits at the clinic. Peterson and one with Dr. two with Dr. She agreed and found some of the ideas helpful. Rather than dreading a call from him. Peterson congratulated her on her progress. Marks could support it. and the case of Ruby provides a basis for addressing these. There are other possible concerns that therapists face in providing treatment to the large and growing group of patients with symptoms of depression. and she resolved to continue to stay involved and to show her love and interest in a way that did not enable his drug use and that empowered his growth as a human being. Ruby could access care when it was convenient and important for her. While some therapists would select cognitive restructuring or behavioral activation. She continued to walk with her neighbor on some days. Peterson did not need constructs like “lack of commitment. WHAT IF THERAPY DOESN’T WORK Sadly. other possibilities might include helping Ruby connect with a behavioral health provider working in a traditional model of care. This model is formed around building patients’ access to therapy at the time of need. as many will decline and some who say they will go ultimately . Of course. Dr.” In providing care to Ruby. we will consider potentially important concerns that therapists may encounter in providing care to patients like Ruby. and it is based on the basic science of relational frame theory. THERAPY PROBLEMS Therapists are often frustrated by problems such as missed appointments and patient “lack of commitment.98 Mood Disorders every day. Perhaps the first concern for most therapists is the selection of a therapeutic approach. Dr.” as her job description by definition was to provide care in response to patient motivation. ACT encourages the therapist and patient to go back to the basics of functional analysis with an attitude of curiosity and to be guided by results. the therapist is working in the Primary Care Behavioral Health model. Dr. I selected ACT because language plays an important role in the generation and maintenance of depression symptoms. She continued to feel sad about her son at times. and Ruby agreed to place it in her journal where she could review it when she needed to. Peterson’s appointments were same-day. ACT provides a unique perspective on language. Peterson agreed to place this summary in the medical chart where Dr. Important Issues In this section. Referring primary care patients to specialty mental health care is a difficult decision. and together they made a brief summary of the changes that had been most helpful to Ruby. day by day. therapy doesn’t always work at all times for all patients. and the neighbor had invited her to join a women’s book club. where appointments are longer and treatment is manual-based. Since about half of Dr. Ideally. Ruby believed in silence. is to gain a better understanding of the patient’s worldview. If therapy doesn’t work in primary care. Peterson used this to enhance treatment outcomes. in meditation. it is important for therapists to obtain information about the effectiveness of medication treatments for depression from studies not sponsored by pharmaceutical companies. the therapist works as a consultant to the primary care provider. and Dr.Treatment of Depression 99 do not. as well as other mental health problems. That being said. To refer automatically to a mental health specialist would have been to challenge her already overwhelmed resources and to possibly contribute inadvertently to her mounting symptoms of depression. RELAPSE PREVENTION AND TERMINATION In the Primary Care Behavioral Health model. therapists will know the evidence. and listen carefully to the patient preferences and patient report of direct experience. Peterson concerned doing no harm to Ruby. We need to respect these. What does the patient believe caused the problem? What does the patient believe will help? Cultural beliefs often provide protection to the mental health of members of the tribe. A part of that plan is always to have the patient make contact with the primary care behavioral health provider for a booster visit whenever indicated. A good guideline is to note the sponsor of the article before reading the article. it is good to offer the patient more intensive care but to keep the door open in primary care—patients do tend to “vote with their feet. To avoid making this mistake.” ETHICAL CONSIDERATIONS The most significant ethical consideration for Dr. . make it available to patients. CULTURAL FACTORS A very interesting recent book by Ethan Watters (2010) suggests that one of the most powerful ways to address cultural factors in treating depression. but less so today than in previous years. it is important to be open—some patients with symptoms of depression find medications helpful and some do not. so the idea of termination does not apply. COMMON MISTAKES Assuming that medications will solve the problems faced by a person with symptoms of depression is a somewhat common mistake. even though we do not understand them. A consultant does not have a caseload. The issue of relapse prevention is solved nicely by having the primary care provider follow a relapse prevention plan recorded in the medical chart note. S. Ruby’s dance is ongoing. Hayes. A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. F. J. & Geller. & Glenn-Lawson.. A preliminary trial of twelve-step facilitation and acceptance and commitment therapy with polysubstance-abusing methadone-maintained opiate addicts. Hayes. Herbert.. C. J.. Blackledge. Journal of Consulting and Clinical Psychology. C..100 Mood Disorders THE ART OF RUBY The art of Ruby was in the dance she did with Dr.. P.. Peterson and Dr. G.. M. 689–705. L. 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Day. & Robinson.. J. C. Living life well: New strategies for hard times. Coping or acceptance: What to do about chronic pain? Pain. J. Robinson. 2000. (2005). O. Demler. R... S. Robinson. CA: New Harbinger. D. H. K. Robinson. & Robinson. .. & Melin L. Reno. (2008). P. & Strosahl. T. K. Merikangas. (1996). antidepressant medication. New York: Springer Science + Media. McCracken. CA: New Harbinger. & Reiter. 102–108. New York: Free Press. Group cognitive and contextual therapies in treatment of depression. M. P. Acceptance and commitment therapy and yoga for drug-refractory epilepsy: A randomized controlled trial. Journal of Clinical Psychology. L. Real behavior change in primary care. 438–445.. L. 593–602. Berglund. CA: New Harbinger... K. Torneke. if they receive any treatment at all (Young et al. revolutionary approach to treatment that could replace CBT (Hayes et al. Critics of this view believe that the skills taught in ACT are not incompatible with traditional CBT approaches. The author briefly mentions that ACT was chosen over other modes of therapy because of its focus on the role of language in the “generation and maintenance of depression symptoms. especially when augmented with therapist support. can be effective in reducing depressive symptoms (Spek et al. this case study provides an example of the fact that it is possible to deliver effective. an exciting and burgeoning area of research has been in the development of various programs that deliver cognitive behavioral therapy (CBT) via computer programs or the Internet. These programs can be widely disseminated and reach a larger number of people who may not have access or the means to engage in traditional therapy. In any discussion of therapy as a treatment for depression. In fact. For example. the case conceptualization in this chapter glosses over the ongoing and lively debate over the merits of traditional cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT). 2001). Furthermore. In fact..COMMENTARY Olga V.. The reality. and studies have shown that these interventions. The ACT camp holds that this therapy is a new. 2006). from the description of the treatment procedure. and that there is nothing dramatically different about ACT (Hofman & Asmundson. it is always important to consider if there are any advantages of choosing one therapy orientation over another. is that most individuals suffering with depression never make it as far as receiving adequate treatment for their symptoms. Indeed. empirically supported treatment within the context of a primary care setting that is not simply based on medication management. Alloy When thinking about effective treatments for depression.. 2008). however. it is likely that the first two modalities that come to mind are antidepressant medications or a traditional 50-minute therapy hour.” However. this case study is representative of a newer movement that seeks to deliver therapy in novel ways. this speaks to a criticism of ACT in that the techniques used in treatment are not specifically linked to the philosophical and theoretical . it does not appear that language work was the focus of Ruby’s treatment. However. Obraztsova and Lauren B. it would be interesting to understand why Ruby’s treatment providers chose ACT as their treatment orientation and why they believed it might be particularly efficacious for Ruby. 2007). Zum Vörde Sive Vörding.” and “acceptance” (Forman et al.. and there have been only a handful of studies to date that have used this “head-to-head” comparison between these two therapy modalities. A close examination of the interventions developed by her treatment team reveals that they were based in large part on the principles of behavioral activation—that is. 2008). After all.. 2007). this is a burgeoning area of research. but what does the empirical evidence say about the merits. is whether it is important to look for the unique aspects of these two therapies. Although one of the goals of clinical scientists is to fi nd and isolate the “active ingredient” in therapy as a way to improve and streamline future interventions. This is not to say that all therapies are exactly the same. of one treatment modality over another? A meta-analysis of existing treatment studies has shown that ACT is superior to treatment-as-usual. Unfortunately. that are shared by different therapy orientations. 2008).g. such as the therapeutic alliance between the client and therapist or client engagement in treatment.. or if it was something else entirely.. Furthermore. . these common factors can predict improvements seen in the clients regardless of the treatment implemented (Castonguay et al. The question that arises out of these studies. a number of cases will show some improvement over time even without the presence of an active intervention (e. There is. whereas those who received ACT showed changes in “experiential avoidance.. or a placebo as treatments for depression have shown. However. if any. research has shown that behavioral activation itself. Behavioral activation is an important shared component of both CBT and ACT. previous research has shown that improvements shown as a result of therapy are mediated by different mechanisms. In fact. Researchers have identified a variety of common factors. 2005). the aspects of therapy. Dobson et al. especially for treatment of depression (Powers.Treatment of Depression 103 basis for the therapy (Hofman. but showed no differences in outcome when compared to traditional CBT. so it is unclear if these cognitive changes were responsible for her improvements. however. that is. rather than anything specific to the therapeutic intervention itself. however. 1996). depending on the treatment modality (Hayes. For example. & Rees. is an effective treatment for depression on par with traditional cognitive therapy (Mazzucchelli. Kane. It is likely that engaging in positive life activities was associated with Ruby’s improvements in mood. DeRubeis et al. 2009). 2008). even without a cognitive component. another real possibility that changes in Ruby’s external circumstances. encouraging Ruby to engage in more pleasurable activities that may have fallen by the wayside during her life transitions. as clinical trials comparing medication. but common factors may explain why there is not one therapy that is “better” or outperforms all other empirically supported therapies in randomized controlled trials. However. There has been growing evidence that ACT is an effective treatment for a variety of mental health issues. were what produced improvements in her mood above and beyond those due solely to treatment. the clinicians did not collect this information from Ruby.” “acting with awareness. 2009. therapy. & Emmelkamp. individuals receiving cognitive therapy showed improvements in “observing and describing” their experiences. real cases such as this one remind us that there are myriad factors at work that influence outcomes. References Castonguay. R. cognitive therapy.. between her therapy appointments that resulted in some positive changes to her situation. R. 62(4). Hofmann. Gallop.. S. & Rees. & Hayes. J. R. treatment never occurs in a vacuum. and antidepressant medication in the prevention of relapse and recurrence in major depression. B. and in Ruby’s case.. G.. 383–411. (2008). et al. Goldfried.. E. R.. S. Masuda. Randomized trial of behavioral activation. R. S. Journal of Consulting and Clinical Psychology. M. M. Wiser. (2005). Shelton. such as the shutting down of her business and changes in her husband’s work schedule. (2007). Hayes.. J. Journal of Consulting and Clinical Psychology. M.. Behavioral activation treatments for depression in adults: A meta-analysis and review. P. Young. Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review. C. & Lillis. the case description shows that Ruby experienced a variety of life changes. C. G. Forman. 31(6).. 1–16. D. E. Dimidjian. R. Acceptance and commitment therapy: Model. Predicting the effect of cognitive therapy for depression: A study of unique and common factors. At the same time. A Randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. (2008).. G.104 Mood Disorders More specifically. Without a doubt. 15(4).. 280–285.. Kane. 28(1). Amsterdam. 15(4). (1996). 16(4).. Behaviour Research and Therapy. Kohlenberg. A. (2009). G. J. Acceptance and commitment therapy: New wave or morita therapy? Clinical Psychology: Science and Practice. Schmaling. Hofmann. Behavior Modification.. Climbing our hills: A beginning conversation on the comparison of acceptance and commitment therapy and traditional cognitive behavioral therapy. 772–799.. T. J. Clinical Psychology: Science and Practice. D. What can be taken away from case studies such as this one? One is that there are many avenues for treating depression that may be different from a weekly therapy appointment or traditional CBT. L. A. Archives of General Psychiatry. R. F. A. W. S. P... (2006). 286–295. & Asmundson. M. and it is difficult to assess whether the approach used to treat Ruby’s depression would work for individuals with a more severe or chronic case of depression. .. D. S. Mazzucchelli... 44(1). Yeomans. S. K. (2008). Salomon. Luoma. B. 64(3). S. & Geller. Hollon. 1–25. K. Hollon. C. There is a steady movement toward openness to integrating different techniques and modes of administering therapy. S. Herbert. however. G. Moitra.. P. Bond. C. J. Clinical Psychology: Science and Practice. R. processes and outcomes. J. Hayes. it was probably an interaction of events that were dependent on and independent of her behavior that produced mood changes. 76(3). D. Dobson. D.. (2008). 468–477.. Raue. P. J. J... and this approach is indicative of the reality that help is available to them as well. J. 497–504. et al. DeRubeis.. each case is unique. S.. Ruby is not a unique case—there are a multitude of people whose lives are too hectic to make a commitment to therapy. Cognitive therapy vs medications in the treatment of moderate to severe depression. 409–416. V. M. & Pop. R. S.. Sherbourne.. 37(3)...Treatment of Depression 105 Powers. Keyzer. M. G. B. C. P.. & Emmelkamp. H. V. (2001). Psychological Medicine. 73–80. Klap. I. 319–328.. P. Archives of General Psychiatry.. B. 58(1). K. (2009). Riper. A. Acceptance and commitment therapy: A meta-analytic review. (2007). Cuijpers. M. B. J. & Wells.. Spek. .. Nyklicek. I. M. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychotherapy and Psychosomatics. D. Young. Zum Vörde Sive Vörding. 78(2). The quality of care for depressive and anxiety disorders in the United States. 55–61. Hayes. & Lillis. Compared with usual-care patients with diabetes. Piasecki. Robinson. see Robinson. Strosahl. ACT is also included on the evidence-based treatments list provided by the American Psychological Association Division 12. 1999). and one of the first randomized control trials conducted in primary care behavioral health treatment of depression included ACT interventions (for detailed information. Piasecki.. ACT has moderate support for depression treatment and strong support for treatment of pain (http://www. and the evidence for possible treatment approaches. Gifford. In the case of Ruby. & Glenn-Lawson. Zum. diabetic patients receiving a four-hour ACT intervention had better self-reported diabetes management and significant improvement in Hemoglobin A1C measurement (Gregg. there is already promising research on its application to problems that commonly occur (many co-morbidly with depression) in the primary care setting (Hayes. the Substance Abuse and Mental Health Services Administration (SAMHSA). Kohlenberg. 1986). Additionally.. the training background of the clinician.div12. Robinson Perhaps the most important issue in the thoughtful commentary provided by Obraztsova and Alloy is that of clinician choice in treatment selection. Hayes. 2004) and those who experience problems with chronic pain and disability behavior (McCracken & Eccleston. Luoma. Bond. Vorde. as well as substance abuse (Hayes. Wischman. & Emmelkamp. including anxiety (Hayes. Antonuccio. Finally. ACT is also likely to be helpful to depressed patients who engage in health risk behaviors such as smoking (Gifford. & Wilson. 2009). 2004). 1996). Bissett. et al. Other factors include patient preference and the context of care. & Nilsson. recent metaanalyses of ACT studies have concluded that ACT is better than usual care or waiting lists and as effective as other cognitive-behavioral or psychotherapies in the treatment of many traditional mental health problems commonly seen in primary care (Powers. One of the first randomized control trials of ACT concerned depressed patients (see Zettle & Hayes. Wilson. While ACT is a relatively new form of cognitive behavioral therapy (CBT). Dahl. 2004). 2006). 1996. Peterson and Dr. Callaghan. Specifically. & Del Vento. Wilson. Many factors influence the decision-making process.html). 2007). a . and the feasibility of implementation are heavy-hitters.org/PsychologicalTreatments/treatments. Marks selected ACT for all of these reasons and more. 2003. Drs. et al.RESPONSE Patricia J. Masuda. Sive Vording. g. depression and anxiety. Marks sees 20–30 patients per day. which means. She was not tied to 20 or 30 treatment manuals characteristic of earlier cognitive behavior therapy approaches. Peterson had attended both basic and advanced trainings in ACT and was familiar with both the APA Division 12 list and the NREPP resource. and this helps them track health-related quality of . They use the Duke to assess improvement. For Ruby. Equipped with a conceptual framework and a set of basic tools. Many of Drs. Research evidence for ACT was scored at 3. Dr.0 scale. Peterson tools for addressing clearly cognitive (as well as behavioral) problems that predisposed her to recurrent depression. including nursing staff. each of which targeted a specific diagnosis. but also the extent to which the approach can be implemented and disseminated. Peterson. Dr. aspx?id+191). and ACT dissemination efforts received a perfect score of 4. Marks and Peterson a set of tools that address processes that promote psychological flexibility. The NREPP review includes not only evaluation of an approach’s evidence base. provides a National Registry for Evidenced-based Programs and Practices (NREPP) to help providers make informed decisions about treatment approaches. Dr. and about half of them have psychological problems.0 on a 4.Treatment of Depression 107 division of the Department of Health and Human Services. Mark and Peterson’s patients want help but face many barriers to consistent participation in treatment. or insomnia and depression). She did not need to ponder which treatment manual to use fi rst when patients presented with more than one problem (e. NREPP lists ACT as an empirically supported method (http://174.140. She preferred ACT because of the ease with which she could disseminate it.325 out of 4. also liked that ACT strategies could be applied to their own lives and their work routines in ways that buffered them from the experience of burn-out and enhanced their resiliency in working in a high-stress environment. when patients are ready and requesting help. as the evidence suggests. to pursue valued directions in her relationships with her husband and son and in her committed pursuit of activities that satisfied her needs for creativity and lifelong learning.. Dr. ACT offered Dr. that the same basic procedures work well with a variety of diagnoses. Peterson sees 10+ patients per day. Ruby was fused with “unrecognized rules” and with self-stories that led her to an inflexible pursuit of unworkable strategies.167/ViewIntervention. In years of providing services in the primary care setting (where most depressed patients seek care). Dr. Peterson had learned to build ACT into her interview techniques and to translate ACT for primary care providers. Marks and other primary care providers. and all have psychological problems. ACT supports a focus on the patient’s pursuit of a meaningful life and offers front-line providers like Drs. she could help patients with different problems make gains in psychological flexibility. such as generalized anxiety disorder or major depression. Dr. ACT is a trans-diagnostic approach. with her new perspective. The ACT approach helped Ruby develop a new relationship with her unworkable rules and self-stories and. Marks and the other primary care providers in the clinic felt that they could understand enough about ACT to easily support interventions initiated by Dr.153. measurement comes down to choosing the most pertinent and most time-effective approaches. There are a variety of ACT fi rst-reads available from New Harbinger Publishing Company. However. . They could certainly use the Acceptance and Action Questionnaire to assess process factors associated with treatment. and reading is a good way to begin to bring ACT ideas into play in treating depression. whatever your practice setting. A CBT-Practitioner’s Guide to ACT: How to Bridge the Gap between Cognitive Behavioral Therapy and Acceptance and Commitment Therapy.108 Mood Disorders life over the course of a patient’s life. I recommend that readers study Joseph Ciarrochi and Ann Bailey’s book. as well as the ones that make the most sense to the patient. Concerning the issue of sorting out the differences and similarities between ACT and other CBTs. presented to our university clinic seeking a new psychiatrist to manage her bipolar illness. leading her to engage in a variety of activities. and energy. . and low energy. but endorsed experiencing daily mood elevations above her euthymic mood state. which lasted approximately one month. Her thoughts were racing with ideas. associated with concomitant bursts of energy. including sleeping up to 12 hours per night. During that time. racing thoughts.{5} Psychiatric Treatment of Bipolar Disorder: The Case of Janice Jeffrey J. She had moved to the Southeast due to her husband’s job relocation three months ago. as she was a student at the time). Dunlop Case History PRESENTING COMPLAINTS Janice. feelings of worthlessness. The depressive symptoms were negatively affecting both her marriage and her work. Rakofsky and Boadie W. running long distances. Some of her behavior during that time was reckless and impulsive. a 30-year-old married Caucasian woman. believing that she could read other people’s minds and feeling overly confident about her abilities. despite sleeping only three hours per night. a loss of interest in some activities. including cleaning her house. and her energy increased. her mood was euphoric. She reported emerging from the depths of a severe major depressive episode one year ago and since then had continued to experience milder ongoing depressive symptoms. She had no wishes to be dead. such as driving far above the speed limit and spending $400 in one day (more money than she could afford to spend. She denied experiencing inappropriate sadness. she became easily distractible. She endorsed psychotic-grandiose thoughts. and goal-directed activity that would last for a few hours. Janice reported experiencing her fi rst and only full manic episode four years ago. and writing novels. She denied all other symptoms of mania during these brief periods and would sink back into the feelings of low interest. and had few social contacts in her new city. self-esteem. nor any thoughts of suicide or her own death. Janice’s physical health was challenged by having polycystic ovarian syndrome (PCOS). . and elevated levels of androgens. She reported drinking no more than three drinks per night and denied that this has ever caused problems with her social or work roles. increased body hair. Janice was taking divalproex (Depakote ER) 1. while her mother. At the time of her evaluation. as she reported occasional nightmares and flashbacks of his hands on her. following her. This resulted in a diagnosis of cannabis dependence. and a maternal cousin had all been diagnosed with bipolar disorder. approved for the treatment of major depressive disorder and several anxiety disorders. and had last used marijuana four years ago. She denied ever feeling like others were spying on her. She denied ever attempting to end her life. once during college after experiencing a particularly frightening flashback of her sexual abuse. and once after developing suicidal ideation in the context of a severe depression. or conspiring against her. cutting. Janice’s alcohol intake was moderate. For several years during her adolescence. nor had she ever seen images or figures that were apparent only to her. including burning. a serotonin-norepinepherine reuptake inhibitor. maternal grandmother. During the day. a decline in her school grades. suggesting possible hypothyroidism. an endocrine disorder causing menstrual irregularities. five maternal aunts. and caused her psychotherapist to terminate her therapy. She denied current use of illicit drugs. Janice had her first major depressive episode at age 17 and subsequently experienced three more episodes. her blood level of this medication had never been measured. Additionally. To combat her depressive symptoms. and on occasion he hit her hard enough to leave bruises on her arm. but used to engage in self-mutilating behaviors. avoidant and hypervigilant behaviors.500 milligrams (mg) nightly for control of bipolar disorder. insulin resistance (with associated impaired glucose tolerance). recent blood work indicated mildly elevated levels of thyroid stimulating hormone. his temper would rage. These experiences continued to affect her into her adulthood. paternal grandfather. she was also taking 300 mg daily of venlafaxine XR. ovarian cysts. and choking. and a dramatic startle in response to loud stimuli. Her use at that time had been quite heavy and preceded her manic episode by several months. such as testosterone. and one uncle all had been diagnosed with depression.110 Mood Disorders The patient denied ever hearing voices commenting about her or commanding her to act in a specific way. in an effort to control emotional pain and as forms of self-punishment. She had been hospitalized twice. Her father. her father would come home after a night of drinking and molest her while she was sleeping. Although she had been on this dose for one year. Brief Personal History Janice grew up as an only child to Italian-American parents living in the Midwest. lifetime prevalence rates of bipolar type I are similar between the sexes (Merikangas et al. tragedy struck when she had her fi rst manic episode upon completion of graduate school. The bipolar spectrum includes type I illness. Among her hobbies. along with increases in the speed of thoughts. These episodes often will cause major impairment for patients. resulting in medical or psychiatric hospitalization..Psychiatric Treatment of Bipolar Disorder: The Case of Janice 111 Janice earned a master’s degree in social work at age 26. and bipolar NOS. Bipolar spectrum disorders affect approximately 5% of the population. though this work was not intellectually challenging and she was highly fearful of her male coworkers who chastised her loudly when she made errors. & Williford. 2004). A mixed episode is defi ned as a week or more during which the symptomatic criteria are met concurrently for both a manic episode and major depressive episode. she had still not embarked on a career in social work. 2000). she had worked as a waitress in a local restaurant. McBride. However. However. She reported no history of legal problems. 2007). Her husband has also been diagnosed with bipolar disorder. which includes several bipolar variants. self-esteem. ultra-rapid cyclers who experience four or more mood episodes within the past month. Key Principles Bipolar disorder is a mood disorder characterized by a history of mania. Unlike major depression. 2005) and among those with rapid cycling (Schneck et al.. hypomania. such as patients with ultra-rapid cycling or those with recurrent hypomanic episodes without intercurrent depression. with bipolar type I comprising 1% (Merikangas et al. Bauer. speech. which requires patients to have experienced at least one manic or mixed episode. distractibility. meaning that they have had four or more mood episodes in the previous 12 months (Schneck et al. A manic episode includes an elevated or irritable mood lasting at least one week. 2007). and she believes he understands the struggles that she faces.. incarceration.. which requires at least one hypomanic episode and one major depressive episode. and risky behavior. or major occupational and/ or social impairment. A hypomanic episode may include similar symptoms but can be as short as four days and does not lead to any significant impairment. she enjoys competing in triathalons and running long distances. 2004). type II illness. 2005). and ultra-ultra rapid cyclers (also known as ultradian cyclers) who experience four or more mood episodes within a week . She has not had children and has no interest in becoming a parent yet. et al. or mixed episodes along with mood episode recurrences over time (American Psychiatric Association. goal-directed activity. Her marriage of two years is a source of strength. At the time of her evaluation in our clinic. Within this group are severe rapid cyclers who experience 10 or more episodes within a 12-month period. Instead. energy. Fifty percent of bipolar patients have experienced early childhood trauma in the form of physical or sexual abuse (Brown. Twenty percent of bipolar patients are rapid cyclers. females tend to be overrepresented among type II bipolar patients (Baldassano.. and those that exist were discovered with post hoc analyses. Patients with mixed episodes tend to respond better to divalproex than lithium (Swann et al.. are effective in treating bipolar depression (Smith et al. 2010). 2004). have a positive family history of lithium responsiveness. anti-apoptotic and glucocorticoid signaling cascades have been implicated.112 Mood Disorders (Kramlinger & Post. have mood congruent psychotic features. Mood stabilizers. and have a mania-depression-euthymia episode pattern (Maj. and lamotrigine. Wozniak. Starace. 1990). divalproex dosage is guided by serum concentrations drawn more than 12 hours after the last dose. Janice can be considered an ultra-ultra rapid cycler currently. & Nolen. Pirozzi. Ultra. demonstrated by twin studies with identical twin concordance rates ranging from 40–75% compared with fraternal twin concordance rates ranging from 6–11% (Kieseppa. and ziprasidone. including aripiprazole. 1984. The genetic contribution to the illness-phenotype may be a deficit in cellular resilience in the face of external stressors. because she is experiencing daily cycling between states of hypomania and depression. olanzapine. Clinicians typically up-titrate the divalproex dosage until reaching blood levels close to 100 mcg/ml. 2006). are non–rapid cycling. With few predictors empirically studied. Baker. For the treatment of mania and long-term maintenance of bipolar disorder. 2006). also have indications for the treatment of various mood components of bipolar disorder. There are few predictors of response to specific medications in bipolar disorder. Maj. even though this rate of cycling did not occur until she was started on antidepressant medication. though studies on the topic are confl icting and are confounded by the gender composition and lithium use between study samples (Kupka. & Lonnqvist. & Bowden. & Starace. Pirozzi.. 2010) and may have some benefit in treating rapid cycling (Calabrese & Delucchi. as this strategy was found to be most effective when treating acute mania (Allen. Partonen. Del Vecchio. treatment selection remains trial and error. Leverich. 2005).. 1996). Neurotrophic. & Kemali. Some second generation antipsychotics. Luckenbaugh. An association between hypothyroidism and current rapid cycling has been proposed. female gender (Schneck et al. with a target of 50–100 micrograms per milliliter (mcg/ml). 1989. However. quetiapine. there is no established effective serum concentration of divalproex for the treatment of bipolar depression. 2004).. such as divalproex. risperidone. Pfennig et al. illicit drug use. and early childhood trauma (Kupka et al. The causes of bipolar disorder are unknown.. Factors associated with increased cycling include antidepressant use (Schneck et al. Haukka.. Unresolved residual symptoms from a previous episode increase the risk for subsequent episode recurrence (Perlis et al. though there is a strong genetic risk. 1997). Hirschfeld. Post. bipolar type I. all of which affect cellular plasticity and cell survival .and ultra-ultra rapid cycling episodes are defined by mood-episode symptom criteria but not duration criteria. carbamazepine.. Lithium responders tend to experience full inter-episode recovery. and heritability estimates as high as 85% (McGuffi n et al. divalproex. 2003). Kaprio. Medications with an indication for the treatment of bipolar disorder include the mood stabilizers: lithium. 2008).. 2003). & Pope. & Weiss. 2009). in the event that she could not do so. Assessment Strategy To establish a diagnosis of bipolar illness. & Vornik. & Mathews. 2001). As a result. a self-report form that has high specificity but poor sensitivity among community samples. as they typically are not bothered by their manic symptoms and therefore are less driven to seek help. Lewis. Over one-third of patients will wait 10 years before being accurately diagnosed with bipolar disorder after their fi rst psychiatric assessment (Hirschfeld. with the patient’s permission. However. Leverich. Hypomanic patients are also not likely to present to a provider. Austin. They are less likely to present to an outpatient clinic. the clinician should consider interviewing family members over the phone. Actively manic patients are more likely than depressed patients to present to an emergency room. which affect a patient’s ability to remember previous hypomanias. Some commonly used screening tools include the Mood Disorders Questionnaire (MDQ). When interviewing Janice. To avoid this error.Psychiatric Treatment of Bipolar Disorder: The Case of Janice 113 (Hunsberger. and lack of significant impairments during a hypomanic episode. and more psychiatric comorbidity (Post. no family members were available to accompany her to the interview. In order to diagnose bipolar disorder in the outpatient setting. Janice was able to recall an episode of mania. Xing. up to 40% of assessed patients with bipolar disorder are misdiagnosed as having unipolar depression (Ghaemi. 1999). but endorsed illness characteristics typical of bipolar illness (two or more short depressive episodes. family history of mania. Muller. This can be challenging to elicit from a depressed patient during his or her initial assessment. 1996). initial evaluations should be performed with family members of the patient in the room. Sachs. The opposite is true for bipolar depressed patients. onset of illness before 30 years of age) (Angst et al. Pandurangi. Stoll. and are often transported against their will by family members or law-enforcement officers. 2003). leading to many missed cases of . Stress sensitization as a result of early life trauma and episode sensitization resulting from multiple mood episode recurrences may worsen the course of illness. the clinician must assess for current or previous symptoms of mania or hypomania. the interviewer must assess the patient for symptoms of depression and also must determine whether the patient has ever had a manic episode in his or her lifetime. & Goodwin. Most clinicians will rely on a clinical. as they are neither bothered by their symptoms nor causing much concern to those around them. leading to more treatment resistance. mood-state congruent recall-bias (Watkins. increased rates of rapid cycling. Reasons for this diagnostic delay include lack of insight during previous manic episodes (Ghaemi.. Thankfully. to enhance detection of episodes in the patient’s life that were consistent with mania or hypomania. Vache. 2011). who are much more likely to present to an outpatient clinic. However. 1995). Chen. Chiou. screening tools and structured or semi-structured interviews are used as well. Verney. & Manji. nonstructured interview to assess for bipolar illness. . it should be a time when they were sleeping their “normal amount” (may vary between 6 and 10 hours. The Hypomania Checklist (HCL-32). a limitation of the SCID is that if a clinician strictly adheres to its “Past Manic/Hypomanic Episode” algorithm. we mean a period of at least two consecutive months during which the patient had no symptoms of depression or mood elevation. Though quite cumbersome to be used in its entirety for clinical practice. By euthymia. Identifying this period of euthymia then can serve as a touchstone for comparing other time periods when their mood or behavior was either elevated or depressed. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID) is a semi-structured interview frequently used in clinical trials (First. were motivated to pursue their goals. it is very helpful to identify a period of euthymia for the patient. may be easier for a patient to recall years later. which emphasize previous episodes of euphoria or irritability. More specifically. or arrogant? Early in an interview. that you could go several nights with less sleep? 2. or becoming abnormally super-focused on a single project? 3. The SCID’s structured approach to interviewing provides a significant advantage over traditional. For example. and experienced stable interpersonal relationships. This can be explored by asking patients to identify a time in their life when they felt the most under control and contented. unstructured interviews. more than normal for you. Did you ever have a period of time when you were more active and productive than normal for you. Spitzer. getting involved in more activities. that you felt invincible. overly confident. missing opportunities to help the patient recall an earlier episode if one ever occurred. .114 Mood Disorders bipolar illness (Hirschfeld & Vornik. 2005). starting more projects (regardless of their completion). 2004). and were not getting into confl icts with others. Thus. traditional interviews may omit questions about each possible manic symptom. manic symptom questions will not be asked if the patient answers “no” to the screening questions. either due to irritability or by being too talkative or intrusive with others. However. depending on the person). rather than previous episodes of a particular mood state. another self-report form. has high sensitivity and moderate specificity when used among clinical samples of bipolar disorder and major depressive disorder patients. it does not distinguish between bipolar type I and II (Angst et al. Both the MDQ and the HCL-32 fail to account for substance use as a possible cause for the manic or hypomanic symptoms endorsed by the patient. more than normal for you. Episodes of increased energy and activity level. However. Did you ever have a period of time when you were feeling so full of energy. 2002). Gibbon. Useful additional probes for bipolar illness include: 1. it provides helpful probe and follow-up questions for each manic symptom. structured interview questions with additional clinical probes provide the optimal approach to evaluation for possible bipolar symptoms. Did you ever have a period of time when you were feeling so good about yourself. & Williams. severe-rapid. By defi nition. Additionally. occurs in 17. The tendency of manic patients to impulsively engage in substance use makes it challenging to accurately determine the sequence of events and ultimately the diagnosis.Psychiatric Treatment of Bipolar Disorder: The Case of Janice 115 Having identified the presence of bipolar illness. but the episode persisted long after the use had ended. Thyroid disease is more common among women than men with bipolar disorder. bipolar type. comorbid medical illnesses. mania vs. and prior medication trials. Differential Diagnosis Illnesses such as schizoaffective disorder-bipolar type. Sisk. at which point their diagnosis would change to schizoaffective disorder. & Kupfer. Although this difference is expected given higher rates of thyroid disease among women compared to men in the general population.. 2007). and borderline personality disorder may have a clinical presentation similar to bipolar disorder and should be ruled out as an explanation for the patient’s current clinical presentation.. The individual contributions of valproate and bipolar pathophysiology to the risk for PCOS are unclear (Reynolds. Lifetime comorbid anxiety disorders are prevalent at a rate of 51%. corticosteroids) just before the onset of the mania with a resolution of manic symptoms within 30 days after cessation of substance use. posttraumatic stress disorder. substance-induced mood disorder. mixed vs. whereas bipolar patients only experience psychosis during mood episodes. 2005). 2004). Levine. II vs. For Janice. a patient originally considered to have bipolar disorder could develop psychotic symptoms in the absence of a mood episode. These factors include clarifying current episode status (depression vs. a bipolar patient may be more sensitive to the manic-inducing potential of these substances and may demonstrate both autonomous mood episodes and those induced by these substances. Substance-induced mood disorder can be differentiated by the use of known manic-inducing substances (cocaine. Patients with schizoaffective disorder will demonstrate psychotic symptoms even when free of mood episodes. . Use of anxiolytic substances (e. over time. However. alcohol. 2000). rapid. Gershon. early childhood trauma). her cannabis use preceded her fi rst manic episode. Assessment should not be considered complete simply by identifying bipolar illness. ultra. & Rasgon. other factors become important for treatment planning. not otherwise specified). Polycystic ovarian syndrome (PCOS) has been associated with bipolar illness. in particular. euthymic state). concurrent substance use. prognositc variables (age of onset of illness. rapid cycling status (none. with rates varying between 6 and 41% among bipolar women taking valproate. mood disorder secondary to a general medical condition.g. one study found that the rate of thyroid disease for bipolar women was four times higher than in the general population (Baldassano et al.8% in the general population (Simon et al. posttraumatic stress disorder (PTSD).2% compared with 7. a bipolar patient cannot also have schizoaffective disorder. subtype (I vs. stimulants. Substance use disorders have been found in 60% of bipolar patients and are higher than in any other Axis I sample (Chengappa. ultraultra). flight of ideas. Borderline personality disorder. etc). Ressler. cannabis) prior to the onset of a full manic episode is common. Impulsive behaviors intended to control others’ behavior or provide emotional self-soothing rather than arising from the grandiose-invincibility component of mania. Janice. Unlike manic patients. falling in love). hyperactivity. Profound self-hatred above and beyond what would be expected during an episode of depression.116 Mood Disorders benzodiazepines. 4. suggesting a nonpsychiatric illness. such as a brain tumor or a stroke. may also be misdiagnosed as bipolar disorder.g. such as seizures. that occurs in the absence of other typical manic symptoms (decreased need for sleep. although displaying earlier episodes of self-injurious behavior. Mood disorders secondary to a general medical condition are considered when there is an unusual age at first onset of mania (greater than 50 years old) or when there are associated symptoms. Mood-state elevation. a bipolar patient can also have episodes produced by otherwise clinically “silent” medical conditions.. These two conditions also commonly co-occur in the same individual and may share neurobiological substrates (Rakofsky. Patients with PTSD may be easily misdiagnosed as having bipolar disorder. She is able to maintain a healthy relationship with her husband and can . an unsurprising outcome given the early trauma that many bipolar patients experience and the impairments in emotional regulation that are central to these conditions. the presence of other typical PTSD symptoms. whereas in mania the high levels of activity typically reflect a sense of being driven to achieve goals for their perceived high value. rapid speech. However. 2012).” the content of these thoughts in PTSD is usually limited to anxious worries. Mood-state changes in response to feared or actual abandonment. Although patients with either condition may endorse experiencing “racing thoughts. & Dunlop. and vice versa. Posttraumatic stress disorder (PTSD) is an under-recognized condition that is often mistaken for bipolar disorder. does not meet full criteria for borderline personality disorder. as patients may try to self-medicate against troubling symptoms of an emerging episode. Finally. triggered by a positive event (e. but this activity serves to suppress intrusive thoughts and memories related to their trauma. rather than exciting ideas or plans as in bipolar disorder. racing thoughts. 2. PTSD patients do not experience feelings of grandiosity. 3. It is important to note that a patient can have both borderline personality or PTSD and bipolar disorder. Important clues to differentiating this condition from bipolar disorder are: 1. PTSD patients commonly have high levels of goal-directed activity. as these patients often present with intense irritability and decreased sleep. in contrast to untriggered or non-abandonment related mood episodes. with its characteristic mood lability. and the presence of insomnia rather than a decreased need for sleep can help distinguish these two conditions. a history of traumatic events. suggestive of dysphoric mania. in combination with experienced environmental stressors (early childhood trauma). Additionally. the childhood trauma is likely to negatively affect her long-term prognosis (Leverich. values. and goals. Although she has had psychotherapy in the past. The sexual trauma that she suffered as an adolescent may have affected her developing brain’s reward-processing circuits and hypothalamic-pituitary-adrenal axis. Janice likely inherited multiple risk alleles for mood disorders. though helpful for some with PTSD.. the only psychotherapy for which the Institute of Medicine found sufficient evidence to suggest efficacy in the treatment of PTSD (Institute of Medicine [IOM]. and activities that they have avoided . In addition to her bipolar illness. may exacerbate the cycling as well. aggressively. ultimately affecting mood regulation and making her more likely to experience mood cycling as an adult. type I. et al. She demonstrates a solid sense of self. 2008). her elevated thyroid-stimulating hormone level. and it is unclear if the divalproex dose is fully optimized. Janice suffers from PTSD. Her parents’ contribution to her illness can be conceptualized in two ways. especially one that interacts with two neurotransmitter systems (serotonin and norepinepherine) may be contributing to the constant cycling into hypomania. and her impulsive behaviors were limited to her single manic episode. Additionally. along with some of her remaining depressive symptoms. First. The physical and emotional abuse committed by her parents could have occurred during the heights of their own depression or mania. Second. her parents’ own psychiatric illnesses provided the psychosocial context for the emergence of her illness at age 17. or to be neglectful of the patient’s welfare. 2002). they occurred as a means of escape from the memories and feelings when her PTSD symptoms were at their worst. Her current bipolar medication regimen. stemming from her childhood sexual molestation. Her use of an antidepressant. she has never had exposure therapy. This therapy utilizes imaginal and in-vivo exposure. though she is still symptomatic.Psychiatric Treatment of Bipolar Disorder: The Case of Janice 117 tolerate extended separations from him when he travels for work. This high predisposition (which is probably largely genetic). leading them to act impulsively. Case Formulation Janice meets criteria for bipolar disorder. She is currently in a subsyndromal depressed mood episode. given the significant family history of bipolar disorder on her father’s side of the family and the family history of unipolar depression on her mother’s side of the family. is providing her minimal benefit for this comorbid condition. requiring patients to retell their trauma in detail during therapy sessions and to approach the people. may have given rise to the phenotypic expression of her bipolar illness. Although she had a history of self-injurious behaviors. alternating with hypomanic symptoms on a daily basis. Divalproex in combination with venlafaxine has helped to reduce the intensity of her depression. indicating inadequate peripheral thyroid hormone levels. Janice is at very high risk for psychiatric affective illness. places. His bipolarity could be an additional burden.118 Mood Disorders following the trauma. because both she and her husband have the illness. she resorted to self-mutilating behaviors. This could also increase the emotional burden on the patient. Additionally. She is removed from her family of origin geographically and no longer maintains contact with her father. she still consumes alcohol. her unwillingness to take on a social work job reflects a fear of failure that her unpredictable bipolar mood symptoms have reinforced. 2010). she also developed substance dependence with marijuana. and where appropriate. Like so many others with comorbid bipolar disorder and PTSD. Treatment Planning The two most important targets for Janice’s treatment planning were to eliminate the remaining depressive symptoms and the constant cycling. so we increased her dose from 1. She fi nds it difficult to trust men and is quite fearful of them. which can present many problems for her: increasing her risk for relapse back into marijuana use. her lingering depressive symptoms are causing tension between the two of them. Lee. Her divalproex level was 86 mcg/ml. as she would have to care for children requiring close parental supervision and frequent medical contact. her work performance is affected by her fatigue and loss of interest. and potentially worsening the course of her bipolar illness. Socially. She worries appropriately that she may be fired and without income. there is a high likelihood that future progeny will also develop bipolar disorder symptoms or attention deficit/hyperactivity disorder (Birmaher et al. However. she suffers from painful intrusive memories and nightmares of her father abusing her. patients habitutate to the distressing memories.500 mg to 1. though to her credit she has been able to maintain sobriety for several years.750 mg daily. She credits her marriage and medications for this improvement. Olden. decrease avoidance of trauma reminders. Over time. she has the support of a husband who also has bipolar illness and is able to understand her challenges with mood symptom changes and uncomfortable medication side effects. This fear makes it hard for her to go to work. affecting her stability should he develop a mood episode recurrence. which reinforces her sense of self as being incompetent. Psychologically. Perhaps internalizing a belief that she is a bad person or tainted by the trauma she endured. replace expectations of danger to cues in their environment with expectations of safety (Cukor. although again she has managed to resist these urges over the last few years. & Difede.. She is not part of any support or self-help groups. Having recently moved to a new city. . increasing her level of stress. Although she is employed. However. she has few friends or social supports but is using her recreational interests as a way to meet new people. as revealed by her workplace experience. 2010). increasing her risk for developing a dependence to alcohol. However. Her desire to become a social worker may be viewed as an attempt to provide the nurturance to clients that she never received as a child. She was already prescribed oral contraceptive pills to control her PCOS and was not interested in becoming a mother at the time of the evaluation. Despite her participation in triathlons and her daily exercise schedule. headaches. She was also encouraged to attend Narcotics Anonymous meetings.0 mEq/L. marijuana relapse. she relapsed into a full depressive episode. she self-tapered off the divalproex and quickly began to lose the weight she had gained earlier. Divalproex is teratogenic. given her previous history with marijuana dependence. over the next several months on the combination of divalproex and lithium. the cycling resolved and the patient also reported an improvement in her symptoms. and exercise. Additionally.8–1. a therapy with proven benefits in bipolar disorder when initiated during acute episodes (Frank et al. another mood stabilizer (with a target blood level of 0. Expected future stressors were managed by using problem-solving techniques to avoid any threat to social rhythms and to enhance interpersonal effectiveness. she gained 15 pounds. she was unable to lose the added weight. We wanted to avoid antidepressants and benzodiazepines. such as rebound anxiety and depression. she was referred to a therapist who specializes in working with bipolar patients. and electrical “zap” sensations. given her bipolarity and her history of substance dependence. However.. and worsening of her course of illness. explained her risks of dependence. she relapsed into yet another depressive episode. For her alcohol use. Her therapist employed elements of interpersonal and social rhythm psychotherapy (IPSRT). Lithium carbonate. Two months later. and thus before a woman becomes aware of her pregnancy. her depression fully resolved. she was . her therapist utilized elements of exposure therapy once the patient’s mood cycling was under better control.Psychiatric Treatment of Bipolar Disorder: The Case of Janice 119 She was tapered off venlafaxine ER by sequentially reducing the dose by 50% at one-week intervals over several weeks to eliminate one possible cause of her cycling. To address the PTSD symptoms and also to provide adjunctive bipolar support. Janice was strongly counseled to remain on her birth control pill and to discuss any plans about pregnancy before attempting to conceive. waking. Once again. two weeks after coming off venlafaxine. However. She was referred to an endocrinologist who initiated treatment with thyroid replacement hormone and monitored her PCOS symptoms as the dose of divalproex was raised. We chose this slow taper to avoid a worsening of her depression and to avoid venlafaxine discontinuation effects. Without consultation with her psychiatrist. 2005). This part of the therapy entailed repeated sessions with Janice emotionally engaging and sharing highly detailed memories of her father molesting her. we provided psychoeducation. while simultaneously applying newly learned breathing and relaxation techniques. With these changes in place. Believing that divalproex had contributed to her fatigue and was partly to blame for her weight gain.0 mEq/L) was added to her regimen and optimized to a blood level of 1. causing serious neural tube defects during the fi rst week after conception. This treatment helps patients to improve mood regulation by encouraging them to keep regular hours of sleep. fatigue. eating. two medication classes used to treat PTSD symptoms. This is even more crucial when treating a patient who has both bipolar illness and PTSD stemming from early childhood trauma (Rakofsky. and that her doctor would not be upset by her decision to stop taking divalproex. the patient may reject the physician’s recommendations. This reinforced the therapeutic alliance by establishing the physician’s role as a nonpunitive. she maintained a euthymic state for several months. Understanding the patient’s treatment goals is also part of strengthening the therapeutic alliance. 2009). Given her experience of being victimized and forced to do others’ bidding as a child. developing the therapeutic alliance is necessary. Anecdotally. By doing this. As with all bipolar patients. A patient with early childhood trauma and PTSD symptoms may have difficulty trusting physician-authority figures who attempt to provide reassurance about these medications. 2011). It was also explained to her that in the future it would be to her advantage to consult with her psychiatrist about medication changes before acting on them.120 Mood Disorders strongly opposed to restarting it. Given its weight-neutral properties and data demonstrating improvement in depression when added to lithium. a life-threatening. Nonspecific Factors in Treatment With all patients. et al. expert-consultant. It was slowly titrated to 200 mg over six weeks to avoid the risk of developing Stevens-Johnson syndrome. willing to support the patient’s broad goals of achieving better illness control with minimal medication side effects. it was important to encourage Janice’s autonomy within the treatment setting. Treatment recommendations were framed as expert recommendations to which she could choose to adhere if she believed the benefits outweighed the risks. This patient’s specific goals included fi nding a medication regimen that would improve her depressive symptoms without worsening her cycling or causing physical side effects. it was important to remind Janice that fi nding the right medication or combination of medications is a trial-and-error process. She may be unwilling to try these medications and thereby deprive herself of potentially gaining better control of her bipolar illness. . exfoliative rash. her expectations were framed appropriately. With this combination of lithium and lamotrigine. The medications used in the treatment of bipolar illness cause both nuisance and serious side effects. the anticonvulsant lamotrigine was started (van der Loos. & Dunlop. When she reported that she had self-tapered off divalproex and expected her doctor to be infuriated with her. If the therapeutic alliance is weak. some patients view medicines like lithium as a chemical restraint only for the most severely and chronically ill patients and therefore not appropriate for them. Levy.. so she can be fully informed of the risks of tapering. She was able to understand that reaching her treatment goals might require a number of trials with different medications and that it would be impossible to predict with accuracy which medication or combination of medications would provide the best efficacy for her. she was gently reminded that ultimately the medications she takes are her own choice. leading to increased mood destabilization. In those cases. To manage these possibilities. such as an eating disorder or substance abuse. she may engage in other behaviors that may affect the stability of her illness. followed due to a relapse. she might have been inclined to underreport the true intensity or number of her depressive symptoms. she was reminded frequently that although she is a patient.Psychiatric Treatment of Bipolar Disorder: The Case of Janice 121 Potential Treatment Obstacles Obstacles to successful treatment of bipolar patients include repeated self-tapering off medications without prior physician consultation. Perhaps a neurological or endocrinological condition. adding other medications such as atypical antipsychotics. Trials with other mood stabilizers. Here. so medication is clearly justified. who wishes . Further consultation with her therapist at this point would strengthen the psychiatrist’s psychological formulation of the patient and would help to explain her lack of improvement. so the decision to treat is straightforward. or if she believed that more medications with weight-gain risks would be added. Management of bipolar disorder with psychotherapy alone is ineffective. Reassessment of the biopsychosocial formulation would also be warranted if poor treatment response continued. The plan was to optimize the current mood stabilizer that she was taking and taper her off the antidepressant she had been prescribed. or electroconvulsive therapy would have been options to consider. More difficult ethical considerations arise when hypomanic or manic patients refuse medication that will reduce their elevated mood state. In Janice’s case. Perhaps her substance use has escalated. one of the motivations behind the self-tapering of divalproex may have been to test the physician’s resolve or to reenact the early childhood trauma that involved an angry and sadistic male authority figure. Ethical Considerations Treatment of psychiatric conditions always requires pause for ethical reflection. the autonomous wishes of the individual confl ict with the paternalistic goals of the clinician. Janice is requesting help with her depressive symptoms and cycling. she still makes the fi nal decisions regarding her treatment. depending on the nature of the persisting symptoms. If Janice believed that she had to please her physician in order to maintain his positive regard. or a comorbid psychiatric illness. undetected at the initial patient interview. pramipexole. WHEN TREATMENT IS NOT WORKING The patient was informed from the initial visit that the medication trials would be a matter of trial and error. If treatment was still not effective. If this is the case. Underreporting of mood symptoms is another common problem. including lithium and lamotrigine. The physician’s role is to guide her and to provide expertise to help her meet her goal of reduced illness burden. might explain treatment refractoriness. or at least “improve functioning. & Duncan. Sternberg. For Janice. the ideal approach is to maintain a strong therapeutic alliance and agree to disagree about the need to use medication. Thus. Because the patient is the one who must swallow the medication. It requires a consideration of the patient’s past mood episodes and the degree of impairment and distress they produced. and collaboration with the patient’s primary care physician. Andersen. Another challenging ethical consideration emerges from the interplay between psychiatric symptom control and deleterious physical consequences of medications. Keeping an open line of communication and expressing concern and support. when dosed inappropriately). . the distress from her condition was significant enough to warrant maintenance treatment. provide an opportunity for the patient to acquire greater insight over time. errors in diagnosis can occur frequently. full ethical decision making about maintaining long-term treatment in order to prevent mood episodes requires full and frank discussion with patients. situations often arise in which patients are not in dire circumstances. despite refusal of treatment. due to limited insight or dissatisfaction with previous treatment experiences. exercise. we respected her concerns about weight gain and explored alternative medications. as errors can easily arise at many steps along the treatment path. and divalproex may contribute to PCOS. Only time will reveal whether her current medication plan is sufficient to maintain her euthymia. but the patient refuses. as in Janice’s case. These points in treatment are particularly challenging when concerned family fervently wish for an intervention to be made. and perhaps to become more open to interventions. lithium frequently interferes with thyroid and kidney function (the latter. Thus. 2003). through education about diet. Weight gain and its consequent risks for cardiovascular diseases and stroke present the unhappy situation that some people treated with these medications will die sooner as a result of their medication than they would had they been untreated (assuming the patient did not die of suicide or the consequences of substance abuse arising from lack of treatment). but their behavior and judgment are impaired to the point that they appear likely to enter dangerous situations in the future. Common Mistakes to Avoid It is easy to go astray in treating bipolar disorder. There is also an ethical requirement that the prescribing physician strongly encourage the patient to actively work to avoid deleterious physical health consequences of medications. However. or are clearly unable to provide basic care for themselves. Most of the effective medications for bipolar disorder cause weight gain.122 Mood Disorders to prevent harm. First.” Current legal standards allow patients to refuse treatment unless they present an imminent risk of hurting themselves or others. regardless of the ethical reasons justifying the intervention. forcing treatment on all but the most disordered patients is typically an ineffective approach. However. appropriate laboratory testing. Phillips. Antipsychotics may contribute to metabolic problems such as diabetes and dyslipidemias (Dunlop. treatment with a selective serotonin reuptake inhibitor (SSRI) antidepressant may be effective with little risk for manic mood induction. as it permits early detection and treatment of break-through symptoms. Assuming that her current stability persists. she and her therapist continued to monitor her social rhythms and anticipate upcoming stressors that could disrupt her social rhythms and mood states. as patients will often describe these mood elevated states as being revved up. For some patients with bipolar type II disorder with prominent depressive or anxious symptoms. 2010). Looking Forward: Focus on Relapse Prevention Close follow-up is the key to preventing mood episode relapses. her weekly psychotherapy visits also helped to monitor for symptoms of relapse.Psychiatric Treatment of Bipolar Disorder: The Case of Janice 123 even among experienced clinicians. Upon remission from her mood episode. the greatest period of relapse risk will occur if/when she decides to conceive children. visit frequency was reduced to 6-week. given that depressive symptoms are so prominent over the course of illness for most patients. Second. 2011). but greater caution is required for bipolar type I patients (Amsterdam & Shults. Hypomanic symptoms can be mistaken for anxiety. Substance use may lead to forgetting to take medications and an overall worsening course of illness. Additionally. More subtly. or if they feel as if their concerns are dismissed by physicians. Although some side effects are unavoidable. recreating a relationship of forced submission between the doctor and patient with regard to medication adherence will only lead to resentment and possibly termination of treatment. like being in an anxious state (Rakofsky & Dunlop. Medication side effects can also lead to non-adherence if patients are not warned ahead of time of their possible occurrence. then 8-week intervals. failure to empathize with the patient’s trade-off between improved illness stability and increased physical side effects can drive a wedge between the patient and doctor. All of these efforts can reduce the likelihood of relapse. Ongoing monitoring of her substance use to ensure that it does not escalate will be important as well. rather than behaviors characteristic of borderline personality. Promiscuity and impulsive spending that occur during states of interpersonally triggered dysphoria may also be interpreted as symptoms of hypomania or mania. it can be difficult to resist adding antidepressants to a patient’s regimen to treat symptoms of depression and anxiety. Although they are less . Additionally. Medication adherence was encouraged by the therapist asking about any recent medication changes or problems with the medications. failing to refer a patient like this to a psychotherapist would deprive her of the opportunity to deal with the psychological aspects of having bipolar illness and with the pain of her early life trauma. She will need to be regularly asked about her substance use and her attendance at Narcotics Anonymous meetings. As her stability increased. and urging the patient to contact her psychiatrist before her next appointment if troublesome side effects emerged. As part of her psychotherapy. Janice had appointments with her psychiatrist at monthly intervals. Efficacy and safety of long-term fluoxetine versus lithium monotherapy of bipolar II disorder: A randomized... J. P. The advantages and disadvantages of this choice should be discussed at length with her psychiatrist and psychotherapist. Gamma. J. 272–275. C. Imedex and MedAvante. Dr. R. Adolfsson. Gamma.. 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J.. and it matters in understanding how family members may best be involved in the therapeutic . borderline personality disorder. a parent) is present. trauma) may be similar and the emotional dysregulation associated with each of the disorders can be quite similar.g. First. it is essential that the person providing treatment have command of this information in order to educate the patient.COMMENTARY W. the disorders may indeed be comorbid in the sense of relatively independent but co-occurring. psychoeducation is a critical part of all evidence-based somatic and psychosocial treatments. borderline personality disorder. particularly when another BP individual (e. clinical information regarding the background and scientific fi ndings relevant to treatment of this disorder. In addition to educating the patient about the disorder. It matters directly in the presentation of the treatment rationale. bipolar disorders (BP) are marked by the frequent presence of comorbid disorders.g. the role of the family in BP is nicely described. so distinguishing BP as a separate disorder is essential to efficacious treatment outcomes. Of course. As a part of the overview. As was the case with Janice. They first provide an excellent descriptive.. chief among which are substance use disorders. Nevertheless.” Rakofsky and Dunlop describe the successful treatment of a patient with a complicated history of bipolar disorder. so each may require separate and independent treatment. Familial information is important for both the BP individual and family members. This information is important for several reasons. it is essential to obtain an appropriate differential diagnosis. and anxiety disorders such as posttraumatic stress disorder (PTSD).. thus. “Psychiatric Treatment of Bipolar Disorder: The Case of Janice. the treatment of choice for each of these disorders differs. Edward Craighead and Anjana Muralidharan Background In the case study. pointing to both the possible role of genetic vulnerabilities and interpersonal interactions. It is particularly difficult to distinguish between BP II diagnosis. Because the interventions for BP are fairly disorderspecific. and PTSD because the life experiences (e. effective intervention includes a coherent and compelling rationale for the treatment—a treatment that usually is long-term and requires adherence to a prescribed regimen of medications and psychosocial therapies. BP may be related to other diseases (e.g. the authors suggest several supplementary questions designed primarily to help with differential diagnoses. Having this information at hand. namely. 2003. including treatment by an endocrinologist. while at the same time not burdening the practicing clinician and the patient with the unnecessary elements of the SCID.. he knew the serum levels needed to be evaluated and monitored. As noted by the authors.g. Lish. they employed a multifaceted. Even though there is emphasis on “trial and error” in the use and evaluation of medications employed. thyroid disorder.. Janice’s treatment team is to be commended for utilizing another positive and overarching aspect of treating BP.. polycystic ovary syndrome). Dime-Meenan. Medication Treatments The medication interventions demonstrate the expertise of the treatment team. a longitudinal measure such as the LIFE interview. & Vornik. The adjustment . so it frequently is just as important to involve other medical specialists for evaluation as it is to obtain a thorough familial and psychosocial history. coupled with her abuse. The use of some post-test and follow-up measures (e. Whybrow. This is nicely demonstrated by the “clinical use” of the SCID interview. interdisciplinary approach to her treatment. but with a fi rst-episode patient. the treating physician can make a more effective decision regarding the types of medication that can best be employed. Utilizing such a semi-structured format prevents the inadvertent oversight of important problems and symptoms. there were clear indications of BP. With Janice. the distinction between BP depression and MDD depression is usually less clear. Equally important. It seems highly likely that Janice was biologically vulnerable to mood disorders given that her father’s family had multiple instances of BP and several members of her mother’s family suffered from major depressive disorder (MDD).Psychiatric Treatment of Bipolar Disorder: The Case of Janice 129 process. This is essential because approximately one-third of BP patients present with depression in their initial episode of the disorder (Hirschfeld. This vulnerability. One particularly relevant area has to do with family history of BP versus MDD. depending on the life-history information that emerges.” For example. Assessment One of the most important aspects of this case study is the thoroughness of the assessment. & Hirschfeld. Price. Keller et al. a psychiatrist. even though the psychiatrist continued the use of divalproex. It is important to think of additional idiosyncratic questions that might be relevant to an individual patient. and a psychotherapist. it is important to note that this is “informed trial and error. Lewis. rendered Janice vulnerable to BP when faced with stressful situations. 1994). 1987) could have strengthened the confidence in the treatment outcomes. 2002). For example. there are patient characteristics that moderate its utility. one significant predictor is a past history of medication non-adherence (Scott & Pope. Although this is the standard for such treatments. In addition to unpleasant side effects. attitudes and beliefs about mental illness and medication are predictors of medication non-adherence. Psychotherapy Intervention There are two major ways in which psychotherapy helps the BP patient: medication adherence. the treatment team encounters a common occurrence in the treatment of bipolar disorder: medication non-adherence. levels frequently are not drawn and LI adherence suffers as a result. McQuaid. Rates of non-adherence with mood stabilizers in mood disorder patients range from 18–52%. greater levels of collaboration produce greater adherence among reactant patients whereas a more authoritative approach produces better results with less reactant patients (Madsen. The collaborative approach of the “expert-consultant” model was successfully employed in Janice’s treatment and it was skillfully demonstrated and exemplified by the response to the self-taper of divalproex. In this case study. and to engage . otherwise efficacious medications are likely to be of little or minimal effect when the patient is not prescribed sufficient doses or refuses to take the medications as prescribed. as well as a detailed compliance contract outlining how the patient will overcome these barriers.130 Mood Disorders in the dosage levels resulting from the information regarding low serum levels seems to have produced an enhanced treatment effect. They recommend an assessment of intrapersonal. insufficient dosage contributes to ineffective treatment and non-adherence because side effects are felt but the ameliorative effects of the treatment are not obtained. The treatment team employed an expert-consultant or collaborative model for their intervention rather than an “authoritative” approach. social. In the case of Janice. Although it is difficult to predict which patients are likely to be non-adherent to medications. & Craighead. communicating with her previous treatment providers during the assessment phase might have revealed a previous pattern of medication non-adherence. Given the high rates of non-adherence. and changes in the psychological state and coping mechanisms of the individual. Indeed. 2009). Even though “collaboration” is generally indicated. Ramirez-Basco and Rush (2005) suggest a frank discussion of medication compliance at the beginning of treatment with every bipolar patient. When the team added lithium (LI) to the treatment regimen. and cognitive barriers to compliance. indicating that a discussion of this topic earlier in the intervention may have been helpful. the blood levels were again monitored in order to determine effective dosing levels. interpersonal. Although fostering collaboration with the patient in making clinical decisions has been widely suggested. It is important to communicate to patients that full adherence can be difficult to achieve. Obviously. it can on occasions be contraindicated if it does not match the expectations of the patient. providing them with communication skills to buttress this strength may have positively impacted her course of illness. This preemptive discussion is an opportunity to prevent medication non-adherence before it interferes in treatment (Ramirez-Basco & Rush. This is important because of its role in medication adherence and its impact on the psychological functioning (especially depression) in the prevention of relapse or recurrence of this cycling disorder. & George. and the results indicate that this individual enjoyed a much more satisfying quality of life as a result of the treatment. 2005). a family-focused approach may have had a positive impact on her symptoms. Miklowitz. 2008). In addition to the individual psychotherapy that Janice received. Frank et al. a treatment that includes psychoeducation about bipolar illness. ..Psychiatric Treatment of Bipolar Disorder: The Case of Janice 131 in open discussion of what is likely to interfere. however. Finally. Saleem. 2007).g. Given that Janice struggled foremost with depressive symptoms. Author Note The writing of this manuscript was supported in part by NIH/NIMH Grant 1 RO1-MH 080880 awarded to W. her husband also had a diagnosis of BP. Edward Craighead. Janice’s relationship with her husband was identified as a source of support. 2007). family-focused therapy has been found to be particularly helpful with symptoms of bipolar depression. communication skills training. particularly for the comorbid PTSD. 2005. it is essential that the therapist be trained in its use and the parameters associated with its success. so learning about the illness may have been doubly beneficial for the couple.. Even though the case was quite complicated with comorbid disorders. In summary. resensitization to the earlier trauma). Finally. Rakofsky and Dunlop did a masterful job of treating this individual with BP disorder. which are not always well controlled by mood-stabilizing medication. Janice’s treatment team is to be commended for using an evidence-based psychotherapeutic intervention: interpersonal and social rhythm therapy (IPSRT. 1999). It is important to keep in mind that psychotherapeutic interventions have only been evaluated as efficacious for BP when used as combination treatments with appropriate medications (Miklowitz & Craighead. There are several reasons that this treatment may have been helpful for Janice.. First. and problem-solving skills training (Miklowitz. Richards. whereas medications seem to have a greater effect on manic phases of the disorder (Simoneau. Second. Exposure therapy is a highly effective intervention. she and her husband may have benefited from family-focused therapy for bipolar disorder. it would be useful to know how the psychotherapy was managed during the post-acute treatment phase. They maintained a consistent strategy throughout the course of treatment. Otherwise. negative outcomes may result from inappropriate use of this intervention (e. they were persistent in following the best evidence available in the treatment sequence. Miklowitz et al. IPSRT was augmented with exposure therapy. . . . Bipolar disorders. Bipolar disorder: A family-focused treatment approach (2nd ed. R. Sachs.). Journal of Abnormal Psychology. E. & Craighead.. Scott. Cognitive-behavioral therapy for bipolar disorder (2nd ed. 44. A. 309–322). Perceptions and impact of bipolar disorder: How far have we really come? Results of the national depressive and manicdepressive association 2000 survey of individuals with bipolar disorder. A. 161–174.. The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members.. R.. R. Monk. S. 62. Madsen. S. 31(4). Gorman (Eds.. P. A. Ramirez-Basco. . Nathan & J. J. J. Richards. McQuaid. 63. (1987). T. Lish. E. Nonadherence with mood stabilizers: Prevalence and predictors. (2007).. Frank. (2007). J. Friedman. & McDonaldScott. Psychosocial treatments for bipolar depression: A 1-year randomized trial from the Systematic Treatment Enhancement Program. Lewis. M.. Journal of Clinical Psychiatry. 384–390.132 Mood Disorders References Frank. W. E. M.. Fagiolini. Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. J. New York: The Guilford Press. . N. Wisniewski. Working with reactant patients: Are we prescribing nonadherence? Depression and Anxiety. D. (2003). A. & Hirschfeld. W.. R. T. Mallinger. J. Kogan.. E. J. Dime-Meenan. 129–134. Reilly-Harrington..). Miklowitz . Simoneau. J. & George. D. A. 996–1004. Endicott. Otto. M. L.. A. R. E. Lavori.. E. 281–294. Keller. 26(2). D.. (2005). 540–548. Archives of General Psychiatry. P. B. Hirschfeld. In P... The longitudinal interval follow-up evaluation: A comprehensive method for assessing outcome in prospective longitudinal studies. (2008). D. Nielsen.. (1999). Thase. L. E. & Craighead. & Vornik. J. Swartz. W. (2009). Miklowitz . Journal of Affective Disorders. Archives of General Psychiatry. A guide to treatments that work (3rd ed. 108(4). A. H. Bipolar disorder and family communication: Effects of a psychoeducational treatment program.. P.). D. S. R. M. (1994). J. Whybrow.. J.. G... (2005). G. 64(2)... & Pope. M. N. J. Kupfer D. 64(4). M. 419–426. . E. New York: The Guilford Press.. M. Journal of Clinical Psychiatry. Miklowitz . A. M.. Miklowitz. J... W. C. & Rush. Saleem. B. pp. W. (2002). M. Price. 588–597. . Archives of General Psychiatry.. . New York: Oxford University Press.... A clinician-rated measure that we have implemented in our bipolar clinic is the Clinician Global Improvement-Severity (CGI-S) scale. We agree with this practice and often do engage in such communications if the clinical situation suggests this potential risk. and an effective treatment regimen with enduring impact. and make several important suggestions that we address in this response. Incoporating scales longitudinally to track patient wellness over time is indeed a helpful tool. Unlike unipolar depression.RESPONSE Jeffrey J. they identify that use of post-test and follow-up measures may serve to strengthen confidence in the treatment. However. which made contacting her prior provider seem less urgent. despite . asking patients questions from the past hypomanic episode sections of the SCID or the LIFE at each subsequent visit may capture between-visit episodes of fullcriteria hypomania that may confirm the bipolar diagnosis. a seven-item scale that condenses the patient’s symptom burden and impairment in important life domains to a single-digit number (1–7) representing the status of his or her overall condition. for which validated patient-rated scales such as the Quick Inventory of Depressive Symptoms. During Janice’s last several clinic visits. Rakofsky and Boadie W. and the Beck Depression Inventory can track symptom severity over time. Follow-up measures and post-test assessments can also provide value through ensuring diagnostic accuracy. Dunlop Drs. For patients with psychiatric histories suggestive of bipolar disorder but with uncertainty arising from hypomanic episodes that may have failed to meet full symptom number or duration criteria. Self-Report (QIDS-SR) (available for free at http://www. because prior medication non-adherence may predict future non-adherence. it is possible that important information had been forgotten by the patient. bipolar disorder lacks such instruments. her CGI-S scores ranged from 1 to 2. Craighead and Muralidharan provide a thoughtful analysis of our chapter.ids-qids. During Janice’s initial evaluation she was forthcoming and knowledgeable about her treatment and psychiatric history. Rating the CGI-S from visit to visit provides a simple yet meaningful way to gauge improvements over a wide time frame and assess the efficacy of the treatments offered. indicating minimal symptom burden and role dysfunction. org). First. A second suggestion was to communicate with Janice’s previous treatment providers to determine if there was a history of medication non-adherence. getting paid mostly by sales commission. We agree with this recommendation.therapistlocator. though point out that. Similar to the ups and downs of her illness. this may be different for providers practicing in less urban settings. Drs. She has recently gained employment as a salesperson. she is learning how to weather the good days and the bad that commission-based jobs. such as hers. Medication adherence was assessed by monitoring her lithium level at regular intervals. and through inquiry at all visits about potential side effects from her medication regimen. Because of our affi liation with an academic center. entail. However. she must contend with the unpredictability of the economy and the whims of consumers as she tries to earn an income for her family. when available. . can be very helpful in tracking down prior treatment records. which can be used to identify therapists trained in FFP.net. Support staff. Craighead and Muralidharan also suggest offering Janice family-focused psychotherapy as another psychotherapy modality. it is often difficult to fi nd experienced therapists trained in these modalities. is: http://www. Finally. A web site managed by the American Association of Marriage and Family Therapists. these options are readily available.134 Mood Disorders her intention to be as forthcoming as possible. which she fi nds to be more satisfying than waitressing. Janice’s post-acute treatment phase therapy focused on helping her manage job-related stress. and her supervisors are more supportive than her managers at the restaurant. which represented a significant risk factor for mood episode relapse. just as with interpersonal and social rhythm therapy and prolonged exposure therapy. { PART III } Anxiety Disorders . This page intentionally left blank . which became more severe and frequent in her senior year of college. She relies on her husband to accompany her to stores or places where she feels uncomfortable. or formal gatherings). and shopping malls. and racing thoughts. Lira Yoon. and the potential embarrassment that her panic might cause. For instance. Craner. Geoffrey L.{6} Panic Disorder with Agoraphobia: A Case Illustration with Treatment Decisions Informed by Clinical Science Julia R. once she was at a friend’s house and began to feel weak. K. she avoids crowds at concerts. For example. For the past several years. as if she might pass out. she immediately called her husband to pick her up. As a teenager she began experiencing occasional panic attacks. She is extremely anxious whenever she is separated from her husband.. Anxious that she might faint. Thorpe. sporting events. because he is unable to be out late with friends or leave town for business. and she became very afraid of having another panic attack. she will not be able to handle it. she noticed that these attacks became more frequent. accompanied by dry mouth. After that. She felt severe anxiety and a sudden urge to leave. and Sandra T.g. a social event with strangers. In these places. she is afraid that if she becomes anxious and he is not around. heart palpitations. She also avoids situations where it would be embarrassing if she started to have severe anxiety (e. Her fi rst significant panic attack occurred while she was studying at the college library. She also fears losing control or going crazy. Her anxiety has put a significant amount of strain on their relationship. She describes these attacks as a sudden need to escape. Annie has avoided situations that may provoke anxiety or panic-like physical sensations. she is concerned about what she will do if she has feelings of panic. Her husband is supportive. weakness in her arms. . but Annie worries about the impact that her panic is having on their relationship. Sigmon Annie is a 36-year-old Caucasian American who lives with her husband of 14 years. However. In addition to acute anxiety. such as time of day. Annie is sensitive to environmental cues. Annie has attended counseling on several previous occasions for a few sessions each time. Her mother and sister experience clinical depression and also tend to worry. but did not fi nd talking about her anxiety helpful. she begins to feel anxious and may have a panic attack. Primarily. she doubts her ability to function independently and second-guesses herself often. but there is no other known family history of anxiety or panic. she might start to feel faint. Her heart beats rapidly and she feels shaky. Fear of this happening makes nighttime anxiety-provoking for her. and experiences increased anxiety in the morning. and also wakes up several hours earlier than she would like. If she has a nosebleed or sees someone with a nosebleed. such as bloating. because she expects that she will experience more anxiety and panic. Although Annie did not report any significant depressed mood or loss of interest. If she begins to feel flushed or shaky during her daily routine. because she cannot get back to sleep after her husband has left for work. She married her high school boyfriend. she has difficulty falling asleep. Annie experiences generalized worry about many areas of her life. She worries excessively about family members. She also has a long history of significant premenstrual exacerbation of her anxiety due to associated physical sensations. Annie has taken Zoloft for many years and also uses Xanax on rare occasions. this sensation might lead to a panic attack. She is sensitive to bright lights. particularly without her husband present. and making decisions about her future. which make her feel dizzy.” Her parents were very protective and she was quite dependent on them growing up. and she describes her childhood as “very sheltered. she keeps it on hand for occasional use. She does not like Xanax because it makes her feel “out of it” and she worries about becoming addicted. fi nances. She dreads getting her period. she feels that she has reached the point at which she wants to move forward in her life without having to rely on others to deal with her anxiety and panic. She is keenly aware of any physical sensations that do not have an obvious cause. Presently. and feels comforted that she has that option if she feels that her anxiety is out of control. She also has intense fears about nosebleeds. Annie is particularly sensitive to many physical sensations and environmental cues because of their association with anxiety. which she attributes to her tendency to feel groggy at that time of day as well as her anxiety about her husband leaving for the day. She worries that if she had a nosebleed with a large amount of blood.138 Anxiety Disorders Annie has also experienced several nocturnal panic attacks that have awoken her in the middle of the night. she doubts her ability to handle her anxiety on her own. her job. Annie has no significant medical history. Annie grew up in a rural area. she did report feeling down and discouraged following panic attacks. Now. She also feels frustrated with herself for letting her anxiety get out of control. . with intense anxiety. Brown. nausea.Panic Disorder with Agoraphobia 139 Assessment CLINICAL INTERVIEW Assessment began with a broad clinical interview to probe for areas of difficulty as well as gain a holistic understanding of Annie’s functioning and quality of life. the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV. Thus. FUNCTIONAL ANALYSIS Situational antecedents for Annie’s panic attacks include being in crowds or in situations where escape might be difficult. shaking. dizziness. Thoughts preceding panic attacks include fear of being unable to cope if she starts to feel anxious. alcohol or drug abuse. She reported excessive worries with fatigue. irritability. As Annie fears nosebleeds in general. rather than just the associated physiological sensations or panic symptoms resulting from encountering blood. was administered. and severe anxiety about having another panic attack. and in anxiety-provoking situations without her husband. medical problems. She reported panic attacks. fear of dying. and fear of going crazy. She also experiences situational avoidance and needs her husband to accompany her in anxiety-provoking situations. and physical sensations resembling panic attacks. & Barlow. other type. this is not best accounted for by her diagnosis of PDA. chills. Annie met criteria for panic disorder with agoraphobia (PDA). Annie reported that her main concern was her panic attacks. 1994). shortness of breath. a structured diagnostic interview. In response to questions about current difficulties. Annie also reported many symptoms consistent with generalized anxiety disorder. and feeling a lump in her throat. her worries are about several areas of her life. the primary focus of treatment was on panic attacks. sometimes out of the blue.” related to her extreme fear of nosebleeds. DiNardo. or that she might have a nosebleed if she starts to panic. Internal antecedents include worrying about future panic attacks. Her severe symptoms include heart palpitations. More mild to moderate symptoms include sweating. as well as being busy at work or with other activities. Annie met criteria for a “specific phobia. fear of doing something uncontrolled. She attempts to cope by escaping . difficulty concentrating. Importantly. as well as thinking that there might be something terrible wrong with her. She reported no history of developmental difficulties. Being with her husband reduces the likelihood of experiencing panic attacks. Furthermore. STRUCTURED INTERVIEW Because Annie reported difficulties with panic and anxiety. In addition to PDA. or traumatic events. that she might faint. and muscle tension. feelings of unreality. accompanied by seven severe symptoms. not exclusively related to panic attacks. which are very distressing to her. Interventions for Annie’s nocturnal panic attacks were drawn from the cognitive-behavioral protocol evaluated by Craske. or taking Xanax. feeling shaking. depression. a self-report assessment questionnaire designed to measure current depressive symptomatology. 4th edition (MAP-4. having feelings of choking. feeling terrified. 2006). she anxiously anticipates them. Overview of Treatment TREATMENT APPROACH The main treatment protocol used was Mastery of Your Anxiety and Panic. Craske & Barlow. which tends to overestimate panic frequency and intensity (Craske & Barlow. feeling nervous. Annie was asked to complete a panic attack record and daily ratings of mood and anxiety. seeking out her husband.140 Anxiety Disorders the situation. fear of losing control. and Mystkowski (2005). feeling afraid. breathing retraining. unsteadiness. Her score of 18 suggests that she is mildly depressed. fear of the worst happening. 1993). Barlow & Craske. SELF-MONITORING Continuous self-monitoring of panic and anxiety is important in assessment and treatment because it is more accurate than retrospective recall. she did not experience a panic attack during the first eight weeks of treatment. Session 1 The fi rst component of treatment involved orienting Annie to therapy. heart pounding or racing. Aikins. The MAP-4 treatment protocol includes psychoeducation. Annie reported her average daily anxiety. interoceptive exposure. Steer. and in vivo exposure. 1996). Annie’s score of 34 is indicative of severe anxiety. Beck Anxiety Inventory (BAI): Annie also completed the BAI (Beck & Steer. a self-report measure designed to assess anxiety symptoms. She endorsed moderate levels of indecisiveness and concentration difficulty. dizziness or lightheadedness. SELF-REPORT MEASURES Beck Depression Inventory II (BDI-II): Annie completed the BDI-II (Beck. 2008). 2007. cognitive restructuring. The therapist and Annie made a plan to focus on panic symptoms first. This would involve . On her daily mood record. and anxiety about panic about 25% of the time for the first several weeks of treatment. However. relaxation training. Lang. and abdomen discomfort. & Brown. She endorsed moderate symptoms of feeling unable to relax. fear of dying. Dreading encountering such situations in the future. Increasing dependence on her husband typically follows episodes of panic and anxiety. Panic disorder was explained as a cycle that begins with a trigger. Biological and psychological factors leading to panic disorder were also discussed. and apprehension about panic attacks. Session 3 In session 3. Next. negative cycles of panic and agoraphobia were introduced. and behaviors were discussed in terms of being part of a negative cycle. avoidance. Treatment began with following a specific protocol (MAP-4). She also noticed that these attacks tended to occur more often during times of stress.Panic Disorder with Agoraphobia 141 learning about panic and anxiety. .e. behaviors. It was explained that cognitive behavioral therapy (CBT) for PDA should involve weekly sessions with between-session readings and homework. and contacting her husband immediately.g. It was explained that monitoring is an important part of treatment in order to gain in-the-moment assessment of panic. She said that she would sometimes have thoughts that she might faint. believing that panic attacks are harmful and inevitable. anxiety. Common behaviors include trying to “steady” herself to prepare for a panic attack. mood. and nausea. It was explained that anxiety is a normal human emotion. Homework assignments included completing a record for any panic attacks. Annie told the therapist that she recognized having many of the beliefs that were suggested as contributing to panic disorder (e. and to help recognize patterns. and then learning strategies to manage and cope with these symptoms. psychoeducation for PDA was introduced. which is perceived as threatening. and that she relies on her husband as a safety person to help her feel more comfortable. The nature of panic disorder and agoraphobia were presented. distraction. as well as symptoms and prevalence. spending a lot of time worrying about future panic attacks). leaving the situation if she is in public. Unhelpful coping methods (i. In turn. this causes more sensations of anxiety. Session 2 Session 2 focused on self-monitoring. such as a physical symptom resembling panic.. She recognized many physical symptoms as being part of her panic attacks. as well as the potential role of stress. These physical sensations. and physical sensations that she experiences when she feels anxious or has a panic attack. most notably heart palpitations. which can lead to a panic attack. based on her needs. but that it can become problematic when it occurs in the absence of threat. she gets “wound up” and has a hard time calming herself down because she fears that the anxiety will escalate into a panic attack. and a daily mood record to track anxiety. Annie stated that she attempts to avoid situations that make her feel anxious. but it was discussed that treatment would also be flexible. She also reports thinking that whatever trigger she is experiencing might be part of a panic attack. Annie was asked to identify thoughts. or that if she has to escape the situation it would be difficult to explain this to others. safety signals) were introduced in relation to contributing factors to PDA. and mood. racing thoughts.. Annie noted that when she starts to feel panicky. thoughts. the therapist introduced the concept of automatic thoughts. the therapist reviewed common mistaken beliefs about panic attacks. treatment shifted toward cognitive skills. She told the therapist that she could see how her reactions ended up increasing her panic. She began to worry that she might get sick. such as thinking that a headache could be a brain tumor. Session 4 During this session. which intensified the feelings and she began to panic. She said that it was hard for her to remember to practice during times when she did not feel anxious. It was emphasized that breathing and relaxation skills should be practiced when not feeling anxious in order to master the skill. The therapist discussed how hyperventilation is related to panic attacks. Sessions 7–9 Annie reported uneven success with relaxation and breathing practice. but beliefs that they are make them more frightening. or lose control. and she agreed to practice breathing and relaxation daily over the next week. it was discussed that when someone thinks that a negative event is more likely to . and it was emphasized that panic attacks are not physically dangerous. She also reported that when she panics. and they problem-solved ways to incorporate practice into Annie’s daily routine. First. Sessions 5 and 6 Sessions 5 and 6 focused on breathing retraining and relaxation. was practiced in session. she started to feel scared and to think that this might be a panic attack. Then. which involves alternately tensing and relaxing various muscle groups. At session 6. and that it had been helpful in those situations. The 15 muscle group relaxation training. She noticed that after feeling dizzy on waking up in the morning. The therapist emphasized the importance of continuing practice. The physiology of panic was discussed. Annie reported that she was able to achieve a state of deep relaxation. either as a trigger or concomitant. the therapist asked Annie to identify thoughts that she has when she feels anxious or panicky. Annie was taught how to control her breathing with slow abdominal breathing. and how they might contribute to anxiety.142 Anxiety Disorders Annie completed a step-by-step analysis of a recent panic attack. which made the possibility of panic attacks in the future more frightening. her thoughts began to race and she started to feel shaky. Annie reported that she had been practicing abdominal breathing when she felt anxious. faint. At this point. Over the next three sessions. Homework included practicing abdominal breathing every day. Afterward. Specifically. she called her husband for comfort and called in sick for work that day. Progressive muscle relaxation training was introduced in session 6. such as that one will have a heart attack. and feared that she would not be able to contact her husband if she had a panic attack. Annie noted that she often fears that there is something medically wrong with her when she feels unusual physical sensations. she starts to worry that she might faint or embarrass herself in public. Annie was given homework to practice identifying automatic anxious thoughts and to reason with these thoughts. During the fi rst exposure session. that she would be able to deal with it and it would not be a catastrophe. realizing that panic symptoms do not result in dangerous consequences. This was the only exercise that produced significant anxiety for Annie. and head shaking. The therapist pointed out to Annie that she is able to calm down before the Xanax begins working. she wrote: “I don’t need an explanation in order to deal with this symptom. and developing a new set of associations through conditioning. breath holding. . dizziness). Annie considered how she tends to view panic attacks as disastrous events and anxiety as a “bad” emotion. and how these thoughts might increase her fear. Annie rated the intensity at a 6 out of 8. She also related that if some of the things that she feared actually did happen (e.. After trying the exercises. She also worked on positive coping self-statements. Next. Annie performed several symptom-inducing exercises. anxiety at a 5 out of 8.” The therapist and Annie also discussed some of her beliefs regarding her medication. For this exercise. the therapist discussed skills that may be used to reason with these anxious thoughts. Annie listed the symptoms that each exercise produced (e. and similarity to panic symptoms at a 4 out of 8. this thought can increase anxiety. Annie reported that when she wakes up in the middle of the night due to anxiety. Annie noted that she often has thoughts that she is going to faint.Panic Disorder with Agoraphobia 143 happen than it actually is. First.g. Annie noted that the probability of actually fainting while panicking would be less than 1%. and then rated the intensity of the symptoms. For example. a nosebleed). such as hyperventilating. Annie was told how panic disorder and agoraphobia can result from conditioning. and as such it was the only exercise used for interoceptive exposure. despite her recognition that it probably takes a half hour for the medication to actually take effect. Annie worked on identifying realistic probabilities for events and putting her thoughts in perspective. It was also explained that thinking that relatively benign events are catastrophic can also increase anxiety and panic. using the explanation provided in the MAP-4 manual.. and the similarity between the sensation and panic symptoms. a rationale was presented for exposure. For example. and that repeated exposure to feared stimuli can result in decreased anxiety through increasing a sense of mastery. She also recognized that even though panic attacks are very stressful. she has been able to get through them each time without anything disastrous happening. the only one that caused significant anxiety for Annie was hyperventilating. even though this has actually never happened as a result of having a panic attack. as well as reading her coping statements. Sessions 10–12 Sessions 10 through 12 involved in-session exposure for panic symptoms.g. Annie wrote these down on a note card to have with her when she feels anxious. she is able to fall back asleep quickly if she takes a Xanax. her anxiety. She started to feel dizzy one morning while driving to work. She again reported that these exercises did not increase her anxiety level. As the in-session exposure exercises were generally unsuccessful at increasing Annie’s anxiety. . and went to work as she usually would. staying somewhere overnight without her husband at a 6. Annie and the therapist reviewed coping skills and positive self-statements.144 Anxiety Disorders At home and during the next session. Annie made an agoraphobia hierarchy. However. a daily event that she associated with increased anxiety and panic. After the next session. Over the next several sessions. and that she was able to sleep well.” At the second exposure session. going to a large store by herself at a 4. because she “knew what to expect. rating her level of anxiety for each situation. waking up with her husband gone at a 6. the treatment plan shifted to include out-of-session exposure. Annie chose an exercise from her hierarchy to practice during the week. Annie rated her anxiety at a 2 out of 8. which she stated was because she knew that she was causing the sensation. As a result. she was asked to try these exercises at home. She did this several times and reported that her anxiety decreased each time. Annie had the fi rst panic attack that she had since beginning therapy. She noted that her anxiety decreased beginning with the second exposure practice. Annie practiced the hyperventilation exercise. and that she would not be able to sleep at night without her husband there. The therapist discussed with Annie that the various symptom-inducing exercises did not significantly increase her anxiety in session. She rated not being able to get in touch with her husband by phone at a 3 out of 8. She reported a significant amount of anxiety before the trip. The therapist suggested that exposure might be more effective for Annie if she began to face situations that she has been avoiding. The fi rst exposure task that Annie attempted was to go to the store by herself twice during the week for a half hour. Annie practiced staying in bed in the morning when her husband left for work. Annie noted that she was feeling that she was making progress with her anxiety. First. Annie reported that she only felt mild anxiety during the trip. This progress was encouraging to Annie. Next. At the next session. Annie took a trip to visit a friend overnight. Sessions 13–16 The next focus of therapy was to practice exposure exercises in real-life situations. and that she also did not feel a strong need to avoid it. and this triggered a panic attack. Annie began to practice exposing herself to these situations. and being home with her husband gone at a 7 out of 8. She reported feeling more confident in her ability to handle her anxiety and to attempt more situations independently. anticipating that she would feel anxious while driving there. During this phase of therapy. She reported that she pulled off the road for a couple of minutes. fi rst with and then without her husband present. she reported that the activity was reduced to a 2 or 3 out of 8 for anxiety. and that she was able to calm herself down without calling her husband. The therapist also discussed with Annie how she may be viewing this severe episode of panic as evidence that treatment was not working or that she was a failure in some way. She has shown marked improvement in several areas. and suggested ways in which he could be Annie’s teammate at home. She reported up to a dozen panic attacks in the course of four days. The therapist emphasized to Annie’s husband the importance of being supportive but not enabling. it was suggested that if Annie asked her husband to accompany her to the store or another anxiety-provoking place. and she was concerned that she was “going crazy. Annie’s case is ongoing. During the past week. Annie continues to have a significant amount of generalized anxiety. and it is estimated that she will continue to see the therapist for another 10–15 sessions. especially with regard to her exposure practice at home. The therapist and Annie made a plan to review coping strategies and to discuss how she could use them more effectively when feeling severe anxiety. and began to dwell on her fear of having more panic attacks. Annie brought her husband with her to therapy. Annie agreed that she was feeling like a failure and that she was back at square one. it was suggested that rather than immediately reassuring her. for example. However. Annie recognized that after the fi rst panic attack. She also noted that her expectation of having more panic attacks ended up increasing her anxiety and panic.Panic Disorder with Agoraphobia 145 Session 17 During this session. or if it might be better if she went by herself. She felt unable to control her anxiety. Annie reported feeling extremely discouraged and having thoughts that her panic would never end. Annie reported fear of going to sleep. she stopped using her coping strategies. Therefore. he could remind her to use some of her coping skills. and anxiety and panic before bedtime in anticipation of having to go to sleep. she had had a series of intense panic attacks. For example. She also reports feeling better able to function independently without relying on her husband to accompany her in many situations. Annie wanted her husband to be included in what she was working on in therapy. Both Annie and her husband noted that they were encouraged by Annie’s progress and were motivated to continue treatment. to the extent that she had not felt any effect from the Xanax. After this. In addition. and she reports continued anxiety related to nosebleeds. They discussed that where she was now in terms of her anxiety was different from when she started treatment. Sessions 18–20 Annie arrived at the next session in a state of distress. he could ask her if she really needed him to come. She has also increased her ability to deal with panic-like symptoms without having them escalate into a full-blown panic attack. by emphasizing the positive things that she had accomplished. Annie and the therapist constructed a treatment plan to . when Annie calls her husband when feeling anxious.” The therapist worked with Annie on looking at her panic attacks step-by-step. This began with several nocturnal panic attacks. particularly in being willing to encounter anxiety-provoking situations and to use coping strategies such as relaxation and self-talk when feeling anxious. Thompson. generalized anxiety. Controlled studies have validated particular interventions for PDA. Munby. Gelder et al. Behavioral aspects were her tendency to escape from feared situations and the development of an avoidance pattern. prolonged exposure to real and imagined feared situations— have produced the most rapid therapeutic gains (Emmelkamp & Wessels. In Annie’s case. 1968). & Burlington. Teasdale. Leitenberg. if identified. & Marset. & Johnston. Leitenberg. Mathews. this begins with identifying the key areas of distress or impairment associated with the client’s concerns. and client-initiated. Bancroft. Interventions for agoraphobic avoidance based on the exposure principle have been validated in randomized. a strong situational element had developed. It is important to assess for the presence of coherent syndromes that. the distressing symptoms included emotional. In waking life. controlled clinical trials and in studies using single-case experimental designs. Mathews. Johnston. 1974. 1968. Johnston. while moving forward in treatment to target other areas of concern (i. 2005).. both generalized and in the form of panic attacks. Gelder. 1973). Imaginal flooding has been shown to be more effective than systematic desensitization (Boulougouris. designed to reduce emotional distress and to encourage greater mobility while helping the client abandon efforts to escape or avoid situations. home-based graduated real-life practice (Mathews. These procedures include the combination of systematic desensitization plus real-life practice (Gelder. & Shaw. Agras. Nocturnal panic attacks will continue to be targeted specifically (Craske et al. . we were able to draw from a corpus of well-researched treatment techniques to address the critical elements. and there was a social component in that she feared embarrassment if she were to leave a public place during a panic attack.. 1981).. Key Principles/Core Knowledge Clinicians draw from a broad professional knowledge base in case formulation and treatment. The chief emotion was anxiety. 1975. Knowledge of psychopathology is important in developing an assessment strategy. Barlow. can lead clinicians to focus the assessment more precisely. & Wright. and behavioral elements. 1973). 1977. Panic attacks occurred during sleep. graduated real-life practice with feedback and praise from therapists contingent upon incremental gains (Agras.e. imaginal flooding plus real-life practice (Emmelkamp. Exposure in vivo and imaginal flooding—confrontive. when the cues (if any) were difficult to determine.146 Anxiety Disorders continue developing skills and pursuing exposure exercises related to PDA. 1971). Gath. Pragmatically. Because Annie’s concerns fit a PDA formulation. cognitive. & Shaw. phobia). Marks. Annie also reported a “fear of fear” pattern in which somatic sensations associated with anxiety had become terrifying in their own right. Cognitive features were evident in Annie’s fears that she was losing control or going crazy. This addresses sources of impairment and potential handicap directly. manualized treatment. Marks. 1994). 1976). & Gelder. It was also essential to identify patterns. 1992. and encourages him or her to trust the protocol and follow the recommended treatment exercises. 1994). Appendix A).g. upon his recommendation. thus. dizziness following an inner ear infection. pheochromocytoma. It is. had several tests performed prior to beginning treatment: a complete metabolic panel. and Klosko (1989) confi rmed the efficacy of panic control treatment. Street & Barlow. Shaw. resting upon established criteria for . Berlin. imperative to rule out any medical conditions that might resemble symptoms of panic attacks before proceeding with treatment of PDA (e. The clinician is called upon to act as morale-booster. Complicating this. 1980. The self-report measures used in Annie’s initial assessment were developed using classical test theory techniques. Traditional “clinical skills” come into play when the clinician explains the rationale for treatment. Cushing’s syndrome. develops a treatment plan in collaboration with the client.Panic Disorder with Agoraphobia 147 Hazlett-Stevens & Craske. Clinicians adapt specific techniques to the unique situation of the client. and hypoparathyroidism. or depersonalization related to intoxication by illicit drugs). Following a structured treatment protocol that has been studied in clinical trials and has been found effective is strongly recommended (Barlow. Hecker & Thorpe. syndromes. 1991. A large-scale outcome study by Barlow. Lancashire. and collaborative problem-solver. Munby. In Annie’s case. 2009a. hypoglycemia. 1996). an evaluation of thyroid function. It was important to assign priorities and isolate the particular problems that were most likely to interfere with her general well-being and her capacity to function and participate fully in family. Panic disorder typically includes a fear of unfamiliar bodily sensations that can evoke concerns about medical emergencies. Johnston. Failing to identify a treatable condition. but stop short of substituting their impressions and hunches about how to proceed for fidelity to a well-researched. she saw her family physician and. occupational. Mathews. and the therapeutic benefits persisted for at least two years following treatment (Street & Barlow. Rapee & Barlow.. & Noshirvani. could fall below acceptable standards of professional practice. or neglecting to recommend a needed medical consultation. Gournay. 2009b. cognitive restructuring.. Craske. hyperthyroidism. many clients first encounter panic attacks following an experience resulting from an actual medical condition (e. Cerny. and breathing retraining (Hazlett-Stevens & Craske. educational. Panic control treatment consists of exposure to somatic cues. and other activities. and a test of hormone levels. asthma. supportive coach. Assessment Strategy Annie presented a variety of specific concerns. Negotiating with the client about specific goals and their relative priorities is important. social. feeling faint because of low blood sugar. or disorders in need of immediate treatment or more elaborate assessment studies.g. Chiu. A host of questions could arise. Chang & Reeve. 2005. In formulating Annie’s . Thorpe. more efficient tests (Bond & Fox. the client seeks to present a fabricated symptom picture? Could Annie’s various symptoms be viewed as offshoots of an across-the-board. half of those with agoraphobia have panic disorder (Kessler. The BAI scores of 393 outpatients with various anxiety disorders (Beck & Steer. the internal consistency of the BDI-II was alpha = . Shear. validity. test-retest stability after one week (r = . State r = .71.58. but accepted practice is to encourage the client to seek a medical consultation in order to assess for such conditions. though in samples from the general community. Ruscio. & Thorpe. 95% of clients who present with agoraphobia meet criteria for PDA. Panic disorder without agoraphobia is three or four times more common than the PDA syndrome. Burns. 2007.148 Anxiety Disorders reliability. with both components of the State-Trait Anxiety Inventory: Trait r = .75). 1996). 2012). Alternative approaches involve selecting only the most discriminating items and scaling them for difficulty in order to produce briefer.47).g.. The base rates for those medical conditions that can create symptoms similar to those of PDA are beyond the standard knowledge base for psychology. & Walters. Epidemiological Considerations Life-time prevalence estimates for panic disorder approach 5%.1%. Thus the BDI-II shows acceptable psychometric characteristics (Beck et al. reaching the store guarantees. Instruments based on classical test theory rest on the often untested assumption that items have equal weight in contributing to the aggregate score. for obscure reasons.94). Wilkes. 1990) indicated satisfactory internal consistency (alpha = . when Annie drives to a large store by herself. 1984). In the standardization sample of 500 mental health outpatients. Could the central problems stem from seizure activity? Could it even be a factitious presentation in which. that she also reached every intermediate location along the way. and standardization. The lifetime prevalence rate for PDA is estimated as 1. & Yoon. In mental health outpatient settings. enduring pattern of unhelpful or self-defeating behaviors best construed as conforming to one or other of the personality disorders? Information on the base rates of such presentations can be helpful pragmatically in that the rarer syndromes may be able to be ruled out quickly and efficiently with the use of appropriate assessment instruments or by consultation with other professionals. of course. Johnston. Johnston.92. 2006. Sigmon. and in 26 outpatients retested after one week the test-retest stability was r = . Scaling is easily achieved when a hierarchy item is viewed as a mini-test.. and concurrent validity with other inventories (e. Jin.93. In 87 outpatients the correlation between BDI-II and Revised Hamilton Psychiatric Rating Scale for Depression scores was r = . Annie and her therapist compiled an idiographic anxiety hierarchy to delineate specific problems and provide structure for treatment. Beck.. and for other reasons apart from those relating to her PDA. Macias. 1996. Newman. However. Baldy-Moulinier. Annie met criteria for specific phobia because. & Crespel. 2008. Similarly. 2001. There is a large overlap among symptoms of PDA. Strosahl. 1999). she also fears others’ nosebleeds. she met separate criteria for GAD. blood-injury-injection type. and specific phobia. and that medical test results indicated that Annie was in good health. published protocols produce outcomes comparable to. and specific phobia. Following an empirically tested generic treatment protocol for PDA guided by a therapist manual and client workbook represents an appropriate standard of practice when the goals are to address the distress and avoidance associated with the syndrome. Hayes. we considered the facts that in outpatient mental health settings the base rates for epilepsy (Picot. & Acheson. Wilson. promotes continued anxiety rather than relief from distress (Hayes et al. as well as symptoms of avoidance of feared stimuli. generalized anxiety disorder (GAD). Fusé. & Tran. 1997. apart from their relationship to panic or symptoms of panic or agoraphobia. Components of the MAP-4 protocol that guided Annie’s treatment—cognitive restructuring. and exposure to interoceptive and external cues—are on the list of well-established techniques among the empirically supported treatments (Chambless & Ollendick. One issue that arose in case conceptualization involved diagnosing comorbid disorders. 2008) and factitious symptom presentations (Catalina. Research by ACT practitioners has shown that clients who avoid rather than enter challenging situations tend to develop additional anxiety symptoms. 2009). Brown. Daurès. and these worries caused distress and impairment above and beyond that related to PDA. Eastwood & Bisson. despite clinicians’ understandable concerns about the need to address each client’s unique circumstances (Barlow. Initial Case Formulation Annie was diagnosed with PDA. 2008) are typically low. Alternatively. Development of an Intervention Model Studies have shown that standardized interventions for panic disorder drawn from well-researched. the therapist could have used acceptance and commitment therapy (ACT.Panic Disorder with Agoraphobia 149 case. 1996). & Cos. 1999). as well as trying to suppress upsetting feeling states. Forsyth. and often surpassing. Although ACT . those resulting from the application of individually focused treatment plans. because Annie worried excessively about many different areas of her life. & Wilson. Beck. applied relaxation. and panic. despite the observation that nosebleeds occasionally cause her to panic and she fears that nosebleeds may result in panic-like symptoms. Behavioral avoidance. such as the experience of anxiety. worry. ACT revises conditioning language into a newer terminology that emphasizes the verbal classes that denote anxiety-provoking situations. GAD. Dujols. but rather that it was the former therapist’s imposition of that form of therapy on the client without any discussion of alternatives and in the absence of collaborative goal-setting and treatment planning. the MAP-4 has received empirical support specifically for PDA. but in CBT the relationship itself is not viewed as the central mechanism of change. Dealing with Nonspecifics Although the scientific evidence supports using standard treatment protocols that have been validated by research. an exercise that has been shown to produce symptoms of depersonalization or derealization (Craske & Barlow. For example. 2004).150 Anxiety Disorders has support in the treatment of anxiety disorders. Like other psychotherapists. & Dawson. 2008).. She had previously had months of therapy with a psychodynamic clinician who had focused entirely on the client’s adjustment and relationship issues in childhood and had not attended to present difficulties with driving away from home and dealing with panic attacks. effective cognitive behavioral therapists show competence in relationship skills (Spruill et al. Strategies for Dealing with Problems Annie occasionally arrived late for appointments and missed one altogether without prior notice. therapists find opportunities to employ their general clinical skills when helping their clients to overcome demoralization and to increase their motivation for treatment. In CBT for PDA specifically. Clinicians will also use their skill and judgment in adapting specific elements of the protocol to the specifics of the client’s presentation. the therapist asked Annie to confront panic elements therapeutically by practicing voluntary hyperventilation rather than staring at a spot on a wall. Research has shown that clients who rated their cognitive behavioral therapists as respectful and understanding made greater progress than those who did not. One of us treated a PDA client whose initial expectations of therapy had been unusually low. Annie feared breathlessness but not feelings of unreality. The issue was not that psychodynamic therapy had necessarily been objectionable in itself. Establishing a positive and productive professional relationship between client and therapist is an important component of psychotherapy. the client stated that she now felt that she had been “cheated” by the former therapist. and took a directive stance once the goals and methods of therapy had been established and agreed upon (Key & Craske. On returning with the new therapist from an early treatment session that had involved driving back and forth across a local highway bridge. 2004. In a subsequent session. Thus. McMillan. Nonspecific aspects of treatment include the client’s initial expectations. she expected the therapist to make . better client outcomes were seen when therapists emphasized empathy and warmth in the early sessions. and was thus chosen in this case. 2006). Owings. Thorpe. Several stumbling blocks had to be addressed in the course of Annie’s treatment. The therapist worked with Annie to review the skills and strategies that she had developed to deal with her panic attacks. acknowledging the difficulties involved and supporting clients as they struggle with their mixed feelings about tackling their problems constructively (Levensky. However. Initially. and she knew what was causing the symptom. Cavasos. ranking their anxiety-provoking potential and similarity to panic.. Kersh. The current therapist briefly registered disappointment that they would have less time than expected to work on the treatment plan. challenging anxious thoughts. The panic episode was analyzed step-by-step. For several weeks following. They also discussed the improvements she had made. but quickly moved on to address the day’s topics. as well as attempting more activities independently. As noted earlier. As a result of being unable to significantly increase Annie’s anxiety to a level sufficient to produce effect from exposure. and the therapist and Annie worked to discover how her thoughts and behaviors continued the series of panic attacks. rather than a sign that Annie was a failure or that her anxiety was completely out of her control. but instead by a nonthreatening. because she was deliberately producing them. receptive attitude. such as being home without her husband.Panic Disorder with Agoraphobia 151 a significant issue of this. as Annie began to practice exposing herself to a variety of feared situations. Annie had a series of intense panic attacks. the therapist suggested to her that she begin to try real-life (in vivo) exposure practice. therapists set the scene for clients to acknowledge the extent of their difficulties and to increase their engagement in and commitment to treatment. resulting in sleep disturbance and avoidance of feared situations. She reported feeling more confident in her ability to handle anxiety-provoking situations. . & Brooks. A significant challenge in Annie’s treatment occurred after approximately 17 treatment sessions. This was a successful shift in treatment. In motivational interviewing. visiting a friend alone overnight. Annie did not report any significant anxiety as a result of engaging in these activities. with the exception of hyperventilation. 2009). The “soft sell” approach adopted by the therapist has elements in common with motivational interviewing and seems to have been more constructive than making lateness an important therapeutic issue. despite attempting a variety of similar exercises over several sessions. and going to shopping malls alone. because a former therapist had spent an entire session attempting to uncover the meaning of her tardiness.g. up to a dozen in the course of a few days. She also felt that these exercises were very different from what she experienced when panicking. and tried to put this episode in the perspective of a stumbling block. she began symptom-inducing exposure exercises in session. and when she could have used particular strategies (e. This is achieved not by a confrontational approach in which therapists attempt to browbeat their clients into compliance. It turned out that Annie was punctual from that point on. relaxation) to stop the escalation of panic. Annie had elevated anxiety and panic. as an expert. . Common Mistakes to Avoid in Treatment Clinicians whose primary work setting is in higher education and research may be vulnerable to talking too much—for example. 2003). This may inhibit questioning from the client. The preferred therapist attitude would be supportive. To return to the topic of motivational interviewing. and supplied the name of the supervisor. Traditional therapeutic postures such as conveying empathy could. raises the important ethical issues of confidentiality and disclosures. by adopting a lecturing style when providing the rationale for recommended treatment interventions. Collaboration with the client in agreeing upon the goals and methods of the proposed treatment plan is an essential fi rst step. interfere with the therapist’s role in encouraging practice. though “Annie” combines the features and characteristics of several of them. and problem-solving with the client when difficulties arise. in early sessions with Annie the therapist adopted this approach by asking the client to give her thoughts and views on the proposed interventions.07 requires that in their published writings psychologists do not disclose “personally identifiable” information on a client without disguising it. yet disciplined. and by including some information drawn from our experience with other clients with PDA. The therapist informed the client at the outset that she was working under supervision. is responsible for effecting all the needed changes. and elements of her personal history and symptom presentation. if the goal is to reduce the client’s distress and impairment as efficiently as possible. age. In the Ethics Code of the American Psychological Association (2002). We satisfied that requirement by altering significant details of the case. and even give the impression that the therapist. interfere with appropriate back-and-forth communication. However. The intent was to encourage Annie to contribute to the intended collaborative atmosphere (Sobell & Sobell. it is inevitable that we would draw from those empirically supported interventions that demonstrably help clients attain those objectives. Thus every clinical issue that we have cited has been presented by an actual client. because the profession of clinical psychology does not follow a standard paradigm for psychotherapy. Standard 4. Preferably the therapist will adopt the role of coach or advisor as the client works on acquiring the needed skills. This is not as straightforward a requirement as we might wish. unless the client has given written consent. such as the client’s name. Presenting an actual case. giving feedback on progress. if overdone. The clinician who treated Annie was a doctoral candidate whose clinical work was being supervised by a licensed psychologist.152 Anxiety Disorders Ethical Considerations The primary ethical directive was to provide competent treatment consistent with accepted standards of professional practice. as we did in this chapter. Archives of General Psychiatry. Barlow.. to accept and adopt the role of being his or her own therapist. Treatment was adapted to her setting and. she practiced staying in bed until her preferred time to get up. and sports events. p. It would have been impossible to cause Annie to sleep in the morning after her husband has gone to work.. so instead. there was no shortage of opportunities for Annie to confront her fear of crowds and possible social embarrassment by seeking suitable exposure in vivo ventures into work settings. D. 326). elevators. despite the rural environment. Ethical principles of psychologists and code of conduct. Specific plans for continued self-initiated practice following treatment termination are agreed upon. and public transportation. M. 2008. It can be helpful to taper sessions to less frequent meetings before termination so that the client has a preview of the impending shift to continued. & Burlington. The Art of This Case There were some issues in trying to modify exposure exercises so that Annie could realistically enact them between sessions. 19. social gatherings. thus. that problems must be resolved perfectly before we terminate). 2008). 57. Annie reported significant anxiety in sleeping in the morning after her husband had gone to work. “the primary task of termination involves relapse prevention strategies” (Hazlett-Stevens. . Leitenberg. The most salient cultural factors had to do with Annie’s rural location and the relative absence of such urban amenities as high-rise buildings. A. Social reinforcement in the modification of agoraphobia. despite the fact that this was several hours earlier than she needed to wake up for work. References American Psychological Association.g. we have not dealt with issues of relapse or termination. (2002). S. and to address constructively with the therapist the emotions raised by the ending of the relationship (Ochoa & Muran. and typically got out of bed at the same time as him. American Psychologist.. Future difficulties are anticipated by careful preparation through psychoeducation before active treatment ends. 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COMMENTARY Natalie Castriotta and Michelle Craske This chapter clearly outlines the application of an evidenced-based treatment for panic disorder with agoraphobia in the clinical practice setting. The issue of comorbidity is appropriate. Craske. Our comments are structured in the same format as the review. The onset followed an initial unexpected panic attack during Annie’s time as a college student. we comment on the clinical science supporting the clinical choices that were made. Demler. Grisham. Chiu. Kessler. Campbell. 2006) as well as overreliance on safety signals in the form of her husband and Xanax (Craske & Barlow. Merikangas. early exposure to familial violence and abuse. characterized by excessive worry about a number of different areas of life. & Walters. The case description indicates signs of typical interoceptive sensitivity to physical sensations observed in panic disorder (Craske & Barlow. anxiety sensitivity) (Roy-Byrne. are consistent with the literature showing that overprotective parenting is characteristic of parents who have children who are anxious (Rapee & Murrell. . Other risk factors for panic disorder with agoraphobia include history of respiratory disturbance. 2001. since panic disorder with agoraphobia often presents with comorbid anxiety and depressive disorders (Brown. Lehman. a 36-year-old Caucasian American. Case Description The case of Annie. and subsequently developed into a full-fledged panic disorder with agoraphobic avoidance behavior. 2006). 1988).e. & Mancill. medical illnesses in self and family. The case description includes comorbidity with generalized anxiety disorder. and high levels of temperamental neuroticism and beliefs that symptoms of anxiety are harmful (i. & Stein. such as having a sheltered and overly protective upbringing and perhaps an overprotective parenting style. nicely captures the phenomenology of panic and agoraphobia. the background experiences. as well as the clinical science supporting additional choices that could have been made or were not fully discussed. 2005). Furthermore. along with comorbidity of a phobia of nosebleeds. 2006). In the sections that follow. which would lead to an independent diagnosis of fear of nosebleeds. Of note.) The self-monitoring of panic and anxiety is not only a useful assessment tool in gauging frequency and severity of panic attacks alongside general mood state at the outset of treatment. however. (For a complete review of recommended measures. other type” that is independent of panic disorder. Overview of Treatment The overview of the treatment is based on the Craske and Barlow (2006) Mastery of Your Anxiety and Panic. it would pertain to fear of blood. The functional analysis clearly describes the situational antecedence to the panic attacks that will subsequently become a target of exposure therapy. the functional analysis continues to adequately describe the role of thoughts. would be. reliance on the Anxiety Disorders Interview Schedule (Di Nardo. The analysis also includes Annie’s husband as being a factor. thereby providing a gauge of severity at any given time as well as providing an index of change with treatment. & Barlow. Furthermore. Caputo. although greater clarification of his role as a safety signal that warrants targeting in treatment should have been garnered from this functional analysis. in that fears of feeling faint are core to the panic disorder fears. include (1) the Anxiety Sensitivity Index (Reiss. 1994) for differential diagnosis is very appropriate and consistent with the evidence-based literature showing enhanced inter-rater reliability using such semi-structured interviews. which has been empirically tested in . & McNally. 1984). & Gallagher. & Williams. and self-monitoring. However. it would appear that if there is an independent diagnosis.158 Anxiety Disorders Assessment The assessment strategy includes a clinical interview and a structured interview. manual. 1986). it is never clearly stated what those other unrelated fears. Brown. and (3) the Chambless Mobility Inventory (Chambless. self-report measures. which would more accurately be categorized as a blood-injection-injury type of phobia. other unrelated fears warrant an independent diagnosis. References are made to this fear of nosebleeds as being a “specific phobia. 1985). It is stated that while certain aspects of the fear of nosebleeds do pertain to panic disorder. Peterson. see Keller & Craske. 4th edition. Overall. Bright. The self-report measures that were selected include the Beck Depression Inventory and the Beck Anxiety Inventory. 2008. (2) the Body Sensations Questionnaire and the Agoraphobia Cognitions Questionnaire (Chambless. and physical sensations in a typical “fear of fear” cycle. While these instruments can be useful in gauging levels of anxiety and depression. Gursky. Jasin. along with the internal antecedence. they are not specific to panic disorder. behaviors. followed by a thorough functional analysis. this represents an adequate assessment strategy. Caputo. but of course is also central to the process of cognitive behavioral therapy as it encourages a scientific observer perspective. Recommended measures that will specifically target features of panic disorder. That aside. Gracixy. such as the physical sensations. is the comorbid diagnosis of specific phobia of nosebleeds. briefer treatments are more valuable. as noted below. For this reason. 2007). 1997).g. However. since focusing on controlling the breath may serve as a way of avoiding facing the physical symptoms (Craske. There is further evidence regarding sudden gains at the start of treatment being predictive of superior outcome at follow-up (Clerkin. Sessions 5 and 6 of this particular treatment focused on both breathing retraining and relaxation training. 2003). the evidence to suggest that these strategies augment or provide additional benefits above and beyond either cognitive restructuring or exposure therapy has been questioned (e. in that study.Panic Disorder with Agoraphobia 159 a number of different studies with slightly different versions. there was also a beneficial effect from continuing phone call follow-up sessions over the subsequent few months. which has shown to be promising for panic disorder (Meuret & Ritz. the question is whether the same results could have been achieved in this case over a shorter duration. Rowe. 2008). wherein relaxation is used as a coping skill for facing . Second. Wilhelm.. Ritz. & Smith-Janik. Thus. 2003). again. Certainly for the purpose of cost-effectiveness. the safety signal perspective has been raised as a potential downside to breathing retraining in particular. 2005) (although. and it is unclear why both were used. whereas other fi ndings show that applied relaxation. may actually exacerbate hyperventilatory symptoms in individuals who have irregular or hypercapnic breathing (Meuret. with some fi ndings showing that it does not add significant benefit (Siev & Chambless. This raises the empirical question of the appropriate number of treatment sessions for completing cognitive behavioral therapy for panic disorder. Teachman. First. Third. The main difference between the manualized treatment. whereas in this case.. both breathing retraining and relaxation training were included. involving biofeedback of exhaled CO2 levels. as usually one or the other would be chosen. recent evidence suggests that the way in which breathing retraining has been done in the panic control therapy protocol. & Roth. First. As it is. Lewin. Fourth. and. 2010). the introduction of exposure therapy to situations that were fear-producing was delayed some time. There are also studies showing that week-long intensive treatments are effective. including up to six sessions of cognitive behavioral therapy alongside expert psychotropic medication recommendations (Roy-Byrne et al. the treatment was spread out so that the earlier sessions focused on one specific skill at a time. brief treatments have been shown to have some effect. which has been studied in various efficacy trials. There are a number of empirical investigations that pertain to this issue. in this case. 2006). & Roth. Meuret. The evidence for relaxation training for panic disorder. although clinical law often dictates longer treatments with more severe levels of agoraphobia and with comorbid personality disorders. the empirical evidence regarding the benefits of breathing retraining and relaxation training are somewhat mixed. Craske et al. and the way in which it was implemented in the current case is the number of sessions. the case description is described through session 20. which is to use slow abdominal breathing. Ritz. Meuret and colleagues have developed a capnometry-assisted breathing training protocol. & Noriega-Dimitri. Wilhelm. is mixed. Most efficacy trials involve 12–16 treatment sessions. with an estimated additional 10–15 sessions still to be completed. interoceptive exposure was discontinued. Pelletier. since little anxiety was induced after the fi rst occasion.) There may have been an overemphasis on fear reduction throughout the exposure therapy. may serve as a safety signal. 2008. some suggest that cognitive therapy does not add significantly to the benefits of exposure therapy (See Bouchard. Sessions 7 through 9 focused on cognitive restructuring. see Craske et al. which has been shown to benefit extinction learning (Rescorla. Furthermore. 1996 for review). (For a review of these issues. such as fears of bright lights or of feeling flushed or shaky or faint. such as acceptance and commitment therapy. Sessions 11 and 12 focused on interoceptive exposure to bodily sensations. as we have argued elsewhere. there is little description of the way in which in vivo exposure was conducted. other studies have shown that cognitive therapy alone is effective for panic disorder (see Bouchard et al. It is this issue regarding the benefits of cognitive restructuring that have led to more interest in alternative treatment approaches. the empirical data pertaining to the efficacy of involving significant others rests upon including the significant other from day one of treatment so that he or she becomes informed . This is a useful technique for the reasons specified in the chapter. As noted earlier. On the other hand. where the experience of fear is the element that is most dreaded. and certainly different from what is typically done in treatment outcome trials. LaBerge. such as weaning reliance on the Xanax. which. What is typically done in panic control therapy is eventually to combine interoceptive exposure with exposure to feared situations (such as hyperventilating while inside a shopping mall). For example. Apparently. This concept is based on the basic science approach of deepened extinction. & Hellstrom. However. but nonetheless.. and conducting exposure in ways that are designed to enhance inhibitory learning. Again. which do not engage in restructuring of thoughts. are not threatening. Examples might have been staring at bright lights or pictures of nosebleeds to generate sensations of faintness or lightheadedness. In session 17. this represents a lengthy period of time. use of more idiosyncratic interoceptive exercises tailored specifically to this particular set of fears. 1993). French. Westling. has been shown to be as effective as cognitive therapy for panic disorder (Ost. It is noteworthy that the in vivo exposure to feared situations did not begin until session 13. The latest science of exposure therapy emphasizes the importance of weaning safety signals and safety behaviors. but rather attempt to distance. & Godbout. may have yielded higher levels of anxiety. Unfortunately. or to teach people to distance themselves from their thinking. although the interoceptive exercises failed to induce significant discomfort in session. or panic itself. there has been some debate in the literature about the role of cognitive restructuring. particularly in the case of panic disorder. Gauthier. which represents approximately 3 months from starting treatment. 2006). the husband attended therapy sessions.160 Anxiety Disorders anxiety-provoking situations. they may well have induced discomfort in agoraphobic situations. for review). which in this case would mean enhancing the learning that the physical symptoms of panic. Lehman. J. If anything. 110(4).. L. Grisham. the nature of the treatment. such as by alarm sounds that are set at random intervals throughout the night to elicit abrupt arousal-induced awakening from sleep. Exposure vs. J. Journal of Abnormal Psychology. P.. D. One might argue that the failure to wean safety signals and safety behaviors and/ or the failure to conduct deepened extinction with the combination of interoceptive exposure in situations that were feared may have in part explained the resurgence of the panic attacks. and can become a coach in the application of cognitive and somatic coping skills and the practice of exposure therapy. B. R. Reference to alternative therapies.. (2001). and Tolin in 2010 would include some of those studies. & Godbout. There is good evidence that involving interoceptive exposure centered on the nocturnal panic attacks themselves is effective. the experience of panic attacks during treatment is not necessarily a bad thing. References Bouchard.. Campbell.. L. A. Gauthier. most often representing a fear of bodily sensations that occur as one is waking from sleep. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. T. C. the evidence regarding the efficacy of panic control treatment is somewhat outdated and fails to take into account several studies that have used the versions of this treatment over the last 10–20 years. it would have been important to address the role of the husband as a safety signal and to discourage that function from an earlier stage than session 17.. Although the chapter notes that there are a lack of cues for panic attacks during sleep. & Mancill. there is a description of an upsurge of the occurrence of panic attacks and the failure of Xanax to have any ameliorating effects. That being said. this may illustrate the downside of continuous reliance upon Xanax. L. In session 18. C. 585–599. (1984)... Finally. Brown. French. However. such as acceptance and commitment therapy. since there is a lack of more than one randomized controlled trial for the treatment of anxiety disorders. is somewhat overstated. C. 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Reactivity to imagery and nocturnal panic attacks. 1023–1032. Craske. Tsao. C. C. . M. A. Lancet. P. 290–298. M.. Clinical Psychology Review. G. 368. A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder... W. RESPONSE Julia R. Craner. However. The commentary was quite correct in noting that efficacy studies for panic disorder indicate that 12–16 sessions are generally effective. Concerning differential diagnosis for comorbid disorders. this is only one aspect of her fear of nosebleeds. for example. such as avoiding watching sports games. Annie was diagnosed with panic disorder with agoraphobia. she does not have fears related to getting her blood drawn. such as finances and relationship issues. K. and that the nosebleeds will lead to catastrophic medical consequences. if her fears of nosebleeds were confined to the physical symptoms or anxiety experienced in response to having or seeing a nosebleed. even though Annie has fears that if she gets a nosebleed she will lose a significant amount of blood. this would fit better with her primary diagnosis of panic disorder with agoraphobia. and specific phobia blood-injection-injury type. given that she has excessive worries about a wide array of situations. Annie also met criteria for generalized anxiety disorder. Geoffrey L. she reported significant avoidance behavior. There are many benefits of brief treatment. We appreciate the observations that there are different choices that can be made when making decisions based on clinical research. generalized anxiety disorder. not only panic and agoraphobic experiences. these are fears of the nosebleeds themselves. In addition to intense fears of nosebleeds. The diagnosis of specific phobia in addition to panic disorder with agoraphobia is based on several considerations. Notably. Lira Yoon. Sigmon In this short section. For these reasons. that she will see people in movies getting nosebleeds. which may make her feel faint and lead to either medical consequences or a panic attack. we found the commentary to be insightful and thorough. and Sandra T. First. by her report. Annie also fears that other people will get nosebleeds around her. and making sure to keep a humidifier running in the house to avoid nosebleeds due to dryness. Thorpe. we will respond to the commentary on the evidence basis for our treatment approach of panic disorder with agoraphobia for Annie. we believe that Annie meets criteria for specific phobia. manualized treatment . However. She reported that she does not fear blood in general. However. including cost-effectiveness. that if others are injured they will get a nosebleed. Overall. rather than the anxiety symptoms that they elicit. we would like to take this opportunity to clarify a few points with regard to the treatment approach. 2006). and cognitive restructuring. researchers have indicated that breathing retraining may work not through reduction of hyperventilation. Although some studies have indicated that these aspects of treatment may not be essential. Research indicates that clients seen in private practice often require a greater number of sessions to receive treatment benefit. with regard to the sequence of treatment. which contains these components (Craske & Barlow. it is important to discuss the actual applications of such treatments in everyday clinical settings with a heterogeneous group of clients. For example. 2006). the approach that was chosen included breathing retraining. relaxation training. several research studies have indicated that progressive muscle relaxation. Furthermore. particularly those with comorbid diagnoses (Stirman & DeRubis. and this is the approach that was taken when planning the future number of sessions with Annie. cases arise in practice in which a clinician has to decide whether to forge ahead or slow down. The research literature indicates that when clinicians are presented with complex cases. does not complete homework assignments. we feel that additional sessions are appropriate for her.Panic Disorder with Agoraphobia 165 must often be individualized to meet idiosyncratic client needs. based on the clinical experience with the client. depending on what the client presents with. is helpful in relieving anxiety symptoms in both patients with panic disorder and generalized anxiety disorder (Conrad & Roth. Regarding mechanisms of action. the choice to follow a manual with demonstrated research support is the rationale for including these components. such as comorbid diagnoses. 2006). Considering that Annie meets criteria for three separate anxiety disorders. It is possible that had treatment followed a more aggressive course in beginning exposure sessions earlier without the above components. additional issues that come up. 2007). However. Finally. This practice enhances both research and clinical outcomes and is a valuable step toward increasing the effectiveness of psychotherapy. as well as different choices that could have been made during this process. or has difficulty with comprehension may require treatment to be delivered over a longer period of time to address these issues as they arise. . Randomized controlled trials of ESTs typically use more homogeneous samples than those that confront clinicians in practice (Greenberg & Watson. Thus. treatment could have been briefer without compromising effectiveness. Therefore. whether essential to treatment or not. and comorbid diagnoses. Utilization and dissemination of empirically supported treatments is a critical topic in psychotherapy and psychotherapy research. 2006). to be extremely helpful in dealing with anxiety. Clinicians utilizing empirically supported treatments (ESTs) are charged with the task of providing effective psychotherapy while making accommodations for unexpected events. but through distraction and/or increasing sense of control (Craske & Barlow. ESTs may need to be modified (Ruscio & Holohan. 2008). she found these strategies. One type of modification strategy in treating comorbid diagnoses involves delivery of multiple ESTs (Ruscio & Holohan. a client who misses multiple sessions. Often. 2006). and that she experienced a significant stumbling block when she had several escalating panic episodes during treatment. there has been empirical support for the treatment manual chosen. particularly diaphragmatic breathing. ) Evidence-based practices in mental health. Levant (Eds. Ruscio. New York: The Guilford Press. D.. R. A. S. Beutler. empirical.. In J.. . L. W. & Holohan. Craske. Washington. C. D. pp. Norcross. L.) Evidence-based practices in mental health. T. H. 21(3). M. A. S. In D. & Barlow. J. Research patients and clinical trials are frequently representative of clinical practice. (2008). M. DC: American Psychological Association. DC: American Psychological Association. Norcross. Clinical Psychology: Science and Practice.. Applying empirically supported treatments to complex cases: Ethical. R. (2006). M. 243–264.166 Anxiety Disorders References Conrad. & Barlow. (2007). J. 13(2). Muscle relaxation therapy for anxiety disorders: It works but how? Journal of Anxiety Disorders. G. & R.. (2006). Stirman. 1–64).) Clinical handbook of psychological disorders (4th ed. Greenberg. (2006). & Watson. & Roth. Washington. & R. (2006). In J. Beutler. New York: Oxford University Press. L. Change process research. W. Panic disorder and agoraphobia. Barlow (Ed. Levant (Eds. G..). D.. 146–162. & DeRubeis. Mastery of your anxiety and panic: Therapist guide (4th ed. H. and practical considerations. Craske. Electric cables were attached to his genitals and electric shocks administered. At the time of treatment. His torture experiences included being beaten with cables. he traveled by airplane to Malaysia. Bryant and Angela Nickerson Hakim is a 36-year-old Iraqi Shi’ite Muslim who was granted refugee status in Australia in 2001 after fleeing Iraq in 2000. Hakim was continually threatened with the death of his family if he did not confess to the crime of “religious incitement” and name others who were active in the religious community. he was granted a three-year temporary protection visa (TPV). lodging. His toes were broken with wooden bludgeons and his toenails were removed with pliers. Hakim was arrested in late 1999 and was held in an Iraqi prison for a period of four months. then Australia. Hakim fled Iraq. for weeks at a time. burned with cigarettes. Hakim was living with his cousin’s family in a one-bedroom apartment. for a period of three weeks. Throughout this time he was tortured on numerous occasions. which he still held at the time of treatment. His wife and four children were regularly visited by the Mukhabarat (Iraqi secret police) and were harassed and intimidated. before enlisting the services of people smugglers to travel fi rst to Indonesia. Hakim was unable to apply to bring his wife and four children to Australia. He was kept in solitary confi nement. and fi nancial support. Further.{7} Treatment of Complex PTSD: The Case of a Torture Survivor Richard A. Following his release from prison. sometimes daily. Following his release. he was ineligible for employment assistance and access to English classes. He relied on his cousin for food. and hung naked by his hands. . crossing the border into neighboring Iran. Hakim had sporadic telephone contact with his wife and children. on a starvation diet. Upon his arrival in Australia. From there. Hakim was held in a detention center for seven months. Throughout his imprisonment. He endured a dangerous boat trip across treacherous seas to Australia—a trip renowned for boats sinking with asylum seekers on board. Due to the restriction of rights and access to services associated with TPV status. 168 Anxiety Disorders Hakim was referred to a specialist trauma outpatient unit in Australia by his local general practitioner. Hakim also attended regular appointments with a caseworker at a local mental health service center, who assisted him with managing psychosocial challenges. Hakim exhibited symptoms of posttraumatic stress disorder (PTSD), including frequent intrusive memories related to torture experiences and traumatic events experienced in detention, occasional flashbacks of particular incidents (e.g., sexual torture), avoidance of trauma reminders and memories and extreme hyperarousal reactions. Further, Hakim presented with high levels of anger and a preoccupation with injustice; strong feelings of guilt and shame related to torture experiences; depressed mood and a pervasive sense of hopelessness about the future. Since his arrival in Australia, Hakim had started drinking alcohol in an effort to escape the incessant memories of his torture experiences; at the time of referral, he was drinking approximately half a bottle of whiskey three to four times per week. He was highly distrustful of anyone outside his family and suspected that he was being monitored by government officials. Key Principles/Core Knowledge What are the key principles/core knowledge do you use in initially approaching the case? Explicate principles from basic science Contemporary cognitive behavioral models that underlie best-practice interventions for trauma survivors draw on theories of cognition, learning, and memory (Foa, Steketee, & Rothbaum, 1989; Ehlers & Clark, 2000). Fear conditioning is considered a key mechanism by which posttraumatic stress responses develop. Cues present at the time of the traumatic event are paired with strong fear reactions, leading to conditioned fear responses that activate fear networks when the individual encounters these stimuli in another setting (Mowrer, 1960; Keane, Zimmerling, & Caddell, 1985; Foa, Steketee, & Rothbaum, 1989). Subsequently, the process of generalization also results in other internal (e.g., memories, thoughts) and external stimuli precipitating anxiety reactions. That is, when a traumatic event (unconditioned stimulus) occurs, people typically respond with fear (unconditioned response). It is argued that the strong fear elicited by the trauma will lead to strong associative conditioning between the fear and the events surrounding the trauma (Milad, Rauch, Pitman, & Quirk, 2006). As reminders of the trauma occur (conditioned stimuli), people then respond with fear reactions (conditioned response). This model proposes that successful recovery from trauma involves extinction learning, in which repeated exposure to trauma reminders or memories results in new learning that these reminders no longer signal threat (Davis & Myers, 2002). More cognitively oriented models emphasize that appraisals of the traumatic event and associated symptoms have also been identified as key etiological and maintaining factors in PTSD (Ehlers & Clark, 2000). Anxiety responses and maladaptive beliefs about the traumatic event and Treatment of Complex PTSD: The Case of a Torture Survivor 169 the individual’s reactions then lead to avoidance behaviors in an attempt to evade feared stimuli and associated memories. Such models can be used to conceptualize the development and maintenance of PTSD reactions in torture survivors. These theories suggest that certain stimuli (e.g., bright lights, the bearded torturer, the smell of sweat) were paired with feelings of terror at the time of the torture. When Hakim encounters similar environmental cues or memories of the event, trauma memories are reactivated in the form of intrusive memories, flashbacks, and nightmares. Associated fear responses are thus elicited, even in a comparatively safe environment such as his cousin’s apartment in Australia. This leads Hakim to attempt to avoid distressing triggers in multiple ways, including refusing to talk about his experiences, staying inside the apartment, and avoiding watching television for fear of encountering reminders of his experiences. Contemporary models have also drawn on learning theories to describe the psychological effects of torture. Theories of learned helplessness (Seligman & Maier, 1967; Seligman, 1975) and research with torture survivors (Basoglu, 2009; Basoglu, Livanou, & Crnobaric, 2007; Basoglu & Mineka, 1992; Basoglu et al., 1997) have identified factors such as controllability, threat appraisal, and helplessness as important in predicting psychological responses following torture. Sustained exposure to situations that are typically characterized by uncontrollability, threat and helplessness are likely to contribute to more severe PTSD reactions and greater psychological distress. This may result in chronic states of anger and difficulty regulating emotional responses (Silove, 1996), in addition to damage to the individual’s sense of agency and self-efficacy. Other theorists have suggested that exposure to sustained human-perpetrated trauma such as torture may precipitate personality change and alter the way in which the torture survivor sees himself or herself and the surrounding world (Barudy, 1989; GorstUnsworth, Van Velsen, & Turner, 1993; Silove, Tarn, Bowles, &Reid, 1991). Lack of trust and high levels of suspicion of others following interpersonal violence and torture are also common (Gorst-Unsworth, Van Velsen, & Turner, 1993; Doerr-Zegers, Hartmann, Lira, & Weinstein, 1992). Hakim’s torture experiences occurred over an extended period of time, were unpredictable, intentional, and characterized by great brutality. Throughout his imprisonment, Hakim had virtually no control over his circumstances; torture was often perpetrated at what appeared to be random intervals, and was designed to infl ict maximum pain, humiliation, and psychological distress. During torture, Hakim was forced to identify friends and colleagues who had been active in the religious community, for which he continued to feel great guilt. He also harbored feelings of shame for being unable to withstand torture and for disclosing these relationships. Imprisonment, torture, and immigration detention led to Hakim feeling unable to exert any control over his environment. He held a marked sense of helplessness, believing that his own actions had no influence on the external world. For this reason, Hakim felt that he was incapable of performing even relatively small daily tasks. Hakim’s profound sense of hopelessness led him to feel highly pessimistic about his future, and he believed 170 Anxiety Disorders that it was highly unlikely that he would ever see his wife and children again. Hakim often ruminated about the injustices that had occurred in his life. He was frequently irritable, and his anger responses were often out of proportion to triggering stressors. Following his torture experiences, Hakim was left with a pervasive sense of distrust and suspicion of other people; he also thought that he was being closely monitored by the government, who he believed was following him and tapping his telephone lines. Assessment How did you develop an assessment strategy in this particular case? What were key questions that you needed answered and how did these direct case formulations? What did you rule out and how? What is your view of the psychometric standards (validities) of the assessment strategies you decided to use? Considering Hakim’s history of trauma, PTSD was considered to be a likely diagnosis. Other common responses following torture include depression, anxiety, anger, shame, guilt, humiliation, emotion dysregulation, self-harm, and perceived personality change (Basoglu et al, 1994; Gorst-Unsworth, Van Velsen, & Turner, 1993; Man Shrestha et al., 1998; Momartin & Coello, 2006; Silove, 1996; Turner & Gorst-Unsworth, 1990; Vorbr üggen & Baer, 2007). Thus, in order to formulate the case, it was necessary to investigate a broad range of psychological reactions, with a focus on those that would determine the type of treatment to be employed. ASSESSMENT Assessment was carried out over two 90-minute sessions. Psychometric measures were kept to a minimum to avoid over-burdening Hakim, especially considering that the assessment was undertaken via an interpreter. Considering the likelihood that Hakim was experiencing PTSD, a standardized measure of this disorder was implemented to systematically assess symptoms and track treatment progress. The Harvard Trauma Questionnaire (Mollica et al., 1992) is a 32-item scale, with 16 items indexing exposure to a number of trauma types commonly experienced by refugees and 16 items assessing symptoms of PTSD. It has been used with a number of refugee groups, validated with Iraqi refugees (Shoeb, Weinstein, & Mollica, 2007; Schweitzer, Melville, Steel, & Lacharez, 2006; Nickerson, Bryant, Steel, Silove, & Brooks, 2010; Steel, Silove, Bird, McGorry, & Mohan, 1999; Mollica et al., 2001), and exhibits strong psychometric properties (Mollica et al., 1992). According to this scale, Hakim had experienced 9 out of a possible 16 trauma types throughout his life; he exhibited substantial reexperiencing, avoidance, and hyperarousal symptoms, consistent with a diagnosis of PTSD. As indicated above, research has documented high levels of depression in torture survivors (Man Shrestha et al., 1998; Carlsson, Mortensen, & Kastrup, Treatment of Complex PTSD: The Case of a Torture Survivor 171 2006). Further, depression is commonly comorbid with PTSD in refugees (Mollica et al., 1999; Ekblad, Prochazka, & Roth, 2002; Momartin, Silove, Manicavasagar, & Steel, 2004).Thus, it was deemed important to assess symptoms of depression in Hakim. A structured subscale of depression, adapted for use with refugees, was drawn from the Hopkins Symptom Checklist (HSCL-25; Mollica et al., 1987). This scale has been used with numerous refugee groups (Mollica et al., 1999; Silove et al., 2007; Carlsson, Martenson, & Kastrup, 2006) and has sound psychometrics (Mollica et al., 1987). Administration of this scale to Hakim revealed that he met diagnostic criteria for depression, experiencing such symptoms as low mood, anhedonia, sleep difficulties, and hopelessness. Other potential psychological reactions were investigated throughout the assessment interview. A general overview of the types of traumatic events that Hakim had experienced was also elicited. Hakim reported that he was highly anxious about the fate of his family and spent a lot of time worrying about their well-being and future. He believed it was unlikely that he would ever see them again. It also became apparent that Hakim constantly ruminated about the injustices that he had endured. He felt irritable much of the time and occasionally exploded into anger attacks. From Hakim’s reports, it appeared that, when angry, he shouted at those around him and occasionally broke objects around the house. The potential for violent behavior when angry was a key consideration for Hakim’s treatment. Hakim’s general emotion regulation capacity was also assessed. It appeared that, when he became distressed, Hakim either became angry, retreated to his room and isolated himself from those around him, or drank alcohol. He did not report in engaging in any self-harming behavior. Finally, it was important to explore Hakim’s suspicion of others and his belief that he was being monitored by the Australian government. After discussing this with Hakim, it appeared that these beliefs were based on long-term experience of betrayal and distrust in Iraq, rather than being indicative of delusional beliefs or a psychotic disorder. CONTEXTUAL FACTORS There are a number of contextual factors that should be taken into consideration when approaching the assessment and treatment of torture survivors, due to potential similarities between the torture setting and the therapeutic environment. Therapy sessions with Hakim were undertaken in a large, bright room with windows so as not to resemble the cell in which he was incarcerated and tortured. Perceived differences in power between the therapist and the client may also be reminiscent of those between the torturer and victim, and so Hakim’s assessment was undertaken in a sensitive manner, avoiding an interrogatory style of questioning. Every effort was also made to ensure that Hakim had a sense of control throughout the assessment. Assessment and therapy were conducted using an interpreter, with Hakim being provided with a female Shi’ite interpreter at Hakim’s request. 172 Anxiety Disorders Epidemiology What epidemiological considerations such as base rates and comorbidity, if any, came to play in diagnosing or case formulation? PTSD is a reasonably common disorder, which is not surprising, considering that most people are exposed to traumatic stressors at some time in their lives. The National Comorbidity Survey conducted in the United States indicated that 61% of a representative sample of adults reported exposure to a traumatic stressor (Kessler, Sonnega, Hughes, & Nelson, 1995). Another large-scale population study of adults in Detroit found that 90% reported exposure to a traumatic stressor (Breslau, Davis, Andreski, & Peterson, 1991). Despite the frequency of exposure to traumatic events, relatively few people actually develop PTSD. For example, the National Comorbidity Survey found that only 20.4% of the women and 8.2% of the men ever developed PTSD (Kessler et al., 1995), and the Detroit study found that 13% of the women and 6.2% of the men had developed PTSD (Breslau et al., 1991). Although men are more likely to be exposed to trauma than women, women have at least a twofold risk of developing PTSD compared to men (Breslau et al., 1997). There is a tendency for more severe traumas tend to result in more severe PTSD. For example, there is evidence that interpersonal violence leads to more severe PTSD than impersonal trauma (Darves-Bornoz et al., 2008). Torture survivors are at particularly high risk for PTSD. A recent meta-analysis reported an unadjusted PTSD prevalence rate of 30.6% in tortured refugee populations (Steel et al., 2009). There is also strong evidence that PTSD is more often associated with other psychiatric disorders than occurring as the sole diagnosis. Lifetime comorbidity prevalence rates with PTSD have been reported between 62–92% (DeGirolamo & McFarlane, 1996; Kessler et al., 1995; Perkonigg, Kessler, Storz, & Wittchen, 2000). The major overlap between PTSD and other disorders is with depression, other anxiety disorders, and substance abuse. The psychological sequelae of torture typically extend beyond posttraumatic stress reactions (Kagee & Naidoo, 2004; Silove, 1999), with one meta-analysis fi nding a depression prevalence rate of 30.8% (Steel et al., 2009). Case Formulation What was your initial case formulation, how did you come by it and how is it evidence-based? What diagnostic issues arose, why and how did you handle these? The initial case formulation was based around the predominance of Hakim’s posttraumatic stress symptoms, precipitated by his exposure to numerous traumatic events in Iraq and in immigration detention in Australia. Hakim was experiencing frequent intrusive memories related to his torture experiences. Most commonly, these memories were triggered by reminders of the trauma, either external (for example, seeing a man with a beard on the television) or internal Treatment of Complex PTSD: The Case of a Torture Survivor 173 (for example, the chronic pain Hakim experienced in relation to his injuries). Hakim also experienced flashbacks, in which his experience of the memory was so vivid that he dissociated from reality. Hakim found these flashbacks particularly frightening, as they were unpredictable, and he feared losing control in an unfamiliar situation. As a result of these distressing reexperiencing symptoms, Hakim went to great lengths to avoid reminders of the torture. He rarely left his cousin’s apartment, avoided watching television or reading the newspaper, and self-medicated with alcohol to manage both associated anxiety and physical pain. Hakim believed that he was unable to cope with the memories of the torture; he feared that he would “go crazy” as a result of the memories. Hakim’s avoidance of potential triggers of traumatic memories served to reinforce his beliefs that he would not be able to cope with the memories when they arose and prevented him from being exposed to corrective information. Further, Hakim had great difficulty tolerating distress, and when he experienced strong negative feelings, he would become angry or attempt to avoid them by drinking alcohol or isolating himself alone in his room. Each of these behavioral consequences of Hakim’s belief that he could not cope with negative emotions served to exacerbate his fear and sadness and acted as another form of avoidance. Hakim’s torture experiences had also challenged his fundamental beliefs about the benevolence of humankind. This is consistent with research indicating that traumatic events can substantially impact the way in which the individual perceives the external world (Janoff-Bulman, 1992). As a result, he was highly distrustful of other people, even those who were close to him, and especially those in positions of authority. This resulted in Hakim withdrawing socially from those around him. He preferred to spend time alone and did not engage in any social activities. Hakim’s isolation prevented him from obtaining disconfirming information about the potential good in other people. He approached situations expecting to be treated unjustly and so was combative and defensive, creating circumstances of interpersonal confl ict. This again contributed to Hakim’s global negative beliefs about the world. Hakim also reported that he had great difficulty reconciling what had happened to him and those close to him with his religious beliefs. Hakim stated that he was unable to understand why this had happened, and that his religion offered no assistance in finding an explanation. While previously Hakim’s faith had been of great comfort to him in times of adversity, recently he had withdrawn from his religious community and had ceased adhering to Islamic tenets. This further contributed to his social isolation and negative global beliefs about the world. This situation also contributed to an underlying sense of guilt because Hakim felt that he was not honoring Allah and that he was inadequate, as his persistent psychological problems indicated that he was not accepting Allah’s will. Hakim’s beliefs about injustice also substantially contributed to his psychological symptoms. Hakim reported that he believed that those who acted in a way that was immoral or unjust appeared to be rewarded, while those who attempted to live a “good life” were punished. His frequent rumination on this topic appeared to contribute to ongoing feelings of anger, and Hakim now reported that he expected 174 Anxiety Disorders to be treated unjustly in a number of situations. His anger as a result of this (for example, toward his caseworker and immigration officials) had created difficulties in the process of accessing necessary resources and undertaking the immigration process, further reinforcing Hakim’s beliefs that he was treated unjustly. Intervention How did you develop an intervention model for this case? What other interventions did you consider and reject, for what reasons? The case formulation based on the initial assessment suggested that Hakim’s PTSD symptoms played a major role in maintaining his psychological distress. Thus, PTSD symptoms were a central treatment target, and various interventions focusing on PTSD were considered for implementation. International guidelines suggest that trauma-focused interventions are the optimal treatment for PTSD in non-refugee populations (International Society of Traumatic Stress Studies Treatment Guidelines, 2008; National Health & Medical Research Council Treatment Guidelines, 2007; UK National Institute of Clinical Excellence, 2005). Further, emerging research with tortured and non-tortured refugees suggests that trauma-focused interventions are efficacious in reducing symptoms of PTSD in these groups. Thus, it was determined that trauma-focused therapy would be a potentially effective intervention for reducing Hakim’s PTSD symptoms. There were some concerns regarding how Hakim’s difficulties with emotion regulation would influence the implementation of trauma-focused treatment for his PTSD symptoms. Numerous commentators have suggested that people presenting with emotion regulation difficulties, such as torture survivors, may not manage the distress associated with exposure (for discussion, see Herman, 2001; Neuner et al., 2008; Silove, 1996; Silove, Tarn, Bowles, & Reid, 1991). Further, theorists have suggested that the exposure therapy aspects of trauma-focused interventions may be contraindicated in the case of high levels of anger (Jaycox & Foa, 1996). It was possible that Hakim’s difficulty trusting others may have prevented him from openly discussing the behavioral consequences of his anger responses with the therapist. Further, it was possible that Hakim’s alcohol use may also be exacerbated following exposure therapy. The potential consequences for Hakim’s anger and alcohol use following the initial increase in psychological distress associated with exposure therapy led to the exploration of additional treatment options. Recent research with survivors of childhood sexual abuse and refugees has suggested that the implementation of a skills-building phase prior to the commencement of exposure therapy may be useful in those with emotion regulation difficulties (Cloitre, Koenen, Cohen, & Han, 2002; Cloitre et al., 2010; Kruse, Joksimovic, Cavka, Woller, & Schmitz, 2009). Considering Hakim’s difficulties tolerating strong emotions, it was decided to implement a phase-based traumafocused treatment consisting of the following components: (1) training in emotion regulations skills, (2) adapted exposure-based therapy, (3) in vivo exposure Treatment of Complex PTSD: The Case of a Torture Survivor 175 therapy, (4) cognitive restructuring, (5) goal-setting and social reconnection, and (6) relapse prevention. The emotion-regulation training component of therapy focused on assisting Hakim with identifying and labeling emotions, examining how Hakim usually dealt with strong negative emotions, evaluating the effectiveness of these strategies, and developing, implementing, and evaluating new strategies. For example, upon entering treatment, Hakim frequently stated that he felt “bad” or “upset.” Thus, the fi rst step of this aspect of treatment was to assist Hakim to describe his emotions more specifically, for example to recognize when he was feeling angry, sad, fearful, or guilty. Following this, Hakim was able to identify common ways in which he would act on or cope with these feelings. Hakim reported that when he felt angry, he often slammed doors, shouted at others, or broke household objects. Finally, he would retreat to his room and ruminate about the injustice of the situation. Hakim recognized that when he felt anxious he would often avoid reminders of past traumatic events and would drink whiskey to subdue the sense of fear associated with the memories. The next aspect of treatment was to assist Hakim in examining how effective these strategies were in reducing the associated negative emotions. While Hakim reported that there were certain benefits stemming from each of these actions (e.g., a feeling of power associated with becoming aggressive that combated his sense of helplessness; numbness to emotions as a result of consuming alcohol when feeling fearful), he recognized that the negative consequences (e.g., strained interpersonal relations, increased feelings of fear, sadness, and guilt after drinking) generally outweighed the positive consequences of these strategies. Hakim and the therapist then worked together to identify alternative strategies to be used when Hakim was experiencing negative emotions, such as listening to music, taking a shower, or reading a magazine. Hakim experimented with these strategies between sessions, and the effectiveness of each strategy was evaluated in the next therapy session. Certain strategies were more helpful than others, and Hakim increased the frequency of these behaviors, resulting in a gradual reduction of aggressive and drinking behaviors. It is important to note that an underlying principle of each of these preparatory skills was to increase Hakim’s perception of control and mastery over his psychological state; this was a pervasive problem for him, emanating from his trauma experiences, and so it was important to enter cognitive behavioral therapy (CBT) with a sense of agency and control. While the components of the next phase of treatment overlapped in implementation, they will be described sequentially for clarity. Traditional exposure-based therapies that primarily focus on a single traumatic event have limited applicability to address the myriad traumas experienced by refugees and torture survivors. Accordingly, in recent years, therapeutic approaches have been developed with refugee and war-affected groups that facilitate the discussion of numerous events within the individual’s life (e.g., Cienfuegos & Monelli, 1983; Neuner et al., 2004; Schauer, Neuner, & Elbert, 2005; Weine et al., 2006). We drew on these interventions by using a narrative approach to implement exposure therapy with Hakim. The goal was to discuss both positive and traumatic events that had occurred in 176 Anxiety Disorders Hakim’s life in order to facilitate the integration of traumas into his life story and the emotional processing of traumatic events and to help Hakim learn that he could cope with talking about these distressing memories. Initially, a time line was drawn on a large blank sheet of paper to represent Hakim’s life so far. It was estimated that this component of therapy would take approximately six sessions; thus the time line was divided into six components, with each representing an equal time period in Hakim’s life. Hakim was then asked to identify key positive and negative events that occurred in each time period. Examples of positive events included a childhood memory of playing soccer with friends, a memory of Hakim working with his father in the family carpentry store, and the day that Hakim’s daughter was born. Each of these positive events was described in detail, alongside the associated emotions and personal characteristics that were associated with these events (e.g. loyalty, enjoying making things, the importance of family). Negative and traumatic events were also described for each time period. Those traumatic events defi ned as the most distressing were explored in detail in accordance with traditional prolonged exposure therapy. For each of these events, Hakim described the narrative of the experience, in the present tense, providing sensory details, cognitions, feelings, and physical sensations. Many of the traumatic events that Hakim had been exposed to were centered on torture experiences, which were prolonged and repeated in duration. As it was not feasible to discuss all of these experiences in detail, Hakim was asked to identify several particularly distressing events that could be used to represent the others. Exposure therapy was continued with each memory until distress reduced markedly and Hakim had reached a point of relative safety in the experience (e.g., being back in his cell following a torture experience). Exposure to the memory of each event was repeated again until associated distress reduced. One important aspect of undertaking exposure therapy with Hakim was his initial belief that he would not be able to cope with the memory. Hakim specifically feared that he would “go crazy” if he deliberately thought of the traumatic event and was reluctant to engage in exposure therapy for this reason. Following the presentation of a strong rationale for the use of exposure therapy, Hakim agreed to the implementation of this therapeutic technique. While discussion of the trauma memories was initially highly distressing to Hakim, a major benefit of treatment for Hakim was the realization that he could speak about what had happened to him and that the salience of the associated emotions reduced with time. In vivo exposure therapy was also implemented alongside imaginal exposure therapy. This therapeutic technique proposes to expose the client to feared situations, thereby challenging beliefs about the danger associated with these situations and reducing avoidance behaviors. Overall, Hakim was highly avoidant due to his fear of eliciting trauma memories. For this reason, he avoided leaving the apartment, watching television, and reading newspapers. He also avoided engaging in physical exercise for fear that this would exacerbate his torture-related injuries, causing physical pain that would remind him of the torture experiences. Hakim’s lack of trust in people led him to avoid going to places where there would be other people, for fear that he would be harmed, further exacerbating his social For example. Hakim and the therapist jointly identified a feared situation to which he would expose himself prior to the next session. and the absence of safety behaviors were carefully operationalized.” Working with survivors of torture and extreme trauma poses considerable challenges to traditional models of cognitive therapy that were developed with survivors of discrete civilian trauma. It was decided jointly by the therapist and Hakim that he would begin to go for short walks. Hakim was able to reengage in physical exercise.” “Terrible things always happen to good people. who were then imprisoned and interrogated. and further. while bad people are rewarded. Hakim had been very physically active prior to his torture experiences in Iraq. This process was continued with a number of feared situations on Hakim’s hierarchy. which can be overwhelming. considering the experiences he had endured. crying. to learn that he could cope with previously feared situations and trauma memories. begging). The activity. It was of key importance when working with Hakim to acknowledge that these cognitions were completely understandable. Hakim went for a 15-minute evening walk around the block with his cousin. and Hakim’s confidence in his ability to cope with the distress had increased. Whereas previously Hakim seemed to have believed that people were generally good. The exposure was then evaluated during the next treatment session. Key related cognitions included “I am a weak person. Cognitive therapy was considered to be a key aspect of Hakim’s treatment. Hakim felt very strongly that he should have been able to withstand the torture and was also deeply ashamed of his own response to many of the acts of torture (e. This ranged from reading the newspaper (expected distress: 3/10) to going to a shopping mall alone (expected distress: 10/10). Following the session. but that this anxiety decreased relatively quickly and he was able to have a conversation with his cousin. At the end of each session. As with many torture survivors. Hakim harbored strong feelings of guilt and shame following his torture experiences. His physical injuries had prevented him from being able to engage in physical exercise for a long time.Treatment of Complex PTSD: The Case of a Torture Survivor 177 isolation.” and “I can’t trust anyone. he now harbored thoughts such as “Most people are evil. In this way.” “I should have acted like a man..” Hakim’s experiences had also transgressed his basic beliefs about humankind and justice in the world. Hakim reported that he had felt considerably anxious during the experience. a hierarchy of feared situations was constructed by which Hakim rated each situation in terms of the distress he expected it to induce. he was fearful that the pain associated with the physical activity would trigger trauma memories and that he would be unable to cope. the duration.g. the distress associated with the memories had lessened somewhat. Following a number of sessions of imaginal exposure therapy.” “I have destroyed my family’s honor. in which he had been forced to name other people from his religious community. It . It became apparent throughout therapy that these experiences had fundamentally challenged Hakim’s self-concept—that he no longer felt that he was a person of value. screaming. and to have social contact with his cousin outside the home. At the next session. In treatment. not least because the extreme trauma that survivors have experienced offers much evidence to support negative beliefs about other people and the world. partly because he was displaced from his home country and was living in an environment where he did not know the language and partly because of his negative beliefs about the world and humankind. focusing on injustice means I will be better prepared when it happens again). which appeared to have shattered underlying cognitive frameworks about the world and humankind. Further. An important component of Hakim’s treatment focused on the reestablishment of social connections and goal-setting for the future. An alternative strategy that was implemented during treatment was considering the extent to which ruminating about these beliefs was helpful in assisting Hakim to meet his life goals. this form of motivational interviewing led Hakim to distract himself at times when he was ruminating on the injustice of these past events because he realized that spending time on these thoughts was only interfering with his capacity to function. psychoeducation was provided about the nature and purpose of torture. While Hakim could identify several pros associated with his cognitions (e. Hakim was extremely socially isolated. the fact that torture was intended to cause emotions such as guilt. Hakim had been exposed to extreme violence and cruelty. Discussions around the fact that torture was perpetrated to cause maximum psychological damage and that torture techniques were designed to break even the strongest person helped to alleviate some of the shame and guilt that Hakim felt about his own behavior under torture. he was also able to see several negative aspects associated with thinking in this way. As previously indicated. An important part of this motivational aspect was to assist Hakim in recognizing that his attempts to master these ruminating patterns actually reflected his desire to be honorable in Allah’s eyes. For example. particularly in the context of social relations. Difficulties were also encountered in challenging Hakim’s beliefs about humankind and justice. changes in cognitions about the world and other people were minimal throughout treatment. overall. However.. and so by adhering to the treatment strategies he was directly honoring Allah. Hakim was able to see that not all people were evil. and slowly meeting new people in Australia. To assist in the management of ruminating. to avoid providing the torturers with the satisfaction of having achieved their goals. for the most part. The way in which Hakim’s . However.g. and humiliation provided further incentive for Hakim to challenge these interpretations. success in restructuring these thoughts was relatively limited in Hakim’s case. he often stated that he believed that Allah tested his followers by giving them difficulties. shame. Hakim’s negative beliefs about humankind and justice remained intact throughout therapy. Throughout the last several years. overall.178 Anxiety Disorders must be noted that. In an attempt to assist Hakim in evaluating his behavior under circumstances of torture more realistically. not trusting people means that they are less likely to be able to hurt me. Attempts were made throughout the therapeutic process to assist Hakim in gathering evidence about the world that contradicted his beliefs about malevolence and injustice. by spending time with family and friends. which led him to avoid other people and abandon previously held social networks such as the religious community. The pros and cons of ascribing to these beliefs were identified and weighed. in addition to negative global beliefs about humankind and the world. and it was extremely . Hakim’s reexperiencing symptoms had decreased markedly. As previously noted. It was difficult for Hakim to admit to and discuss these feelings. reading a book) to medium (e. increased interest in daily activities. Hakim still met clinical criteria for major depressive disorder. ranging in magnitude from small (e.. which Hakim joined toward the end of therapy. While Hakim was able to recognize that he had behaved in an entirely understandable way in the torture situations. in which a plan to continue therapy gains was developed. as had the extent to which he avoided feared internal and external stimuli. a local torture and trauma service held an Iraqi men’s cooking group. Furthermore. following a reduction in fear of trauma memories and associated avoidance. Nonspecifics How did you deal with non-specifics in this case? There were several factors that had the potential to influence the progression of therapy in this case.g.g. such as the therapist... Following the development of the narrative that chronicled Hakim’s history to date. and strategies for managing recurring symptoms were discussed. Hakim also reported improved mood. Hakim had considerable difficulty with trusting other people. plans were made whereby Hakim would be exposed to other people. attending English classes) to large (e. For example. He was still preoccupied with issues of injustice. additional sheets of paper were attached to Hakim’s time line to represent his future. Hakim’s treatment was moderately successful. This also served as behavioral activation to combat Hakim’s symptoms of depression and lack of interest in daily activities. drawing on the strengths and interests that had been identified throughout the time line process. This was particularly salient when he perceived a person to be in a position of authority. By the end of treatment. at the end of treatment. Goal-setting was also implemented as a therapeutic strategy to assist Hakim in planning for the future. fi nding employment). which allowed him to engage in social interaction outside the environment of the apartment. However. warning signs were identified. The fi nal aspect of Hakim’s treatment comprised relapse prevention. Hakim’s sense of vulnerability in this situation was further heightened by the feelings of shame and guilt that he harbored regarding his behavior in the torture situation. Goals for the future were then developed jointly with Hakim. although he was much better able to manage his anger reactions and other negative emotional responses. as is common in survivors of torture and severe interpersonal trauma. Hakim also continued to go for walks with his cousin and his cousin’s friends. Overall. and greater hope for the future. Step-by-step plans were then formulated to assist Hakim in working toward these goals.g. he still harbored strong feelings of shame and guilt about his behavior.Treatment of Complex PTSD: The Case of a Torture Survivor 179 social isolation was maintaining his psychological symptoms was discussed in therapy and. had resulted in deep and lasting feelings of humiliation in Hakim. yet reiterating the rationale for the intervention strategies and reminding him of his initial commitment to therapy. and one of the most salient traumas would have remained unexplored. was unable to seek employment.. who was understandably initially reluctant to disclose these experiences to the female therapist and female interpreter. This had been established from the beginning of treatment. At the beginning of the intervention. it is possible that. he may have not been willing to discuss this experience at all. there were several instances in which Hakim did not complete assigned between-session tasks. Understandably. it was acknowledged that there would be times that Hakim would not feel like attending treatment sessions. distortions. differences between this program and other types of treatment (e. Therapy Problems What were your strategies for dealing with therapy problems (missed apt. it was necessary to take the time to build a trusting therapeutic relationship with Hakim prior to exposure therapy. if the interpreter had been male.180 Anxiety Disorders important to the therapeutic relationship that these be normalized. and was not able to sponsor his wife and children to come to Australia. these issues were of considerable concern to Hakim. Ongoing stressors were important aspects that also had the potential to influence the intervention. which he considered the most distressing component of treatment. including sexual torture (the attaching of electrodes to his genitalia and the administration of electric shocks). Hakim held a TPV. and that these should be discussed openly in therapy. Hakim had specifically requested a female interpreter from the same religious group as he. Further. or completing required tasks. The nature of the torture that Hakim had experienced. the importance of committing to the treatment was emphasized. Overall. At the time of treatment.)? One factor that presented challenges to the treatment process was Hakim’s noncompliance with appointment times and between-session tasks. On a number of occasions. Further. He relied on his cousin for fi nancial support. Hakim failed to attend treatment sessions without informing the therapist prior to the session. medical. casework) were emphasized. lack of commitment etc. and thus his access to services was greatly restricted. but it was necessary to discuss this again at several points throughout the therapy. This was conceptualized by the therapist as a form of avoidance of talking about distressing subjects or engaging with trauma memories. particularly in relation to in vivo exposure. This further highlights the importance of inquiring as to the client’s preferences in terms of demographics of the interpreter. while normalizing Hakim’s desire to avoid treatment. These concerns were frequently exacerbated during therapy because of media reports of asylum seekers in detention . and a commitment to engage in treatment as much as possible was elicited from Hakim. and he often considered them to be of greater priority than his PTSD and other psychological symptoms.g. this media coverage fueled Hakim’s anxieties. he would hold another TPV. Contact was made (with his permission) with the caseworker who was managing Hakim’s resettlement process. (b) they feel that they have the control to terminate it whenever they wish. Hakim may have been deported to Iraq. At the time of treatment. We then contract with the patient that he or she will do a single session of exposure. In these cases. At the beginning of treatment. casework) were outlined. we typically conduct a very brief form of the trauma narrative so as to convey to the patient that they can manage the distress. Hakim held a TPV. At the end of this three-year period. and (c) they understand that experiencing some distress is actually an indication of progress. We have had other torture survivors who cannot tolerate the distress of exposure. if this was granted.g. Problems WHEN THERAPY IS NOT WORKING What would you have done if therapy wasn’t working like you thought it would? It was possible that Hakim may not have responded to exposure-based therapy at all.. we attempt a behavioral experiment in which we explicitly ask the patient to outline his or her fears and expectations of exposure. If the visa application was denied.Treatment of Complex PTSD: The Case of a Torture Survivor 181 centers in Sydney attempting suicide or rioting in the facilities. It was emphasized to him that the goal of therapy was to address his PTSD symptoms. and there was a need to focus on these strategies while he allocated time to other professionals to assist with other issues. or even the anticipation of exposure therapy. Ethical Considerations What ethical considerations came into play? One primary ethical consideration that arose in the present case was the use of exposure-based therapy. Accordingly. Hakim was extremely worried . considering Hakim’s current situation. this time was devoted to discussing psychosocial difficulties that he was experiencing and ensuring that Hakim was still regularly seeing his caseworker to manage these issues. the scope of the psychological service that could be offered was explained to Hakim. and then strongly endorse their strength in managing these memories. Fifteen minutes were designated at the start of each therapy session to review Hakim’s week—often. Patients are reassured that it will then be their decision to proceed or not with the treatment. In these cases. Hakim was required to reapply for refugee status. and differences between this treatment and other services (e. medical. the goal is to test whether the feared outcome of doing exposure does actually occur. Many patients can tolerate exposure if (a) they are initially given some experience of mastery. which was a temporary visa issued by the Australian government affording Hakim three years of asylum in Australia. it was likely that the reliving of these memories would trigger thoughts about possible traumatic events that Hakim may endure in the future. it is worth noting that several studies undertaken with individuals in insecure circumstances. Ekblad. including refugee camps (Neuner et al. by avoiding thinking about the trauma or engaging in any activities that might trigger reminders of the traumatic events. In this context. Hakim evidenced both reduced reexperiencing symptoms related to past trauma and reduced thoughts associated with possible future negative events.. Accordingly. and possibly killed. it was deemed appropriate to proceed with exposure-based therapy while carefully monitoring Hakim’s level of distress. rather than the extinction of all anxiety associated with past traumas and current fears for family. as a result of fleeing to Australia. it would not necessarily solve his anxieties about his family in Iraq... As exposure therapy comprises exposure to memories of past traumatic events. will elicit high levels of distress. especially in the early stages. exacerbating fears that Hakim already harbored. As Hakim was not at immediate risk of being sent back to Iraq. following the completion of the exposure component of treatment. where he believed he would once again be incarcerated and tortured. 2004). While he initially reported an increase in thoughts about possible future traumatic events in Iraq. suggest that trauma-focused treatments may be useful in reducing symptoms of PTSD in these groups when they emphasize the role of mastery. Prior to the commencement of exposure therapy.182 Anxiety Disorders about the possibility of being returned to his country of origin. By emphasizing mastery of the recall of these memories. and informed him that he could expect to experience increased . His instinct was then to reinstate avoidance behaviors. One common mistake in clinical practice is to discontinue this treatment component at this point for fear that it is worsening the individual’s symptoms and resulting in “retraumatization. & Livanou. he experienced more intrusive memories and nightmares than he had previously. 2010). 2004. therapy was able to repeatedly point Hakim in the direction of having a degree of control over his state. and that although it would ease the distress of the trauma memories. Neuner et al.” As exposure therapy involves the suspension of many avoidance behaviors and deliberately entertaining the memories. Neuner et al. Hakim reported that. as well as case studies with asylum seekers (Basoglu. following the fi rst two sessions of imaginal exposure therapy. the therapist worked with Hakim to ensure that he fully understood the rationale underlying exposure therapy. it is to be expected that there will be an initial increase in PTSD symptoms following early exposure-based sessions. Baarnhielm. particularly with survivors of extreme violence. 2008. Common Mistakes What common “mistakes” did you work to avoid in treatment? It is important to note that the implementation of trauma-focused therapy. This likelihood underscores the need for the therapist to explain clearly to Hakim the rationale for using exposure. Hakim and the therapist agreed that a gradual reduction of session frequency would be the most beneficial way to end treatment. Patients can quickly learn that by raising other matters. particularly due to the strong therapeutic alliance that had been developed across the course of treatment. Prior to the tapering off of sessions. which can then become an avoidant technique. therapy attention can be diverted away from trauma-related strategies. which rendered the therapeutic relationship even more important as the therapist represented one of the few people with whom he felt comfortable discussing his feelings and experiences. while allowing Hakim to “check in” regularly with the therapist regarding any difficulties that he was experiencing with the therapeutic skills. and strategies for managing symptoms learned in treatment were reiterated. relapse prevention was also addressed with Hakim. In the interest of attending to the patient’s immediate needs. the therapist can both recognize ongoing issues and give adequate therapy time to trauma-focused strategies. Another common error in working with traumatized patients who are persistently enduring weekly crises and ongoing stressors is to be diverted from the core elements of CBT by needing to attend to these other matters. Hakim was able to continue with the treatment. By explaining to the patient the benefits of dealing with the core problem of PTSD. it was decided that time be allocated to discussing these current matters—but this was firmly limited in order to ensure that exposure and cognitive restructuring were achieved. and had great difficulty trusting people in positions of authority. and his distress and reexperiencing symptoms reduced over time. it is tempting for clinicians to focus on these matters. The trajectory of recovery was discussed (including the difference between a short-term lapse and a long-term relapse). Hakim was relatively socially isolated in Australia. Following early exposure sessions. concerns about events that were occurring to him or those he knew back in Iraq. Relapse Prevention and Termination How did you deal with relapse prevention and termination? Termination was a salient consideration in Hakim’s case. Together. .Treatment of Complex PTSD: The Case of a Torture Survivor 183 intrusive symptoms following initial exposure therapy sessions and that these would begin to decrease fairly quickly. Nearly each week Hakim would arrive at the session with marked. early warning signs of increased symptom intensity were jointly developed. the therapist addressed the issue of termination. and usually justified. the therapist reiterated the rationale for treatment and reminded Hakim that this was an expected (and important) part of the healing process. but this can disrupt attention to core strategies that are needed to initiate recovery from the effects of the trauma. When it became apparent that Hakim’s PTSD symptoms were improving considerably. On the premise that Hakim will be better placed to manage these ongoing stressors if his anxiety and depression secondary to the PTSD are alleviated. Cloitre et al. Motivational interviewing and cognitive restructuring were also undertaken in the context of his religious beliefs. Neuner. Cultural Factors What cultural factors did you consider and what difference did these make? Cultural and contextual factors are of primary importance when implementing interventions with survivors of torture. cognitive restructuring. 2009).184 Anxiety Disorders The Art of the Case What is the *art* of the case and how was it (if at all) informed by scientific evidence? The present case highlights the lack of research evidence that is available to guide the treatment of torture survivors. 2010. we drew on the major change mechanisms identified in treatments that work. behavioral activation. emotion regulation... Mortensen. Nickerson. and evidence derived predominantly from work with survivors of childhood abuse that emotion-regulation skills training may significantly add to the tolerability of these interventions (Cloitre et al. the circumstances in which torture occurs. and enhancing mastery were all core factors that needed to be enhanced if Hakim was to address his traumatic past. Carlsson. Buckley. there have been few treatment trials specifically evaluating the efficacy of treatments for torture survivors (Bichescu.. often in circumstances that include mass violence and the collapse of institutions that provide an organizing framework for society. 2005. & Elbert. & Kastrup. Schweitzer. Schauer. Tol et al. 2010. 2011. importantly. 2004. Thus.. 2002. & Rossi. et al. The treatment implemented in the present study was based on preliminary research evidence suggesting that trauma-focused therapy is effective with survivors of refugee trauma. Palic & Elklit. The roles of extinction learning. The manner in which these were delivered required flexibility and therapeutic creativity. it is of key importance that the therapist has some . 2010). While there has been a recent increase in studies examining the efficacy and effectiveness of psychological treatment for refugees and survivors of mass violence in general (for reviews. such as framing his attempts at tolerating distress and adhering to treatment as a sign of him honoring Allah. The purpose of torture is often to instill terror in the community at large. However. we used a time line that allowed Hakim to contextualize both his traumatic experiences and positive experiences in his life overall. see Nicholl & Thompson. 2002). Although some commentators argue that exposure-based therapies are not appropriate for this form of trauma survivor. in addition to extracting a confession or serving as punishment. For example. including the factors underlying political or religious violence are specific to individual settings. this also emphasized to him that he had mastered much adversity and was in a position where he could influence his future in some way. Halvorsen & Stenmark. 2007. Torture occurs in a specific context. and considered how they could be best applied to assist Hakim. Psychological Medicine.). C. 79(2). Ekblad. (2004). and thus his behavior under torture was a great source of shame and guilt to him. & Mineka. S. Journal of Anxiety Disorders. Hakim’s humiliation at the sexual torture he had endured was very salient. (1989).. Livanou. inhuman. (1997). and degrading treatments: Implications for an evidence-based defi nition of torture. M. S. S. (2009). Torture and its consequences: Current treatment approaches. Such cultural factors are also likely to influence the extent to which the client feels he or she is able to discuss such events and feelings with the therapist.. Psychological preparedness for trauma as a protective factor in survivors of torture. Basoglu. 27(6). Conclusion The case of Hakim highlights that torture survivors. M.. Social Science and Medicine. Cambridge: Cambridge University Press. 357–369. In M. in Hakim’s culture. can benefit from evidence-based therapy. M. M. like other victims of prolonged trauma. M. Basoglu (Ed.. Basoglu. Basoglu. 64(3). Further.. M. as he felt that he had not acted as a man should. 715–727. S. knowledge of the client’s culture prior to the commencement of therapy is highly advantageous for managing such issues during treatment.. American Journal of Orthopsychiatry. . M. and degrading treatment: Is the distinction real or apparent? Archives of General Psychiatry. 135–145. inhuman. & Crnobaric. Torture vs other cruel. Cognitive-behavioral treatment of tortured asylum seekers: A case study. The role of uncontrollable and unpredictable stress in post-traumatic stress responses in torture survivors. 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Australian and New Zealand Journal of Psychiatry.. post-migration living difficulties and social support as predictors of psychosocial adjustment in resettled Sudanese refugees. D. 537–549. Besic. 40. D. Komproe. Silove. D. 1–9. & Griffi n. R... 211–232.. Sharma. American Journal of Orthopsychiatry. S. (1991).. Journal of Experimental Psychology. Silove. Seligman. The psychological treatment of refugees and asylum seekers: What does the literature tell us? Mots Pluriels. & Gorst-Unsworth. M. Schweitzer. Schweitzer. British Journal of Psychiatry. R. (2009). 76(1). H. International Journal of Social Psychiatry. J. J. Resick. 55(1). Seligman.Treatment of Complex PTSD: The Case of a Torture Survivor 189 Schulz . D.. J. International Review of Psychiatry. Humiliation: The lasting effect of torture. (1999). 2. 321–329. Bryant.. The effectiveness of cognitive processing therapy for PTSD with refugees in a community setting. T. International Journal of Social Psychiatry. Frommer. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass confl ict and displacement: A systematic review and meta-analysis. 157.. S. Trauma.. A family beliefs framework for socially and culturally specific preventive interventions with refugee youths and families. W.. F. Thapa.. N. Vorbr üggen.. 302(5).. Cognitive and Behavioral Practice. (2006).. anxiety. Klebic. C.. Feetham. 322–331. Marnane. The psychosocial effects of torture. Loneragan. Turner.. 74(1). Military Medicine. Z. Tol. & Rossi.. (2007)... Kulauzovic. San Francisco: Freeman. R. Knafl.. The Harvard trauma questionnaire: Adapting a cross-cultural instrument for measuring torture. F. (2006). M. trauma and posttraumatic stress disorder in Iraqi refugees. K.. Bowles. P. 12. C. 53(5). P.. Silove. (2002). Melville. 447–463. M. & van Ommeren. Buckley. 25(4). Steel. V. Silove. 1–9. Y. S.. (2007). A. Brief multi-disciplinary treatment for torture survivors in Nepal: A naturalistic comparative study. 2(6). Shoeb. Steel. McGorry.. T.. P. Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers. (1996). & Maier. M. C. E. These circumstances would be highly stressful for any mammal. Rothbaum Richard Bryant and Angela Nickerson describe the case of Hakim. They also assessed for depression. anger. probable fears about their safety. getting him more physically and socially active and engaged. They assessed for paranoid delusions of reference and determined that the patient was not psychotic but was reacting to past instances of actual government monitoring. Hakim’s PTSD is likely exacerbated by his psychosocial circumstances. alcohol abuse (although this was never formally diagnosed in the case presentation). Hembree. They assigned in vivo exposures that did double duty as good exposures to allow anxiety to decrease and to disconfi rm erroneous probabilities of danger. It is very commendable . which was important. They assessed for PTSD as a primary presenting complaint both due to his history and the referral question. they used a case conceptualization approach: forming hypotheses about the nature of his difficulties and designing treatment to address these difficulties. This is an excellent example of using cognitive as well as exposure principles in the treatment of PTSD (Foa. using a large. but that also served as behavioral activation exercises. Their approach to treating Hakim and describing that treatment are theory-driven and empirically driven. & Rothbaum. punctuated by multiple injustices and misfortunes. including his separation from his wife and four children. even in the therapy room setting. They were sensitive to cultural factors. 2007). This is a heart-wrenching case. restrictions of visa status and resulting dependence on his cousin. and stressful living conditions with limited resources. and familial stressors. social isolation. a 36-yearold Iraqi Shi’ite Muslim who fled Iraq in 2000 and was granted refugee status in Australia in 2001. & Rothbaum. such as ensuring that the assessment was undertaken in a manner that avoided an interrogatory style of questioning. 2007). The therapist was able to point out that Hakim’s behavior served as a self-fulfi lling prophecy to help educate him that he needed to change his behavior. physical pain caused by injuries sustained during the torture.COMMENTARY Barbara O. especially by what is known about torture survivors. depression. as his depression and inactivity and hopelessness seemed to account for significant dysfunction and often co-occur with PTSD (Foa. bright room with windows to differentiate it from his cell. They describe multiple presenting problems including PTSD. Hembree. Within this context. Although it may be a tautology because the patient did not improve as much in his cognitions (guilt. merely by doing that repeatedly. PE) really have more in common than they have differences.Treatment of Complex PTSD: The Case of a Torture Survivor 191 that the therapist operationalized safety behaviors and instructed the patient in in vivo exposures. and likely feels inadequate that he cannot protect them. Eye movement desensitization and reprocessing (EMDR) emphasizes the saccadic eye movements during exposure (Shapiro.. and all involve “going there” to some extent—visiting the aspects of the trauma to evaluate these fears and beliefs. as he was abducted and tortured because of his religious beliefs. 1993). they need to “go there”—to be able to expose themselves in detail to what happened. “God spared me for a reason so it is up to me to discover what it is. Exposure therapies emphasize the importance of exposure.. Sometimes patients are angry with God for what happened. they just emphasize different aspects or mechanisms. especially without safety behaviors. sometimes they lose faith in God (e. However.. Sometimes.. the event strengthens faith (e. it was very fruitful. Basoglu et al. The authors could . “How could God have allowed this to happen?”). Cognitive processing therapy (CPT) emphasizes cognitive restructuring and “stuck points” (Resick & Schnicke. CPT. I have become convinced lately that the majority of the empirically supported cognitive behavioral treatments for PTSD (e. The authors describe a very nice intervention. His self-statements sound reminiscent of patients who have experienced what have been called “moral injuries. I have found that religion often plays a role in the maintenance of PTSD symptoms. they were directly relevant. 1995).g.g. Often. citing that they knew they were in danger under that regime and with their activities and that the danger would cease when that regime lost power. Others have found that victims of political torture have displayed less PTSD than would be expected (Basoglu et al. he was tortured for his religious beliefs. essentially setting up a behavioral experiment when patients are too fearful about their reactions to exposure.” and therefore these would need to be addressed. But I have often seen therapists shy away from religious beliefs due to their discomfort. By avoiding thinking about what happened.. In this case. I think it is imperative for trauma survivors to be able to think about their experience. In general.”). All of these approaches aim to have patients change their dysfunctional beliefs about the traumatic event and modify their behavior. the error of their beliefs becomes apparent. they cannot hope to modify these beliefs. I hypothesize that to be able to modify these thoughts. 1997. 1994).g. and their future differently than before treatment. It is also commendable that the therapist used the patient’s religious beliefs in therapy. it seems that maybe some other cognitive behavioral techniques also could have been applied. but I think modern exposure therapists and theorists place a huge emphasis on the “processing” that takes place following the imaginal exposure in which the patient’s beliefs are often challenged and certain realizations are made explicit. their behavior. blame). although it was not necessary with this case. In this case. in Hakim’s case. He also continues to fear for his wife and children. the behavioral aspects of this case were exceptionally well conceptualized and administered. as his difficulties were reframed as serving Allah. he cannot tolerate it. especially when using exposure therapy for PTSD patients: (1) The patient gets distressed. that they can trust the therapist. and they terminate exposure. the therapist will not collude in their avoidance. the therapist has faith in their ability to handle it. and that if he becomes too distressed. torture is designed to elicit information and these emotional responses.192 Anxiety Disorders have used any of these empirically supported treatments for Hakim but made their decisions based on his case conceptualization. at least there is still hope. resulting in more physical impairment.” patients learn that they can tolerate the distress. and then. (4) The therapist attends to “red herrings” presented at the beginning of the session and doesn’t get the agenda covered. and it is my job to keep us focused on the goal. there would be no hope of helping them. does he need to decide to forgive himself for what he deems were weaknesses under torture? There are several “rookie mistakes” that I see in less experienced therapists. and that would be a better exposure. (3) The therapist misses the core fear. if they had missed that. But I also think that Hakim needs to fi nd some acceptance of himself for his actions. I will conceptualize it for patients that if I think their PTSD is primary. listening to music would mean that they could not monitor the environment. The fact that he did not improve as much as hoped on some dimensions makes me wonder if he still withheld some important information. I will acknowledge the issue . For some. the therapist gets distressed. the best thing I can do for them is deliver the treatment that I think will have the most impact for them. it lessens as exposure continues. for example. Hakim did in fact disclose the names of religious friends and colleagues to the torturers. What this teaches the patient is that he was right to avoid the memory and all reminders. they would have missed an important component of his treatment. For example. It also may be useful to continue the questioning to ask him what he thought would have happened had he not disclosed names. more Socratic questioning may be useful. using exposure and cognitive techniques to help the patient understand the context and the realities of the situation. that is. but for others. It also might be useful to ask the patient how he needs to think about it differently. whereas if he were more physically disabled or murdered. If he feels helpless now in regard to taking care of his family. and possibly even his death. I agree with the approach of the authors. Patients with PTSD often have chaotic lives and can be upset. nothing terrible happens. some of our veterans from the wars in Iraq and Afghanistan with PTSD often ride public transportation for an exposure. By “holding their feet to the fi re. In the case of Hakim. listing all those responsible for his situation and ascribing responsibility to them all. It is important to figure out the “perfect” exposure and what exactly you are exposing the patient to. As the authors mention. (2) The therapist fails to identify safety behaviors during in vivo exposures. In this case. I fi nd it is often useful to help distribute responsibility for the outcomes. It may be that the torture would have escalated. and for this. it seems that his reaction to some of the torture was the crux of the issue. listening to music might be a distraction from the exposure. When patients feel particularly guilty and responsible for the outcomes of the traumatic event(s). in which case the teaching of distress tolerance skills has been empirically supported (Linehan.Treatment of Complex PTSD: The Case of a Torture Survivor 193 and its impact. Treatment for PTSD related to childhood abuse: A . and the authors have presented a case in which it was.. yet it became simpler by taking it apart. Sarimurat. K. Drs. . (1994).g. K. . Paker. I will address these issues at the end of the session. Ozmen. starting with a skills-building phase before exposure techniques were implicated. C. as PTSD is not a simple disorder in and of itself. Psychological preparedness for trauma as a protective factor in survivors of torture. 1993).... I am not exactly sure what distinguishes this case as “complex” PTSD.. M. P. Cloitre.. and it is not always clear what makes a case complex.. Only PTSD and depression seem to have been formally diagnosed. It is impressive that the patient had a choice of demographic and social characteristics of his interpreter. Psychological Medicine. Mineka. 151(1). It appeared to be a complicated case. M. It was clearly an enriched environment in which he had access to empirically supported (or at least empirically informed for torture survivors) treatment and presumably for free. M.. including the Australian society. M.. S. & Gok. no details were provided on whether the imaginal exposures were tape-recorded and the patient was instructed to listen to them as homework. Linehan. Other more minor comments include the points that no pre/post assessment results were reported. His good fortune and the beneficence of others. It is heartening that the authors did not fall prey to any of these common mistakes. The authors do not mention if the patient likely met criteria for borderline personality disorder.. no follow-up was reported. it is not clear if this was necessary or served to delay his treatment and possibly made his treatment more difficult. O. M. Marks. yet fi rm. Petkova. Stovall-McClough. . L. and with an interpreter who was of the same culture and religion. Incesu. Livanou. E. Aker. S. M.. 1993). (1997).. As a critique. as it was conducted with an interpreter. C. Paker. N.. However. . References Basoglu.. we clinical researchers are criticized that such an approach is not possible. E. Psychological effects of torture: A comparison of tortured with nontortured political activists in Turkey. They hardly mention the complication that an interpreter causes and describe an ecologically valid and culturally sensitive approach. S. Zorbas. Bryant and Nickerson present a lovely case steeped in both empirically supported treatment and individual case conceptualization. 2010). (2010). That termed is used often lately (e. She demonstrated deliberate human kindness and caring. sets up a stark contrast with the torturers. Jackson. 76–81.. In summary. and by a person in a position of authority. American Journal of Psychiatry. and if there is time. Nooner. Oftentimes.. C. Cherry. The therapist must be sensitive. the authors emphasize Hakim’s inability to tolerate distress and use this as justification for providing him with a stepped approach (à la Cloitre et al.. 27(6). I. . 1421–1433.. T. The therapist was fi rm in not allowing the patient to avoid and maintain his dysfunctional patterns. both in his new culture. . Basoglu.. Paker. . London: Sage Publications. E.2010..09081247 [pii] 10. (2007). . protocols and procedures. 167(8). Interpersonal Violence: The Practice Series. New York: Guilford Press. M. Resick. & Schnicke. doi: appi. P. therapist guide. New York: Guilford.194 Anxiety Disorders randomized controlled trial.09081247 Foa. Cognitive processing therapy for rape victims: A treatment manual. M. A. (1993). New York: Oxford University Press. B. M.2010. F. Hembree. (1993). American Journal of Psychiatry. Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences.ajp. O. E. Linehan. Shapiro. B. (1995). Cognitive-behavioral treatment of borderline personality disorder.ajp. 915–924. & Rothbaum.1176/appi. Eye movement desensitization and reprocessing: Basic principles. 2000). using methods designed to infl ict maximum psychological harm (McIvor & Turner. which lent further cognitive evidence in support of these beliefs. In other cases of torture and refugee trauma. While we are unable to comment on all of these important points due to space limitations. manifesting in negative behaviors such as social withdrawal and alcohol abuse. Dr. for example fundamental challenges to beliefs that assist the individual to make sense of the world. and has great potential to shatter fundamental beliefs of victims about themselves. 1996). Ehlers & Clark. the moral injury concept provides a useful framework within which to conceptualize the effects of gross human rights violations on Hakim’s worldview.. who evidenced generally negative beliefs and expectations about the surrounding world and others (“people are generally bad and can’t be trusted. posttraumatic changes to one’s worldview. Dr. and humanity. The concept of “moral injury.” “there is no justice in the world”). and clinical issues. Silove. Furthermore. 1980) and human benevolence (Janoff-Bulman. highlighting a variety of conceptual.” recently employed to explain the impact of war experiences that transgress combatants’ deeply held moral beliefs.. the world. empirical. Rothbaum commented that the self-statements used by Hakim may be seen as sequelae of “moral injuries”. This can be seen in the case of Hakim. 2009). Rothbaum also made the excellent suggestion that techniques focusing on the distribution of responsibility may have been useful with Hakim. and values (Litz et al. The potential for traumatic events to dramatically alter beliefs and cognitions is well-documented through cognitive models of PTSD (e. Torture is an experience characterized by human degradation and violation. such as justice (Lerner. The cognitive effects of such experiences may manifest in (often realistically) negative assumptions and expectations about humankind and the world in general. we have found that patients often benefit . expectations. we will address some of the most pertinent below. 1995. may be extended to describe the lasting psychosocial impact of being victim of or bearing witness to acts that transgress deeply held moral beliefs and expectations. indeed.RESPONSE Richard A. 1992). may substantially influence the way in which the individual navigates the external world and relates to others.g. Bryant and Angela Nickerson Barbara Rothbaum’s commentary on Hakim’s treatment provides a valuable perspective on this case. which may have prevented Hakim from “going there” and hampered the effectiveness of the treatment strategies. thoughts. even one with emotion dysregulation problems. Further. However. Rothbaum also raises the issue of complex PTSD. Although we do not have the benefit of evidence concerning the defi ning clinical features of torture-related PTSD and its treatment.196 Anxiety Disorders from discussions concerning trauma-related responsibility and control. we were very aware of other torture survivors who have not responded positively to their initial exposure session and have balked at proceeding. The problem at the outset of therapy is that one never knows how a person will respond to treatment. this process may have helped Hakim to recognize that these outcomes represent some of the core goals of torture. Perhaps we should have commenced exposure sooner. as soon as they have mastered their first experience of it. This may indeed be the case. which is the defi ning feature of complex PTSD (Bryant. The most important point is that it is critical to . rendered the therapeutic relationship of key importance in this case. Dr. It is common for PTSD patients to express concern about exposure therapy. Although the relationship was an important aspect of treatment (and likely therapeutic in itself).. and guilt. However. it is appealing to reduce the likelihood that torture survivors will terminate treatment prematurely because they cannot tolerate the distress associated with their trauma memories. there is enormous relief and significant motivation to proceed. Rothbaum posited that Hakim may have been withholding certain information throughout the course of therapy. in the current case. Rothbaum makes a cogent point in suggesting that we may have delayed the most effective component of treatment. 2010). There are solid justifications for both approaches. Dr. Dr. to explore responsibility regarding the consequences of torture. As augmented exposure therapy that prepares the patient with emotion-regulation skills has been shown to be effective. This fi rst session of exposure is often a powerful behavioral experiment that can quickly teach patients. that they can master the memories. combined with his suspicion of others. 2010). which is designed to infl ict psychological damage. humiliation. Many torture survivors lack emotionregulation skills. it seems a logical approach (Cloitre et al. and feelings. As Dr. Hakim’s shame and guilt. This may then have provided further motivation for Hakim to alleviate feelings such as shame. Assisting Hakim to realize that the torturers were responsible for these outcomes may have alleviated some of the guilt he felt. it may have been constructive. In the case of Hakim. We should also add that we have proceeded with exposure with such patients and they have enjoyed rapid symptom relief. to prevent the torturers from succeeding in their purpose. Rothbaum suggested. precluding the full processing of the events to which he had been exposed. it is certainly possible that there were elements of his experiences that Hakim was unwilling to disclose. This knowledge provides disconfirming information of many of patients’ fears and doubts about recovery. including Hakim’s actions. and whether we were correct in preparing him to tolerate the distress that was expected with exposure or whether we should have “jumped in” and commenced straight away. but even in hindsight it is sometimes difficult to know. (2010). D.. Jackson. W. P.. Clinical Psychology Review. M. 879–881. (2010). Nooner.. T. Janoff-Bulman. Nash. K. K.Treatment of Complex PTSD: The Case of a Torture Survivor 197 engage these trauma memories as soon as one can because this will be important for facilitating treatment gains. (1980). Shattered assumptions: Towards a new psychology of trauma. E. D. Moral injury and mora repair in war veterans: A preliminary model and intervention strategy.. 29. American Journal of Psychiatry. Treatment for PTSD related to childhood abuse: A randomized controlled trial. 167(8). C. S. Delaney. American Journal of Psychiatry. (2000). Assessment and treatment approaches for survivors of torture.. The complexity of complex PTSD. Behaviour Research and Therapy. 695–706. (1992). A cognitive model of posttraumatic stress disorder. . British Journal of Psychiatry. S. (1995). R. J... Silove. & Clark. C.. McIvor. The belief in a just world. (1996).. N. New York: Free Press. Silva. & Turner. Lerner.. New York: Plenum. et al. Cloitre. 2. A. Lebowitz. A. 915–924. International Review of Psychiatry... Stovall-McClough. Zorbas. L. et al.. References Bryant. Stein. B. C. R. 705–711. 167(8). (2009). M. Torture and refugee trauma: Implications for nosology and treatment of posttraumatic syndromes.. L. Litz . P. M. 319–345. W. Cherry. J. R. Ehlers. 166. 211–232. 38(4). 2008). Heimberg. most people with social anxiety disorder do not seek treatment unless they have developed another disorder (Schneier et al. approximately 63–90% of people with social anxiety disorder meet criteria for at least one other comorbid diagnosis (Ruscio. 2005). & Kessler. Wittchen.. Social anxiety has an early age of onset (Schneier. Hope Social anxiety disorder. Johnson. Chiu. Epidemiological Considerations Despite the high prevalence rate and life impairments. 2000). McGonagle. and specific phobia. A twelve-month prevalence rate of 6. The most common comorbid diagnoses among individuals with social anxiety disorder in community samples are other anxiety disorders. Recent prevalence rates suggest that 12. Brown. 2010). alcohol abuse. and social anxiety disorder appears to have an earlier age of onset relative to the comorbid conditions (Magee.{8} Treatment of Social Anxiety Disorder: A Case Complicated by Panic Disorder Milena Stoyanova and Debra A. Demler. 1992). 1997). the excessive fear of being humiliated and embarrassed in social situations (American Psychiatric Association. Chiu.. Hornig. 1996). & Weissman.1% of people are affected by social anxiety disorder at some point in their lives (Kessler et al. & Walters. Brown. is the fourth most common psychiatric disorder after major depressive disorder. Liebowitz. & Holle. Eaton. Stein. 2005). Sareen. with reliable diagnoses being reported as early as 6 years of age (Bögels et al. 1994) and rate their quality of life significantly lower than individuals without social anxiety (Safren. & Kessler. In fact. 1992).8% demonstrates that social anxiety disorder is the second most prevalent disorder after specific phobia (Kessler.. Those affected by social anxiety disorder report moderate impairment in personal and professional life due to their fears of being negatively evaluated by others (Schneier et al. followed by mood disorders .. a more complex symptom presentation may pose challenges for the clinician. While the effectiveness of CBT interventions for the treatment of social anxiety has been well established. 1996. Abbott. Heimberg. Heimberg et al. 2009). & Mindlin. & Glass. with treatment gains being maintained at three-month follow-up (Ledley et al. Spaulding.52).and post-treatment... 1997). 1990. 2000.. While the presence of a comorbid mood disorder has been associated with greater interference and symptom presentation at pre. Effect sizes for within-session change in the active treatment across 6 of 7 key measures were large (median Cohen’s d = 2. their symptoms have reduced to a subclinical level. & Neary. The Case of Andy Andy was a 38-year-old European American man who initially contacted a university training clinic for problems with anger. such as pounding heart. Schneier et al. However. Beidel. 1996). Mueller. 2006). & Turk.) Specifically. Hope. & Turk. 2002. & Jacob. typically 75–80% of participants receiving the cognitive behavioral treatment are classified as “responders. Juster. Juster. . Rapee. Furthermore. Heimberg.. the effectiveness of CBT in a group format for the treatment of social anxiety disorder has also been demonstrated in community clinics (McEvoy. The treatment gains were maintained at a five-year follow-up (Heimberg. 1992). Holt. including the name. have been modified in order to protect the client’s anonymity. Tran.” meaning that they have made clinically significant change. In a different study. The more recently developed individual version of the treatment used with the present case (Hope. Turner. Less is known about how a comorbid anxiety disorder impacts treatment response. Andy also described experiencing physical symptoms. 1998) and pill placebo (Heimberg et al. Wolff. Across studies. 1998). Written consent was obtained from the client for inclusion of his de-identified information in this chapter. Heimberg. the presence of depression resulted in lower treatment response (Chambless. the rate of improvement did not differ based on presence or absence of comorbid condition (Erwin. 1992). Hope. to aid in resolving treatment challenges for social anxiety. in many cases.Treatment of Social Anxiety Disorder 199 and alcohol or substance use disorders (Magee et al. 2010a) was more efficacious than a wait-list control group. (Identifying details. The efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder has been well established. 2008. Specifically. cognitive behavioral group therapy (CBGT. Heimberg & Becker. he reported being easily angered by others and stated that his feelings of anger exacerbated when he was around large groups of people. guided by a case formulation approach. 2002) was more effective than an educational supportive treatment (Heimberg et al.. 2007) and private practice (Gaston. This chapter will illustrate the use of specific treatment strategies.. Ruscio et al. factors such as comorbid conditions that may complicate treatment have been less discussed in the literature. and. & Liebowitz. feelings of unreality. dating situations. Thus. going to restaurants. beginning within the previous year. shortness of breath.. whereas anger was the response elicited when a situation was perceived as threatening but unavoidable. He identified a number of social situations as anxietyprovoking. at the airport. Given Andy’s anxiety symptoms and concerns about being around people. Andy described experiencing unexpected panic attacks in various situations. In addition to social anxiety and panic disorder. going out with his friends. participating at meetings. 1994) was administered. when around people. Andy reported being extremely concerned about his panic attacks and worried about future ones. he was referred to the Anxiety Disorders Clinic for a more thorough evaluation of his anxiety presentation. Di Nardo & Barlow. Andy described anger problems as his primary reason for seeking therapy. it was not seen as the primary problem. He stated that he would avoid leaving his house. Assessment Strategy The initial assessment was completed over two sessions. as Andy’s outbursts and irritability resulted from his intense fears of embarrassing himself in front of others. Andy described an increase in arguments with his girlfriend. at the grocery store. Andy described depressive symptoms consistent with dysthymic disorder. or doing something uncontrolled. dying. Andy described experiencing four to five full panic attacks and 12 to 15 limited symptom attacks (1–2 symptoms only) in the previous month. described further below. Although anger was the initial complaint. and fears of fainting. stomach distress. He engaged in distracting activities if a panic felt imminent. 1985). or just being out in public. He described that the unexpected panic attacks had been more recent. such as parties. and being assertive.200 Anxiety Disorders sweating. He described other physical symptoms. speaking with unfamiliar people. when he noticed becoming more concerned about doing or saying something that might embarrass him in front of his peers. the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV. During the second meeting. As a result. the underlying concern was related to his social fears. and when home alone. such as sweating. He reported being concerned that others may think that he is a “loser” or a “fool” because of what he said or did and reported experiencing panic attacks while interacting with others. Andy was concerned about his physical symptoms and reported that he often worried that the palpitations and accelerated heart rate might be an early sign of heart problems. He described experiencing anxiety in social situations since he was a child and stated that the anxiety intensified when he was in high school. The ADIS-IV was completed to further assess his anxiety concerns and . Brown. During his initial visit. and hyperventilating. at restaurants. initiating and maintaining conversations. Aside from the expected panic attacks. such as while driving. which resulted in her moving out and ultimately prompted him to seek treatment. which has been reported in up to 84% of individuals with social anxiety disorder (Barlow et al. talking to authority figures. lightheadedness. This is a four-item measure assessing a respondent’s subjective improvement related to social situations since the beginning of therapy. 1996) prior to beginning treatment and at every other session. 1996. The measure. Miller. The ADIS-IV is a semi-structured clinician-administered interview that assesses for anxiety disorders. & Weems. scores of 4 to 15 suggest improvement in symptoms. using a scale that ranges from 0 (none) to 8 (very severe). A scale from 1 (not at all characteristic) to 5 (extremely characteristic) is used to rate each statement to yield a total score ranging from 12 to 60. Gursky. 1986) is a 16-item questionnaire that measures discomfort with anxiety relevant symptoms. In addition to providing a DSM-IV-TR (American Psychiatric Association. To monitor Andy’s progress. has demonstrated good test-retest reliability and strong internal consistency (Leary. 1992). including good test-retest reliability (Reiss. 2000) diagnostic impression. Scores range from 0 to 63. 1983). Peterson. using a scale from 1 (much less) to 4 (not different) to 7 (much more). 1969). & Juster. & McNally. mood disorders. Heimberg. The Anxiety Sensitivity Index (ASI. panic symptoms. The BDI-II is a 21-item self-report questionnaire designed to measure level of depressed mood over the past two weeks.. and somatoform disorders. Hayes. 2008) weekly. Hope et al. the original SASCI form was modified for this case to further assess subjective change related to panic symptoms that are unrelated to social situations (Panic Session Change Index. & Brown. a Fear and Avoidance Hierarchy. A total score is obtained by summing all items. The BFNE is a 12-item questionnaire that assesses for fear of negative evaluation. Sprinkle et al. 2001) and high internal consistency (Peterson & Reiss. Additionally. the Anxiety Sensitivity Index (ASI. a list of feared situations. with higher scores indicating more severe depressive symptoms. Reiss. with scores ranging from 4 to 28. Additionally. Reiss. 2002). substance use. A score of 16 indicates no change since starting treatment. The ADIS-IV was conducted at pre. Gursky. adapted from the original Fear of Negative Evaluation (FNE. Leary. and depressed mood. Silverman. a rating was provided for each situation to indicate level of anxiety .. After generating a list of 10 feared situations. Watson & Friend. 2006. PaSCI). and scores of 17 to 28 indicate deterioration. and it has demonstrated excellent internal consistency and test-retest reliability (Beck et al. where a score of 4 or above meets the clinical threshold for a DSM-IV diagnosis. ASI total scores range from 0 to 64.and post-treatment by a trained clinician who did not act as the therapist..Treatment of Social Anxiety Disorder 201 was also administered at post-treatment. Steer. more specifically assessing for beliefs about somatic or danger consequences of anxiety. Hope. The ASI has demonstrated excellent psychometric properties. and the Beck Depression Inventory II (BDI-II. 1986). was constructed (Barlow & Craske. To further assess Andy’s social anxiety. with higher scores indicating greater anxiety sensitivity. 2010a). the interviewer gives a Clinician Severity Rating (CSR) for each diagnosis to illustrate the degree of impairment and distress resulting from each disorder. starting with session 8. The same scoring is applied as the SASCI. Peterson. he completed the Social Anxiety Session Change Index (SASCI. he completed the Brief Fear of Negative Evaluation (BFNE. 1983). Beck. & McNally. Case Formulation In general. but see also Sanderson. He began to associate bodily symptoms such as lightheadedness. which ultimately affected his relationship with his girlfriend. Additionally. a diagnosis of dysthymic disorder with a CSR of 4 was assigned. dizziness. and chest pain with fainting. & Barlow. The avoidance and distracting behaviors further contributed to his belief that the . Anxiety and avoidance ratings were collected during the tenth and last treatment session. Although they had been dating for several years. having a heart attack. Andy’s score of 37 on the ASI also confi rmed his apprehension about panic-like symptoms. indicating that his symptoms related to social interactions and the experiencing of unexpected panic attacks were both markedly disturbing and disabling. no avoidance) to 8 (extreme anxiety. His initial BFNE score of 46 indicated that he experienced a moderately elevated fear of negative evaluation. which was consistent with his reported fear of experiencing physical sensations. Soon after she moved in with him. Andy tried to manage his worries about the physical implications of panic attacks by avoiding various activities that induced sensations similar to panic. The frequent avoidance of social interactions maintained Andy’s belief that he would not be able to initiate and sustain friendships because of how he acted around people. Andy became increasingly concerned about other students’ opinions of him and often avoided speaking in class or interacting with others between class periods. The presence of clinically significant uncued panics is less common. Lehman. Results from the ADIS-IV indicate that Andy was assigned co-principal (equally severe) diagnoses of social anxiety disorder (generalized) and panic disorder with agoraphobia with a CSR of 6. Rapee. He has been nervous in social settings since he was a child. and doing something uncontrolled. they began having more frequent arguments related to their social life and Andy’s avoidance of social events. detached feelings. 1990). Grisham. Andy also became apprehensive about physical sensations in his body. 1985). Andy never told his girlfriend about the anxiety because he was worried that she might think badly of him and leave him. using a scale ranging from 0 (no anxiety. cued panics in social situations are a common presentation of social anxiety disorder (Barlow et al.202 Anxiety Disorders and degree of avoidance. complete avoidance). which was consistent with his self-report but somewhat lower than expected. Andy demonstrated hypersensitive reactions to external and internal experiences. but his symptoms worsened in high school when he was expected to participate in class discussions and give formal presentations in front of his peers. He often avoided social gatherings due to anxiety. 2001. which was consistent with his BDI-II score of 25. Campbell. & Mancill. The stress of the relationship appeared to have exacerbated his anxiety.. leading to further arguments with his girlfriend. As noted above. DiNardo. While his fear of negative evaluation intensified due to their frequent arguments. occurring in only 3% of individuals with social anxiety disorder in one recent study (Brown. Another goal during the initial sessions was to help Andy make an informed decision about treatment by discussing his initial reason for seeking help (anger problems) and results from the subsequent ADIS-IV interview. Allen. However. Heimberg. he had difficulty identifying whether the threat was social evaluation or the physical sensations. the next step was to determine which anxiety disorder to address in treatment fi rst. Andy’s symptoms worsened after his girlfriend decided to move out (a few months before he initiated treatment). As we discussed the history of his symptom presentation and examined the chain of events leading up to specific times when he felt angry. and exposure) were tailored to specific symptoms as outlined in Managing Social Anxiety: A Cognitive Behavioral Therapy Approach (Hope. A functional analysis was used to determine the relationship between his anxiety and recent anger difficulties. he attributed the separation to his anxiety. Intervention Model and Course of Treatment Treatment consisted of 29 sessions over the course of 12 months and utilized cognitive behavioral techniques specific to social anxiety and panic symptoms. Flückiger. it became clear to both Andy and the therapist that Andy would get angry when he was unable to leave a social event or felt pressured by his girlfriend to attend a social gathering. 2004. Horvath. Given the complexity of the case. Barlow. Once it was agreed that the anxiety was triggering his irritability (e. & Turk. 2003).. & Choate. both of which are associated with positive treatment outcomes (Frank & Frank 1993. and avoidance (Barlow. the first three sessions were spent on developing a shared rationale for treatment and agreement on the tasks and goals of therapy.g. Barlow & Craske. The worsening of his symptoms prompted him to ultimately seek treatment. cognitive restructuring. Craske. which revealed significant anxiety difficulties. insisting on leaving social events. 1999. Finally. Since most of his panic attacks occurred in social settings. anticipatory anxiety. and he reported having more frequent panic attacks.Treatment of Social Anxiety Disorder 203 sensations were dangerous and harmful to his body. & Symonds. 2002. leaving a restaurant after noticing physical sensations). the therapist focused on identifying which symptoms were more distressing to Andy on a daily basis. which further reinforced his view of inadequacy and intensified his fears of negative evaluation. the general principles of CBT (psychoeducation. Although they were still romantically involved at the beginning of treatment. 2010a) and Mastery of Your Anxiety and Panic (MAP-4. Del Re. The therapist and client used self-monitoring data to examine several examples of recent situations related to social anxiety and panic disorder to explore specific fears. consistent with the guidelines outlined by the American Psychological Association (APA Presidential Taskforce on . Andy displayed some difficulties differentiating between panic and social anxiety. he began to isolate himself from close friends and family and frequently experienced days when he was depressed. 2006) treatment protocols. As the anxiety disorders share common elements such as fear/panic. 2011). Furthermore. rather than trying to identify which treatment to do fi rst. emphasizing the importance of monitoring to not only understand his experiences but also to help monitor treatment progress. Sessions 4 through 7 focused on psychoeducation about the nature and treatment of anxiety disorders to lay the groundwork for the overall treatment. 2006) emphasizing the importance of including client’s preferences in treatment planning. While Andy’s ultimate goal for treatment was to reduce his social anxiety. for template) in session based on a recent panic attack in which he described the triggers. Though Andy stated that he had completed his homework after it was introduced. worry about panic attacks. This was consistent with the overall treatment plan. Strategies for Handling Homework Noncompliance The therapist used the procedures from the treatment to address the problem of homework noncompliance. Given that Andy experienced both anxiety related to social situations and unexpected panic attacks. he was to continue monitoring and to bring forms for both weeks to the following session. at the next session he indicated that he had forgotten to bring the paperwork. rated maximum fear using a 0–10 scale. the therapist decided to explore reasons underlying the homework noncompliance. A second monitoring form was introduced to allow Andy to track his anxiety about social interactions. he fi rst wanted to focus on panic symptoms and the associated worry due to the discomfort they produced. while initially focusing on reducing the frequency of and worry associated with panic attacks. The therapist and client discussed his anxiety and panic attacks without having his monitoring forms present. since Andy would fi rst need to learn how to manage his panic attacks in social and nonsocial situations before we could introduce treatment for his social evaluative fears. 2006. Potential barriers were explored. Education about the three components of anxiety— physical sensations. Using the three components system of anxiety. and depressed mood. thoughts. and the difference between subjective and objective monitoring was described.204 Anxiety Disorders Evidence-Based Practice. and during this discussion Andy revealed that the reason for not having the monitoring form was because of heightened anxiety. First. and examples from both social and panic-related situations were discussed. Thus. whether the attack was expected or unexpected. Andy practiced completing a Panic Attack Record form (see Barlow & Craske. checked off symptoms that he experienced. and behaviors —was presented. he described his thoughts (“I will get it wrong and my therapist will think badly of me” and “My writing is bad and my therapist . When he again arrived without the paperwork. therapist and client decided to do a hybrid of both social anxiety and panic disorder treatment. and documented thoughts and behaviors. it was important to teach him how to distinguish between a panic attack (a sudden rush of intense fear and discomfort) and anxiety (slow building worry or anticipation of a future event). the therapist returned to the homework rationale. Self-monitoring of symptoms was introduced. Continuing the Course of Treatment After addressing the homework problems. and (3) myths and mistaken beliefs about panic symptoms. for details) was introduced as a coping skill that teaches clients how to breathe through their diaphragm rather than chest muscle. Given that overbreathing appeared to contribute to his panic attacks. The main concepts conveyed were (1) a biopsychosocial model of the etiology of anxiety (focusing on biological. 2006. he recalled several specific incidents in high school (e. At the end of the educational component. A discussion about the purpose of this skill followed so that the client learned to use it to face social situations that are anxiety-provoking (e. being criticized for his spelling and other students laughing while he read in class) that contributed to the expression of his social anxiety. breathing retraining.. his anger). The diaphragmatic breathing was formally practiced in session. The fight-or-flight system was discussed in more detail to illustrate the protective function of panic. and stressful life experiences as they affect the development of social anxiety and panic).. Andy was able to see the connection between social anxiety and panic attacks and his anger and expressed a feeling of relief after gaining a better understanding of the physical symptoms of anxiety and panic. homework. the avoidance piece would be discussed later in treatment when Andy was ready to make it an exposure.. . While this strategy facilitated avoidance to some degree.g. playing in a dart tournament.e. During session 8. walking into a restaurant alone). shortness of breath). This discussion further confirmed that social anxiety was affecting treatment and thus needed to be addressed as well. While he described always being a shy person. (2) the protective function of panic and anxiety. and behaviors (not completing the homework). the normal course of treatment was resumed.Treatment of Social Anxiety Disorder 205 will laugh at me”). sweating. the effects that anxiety and fear have on breathing. Problem solving was used to improve homework compliance. and Andy was instructed to practice the skill daily on his own. there was more extensive focus on the fight component. breathing retraining (see Barlow & Craske. as it was relevant to Andy’s experience (i. and the physiology related to hyperventilation were presented. learning to regulate his breathing was the next step. rather than use it to eliminate uncomfortable sensations and anxiety. and exposures (in session and outside session)—to address social anxiety and panic attacks. The session began with a discussion about breathing and the changes in breathing that were experienced during panic attacks. Information about the physiology underlying social anxiety and panic was presented. psychological. the goal at this point was to get the homework completed. his physical sensations (heart racing. Education about normal breathing.g. the therapist reviewed the rationale behind the main components of treatment—cognitive restructuring. and it was decided to have Andy present his homework in session and not hand the forms to the therapist until the end of session. In comparison to most clients. including waiting for friends before walking into a restaurant. Table 8. He identified several safety behaviors and distractions. Several dimensions were considered while generating the list to allow for a more accurate depiction of his anxiety and avoidance levels (e.206 Anxiety Disorders Session 9 and 10 focused on establishing a Fear and Avoidance Hierarchy. alone or with others.g. meeting friends there Crowded place (grocery store. only speaking to familiar people. sitting in the middle row Initiate a conversation Going to store and asking questions Anxiety Avoidance Pre-treatment Post-treatment 7 1 Pre-treatment 8 Post-treatment 2 7 1 8 1 7 2 8 4 7 3 7 2 7 2 7 3 6 2 5 3 6 2 5 3 4 2 7 1 5 1 3 1 5 2 3 1 Note. Andy’s Fear and Avoidance Hierarchy Situation 1 2 3 4 5 6 7 8 9 10 YMCA. and looking for the exit sign when he entered a store. the same scale was kept for the hierarchy even though the Hope et al. Ratings are 0 to 8. such as relying on safety signals or distractions. Andy identified his safety signals (objects that he believed provided safety) as being with familiar people. proximity to an exit). Andy rated his anxiety and avoidance for each situation. with higher ratings indicating greater anxiety and avoidance. mall. Since Andy was initially introduced to the panic monitoring forms that utilize a 0–8 point scale. Session 11 focused on a discussion of unhelpful ways of dealing with anxiety. sports game. (2010a) manual uses a 0–100 point scale. It also appeared that Andy engaged in distracting behaviors as soon as he noticed any physical sensations and would often leave situations to reduce his symptoms. Andy and his therapist collaboratively generated a list of anxiety-provoking situations incorporating both situations relevant to social anxiety and panic. health club Play darts while others watch (being the center of attention) Going to a party alone. having access to his own car. acting busy when he is at the store so that he does not have to interact with the store staff.1.1 provides Andy’s Fear and Avoidance Hierarchy. The client and his therapist discussed why distractions might appear helpful in the short term but prevent corrective learning and further maintain the fear in the long term. and carrying a cell phone at all times. concert) Karaoke (just going) Restaurant with 6 or more friends Going to a party with friends Movie theater.. During our discussion of safety TABLE 8. number of people. . For example. & Emery. which was described as the further exploration of one’s thoughts by identifying what he was afraid of in a given situation. Rush. 2001) because Andy was using it to escape feared physical sensations that he continued to believe were harmful if allowed to continue.. Andy was able to generate rational responses for social anxiety (“Even if I’m nervous. the therapist decided to de-emphasize the cognitive aspect and just use the cognitive restructuring procedures one last time to generate generic coping self-statements to be used in exposures. Andy described his automatic thought as: “What will my friends think of me?” The therapist helped Andy change questions into statements about how he feared that question would be answered (“They will laugh at me and think I’m an idiot”) to aid in the cognitive restructuring process. while recalling recently having dinner with friends. catastrophizing. Andy seemed to struggle with identifying automatic thoughts and often reported them in the form of a question. 1979). Given that the breathing retraining was counterproductive and may not be essential for a good treatment outcome (Schmidt et al. and disqualifying the positive. the therapist and client proceeded to recognizing logical errors in his thinking and challenging his automatic thoughts. Andy’s automatic thoughts were explored using the downward arrow technique (Beck. were fi rst identified. Automatic thoughts. I can still talk to people”) and panic (“I have never had a heart attack”) in session but was unable to do it on his own and stopped practicing on his own. the relationship between thoughts. Though he had a good understanding of how his thoughts affect his emotions. fortune-telling. it became apparent that the diaphragmatic breathing had become a safety signal (Taylor. and so on. Andy and the therapist agreed to discontinue the use of breathing retraining to allow him to learn that his worst feared outcome related to panic would not happen and that the anxiety would be manageable. followed by further careful questioning of what he pictured happening as a result. Sessions 12 though 17 focused on teaching Andy cognitive restructuring skills. The most common thinking errors for Andy were mind reading. as recommended in Hope and colleagues (2010b).. First. . Andy’s automatic thoughts had themes typical of both social anxiety and panic: “They will think I’m a fool” and “I will have a heart attack. Using the disputing questions to challenge his automatic thoughts.Treatment of Social Anxiety Disorder 207 signals and distracting behaviors. or irrational thoughts about the self. others. Examples of disputing questions included. 2000). and behaviors was reviewed with an emphasis on how thoughts affect emotions. Disputing questions were presented as a tool to help Andy challenge his automatic thoughts by exploring evidence for and against his assumptions (Hope et al. 2010b). After trying to resolve the problem without success. Andy’s coping self-statements were “I can survive an embarrassing situation” for social situations and “A panic attack will not kill me” for feared physical sensations. “Do I know for certain that ____ will happen?” or “What evidence do I have that (the opposite) is true?” or “What’s the worst that can happen?” and “How can I cope with it?” Cognitive restructuring was practiced over the next few sessions to help Andy master this new skill. and the future (Beck.” After assisting Andy in identifying his automatic thoughts. Shaw. feelings. 1995). He described that he had . Andy appeared comfortable and ready to face this very challenging in vivo exposure. However. He described his passion for the game but stated that he had only been able to play darts alone or with his closest friends. he described that while his anxiety was elevated at the beginning. Sessions 19 through 23 focused on exposure. which helped him stay in the situation. and toward the end of the game. focusing on his anxiety in anticipation of. He indicated that he had enjoyed the holiday season and described several planned and spontaneous social activities that he had attended. he was praised for his efforts to face his fears and overcome his social anxiety. we discussed what he learned from the experience. focusing on managing the intensity of anxiety and staying in the situation. he decided to officially register for the tournament as he saw it as a good opportunity to practice facing his fears. Andy described an upcoming darts tournament. focusing on using the exposures to help Andy learn that his feared catastrophic outcome was not likely to occur. Given Andy’s reliance of avoidance behaviors in the past. which would be achieved with repeated practice. After Andy described his successful exposure. a previously avoided anxiety-provoking situation. He described feeling elevated anxiety in anticipation of the event and admitted to considering escaping. which he had previously avoided due to panic and social anxiety. Andy recalled his anxiety levels during the tournament and described that his anxiety stayed elevated for the fi rst part of the event but dropped somewhat after his turn. the therapist and client reviewed the role of avoidance in maintaining his anxiety and discussed how to effectively manage his panic and anxiety. Overall. The purpose of exposure was reviewed. Some time was devoted to preparing for his upcoming tournament and possible barriers. An emphasis was placed on tolerating the anxiety and fear. he noticed a gradual reduction during the game and even described enjoying the experience. Session 18 focused on reviewing Andy’s anxiety and exposure practices over the holiday season. his outside-session practices were reviewed at the beginning of each session and modifications were made as needed. He seemed encouraged by his experience and planned to continue outside-session exposures on his own and review them in session. Andy appeared more relaxed and described using the self-statements generated during the previous session to play darts with two friends. During the next session (session 20). distraction) were discussed. and his experience was further explored. he described generating a self-statement (“Even if we lose. In session 19. Andy was eager to continue outside-session exposures and described several social events during the upcoming holiday season. Given that Andy had already initiated in vivo exposures on his own. Overall. Prior to leaving session. Andy was praised for initiating exposures on his own. and unhelpful ways of dealing with anxiety (avoidance. during. Andy reviewed his experiences during the darts tournament. it’s not the end of the world”). who offered some safety. and his anxiety had been manageable. while not focusing on immediate symptom reduction.208 Anxiety Disorders At the beginning of session 17. Additionally. he reported engaging in less avoidance than he had in the past. After a discussion in session. and the goal of learning something new (that what he was most worried about was not likely to happen) was reiterated. it also appeared that the physical symptoms continued to cause him discomfort and distress. as this is a realistic possibility in any competition. and how it was going to help him overcome his fear of negative evaluation.3. After gentle questioning (without being judgmental or blaming). Andy concluded that losing is part of life and stated that it would not be that bad. the therapist encouraged him to continue practicing his exposures and to continue monitoring during the weekly brief phone conversations. Andy had completed exposures to several items on his Fear and Avoidance Hierarchy outside-session and was encouraged to continue practicing until his anxiety decreased to a mild level. claiming a busy work schedule. and straw breathing) and were first practiced in session and followed by daily homework practices. Although he described worrying less about panic attacks (because he knew that they were not harmful). fi ling taxes. which might have affected completion of self-monitoring and exposure homework. Although Andy’s team won the fi rst round in the tournament. Andy revealed that he was experiencing several stressors (relationship problems. while in-session focus shifted to panic sensations.4). At this point.2. The therapist followed the recommended steps proposed by Persons (2008) to address non-adherence behavior: assess. To keep him engaged in treatment. 2006). Andy reported that the interoceptive exposures were helpful and reduced his fears of physical symptoms in casual conversations and other social events. worry about panic. conceptualize. the therapist and client discussed the possibility of losing. and intervene. spinning while standing. heavier work load. interceptive exposures to the symptoms of dizziness and lightheadedness were identified (staring at self in mirror. and fi nancial difficulties). Also. it was important for the therapist to explore possible factors that may have contributed to worsening in symptoms and assessed what may have led to his cancellations given his previous good attendance. and what it would mean if they lost. Andy missed the following five weeks of treatment. The therapist presented this return in symptoms as an opportunity to examine how avoidance affected Andy’s anxiety and depression over the last five weeks.Treatment of Social Anxiety Disorder 209 accomplished his goal of playing in the tournament (rather than being focused on winning). The conversation focused on what the goal of the exposure was (stay in the situation despite fear and anxiety). 8. interoceptive exposure practices in session focused on helping Andy learn to manage his panic attacks by targeting his core fears of physiological symptoms (Craske & Barlow. Thus. this incident was used to illustrate the difference in anxiety levels when Andy was actively working on his . Since his self-report questionnaires revealed that his social anxiety. Strategies for Handling Poor Attendance and Partial Relapse Sessions 24 through 27 focused on exploring the recent break from therapy and restarting treatment. and 8. Given that he reported that feelings of dizziness led to his concern of fainting and dying during his most recent dart tournament and social gatherings with his friends. and depression were elevated relative to the previous session (see Figures 8. . he stated that he felt happier and described spending more time with his friends and attending more social events. His symptoms began to improve immediately. Andy described that he was more assertive with his girlfriend when she recently visited him and requested to move back in without making any financial contributions. Although initially resistant. Andy reported that his mood had continued to improve since the recent break-up. Furthermore. which he reported doing right away. and his goals for the relationship were reviewed. which he found helpful. he expressed feelings of guilt and described an increase in depressive symptoms. he described feeling happier than when he started treatment. which further motivated Andy to continue exposure. Andy re-rated items on his Fear and Avoidance Hierarchy (see Table 8.210 Anxiety Disorders anxiety versus when he began to avoid more. His scores demonstrated a decrease in his ratings. He asked her to leave and ended the relationship. Overall. as described above. Later. Relapse Prevention and Termination Session 29 focused on a review of Andy’s progress. He had already begun to expand his social circle and participate in more social events.1). and skills learned in treatment. whether they concerned social situations or physical sensations. followed by relapse prevention. helped him to learn that they were not dangerous. Attention was then turned to his recent stressors and how they may have exacerbated his anxiety. His change score improved by the last session. A functional assessment of the arguments revealed that Andy’s decrease in social anxiety symptoms and increased comfort with being more assertive were changing the relationship. Andy and his therapist developed a plan for the next few months. The therapist also used this opportunity to stress the importance of continuing exposures even after treatment is terminated. with a relapse at session 28. focusing on continued exposure to maintain gains made in treatment. His scores demonstrated that his social anxiety and panic symptoms started to improve after session 8. It was decided to spend session 28 focusing solely on his relationship difficulties. Session-by-Session and Post-Treatment Assessment Andy’s session-by-session scores on the SASCI and PaSCI are displayed in Figure 8. Key take-home points from treatment were discussed. Andy had come to believe that his girlfriend was in the relationship primarily for fi nancial support. Andy soon revealed experiencing more confl icts with his girlfriend. Andy reported that facing his fears. Andy indicated that the treatment helped him become more assertive to deal with the unhealthy relationship and to feel more comfortable around his friends. challenges encountered. His experiences were normalized given the recent break-up. Andy was encouraged to resume his exposure practices.1. During a telephone conversation scheduled between sessions. Specifically. Also. which indicated that his fear of negative evaluation declined during treatment but remained slightly above the reported mean scores for controls (Weeks et al. and depression had dropped to a subclinical level (a CSR of a 3 or less). which was also initially a 6. a CSR of 3 for his social anxiety disorder. the CSRs at post-treatment demonstrated that Andy’s symptoms associated with panic. His scores on the BFNE dropped to 37 (from an initial pre-treatment score of 46).2). A more comprehensive 40 ASI Score (0-64) 35 30 25 20 15 10 5 0 1 FIGURE 8. Social Anxiety Session Change Index (SASCI) and Panic Session Change Index (PaSCI) Scores by Session Results from the ADIS-IV diagnostic assessment administered by the original diagnostic interviewer (not the therapist) at post-treatment indicate that Andy was assigned a CSR of 2 for panic disorder with agoraphobia. 3 5 7 9 11 13 15 17 19 21 23 Bi-weekly Scores on the Anxiety Sensitivity Index (ASI) 25 27 29 post . social anxiety. demonstrating that depressive symptoms were no longer clinically severe. Andy’s fear of physical sensations associated with anxiety as measured by the ASI decline over time to 12 (from an initial score of 37).Treatment of Social Anxiety Disorder 211 SASCI and PaSCI score (4-28) 20 SaSCI 18 PaSCI 16 14 12 10 8 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Session FIGURE 8. indicating that he was significantly less concerned about his physical sensations (see Figure 8..1. This change on the CSR would have classified Andy as a “responder” in one of the treatment outcome studies described earlier. which is a decrease from his initial CSR of 6. A CSR of 3 was assigned to his dysthymic disorder (decrease of 1 point). self-report measures administered post-treatment demonstrated improvement in symptom presentation. Overall.2. 2005). symptoms of depression. which were not directly targeted in treatment. perhaps because of ongoing stressors.4). His ratings from week to week were more variable than often seen.4. particularly from the relationship. 1 3 5 7 9 11 13 15 17 Session 19 22 24 26 27 Bi-weekly Scores on the Beck Depression Inventory-II (BDI-II) 29 post . The 35 BDI Score (0-63) 30 25 20 15 10 5 0 pre FIGURE 8.212 Anxiety Disorders 48 BFNE Score (12-60) 44 40 36 32 28 24 20 pre FIGURE 8. Additionally. also decreased. as well as the core principles underlying exposure-based interventions. these results indicate that Andy responded well to treatment.3. Overall. Andy’s depressive symptoms on the BDI-II reduced from a moderate range (25) to a mild range (18) at the end of treatment (see Figure 8. His symptoms related to social anxiety and panic decreased substantially after treatment. and ASI. ADIS-IV.3. 1 3 5 7 9 11 13 15 17 Session 19 21 23 25 27 29 post Bi-weekly Scores on the Brief Fear of Negative Evaluation Scale (BFNE) depiction of his BFNE scores is presented in Figure 8. especially on the Fear and Avoidance Hierarchy. Importance of Principles from Basic Science for This Case This case required a thorough understanding of the nature of social anxiety and panic. Understanding the phenomenology of panic in the context of social anxiety and uncued panics in panic disorder was also crucial to developing the treatment model. it took some time to arrive at a shared rationale. . Frank & Frank. such as the therapeutic alliance and having a shared rationale and treatment goals (e. but he may have felt differently if treatment had been less successful.Treatment of Social Anxiety Disorder 213 complexity of the case prevented the application of a single standardized protocol. Horvath et al. If these strategies had not been successful. as fi rst put forth by the client. three primary alternate strategies would have been considered. and confl ict with her was an important impetus for Andy to seek treatment initially. the initial development of a collaborative treatment plan was extended from a typical time frame of one session or less to three sessions and then revisited periodically. 2003.g. Another possible treatment approach would have been to return to the original conceptualization of the problem as one of anger. in the background of treatment was the client’s ongoing problematic relationship with his girlfriend. treatment in this case relied on established procedures for treating social anxiety and panic. This process was facilitated by self-monitoring data that informed the discussion and helped the therapist and client jointly test hypotheses about the nature of his experience in problematic situations. The case formulation was guided by knowledge of the psychopathology of social anxiety and its often earlier onset relative to panic. Given the client’s initial conceptualization of his problem as anger. Nonspecific Factors in Therapy Psychotherapy has often been considered the sum of nonspecific and specific factors. van Apeldoorn et al. There is an established body of literature of the efficacy of certain medications for both disorders (see Blanco et al. Nonspecific factors often refers to common factors across all psychotherapies. Alternative Strategies to Consider Although not a prototypical course of cognitive behavioral treatment for anxiety. 2008). It is possible that a treatment approach that focused on his interpersonal relationships might have been a viable alternative. Recognizing Andy’s anger as the “fight” aspect of the fight or fl ight response in the face of feared situations resulted in a very different treatment approach from one focused on anger management.. One possibility would have been a referral for pharmacotherapy for the social anxiety and panic. Medication could have been added to the current treatment or considered on its own.... 1993. In this case. This relationship was the focus of treatment in session 28 but was in the background throughout. Finally. Andy was not on medication when he came to the clinic and preferred not to take it. and to treat the anger directly. 2011). even though it involved some avoidance behavior. 2011). and such individuals make up most participants in treatment outcomes studies (Hays. About the time that the therapist planned to initiate in-session exposures. there were additional modifications to the treatment that avoided common mistakes related to the inflexible application of a protocol and/or inattention to the case formulation. Cognitive behavioral treatments require clients to engage in difficult therapeutic exposures. Cultural Factors Cultural factors were less salient in this case because both the therapist and client identified primarily with the majority European American culture of the United States. Clients must understand why they will be asked to face these challenges and must freely choose to undertake them. As noted above. was the primary problem and why the recommended treatment was a reasonable approach. breathing retraining was dropped when it became a safety behavior. became a focus of sessions at key times. the client’s life stressors.. the client began self-initiating in vivo exposures. Cases described elsewhere describe adaptations to treatment for social anxiety with recent immigrants (Weiss. the therapist took time to arrive at a shared rationale before launching into treatment procedures. First. appropriate in vivo opportunities were readily available. not anger. therapist guiding Andy to notice that predicted feared outcomes had not occurred) without the use of formal terminology. 1995). formal cognitive restructuring was curtailed. Fourth. Fifth. which were quite successful. Andy’s true informed consent required that he understand why the therapist believed that anxiety. the therapist and client initially had different conceptualizations of the case.214 Anxiety Disorders Ethical Considerations The primary ethical consideration in this case was to provide the client with true informed consent for treatment. as the client was not able to use it effectively on his own. the therapist addressed homework noncompliance (not bringing in paperwork) early in treatment and accepted a good shortterm solution. the therapist and client agreed to use session time to plan and debrief in vivo exposures. a man coming to understand his sexual orientation as gay (Walsh & Hope. Avoiding Common Mistakes Even while drawing from two primary CBT protocols. Second.g. particularly in session 28. Therefore. 2010). particularly the romantic relationship that was in the background of much of therapy. Third. no in-session exposures for social anxiety were conducted. . In-session discussion of exposures utilized cognitive techniques (e. Finally. Therefore. For this particular client. Singh & Hope. which is not always the case for more socially isolated clients. which can be quite uncomfortable. Hayes.. 1998). 2005. The growing evidence demonstrating that anxiety disorders have more commonalities than differences has inspired several research groups to begin developing transdiagnostic treatment protocols for treatment across the anxiety disorders (Norton & Hope. 1995. and an interdisciplinary intervention for a woman with associated speech difficulties (Laguna. Turner. 2004). Although the social anxiety was “primary” in the sense that it had an earlier onset and many panic attacks were cued by fears of negative evaluation. In this case. it appears that using a transdiagnostic treatment approach may become more common in the near future. as well as depressive symptoms. & Hope. Healey. & Barlow. Abel. Guiding the collection of self-monitoring data to develop the rationale and attending carefully to the client’s application of the treatment procedures produced an ideographic treatment experience with a sound scientific basis that resulted in a positive outcome. and dissociative disorders (Unified Protocol. Erickson.. 1998).” Conclusions. & Tallman. Kessler et al. and Clinical Implications The present case demonstrated the effectiveness of CBT for the treatment of social anxiety complicated by recent onset of uncued panic. see Barlow et al. . worry. 2001. Janeck. Norton. The so-called “art of therapy” involved the therapist’s creative development and application of a case formulation. 2004). given the client’s difficulties differentiating between his experiences.. Our approach was successful at reducing symptoms related to social anxiety and panic. Thus. depression. focusing first on a protocol for one disorder and then moving to a second if needed.Treatment of Social Anxiety Disorder 215 an African American woman (Fink. Typically in our clinic. there is considerable evidence that the anxiety disorders share a core vulnerability. In addition to high comorbidity among the anxiety and mood disorders (Brown et al. grounded in the empirical literature. & Beidel. we treat such cases sequentially. the more recent uncued panic attacks were quite distressing to the client. based on a case formulation. 1984). 2007) and for a broader range of emotional problems— anxiety. 1996). & Newman. somatoform. although the latter were not directly targeted in treatment. we focused on a more integrated approach. providing support for the similarities among the anxiety and mood disorders. There is considerable evidence indicating that CBT targeting a primary anxiety disorder is also successful at reducing symptoms of comorbid anxiety or mood disorder not targeted in treatment (Borkovec. perhaps due in part to the overlap in symptoms across social anxiety and panic (panic attacks. Brown. anticipatory anxiety. and avoidance behavior). & Hope. 1995. namely negative affectivity—the sensitivity to experience negative emotions even without the presence of aversive events or stressors (Watson & Clark. The “Art of Therapy. Anthony. using cognitive behavioral techniques from established protocols for both social anxiety and panic disorder. .63. & Newman. Depression and Anxiety.. M. D..1016/S0005-7894(04)80036-4 Barlow. Blanco.. Cognitive therapy: Basics and beyond. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a .3. D. & Mancill. Cognitive therapy of depression. A.. A. J. (1979).1037/0003066X.. B. the decision-making process was always based on science.. M. (2010). A. Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed. (2003) Pharmacological treatment of social anxiety disorder: A meta-analysis. (2000). K. doi:10. E. & Cerny. L. 168–189. American Psychologist. D. T.216 Anxiety Disorders This case further demonstrated the importance of continuing to engage the client in treatment.. 61. L.. & Leibowitz. Allen. New York: Guilford Press. H. D. Vermilyea. Blanchard.271 Barlow.. L.1002/ da. A. (2006 ). (2004). C.. Stein.. Rush. M.. G. R. Pine.20670 Borkovec. Problematic behavior that may interfere with treatment should be addressed right away using non-confrontational approaches. Depression & Anxiety. doi:10. using evidence-based approaches combined with ongoing assessment of adherence and progress..3. Beck. (2002). R. Social anxiety disorder: Questions and answers for the DSM-V. doi:10. Barlow. C. B. doi:10. 27. The phenomenon of panic. L... B. 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(1995). & Craske. & Voncken. A.10096 Bögels. A. Vermilyea. Anthony. Abel. L.4.3. D. H. Washington. Diagnostic comorbidity in panic disorder: Effect on treatment outcome and course of comorbid diagnoses following treatment. Evidence-based practice in psychology. M. T. References American Psychiatric Association. 205–230. doi:10. J. (1985). Marshall. M. Toward a unified treatment for emotional disorders. P.. Journal of Abnormal Psychology. Lehman. New York: Guilford Press. A. DC: American Psychiatric Association. B. TX: Psychological Corporation.. B.61. Campbell. 35... S. Journal of Consulting and Clinical Psychology. Clark. Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. T. F. S. & Emery. A. doi:10. Zollo.55. DiNardo. G. M. M. doi:10. 11. .1007/BF01173521 Heimberg.. (2006). S.. 14. Assessment of anxiety in social interaction and being observed by others: The Social Interaction Anxiety Scale and the Social Phobia Scale. doi:10. C. 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His data are characterized by considerable . this client’s failure to provide homework data. “Should we even consider Andy’s outcome to be a good one. we might take away to help us treat similar cases more cost-effectively in the future. I am not ready to concede that Andy benefited significantly from the treatment. as though we actually know what caused what. there invariably are so many competing and confl icting forces at play (for example. a 38-year-old European American client suffering from social anxiety disorder. Indeed. if anything. so many choice points and potential decisions—typically governed mostly by inexplicable clinical intuitions—that we’ll never really know why the therapists did what they did. given the range of possible outcomes? Might the result have been much better if the therapists had made different decisions along the way?” Without a meaningful comparison. As skeptical scientists. we always can offer post hoc explanations. however. Indeed. citing summary data from several measures in support of this claim. principles from basic science (described only vaguely). They attribute their successful outcome to their reliance on a creative combination of empirically established treatment procedures (described as CBT). which is exactly the problem with case studies. skeptics might go further and ask. we must ask: “What might have happened if the therapists had taken a different fork in the road at each juncture?” We’ll never know. of course. when I look at Andy’s outcome data. in fact. 29-session treatment experience with Andy. or that his treatment moved him into the normal range of functioning. which isn’t available in this case. The authors present a chronological account of their intervention and conclude that their treatment was successful. or what would have happened if the therapists had made different choices. McFall Stoyanova and Hope report their year-long. Once the outcome is known. I believe that it is virtually impossible to draw meaningful strong inferences from such case studies because they simply involve too many twists and turns in the plot. such questions are moot. these questions stand as silent cautions against the common temptation to draw inferences with confidence. I kept wondering what. Reading this case. to name just two) that interpreting cause and effect is impossible in a single case. of course. Nevertheless. not a basis for interpretation. the therapists decided to spend the first three sessions “developing a shared rationale for treatment and agreement on the tasks and goals of therapy. for example. is that one needs to be highly skeptical of any strong inferences. it contributes little to our scientific understanding of psychological phenomena.” Does this formulation tell us anything that we didn’t already know about Andy. with dramatic ups and downs all across the 29 sessions. what other options were considered. In the beginning. however. in my view. in the course of his random ups and downs.” Might the treatment outcome have been more dramatic and rapid. as viewed through the eyes of a narrator with a unique perspective on the events. We don’t really know. because it deals with the human condition. This can’t be ruled out. rather than sticking to a formula. Stoyanova and Hope decided that Andy’s problem was that he “demonstrated hypersensitive reactions to external and internal experiences.222 Anxiety Disorders instability. if the therapists had moved quickly to use exposure procedures? Several early sessions were devoted to analyzing. The case study then becomes a source of hypotheses. Science—à la Karl Popper—is a process of homing in on “truth” by systematically eliminating plausible rival hypotheses. why the therapists chose the path they did. Though interesting. That is. Case studies don’t offer much help of this kind. but it is a one-of-a-kind experience. interpreting. in case studies such as this. all case studies are fi lled with such tantalizing conundrums. The main take-away message for me. Moreover. perhaps the therapists simply stopped their treatment precisely at a point when the client was doing better than usual. It is interesting. or what would have happened if they had chosen differently. . thereby unintentionally capitalizing on the instability of his symptoms and incorrectly overestimating the treatment’s impact. the therapists persevered until Andy seemed better. at each point. To their credit. Reading a case study is like reading a novel.) Essentially. and stopped only when he did. Might the therapists have short-circuited that problem by simply insisting that all treatment sessions were contingent on the client providing the required data? And what might have happened if the therapists had adhered more rigorously to the treatment protocol that has been shown to be effective in controlled research? (One is reminded of Meehl’s papers about the limited circumstances under which it is best to use clinical judgment. in this particular case. this raises the possibility (always in the minds of good skeptics) that the positive outcome the authors attributed to their treatment may have been illusory. if the therapists were determined to continue treatment until Andy seemed better. based on his presenting complaints? Does it have a specific implication for the design of the intervention? What other formulations were considered? At the start of the intervention. and dealing with the client’s failure to provide homework data. the therapists should be the fi rst to critique their own interpretations and decisions—from the beginning to the end of their intervention. These uncertainties limit the information value of this report. and all such case studies. for instance. but they can be useful for raising hypotheses.RESPONSE Debra A. Flückiger. why decisions were made at various points. including about how quickly to start and stop the intervention or how to handle homework noncompliance. nonspecific treatment factors. we could have attempted to start exposure right away. or therapist’s instinct—was used to guide the decision. Exposure- . and having a shared rationale and goals accounts for a significant portion of variance across numerous studies (e. & Symonds. Gorman. The nature of the case report requires that the clinician report. As noted by McFall.g. as best he or she can. and (3) the formulation offered little additional information.. We will respond to each in turn. Stepping outside the confi nes of a clinical trial. What is important is that. Fyer. but rather to illustrate a scientific approach to clinical work that draws on research on basic psychopathology. (2) it is not known how successful treatment would have been had the therapist made different choices. we sought to describe how a highly expert clinician with a strong scientific orientation applies the research literature to a relatively complex. as one has in a time-limited clinical trial. we had no time constraints. Del Re. This function largely applies to new areas of scientific inquiry. whenever possible. An important purpose of a case report at this stage of scientific inquiry is to help bridge the gap between treatment as reported in randomized controlled trials and what practitioners perceive to be their own realities of practice. The primary purpose was not to demonstrate the efficacy of the treatment. rather than spending three sessions seeking a shared understanding of the problem. and as such does not describe treatment for social anxiety disorder. 1985). 2011). Horvath. multi-problem case. It is impossible to know if the best choices were made or even whether these were the most important decisions to report. Hope and Milena Stoyanova McFall raises a number of points in his comments on our chapter describing the treatment of Andy. which has been extensively researched since it was called “neglected” more than 25 years ago (Liebowitz. However. conventional clinical wisdom. in this particular case. ruling out competing hypotheses for change. we agree with McFall that one cannot draw scientific conclusions from case studies. & Klein. His primary critiques reflect three themes: (1) it is impossible to draw scientific conclusions of cause and effect for treatment outcome from a case study. and clinical trials. the scientific literature—not a discredited theory. First. (1985). or to childhood maternal bonding experiences. our reading of the literature is that homework compliance is related to treatment outcome but does not account for so much variance in outcome that it warrants threatening to end treatment (e. V.. Psychotherapy. M. & Patterson. Roesch. & Symonds. Finally. D. F.04. Similarly. and another therapist might have offered a formulation relating the presenting problems primarily to the dysfunctional romantic relationship. can have a positive impact on treatment engagement (e. Gorman.2009. for example.. 710–715. We would argue that such a strategy is not modal strategy employed in clinical practice. (2010).009 Horvath... This is especially true when it appears that the noncompliance is simply a sample of the problem for which the client sought treatment. T. and strategies that enhance motivation.” The client did not articulate this formulation on his own. M. & Schmidt. 2010). 34. Del Re. Archives of General Psychiatry. The relationship between homework compliance and therapy outcomes: An updated meta-analysis. 729–736. A. Mausbach.g... L. 429–438. R. Mausbach. Buckner & Schmidt.. Social phobia: Review of a neglected anxiety disorder. 9–16. C. 2009). Roesch. & Klein. Fyer. T.g. B. D. Alliance in individual psychotherapy. J. (2011).. doi:10. McFall questioned the added value of the case formulation that the client “demonstrated hypersensitive reactions to external and internal experiences. Moore. C.1037/a0022186 Liebowitz . Cardenas. Moore.brat. Certainly when psychopathology interferes with treatment.. Cognitive Therapy and Research.. addressing the interference itself is consistent with treatment goals. 48. 47. Behaviour Research and Therapy. D. doi:10.1007/s10608-0109297-z . R. Cardenas. B. 42. Flückiger. doi:10. S. A randomized pilot study of motivation enhancement therapy to increase utilization of cognitive–behavioral therapy for social anxiety. A. including that the treatment is appropriate. A. (2009). J.224 Anxiety Disorders based therapies are challenging for clients. N. Our formulation is closely tied to the basic science on the psychopathology of social anxiety and panic and is obvious only if one regularly uses such basic science to derive formulations. & Patterson.. O.1016/j. J. References Buckner... g.. Abramowitz and Brittain Mahaffey At her initial evaluation. conscientious. and had never committed any violent behavior. and that it was a matter of time before she lost control. a 29-year-old Caucasian female in her first year as a graduate student. trying to reassure herself that they were senseless.” She also analyzed the possible meanings of her thoughts over and over. when at the library. She had mental rituals involving the repetition of positive phrases (e. I’m good. intrusive thoughts. this recognition would elude her and she would resort to using rituals to calm herself. described the presence of unwelcome. for example. During anxious episodes. that is. Cassie described constantly trying to dismiss these unwanted thoughts from her mind. she also experienced unwanted impulses to stab others. or other quiet places such as plays or other performances. I’m good”) to undo the “bad thoughts. “Cassie” (note: a pseudonym is used here. When not anxious. “I’m good. Case History BRIEF PERSONAL HISTORY Cassie was raised in an upper-middle-class community in the northeastern United States. Her .{9} Psychological Treatment of ObsessiveCompulsive Disorder: The Case of Cassie Jonathan S. she worried that these intrusions meant that a “dark” part of her wanted to do such things. however. She ruminated. she had good insight into the senselessness of her obsessivecompulsive disorder (OCD) symptoms. She considered herself religious with strong moral values. yet recurrent and distressing. and some facts have been altered in this chapter to protect client confidentiality). about how she could simply yell a curse word with relatively little effort. These included unwanted impulses to yell curse words during classes. Although Cassie was highly deliberate. When in the presence of knives. Cassie could recognize that these thoughts were meaningless and were probably not going to lead to any inappropriate behaviors. and (c) Mowrer (1958) and Dollard and Miller’s (1950) avoidance learning model. Yet attempts at thought control usually fail because searching for the to-be-suppressed target thought ironically results in having such thoughts (Wegner. 1978). Cassie graduated from a Christian college and was pursuing a graduate degree in exercise physiology. which gradually began to interfere with her daily functioning. Finding these thoughts troubling. the person also becomes hypersensitive to (constantly vigilant for signs of) the to-be-suppressed thought..226 Anxiety Disorders relationship with her parents and younger sister had always been very close. & Wright. 1987). 1980) demonstrates that obsessional anxiety results from catastrophic beliefs about normally occurring. Moreover. Schneider. (b) Wegner’s ironic process model of thought suppression. Cassie began having thoughts about doing this to her parents. Carter. when she heard a story on the news about a boy who had killed his parents in their sleep. experience the same sorts of intrusions from time to time. She reported no desire to commit harm or do any of the things featured in her unwanted thoughts. “Even when I try to get rid of . 2004).g. it leads to a secondary misappraisal (e. deep down. she was actually a cold-blooded killer. Cassie had no history of violent or aggressive behavior and was not angry with her parents.g. Cassie began avoiding situations that triggered her intrusive thoughts. leading to more thought occurrences. Beck’s cognitive specificity model of emotion posits that psychological distress is the result of dysfunctional thoughts and beliefs about situations and experiences. only to fi nd that she could not do so. She also reported satisfaction with her social life and denied previous abuse of alcohol or drugs. yet do not misinterpret them as harmful or significant (e.. When the very intrusion that the person is trying to dismiss becomes more frequent. The distress that results from the misinterpretation of intrusive thoughts leads to urges to control or reduce this distress. Rachman & Hodgson. Examples of such beliefs include the idea that “only bad people have bad thoughts” and that “one can and should rid their mind of such thoughts to prevent something bad from happening. Rachman & de Silva. She reported outstanding school achievement and participation in numerous extracurricular activities.” The vast majority of the people. senseless intrusive thoughts. fi rst and foremost by using thought suppression or distraction techniques (Purdon.g. Her inability to rid herself of these thoughts then led her to fear that. she tried dismissing them. which is based on the principles of classical and operant conditioning. Shortly thereafter. Cassie reported that her obsessional problems began six years prior.. Research with individuals with OCD (e. however. Psychological Principles Relevant to Understanding Cassie’s OCD Symptoms Three research-supported psychological principles are relevant to understanding Cassie’s OCD symptoms: (a) Beck’s (1976) cognitive specifi city hypothesis. 2005).. Moreover.e. which aims to elucidate the factors that maintain the obsessional problem. This assessment. such as the Obsessive Beliefs Questionnaire and Interpretation of Intrusions Inventory (Obsessive Compulsive Cognitions Working Group. & Menzies. For example. is guided by the theoretical principles described in the previous section and informs the treatment plan (as discussed later in this chapter).Psychological Treatment of Obsessive-Compulsive Disorder 227 this thought. this outcome negatively reinforces the mental rituals. Tolin. Next. She also believed that it was immoral even to think about harming others. Assessment Strategy While there is merit to diagnostic assessment to rule in or out possible differential diagnoses. Yet even if brief. Mental rituals. the individual mistakenly attributes this to the rituals and avoidance (i. This must mean I am truly a bad person”.. Shafran. Rituals and avoidance behavior also prevent the person from learning that intrusive thoughts are not dangerous or significant in the first place. Assessment also involves collecting detailed information about the person’s responses to the obsessional thoughts and anxiety. Abramowitz. Mowrer. the external triggers— situations and stimuli associated with unwanted intrusions—are assessed. and anxiety is (temporarily) relieved. It begins with the collection of detailed information about the form and content of the intrusive obsessional thoughts themselves. Hamlin. 1997. further consolidating this as a strategy for dealing with upsetting intrusive thoughts. when catastrophic consequences do not occur. Cassie reported that using knives (particularly when others are nearby). completing a self-perpetuating vicious cycle (Rachman. 2002). This ensures that the mistaken beliefs described above remain intact. 1950. phobic avoidance. it is the idiographic cognitive-behavioral functional assessment that contributes most to the successful treatment of obsessive-compulsive symptoms. e. 1958). These cognitions form the basis for the obsessional anxiety and the urge to avoid and perform rituals. Cassie reported being concerned that she would impulsively act on her unwanted thoughts.g. reduce anxiety. sometimes results in a temporary decrease in obsessional anxiety (de Silva. Synodi. Cassie explained that the ritual of mentally . a near miss). They can be measured using psychometrically validated self-report instruments designed for this purpose. 1998). such as analyzing the meaning of unwanted thoughts or trying to seek assurance that they are unimportant. 2003). For example. and being in “quiet” places such as libraries and performances provoked obsessional thoughts. causing them to become habitual (Dollard & Miller. What does he or she do to try to control the intrusions. and other neutralizing strategies. Foa. and prevent feared disastrous consequences? It is important to understand the patient’s beliefs about how these behaviors work. reading or hearing about violent crimes. it keeps coming back. The patient’s beliefs and interpretations of the intrusive thoughts are also assessed. as well as through clinical interviewing. Rachman.g. should be carefully assessed. Beck et al. The details of these behaviors. and thus often lead to further obsessions and distress. 1997. It is often necessary to spend time carefully introducing the concepts of neutralizing and mental rituals since patients might not recognize such behaviors as a part of OCD. she reported “testing” herself when she had urges to yell curse words in public places. “the thoughts .” Assessment also included a clinical interview and self-report measure of OCD symptoms (the Dimensional Obsessive-Compulsive Scale [DOCS]. 2006. using distraction or simply telling herself not to “think about it. Abramowitz et al.” Indeed. Cassie reported often trying to rid her mind of her unwanted thoughts. rationalizing the meaning of unpleasant thoughts) was assessed on a scale from 0 (none) to 8 (30 times or over 2 hours per day). Salkovskis.. Cassie also described “mentally reasoning” about the possibility that she would commit the acts she obsessed about.g. plays. since Cassie had reported difficulties with mood and anhedonia. knives. First. were considered normal stimuli that occur in 90% of the population (Rachman & de Silva. Neutralizing (rituals): Daily time spent performing neutralizing behaviors (e. and other “quiet places. Finally.228 Anxiety Disorders repeating “I’m good” helped to dismiss unwanted thoughts and to keep her reassured that she wasn’t the “kind of person” who would do such terrible things. lists of avoided circumstances are developed (e. Case Formulation Cassie’s difficulties were conceptualized using the evidence-based psychological principles described earlier (also see Abramowitz. such rituals have no natural terminus. 2010) and depression (Beck Depression Inventory [BDI]. Avoidance: The degree to which Cassie was avoiding situations associated with unpleasant intrusive thoughts was rated from 0 (never avoids) to 8 (invariably avoids).” in Cassie’s case). Cassie said that on some occasions she spent up to three hours engaged in this type of “analyzing.. Cassie described several types of rituals. and their function. it increased her chances of losing control and acting out. She believed that if she didn’t perform this ritual.. Her anxiety associated with such thoughts was considered a result of misinterpretations of the thoughts’ presence and significance (e. 1996). Cassie’s intrusive thoughts. Assessment data were used to test hypotheses about the validity of this conceptualization.. going to church. To this end..g. This involved sub-vocally whispering the curse word to make sure she could resist the urge to say it louder. For the purposes of monitoring progress through the course of treatment. 1978). Cassie’s therapist asked Cassie to rate the following symptoms during the assessment and weekly through the treatment program: Fear of intrusive thoughts: This was rated on a scale from 0 (none) to 8 (severe). 1996). however unpleasant. libraries. Research demonstrates that a combination of four psychological (cognitive-behavioral) treatment techniques is highly effective in achieving these aims: (a) psychoeducation about the universality of intrusive thoughts and the effects of avoidance and rituals. see Abramowitz. these strategies prevented Cassie from discovering that her intrusive thoughts were senseless and were not foreboding of inappropriate behavior. and the toll they had taken on her functioning. she was depressed about the obsessional intrusions and distress. In this case. along with presentation of corrective information. and they became “compulsive. will help Cassie to discover that such thoughts are not threatening. preoccupation. yet assessment suggested that these symptoms were secondary to her obsessional complaints. and increased thought frequency. Treatment Planning The case formulation described previously dictates that successful treatment of OCD must help Cassie learn that her intrusive thoughts are universal and harmless. Cassie resorted to them whenever intrusions occurred. Repeated and prolonged exposure to situations that evoke intrusive thoughts (i.. and that resistance to such thoughts is not only unnecessary.. Rachman. as well as to the thoughts themselves (i. Cassie had not experienced depressive symptoms until her OCD symptoms began to intensify over the last few years. Since Cassie’s OCD symptoms are conceptualized as a fear of intrusive thoughts.g. Yet because thought suppression. (b) cognitive therapy targeting mistaken beliefs about intrusive thoughts. Thus.. Cassie’s thought suppression attempts and avoidance of situations that triggered the intrusive thoughts were viewed as methods to prevent or control intrusions and related distress. Cassie reported depressive symptoms. corrective information consists of learning that disastrous consequences do not occur.e. indeed..e.Psychological Treatment of Obsessive-Compulsive Disorder 229 mean I am an evil person”). and rituals were sometimes effective in temporarily reducing distress. Rituals and neutralizing were conceptualized as methods of escape from intrusive thoughts already in progress. avoidance. It also suggests that Cassie must develop healthier (more realistic) ways of responding when such thoughts arise in order not to rob herself of opportunities to learn that her beliefs about such thoughts are. Cassie’s subjective resistance to the thoughts was actually serving to maintain her obsessional problem.g. “I will lose control and yell curse words”). situational or in vivo exposure). 2003). Exposure is thought to weaken the misappraisal of such intrusions and thereby to weaken fear responses to such thoughts . That is. but maladaptive (e. and (d) response prevention (for a review. (c) exposure. imaginal exposure).” In the long term. Foa and Kozak (1986) suggested that the reduction of pathological fear requires confrontation with the feared stimulus. 2006). as well as methods to prevent feared disastrous consequences (e. Her anxiety-driven attempts to suppress the obsessions merely led to greater attention to the thoughts. mistaken. the primary component of treatment is exposure therapy. g.. She also practiced gradually confronting situations that she had been avoiding because they triggered her obsessions (e. a hierarchy of situations and intrusive thoughts for exposure was collaboratively developed.g. libraries. The therapeutic relationship was also an important emphasis. Rituals and neutralizing strategies identified in the functional assessment were also targeted for either immediate or gradual fading. Lindsay. Wilhelm & Steketee. Response prevention. church services. coming across as confident and conveying strong beliefs about the efficacy of the intervention. and Cassie’s therapist introduced the cognitive behavioral model of OCD. The treatment techniques were also explained.e. Following the introduction of cognitive techniques. another necessary ingredient. and cognitive therapy are efficacious over and above nonspecific variables (e. Treatment lasted 16 sessions (session 16 focused on relapse prevention) and was conducted weekly. until anxiety was reduced by at least 50%) exposure was both practiced in-session and assigned between sessions.g. Cassie’s treatment began with two information-gathering/psychoeducational sessions during which rapport was built. during which Cassie learned techniques for logically disputing and challenging her mistaken beliefs about the significance and meaning of intrusive thoughts (e. Cassie practiced confronting her feared thoughts using a digital voice recorder in which she vocalized her intrusions and played them using headphones until her anxiety decreased (i. During the second session. During sessions 5 through 15. response prevention. The therapist acknowledged that these nonspecific factors were likely present. the functional assessment was conducted. For example. Repeated and prolonged (e. Nonspecific Factors in Treatment Nonspecific factors play a role in all forms of treatment for psychological problems.g.. The therapist recognized that a strong working alliance was necessary . Accordingly. habituation). 1997).. entails refraining from rituals and neutralizing. Cassie sought out treatment from a recognized expert in the treatment of OCD. knives). since these behaviors would foil exposure and would ensure that dysfunctional beliefs about intrusive thoughts remain intact. 2006). She therefore likely had expectations of improving merely because her provider was an expert. as discussed previously. cognitive-behavioral therapy for OCD being no exception. & Andrews. Next. Graded exposure (moving up the hierarchy at the patient’s pace) and response prevention were begun during session 5. Although there is scientific evidence that the specific techniques of exposure. it is important to take advantage of these factors since they are inexorably linked to psychological therapies. cognitive therapy was introduced in session 3. following her initial intake assessment.. Crino.230 Anxiety Disorders (Foa & Kozak. Cassie was instructed to go out to dinner with a friend and to hold her knife while thinking about stabbing her acquaintance. 1986).. and Cassie was given a rationale for their use. Cassie and the therapist considered alternative ways of thinking about her obsessional thoughts that were consistent with the conceptualization of OCD symptoms. For example. as opposed to needing to ask others for reassurance. Once Cassie began completing exposure exercises on a daily basis. Cassie felt that it was morally wrong to purposely think thoughts about harming others. which are anxiety-provoking. to get more oxygen into her body. not all patients show . given his past responses. Cassie was able to recognize that he would think it was all right. The second obstacle that arose during treatment was that Cassie became afraid that the anxiety provoked during exposures might harm her.Psychological Treatment of Obsessive-Compulsive Disorder 231 to cultivate the trusting relationship that Cassie would require before she would engage in exposure therapy techniques. She believed that this was in direct violation of the Bible. these ratings indicated that Cassie was improving. and she worried that such sinful behavior would offend God. Potential Treatment Obstacles Two potential obstacles arose during Cassie’s treatment. such as her racing heart (which she was afraid indicated a heart attack) and increased breathing (which she feared meant that she was going to suffocate). Cassie’s therapist dealt with this obstacle by spending time with Cassie teaching her about the various functions of the anxiety response (fight-or-fl ight system) so that she understood that the purpose of her heart racing was to circulate blood. Once Cassie understood that the purpose of anxiety (fight/fl ight) was to protect her from harm. Cassie decided that she would need to speak with her pastor to gain his permission before trying exposure. Thus. However. Specifically. It turned out that. Consequently. the intensity and frequency of her avoidance behavior. Because of her strict religious upbringing. the therapist asked Cassie whether she frequently sought reassurance from her pastor—which Cassie indicated that she did. and increased breathing. Cassie’s therapist therefore dealt with this situation by asking Cassie what she thought her pastor would say about doing exposure. which often amounts to asking the same (or similar) questions to religious authorities in search of reassurance that the behavior in question is not sinful. the therapist asked Cassie to rate her fear of the intrusive thoughts. the therapist helped Cassie to rely on her own judgment. in addition to obtaining Cassie’s subjective report regarding her progress. Many strictly religious individuals with OCD engage in such behavior. she was worried about the physiological signs of anxiety. and the severity of her neutralizing rituals. The fi rst obstacle was that Cassie expressed some reluctance to engage in exposure therapy due to concerns about being faithful to her religious beliefs. she felt more comfortable allowing herself to engage in exposure exercises. on numerous occasions. When Therapy Is Not Working Once each week. Cassie had already asked her pastor about her intrusive thoughts and had been told (on numerous occasions) not to be worried about these intrusions. Thus. Thus. mistaken beliefs about obsessional thoughts and situations can persist. Cassie’s therapist inquired about any rituals that she had performed to control her anxiety.. when this exposure task evoked little anxiety (unexpectedly). These difficulties can be easily overcome provided the therapist is constantly assessing to make sure each exposure item has a purpose and matches the patient’s obsessional fear. and additional assessment is needed. That is. and (c) performing neutralizing rituals immediately before. To this end. failure to make treatment gains can be attributed to one (or more) of the following problems. especially when practicing between sessions (without therapist supervision). (b) failing to confront the key anxiety-provoking elements of an exposure situation.232 Anxiety Disorders such improvement. Usually. leading to an ineffective treatment program. It is therefore not surprising that many patients “cut corners” or complete exposure inadequately. Before doing some of her exposures. during.g. The best way to tell whether exposure is being done correctly is to assess for the typical increase in anxiety at the beginning of the practice. PROBLEMS WITH THE IMPLEMENTATION OF EXPOSURE Exposure therapy is difficult since it requires that patients confront thoughts and situations that evoke uncomfortable levels of anxiety (without resorting to safety behaviors and rituals). for example. as opposed to prolonged. Examples include (a) conducting brief. PROBLEMS WITH THE TREATMENT PLAN One possibility is that the exposure hierarchy is missing key items. the therapist should inquire about whether the exposure exercises that comprise the treatment plan are well-matched with the patient’s actual fears. it is important to consider possible explanations. exposures in which the patient avoids becoming very fearful. and the gradual decrease in anxiety that occurs naturally with time. and do not do so in multiple contexts. involving the patient in developing the exposure hierarchy is critical. then the treatment hierarchy will need to be adjusted. if patients do not confront circumstances and intrusive thoughts that match closely with their actual fears. Cassie prayed to God to prevent her from acting on unwanted violent thoughts. Perhaps important anxiety-provoking elements have been overlooked. little or no anxiety is provoked). Perhaps the patient has difficulty articulating his or her fears. If they are not. it is best to review the rationale and procedures of exposure and to conduct exercises with the patient in order to ensure that future exposure will be implemented correctly. PROBLEMS WITH EXCESSIVE REASSURANCE-SEEKING A key aim of exposure therapy for anxiety is to teach patients (with OCD or other anxiety problems) to become more comfortable with an acceptable level . or after the exposure. When it is clear that exposure is being implemented improperly (e. When this is the case. focusing on how exposures are designed to evoke uncertainty for the patient. In such instances. in some instances it may be useful to allow a single consultation visit with an expert—for instance.) interferes with the treatment of OCD because it prevents direct exposure to the actual feared situation. even during exposure exercises. Cassie desired to speak with her pastor before conducting exposure to “sinful thoughts. However. On the other hand. or not?”). Some patients are particularly persistent at questioning the therapist to try to gain assurance of safety and have difficulty resisting this behavior.. As with performing compulsive rituals such as washing and checking or.g. this undermines the goal of teaching patients to live with acceptable levels of risk and uncertainty.. excessive reassurance-seeking (e.g. How can I help you to do that? . the therapist should supervise such a consultation to ensure that excessive reassurance seeking does not take place. 2011). The best way to stop the obsessional doubts is for you to work on tolerating the distress and uncertainty. mental neutralizing. asking similar questions to different people). A general rule that therapists can keep in mind is that questions about risk in a given situation should be answered only once.” Although the therapist was able to help Cassie see that such a consultation was unnecessary. there can never truly be an absolute guarantee of safety. or more subtly (e.. etc. asking the same questions to the same person). such as: It sounds like you’re feeling uncomfortable and are searching for a guarantee right now—that’s your obsessional doubting. it is likely that patients are obtaining reassurance—be it in an obvious way (e. it would not be helpful for you if I answered it again. When therapy is not progressing as expected. asking questions repeatedly. Additional attempts to gain assurance should be pointed out to the patient and addressed in an empathic way.. if doing so would prevent the patient from dropping out of treatment. the first inclination may be to ease the patient by guaranteeing her that she is not in any danger. Unnecessary reassurances of safety impinge on the match between the patient’s fear and the exposure situation and reinforce the excessive need for such an opinion in everyday life (which is not practical). Since I have already answered that question. scouring information. The most preferable response uses a compassionate approach. It is often useful to explain to patients that although exposure exercises present low risk.Psychological Treatment of Obsessive-Compulsive Disorder 233 of uncertainty (Abramowitz et al. sinful person.g. it is not necessary to try to convince the patient that she is indeed putting herself at high risk for negative consequences. However. in Cassie’s case. Requests for assurances from the therapist or an outside “expert” should be considered and discussed in light of whether or not they will be helpful for moving the patient toward overcoming their need for certainty. which involves being uncertain about the consequences. Patients with OCD vary with respect to how much they are able to manage uncertainty about obsessional thoughts (“Do these thoughts mean I am a terrible. Patients with OCD must learn to reduce their fears of uncertainty and compulsive urges to attain certainty. which is intuitively the opposite of what a treatment for anxiety problems would be expected to include. such OCD symptom accommodation will impede progress with exposure. we assert that it may be unethical to fail to consider exposure therapy in favor of less effective or unsubstantiated treatments. and then revisit the rationale for not providing such assurances. 2007). such as a patient making a statement about a homework exposure they are planning (“I’m going to go into the church and purposely think about curse words”) and then scrutinizing the therapist’s facial expression for signs of concern. Deacon. by taking issues of danger and risk into consideration when conducting exposure. FAMILY ACCOMMODATION Finally. carrying minimal risk of harming patients (Olatunji. In fact. if family members have been providing reassurance or assisting with other rituals. In such instances. 2009). indeed. it is important to determine whether family members at home are. by reviewing the cognitive behavioral model of OCD and the rationale for exposure-based therapy) to the family.234 Anxiety Disorders Reassurance seeking can also be more subtle. given its well-established effectiveness. Yet. it may place patients at greater risk than do other forms of psychological treatment. which aims to allow the patient opportunities to confront obsessional anxiety and avoided situations. It is unfortunate that ethical concerns related to maintaining proper boundaries may prevent some therapists from employing exposure therapy when indicated (Richard & Gloster. patients temporarily experience anxiety and fear during exposure. It is best for the patient and family to come to an agreement (perhaps in a session with the therapist’s arbitration) about how requests for assurances and help with rituals will be managed going forward. the therapist should inquire of the patient as to whether the statement constituted assurance seeking.. Effective exposure often requires accompanying .e. Indeed. For example. Similarly. if a patient’s family has been helping the OCD sufferer avoid certain situations out of concerns that the patient might become overly anxious or hostile. interfering with treatment progress by accommodating OCD symptoms. when cognitive behavioral therapy for OCD is not working as expected. the therapist should convey the reasons for ending this behavior (i. unwittingly. clinicians can significantly decrease the probability of harm. & Abramowitz. Yet the available research evidence demonstrates that exposure therapy is safe and tolerable. a major concern expressed by professionals and the lay public alike is that this treatment is unethical because it is harmful to patients. Ethical Considerations EXPOSURE THERAPY: IS IT ETHICAL? Despite the well-established benefits of exposure therapy. This is not to say that there are no risks in conducting exposure therapy. Many individuals with this presentation of OCD also view God as petulant. Instructions to flagrantly violate religious laws are neither appropriate nor necessary to reduce fears of committing religious sins. unethical. In cases where this is a significant concern for the patient. It should also be explained that exposure therapy can help the patient to become a more faithful follower of his or her religion since it can help him or her to trust (i. rather than actually eating food with mold. easily angered. exposure would involve taking acceptable risks such as eating food that is one day past its “sell by” date. Her pathological anxiety involves uncertainty over whether or not her food is contaminated. WORKING WITH STRICTLY RELIGIOUS PATIENTS Conducting exposure and response prevention with religious patients. for centuries. As an analogous situation. temporarily crossing a boundary). Informing patients that. Still. Deciding on the specific situations for exposure is one delicate issue. training manuals for pastoral counselors specifically recommend suggesting that people with such fears purposely . Deacon. theologians have prescribed strategies similar to exposure and response prevention for people with excessive fears of committing sins or offending God is another way to explain that exposure is not inconsistent with religious ideals. therapists should be aware that confidentiality can be compromised when exposure occurs outside the office. Exposure should entail situations that evoke doubts and uncertainty about sin. Cassie’s unwanted thoughts would not be considered violations by most religious authorities. 2009)..Psychological Treatment of Obsessive-Compulsive Disorder 235 consenting patients on field trips outside the office (i. but that are not actual violations. It is also important for therapists to help religious patients come to understand that the purpose of exposure is to help engender healthy religiosity. 1994). and vengeful (Abramowitz. various strategies may be employed to minimize the likelihood that confidentiality will be compromised. murder someone) and (b) remain remorseless. even though there is no actual confi rmation) that God understands the nonintentional nature of the thoughts and does not require reassurance. and harmful boundary violations (Gabbard. According to most religions. 2008). Indeed. Yet. such as Cassie. This issue should be discussed with the patient as part of the informed consent process. Therefore..e. not what to do when there is clearly mold growing on her food. have faith. rather than representations of their fears. as authors have pointed out (Olatunji. this practice is not inherently unethical and provides patients with an opportunity to confront their actual fears. which some view as problematic because this might increase the probability of inappropriate. presents a number of additional ethical challenges. Therefore. which is inconsistent with most religious doctrines.. as opposed to the use of religious rituals merely to reduce excessive fear of having committed sins.e. people have not sinned unless they (a) intentionally decide to do things that they know are evil (e. consider an OCD patient with the obsession that her food might be contaminated with mold. & Abramowitz.g. . The best way to avoid challenging obsessions is to ensure that intrusive thoughts are differentiated from misinterpretations and appraisals of obsessions. It is also usually illogical. Intuitively. One of these is the tendency to use cognitive therapy and exposure to try to challenge the validity of the obsessional thoughts per se. INCLINATION TO CHALLENGE THE OBSESSIONAL THOUGHT It is tempting for therapists to fall into the trap of challenging the logic of obsessional thoughts per se (e. “I have to be extra careful because I am a sinful person who could lose control and act badly at any time”). but rather as a stimulus about which the person has automatic thoughts and interpretations. It is these beliefs that require modification if treatment is to be successful..236 Anxiety Disorders act contrary to their “moral scruples” (Chiarrocchi. 1995). directly challenging the validity of these thoughts will likely have only a transient therapeutic effect. These missteps are described in this section. and information is provided about how they may be dealt with. this can be clarified if the therapist considers the unwanted intrusive thought not as the cognitive basis of distress itself. “the impulse to yell curse words in a library”) rather than challenging the patient’s faulty beliefs and interpretations of the thoughts (e.g. as opposed to the patient’s misinterpretation of the thoughts. obsessional intrusions are considered the “event” or “stimulus” about which the patient has dysfunctional beliefs. Moreover. (b) allowing oneself to purposely evoke “impure” thoughts. Yet.g. Because both are cognitive events. even if doing so might violate the rule in question. Chiarrocchi’s (1995) self-help book on scrupulosity (The Doubting Disease: Help for Scrupulosity and Religious Compulsions) presents an excellent discussion of this topic and is a useful resource for helping patients (and therapists) and clergy with ethical questions about the use of exposure therapy with religious patients. from a Beckian perspective. However. disentangling them can be tricky. . Common Missteps to Avoid in Treatment There are two missteps that many therapists make when working with individuals with presentations of OCD that are similar to that of Cassie. and (c) disavowing oneself of repetitive confessions and redundant prayer (Jones & Adleman. The second is allowing the patient to use cognitive therapy as a form of reassurance-seeking ritual. such challenges could turn into reassurance-seeking rituals or maladaptive neutralization strategies used in response to the particular obsession (as we discuss further below). 1959). Because most patients already recognize their obsessions as irrational. the obsession itself seems like a good target for cognitive therapy because it is both a cognition and foremost on the patient’s list of complaints. Specific guidelines include (a) emulating conscientious people. Her score of 8 on the DOCS and 5 on the BDI. taking “risks”). so such experiences will never be completely absent. recognized Cassie’s behavior as an OCD symptom rather than an appropriate cognitive intervention. after learning about the conceptual model discussed above. For example. evaluation of treatment outcome should include re-administration of any self-report and interview symptom measures. severity of avoidance behavior. indicated that she had made good progress (pre-treatment scores were DOCS = 26. aware of this tendency. Freeston and Ladouceur (1999) suggest that if the patient repeats the same cognitive analysis. it means that such material is being used for the purposes of neutralizing. Cassie also completed the BDI and DOCS. Moreover. is not zero. Cassie’s therapist asked her to provide current ratings of her fear of intrusive thoughts. Cassie was also told . rather than telling patents that they “probably won’t act out their thoughts.g. and frequency of neutralizing. holding a knife while sitting close to the therapist) to demonstrate that her feared consequences were unlikely. she felt that she had to repeat this phrase three times “perfectly” before she could stop the ritual. Like most patients. while acceptably low. Cassie was taught how to use her cognitive challenges to think less catastrophically about her intrusive thoughts. uses it in a stereotypic way. In contrast. Termination and Relapse Prevention ASSESSING TREATMENT OUTCOME In addition to informally assessing progress. At treatment termination.” it is better to explicitly say that the probability of acting on obsessional thoughts. the healthy use of cognitive therapy techniques allows the patient to generate new interpretations of obsessional stimuli that lead to acting appropriately during exposure (tolerating the distress. For example. Cassie at fi rst began ritualistically repeating the phrase “obsessional thoughts are normal” to reduce anxiety associated with her obsessions. therapists can reduce the chances that cognitive therapy techniques will become rituals by avoiding the provision of guarantees. However. In general. Cassie’s therapist. and then to engage in an exercise (e. Cassie reported some residual OCD symptoms. She was also initially preoccupied with fi nding the single “best” way of challenging her misinterpretations and identifying the phrase that “most completely” reassured her that she would defi nitely not act on her unwanted thoughts. treatment helped Cassie respond to obsessional stimuli in new healthy ways. it is possible for psychoeducational material and challenges to maladaptive beliefs learned in cognitive therapy to be converted into reassurance-seeking rituals or neutralization strategies. Her therapist emphasized that “normal” obsessions and rituals are a part of everyday life for most people. however.Psychological Treatment of Obsessive-Compulsive Disorder 237 WHEN COGNITIVE THERAPY BECOMES A RITUAL As mentioned above. or requires increasing efforts to reduce distress. BDI = 27).. For example. PREPARING FOR STRESSORS Cassie’s therapist explained that Cassie should expect to experience residual OCD symptoms from time to time. if available. Conclusions The treatment program used to help Cassie was based on a conceptualization of OCD symptoms (i. a less formal strategy involving telephone calls and less frequent (perhaps monthly) appointments could be undertaken. This assumption of normality. such as that run by a local affi liate of the International Obsessive Compulsive Disorder Foundation (www. Alternatively.g. coping mechanisms to reduce anxiety) that have their basis in normal human behavior and cognition. rather than implicating some cognitive deficit or brain dysfunction.. some patients desire additional treatment. Cassie’s therapist helped Cassie to identify potential “high risk” periods during which she could ready herself to apply the techniques learned in therapy if necessary. CONTINUING CARE Although Cassie was ready to end her course of treatment and continue working on her own to manage her residual OCD symptoms. these are triggered by increased life stress. as well as knowledge of how and why exposure works to . following a death or illness in the family. follow-up sessions can be considered (relapse prevention programs for OCD are described elsewhere [e. Patients who have a conceptual model for understanding their own difficulties. Clinical experience suggests that those who have made little progress after 16 to 20 sessions of cognitive behavioral therapy are unlikely to benefit further by adding additional sessions. intrusive thoughts. is another good option. such as in the midst of occupational or family confl ict. which can (and should) be demonstrated to patients.. This conceptualization involves empirically supported psychological phenomena and processes (e.g. Foa. 1994]).ocfoundation. If residual OCD symptoms are minimal. or around the time of childbirth. is often reassuring to individuals who fear that their OCD is a “brain disease. thought suppression.. Attending a support group.org). and (b) mental or behavioral rituals performed to reduce anxiety. obsessional thinking) that identifies two distinct phenomena: (a) intrusive thoughts or ideas that evoke anxiety. Hiss. Such individuals might be referred for supportive psychotherapy to help manage existing OCD symptoms.238 Anxiety Disorders that distress and functional impairment could be minimized with continued practice of the skills learned in treatment. Often.” Providing a clear and compelling model of OCD and rationale for treatment to patients is extremely important for successful treatment.e. yet there is concern about possible relapse. & Kozak. H.. In J. Mowrer. M. Teetering on the precipice: A commentary on Lazarus’s “How certain boundaries and ethics diminish therapeutic effectiveness. Losardo. H. 22.. J. 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In R. A cognitive theory of obsessions: Elaborations.. (2003).. S. 5–13.. Abramowitz. 35. Englewood Cliffs. S. Cognitive-behavioral approaches to the understanding of obsessional problems. New York: Guilford Press. A cognitive theory of obsessions. A. S. New York: Academic Press. C. R. Richard & D.. Deacon. Oakland. F.. Empirical investigations of thought suppression in OCD. (2009). E. (2004). G.. (1996). Behaviour Research and Therapy. Journal of Behaviour Therapy and Experimental Psychiatry. D. L. S. Comprehensive handbook of the exposure therapies (pp. Cognitive therapy for obsessive-compulsive disorder: A guide for professionals. The cruelest cure? Ethical issues in the implementation of exposure-based treatments. 505–517. NJ: Prentice-Hall. D.. T. factor analyses and testing of a brief version. 33–50). S. S. & Abramowitz. M. Carter. Wilhelm. 26(4). . 53. Attributions for thought suppression failure in obsessive–compulsive disorder. 121–136. Tolin. 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C. P. J.. S. T. the authors of this case were experts in the treatment of OCD and spent the time necessary to adequately understand Cassie’s clinical presentation and to design an appropriate treatment strategy. both CBT and medication may be necessary. The authors did an excellent and thorough diagnostic assessment. Of course. there may be differences in the specific homework activity that is selected and whether or not the therapist must accompany the patient when he or she completes initial homework assignments. OCD is a complex and severe disorder. For example. Early adulthood is a common age of onset for this disorder. a therapist may have considered this statement to represent a specific phobia and may not have probed further. In the most severe cases. a new job. Cassie’s case history is quite typical of people with OCD. but there is agreement that homework assignments are critical to positive treatment outcome. Certainly an event such as a story on the news about a boy who killed his parents in their sleep would be discomforting to most of us—but not everyone who heard that story developed OCD. and once weekly clinic sessions will not produce the desired treatment outcome. without a comprehensive understanding of all of the factors that may play a role in the etiology and maintenance of the disorder. there are many variations in how exposure therapy may be implemented. Again. “I am afraid of knives. Cassie may have come in saying. in addition to clinic treatment sessions. As illustrated by this commentary. If I were interviewing Cassie. I would have wondered. thereby neglecting Cassie’s fear of losing control and hurting her family. Another area of agreement was the use of homework assignments.” Without a thorough diagnostic assessment. As her therapist. Often. or a move away from home (Rachman & . but there is no disagreement that CBT is the treatment of choice for people with OCD. Medication may reduce general levels of arousal but is less effective in reducing symptoms of obsessions and compulsions. Beidel Cassie’s treatment illustrates the very effective use of cognitive behavior therapy to treat obsessive-compulsive disorder (OCD). Another area of agreement was the use of cognitive behavioral treatment (CBT).COMMENTARY Deborah C. novice therapists initiate treatment too quickly. the birth of a child. I would have pressed her for the specific circumstances in her life at the time when she pinpointed the onset of her fears. “Why that thought at that time?” Often the etiology of OCD is related to the presence of certain stressful life events such as marriage. Therefore. neglect of these factors represents one of the most common reasons for incomplete treatment or relapse. Cassie may have been at higher risk for acquiring a fear of behaving in an uncontrollable manner. until they were dead. over and over again. Understanding the potential role of stressful life events in the etiology of this disorder is also important for treatment planning and the long-term maintenance of treatment gains. because her obsession could not be reproduced in real life. A family member with OCD could indicate (a) the presence of a genetic predisposition that made her more likely to develop this disorder.242 Anxiety Disorders Hodgson. I would want to know if Cassie had other ritualistic behaviors. or flooding. and often it is a matter of therapist time and patient motivation when deciding whether to use a graduated or hierarchical approach. Cassie’s treatment involved creating a hierarchy of situations and intrusive thoughts. it is often necessary to teach the patient general stress management strategies to guard against relapse or reoccurrence. or (b) the presence of a learning history. Carrie’s flooding scene would also include her concern that such sinful behavior would offend God and that she would go to hell as a result of her actions. a thorough clinical interview is necessary in order to develop a comprehensive treatment program. perhaps at a sub-syndromal level that had been heretofore undetected. An alternative strategy is intensive exposure. Flooding is based on an extinction model of learning that states that behavior change occurs as a result of repeated presentations of unreinforced events . Whereas graduated exposure allows the patient to confront his or her fears in a controlled fashion. Thus. I would be most interested in personal factors that increased the likelihood that Carrie would develop a disorder. flooding would have involved creating an imaginal scene where she would imagine that she actually acted on her thoughts—specifically. Furthermore. understanding the factors that played a role in the frank onset of the disorder can be critical to maintaining treatment gains. confronting the fear that she had to be an evil person because only an evil person would commit such a horrific act. In Cassie’s case. in an environment of general stress (such as the stress of moving across the country for a new job or the stress of caring for a newborn infant). once symptoms are eliminated. Both approaches are efficacious. Family history would be an important but complicated area to investigate. 1980). whereby Cassie might have observed her parents or other relatives being overly worried and concerned whenever they heard about traumatic or violent events. Finally. Addressing current environmental stressors will enhance the efficacy of the immediate intervention. She would have been asked to graphically imagine walking into her parents’ room and stabbing them. Cassie would have been asked to imagine that she lost control and killed her parents with a knife. Basic conditioning studies suggest that people with higher levels of general physiological arousal more easily acquire fears when presented with fear-conditioning paradigms. This commonly used and highly effective approach is known as graduated exposure. flooding immediately immerses the patient in the situation/event at the top of the hierarchy. Both approaches involve engineering situations or events that allow patients to confront their fears. Given the severe and chronic nature of this disorder. as the number of presentations (sessions) increases. 1980). behaviors such as cognitive avoidance (e. In many instances. It is important to note that for within and between session habituation to occur. On the other hand. Foa & Kozak. as noted above. a confident therapist and a clearly explained rationale of the science behind the procedure will engage cooperation. unlike a more graduated approach. 1986. In Cassie’s case. cognitive restructuring. 1999. & Cahill. 1999. Radomsky. Such distractions are considered to interfere with the learning process that underlies extinction and undermine its effectiveness (Clark. cognitive distress. imagining that she is not really stabbing her parents but stabbing the mattress. the patient’s imagination of what occurs in the flooding session is far more extreme than the situation presented by the therapist. Foa & Kozak. Over a number of treatment sessions. Furthermore. treating Cassie with flooding would not include specific attention to cognitive restructuring. Roth Ledley. cognitions are considered a form of behavior and. or engaging in any type of avoidance behavior (e. shifting attention away from perceived threat cues to non-feared environmental elements). & Dugas. When Cassie can imagine stabbing her parents while they sleep without the elicitation of anxious distress. the peak anxiety elicited by the scene lessens and the time it takes for the arousal to return to baseline decreases. doing rituals in her head. 2006). the increase in anxiety followed by a decrease to baseline is known as within session habituation. symptom reduction is often achieved in a shorter period of time with the need for fewer sessions. Foa. Clark.g. 2002). a time frame not always appropriate for many clinical settings. 1986. 2007) must be avoided. Cassie’s flooding scene would include exposure to the physiological arousal. Parrish. For flooding as well as graduated exposure. & Grant. Homework refers to exposure exercises that Carrie would carry out between weekly sessions to generalize in-session treatment gains (Huppert. patients need to remain in contact with the feared object/situation and not engage in behaviors that would lessen the focus on the object or situation (Rachman & Hodgson.g. During any one session. 2008)...Psychological Treatment of Obsessive-Compulsive Disorder 243 (Baum. I would have accompanied . Sloan & Telch. From a strictly behavioral conceptualization. homework assignments represent an integral ingredient in exposure treatment for all modalities. 1970). and behaviors that are part of her obsession and to continue to imagine that scene until the elicited arousal has habituated (returned to baseline levels). Huppert. Hofmann. 2006. and attempts to physically or mentally escape (Barlow. Thus. The decision to use a graduated or intensive approach often depends on therapist and patient factors. because there is no need to proceed up a hierarchy. Mobini. would be included as part of the flooding scene. she would show between session habituation. & Foa. 2008. Flooding sessions are often at least 90 minutes in length. 2007. both flooding and graduated approaches require the therapist to accompany patients to actual places that are currently avoided—a therapy component known as in vivo exposure. Patients are sometimes resistant to flooding—however. Therefore. the repeated presentation of this exact same scene produces a pattern where. From the standpoint of a standard behavioral approach. indicating that her obsessions had been successfully treated. 2002. 37. that contribute to feelings of general anxiety or worry? Because we know that these factors can create stress. or problem-solving skills. E. Emotional processing theory: An update. The case description does not indicate if. S. 1400–1412.. (1999). Clark. Emotional processing of fear: Exposure to corrective information. 20–35. Hofmann. G. M.. additional anxiety management strategies may be needed. Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed. S. In B. a regular program of exercise. (2002). H. For example.). Hofmann. However. References Barlow. 128–139. patients are often unable to complete those assignments on their own (at least initially). Anxiety disorders: Why they persist and how to treat them.244 Anxiety Disorders her to church and stayed with her until her anxiety dissipated. Journal of Psychotherapy Integration. Anxiety-control strategies: Is there room for neutralization in successful exposure treatment? Clinical Psychology Review. E.. Mobini. therapists direct patients to do these assignments on their own. C. As noted. all designed to reduce her general level of distress and therefore reduce the likelihood of relapse.. (2006). & Foa. Radomsky. Cassie’s treatment was discontinued or if there was a second phase to the treatment. S. & Cahill. (2007). J. Psychotherapy: Theory..). Research. Psychological Bulletin. Extinction of avoidance responding through response prevention (flooding). 28. J. Practice. M. Clinical Psychology Review. . (2007). The use of homework in behavior therapy for anxiety disorders. (1986). 45. New York: Guilford Press. M. & Kozak. such as limited economic resources or specific family stressors. is she a person with high trait anxiety and therefore more likely to be reactive to specific life events? Are there overwhelming environmental factors. (2006).. Huppert. Psychological Bulletin. J. Cognitive processes during fear acquisition and extinction in animals and humans: Implications for exposure therapy of anxiety disorders. I would continue to see her to provide her with general anxiety management strategies. confronting actual fears is an important element of the treatment plan. 16. Baum. Roth Ledley. 1987–2001. Behaviour Research and Therapy. O. D. Behaviour Research and Therapy. leading them to conclude that “behavior therapy does not work.” As Cassie’s treatment plan illustrates. Pathological anxiety: Emotional processing in etiology and treatment (pp. B. G. L. M. 74. Huppert. (1970). 28. S5–S27. New York: The Guilford Press.. Foa. 276–284. J. after reduction of immediate obsessions and compulsions. 450–462. 200–211. E. it is imperative that they be considered. Foa. 44. & Dugas. such as relaxation training. 3–24). D. Training. D.. In many instances. S. & Grant. Clinical implications of attentional bias in anxiety disorders: An integrative literature review. Parrish. S. A. Enhancing exposure-based therapy from a translational research perspective. A. (2008). D. B. If they exist for Cassie. (2008). depending upon Cassie’s personal predispositions. Rothbaum (Ed. 99. B. D. P. . . Sloan.Psychological Treatment of Obsessive-Compulsive Disorder 245 Rachman. M. & Telch. Behaviour Research and Therapy. S. T. (2002). J. J. Obsessions and compulsions. 40. J. 235–251. The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation.. Engelwood Cliffs. NJ: Prentice Hall. & Hodgson. R. (1980). In fact.. it would be difficult to deem any attempt to determine such factors as much more than a guess or hypothesis that cannot be tested empirically. We typically explain to patients that OCD is caused by some combination of biological/genetic and learning/environmental factors—much like how cold air and moisture are both required to produce a blizzard. Although the patient was happily married without any history of homosexual encounters.. it is interesting to speculate about the possible factors that might increase one’s vulnerability to developing an anxiety disorder such as OCD. raises two issues in particular that we wish to comment on further: (a) the origins of obsessional fears. it is notoriously difficult to pinpoint the precise factors that might have led to the development of OCD symptoms for someone like Cassie. Beidel very thoughtfully raises a number of important points regarding the treatment of obsessivecompulsive disorder (OCD). can be learned in three ways (including combinations of these): (a) through personal experiences (e. Rachman. Beidel. Rather. Obsessional fears. he worried that his unwanted images of this man’s penis meant that he . As a result.RESPONSE Jonathan S.. (b) vicariously (e. Etiological Factors and Cognitive Behavioral Therapy As Dr. Accordingly. 1977). and (c) through the transmission of information regarding threat (e.g. however. And we agree with all of them. One example is a man with intrusive sexual obsessional thoughts about one of his male friends. becoming very ill after using a public toilet). we occasionally do work with OCD patients who describe conditions that are hard to deny as etiological factors. we prefer to use session time to develop and implement the treatment plan. It is also likely that the combination of factors is different for different OCD sufferers. All of this notwithstanding. Dr. watching or hearing about someone else becoming ill from a public toilet). like other forms of fear. Abramowitz and Brittain Mahaffey In her commentary on our case description of Cassie. Beidel points out. Dr.g. and (b) the use of distraction in exposure therapy.g. There might also be biological or genetic factors that set the stage for these learning experiences to really affect the individual. reading statistics about germs and illnesses found on public toilets. we do not spend much time trying to unravel the patient’s history or understand factors that might play a role in the onset of OCD symptoms. rather than distract themselves from. writing e-mails. 1986). but which cannot be directly observed. & Steketee. research indicates that focusing attention on the feared stimulus during exposure results in greater anxiety reduction and better outcome relative to distracting from the stimulus (Grayson.” or “You’re driving on a street crowded with pedestrians.” and that one can sin by thinking immoral things. the exposure stimulus. We also agree with Dr. Accordingly. Distraction versus distraction Dr. Indeed. 1982. this man volunteered that during his strictly religious upbringing he had been admonished time and time again by religious authority figures that homosexuality was wrong. On interview. “Look at you! You’ve got ‘bathroom germs’ on your hand but you’re putting on makeup. As a result. Behaviour Research Therapy. and you’re listening to your favorite song!” to reinforce that the patient can manage the situation and obsessional anxiety better than was thought. the majority of religious individuals do not suffer with obsessions and compulsions. Regularly asking questions such as “How are you feeling now?” “What are you telling yourself?” “What’s your SUDS (Subjective Units of Discomfort)?” is also a good way to maintain this focus and to continually assess thoughts and feelings during the exercise. which the patient might use to reduce anxiety. he engaged in compulsive praying and reassurance seeking regarding his “true” sexuality. judicious use of distractions in the therapy session—as well as repeatedly reminding the patient of what he or she is exposed to—can help the patient better achieve mastery over the obsessive fears. even in this rather clear instance. we feel it is also important for the patient to learn that he or she can function or “get along” in life while still exposed to the obsessional cue and while still feeling anxiety. 15. He also reported having learned through similar channels that “God knows all of your thoughts. . we encourage patients to focus on. even while patients engage in other activities. Thus. Beidel that it is important to assess for cognitive avoidance. 375–387. driving) while in the exposure situation so that he or she can get used to managing the situation and behaving “normally” while anxious. We use remarks such as. while deliberate distraction that functions as an escape from anxiety and a disruption from the obsession is likely to hinder the effects of treatment. the possibility that his religious upbringing contributed to the OCD symptoms was discussed merely as a possibility.g. However.. Foa. (1977). Yet. Indeed. we might shift the topic of conversation or help the patient to engage in some sort of routine activity (e. Thus. Beidel also raises the important issue of distraction affecting habituation of anxiety during exposure therapy.Psychological Treatment of Obsessive-Compulsive Disorder 247 was gay and would be damned to hell by God. Reference Rachman S. The conditioning theory of fear-acquisition: A critical examination. This page intentionally left blank . { PART IV } Psychotic Disorders and Organic Brain Syndromes . This page intentionally left blank . . 2007. negative symptoms. Affected individuals typically experience substantial impairments in personal. Such heterogeneity in illness features (e. The impact of these deficits can be catastrophic for the individuals as well as their families and communities.. which are areas of active research pursuits.. disorganization.. psychiatric. and substance use (Kavanagh et al. They can present with an array of comorbid medical (Carney et al. describe different modes of onset. Volkow. schizophreniform disorder...{ 10 } The Initial Evaluation and Treatment of Schizophrenia and Related Psychotic Disorders Belinda McIntosh and Michael T. Epidemiology and Key Principles Patients with schizophrenia and related psychotic disorders are identified at varying stages of illness. there is much heterogeneity in the way in which persons with schizophrenia present.. Schizophrenia has a higher prevalence in men than women.g. 2009) conditions. Schizophrenia is among the top ten causes of disability in the world (Murray et al.. cultural. Saha et al. 1997) and must be considered in the diagnostic formulation.. neurocognitive deficits) is likely underpinned by heterogeneity in etiology and pathophysiology. The lifetime prevalence of schizophrenia has been estimated at roughly 1% (Perala et al. and demographic factors add further layers of complexity to the presentation (Strakowski et al. 2006). Compton Despite advances in treatment approaches over the past few decades. Regier et al. 1996). Because accurate diagnosis is . 2002. 2003). and there is some evidence for an increased risk of schizophrenia at higher latitudes (Saha et al.. In addition to the epidemiological variability of schizophrenia.g. economic. and are seen in a multitude of treatment settings. 2004. 2006. schizoaffective disorder) continue to represent a class of disorders that are a leading challenge facing mental health clinicians today. Lyketsos et al. and social functioning.. Koskinen et al. 2005). 2010.. Social. 2002). with a ratio of about 1.4:1 (Aleman et al. schizophrenia and related psychotic disorders (e. Margolese et al. 2009. 1990. positive symptoms.. occupational.. Patients with schizophrenia and related psychotic disorders typically come to clinical attention after psychotic symptoms are manifested. M. He voiced concern that he may have attention deficit/hyperactivity disorder (ADHD) and complained of inattentiveness. Occasional headaches. However. anxiety. Mr. though he was never formally tested. He stated that in the past his teachers and parents remarked that he might have ADHD. Case History PRESENTING COMPLAINTS Mr. which sometimes caused him to miss work and school. care must be taken to consider all of these variables when assessing an individual presenting with psychotic symptoms. He could not provide a time line for these symptoms. reported occasional feelings of sadness and described recent and worsening anhedonia. mania. He did not recall having any problems with depression. or psychosis earlier in life. The following section details his initial presentation. impulsivity. He specifically requested stimulant medication for ADHD. functional impairment due to premorbid declines in academic and social functioning. paranoia.” He also complained of difficulty remembering things and concentrating at work.252 Psychotic Disorders and Organic Brain Syndromes fundamental to planning treatment. M. course of treatment. and clinical outcome. He reported sleeping 16 hours or more per day. this was his fi rst encounter with a mental health practitioner. and any perceptual disturbances. being unable to get out of bed. as well as prodromal symptoms. He described a long history of vacillating between high self-confidence and very low self-confidence. muscle tension. distractibility. In this case. and feeling stressed. and all other depressive and anxious symptoms. . appetite changes. is often present long before the onset of psychosis. but stated that the previous two weeks had been particularly difficult. as with many. In fact. Such was the case with Mr. lightheadedness. substance use. He was recently reprimanded by his supervisor at work for tardiness and absenteeism. who presented to the outpatient mental health clinic with complaints of “feeling very depressed. and potential psychiatric comorbidity. He denied excessive worry. ADDITIONAL PERSONAL HISTORY His past psychiatric history was unremarkable. or treated. months passed before this diagnosis could be confi rmed. along with the ensuing work-up. M. This case illustrates the complexity of making a diagnosis of schizophrenia in a patient who presents with a vague history. nonspecific symptoms. diagnosed. and difficulty breathing were the only physical symptoms reported. He also denied grandiosity. is a 22-year-old single male college student and part-time employee at a coffee shop. and fidgeting. although schizophrenia was high on the list of differential diagnoses from early on. He reported having many acquaintances but no close friends.Treatment of Schizophrenia and Related Psychotic Disorders 253 He reported significant substance use. Assessment Strategy The clinician’s approach to assessing Mr. Key goals of the assessment included making a provisional diagnosis. the clinician observed the patient during the clinical interview. he was enrolled at the local community college. social. familial. which included alcohol and marijuana. but stated that he was teased by peers for having a foreign accent. he began attending a four-year college. Psychosocial history revealed that he was born in Brazil but immigrated to the United States with his family at the age of 12. However. time. he was drinking one-quarter to one-third liters of rum at least twice per week. his medical history was unremarkable. Once obtained. M. functioning. He began consuming alcohol at the age of 17. He was cooperative with the interview. Mr. Otherwise. based on his report. and social issues. Family history was significant only for unspecified anxiety disorders in two second-degree relatives. He described some difficulty making friends upon moving to the United States and starting middle school. examined within the context of any prevailing medical. Obtaining Mr. He described feelings of alienation from peers beginning in the 11th grade. after two years there. past medical. psychiatric. He did fairly well in school. and lived alone in an apartment near campus. he was expelled due to poor academic performance. M. M. earning average to above-average grades through middle and high school. and situation. MENTAL STATUS EXAM In addition to obtaining presenting complaints. At the time of presentation. and substance abuse history. ruling out potentially confounding diagnoses. He smoked marijuana occasionally over the previous two years at a rate of about twice per month. thereby acquiring significant additional clinical information. After graduating from high school. and overall health against which treatment response could be gauged. worked part-time. presented as a young man of average height and build who appeared his stated age. place. He was alert and was oriented to person. He denied any history of physical abuse. . He has never had a significant romantic relationship. the initial history was used to guide the rest of the assessment. Details of his birth and early childhood development were unremarkable. but his responses. He was not taking any medications at the time of the initial visit. Mental status examination on the initial visit was obtained during the course of a 60-minute in-person diagnostic interview conducted in the clinician’s office. involved consideration of his presenting complaints. At the time of presentation.’s medical history revealed that he had experienced a febrile seizure at the age of three years and had undergone a tonsillectomy at age nine. and establishing a baseline level of symptoms. substance abuse. Eye contact was poor. when asked about his current peer relationships. schizophrenia. In fact. he began by describing in great detail specific incidents that occurred in junior high school before ultimately responding that he had recently been rebuffed by a campus group that he was interested in joining. . frequently making references to being unusually smart and capable of thinking in ways that most people cannot. delusional disorder. CONSIDERATION OF DIFFERENTIAL DIAGNOSIS After gathering history from the patient and performing a mental status examination. increased alcohol and marijuana intake. I have a problem with my knee. based on his ability to tolerate the structure of the interview. volume. diagnostic considerations included a broad array of possibilities from the following categories: anxiety disorder. psychotic disorder due to a general medical condition. Thought process was mostly linear and logical. decline in functioning. He was quite talkative and exhibited normal rate. he was overly inclusive of detail. remain seated for an extended period. He denied any suicidal or violent ideation. He did. and substance use disorder. Insight and judgment were deemed to be limited..” Affect was incongruent and somewhat odd. and delirium must also be considered. mood disorder.. For example. Differential diagnoses when evaluating first-onset psychosis typically include bipolar disorder. M. 2010). however. but at times he was circumstantial. personality disorder. the potential Axis I diagnoses included prodromal schizophrenia. Psychomotor agitation was evident in that he shifted often in his seat. were often vague (impoverished content of speech). and await the completion of the clinician’s questions and comments before responding. There were rare instances of tangential thinking and on one occasion he made a loose association. and social withdrawal. Impulse control was observed to be fair. psychotic depression. and psychoactive substance intoxication or withdrawal (Del-Ben et al. In cases of older individuals and persons with medical problems. In general. Based on this review and consideration of the history.254 Psychotic Disorders and Organic Brain Syndromes though lengthy.. schizophreniform disorder. brief psychotic disorder. particularly the cognitive complaints. American Psychiatric Association. come across as somewhat grandiose. He said. He smiled inappropriately throughout the interview. psychotic disorder. schizoaffective disorder. but he described it as a thought exercise rather than a special power.” He denied paranoia and did not demonstrate overtly delusional thinking. An early challenge in treating schizophrenia and related psychotic disorders is to make the correct diagnosis as expeditiously as possible to avoid further treatment delay. and tone of speech. dementia. the clinician conducted a thorough review of symptoms through a diagnostic interview guided by the Diagnostic and Statistical Manual of Mental Disorders. He admitted that this sounded odd. At the end of the initial encounter with Mr. substance-induced psychotic disorder. 2000) criteria. In order to narrow the list of differential diagnoses in the case of Mr. the clinician gave thought to potential differential diagnoses. ADHD. “I was picked on in school. 4th edition (DSM IV-TR. M. he talked about reading other people’s thoughts as a means of entertaining himself. Mood was reported as “stressed. unraveling Mr. These conclusions provided the basis for the decision to begin Mr. there were no indications that he posed an imminent risk of causing harm to himself or others. M. the clinician arrived at the provisional diagnosis of prodromal schizophrenia. onset characteristics and duration of those symptoms. Given the mild thought disorder and odd thinking. ADDITIONAL HISTORY AND REPEATED MENTAL STATUS EXAMINATIONS A complete assessment can often take more than one session because it involves ascertaining relevant details regarding presenting symptoms. and sleep disturbance. and considering the concomitant social and academic dysfunction. developmental. unsuccessful in gaining any collateral history on this initial visit. and academics Axis V: Global Assessment of Functioning (GAF) = 55 The clinician was. it was also important on Mr.’s treatment on an outpatient basis.’s fi rst visit to determine whether there were any acute safety issues requiring immediate attention. medical. alcohol abuse.’s diagnosis would require additional visits. M. cannabis abuse. . as Mr. and substance-induced mood disorder. cognitive decline. unfortunately. the extent of impairment in functioning. M. This information is derived from a thorough review of the patient’s past psychiatric. work. social. As with many such evaluations. M. and predisposing and precipitating factors. ASSESSMENT OF RISKS AND SAFETY Besides establishing a provisional diagnosis. psychological. In this case. The clinician incorporated medical. He also demonstrated sufficient capacity to care for himself in his existing surroundings. and functional information into a complete multi-axial diagnostic assessment: Axis I: Prodromal schizophrenia (provisional) Rule out attention deficit/hyperactivity disorder Rule out alcohol abuse Rule out cannabis abuse Rule out substance-induced mood disorder Axis II: Deferred until more longitudinal information can be gathered Axis III: History of febrile seizure History of tonsillectomy Axis IV: Moderate psychosocial stress due to problems with primary support.Treatment of Schizophrenia and Related Psychotic Disorders 255 ADHD. was estranged from his parents and was reluctant to allow the clinician to contact his coworkers. The conclusion from this testing was that Mr. increasing signs of suspiciousness. assessment of a patient continues beyond the initial visit and includes gathering more details by obtaining collateral history from other sources. Frequently. Key questions guiding the ongoing assessment originate from the developing differential and provisional diagnoses. such as family and peers. There was a slight elevation on the paranoia scale of his Minnesota Multiphasic Personality Inventory 2. stating that he had lost his “fi re. During subsequent visits. but it did not rise to a level of clinical relevance. By the . A urine drug screen was negative. the clinician ordered a comprehensive metabolic panel. Among the tests administered by the psychologist were the Minnesota Multiphasic Personality Inventory 2 and the Wechsler Adult Intelligence Scale III. One recommendation on the basis of these fi ndings might be to consider treatment with a psychostimulant. M. was a person of average intellectual ability who likely suffers from an attention deficit disorder with specific deficits in processing ability. PSYCHOLOGICAL AND NEUROCOGNITIVE TESTING The clinician referred Mr. since testing results were not available for a couple of weeks. as his symptoms unfortunately continued to evolve. M. and difficulties “getting [his] thoughts together”). Of note. Over time. As time passed. psychological. which revealed no abnormalities. there is little data to support the use of the MMPI in determining a differential diagnosis. brain magnetic resonance imaging (MRI) was completed. and subsequent drug screens were negative. and doing a variety of cognitive. though it can be helpful in understanding personality profi les. he began to express concern about being the subject of police surveillance based on a minor traffic violation that had occurred the previous year. social. the clinician had had the opportunity to observe Mr. and biological tests when indicated. complete blood count. M. or maladaptive personality features. He also reported lack of interest and motivation.’s complaints about cognitive symptoms progressed (e. M. Incidentally.” LABORATORY TESTS AND NEUROIMAGING In order to exclude potential medical causes for his reported decline in cognitive functioning. the mental status examination was repeated. Despite the lack of evidence favoring brain imaging as part of the diagnostic workup for fi rst-episode psychosis. odd and restricted affect. He denied using any substances during this time. for testing to assess his current level of psychological and neurocognitive functioning and to determine whether or not there were any cognitive deficits. and family history. all of which were determined to be within normal ranges.. as well as a mental status examination. perceptual problems.g.256 Psychotic Disorders and Organic Brain Syndromes substance use. and tests of thyroid function. and illogical thinking became evident. problems with concentration and memory. For example. Mr. who also possesses schizoid personality traits. Suspiciousness.’s reports of difficulties in middle and high school are consistent with those of many young people who later develop schizophrenia. he was floridly psychotic. By then. with improved insight and a fi rmly established rapport.. Mr. was experiencing the onset of a psychotic disorder and. as such. and adolescent sister and observed that Mr.’s tone toward his parents was at times hostile and at best indifferent. It involves impairments in attention. M. Yung et al. Indeed. M. Mr. He was also observed holding conversations while no one else was present and pacing at times. The clinician met with his mother. For Mr. presented with frank psychotic symptoms. father. Included within . was no longer enrolled at the community college. delusions).g. and deterioration in role functioning are common (Compton et al.. concentration. Relevant Aspects of the Early Pre-Treatment Course of Psychotic Disorders The schizophrenia prodrome. expressing bizarre persecutory delusions and reporting nearly constant auditory hallucinations. hallucinations.Treatment of Schizophrenia and Related Psychotic Disorders 257 time the testing results were available. M. the clinician felt certain that his initial symptoms had represented the prodromal phase of schizophrenia or a related psychotic disorder. especially during these episodes of talking to himself.” In retrospect. he had lost his job. M. the clinician had become highly concerned that Mr. M. As is not uncommon in the initial stages of treatment engagement. was reluctant to prescribe a stimulant. 2010. M. When he returned to the clinic three months later. 1996). M. defi ned as the time from onset of behavioral and psychological changes to the onset of frank psychotic symptoms (e. His mother and father expressed concern that he appeared to them “depressed” and “withdrawn. vague perceptual anomalies to frank hallucinations. refused. the onset of psychotic symptoms—the evolution from intermittent. 2010.. sleep. did not return to the clinic for three months and was unable to be reached. social withdrawal.” They stated that he was not maintaining his personal hygiene or contributing to the household. Even before the onset of prodromal features. although the prodrome had lasted at least two years. it became clear that the family knew very little about schizophrenia or about mental illnesses in general. individuals who later develop psychotic disorders commonly experience a subtle and gradual decline in both academic and social functioning during the “premorbid period. has been well characterized. and mood. drive. The clinician recommended a trial of an atypical antipsychotic. and had moved back to his parents’ home. On this visit. after extended time in treatment.. Mr. M. At that point. During this family meeting. which Mr.. and the emergence of persecutory delusions from initial suspiciousness—comprised approximately four months. Larson et al. during which Mr. described having an awareness of progressive losses in cognitive functioning and consequent academic decline over the preceding two years. he allowed the clinician to contact his family. the assessment of schizophrenia and related psychotic disorders is a multifaceted and sometimes protracted endeavor. Guided by DSM-IV diagnostic criteria. M. 2005. Perkins et al...). In ruling out an affective psychotic disorder. such as anhedonia and dysphoria. Though psychological and neurocognitive testing and brain imaging were included in Mr. and medical tests. Compton et al. given that families commonly initiate treatment seeking (though that was not the case for Mr. mental status examination. or early detection and treatment. 2011. 2004). the patient’s symptoms—and the evolution of those symptoms over time—were considered to make a firm diagnosis of schizophrenia. Secondary prevention. openness to education about the illness. anhedonia and hallucinations were more specific for schizophrenia than other markers (Gelber et al. the predominance of auditory hallucinations. The duration of untreated psychosis has drawn substantial interest in the field of psychology and psychiatry. given convincing evidence that a longer period of treatment delay is associated with diverse poorer early-course outcomes (Marshall et al. 2010). In a study differentiating affective psychoses from schizophrenia. may have been spurred by an attempt to self-medicate some of the emerging symptoms.258 Psychotic Disorders and Organic Brain Syndromes these recent months. Oliveira et al. the clinician considered the relative lack of affective symptoms. Given the . Patients presenting with an exacerbation of multi-episode schizophrenia are often more easily identified as having schizophrenia than are first-episode patients. Ruling out a primary substance use disorder and a substance-induced psychotic disorder was crucial given the patient’s history of marijuana use. and anhedonia. psychological and neurocognitive testing. The clinician also considered that the age at onset of prodromal and psychotic symptoms were consistent with the typical course of schizophrenia. This allowed the clinician to rule out the possibility that the psychotic symptoms were directly induced by the physiological effects of a psychoactive substance. the clinician considered positive and negative fi ndings from the history (reported by patient and family). which characterized his prodromal state. As this case demonstrates. is another critical interval that has been referred to as “duration of untreated psychosis” (Compton et al. His early substance abuse. 2005). The family’s level of awareness. An extensive exploration of his history of substance abuse and subsequent drug testing revealed a relative lack of correlation between the onset of psychosis and the use of substances. which began in high school. and willingness to support the treatment plan are critical factors to consider in treatment planning and determining prognosis.. such tests are not always performed on first-episode patients and are not required in order to make the diagnosis of a psychotic disorder. Engaging families is of utmost importance.. in this case. can be promoted through efforts to reduce the duration of untreated psychosis. or the period that occurs after that onset of psychosis and before treatment is sought or initiated. INITIAL CASE FORMULATION In formulating this case. 2008.. M.’s assessment. paranoid type.. the baseline physical and neurological examination is crucial. he admitted to having taken high doses of stimulant medication along with the risperidone. they agreed to a trial of antipsychotic medication. Despite starting risperidone. Mr. Mr. the initial prognosis was relatively poor. While in the crisis stabilization unit. ongoing pharmacotherapy. 2009). Although this development raised the suspicion of stimulant abuse possibly leading to the development of psychosis. he was stabilized on a final dose of 4 mg of risperidone and was transferred to a residential treatment facility where individual and family psychoeducation. M. and his family wanted to avoid hospitalization. was started on risperidone 2 milligrams (mg) at bedtime. Of course. Treatment Planning Both pharmacologic treatment and psychosocial interventions are indicated in the treatment of schizophrenia. In this inpatient setting. after becoming verbally aggressive at home. Assessment As exemplified by Mr. substance abuse counseling. M.’s assessment. supplemented with collateral reports and any prior psychiatric records. family therapy. the initial medical evaluation serves as a baseline for future comparisons in terms of potential side effects of the chosen pharmacologic agents. was admitted to a crisis stabilization unit a week later.. given that antipsychotic agents will be started. psychiatric. M. Mr. Much of the remaining assessment pertains to excluding medical causes of psychosis and identifying any medical. M. Of note. the initial evaluation of a potential psychotic disorder requires a multipronged approach. In keeping with the established guidelines for the treatment of fi rst-episode nonaffective psychosis using second-generation antipsychotic agents. received treatment in outpatient. social and vocational skills training. Furthermore. obtaining all relevant aspects of the history. although the patient and his family were initially highly resistant to accepting the diagnosis of schizophrenia. impairment in affect and functioning. He stated that he felt too slowed down by the risperidone and thought that the stimulant would help with his thinking. Thus. . over time. M. especially movement abnormalities and metabolic side effects (Freudenreich et al. expressing a strong preference for a trial of outpatient treatment. and cognitive behavioral therapy were core parts of the treatment program. and partial hospitalization settings at varying points depending on the nature of his symptoms and his ability to engage in the process. and lack of insight on the part of the patient and the family. and substance abuse comorbidities. is a necessary first step. reported cognitive decline. inpatient. Mr. the primacy of psychostimulants contributing to the development of psychosis was not borne out.Treatment of Schizophrenia and Related Psychotic Disorders 259 relatively early age at onset and the insidious course. an electroencephalogram is commonly done to rule out temporal lobe epilepsy if clinical features are consistent with this. erythrocyte sedimentation rate and antinuclear antibody). social skills training. specific fi ndings from such scans (e. During the initial evaluation. 2009. supported employment. supportive housing. This genetic syndrome. 2006).. complete blood counts. Psychosocial interventions include psychoeducation.. 2001). thyroid stimulating hormone. and immune disorders (Shprintzen et al. 2001). Additional tests may be warranted... family therapies. They include pharmacologic and psychosocial interventions aimed at reducing symptoms and fostering recovery in patients with schizophrenia and related psychotic disorders.g. McKay et al.. 1997).. PHARMACOLOGIC TREATMENT OF SCHIZOPHRENIA Pharmacologic treatment of psychosis in schizophrenia calls for the use of antipsychotic medications. congenital heart anomalies. 2010) and the American Psychiatric Association (Rose. 2005). as well as testing for neurosyphilis and human immunodeficiency virus. The fi rst-generation antipsychotic medications exert therapeutic effect through blockade of dopamine D2 receptors. such agents . family history.. Integrated substance abuse treatment is indicated in many patients with schizophrenia who present with concurrent substance abuse or dependence. Although the need for routinely conducted neuroimaging during the first-episode evaluation continues to be debated (Compton et al. and vitamin B12. and epidemiological/environmental considerations (Freudenreich et al. ceruloplasmin. characterized by variable phenotypes such as cleft palate. depending on the clinical picture.260 Psychotic Disorders and Organic Brain Syndromes Commonly ordered laboratory tests include basic metabolic markers. inflammatory markers (e. 2009). testing for chromosome 22q11 deletion (velo-cardio-facial syndrome) may be warranted if certain clinical and morphologic features are present (Murphy et al. is also commonly performed. is associated with a lifetime prevalence of psychosis of approximately 25 times that of the general population (Hodgkinson et al. Finally... Pharmacologic treatment of schizophrenia includes antipsychotic medications as well as a number of adjunctive agents for treating associated symptoms and side effects. using either computed tomography or magnetic resonance imaging. Neuroimaging.g. and cognitive behavioral therapy for psychosis. However. assertive community treatment. Treatment The following recommendations for treatment during the acute and chronic phases of schizophrenia are based on the most recent guidelines from the Schizophrenia Patient Outcomes Research Team (Kreyenbuhl et al.. diminished cortical volume and resultant ventricular enlargement) may enhance the confidence of the diagnosis and provide information that is relevant to treatment planning and prognosis (Lehman et al. 2004). . 2010.over fi rst-generation antipsychotic agents (Buchanan et al. 74% of patients had switched to another agent or had discontinued treatment by the end of the 18-month trial.. Olanzapine was associated with the lowest discontinuation rate. the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the Cost Utility of the Latest Antipsychotics in Schizophrenia Study (CUtLASS). history of adherence. The American Psychiatric Association (APA) guidelines for the treatment of schizophrenia call for the use of second-generation agents in first-episode patients due to the increased risk of extrapyramidal side effects and tardive dyskinesia with the fi rst-generation antipsychotic medications (Dixon. The recently published guidelines are influenced by conclusions from two large studies of antipsychotic effectiveness. quetiapine. The primary outcome measure was time to discontinuation of randomized treatment. The other second-generation antipsychotics demonstrated no significant advantage over perphenazine. Though prior studies suggest that second-generation antipsychotics are superior to fi rst-generation agents in preventing relapse.and second-generation antipsychotic medications. The CUtLASS trial compared quality of life in 227 patients living in the United Kingdom who.Treatment of Schizophrenia and Related Psychotic Disorders 261 can cause significant extrapyramidal side effects. in terms of time to discontinuation.. Metabolic side effects were greatest with olanzapine. as well as diverse side effects related to their effects at other receptor types. 2006). In contrast. This study revealed no difference in outcome between the fi rst. The second-generation antipsychotic agents similarly antagonize dopamine receptors but also block serotonin 5HT2A receptors.and second-generation antipsychotic treatment groups (Jones et al. or to the fi rst-generation antipsychotic perphenazine (Lieberman et al. and costeffectiveness in deciding on an antipsychotic medication. 26. the Schizophrenia Patient Outcomes Research Team (PORT) recommendations give no preference to second. They were randomized to receive either a fi rst. due to inadequate response or adverse effects. risperidone. Rose. CATIE was a large National Institute of Mental Health (NIMH)–funded pragmatic comparison of the effectiveness of fi rst. In this study. The study revealed substantial discontinuation rates overall.. with the specific agent being chosen by the treating physician. and 56 weeks post-randomization. patients were randomized to one of the then-available second-generation antipsychotic medications (olanzapine. 1997).or second-generation antipsychotic medications (with the exception of clozapine) as fi rst-line agents for the treatment of acute . Participants were blindly rated on measures of social and vocational functioning and overall quality of life at 12. were randomized to a trial of a different antipsychotic medication. at 64%. 2005). and ziprasidone). susceptibility to certain side effects. relevant medical history. the current recommendations support the use of either first. Both guidelines suggest consideration of factors such as current symptoms.or second-generation antipsychotic. The rates of extrapyramidal side effects were relatively low in all groups (Lieberman et al. 2010). history of past medication response. 2005). Though studies demonstrate that clozapine is more effective than other antipsychotics in the treatment of positive and negative symptoms of schizophrenia (Lieberman et al. The recommended dosage range for fi rst-generation antipsychotics is typically expressed in terms of chlorpromazine (CPZ) equivalents and is considered to be 300–1. The recommended dosage of antipsychotic varies by agent and is generally lower for fi rst-episode patients than for patients experiencing an exacerbation of multi-episode schizophrenia.. these involuntary movements can include akathisia. Lieberman et al.262 Psychotic Disorders and Organic Brain Syndromes psychosis in patients with prior episodes of psychosis (Buchanan et al. and some evidence suggests improved outcomes associated with long-acting injectables. Treatment with antipsychotic agents requires close monitoring for side effects and adverse events. Long-acting injectable formulations currently exist for several fi rst.. are associated with elevated risk for cardiac arrhythmias... 2010). it remains an option only for treatment-refractory patients because of the risk of agranulocytosis. Abnormal involuntary movements are common consequences of the use of high-potency antipsychotic agents such as haloperidol and fluphenazine.. and sedation. People with schizophrenia who. For treatment of first-episode psychosis in treatment-responsive schizophrenia. metabolic abnormalities. First-episode patients show heightened responsiveness to the therapeutic effects of antipsychotic agents. 2003b).. Olanzapine is not recommended as first-line in treating psychosis in first-episode patients (Buchanan et al. Clozapine is recommended for people with schizophrenia whose psychotic symptoms have not responded sufficiently to two adequate trials of other antipsychotics. through treatment with an antipsychotic agent. and tardive dyskinesia. orthostatic hypotension. Metabolic abnormalities. the recommended dosage generally falls within the lower half of the therapeutic range. though less likely to cause movement abnormalities.and second-generation agents.000 mg CPZ equivalents for an exacerbation of multi-episode schizophrenia and 300–500 mg CPZ equivalents for fi rst-episode patients (Buchanan et al. Low-potency antipsychotics such a chlorpromazine and thioridazine. acute dystonia. 2010). lipid profi le alterations. as well as increased sensitivity to side effects and adverse events. Recommended dosage range for second-generation antipsychotics for acute treatment of psychotic symptoms in treatment-responsive patients with schizophrenia has been published in the PORT guidelines (Buchanan et al. hepatotoxicity.. 2010).. weight gain. parkinsonism. The recommended dose is 300 to 800 mg daily (Buchanan et al. 2010). Some patients prefer a monthly or semi-monthly injection over the daily use of oral medications. metabolic side effects. 2003a. .. experience sustained relief of psychotic symptoms should be offered maintenance treatment to prevent relapse (Buchanan et al. 2010) due to the increased incidence of weight gain and metabolic side effects with olanzapine and considering the lack of consistently robust evidence that olanzapine is more effective than the other second-generation agents for the treatment of psychotic symptoms in first-episode patients (McEvoy et al. and other adverse events. including elevated glucose. The benefits of continuation of treatment with an antipsychotic agent beyond the acute phase of schizophrenia are well established. 2007). weight gain. 2010). Aripiprazole and ziprasidone have not been shown to cause significant weight gain or metabolic effects (Newcomer. many other common adjunctive medication strategies are not supported by the current recommendations. for the management of acute agitation in persons with schizophrenia (Buchanan et al. When treating psychotic symptoms in a patient with schizophrenia using a fi rst-generation antipsychotic agent. were approved by the Food and Drug Administration between 2009 and 2010 (Citrome. supported employment.. Paliperidone is a second-generation antipsychotic drug that was approved for treatment of schizophrenia in 2006. and asenapine. when considering such factors as prior history of extrapyramidal symptoms. 2010). Given insufficient evidence of the efficacy of adding lithium or an anticonvulsant to treat residual psychotic symptoms. family therapy . 2010) or the APA guidelines for the treatment of schizophrenia. First-episode patients are more susceptible to extrapyramidal symptoms when treated with high-potency fi rst-generation antipsychotics (Buchanan et al. family. The decision to start an antiparkinsonian agent should be made on an individual basis. Comparative studies of their metabolic effects are underway. The use of adjunctive medications in treating associated psychiatric symptoms in individuals with schizophrenia is common in clinical practice. 2010). three new antipsychotic medications.. However. Current evidence-based psychosocial treatments that are recommended for the treatment of people with schizophrenia include assertive community treatment (ACT). are common in certain second-generation antipsychotic agents and some low-potency fi rst-generation agents. social skills training. 2010). 2005). Olanzapine and clozapine are more likely than other second-generation antipsychotic agents to cause weight gain and glucose elevation. their use is not routinely recommended. This practice of “antipsychotic polypharmacy” is not supported by evidence to date and is not included in the PORT treatment recommendations (Buchanan et al. Since then. Current guidelines support the use of rapidly acting benzodiazepines. cognitive behavioral therapy. followed by quetiapine and risperidone.Treatment of Schizophrenia and Related Psychotic Disorders 263 and insulin resistance. current recommendations do not support the use of prophylactic antiparkinsonian agents to reduce the risk of extrapyramidal side effects (Kreyenbuhl et al. and community-based interventions. and characteristics of the chosen antipsychotic medication (Buchanan et al... THE PSYCHOSOCIAL TREATMENT OF SCHIZOPHRENIA Recommended psychosocial treatments for schizophrenia include individual. patient preference. 2005). which demonstrate an intermediate effect on weight and glucose metabolism (Newcomer.. Another common practice is the addition of another antipsychotic agent when psychotic symptoms fail to respond adequately to treatment with the fi rst antipsychotic agent. 2011). lurasidone. iloperidone. Studies show significant improvements in symptom reduction and functional outcome when psychosocial interventions are integrated with pharmacologic management. in conjunction with antipsychotic agents. 2010). . ACT consists of a multidisciplinary team that includes a medication prescriber. 2005).. Current guidelines for the treatment of schizophrenia also call for offerings in the area of environmental support (Kreyenbuhl et al. 2010). Though the current guidelines do not yet include recommendations for supported education or supportive housing. The most recently published APA and PORT guidelines specifically recommend supported employment as a means of improving functional outcomes in people with schizophrenia (Kreyenbuhl et al.264 Psychotic Disorders and Organic Brain Syndromes (including family psychoeducation). crisis management. Family interventions are recommended for people with schizophrenia who have ongoing contact with family members. is effective at improving treatment adherence (Pitschel-Walz et al. 2007). weight management has become increasingly important. For these reasons. and outreach to patients in the community. Cognitive behavioral therapy is effective in reducing positive and negative symptoms of schizophrenia (Turkington et al. 2010).. Current guidelines also recommend psychosocial interventions for weight management. 2004). including the use of multifamily groups. Critical components of effective family interventions include psychoeducation (Bauml et al.... Wykes et al. With the proliferation of prescriptions for secondgeneration antipsychotic medications over the past decade.. Current guidelines suggest that clinicians should implement a psychosocial intervention of at least three months duration . preventing relapse.. Lehman et al. Interventions aimed at reducing these two risk factors in patients with schizophrenia could improve overall health outcomes for these patients (Goff et al. 2006). In fact. and coping skills training.. Family interventions lasting longer than six months have been shown to decrease rates of relapse and hospitalization following a recent exacerbation of schizophrenia (Dixon et al. morbidity and mortality rates are persistently elevated among individuals with schizophrenia compared to the general population. and substance abuse treatment in individuals with psychotic disorders. supportive therapy. 2008). Pfammatter et al.. 2010). 2005). current guidelines support the use of individual and group-based cognitive behavioral therapy for the treatment of schizophrenia (Lecomte et al. employment. 2006). 2010... improves the acquisition and maintenance of competitive employment (Cook et al... common in patients with schizophrenia.. and reducing family burden (Pfammatter et al. Supported employment. 2008. 2008) and improving functional outcome. which integrates psychiatric and vocational services. ACT should be offered to people with schizophrenia who are homeless or at high risk of hospitalization (Dixon et al. low patient-to-staff ratios. Obesity and smoking. 2006). these interventions are clearly beneficial for many patients with schizophrenia. 2010. Family therapy. People with schizophrenia often benefit from additional support in the areas of housing. frequent patient contact. and education. are high-impact modifiable risk factors that can lead to significant medical morbidity and premature death. ACT reduces rates of hospitalization and homelessness in people with schizophrenia and related psychotic disorders (Coldwell et al. smoking cessation. 2006). and psychosocial interventions for weight management and substance abuse (Dixon et al.. the clinician consistently demonstrated interest in alleviating Mr. his attitude toward the clinician was much more amiable.’s own recovery goals. For . Mr. and weight monitoring. and difficulty with thinking. demonstrated an oppositional orientation toward his parents and other authority figures prior to and during treatment. The patient-centered approach includes prioritization of the patient’s own stated goals in treatment (Tempier et al.. 2010). Targeted substance abuse treatment that includes motivational enhancement and behavioral strategies should be an integral part of the treatment plan for all persons with schizophrenia who have a comorbid substance use disorder (Dixon et al. his functional impairment (due to negative symptoms and disorganization) led to unemployment and loss of health insurance. stress. some potentially significant obstacles to treatment are tied to symptomatology. have the potential to significantly affect treatment adherence. M. M. This was maintained throughout treatment. The clinician’s response to missed appointments was to discuss them in terms of Mr. TREATMENT OBSTACLES In schizophrenia. even though much of the treatment was aimed at decreasing psychotic symptoms. Though studies of psychosocial interventions to improve treatment adherence have yielded mixed results. though even brief interventions have been shown to improve substance abuse and psychiatric outcomes in patients with schizophrenia (Graeber et al.’s illness progressed. close attention to those environmental and psychoeducational strategies that may improve adherence to treatment are critically important. including patient and clinician factors. On the contrary. Discussion NONSPECIFIC FACTORS IN TREATMENT Nonspecific variables. Financial difficulty and challenges obtaining transportation limited the frequency of his follow-up visits. the fact that the clinician was relatively young may have contributed to the establishment and maintenance of a therapeutic rapport. Potential treatments were discussed with the patient in terms of his own stated goals. 2003). such interventions should include nutritional counseling. excessive sleeping. The optimal duration of treatment has not yet been determined.’s primary complaints of depression. In this case.. 2010). thus facilitating a sense of collaboration between the patient and the provider. The clinician strove to preserve the rapport by making continual efforts to join with the patient. 2010).. These considerations informed the selection of pharmacologic and psychosocial interventions. According to the guidelines. behavioral management.. M. M. using a patient-centered approach to treatment.Treatment of Schizophrenia and Related Psychotic Disorders 265 for patients with schizophrenia who are overweight or obese (Dixon et al. thereby influencing outcome. As Mr. In this case. initially there was no evidence that he was at imminent risk of harming himself or others. which would adversely affect his ability to maintain employment. Early in treatment. informed consent is crucial. non-adherence. WHEN THERAPY IS NOT EFFECTIVE Unfortunately. This changed after he became verbally aggressive and threatening at home.. M. Whenever treatment response is inadequate. benefits. there are many instances of inadequate response to treatment. Given the potential for significant metabolic. However. benefits. M. the clinician made the patient and family aware of the risks. and alternatives to the chosen treatment as part of the process of gaining informed consent. the family became more supportive of such interventions. it is important to consider possible explanations. has the capacity to provide or withhold such consent. In the case of Mr. in the treatment of schizophrenia. especially when working with a patient or family who are already skeptical or reluctant about initiating treatment. ETHICAL CONSIDERATIONS Obtaining true informed consent for treatment from a psychotic patient can be challenging. and alternatives to the proposed treatment. any patient. The laws governing involuntary hospitalization vary across the United States. The clinician paid sustained attention to developing a trusting relationship with the patient while providing psychoeducation to the patient and family.. this posed a significant obstacle because they were hesitant to agree to a trial of antipsychotic medication. M. the clinician must also weigh the potential benefits of the hospitalization against the impact that it will have on the therapeutic alliance and treatment course. substance use (including nicotine). therefore there were insufficient grounds for admitting him to the hospital against his will. . including but not limited to inadequate dosage. Another barrier to treatment was Mr. movement. In treating Mr.266 Psychotic Disorders and Organic Brain Syndromes example. At the same time. weighing the costs of the illness against the costs of the treatment. and environmental stress. he would be less likely to require hospitalization. who can demonstrate and articulate reasonable understanding of his or her illness. he was reminded that by keeping his appointments. regardless of psychotic symptoms. as well as the risks. Involuntary hospitalization presents a specific ethical dilemma frequently encountered by clinicians who treat patients with schizophrenia. When deciding on involuntary hospitalization. it can be tempting for clinicians to provide less information about potential risks of the medications. As his symptoms progressed. Treatment response was measured at follow-up visits by clinical interview. and other side effects with antipsychotic medications.’s and his family’s relative lack of knowledge about mental disorders. Since relapse prevention is intricately linked to treatment adherence. and developing an intervention plan. In the case of Mr. Such interventions include psychoeducation. of note. including patient.. cultural. Adjustments to pharmacotherapeutic and psychosocial interventions to decrease the burden of the treatment itself resulted in improved adherence to all treatment modalities. at any point. and other substances. treatment of schizophrenia is typically a lifelong undertaking. In the case of Mr. Stigma is one example of the latter. Once remission from psychotic symptoms is achieved. which is known to be associated with poor treatment engagement. schizophrenia is probably the most stigmatized of all health conditions. 2001) to increase the likelihood of positive treatment outcomes.. Available pharmacologic agents serve to reduce symptoms rather than bring about a cure. failing to engage the family (for patients who have significant and ongoing contact with family members). evidence-based practices were integrated within the recovery model (Frese et al. be influenced by multiple variables. M. A fi xed treatment plan. The treatment plan was continually reassessed and adjusted to accommodate Mr. including assessing the patient. approaches that enhance treatment adherence are likely to decrease the risk of relapse. or one that is not frequently reviewed. marijuana. peer support. While adherence is important. The treatment of schizophrenia is often a long-term undertaking. the treatment plan must also be adaptable. M. is essentially flawed and is likely to .’s changing needs and capabilities.Treatment of Schizophrenia and Related Psychotic Disorders 267 COMMON MISTAKES TO AVOID IN TREATMENT Common mistakes to avoid in treating patients with schizophrenia include naively challenging the patient’s delusional system. The course of treatment can.. Challenges with non-adherence were explored in individual treatment and group therapy. making a case formulation. and failing to continually reassess suicide risk. M. Conclusions This chapter has reviewed key principles in the initial evaluation and treatment of schizophrenia and related psychotic disorders. and societal factors. prematurely engaging in exploratory or insight-oriented therapy. Non-adherence is a frequently encountered barrier to effective treatment intervention. and abstinence from alcohol. Pharmacologic and psychosocial interventions help to improve and preserve functioning over the life span of persons diagnosed with schizophrenia and related psychotic disorders. relapse prevention becomes a significant priority in treatment. substance abuse and family support were significant modifiable prognostic factors to which the clinician paid close attention. failing to address comorbid substance abuse problems on an ongoing basis. RELAPSE PREVENTION Because the course of schizophrenia is commonly chronic. S1–9. asenapine. R.. Kelly.. 1279–1285. 123(2).. L.. M. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. (2009).. S. J. Mullins. are inherently superior.. H. 164(3). Compton. & Selten. 225–232. J. Journal of Clinical Psychiatry.268 Psychotic Disorders and Organic Brain Syndromes engender increased risk of non-adherence. Sex differences in the risk of schizophrenia: evidence from meta-analysis.. L.. A.. 21(11). Kahn. T. K. (2006). Fischer. B. A. C. McFarlane. M. predominantly African American population. S. M. M. F.. M. M. E. Characteristics of the retrospectively assessed prodromal period in hospitalized patients with fi rst-episode nonaffective psychosis: Findings from a socially disadvantaged. N. T. J. Compton. . M. (2005). (2010).. 72(2). Esterberg. M. Gold. 36(1). Bauml. An exploratory study of potential prognostic usefulness of the routinely conducted computed tomography scan in patients hospitalized for a fi rst episode of psychosis. T.. Clinical Schizophrenia and Related Psychoses.. 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B. R. 587–599. R.. R. 35(3). 58(10). 46(5).. M. J. Roizen. Volkow. W... (1990). and schizoaffective groups: Patients’ opinions and attitudes. Hachey. Bauml. 34(3). T. (2005). The confounding and potentially exacerbating role of drugs and alcohol is also characteristic and frequently complicates the diagnostic picture. despite the lack of supporting evidence. The authors also provide a sound overview of evidence-based treatments that should be considered. this section was necessarily too brief to give the reader an adequate sense of the richness and sophistication of current psychosocial treatments. Mr.. 2004) and an empirically supported behavioral treatment for substance abuse (Bellack. especially increasing social isolation. Bellack McIntosh and Compton have done an excellent job of describing the onset of schizophrenia in a young person. my colleagues and I have published book-length manuals on Social Skills Training (Bellack et al. The section on psychological treatments aptly pointed out that there are a number of evidence-based psychosocial treatments and that the complexity of the illness generally dictates a multidimensional approach. They aptly represent the subtle disease process that unfolds over time. It is clear that many individuals are not responsive to antipsychotics and that many others are only partially responsive. The section on polypharmacy should be mandatory reading for the legions of community providers who persist in the belief that polypharmacy is appropriate. due to space constraints. & Gearon. Bennett. at a circumscribed point in time. it appears that the common practice of adding a dab of this and a dab of that is more often iatrogenic than helpful and contributes to non-adherence as well as needless public expense. The section also did not underscore the fact that there are detailed manuals supporting each of the identified treatments and that effective implementation requires extensive training and systematic application of the manualized procedures employed in the clinical trials. with a common denominator of a gradual decline in functioning. However. The section on psychopharmacological treatments does an excellent job of summarizing the data on fi rst.versus second-generation antipsychotics and the critical role of side effects versus efficacy in selecting treatments. However. making differential diagnosis difficult. combining several psychosocial treatments and pharmacotherapy.COMMENTARY Alan S. For example. 2007). if not impossible. M expressed a number of vague complaints. and declining performance at school or work. As is the case with many young persons. Becker and Drake (2003) published a monograph on Individual Placement . it is a case management strategy that employs small. This syndrome includes inability to work or engage in gainful activities. The section on assertive community treatment (ACT. MMPI. chronicity is the central component of the illness. and the diagnosis turns out to have been correct over succeeding months. The justification for the provisional prodromal schizophrenia diagnosis is not entirely clear. Rather.Treatment of Schizophrenia and Related Psychotic Disorders 273 and Support. is an example of the complexity of assessing and treating young persons with symptoms of serious mental illness. few consumers with schizophrenia actually receive evidence-based psychosocial treatments and state-of-the-art pharmacotherapy. Nonetheless. a brief neuocognitive battery or a screening instrument such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS. whether at home. they do not address the equally important goal of preventing early illness from evolving into chronic disability. Stein & Santos. it is not a treatment per se. M. 1998) would have been more appropriate than an MRI.. As noted by the authors. including the risk associated with extended periods of untreated psychosis. in shelters. and WAIS was similarly unclear If there was some question about cognitive impairment. M. 1998) was somewhat surprising. Moreover. and at best there is minimal data to support the use of the MMPI in differential diagnosis. M. is a young person with recent onset of illness. For many individuals with schizophrenia and related serious mental illnesses. the most widely researched approach to supported employment. The case summary of Mr. several questions are raised by the summary. Mr. given the background clinical information provided. A manual for implementing McFarlane’s Multiple Family Group Treatment for working with the families of people with serious mental illness was also published as a book (McFarlane. many community clinicians operate under the false assumption that calling what they do by the same name as an evidence-based treatment makes it equivalent to doing it correctly. tangentiality. or on the street for homeless persons. its use is limited to highly impaired. In contrast to Mr. fi rst-episode persons. M. but the clinical report makes it seem as if the interviewer was more prescient than analytical. given that Mr. but the justification for the MRI. ACT is an evidence-based treatment that can be an extremely helpful component of a comprehensive approach for assisting people with serious mental illness. McIntosh and Compton clearly highlight the goal of preventing psychotic exacerbations and relapse. to engage . was not exhibiting hallucinations or delusions and reportedly manifested minimal thought disorder (some poverty of content. Randolph. However. and some additional points warrant consideration. chronic patients who are unable or unwilling to come to the clinic for care. 2002). and one example of a loose association). Unfortunately. However. Concern about fostering chronicity is especially important in the care of younger and fi rst-episode cases. As such. not symptomatology. ACT is both too costly and too intrusive for use with younger. it could be iatrogenic by promoting dependency and fostering chronicity. It was nice to see the metabolic and blood work conducted. interdisciplinary teams to provide comprehensive services where the patient resides. The decline in social and school functioning was certainly suggestive of an invidious process. Bertelsen et al. in press). 2008).. As was the case with Mr. to care for oneself and to manage one’s illness. Many younger persons will not come to treatment multiple times per week. and avoid the harmful effects of self-stigma and hopelessness. may be structured (Nuechterlein et al. and to suffer from self-stigma (negative. As in the case of supported employment. Peter McGorry’s program in Melbourne is a prototype for these innovative approaches (Cotton et al. they have not fully incorporated the self-stigma that characterizes chronic patients and often do not see themselves as ill or in need of care. However.and smart phone– driven strategies) as well as the aesthetics and lifestyle of younger persons. but they do not adequately emphasize that SE and supported education (a parallel approach focused on return to school) may often be the central treatment component around which other strategies. Prevention of chronicity is a primary goal of most first episode programs (e. including pharmacotherapy. Consequently. has been shown to be very helpful when tailored for the needs of younger persons.. Many chronic persons are used to coming to community mental health clinics multiple times per week and participating in diverse treatment groups. Amminger et al. A related goal for most young persons is resumption of normative social relationships. Amminger et al.. it should be emphasized that there are important clinical differences between the application of these strategies with fi rst-episode and more chronic persons. The lifetime prevalence of suicide among persons with schizophrenia is second only to those with major depression. and the rates are most elevated for younger males (Melle . Importantly.. Younger and fi rst-episode persons have by definition not been removed from school (or work) and the social environment for extended periods (often years).g. more chronic patients can be demoralizing and can provide unwanted modeling of chronic behaviors and expectations.. Emphasis is placed on helping the young person resume normative social activities. another evidence-based treatment. M.. computer. The Danish OPUS program is an excellent example of how SST can be incorporated into a program for recent-onset persons (Bertelsen et al. Importantly. and attending groups with older.. return to work or school is often a primary goal of the young person and can be a mutual commitment that connects an otherwise treatment-resistant young person to the treatment team. 2008). Treatment providers and other patients are often their primary social contacts. many innovative programs for younger persons have developed geographically and structurally distinct centers with a greater emphasis on technology (e. Treatment content and structure need to be adjusted accordingly (Ramsay et al. McIntosh and Compton accurately note the potential value of social skills training (SST).274 Psychotic Disorders and Organic Brain Syndromes in rewarding social interactions and maintain close relationships with others. maladaptive beliefs about the nature of mental illness and one’s responsibility for being ill).g. McIntosh and Compton note the use of supportive employment (SE). in press. 2008). social skills training (SST). 2011.. return to school or work. 2008). Consequently. Two other issues discussed in the chapter merit comment.. many persons suffering from schizophrenia gradually lose contact with peers and become socially isolated.. & Drake. S.. it should be underscored that state of the art practices. L. R. S. J. Harrigan. as described here. H. While there are no evidence-based practices for dealing with suicidal risk in young persons. The fi nal point pertains to substance use. M. S... & Agresta. reports regular use of a considerable amount. especially in regard to preventing the development of chronic disability. (2007). A working life for people with severe mental illness. However. it would be prudent to revisit this issue once a good relationship has been established. R. Behavioral treatment for substance abuse in people with serious and persistent mental illness. That is clearly a critical decision for the clinician. M. Becker. 2010). Mueser. New York: Guilford Press. D. M. H. It can generally be assumed that people with schizophrenia underestimate their use of substances. A. M. K. (2003). this issue warrants greater attention with Mr. (in press). However. Social skills training for schizophrenia: A step-by-step guide (2nd ed. E. McIntosh and Compton have done an excellent job of describing a typical case of early-onset schizophrenia. Schizophrenia Research. References Amminger. Conversely. alcohol abuse is a serious problem that contributes to non-adherence to mental health treatment and may itself exacerbate symptoms and increase disability. the discussion did not sufficiently emphasize some of the unique issues associated with treating younger persons. P... Many younger persons often start out receiving care paid for by their parents’ private insurance. Outcome in early-onset schizophrenia revisited: Findings from the Early Psychosis Prevention and Intervention Centre long-term follow-up study. there are a number of emerging strategies. P. J. D. the reader should be aware that suicidal risk must be assessed on an ongoing basis. New York: Oxford University Press. T.. Given that Mr. The public mental health systems that provide the bulk of care have neither the fi nancial resources nor the trained staff to provide a full complement of evidence-based practices.. Herrman.. . G. Bellack. are rarely available in the community.Treatment of Schizophrenia and Related Psychotic Disorders 275 et al.. New York: Routledge Press. The authors include alcohol abuse as a rule-out diagnosis and refer to the potential need for substance abuse treatment in young persons with schizophrenia. S.. S. Jackson. Bennett. Bellack. but they quickly spend down lifetime limits and are supported by Medicaid or (less frequently) Medicare. and this is an issue of considerable interest in the field. Henry.... (2004). M. While not necessarily germane to the task of outlining appropriate assessment and care. They aptly describe treatment options and underscore the importance of multidisciplinary treatment approaches that continue over time. J. as suggested by the authors. Gingerich. & Gearon.. M. In sum.). G. A. Alvarez-Jimenez. & McGorry. McIntosh and Compton underscore the importance of assessing for risk of self-harm during the initial presentation. but they focus on the decision to initiate outpatient versus inpatient care. P. including the pernicious decline in functioning. Harris. E. Whether or not he is using alcohol to self-medicate. Woodhead. & Drake. 14. Norton. Psychiatric Rehabilitation Journal.. I. Øhlenschlæger.. (2011).J. (1998). (1998). Stein.. T.Ø. Cristofaro. Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a fi rst episode of psychotic illness: The OPUS trial... 5. N. Vaglum. & McGlashan. Larsen. Simonsen.. T. C.. E. 31. R. Killackey. S. Le Quach.. B... San Antonio. Joa. (2008). Krarup. Life and treatment goals of individuals hospitalized for fi rst-episode nonaffective psychosis. Assertive community treatment of persons with severe mental illness.. I. P. Gleeson. Jeppesen. K. S. 158–170. D. Friis. Penn. A. (in press). W. K. Hall. M. B. Goulding... M. Thorup. R. J. T... Petersen. R. R.. Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment.. S. Subotnik.. P. New York: W.. H.276 Psychotic Disorders and Organic Brain Syndromes Bertelsen. Group programmes in early intervention services. Opjordsmoen. F.. E. Haahr. M. 340–349. Luxmoore. . Rund. A.. Early Intervention in Psychiatry. E. D.. K. 65. G. & Compton. Archives of General Psychiatry.. J. 259–266. W. Broussard. Nuechterlein. M. P. Repeatable Battery for the Assessment of Neuropsychological Status. Psychiatry Research. E. M. J. Albiston.. D.. Multifamily groups in the treatment of severe psychiatric disorders. D. M. S.. Christensen. G. (2002). D.... Becker. Course and predictors of suicidality over the fi rst two years of treatment in fi rst-episode schizophrenia spectrum psychosis. J. Melle. & Santos. L. TX: The Psychological Corporation. Ramsay. L. Johannessen. I. 762–771. S. Archives of Suicide Research. P. L. 2008. & Nordentoft. Kaslow. D... C. Turner. L. Ventura. R. (2010). Randolph. (2008). T. U. O. B.. McFarlane. & McGorry. Jørgensen.. New York: Guilford Press.. P. Cotton.. fi rst-episode patients like Mr. In this case. Dr. such as transient auditory hallucinations. Considered within the context of social and academic dysfunction. the odd thinking provided grounds for conceptualizing all the signs and symptoms parsimoniously under a single diagnosis. as rightly recognized by Dr. Yet. and sleep disturbance. M. and substance abuse treatment. He also points out that assertive community treatment and some other psychosocial treatments are geared toward the more chronically ill patient with schizophrenia. M. the presence of attenuated psychotic symptoms.RESPONSE Belinda McIntosh and Michael T. Bellack stresses the importance of working to avoid fostering chronicity and the development of internalized stigma in young people who are diagnosed with schizophrenia or a related psychotic disorder. In this case. Indeed. although many patients with schizophrenia receive pharmacotherapeutic and psychosocial treatments in keeping with the spirit of the recommendations. Bellack’s commentary highlights a number of important points in the assessment and treatment of patients with schizophrenia and related psychotic disorders. Bellack stresses that there are a number of manualized psychosocial treatments to guide clinicians wishing to provide evidence-based supported employment. benefit from treatment that promotes developmentally appropriate advancement in social. Compton Dr. . He emphasizes that. cognitive decline. social skills training. occupational. prodromal schizophrenia was the only one that captured all the presenting symptoms. He also aptly cites that the bulk of mental health treatment for patients with schizophrenia occurs in community mental health settings that lack the resources to adequately provide these treatments. would have bolstered the provisional diagnosis. Dr. the clinician determined that the odd thinking (the idea that Mr. Bellack. non-psychotic thinking and overt delusions. Among the diagnoses under consideration. the presentation falls short of meeting the usual defi nition for the schizophrenia prodrome. Bellack points out that the provisional diagnosis of prodromal schizophrenia seems prescient given the lack of hallucinations and delusions and the relatively mild thought disorder evident on initial mental status examination. and academic functioning. could read others’ thoughts and that his mind worked in ways that other people’s did not) lay somewhere on a continuum between mildly grandiose. often the treatments being applied are not evidence-based. Dr. 278 Psychotic Disorders and Organic Brain Syndromes More programs geared specifically toward young adults are needed. Such programs ideally would work in conjunction with local high schools, colleges, or universities to provide reasonable accommodations to facilitate the return to school, such as academic support through tutoring, as well as training in social skills, organizational skills, study habits, time management, and stress management. When effectively applied in academic and occupational settings, the recovery model can do much more than prevent functional decline—it can improve baseline functioning. Dr. Bellack also remarks on the lack of evidence in support of obtaining MRIs and conducting an MMPI as part of the diagnostic work-up for schizophrenia. As is the case with most real-life cases of new-onset psychosis, the evaluation was partly influenced by the conventional practice in the treatment setting to which the patient presented. In the case of Mr. M., an MRI was completed as part of the routine work-up for fi rst-episode psychosis. Dr. Bellack notes that there are scales in existence for measuring cognitive decline in putatively prodromal patients. In the case of Mr. M., the use of a scale such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) would indeed have been appropriate. In the case of Mr. M., upon being referred for testing, he presented to a psychologist covered by his health care plan, who administered tests, including the MMPI, based on his training and clinical suspicions. Dr. Bellack calls attention to the importance of ongoing assessment of substance abuse and suicide risk in patients with psychotic disorders. In particular, in a young person with a fi rst episode who demonstrates significant substance abuse, the need for ongoing assessment and motivational interviewing cannot be overstated. Given Mr. M.’s substantial alcohol use and the known deleterious effects of alcohol (exacerbation of symptoms, increased disability, and contribution to treatment non-adherence), it was important for the clinician to regularly revisit the issue of substance abuse. With regard to suicide, though Mr. M.’s risk was deemed low on his initial presentation, constant vigilance by the clinician was essential, given that suicide risk evolves over time with changes in age, level of insight, substance use, and other factors. Assessment of suicide risk and substance abuse on an ongoing basis should be accompanied by consistent implementation of evidence-based practices to diminish the associated risks. { 11 } A Contextual Approach to Dementia Care in Alzheimer’s Disease Christina Garrison-Diehn, Clair Rummel, and Jane E. Fisher Services in this case were provided by caregiver coaches employed by the University of Nevada, Reno Nevada Caregiver Support Center (NCSC), a grantfunded program designed to promote quality of life in dementia care, both for individuals with dementia and their family members. This case study involved a contextual intervention for a 91-year-old woman, Marilyn, and her 60-yearold daughter, Betty, who held power of attorney for Marilyn. Marilyn lived in a skilled nursing facility and was diagnosed with “dementia with behavioral disturbances,” chronic heart failure, and chronic kidney disease. Marilyn and her daughter were initially referred to the NCSC by a state senior advocate after the facility requested that Marilyn be temporarily moved to a geriatric psychiatric inpatient unit because she displayed increased crying behavior and “resistance to care.” Marilyn’s daughter, Betty, contacted NSCS coaches at that time for assistance. During the assessment, it was discovered that Marilyn’s change in behavior was due to pain related to a broken tooth. The tooth was repaired, and Marilyn’s behavior returned to baseline. Once Marilyn’s behavior returned to baseline, the facility withdrew the request that Marilyn be moved to the psychiatric unit. Five months later, NCSC staff were again contacted by Marilyn’s daughter in response to the facility’s request that Betty relocate Marilyn to another facility because her crying was disruptive to other residents and staff. Direct care staff reported that Marilyn’s increase in crying was due to her dementia, citing statements that Marilyn had made about wanting to see her father (her father had passed away decades earlier) as evidence that her crying was due to confusion and grief over her father’s death. Betty reported concerns about her mother’s health because the frequency and intensity of her mother’s crying had increased dramatically over the course of a couple of days. Betty also expressed concern about fi nding another local facility that would accept Marilyn, due to her high frequency of crying behavior and Medicaid status. 280 Psychotic Disorders and Organic Brain Syndromes Background Marilyn had lived in the facility for one year and was well liked by staff. According to her daughter’s report, Marilyn was a cheerful, affectionate individual who enjoyed interacting with people throughout her life. Following treatment for her broken tooth and the subsequent elimination of dental pain, NCSC coaches observed Marilyn’s interpersonal behavior in friendly interactions with staff: complimenting specific staff members, laughing and smiling regularly, and often holding the hand of individuals who visited with her. Marilyn also received ongoing services through the NCSC’s companionship program. The companionship program trains undergraduate psychology majors to work with people with dementia and pairs the students with NCSC clients who enjoy social interaction. The companionship program aims to increase positive social interactions available to the clients with dementia, as well as training future health care workers through dementia education. The program also involves an individualized behavioral monitoring component to assist in the detection of adverse events and excess disability (the behavioral monitoring system is discussed in detail in the assessment section below). Caregiver Coaching Betty visited her mother every evening and thus had frequent contact with nursing and direct care staff at the skilled nursing facility. Betty had received skills training from NCSC coaches on asserting herself in situations in which she felt she needed to advocate for her mother’s care at the facility. Betty had used these skills effectively in the past in advocating that a similar behavioral change (increased crying) was due to pain from a broken tooth. Betty initially advocated for her mother, noting to staff that the change in behavior was sudden and reminding them that pain was the cause of a similar behavior change in the past. Betty contacted NCSC coaches after skilled nursing staff responded to her concerns with comments that the behavior change was due to the progression of Marilyn’s dementia and that Betty needed to look for another facility for Marilyn. Medical Status Marilyn’s primary care physician prescribed four medications for her medical conditions. In addition, a psychiatrist had prescribed three psychiatric medications after being consulted by the facility staff regarding Marilyn’s crying and resistance to care. The psychiatric medications included Zoloft, Ativan, and Risperdal. Zoloft and Ativan were regularly scheduled, while Risperdal and higher doses of Ativan were prescribed PRN (on an as-needed basis). During the time that Marilyn was displaying a high frequency of crying behavior, she A Contextual Approach to Dementia Care in Alzheimer’s Disease 281 received the PRN medications every day, in addition to her regularly scheduled medications. NCSC staff observed Marilyn after she received a PRN dose of Ativan and were concerned by her presentation of being slumped to one side in her chair and nonresponsive. When asked about Marilyn’s presentation, facility staff reported that this was Marilyn’s response to the PRN administration. Marilyn was observed at other times after receiving a PRN dose of Ativan, slurring her words and continuing to cry. It appeared that the PRN use of the sedating medications was not reducing Marilyn’s distress but was impeding her ability to communicate. Key Principles and Core Knowledge Key principles in conceptualizing behavior change in persons with dementia that are: (a) degenerative forms of dementia produce deficits in an elderly person’s ability to tact, communicate, and respond effectively to adverse events such as pain, discomfort, and distress; (b) abrupt behavior changes due to adverse events often mimic declines due to degenerative dementia; (c) the misattribution of behavior change to irreversible neurodegenerative disease rather than a treatable adverse event is a leading cause of excess disability in older adults with dementia. CORE KNOWLEDGE The label dementia is a summary term for a group of symptoms caused by changes in neurological functioning that accompany certain diseases and conditions. Alzheimer’s disease (AD), the most prevalent cause of dementia, accounts for approximately 70% of individuals with dementia; vascular dementia accounts for 17%, and other diseases and conditions, such as Lewy body disease, Parkinson’s disease, frontotemproal dementia, and normal pressure hydrocephalus, account tor the remaining 13% (Plassman et al., 2007). AD affects an individual’s ability to express and comprehend language, recognize objects, execute motor activities, make sound judgments, and complete complex tasks. In addition, behavioral and emotional changes often accompany the progressive cognitive declines, including apathy, anxiety, repetitive vocalizations, and wandering. The dearth of treatment options to stop or reverse impairment caused by degenerative forms of dementia necessitates an increased focus on interventions that promote maintenance of adaptive skills and the prevention of the premature loss of behavior, that is, excess disability (Dawson, Wells, & Kline, 1993; Fisher & Carstensen, 1990; Yury & Fisher, 2007). Individuals with AD become progressively dependent on others for their care. Due to the decrease in cognitive functioning and verbal ability, caregivers fi nd it increasingly difficult to identify and manage their family member’s needs (Pinquart & Sörensen, 2003). Placement in a long-term care facility is common, with approximately 70% of individuals with dementia living in a facility at the end of their life (Mitchell, Kiely, & Hamel, 2004). The leading cause of long-term 282 Psychotic Disorders and Organic Brain Syndromes care placement is difficulty managing behaviors such as agitation, resistance to care, repetitive vocalizations, and wandering (Buhr, Kuchibhatla, & Clipp, 2006). These challenging behaviors, often referred to as neuropsychiatric symptoms or behavioral and psychological symptoms of dementia (BPSD), have a prevalence rate of over 60% in individuals with dementia (Lyketsos et al., 2002). The high prevalence rate, in combination with caregiver stress over how to manage these behaviors, has led to the implementation of a variety of pharmacological and behavioral interventions. The medical model of dementia considers challenging behaviors to be symptoms of neuropathology. Conceptualizing these behavior changes as symptoms of underlying disease entails interventions designed to reduce or eliminate symptoms and involves psychotropic medications as the first line of treatment. While there is some evidence for the efficacy of specific psychotropic medications to reduce behavior problems, such as agitation (Schneider, Dagerman, & Insel, 2006a; Sink, Holden, & Yaffe, 2005), research indicates that the adverse effects of these medications offset the advantages (see Ballard et al., 2009; Banerjee et al., 2011; Mittal, Kurup, Williamson, Muralee, & Tampi, 2011; Schneider et al., 2006b). Adverse effects of conventional and atypical antipsychotics include increased risk of falls, delirium, premature loss of language, depression, parkinsonism, akathisia, tardive dyskinesia, and antipsychotic sensitivity reactions (Ballard & Margallo-Lana, 2004; Kolanowski, Fick, Waller, & Ahern, 2006). Landi and colleagues (2005) found that elderly users of any psychotropic drug had a 47% increased risk of falls. Among the most startling adverse effects of antipsychotic medication is an increased risk of mortality in patients receiving these medications (Ballard et al., 2009; Mittal et al., 2011; Musicco et al., 2011). In a randomized placebo-controlled trial, Ballard and colleagues (2009) found that over 12 months the cumulative probability for survival was 70% in the treatment group (antipsychotic medication) versus 77% in the placebo group. Musicco and colleagues (2011) conducted a retrospective population cohort study in Italy and found that mortality was increased twofold in the group receiving atypical antipsychotics and increased fivefold in the group receiving conventional antipsychotics compared to the group not receiving antipsychotics. The serious risks associated with antipsychotic medications are particularly concerning, as estimates of antipsychotic use in nursing home residents with dementia range from 32–58% (Kamble et al., 2009; Ronchon et al., 2007). Given the high risk of adverse effects associated with psychotropic medication, they should be used only as a last resort after reversible conditions such as pain, infection, and medication interactions have been ruled out, functional assessment has been conducted, and behavioral interventions have been tried, and only if the behavior places the individual at risk of harm. Marilyn was prescribed seven drugs, which is not uncommon for an individual of her age and health status (Qato et al., 2008). Polypharmacy increases the risk of adverse drug reactions. Other factors that increase the risk of adverse drug reactions include depression, mobility issues, number of comorbidities, and specific drug types, including psychotropic, anti-infective, and anti-coagulants (Cecile et A Contextual Approach to Dementia Care in Alzheimer’s Disease 283 al., 2009; Field et al., 2001; Field, Mazor, Briesacher, Debellis, & Gurwitz, 2007; Gurwitz et al., 2000). The Contextual Model of Dementia Within the contextual model of dementia, challenging behaviors are viewed as the result of an interaction between the individual’s physiological state, learning history, and current environment (see Fisher & Carstensen, 1990; Fisher & Swingen, 1997; Hussian, 1981). An idiographic approach to assessment and intervention is taken because of the significant variability in the topography and etiology of behavioral changes across persons with dementia. The decline in verbal functioning that results from degenerative cognitive disorders results in an inability to accurately report internal psychological or physiological states such as pain, fear, and overstimulation, as well as a diminished ability to access relief. As a result, persons with dementia may communicate distress, pain, or an unmet need through behaviors that appear bizarre or inappropriate. The contextual model posits that challenging behaviors are adaptive in that they serve as a form of communication (see Fisher & Carstensen, 1990; Fisher & Swingen, 1997; Hussian, 1981). For example, a nursing home resident may engage in repetitive vocalizations as a means of auditory stimulation or to access attention from a staff member. Unfortunately, these behaviors are frequently misattributed to underlying neuropathology and the inevitable consequences of the disease. The misattribution of behavioral disturbances to the progression of dementia increases the risk of excess disability in persons with dementia. Excess disability is defined as impairment in functioning beyond that which can be accounted for by the disease (Dawson, Wells, & Kline, 1993). In a person with dementia, excess disability involves a premature reduction of the frequency of adaptive behavior, resulting in greater impairment than that due to the progression of dementia (Fisher et al., 2007). For example, although individuals with dementia will eventually lose all verbal abilities, the use of a psychotropic medication to treat aggression puts the individual at increased risk of premature loss of verbal abilities. Lending support to the contextual model are studies that have found that modification of the individual’s social and physical environment results in a reduction of behavioral problems and a decreased risk of excess disability (Ayalon, Gum, Feliciano, & Areán, 2006; Buchanan & Fisher, 2002; Burgio & Stevens, 1999; Cohen-Mansfield & Werner, 1998; Gitlin et al., 2010; Yury & Fisher, 2007). Ayalon and colleagues (2006) conducted a meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms in dementia. The analysis included three randomized control trials and six case studies utilizing a variety of interventions (unmet needs interventions, behavioral interventions, caregiving interventions, and bright light therapy) that decreased neuropsychiatric symptoms. Buchanan and Fisher (2002) conducted functional assessment 284 Psychotic Disorders and Organic Brain Syndromes with two individuals with dementia who were displaying disruptive vocalizations. The functional assessment results were used to determine interventions for the behavior (noncontingent reinforcement of attention and music), which reduced the frequency of disruptive vocalizations in both cases. Gitlin and colleagues (2010) conducted a randomized trial examining the efficacy of training caregivers of individuals with dementia in modifying the environment to reduce problem behaviors. The trial found a significant decrease in problem behavior in the treatment group (67.5%) over the control group (45.8%). Assessment Assessment focused on the detection of excess disability and factors contributing to reductions in adaptive functioning and increases in problem behaviors. Changes in Marilyn’s cognitive functioning, medical status, adaptive behaviors, and problem behaviors, as well as environmental factors associated with the occurrence of problem behaviors, were assessed. COGNITIVE FUNCTIONING The Mini Mental State Exam (MMSE) was used to monitor Marilyn’s cognitive status. The MMSE is a quick assessment of cognitive functioning, with scores ranging from 0–30 (Folstein, Folstein, & Fanjiang, 2001). A score of 24 or less is considered impaired, and a score of 10 or less is considered severely impaired (Perneczky et al., 2006). Marilyn received scores in the severely impaired range on the MMSE during baseline (times when she displayed mainly adaptive behavior and a lack of problem behavior), and she was unable to engage in the testing during periods when she was crying. ADAPTIVE AND PROBLEM BEHAVIOR MONITORING Undergraduate students visiting Marilyn through the NCSC companionship program were trained to monitor high frequency, typically stable adaptive behaviors and the occurrence of any unusual behaviors during their daily visits. Monitored adaptive behaviors are selected individually for each client with dementia. In Marilyn’s case, students were monitoring the occurrence of the adaptive behaviors of engagement in conversation, smiling, and eye contact. The students also monitored the frequency of crying as Marilyn’s problem behavior. Student observations of Marilyn corresponded with facility reports that there was an increase in her crying behavior and also indicated that there was a decrease in her adaptive behavior. MEDICAL STATUS NCSC coaches and Betty contacted Marilyn’s nurse care managers to inquire whether medical assessments had been conducted to rule out conditions such as A Contextual Approach to Dementia Care in Alzheimer’s Disease 285 pain, infection, or medication reactions that could contribute to the precipitous decline in Marilyn’s mental status. Nursing staff reported that Marilyn had been thoroughly assessed and that tests were negative for medical changes. During these interactions, it was emphasized to NCSC coaches and Betty that Marilyn’s increase in crying was due to her “dementia getting worse” and that the facility was no longer able to care for her due to the disruptive nature of the behavior. DESCRIPTIVE ASSESSMENT OF ENVIRONMENTAL FACTORS After inquiring about assessments to rule out medical changes, behavioral observations of Marilyn’s crying behavior were conducted by NCSC coaches to determine if environmental factors were contributing to Marilyn’s behavior. Coaches observed Marilyn across naturally occurring functional conditions. This type of behavioral assessment is referred to as a descriptive assessment, distinguished from an experimental functional analysis, in which possible functional conditions are systematically varied in a controlled manner and setting. Descriptive assessment was appropriate in the clinical situation, given resource limitations; and though descriptive assessment yields less conclusive evidence than experimental functional analysis (due to the correlation nature of the data), it is a useful tool (Anderson & Long, 2002; Lerman & Iwata, 1993) in the clinical setting. Marilyn was observed crying across naturally occurring conditions, including attention given (e.g., Marilyn was observed crying when staff and family members would speak or pay attention to her), demands placed on her (e.g., Marilyn was observed crying when staff and family members would ask her to do something), preferred items given to her (e.g., Marilyn was observed crying when items such as jewelry and food that she favored were offered to her), and when Marilyn was alone. Given the prevalence of Marilyn’s behavior across all conditions, it was determined that her crying behavior was not environmentally maintained but was likely due to something physiological or medical. Given the hypothesis that a physiological problem (e.g., pain) was causing the increases in Marilyn’s crying behavior, NCSC coaches again checked with the facility nursing staff to confi rm that medical assessments were conducted to rule out pain, infections, or possible medication changes that could contribute to the behavioral change. As mentioned earlier, nursing staff initially informed NCSC coaches that a urinalysis had been conducted and a urinary tract infection (UTI) had been ruled out. NCSC coaches asked for the actual urinalysis report ruling out the possibility of a urinary tract infection and discovered that it had been five weeks since the urinalysis was conducted. At that time, Marilyn’s crying behavior had been occurring for one week;, thus the crying behavior had begun a full month after the most recent urinalysis. A urinalysis was conducted and it was determined that Marilyn was suffering with a severe urinary tract infection. Marilyn was immediately put on IV antibiotics for the infection; as the infection cleared, her crying behavior diminished to baseline levels. Given this behavioral change, the long-term care facility withdrew the request that Marilyn move to another facility. Marilyn continued 286 Psychotic Disorders and Organic Brain Syndromes to enjoy visits from students in the companionship program, and her monitored adaptive behavior of making eye contact, smiling, and engaging in conversation returned to baseline levels. Epidemiological Considerations Marilyn’s dementia diagnosis was nonspecific and the etiology was unknown. Across and within the types of dementias, the rate of decline varies (Hui et al., 2003; Soto et al., 2008; Xie, Mayo, & Koski, 2011), based on a confluence of factors (see Behl, Stefurak, & Black, 2005; Gauthier, Vellas, Farlow, & Burn, 2006). Excess disability can convolute the assessment of cognitive decline, given that it reflects an accelerated declining trajectory (i.e., what appears to be a rapid decline may be due to another medical issue, rather than the underlying). In this case, NCSC coaches aimed to rule out possible causes of excess disability before considering the changes as due to Marilyn’s dementia. Initial Case Formulation NCSC coaches hypothesized that Marilyn’s change in problem behavior (increased crying) and adaptive behavior (decreased eye contact and smiling) was due to a medical condition that remained undetected due to Marilyn’s inability to self-report discomfort. This hypothesis was informed by the contextual model and Marilyn’s history of similar behavioral changes associated with tooth pain. Marilyn’s specific observed behavioral changes also indicated that she may be experiencing discomfort; crying is an observable behavior sometimes indicative of pain, and a lack of eye contact can be a sign of delirium (White & Bayer, 2007). Delirium is associated with illness, medical conditions, and adverse medication events and is often poorly detected in the dementia population by medical providers (Fick, Agostini, & Inouye, 2002). Diagnostic issues arose in that NCSC coaches work in the field of psychology and must abide within their scope of practice. Tests to rule out possible medical conditions or medication side effects are in the scope of medical providers. This was handled through asking what tests had been run and coaching Betty to advocate that medical issues, such as pain, be ruled out by the medical staff. NCSC coaches were limited by information given by staff (e.g., incorrect information about the date of the last urinalysis). Nursing staff made incorrect assumptions in assessing probable causes of Marilyn’s change in behavior. NCSC coaches are doctoral students training to be psychologists, not medical professionals, but they are aware that urinary tract infections and other adverse medical events such as pain are common causes of sudden changes in mental status in skilled nursing residents (Juthani-Mehta et al., 2009). Nursing staff at the facility also verbally reported during the period of Marilyn’s crying that they were aware that urinary tract infections cause leading to excess disability and unnecessary suffering on the part of the person with dementia. are often a sign of an adverse event such as medication side effects. pain. 1999. that it is the result of neuropathology) can lead to a lack of medical assessment and intervention of true medical issues (pathology). even though behavioral problems are not part of the dementia diagnostic criteria (see American Psychiatric Association. If nursing staff had approached Marilyn’s change in behavior from the contextual model. Yury & Fisher. in explaining behavior change in persons with dementia. as in this case. Because of the heuristic that behavioral problems are part of the progression of dementia. or heuristic error. these secondary issues can go undetected and untreated. One could surmise that Marilyn was suffering from extra excess disability—excess disability caused by the urinary tract infection and excess disability caused by the high doses of sedating medication. and can be reduced or eliminated in the absence of any change in the underlying neurological disorder (see Ayalon. 2010. Behavioral problems are often incorrectly conceptualized as a consequence of the progression of dementia. infection. Representative heuristics involve a choice made because it “reflects the salient features of the process by which it is generated” (Kahneman & Tversky. Marilyn’s urinary tract infection may have been identified and treated earlier. 1972. If nursing staff were aware of this phenomenon. the intervention model was out of the scope of the NCSC coaches and within the .A Contextual Approach to Dementia Care in Alzheimer’s Disease 287 changes in mental status. such as the UTI.. Once it was determined that the UTI was causing the behavior changes. The sedating medication reduced Marilyn’s ability to communicate her discomfort even more than the resulting change to her mental status caused by the urinary tract infection itself. Gitlin et al. 2006. 2000). 2007). or an overwhelming environment. & Areán. We would argue that the medical model’s view of behavioral challenges as symptoms of dementia contributes to this misattribution.. Feliciano.” Heuristics are cognitive shortcuts or rules that a person follows in making decisions. Buchanan & Fisher. p. the question emerges of why it took NCSC coaches inquiring about the specific date of Marilyn’s last urinalysis to intervene and result in the proper assessment and treatment of Marilyn’s urinary tract infection. which resulted in Marilyn suffering with a urinary tract infection longer than necessary and receiving sedating medication to reduce the crying. Nursing staff had decided that Marilyn’s crying was due to her dementia “getting worse” and that she was grieving her father. 430).e. 2002. Kahneman and Tversky (1972) describe heuristics as “subjective probability judgments. Behavioral disturbances in persons with dementia. Heuristics can be useful in many situations (children following the rule of not speaking to strangers) but can also lead to poor choices on the part of the decision maker (Tversky & Kahneman. reducing her suffering and preventing the excess disability. The nursing staff’s decision that the crying was related to dementia led to a lack of proper medical assessment. Burgio & Stevens. vary widely in incidence across persons with dementia. Gum. 1974). This conclusion constituted a representative heuristic error. It is ironic that a biological perspective of behavioral change in dementia (i. The antibiotic treatment was the necessary intervention to combat the UTI and behavior changes secondary to the infection. As mentioned above. Staff members often made statements to NCSC coaches that Marilyn’s dementia had gotten worse and that she needed to move to a more restrictive facility. Betty made several statements expressing gratitude to the coaches.288 Psychotic Disorders and Organic Brain Syndromes scope of her medical team. The ombudsman’s office conducted an investigation and intervened to prevent the facility from expelling Marilyn. Alliance with specific staff grew stronger over this time period. stroke. It can be argued that inadequate assessment and the subsequent administration of high-risk drugs for a behavior problem that was the result of discomfort due to an undetected medical problem fall within the realm of neglect. but consistently displaying warm and respectful behavior toward facility staff. Antibiotic medication for the UTI was administered long after acute behavior changes were observed by the staff. .. confusion. A behavioral modification intervention was not considered because the descriptive assessment did not give evidence to environmental factors. possibly causing the behavioral change. Betty contacted the state ombudsman’s office after the UTI was treated and Marilyn’s behavior returned to baseline. Nonspecific Factors Caregiver coaches worked closely with Betty in assessing Marilyn. these types of medications are associated with several risks. NCSC coaches responded by continuing to advocate to rule out excess disability. advocating for her mother with facility staff). such as increased falls. The facility’s request to Betty to move Marilyn due to her crying behavior also carries ethical implications. She displayed increased assertiveness (e. and death. Betty and her primary coach had strong rapport due to the previous incident of Marilyn’s tooth pain and ongoing caregiver support provided by the NCSC. following the direct instruction and guided practice that she had experienced through her coaching. Marilyn was given the sedating medication to control her crying behavior. at the same time that high doses of sedating medication were given to control her crying behavior. often displaying frustrated behavior that NCSC coaches were investigating Marilyn’s case. Facility staff members were initially less amenable to NCSC coaches. The untreated UTI caused Marilyn discomfort and distress that could have been avoided or at least lessened by proper. Ethical Considerations The inaccurate assumptions by staff about Marilyn’s behavior led to a severe UTI being untreated for several days.g. especially after the UTI was diagnosed. timely assessment and treatment. Washington. 137–154.. Marilyn died four months after this incident. Archives of Internal Medicine. several similar situations have been encountered across settings. Journal of Applied Behavior Analysis. Ballard. Dewey. DSM-IV-TR).. Assessment of Marilyn’s adaptive behavior and crying behavior was ongoing as a part of these services. R. . this case is not unique. 35(2).. G. The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomized placebo-controlled trial. 8. C.. Banerjee. & Black. A. 151–157.. one other UTI was discovered by staff. Baldwin.. Behl.. 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S. Reynish. Schumm. Prevalence of dementia in the United States: The aging.. M. 295–306. Dagerman. Predictive value of rapid decline in Mini Mental State Examination in clinical practice for prognosis in Alzheimer’s disease. 167(7). Fisher. S. A. N. L. & Yaffe. Clinical Case Studies. Journal of the American Medical Association.. N. (1974).. Ousset. (2007). L. S. P. 29. K..... Xie. 31(2). T. Qato. New England Journal of Medicine.. (2007). Arbus. K. Preventing excess disability in an elderly person with Alzheimer’s disease... 165–172. et al. 1124–31 White. S. (2008). C. 45–62. Neuroepidemiology.. S. Cantet. G.292 Psychotic Disorders and Organic Brain Syndromes Plassman. placebo-controlled trials. K. Tariot. Bronskill.. et al. J. Conti. Sykora. Stukel. K. L. . J.. S. Schneider. Science. A.. F. American Journal of Geriatric Psychiatry. Hsiao. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. L. P.. B. T. Ronchon.. Efficacy and adverse effects of atypical antipsychotics for dementia: Meta-analysis of randomized. H.. M.. 596–608.. & Koski.. Gomes. G. K. 125–132. 300(24). 14. D. M.. Heeringa. G.. & Fisher. K. Identifying and characterizing trajectories of cognitive change in older persons with mild cognitive impairment. 109–116. Dementia and Geriatric Cognitive Disorders. 293(5).. Variation in nursing home antipsychotic prescribing rates. S.. 6. (2005). Schneider. 191–210. 2867–2878. Ferguson. but we also need to develop an individualized formulation for each specific case. leading to staff misattributing her crying to the normal progression of dementia) and a key to understanding specific concerns (i. As is true for many of our clients. In her case. with implications for empirically supported practice and professional development. Any suggestions for where they could start?” This verbatim request came to us via e-mail from a local colleague the same week that we first read the case study of Marilyn and her daughter Betty. She was placed in serious risk of other problems. 2008). these same diagnoses can also misdirect if accepted too readily as a causal explanation... they had difficulty generalizing this experience . her undiagnosed urinary tract infection resulted in discomfort.e. This commentary highlights some of the points made by the authors of the case study. In the case of Marilyn. we are impressed with this coincidence and the urgency experienced by families in these situations. The contextual approach used by these authors defines behaviors as influenced by social and physical environments (past and present) along with physiological states and conditions (Fisher. the centrality of “behavior as communication” in dementia). Such a discharge/transfer is complicated and difficult for both patients and their families. a broken tooth) that had resulted in Marilyn displaying excess crying.COMMENTARY Ann M. Despite already knowing the importance of good dementia care. We also hope to extend our discussion to review some of the skills needed for working with older adults in a variety of settings. and the daily quality of life was disrupted for her and her daughter Betty.. The contextual approach helps us to do that. The staff at her care facility had a previous example of a physical condition (i. over-medication. & Sylvester. and the risk of discharge to an unknown new facility. but they must be accompanied by a focus on the relationships between behaviors and environments for a specific person. George “Friends of a friend need help with fi nding a placement for their mother who is getting removed from her nursing home for aggression. Understanding physical and mental health conditions that are common among older adults is important. while looking to psychiatric diagnoses to provide us with information. Diagnoses offer some information. All clinical work is rooted in an initial conceptualization. excess disability. We are struck by how common this is. Cherup.e. Steffen and Nika R.e. Drossel. Marilyn’s diagnosis functioned both as a deterrent (i. acute. and the literature provides us with resources to help (Fisher et al. and they may need to collaborate with medical staff in administering drugs. thus is not the endpoint of assessment but rather the beginning.. delirium in dementia patients is unrecognized up to 50% of the time and can be deadly (Inouye. This case study demonstrates the importance of dementia-specific education. and ongoing support for professionals in a variety of disciplines. The presence of a dementing illness increases the risk for delirium and excess disability due to physical health concerns. training. The contextual approach frames challenging behaviors as communication. The assessment strategy used with Marilyn also reminds us of how important it is to assess positive adaptive behaviors and not focus solely on problems. crying). such as dementia. Marilyn’s case makes this clear in several dramatic ways. engaging in conversation) and the targeted problem behavior (i. “problems” serve important functions that merit attention. It is even more challenging for medical staff in acute hospital settings to recognize signs of delirium and excess disability in dementia patients. Even when “textbook perfect” functional analyses of behavior are not possible. as well as . As difficult as it was for facility staff members to see Marilyn’s crying as conveying more than a progression of her illness. smiling.e. leading to the ultimate question: “If crying functions adaptively. She was harmed by the increased use of medications to “manage” her behavioral symptoms of crying (American Academy of Neurology Ethics and Humanities Subcommittee. how might this behavior help Marilyn to communicate and solve a problem?” This question was best addressed by individualized assessment of specific behaviors in their naturally occurring physical and social environments. Along with knowledge of assessment and dementia-specific issues. eye contact. 2011). they had daily experiences with her over a relatively long period. Mental health professionals working in traditional office settings may doubt the feasibility of descriptive behavioral assessments/monitoring. & Teri. this contextual approach helped to defi ne assessment questions. Other sources of monitoring include the development of simple forms and instructions for family. 2007). Behavioral assessments for individuals with dementia are possible. designated volunteers who are already familiar with the setting. 2006).. Mental health professionals must help families communicate with prescribing physicians. and care staff. 2008. and long-term care settings. In community. working with older adults often involves attention to medications. Attention means assessment. McCurry. An initial diagnosis. Steffen. it was vital that the caregiver coaches and her daughter Betty understood that dementia involves both significant disruption in communication abilities and increased risk for delirium. 2007. In the case of Marilyn.. there are certainly “good enough” strategies to determine whether problem behaviors are linked to specific environments or are occurring across multiple life domains. 1996). McCurry & Drossel. For Marilyn. This case study offers the creative solution of undergraduate companions who were available to monitor both specific adaptive behaviors (e.294 Psychotic Disorders and Organic Brain Syndromes to her newest incident of distress.g. not just in long-term care environments (Logsdon. but could have also led to a fall. 2009). there are many individuals like “Marilyn” and “Betty” who need our attention and help. 46. 59. Hinrichsen.. American Psychological Association. from an increasing variety of ethnic and cultural backgrounds (Hinrichsen. 2002) or exposure to Medicare and Medicaid policies and practices (Hartman-Stein & Georgoulakis. Knight. As the e-mail from our colleague reminded us. 1180–1183. 2011). Patterns of demographic changes in the United States and abroad make it clear that we will be assessing and treating clients. We realize that many licensed mental health clinicians who work with older adults have had little or no formal education or supervised training experiences in geriatrics (Qualls et al. Clinical practice with older adults involves the ability to work with professionals from other disciplines and the understanding of a variety of care settings (Sorocco & Lauderdale. 2006. and ultimately to respiratory problems and death. Neurology.apa. 2008. 2008). 283–289. Karel. org/pi/aging. but some basic issues generalize for all of us. and professional development. 2004. In summary. Those interested in exploring additional sources of professional development should be encouraged by the growing volume of resources for clinicians (APA. Duffy. assessment. . Hinrichsen 2010). Laidlaw & Pachana. Zeiss. & Molinari. Pachana. Knight. Qualls. Her PRN Ativan was observed to have negative effects on her alertness and behavior. 2009). Mental health professionals working with older adults and their family caregivers benefit from understanding the risks of polypharmacy and learning how to help families communicate effectively with health providers (Arnold. treatment. The NCSC coaches were also effective because of their consultation/liaison skills. Hinrichsen & Zeiss. Each setting is different. & Beck. this case study highlights a number of issues related to conceptualization. 2010. & Duffy. Polypharmacy and older adults: A role for psychology and psychologists. and consultation approaches (Lau & Kinoshita. References American Academy of Neurology Ethics and Humanities Subcommittee (1996). 236–260. 2006). Issues of cultural diversity also influence clinical work with older adults and their care providers. 2008) and supervisors/educators (Hinrichsen. Professional Psychology . M. Ethical issues in the management of the demented patient. decreased mobility. 39. www. this included knowledge of the nursing home organizational structure and mechanisms for communication and treatment planning.A Contextual Approach to Dementia Care in Alzheimer’s Disease 295 by the absence of antibiotics needed for her UTI. 2010. Older adults are commonly on multiple medications for physical health issues and are at much higher risk for side effects and adverse events than are younger adults. Knight. Arnold. as well as working with health care professionals. Guidelines for psychological practice with older adults. consultation/liaison. American Psychologist. Karel. fractured hip. Karel. (2008). Karel.Research and Practice. Our attention to diversity will help us understand how these might influence assessment. (2004). 91–98. (2009).. W. J. 601–608. Karel. Handbook of behavioral and cognitive therapies with older adults..). 75–84. In D. K.. Iwamasa (Eds. S. Washington. Knight. (2011).. S. Public policy and the provision of psychological services to older adults.. A. (2010). Treating dementia in context: A step-by-step guide to working with individuals and families. S. J. V. Hinrichsen. M. & L. Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Cognitive behavior therapy with older adults: Innovations across care settings. In D. M. L. G. Qualls. New York: Springer. Lau.Research and Practice. Aging. S. Why multicultural issues matter for practitioners working with older adults. A. M. Steffen. M. M. 435–442.). 28–36.. Cherup. Niederehe. In D. 1157–65. 97–103. Culturally responsive cognitive-behavioral therapy: Assessment. (2008). B. Hinrichsen.. mental health.. N. L. C. K. 33. M. Introduction to special issue: New interventions for dementiarelated concerns. Sorocco. Hinrichsen. (2006). Thompson (Eds. M. Pikes Peak model for training in professional geropsychology. A. Inouye. 64. B.. practice. Karel. P. H. New York: Springer.). Training and Education in Professional Psychology. A. and need for continuing education.. & L. (2011). Professional Psychology . 37. Ferguson. & Sylvester. & Georgoulakis. 40.W.. Restraint free care of persons with dementia. & Gallagher-Thompson. M. (2009). A.. sources of training. & Teri. Cognitive-behavioral therapy with culturally diverse older adults.. 354. S. 1–3.. G. & Drossel. Hinrichsen. C.296 Psychotic Disorders and Organic Brain Syndromes Fisher. D. A. Attitude. Segal. 30. Delirium in older persons. Professional Psychology – Research and Practice. H.. Knight. . Karel.. Professional Psychology . Clinical Gerontologist. & Pachana. A. J. & Zeiss. A. M. Laidlaw. M. (2006). S.. D. A. Steffen. (2007). Gallagher-Thompson. McCurry. A.).Research and Practice. Washington. G. Y. S. Professional Psychology . New York: Springer Publishing Co. Zeiss. S. (2006). 4. Handbook of behavioral and cognitive therapies with older adults. Training and Education in Professional Psychology. Psychology and Aging. A. G. Thompson (Eds. Pachana. Hartman-Stein. (2010).. knowledge. and skill competencies for practice in professional geropsychology: Implications for training and building a geropsychology workforce. 205–214. Logsdon. (2007).. Knight. New York: Springer. Gallagher-Thompson. (2002). American Psychologist. Thompson (Eds. N. How Medicare shapes behavioral health practice with older adults in the US: Issues and recommendations for practitioners. New England Journal of Medicine. & Kinoshita. Competency-based geropsychology training in doctoral internships and postdoctoral fellowships. G. G. J. B. & Lauderdale. M. G. N. K.. W. Norman. Steffen. W.. & Duffy. DC: American Psychological Association Press. R. and supervision. (2010). M. J..Research and Practice. S. G. (2008). K. L. Qualls.. Gallagher-Thompson. Steffen. 22.. 41. & Molinari.. & Beck. Karel. Psychologists in practice with older adults: Current patterns. M. J. M.. (2008).. Hays & G. E. Hinrichsen.. G.. and demographic change: Challenges for psychotherapists. McCurry. M. Handbook of behavioral and cognitive therapies with older adults. M. Training geriatric mental health providers in CBT interventions for older adults. 29–35. Duffy. DC: American Psychological Association Press. & L. In P. A. 4. J. Drossel. 2009). and their descriptive behavioral analysis skills were essential to conducting a prescriptive assessment. registered nurses. & Duffy. a geriatric physician. Due to the complexity of the problems experienced by older adults. play in caring for older adults. During the course of this case. licensed practical nurses. their knowledge of the potential adverse effects of psychotropic medication. Effective interdisciplinary collaboration often requires a delicate balance of interpersonal skill in respecting other professionals’ training and scope of practice. as well as asserting and often educating others about the potential role of clinical psychology in enhancing the quality of life of older adults. population. caregiver coaches’ awareness that confusion is a secondary effect of infection in older adults. given the rapidly increasing demands presented by the aging population (see Knight. Census Bureau. Qualls. (b) awareness of the role that other heath fields. social workers. 2004). Karel.000 persons turn 65 every day. Clair Rummel. the fastest growing segment of the U. . as Steffen and George also note. and Jane E. and this age wave will continue for the next 20 years. such as social work and nursing.S. Specialized training in geropsychology should be a priority within clinical psychology training programs. In this case study. a psychiatrist. Training in geropsychology necessitates (a) awareness of how certain medical problems and medication can affect behavior.RESPONSE Christina Garrison-Diehn. 2010). and various nursing home administrators. Steffen and George cogently highlight the complexity of assessment in working with older adults. the Nevada Caregiver Support Center (NCSC) coaches interacted with certified nursing assistants. Persons over the age of 85. Hinrichsen. interdisciplinary communication skills are critically important for individuals working in the field of gerontology. their ability to collaborate with professionals in other disciplines. a geriatric pharmacist. will increase by over 300% by 2050 (U. Fisher Steffen and George’s commentary on our case study highlights the growing need for specialized clinical training for clinical psychologists providing services to older adults. and (c) expert knowledge and skill in psychological assessment and treatment (see American Psychological Association.S. Over 10. . Pikes Peak model for training in professional geropsychology. Knight. American Psychologist. 59(4). 205–214. Qualls.gov/prod/2010pubs/p25-1138.. 2012). http://www.. B. The next four decades: The older population in the United States: 2010 to 2050. G. . (2009). U. G.298 Psychotic Disorders and Organic Brain Syndromes References American Psychological Association (2004). 236–260.. Karel. Census Bureau (2010). J. A. S. H.census. M.pdf (accessed January 20. & Duffy. M. 64(3).S. American Psychologist. Guidelines for psychological practice with older adults. Hinrichsen. { PART V } Personality and Dissociative Disorders This page intentionally left blank { 12 } Borderline Personality Disorder Shireen L. Rizvi and Kristalyn Salters-Pedneault Borderline personality disorder (BPD) is a serious psychological condition characterized by emotion dysregulation, interpersonal difficulties, an unstable sense of self, and cognitive changes (i.e., paranoid ideation or dissociation) under stress (American Psychiatric Association, 2000). BPD is also associated with high-risk behavioral dysregulation, including recurrent suicide attempts (approximately 75% of people with BPD have made at least one suicide attempt; Soloff, Lynch, Kelly, Malone, & Mann, 2000), deliberate self-harming behaviors (e.g., cutting or burning; APA, 2000), and a high rate of suicide completion (up to 10% of patients with BPD; Paris & Zweig-Frank, 2001). Individuals with BPD also have high rates of both Axis I (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004) and Axis II (Zanarini, Frankenburg, Vujanovic, et al., 2004) comorbidity. Particularly common comorbid diagnoses include major depression, substance use disorders, posttraumatic stress disorder, and eating disorders (Zanarini et al., 2004). While at one time BPD was viewed as essentially untreatable (Gunderson, 2009), there is now a growing body of evidence that suggests the long-term course of BPD is not as dire. First, longitudinal studies of BPD have indicated that a majority of BPD cases will remit within 10 years (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006; Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010). Second, there has been an increase in the number of evidence-based treatments for BPD in recent years. To date, the treatment with the most empirical support is dialectical behavior therapy (DBT; Linehan, 1993a, 1993b). A number of randomized controlled trials of DBT in patients with BPD have been conducted, demonstrating DBT to be superior to treatment-as-usual or community treatment by experts for BPD on a number of measures, including reductions in inpatient days, severity of suicide attempts, and attrition (for a review, see Feigenbaum, 2007). A recent meta-analysis on DBT suggests a moderate effect size for suicidal and self-injurious behaviors in DBT, compared to treatment as usual (Kliem, Kroger, & Kosfelder, 2010). This chapter describes the case formulation for the long-term (approximately four-year) DBT treatment of a woman diagnosed with borderline personality 302 Personality and Dissociative Disorders disorder (BPD). Although DBT is often cited as a 12-month-long treatment, this length is an arbitrary artifact of the constraints of clinical trials. DBT experts, including Linehan, assert that longer term treatment is often necessary due to the severity and chronicity of the disorder. The case represents several complicating features that are often associated with BPD. First, the woman had a number of severe comorbid conditions and problems including substance use, posttraumatic stress disorder, depression, dissociation, frequent episodes of self-injury, and chronic suicide ideation. Second, she had experienced numerous traumatic events throughout her lifetime and had experienced a significantly impoverished childhood. Third, she was quite isolated in her life, and her only network of associates involved others in the mental health system. Fourth, she had a significant treatment history, including numerous short-term and long-term hospitalizations, with limited positive effects. Taken together, at the time of presentation for treatment with the first author, she was a self-described “full-time mental patient.” Moreover, this case was specifically chosen for this volume because it also features another “real world” clinical problem, in that the therapist had to terminate prematurely based on a move to a different city. Thus, we strive to also illustrate a successful treatment transfer within the context of a complicated, evidence-based, and flexible case formulation and treatment plan for this young woman. Background Information Melissa was a 25-year-old Caucasian woman from the southern United States who was receiving treatment at a Veterans Administration (VA) hospital following her two years in the Armed Forces. (Details about the case have been modified to protect the identity of the client.) She was currently unemployed and was receiving service-connected disability and other resources from the VA to support herself. She was raised by her two biological parents, along with two younger sisters, in a fi nancially and intellectually impoverished environment. Melissa reported significant neglect and physical abuse throughout her entire childhood. In addition, her father began sexually abusing her when she was six years old; this abuse continued at the rate of a couple of episodes per month, until she was 16. (Melissa’s memories of childhood abuse were consistently accessible; these memories were not recovered through any therapeutic process.) At that point, she left home and lived with friends or on the street for two years before joining the military at age 18. She managed to complete her high school education via a GED (general equivalency diploma) when she was in the military. Prior to starting treatment with the fi rst author, Melisssa had an extensive treatment history since her discharge from the military, including multiple and extensive psychiatric hospitalizations. She had recently been a resident of a transitional residential house for female veterans with psychological disorders; however, she was prematurely discharged due to a positive urinalysis for alcohol. At the time of intake, she was living with three roommates, two of whom were veterans with mental illness and substance use problems. Borderline Personality Disorder 303 In her psychiatric records, Melissa was diagnosed with BPD, posttraumatic stress disorder (PTSD), polysubstance dependence, major depressive disorder, and, at times, by different clinicians, an undifferentiated form of schizophrenia. There were reports of at least two near-lethal suicide attempts (by overdose of medications with alcohol), repeated self-injury (usually in the form of cutting), and mention of visual and auditory hallucinations. These hallucinations most often appeared in the form of voices telling her that she is a bad person and worthless and appeared under times of considerable psychological stress, usually related to PTSD symptomatology. During her time in the Armed Services, she was not directly involved in any combat experiences and did not experience any combat-related trauma. However, she did report to a previous therapist that she was sexually assaulted on two separate occasions by fellow (male) soldiers. Other than mentioning that it had occurred, she did not provide details about either of the assaults, and notes documented that she would appear to dissociate (shut down, become nonverbal) when the topic was raised. She also reported a significant loss while in the military; the man whom she was engaged to marry committed suicide shortly after one of these sexual assaults. An intake session was conducted with the primary function of information gathering and rapport building. Melissa appeared significantly younger than her age, in part because her dress was boyish, oversized sportswear. She was cooperative during the session but expressed hesitation and anxiety about starting treatment with yet another clinician. She had felt connected with her previous therapist, who recently had transitioned away from the VA hospital, and expressed sadness over that loss. It was established that the previous therapist had largely conducted supportive psychotherapy and that, although Melissa felt as though she was doing better than when she initially started that treatment, there were still a number of problematic behaviors occurring on a frequent basis. When asked, she stated that she was unclear about her goals for the future. She said that she had been considering going back to school for the past two years but had not yet taken the initial step of calling the veterans’ program at a nearby university. She expressed a desire to not drink anymore (she had been sober for the past three months, since getting prematurely discharged from the transitional residence) and was ambivalent about stopping self-injury, reporting that it was “the only thing that worked besides alcohol” when she was emotionally distraught. Assessment Strategy Melissa had received an extensive evaluation when initially enrolled in the clinic (prior to initiating treatment with her previous therapist). This evaluation included structured and semi-structured clinical interviews, using the Clinician Administered PTSD Scale (CAPS; Blake et al., 1990) and relevant sections of the SCID (First, Spitzer, Gibbon, & Williams, 1997; including the psychotic 304 FIGURE 12.1. Personality and Dissociative Disorders Sample Diary Card Obtained During Melissa’s Treatment disorders and substance abuse/dependence sections), self-report symptom measures (i.e., the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993), and the Alcohol Use and Dependence Inventory (AUDIT; Babor et al., 2001). Thus, prior to beginning treatment, we had access to a comprehensive psychological evaluation, as well as extensive records from the previous therapist. Because of this evaluation, the focus of our initial treatment assessment was on evaluating changes in symptom levels and problematic behaviors over the course of treatment with her most recent therapist. Another assessment strategy within DBT is to collect weekly in session a “daily diary card,” a self-report monitoring form, on which the client is asked to record presence/absence/ severity of various behaviors and emotions each day (Linehan, 1993a). See Figure 12.1 for an example of a completed DBT diary card used in treatment with Melissa. In terms of ongoing outcome monitoring, the diary card provides some evidence for the effectiveness of various interventions used throughout treatment. In addition, and perhaps just as useful, the diary card provides information about behavior that is not changing with intervention and can suggest to the therapist that a modification is necessary. Initial Case Formulation and Treatment Approach Given the multi-diagnostic nature of Melissa’s problem areas, her primary diagnosis of BPD, and her self-injurious behavior, she appeared to be a good candidate for DBT. Other treatments for BPD have gained empirical support in recent years (e.g., schema focused therapy [Young, Klosko, & Weishaar, 2003], mentalization based therapy [Bateman & Fonagy, 2004], transference focused therapy Borderline Personality Disorder 305 [Kernberg, Selzer, Koeningsberg et al., 1989]). Given these treatment options, a choice arose as to the best course for Melissa. DBT was chosen for several reasons. First, a couple of published randomized controlled trial (RCT) studies by Linehan and colleagues have indicated support for DBT’s efficacy for BPD plus substance use disorder (SUD). In one of the studies, poly-substance dependent women in DBT were significantly more likely, compared to treatment-as-usual participants, to remain in treatment (64% and 27%, respectively), had significantly reduced their drug use as measured by structured interviews and urinalyses throughout the treatment year, and had attended significantly more individual therapy sessions (Linehan, Schmidt, Dimeff, Craft, Kanter, & Comtois, 1999). In the second RCT efficacy trial of DBT for BPD-SUD, women with opiate dependence and BPD were all provided an opiate replacement medication and randomized to either DBT or a more rigorous control condition (Comprehensive Validation Only with Twelve Step; Linehan, Dimeff, Reynolds, et al., 2002). Results from this trial demonstrated significant improvements in both conditions on all major outcomes. Other treatment approaches for BPD have not yet focused on the BPD-SUD comorbidity specifically. Given Melissa’s recent lapses of alcohol use, a treatment that had some focus on SUD seemed important. The second advantage for DBT relates to the comprehensiveness of the treatment. The severity of Melissa’s problems seemed to warrant more treatment than individual therapy; however, the ultimate goal of having Melissa be more independent from the mental health system favored an outpatient treatment approach. DBT’s comprehensive approach is designed to fulfi ll the majority of the client’s mental health treatment needs via individual therapy, group skills training, and as-needed phone consultation. Other treatments, such as Alcoholics Anonymous, pharmacotherapy, and inpatient stays, are considered ancillary. In addition, the therapist providing DBT attends a weekly consultation team, designed to enhance therapist capabilities and increase motivation to treat difficult clients (Linehan, 1993a), which adds to the comprehensiveness of the treatment approach. The therapist was already attending a DBT consultation team because of other clients and committed to remain in the team as long as she was treating Melissa using the DBT model. Third, the theoretical foundation of DBT, namely behavior therapy, was consistent with the training and orientation of the therapists. Although there have yet to be studies examining specifically therapist allegiance effects in the delivery of DBT, it seems likely that therapist training and experience in a particular model would lead to more beneficial outcomes for a client than if the clinician tried a novel therapy in which he or she had little or no experience. DBT strives to balance standard change strategies from cognitive behavioral therapy (CBT) with acceptance strategies through a dialectical process. The primary “dialectic” acknowledged in DBT is the tension between acceptance and change; both the therapist and client must unconditionally accept the current moment, while at the same time moving toward changing unhealthy behaviors. The change strategies most frequently employed include functional analyses of problem behaviors, contingency management procedures to increase adaptive 306 Personality and Dissociative Disorders behavior and decrease maladaptive behavior, cognitive restructuring, exposure, and skills training. Acceptance is conceived of as an active process and is most often demonstrated by the therapist through the use of specific validation strategies (Linehan, 1997). DBT is considered a principle- (or theory-) based treatment, different from a protocol-driven treatment (Wagner, Rizvi, & Harned, 2007). DBT is informed by three guiding theories or principles: biosocial theory, behavior theory, and theory of dialectics. The biosocial theory is used to explain the development and maintenance of BPD behaviors. In biosocial theory, BPD develops as the result of an interaction between a biologically based vulnerability to emotional reactivity and what is referred to as an “invalidating environment” (i.e., an environmental context in which emotional experiences and expressions are judged, punished, neglected, or responded to inconsistently). Over time, this transaction results in emotional dysregulation, including greater reactivity to emotional stimuli, greater emotional intensity, and slower recovery from emotional events (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). DBT also adheres to the basic principles of behavior therapy. Behavior (broadly defined to include verbal behavior, emotional responses, and overt action) is presumed to function according to the principles of classical and operant conditioning, observational learning (modeling), and rule-governance. These principles are also assumed to affect therapists’ behavior. In DBT, behavioral theory influences all aspects of intervention, including assessment methods, case conceptualization, intervention strategies, and the creation and use of the therapeutic relationship. The behavioral conceptualization of BPD emphasizes skills deficits, conditioned responses, environmental contingencies, and motivational factors in the maintenance of problem behaviors. Specifically, behaviors are viewed as maintained by some combination of deficits in ability, cued responding, reinforcement, and/or cognitive factors (i.e., attentional factors, beliefs, attitudes, and interpretations). Thus, behavioral interventions include psychoeducation, skills training, exposure, contingency management, and cognitive processing and restructuring. Dialectical theory makes several important assumptions: (a) that reality is composed of opposing forces (thesis-antithesis) that exist simultaneously; (b) that all events are interrelated and connected; and (c) that all forces experience constant change. From this perspective, tension and confl ict are both unavoidable and necessary for change. The DBT therapist searches for a balance between the opposing forces, which in turn elicits its own antithesis. Further, the DBT therapist models dialectical thinking for the client; this can be very useful for clients who have a tendency toward rigid, dichotomous styles of thinking. The primary dialectic that informs all aspects of DBT is between change and acceptance; interventions include both change- and acceptance-oriented techniques, and clients are taught skills for both changing and accepting themselves and reality as it is (see Linehan & Schmidt, 1995, and Fruzzetti & Fruzzetti, 2003, for more in-depth discussion of dialectical theory). Borderline Personality Disorder 307 DBT follows a stage model of treatment, which posits that current treatment tasks and goals must be determined by the client’s current level of disorder (Linehan, 1993a, 1999). The fi rst stage of treatment for all individuals in DBT is considered the “pretreatment stage” in which the treatment task is to gain commitment to treatment in general and DBT treatment goals in particular (e.g., no self-harming). Stage I treatment is conducted when the individual is at the level of “behavioral dyscontrol,” specifically, the client engages in behaviors that block or prevent a reasonable life expectancy and is deficient in controlling action. Stage II treatment is for individuals in what Linehan labeled “quiet desperation,” i.e., a stage during which the individual no longer has behavioral dyscontrol but feels as though she or he is miserable. Stage III is conceptualized as “ordinary problems in living,” in which the individual may work to alleviate the effects of more mild Axis I problems and/or occupational and relationship issues. Finally, Stage IV has been described as achieving the capacity for joy and freedom, in which the individual learns to “crack open each moment” as a means of alleviating suffering and gaining the wisdom of one’s place in the universe. In its standard, outpatient Stage I form, DBT includes four different modes of treatment. These modes include individual therapy, skills training (usually in the form of groups), as-needed telephone consultation, and a consultation team for DBT therapists, designed to improve adherence to the model and to reduce potential for burnout. Skills training groups follow a particular schedule in terms of information taught and homework assigned, as guided by the manual (Linehan, 1993b). Individual therapy sessions are guided by a treatment hierarchy that reflects prioritized targets of treatment. Life-threatening behaviors (such as suicide, deliberate self-harm, and homicidal behaviors) are given fi rst priority. Therapy-interfering behaviors (such as failure to attend sessions, noncompliance with the parameters of therapy) are targeted next. Finally, severe Axis I disorders and problematic behaviors that interfere with quality of life are addressed. DBT case formulation is also informed by what are termed dialectical dilemmas, or patterns of behavior common to individuals with BPD that often interfere with successful targeting of Stage I behaviors, thus becoming secondary targets of treatment. An in-depth description of the dialectical dilemmas are beyond the scope of this chapter; information can be found in Linehan (1993a). Prior to the current treatment episode, Melissa had been attending DBT skills groups offered at the VA but had not been in full, comprehensive DBT. It was determined that she might benefit from more comprehensive DBT services, for the reasons cited above. Melissa was considered a Stage I client, in that a number of her presenting problems were indicative of behavioral dyscontrol (e.g., self-harm behavior, uncontrolled substance use, severe flashbacks), and she presented with skills deficits in a number of areas, including distress tolerance and emotion regulation. The development and maintenance of Melissa’s target behaviors can be readily understood via the biosocial theory. In terms of biological sensitivity, Melissa describes herself as always struggling with intense, negative emotions, even at an early age. She further describes a history of depression suicide attempts. and eventually to be in a committed. she was asked to weigh the pros and cons of continuing to intentionally hurt herself. as such. Melissa was oriented to DBT. Given the target hierarchy. suggesting that there may also be a genetic vulnerability. the therapist was also aware that getting Melissa to shift from “full-time mental patient” to a person with a life worth living was going to be an important task in this fi rst year. she saw therapy as the only activity she had to engage in on a regular basis. was told that eliminating her self-injury. 1993a) were used to discuss this issue. nonabusive relationship with a man. She was informed about the treatment hierarchy and. and devil’s advocate was used to strengthen this commitment (“Now that you’ve agreed to do this for six months. Melissa stated that she too wanted to develop a life worth living and to stop self-injury. Although this helped with commitment early in treatment. she committed to no self-harm/suicide during the next six months.308 Personality and Dissociative Disorders and bipolar disorder in her family. I have to tell you. at which point we would reevaluate). to live more independently and in a less stressful housing situation. foot-in-the-door and door-in-the-face techniques were used to elicit a length of commitment that was acceptable to her (in this case. Melissa was also asked to name her own goals. She also reported wanting to get a college degree. given Melissa’s commitment and agreement to the model. and strong suicide ideation would be the first priority of treatment. she was not treatment averse. and a discussion was had about the differences between DBT and the types of treatment that she had experienced previously. Melissa started in the pre-treatment phase. She was asked to commit to this treatment and all its components for one year and was also asked directly to commit to not engage in any suicidal behavior anymore. if anything. STAGE I TREATMENT PHASE The treatment quickly moved into the Stage I phase. Melissa did not voice any hesitation about the treatment model and length of treatment. which involved orientation and commitment to treatment goals. Her initial reaction to this request was one of hesitance: “I know it’s not good for me but I’ve been doing this for years—how do you expect me to just give it up now?” Various DBT commitment strategies (Linehan. which is of course partially informed by . Melissa agreed to continue in DBT skills training groups. A notable difference included the DBT therapist—and treatment generally—as active and directive. this is going to be the hardest thing you’ve ever done— are you sure you want to go through with this?”). At this point. Course of Treatment PRE-TREATMENT PHASE As with any DBT case. both for treatment as well as overall life goals. Specifically. fear. specifically “I can’t stand this. specifically cutting on her upper thighs with a razor blade. The idiographic target list for Melissa within the life-threatening behavior category was: eliminate suicide attempts. having had a number of nightmares that had elements of her previous traumatic events within them (i. Melissa had not slept well the night before. The urge to cut began with the thought that “cutting will make this all go away and help me feel better. The standard strategy for targeting these.. Essentially. high urges to use alcohol (rated 4). is through thorough behavioral analyses (BAs) of occurrences of behavior (Linehan. At the next therapy session. is to keep the therapist apprised of any suicidal behavior as well as any changes in urges to self-harm or suicide. A graphical representation of the BA is presented in Figure 12. thinking about self-harm leading to a reduction in negative emotions). and shame. especially early in treatment. coupled with agitation related to the content of her nightmares. eliminate self-injurious behavior. As mentioned. She reported bleeding but not enough to require medical attention. gain recommitment to not engage in self-injury. 1993a). It is of course.2. graphic rape scenes. A detailed example of a BA and the consequences of the analysis are presented here. all rated 5). potential solutions and therapeutic interventions are generated so that future prompting events or similar situations will not lead to the dysfunctional behavior. the focus of the session was to conduct a BA.g. and sad about the situation. high suicide ideation (rated 4). Melissa reported that the prompting event for that day’s self-injury was an intense verbal confl ict between two of her roommates. eliminating life-threatening behavior was the number one treatment target in individual therapy. and severe negative emotions (anger.g. the therapist was made aware of this incident via the diary card and noted that the self-injury occurred on a day with highest self-harm urges (rated 5 on a scale of 0–5). the diary card is an important treatment tool for many reasons.Borderline Personality Disorder 309 safety concerns. From that behavior analysis. and develop appropriate solutions for future risky situations. Unlike in other treatments where this might be the cause of punishment or termination of treatment (e. This lack of sleep.” “They might hurt me too. discussed above. Melissa engaged in an act of self-injury.e. This confl ict led to a number of thoughts for Melissa. substance abuse treatment programs that kick out clients if they relapse). angry. not uncommon for a client to engage in a behavior that she previously committed to stop.. Thus. sadness.. and decrease suicide ideation and suicide/self-harm related affect (e. Melissa was introduced to the DBT diary card. which took place in a common area of the apartment late at night.” She also reported feeling scared. despite her stated commitment. the dialectical approach of DBT can handle the seeming opposition of wholehearted commitment to change a behavior and a continuation of the behavior. Early in treatment. but one of its most important functions. were “vulnerability factors” that made her more susceptible to the effects of her roommates’ argument than she might have otherwise been. along with other behaviors of interest in DBT. images of her father’s face).” and “I need to escape this pain.” Melissa identified consequences of the self-injury to be the feeling . Of the alternatives generated. she indicated that leaving the apartment was an effective alternative during the daytime. nightmares. “I must stop this pain” FIGURE 12. Linehan.2. including collaboration in doing BAs and generation of alternative responses as well as commitment to stop .310 Personality and Dissociative Disorders VULNERABILITY (tired. For example. agitation) goes to bathroom. 1993b) of “distract” and “self-soothe” and calling her therapist if that didn’t work to get additional cheerleading and help with alternatives. “What if they hurt me too?” CUTS SELF WITH RAZOR “I can’t take it anymore”. more functional methods for handling emotional distress (delayed). guilt and shame Example of a Behavioral Analysis of Self-injury of relief from negative emotions (immediate and short-term) but then feelings of guilt about breaking her commitment to the therapist and working against her own long-term goals of fi nding other. Melissa recognized that her cognitive expectations (“cutting will make me feel better”) were somewhat at odds with the actual consequences of the behavior. this was not a viable option. The therapist validated that Melissa’s first instinct was to revert to self-harm—this was an overlearned behavior that occurred in the absence of well-rehearsed alternatives— yet also stressed that the only way to learn to do something new is to “close the door” on self-harm by eliminating it as an option. but if similar fights happen again late at night. Melissa and the therapist examined the BA carefully to determine links in the chain of events that provided an opportunity to do something different with more skillful behavior. Melissa then evaluated the pros and cons of each to determine which alternatives she would attempt in similar situations in the future. & Rizvi. She identified a number of different DBT skills that she would try in similar situations at the point of noticing an increase in urges: these included the distress tolerance skills (Linehan. Chittams. Sylvers. Although she did feel an immediate reduction in negative affect following the cutting. I can’t stand it”. Furthermore. she ended up feeling worse just a short while later due to the added disappointment in herself. It is important to note here that the quality of the therapeutic relationship can be an essential tool in many aspects of DBT. which is consistent with empirical literature on effects of self-injury (see Welch. 2008). finds razor fear fear intensifies immediate relief PROMPTING EVENT (roommates’ fighting) “This is awful. as opposed to pathological. these uses were sporadic. while Melissa had made great strides in increasing her behavioral control. a pattern became evident whereby the prompting events for the great majority of self-harm and substance use incidents was something related to her trauma history. did not lead to severe negative consequences.Borderline Personality Disorder 311 maladaptive behaviors (Rizvi. her PTSD symptoms related both to her experiences of childhood sexual abuse and military sexual assaults continued to be severe and disabling. and had stopped engaging in self-harm for a period of five months. Thus. 1996) can be used to the therapist’s advantage early in treatment. Although she had intermittently used alcohol and other drugs during the nine-month period. cognitive. elements of the Prolonged Exposure protocol (PE. 2011a. This positive reinforcement of honesty was done in order to prevent Melissa from covering up future incidents as a way of diminishing the therapist’s disappointment. Through repeated BAs of these behavioral incidents. due to its relation to higher order targets and its effect on her day-to-day functioning. However.. and engaged in persistent suppression of memories.e. coupled with behavioral. Melissa identified “not wanting to let [the therapist] down” and associated guilt as a major negative consequence to harming herself.b). although treatment was relatively new with this therapist. Despite the severity of her baseline presentation. That is. She responded well to the structured nature of the treatment. A hierarchy was created of traumatic events from her lifetime. it was decided that the first traumatic “event” that would be addressed via PE . response to self-harm by indicating that she was indeed disappointed by the reoccurrence of self-harm. an exposure-based approach to PTSD symptom reduction was selected. one binge drinking episode was directly related to seeing someone who resembled one of her rapists on the street. The therapist encouraged this as an adaptive. and she was asked to rate them on a 0–100 subjective units of distress scale to indicate the level of distress that thinking about each one caused. As a result of this hierarchy. 1997) were implemented. Foa & Rothbaum. she had enrolled as a part-time student at a local university. Melissa would rarely leave her apartment after dark. Another self-harm episode occurred as a way to stop experiencing intrusive memories of childhood sexual abuse. it was determined that working on her PTSD at this point in treatment would be most beneficial. By nine months into treatment. Often. Specifically. For example. thoughts. and she enjoyed learning and practicing the DBT skills. she was compliant with attending sessions and completing homework assignments. had starting taking martial arts classes and was working toward a black belt. the therapist also stated that she was still committed to working on the problem collaboratively and praised Melissa’s honesty in disclosing the event. and were always followed by recommitment to abstinence. and emotions related to the traumas). In collaboration with Melissa and with support from the therapist’s consultation team. Melissa moved fairly quickly through Stage I of DBT. the tendency of an individual with BPD to attach to others quickly (see Gunderson. avoided men or endured proximity to men with great discomfort. Given Melissa’s high level of reexperiencing. and emotional avoidance of trauma-related cues (i. although still present. mostly related to timing. every effort was made to create a corrective learning experience for Melissa in her transfers between therapists. Because Melissa’s learning history included abandonment experiences that were not predictable. While she had told previous therapists about these events. the exposure was titrated initially to prevent intense flooding of memories. although Melissa reported some benefit from the initial exposure-based work. Melissa had moved from Stage I to Stage II of treatment.312 Personality and Dissociative Disorders was the sexual abuse perpetrated by her father. in contrast to the PE model. or sufficiently processed. Further. FIRST TERMINATION AND TREATMENT TRANSFER Termination can be a particularly vulnerable time for patients with BPD due to potentially strong reactions to perceived abandonment. she continued to believe that a new therapist might judge her harshly upon hearing about them. While some therapists would hesitate to do this in order to avoid unnecessary anticipatory anxiety. Prior to transfer. her ratings of anger and shame related to her traumas remained quite high. Melissa’s opinion on the suitability of this match was solicited. which are often related to a learning history of actual abandonment experiences. She agreed to conduct two joint meetings with her old and new therapists in order to talk about the impending transfer and to test her beliefs that her new therapist would judge her. Melissa was told of impending termination with her therapists months ahead of time. Melissa had achieved a measure of behavioral control and her PTSD symptoms. A particularly sensitive part of the transfer process related to Melissa’s deep shame about traumatic events that had occurred in her childhood. Typical of Stage II presentations. and any issues that she wanted to address prior to commencing treatment with the new therapist. Several months passed with the focus on PTSD. She reported experiencing great relief when her new . and once a potential replacement therapist was identified. including some reductions in her ratings of fear. while also concurrently monitoring DBT targets via continuous use of the diary card. goals that she was interested in addressing with the new therapist. The standard PE protocol for imaginal exposure was implemented with a few deviations. For example. Continued exposure-based work was identified as a potential focus for further treatment. Trauma-focused work and more in-depth Stage II work were put on hold. were becoming more manageable. we viewed this as critical in order to involve Melissa as much as possible in the process of transfer. however. Many more sessions than required by the protocol were spent on a series of events remembered by Melissa. Melissa spent several therapy sessions discussing the goals she had met in therapy. which suggests full immersion in the memory and reporting in the present tense. Melissa kept her eyes open and described the events to the therapist using the past tense. Melissa was consulted about the qualities that she was looking for in a therapist. First. According to DBT conceptualization. as termination approached. controllable. e. Melissa noted that she struggled particularly with using and applying the mindfulness skills. At this point in treatment. She reported that despite having a working understanding of mindfulness. A discussion of the learning history around emotional experiences (particularly within her family of origin) was helpful in normalizing this response. This fading was built into the contingencies around phone consultation. when Melissa’s therapy with the new therapist ended and she was again transferred within the clinic. she continued her attendance at weekly DBT skills meetings (and eventually began attending a weekly advanced DBT skills group that focused on fully integrating skills into daily living and making the use of skills more automatic). Melissa would have suffered very serious consequences from expressing even small emotional responses. Thus. the ongoing use of skills was discussed weekly in individual therapy.. A primary goal was to ensure that Melissa maintained and deepened her use of skills.Borderline Personality Disorder 313 therapist reacted to her trauma disclosure with compassion and nonjudgment. In order to address this skills deficit. while also drawing on a variety of skills. Melissa tended to have three or four distress tolerance skills that she would rely on exclusively (i. with an emphasis on mindfulness of emotions.. While the pain of her previous therapist’s departure was acknowledged and processed in the first few sessions. Melissa and her new therapist were able to continue the work she had been doing in her previous treatment with little disruption. the therapist began to encourage Melissa to independently generate skills that she had not practiced as frequently. the fading of direct therapist intervention began. Thus. Phone consultation was also used toward this goal.) STAGE II TREATMENT PHASE Due to the work done during the process of treatment termination and transfer.g. mindfulness skills became one of the foci of the therapy for almost a full year. distracting with TV/movies. It stood to reason that she was both deeply afraid and highly judgmental of her feelings. a similar process was followed. This time. (Two years later. Whereas a great deal of Melissa’s skill use was generated by therapist suggestion. In moments of intense emotional distress. self-soothe. Melissa reported that she was confident because she “had done this before” and was able to predict and control the process of transfer. but only after she had tried at least three skills on her own. the focus of the treatment was quickly shifted to maintaining the gains made in Stage I treatment and continuing to address the goals identified for Stage II treatment. encouraging Melissa to generate her own choices about skills and to consider the context in choosing skills. she felt intensely uncomfortable practicing mindfulness because she could not see how she could just notice and accept her emotions without being reactive to them (e. playing video games). the therapist began to fade back more. In her childhood. trying to change them or engaging in mood-dependent behavior). Melissa was encouraged to continue to contact her therapist by phone if she was in need of coaching. . Because Melissa was quite avoidant of the narrative writing. To promote generalization and deepen cognitive processing of shame and angerrelated themes. Despite great discomfort with this exercise. despite the fact that she reported that she no longer blamed herself for the events and accepted that she was not alone in the experience. then by longer periods of time. without trying to change. Melissa’s previous imaginal exposure work had led to come fear reduction on the targeted events. Melissa completed written narrative accounts of the selected traumas and read those accounts in session and for homework. The 5-second duration was arrived at collaboratively—Melissa did not think she could tolerate more than 5 seconds of emotional exposure. Finally. but little generalization had occurred and there had been no movement in her shame and anger scores. Additional trauma-focused work was also completed.314 Personality and Dissociative Disorders Mindfulness skills are a core component of DBT skills training (Linehan. Melissa began to report marked shifts in her fear scores at this point. until she could engage in a 10-minute exercise in moderately distressing situations). frequency. in a discussion of her shame scores and brainstorming about why they might not be changing. They are designed to teach clients how to become more aware of the present moment exactly as it is. Resick & Schnicke. For example. Melissa was convinced that this behavior made her a perpetrator of sexual abuse. rather than imaginal reliving of the trauma. judge. 1993b). she was fi rst encouraged to practice mindfulness of emotions once a day for five seconds during a time that she was at her emotional baseline. by attending to “what is. Melissa was first incredulous and later relieved to learn that sexual abuse was not as uncommon as she had believed. As mentioned. and the duration. 1993).” She also stated that she felt entirely alone in the experience of sexual abuse. and that often children are confused by the abuse. we began to conduct exposures based on a modified cognitive processing therapy approach (CPT. These approaches were combined with psychoeducation about sexual assault and cognitive restructuring.” individuals can learn to detach from thoughts about what “should” or “shouldn’t be” and thereby reduce their own suffering. Melissa revealed to the therapist that part of her shame about her childhood sexual abuse was related to the fact that when the sexual abuse began she had welcomed it because it was preferable to the physical abuse that she was accustomed to and because she felt as though it was “the only time [her] father loved [her]. but she still did not experience changes in her shame and anger scores. which we then reviewed in session. The idea behind repeated mindfulness practice is that. Melissa revealed that she had very deep shame about some sexual behavior that she had engaged in with an extended family member of about her same age. and she revealed that she had decided long ago that she could not have children herself . We decided to alter our approach slightly. Melissa willingly engaged in her practice. In this evidencebased approach to PTSD. In order to make Melissa’s approach of emotions gradual. she was asked to come into her sessions an hour early to work on her accounts in the waiting area. and intensity of the mindfulness exercises were increased gradually over the course of the year (first by 5-second intervals. or avoid it. STAGE III TREATMENT PHASE At this point in treatment (about 3 years after initiating comprehensive DBT). She began by approaching peers in her college courses to make small talk. but soon challenged herself to build closer friendships. Melissa and her therapist brainstormed about ways to maintain her use of skills. which focused on addressing her residual anger related to childhood traumas and difficulties in relationships. in preparation for transfer. Melissa moved into Stage III treatment. Due to clinic constraints and the substantive progress that Melissa had made in therapy. Melissa was now experiencing the full range of emotions (including positive emotions such as joy) on a regular basis. This new therapist would not be available for phone consultation and would be less able to coach Melissa on her use of specific DBT skills. she challenged herself to begin pursuing romantic relationships (despite the significant fear and guilt that this triggered) and had begun dating by the termination of therapy. the therapist and Melissa looked up some legal defi nitions of sexual abuse and decided together that it would not be considered abuse by any defi nition. After fleshing out the details of the behavior (the behavior was apparently consensual. So. Melissa had reported high believability of thoughts that she was to blame for her traumas. non-coercive. Prior to this work. While Melissa had already made strides in becoming more involved in meaningful activity. Relapse Prevention and Termination As therapy drew close to an end. This shift opened up the possibility that Melissa was ready to work on deficits in relationships. and very low levels of shame on most days (1–2 of 5). giving her a chance to practice her interpersonal effectiveness skills. and she reported that she no longer felt “stuck” in continuous high levels of fear or shame (although she still experienced intense emotions occasionally when triggered). A discussion about normal consensual sexual exploration among children was had. an effort was placed to more explicitly and directly talk about relapse prevention. As is typical of individuals in Stage III treatment. Melissa also began thinking about meaningful goals in terms of her relationships and articulated her desire to someday get married and have children. including continuing to attend the advanced DBT group and reviewing her skills handouts regularly. based on the second therapist’s impending move. By the end of treatment she reported very low believability of thoughts of self-blame.Borderline Personality Disorder 315 because this childhood behavior was an indicator that she was a pedophile. the decision was made to assign Melissa to a therapist who was not DBT trained (but who had a substantial background in cognitive behavioral treatments). her intense fear and shame had inhibited her work in relationship-building. To that end. and high levels of shame on most days (4–5 of 5). Melissa began to work on gradually approaching more relationships. She also agreed to continue . and initiated by both parties). Melissa had used alcohol on several occasions. In addition. she would be unable to maintain her gains. Within a few weeks of transfer. Melissa articulated some fears about transferring to a non-DBT therapist. Melissa continued to periodically struggle with moderate symptoms of BPD and PTSD. she corrected this course very quickly. Addressing other ancillary providers’ responses to suicidal behavior was necessary in order to not inadvertently reinforce behavior that we were trying to decrease and also to present a consistent therapeutic response to Melissa’s behavior. who may idealize their therapists and have difficulty taking credit for their own accomplishments. based on the authors’ collective experiences and the experiences of members of the DBT consultation team. and she believed that without them. Treatment failure in DBT is not an uncommon experience (Rizvi. urgency. to prevent some of the most common problems that occur in treatment with BPD. As termination approached. specific efforts were made. 2006. This attribution is not uncommon in patients with BPD. specifically. engaging in hobbies. . she was in college. with the help of her new therapist. The therapist would attempt to educate unfamiliar treaters on deliberate selfharm and differentiating it from suicidality. at the end of nearly four years of DBT treatment. 2004). and continued her work in therapy. she began regularly attending AA meetings again. In sum. beginning at the start of therapy. 1993a) was used to consult to other treatment providers. such as her psychiatrist and hospital staff during the times that she was hospitalized. and high-risk nature of the client’s presentation. and building relationships. and Melissa was no exception. by talking to the providers directly. However. would state the therapist and client’s preference for community stabilization over inpatient hospitalization if possible. she attributed a great deal of her success to her two therapists. 2011). given the lack of any evidence that hospitalization decreases suicidal behavior in individuals with BPD (Comtois & Linehan. Avoiding Common Mistakes in Therapy Working with clients with severe BPD can lead to many therapeutic mistakes based on the complexity.316 Personality and Dissociative Disorders to fi ll out her diary card weekly so that any lapses could be detected as early as possible. Melissa had begun building an active and meaningful life. the therapist asked Melissa to track the number of times that she spontaneously used DBT skills without any therapist suggestion. Despite planning and relapse prevention. and would encourage as short a hospitalization as possible. Melissa quickly learned that she was applying her skills automatically dozens of times a day without any therapist intervention. Paris. The DBT strategy of “environmental intervention” (Linehan. did not evidence a full relapse. The frequency and intensity of these behaviors were very significantly diminished. Melissa’s transfer to the new therapist was not without difficulties. In fact. In Melissa’s treatment. the therapist actively worked to desensitize phone calling for Melissa by processes of shaping. After a couple of weeks of this. Thus. and how to handle multiple different outcomes. Melissa had to initiate the scheduled phone checkins. it suggests to the client that she is capable of doing something difficult and leads to the opportunity to learn new behavior—an opportunity that is lost if the task is completed for her. it was clear that the therapist was one of the main sources of social support. Third. Another potential pitfall in DBT treatment (and perhaps treatment more generally with BPD clients) is for the therapist to make a number of mistakes with regard to phone calls (Manning. Melissa felt far more at ease reaching out to the therapist than she had previously.or herself. as the calls are intended. On the other end of the continuum are BPD clients who want to avoid “bothering” the therapist at all costs and then do not call the therapist even when they are at high risk of life-threatening behavior. and the therapist initiated the call. and thoughts and feelings about the experience were discussed. Melissa was assigned the task of calling the therapist twice during the week but at non-prescribed times. rather than make the call herself. to behave in a manner consistent with the belief that the client is a capable adult who needs to learn the skills necessary to function in life more independently. the therapist engaged in exhaustive coaching of the client in how to prepare for the call. Melissa more often than not fell into this latter category. 2011). At the beginning of treatment. For example. Thus. it would have been very easy for the therapist to call the local university veterans’ program on Melissa’s behalf and enroll her in their program. given the paucity of social contacts early on. First. after a couple of weeks. Once she mastered this task. . Melissa was told to call the therapist when she felt that she could use coaching. what to expect. Again.” as one very common mistake committed by treatment providers working with BPD is to do “for” the client. however. it was important. She fi rst set up specific times during the week when they would have a very brief phone check-in (less than 5 minutes). However. With BPD clients. early in treatment. it took a great deal of effort to not do this for Melissa. it can easily lead to the client reaching out to the therapist when she is feeling lonely or “just wants to talk.Borderline Personality Disorder 317 However.” rather than for skills coaching during difficult situations. this is not an uncommon experience. on many levels. of which she might be completely unaware. given how easy the task was for the therapist and the perceived benefit that Melissa would garner. Breaking down a “simple” task such as this in a problem-focused manner achieves many goals. as opposed to helping the client do for him. it is important to balance environmental intervention with “consultation to the client. Second. it highlights to the client the very specific steps necessary to engage in a task. As a result of these collective experiences. choosing to not call the therapist for help even when she felt that she could benefit from it. and troubleshooting around this was addressed. it models for the client how to break down a complicated task into components that can be addressed systematically. what to say. and whether interventions seem to be working. These inevitable breaks in the therapeutic alliance can be powerful experiential learning opportunities. 1994).g. rather than protocol-based. with limit setting) and genuineness.e. Patients with BPD can often feel invalidated by a therapists’ push toward change (e. together with the use of the DBT consultation team. 2000). These practices.. “How can you tell me what a good job I’m doing? You must not appreciate how horrible I feel”). breaks are unavoidable.. this monitoring allows the therapist to track what target behaviors need to be addressed. The therapist models assertive communication (for example. how these behaviors are changing over time. In order to increase the likelihood of these positive outcomes. non-destructive.g. & Davis. Gutfreund. There is such marked heterogeneity within BPD. decisions about how and when to apply an intervention are informed by data monitoring. Given the difficulty of treating BPD. that it is hard to imagine a prescriptive approach to treatment. while also honest and forthcoming (“radically genuine”). while also coaching the client on these skills.318 Personality and Dissociative Disorders Nonspecific Factors in Treatment A strong therapeutic alliance is critical to therapeutic success in any treatment population (Martin. many of the therapists’ decisions require a trial-and-error approach. it is unlikely that a protocol-driven approach would be appropriate or adequate. because of the dichotomous thinking that is endemic to BPD. “How can you expect me to do this. Individuals with BPD can be very sensitive to perceived criticism or rejection and can be prone to having very strong emotional and potentially destructive behavioral responses to breaks in the alliance. Yeomans. Many clients with BPD have maladaptive beliefs related to relationships in which any confl ict within the relationship signals rejection or abandonment.. but these techniques are applied using a flexible and idiographic approach. you clearly don’t understand my pain”) or by attention paid to the patient’s successes (e. a repair. Art versus Science in DBT The fact that DBT is a principle-based. are an attempt to make any confl ict within the therapeutic relationship explicit. experiencing a break in the alliance. The techniques used in DBT are evidence-based. with so many layers of complexity introduced by comorbid problems. but it may be even more important in treating patients with BPD given the nature of the pathology (Rizvi. That said. Selzer et al. “Everyone who I get close to hurts me”).. DBT therapists are trained to be validating. Whenever possible. A strong alliance may also provide the opportunity for the extinction of generalized fear associations (i. and instructive. That said. 2011. treatment calls attention to the interplay between “art” and “science” in therapy. Thus. Garske. and a continuation of the therapeutic relationship may disconfi rm these beliefs. . Perhaps more than any other psychological disorder. As such. BPD represents a significant challenge to the treatment provider. Conclusions Overall. artful but judicious clinical decisions were made. it is only after several months pass that it is possible to see measurable gains. at termination Melissa continued to face some significant challenges and was not yet ready to graduate from treatment. Change is typically nonlinear. consider the therapists’ decision to inform Melissa of impending termination months ahead of time. we were fortunate to be providing Melissa with treatment in a setting that allowed for a great deal of therapist flexibility and support. and switch course. . monitor Melissa’s progress. Whether gains could have been achieved faster or whether even more could have been done to alleviate her suffering and help her attain her goals is unclear. Or. an individual clinician in private practice who does not engage in ongoing peer supervision/consultation). the therapists decided to take this long-term approach to termination in order to promote new learning and to challenge preexisting maladaptive beliefs about the end of relationships.g. 1993a).. this approach did not address her shame and anger related to her traumas. For example. this outcome is not atypical among patients with BPD. its model is a community of clinicians treating a community of clients (Linehan. as in the case of Melissa. In this case. This course of action lengthened the duration of Melissa’s distress about termination. this level of treatment with Melissa would not be possible. DBT is a team-based treatment. changing course and using a different technique to promote cognitive processing addressed this obstacle. while Melissa derived benefit from imaginal exposure to trauma cues. To that end. the therapists were cognizant of the necessity of using empirical evidence from both the broader literature but also evidence from Melissa’s progress to guide the treatment. At several points in her treatment. and other therapists may have chosen to handle this differently. In addition. Note that while we view this case as a success. Although recognizing that there often was not a “right” answer for what to do. in many settings.Borderline Personality Disorder 319 This balance between the art and science of therapy is evident in Melissa’s case. the parameters of treatment might have been constrained by resources or time. given the number of obstacles that present themselves along the way. and it can be difficult to note progress over time. Melissa represents a successful treatment case. It remains an empirical question whether therapists operating outside the context of a consultation team could achieve similar (or better) outcomes with BPD clients. fi nd that certain targets were not moving. Sometimes. Maintaining a commitment to a particular therapy approach can sometimes be demanding. Melissa’s therapists would test an intervention. In settings where the team approach is not utilized or possible (e. an individual clinician isolated in a rural setting. . Cognitive behavioral treatment of borderline personality disorder. Foa. Kroger. New York: Oxford University Press. 121–128). (2007). T. Journal of Mental Health. W.). O’Donohue. & Rothbaum.... The Behavior Therapist. Gunderson. 936–951. TX: Psychological Corporation. A. & Fonagy P. F. 13. Because DBT is theory driven. Kernberg. (2006). C. E. B.. M. C. W. Carr. (1997). M.. M. (2003). T.. New York: Wiley. The borderline patient’s intolerance of aloneness: Insecure attachments and therapist availability. & Applebaum. (1997). D. Cognitive behavior therapy: Applying empirically supported techniques in your practice (pp. & Williams. & Brown. A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Batemanm A.. Linehan. S. O. K. F. World Health Organization. Melissa’s case illustrates the effectiveness of DBT for a complicated client presenting with BPD and a number of comorbid conditions. 161–170. Selzer. Gunderson. . B. A. J. W. Fruzzetti. A.. (2001). R. A. R. & S.. B. 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The PTSD checklist: Reliability. M. & Silk... B.. M. & Silk. E. R. Reich. Zanarini. G. Schema therapy: A practitioners guide. D. W. A. P. 20. Frankenburg. (2008). & Silk. C. C. (2006). American Journal of Psychiatry. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. D. F. A.. C. W. K. M. Reich. B. M. 163(5). Hennen. J. F. 76. W. M. Factors related to drop-outs by borderline patients: Treatment contract and therapeutic alliance. Chittams. T. 45–51.. D. R. A. Weathers. Reich. (2007). J.. 663–667. S. E. & Harned. San Antonio. S. J. R. T. J. so the few studies with patients with BPD that have evaluated more than one year of treatment have been done in Europe (e. and there is no evidence that schizophrenia is primarily a disorder of emotion dysregulation. funding structures in other countries often do not have these arbitrary time limitations (but generally do not have as much overall funding. In this case. In contrast. Kliem. one key step taken by the therapist was to determine whether Melissa’s problems fit into the set of problems for which DBT has been shown to be effective. and had an enormous record of prior.. severely dysregulated people sometimes exhibit delusions or hallucinations and can easily be misdiagnosed.g. answering these questions was not simple. Fruzzetti The case described by Rizvi and Salters-Pedneault provides an excellent example of the successful application of clinical science in the treatment of a client with multiple severe and chronic problems. But. There are no published studies using DBT to treat schizophrenia. I will highlight key DBT implementation issues throughout the case. However. either). treatments (both inpatient and outpatient). met the criteria for multiple diagnoses. Thus. et al. careful record review. necessarily. she had been diagnosed with undifferentiated schizophrenia. 2009. So. 2006). the structure of research funding in the United States has effectively limited clinical trials to one year or less (cf. but also will address systemic issues for both the client and for therapists employing rigorous clinical science in their use of dialectical behavior therapy (DBT). & Kosfelder. people with severe BPD sometimes are incorrectly diagnosed with schizophrenia or other problems. treatment continued (appropriately and successfully) for about four years. 2010). Kröger.. van Dyck. This included the SCID and other formal evaluations. Spinhoven. essentially failed. During acute presentations. Thus. Although DBT was developed specifically to treat multi-problem people with severe emotion dysregulation (about which BPD is a kind of prototype). these adjustments included changing therapists and managing a rather extreme set of difficulties not specifically included in any randomized clinical trials of DBT. Bateman & Fonagy.COMMENTARY Alan E. the clinicians involved had to adjust the treatment substantially. For example. Giesen-Bloo. initiation of daily . The fi rst essential clinical science questions really were “What treatment(s) have evidence for Melissa’s problems? Is DBT appropriate for her?” Melissa presented with a long list of problems. in the case of Melissa. Another example of dialectical management involved careful balancing of consulting with the patient about managing her interactions with other treatment providers through direct contact and discussion with them (including orienting them to how this works in DBT).3 in the case) of current behavioral problems. until she committed to the treatment. The therapist and her team determined that there was sufficient evidence supporting the use of DBT for Melissa’s main difficulties (BPD plus substance use disorder). including all components and functions (Linehan. therapist consultation team) was stable. not only as a “mental patient”). new evidence supports . This kind of assessment can be complicated and time-consuming. since that time.324 Personality and Dissociative Disorders self-monitoring (diary cards. For example. PTSD is treated in Stage II. including (a) case conceptualization employing a transactional model (emotion vulnerabilities transacting with and within an invalidating social environment.. but in this case PTSD was targeted a bit earlier. Both acceptance and change strategies were employed in the service of increasing emotion regulation and helping the client to learn skills as solutions to her difficulties (client empowerment). but obviously is essential: Treatments that are effective for some problems may not be for others. Interestingly. the therapist employed a whole range of appropriate DBT strategies on both sides of the dialectic. In addition.g.2 in the case) and detailed functional analyses (“chain analyses”. see Figure 12. the therapist utilized the “pre-treatment” phase very successfully: She provided the treatment while not yet “in” the treatment. and 100% accepting of her when she did self-harm. the focus was on both acceptance (understanding and validating her suffering) and change (identifying important goals and committing to developing a life worth living. successfully orienting Melissa and enhancing her collaboration. based on a careful assessment of client behaviors. the structure of the treatment (individual therapy. given the extent to which it interfered with Melissa’s basic safety and stability. skill training and coaching. she used a variety of validation strategies. The expert application of dialectics in this case is evident throughout. and fidelity to the treatment was consistent. opportunities for generalization of skills. In some ways. 1993). She used change strategies from behavior therapy (stimulus control. Thus. they could be 100% committed to Melissa stopping her self-harm. 2005). The therapist also demonstrated flexibility in treating Melissa’s PTSD. In addition. this was a deviation from the protocol. (b) establishment and use of a treatment target hierarchy. Fruzzetti. and not providing validation in response to dysfunctional behaviors. It is important to note that the therapist employed comprehensive DBT. (d) focus on acceptance and validation. and contingency management and shaping). Typically in DBT. the delivery of the treatment was also adherent to the model. including providing appropriate kinds of validating responses when the client expressed emotion accurately. see Figure 12. Moreover. Thus. (c) focus on change (behavior therapy). and few (if any) evidence-based alternatives available because no other treatment has evidence to date explicitly for these co-occurring problems. Shenk & Hoffman. group skills training. and (e) dialectical synthesis throughout all strategies (e. exposure and response prevention. acceptance and change). And. they might have arranged for Melissa to take a “holiday” from treatment (for example. it may be important to move from distress tolerance skills (to interrupt impulsive and dangerous behavior chains) to specific emotion regulation skills a bit earlier as the client develops high negative emotional arousal. for several weeks or a month) as an assessment of how she might fare on her own. Melissa. the therapists and teams handled this transition sensitively and thoroughly. the therapist chose the treatments with the best evidence to import into DBT for treating PTSD. There are advantages and disadvantages to each.. and the treatment team had several options: (a) continue treatment.Borderline Personality Disorder 325 exactly this kind of deviation (e. which might have been the most empowering for Melissa. They decided to refer Melissa to a non-DBT therapist (although an ongoing “advanced” DBT skill group was apparently still available to her).g. and generally includes some in-depth video observation and feedback on part of individual sessions (or group skill training) and/or role-plays both to demonstrate patient-therapist interactions and to provide practice opportunities to build therapist mastery. This helps her to move her energy from tolerating intense distress to managing more normative (or. with a new DBT therapist. For example. but it is not clear whether they considered the third option. we have no data to tell us about factors related to relapse after a long-term course of DBT. Subsequent sessions could then have been used in a targeted way to help her learn how to manage whatever she could not previously manage independently. There are many skills. or (c) discontinue treatment. (b) continue treatment. more research is needed to understand both the specific processes that are involved in dysregulation. prior to her therapist leaving. Within DBT it is often difficult to know which skills to coach or to encourage clients to use in a given situation. Thus. There are no clear data suggesting how to handle a change in therapists. One decision that might have generated some discussion and even disagreement on the treatment team occurred around the time that the second DBT therapist was about to move away. at least less dysregulated) emotional reactions before they grow to become severe and difficult to manage or tolerate. However. Clinically. the therapist. The team was . The consultation team in DBT provides the therapist with support and opportunities to become more skillful. much less what combination of interventions (or not receiving treatment at all) promotes maintenance versus relapse. in particular in a complicated case like Melissa’s. The authors allude to one of the “traps” that can happen when they discuss how Melissa often utilized a small set of distress tolerance skills to manage intense distress (in the context of transitioning to a new therapist). as well as which skills are needed in the long-term to become successful at emotion selfmanagement such that a person’s distress stays in the normal range. first prolonged exposure and then cognitive processing therapy. Harned et al. And. with a non-DBT therapist (which they chose).. Clearly. and no clear data to guide these decisions. This also highlights a part of the treatment that was not discussed at length in the case presentation but was obviously present: the role of the consultation team. providing opportunities for the client to use her skills to manage the associated difficulties in stride. 2010). Unfortunately. although not necessarily obvious to her. not treating the client as fragile) and a constant push for skillful behaviors and change (empowerment). K. I. American Journal of Psychiatry.. In DBT.. Shenk... Journal of Traumatic Stress. of emotion. . van Asselt. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Development and Psychopathology. Kröger.. J.. (2010). S. on the one hand. Dirksen. 421–429. E. References Bateman.. Rather. van Tilburg. Linehan. Overall.. 649–658. it is assumed that the combination of warmth and validation. Journal of Consulting and Clinical Psychology. will build a meaningful and real relationship. Archives of General Psychiatry. building or maintaining the alliance is not a treatment target per se. & Kosfelder. New York: Guilford Press.. 1007–1030. to a complex and severe case. M. M. One interesting question that this case raises involves the role of the therapeutic relationship in DBT. Jackson. which then will enhance the prospects of the client learning new skills and establishing patterns of behavior. C. Cognitive-behavioral treatment of borderline personality disorder.. & Arntz. 936–951. the case of Melissa provides an excellent example of applying science (e. Family interaction and the development of borderline personality disorder: A transactional model. C. 1355–1364. Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. & Linehan.. R. BPD) in general. 63. & Hoffman. Fruzzetti. Kremers. with an excellent outcome. M. S. Thus. C. (2010). W.. P. on the other hand. How the relationship is viewed in psychotherapy determines certain therapeutic strategies.D. and the science and theory of DBT specifically. but instead assume that the therapeutic relationship is a consequence of doing the treatment intensely and well. Spinhoven. social interactions.. Harned. Comtois. Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling.g. J. M. 17. A. Kliem. we do not wait for the relationship to develop to provide the treatment at full speed and assume that improvements will flow from the success of the relationship. M. A. 23.. (2006). C. Nadort. (2005). 166.. & Fonagy. A.326 Personality and Dissociative Disorders likely an important piece of Melissa’s treatment. P. T. and respect (e. (1993).. P. (2009). 78. M. S. Dialectical behavior therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with borderline personality disorder.. Giesen-Bloo.g.. A. vanDyck. with some insight into the fact that she was transitioning to a new stage in her therapy. She did express fear about possible termination. at least for a short while. clients’ perceptions of their therapists were related to outcome. & Linehan. regardless of how the client feels about them. was available. As he noted. She chose to continue with the non-DBT therapist. and that termination would be reconsidered in the not-distant future.RESPONSE Shireen L. Fruzzetti notes that the DBT therapist does not wait for a positive therapeutic relationship before moving forward with interventions and that a positive relationship is a consequence of effective treatment. rather than a precursor. Atkins. these options were presented to her. Fruzzetti makes an important point in noting that a third option of discontinuing treatment. Second.” We would like to respond to two issues that were raised in the commentary: (a) the possibility that Melissa might have taken a “therapy vacation” after the second therapist terminated with her. Furthermore. and controlling. DBT therapists were rated as less controlling (Bedics. and her departing therapist worked with her to support her in making this decision. the idea of therapy termination was considered (as well as a “stepped-down” version of therapy. In Melissa’s case. in that DBT clients who perceived their therapist as affi rming and protecting reported less frequent occurrences of self-injurious behaviors. it should be noted that it was very easy to generate a . In Melissa’s case. and (b) the nature of the therapeutic relationship vis-à-vis therapeutic change. First. As treatment approached termination. Interestingly. the lack of research in the area of complex clinical decision making with BPD clients means that we often had to follow evidence-based principles and/or attempt to make reasonable decisions that we could justify in our “wise minds. Out of respect for Melissa’s autonomy. Comtois. 2012). Rizvi and Kristalyn Salters-Pedneault Fruzzetti’s commentary on the case of Melissa highlights some of the important decisions we made during her treatment. we may fall victim to our own bias that some therapy is always better than no therapy. accepting. These data suggest that DBT therapists indeed may “charge ahead” early in treatment. As therapists. and that this can lead to good outcome. recent research that has examined the trajectory of the therapeutic alliance in DBT found that DBT therapists are rated in early sessions as warm. involving once a month sessions) as the departure of the second DBT therapist approached. and it may be that a vacation from therapy might have helped her approach this fear. D. and decision-making points that we faced in treating this complicated case. seemed to appreciate the radically genuine stance of the DBT therapist. M. Fruzzetti’s commentary highlights some of the challenges. . A. M.328 Personality and Dissociative Disorders positive relationship from the start. complexities. Atkins.. Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus non-behavioral psychotherapy experts for borderline personality disorder. further. Melissa was always quite likable and. Journal of Consulting and Clinical Psychology. & Linehan. Comtois. C.. (2012).. K. Because few patients present with isolated problems. D. 66–77. References Bedics. we expect that these challenges are universally experienced by clinicians within and outside the DBT modality. 80. J. 519) in conjunction with “an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (APA. 526). memory. which we favor and recommend to the reader. This disorder. We fi rst present the posttraumatic model (PTM) of dissociation. 526). Strosahl. and the empirically based approach that we adopt in the case at hand.. More specifically. and Gep Colletti Dissociative identity disorder (DID) is defined as the existence of at least two “distinct identities or personality states that recurrently take control of the individual’s behavior” (p. and that they serve as a counterpoint to empirically grounded treatments. we propose that evidence-based methods can be implemented to treat the emotional dysregulation and manifold symptoms that accompany the typical presentation of DID. purportedly reflects a “failure to integrate various aspects of identity. . In contrast. p. 1993) and acceptance and commitment therapy (Hayes. p.” a 49-year-old Caucasian woman who presented with symptoms of DID and was successfully treated with a multifocal cognitive behavioral intervention that included methods derived from dialectical behavior therapy (Linehan. Liam Condon.” Key Principles/Core Knowledge In this chapter. 2000. we provide a case study of “Ms. which we eschew. we contend that treatments with a sole or major focus on trauma provide a cautionary example of how not to treat patients with DID. M. and consciousness” (APA. 2000. which serves as a backdrop against which to view both the traditional treatment of DID and the controversies that have dogged DID from the time of Freud to the present. formerly known as multiple personality disorder.{ 13 } The Treatment of Dissociative Identity Disorder: Questions and Considerations Steven Jay Lynn. 1999). & Wilson. We present this introductory information to bring into relief the sharp contrasts between the conventional treatment of DID. and is therefore better described as “identity fragmentation” than as the “proliferation of separate personalities. 142). I am going to refer to you as the one who covers her mouth with a hand when she talks’” (p. From this perspective. most notably physical abuse. such as the Academy Award– winning movie The Three Faces of Eve and the Emmy Award–winning movie Sybil. both hypnosis and drug-facilitated interviews are highly suggestive approaches that can increase the confidence in inaccurate memories (Lynn. These interventions include (a) making contracts (e. & Lilienfeld. “In some cases . an argument that presaged concerns expressed by modern critics of the posttraumatic model of DID (see Lynn et al. in arriving at a diagnosis and in initial interventions.. 90). December 10. if not all. . memories (Lynn. (b) “fi lling in” the host personality regarding events for which she was purportedly amnesic when different alters were “in control” (p. To do so. function. Putnam suggests that from the earliest meetings with the patient. then the “therapist should make one up” and Putnam notes. & Cardena. which research suggests are thought to be fraught with risk of creating.g. Individuals who undergo horrific trauma in early life are thought to compartmentalize their previously intact personalities into discrete multiple personalities—often called “alters”—as a means of coping with intense emotional pain. 2001. 2006).g. therapists can concretize and reify the presence of alters with many of the following highly suggestive interventions that Putnam (1979) recommends. Knox. M. If the alter avoids giving a name. 1996. one of the therapist’s pivotal tasks is to obtain a history for each alter. Gleaves. 2006). Google Scholar. or both. Fassler. Proponents of the model posit that DID arises primarily from a history of severe childhood trauma. Fassler. journals. Putnam further notes. Freud argued that most.. 90). or description that I can use as a label to elicit this other part directly” (p. cases of multiple personality resulted from the suggestive influence of therapists upon patients. it is imperative that the therapist “meet and interact directly with alter personalities” (p.. . facet. “for a name or an attribute. . Indeed. sexual abuse. Notably.330 Personality and Dissociative Disorders The PTM (e. the therapist asks highly leading and direct questions such as. “I will not hurt myself or kill myself”) with different personalities (p. etc.) of yourself that comes out and does or says things that you would not do or say?” and asks . 1997) is commonly reflected in media portrayals of DID. Although treatment varies somewhat among therapists who endorse the PTM. . 151). May. “Do you ever feel as if there is some part (side. 144). hypnosis or a drug-facilitated interview may be useful to facilitate the emergence of an alter” (p. 2012). 151). which often involves using potentially suggestive methods (e. 2004).g. Putnam’s (1989) now classic volume (896 citations.. “I will say something such as this: ‘Since you are not willing to share your name with me at this time. Ross. (c) treating people as if they were “multiples.” despite their strongly expressed resistance to the diagnosis (p. Diagnosis and Treatment of Multiple Personality Disorder. Freud’s concerns are probably not far off the mark. Gleaves. Ross (1994) has gone so far as to claim that abuse is almost always required to cause DID. 91). Lilienfeld. In all likelihood. rather than uncovering. & Loftus. diaries) to recover memories. Knox. both describes a trauma-based DID treatment approach and illustrates the outright suggestive and potentially harmful aspects of conventional DID treatment that we sought to avoid in our work with Ms. (d) “assembling whole memories . 1993. again suggesting that alters may be created rather than discovered in therapy. objective corroboration of the abuse is lacking. 1996. Sarbin.. which include suggestive questioning regarding the existence of possible alters. see also Aldridge-Morris. Interestingly. (b) generating an “ongoing ‘map’ or ‘roster’ of the patients alternate identity system” (p. and (i) “talking through. Ross & Ness. 2008. and (c) conducting pharmacologically facilitated interviews for “emergency situations when other methods of assessment have failed.g.” which involves exhorting the entire personality system to listen to a particular directive or communication (p. (f) mapping the purported personality system (pp. 125).g. 1995). debate has swirled around the genesis and treatment of DID. Moreover. (g) age regression for memory recovery (p. 2010). television and fi lm portrayals of DID) and sociocultural expectations regarding the presumed clinical features of DID. 1992. e. many DID patients show few or no clear-cut signs of this condition (e. 227). Prospective studies that circumvent the pitfalls of retrospective reporting often fail to substantiate a link between childhood abuse and dissociation in adulthood (Giesbrecht et al. text revision. 1999. the guidelines preserve many of Putnam’s recommendations and explicitly endorse the practices of: (a) directly “accessing alters” (e.” p. repudiate the practice of the therapist “making up names” for supposed alters. and the overwhelming majority of studies of self-reported trauma and dissociation are based on cross-sectional designs that do not permit causal inferences.. DID can result from the sorts of methods we reviewed. 198–199). including hypnosis” (p. Merskey. psychotherapists who use hypnosis tend to have more DID patients in their caseloads than do psychotherapists who do not use hypnosis (Powell & Gee. in a hospitalized patient who is engaging in high risk behavior in dissociated states. McHugh. DID is arguably among the most controversial disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th edition. but who has been refractory to other methods of inquiry. 98). DSM-IV-TR). 2010). however. 1999). as well as media influences (e. the number of alters per DID individual tends to increase substantially over the course of DID-oriented psychotherapy (Piper. More recent DID treatment guidelines. According to the rival sociocognitive model (SCM. 1997). Spanos.. Indeed. 261). 97).g. Curiously.. 228). and sodium amytal interviews.g..g.The Treatment of Dissociative Identity Disorder: Questions and Considerations 331 from fragments” that are supposedly spread across several alters (pp. (h) internal group therapy with different personalities (p.. 1989.. 201). 1984). “I need to talk to the one(s) who went to Atlantic City last night and had unsafe sex. and most DID diagnoses derive from a small number of therapy specialists in DID (Mai. Lilienfeld et al. hypnosis for memory recovery. (e) using dream material to “provide access to deeply hidden trauma” (p. In most studies (e. Proponents of the SCM have also cited a number of reasons to question the widely received notion that childhood abuse causes dissociation. raising the specter that alters are generated by treatment. 210–211). alters) prior to psychotherapy (Kluft. but see Bremner. For the past 25 years or so. the link between abuse and dissociative disorders may be due to (a) global familial maladjustment rather . developed by many leading exponents of the PTM and promulgated by the International Society for the Study of Dissociation (2005). 1995). & Green. 2010)..e. Notably. she experienced intense confl ict and self-recrimination. anger.g. Dissociative symptoms may be preceded or triggered by internal (e. Sexton. at least 10 studies support at least a moderate association between dissociation and fantasy-proneness/imaginative abilities (Giesbrecht. media). Lynn. These “parts” became crystallized in conjunction with her growing familiarity with DID through books and movies and early contacts with a therapist who reinforced her presentation of dissociative symptoms.g. & Lambert. mood disorder. She reported that shortly after this event.g.g. see Colletti. 2010. troubling cognitions. Interestingly.. childlike parts that required protection by an “adult protector.332 Personality and Dissociative Disorders than the abuse itself. Hulsey. dissociative experiences can be predicted at least as accurately by absorption and fantasyproneness abilities as by the report of trauma (Pekala. Moreover. patients with dissociative disorders (e. 2001). profound involvements in fantasy and imaginal activities). and . & Merckelbach.” angry adult).g. 1993). eating disorders.. Angelini. but also by her excellent treatment response to hypnotic suggestions and her ability to use imaginative rehearsal interventions to advantage. Conceptualization of Dissociation Our treatment conceptualization centered on the idea that the core symptoms of DID (i. reflected not only by her longstanding history of fantasy involvements. which originated in childhood. Lynn.’s dissociative symptoms appeared to be a history of fantasy versus reality-based coping. such as anxiety. & Laurence. She reported a history of childhood imaginary playmates and fantasy-proneness (e. guilt. she experienced intense anger regarding her sister’s death. Lynn. automatic cognitions) and external stimuli. as if she were split into angry and excessively protective aspects of herself.’s sensitivity to media and therapist cues was probably associated with her high suggestibility and fantasy-proneness. believed-in/imagined distinct personalities) can often be understood as manifestations of a dysfunctional avoidance-based coping strategy associated with (a) failure to acknowledge and/or take responsibility for puzzling and selfdefeating behaviors. including therapist suggestions or suggestive influences in everyday life (e. Lilienfeld. When she was 5 years old. and personality disorders (Nash. M. accompanied by guilt at not being able to prevent it. 1988). Rhue. Haralson.. DID and dissociative disorder not otherwise specified) score higher on measures of hypnotic suggestibility than do patients with schizophrenia. M. anxiety... abetted by (b) the use of imagination and attention-regulating strategies to create a credible feeling of distance or separation from aversive personal or interpersonal events. anxiety disorder. & Kumar. she imaginatively elaborated and segregated confl icting and chaotic emotions into different “parts” (e.g. and negative feelings (e.. or (b) other frequently overlapping conditions. During adolescence. The diathesis for Ms. Ms. The avoidancebased nature of dissociative symptoms increases the likelihood that they will recur and even proliferate by means of negative reinforcement. memories. described them. Huntjens et al. 2012). especially at expense to herself)..The Treatment of Dissociative Identity Disorder: Questions and Considerations 333 college student control participants (Frischholz. M.. . mildly disoriented.g. including depersonalization.. Ms. rigid. moved. & Scahs. it became apparent that Ms. were in conformance with the fi ndings of 19 studies that report a link between dissociation and sleep problems (van der Kloet. psychologically speaking. In short. deBeurs. were exacerbated by poor sleep.. In fact. to reifying her purportedly separate parts and using their imagined presence as a way to comprehend puzzling thoughts. Van Dyck. M. from feeling “as if” she were composed of different parts and mentally elaborating such parts. M. M. challenging the widespread idea that amnesia (i.” as Ms. Nixon. 2003). 2000).e. she truly embodied only one personality. clinicians should be skeptical about claims that patients somehow house independent personalities with separate streams of memories and histories. she did not have to “automatically” help anyone who sought her help or support. M’s dissociative symptoms. M. Studies of cognitive inhibition in high dissociative clinical and nonclinical samples typically fi nd a breakdown in such inhibition. & Phaf. Increasingly coordinated and frequent avoidance-based responding to aversive events and internal experiences through dissociation became steadily more maladaptive. in fact. & deZutter. This fi nding is strikingly discrepant with the presumed defensive function of dissociation. exhibited little inhibition: She startled easily. Merckelbach. We also shared with Ms. Moulds. Late in treatment. Braum. Accordingly. & Felmingham. not successful in defending her against anxiety and dysphoria.. especially when they challenged well-ingrained self-perceptions.g. 1992). 2008. further reinforcing her sense of personality fragmentation. Interestingly. and behaviors. We have termed this state of affairs the dissociative trap (Colletti et al. and stimulus-bound. and that it was therefore imperative that we work together to help her fi nd more adaptive ways of coping. 2000. Sergeant. Ms. Ms. Giesbrecht. M. researchers have found that patients with DID and others with high levels of dissociation display better memory for to-be-forgotten sexual words in directed forgetting tasks (Elzinga. and dysphoric the following day. Lipman. the idea that although she might have felt at times that she housed distinct personalities. was guided by the fact that researchers have failed to fi nd support for the idea that alters or “parts. 2010). thereby precluding more adaptive and situationally appropriate coping. caused by the medical conditions described below. are psychologically distinct entities. 2006). When scientists present certain information to one alter. emotions. we repeatedly shared with Ms.’s experiences of sleep paralysis and fragmented sleep. objective measures of memory (e. higher levels of hypnotic suggestibility are associated with PTSD avoidance symptoms (Bryant.. M. Guthrie. extreme inhibition) is a core feature of dissociation (Giesbrecht et al. and on occasion she displayed exaggerated and histrionic reactions to interpretive statements made in therapy. that her “dissociative coping style” was. which often left her feeling depleted. Our treatment of Ms. 2010). behavioral tasks or event-related potentials) reveal that the information is typically accessible to another (Allen & Movius. In fact. including terrifying sleep paralysis symptoms. (e. 1998. In addition to the dramatic increase in DID’s prevalence since the mid1970s. Ross.e.334 Personality and Dissociative Disorders Epidemiological Considerations Population prevalence estimates of DID vary widely. Estimates of DID in inpatient settings range from 1–9. 2006).. Coons. & Ellason. Kemp. .6% (Rifkin et al. Knox. DID is reported to be between three and nine times more common in women than men. as compared with the male average of eight. & Sethi. she vacillated repeatedly from being scared and vulnerable one moment. this imbalanced sex ratio may be an artifact of selection and referral biases (Lynn. 1984). suggestive methods in psychotherapy) or increased awareness of DID in the patient population and more accurate diagnosis of the condition. and Torem (1988) reported no significant differences between BPD and DID patients on measures of personality traits. she fi rst presented for treatment at a university psychological clinic at the suggestion of her physician. In fact. Jin. During the examination.. from extremely rare (e. Gilbertson. erythrocyte sedimentation rate). 1988. Ross. APA. see below) by 1990. repeated kidney stones and infections. Ghisalbert. Ross. Ms. Ellason. rather than in clinical settings (Putnam & Loewenstein. from only two or three separate identities to an average of approximately 16 (interestingly. 2000). all of which were documented in writing and in conversations with a number of her physicians.. and lupus.. M. to being angry and aggressive the next. 1997). & Lilienfeld. a fact that applies to the case of Ms. the exact number reported by Sybil. Comorbidity. 2000). cysts on her bladder. and Assessment To meet criteria for DID. and Fuchs (1996) reported that DID patients meet criteria for an average of 8 Axis I disorders and 4. peripheral muscle weakness and sometimes severe chronic pain. Fassler. Piper. This dramatic increase has provoked considerable controversy as to whether the rise in DID cases is attributable to sociocognitive influences (e. M.g. 2002).. 1997. ovarian cysts. 1998. there has been an increase in the number of “alters” reported. who was alarmed by her startling and disturbing behavioral changes during a pelvic examination in his office. media coverage. Duffy. Horevitz & Braun. M’s medical history was remarkable: She had surgery for cervical cancer. which parallels extensive media coverage of the disorder. chronically abnormal blood values (i. often experienced dissociative reactions in response to medical procedures. and women also tend to have more identities (an average of 15. DID typically is manifested against a backdrop of substantial preexisting psychopathology. 1998) to rates approximating that of schizophrenia (1–2%. In particular. Ms. Diagnosis. However. Rifkin. an individual’s symptoms cannot be attributable to substance use or to a medical condition. a large proportion of males with DID may end up in prisons (or other forensic settings). One-half to two-thirds of patients with DID meet diagnostic criteria for borderline personality disorder (Coons et al. Dimatou. labeling of puzzling symptoms as DID.5 Axis II disorders.g. 84 over a period of 4 to 8 weeks) and validity. college students. schizotypal personality disorder. 1991). Torem. was assessed for dissociative experiences and symptoms with the 28-item Dissociative Experiences Scale (DES-II. very goodto-excellent temporal reliability (weighted kappa . met all diagnostic criteria for PTSD. and good convergent . identity confusion. achieved a high score on all five dimensions. being sexually molested by her treating optometrist during the same time period.The Treatment of Dissociative Identity Disorder: Questions and Considerations 335 cognitive and adaptive functioning.. Ms.. Ms. 1994). did not qualify for any of these diagnoses. 1993. The SCID-D possesses good interrater agreement (r = . Armstrong. Lauer et al. Crowley. substance abuse or dependence. Ms. related a history replete with highly aversive events. scored 39 on the DES. Steinberg. with the ability to differentiate participants with DID from those without a dissociative disorder (e. 1993. unstable and intense interpersonal relationships). and the experience of the death of a neonate under her care as a nurse in the context of a live abortion incident. Vance. alcoholics. North et al. & Fuchs. emotional numbing. identity disturbance. cognitive behavioral therapy. Bernstein-Carlson & Putnam. which provided warrant to use tactics (e. and affective instability. M. M. A cutoff of 30 correctly identified 74% of patients with DID and 80% of subjects without DID in a multicenter study (Carlson. Kao. she reported experiencing the death of her sibling at around age 5. & Baum. M. normal adults. sexual and eating disorders... Ursano. M. met at least five diagnostic criteria for borderline personality disorder (i. Bowman.. 2000. being raped prior to the start of treatment.g. M. intense anger. phobics).e. M.86). met diagnostic criteria for DID based on the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D. Although patients with DID also often meet criteria for major depression. inappropriate. 1993): Ms. Ross & Norton. M. 1993).86). depersonalization. Coons. and clinician ratings. The 250-item SCID-D incorporates DSM-IV criteria for dissociative disorders. 79. 1988). Assessment Strategy Ms. including highly disturbing flashbacks triggered by seemingly innocuous statements by the therapist. mindfulness training. and identity alteration. or difficulty controlling anger.g. severe dissociative symptoms. derealization. Ross. Epstein. et al. Putnam. an abortion while in college. & Loewenstein. 1996) of 135 patients with DID. The DES possesses adequate test-retest reliability (r =. as noted above. affect management techniques) in treatment found to be effective with patients with borderline personality disorder (Linehan. and schizophrenia (Fullerton. 2006). Ms.2% were diagnosed with PTSD.72–. Ms. Ms. Posttraumatic stress disorder (PTSD) is commonly comorbid with DID (Loewenstein.77–. the most frequently used self-report measure of dissociation (Brand. and assesses five core symptoms: amnesia. Importantly. For example. and startle responses. 1993).. schizoaffective disorder. M. Ross. In a study (Ellason. suggesting noteworthy commonalities between the two conditions. . 1995).g. Berg. 2008. To avoid the appearance of a sole emphasis on dissociative symptoms and to glean information across multiple domains of both abnormal and normal-range personality. Dahlstrom. Lynn. dissociation increases the risk of commission errors (e. affect management. engendering false memories. problems in discriminating perception from vivid imagery. amnesia) in their autobiographical memories of childhood (Belli. as it can lead patients to mistakenly believe that they have significant gaps (e. Montgomery. and problem solving in everyday life. Kirsch. clinicians should assess patients’ exposure to information about .. Tellegen. confabulations/false positives. & Loftus. given the probable importance of sociocultural influences in the presentation of DID. Notably. it is important to secure objective confi rmation of childhood abuse and other highly aversive events. 2000). clinicians should not use hypnosis to recover allegedly dissociated or repressed memories: Hypnosis does not enhance the overall accuracy of memories and is associated with a heightened risk for confabulation (Lynn..336 Personality and Dissociative Disorders validity (e. Given the propensity for pseudomemory formation in highly dissociative individuals. 2010. Graham. we recommend also administering the Minnesota Multiphasic Personality Inventory-2 (Butcher. the treatment recounted below pointedly did not focus on past traumas or historical events as much as on enhanced coping.g. Moreover. She also reported amnesia associated with dissociative episodes and was troubled by her failure to recall key interpersonal interactions that others remembered well. Ben-Porath. Costa. & Martin. Several points are noteworthy in evaluating DID. Moreover. 2004). we were not able to obtain such confi rmation in the case of Ms. Merckelbach. Yuille. it is often perfectly appropriate for practitioners to use hypnosis for other purposes. such as relaxation and affect management. as hypnosis appears to enhance positive treatment expectancies and can serve as a catalyst to cognitive behavioral interventions (see Lynn. 2012). a severe animal attack. M. & Kirsch. Accardi. Holmes et al. Fassler. Ms. Unfortunately. Schwartz. However. & Lynn. Lilienfeld. Birt. First. clinicians should not assume that patients who present with symptoms of DID have necessarily endured childhood abuse. errors in response to leading questions) (Giesbrecht et al. 2001) and the NEO-PI-3 (McCrae. & Kaemmer. Rhue. & Cleere. Porter. it is appropriate for clinicians to routinely assess for a history of such events. Second. Fourth. M. DES. which apply to the case of Ms... see.g. however. Winkielman. clinicians should avoid repeated questioning about historical events. met all of the diagnostic criteria for DID. with the exception that we did corroborate key aspects of her medical history. Giesbrecht. 2005). M.g. Lilienfeld. Third. In short. 2005). Knox. based both on formal assessment and her enacting distinct “parts” during sessions and reporting such alterations outside sessions. individuals with high levels of dissociation may be more prone than are other individuals to develop false memories of emotional childhood events (e. 1998) and possibly infer that these normal gaps in memory are caused by dissociation or repression of traumatic events. as well. & Sapirstein. & Lehman. Read... and. journaling incidents of abuse) should be noted as well. The use of suggestive procedures (e. and problems interacting with her family. Nevertheless. she insisted that her problems were the product of stress at work. books. more frequently alternated between speaking in a childlike voice and like an angry adult. The patient became frustrated with the fact that therapy did not provide a “quick fi x” for her problems with her job. the graduate student completed his graduate studies and transferred the case to his supervisor. often most important. and DID was considered a rule-out diagnosis. GC witnessed increased irritability. GC. As therapy . she met the criteria for borderline personality disorder. In session. which we will discuss in turn: (1) treatment with the initial therapist. not surprisingly. guided imagery. M. magazines. The therapy was. and experienced difficulties recalling anything beyond the gist of the previous session. vitriolic anger. derealization. When the patient initiated treatment with a psychotherapist. M. noted that her mood and behavior fluctuated dramatically and sometimes unpredictably both within and between sessions. the patient recounted many traumatic experiences. the Internet.. and (3) conjoint treatment with Gep Colletti and Steven Jay Lynn (SJL). Ms. one of the authors of this chapter. can be divided into three phases. frequently disrupted and did not proceed in a linear course. impeding progress and often stymieing the behaviorally oriented problem-solving approach that the therapist adopted. At the start of treatment with her second therapist. Emotional outbursts during sessions escalated. with episodes of anger and anxiety flaring up frequently within sessions. Over the next two years. Ms. setbacks with physical ailments. the therapist. with increasing emotional lability and crisis phone contacts between sessions. prior to yet another angry outburst or childlike presentation. began to experience more frequent crises both in and out of sessions. who fully appreciated that this was a complex case that required intensive psychotherapy. After more than two years of treatment. related to the serious medical concerns we described above. M. (2) treatment with Gep Colletti (GC). seemingly innocuous statements by the therapist could trigger memories of highly aversive events. The patient reported feeling “spaced out” in session. a graduate student at a local clinic. Initial Case Formulation The treatment of Ms. and problems in focusing attention. only to later apologize and express deep regret.g. dream interpretation. as it became increasingly apparent that the patient met criteria for DID. Her memory for what transpired when she appeared to be enacting different “identities” was spotty and at times devoid of meaningful content. She reported hearing “voices in my head” and experienced herself as “splitting off” into an angry “adult protector” or defender of others and childlike aspects of herself that required protection.The Treatment of Dissociative Identity Disorder: Questions and Considerations 337 DID conveyed by movies. and cue-triggered flashback-like experiences in session that were followed by amnesia. depersonalization. previous therapists. reported that she often was aware of “missing time” at home. as described above. & Zaveri. placebo effects. Classen.338 Personality and Dissociative Disorders progressed. as well as other approaches described below. She also reported more incidents of abuse during childhood. & McIninch. 1990. role-playing and rehearsal. and randomized controlled trials are nonexistent. with more frequent episodes of depersonalization and disturbing episodes of amnesia. as well as disorientation at times of high stress. 2005. or other artifacts. 1994). 2001. GC instituted empirically supported cognitive behavioral approaches to treat different aspects of the symptom picture. including activity scheduling (i. & Ellis. 2009). there were few guideposts in the empirical literature to steer the therapy of a patient with DID. (d) “No matter what I do to help myself I will never get well”.” Additionally. Recurrent maladaptive thoughts and core beliefs that were addressed included (a) “Someone will learn I feel weak and afraid”. but I am mentally. (2009) were able to identify only eight studies that examined treatment outcomes for DID and other dissociative disorders. The literature on the pharmacological treatment of DID is scant. Rosenstein. & Warmerdam. . and (f) “If I get angry. applied relaxation and progressive muscle relaxation to reduce anxiety and psychophysiological reactivity (Carlson & Hoyle. Although case studies of the treatment of DID. the patient’s day-to-day functioning improved significantly. (b) “It is dangerous to trust others and let them see your vulnerability because you will most certainly be hurt”. and rational disputation of thoughts (see David.” Notably. with fluctuation between these two extremes. Lynn. I will lose control. Gold. 1998). 1974. or physically.e. Rea. Elhai. Given this state of affairs. Cuijpers. some of these thoughts related directly to the putative role of different “parts. van Straten. 2010). Hutzell & Eggert-Jenkins. 2011) of situations in which the patient modeled appropriate assertive responses in the context of family demands. from a variety of psychotherapeutic perspectives ranging from logotherapy and mutual storytelling to cognitive analytic therapy have been reported (Brandsma & Ludwig. Morris. were implemented. Extant studies do not permit an evaluation of the extent to which symptom reduction in dissociative patients is due to regression to the mean. (c) “To be weak or incapable of doing something is unacceptable”. and studies of depersonalization disorder have found little or no evidence of efficacy for such pharmacological treatment (Simeon. Ost. mostly as a function of whether or not she experienced a crisis. and her therapist concluded that her presentation now met criteria for DID. Kellett. increasing pleasant activities and interactions.. (e) “I must protect those I love. Over the next few years. so did manifestations of her dissociative symptomatology. Treatment Strategy Unfortunately. including imaginal rehearsal (Hackman & BennettLevy. Weiss. the passage of time. McNary. Brand. Masino. unable to do it”. the empirical literature on such approaches is slim. yet ranged from competent to impaired. 1993. 2007) for depressed mood. monitoring mood and daily activities. including her full-time career of nursing. At the invitation of GC. GC began to attend weekly clinical hypnosis seminars in which the fi rst author (SJL) presented an approach to dissociation that was based on combining empirically supported techniques to treat specific symptoms and problems in living. the patient continued to report hearing “voices in her head” and experiencing herself as “splitting off” into an angry and aggressive adult “protector” or defender of others and childlike aspects of herself that required protection. and her ability to accept positive feedback. (7) restructure maladaptive thinking patterns. while individual sessions occurred four to six times a month. frequent hospitalizations. SJL became a co-therapist.The Treatment of Dissociative Identity Disorder: Questions and Considerations 339 Effective parenting was perhaps the only area of functioning that consistently remained unimpaired and preserved throughout crises. (3) validate feelings and the idea that conflict is inevitable and can be managed. CO-THERAPY In 1999. geared to (1) provide education regarding her long-standing pattern of using dissociation as an avoidance maneuver. (8) enhance decision-making skills. SJL provided emergency coverage for GC and conducted a phone session with the patient who “hit if off” with SJL. and beliefs.. The Treatment Agenda GC and SJL (see Colletti et al. (6) increase assertiveness and improve social interactions with a focus on respect for others and reciprocity in relationships. (4) assist her in accepting responsibility for her behavior to minimize the need to resort to different “parts” to mitigate responsibility. During this time period. with the patient’s input. and demoralization due to her inability to pursue fulfi lling activities. SJL attended sessions two to three times a month. she met the formal criteria for DID. which was scaled down to part-time. For example. and an urge to retreat by way of not concentrating on ongoing activities and situations. Dissociative episodes were likely to occur before or during the many medical procedures she endured. Dissociation persisted in session and out of session. she reported disturbing periods of amnesia. She also reported considerable confusion and disorientation at times of high stress. and it became increasingly obvious that it was necessary to more directly confront her dissociative symptoms. (9) deepen her capacity to experience and accept the gamut of emotions in the here and now without engaging in experiential avoidance. (11) experience and accept expressions of care and . that included the following goals. emotional numbing. Not surprisingly. 2010) proceeded to create an agenda. Serious medical problems persisted. (10) assist her in working through grief and loss issues. and with the patient’s agreement. self-control abilities. At this time. (5) facilitate positive treatment expectancies. (2) develop a unified positive sense of identity. attitudes. often resulting in severe and chronic pain. including the death of her father. We also talked about what we called “AC/DC. & Lillis. (c) seek out positive emotional experiences. problem-solving therapy (D’Zurilla & Nezu. variable and limited in duration. tolerance.. including rational disputation. & Schwartz. and emphasized that she could accept and tolerate a gamut of feelings and thoughts and be able to accommodate a sense of unity of self and purpose. (d) do “the next right thing. not reward . & Street. Olasov. to learn that many of her fears are unfounded. A number of the evidence-based interventions we employed. activity scheduling and behavioral activation. M. Saunders. Driskell. and acceptance to promote emotional regulation are allied with both DBT and ACT. to (a) use assertiveness skills. M.. and always available at full strength. 1999. 2006). we would help reduce.340 Personality and Dissociative Disorders concern extended by others to her. Luoma. developing a unified positive sense of identity. were adapted from those used commonly in two so-called “third wave” cognitive behavioral therapies: dialectical behavior therapy (DBT. Consistent with the practice of DBT. & Salas. Bond. and that education regarding the function of her dissociative responses was prerequisite to Ms. 1985. even when she experienced emotional duress and confl ict. and that she is able to cope in the absence of DC. Masuda. Meadows. and imaginal rehearsal. we encouraged Ms. 2007.” Moreover. Meichenbaum.g. (b) identify and label emotions. Jaycox. and (12) help her cope with medical evaluations and treatment procedures. we explained that relying on DC does not permit Ms. 2010). to regard a thought simply as a thought. Dimeff. 2006) and acceptance and commitment therapy (ACT. The interventions that emphasized mindful awareness. 2002). is “like battery power. Hall. and self-hypnosis (see Lynn et al. We spoke with her about the origins of her dissociative tendencies. M. exposure therapy (Rothbaum. We also added a number of interventions with an evidence base that supports their use: stress-inoculation training (Foa. M. 2007). & Linehan. mindfulness/attention training (Baer. Linehan et al. we agreed that consistent reference to a unitary self would be paramount in treatment. as “it is reliable. Hayes. to practice cognitive defusion (e. 2003). 2003. Koerner. When the authors began to collaborate. Hembree. Our treatment was guided by the belief that if we attended to her experiential avoidance and the anxiety-reducing function that animated it. M.” control via acceptance (AC) versus control via dissociation (DC). we encouraged and/or taught Ms.. 1996). Ost. rather than a fact) and to calibrate her actions to her values. while highly portable and applicable in a broad number of situations. her dissociative responses and obviate her need to conceptualize her experiences in terms of “parts. and noted that AC was advantageous.. Dancu. simultaneously. we will not key the interventions to the specific goals presented above. Consistent with ACT.” and (e) develop distress tolerance. if not eliminate. 2008.” DC. with evidence of treatment efficacy. As we implemented educational tactics—deliberately designed to modify her self-conceptualization and. the fact that conflict and strong feelings are a normal and often healthy aspect of everyday life. As the interventions described below often relate to multiple aspects of the treatment agenda.” We continued many of the interventions fi rst instituted in GC’s treatment of Ms. We consistently reinforced her ability to observe her thoughts and feelings without the imperative to take action. When Ms. and encouraged her to become mindfully attuned to her momentto-moment experience and to develop a nonjudgmental stance toward the stream of experiences in her field of awareness. We also assisted Ms. SJL taught her to take diaphragmatic breaths. In this way. We encouraged her to embrace a problem-solving approach in which she assesses and evaluates different possible outcomes of decisions and imagines herself responding in appropriately assertive ways in a variety of scenarios. and situations in which she felt her personal autonomy was undermined by individuals in authority with whom she dealt concerning disability issues. M in identifying. labeling. and she began to feel more comfortable in an expanding circle of situations and more confident in her ability to modulate her anger. We conducted imaginal exposure sessions in relation to each of these areas of concern. When she became anxious or disoriented in session.” make reassuring self-statements. We also suggested that Ms. could better cope in target situations (e. M. M. and to increase assertiveness. and after each 50-minute exposure. and that the flotsam and jetsam of cognitive activity neither invariably reflected on her personhood nor qualified as “facts” about herself or others. contact her “moment-to-moment experience. asserting her needs for privacy while undergoing certain medical procedures). using problem-solving . These circumstances included invasive medical procedures in which she became concerned about her physical integrity.The Treatment of Dissociative Identity Disorder: Questions and Considerations 341 a dissociative presentation—Ms. and amnesic episodes decreased in therapy session. M. spoke less about her parts and increasingly referred more to herself as a whole person. disorientation. experienced flashbacks. we discussed how Ms. ruminating about her daughter’s safety and security and the death of her father. practice nonjudgmental awareness and what we called “attention training” by focusing on her breathing and counting breaths in cycles of 1–10 breaths. In keeping with these developments. and nonjudgmentally accepting her feelings. to decrease avoidance. To facilitate problem solving and impulse control. she was instructed to focus on her breaths and to alternate her attention between different stimuli in her immediate field of awareness.. concerns about losing control. M. we fostered assertiveness in everyday life. We helped Ms. These distracting activities often succeeded in reorienting her attention to the present and diminishing anxiety and dissociation. including her daughter. We also assisted her in recognizing that her “thoughts were thoughts” that had no power to hurt anyone. unless such action was carefully conceived and deemed to be congruent with her values and her best interests. M. to participate in role-plays in which she “interacted” with people at work and with family members.g. M. and engage in productive “self-talk” to foster calm problem solving and the ability to pursue her objectives as she delineated them. all the while maintaining contact with her feelings. to resolve confl icting feelings and to gain confidence in her ability to encounter others appropriately and in a measured way. unpredictable outbursts. we invited Ms. and dissociation. to identify a number of circumstances that were reliably associated with anxiety. who often made unrealistic and excessive demands on her time.. It became apparent that these episodes of sleep paralysis. “I must be a perfect mother”. Ms. I must be there for them. suggestions for specific responses following hypnosis) were used to generalize treatment gains by encouraging Ms. “I must never say ‘no’ to my own mother”.g. to perform a rapid body scan to not only identify loci of physical tension and to begin to “release and relax. “If someone needs me. skills related to limit setting with her family members.g. with some embarrassment. Hypnosis. 2010. bringing her thumb and forefi nger together to anchor feelings of being more calm. M. and subsequently self-administered. 2011).” Hypnosis was used to promote (a) equanimity after exposure sessions. which occurred three to five times a month. and mindfulness practice on a daily basis. Late in therapy. and say to herself. to be involved in as many enjoyable activities (e.3% of students. 28. often were followed by fatigue and disorientation during the daytime. with each step promoting progressive calm and ease.. to be more accepting of positive feedback from others. Importantly. that she experienced terribly upsetting “nightmares” that paralyzed her and were accompanied by the sense of a “presence. craft work) as her physical limitations allowed. SJL explained that she was probably experiencing sleep paralysis. to be aware of “moments of optimism” and positive accomplishments in everyday life. We also practiced with Ms. hypnosis was never used to retrieve or refresh past memories or to call up purported alters. proved to be highly responsive to hypnotic suggestions. played an important part in the treatment of Ms. “that was then. nothing to disturb. and to enhance self-soothing/relaxation. and we continued to dispute evidence of negative cognitions and all-ornone thinking (e. Ms. reported that after a night of fragmented sleep.. she felt much more “spaced out” and vulnerable to emotional upset. M.” like “the boogey man” under her bed. and (d) nonjudgmental attention to moment-to-moment experiences. for a more complete discussion of the use of hypnosis in this case). M. To further facilitate a sense of grounding in the present. Ms. (c) a measured approach to problem solving and role-played interactions. (see Colletti et al. M.” but also to “get in touch with and connect” with different parts of her body. we taught Ms.e. fi rst administered by SJL. was able to control episodes of mental confusion and “feelings of overwhelm” with self-administered suggestions to feel calm and relaxed and view herself walking 10 steps down a staircase.” We attempted to foster behavioral activation by encouraging Ms. Post-hypnotic suggestions (i. I am a whole person in the present.. she also disclosed. a not uncommon sleep problem reported by one estimate to be 7. “with nothing to bother. problem-solving skills. Ms. However. noted that the quality of her sleep was generally very poor. More specifically. Sharpless & Barber. M. this is now. M. M. M. at ease. and accepting). “I must have a full-time job or I am worthless”) using the Socratic method..342 Personality and Dissociative Disorders techniques as well as cue-controlled relaxation (e.g.6% of the general population. . writing. with numerous nighttime “wake-ups” due to severe chronic pain. and 31. no matter what”. couched as self-hypnosis.9% of psychiatric patients (lifetime prevalence. M. (b) imaginative rehearsal with suggestions for vivid imagery and suggestions to maintain a coherent sense of self. and we encouraged her to do the following: (a) remain in bed (contrary to recommendations for treating insomnia. Lynn et al.The Treatment of Dissociative Identity Disorder: Questions and Considerations 343 Coincidentally. along with sleep hygiene and cognitive behavioral treatments for insomnia (see Bootzin & Epstein. SJL was exploring the relation between sleep problems and dissociation with his colleagues Harald Merckelbach. was reinforcing sleep difficulties. and Dalena van der Kloet (Giesbrecht et al. we suggest that practitioners implement the above steps to treat sleep paralysis.. and only during a crisis. fi rst reported these problems. she often would get out of her bed and be awake for hours afterward. 2010. she can now better tolerate negative affect and is . van der Kloet et al.. We noted that her leaving the bed. which reduced fatigue. noted that after she experienced nightmares and sleep paralysis. she still was plagued with feelings of depersonalization during the day and night. In session. 2009). Ms. She practices mindfulness on a regular basis. in press. look under the bed. (c) reassure herself that her fears are unfounded. By this time in the therapy. was instructed to not look under the bed. M. (b) immediately reassure herself that the experience of the presence was a manifestation of sleep paralysis. Importantly. Interestingly. including amnesia and disorientation. in response to aversive stimuli. tiredness. M. The patient achieved considerable success with this approach. this reportedly occurs only rarely outside session. but appropriate for her terrifying experiences). We strongly recommend that clinicians who treat patients with symptoms of DID assess for sleep-related problems. flashbacks.. she rarely speaks in a different voice or behaves as if she were a person of a different developmental level. If such problems are evident. medications can be used to treat sleep-paralysis (e.. Outcome The treatment was almost entirely successful in eliminating startle reactions. Additionally. on occasion. After two weeks. 2012). M. reminds herself to use self-hypnosis and other extra-session coping skills in trigger situations. sodium oxybate/Xyrem) if psychological interventions are not sufficient to normalize sleep. M. rarely experienced dissociative symptoms in session. and the ability to evaluate alternative behaviors in situations that require problem solving. impulse control. if indicated. Timo Giesbrecht. the patient exhibits improved anger management. we found that dissociative experiences were more reliably associated with sleep paralysis and narcolepsy than with insomnia (see also Koffel & Watson. and dissociative responses. and takes considerable pride in doing so. in this instance. Ms. and (e) use the self-hypnotic relaxation and self-soothing and breathing techniques that she had used to advantage in other contexts in order to resume sleeping. and depersonalization during the day. (d) if (c) does not prove reassuring. Ms. around the time that Ms.g. Ms. because excessive reassurance seeking could maintain sleep problems. yet. Scott Lilienfeld. expressed relief at knowing that these residual symptoms might be related to sleep difficulties. 2011 for a review). M. Notably. The dual therapist approach provided enhanced opportunities to (a) share expertise and provide consultation and emergency coverage. to mitigate adverse consequences of stressful life events. When the therapist and patient were following a meandering . and self-hypnosis on a regular basis.344 Personality and Dissociative Disorders more accepting of herself even when she displays anger. participating in fewer sessions per month. as a result. M. thereby alleviating or “loosening” dichotomous thinking. She has succeeded in raising a child who is now employed full-time and in a gratifying relationship. much of our treatment has been geared toward Ms. The attention lavished on Ms. anticipates potential anxiety and dissociation triggers. M. M. as is the need for intersession contact with GC. the other therapist often would say something to diffuse tension in the relationship and point out that Ms. and SJL is less involved in treatment. Unfortunately. it was evident in the way that the therapists managed the treatment. when the patient expressed anger directed at one therapist. chronic pain. her sense of neediness and dependency has diminished. in all likelihood. her physical disabilities. as the patient’s confidence has blossomed over the past few years. and (d) dialogue in front of the patient to discuss different viewpoints and possibilities. was considerable and. exporting what she has learned in therapy to the real world and maintaining treatment gains. Although day-to-day functioning has clearly improved in most areas. If there was “art” in treating this case. serious medical problems persist. Relapse Prevention Importantly. We now talk about her engaging in “adaptive dissociation” in which she can experience a sense of detachment from aversive medical procedures. (b) improve treatment planning. The frequency of crises is dramatically reduced. and uses self-talk and rational disputation.’s reaction was often (but certainly not always) exaggerated or based on a misunderstanding of the intent of the therapist. strengthened the alliance with Ms. and the patient is often unable to pursue pleasurable activities due to severe chronic pain and infrequent yet highly disturbing hospitalizations. (c) better identify exaggerated transference reactions in response to one or both therapists. and interactions with the medical community suggest the need for ongoing treatment. Nevertheless. M. who were unstinting in the optimism they expressed that change was possible. without experiencing amnesia or a fragmentation of self. mindfulness. in relation to both therapists. Nonspecific Factors and Therapy Dynamics The therapy arrangement was unconventional and noteworthy. For example. activity scheduling. as well as self-soothing techniques. M. Ms. More specifically. employs problem-solving. the co-therapist was often able to redirect the conversation to the topic or treatment objective at hand. as we did in the case of Ms. appeared to feel entirely comfortable sharing pertinent life experiences with us. We recommend that clinicians conduct a careful assessment and functional analysis of problems and implement established evidence-based treatments to treat relevant symptoms and problems in living. well-controlled research is lacking to support any treatment of . Ethical Considerations No major ethical considerations came into play.” it was typically evident to one therapist before the other. it is wise for therapists to adopt a flexible approach that takes into account the somewhat experimental interventions implemented. at the present time. and humor was used to advantage to defuse the tensions that inevitably arose in therapy and to solidify the therapeutic relations. illustrates how a present-centered. Our approach was not designed to uncover instances of sexual or childhood abuse. M. Finally. necessarily forcing therapists to extrapolate/generalize from allied literatures. forward-looking cognitive behavioral treatment. Common Mistakes to Avoid The approach we used was sharply at variance with the traditional treatment of DID. we carefully avoided reinforcing or reifying Ms. which we believe holds the potential to produce iatrogenic effects. when one therapist was unclear or obtuse. There are no empirically supported treatments for DID. the other was often able to remedy the situation and foster better communication. which encompasses elements of so-called third wave therapies. can be used to alleviate symptoms of dissociation and the presentation of multiple selves. Under these circumstances. and we did our level best to not ask leading questions.” We did not use hypnosis for memory recovery. Conclusions The case of Ms. Moreover. At times when it appeared that therapy was “not working.The Treatment of Dissociative Identity Disorder: Questions and Considerations 345 course. M. M. although Ms.’s presentation of “multiple personalities. making it possible to determine whether it was resistance/avoidance on the part of the patient. We also were sensitive to the language that we used in therapy. or therapist insensitivity. In keeping with our intent to avoid such potentially damaging effects. We believe that many of the interventions we used will eventually be found to be helpful in treating people with symptoms of DID. nor did we use any special memory recovery procedures. However. M. it bears mention that the therapist’s styles were highly compatible. An exercise in deception. G. Winkielman. We conclude our chapter with a call for researchers to develop empirically supported multicomponent treatments for DID and to identify the relative efficacy of specific interventions that make up such multifocal treatments. B.3.. R. C. M. N. W. W. 10(2). & Lynn. Psychological assessment of patients with dissociative identity disorder. doi:10.4. 38(1). International Journal of Clinical and Experimental Hypnosis. (1993).. Armstrong.. & Zaveri. P.. S. (1993). Putnam.. Journal of Nervous and Mental Disease. 21–41. N. 5. (2011). R. doi:10. 435–458.. McNary. 1–6.1016/S0167-8760(00)00128 8 American Psychiatric Association. Read. K. Understanding and treating insomnia. M. Bowman. 51(4). J. 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Barry. dissociative symptoms comprise an extremely heterogeneous class of experiences and complaints.COMMENTARY Harald Merckelbach Is there evidence-based physics? If you would ask a scientist. I doubt whether that conclusion is justified. Why. Sinason. Some authors have argued that. Legatt.. p. Smolin. Spinal fusion is a surgical intervention that is performed on a wide scale to alleviate chronic low back pain. The authors also administered a trauma self-report scale to their patients and found that 74% of the dissociative patients said that they had a traumatic background. the study illustrates that some clinicians still use the diagnostic category of DID. & Lipschitz. Bodkin. he or she would probably burst into laughter. More important. its fi ndings seem to underpin the trauma-focused treatment of dissociative symptoms propagated by some clinicians (e. like physical therapy. Consider the example of spinal fusion that Groopman (2007) describes in his How Doctors Think. & Hudson. Kaplan. that few treatments in that domain are backed by a solid corpus of knowledge derived from research. It is like talking about black darkness or fourlegged horses. 2006. 2011). For example. 2006). whereas this was true for 29% of the patients without dissociative symptomatology. Part of the problem here is that chronic low back pain is not a well-circumscribed diagnostic entity. . 627). of course. Yet prospective trials have not shown it to be more effective than noninvasive treatments. Things are much the same for patients who have been given a diagnosis of dissociative identity disorder (DID). Foote and coworkers (2006) employed a structured interview for dissociative disorders in their sample of inner-city psychiatric outpatients and reported a prevalence rate of 29% for all dissociative disorders and a prevalence rate of 6% for DID specifically. do we speak of evidence-based treatments in psychopathology? The answer is. then. Such state of affairs is not unique for psychopathology.g. At minimum. DID was a fashionable diagnosis but that it has declined in recent years (Pope. The authors concluded that “our findings add to the growing amount of data concerning both the association between childhood trauma and adult dissociative psychopathology and the surprisingly high prevalence of dissociative disorders in the clinical population” (Foote. Although the diagnostic label suggests otherwise. for clinicians. Strictly speaking. the question rises whether their patient is a straightforward example of “spontaneous developing” DID—an example that would provide a falsification of the sociocognitive model. much less specific or tailored interventions. With these considerations in mind. Interestingly. What is it.’s approaches are not evidencebased.” Nevertheless. Kohlenberg demonstrated how instrumental conditioning can be used to reduce the behavioral manifestations of DID. while the patient was in therapy.g. DID books.’s case vignette is that the DID symptoms of their patient became stronger over time. Having said this. In 2003.. the authors either did not read or ignored the critical literature on narco-analysis and the risks that this method conveys in terms of false memories (e. Simpson. as Lynn and colleagues make clear in their chapter. A case in point is drug treatment for dissociative amnesia. 1998). The cognitive behavioral interventions that they employed to treat DID patients have demonstrated their efficacy in a different context. Kihlstrom. and DID therapists. “at the present time. 1997).. the fascinating paper by Robert Kohlenberg (1973). anyway? Lynn and coworkers argue that the DID symptoms of their patient can be . Many clinicians treating patients with dissociative symptoms seem to be ignorant of this risk. The fi rst concerns Lynn et al. Kohlenberg’s and Lynn et al. the authors’ case description provides a valuable catalogue of treatment options. Evidence for its efficacy is largely lacking (but see Ellason & Ross. That suggestive misinformation may encourage the development of DID symptoms is a recurring theme in many critical papers on DID (e. Morgan. & Lippmann. One remarkable aspect of Lynn et al. 2003). Piper. this trauma-focused approach has a poor track record. 1995. 1995). notably that of the anxiety and mood disorders. Even worse is that it may produce iatrogenic exacerbation of symptoms (Lilienfeld.g.The Treatment of Dissociative Identity Disorder: Questions and Considerations 353 But. such as alter switching. a group of clinicians published an enthusiastic report about the apparent safety and efficacy of intravenous diazepam (Valium) for facilitating memory retrieval in dissociative patients (Ballew. four points remain to be discussed. In fact. The basic assumption of the authors was that dissociative symptoms reflect a primitive defense against traumatic stress and that diazepam may help to overcome this defense maneuver. 2007). As Lynn and associates themselves acknowledge. it was only after a series of treatment sessions that she began to meet the criteria for DID. Lynn and colleagues are to be commended for their detailed description of how cognitive behavioral interventions can help to treat the emotional dysregulation that is typical for patients who have been given a diagnosis of DID. Clearly. because—as the sociocognitive model emphasizes—these sources may have conveyed suggestive misinformation that helped to create typical DID features. namely. their approach has an historical antecedent. The second point has to do with the nosologic status of DID.’s recommendation that clinicians should assess their patients’ previous exposure to DID movies. well-controlled research is lacking to support any treatment of DID. Assuming that the authors went to great lengths to avoid the suggestive shaping of DID symptoms in their patient. Since North et al. 2003).g. The point that I want to make is this: there are good reasons to assume that patients with DID perform poorly when it comes to providing their therapists with consistent reports about their symptoms. What would Lynn and coworkers advise clinicians to do? To treat DID as a mood disorder complicated by Briquet’s syndrome and other comorbid symptoms? The obvious advantage of this view would be that it opens a rich literature on cognitive behavioral treatment interventions. A related issue. . raising the distinct possibility that DID is a severity marker rather than a nosologic entity per se. and Wetzel (1993) who presented an in-depth analysis of the extensive comorbidity that is characteristic of DID. This being the case. it would be wise to carry out a more thorough evaluation of the totality of signs and symptoms? For example. sleep disorder scales). 1993).g. one wonders why Lynn and coworkers apparently did not rely on progress and outcome data independent of their patient’s self-reports (e. 2006). Sierra. 1995).g. and hypnosis. Does that imply that DID is a complex mood disorder? The idea is attractive and reminds us of North. is the phenomenon of symptom exaggeration. such as imaginal rehearsal.354 Personality and Dissociative Disorders understood as a self-defeating repertoire to cope with guilt. clinicians might administer a battery of well-validated tests (e.g. Lynn and colleagues focus on the systematic evaluation of dissociative symptoms. suggesting the possibility of symptom exaggeration and confabulation (e. The fourth issue pertains to the treatment strategy of Lynn and coworkers. Ryall. Simpson. Piper... When are these interventions encouraging regressive behavior and when can they applied successfully? Articulating this demarcation line more precisely will assist clinicians in their efforts to help patients who have been given a diagnosis of DID. In their section on assessment strategy. (1993) wrote their text. and this might inform the treatment plan. It capitalized on interventions that require the imaginative involvement of the patient. Ricci. In one of our own studies. 1995). we know near to nothing about the natural course of DID and its precise relationship to Briquet’s syndrome (a condition similar to somatization disorder in DSM-IV ) is still ill-understood. & David. Would they agree that if DID is a severity marker of a polysymptomatic condition. Such interventions have also often been criticized for their potential to cause artifactual symptoms and false memories (e. Patients with DID are known to have elevated scores on the validity scales of the MMPI. role-playing. Symptom fluctuations are also a hallmark feature of Briquet’s syndrome (North et al. MMPI. and anxiety. arguably the strongest quarter of clinical psychology (see also Hunter. collateral information from others). depression scales..51 between dissociative symptoms as measured by the Dissociative Experiences Scale (DES) and symptom exaggeration as indexed by the Structured Inventory of Malingered Symptomatology (SIMS) in a sample of undergraduates (Giesbrecht & Merckelbach. little progress has been made in determining whether DID is sufficiently different from other conditions to afford it its own DSM-5 entry.. For example. Phillips. Chalder. The third question concerns the diagnostic assessment of DID patients.. metaphors like “AC/DC” control. we found a correlation of r = 0. but slightly taboo. anger. The Treatment of Dissociative Identity Disorder: Questions and Considerations 355 References Ballew, L., Morgan, Y. & Lippmann, S. (2003). Intravenous diazepam for dissociative disorder. Memory lost and found. Psychosomatics, 44, 346–347. Ellason, J. W., & Ross, C. A. (1997). Two-year follow-up of inpatients with dissociative identity disorder. American Journal of Psychiatry, 154, 832–834. Foote, B., Smolin, Y., Kaplan, M., Legatt, M. E., & Lipschitz, D. (2006). Prevalence of dissociative disorders in psychiatric outpatients. American Journal of Psychiatry, 163, 623–629. Giesbrecht, T., & Merckelbach, H. (2006). Dissociatieve symptomen en slaap [Dissociative symptoms and sleep]. Tijdschrift voor Psychiatrie [Dutch Journal of Psychiatry], 3, 207–215. Groopman, J. (2007). How doctors think. New York: Houghton Miffl in. Hunter, E. C. M., Phillips, M. L., Chalder, T., Sierra, M., & David, A. S. (2003). Depersonalization disorder: A cognitive behavioral conceptualisation. Behaviour Research and Therapy, 41, 1451–1467. Kihlstrom, J. F. (1998). Exhumed memory. In S. J. Lynn & K. M. McConkey (Eds.). Truth in memory (pp. 3–31). New York: Guilford Press. Kohlenberg, R. J. (1973). Behavioristic approach to multiple personality: A case study. Behavior Therapy, 4, 137–140. Lilienfeld, S. O. (2007). Psychological treatments that can cause harm. Perspectives on Psychological Science, 2, 53–70. North, C. S., Ryall, J. M., Ricci, D. A., & Wetzel, R. D. (1993). Multiple personalities, multiple disorders: Psychiatric classification and media infl uence. Oxford: Oxford University Press. Pope, H. G., Barry, S., Bodkin, A., & Hudson, J. I. (2006). Tracking scientific interest in the dissociative disorders: A study of scientific publication output 1984–2003. Psychotherapy & Psychosomatics, 75, 19–24. Piper, A. (1995). A skeptical look at multiple personality disorder. In L. Cohen, J. Berzoff, & M. Elin (Eds.). Dissociative identity disorder (pp. 135–174). Northvale, NJ: Jason Aronson. Sinason, V. (2011). Attachment, trauma, and multiplicity: Working with dissociative identity disorder (2nd ed.). London: Routledge. Simpson, M. A. (1995). Gullible’s travels or the importance of being multiple. In L. Cohen, J. Berzoff & M. Elin (Eds.). Dissociative identity disorder (pp. 87–134). Northvale, NJ: Jason Aronson. RESPONSE Steven Jay Lynn, Liam Condon, and Gep Colletti We thank Professor Merckelbach for his thoughtful commentary, which raises important questions about the treatment of DID and is replete with interesting observations (e.g., DID may represent a complex mood disorder, DID is a severity marker of a polysymptomatic condition, the need to take symptom exaggeration into account in a complete evaluation of DID). For example, Merckelbach questions whether our patient’s DID symptoms could be an example of “spontaneous developing DID, and thereby provide a falsification of the sociocognitive model,” as he presumed we “went to great lengths to avoid the suggestive shaping of DID symptoms.” Shaping influences on patients may be subtle (e.g., exposure to movies, books, magazine misinformation about DID), and symptoms may appear to arise “spontaneously.” Yet in the case of Ms. M., potentially suggestive influences were less than subtle, if not blatant. Indeed, she was not only an avid consumer of media with trauma-based depictions of multiple personalities, but relatively early in her treatment (before SJL came on board), her previous therapist at some point began to interact with supposedly separate personalities, potentially reifying them and rewarding their manifestation. Merckelbach understandably wonders why we did not rely on collateral information from others. The answer is simple. The patient did not want her parents and friends to know that she was participating in psychotherapy. Still, we agree that such information can be invaluable (e.g., we were able to obtain medical information that confi rmed her self-reports), especially in cases in which patients relate highly improbable stories about extreme abuse (e.g., satanic ritual abuse). We agree with Merckelbach that it is important to demarcate the line between interventions that encourage regressive behavior and false memories and interventions that promote adaptive coping. He singles out the techniques of hypnosis, the AC/DC metaphor, imaginal rehearsal, and role-playing as potentially problematic. In the case of Ms. M. we used hypnosis, imaginal rehearsal, and roleplaying to facilitate affect management and problem solving, never to recover memories. Similarly, we used the AC/DC metaphor to highlight the problems with “dissociative coping” and to tout the benefits of acceptance and engagement with anxiety-eliciting situations, rather than experiential avoidance. We recommend that therapists scrupulously monitor the effects of any intervention, even The Treatment of Dissociative Identity Disorder: Questions and Considerations 357 those not presumed to be at high risk for producing false memories or “regressive reactions.” It is right for Merckelbach to question whether our therapy with Ms. M. is truly “evidence-based.” Unfortunately, no single protocol for DID can claim convincing empirical support. Accordingly, we were careful to call attention to the “somewhat experimental” nature of the interventions we employed. Our definition of “evidence-based” was admittedly liberal. More specifically, our therapy proceeded with a keen recognition that evidence-based practice related to DID must, of necessity, involve a creative synthesis of information derived from limited systematically collected data, as well as scientifically informed decisions based on theoretical formulations and empirically supported treatments originally developed for other disorders. Regrettably, that is sometimes the best that a scientifically minded clinician can do when rigorously evaluated treatments for the disorder at hand are nonexistent. This page intentionally left blank { PART VI } Other Adult Disorders This page intentionally left blank { 14 } The Use of Family and Individual Cognitive Behavioral Therapy with a Patient with Anorexia Nervosa Barbara Cubic This chapter will focus on a case example of a patient with anorexia nervosa to illustrate both evidence-based assessment and treatment. In reading the case study, it is important to realize that, although evidence is developing for the treatment of eating disorders, especially bulimia nervosa and binge eating disorder, highly effective interventions for anorexia nervosa do not currently exist, and for many clinical situations recommendations for care must be based on expert opinion and experience because there is not sufficient data from systematic research (American Psychiatric Association [APA], 2006). The focus of the case study is on the outpatient portion of the treatment of an individual with anorexia nervosa, following a brief hospitalization for medical stabilization. Although an interdisciplinary approach was utilized, the emphasis of this chapter is on the individual and family therapy provided by the psychologist. The intervention described reflects the integration of individual and family therapy for anorexia nervosa and the difficulties that are often encountered with this patient population. In the treatment utilized, the behaviors and belief systems of both the patient with anorexia nervosa and the patients’ family members were explored in depth early in the assessment phase. A Maudsley family therapy method (Lock, Le Grange, Agras, & Dare, 2001), which empowers the family unit to address the disorder, was used to challenge maladaptive beliefs and behavioral patterns in the patient with anorexia nervosa and to address dysfunctional patterns in the family. Simultaneously, in individual therapy, cognitive restructuring strategies and behavioral techniques were primarily used to alter maladaptive beliefs and behavior patterns, especially those related to weight, eating, activity, purging, and body size. The case will also demonstrate how beliefs held by patients and family members dealing with anorexia nervosa can impact the effectiveness of therapeutic interventions used. 362 Other Adult Disorders Evidence suggests that patients with anorexia nervosa, who weigh less than 85% of their expected weight, may have difficulty being treated outside inpatient settings (APA, 2006). However, the limited number of specialized eating disorders treatment facilities, the geographic location of the available resources, the fi nancial costs of these treatments, and difficulties obtaining authorizations from insurance for ongoing inpatient care after medical stability is achieved lead to a substantial number of patients with anorexia nervosa being treated as outpatients. Outpatient options for patients with anorexia nervosa are also critical, as research suggests that a majority of adolescents with eating disorders receive no treatment at all (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). Thus, the case of Amelia was chosen to provide a real-world example of evidencebased care when inpatient options are not pursued by the patient or their family or are unavailable. Additionally, the case of Amelia was chosen because it reflects how eating disorders are really best viewed as clinical syndromes with multiple determinants, various courses, and combinations of maladaptive behaviors and attitudes due to the frequent overlapping and interchanging between symptoms across diagnostic categories, especially between anorexia and bulimia nervosa. The case also shows how psychological, biological, sociocultural, and personality factors all play a part in the development and progression of an eating disorder. Please note that the identifying information has been altered due to the sensitive nature of a case study, but the details are in keeping with an actual case of anorexia nervosa treated by the author. Demographic and Referral Information Amelia was a 15-year-old female Caucasian high school sophomore who resided with her father, mother, and 17-year-old brother, who was planning to leave for college in the fall. Amelia was referred by a social worker employed at a local children’s hospital and her outpatient pediatrician after she had been released from a short-term inpatient medical hospitalization for anorexia nervosa. The referral was made to a psychologist to assist in assessment, treatment planning, and treatment implementation because the family requested outpatient treatment in their local area, although inpatient treatment at a specialized facility for eating disorders had been recommended. The presenting issues included malnourishment, amenorrhea, fear of weight gain, food obsessions, excessive exercise, purging through self-induced vomiting, depressed and irritable mood, and denial about the severity of the problem. Assessment Strategy The evaluation consisted of a clinical interview with Amelia and her mother and father followed by individual interviews with Amelia and her parents. In addition Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 363 to a general clinical interview with Amelia, the Eating Disorders Examination (Cooper & Fairburn, 1987) was used to guide the process of assessing all diagnostic criteria for eating disorders established by the Diagnostic and Statistical Manual of Mental Disorders (4th edition; DSM-IV; APA, 2000). The interviews were supplemented with data from the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ, Rieger et al., 2000; Rieger, Touyz, & Beumont, 2002) and the Eating Disorder Inventory-3 (EDI-3, Garner, 2004), completed by Amelia; the Family Environment Scales (FES, Moos & Moos, 1994), completed by Amelia and all of her family members (father, mother, and brother); food monitoring by Amelia; and medical information provided by her pediatrician. Behavioral observations are provided in Table 14.1. Figure 14.1 provides information about Amelia’s ANSOCQ scores; Figure 14.2 shows Amelia’s EDI-3 profi le; and Figure 14.3 shows details about the family’s FES scores. The utility of the assessment approach and the psychometric properties of the psychological measures will be TABLE 14.1. Behavioral Observations Regarding Amelia BEHAVIORAL OBSERVATIONS (indicated response is in bold and findings of significance are described): Appearance Speech Affect and Mood Thought Content Suicidal Ideation Homicidal Ideation Psychotic Features Orientation Memory Intellect Judgment Insight Within Normal Limits Within Normal Limits Within Normal Limits Within Normal Limits Absent Absent Absent Within Normal Limits Within Normal Limits Within Normal Limits Within Normal Limits Within Normal Limits Other Findings Other Findings Other Findings Other Findings Present Present Present Other Findings Other Findings Other Findings Other Findings Other Findings The ANSOCQ consists of 20 items each scored on a Likert Scale from Pre-contemplation (1) to Maintenance (5) resulting in a possible total score of 100. Less than 1.5* Pre-Contemplation 1.5 – 2.4 Contemplation 2.5 – 3.4 Preparation 3.5 – 4.4 Action 4.5 or Greater Maintenance * = Amelia’s Score of 1.3 was in this range FIGURE 14.1. Amelia’s Anorexia Nervosa Stages of Change Results (ANSOCQ) Adolescent Clinical Sample of Anorexia Nervosa-Purging Subtype FIGURE 14. and anxiety.” and her affect was consistent with a significant degree of depression.S. well maybe a little sad. Her skin and hair appeared dry. She was willing to discuss her family and general issues. Her thought content was overly focused on weight. decreased self-confidence.2. discussed later in the chapter to show that an evidence-based assessment was conducted. She was selective about which questions she would respond to and acknowledged that she was only participating in outpatient treatment to avoid another inpatient hospitalization. poor sleep. and impaired concentration. anhedonia. and she demonstrated poor insight about her eating disorder and her degree of social isolation from peers. and body image issues. body image. or family confl icts were asked. which included a depressed mood. Clinical Interview Information Amelia was notably underweight and appeared pale and malnourished. weight. irritability. She was 5 feet tall and weighed an estimated weight of 78 pounds (BMI = 15. decreased energy. Amelia self-reported experiencing symptoms of depression.2. food. She described her mood as “fi ne. irritability. most recent weight had been taken by the nutritionist two days prior to psychological assessment).364 Other Adult Disorders 27 Amelia's Scores 24 AN-P Scores 21 Raw Scores 18 15 12 9 6 3 0 DT B BD LSE PA II IA ID ED P A MF EDI-3 Subscales DT = Drive for Thinness B = Bulimia BD = Body Dissatisfaction LSE = Low Self Esteem PA = Personal Alienation II = Interpersonal Insecurity IA = Interpersonal Alienation ID = Interoceptive Deficits ED = Emotional Dysregulation P = Perfectionism A = Asceticism MF = Maturity Fears Eating Disorder Inventory-3 (EDI-3) Profile of Amelia’s Raw Scores on the Eating Disorders Risk Scales Compared to the Means on the EDI-3 for the U. Her judgment appeared impaired in relationship to her eating behavior and health. . but she would become reticent to speak when questions about eating. the diet became increasingly restrictive. BMI = 22.3. Amelia’s mother estimated that Amelia’s weight was 113 pounds before she began practicing intensely for soccer (she was already 5’ tall. she experienced an injury during a soccer match and had to discontinue the sport. she decided to excel at soccer and practiced vigilantly. she decided to start a diet to stay in shape because she couldn’t exercise. Amelia’s weight was 71. However. Amelia was always a thin. In the 9th grade. By the spring of the next year. she has never regained enough weight to approximate a healthy weight range for her size. and she could not actively exercise as she had before. leading to a significant amount of weight loss. Following this weight loss. highly active individual who excelled at school and sports.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 365 70 T-Scores 60 50 40 Amelia Brother 30 20 C Ex Con Ind AO ICO ARO MRE Org Ctl FES Subscales 70 T-Scores 60 50 40 Father Mother 30 20 C Ex Con Ind AO ICO ARO MRE Org Ctl FES Subscales C = Cohesion Ex = Expressiveness Con = Conflict Ind = Independence AO = Achievement FIGURE 14. ICO= Intellectual-Cultural ARO = Active-Recreational MRE = Moral Religious Emphasis Org = Organization Ctl = Control Family Environment Scale (FES) Profiles for Amelia and her Family Prior to the 10th grade.1) prior to this significant weight loss.5 pounds (BMI = 14) and . Soon thereafter. in the fall of her sophomore year. In the present. but currently had a tense relationship with her mother. who now drank routinely and who had attempted daily to force her to eat and was the instigator of her getting treatment. she felt that he was overly harsh to her and had unrelenting standards. She described a close relationship with her mother in childhood. Only after she required medical hospitalization did her father begin to cooperate with the mother in seeking treatment for Amelia. Amelia indicated that she felt as if her father overvalued academic and sports excellence. It is also important to note that Amelia’s eating disorder appeared to develop in response to her thwarted goal of excelling at soccer and in the context of dynamics within the family. She felt that as a child she had strong peer relationships and continued them to date. despite the fact that Amelia’s weight had dropped over 40 pounds. Of important note is the fact that both Amelia and her parents admitted that her father did not see a problem regarding Amelia’s health prior to her hospitalization. The mother made it clear that she was not in denial about the severity of Amelia’s problems but admitted that she had tried to control/fi x the problem herself by monitoring Amelia’s eating and forcing her to get treatment. she became easily frustrated if she did not excel. The mother denied fi nding any direct evidence that Amelia was purging. as she questioned . Her older brother was a senior while Amelia was a sophomore.366 Other Adult Disorders she was medically hospitalized at the children’s hospital. this had led to considerable family confl ict (this confl ict was acknowledged by all family members) because of the mother’s high need for control. but she believed that her daughter was. She was currently preoccupied with restricting her eating and with a desire to exercise (although she had been restricted from exercise). She felt that her father was emotionally unavailable and reported that he also drank frequently. Amelia’s mother indicated that she had tried to educate herself about anorexia since her daughter developed the disorder. Amelia described her relationship with her brother as close and indicated that she dreaded his leaving home to attend college. When her father used to coach her soccer team. and he had been increasingly attempting to establish his independence. Amelia was not having a menstrual cycle. Amelia perceived her home life as vacillating from an environment in which she had been supported but highly controlled as a child and adolescent to a current environment that was chaotic. which she attributed to the fact that her interests were different from those of most of her peers. growing increasingly smaller over the last year. Her social support system was limited. indicating that she had always focused on academics and sports. revolving around her older brother planning to leave the household and a sense of detachment from her parents because of their routine of drinking. She expressed frustration about having to deal with her concerns alone and indicated that there had been increased confl ict between her and Amelia’s father until recently because he did not see that a problem was developing. although her mother felt that she had become increasingly socially isolated. Amelia described herself as a high achiever. as the team was off season) or from any exercise until she regained weight. She had a previous eye surgery and the sports injury described earlier (a broken left leg). Soon thereafter. Her mother felt that Amelia’s brother misunderstood the issue but “cares and tries to be supportive” of Amelia. She was taking a daily vitamin and Tums to increase her calcium intake. and weight control. indicating that two months earlier she began to purge three to four times a week through self-induced vomiting after her mother was insistent that she eat. healthy eating. Assessment Data The Anorexia Nervosa Stages of Change Questionnaire (Rieger et al. Amelia’s father was reluctant to provide additional details about his perspective of Amelia’s disorder but did indicate that after Amelia had continued to lose weight her mother took her to see the pediatrician. Studies have shown that clinicians are generally poor at predicting a patient’s investment in treatment for anorexia nervosa (Geller.” Both parents indicated that the family had always encouraged highly active lifestyles.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 367 why Amelia appeared to be eating when forced to do so. Amelia had no known medical concerns that were unrelated to her anorexia nervosa. and the mother had begun to do so increasingly in recent years).5 pounds because of bradycardia.. Amelia was hospitalized at the children’s hospital at a weight of 71. but she would not cooperate and did not benefit from the treatment. She denied any episodes of binging or other methods of purging. As mentioned earlier. Amelia stated that it was not clear to her how much weight she needed to regain to reinitiate activity or how quickly she was expected to gain weight (although her mother and nutritionist seemed clear on the goals). She was released from the hospital at a weight of 78 pounds after being categorized as medically stable. Amelia had been banned from playing on her soccer team (although this was a moot point. Amelia was referred to a counselor and a psychiatrist. Her nutritionist established the goals of an increase in caloric intake of 200 kcals daily over previous intake with a plan of a one-pound weight gain weekly. There was no known family history of serious medical problems or mental illness. When questioned directly about purging.5) long term. Amelia admitted to the behavior. Amelia was scheduled to follow up with a nutritionist (who had seen her during her hospitalization) and with the author of this chapter for therapy. who evaluated her medically. She had refused any psychotropic medications. so this . At the time of evaluation. Following discharge. “even suggesting that the two go out for ice cream” to get his sister “back on track. both parents engaged in alcohol abuse (the father drank excessively throughout Amelia’s life. Amelia’s target weight range was 82–87 pounds (BMI = 16–17) short term and a minimum of 92–100 pounds (BMI = 18–19. sports participation. 2000) was administered to obtain an objective assessment of Amelia’s preparedness to recover. 2002). Before her hospitalization. yet was not gaining weight. and mild body dissatisfaction (i. Third. the mother and siblings within the family felt that there was a strong focus on academic performance. especially regarding how to capitalize on any characteristics Amelia showed that might allow her to succeed at recovery in an outpatient environment. The ego-syntonic nature of the disorder may best be supported by the fact that there are now over 400 web sites dedicated specifically to encouraging anorexic lifestyles.. all family members agreed on the areas of emphasis for the family (i. and confl ict within the family.e. religion). as research shows that 9. The FES profi le also reflected some notable incongruities and points of interest. morality. the mother appeared to be the parent who focused on organization and planning for the family and the decision maker in terms of how rules were set regarding family life. Moos & Moos. On the Eating Disorder Inventory-3 (EDI-3. Garner 2004). 1994). even though she was in an emaciated state. Despite the fact that family members acknowledged confl ict. 2006). Each family member completed the Family Environment Scale (FES. which suggested an overall defensive stance. 2001). also known as “pro-ana” web sites (Reaves. control. This minimization. Amelia obtained scores that reflected denial or minimization of her problem. This was consistent with her clinical interview. Although Amelia’s responses showed that she was in a pre-contemplation stage. as seen on the EDI-3 profi le. Amelia’s mother felt that the family was cohesive. whereas the father felt that this was not an emphasis (he was challenged regarding this by the family at the time of the feedback session). In contrast. In general. this did not warrant abandoning an outpatient treatment approach.. Second. as it is not uncommon for patients with anorexia to be ambivalent about treatment. Despite this tendency toward minimization. the mother and brother perceived the family as a safe place to express emotions. . there appeared to be a strong battle between the mother and the siblings for control. as anorexia nervosa is an ego-syntonic disorder. was consistent with the degree of denial about the seriousness of her problems seen in the clinical interview and likely did not reflect a deliberate attempt on her part to deceive the evaluator. academics. Rather.e. her EDI-3 profi le reflected a high drive for thinness. moderate tendencies toward bulimia. the level of confl ict seen on the FES profi les was lower than expected.1% of inpatients being treated for anorexia nervosa also are in this stage at the beginning of treatment (Vandereycken. The FES assesses the family member’s view of the family’s overall functioning. First. given information provided during the clinical interview. Amelia and her father and brother described an excessive degree of organization. whereas the father and Amelia felt that the family was not structured in a manner that was conducive for the expression of emotions. active sports. Amelia admitted to the expected degree of self-doubts regarding body image for females her age without any eating-related difficulties). recreational. This early emphasis on motivation for change also often has to occur in inpatient settings. this profi le was consistent with a lack of insight about her eating disorder and is not uncommonly seen. this meant that more time needed to be focused on creating motivation for change.368 Other Adult Disorders objective measure was used to assist in treatment planning. However. purging subtype Depressive disorder. and the fact that Amelia had diagnoses of a depressive disorder and obsessive-compulsive traits is not surprising. amenorrhea. was in confl ict with her parents and would be leaving the home soon. impact of her eating disorder on her physical health. However. The restricting type involves severe dieting without the presence of binging or purging. psychological well– being. She was also raised in an environment that appeared to place significant emphasis on excellence. Amelia appeared to be an individual who had predisposing traits (perfectionism.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 369 DIAGNOSTIC IMPRESSIONS Axis I Axis II Axis III Axis IV Axis V Anorexia nervosa. given that common comorbid disorders for anorexia nervosa include obsessive-compulsive disorder and depression or dysthymia (Walsh. Additionally. not otherwise specified Rule out obsessive compulsive personality disorder Malnourished. and personality factors play a part in the disorder’s development and progression. Wheat. as psychological. 2000). brother transitioning to college. overinvestment in a thin physique. the binge-eating/purging type involves regular binging and/or purging behaviors. and body size and shape. and she would be left alone to cope with her parents and their drinking. achievement driven) for the development of anorexia nervosa. 2000). Additionally. athleticism. Her powerlessness stemmed from her injury. it was further exacerbated by the stress of knowing that her brother. & Freund. 1997). sociocultural. highly active. Given that bulimia nervosa is not diagnosed if anorexia nervosa is present (APA. As she lost a significant amount of weight (originally modest weight loss through training for improving her soccer and later dieting that led to a dramatic weight loss). individuals who develop eating disorders almost always report dieting as a precipitant of their disorder (Romano & Halimi. a major source of support. the case conceptualization must also be multifactorial. recent episode of bradycardia Isolation from peers. Amelia’s traits were likely triggered into the development of an eating disorder because she engaged in dietary restraint at a time when she was experiencing a sense of powerlessness. 2000). and the family. a mood disorder diagnosis was appropriate. she also appeared to have an increased sense of control and self-esteem. no other eating disorder diagnosis was warranted. dealing with parent’s alcohol abuse 40–45 Initial Evidenced-Based Case Formulation There are two subtypes of anorexia nervosa: restricting type and binge-eating/ purging type (APA. when her efforts to excel at soccer were thwarted. Amelia reported receiving reinforcement for her weight loss early on in the form of comments about how her physical attractiveness and athletic performance had . biological. Just as the assessment of a patient with an eating disorder should be multifaceted. Amelia was diagnosed with the latter. and many clinicians in the eating disorder field recognize that there are limited data on empirically based approaches to assessment and treatment (Gowers & Bryant-Waugh. she and her family were informed from the start that full participation would be necessary. Thus. thus allowing the patient to see therapy as not only connected to meeting weight goals. These events were occurring in the context of a family environment where her mother was portrayed as extremely controlling. as well as the recovery process. Simultaneously. was recommended as the model of care to allow for a team approach. 2006). & Taylor. Additionally. family. She also likely was feeling increasingly isolated from her peers and her older brother and less powerful to make her own personal decisions. it was likely that subsequently. A delay in commitment to treatment also likely negatively impacted her commitment to treatment in the present. she could avoid further comment and oversight by her mother. The longer she remained malnourished. Brozek. refeeding involves greater risk. 2004). The level of denial exhibited by both Amelia and her father was an additional obstacle to her mother’s efforts to get treatment for her. 2006). It was also helpful that the therapeutic weight goals had been established by the nutritionist. Individual sessions were slated at a frequency of two times a week and then .370 Other Adult Disorders improved secondary to weight loss. Individual. Henschel. Treatment Anorexia nervosa is notoriously difficult to treat. the disorder requires that immediate actions be taken to create weight regain. in addition to close medical monitoring. since Amelia had already been discharged and was seeking outpatient therapy. Amelia had already experienced one hospitalization for stabilization. Kalm & Semba. the more likely it was that her compulsive and restrictive tendencies were exacerbated. and both parents drank excessively. By eating a minimal amount. Prognosis declines significantly when immediate medical hospitalization is required because treatments are less effective. Mickelsen. the impact of starvation at a biological level was intensifying with time. but be prolonged in duration (Keys. her father was emotionally unavailable. and pharmacological treatment. she then purged so that she did not feel the associated anxiety related to feeling out of control or due to a fear of weight gain. and this was clearly relevant to Amelia’s case. And the family was instructed from the start of treatment that if Amelia were unable to achieve appropriate weight goals in an outpatient setting. 2005). even with weight restoration. but remained highly cognizant of the weight goals. The therapist was cautious not to overemphasize weight gain as the focus of therapy to Amelia in order to ensure rapport. nutritional. Additionally. inpatient hospitalization in a facility focused on eating disorders would be necessary immediately. 1950. given the biopsychosocial nature of anorexia nervosa (APA. her emerging purging behavior appeared to be the indirect result of the anxiety that she felt in response to the pressure of eating in front of her mother. maladaptive behaviors might decrease in frequency and intensity. and gray matter deficits often persist (APA. Dunn. Bozzelli. Sessions with her nutritionist were scheduled weekly. several initial steps were important to enhance the therapeutic alliance. shifting the focus regarding nutrition to other members of the treatment team (i. As it was not currently medically necessary and dietary intake was being measured by the nutritionist. The therapist understood that normalizing eating would be addressed over time when trust was established. her pediatrician was reminded that she should consider re-referral to a psychiatrist. Consideration regarding psychotropic medication was indicated. The family was informed that immediate hospitalization should be considered if any degree of additional weight loss occurred. the therapist reviewed the patient’s dietary intake and exercise level through food and activity monitoring. 2006). Also. Cecelic. Antidepressants have the potential to either curb appetite or initiate a weight gain that is too rapid. Maradiegue. The therapist also conversed openly with Amelia about the reality of societal pressures for thinness and achievement that Amelia had experienced. & Frances. 2006). Therefore.g. Comtois.. and a referral to a psychiatrist was attempted.. or if medical problems reemerged. given the level of depressive symptoms present (APA. if antidepressants were indicated for Amelia. & Chew-Graham. 2003). that she must ascertain the impact of medications on appetite. depending on the medication prescribed. Russo. Because of the ego-syntonic nature of anorexia nervosa. The therapist also recognized that the evidence suggests that changes in eating habits are best accomplished by integrating these goals into a treatment contract that focuses on all of the issues associated with anorexia nervosa. it was underscored that she and her family would have to work even harder to overcome her symptoms in the outpatient setting if no pharmacological interventions were added. rather than focusing exclusively on weight and nutritional goals (APA. 2006) and might have intensified Amelia’s fears about treatment because of feared uncontrollable weight gain. if the physician felt ill-equipped to provide the pharmacological intervention. Amelia’s pediatrician was reminded that if Amelia were more open to the option of medication in the future. family sessions were also slated twice weekly. but did not recommend immediate changes above those in place by the nutritionist. 2004. Henderson. Because of Amelia’s reluctance to try medications. & McCann.e. Additionally. and Amelia had regular appointments every two weeks with her pediatrician.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 371 would be tapered if short-term treatment goals and weight gain were achieved. This later step was taken as surveys of primary care practitioners consistently show that they feel they have limitations in perceived skills and competency in the treatment of eating disorders (Clarke & Polimeni-Walker. but both the referral and psychotropic medications offered by the pediatrician were declined by the patient and her family. Cummins. if weight gain did not occur at an adequate pace. 2003. 1996) and in knowledge and beliefs about identification and management of specific eating disorders (e. It was critical that the therapist conveyed empathy regarding weight and body image issues and the patient’s struggle with normalizing eating. May. the nutritionist) allowed the therapist . This decision was made as recommendations suggesting immediate dietary changes or alterations in activities would convey a lack of understanding (APA. 2002. 2000). Numerous forms of individual psychological treatments have been utilized to treat patients with anorexia nervosa. “I’ll lose control if I eat”). In contrast. During the first phase. it was important to capitalize on the sibling closeness to allow more communication and support between siblings.372 Other Adult Disorders to focus more directly on the psychological issues associated with anorexia nervosa and the problems within the family. The family therapy also needed to increase the emotional connection between daughter-father and to decrease the controlling relationship between daughter-mother.g. This was accomplished by focusing on building the relationship between the parents. subsequently. Eisler. Le Grange. especially those contributing to the anorexia nervosa. and her parents needed to work effectively as a unit “in charge” of their daughter’s eating. Agras. and the patient was asked . Family sessions were held weekly. During this phase. Russell. Lock. 2002). family meals were conducted that were observed by the therapist. the family was also taught how to identify dysfunctional thoughts. “I’ll never be able to stop gaining weight”. To do so. Treasure. “I’ll become fat”. family support and therapy have consistently been shown to be important in the effective treatment of adolescents (Dare. at the beginning of therapy the clinician decided that family therapy was indicated for a multitude of reasons. mainly utilizing him as a source of encouragement. 2000. who intervened with the family to help them gain immediate control over Amelia’s maladaptive eating habits. Therefore. Once the family had accepted the premise that the family must fight the anorexia nervosa. Lock. The treatment was offered in three phases. the therapist requested that family members empathetically verbalize the emotionally driven beliefs of anorexia nervosa (e. they were asked to support Amelia in changing dysfunctional behaviors that were contributing to the anorexia nervosa. the family members were unaware of many of these thoughts because they represented beliefs held by society and the family’s support network (e. 2001) in which observations of family interactional patterns are made and parents are empowered to participate in assisting their child to reengage in eating. To interrupt the cycle of anorexic behaviors. the serious nature of eating disorders was underscored to the father in order to increase his investment in Amelia’s treatment. Amelia’s brother’s involvement was also solicited.. 2011). but the success rates are modest at best (Steinhausen. Also. The family needed to understand anorexia nervosa and to commit as a unit to helping Amelia overcome the disorder. then the therapist worked with the parents to increase effective communication between them about what approach would best work for them to refeed Amelia. utilizing elements of a Maudsley approach (Lock. FAMILY THERAPY The family-based treatment approach that was used is predicated on the assumption that anorexia nervosa has arrested normal development (Dare & Eisler. Amelia was unable to be resourceful in overcoming her eating disorder. & Dodge.. thought processes around ways to lose weight or the importance of thinness).g. as well as addressing the impact of the parental alcohol use on the family’s functioning. & Dare. The therapist facilitated communication among family members. (2) enhancing negotiations between Amelia and her brother with their parents to ensure that they had a level of autonomy consistent with their level of development. shopping for clothes. For example. During this phase. In Phase 2. Phase 1 continued until Amelia succumbed to the family’s demands that she eat. confl icts.g. the therapist guided the family members in assisting one another in refuting automatic thoughts contributory to the anorexia nervosa and altering dysfunctional behaviors through discussion of the thought records as well as general discussion. events requiring decision making). the therapist had the role of teaching the family members how to develop rational responses or alterations in behavior. (3) redefi ning the emphasis that the family placed on unrelenting standards. and relationship skills) and used techniques that research has suggested have the most benefit (e.g. Most notably. which focused on reestablishing normal adolescent development for Amelia. Over time. with the emphasis being on the automatic thoughts and emotions that occurred. strategies were discussed for reestablishing peer connections and for communicating her needs to her family without using her eating disorder to do so. mealtimes. motivational enhancement. with the emphasis being on four key concerns: (1) encouraging the father to be more actively involved in parenting and more open to expressing his thoughts and feelings. especially those describing situations that elucidate family dynamics affected by the anorexia nervosa (e. each family member was asked to complete dysfunctional thought records. Progress in each of the areas addressed in Phase 2 was substantial. INDIVIDUAL THERAPY Individual therapy focused on goals regarding behavior and belief change for each of the eating disorder–related domains (including body image. Early in this phase.. the family and individual therapy content was highly congruent.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 373 to verbalize rational beliefs that countered these anorexia nervosa thoughts. self-esteem. family issues were discussed. emotional expression. support. cognitive behavioral therapy [CBT] to address purging). in the family session. the patient was asked to repeatedly identify how strongly she believed the self-generated rational responses and was assisted by the therapist in developing believable rational responses. regardless of the source of the beliefs. Throughout Phase 2. especially those related to thinness. Then. although admittedly the data are sparse on effective interventions in general for anorexia nervosa and even more so on dismantling studies that demonstrate what specific elements of a .. Treatment then shifted to Phase 3. and (4) challenging the parents to modify their drinking. The ultimate goal of Phase 1 was to obtain the entire family’s commitment to altering maladaptive beliefs and behaviors associated with the anorexia nervosa. typical cognitive restructuring techniques were used but were integrated into a family systems model. During this process. each family member was asked to discuss his or her perception of the situation. with the exception of getting the parents to commit to significant modifications in their alcohol use. 2004). and purging were introduced. and to examine the utility and validity of these rules for her in the present. these strategies included distraction. She and her parents also discussed . Treatment Outcome Initially. and Amelia was taught to record automatic thoughts as they pertained to eating situations and body image concerns on daily thought records. She met weight goals 85% or more of the time and gradually was allowed to return to modest amounts of exercise.. exposure and temptation exposure with response prevention).g. This has caused her shame and a feeling that her parents are disappointed with her. meal planning) through techniques such as stimulus control methods and behavioral contracting with contingencies.g. During the advanced family sessions. Amelia described that she felt “like an outsider looking in. Relying more on the data supporting CBT as the most effective intervention (APA. excessive exercise. worth. Amelia’s behavior was often not recovery oriented (criticizing the providers. Amelia was not coming entirely clean with the struggles that she was having with purging and appeared to be focused on the “disappointment” that she had caused the family. & Stewart. Maladaptive core beliefs related to control. and responsibility. The patient was also taught to identify beliefs learned in childhood regarding eating. it is important to note that the majority of the time she self-disclosed purging behavior as treatment progressed. She purged two to three times a week during the early phases of treatment. As therapy progressed. and she purged less than once every two weeks in the middle phases. but this decreased quickly. there was increased focus on the patient developing her own autonomous goals regarding personal development. 2006) for purging in bulimia nervosa. Cognitive restructuring was increasingly emphasized to decrease the use of eating disorder behaviors to escape emotions and problems.. White. and practicing of coping phrases (Williamson. Amelia was slowly taught to engage in “non-dieting” weight control to normalize eating (e. 2000). elements of interpersonal therapy (IPT) and acceptance and commitment therapy (ACT) were also incorporated. dishonesty) but over time Amelia did surprisingly well with the behavioral and nutritional components of the treatment.374 Other Adult Disorders therapy approach might be most beneficial (APA. given that researchers have struggled to retain patients with anorexia nervosa in treatment trials. delay techniques (e. and trust were challenged. The cognitive model was introduced. weight. Rational responding was role modeled. When relevant. cognitive and behavioral strategies to disrupt dietary restriction. Early in treatment. However. the family was participatory and expressed their emotions appropriately.” as if she didn’t fit into the family because she sensed that she doesn’t meet parental expectations. given the degree of social isolation that Amelia experienced and the need to teach her strategies for emotional regulation. York-Crowe. and journaling regarding general issues was encouraged. and Amelia disclosed that she used the eating disorder as a way of “pleasing herself.” “I only run right to it after a bad day”) and was called on her behaviors. & Zucker. The father generally avoided the topic or switched subjects when his drinking was discussed. Amelia was asked to make a list of all of her “passions” that might give her a focus away from eating and weight. 2005). In approximately half of patients with the diagnosis. which may also be contributors to the comorbid psychiatric disorders. Both parents described feeling as if their life “was on hold” because of Amelia’s eating disorder. suicide. 2007). medication reactions.3 to 1% of female adolescents develop anorexia nervosa (Treasure. but the parents denied it. some features of bulimia nervosa will emerge (Tozzi et al. Amelia stated that they’ve tried to cut back unsuccessfully. An extensive support plan for how others can help her overcome her urges to restrict. 2010). exercise excessively.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 375 her long-standing history of being a loner. Claudino.. & Vitousek. Grilo. Ways to socially engage more with peers was addressed in therapy and she was connecting gradually to more peers. and body image distortion (Wilson. The voluntary starvation is often accompanied by a high need for control. Her father continually acted as if he were “walking on eggshells around her eating disorder” (afraid to say the wrong thing) initially. perfectionistic qualities. Toward the end of therapy. an extreme fear of weight gain. Her mother was encouraged to test herself by not drinking and “seeing what happens inside” and to seek her own treatment if needed. pneumonia. encephalitis. The condition is characterized by extreme emaciation achieved through severe dietary restriction and compulsive exercise or ancillary purgative methods (APA. it is often difficult to tease out the many biological factors related to the maintenance of the anorexia nervosa that are actually the adverse effects of the eating disorder behaviors. In post-pubertal females. such as anxiety and depression. accidents. and very low . Both parents acknowledged that the drinking is nightly. seen in these patients (Garfi nkel & Kaplan. but he became increasingly paternal and supportive of his wife and her efforts to get Amelia to eat as sessions progressed. Simultaneously. Neither parent made a commitment to change their drinking habits. Amelia remained overly focused on disappointing him.” Issues of her mother’s control and her father’s emotional repression were also addressed. Empirical Underpinnings KEY PRINCIPLES/CORE KNOWLEDGE USED TO APPROACH THE CASE Current estimates are that approximately . and the medical complications that accompany anorexia nervosa are often life-threatening and include cardiac conditions. 2000). amenorrhea is present. Her mother was willing to talk about the issue but was somewhat defensive (“I have to escape. Attempts were made to address Amelia’s parents’ alcohol use. especially severe dietary restraint and purging. or purge was created. 1985). behavioral interventions are utilized to alter entrenched anorexic patterns of dietary restraint. & Nicholls. improving communication patterns. and when the cognitions are accompanied by extreme dietary restraint. This is true even when there is striking evidence that would be . 2004). & Marmore. Also. there is a greater mortality risk (Herzog. Lock. 2011). 2002). Loeb. 1995. and the patients are taught a variety of new life skills. Lock. and elements of CBT (Williamson. 2008). While these generalizations regarding family dynamics at times historically have proven to be useful clinically. Lock. Keel & Hardt. 2002). Le Grange. 2010). in reality patients with anorexia nervosa come from a variety of families (Le Grange. This diversity across families means that the cognitions and behaviors displayed by various family members can be both congruent and incongruent with the patient with anorexia nervosa. compulsive exercise and purging. or personality disorders are present. Approaches from acceptance and commitment (ACT) and mindfulness-based treatments are also incorporated (Bowers. Furthermore. TYPICAL COGNITIONS IN ANOREXIA NERVOSA As in all psychological disorders. York-Crowe & Stewart. when comorbid mood. 2002). however. Families of patients with anorexia nervosa have often been characterized as having unrelenting standards. there are variations in beliefs maintained by patients with anorexia nervosa.. Loeb. as the patient becomes increasingly malnourished. 2010. espousing rigid rules. 1995). patients with anorexia nervosa are taught to identify the typical cognitions that contribute to their illness. 2003). but the success rates are modest at best (Steinhausen. but current research demonstrates that these characteristics may be moderating factors in predisposed individuals (Smith & CookCottone. Numerous forms of psychological treatments have been utilized to treat patients with anorexia nervosa. it becomes even more difficult to alter the behavioral patterns and belief system that the patient utilizes to maintain her illness. These maladaptive cognitions often appear to be part of the foundation for the development of the disorder. motivational enhancement. In individual CBT. 2004). Nussbaum.376 Other Adult Disorders body weight (Quadfl ieg & Fichter. Additionally. 2010. 2008. Family therapy approaches have often been used as a main intervention in encouraging a commitment to ingesting nutrition. dismantling dysfunctional family dynamics. & Nicholls. there is evidence that families of patients with anorexia nervosa may not be substantially different from other families (Dare & Eisler. White. 2010) and eclectic approaches that utilize support. and are instructed on ways to modify their beliefs. there are also typical cognitions seen across patients (Cubic & Bluestein. Additionally. and teaching family members how to understand and deal with anorexia nervosa (Lock et al. obsessive-compulsive. and displaying dominating and controlling behaviors. the beliefs become more entrenched as the disorder progresses (Cubic & Bluestein. Interventions that show some promise are family approaches (Dare & Eisler. 1996). Lock. For example.” “Being fat would be the end of the world.” “Having anorexia makes me superior to others who can’t show this degree of self-restraint. 2000).” Weight Control Beliefs • • • “Gaining any amount of weight is terrifying. I become completely unattractive and must avoid others.” “If I feel negatively about something. my accomplishments in life mean nothing.” Minimization of the Eating Disorder • • • “An eating disorder is not a serious problem and does not have serious medical complications.” .” “I must be perfect at everything I attempt.” “Unless I can control my weight.” Feelings about Obesity • • “People who are obese are lazy and overeat. 2004).Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 377 contradictory to the entrenched anorexia beliefs. patients will continue to believe that they are in need of additional weight loss and will assume that their perceptions of feeling fat are realistic (APA.” “Being anorexic is part of who I am and therefore I cannot change it. Other typical cognitions include the following (Cubic & Bluestein. 1987). Control/Perfection Issues • • • • “Demonstrating control over food intake and weight shows selfdiscipline.” Body Image Dissatisfaction • • • • “My body is disgusting/will become disgusting.” “If I gain any weight. These body image–related thoughts are only one set of beliefs that appear to maintain the illness. despite the emaciated physique.” “The only way to control my weight is to constantly check it. a set of beliefs that becomes delusional in proportion and cannot be easily modified through the introduction of rational evidence is related to the patient’s body image distortion (Cash & Brown.” “Feeling fat and being fat are the same thing. This is illustrated by the fact that. it must be because my body is disgusting/fat.” Dealing with Emotions • “Being thin equals being happy.” “Giving into sensations of hunger means that I am a failure.” “I can be any weight I want to be if I simply try hard enough. Inflexibility in food variety.” “If I eat anything that is not on my diet. . then there will be no negative consequences. Keys et al. stereotypies such as chewing gum. Typical behavioral patterns (Cubic & Bluestein. purge).” Eating Habits • • • “If I eat anything that was unplanned.” “My anorexia nervosa helps me avoid dealing with things. then I have ‘blown it’ for the day.” “As long as I can ‘undo eating’ (i. and behaviors ultimately leading to a lack of dietary control. 2005.” TYPICAL BEHAVIOR PATTERNS Voluntary starvation and its subsequent malnourishment have been studied for several years in different areas of science. Just as there are a variety of cognitions that maintain anorexia nervosa. acceptable) to eat and those which are ‘bad’ (i..” “After eating fatty foods.. often less than 500 calories a day. 1950) demonstrated that even when individuals are not suffering from disease states such as anorexia nervosa. especially those with caffeine. nail biting. restrict. 1950).e.e. Once the weight is restored after emaciation.. I might as well have binged. and smoking. then restricting my food intake will make me feel better. increased ingestion of liquids.” “Chronic dieting is the only way to maintain long-term weight loss..e. as well as the additional difficulties created by the volitional dietary restraint. even after weight restoration. or compulsively exercise to avoid the anxiety. These behavior patterns include preoccupation with food and cooking. Subsequently. starvation alone can lead to some predictable behavior patterns. A landmark study (Keys et al. such as binging. patients will often feel the need to increase their motivation for dietary restraint and will use higher levels of cognitive control to maintain these destructive behaviors.” “If I eat. 2005). & Wilson. the anxiety will be intolerable and I must purge. As the therapist attempts to alter the unhealthy behavior patterns. 2004) will be in the following domains: Dieting Behaviors • • Extreme caloric restriction. Walsh.378 • • • • Other Adult Disorders “I can’t tolerate feeling negative emotions.” Acceptable Foods • • • “There are foods which are ‘good’ (i. forbidden). but may be prolonged in duration (Kalm & Semba. when starvation is accompanied by an illness such as anorexia nervosa. Schebendach. the behavior patterns that maintain anorexia nervosa are also diverse.. these behavior patterns may decrease in frequency and intensity.” “If I feel upset. I can literally see my body growing. a persistent disturbance in eating often remains (Sysko. the therapist must be aware of the behavioral and physiological effects of starvation. 2005) and strengthened the data collected in the general clinical interview and developmental . spitting food into napkins. Food rituals such as moving or shifting food around the plate. Doll. Non-purging behaviors such as increased dietary restraint or increased excessive exercise after engaging in eating. diuretic abuse. and Case Conceptualization Given the complexity of eating disorders and the difficulties encountered in treating anorexia nervosa in particular. a multifaceted assessment is recommended to determine the level of care needed and to guide treatment planning (APA. For example. which involve calorie counting while exercising simultaneously. a structured interview for the diagnosis of eating disorders can lend valuable information. Diagnostic Formulation. Ancillary Behaviors • • • • • Body-checking behaviors such as weighing. or combining foods in an unusual way in order to make it appear that more food has been eaten. Restriction of complete intake after certain times of the day. trying on of clothes. the Eating Disorders Examination (Cooper & Fairburn. typically defi ned by the patient as foods that have high fat or sugar content. which include self-induced vomiting. laxative abuse.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa • • • 379 Consumption of low or no-calorie foods and beverages in order to create a false sense of satiety. Compensatory Behaviors • • Purgative behaviors. Marked repetitive exercise behaviors. Assessment Strategy. 2006). Cooper. Preoccupation regarding shopping and cooking food for others. Engaging in body movement when exercise is restricted. for example. moving the legs restlessly. Secretive behaviors aimed at hiding the amount of food eaten or lying about intake and exercise. or subtle techniques such as using the fi ngers to circle the wrist or tracing bones with a fi nger. 1987) used in Amelia’s assessment has been shown to be a reliable interview measure to assist with diagnosis of eating disorders (Fairburn. Compulsive Behaviors • • • Engagement in predetermined types and durations of exercise. & Davies. or attainment of rigid numbers of times that exercise must occur. or use of enemas. ruminating. To assess a patient suspected of having anorexia nervosa. bodysize estimation techniques. Avoidance of feared or forbidden foods. Use of diet aides and nutritional supplements. Friborg. The psychometrics of the EDI-3 appear to remain strong across international populations as well (Clausen. 1997). Garner. Supplementing the interview with measures of the patient’s readiness for change. Given that anorexia nervosa is difficult to treat. the ANSOCQ was administered to determine Amelia’s motivation for change. Monitoring of a patient’s nutritional intake (including episodes of binging and purging) and exercise activities are also regularly a part of the assessment of a . & Garfi nkel. Bohr. Test-retest reliabilities for the FES-R generally fall in the moderate range.. 2004). 2011). 1982).90 to . & Burt. such as the Eating Disorder Inventory-3 (Garner. and General Psychological Maladjustment. The Family Environment Scale-Real Form (FES.g. expressiveness. & Rokkedal. Ineffectiveness. Overcontrol. 2008). Interpersonal Problems. 1985). Gullone. Readiness for change has been shown to predict treatment outcomes for inpatients with anorexia nervosa (Bewell & Carter.380 Other Adult Disorders history. 1984) and consists of 20 items measuring an individual’s perception of weight.g. and confl ict).. achievement orientation. Affective Problems. 1994) measures the social and environmental characteristics of families. was also very helpful as it assisted in accurately classifying Amelia’s motivation for change and underscored the need for the clinicians to use strategies most beneficial for the pre-contemplation phase of change in order to help her move toward recovery. Moos. and eating behavior with scores ranging from pre-contemplation to maintenance. and the degree of emphasis that the family places on organization and control. the Eating Attitudes Test (Garner. & Moos. Needleman. however. and the information can guide clinicians in understanding the family system of a client. and Body Dissatisfaction subscales) ranges from . measures of cohesion. Six composite scores can be developed from the EDI-3: Eating Disorder Risk. the family’s ability to create personal growth within its members (e.. and moral-religious emphasis). as it is considered the most widely used self-report measure assessing psychological characteristics shown to be clinically relevant for patients with eating disorders. for example the Anorexia Nervosa Readiness for Change Scale (Rieger et al. 2004) across studies. shape. Olmsted. Multiple objective measures to obtain baselines regarding eating habits and eating-disordered characteristics are available. The main measure used with Amelia to assess her level of symptomatology was the Eating Disorder Inventory (now in its 3rd revision. and Three Factor Eating Questionnaire (Stunkard & Messick. independence. the internal consistency of the measure may be questionable (Boyd. intellectual-cultural orientation. 2004). This measure is based on the Transtheoretical Model of Behavioral Change (Prochaska & DiClemente. Rosenvinge. The test-retest reliability of the Eating Disorder Risk Composite (the measure most specific to individuals with eating disorders and composed of the Drive for Thinness. The FES is composed of 90 items that load onto ten subscales measuring familial relationships (e. Bulimia.97 (Garner. The EDI-3 is composed of 91 items that load onto three scales specific to eating disorders and nine other scales that are relevant but not specific to individuals with eating disorders. especially in an outpatient setting. active-recreational orientation. 2000). g. Bennett. family therapy and individual therapy utilizing eclectic approaches. but rather will receive their advice and treatment in primary care settings (Cubic & Bluestein. combined with psychopharmacological interventions. Additionally. 2004).5 million deaths are attributable to these conditions annually. nutritional counseling. decisions about how and when to intervene in anorexia nervosa require awareness by physicians. In contrast. mental health professionals. Steer. Epidemiological Considerations More people worldwide now die from being overweight and obese than from being underweight (World Health Organization [WHO]. multifaceted body image assessment measures and measures of secondary psychopathology were incorporated as needed (e. debilitating illness and has one of the highest mortality rate s of any psychiatric disorder (Gowers & Bryant-Waugh. and life transitions at these ages might be related to this phenomenon. Therefore. 2006) and were used in the case of Amelia. Williamson. Evidence for the Intervention Model When anorexia nervosa is properly identified. in the United States approximately 10 million females and 1 million males met the criteria for a diagnosis of anorexia or bulimia and another 25 million more are struggling with binge eating disorder (National Institute of Mental Health. as both generally begin when concern about weight or the potential of weight gain is provoked in adolescence by changes from puberty or comments by peers. Beck. Many patients with eating disorders will never seek assistance from professionals in mental health. Goreczny. & Brown. Body Image Assessment [BIA. accompanied by periods of stress. Depression Inventory-II [BDI-II.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 381 patient with an eating disorder (APA. the WHO estimates that 1. 1989]) to monitor Amelia’s progress. & Gleaves. . is an increasingly prevalent.. Eating disorders are also occurring in greater frequency during middle and late life (Zerbe. 2004. and nutritionists of those cognitions and behaviors held by individuals with anorexia nervosa. as well as the beliefs and behaviors of their family members. 2003). which in part develops out of an intense fear of obesity. 2011). Thus. 2004). Steinhausen. In fact. Davis. and close medical monitoring have been utilized to treat anorexia nervosa with moderate success (APA. The treatment team must also decipher which beliefs may facilitate or sabotage the patient’s progress. primarily from pediatricians. Anorexia nervosa. 2006). 1996]. information on risk factors and prevention is crucial. especially because it is often difficult to differentiate typical dieting in adolescence from the early development of an eating disorder (Cubic & Bluestein. 2011).5 billion individuals are overweight or obese worldwide and that greater than 2. 2002). in part due to the difficulties conducting randomized treatment trials because the disorder is fairly rare (Gowers & Bryant-Waugh. While some data suggest that during active phases of anorexia nervosa. family members would have been encouraged to develop healthier communication patterns and to engage in healthier activities. physiological. if the approach used had not been yielding progress. . and neuropsychological symptoms related to anorexia nervosa.382 Other Adult Disorders Subsequently. 2002). 1999). Sperry. neuropsychological effects of starvation would make insightoriented interventions inappropriate. outside therapy. Within the context of the individual therapy offered. 2006). effective treatments for anorexia nervosa in adolescence (Dare & Eisler. a shift to a more insight-oriented approach might have been considered. 2002). Wilson. If the approach used was not sufficient. they are rarely used in the United States (Mussell et al. Relevant elements of interpersonal therapy (IPT) were also incorporated. Because a cognitive therapy approach was used. 2004). Past issues were addressed only as they related to helping the patient understand patterns of learned behaviors. to date there is still minimal empirical guidance regarding how to choose effective treatment. APA. a decision was made to utilize the approach developed at the Maudsley Hospital in London. Additionally. Effert. the focus was primarily on the present. 2000. 2002. and appropriate expression of emotions. more discussions would have been focused on ways to increase the patient’s sense of self-worth. Alternative Options Considered Despite increased understanding of the psychological.. 1999) and because Amelia was fairly estranged from her peers. that were not related to eating or exercise. Family members would have been encouraged to be aware of how their own issues and fears related to these domains exacerbate the family tensions and Amelia’s anorexia nervosa. affects both specific and general psychopathology. and leads to gains that are usually maintained at 6–12 months of follow-up (Fairburn. autonomy. Within the context of the family therapy. produces substantial symptom change early in treatment. Then. although research indicates that CBT and IPT are the most highly effective therapies for bulimia nervosa. It is important to note that. & Detweiler. as the CBT treatment of bulimia nervosa is highly efficient. 2008). as it is one of the only established. it is critical that discussions center around all issues contributory to the anorexia nervosa—not just issues regarding eating. which empowers the family to work with the patient to fight against anorexia nervosa. given developing evidence supporting this approach for bulimic tendencies (Wilson. studies have shown that psychoanalytic interventions may be helpful to some patients with anorexia nervosa (Keel & Hardt. elements of CBT were utilized to address the purging behavior seen in Amelia’s case. Evidence is also mounting that the use of mindfulness and ACT approaches in the treatment of eating disorders may be appropriate (Heffner. especially anger. excessive exercise). therefore the clinician providing the family and individual therapy was designated in this role. the family unit was strengthened. and perfectionism were also sources of complication in the therapy. The evidence suggests that when a specific clinician on the team is designated as the facilitator of communication to ensure continuity. and other nonspecific medical issues related to purging. social desirability issues. lack of assertiveness skills. The initial focus was on the maladaptive patterns of eating-related behavior (restricting. body dissatisfaction and distortion. which allowed routine monitoring of vital signs. body and weight checking behaviors. and adapting the treatment plan as needed. Delineation of roles and responsibilities of providers was also crucial. growth patterns. 2006). as this individual was a specialist in the treatment of eating disorders. weight. purging. body. need for control. A full physical examination of the patient was performed regularly by the primary care physician. As therapy progressed. and the disturbed attitudes toward eating. routine communication among the providers was essential in assessing the patient’s needs. relationship skills were taught to alter mistrust. Several strategies were used to deal with therapy complications. By uniting the parents in challenging Amelia’s eatingdisordered beliefs and behaviors. Therapy sessions were designed to reinforce that Amelia was not a “bad person” but had learned maladaptive ways of dealing with life’s stressors and standards. 2007). and the patient’s sense of an external locus of control became more of the focus. . Therefore. discomfort with sexuality. and that she could learn adaptive coping skills. Comorbid mood disturbances (especially depression. general difficulties in relationships. cardiovascular function. especially regarding the pressures to be thin. they fear weight gain (Hayes. and if they engage in treatment. treatment planning. shame regarding the body. treatment outcomes are improved for patients with eating disorders (APA. Issues regarding a lack of self-worth. including height. monitoring progress. Strategies for Dealing with Therapy Complications Individuals who seek help for an eating disorder rarely do so without ambivalence. This provider also ensured that all members of the treatment team were in agreement with any adaptations to the treatment plan. Therefore Amelia’s current problems were discussed within a context of how her thoughts and behaviors were an understandable reaction to life experiences and messages learned during childhood and adolescence.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 383 Nonspecifics of the Case An interdisciplinary team was utilized to provide treatment to Amelia in an outpatient setting. Therefore. and Amelia’s difficulties expressing negative emotions. and hopelessness) may also need to be treated. anxiety. and weight that had developed. 2006). In other words. which contribute to dieting behavior (Gordon. such as the cultural value on thinness. dopamine. had the outpatient approach used been unsuccessful. Additional stressors (especially her parents’ alcohol use) and the initial degree of resistance regarding treatment that Amelia displayed also suggested the need for treatment within an intensively supervised inpatient setting. similarly to the approach that was used in this case. the principle of autonomy that recognizes that a competent individual has the right to make an informed choice about medical treatment had to be balanced with the principle of beneficence that requires health care providers to do what is in the best interest of the patient. 1999). particularly when such illness threatens their survival. especially in determining what information given by Amelia would or would not be shared with family members. 2001). After discharge from the inpatient facility. Biological factors also combine or interact with various sociocultural factors. Treating Amelia required walking a thin line between coercion and Amelia’s right to consent to treatment. Therefore. A second ethical issue is confidentiality. hospitalization would have been recommended prior to the onset of further medical or psychiatric instability.384 Other Adult Disorders Alternative Approaches At the beginning of outpatient therapy. in keeping with treatment guidelines (APA. which underscores that involuntary treatment can be a means of helping patients with serious psychiatric illnesses like anorexia nervosa to recapture their autonomy. A Maudsley approach requires considerable family involvement and focuses on uniting the parents to take control over the adolescent’s eating. if the outpatient approach used described in this chapter were not successful. A biological predisposition for eating disorders has been suggested by evidence that dysfunction in serotonin. there were factors suggesting that hospitalization for Amelia in a specialized program for eating disorders might be appropriate because of her rapid weight loss and level of eating-disordered symptoms. Therefore. and norepinephrine modulators are possible predisposing factors (Romano & Halimi. efforts would have then been made to assist Amelia in engaging in appropriate food intake to maintain a healthy body weight and to reintegrate successfully back into her home life and peer group. thus Amelia’s . 1997). a stronger emphasis on the need for psychotropics as a treatment modality would have been underscored. Ethical Considerations Perhaps the most challenging ethical consideration in the treatment of anorexia nervosa relates to the best way to respect individual autonomy while intervening to stop the physical and mental deterioration created by the starvation and the disorder. One perspective that can be considered is that of compassionate interference (Verkerk. Patients with bulimia nervosa are sometimes of normal weight and deliberately conceal their disorder. it was important to avoid the mistake of being oblivious to the phenomenon of dieting and the emphasis in America on dieting. Perhaps even more alarming are fi ndings suggesting that up to 47% of 5. even though Amelia was hesitant to engage in treatment. placing emphasis on how Amelia’s behaviors. ethical consideration needed to be given to weighing the risks of inpatient versus outpatient treatment. she had already been discharged and was being evaluated in the outpatient setting. 2006). Amelia and her family were provided with specific information regarding a target weight and nutrition goals. and the medical and physiological consequences of dieting and eating disorders.g. at the start of therapy a verbal agreement was made that only issues revealed in individual therapy related to matters of safety (e. rapport was needed for Amelia to open up. Therefore. . beliefs. Additionally. the impact of societal pressures for thinness. To address Amelia’s minimization of the eating disorder. the benefits of engaging Amelia and her family into treatment as an outpatient appeared to outweigh the likelihood that the family would pursue no treatment if only forced into inpatient options. the benefits of having one therapist in these two roles seemed to outweigh this consideration. Although guidelines suggest that Amelia’s prognosis would have been better if she had remained in an inpatient setting until she was > 90% of her target weight (APA. to develop rapport with Amelia and motivate her for treatment. set point theory. To avoid this mistake. 2009). Therefore. dieting is becoming the norm. and she and her family were refusing inpatient care. an alternative approach was used to address this issue. the energy regulation model. To avoid confl icts over weight issues. Common Mistakes Avoided According to the Youth Risk Behavior Surveillance (Centers for Disease Control.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 385 parents needed to be well-informed. Psychoeducation emphasized factors related to the development of eating disorders. 2005). and often therapists can underestimate the severity of anorexia nervosa. disclosure of suicidal intent. identification of previously unknown severe eatingdisordered behaviors) would be shared with the parents.. Simultaneously. Therefore. 29% of high-school-age males and females report fasting for at least 24 hours or longer in the most recent month. and traits deviated from normality. While one way of resolving this issue might have been to have separate therapists provide the individual therapy versus the family therapy. Thus. The impact of starvation on behavior and cognitive process was illustrated by discussing the fi ndings of the Keys (1950) study cited earlier. therefore empathy and direct questioning were used.to 8-year-olds desire to be thinner because they believe it will make them more popular (Dohnt & Tiggemann. that is. assessment results were reviewed carefully with her. she needed to feel safe in disclosing her thoughts and feelings in individual therapy. g. Emphasis was on increasing Amelia’s recognition of her strengths and weaknesses and how the composite of these characteristics lead to their uniqueness. therapy focused on ways to build Amelia’s global self-esteem by identifying and modifying cognitive distortions regarding thinness. Initially. 1999). Therapy guided her in the modification of a definition of self from one that was based on external factors (e. Amelia was also taught to explore the advantages and disadvantages of eatingdisordered behaviors and beliefs that one must be thin. issues related to body image were thoroughly covered and specific ideas were imparted about how she could address body image concerns. Self-therapy sessions and journaling were encouraged. like many individuals with anorexia nervosa. worth. regardless of accomplishments or physical traits. Amelia wore a bathing suit to the beach). In Amelia’s case. and Amelia was taught to identify cognitive errors related to body esteem.. 2002). yoga). achievements) to one that was based on her self-worth.. which encourage anorexic behavior as a lifestyle choice. grades. The focus of cognitive restructuring shifted at the end of therapy toward situations that precipitated body image concerns. Prior to the termination of therapy. therapy attempted to expand Amelia’s notion of self as more than an “anorexic” or a “body. which incorporated relaxation. shape. 2002). .g.g. Art of the Case In addition to the direct therapeutic approaches aimed at treating the eating disorder. Body image desensitization tasks were utilized. others’ expectations. scales. and acceptance. problem-solving about future potential problems was initiated. body image refers to our mental picture of the size. and mirror confrontation.. in order to ensure a successful long-term outcome for Amelia. Simply stated. imagery. Homework assignments were also developed that provoked problematic thoughts that could then be addressed (e. issues regarding body image were addressed. Amelia.” This was crucial to offset messages that Amelia had received from “pro-ana” web sites. Positive body enhancement alternatives were encouraged (e.386 Other Adult Disorders Relapse Prevention and Termination As Amelia’s general functioning and insight increased. and overall form of our bodies and body parts and the feelings that we derive from this picture (Cash & Purzinsky. As body image issues are generally pivotal to the development and maintenance of eating disorders (Cash & Strachan. horseback riding. Amelia was encouraged to participate in ALATEEN to enhance her ability to cope with her parent’s alcohol abuse. indicated that chatting on these web sites actually provided her with a social network (Morris. the therapist reviewed with Amelia critical events contributing to her feelings about her weight/body. Additionally. In fact. weight concerns. Stone. young age. Comparing Caucasians. there appears to be a correlation with being born into or identification with Caucasian middle. Gleaves. Gleaves. & Barzegarnazari. Green. Anorexia nervosa has an average lifetime prevalence of . Females between 15 and 19 years of age make up 40% of all cases (Gowers & Bryant-Waugh. 1998).to upper-class values (i. some data (Demarest & Allen. Furthermore. and health among African Americans. Caucasians. statistics suggest that the prevalence of obesity is higher among African American females than any other group in the United States. social desirability. 2000). 2011). Striegel-Moore. with 4 out of 5 African American women being classified as overweight or obese (Office of Minority Affairs. Hispanics were equal to or higher than Caucasians on all indices of body image. body size. Viesel. 2000). 2004). and Hispanics. 2000). African Americans reported the greatest body satisfaction and were least likely to overestimate their weight. Hirsch. When eating disorders do occur in African Americans. The disorder rarely occurs in underdeveloped nations (Gelder. weight. and socioeconomic status. Snow. Hispanics. Mayou. and health. Green. 2004).1% in men for in countries such as the United States (Treasure. 2000) suggest that African American women are not more body satisfied than Caucasians. Snow. controlling for age. leading to higher obesity rates and rates of binge-eating disorder equal to or greater than those seen in Caucasians (Cachelin.. believing that men wanted someone thinner.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 387 Cultural Factors The demographics in the case of Amelia are consistent with the literature on anorexia nervosa and cultural factors.3–1% in women and . There were also gender differences on global body image. Furthermore. across genders in college age individuals (Miller. Caucasian women had the greatest distortion. & Zucker. African American women have historically seemed immune to eating disorders such as bulimia nervosa and anorexia nervosa. . Claudino. & Corbett. and figure thought most attractive to the opposite sex. minority women who do have eating disorders tend to be similar to Caucasian patients in general and in their eating disorder pathology (Le Grange. younger participants (<25 years old) had the most distorted views of the preferences of the opposite sex. Unfortunately. Higher risk is associated with female gender. and African American men and women on their estimation of their current figure. and there were no racial differences among the women’s body satisfaction. acculturation to mainstream Caucasian values and standards. African American women had the most accurate view of what men found attractive. and periods of being overweight during puberty (Gowers & Bryant-Waugh. ideal figure. & Brownell. 2000).e. 2010). Hirsch. However. a fact often attributed to the more positive body image of African American women (Miller. these cultural attitudes in the African American population may have reduced the stigma associated with obesity. Striegel-Moore & Smolak. & Geddes 2005). & Corbett. In examining physical appearance. (2000). F. Retrieved from http://www. In R. G. 36. American Psychiatric Association. Body images. T.).. Understanding body images: Historical and contemporary perspectives. F. E. W. 368–371. Cognitive therapy of anorexia nervosa. & Brown. & Burt. R.. and treatment seeking in a community sample of Hispanic. H. Gullone. A. 247–253. Purzinsky (Eds. Black and White Women. as they impact an individual physically. text revision). C. Bewell. eating disorders. T. & Carter. M. and developmentally. Cash & T. the case of Amelia illustrates the challenges of treating patients with anorexia nervosa and underscores the need for more research on the disorder. C. San Antonio. 24. Cash. 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Agras. relapse. Given the severity of complications and problematic outcomes associated with adolescent AN. & Lohr. Le Grange. A number of studies have revealed that FBT led to weight restoration and remission from AN in a substantial number of adolescent participants (Fairburn. treatment of adolescents with AN has additional challenges associated with the ethics of confidentiality. 2005). Bryson. Mitchell. 2001. 2005. Lock et al. & Nielsen. Agras & Dare. medical complications. treatment refusal. Lock & Le Grange. 2005. As described by Dr. anorexia nervosa (AN) (and especially AN accompanied by bulimic symptoms) is particularly difficult to treat effectively. Lock. 2010). & Vitousek. 2005). 2002. and small sample sizes (Bulik.. National Institute for Health and Clinical Excellence [NICE]. 2010). In contrast to other types of family therapy that have been used for the treatment of adolescent AN. Le Grange & Lock. Fairburn. Fichter. Crow et al. patient autonomy. As Dr. Cubic’s case presentation eloquently highlights the numerous challenges of using evidence-based interventions in the treatment of eating disorders. Wilson. 2005. Wales. Crosby.. Sedway. 2007). 2010. and long-term outcome data indicate high levels of treatment nonresponse. Preliminary data also support the use of this approach in adolescent BN (Le Grange. Berkman. Peterson Dr. Treasure. FBT empowers the parents to actively facilitate weight restoration by supervising increased food consumption and limiting energy expenditure (Lock. 2005. among the different types of eating disorders. family based therapy (FBT. 2011.COMMENTARY Carol B. Evidencebased treatment of AN is limited in scope and is based on a research literature characterized by inconsistent fi ndings. Quadfl ieg. & Leventhal. 2001. Attia. Treasure et al. Cubic emphasizes in her case description.. 2004. as well as more generally. modest outcomes.. Lock et al. methodological limitations. Rathouz. 2006. Steinhausen. 2005. Lock & Le Grange. . 2005. 2009. 2005) has provided a revolution of sorts in the eating disorders field as an approach to treating adolescents with AN. Brownley. and mortality (Arcelus. co-occurring psychiatric symptoms. Wilson. the patient’s co-occurring mood disorder (which may have been secondary to the effects of semi-starvation). 2007). Cooper. although the importance of dietary education for adolescents is emphasized in the National Institute for Health and Clinical Excellence (NICE) Guidelines (2004) and. 1991)—it can be exceedingly difficult to engage the patient. Dr. and because FBT typically consists of family sessions exclusively (Lock et al. Cubic describes. and her use of state-of-the-art assessment measures.394 Other Adult Disorders Based on the treatment outcome research for adolescent AN. including parental ambivalence about engaging in treatment. FBT was an ideal choice in this case because questionnaire assessment as well as interview data indicated that the patient was ambivalent about gaining weight and engaging in treatment. 2006. and both parents’ alcohol abuse. 2001). In such cases—which. 2007). & O’Connor. can be helpful clinically in allowing the psychotherapist to focus on other aspects of recovery. including her emphasis on developing and maintaining therapeutic rapport. Grilo. It can also be difficult to form a collaborative goal of weight restoration when the symptoms are ego syntonic. as Dr. in all likelihood. Cubic emphasizes. Cubic’s case presentation is exemplary in a number of respects.. . 2005. several aspects of this case made it challenging to conduct FBT. Family involvement appeared to play a critical role in weight restoration and. In addition to using FBT. As Dr. However. Cubic’s use of adjunctive individual therapy was a clear departure from standard FBT procedures. self-report is characterized by denial or minimization. The cognitive behavioral focus of Dr. & Dare. as Dr. 1950). her clinical skills in collaborating effectively with both the individual and the family in facilitating a positive treatment outcome.. and several comparison trials suggest that FBT using separated individual and family sessions can be efficacious (Wilson.. Cubic emphasizes. was essential in creating and sustaining momentum for the patient to increase her food consumption as the primary mechanism for weight stabilization and psychological improvement from ameliorating symptoms of secondary starvation (Keys et al. In addition to its clear support within the empirical literature. Simic. Wilson et al. one study does suggest that separating individual from parent sessions may be advantageous in cases with high levels of family criticism and anxiety (Eisler. are quite common in AN (Couturier & Lock. For these reasons. albeit primarily based on adult samples (Wilson. Cubic’s individual sessions with individuals was consistent in some respects with the current evidence-based treatment literature for AN given that cognitive behavioral therapy (CBT) has modest support. & Heiser. 2008). An additional departure in this case was the adjunctive use of nutritional counseling. Dr. Vitousek. Dr. including the Eating Disorders Examination (Fairburn. & Vitousek. and patients state clearly that they believe that AN is beneficial. Daly. Cubic’s decision to utilize FBT in this case study is rooted soundly in the current literature. FBT is particularly well-suited for adolescent patients who are hesitant or unwilling to change their behavioral patterns at the beginning of treatment because the family can serve as the primary facilitator for weight restoration. The use of individual therapy in the context of FBT has been minimal in treatment outcome studies. Russell. .. CBT has more consistent empirical support for the treatment of other types of eating disorders. shape. a treatment based on the transdiagnostic theory of eating disorders (Fairburn. 2005. although the extent to which the elimination of these behaviors was a clinical focus (and strongly emphasized in CBT-E) is not clear.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 395 2007). Pike et al. For this reason.g. hobbies) and their relative value in influencing their self-evaluation. 1997). 2005.. Dr.g. The techniques used by Dr. Garner et al.” in which patients create a pie graph to depict aspects of themselves (e. the decision to utilize cognitive restructuring techniques in clinical settings often varies on a case-by-case basis. particularly the emphasis on expanding self-evaluation beyond body shape and weight. In addition. body shape). 2003).. this technique has been featured in other AN treatment manuals that have been used in randomized controlled trials (e. 2003). Promising data from Oxford also indicate that a revised version of CBT called CBT-Enhanced (CBT-E.. Cubic in this case report are consistent with those included in published CBT manuals for the treatment of AN (e. Wilson et al. Outcomes for CBT in AN (including patients with AN who binge eat and purge) have been more mixed. few dismantling studies have been conducted in the eating disorders treatment literature.g. 2010). Cooper. & Bauer. Halmi et al. 2008). weight. Addressing overevaluation of weight. Adolescents in particular may struggle with the “meta-cognition” required to use cognitive restructuring effectively (although they are often able to label maladaptive cognitions as “black or white thinking. Nonetheless. she did focus on reducing behavioral avoidance of body exposure. The extent to which CBT-E is potentially effective for the treatment of adolescent patients with AN is unclear. Cooper. which is an essential element of CBT-E. including bulimia nervosa and binge eating disorders. 2008). & Fairburn. McIntosh et al.. Walsh. 2008). Cubic. Wilson. 2005.. McIntosh et al. weight. As Dr... 2007). academic performance.. 2005. and the extent to which cognitive restructuring is necessary to facilitate recovery is unclear (Fairburn. in spite of a sound theoretical rationale for its use (Fairburn. one study of CBT for AN demonstrated that it was better than nutritional therapy in preventing relapse in adults who had been weight restored as inpatients (Pike. several approaches overlap with the recently published CBT-E manual (Fairburn. Cubic mentioned the frequent occurrence of body checking behaviors. & Shafran. Cubic’s work in this case. Individuals whose cognitive capacity is impaired due to the effects of semistarvation or limited insight may be unable or unwilling to use this technique. may be efficacious as an outpatient treatment for AN (Murphy. an understanding of mechanisms of effective treatment remains speculative. to increase the number and focus of other aspects of self-esteem (marginalized domains). As noted by Dr. Straebler. and control over eating (Fairburn. 2008).g. and control over eating with the use of the “self-esteem pie. 2003) and was emphasized in Dr. Vitousek. Fairburn. Cubic summarized.” even if they have difficulty revising . Although CBT-E does not directly emphasize cognitive restructuring. 2008). is a helpful component of CBT-E (Fairburn. and to explore the benefits of expanding self-definition and reducing the relative importance of shape. Cognitive strategies are then used to emphasize the risks of overvaluing one aspect of self-evaluation (e. The implementation of FBT included several notable deviations from the treatment manual administered in research trials. Preliminary data support several other relatively new approaches for the treatment of AN. Fitzpatrick et al. One possibility would have been adolescent-focused individual therapy (AFT. Cubic’s treatment was consistent with the NICE Guidelines (2004). another consideration. particularly family psychopathology. which are based on a comprehensive review of the treatment outcome literature and recommend starting with outpatient treatment and progressing to more intensive treatment.g. emotion-focused therapy (Wildes & Marcus. 2009).. 2006). Robin et al.. although FBT clearly has the strongest indication in this case. 2007). 2009.. emotions. and a more recent comparison study indicated that although rates of remission were higher at follow-up for FBT. 2010). Cubic’s rationale in incorporating CBT and collaborating with a dietitian to facilitate a positive outcome for this adolescent patient. However. however. including behavioral exposure therapy (Steinglass et al. However. and self-efficacy and utilizes separate family sessions along with individual sessions. In conclusion. One early study provided modest support for AFT (Robin et al. Given the patient’s low body weight. a psychotherapeutic approach that emphasizes autonomy. and even more limited support for treatment of adolescents with AN. 2005. who seemed to be able to utilize this technique successfully. 2011). Dr. Boutelle. Cubic’s case... & Crow. 1997) and a critical component of termination given the high relapse rates in AN (Fichter et al.. 1999).. Dr. and acceptance and commitment therapy (Berman. the skilled use of a variety . an effective emphasis on therapeutic rapport. only if necessary.396 Other Adult Disorders them). At present. had it been feasible. The more recently developed CBT-E has empirical support for use with adult eating disorder patients with bulimia nervosa and binge eating disorder but has more limited research evidence supporting its use with adults with AN. 2011). would have been starting with inpatient treatment. Wilson et al. The research literature suggests several alternative approaches that could have been used instead of FBT (and CBT). facilitating minimal guidance from current research in determining optimal treatment settings. supported Dr. minimal research has compared various types of treatment settings (Fairburn. 1999)... Cubic’s emphasis on relapse prevention skills in the fi nal phase of treatment is consistent with the vast majority of CBT manuals for eating disorders (e. several complicating factors. Garner et al. In addition. assertiveness. this case study illustrates the successful integration of two evidence-based approaches for the treatment of AN that currently have the most empirical support: FBT and CBT. Finally. particularly the use of individual psychotherapy and nutritional counseling as an adjunctive treatment to family sessions. cognitive restructuring appeared to be quite well suited for this patient. although because these treatments are being developed for adult populations the extent to which they will be effective with adolescents with AN is unclear. including hospitalization. In Dr. FBT and AFT are the primary evidence-based treatments for adolescent AN. The use of state-of-the-art assessment data. AFT yielded comparable outcome for body mass index and psychological symptoms (Lock et al. Fairburn. W. New York: Guilford. J. H. Mortality rates in patients with anorexia nervosa and other eating disorders. G. Fairburn.. S26–S30. I. Cognitive behavioral therapies for eating disorders. S. Halmi. W.. A. 212–216. 31–39. M. J. Wales. Boutelle. G. M.. J.. Swanson. S. 724–731. & Dare. J. E. Adolescent focused therapy for adolescent anorexia nervosa. 1342–1346. A. Le Grange. C. In D. Attia.. Russell... B. G. G. M. Peterson.. E. 61. J. K. J... J. unremitted patients with anorexia nervosa. (2009). A randomized controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: A five-year follow-up. J. Raymond. & Lohr. Eating Disorder Examination (edition 16. I. (1997). Vitousek. & Lock. Fairburn. (2007). N. pp. T. & Shafran. C. (2003). 509–529. K. Crow.. E. Z. & Lock.). A. Twelve-year course and outcome predictors of anorexia nervosa. G. A case series investigating acceptance and commitment therapy as a treatment for previously treated. K. 552–560. (2008). & Mitchell. C. & Nielsen. J. C. Cognitive behavioral therapy for anorexia nervosa. M. Garner & P. N.. European Eating Disorders Review. 17. Predictors of treatment acceptance and completion in anorexia . S. N. D... Fitzpatrick. 39.. 87–100. & Pike. Specker. In C. Mitchell. Couturier.. R. C. International Journal of Eating Disorders. Agras. 48. M. Fairburn. References Arcelus.0D). C.. K. Brownley. Journal of Contemporary Psychotherapy. (2011). K.. C. J. 68. New York: Wiley. E. 40.. Quadflieg. and a successful integration of individual and family collaboration further appeared to serve as critical components of the successful outcome. American Journal of Psychiatry. Behaviour Research and Therapy. 310–320. A. M. Wilson. & Kraemer.. (2006). Fichter. Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. (2005). Cooper.. Berkman.. (2009). 40. A. Increased mortality in bulimia nervosa and other eating disorders. M. R. 41. A. (2007). Simic. & Crow. S. Z. New York: Guilford. Bryson.. Archives of General Psychiatry. 91–144). G. & Hedlund. Journal of Child Psychology and Psychiatry... Crow. Berman. Mitchell. D. Eckert.. E. Denial and minimization in adolescents with anorexia nervosa.). Handbook of treatment for eating disorders (2nd ed. (2010). S. Fairburn (Ed.. Anorexia nervosa: Current status and future directions...Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 397 of evidence-based psychotherapeutic techniques. S. 426–434... Bulik.. 39. Anorexia nervosa treatment: A systematic review of randomized controlled trials.. (2005). 166. & O’Connor.. N. International Journal of Eating Disorders. Sedway.. Cooper. (2006). Evidence-based treatment of anorexia nervosa. C.. S... L. 37 (Suppl). 425–435. N. Cognitive behavioral therapies for eating disorders (pp. (2009). (2008). S. D. 265–308). K. Hostee. M. Annual Review of Medicine. International Journal of Eating Disorders. G. Garner. Moye. M. Eisler. J. C. D. F. International Journal of Eating Disorders. S. E. J. K. Garfi nkel (Eds. . & Taylor. International Journal of Eating Disorders.. D. bulimia nervosa and related eating disorders. D. C. S. 44. 44. 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Minneapolis: University of Minnesota Press. C. Journal of the American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry... W. Lock.... A. Keys... A. & Jo. Archives of General Psychiatry. (2010). Le Grange. Reconstructing the internal world of the eating-disordered individual: Overcoming denial and distortion in self-report. B.. 159. 37. (2005). The dearth of psychological treatment studies for anorexia nervosa. S. 1049–1056. C. Sysko. Rathouz. J... Three psychotherapies for anorexia: A randomized controlled trial. National Institute for Clinical Excellence (NICE. A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. T. B. Cooper. American Journal of Psychiatry. & Heiser... C. Bulik. L.398 Other Adult Disorders nervosa: Implications for future study designs.. 134–141. 10. Archives of General Psychiatry. New York: The Guilford Press. (2007). Jordan... 160. B.. J. & Zucker.. 741–747.. H. A. London: NICE. McIntosh. Gilroy.and long-term family therapy for adolescent anorexia nervosa. Cognitive behavioral therapy for eating disorders. & Bauer. Bryson. Mckenzie. A... & Joyce. A. J. W. Agras. W.. Mickelsen. S64–S67. L. Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. & Kraemer. (2001). . (1950). S.. American Journal of Psychiatry.. R. (2010). 1284–1293. A comparison of short. J.. V. International Journal of Eating Disorders. Psychiatric Clinics of North America. (2005). J. 647–666. 1482–1489. D. & Walsh. J.. N. (2011). 64.. R. W. B. Claudino. Straebler. 1025–1032. & Dare. J. Lock. Vitousek. Robin. Eating disorders: Core interventions in the treatment and management of anorexia nervosa. (2002). 2046–2049. R. Le Grange. C.. International Journal of Eating Disorders. 162. W. K. B. & Leventhal. Treasure. K.. D. Crosby. M.. J. 38. 37. Lock. & Le Grange. S. Walsh.. American Journal of Psychiatry.. International Journal of Eating Disorders. M. Treatment manual for anorexia nervosa: A family-based approach. (2003).. & Fairburn. W. S.. Steinglass. S. & Sikand. 33. A. (1999). (2005). E. (2007).Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 399 Wildes. T. 421–427. International Journal of Eating Disorders. J. & Vitousek. D. Wilson. American Psychologist. 199–216. Psychological treatment of eating disorders. G. 1. Psychological treatment of eating disorders. Development of emotion acceptance behavior therapy for anorexia nervosa: A case series. & Marcus. M. (2011). 439–466. Grilo. Annual Review of Clinical Psychology. T. Wilson. G. M.. 44. C.. M.. 62. . K. Therapeutic competence also requires sophisticated case conceptualization skills and education and training in various treatment modalities (e. and clinical expertise (Rector & Cassin. and developmental manifestations of these disorders (Garner & Keiper. Claudino. 2000). Dr. Addressing all psychological disorders requires therapeutic competence. & Vitousek. as recommended by Garner and . Dr.RESPONSE Barbara Cubic Provision of evidence-based assessment and treatment is based on synthesis of state-of-the-art research. 2006). the therapist can develop treatment plans that implement or adapt evidencebased approaches with each patient with an eating disorder as indicated. Lock & le Grange. the decision was also made because eating disorders are heterogeneous (APA. patient factors. To master the content needed. as well as accompanying comorbidities (Treasure. individual. Peterson points out that the treatment approach described integrated two evidence-based approaches for the treatment of anorexia nervosa (AN) with the most empirical support to date: family based therapy (FBT) (Lock. Given that Amelia showed elements of both anorexia and bulimia nervosa. 2009). particularly family issues. Peterson’s observation that the “implementation of FBT included several notable deviations from the treatment manual administered in research trials. 2005) and cognitive behavioral therapy (CBT) (Wilson. a therapist must understand information related to the complex physical. 2001. a shift toward expert competencies requires that a clinician train under clinical exemplars that provide care within interdisciplinary teams. Peterson correctly notes that this decision was made in part due to several complicating factors. le Grange. Agras & Dare. however. Therefore. 2005. Additionally. social. Grilo. group. & Zucker. and this choice by the clinician likely warrants further elaboration. 2010). but it can be easily argued that an advanced level of competence is particularly essential to appropriately treating eating disorders. Once therapeutic competence in the area of eating disorders is established. selection of an evidence-based approach that fit the individualized needs of the patient and addressed her restrictive as well as purgative behaviors was necessary. particularly the use of individual psychotherapy and nutritional counseling as an adjunctive treatment to family sessions” is accurate.g. mental. 2007). family) and the evidence-based approaches used. 2010) and nutritional implications of the disorders (American Psychiatric Association [APA]. Dr. Wilson. In the commentary on the case of Amelia. although several factors suggested that an inpatient approach might be useful in the case of Amelia. D. 375. (1997). 50–63). A. Because this approach was incrementally successful. S64–S67. 439–466. & Dare. M.. . Rector. a more intensive and costly intervention was not required. while the decision to utilize an outpatient approach was in part due to a lack of local specialized inpatient resources. M. 37. M. 1. (2010). Claudino. M. integration approach was chosen. Psychological treatment of eating disorders. 199–216.. in this case. Garner. & Zucker.. Family-based treatment of eating disorders. N. the decision was also in keeping with Garner and Needleman’s (1997) recommended stepped care approach.. which allowed Amelia to remain in her natural environment. T.. L.. Diagnostic and statistical manual of mental disorders (4th ed. rather. D. Lock. Treatment manual for anorexia nervosa: A family-based approach. Eating disorders.Family and Individual Cognitive Behavioral Therapy for Anorexia Nervosa 401 Keiper (2009) a decision tree. Hersen (Eds. family and individual treatment with support group involvement was also recommended). Anorexia and bulimia. Lancet. or costly intervention. Additionally.). (2005). American Psychiatric Association. In J. C.. J. References American Psychiatric Association. C. Handbook for the treatment of eating disorders (pp.. Thus. dangerous. 583–593. 153–161.. G. New York: Guilford Press. that is. S. Grilo. 62. fi xed rules were not used. Wilson. Garner & P. Stepped-care and decision tree models for the treatment of eating disorders.g. Washington. (2007). Agras. E. International Journal of Eating Disorders.).. even if starting at this level doesn’t have the highest probability of success. (2005). varying evidence-based rules were drawn up for treatment decision making.. E. W. New York: Guilford Press. one in which varying choice points to determine varying treatment pathways for patients are used and integration of modalities occurs (e. D. T. (2000). (2001). This approach recognizes that treatments for eating disorders should begin at the least intrusive. text revision). (2010). K. Thomas & M. Journal of Contemporary Psychotherapy. In D. Annual Review of Clinical Psychology. D. M. Psychological treatment of eating disorders. Wilson. Treasure. (2009). a less intensive approach was implemented. Washington. 40. Le Grange. American Psychologist.. Practice guidelines for eating disorders. Garfi nkel (Eds. S. DC: Author. 1429–1460). In other words. Clinical expertise in cognitive behavioral therapy: Defi nition and pathways to acquisition. D. Handbook of clinical psychology competencies (pp. J. & Le Grange. Garner. & Keiper. & Cassin. (2006). Lock. New York: Springer. & Vitousek. M. DC: Author. N.. A. C. & Needleman. C. J. G. non-extant relief. The following is a description of the intake and assessment procedures used by the biobehavioral therapist in Patient M’s case. who participated in an interdisciplinary treatment program that included eight sessions of biobehavioral treatment with a therapist trained in pain management techniques. a little of Patient M’s clinical history is relevant.{ 15 } Chronic Pain Robert Gatchel and Rob Haggard The following case involves Patient M. L5. Patient M strained the muscles in his lumbar/lower back region and damaged vertebral discs L4. He has a self-reported history of substance abuse (mostly THC/marijuana and alcohol). Previous treatment for his injuries included prescriptions for opiate pain relievers. as well as his reason for referral to this program. Key Principles and Core Knowledge A stepwise approach was used to arrive at a clinical conceptualization of the potential biopsychosocial problems that might be confronting Patient M in his . After 18 months of minimal. Consequently. he now experiences deep referred pain to his right sciatic nerve and radiating pain from his lower back into his shoulder and neck region. In bracing for the impact. he has been on disability leave from work while receiving workers’ compensation supplemental to his prior income. For at least the past two years. Patient M was injured when an inexperienced coworker accidentally dropped some crates of equipment off a front-loader in the warehouse. Before describing the interdisciplinary treatment regimen in detail. and recommendations for bed rest to avoid aggravating his injury. Patient M is a 34-year-old Caucasian divorced male who has supported himself and his family primarily as a warehouse manager for eight of the last ten years. Patient M was referred to this interdisciplinary program by his primary care physician as part of a rehabilitation plan to help restore M’s physical and behavioral functioning levels to the point that he might be able to return to work in a modified environment. eight sessions of physical therapy. and S1. a patient with chronic low back pain (CLBP). Because every patient is unique. as well as gate and posture. Additionally. a patient with CLBP resulting from a work-related injury). clinicians have a large battery of assessment tools and techniques they can choose from. it would be far too time-consuming to develop an individual strategy for each patient’s case. Also included in Patient M’s intake evaluation was a functional capacity evaluation (FCE) by the staff physical therapist. Instead. along with their seasoned judgment. lifting capacity. for particular patient types that are typical in their clinical setting. and space to perform the FCE. These are further used to support the diagnostic fi ndings and provide valuable information. along with the medical evaluation. & Minotti. This is highly desired in cases that involve disability if there are adequate personnel. In the case of Patient M (i. but to also rule out any comorbid factors that might impair the patient’s rehabilitation. Assessment is then based upon clinical judgment and experience for broad diagnoses. he would then have been referred out for a more . 2010). or person). The prognosis from his physical fi ndings was positive overall. place. the stepwise approach. and cardiovascular endurance. The FCE helps to quantify range of motion.e. along with fi ndings from prior clinical research that illuminate techniques for measuring more specific symptoms. it is highly desired to have a thorough medical examination conducted by a member of the interdisciplinary treatment team prior to involvement in clinical interviews with the biobehavioral clinician. this medical intake evaluation will evaluate range of motion. Patient M’s physical examination only confi rmed prior diagnostic fi ndings from his referring physician. If Patient M had produced symptoms indicative of cognitive impairment (disorientation to time. muscle strength and endurance. although Patient M found it disheartening that he would still require some at-work accommodations that included a modified work environment. areas of tenderness. with a tailored exercise and physical therapy treatment plan. an initial clinical interview was conducted that included a mini-mental status examination to rule out potential confusion or cognitive impairment. The purpose of this is not only for confi rmatory fi ndings regarding prior diagnoses. allows for the recognition that there is no single assessment or method for every patient case. The results of Patient M’s FCE helped to determine that much of his muscle strength and endurance had atrophied or diminished in the time since his injury but that. and neurological symptoms. Gatchel (2005) has previously recommended this strategy for its demonstrated time-efficiency and costeffectiveness for biopsychosocial assessments of patients. His feelings toward these recommendations would be addressed during treatment with the biobehavioral clinician. when used by trained clinicians. Assessment In addressing the full picture of a patient with chronic pain from the biopsychosocial perspective. equipment.. By training and experience. he could regain much of what had been lost.Chronic Pain 403 rehabilitation (Gatchel. Kishino. for the biobehavioral clinician to apply to his or her treatment agenda. fi nancial. Kerns. 2005. Turk. he also experienced some ideation regarding death but a resolve not to commit suicide. it was determined that he (along with his mother and some siblings) had a familial history of moderate unresolved depression. In order to make sound clinical judgments based upon empirical fi ndings. the Beck Depression Inventory-II (BDI-II). Because such symptoms were not present with Patient M. respectively. His reduced income and productivity were the source of interpersonal confl ict between him and his ex-wife. In the case of Patient M. Patient M had worked for the warehouse where he was injured for eight years. he and his wife of seven years separated. 1985). mostly regarding disputes of child support payments for their two sons (ages seven and five at the time). prior work history (including level of job satisfaction and number of job changes). assessment tools should have well-defi ned norms to allow for patient comparisons.. et al. and the Multidimensional Pain Inventory (MPI. While there are many comprehensive psychosocial evaluation tools available for use. it could then be determined. Referring back to the stepwise approach (Gatchel.404 Other Adult Disorders comprehensive neuropsychological examination. the ones with the most corresponding empirical data in pain populations thus far include the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Structured Clinical Interview for the Diagnostic and Statistical Manual (SCID-I & SCID-II). as these symptoms would take priority over his intake into the pain management program and would have interfered with the validity of the remaining intake measures as well. after a friend helped him get an interview to become the manager there. a visual analog scale (VAS). Patient M had a high school education and had maintained consistent employment following graduation from public school. He was receiving workers’ compensation payments at the time of his assessment and treatment in the pain management program. divorce/separation. or reduced physical functioning since the injury. his evaluation included the SF-36. or workers’ compensation issues related to the current injury that remain unresolved. Most of these depressive symptoms were comorbid to his reduced physical functioning and stressors related to losses of both income and productivity. High elevations on any of these measures would be deemed indicative of pathology and thereby would require additional. 2010) to biopsychosocial assessment. In his particular case. any head injury or traumatic brain injury history. Due to the nature of the clinical practice in the pain . and their divorce became fi nal within six months following his injury. testing of biopsychosocial indices. what further assessment tools to include in the intake evaluation for Patient M. & Rudy. Just one year prior to his injury. fi nancial history. more comprehensive. the more comprehensive portions of the clinical interview were directed at the following: personal and familial mental health history. demonstrated with the BDI-II and MPI. Patient M’s depressive symptoms and dysfunctional coping skills. based upon the clinical interview. life-change stressors such as loss of income. and any legal. required more comprehensive evaluation on the part of the therapist. the Pain and Disability Questionnaire (PDQ). Prior to this. Gatchel. Because Patient M’s case is one of CLBP. he had performed similar work at a competitor company for four years. and 3 [Hysteria]) typically respond well to treatment for musculoskeletal pain. & Gentry. 2006). The use of the MMPI-2 as a pre-treatment screening measure has become standard procedure in many pain treatment programs because multiple studies have reproduced the above fi ndings with these profi les (Bradley. McGill. with scale 2 [Depression] diminished by comparison) do not seem to benefit as much from treatment. 1995). a patient would have to produce a minimum of four elevations on the Clinical Scales of the MMPI-2. A key difference between these two diagnostic patterns is that individuals with NT profi les (elevations on Scales 1 [Hypochondriasis]. The fourth profi le mentioned above. on evidence that such patients typically lack a singular specific coping style with which to manage life stressors. often meeting criteria for the Diagnostic and Statistical Manual of Mental Disorders (4th edition. and thereby experience much severe emotional distress. who conducted research with both the SCID I and II. Selby. 2006). text revision. The sample was composed of patients with chronic occupational spinal pain disorders. it will often be decided to provide more cognitive behavioral therapy (CBT). Lawlis. Margolis. leaving them more resistant to traditional psychiatric and behavioral medicine approaches (Gatchel et al. & McCoy. Results from the MMPI-2 demonstrated four particular and distinct profi le patterns of interest. and results obtained with the MMPI-2 in the same sample. pain patients who respond with the CV profi le (elevations on Scales 1 [Hypochondriasis] and 3 [Hysteria]. In contrast to this. & Eddington. Some important items regarding a patient’s psychosocial profi le are brought to light with the results produced by the MMPI-2 that partially help to determine whether short-term or long-term biobehavioral therapy will produce positive results with regard to his or her rehabilitation.. had been previously described in the psychiatric literature as a “Floating Profi le” and is a significant indicator of psychological distress and turmoil. Prokop. based. Mayer. In order to be “flagged” for interdisciplinary staffi ng in this pain management practice. Gatchel and colleagues (Gatchel et al. .. 2 [Depression]. Mooney. Individuals who produce such profi les are often identified as having an Axis II personality disorder. 2006) have designated this as the “Disability Profi le” (DP) for the specific purpose of identifying patients who may have symptoms that would require more intensive interdisciplinary care. in part. While the majority of participants in this sample produced a normal profi le from their MMPI-2 responses (demonstrating no significant pathology). Prior research with pain populations had to this point identified the Neurotic Triad (NT) and Conversion V (CV) profi les as significant for preoccupation or focus on somatic or bodily concerns. 1983.. DSM-IV-TR) Cluster B category of borderline personality disorder. Some background on the empirical basis for using the MMPI-2 in this clinical setting includes prior research by Gatchel and colleagues (Gatchel. Turk & Fernandez. the MMPI-2 was administered in Patient M’s case.Chronic Pain 405 management program. 2006). there were three additional profi les that indicated a potential role of psychopathology in such chronic pain patients. which was identified by Gatchel and colleagues (Gatchel et al. 1978. During staffi ng. the issue was “flagged” in his file for further probing during his one-on-one biobehavioral sessions with the trained clinician. key questions were addressed prior to beginning treatment. Epidemiological Considerations The fi ndings pertaining to Patient M’s depressive symptoms. The answer to this. particularly for alcohol. physical therapist. The results of his MMPI-2 further supported the prior findings. et al. The elevated Depression. while patients with a normal profi le were significantly more likely to retain work one year after treatment than the other three code types. Additional concerns were his self-reported history of substance abuse. stepwise approach to assessment of Patient M’s history and symptoms. but also indicated that Patient M would respond well to biobehavioral interventions that include CBT and biofeedback. Findings also showed that. and biobehavioral clinician to each share their conceptualization of the patient. Instead. was yes. pain patients with the DP code type were exponentially more likely than those with a normal profi le to have at least one Axis I diagnosis. there was also a preponderance of Axis II personality disorder symptoms based upon clinical interview and MMPI-2 results (Gatchel. Gatchel and colleagues have demonstrated that more than one-half of chronic occupational or chronic heterogeneous pain disorder patients were identified as having the Disability Profi le/MMPI-2 response pattern (Gatchel et al. flagged him for further evaluation with the MMPI-2. and to then arrive at a unified set of goals for his treatment formulation. Patient M’s case was staffed at the weekly interdisciplinary team meetings. Initial Case Formulation Through a comprehensive.. 2006).406 Other Adult Disorders In two studies sampled from two very different socioeconomic stratifications. More than two-thirds of patients from both chronic pain populations produced the DP code type.. from his initial assessment with the biobehavioral clinician. the biobehavioral clinician contacted him via telephone and discussed further specifics of what treatment would entail. 2006). Hypochondriasis. Chief among these was the question of whether Patient M would truly benefit from the interdisciplinary treatment modality (and biobehavioral therapy in particular). based on the evaluation findings. but this was not something that the treatment team felt would necessarily preclude Patient M from participating in treatment. After the group decision was made to accept Patient M into interdisciplinary treatment. Among patients with a DP code type. and Hysteria scales were indicative of somatic concerns with Patient M. which allowed the physician. The administrator for the practice then prepared all of Patient M’s appointments in advance and coordinated . as well as supportive of a positive outcome from interventions for musculoskeletal pain. as he had produced a Neurotic Triad on the MMPI-2. . Session 6: The therapist introduced. This session also introduced the patient to the gateway theory of pain and how emotions and coping techniques may contribute to either pain symptoms or pain relief. His homework in this session was also aimed at identifying and correcting more of these types of thoughts. In general. Biofeedback was reinstituted one last time during this session and included the introduction of a third guided progressive muscle relaxation focusing on simultaneously relaxing one group of muscles while relaxing another. . these sessions consisted of the following (Gatchel. Session 2: The therapist continued to focus training on relaxation skills and introduced the concept of biofeedback by taking baseline readings of thoracic-muscle tension with electromyography. along with Patient M practicing with the read-outs. Gatchel et al. which then moved into a review of the patient’s progress thus far. progressive muscle relaxation training. 2003. within the same two-hour block. Biofeedback was put aside during this session to focus more on the complex process of identifying and disputing automatic thoughts that might be deterring Patient M’s progress in rehabilitation. while rehearsal and planning of relaxation skills for both anticipated and unexpected stressors was discussed with the patient. was also provided in this session. Peterson. Specifically. Session 5: Distraction methods for coping with painful symptoms and stimuli were introduced. McGeary. and included a guided progressive muscle relaxation session focusing on passive relaxation. & Moore. and peripheral temperature at a digital extremity. central to relaxation training.Chronic Pain 407 biobehavioral and physical therapy appointments to occur on the same day. and biofeedback within a CBT framework. along with the self-rewarding concept of scheduling pleasant activities in order to reduce stress.. 2010): • • • • • • • Session 1: The patient was introduced to the overall structure of the program and how the different components and team members interacted with one another. the concept of disputing “thinking errors” or automatic thoughts with nonproductive feelings or behaviors associated with them. This session also included a guided progressive muscle relaxation session with a tensing-relaxing modality. An introduction to diaphragmatic breathing. Whitfi ll et al. Session 3: This session continued training with biofeedback. 2009. Session 4: Biofeedback training continued. his eight biobehavioral treatment sessions would include training in self-regulatory coping skills. The patient was also prepared for his termination session coming up at the end of the week. Biofeedback and progressive muscle relaxation training with the patient’s preferred modality (tense-release or passive) was also included in this session. diaphragmatic breathing via strain gauge. and practiced with Patient M. Session 7: A review of Patient M’s homework regarding “thinking errors” opened this session. 1987). Further reasons for applying the BPS model and interdisciplinary treatment strategy are described below. Due to the nature of the pain management clinic in which Patient M was being treated and. and self-reward systems). 2001). based upon previous research fi ndings (Gatchel. behavioral health. based on the BPS model.. Because of the degree of challenges presented by treating chronic patients (even within the empirically sound interdisciplinary model). pacing. these comprehensive assessments are useful in predicting treatment success and for normative comparisons. combined with the pacing skills and cognitive coping skills from CBT. including medicine. as described in some detail earlier. Turk & Monarch. The treatment strategy. necessarily calls for an interdisciplinary treatment approach. his chronic pain condition. Development of an Intervention Model The intervention with an interdisciplinary treatment program that includes a CBT component is standard practice in this pain management program. The biopsychosocial (BPS) model of chronic pain serves as the framework for such interdisciplinary care. Planning for future stressors and coping with pain relapse were also emphasized before this fi nal session concluded. even more specifically. Also. would help him to achieve a more reasonable degree of rehabilitation. 2005). the pragmatic applications of these comprehensive BPS assessments help . composed of providers from multiple clinical and medical disciplines who will collaboratively treat cases from their respective areas of expertise. Furthermore. nursing. it became standard practice and was applicable to the case of Patient M and others like him because of the abundance of empirical. 2003. 2005. physical therapy. homework was assigned that included self-talk/ thought logs to be returned at the beginning of each session. and the BPS model is now recognized as the most comprehensive and heuristic approach to the evaluation and management of chronic pain conditions (Gatchel. with an emphasis on continuing to practice those skills in order to maintain his gains. and other arenas. Within the treatment sessions. so that maladaptive thoughts regarding pain could be addressed. Gatchel et al. Also included were additional strategies aimed at improving Patient M’s self-efficacy through the development of multiple skills that improve pain coping (including distraction. evidence-based support for interdisciplinary treatment of musculoskeletal pain. However.. 2002. In addition to this. Turk & Rudy. a comprehensive stepwise assessment approach (as described earlier) is recommended for use in such settings in order to determine whether a patient is an optimal candidate for the services offered (Miller et al. his concurrent physical therapy included an emphasis on flexibility and core strengthening that. no alternative treatment modalities were considered as necessary options at this point in time.408 • Other Adult Disorders Session 8: This session primarily reviewed all the new coping skills and progress that Patient M had made by this point. Chronic Pain 409 to uniquely tailor treatment goals based upon evaluative findings. Compensation received for injuries (e. with regard to secondary gain issues. traditional biomedical reductionist model. and (c) in their responses to the same treatment. family. Patient M was forced to deal with his financial compensation by his employer’s workers’ compensation insurance. and personal injury litigation) is an important domain addressed by the BPS model. & Gatchel. personality disorders. This latter point is of great import. Lou. This dynamic approach has the potential to far surpass the outdated. Polatin. as these individuals are at higher risk for being denied treatment either by their insurance carrier or by traditional treatment facilities because mental health issues are often “carved out” from medical treatment (Dersh. like many other chronic pain patients. By their very nature. Nonspecifics in This Case As mentioned previously. the comprehensive assessment and treatment approach of an effective interdisciplinary program is designed to address physiological and psychosocial issues from a holistic. short. Further. negative consequences that were not all within his realm to control. allencompassing design that addresses not only the individual patient’s needs.and long-term disability. & Kishino. More about some of the concerns he experienced regarding his rehabilitation and workers’ compensation follows later in this discussion. including return-to-work. including friends. workers’ compensation. research has borne out that objective outcomes. future health care . Of particular interest is the identification of chronic pain patients who present with personality disorders.. the BPS model allows for more individual patient considerations. with the resultant fear of potentially losing that based upon his performance in the interdisciplinary treatment program. found that his chronic pain-related disability affected his life with many adverse. Because of the interactive and synergistic dynamic of these multiple domains. psychosocial. 2006) have demonstrated that individuals differ quite significantly in at least the following three areas: (a) frequency with which they report physical symptoms. such as Patient M’s case of unresolved CLBP resultant from a work-related injury. many times the very nature of a patient’s treatment outcome has little to do with his or her objective physical conditions. and drug use. and sometimes even related legal variables that patients with chronic pain conditions encounter. The emphasis of the biopsychosocial model is a focus on the complex interactions among biological. which breaks down medical diagnoses into separate and distinct physical and psychosocial components. and so on.g. these interactions may perpetuate and exacerbate a chronic pain syndrome. Factors illuminated by these methods include psychosocial variables for clinical syndromes. For persons receiving compensation for a work-related injury (or even personal injury compensation). coworkers. as Gatchel and colleagues (Gatchel. Patient M. 2002). Because of these idiopathic differences. Thus. but those of his or her social support network. (b) their tendency to visit physicians when experiencing identical symptoms. Clinicians must make themselves aware of the relationships among these constructs during their clinical interviews and intake evaluations with chronic pain patients. pursue fi nancial compensation (perhaps through personal litigation or workers’ compensation claims). Much of this complexity revolves around the evidence that. can be even further complicated when there are simultaneous interactions among the constructs of pain and the related constructs of disability and impairment. patients receiving compensation for injury at some point. Polatin. Already noted earlier are the often dynamic interactions among the biopsychosocial components of pain.g. impairment.. during Patient M’s fi rst week in the interdisciplinary treatment program. While these three constructs do not typically display high concurrence with one another. Gatchel. This disconnect among these three domains in the evaluation of CLBP was noted in a report by Waddell that demonstrated correlations among the three constructs. if not all. it is vital to have an awareness of the differences among the three in order to fully understand the complexities associated with addressing them (Gatchel. are substantially lower when compared to rates from the general population for similar injuries. Gatchel et al. 2010). With these concerns raised. for instance).. but no significant overlap among them (Gatchel et al. This appointment occurred during his second week of treatment. there is a high degree of discrepancy among levels of chronic pain. It is because of these individual differences that the interdisciplinary team meets to staff all of the patients who are deemed appropriate for interdisciplinary care. While these conceptual domains are related to one another. these are issues that face most.. When considering the concept of secondary gain. and disability. he expressed anxiety regarding the potential loss of his fi nancial package and this. like Patient M. Secondary gain is broadly described as a set of behaviors (conscious or unconscious) that include an individual’s attempt to avoid activities (work. An example of this occurred with Patient M’s medical . it is important to understand what secondary gain actually entails. the relationships among them are not direct. However. The following information further emphasizes the important relationship between secondary gain and compensation injuries. 2005. 2004). or attempt to receive non-fi nancial means of support that would not otherwise be afforded to him or her (Dersh. quite often. regardless of the severity of injury or treatment (e.. 2010). affected his motivation during both physical and biobehavioral components of treatment. Misunderstanding these domains may result in improper treatment goals and outcomes for chronic pain patients. 2001). & Gatchel. as in the case of Patient M. a separate appointment was arranged with a consultant to the team who specialized in workers’ compensation and return-to-work accommodations. There is a wide range of differences from one patient to the next with regard to these domains (Turk & Melzack. Gatchel et al. in turn. it may also occur to the reader that the treatment of chronic pain patients. Initially.410 Other Adult Disorders utilization. Leeman. 2010). Patient response to treatment may often be closely tied to fi nancial secondary gain when compensation for illness or injury comes into play. When these issues were specifically addressed by the biobehavioral clinician. and recurrent injury rates. 2005. and it seemed to help ease some of his concerns. or more than two cancellations with 24 hours notice would cause his treatment with the pain management program to terminate. Further issues did subsequently arise with Patient M during treatment. His disability rating. based on his performance during the functional capacity evaluation. fell somewhere between his selfreported pain levels and his medical results. it is important to understand that these are not issues unique to Patient M or this pain management practice in particular. there are often more complex issues at play. Prior to his fi rst appointment and. All of these issues were confronted directly with Patient M during his biobehavioral treatment sessions. during his acceptance into the program. they also tend to self-report and display more emotional lability. it is important to note that. many patients receiving (or looking to receive) some form of compensation do report significantly higher symptoms across self-report measures of these indices than do patients without the secondary incentive (Gatchel et al. he was verbally informed about the missed appointments policy of the program. Many clinicians who are naïve to the processes involved in the biopsychosocial model— and. specifically that more than one cancellation with less than 24 hours notice. indeed. and disability can be complex when secondary gain issues are at play. Patient M’s progress might have been impaired or sabotaged by his secondary gain issues. All of these self-report measures . a single no-show appointment. most providers trained from the standard biomedical approach are naïve to these concepts—might perceive these discrepancies as evidence of malingering. stating his understanding of these terms should he be accepted into the program. However. which demonstrated very little objective physiological impairment. but he self-reported high levels of pain during his biobehavioral assessment and functional capacity evaluation. Further. these criteria were reiterated by the program administrator during her portion of the patient debriefi ng and appointment scheduling. and these were in regard to his cognitive distortions concerning his levels of impairment and disability. when compared with similar patients with no such secondary gain issues. worries over early termination of his workers’ compensation benefits. and some additional behaviors that initially indicated a lack of commitment on his part to actively participate in treatment. impairment. a non-contractual “Patient Agreement” was included in Patient M’s intake paperwork that he was required to read and sign. as in the case of Patient M.Chronic Pain 411 evaluation. 2010).. If these issues had not been sufficiently addressed during biobehavioral treatment sessions (and at the intake and mid-treatment team staffi ngs). Strategies for Dealing with Problems in Therapy All of the discrepancies seen in Patient M’s results relate back to the aforementioned issue of secondary gain in the context of compensation injuries. as witnessed in reports of increased anxiety and depression. Finally. Though arriving at an accurate conceptualization of levels of pain. In addition to this. Before detailing Patient M’s treatment complications further. However. along with a frank discussion among Patient M. These functional fi ndings provided a rich source of feedback during biobehavioral counseling sessions with his clinician. When they come to understand that the financial trade-off is significantly less than what they are giving up to maintain their level of function. after all. like many others in his situation. Patient M. and a workers’ compensation consultant. Therefore. a consultant was available for those concerned about returnto-work and workers’ compensation issues. but his functional measures assessed during physical therapy did improve. in understanding. needed to be educated about the realities related to his particular secondary gain. Patient M’s self-report measures did not immediately improve dramatically during initial treatment. were employed to address some potential secondary gain issues that might have been “holding him back. in this case his workers’ compensation benefits. it appeared that Patient M was producing some resistance to participating in treatment.” Trust and rapport had already been established with Patient M and members of the interdisciplinary team. or simply fi nd a professional already trained to understand and explain these details to patients. It is therefore extremely beneficial to either educate oneself as a clinician in this arena. A reexamination of his clinical evaluations. As is typical with many chronic pain patients. the focus of treatment was being met and. then many times they are more motivated to participate in treatment. his biobehavioral clinician. the emphasis on rehabilitation is not complete or immediate alleviation of symptoms. 2010). in these situations. was helpful in preparing for his course of treatment. The one-on-one meeting that Patient M had with this consultant helped to alleviate many of his misunderstandings.. along with a better understanding of his secondary gain issues. Many times. patients misunderstand what they are actually receiving (or as compensation) and continue to display disability or impairment. Functional improvement. helped to improve some of his selfreport scores.” Clinical awareness regarding the norms for pain patients who produce the MMPI-2 pattern witnessed in Patient M’s evaluation helped to determine that he had a preoccupation with his condition which. and this increased his motivation to participate in his own rehabilitation. For patients in this pain management program. Early on. Issues about which the workers’ compensation consultant informed Patient M included the possibility that he and other injured workers may be unable to regain employment in the job market as potential new employers view them as a “pariah. it was somewhat less complicated to break down for him the very complex disability systems that he and other patients were not likely aware of (Gatchel. et al.412 Other Adult Disorders were somewhat more elevated for Patient M than his physiological measures indicated were likely. Ethical Considerations One of the early ethical considerations or concerns the treatment team encountered was whether or not to continue or renew prescriptions for some of Patient . The Pain Medication Questionnaire (PMQ. The “Art” of This Case One might feel that it takes a degree of “art. would likely have raised more concern. Part of the informed decision to treat Patient M is solidly based on the science of the measure used to determine his likelihood to misuse prescription medications. but his score was in the lower range. though he still had some resonating guilt associated with that use. psychopathology and physical/life functioning. The PMQ is also a relatively brief. Some of these characteristics include a history of substance abuse problems. 26-item self-report instrument requiring only a third-grade reading level. Gatchel. these alone were not alarming enough to prevent his entry into the interdisciplinary treatment program. Patient M had not smoked marijuana since he was in his early twenties. These concerns were addressed with an additional measure. . was considered moderate (no more than 3–4 drinks. Using the PMQ can help physicians to decide whether prescribing pain medications for a particular patient is sound in a variety of ways. 2010). as well as those specific for known opioid abuse). thereby sabotaging his own treatment success. to adequately assess whether a CLBP like Patient M has the potential to misuse his pain medications. with its use instituted in cases where analgesic misuse is suspected within this setting. While Patient M selfdisclosed a history of alcohol abuse and THC/marijuana use. Furthermore. higher incidence of requests for early prescription refi lls. and with good internal consistency: Cronbach’s α of 0. The PMQ has also demonstrated good validity (when compared with other measures of substance abuse/use. on no more than 2–3 days a week). During its initial design.Chronic Pain 413 M’s opiate medication for pain analgesia during the time that he participated in the program. (Adams et al. 2010) is designed for use in a chronic population to assess potential misuse or abuse of prescription pain medications. and the decision to not only treat him in the pain management program. Upon further probing. was based upon the objective fi ndings with the PMQ. based upon his conservative upbringing. The PMQ. A high score on the PMQ. One of the advantages of administering the PMQ is that it has well-demonstrated reliability and validity (Gatchel.” or in this case informed experience. Holmes and colleagues identified further characteristics associated with patients who obtain high PMQ scores.86. 2010). The PMQ has demonstrated significant reliability when studied (with a test–retest reliability coefficient of 0. Adams and colleagues (2004) demonstrated a positive relationship between higher PMQ scores and other concurrent measures of substance abuse. but also to renew his opiate prescriptions. making it easy to administer and to use in various clinical settings (Gatchel. and a treatment dropout rate more than twice that of low-scoring patients. More specific to this was the concern that he might be at risk for potentially abusing or misusing his prescription pain killers..73). and he did not appear to self-medicate his pain symptoms with alcohol. in addition to these items. his alcohol consumption. though higher than recommended. 2004. These types of flags or alerts might be used in determining that a patient will require more drug screenings during the course of treatment.414 Other Adult Disorders when included in a patient’s chart. Without paying attention to the individual details of a case. was able to be closely monitored by all . 2010). Patient M. It is in fact true that many patients who abuse or misuse pain medications are likely to have comorbid psychosocial conditions. High scores on the PMQ may also alert physicians not to provide early refi lls of medications. These may also need to be considered in treatment. Screening “flags” for potential medication misuse might be based on scores from the PMQ. if called for. including Axis II personality disorders. particularly for patients with chronic and persistent pain. resulting in overuse and underuse in different circumstances (Gatchel. Cultural Factors Unfortunately. one runs the risk of undertreating some patients. basing decisions on empirical evidence and individual circumstances allowed Patient M to receive the appropriate amount of analgesic medication while also participating in a comprehensive interdisciplinary pain management program. Instead of having an all-patientencompassing policy of no refi lls or. nor to merely refi ll them over the phone. The biobehavioral clinicians can tailor their treatment plan to the specific needs of the patient and. refi lls for high-risk patients must be approved during an in-office visit so that the physician may once more evaluate any signs of misuse. Instruments like the PMQ help with documenting treatment. while atypical of some patients who are on long-term opioid treatment. refi lls-for-all policy. as with the case of Patient M. treatment providers have often participated in black-or-white strategies for their use. such as with determining whether to treat a pain patient with opioid analgesics. in addition to the original reason for referral—the pain condition itself. and Axis I depression and anxiety disorders. Common Mistakes to Avoid One of the common pitfalls that many pain management professionals tend to fall into (indeed. demonstrates due diligence in monitoring prescription use and potential abuse/misuse in the event of any potential Drug Enforcement Agency (DEA) audit (Gatchel. while overmedicating or supporting a newly developed addiction in others. Pain-reducing medications play a vital role in chronic pain management. because of the cultural and legal stigma associated opioid narcotics. may include education about the potential dangers of misuse and tolerance buildup. Documentation in the patient’s medical chart in case of a DEA audit must be consistent for these evaluations. Instead. conversely. 2010). Much of this needless fear can be alleviated by making certain to document the steps taken in order to minimize the risk of potential abuse/misuse of prescription analgesics. this potentially occurs in all professions) is to see all cases as monochromatic. and any issues that raised flags or questions were followed up with colleagues at team staffi ngs. he had been receiving workers’ compensation supplemental to his prior income. An additional treatment obstacle did threaten to compromise treatment success early on. and coping strategies that he had learned as part of his comprehensive care with the biobehavioral clinician. booster sessions with the biobehavioral clinician were set up at one-month. and physician care. Relapse Prevention and Termination It is important to note that a sound “exit strategy” needs to be in place in order to discontinue the use of pain medications when a patient is not attaining the appropriate goals of treatment. in fact. Patient M successfully completed the interdisciplinary treatment program. and was still using some of the pacing. Pain medication is only one tool in the toolbox of comprehensive interdisciplinary care. One of the initial concerns with Patient M was a self-reported history of substance abuse (mostly THC/marijuana and alcohol). but referrals for detoxification programs and drug rehabilitation specialists were on hand should colleagues from this arena be needed. at his prior place of employment. biobehavioral treatment progress. A stepwise approach was used to arrive at a clinical conceptualization of the potential biopsychosocial problems that might be confronting Patient M in his . Gatchel and Okifuji (2006) have identified interdisciplinary pain management to be the most treatment. Interdisciplinary pain management has proven to be effective for many chronic pain patients like Patient M and. Patient M was referred to this interdisciplinary program by his primary care physician as part of a rehabilitation plan to help restore M’s physical and behavioral functioning levels to the point that he might be able to return to work in a modified environment. In the nearly two years prior to treatment in the program. This did not turn out to be an issue for Patient M. however. the research supports this treatment strategy. A one-year follow-up. albeit with some accommodations. Patient M’s staffi ngs included discussions of his particular pharmacotherapy. physical therapy.Chronic Pain 415 members of the treatment team because of the documentation in his chart. relaxation. which concerned the treatment team with regard to refi lling his pain prescriptions. and six-month intervals following discharge. In summing up. three-month. His fear of losing this source of income prior to being fully rehabilitated was addressed through consultation with a specialist informed about workers’ compensation issues. Clinical administration of Pain Medication Questionnaire helped to determine that misuse was not truly a “flagging” concern for Patient M. comprehensive evaluation was pre-arranged so that the treatment team could determine whether their program worked in the case of Patient M.and cost-effective method of pain management. Indeed. meaning that documentation of all treatment modalities was also included in Patient M’s chart. In order to prevent relapse into some of the cognitive distortions encountered during his treatment. Patient M was working full-time. one year later. L.10. B. Bradley.. (2010). J. Robinson. T. Polatin. Chronic pain and psychopathology: Research fi ndings and theoretical considerations... J. Journal of Behavioral Medicine.. (1978).. Psychological Injury and Law. et al.. (1996). 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(2006). 31(25). 77–92. Stowell.. P. Psychological approaches to pain management: A practitioner’s handbook (2nd ed. Selby. Gatchel (Eds. Stowell. Sternbach.. & Okifuji. Turk. (1987).. Polatin. J. E. L.. A. M. Weiner’s pain management: A practical guide for clinicians (7th ed. 23.). J.. C. C. doi: http://dx.Chronic Pain 417 Gatchel. 345–356.. R. E. (2005). Waddell.08. Handbook of pain assessment (2nd ed. (2006). J. New York: Academic Press. Clinical Orthopedic Related Research. Biopsychosocial perspective on chronic pain. & Melzack. A. 779–793.. Journal of Behavioral Medicine. S. D.. Pain Practice. Boswell & D.). N. McGill.. 190–202. R. (1983). . Turk. 221. C. Spine. Pain. & Moore. C. New York: Guilford. Baylor University Medical Proceedings. most useful screen for psychopathology in chronic occupational spinal disorders. R. Miller.. B. Concepts of multidisciplinary pain management. & Rudy. Adams. V. Gatchel. P.. Treatment.doi. Pain Practice. B. Turk. 237–249.2006. D..). T. T. (1995). 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Gatchel presents the reader with an overview of the assessment and treatment procedures that he employed in addressing the pain symptoms of a patient who participated in an interdisciplinary pain rehabilitation program headed by Gatchel. 2005). and severity of functional limitations and lifestyle impairments that accompany injuries and injury-related pain. The author describes the stepwise approach as a cost-effective assessment strategy for determining the number and severity of problems the patient is experiencing and the order in which these problems should be addressed. Although the author directs the reader to published work in which the stepwise approach has been presented previously. A maximally effective stepped care approach to the management of pain and pain-related impairment falls logically out of a biopsychosocial assessment. and severity of injuries sustained as a consequence of the injury-causing event. The author indicates the use of a stepwise approach to determine the focus of assessment and to formulate an effective and workable strategy for intervening in the patient’s presenting problems and other personal and environmental factors that are likely to influence the patient’s participation in treatment and the level of benefit derived from it. & Lewandowski. readers of the current chapter.COMMENTARY Melanie Duckworth Using the biopsychosocial model of pain assessment and treatment. The contribution that a comprehensive and sound assessment approach makes to diagnostic accuracy and treatment efficacy cannot be overemphasized. type. (b) vary with respect to the number. and (c) require different types and levels of intervention to achieve the desired functional outcome (Duckworth. The following is a summary of my comments on the key dimensions of the chapter. This more detailed description might include mention of the clinical questions and responses (as well as the response sets on standardized assessment instruments) that are considered critical in moving from one step to another across the assessment process. type. This approach appreciates that patients who report pain (a) vary with respect to the number. 2008. . Turk. would benefit from a more fully explicated description of the stepwise assessment approach. Mayer. Spitzer. Spitzer. The author notes that this fourth MMPI-2 profi le.420 Other Adult Disorders The use of standardized assessment instruments allows the treatment provider to accomplish the following objectives: • • • • • efficiently gather information beyond that gathered in a standard clinical interview. Butcher. Given that the personality disorders are numbered among the most controversial. 2006). the author describes the identification of a fourth MMPI-2 profi le. evaluate long-standing. & Williams. he is uniquely positioned to provide the reader with an overview of those standardized instruments that are often used and/or best supported in the context of pain assessment and treatment.” is often obtained by individuals identified as having a personality disorder. Gibbon. First. This chapter is also considered to provide a unique opportunity to acquaint the reader with the author’s thoughts related to the clinical relevance and appropriate . Gibbon. functional impairment. the author’s emphasis on this MMPI-2 profi le as characteristic of patients who “typically lack a singular specific coping style with which to manage life stressors. This profi le served as a significant indicator of psychological distress and turmoil among pain patients (Gatchel. and least discriminating diagnoses within the Diagnostic and Statistical Manual of Mental Disorders (Grove & Tellegen. 1991). In discussing recent MMPI-2 research that addresses pain and pain-related outcomes. The reader would be advantaged by having the author weigh in on the combination of brief. & Eddington. overlearned coping strategies and styles that will serve either to enhance or to interfere with recovery efforts. leaving them more resistant to traditional psychiatric and behavioral medicine approaches” is particularly appreciated. and thereby experience much severe emotional distress. Williams. and disability. more fully examine the interplay among the immediate physical and psychosocial problems with which the patient is presenting. Tellegen. He highlights the Minnesota Multiphasic Personality Inventory-2 (MMPI-2. 1994) and describes recent research that he has undertaken with some of his research colleagues to establish and/or confi rm the relation of MMPI-2 profi les to pain and coping behaviors evidenced by pain patients. paincoping strategies and styles. First. Graham. Dahlstrom. & Kaemmer. and context-valid assessment instruments that might be used to document specific forms of emotional distress. 1989) and the Structured Clinical Interview for the Diagnostic and Statistical Manual (SCID-I & SCID-II. place the patient’s report of symptoms and functional impairments in the context of reports made by similarly injured patients. 1994. labeled by the researchers as the “Disability Profi le. least psychometrically sound. Given the extensive nature of the clinical research that the author has generated related to the assessment and treatment of pain. prioritize and evaluate the effectiveness of intervention efforts. The author appropriately emphasizes the use of standardized assessment instruments. & Lorna. reliable. In this manner. Ditto. It is important and often therapeutically beneficial to help patients understand that reducing pain is not the primary goal of pain treatment. including cognitive distortions related to levels of impairment and disability and missed appointments. & Feverstein. the author may wish to provide the reader with data that support the incremental effectiveness of biofeedback relative to other components of a multicomponent intervention and relative to other strategies for reducing muscle tension and/or stress. the behaviors identified and targeted by the described pain rehabilitation program are reasonable. Polatin. The author’s selection of intervention strategies is consistent with his databased approach to problem identification and problem evaluation and falls logically out of the stepwise assessment that he performed. 2010). & Mayer. Most appreciated was the author’s description of pain. Again. 2002). He generously provides the less practiced biobehavioral therapist with a detailed description of the content and structure of the eight-session treatment program in which the patient participated. affective-physiological. The nonspecifics addressed by the author relate to fi nancial compensation and the possibility of secondary gain behaviors occurring in the context of injury compensation. Given the emphasis placed on costeffectiveness and derived treatment benefit throughout the chapter. The author describes the patient’s experience of depression as a condition co-occurring with the patient’s injury-related pain problem. Through in-session and homework assignments. the author addressed potential therapy-interfering behaviors. the use of biofeedback in the context of pain and stress management is considered controversial by some pain researchers and treatment providers (Bush. and disability as overlapping constructs that are not always directly related. & Karst. the author characterized some of the patient’s “secondary gain” behaviors as suggesting the patient’s lack of understanding of the relation of pain to impairment and recovery of function. and fear of re-injury. Kapitza. The author also provides the reader with a clear and convincing example of the interplay between cognitive-behavioral strategies for improving pain coping and physical therapy efforts aimed at restoration of physical function. fear of movement. Gatchel. Pussie. For the current case. The author’s timely identification and direct management of patient concerns and behaviors that have the potential to significantly reduce motivation for treatment can be critical to the treatment benefit derived by this patient. Rather than conceiving of the patient’s reports of pain and fear of movement as designed solely to influence compensation. the problems experienced by the patient selected for presentation are consistent with fi ndings that suggest depression to be among the most commonly occurring psychiatric conditions experienced patients with chronic pain (Dersh. impairment. the program addresses those motivational-cognitive.Chronic Pain 421 assessment of constructs such as pain acceptance. The explicit use of a written patient agreement and . 1985. Bernatech. Although many of the pain rehabilitation treatment strategies described within the current chapter are empirically supported. and behavioral factors that are most predictive of a successful treatment outcome. Tellegen. J. R. C. . J.. Butcher. country of origin. ethnicity and/or race. Most impressive and training-relevant. 307–321. and sexual orientation. the patient will need to learn and engage in self-directed strategies maintaining and maximizing gains made over the course of participation in the pain rehabilitation program. References Bush. religion. Iezzi.” Although time-limited. In discussing the cultural and legal stigma associated with use of opioid narcotics. The author suggests that cultural and legal stigma associated with use of opioids may influence prescribing practices among some treatment providers. This approach to managing patient motivation to participate in pain treatment is forwarded by other pain researchers and clinicians. Ditto.. & Kaemmer. Minneapolis: University of Minnesota Press. D. N. Graham. M. & Feuerstein. A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain. 2008). B. Dahlstrom. Information related to the use of scheduled telephone (and/or electronic) contacts to evaluate and motivate the patient’s continued compliance with treatment recommendations would augment the reader’s understanding of treatment termination and relapse prevention in the context of pain management. the author might have described research that suggests that clinical judgments related to risk of pain medications misuse/abuse are at times influenced by other cultural factors in the patient and the treatment provider. 4. gender. even in the absence of pharmacotherapy. B.422 Other Adult Disorders the specification of the consequences of missed appointments would improve motivation for therapy across patient populations and intervention contexts. substance abuse might be conceptualized as a disabling factor. as well as other professionals working in the context of compensated and litigated injuries and pain (Duckworth. Tait and Chibnall (2005) provide a review of racial and ethnic disparities in both the evaluation and treatment of pain. W. & O’Donohue. The author correctly identifies the discontinuation of medication as a circumstance that warrants an “exit strategy. is the author’s direct approach to helping the patient understand the relation of willing and active participation in the rehabilitation program to the larger workers’ compensation context.. Within this literature. A.. (1989).. with persons from ethnically diverse backgrounds being more likely to have their reports of pain minimized by health care providers and more likely to receive undertreatment for pain as well as other medical conditions. Although there is no universally accepted listing of factors that might be included under the term cultural factors.. however. (1985). It can be presumed that. age. Health Psychology. the literature often references such variables as ability/disability. the eight-week pain rehabilitation program that the author describes provides a high degree of contact with and guidance from a host of primary and allied health care providers. MMPI-2 (Minnesota Multiphasic Personality-2): Manual for administration and scoring. Spitzer. Structured Clinical Interview for Axis I DSM-IV Disorders.). L. Motor vehicle collisions: Medical. M.. D. Gatchel. P. & Lorna. Iezzi. 595–601. M. (2002). M. Turk. B. The potential of treatment matching for subgroups of patients with chronic pain: Lumping versus splitting. T. Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II) (Version 2. R. M. K. L. O’Donohue (Eds. J.. and legal consequences. W. 35. T. 44. Duckworth. Gibbon.. New York: Academic Press/Elsevier. T. Journal of Personality Disorders. New York: New York State Psychiatric Institute. O’Donohue (Eds.. Clinical Journal of Pain. psychosocial. R. Duckworth. Iezzi. M. Problems in the classification of personality disorders.. M.. Motor vehicle collisions: Medical. T. Spitzer... T. Professional Psychology: Research and Practice. Williams. 31–41. First non-contingent respiratory biofeedback placebo versus contingent biofeedback in patients with chronic low back pain: A randomized double-blind trial. Applied Psychophysiology & Biofeedback. Kapitza. & Williams. Gibbon. W. P.). Duckworth. (1994).. &Mayer. & Karst. 5. (2005). T. Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability. T. B. M. B. and legal consequences.0). Iezzi.. 459–468. Grove.. W. Iezzi. 36. Tait. B. B. J.. (2008). J. P.. & W. J. G. (2010).. P. 44–55. C. Polatin. P. First.. & O’Donohue. Duckworth. M. In M.. R. First. Passie. R. P. . & Chibnall. T. Managing MVC-related sequelae in the primary care setting: Normalizing experiences of emotional distress. T. 21. New York: Academic Press/Elsevier. & W. M. In M. Journal of Occupational and Environmental Medicine. (2005). C.. W.Chronic Pain 423 Dersh.. Bernateck. New York: Biometrics Research Department. (1994). M. 207–217. psychosocial. (2008). & Tellegen. & Lewandowski. T. Introduction.. (1991). New York State Psychiatric Institute. Racial and ethnic disparities in the evaluation and treatment of pain: Psychological perspectives. A. This case study was specific to one particular patient’s case.RESPONSE Robert Gatchel and Rob Haggard While not clearly spelled out in the reference to the stepwise approach. and neurological symptoms. these interactions may exacerbate a chronic pain syndrome. this entire chapter actually describes the process of the stepwise approach to assessment and treatment of chronic pain populations. as well as gate and posture. In further defi ning these comorbid conditions. While the techniques used within this particular case are recommended.. drug dependence/opioid dependence would be screened for and treatment options explored based upon fi ndings. it is up to each clinician to use his or her own judgment in discerning which of these key modalities will be most effective in their therapeutic practice. 2010). Again. The emphasis of the biopsychosocial model is on the dynamic interactions among biological. including suicidal ideation. or other diagnostic criteria for a comorbid mood disorder that need to be addressed apart from the pain management program. The medical intake evaluation should also evaluate range of motion. It is only by addressing these within the context of an interdisciplinary program that these aspects of a patient’s care are fully explored and resolved. psychosocial. . but many of the critical points may be generalized to all patients in an interdisciplinary pain program. Some of these include a thorough medical evaluation for confi rmatory fi ndings regarding prior diagnoses and to rule out any comorbid factors that might impair the patient’s rehabilitation. anxiety. Intake questions for the behavioral medicine personnel to address include ascertaining whether there are any clinical symptoms of depression. areas of tenderness. and sometimes even related legal variables that chronic pain patients often experience (Gatchel et al. the last of which resulted in a fi nding of not guilty by reason of insanity.{ 16 } Pedophilia: A Case Study in Empirically Supported Treatment Jill D. and risk management of this client. highlighting what is known from the scientific literature and future directions which will aid in the clinical care of individuals with pedophilic diagnoses. He presents with no prior history of psychiatric hospitalization but several instances of court-ordered outpatient treatment resulting from prior sex . Background Information John Smith (note that a pseudonym has been used) is a Caucasian male in his late thirties who resides in an inpatient psychiatric treatment facility for individuals with criminal behaviors and co-occurring serious mental illness. We will also discuss the application of empirically supported practices and clinical science to the assessment. Stinson and Judith V. we will describe the clinical case of an adult male who meets diagnostic criteria for pedophilia and who has acted on his pedophilic interests on several known occasions. His commitment to this facility resulted from a series of sexual offenses against young male victims. urges. the terms child molester and pedophile are often confused and are used interchangeably within the psychiatric and scientific literature as well as the popular media. 2000) as a mental disorder involving recurrent and intense sexually arousing fantasies. Becker Pedophilia is defi ned in the Diagnostic and Statistical Manual of Mental Disorders (4th edition. we will address important historical and clinical characteristics of the case. treatment. which may be accompanied by acting on those urges or clinically significant distress or impairment for the affected individual. or behaviors involving prepubescent children. as well as treatment efforts and indicators of risk. While it is generally recognized that individuals may engage in sexual behaviors involving children without meeting criteria for pedophilia. American Psychiatric Association. text revision. In doing so. In this chapter. nonexclusive type.426 Other Adult Disorders offending behaviors. spanning his early childhood and adolescence. HISTORY OF SEXUAL OFFENDING John’s fi rst contact with the criminal justice system occurred at the age of 18. most notable of which is frequent sexual abuse by multiple perpetrators. John received minimal intervention during these periods to help him address sexual trauma and associated difficulties with depression and anxiety. He has indicated that he was fi rst sexually abused by a male neighbor at the age of two. He has been employed in a sheltered workshop setting during his current hospitalization. his poor progress in treatment. This male victim was the child of the female relative who had in fact molested John as a youth. John maintains minimal to no contact with any family members or supportive others in the community. when he was arrested for molesting a two-year-old male child from his neighborhood. In addition to pedophilia. Hospital records note that he has described significant experiences of emotional abuse and neglect by his mother and father throughout his childhood and adolescence. John endorsed significant mood-disordered symptoms as well as . CHILDHOOD EXPERIENCES John has reported a number of disruptive and aversive childhood experiences. He was again arrested several months before the end of his probation for molesting a six-yearold male relative whom he was babysitting at the time. He has also reported that several of his family members suffered from depression and bipolar disorder. and his legal status. John also carries a mood disorder diagnosis and some indications of personality psychopathology on Axis II of an antisocial and borderline nature. and he has reported poor relationships with his various stepfathers. sexually attracted to males. His mother remarried several times. as well as a male mentor during late childhood and early adolescence. Cognitive and achievement testing have also indicated borderline intellectual functioning and below average academic abilities. and that some relatives have been psychiatrically hospitalized due to suicide attempts or suicidal ideation. and then later abused by both male and female members of his family during childhood and early adolescence. His childhood was additionally disrupted by his parents’ early divorce and his frequent moves between his mother and father. The latter incident led to the arrest and conviction of the perpetrator. including his risk to others. He completed the ninth grade and received special education services throughout his academic career. At the time of his offense. He has a limited history of gainful employment and previously received disability income. He was convicted and given a probationary sentence. He has occasionally made efforts to establish contact with the female relative who perpetrated sexual abuse against him as a child. Little is known about his prenatal development or early childhood care. He has been residing in his current placement in excess of 15 years due to a number of factors. John also participated in sex offender group treatment utilizing a relapse prevention framework. Treatment records describe minimal progress and note the frequent occurrence of offense-related behaviors. John attempted to engage in a self-study treatment program for sexual offenders by purchasing a variety of self-help books . particularly those who are “youthful” or “childlike” in appearance and behavior. Upon his admission to the hospital following his second sexual offense. though John has described it as group therapy with an emphasis on relapse prevention. keeping victim memorabilia such as pictures or letters from family members describing the victim. It was determined that his mental illness prevented him from appreciating the nature and seriousness of this offense. and coercive sexual behaviors with vulnerable and lower functioning peers. both of which involved prepubescent male children. and has collected photographs of prepubescent and adolescent male youths while hospitalized. through continued contacts with former clients from his facility or through surreptitious Internet and e-mail access. including collecting pictures of children. questions have arisen regarding his openness in treatment and his willingness to conform his behaviors to the standards of his current environment. denial and resistance to treatment. all of whom are presumably of the age of consent. and who also appear to function at a lower cognitive and emotional level than he. Hospital reports further suggest that John has demonstrated problematic and sexualized interactions with male peers. He has reported sexual fantasies and urges involving prepubescent male children. and the development of a relapse prevention plan to aid him in identifying and avoiding potential risk. John has additionally made efforts to solicit intimate contact with males in the community. John was enrolled in relapse prevention treatment for approximately 10 years.Pedophilia: A Case Study in Empirically Supported Treatment 427 some symptoms of a psychotic nature. Treatment John has been involved in several different sex offender treatment programs since the onset of his sexual offending behaviors at the age of 18. and he was hospitalized for psychiatric care as not guilty by reason of insanity rather than being sentenced to a correctional institution. and overall failure to make adequate progress. describing the deviant assault cycle characteristic of John’s two sexual offenses. Following his own dissatisfaction with the treatment that he received and his perceptions of frequent setbacks. John has engaged in only two known sexual offenses in the community. With regard to his sexual offenses and diagnosis of pedophilia. Little is known regarding the modality of treatment. While these efforts have not involved explicitly inappropriate sexual contacts or materials. including his two victims. primary treatment goals included identifying risk factors and triggers for sex offending behavior. While engaged in this form of treatment. He first received treatment in a community outpatient setting but was terminated for non-compliance with treatment requirements. his appreciation of his own risk has also improved. 2008). avoiding potential triggers for sexual interest. he made moderate progress toward developing adaptive replacement skills. and that he would not be safe in a community setting. and attending 12-step programs available at the facility. Though he became increasingly frustrated with his progress using this particular form of treatment. He has stated that he needs sex offender treatment. to aid in self-management of negative mood states. characteristics of borderline personality disorder. He has been engaged in Safe Offender Strategies for approximately three years and was recently moved to a less restrictive treatment setting that also utilizes this treatment approach. controlling emotional lability. John attended DBT skills groups. and significantly reducing his problematic sexual behaviors. As part of the program as a whole. John has also participated in an inpatient program utilizing dialectical behavior therapy (DBT. His self-defi ned treatment goals in this project included reducing or eliminating his need for sexual contact with others. and boredom. Treatment documentation suggests that while John continued to struggle with remaining open in treatment. and problematic interpersonal relationships. and to encourage the use of adaptive skills to cope with everyday vulnerabilities and stressors. Though treatment providers have generally agreed that John has benefited from such an approach. Primary treatment goals identified by John for this new approach included monitoring his sexual thoughts and urges related to children. Stinson & Becker. utilized a different philosophical approach to treatment and emphasized the role of self-regulation in the development of maladaptive sexual behaviors (see Stinson. loneliness. John was then offered the opportunity to participate in a new form of sex offender treatment based on emerging etiological research and preliminary pilot testing. This treatment used an individualized approach to improve his motivation and commitment to treatment. Linehan. behavioral chain analysis groups. & Becker. and other relevant programming on a weekly basis. Safe Offender Strategies (Stinson & Becker.428 Other Adult Disorders on sexual addiction. as perceived by his treatment providers in the facility. as well as his understanding of important self-regulatory deficits that may have contributed to his sexual and other maladaptive behaviors. 2010. . he began using it as a justification for gradually withdrawing from the relapse prevention treatment offered to him by the facility. diary card groups. 1993). He again made minimal progress. some concerns have been expressed that his antisocial personality disorder traits at times interfere with his ability to form meaningful relationships with providers and limit his openness to the interventions offered. 2012). as well as by his own estimation. He was placed in this environment due to his history of mood instability. he completed assignments on his own to reduce his problematic sexual behaviors. Sales. Thus. primarily designed for substance abusers. For a period of approximately nine months. and developing healthy relationships with others. While engaged in ongoing sex offender treatment efforts. This treatment. managing his anger. The goals of the program are to reduce problematic and maladaptive behaviors. depression. . Harris. and that civil commitment as a sexually violent predator did not suit his current level of predicted risk. 2003. Nichols & Molinder. Hanson & Thornton. Cognitive and achievement testing utilizing the Wechsler Adult Intelligence Scale III (WAIS-III. Wilkinson. John underwent further examination of his risk. it additionally emphasized a need for treatment that could aid him in better understanding his emotional vulnerabilities and difficulties with managing his own urges and behaviors. immediately prior to his involvement with Safe Offender Strategies. 1993) were initially used to ensure John’s ability to comprehend and retain treatment-related information. 1997) and the Wide Range Achievement Test-3 (WRAT3. 2003). However. actuarial risk assessment instruments were used to aid in decision making regarding his amenability for placement in a less restrictive setting. 2000. This testing confi rmed John’s ambivalence regarding treatment and his reluctance to accept responsibility for many of his behaviors related to his offending in the community and his problematic sexual behaviors in the hospital. a number of assessment instruments were utilized to assist in treatment planning and risk management.g. The Multiphasic Sex Inventory II (MSI-II. 1996) was administered during the point at which John began to struggle most with treatment engagement and progress. John’s scores were consistent with those in the moderate range of risk for reoffending in a community setting. which could be accommodated within a number of structured but less restrictive treatment alternatives available in his area. Treatment interventions were thus tailored to fit his level of comprehension. Phenix. & Thornton. Finally. Hanson. On the Static-99R and Static-2002 (e. reading. As his criminal history and commitment status made him eligible for consideration for civil commitment under his state’s sexually violent predator statutes. John was ultimately hopeful that it would result in additional privileges and the possibility of eventual release into a community setting.. and abstraction abilities. Wechsler. after his most recent course of treatment with Safe Offender Strategies. He continues to receive dialectical behavior therapy programming on his treatment ward and Safe Offender Strategies for sex offender treatment. Current Status of the Case John was recently transferred to another psychiatric facility in a minimum security setting within the same state.Pedophilia: A Case Study in Empirically Supported Treatment 429 Assessment Given John’s ongoing difficulties with treatment engagement and progress. The results of this examination determined that he was likely to be best served in the least restrictive treatment environment available. Though he was somewhat ambivalent about this transition. John was able to make the transition into minimum security with the hope of achieving community placement at some point in the future. Thus. As was seen at his former treatment facility. 2002. Much of this literature. 2001. & Blak. which may suggest a need to consider multiple etiological factors for these offenders. he has been somewhat resistant to treatment. necessitating some additional treatment interventions in these areas. Though he has not engaged in any overtly problematic sexual behaviors. social skills deficits. Seto. Fazel.. 1998). The literature describing sexual offenders with an intellectual or developmental disability characterizes sexual offenses against children among this group as the result of opportunistic offending or impulse control deficits. Maletzky & Steinhauser.and personality-disordered presentation. Kuban. but also a history of serious mental illness. and his treatment goals have remained focused on monitoring and managing his sexual urges toward children and learning effective strategies for coping with mood and interpersonal difficulties. However. the scientific literature describing child sexual abusers often fails to differentiate those who commit these offenses due to sexual interests in children from those who commit such offenses for other reasons. 1997. In other words. the empirical literature describing sexual offenders with serious mental illness and/or intellectual and developmental disabilities is relatively sparse. Klassen. it is also recognized .g. intellectual impairments. Though a significant research literature exists describing the characteristics of men who have committed sexual offenses against children. Not only does he present with a diagnosis of pedophilia. much of this literature is not specific to those who would specifically meet diagnostic criteria for pedophilia. including psychiatric symptoms or impulse control deficits. Minister of Public Works and Government Services Canada. 2008. However. which is still a significant number upon which to base the research evidence. Comparatively. Langstrom. Sjostedt. Still. KEY PRINCIPLES AND CORE KNOWLEDGE The case of John Smith is a complex one.430 Other Adult Disorders His treatment providers have since expressed some concerns regarding John’s behavior. Brown & Stein. Dickey. however. Thus. 2007. his struggles with anger and mood instability have become more prominent. attributing this to difficulties with relating to his new treatment team and sex offender group facilitators. recent research estimates that approximately 40–50% of child sexual abusers likely meet diagnostic criteria for pedophilia (Blanchard. 2002. Grann. Sjostedt. Seto & Lalumiere. John continues to report that he is satisfied with his current treatment. 2001). relates to those offenders with prominent symptoms of a psychotic disorder rather than mood. sexual and other trauma during critical developmental periods. or lack of prior sexual education experiences rather than strong sexual interests in prepubescent victims (e. & Grann. and personality pathology that has hampered efforts to form healthy and meaningful relationships with others. Lindsay. Some research indicates that sexual offenders are more likely than other criminal offender populations to be psychiatrically hospitalized (Fazel. & Langstrom. several different literatures are relevant in discussing this case. 2010). ” subjecting them to increased perceptions of risk and poorer prognosis. this instrument has been recently demonstrated as an effective tool for corroborating paraphilic diagnoses. 2011.Pedophilia: A Case Study in Empirically Supported Treatment 431 within this literature that some such offenders do harbor pedophilic sexual interests (e. Individuals with intellectual. . Finally.g. retaining.. or other cognitive deficits may often be overlooked within the context of correctional. and Case Formulation Individuals with histories of sexual offending present with complex diagnostic and assessment needs. Stinson & Becker.. Hare.g. personality pathology. The use of the MSI-II. and potential sources of future risk. Intellectual and achievement testing provided estimates of relevant functioning so that treatment materials and discussions could be modified to his capabilities. as well as contributing to an understanding of the client’s risk.. As was noted above. Reyes et al. Another useful measure often applicable to those with a history of sexual offending and personality pathology is the Psychopathy Checklist-Revised (PCL-R. or other treatment systems. prominent problems with impulse control. we needed a better understanding of the nature of his cognitive and learning deficits. Stinson & Becker. Craig & Hutchinson.g. greater social skills and interpersonal deficits.. 2008). Key Questions. Given John’s additional history of psychiatric symptoms. and treatment resistance. Minister of Public Works and Government Services Canada. Though it was not used in this case. in order to most effectively assist John. developmental. especially when offenders have engaged in sexual offenses against children and may have pedophilic sexual interests (e. a more thorough assessment of his mood-disordered symptoms assisted in identifying barriers to treatment. 1998. developmental. and implementing treatment materials and strategies than their nondisabled counterparts. it is apparent that sexual offenders against children with serious mental illness and intellectual or developmental disabilities may have multiple etiologies underlying their sexual behavior.g. the PCL-R can additionally provide information regarding other problematic behaviors that may be a focus of treatment or that may in fact hinder treatment efforts. This can be very detrimental to their progress. Taylor. Wilcox. psychiatric or cognitive impairments that can interfere with their ability to benefit from standard sex offender treatment interventions. 2009). Vaughn.. Their difficulties in treatment may be falsely labeled as “resistance. 2003). Assessment Strategies. as they may have greater difficulties with understanding. Scheyett. & Parish. and a greater need for structured aftercare programming (e. helped treatment providers to defi ne the nature of his treatment resistance and minimization. other assessment strategies would be further recommended for his case. Sadly. In reviewing these literatures. the literature has noted the infrequency with which many agencies screen for intellectual. other treatment targets. 2004). 2006). psychiatric. 2005. or other cognitive impairments (e. for example. Further. 432 Other Adult Disorders In order to assess his risk. . few research studies have identified instruments that can more accurately assess sexual pathology and risk concerns for this group. As described above. and clinicians must look toward using an individualized approach that best fits the client’s needs. treatment providers used a combination of static actuarial risk instruments (i. a diagnosis of pedophilia characterizes a subsample of individuals with sexual offenses against children. the Static-99. On these instruments. while the literature notes that some forms of assessment have not been normed on seriously mentally ill or cognitively disabled sexual offenders. Static2002.. cognitive disorganization. as some of the static indicators suggested a higher degree of risk than those that were more dynamic and reflective of general characteristics of similar others in his current setting. In the case of John Smith. autistic features vs. the factors to be addressed in this case are not readily generalizable to other samples of individuals with similar behaviors and pedophilic diagnoses. Hanson. clinicians must often be somewhat creative in selecting the most appropriate instruments for individuals with prominent psychiatric symptoms or intellectual and developmental disabilities until such time as more research is available describing appropriate measures. John’s scores typically varied widely. as were seen in this case. active psychosis vs. Due to the wide-ranging continuum of such deficits (e. traumatic brain injury). though an even smaller number of these individuals additionally demonstrate serious mental illness and cognitive deficits. and treatment progress. 2003) and an “in-house” risk assessment tool developed by John’s facility to categorized and examine relevant dynamic indicators of risk. Given this.g. psychiatric symptoms. Epidemiological Considerations John’s case was particularly challenging. Evidence-based Case Formulation and Diagnostic Concerns We have already noted the complexity of the psychiatric and cognitive needs in this case. many of which are only briefly mentioned in the empirical literature with regard to individuals with a diagnosis of pedophilia. Harris. Thus. so this provided additional challenges in developing a standardized intervention approach informed by the literature. A combination of these instruments was used in order to “balance” these discrepancies.. including institutional aggression. 2000. Phenix. given the complexity of his psychiatric and behavioral presentation. moderate mental retardation vs. targeted delusions vs. psychotic disorders in remission.e. Importantly. there is no one approach that is best for assessing such clients. Hanson & Thornton. & Thornton. as it was recognized that the initial samples used to develop the norms of the static actuarial instruments did not include a significant number of individuals with psychiatric and cognitive characteristics comparable to John’s. and his history of institutionalization and hospitalization. and partly to the severity of his behaviors. as the . He lacked many early intervention resources that could have aided him in emotional and cognitive development. it is quite possible that prior experiences of sexual trauma can contribute to difficulties with maintaining appropriate sexual boundaries and forming normative adult relationships. and intellectual disability literatures are history of trauma. 2004. personality pathology. 2002. mental illness. he had made complaints regarding the treatment materials. Subsequent social and interpersonal deficits may have increased his struggles with engaging appropriately with a pro-social peer group. and interfere with the development of healthy boundaries and relationships. Lindsay. At that time. Thus. negatively impact social and interpersonal functioning. John expressed similar discontent with his treatment and treatment progress. Regarding this last point. frequent experiences of sexual abuse by multiple perpetrators are significant considerations in forming opinions about his case. including his relatively lengthy history of sexual interest in children. Other considerations highlighted within the sex offender. damage self-identify and self-esteem. Further. The empirical literature notes the high rates of prior experiences of trauma in seriously mentally ill and intellectually/developmentally disabled sex offender populations. particularly concerning sexual trauma (CoxLindenbaum & Watson. availability of resources. 2002. noting that they were sometimes difficult to read. John Smith’s family of origin was characterized by abuse and neglect. For John. McElroy et al. It is believed that trauma can precipitate or exacerbate predispositions to psychiatric symptoms. and his “sneakiness” or perceived efforts to engage in offense-supportive behaviors without the knowledge of his treatment providers. Of note is the fact that he had attributed part of his treatment “failure” while on probation in the community to an inability to complete homework assignments in a timely manner. it would seem that his cognitive impairments also interfered with his ability to simply understand and complete written assignments.Pedophilia: A Case Study in Empirically Supported Treatment 433 initial contacts with his treatment team several years ago revealed a significant degree of frustration with his treatment progress. and unique experiences that may affect willingness and ability to engage in treatment interventions. Kafka & Hennen... and these interpersonal struggles likely impacted his ability to relate to treatment providers during his hospitalization. particularly programming that heavily emphasizes verbal skills and abstract reasoning. which had resulted in his separation from his social support network and limitations in developing supportive and normative relationships with community members. His psychiatric symptoms may have further interfered with this. and that he required assistance with completing homework assignments. it was apparent that there were many factors contributing to his struggles with treatment. diagnosis of a serious and persistent mental illness. 1999). attributing this partly to the treatment providers and treatment team. In sum. Cognitive deficits may have impaired his ability to adequately and consistently participate in treatment programming. cognitive and educational limitations. his interpersonal style. Dunsieth et al. 2002. and he also experienced sexual trauma by perpetrators outside the home. and strategies to help the offender avoid risky behaviors in the future. Initial research regarding the effectiveness of a relapse prevention approach suggested positive changes in reducing sexual recidivism for those who had successfully completed treatment (Hanson. Also. Laws. or merely that he was unable to control his sexual urges and behaviors in a supervised environment. Treatment providers were similarly unhappy and frustrated with John’s progress in relapse prevention. Marlatt & Gordon. 1989). In fact. Marques.. He failed to understand how his pursuit of male peers on his hospital ward. 1985) and later discussed as a treatment for sexual offenders (e.g. and psychiatric limitations. and in some ways too unrealistic for one with his interpersonal.. To John. Discussions of his treatment progress often highlighted his continuing sexual urges toward children—a hallmark feature of his pedophilia—and viewed the recurrence of such urges as a lapse that would inevitably lead to relapse. who were certainly adults. or that he was utilizing grooming techniques similar to those used on his child victims. The fi rst treatment that he had received. 2002). Gordon. John appreciated the teachings of relapse prevention in a very concrete and specific way. In light of this. triggers or risk factors that may lead to reoffending. Murphy. being around children. Also.. This approach emphasizes the understanding of the offense cycle.e. immature. sexual urges toward children. For example. later research utilizing sound empirical methodology suggested no significant differences between those who had received relapse prevention and those who received other or no treatments (Marques et al.434 Other Adult Disorders complexity of his psychiatric and personality presentation simply added to his burden of expected treatment change. John had difficulty with relating the avoidance-based strategies he had been taught in sex offender treatment to real-world examples. DEVELOPING AN INTERVENTION MODEL As was noted in the discussion of John’s treatment history. Quinsey. or trying to solicit friendships with children). However. perhaps in part due to his cognitive deficits.g. both in the community and while inpatient. and some of these limitations can be seen in John’s case as well. the confrontational way in which the treatment was being administered seemed to result in resistance to treatment. Harris. 2005). the fact that they were younger. was relapse prevention. many of the key elements so critical to relapse prevention were not associated with more positive outcomes for those who had received treatment. John was largely unable to avoid such urges. & Seto. and childlike. intellectual. questions have arisen regarding the effectiveness of such treatment with sexual offenders. might be a sign of lapse or relapse.. he had received several different forms of sex offender treatment with correspondingly different treatment goals in both the community and residential inpatient care. seemed separate and distinct from the risk factors that he had identified as part of his sex offender treatment (i. They felt that the strategies being taught were too simplistic to counterbalance John’s pedophilic urges and risk toward others. not only for . a treatment method based on the work of Marlatt (e. as he found the materials too abstract and difficult to understand. this was only a briefly used method of intervention. evidence of the role of self-regulatory deficits and the need to . selfstudy program based on the principles of addiction. Another treatment approach that John had self-selected was a 12-step. and that a change in sexual behavior can be achieved through support. For John. 2011). and he felt that they lacked specificity in how he should cope with his pedophilic urges. This form of treatment assumes that sex offending behaviors are the result of a sexual addiction. abstinence. 2010. and self-management using client skills is also key in fostering therapeutic change across multiple dimensions. Becker. Though investigations of treatment success with Safe Offender Strategies have not yet been published within the empirical literature. It also used a combination of validation and motivational interviewing (Miller & Rollnick.. a treatment that would incorporate these principles as part of sex offender treatment seemed to fit best with his psychiatric. and maintaining the will to refrain from offending. Safe Offender Strategies is a 10-module. & Crow.e. Sales. as well as the development of healthier relationships and boundaries with others. individually paced approach to sex offender treatment that encourages collaboration between client and treatment provider to identify client strengths and areas of treatment need (i. This approach emphasizes the role of self-regulation and self-regulatory deficits in the etiology of sex offending behaviors. Clients then progress through each module. self-monitoring. A focus on acceptance. Several such programs exist. Robbins. often based on the work of Carnes (2001). emphasizing different areas of dysregulation and skills development. and additionally recognizes the role of reinforcement in the development of maladaptive regulatory strategies. which has been based on the work of Stinson. As John was already residing on a treatment ward utilizing dialectical behavior therapy and skills-based coping strategies. so it was initially hoped that this approach would also address some of John’s specific needs. Stinson. The third sex offender treatment approach used in John’s case is Safe Offender Strategies. There has been virtually no empirical research evaluating the effectiveness of 12-step approaches in sex offender treatment. and Becker (2008.Pedophilia: A Case Study in Empirically Supported Treatment 435 John. This approach was not endorsed or supported by the hospital or treatment team. Treatment materials were designed and piloted on clients with serious mental illness and intellectual/ developmental disabilities in long-term inpatient care. 2008. as these individuals are perhaps more sensitive to criticism of their ability to participate meaningfully in treatment. see also Stinson & Becker. and sex offender treatment needs. The use of such confrontational approaches in individuals with intellectual or cognitive impairments may lead to treatment disengagement or “shutting down” on the part of the client. areas of dysregulation and self-regulatory deficit related to sexual offending and maladaptive behavior). though it was generally recognized that John had experienced such a lack of success in other treatment modalities that his desire to pursue alternative treatment was understandable. but for other clients as well. cognitive. though they are occasionally used in some settings. 2002) strategies to increase client engagement. Stinson. & Sales. Ultimately. John was also unhappy with relapse prevention. 2010). & Sales. Stinson. First. and the considerations of John’s psychiatric and cognitive abilities. and ultimately he was able to transfer to a less restrictive setting in which to continue his treatment involvement. Preliminary results at one of three pilot sites using this approach have demonstrated treatment effectiveness in increasing client engagement and participation in treatment. relapse prevention.e. while engaged in Safe Offender Strategies. 2011). personal preferences may still be important. Related to the 12-step program for sexual addiction. DBT). and self-harming behaviors. . particularly when the individual is still professing a desire to remain in treatment. the emphasis on skills-based learning. Becker.. reduce or avoid sexual urges toward children. A change in treatment philosophy facility-wide was also instrumental in facilitating this change for John and others involved in sex offender treatment programming. decisions regarding treatment change were made based on several factors. Further. and depression. John was initially cautious regarding the use of another treatment approach. John already had prior experiences with relapse prevention that were unsuccessful and resulted in his termination from treatment and an additional sexual offense. and to build healthy relationships with others. John’s goals. and skills development appealing. John’s goals while involved in relapse prevention were to avoid sexual urges related to children. were to self-monitor his sexual urges toward children and his anger. and refrain from engaging in sexual behaviors with peers in the hospital. John’s goals were to remain abstinent from sexual behavior in the hospital. The third and fi nal treatment selected was based on John’s success on a program that already utilized some of the principles of Safe Offender Strategies (i. With regard to the 12-step program. and improvement in self-regulatory functioning and life skills (Stinson & Becker. reduction in aggressive. Finally. DBT) and its emphasis on self-regulatory functioning. sexually aggressive. & Crow. avoid contact with children (including viewing them on television). emphasizes the identification of important precursors of risk and the development of strategies to help avoid or reduce this risk. emotion modulation. The literature on offenders with intellectual and developmental disabilities would also seem to question the effectiveness of such an approach. he did fi nd its correspondence with his overall treatment programming (i. which he developed with treatment providers. 2008..e. loneliness. However. the research literature as well as experiences of treatment providers at the hospital began to question the effectiveness of relapse prevention. the validation and motivational interviewing strategies did anecdotally increase his participation in treatment efforts. While it is not always true that a sex offender must or will like being in sex offender treatment. The fi rst. Robbins.436 Other Adult Disorders improve self-regulatory functioning among sexual offenders has been presented (Stinson. to develop more adaptive strategies for coping with these urges and emotions. this was self-selected primarily out of John’s frustration with treatment and the lack of other available resources. Each of these three approaches reflects different treatment goals for John. and to build his social support network. given his history of trauma and lengthy period of institutional care. though not directly related to John. his amenability to treatment. naturally. it is far different from outpatient community treatment. Though John overtly expressed a desire to engage in treatment and change his behaviors. which made it difficult for him to consistently attend and participate in a range of treatment services. Decisions regarding his risk and relaxation of supervision procedures were made by administrators who reviewed his case and who may have had little daily contact with John in a treatment context. John had difficulty with developing trusting relationships with treatment providers. Also relevant. John presented with a significant degree of resistance to treatment change. and his future risk. and emotional and physical abuse and neglect. By nature. but more highly structured and security-minded than a non-forensic psychiatric one.Pedophilia: A Case Study in Empirically Supported Treatment 437 Nonspecific Factors John presented with a number of stressors. and resistant to discuss his behaviors that may have had sexual connotations. Though there was some individual flexibility in terms of his treatment planning and intervention strategies. psychiatric symptoms. First. And. and interpersonal problems that impacted his overall presentation. Other staff resources were utilized elsewhere. . Several challenges are particularly relevant to the current discussion. Most notable among these were his history of unhealthy relationships with members of his family. Perhaps not surprisingly. while John did briefly receive individual therapy. the facility is less ordered and inflexible than a correctional setting. was the role of the institution. largely due to resource limitations and standard practice of care. As a part of this particular institution. so his individual therapy could not continue past that one experience. John received a broad spectrum of psychiatric and behavioral treatment from a wide range of interdisciplinary treatment providers. He presented as guarded. and his efforts to solicit support often resulted in attempts to sexualize the relationship or involved contact with family members who were former victims and/or perpetrators of sexual abuse. cautious. John resides in a psychiatric setting for those with histories of criminal behavior. treatment providers encountered variable though noticeable resistance in group and individual sex offender treatment. He had few friends or prosocial peer relationships. he was still somewhat confined by the available resources of his institution. Strategies for Challenges in Therapy John’s case was not an easy one. His psychiatric symptoms worsened at times during the course of treatment. These factors also influenced his amenability and progress in treatment over time. as well as in other treatment programming available to him on his residential ward. His sex offender and other treatments were administered in a group format. extensive history of sexual trauma. it was from a psychology intern who was only available to work with him for a limited time. For example. apply them in the moment.g. While it is certainly likely that other factors additionally interfered (e. John had received prior treatment in a community setting. the most significant impact of this trauma was on John himself and likely had a significant impact on his later difficulties with forming interpersonal relationships. would remain withdrawn from group discussion.” The combination of such frustrations and difficulties all likely contributed to this resistance. Assessment using the MSI-II (Nichols & Molinder. or inhibit strong sexual impulses may have made it all the more difficult for him to benefit from “treatment as usual. or a failure on the part of the treatment and the treatment providers. as his scores on this instrument indicated a high degree of ambivalence regarding his need for treatment and limited willingness to take responsibility for his behaviors. involvement of the DBT consultation team at the facility. especially given their difficulties with social interactions over time and prior experiences in treatment that may have attributed treatment failure to their own shortcomings. but some of it resulted from John’s own difficulties in working with treatment providers. trainings related to enhancing client motivation and working with difficult cases. and his cognitive deficits may have in part contributed to his inability or unwillingness to engage in treatment to the satisfaction of his treatment providers. experiences of neglect and abuse in his primary family group. either due to deficits. Some interpreted this lack of progress as unwillingness to change.. his lack of insight into the seriousness of his behaviors at that time). and occasionally rotating group facilitators so as to give them a temporary break when needed. 1996) somewhat explained this. his current hospitalization and history of psychiatric treatment. His mood disorder symptoms also likely contributed to his feelings of hopelessness in treatment. though he would often bring other materials to work on during group. Some of this was resistance to the treatment itself. This allowed them to better understand his own frustrations and realize that it was not merely unwillingness on his part. . though increased collaboration between John and his treatment providers did help somewhat. and social difficulties perhaps resulting from his cognitive deficits and psychiatric symptoms. which has been discussed above. limited resources.438 Other Adult Disorders He generally attended treatment programming in a consistent manner. while others characterized it as an inability to do so. This challenge was difficult to overcome. Other sources of resistance might have included John’s own (at times accurate) perception that treatment providers were frustrated with him. A second challenge was the treatment providers’ own frustration with John’s lack of progress in treatment and his continued behavioral problems on the ward. It may be the case that engaging individuals with similar disabilities in treatment is more difficult. and would participate only when prompted by group facilitators. Other important strategies included building in support for treatment providers through supervision and consultation. Obviously. A third challenge related to John’s history of extensive sexual trauma and other experiences of abuse and neglect in his family of origin. his personality pathology. an inability to understand treatment materials. Pedophilia: A Case Study in Empirically Supported Treatment 439 trusting others. and sources of support to his own goals and personally reinforcing activities or items helped to not only increase his treatment investment but also made treatment gains more meaningful. treatment providers relied heavily on strategies designed to normalize his emotional response (i. urges. given his history. validation in a DBT context) and to help him understand his own ambivalence toward commitment and change (i. as has been endorsed in the literature for individuals with intellectual and developmental disabilities. for John. No one single approach has been recommended to address any of these issues. and behavior. However. his secretiveness and desire to hide his own sexual practices. working with him to cope with such an extensive background of sexual. Simply acknowledging John’s struggles and inhibiting the all-too-common desire to push him toward immediate and permanent change of his behavior significantly helped him to view therapy in a more beneficial manner. thoughts.e. learning and using healthy sexual boundaries. It is not surprising that these effects were salient to treatment providers. measures of progress. motivational interviewing). It also allowed us to overcome the obstacle of his interpersonal deficits—he rarely responded to praise and attention from treatment providers. treatment goals aimed at fostering healthy relationships had to overcome these barriers. as he did not appear to strongly value these relationships—and to simultaneously develop a plan that could be maintained in other settings. and other factors that may impact treatment efforts are examined within the context of individualized support plans. while it is also recognized that these effects did not arise solely as a result of his trauma history. The use of positive behavioral support.. and emotional abuse while still trying to cultivate some desire on his part to foster interpersonal relationships was difficult.. was recommended and used in John’s case. tailoring treatment goals. However. and managing his emotions. as well as his desire to isolate himself and abstain from developing any intimate bonds with others. and his unwillingness to reveal details about his own fears and concerns with his treatment. Many of these needs were ultimately addressed through the development of a highly individualized treatment plan. Though this approach is commonly used within the treatment and behavioral change strategies for individuals with cognitive disabilities. Thus.e. in which various functions of behavior. in addition to those barriers that more directly interfered with his ability to trust treatment providers and approach treatment in an honest and trusting manner. Still. he often struggled with his nearly equal desires to form sexual relationships with children. the treatment literature was helpful in selecting strategies that were not specific to sex offender treatment but instead aimed at working with disengaged or ambivalent clients in order to enhance therapeutic alliance and treatment commitment. Though John wanted a normative sexual partner. . it is less often applied in a sex offender treatment setting. Thus. other impacts relevant in the treatment environment include his hostility toward perceived attempts to control his sexual behaviors. Regarding John’s resistance to treatment and his struggles with his own history of traumatic sexual experiences. physical. reinforcers in the environment. and progress over time.e.. so including him in the process was also beneficial in making changes to treatment when needed. right of self-expression. to attend hospital events in which children may be present. and other relevant and fundamental rights or needs. and efforts to engage John in treatment programming had to include these factors. characteristics. John presented with a risk of sexual offending toward children. which so notably impacted his commitment. Similarly. it was important for treatment providers and the client to work together to discuss such problems and collaborate to fi nd more beneficial treatment alternatives. Areas of particular concern included acquiescence or vulnerability to coercion from authority figures. Social and interpersonal skills deficits were also a prominent concern. and manipulation. additional assessment tools were used to help clarify diagnostic and motivational issues. right to privacy. there is some need to balance the client’s risk with his right to treatment. performance. and the role of past experiences characterized by trauma. Will this create too much stigma? What if the client isn’t bothered by his sexual desires? Isn’t this just a legal issue rather than a psychiatric one? Is this really a mental illness? Additionally. When treatment did not go as planned. John’s case presents with other ethical issues that must similarly be considered. He lived within a forensic hospital setting. difficulties with understanding and implementing treatment materials. Attempts at treatment with several prior approaches were ineffective and seemed to make little impact on the extent and seriousness of his pedophilic urges and corresponding behavioral problems. considerations of the impact of psychiatric medications. Ethical Considerations No complex diagnostic or treatment case is complete without acknowledgement of significant ethical dilemmas. John was given frequent feedback and did express an interest in his treatment. treatment providers needed to be conscientious about consulting this literature and ensuring that assessment and intervention strategies reflected the best current practices in the field. so it was deemed necessary to limit his right to possess pictures of children (i. and this was removed by his treatment team). or to purchase movies or other items in . In particular. One of the first ethical considerations addressed in this case relates to John’s diagnoses of serious mental illness and intellectual disability. A second consideration involves John’s situation at the time of his treatment. Given that a literature exists describing the challenges. abuse. and specialized needs of this population. treatment providers had to be willing to make changes as needed. Merely giving someone the diagnosis of pedophilia can be fraught with ethical complexities. he did possess a photograph of his male relative whom he had victimized. there were many challenges and difficulties with John’s case.440 Other Adult Disorders WHEN THERAPY DOES NOT WORK AS PLANNED As noted above. as a forensic psychiatric inpatient. In this environment. In each of these instances. especially given the history of control and suppression of sexual rights and behaviors among those with intellectual disabilities and the seriously mentally ill (Griffiths. 2002). and often attempted to hide illicit sexual materials that were not allowed (e. as clinicians. A third ethical concern involves a need to provide a support network to aid with treatment progress and aftercare. He often voiced a desire to initiate relationships with adult male peers in the facility.g. 2005). Empirical research has suggested that social support is a critical component of successful treatment and the reduction of risk (e. though he acknowledged the reasons for such treatment. & Watson. In a related vein. or wielding the relationship like a weapon against his treatment team. Though the treatment team wished for John to develop appropriate sexual outlets. and what is realistic given the current situation and current progress in treatment. establishing goals and basic parameters of treatment. Pacheca. intellectually disabled. concerns were raised regarding the ages and appearances of the males toward whom John showed interest. understood the realities of forensic placement. small in stature. However.g. though these often resulted in him sexualizing the relationship.. Federoff. Ethically. and somewhat immature. Richards. & Helmus. and mechanisms for receiving feedback and making needed adjustments to treatment protocols. 2007).. A last ethical matter to be discussed here involves John’s own treatment preferences. and several recent trends in sex offender management have explored options for enhancing social supports available to sexual offenders in the community (e. and were likely to lead to contact between John and his most recent child victim. treatment providers had difficulty with balancing John’s right to intimacy and human contact with his perceived efforts to implicitly satiate his pedophilic urges by pursuing relationships with childlike males and also with the reality that sexual contact was forbidden within the forensic institution.g. as his family members were not always positive supports. Circles of Support and Accountability. Scott.. This right of human intimacy is an important ethical consideration for individuals like John.Pedophilia: A Case Study in Empirically Supported Treatment 441 which children were particularly featured. Harris. including identifying treatment needs. They were often much younger than he. sexual offender who resides in an inpatient setting? John often attempted to develop his own sources of support. He often objected to his things being searched. His efforts to establish contacts with his family were met with concern. e-mails or phone numbers of individuals in the community with whom he was attempting to solicit photographs or sexual conversations). we should have some obligation to consider the client’s own preferences for treatment. Thus. how does one go about establishing good social support networks for a mentally ill. literature describing adolescent males exploring their sexuality. including public safety. Hanson. While there are certainly realities that must be considered that are often out of the client’s . were sometimes abusive. treatment team members and treatment providers struggled with John’s right of sexual expression. what is in the best interests of the client. violating boundaries and trust. Satisfying the need for social support and healthy relationships must be balanced with a number of concerns. or adult males in the community with whom he had established contact through an illicit online dating account. Wilson. & Prinzo. given the relevant risk factors involved. there were issues of termination with current . the mental health treatment literature indicates that one of the common factors contributing to treatment success. In difficult cases like this one. not administered it in an effective way. or contraindicated? In this case. treatment providers must work to avoid predictable or common mistakes. is the opportunity to have input in treatment direction. Avoiding Common “Mistakes” In any complex case. though it ultimately proved more useful to begin asking him what he wanted from treatment and how existing treatment structures could be used in a manner more individualized to his needs. there has to be a balance between staying with a treatment long enough to let it be effective. In other words. Treatment providers were carefully selected. Therapy Termination and Risk Management A number of risk assessment instruments were used in this case to inform future management of John’s risk to others in a community setting. and knowing when it is not effective and it is time to try something new.” In this particular case. in any given agency. treatment providers had great difficulty accepting John’s efforts to engage in self-study of sexual addiction materials. as John was simply moved to a less restrictive facility where he will continue to receive similar sex offender treatment in another milieu setting using cognitive behavioral therapy. Admittedly. But this was another consideration made. regardless of treatment modality or approach. It ultimately proved to be beneficial to allow him to do this to some extent. But what if what the client wants to do seems counter-therapeutic. It was determined at the time of his transfer that SVP commitment was not yet necessary. unnecessary. therapy was not truly terminated. one must avoid assigning case managers or therapists to work with a client like John Smith when they might have a strong aversion to sex offenders. treatment providers might have either stayed with relapse prevention too long. These decisions were made prior to “termination. though other members of his treatment team still struggled with his behavior and interpersonal presentation. one such predictable mistake is assigning individuals to work with a client who fi nd his behavior so unpalatable as to damage the therapeutic alliance. Perhaps we will never know. However.442 Other Adult Disorders control. Another consideration was his eligibility for sexually violent predator (SVP) civil commitment in his state. Another common mistake that was identified and considered in this case was the problem of maintaining a therapeutic approach that was very visibly not working. or even moved away too soon. In sex offender treatment. Being able to guide treatment in some manner often increases treatment efficacy. his behavior. Thus. or had strong preferences for these different approaches to treatment. he did not express a great deal of anxiety or sadness regarding this change.g. future needs. treatment providers understandably had individualized reactions to John.. and his struggles with maintaining commitment and positive therapeutic relationships. some therapists and treatment providers were more warm. As John had not formed particularly strong relationships with his current providers. the therapist’s commitment to the treatment. and cognitive difficulties. Still. who often receive their fi rst treatment services within the context of institutional care (see Watson. Some therapists were more skilled and experienced with different treatment approaches. he may have had difficulty trusting others involved in his care later on. the only occurrence of sexual abuse that was reported and received any attention was that which occurred outside the immediate family. While all of these factors are informed by empirical evidence. have been noted in the literature to have a strong impact on therapeutic outcomes for sexual offenders (e. The literature suggests that this is often a common experience of offenders with intellectual and developmental disabilities. Finally. and this likely had an impact on the therapy. Richards. This could have contributed to John’s resistance to change his behavior or his minimization of its seriousness and impact on others. Similarly. emotional. and non-confrontational. Marshall et al. the “art” most obviously relevant to the treatment was the skill of the therapist. These relationship factors. . and his behavior in treatment. 2003). & Dykstra. validating. while others were challenging and at times rigid in their expectations and measurement of treatment progress.. despite assurances that they had his best interests at heart. a number of group sessions were dedicated to discussions of his progress in treatment. The family’s lack of fi nancial and other resources limited the availability of treatment or intervention services when John demonstrated early signs of behavioral. 2002). Interestingly. they do vary based on the idiosyncracies of the given therapist. Marshall.Pedophilia: A Case Study in Empirically Supported Treatment 443 treatment providers and discussions regarding this transition to other therapists. His early experiences of neglect and abuse within the homes of multiple members of his family may indicate an early normalization of exploitative sexual behaviors. and the relationship of various treatment providers with John himself. though part of the “art” of therapy. 2005. Griffiths. The “Art” of Therapy and Its Relationship to Empirical Science In this case. Cultural Factors Cultural factors that may have been relevant in John’s case include the fact that he came from a relatively impoverished family and that his family of origin was characterized by a significant degree of abuse and neglect. he has been more successful in managing his sexual urges and behaviors. and though treatment providers have continued to work with John’s variations in treatment willingness and commitment. as well as adult females. P. H. working with seriously mentally ill offenders. S. Also needed is a better understanding of the role of trauma and its impact on later treatment involvement and outcomes for these offenders. Diagnostic and statistical manual of mental disorders (4th ed. readers have examined the case of John Smith. Washington. and the needs of offenders with intellectual and developmental disabilities were all crucial in conceptualizing John’s case and developing effective intervention strategies. Center City. & S. D. E. Blanchard. urges. M. L. Carnes. DC: American Psychiatric Association. D. & Stein. J. Sensitivity and specificity of the phallometric test for pedophilia in nonadmitting sex offenders.. In D. R. (2000). R. (2001).444 Other Adult Disorders and he might have implicitly felt that such behaviors were acceptable within some cultural contexts. 41(3). References American Psychiatric Association. Cox-Lindenbaum. & Blak. Dickey. despite a number of recent stressors. M. (1997). Summary and Future Directions Pedophilia is a mental disorder characterized by persistent sexual interests. MN: Hazeldon. Sexual assault against persons with developmental disabilities. Richards. empirical research evaluating strategies for enhancing social support and developing effective aftercare systems is especially valuable when working with pedophilic offenders like John.. Watson . 118–126.). Sexual abuse perpetrated by men with intellectual disabilities: A comparative study. 215–224. T. & Watson.. discussion of individualized treatment planning approaches and how these can be implemented with diverse populations. Klassen. (2001).). Federoff. P. including better integration of literatures addressing special offender groups.. and dealing with challenges and resistance in an empirically supported way. 13. (2002).. fantasies. a client with sexual interests in male children and adults. P. Kuban. Finally. 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NY: NADD Press. D. D. Inc. P. T. San Antonio. Wilcox. Ethical dilemmas: Sexuality and developmental disability (pp. D.. & S. Richards. 175–226). Treatment of intellectually disabled individuals who have committed sexual offences: A review of the literature. R. 85–100. J. Wide Range Achievement Test 3—Administration manual. & Dykstra.. M. S.). I will then briefly outline a strength-based approach to offender rehabilitation. John. in addition to being diagnosed with pedophilia. good lives intervention plan (Laws & Ward. personality psychopathology. The multifaceted nature of the clinical picture means that treatment is bound to be more challenging. Serran. His presentation is complex. John has comorbid mental disorders alongside his pedophilia and therefore is not a straightforward example of a sex offender. & O’Brien. was given a range of cognitive behavioral interventions that represents some of the best treatment available for sexual offenders. and constructive. and functions intellectually at a borderline level. . My aim is to suggest a way of working with John that incorporates a risk reduction focus through the construction of a more constructive. The focus is on John’s array of risk factors and psychological deficits. Second. 2011). he has a major mood disorder (with psychotic features). as well as their interaction. Thus. the Good Lives Model (GLM). and a paraphilia. John has been in treatment for a long time and has made only modest progress. However.COMMENTARY Tony Ward The pedophilia case discussed in the chapter by Jill Stinson and Judith Becker is an excellent example of empirical and theory-driven sexual offending treatment. The patient. I would like to make three observations. features of both borderline and antisocial personality disorder. This fact points to a need to take his mood disorder and personality dysfunction in account when designing a treatment program. Marshall. and any comprehensive case formulation should factor in the causal roles of the different psychological mechanisms generating these problems. strengthbased elements only function as moderators of treatment implementation. First. In this commentary I will examine and comment on the assumptions underlying treatment evident in John’s case and on the specific treatment strategies utilized. John is best construed as a forensic mental health patient with a combination of major mental disorders. 2011. John has participated in a number of treatment programs since the onset of his sexual offending at the age of 18. all three treatment approaches used are examples of a risk management approach. Third. Marshall. a slower pace of delivery) are based on the ..g. and Thomas-Peter (2004). or antisocial peers. and violent offending specifically. culture) of the offender in order to be optimally effective in reducing risk. concluded that the principles underlying the what works approach (i. An essential question. particularly when a treatment target is a reduction in risk of harm to others. The risk principle holds that the greatest level of resources should be directed to the highest risk group of offenders.g.e. which is based on the principles of the RNR model. The need principle states that interventions should address empirically based dynamic risk factors or criminogenic needs such as distorted cognitions. nevertheless exists (Andrews & Bonta. 2010). Notwithstanding the much greater research focus on issues of risk. risk.Pedophilia: A Case Study in Empirically Supported Treatment 449 Risk Management The details of his early treatment are a little sparse but it seems likely that John underwent some form of group therapy.. is the degree to which mentally disordered offenders differ from non-mentally disordered offenders and the implications of these differences for program delivery (Duggan. Duggan notes that the adaptations made to the RNR model for use with mentally disordered offenders (e. and include relapse prevention (see Ward & Maruna. that an offender’s level of risk increases with the presence of each additional risk factor. and that targeting dynamic (i. Day. and control offenders’ specific array of dynamic risk factors. Relapse prevention is an example of a forensic/correctional risk management approach in which the aim is to identify. which as yet remains unanswered. claims that the RNR model is applicable with forensic mental health patients remain largely untested due to a paucity of research studies in this area. including sexual offending. Unfortunately.e. substance abuse. potentially changeable factors that give rise to offending) risk factors in treatment will reduce reoffending rates. Subsequently. in reviewing the relevant research from both the general offender and forensic mental health literature. Key assumptions of the RNR model are that certain empirically based social and psychological risk factors are associated with offending... which did not seem to be particularly effective. The responsivity principle stipulates that programs should be tailored to match the individual characteristics and environment (e. treatment being sequenced so that criminogenic needs are tackled at the end of a program. The what works literature. 2007). Various treatment models have been developed to guide clinicians in the process of managing risk for future violence. intellectual level. Howell. reduce. needs. a substantial knowledge base regarding what works in preventing offending generally. he was in a relapse prevention treatment program for sex offenders. 2008). The most contemporary popular models used are those derived from Andrews and Bonta’s risk need responsivity (RNR) model of offender rehabilitation (Andrews & Bonta. 2010). is concerned with identifying the elements necessary for effective treatment and management programs including the components of treatment. learning style. As the name suggests. three main principles are central to the RNR model. responsivity) and the criminogenic versus noncriminogenic need distinction are likely to be applicable to forensic mental health. increased initial motivational work. and the fact that John has made only modest significant treatment progress. This approach appeared to improve John’s appreciation of his risk factors and helped him to acquire more adaptive coping strategies. as well as additional factors influencing an individual offender. he still appeared somewhat ambivalent about treatment. the focus of the RP program on avoidance goals. novelty. Ward & Stewart. or to become overly preoccupied with their potential for harming others. although. Stinson and Becker’s Safe Offender Strategies program (Stinson & Becker. may well explain his failure to engage fully in the treatment process. Theodosi. but I suspect it is because of his (a) comorbid mental disorders. & Klinger. which were all designed to help John identify and control the factors associated with his deviant actions. Furthermore. his progress has been modest. It seems that the focus of DBT was to eliminate or reduce his personality-based problems with behavioral impulsivity and emotional liability. Furthermore. 2006). as is the case in many other areas of forensic mental health practice.450 Other Adult Disorders clinical assumption that this population has additional needs compared to nonmentally disordered offenders. personality. He aptly comments that. Consistent with this view. Despite the length of time that John has been in treatment and the utilization of different techniques. McMurran. The complexity of John’s presentation and the construction of a case formulation that integrate his mood. as noted by Stinson and Becker. a set of cognitive behavioral techniques used with people diagnosed with borderline personality disorder. 2003). such as mental health concerns (Laws & Ward. Alongside the sexual offending interventions. viewing sex offenders primarily through a risk management lens means that the behavioral manifestations of normal human needs for intimacy. It is apparent that John has remained somewhat . 2010. it made sense that another type of approach was tried. and (c) the focus on risk factors at expense of personal concerns and goals. It makes sense to also use measures designed to assess individuals’ personal goals and values such as the personal concerns inventory (Sellen. pleasure. there is little evidence to confi rm whether the modifications (which increase both the duration and cost of treatment) are necessary. thus neglecting their needs for. Blackburn (2004) states that the literature on mentally disordered offenders does not yet permit robust evidencebased generalizations about what works and that evidence for the effectiveness of psychological interventions remains sparse. 2011). (b) his borderline intellectual functioning. Cox. John also received dialectical behavioral therapy (DBT). and entitlements to. and selfdetermination (or agency/autonomy) may be erroneously dismissed as indicators of deviancy. This treatment approach involves a mixture of relapse prevention and self-regulation elements. Such a dismissal makes it easier to construe offenders as bearers of risk. mastery. It is unclear why this has been the case. what situations to avoid and what psychological and behavioral features to eliminate or control. 2010). and sexual disorders did not seem to have been taken into account during his RP treatment. fundamental human goods (Porporino. In the light of the dearth of studies on the effectiveness of RNR-derived treatment programs with mentally disordered offenders. from the treatment process. According to the GLM. Briefly.. Ward & Maruna. 1999.. Individuals will do the best that they can to obtain primary goods using the strategies that are available to them. and (b) they equip offenders with the necessary capabilities and resources to obtain primary goods in socially acceptable ways. excellence in work and play). Primary goods are essentially activities.g. For offenders like John who have comorbid metal disorders. in addition. The fact that he sought out a self-study program indicates that he is motivated to change—a judgment at odds with those of his various therapists over the years. offending represents attempts to obtain primary goods within the context of personal limitations (e. impulsivity) and environmental disadvantage (e. abilities. primary goods are obtained by various means that are referred to as secondary or instrumental goods. and goals. values. the . Robertson. Ward & Stewart. criminal peers. the GLM-FM posits that the presence of mental illness. strength-oriented theory of offender rehabilitation that focuses on promoting individuals’ important personal goals.g. while at the same time reducing and managing their risk for future offending (Laws & Ward.Pedophilia: A Case Study in Empirically Supported Treatment 451 ambivalent. From a GLM viewpoint. family dysfunction.g. goods) in his or her life and. either temporarily or more permanently.. lack of social skills. The Good Lives Model (GLM) is a comprehensive.e. acts as a major obstacle to the attainment of an individual’s pursuit of primary goods. and Ward (2010) have considered the role of mental illness within the assumptions of the GLM and have applied the augmented model (GLM-FM) to forensic mental health patients. knowledge. criminogenic needs are conceptualized as internal or external obstacles that frustrate and block the acquisition of primary human goods. 2003). The Good Lives Model: A Strength-Based Approach Strength-based perspectives are called that for two major reasons: (a) they take seriously offenders’ personal preferences. experiences. From the standpoint of the GLM. relatedness. poor education. racism). Ward & Maruna 2007. and draw upon this understanding to motivate them to live better lives. agency. An alternative treatment framework that focuses on offenders’ personal goals and strengths may prove to be more appealing while also addressing John’s suite of dynamic risk factors. is frequently unable to think about his or her life in a reflective manner. poverty. 2011. It also proposes that symptoms of mental illness themselves may sometimes provide a means by which primary goods are sought and partially met. Barnao. What this means is that the individual concerned lacks the ability to obtain important outcomes (i. or even disengaged. There is evidence from a wide range of literature to support the claim that all individuals typically seek primary human goods and that their attainment is associated with higher levels of well-being and their absence related to psychological problems of various kinds (Emmons. inner peace. or situations that are sought for their own sake and that benefit individuals and increase their sense of fulfillment and happiness (e.. 2007). and these should be a major focus of any intervention plan. 2011. 2007. constructed that reflect GLM assumptions. For example. Yates. which needs to be supplemented by specific theories concerning concrete interventions such as cognitive behavioral treatment techniques (Ward & Maruna. intimacy. and interests. and so on (Ward & Syversen. Finally. a first point is that the GLM is not a treatment theory. emotional equilibrium (inner peace). What would a good lives plan for John look like? A first point is that his most heavily weighted goods appear to be relatedness. and these programs should be evaluated to assess their efficacy. taking into account the inevitable constraints created by incarceration. social inclusion. need. An important basic ethical assumption is that all individuals possess intrinsic value. Such programs are best understood as GLM-consistent programs and are not the GLM itself (Laws & Ward. Ogloff & Davis. Bearing in mind the above distinction made between a treatment and rehabilitation theory. Second. it does not ignore risk reduction (see Ward & Maruna. and are. 2011. Programs can be.452 Other Adult Disorders GLM-FM provides a useful framework for factoring in variables associated with both sexual offending and those related to the mental disorders themselves. Ward & Maruna. 2009). a growing body of research has found positive results for . they could be conceptualized as ways of seeking intimacy and interpersonal closeness—a normal human need. privacy. in press). Empirical Research Supporting the Utility of the GLM A common criticism of the GLM is its lack of empirical support (Bonta & Andrews. greater detail would be provided on John’s core values. 2003. In response to this criticism. data that answer questions such as: What kind of activities matter most to him? What kind of person does he see himself as? What kind of life would he like to live? A problem created by this absence is that it becomes harder to align the ultimate goal of rehabilitation—to assist individuals to adopt personally fulfi lling and socially acceptable lifestyles—with the mechanics of (risk-oriented) treatment (see Laws & Ward. The entitlements due sex offenders mean that they should be provided with reasonable access to and provision of the resources required to enjoy goods such as sexual pleasure. and because it incorporates the principles of risk. and pleasure. rather than seeing John’s attempts to form relationships with other patients simply as reflecting his deviant sexual preferences. The GLM is a rehabilitation framework that is intended to supply practitioners with a systematic overview of the aims and values underpinning practice. & Willis. the ethical issues noted by Stinson and Becker can be easily accommodated within the GLM. and that this value ought to be reflected in respect for their autonomy and well-being. Ward. using the GLM to guide assessment. preferences. for detail on how to comprehensively work with offenders within a GLM-desistance framework). The GLM functions as a broad map. agency. and responsivity. 2007). leisure. for example. 2007). In my view it provides a more comprehensive framework for offender practice than the RNR. 2004). Willis & Grace. NJ: LexisNexis. Harkins. these studies provide preliminary evidence that the incorporation of the GLM principles in interventions for offenders enhances engagement and contributes toward the establishment of positive therapeutic relationships. D. 202–217.). Barnett. 2008.. 2011. 2009. 10. Morgan. Ward. and Law. (2010). Blackburn. inner peace. Psychology. (2004). 2007). relatedness. .. J. Gannon.. 2007. The Good Lives Model or relapse prevention: What works better in faciltiating and maintaining change? Manuscript under review. and problem solving in sexual offending: How sexual offenders prioritize and operationalize their good lives conceptions. Other researchers have provided support for the underlying assumptions of the GLM (Barnett & Wood. 17. as such. Bouman. 2008. Psychiatry. P. Attending more closely to his personal interests and needs and equipping him with the capabilities to secure these may encourage him to work harder in treatment in the expectation that he could achieve a better life. (2008). & Wilson. Through acknowledging that offenders are people like us. G. as well as promoting long-term desistance from offending. John received the standard set of cognitive behavioral interventions but did not fully invest in the process of change. G. need. & Wood. The psychology of criminal conduct (5th ed. Sexual Abuse: Journal of Research and Treatment 20(4). 297–308. and Law. T. Crime. Lindsay. not simply the promise of a less harmful one. Ware & Bright. Barnao. In my view. Willis & Ward. and responsivity within a broader. & Willis. New Providence. However. Schene. A. 444–465. (2011). J. Browne & Beech. 2008. King. thereby bettering their lives and the lives of people with whom they come into contact. in press. & Ward. Good Lives Model applied to a forensic population. rehabilitation and reintegration endeavors require more than managing risk. Lockerbie. It has theoretical and practice advantages over the RNR while retaining a focus on risk management alongside the promotion of offender well-being. L. Ward. & Collie. the GLM engages offenders in the process of desistance. Robertson.Pedophilia: A Case Study in Empirically Supported Treatment 453 interventions for sexual and violent offending that have incorporated the GLM principles (Barnett. including random controlled trials Conclusions Individuals with a history of criminal offending are more than bearers of risk and. Craig. 2008. Together. Whitehead. Miles. (2010). Barnett. Flak. & Ruiter. & Bonta. “What works” with mentally disordered offenders. it is possible to integrate the principles of risk. Agency. in press). R. M. 2008. & Beech.. clearly further development and evaluation of GLM-derived and consistent intervention programs needs to occur over the next few years. strengths-based rehabilitation theory such as the GLM. References Andrews. Psychology. Miles. Serran. D. Chichester. Morgan. Bouman.. Poster presentation. 50. Duggan. P. (2008). 37–50.. Safe Offender Strategies: Pilot data and outcomes from a new manualized treatment approach.. Rehabilitating sex offenders: A strength-based approach. Schene. T. L. T. & M. 391–406. October). 15. 229–242. T. Assessing risk in sex offenders: A practitioner’s guide. DC: American Psychological Association. P. McNeill.A. G. Subjective well-being and recidivism in forensic psychiatric outpatients. M. (2008).. P. & Ward. & J. (2002). I. Psychology. T. & C. (1999).. D. International Journal of Forensic Mental Health. & Beech. Marshall. (2004). Brayford. The Good Lives Model of offender rehabilitation: Clinical Implications. 1. Cowe. A. Trotter (Eds. Day. M. S. 7–23. H. Rogers. 12. Viewing offender assessment and rehabilitation through the lens of the risk-need-responsivity model.. A. R. Dolan (Eds).). R. & Thomas-Peter. K.. Ogloff. (2010. International Journal of Forensic Mental Health.. The personal concerns inventory (offender adaptation): Measuring and enhancing motivation to chance. 225–234. M. Bringing sense and sensitivity to corrections: from programmes to “fi x” offenders to services that support desistance. (2007).. Aggression and Violent Behavior. D. The psychology of ultimate concerns. The Journal of Forensic Psychiatry and Psychology. Deering (Eds. Changing violent behavior: Forensic mental health and criminological models compared. V. (2006). Soothill. UK: Willan Publishing. Laws.. New York: Guilford Press. 294–305. Craig. research and practice (pp. T..1080/13552600701365613 Marshall. Oxon.454 Other Adult Disorders Bonta. (2007). Evaluation of the N-SOGP Better Lives Programme. M.. Y. Ward. Lockerbie. Browne.. B. D.. 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Safe Offender Strategies is collaborative rather than confrontational. Many treatment programs are very confrontational. 2007). Stinson & Becker. clients work with providers to . and espouse a goal of don’t reoffend. Additionally. Treatment is individualized to suit the complex needs of many individuals with histories of sex offending behavior. Becker. Ward states that the focus of treatment was on risk factors and psychological deficits. Third. Stinson. requiring intervention prior to placement in a less restrictive treatment environment. motivational interviewing. and sex offender treatment needs. including mood and personality psychopathology. This is not. take a one size fits all approach. but could be a reflection of the complexity of his psychiatric.RESPONSE Jill D. First. John has been in treatment for a long time.. risk management. Ward correctly notes that John’s comorbid psychological problems. Harris. which may imply deficits in self-regulatory functioning—the client remains at risk for future sexual recidivism and other related problems. 2011). Scott. Hanson. While research indicates that risk level does need to be taken into consideration (as elaborated further in the riskneeds-responsivity model by Bonta and Andrews. This approach focuses on the whole individual and what his or her needs and goals are in multiple domains. Safe Offender Strategies involves much more than targeting static and dynamic risk factors. the case with the use of Safe Offender Strategies. Second.g. & Helmus. medical. as was necessitated by the multitude of his mental health and other needs. 2007). social support. interpersonal. Ward makes three observations upon which we would like to comment. Many individuals with paraphilias also experience mood and personality disorders (e.g. Stinson and Judith V. Becker Tony Ward’s commentary on our case study of pedophilia and the application of empirical science to this challenging case begins by noting the empirical and theory-driven approach taken in the treatment of John Smith. many of which are additionally identified as dynamic predictors of risk (e. & Messer. complicate treatment intervention. and building a positive and genuine therapeutic relationship. and that strength-based elements only function as moderators in the treatment most recently used to address John’s needs. That he was in treatment for a lengthy duration and made only modest progress does not always imply treatment failure. 2003. in fact. J. risk. cognitive. and how these have shaped his behaviors.. (User report 2007-06). Tromp. Hanson. (2011). R. Ward offers a discussion of his Good Lives Model within the context of sex offender treatment in a case like that of John Smith. J. D. his beliefs and worldview... G. A key component of the treatment is motivation and commitment. both of which emphasize the role of self-regulation and strengths-based treatment. 239–245. S. and behavioral dysregulation through the use of adaptive and healthy strategies.. the introduction of models like Safe Offender Strategies and treatment frameworks like the Good Lives Model. Scott. He identified responsible choices that he has made and how he will continue to exercise personal responsibility in managing his behavior and relationships. and difficulties with maintaining a consistent motivation to work toward change. J. & Messer. A. interpersonal. 185–195. 47(2). D. Assessing the risk of sexual offenders on community supervision: The Dynamic Supervision Project. For John. T. (2007). & Andrews. self-regulatory abilities. Finally.. J. V. & Becker. Still. Risk-need-responsivity model for offender assessment and rehabilitation. Treatment interventions assisted him in learning to listen to and validate others’ feelings while still respecting his own wants and needs. 34(3). Ottawa. J. (2003). R. (2007). J.. ON: Public Safety Canada. a large part of the treatment focused on his expectations about relationships. References Becker.. as well as the identification and strengthening of skills that can assist the client in developing healthier self-regulatory abilities. International Journal of Offender Therapy and Comparative Criminology. as would be needed in a case of John’s complexity. ON: Public Safety Canada. it has been subjected to little empirical investigation and has not been rigorously developed as a manualized treatment intervention. A.Pedophilia: A Case Study in Empirically Supported Treatment 457 identify strengths and form treatment goals that are most important to them. Bonta. (User Report 2007-05). International Journal of Law and Psychiatry. this is a philosophical approach. Stinson. D. based in positive psychology. & Helmus. John additionally learned to self-monitor and self-manage individualized areas of emotional. and clinical concerns. which can inform treatment planning and interactions with a client. K. Sexual offenders with serious mental illness: Prevention. L. Rather than a treatment theory. L. As of yet. Harris. Characteristics of individuals petitioned for civil commitment. are an important evolution in the field of sex offender treatment.. Stinson. . Ottawa. V. This page intentionally left blank . 7 American Psychiatric Association (ApA). 362 diagnostic formulation. 261. 387 demographic and referral information. 372–373 individual therapy. 379–381 case formulation. control via dissociation). anorexia nervosa. 37–38. See panic disorder with agoraphobia (PDA) Agoraphobia Cognitions Questionnaire. 378–379 typical cognitions. 384–385 Family Environment Scale (FES). 280–281. 388 alternative approaches. 375–376 cultural factors. 297 amphetamines. 374–375 typical behavior patterns. 370–374 treatment outcome. 94–96. 380 Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ). 367–369 assessment strategy. 284–285 nonspecific factors. 102–103. 381 ethical considerations. 78 . 361. 386 response. 86–87. 380 antecedent-behavior-consequence (ABC). 368 family therapy. 260 anorexia nervosa. 288 relapse prevention. 46–47. 376–378 Anorexia Nervosa Readiness for Change Scale. 286–288 key principles. 383 relapse prevention and termination. 280 adaptive and problem behavior monitoring. 340 panic disorder with agoraphobia. 369–370 clinical interview. 158 alcohol use. 280 cognitive functioning. attention deficit/hyperactivity disorder (ADHD). 284–286 caregiver coaching. 281–283 medical status. 115 Alcohol Use and Dependence Inventory (AUDIT). 364–367 commentary. 400–401 therapy complications.{ INDEX } Acceptance and Action Questionnaire. 354. 297 American Association of Marriage and Family Therapists. 381–382 key principles. 363 case conceptualization. 58–59. 284 art of the case. 375–376 Maudsley approach. 356 acupuncture. 386 assessment data. ADHD. 383 treatment. 379–381 behavioral observations for patient. 361 bipolar disorder. ADHD. 264 American Psychological Association (APA). 32 adulthood. autism. 289 response. 106. 361–362. autism. 374. 289 assessment. 384. 363. 379 anorexia nervosa (AN). 73 adolescent-focused individual therapy (AFT). 111 borderline personality disorder (BPD). 78 agoraphobia. 367. 369 Eating Disorder Inventory-3 (EDI-3). 364 epidemiological considerations. 301 schizophrenia. 281–283 environmental factor assessment. 47 ancillary behaviors. 304 Alzheimer’s disease (AD). 382 depression. 108 acceptance and commitment therapy (ACT) anorexia nervosa. 373–374 intervention model. 286 ethical considerations. 134 American Professional Society on the Abuse of Children (APSAC). 385 core knowledge. 362–364. 365. anorexia nervosa. 384 alternative options. 288 initial case formulation. 52–53 aggressive child. 283–284 core knowledge. 393 nonspecific factors. 393–397 common mistakes to avoid. autism. 149–150 AC/DC (control via acceptance vs. 293–295 contextual model of dementia. 106–108 dissociative identity disorder (DID). 203. 379–381 diagnostic impressions. 107. 363. 396 Adult Behavior Checklist. 285–286 epidemiological considerations. 260. 284 commentary. 340. 382 art of case. 279. 64–65 punishment. 211 applied behavioral analysis (ABA). 47 attention deficit/hyperactivity disorder (ADHD) adulthood. 309. 304. 200. 55 potential treatment obstacles. 66–67 Autism Diagnosis and Observation Scale (ADOS). 57–58 behavior analysis autism. 34–35 key principles. 404 behavioral and psychological symptoms of dementia (BPSD). 147 Ativan. schizophrenia. 158 Beck Depression Inventory-II (BDI-II). 69–70 skills assessments. 28. 282 antisocial behavior. 60 behavioral analysis. 202. 72 behavioral principles. 64 overcoming regression/relapse. 36–37 potential problems. 27–29 nonspecific factors. 79 Assessment of Basic Learning and Language Skills (ABLLS–R). 62 nonspecific factors. 59–60. 273 Assessment of Basic Learning Abilities (ABLA). 381. 36 schizophrenia patient. 33 ethical considerations. 38 initial sessions. 128 mental status examination. 79. 158. 148. 67 cultural factors. 237. 29–31 late adolescence. 61. 38–39 core knowledge. 37–38 psychosocial intervention. 30–31 autism assessment. 58–59. 79 functional analysis. 33–38 childhood. 263. 73 relapse prevention. 295 atomoxetine. 56–57 case data. ADHD treatment. 228. 201. 59–60. 263 assertive community treatment (ACT). 62–63. 79 asthma. 46–47. ADHD. 55–56. 59–60 Index Assessment of Basic Learning and Language Skills (ABLLS–R). 47–48 commentary. for autism. optional modules. 284. 202. obsessivecompulsive disorder (OCD). 66 epidemiological considerations. 263–264. 282 behavioral intervention. 35–36 Safren et al. 69–70 personal history. 72–73 early childhood behavioral intervention. 71–72 toilet training problems. adverse effects. 43–48 common mistakes to avoid. 58–60 Assessment of Basic Learning Abilities (ABLA). 139. 68 initial referral and intake. See also social anxiety disorder comorbid with bipolar disorder. 70 communication problems. autism. autism. 67–68 feeding intervention. 56–57. 70–71 eating problems. 70–72 case formulation. 5. 54–55 common treatment mistakes to avoid. 263 asenapine. 29–31 drug use and abuse. 61–63 mand training. 43 anxiety disorders. 201. 43–44 early adolescence. 112 schizophrenia. 25–26 cognitive behavioral therapy (CBT). core modules. 81 functional behavioral assessment (FBA). 148. 203 Anxiety Sensitivity Index (ASI). 26–27 epidemiological considerations. 68–69 communication. 63. 67 aripiprazole bipolar disorder. Version 2 (BASC-2). early childhood. 280–281. 52–53 assessment strategy. 78–79 toilet training. 201. 61–62. 54–55 intervention planning. 378–379 . 272 antipsychotics. 55–56 ethical considerations. 140. 34–37. 60–61 case history. 158. 212. 67–68. 286–287 anorexia nervosa patterns. 252 treatments. See also autism avoidance learning model. 6 behavior monitoring Alzheimer’s disease. autism. 310 Behavior Assessment System for Children. 65–66 consultation model. 226 Beck Anxiety Inventory (BAI). 60. 57–58 eating intervention. 72 borderline personality disorder. 55 autism spectrum disorder (ASD). 254 Anxiety Disorders Interview Schedule. 37–38. 34 response. Alzheimer’s disease. 52–53 Safren et al. 39. 158 Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). schizophrenia. 31–33 case formulation.460 antipsychotic polypharmacy. 31. 140. 308–315 breathing retraining and relaxation panic disorder with agoraphobia. 308–312 Stage II treatment phase. 377 Body Image Assessment (BIA). 128–131 common mistakes to avoid. 255. 111–113 medication treatments. 425. 311–312. 108 Chambless Mobility Inventory. 35 bipolar disorder assessment. Alzheimer’s disease. ADHD. 315–316 response. 142–143. See also anorexia nervosa (AN) cultural influence. 323–326 common mistakes to avoid in therapy. 128 dialectical behavior therapy (DBT). 402 art of case. 386 cultural influence. See also marijuana use carbamazepine.Index benzodiazepines. 364–365. 260 chronicity. 403–404. 263 binge eating disorder. 116 nonspecific factors. 406 . autism. See also pedophilia chlorpromazine. 318–319 assessment strategy. science in dialectical behavior therapy (DBT). 205 Brief Fear of Negative Evaluation scale (BFNE). 304–308 mistaken for bipolar disorder. 116. 402–403. 112 caregiver coaching. 362. 280 case conceptualization tool. 262 chromosome 22q11 deletion. 302–303 commentary. 327–328 Stage I treatment phase. 73 Child-directed interaction (CDI). 202. 413–414 assessment. 411–412 epidemiological considerations. 407–408 commentary. 408–409. 406–408 key principles. schizophrenia. Ciarrochi and Bailey. 8–13 child molester. 403–406 biopsychosocial model. 402. 406 ethical considerations. 301–302. 408–409. 381 biopsychosocial model. 129 assessment strategy. 406–408 intervention model development. 304–307. 277 chronic low back pain (CLBP). 158 borderline personality disorder (BPD). depression. 129–130 nonspecific factors in treatment. 303–304 background information. 115. 381 cannabis use. 116. See also anorexia nervosa (AN) anorexia nervosa. 110. 303. 318 pedophilia. 123–124 response. 424 biopsychosocial perspective. 315 461 treatment approach. 402–403 cultural factors. 130–131 relapse prevention. 313–315 Stage III treatment phase. 308 relapse prevention and termination. 402–403 nonspecific factors. 424 stepwise approach. 324–325 pre-treatment phase. 304–308 treatment course. 93–96 A CBT–Practitioner’s Guide to ACT: How to Bridge the Gap between Cognitive Behavioral Therapy and Acceptance and Commitment Therapy. chronic pain. 10 oppositional defiant disorder (ODD) treatment. 301–302. 409. 412–413 initial case formulation. 448 post-traumatic stress disorder (PTSD). 120 personal history. 387 eating disorder. 121 presenting complaints. 414 core knowledge. 158 chelation. 319–320 art vs. 121–122 key principles. 316–317 comorbid with bipolar disorder. 113–115 case formulation. 410 chronic pain. 419–422 common mistakes to avoid. 212 Briquet’s syndrome. 117–118 case history. 402–403. 110–111 potential treatment obstacles. bipolar disorder. 273–274. 122–123 differential diagnosis. 414–415 dealing with therapy problems. 369. 159–160 social anxiety disorder. 118–120 body image. 115–117 ethical considerations. 354 bulimia nervosa. 201. 323–326 fi rst termination and treatment transfer. 387 dissatisfaction. 404. 409–411 relapse prevention and termination. 109–110 psychotherapy intervention. 424 cognitive behavioral therapy (CBT). 405. 8 homework sheet. 402–403. 109–110 commentary. 312–313 initial case formulation. 415–416 response. 133–134 treatment planning. 381 Body Sensations Questionnaire. 102–104. 99 if therapy doesn’t work. 86–87. 30. 339 cultural factors anorexia nervosa. 438. 314 post-traumatic stress disorder (PTSD). 387 autism treatment. 211 clonidine XR. 241. anorexia nervosa. 191 cognitive specificity hypothesis. 115 Cost Utility of the Latest Antipsychotics in Schizophrenia Study (CUtLASS). 106–108 obsessive-compulsive disorder (OCD). 89–93 behavioral health consultant. Work. mood disorder. 237. 405 dialectical behavior therapy (DBT). 331. ADHD. 281 demoralization. 422 depression. 334–335 post-traumatic stress disorder (PTSD). 376. 382. 183 schizophrenia. 394–396 chronic pain. 379 compulsive behaviors. 305 anorexia nervosa. 96–98 The Life. 47–48 Alzheimer’s disease. 309 dementia.Index 462 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). 301–302. 92. 228. 39. 307 dieting. 102–103 assessment. 26 ADHD and substance abuse. 373–374. 303 Clinician Severity Rating (CSR). 99 Duke Health Profi le. 93–96 commentary. 33 bipolar disorder and PTSD. 379 conditional probabilities. 147 daily diary card. 89. schizophrenia. 443–444 post-traumatic stress disorder (PTSD). text revision) (DSMIV-TR). 304–307. 450 dialectical dilemmas. 112. 65–66. mood disorder. 99 pedophilia.) (DSM-IV). 425 Diagnostic and Statistical Manual of Mental Disorders (4th Ed. 141. 115 cognitions. 117. 261 Clinical Global Improvement-Severity (CGI-S) scale. 201. 263 cocaine. 34–37. science in. 439. 98 The Three Ts and Workability Tool. 131 dissociative identity disorder. 99 cultural factors. 388. 150 post-traumatic stress disorder (PTSD). 106–108 therapy problems. 214–215 Cushing’s syndrome. 330 Diagnostic and Statistical Manual of Mental Disorders. 89–90 bipolar disorder. ADHD. 90 myths. 254–255. 246–247 panic disorder with agoraphobia. 436. autism. 407–408 depression. 226 communication. 378–379 differential reinforcement of alternative behavior (DRA). 261. 264 social anxiety disorder. 201. 45 depression acceptance and commitment therapy (ACT). 261 co-therapy. 81–82 Difficult Child subscale. 428. 57 . 61–62. 184–185 social anxiety disorder. 70 comorbidity ADHD and ODD. 95 relapse prevention and termination. 90. 420. 175. 199. 318–319 borderline personality disorder (BPD). 340 pedophilia. anorexia nervosa. 96 ethical considerations. 91 Diagnosis and Treatment of Multiple Personality Disorder. 43 consultation model. anorexia nervosa. 405. 199 cognitive behavioral therapy (CBT) ADHD. 283–284 label. autism. dissociative identity disorder (DID). autism. social anxiety disorder. 113 case conceptualization. 57. 5 Dimensional Obsessive-compulsive Scale (DOCS). 55 Diagnostic and Statistical Manual of Mental Disorders (4th Ed. obsessivecompulsive disorder (OCD). 323–326 dissociation identity disorder (DID). 221 cognitive processing therapy (CPT) borderline personality disorder. 98–99 intervention development. 78 conduct disorder. 172 compensatory behaviors. 31. Play and Health Tool. anorexia nervosa. 177. 215. 99 response. 363. 262. 414–415. 47 clozapine. 72–73 chronic pain. 67 corticosteroids. 237 discriminative stimuli. 128. 376–378 cognitive behavioral group therapy (CBGT). 102–104 common mistakes. See also borderline personality disorder (BPD) art vs. See also Alzheimer’s disease (AD) contextual model of. 133 Clinician Administered PTSD Scale (CAPS). 79. 115. ADHD. 85–86 psychological flexibility and vitality. 304. 344–345 outcome. 361. 66. 234 family based therapy (FBT). 286 anorexia nervosa. 343–344 relapse prevention. 400–401 Maudsley approach. 11 dysthymia. See also anorexia nervosa (AN) anorexia nervosa. 335. 339–343 treatment strategy. bipolar disorder. 45 Eating Attitudes Test. 316–317 epidemiology Alzheimer’s disease. ADHD. 393–394. dissociative identity disorder. 332–333 Fear and Avoidance Hierarchy. 139–140 . 62–63. 174–175 empirically supported treatments (ESTs). ADHD. 4–6. 33 autism. 334–335 epidemiological considerations. 329 diagnosis. 28. 364–367 cognitions of anorexia nervosa. 356–357 therapy dynamics. 6–7 panic disorder with agoraphobia (PDA). 201 fight-or-fl ight system. See also anorexia nervosa (AN) alternative approaches. autism. 90. 338–339 dissociative trap. 281 functional analysis autism. 283 excessive reassurance-seeking. 382. 172 schizophrenia. 376–378 patients and families dealing with anorexia nervosa. 329–332 nonspecific factors. 206. 81 panic disorder with agoraphobia (PDA). 242 Fear of Negative Evaluation scale (FNE). 165 employment. 120 Drug Enforcement Agency (DEA). 354 dissociative identity disorder (DID). 70–71. 384. 365. 368 fantasy-proneness. 251–252 social anxiety disorder. borderline personality disorder (BPD). 117. 8. 352–354 common mistakes to avoid. 201. 148–149 pedophilia. comorbidity and assessment. 361–362 Eating Disorders Examination. 396. 344 response. 363. 152 euthymia. depression. oppositional defiant disorder (ODD). 335–337 commentary. obsessivecompulsive disorder (OCD). 388. 23. 247 divalproex bipolar disorder. obsessive-compulsive disorder (OCD). ADHD. 406 dissociative identity disorder (DID). 114 excess disability. 333 Dissociative Experiences Scale (DEC-II). 191 family accommodation. 380 eating disorders. 339 defi nition. 29 463 environmental intervention. 73 Ethics Code of the American Psychological Association. dementia. 14 eye movement desensitization and reprocessing (EMDR). 79 educational attainment. 232–234 exposure therapy. obsessive-compulsive disorder (OCD). 92. 381 attention deficit/hyperactivity disorder (ADHD). 29. anxiety disorders. 43–44 Duke Health Profi le. schizophrenia.Index dissociative coping style. 368. 393 Family Environment Scale-Real Form (FES-R). 118–119. obsessive-compulsive disorder (OCD). 332–333 core knowledge. 198–199 equine therapy. 112. 432 post-traumatic stress disorder (PTSD). post-traumatic stress disorder (PTSD). 414 drug use and abuse. 129. 205 flooding session. 380 Family Environment Scales (FES). 242–243 fluphenazine. 334 ethical considerations. 329 assessment strategy. 55–56 chronic pain. 13. 379 eating intervention. ADHD case. 12. 96 Dyadic Parent-Child Interaction Coding System IV (DPICS-IV). obsessive-compulsive disorder (OCD). 333 distraction. 344–345 treatment agenda. 345 initial case formulation. 364. 363. 234–235 Eyberg Child Behavior Inventory (ECBI). 380 Eating Disorder Inventory-3 (EDI-3). 334 oppositional defiant disorder (ODD). 89. 232. 130 patient’s self-taper. autism. 45–46 emotion-regulation training. 262 frontotemporal dementia. 79. 372–373. 337–338 key principles. 110. 384 clinical interview of Amelia. 345 conceptualization of dissociation. 210 fear-conditioning paradigms. 329–332 co-therapy. 452–453 guafacine XR. 263 . 131 interpersonal therapy (IPT). 27. 295 medications ADHD. 280–281. 37 imprisonment. 451–452. 77 functional capacity evaluation (FCE). 361. anorexia nervosa. ADHD. 119. 262 Harvard Trauma Questionnaire. 393 Medicaid. ADHD treatment. 448. 38. 47 mild mood disorder. 242–243 International Obsessive Compulsive Disorder Foundation. 112 learned helplessness. 420 mood disorder. 254 Mood Disorders Questionnaire (MDQ). 272–273 individual therapy. autism. 176–177 ironic process model. bipolar disorder. 73 goal-setting. 373–374 intensive exposure. 281 lithium. ADHD. 253 Mastery of Your Anxiety and Panic 4th edition (MAP-4). 275. 45 Mini Mental State Exam (MMSE). schizophrenia. 416. Becker and Drake. 284–285 Medicare. anorexia nervosa. 171 How Doctors Think. post-traumatic stress disorder (PTSD). 275. 147 magnetic resonance imaging (MRI). 147 hypnosis. 457 research supporting. obsessive-compulsive disorder (OCD). autism. 44 bipolar disorder. 222 in vivo exposure therapy. 238 interpersonal and social rhythm therapy (IPSRT). Groopman. 119 chronic pain. 295 medical model of dementia. 164 genetic risk. post-traumatic stress disorder (PTSD). mood stabilizer. 119 lurasidone. 114 hypoparathyroidism. 255–256 methylphenidate. 352 hyperthyroidism. 227 intervention anorexia nervosa. 140. 56 motivating establishing operations (MEO). 149. 263 Impairment Rating Scale. 203 mand training. 68. 384. 96–98 oppositional defiant disorder (ODD). 342 hypoglycemia. 226 generalized anxiety disorder (GAD). 273. 32 haloperidol. 28. 282 medical status. 278 major depressive disorder (MDD). anorexia nervosa. 412. 354. 256. 61–62 social anxiety disorder. Alzheimer’s disease. 429. 112 motivating abolishing operations (MAO). 129 Managing Social Anxiety: A Cognitive Behavioral Therapy Approach. 203 Maudsley family therapy. 158. bipolar disorder. bipolar disorder. 61–63 chronic pain. 174–179 lamotrigine. 284 Minnesota Multiphasic Personality Inventory 2 (MMPI). 58–59. 169 Lewy body disease. 382 Interpretation of Intrusions Inventory. 62 marijuana use. 438 iloperidone. 413. 404–406. 167–168 Individual Placement and Support. 7–8 panic disorder with agoraphobia. 434–436 post-traumatic stress disorder (PTSD). 431. dissociation identity disorder (DID). autism. 113 mood stabilizers. 32. 56 Multidimensional Pain Inventory (MPI). 147 Hypomania Checklist (HCL-32). 146–147. 203–204. post-traumatic stress disorder (PTSD). 374. 55 gluten-casein-free diet. schizophrenia. 403 functional communication training. See also cannabis use ADHD. 415 schizophrenia. schizophrenia. 47 K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children. 256. 149. obsessive-compulsive disorder (OCD). autism. Present and Lifetime Version). 178–179 Good Lives Model (GLM) pedophilia. 149–150 pedophilia. bipolar disorder. 47 bipolar disorder.Index 464 functional behavioral assessment (FBA). 143. 129–130 mental status exam. 170 Helping the Noncompliant Child. 278. 18 Hopkins Symptom Checklist (HSCL–25). mental status examination. 112. 112 Gilliam Autism Rating Scale (GARS). 273. 253–254. 279. 130 lithium carbonate. 404 Multiphasic Sex Inventory II (MSI-II). 408–409 depression. 381–382 autism. chronic pain. schizophrenia. 336. 241. 158 assessment strategy. 226–227 relapse prevention and termination. 159–160 case description. 146–147 nonspecific factors. 235–236 response. 227 obsessive-compulsive disorder (OCD). McFarlane. 261. 281. 172 National Institute for Health and Clinical Excellence (NICE) Guidelines. 246–247 excessive reassurance-seeking problems. 6–7 core knowledge. 147–148 breathing retraining and relaxation. 31 norepinepherine. 261 National Registry for Evidenced-based Programs and Practices (NREPP). 211 Parent-Child Dysfunctional Interaction subscale. 73 465 olanzapine bipolar disorder. 140–146. 234 nonspecific factors in treatment. 22–23 tailoring PCIT. 117 normal pressure hydrocephalus. 256 neuropsychiatric symptoms. 234–235 family accommodation. 237–238 religious patients. 139 cognitive behavioral therapy (CBT). 13 intervention model selection. 225–226 potential treatment obstacles. 232. 231 preparing for stressors. 117 Nevada Caregiver Support Center (NCSC). 246–247 cognitive therapy. 229–230 when therapy is not working. 279. 210. dementia care. 284–285. 204 panic disorder with agoraphobia (PDA). 112 schizophrenia. 273 music therapy. 230–231 personal history. 157–161 common mistakes to avoid. 137–138. 8. 231–234 occupational therapy. distraction. 7 child-directed interaction (CDI). 286–287. 237–238 assessment strategy. 164–165 self-monitoring. 14–15 Oregon Health Sciences University (OHSU). 141 commentary. 149–150 key principles. 238 psychological principles. 153 assessment. 232–234 exposure therapy. autism. schizophrenia. 421 Panic Attack Record. 263 oppositional defiant disorder (ODD) ADHD and. 3 parent-child interaction therapy (PCIT). 140. 152 core knowledge. 17–19 contextual considerations. 281 Obsessive Beliefs Questionnaire. 336 neurocognitive testing. schizophrenia. 228–229 case history. 3 epidemiological considerations. 227–228 case formulation. 237 commentary. 26 assessment strategy. 247 ethical considerations. 123 National Comorbidity Survey. 237.Index Multiple Family Group Treatment. 7–8 key principles. 149 clinical interview. 236–237 continuing care. 238 distraction vs. 4–6 case formulation. 225. 241–244 common mistakes to avoid. 234–236 etiological factors. 139–140. 158–161 Panic Session Change Index (PaSCI). 280. 404 Pain Medication Questionnaire (PMQ). 150 relapse prevention. 157 case formulation. 139–140 intervention model development. 285. 73 Narcotics Anonymous. 139 treatment overview. 119. See chronic pain Pain and Disability Questionnaire (PDQ). 142–143. 394 National Institute of Mental Health (NIMH). 413–414 pain rehabilitation treatment. 9–13 commentary. 6–7 general therapy process. 246–247 treatment planning. 152 functional analysis. 238–239 assessing treatment outcome. 153 response. 256–257 neuroimaging. 17–19 response. 17 pain. 282 neurotransmitter systems. autism. 225–226 cognitive behavioral therapy (CBT). 5 . 140 strategies for dealing with problems. 297 NIMH Multimodal Treatment Study of Children with ADHD (MTA). 107 NEO-PI-3. 141 self-report measures. 148–149 ethical considerations. 146–147 epidemiological considerations. 150–151 structured interview. 7–8. 201. 456–457 risk management. 443–444 current status of case. 402–403 dissociative identity disorder (DID). 443 assessment. 167–168. 128. 281 pedophile. 88 psychoeducation. 437–440 strength-based approach. 7–8.466 parent-child interaction therapy (PCIT) oppositional defiant disorder (ODD). 183 response. 451–453. 195–196 when therapy is not working. 430–431 post-traumatic stress disorder (PTSD). 18 posttraumatic model (PTM). 457 intervention model development. 260–263. 172–174 commentary. 303. 311–312. 330. 86 . 429 assessment strategies. dissociation. 14–15. 329. 111–113 borderline personality disorder (BPD). oppositional defiant disorders (ODD). 56 pharmacologic treatment. 434–436 key principles. 430–431 nonspecific factors. 116 nonspecific factors. 171 core knowledge. 431–432 background information. schizophrenia. schizophrenia. 311–312 Prozac. 444 Good Lives Model (GLM). 254 pervasive developmental disorder not otherwise specified (PDD NOS). 431–432 childhood experiences. 115. 5 Parenting Stress Index. 168–170 cultural factors. 168–170 mistaken for bipolar disorder. 449–451 sexual offending history. 442–443 treatment. 335 contextual factors. 179–180 relapse prevention and termination. 444 art of therapy. 442–443. 426 commentary. 180–181 torture case. 172 ethical considerations. 131 comorbid with dissociative identity disorder (DID). 451–452 therapy termination. 442 core knowledge. 432–436 future directions. 184–185 epidemiology. 212–213 Prolonged Exposure protocol. 18 parent-offspring relationship. 96. depression. 110. 448. 425–427 case formulation. 430–431 cultural factors. 281–283 anorexia nervosa. 432–436 epidemiological considerations. 190–193. 181–182 intervention. 172–174. borderline personality disorder. 181 Primary Care Behavioral Health model. 184 assessment. 195–197 therapy problems. 170–171 borderline personality disorder (BPD) and. 17–19 tailoring. 261 personality disorder mental status examination. 147 physical therapy. 327 chronic pain. 117. 375–376 attention deficit/hyperactivity disorder (ADHD). 29–31 autism. 437 response. 6 Parent Management Training Oregon Model. depression. goal of ACT. 426–427 strategies for therapy challenges. autism. 174–179 key principles. 99 principles Alzheimer’s disease. 427–428 when therapy is not working. 432 ethical considerations. 73 polycystic ovarian syndrome (PCOS). 44–45 parent training interventions. 8 Parent Distress subscale. Short Form (PSI-SF). 190–193 common mistakes to avoid. 324–325 case formulation. 167–168. schizophrenia. autism. 429–431 diagnostic concerns. ADHD. 56–57 bipolar disorder. 168–170 schizophrenia. 114. 425 pedophilia. 169. 263. 329–332 panic disorder with agoraphobia (PDA). 301. 204 psychological flexibility. 440–442 evidence-based case formulation. 251–252 social anxiety disorder. 22–23 parent-directed interaction (PDI). 146–147 pedophilia. 448–453 common mistakes to avoid. 5. 272 Index positive illusory bias (PIB). 331 post-traumatic stress disorder (PTSD). 122 polypharmacy. 3 comorbid with bipolar disorder. anxiety disorders. 34 Positive Parenting Program. 73 play therapy. 440 perphenazine. 184–185. 272 pheochromocytoma. 17–19 Parkinson’s disease. 266 history and repeated mental status exam. Present and Lifetime Version (K-SADS-PL). 254–255 psychosocial treatment ADHD. 255–256 key principles. 251 scrupulosity. 415–416 depression. 260–263 presenting complaints. See also schizophrenia and related psychotic disorders pre-treatment. 435. 264 schizophrenia prodrome. 252 pre-treatment course of psychotic disorders. 235–236 Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). 123–124 borderline personality disorder (BPD). 123 sensory integration therapy. 267 social anxiety disorder. 261. 43 Psychopathy Checklist-Revised (PCL-R). obsessive-compulsive disorder (OCD). 236 selective serotonin reuptake inhibitor (SSRI). 32 schizoaffective disorder. 280 467 risperidone bipolar disorder. 256 nonspecific factors. 253–254 neuroimaging. offender rehabilitation. 272–275 common mistakes to avoid. autism. 38–39 Alzheimer’s disease. mental status examination. 256–257 psychopathy. 267 considering differential diagnosis. 428. 251–252 ethical considerations. 442–443. 257 schizophreniform disorder. 261 Safe Offender Strategies. 260. bipolar disorder. 260–265 treatment obstacles. 254–255 Diagnostic and Statistical Manual of Mental Disorders. 344 obsessive-compulsive disorder (OCD). 263–265. 257–259 punishment. 34–38 schizophrenia. defi nition. 254–255 epidemiology. 266 Schizophrenia Patient Outcomes Research Team (PORT). 265 pharmacologic treatment. 449. schizophrenia. 257–259 psychological and neurocognitive testing. 273. 273–274. 251 schizophrenia and related psychotic disorders. 252–253 chronicity. 265–266 treatment planning. 67–68. 65. 183 schizophrenia. 442–443. 73 quetiapine bipolar disorder. 251. 289 anorexia nervosa. 267 response. 237–238 panic disorder with agoraphobia (PDA). 99 dissociative identity disorder (DID). 210 religious patients. 449–451 post-traumatic stress disorder (PTSD). autism treatment. 153 pedophilia. 68 relapse prevention ADHD. 251–252 laboratory tests. 73 serotonin. 315–316 chronic pain. 148 risk management. 133 reactive attachment disorder (RAD) diagnosis. 386 autism. 456. 449–451 risk need responsivity (RNR). Alzheimer’s disease. 117 . 18. 449 Risperdal. 130–131 psychotic disorders. 112 schizophrenia. 450. 431 psychosis. 6–7. obsessive-compulsive disorder (OCD). 259 when therapy is not effective. 255 treatment. 4th edition (DSM IV-TR). 112 schizophrenia. 263–265 relapse prevention. 457 Schedule for Affective Disorders and Schizophrenia for School-Age Children. 429. Self-Report (QIDS-SR). 278 Revised Hamilton Psychiatric Rating Scale for Depression. 14. 256 mental status exam. 256–257 psychosocial treatment. 277–278 risks and safety. 69–70 bipolar disorder. 253–257 case history. 267–268 assessment. autism. 15 treatment goals.Index psychological testing. ADHD. pedophilia. 436. 277 commentary. 272 psychotherapy intervention. 261 Quick Inventory of Depressive Symptoms. 452–453 risk principle. 259–260 assessment strategy. 19 reinforcement principle. 63. 215–216 commentary. See post-traumatic stress disorder (PTSD) treatment ADHD. 198. chronic pain. 247 substance abuse. 198–199 ethical considerations. post-traumatic stress disorder (PTSD). 272 social skills training (SST). 118–120. 213 assessment strategy. 370–374 autism. L. 243 sexually violent predator (SVP). 190–193. Alzheimer’s disease. 419 Stevens–Johnson syndrome. Skinner. 211 Social Skills Training. 339–343 obsessive-compulsive disorder (OCD). 380 trauma. 190–191 schizophrenia. 174–179. 114. 221–222 common mistakes to avoid. 427–428 post-traumatic stress disorder (PTSD). post-traumatic stress disorder (PTSD). 293 velo-cardio-facial syndrome. 236–237 panic disorder with agoraphobia. dissociation identity disorder (DID). 215–216 alternative strategies. 121 borderline personality disorder. 169. 119 Verbal Behavior. 426–427 principles. 335 Structured Clinical Interview of the Diagnostic and Statistical Manual (SCID). 354 Index subjective units of discomfort (SUDS). 279 University of Oregon Medical School (UOMS). 287–288. 14–15. 212–213 relapse prevention and termination. 60 Veterans Administration (VA). 330 tailoring. 330 Three Factor Eating Questionnaire. 73 State-Trait Anxiety Inventory. 210 response. 66–67. 195–196 Transtheoretical Model of Behavioral Change. 199–200 clinical implications. 434–436 pedophile history. autism. E. 214 continuing course of treatment. 223–224 treatment adaptations. 22–23 thioridazine. 305 Sybil (movie). 262 Thorndike. 30–31 anorexia nervosa. 64–67 bipolar disorder. 231–234. autism. 209–210 treatment course. 302–303 violence. 23 University of Nevada. 285. 110.468 session habituation. 210–212 strategies for handling homework noncompliance. 200–202 case formulation. 402. 304–315 dissociative identity disorder (DID). 205–209 cultural factors. autism. 430–431 treatment. 117. See also pedophilia intervention model. 427–428 skills assessments. 229–230. See also marijuana use Substance Abuse and Mental Health Services Administration (SAMHSA). 57 Stroop Color Word test. 71–72 torture. 205–209. 342–343 social anxiety disorder. 56 The Three Faces of Eve. 172–174. 115 stimulus control. 106 substance use disorder (SUD). 59–60. 140–146 pedophilia. (movie). 420 Structured Inventory of Malingered Symptomatology (SIMS). 223–224 Social Anxiety Session Change Index (SASCI). Bellack. 260–265 social anxiety disorder. 223–224 session-by-session and post-treatment assessment. 214–215 epidemiological considerations. 78–79 sleep problems. 22 urinary tract infection (UTI). 404 . 53 Structured clinical interview for DSM–IV disorders (SCID). 380 toilet training. 148 stepped care approach. 259. bipolar disorder. 202–203 case of Andy. 203–204. 289. 203–204. mood disorder. 204–205 strategies for handling poor attendance and partial relapse. 167–168.. obsessive-compulsive disorder (OCD). 404. Reno Nevada Caregiver Support Center (NCSC). schizophrenia. 331 somatization disorder. 203–204 nonspecific factors. 442 sexual offending. 201. 213 principles from basic science of case. 120 stimulants. 180–181. 32 Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID–D). 354 speech therapy. 210. 274 sociocognitive model (SCM). parent-child interaction therapy (PCIT). 182–183 visual analog scale (VAS). 184–185. 214 intervention model. 254–255. 260 venlafaxine XR. pain management. borderline personality disorder (BPD). 385 ziprasidone bipolar disorder. 138. 138 . 256. 161 panic disorder with agoraphobia. 112 schizophrenia. 4 Wide Range Achievement Test-3 (WRAT3). 263 Zoloft Alzheimer’s disease. 145 Youth Risk Behavior Surveillance. 261.Index Wechsler Adult Intelligence Scale III (WAIS). 429 Wisconsin Card Sorting Test. 381 World Health Organization Adult ADHD Scale. 26 Wechsler Preschooler and Primary Scale of Intelligence III (WPPSI-III). 280 panic disorder with agoraphobia. 273. 32 469 Xanax failure of. 429 Wechsler Intelligence Scales for Children III (WISC-III). 140. 53 World Health Organization (WHO). 85. 143. for panic attacks.