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Case Studies in Clinical Psychological Science

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Case Studies in Clinical


Psychological Science
BRIDGING THE GAP FROM SCIENCE
TO PRACTICE

Edited by
William ODonohue
Scott O. Lilienfeld

3
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Library of Congress Cataloging-in-Publication Data
Case studies in clinical psychological science : bridging the gap from science to
practice / edited by William ODonohue, Scott O. Lilienfeld.
p. cm.
Includes bibliographical references and index.
ISBN 9780199733668
1. Clinical psychologyCase studies. 2. PsychotherapyCase studies. I. ODonohue,
William T. II. Lilienfeld, Scott O., 1960
RC467.C367 2013
616.89dc23
2012024765
ISBN 9780199733668

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 ODonohue and Thelma Farber Lilienfeld.

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{ CONTENTS }
Preface
Contributors
Introduction: Case Formulation and Clinical Science

xi
xiii
xv

WILLIAM ODONOHUE AND SCOTT O. LILIENFELD


PART I

Childhood Disorders

1. Tailoring Parent-Child Interaction Therapy for Oppositional


Defiant Disorder in a Case of Child Maltreatment

AMANDA M. NZI AND SHEILA M. EYBERG

Commentary

17

PATRICK C. FRIMAN AND STACY SHAW

Response

22

AMANDA M. NZI 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

Contents

ix

Commentary 272
ALAN S. BELLACK

Response

277

BELINDA MCINTOSH AND MICHAEL T. COMPTON

11. A Contextual Approach to Dementia Care in Alzheimers Disease

279

CHRISTINA GARRISON-DIEHN, CLAIR RUMMEL,


AND JANE E. FISHER

Commentary

293

ANN M. STEFFEN AND NIKA R. GEORGE

Response

297

CHRISTINA GARRISON-DIEHN, CLAIR RUMMEL, AND


JANE E. FISHER

Personality and Dissociative Disorders

PART V

12. Borderline Personality Disorder

301

SHIREEN L. RIZVI AND KRISTALYN SALTERS-PEDNEAULT

Commentary

323

ALAN E. FRUZZETTI

Response

327

SHIREEN L. RIZVI AND KRISTALYN SALTERS-PEDNEAULT

13. The Treatment of Dissociative Identity Disorder: Questions and


Considerations

329

STEVEN JAY LYNN, LIAM CONDON, AND GEP COLLETTI

Commentary

352

HARALD MERCKELBACH

Response

356

STEVEN JAY LYNN, LIAM CONDON, AND GEP COLLETTI


PART VI

Other Adult Disorders

14. The Use of Family and Individual Cognitive Behavioral Therapy


with a Patient with Anorexia Nervosa

361

BARBARA CUBIC

Commentary

393

CAROL B. PETERSON

Response

400

BARBARA CUBIC

15. Chronic Pain

402

ROBERT GATCHEL AND ROB HAGGARD

Commentary

419

MELANIE DUCKWORTH

Response

424

ROBERT GATCHEL AND ROB HAGGARD

Contents

16. Pedophilia: A Case Study in Empirically Supported Treatment

425

JILL D. STINSON AND JUDITH V. BECKER

Commentary

448

TONY WARD

Response

456

JILL D. STINSON AND JUDITH V. BECKER

Index

459

{ PREFACE }
We chose to edit this book because we believed that it would benefit readers in
several ways. First, as clinical psychologists ourselves, we are deeply concerned
about the large number of professional psychological services sold and delivered
that are not evidence-based. This is a preventable tragedy that often harms the
very people we ought to be helping. Regrettably, too little is done by our professional organizations to call attention to this problem and to remediate it. Certain
professional organizations in particular are complicit in this benign neglect, 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. By illustrating how evidence-based approaches can be put into
practice, we hope that this book will increase the likelihood that current and
future practitioners will deliver them.
Second, we want to highlight the wide variety of evidence-based assessments
and interventions available to clinicians. The stimulating chapters that follow
depict exposure therapies, skills-building interventions, contingency management, behavioral activation, and cognitive interventions, among others, for a
broad array of clinical presentations. Clinicians and students ought to fi nd this
diversity both interesting and challenging to master.
Third, we hope to underscore the complexity and richness of clinical cases.
Following the evidence is not a mechanical or cookie-cutter process, as each
case is unique and has its own complexities. This canard is commonly expressed
by the critiques of evidence-based interventions: I dont want to follow a boring manual. I want to think and make judgments. The cases that follow demonstrate that sophisticated clinicians implementing evidence-based treatments
make numerous individual judgments, with great care and forethoughtdecisions that are nonetheless guided and constrained by scientific evidence. As such,
evidence-based practice is in no way akin to following a cookbook. The case
studies in this book nicely illustrate what Temple University psychologist Philip
Kendall has termed flexibility within fidelityusing evidence-based treatment
protocols as rough blueprints to be modified as necessary.
We should be clear that we are not presenting these cases as further evidence
to support the claims of specific therapies efficacy or effectiveness. This error has
been a common one in our field. The question, Does therapy x work? is all too
often answered in the affi rmative, solely by a case example (Well, this treatment
seemed to work for my client, so it must be effective in general). This is not the
purpose of the cases that follow. Nevertheless, we believe that these cases can
serve as exemplars for clinicians to learn from and apply to their own cases. In the
psychotherapy outcome literature, actual cases are typically presented without

xii

Preface

much detail and are described only in the most abstract fashion. The chapters that
follow enable clinician and student alike to observe fi rsthand the meaty details of
evidence-based treatments and assessment procedures. In addition, they permit
them to see leading psychotherapy researchers apply these techniques skillfully
to their own areas of expertise.
This book should be of interest to a number of audiences. Practicing clinicians,
clinical researchers, and students in training in all mental health professions
(clinical psychology, social work, counseling, psychiatry, psychiatric nursing)
will benefit from the cases and the stimulating back-and-forth discussions of
treatment and assessment approaches presented here. In addition, instructors in
clinical psychology, psychotherapy, 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 would like to thank a number of individuals for their assistance with this
book. We would like to thank Linda Goddard and Olga Cirlugea for their help
in the preparation of the manuscript. In addition, we thank our editor Sarah
Harrington at Oxford University Press for her expertise, guidance, and patience
with us during this project. Finally, we thank the clients whose courageous struggles comprise these clinical cases, and whose life stories here informand, we
hope, will ultimately helpfuture clients.

{ CONTRIBUTORS }
Jonathan S. Abramowitz
University of North Carolina at
Chapel Hill

Julia R. Craner
University of Maine

Lauren B. Alloy
Temple University

Michelle Craske
University of California Los Angeles
(UCLA)

Kevin M. Antshel
SUNYUpstate Medical University

Barbara Cubic
Eastern Virginia Medical School

Russell A. Barkley
Medical University of South Carolina,
Charleston

Melanie Duckworth
University of Nevada, Reno

Judith V. Becker
University of Arizona
Deborah C. Beidel
University of Central Florida
Alan S. Bellack
University of Maryland School of
Medicine
Richard A. Bryant
University of New South Wales
Natalie Castriotta
University of California Los Angeles
(UCLA)
Gep Colletti
Binghamton University (SUNY)
Michael T. Compton
The George Washington University
School of Medicine and Health
Sciences

Boadie W. Dunlop
Emory University
Sheila M. Eyberg
University of Florida
Jane E. Fisher
University of Nevada, Reno
Patrick C. Friman
Boys Town and the University of
Nebraska School of Medicine
Alan E. Fruzzetti
University of Nevada, Reno
Christina Garrison-Diehn
University of Nevada, Reno
Robert Gatchel
The University of Texas
at Arlington
Nika R. George
University of Missouri-St. Louis

Liam Condon
Binghamton University (SUNY)

Ashley E. Greenwald
University of Nevada, Reno

W. Edward Craighead
Emory University

Robbie Haggard
University of Texas at Arlington

Contributors

xiv

Debra A. Hope
University of Nebraska Lincoln

Patricia J. Robinson
Mountainview Consulting Group

Michael E. Kelley
Univeristy of Nebraskas
Munroe-Meyer Institute

Barbara O. Rothbaum
Emory University School of Medicine

Steven Jay Lynn


Binghamton University (SUNY)
Brittain Mahaffey
University of North Carolina at
Chapel Hill
Richard M. McFall
Indiana UniversityBloomington
Belinda McIntosh
Emory University School of Medicine
Harald Merckelbach
Maastricht University
Anjana Muralidharan
Emory University
Angela Nickerson
University of New South Wales
Amanda M. Nzi
University of Florida
Olga V. Obraztsova
Temple University
Carol B. Peterson
University of Minnesota Medical
School
Jeffrey J. Rakofsky
Emory University
Shireen L. Rizvi
Rutgers University

Clair Rummel
University of Nevada, Reno
Kristalyn Salters-Pedneault
Eastern Connecticut State University
Holly A. Seniuk
University of Nevada, Reno
Stacy Shaw
Boys Town
Sandra T. Sigmon
University of Maine
Ann M. Steffen
University of Missouri-St. Louis
Jill D. Stinson
Fulton State Hospital
Milena Stoyanova
University of NebraskaLincoln
Geoffrey L. Thorpe
University of Maine
Tony Ward
Deakin University
W. Larry Williams
University of Nevada, Reno
K. Lira Yoon
University of Maine

Introduction
CASE FORMULATION AND CLINICAL SCIENCE

William ODonohue and


Scott O. Lilienfeld

For a case to be conducted within the paradigm of clinical science, it first must
be formulated along scientific lines. The essence of a scientific approach is the
ceaseless effort to compensate for confirmation bias, the ubiquitous tendency to
seek out evidence consistent with our hypotheses and to deny, dismiss, or distort
evidence that is not (Lilienfeld, 2010; Popper, 1965). Of course, not all case formulation is scientific. Freuds case studies, although beautifully written and ingeniously interpreted, made little or no effort to control for confi rmation bias and a
host of related biases (Lazarus, 1991). To the contrary, Freud often worked hard
to fi nd any evidence that might rescue his clinical hypotheses from refutation.
Many thoughtful scholars have written about case formulations (e.g., Haynes
OBrien, & Kaholokula, 2011; Nezu, Nezu, Maguth, & Lombardo, 2004; Persons,
2008) and these useful analyses have often adopted a cognitive behavioral orientation, which would seem at least prima facie scientific. Although we believe that
these authors offer many valuable insights and helpful practical suggestions, they
leave unanswered a host of questions about the fundamentals of scientific case
formulations. 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, as opposed to unscientific? What are the advantages and disadvantages, if any, of a scientific case formulation? Can a scientific case formulation be
a matter of degree, 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, we address these and other often unasked questions about
case formulations. Proper case formulation is crucial, as case formulation provides the blueprint and foundation for the professionals behavior. This behavior,
in turn, bears direct implications for whether the clients problem will be correctly diagnosed, properly and efficiently understood, and safely, effectively, and

Introduction

xvi

efficiently treated. Without a sound case formulation, incorrect treatment goals


can be pursued; and incorrect assessment methods and less effective or safe treatment methods can be administered. In other words, clients, as well as friends
and loved ones, can experience needless suffering. Physical medicine has been
relatively proactive about defi ning medical errors and taking systematic steps to
reduce them (see, for example, Gawande, 2009). In contrast, those of us in clinical psychology have, to be charitable, displayed an attitude of benign neglect to
the problem of errors in our formulations, which can lead to what may be called
psychotherapy errors (ODonohue & Heaton, in preparation).

The Meta-Questions of Case Formulation


The prominent philosopher of science, 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; carefully observe, and write down what you have
observed! They asked, of course, what I wanted them to observe. Clearly
the instruction Observe! is absurd . . . . Observation is always selective. It
needs a chosen object, a defi nite task, an interest, a point of view, a problem. (p. 61)
The clinician is in a similar epistemic situation. He or she needs a focusa
point of view, to use Poppers words. He or she cannot simply observe and directly
see a case formulation. There is no such thing as purely bottom upthat
is, theory-freeobservation in psychotherapy, because practitioners inevitably
harbor theoretical preconceptions that influence their interpretation of clinical
data. Moreover, virtually any piece of clinical datafor example, a clients yawning during a therapists interpretation of her phobiacan be interpreted in a
multitude of ways, including that this behavior is rather insignificant. 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, important) items while ignoring (many, many) others. For the clinician can
ask about the clients shoe size; history of shoe size; history of shoe buying; the
clients parents shoe sizes and history of shoe buying; the list can go on and on.
The key question becomes: Of all the possibilities that the clinician can observe,
what is the list of legitimate candidates that the clinician ought to observe, 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, 1965) are the best candidates for
constructing this list. Shoe size ought to be observed if and only if research shows
that it helps define a problem (i.e., it is relevant to diagnosis) or helps to understand the cause a problem (i.e., it is relevant to psychopathology), or is relevant to

Introduction

xvii

treatment (i.e., it is an important process or outcome variable in psychotherapy). If


these relevancies are not found in research, then this construct can be ignored.
Perhaps the central mistake in case formulation is to allow favored beliefs,
often untested or tested and found to be inferior to other alternatives, to hold
sway over assessment and treatment methods that have more scientific support
(Lilienfeld, Lynn, & Lohr, 2003). Theories can assist clinicians to select dimensions on which to focus, such as dreams, slips in speech, toileting experiences,
and castration fears. Other accounts can help clinicians to select such clinical
issues as details in ones drawings of a house, or authenticity, or ability to act in
a certain way in a psychodrama. Again, one can see myriad possibilities. The
thesis of this work is that a scientific approach allows clinicians to rationally winnow these possibilities into a viable focus, one that is in the clients best interests
and in which the therapists epistemic duties, such as the knowledge of which
treatment approaches yield the best outcomes, are best honored (ODonohue &
Henderson, 1999). At the same time, a scientific approach is self-correcting, so
that if the initial focus of the practitioner turns out to be misleading or incorrect, the practitioner should be able to shift to a differentand more clinically
usefulfocus.
More specifically, a sound case formulation answers the following meta-questions
(by meta-questions we mean questions about questions, so a meta-question is a
higher level question). We also use the term meta given that the problem is reflexive: Information is needed to determine what information is needed.

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, and how should I make
them?
What are the clients problems? How are these best described (What kind
of constructs should I usee.g., major depressive episode, sadness,
dry drunk, 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 clients 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, OBrien, &
Kaholokula, 2011; Nezu, Nezu, Maguth, & Lombardo, 2004; Persons, 2008), we
argue that:
1. The form of a scientific case formulation is that of a sound deductive logical
argument. This point is s critical, although it is missing from other explications of what scientific case formulations are. We agree with Popper

xviii

2.

3.

4.

5.

Introduction

(1965) that science is a subspecies of rationalityand that formal logical


arguments are the currency of rationality. The premises of the deductive
arguments contain responses to key questions of case formulation (see
below), and together these premises entail certain conclusions and courses
of action. Other explications of case formulation suggest a list of considerations, but these have no formal rational connection. In our account of
case formulation, they are premises of a sound deductive argument. In
addition, the advantage of such arguments is that they can be explicated;
and explicit reasoning increases accountability.
Scientific case formulation is complex. There are multiple arguments that
need to be formed, each has multiple premises, and the nature of these
premises are varied, covering ethical claims, descriptive claims, summaries of research, and so on.
There is one major meta-argument, namely, the clinicians formulation of the
case, and three component deductive arguments: one covering goals, one
assessment methods, one treatment methods. These arguments, in turn,
are interrelated.
At times, ideology rather than science has influenced case formulation. This
is particularly the case with the American Psychological Associations
(APAs) fetish with cultural sensitivity (ODonohue & Benuto, 2011) and
other vague constructs such as professional knowledge, both of which
are used in the APAs ethical code. In both cases, the APA is right to
imply that culture and professional knowledge need to be investigated
by researchers, provided that these researchers can be clear about what
constructs they are measuring. 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. For example, 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, age, personality, religion, political
views, and other variables as they may arise in treatment), there is presently little systematic evidence that tailoring interventions to cultural
backgrounds results in improved treatment outcomes. However, the APA
has precipitously encoded this ideological commitment into its ethical code, indicating that the clinician needs to focus on these variables,
despite the lack of evidence that these are indeed relevant.
Scientific case formulation is not a mechanical process, but involves clinical judgment. As such, clinicians need to be on guard against well-known
biases and heuristic errors, the latter of which stem from the uncritical use
of mental shortcuts or rules of thumb (Ruscio, 2007), such as illusory correlation (seeing statistical associations in their absence) and an overreliance on the representativeness heuristic (judging a book by its cover, such
as assuming that a client who is similar in some ways to previous clients
with Disorder X necessarily has Disorder X).

Introduction

xix

6. Scientific case formulation should take place in the context of systematic


quality improvement processes (McFall, 1991; ODonohue & Fisher, 2009),
namely, processes designed to identify errors in practice and eliminate
them, thereby enhancing client care. This is because no case formulation
process is without error, and quality improvement seeks to minimize error
in the current case as well as in future cases.
The last point emphasizes that explicating a case formulation is crucial to holding health care professionals accountable. Increased accountability is a central
component of health care reform efforts. 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. It can be problematic if the clinician cannot explicate the case formulation or if the explication
shows faults. In a classic statement of behavior therapy, Ullmann (1977) argued
that therapy ought to be data-based and data-generating. Quality improvement
is data-generatingdata such as fidelity to treatment manuals, client satisfaction, and magnitude of clinical change can all be collected and compared with
benchmarks. McFall (1991) also argued that quality improvement data should be
gathered to understand how the clinician can improve (see ODonohue & Fisher,
2009, for a further explication of quality improvement in clinical psychology).

WHY SCIENCE?
Science is widely believed to be superior to other ways of generating knowledge,
such as intuition, for several key reasons:
1. Historically, the scientific method has by far worked the best (see Lilienfeld
& ODonohue, 2012, for key classic readings regarding this important
point). When humans have applied science to problems, we have made the
most progress. Prayer, guessing, unsystematic case studies, and the advice
of gurus have repeatedly been found to be inferior methods for producing knowledge. When science has been applied to problems, progress
has been made: We have cured diseases, put people on the moon, built
bridges spanning wide expanses, and gained a deeper understanding of
the structure and behavior of the universe. When we have applied science
to human behavior, we have also made progress in understanding basic
behavioral principles (e.g., learning principles) and in developing applied
technologies for ameliorating clinical problems (see the subsequent chapters in this book).
Science is intimately involved in error correction. Clinicians, just like everyone else,
can and in fact do have erroneous beliefs. Science minimizes confi rmation bias
and our love of and attachment to our most cherished beliefs by putting them to
the test. Popper pointed out that our tests should be severe. By that, he meant
that we should attempt to falsify our beliefs so that if we are wrong we fi nd this
out efficiently. It is a more severe test of the belief Frank does not swear to

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. In behavioral health care,
we can do harm to our clients if we hold false beliefs. If we think Test x is valid
for measuring a construct (e.g., depression) when it is not, we can come to false
conclusions about our client. If we think Therapy y is the most efficient and effective intervention for alleviating our clients problems when it is not, we can cause
them needless suffering. Finally, we agree with McFall (1991), who argued that
there is no viable alternative to science. Science provides us with knowledge that
no other method can or has. Intuition, gurus, clinical experience, 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. Yet, compared with
science, all fall woefully short when it comes to producing enduring knowledge.

The Key Arguments in Case Formulation


Following ODonohue (1991), 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, as they defi ne the desired
goals and process of the case.
FORMULATING TREATMENT GOALS

There are two major ways in which treatment goals are determined: (1) the client
decides on these, for example, I want to quit smoking (and the therapist agrees
this goal is acceptable); or (2) the clinicians decides on them, for example, You
are suffering from obsessive-compulsive disorder and you ought to try to change
certain behaviors.
We will now explicate the deductive arguments that ought to serve as key components of the clinicians case forumulation.

Argument 1A: Client-Driven Treatment Goals


1. Client C wants to achieve state of affairs S.
2. C is informed about alternatives and the costs and benefits associated
with achieving S.
3. S is a morally permissible state of affairs.
4. S is a practically feasible state of affairs.
5. S is not inconsistent with any overriding states of affairs that C wants to,
or should, obtain.
6. Variables influencing S or S itself are psychological/behavioral entities.
7. If 1, 2, 3, 4, 5, 6 and ceteris paribus (all else being equal), then S is an
appropriate treatment goal.
8. Ceteris paribus.
9. Therefore S is an appropriate treatment goal.

Introduction

xxi

Argument 1B: Other-Driven Treatment Goals


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Significant other O wants Individual I to be in state of affairs S.


I does not want to be in S.
Some factor overrides Is desire not to be in S.
O is in some legitimate position in relationship to S that allows O to
determine treatment goals (e.g., parent, guardian).
O is informed concerning alternatives and the costs and benefits
associated with achieving S.
S is a morally permissible state of affairs.
S is a practically feasible end state.
S is not inconsistent with any overriding state of affairs that I should
obtain.
Variables influencing S or S itself are psychological/behavioral entities.
If 19 and ceteris paribus, then S is an appropriate treatment goal.
Ceteris paribus.
Therefore S is an appropriate treatment goal.

Argument 2: What assessment methods will be used in this case?


1. Therapist T wants information I1 . . . In
2. Information I1 . . . In has been shown in well-designed research studies to
be potentially relevant to the treatment of client C.
3. Gathering information I1 . . . In is morally permissible
4. Gathering information I1 . . . In is practically feasible.
5. Information I1 . . . In is sufficiently complete and comprehensive
information about the principal dimensions of the case.
6. Assessment methods A1 . . . An are reliable and valid methods for
gathering information I1 . . . In.
7. Assessment methods A 1 . . . An are cost-effective methods for gathering
information I1 . . . In.
8. C is fully informed regarding alternatives to gathering this information
and these assessment methods, and consents to the gathering of this
information by the use of these methods.
9. If 18, and ceteris paribus, then assessment methods A1 . . . An are the
proper assessment methods to use in this case.
10. Ceteris paribus.
11. Therefore assessment methods A1 . . . An are the proper assessment
methods to use in this case.

Argument 3: What treatment methods should be used in this case?


1. Treatment goal G entails the realization of states of affairs S1 . . . Sn.
2. F1 . . . Fn are all factors that are known through well-designed research to
be causally relevant to S 1 . . . Sn.
3. F1 . . . fn are cost-efficient methods to obtain S1 . . . Sn

Introduction

xxii

4. F1 . . . Fn-m are the least restrictive methods to obtain S 1 . . . Sn.


5. Client C is fully informed concerning alternative methods and the costs
and benefits of these methods and consents to the use of F1 . . . Fn-m.
6. If 15 and ceteris paribus, then F1 . . . Fn-m are the proper treatment methods to use in this case.
7. Ceteris paribus.
8. Therefore F1 . . . Fn-m are the proper treatment methods to use in this
case.
In addition, there is one meta-argument that collects these sub-arguments and
concludes that all of these cohere into a sound case formulation.

The Meta-Argument: The Clinicians Case Formulation


1. S is an appropriate treatment goal.
2. Assessment methods A z . . . An are the proper assessment methods to use
in this case.
3. F1 . . . F n-m are the proper treatment methods to use in this case.
4. If appropriate treatment goals have been chosen, if the case has been
properly assessed, and if the proper treatment methods have been competently applied, and ceteris paribus, then the client problems should show
improvement.
5. Ceteris paribus.
6. Therefore the clients situation should show improvement.

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. Empirical information concerning specific facts. For example, the clinician
must assess the goals of the client (Argument 1, Premise 1).
2. Moral and ethical knowledge. For example, the clinician must decide
whether a treatment goal is ethically permissible (Argument 1, Premise
3an example of this is whether changing a homosexual orientation in a
client who desires to do so is ethically permissible).
3. Financial information. Costs of assessment methods and treatment methods and alternatives must be considered (for example, in Argument 3,
Premise 5).
4. Causal information. The means to desired ends must be determined (for
example, in Argument 3, Premise 2).
5. Psychometric information. The therapist needs to understand what are
valid inferences and what are error terms in various alternative assessment devices (for example, in Argument 2, Premise 6).

Introduction

xxiii

6. Pragmatic information. The therapist must determine what is practically


possible when informing the client about alternatives (for example, in
Argument 3, Premise 5).
7. Metaphysical claims. The clinicians ontology (What exists?); views about
meaning (What constitutes a good life?; ODonohue, Lloyd, & Lavin,
in preparation); and what is morally acceptable also influence case
formulations.

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. We understand the epistemic limitations of case studies; McFall
(in Chapter 8 of this volume) nicely summarizes these limitations. For example,
case studies are markedly limited in inferring cause-and-effect relations; in addition, they are often of unclear generalizability to other cases. Moreover, like some
published case studies, the cases in this book are often amalgams of several cases
or are partially disguised features due to concerns regarding confidentiality, so
these cases may not always mirror clinical reality precisely.
Rather, 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,
or what are often termed the nomothetic and the idiographic. One of the practitioners major challenges is how to translate the results of group studies, such as
randomized controlled trials demonstrating a treatments efficacy, to the idiosyncrasies of the individual case. Well-conceptualized case studies can demonstrate
how to apply nomothetically derived knowledge to the idiographics of a specific
individual. In this way, 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. The case study by itself certainly is not sufficient to demonstrate causal inferences regarding clinical methods or problem resolution, but at
its best it can help to illustrate how one takes a scientifically supported regularity
and applies it to a specific clinical case.
Let us illustrate with an example. There are strong regularities regarding
electricity. Lets say that an electrician uses such regularities and publishes an
article showing how she used them to wire a particularly complicated house.
She says, in effect, that given that there is a scientifically established regularity
known as Ohms law, in wiring this hot tub I needed to increase the width of
the wire, and doing so, changed resistance by x amount. 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 Ohms
law or to justify her future behavior regarding wiring. It is the scientific established regularityOhms lawthat provides the warrant for the electricians

Introduction

xxiv

behavior. But if the electrician cites Ohms Law, and also shows the instantiation
of this law in the wiring of the hot tub, she is on reasonable epistemic grounds. In
addition, she may instruct other clinicians on how to behave successfully when
faced with a practical problem (see Hempel, 1965, regarding law model scientific
explanation).

The Content and Format of the Book


In developing this book, we followed a consistent game plan. First, we invited
authors who were prominent contributors to the process and outcome literature for a particular clinical problem. We recruited authors who were
well acquainted with the relevant research literature and its gaps, as well as
informed about real world complexities of implementing the assessments and
treatments.
To ensure that the chapters addressed similar clinical questions that often
arise in treatment, 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.
2. 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 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. What epidemiological considerations, such as base rates and
comorbidity, if any, came to play in diagnosing or case formulation?
4. 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?
5. How did you develop an intervention model for this case? What other
interventions did you consider and reject, for what reasons?
6. How did you deal with nonspecifics in this case?
7. What were your strategies for dealing with therapy problems (missed
appointments, distortions, lack of commitment, etc.).
8. What would you have done if therapy wasnt working like you thought it
would?
9. What ethical considerations came into play?
10. What common mistakes did you work to avoid in treatment?
11. How did you deal with relapse prevention and termination?
12. What is the art of this case, and how was it (if at all) informed by
scientific evidence?
13. What cultural factors did you consider, and what difference did these
make? (if relevant in this case)

Introduction

xxv

In addition, to show that case conceptualization is not a mechanical process,


but that there are legitimate options at several choice points (and that reasonable people could disagree), we asked other leading researchers to review the case
study and to provide a brief commentary. In turn, we also afforded the original
author(s) the opportunity to rejoin to this commentary.
This lively and thought-provoking three-way interchange, we believe, illustrates the dynamism of the clinical science approach. Some have falsely characterized clinical science as dry and mechanical, such as following a treatment
manual in a formulaic way. We are convinced that this is a caricature and that the
interchanges to follow show why. We will see that, although there is often broad
consensus on fundamentals, there are interesting disputespossible fodder for
future researchregarding diagnoses, choice of treatment goals, assessment
strategies, and research interventions. Such disputes, we contend, reflect healthy
differences of opinion, which in turn are the lifeblood of scientific progress in
clinical science.

References
Gawande, A. (2003) Complications: A surgeons notes on an imperfect science. New York:
Picador.
Haynes, S. N., OBrien, W. H., & Kaholokula, K. (2011). Behavioral assessment and case
formulation. Hoboken, NJ: Wiley.
Hempel, K. (1965). Aspects of scientific explanation. New York: The Free Press.
Kuhn, T. (1970). The structure of scientific revolutions. Chicago: University of Chicago
Press.
Lazarus, A. A., (1991). A plague on Little Hans and Little Albert. Psychotherapy: Theory,
Research, Practice, Training, 28, 444447.
Lilienfeld, S. O. (2010). Can psychology become a science? Personality and Individual
Differences, 49, 281288.
Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (2003). Science and pseudoscience in clinical
psychology. New York: Guilford.
Lilienfeld, S. O., & ODonohue, W. T. (2012). Great readings in clinical science: Essential
selections for mental health professionals. Boston, MA: Pearson.
McFall, R. M. (1991). Manifesto for a science of clinical psychology. The Clinical
Psychologist, 44(6), 7588.
Nezu, A. M., Nezu, C. M., Maguth, C., & Lombardo, E. (2004). Cognitive-behavioral case
formulation and treatment design: A problem-solving approach. New York: Springer.
ODonohue, W., & Benuto, L. (2011). Problems with the construct of cultural sensitivity.
Scientific Review of Mental Health Practice, 7. 2437.
ODonohue, W., & Fisher, J. E. (2009). The role of quality improvement. In J. Fisher and
W. ODonohue (Eds.), The practitioners guide to evidence based treatment (pp. 132).
New York: Springer.
ODonohue, W., & Henderson, D. (1999). Epistemic and ethical duties in clinical decision making. Behavior Change, 16, 1019.

xxvi

Introduction

ODonohue, W. (1991). Normative models of treatment decisions. The Behavior Therapist,


March, 14, 7072.
ODonohue, W., & Heaton, J. (in preparation). What is a psychological intervention
error?
Persons, J. (2008). The case formulation approach to cognitive behavior therapy. New York:
Guilford Press.
Popper, K. R. (1965). Conjectures and refutations: The growth of scientific knowledge.
New York: Harper.
Ruscio, J. (2007). The clinician as subject; Practitioners are subject to the same judgment
errors as everyone else. In S. O. Lilienfeld and W. ODonohue (Eds.), The great ideas
of clinical science: 17 principles that every mental health professional should understand
(pp. 2948 ). New York: Taylor and Francis.
Ullmann, L. P. (1977). Behavioral community psychology; Implications, opportunities and responsibilities. In M. T. Nietzel, R. A. Winett, M. L. MacDonald, & W.
S. Davidson (Eds.). Behavioral approaches to community psychology. (pp. ixxxvii).
New York: Pergamon Press.

{ PART I }

Childhood Disorders

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{1}

Tailoring Parent-Child Interaction Therapy


for Oppositional Defiant Disorder in a Case of
Child Maltreatment
Amanda M. Nzi and Sheila M. Eyberg

It is a myth that treatments following a manual look the same for all cases. This
case study illustrates how an empirically supported treatment may be substantially tailored to the needs of the family while maintaining treatment fidelity.
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. The caseworker had sent case notes detailing a history of
severe neglect. Until he was removed from his biological mothers home, Alvin
had been confi ned in a high chair during most of every day. He had also witnessed frequent physical abuse of his 3-year-old sister, although he had not himself been physically abused. The case notes indicated that when Alvin was placed
with his grandmother, she had been concerned because he spoke very little and
played alone for extended periods of time, avoiding interactions with both his
grandmother and his sister.

Key Principles/Core Knowledge


In our initial approach to this case, we drew on the literature describing the
characteristics of children with histories of maltreatment. These children are
at higher risk than children in community samples for developing internalizing
and externalizing psychological disorders, social skills deficits, school problems, aggressive behavior, posttraumatic stress disorder, and adaptive functioning delays (Clausen, Landsverk, Chadwick, & Litrownik, 1998; Marcus, 1991).
Children under the age of 6 in the welfare system are particularly vulnerable to
negative outcomes associated with multiple placements, including developmental
delay (Fisher, Burraston, & Pears., 2005) and attachment disruptions (Baer &
Martinez, 2006) if maltreatment occurs on multiple occasions.

Childhood Disorders

Assessment Strategy
Based on information from the case notes, we identified the assessment domains
to include clinical interview, standardized testing, and structured behavioral
observations. We planned to use the clinical interview to elaborate and clarify
the presenting concerns. To address the first referral question concerning Alvins
intellectual functioning, we planned to administer the Wechsler Preschooler and
Primary Scale of Intelligence III (WPPSI-III; Wechsler, 2002). To explore Alvins
behavior problems and his relationship with his grandmother, we planned to
use the Dyadic Parent-Child Interaction Coding System IV (DPICS-IV; Eyberg,
Nelson, Ginn, Bhuyian, & Boggs, in press), which provides a functional analysis
of Alvins 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. Our initial assessment strategy was based on well-researched, multimethod diagnostic procedures.
At the time we met Alvin and his grandmother, Alvin had been in her home
for three months. In the waiting room, Alvin was playing with toys on the floor
by himself. He initially ignored requests from his grandmother to come with us
to the examination room. His grandmother walked over to him and explained
sweetly, Its time to go with the ladies now Alvin. Please dont make me have to
feel bad. After a minute, she attempted to pick him up, and he began screaming
and resisting her efforts as she physically led him to the playroom. Once in the
playroom, Alvin began excitedly playing with the toys. Because of the sensitive
nature of the interview information, we asked his grandmother if she would be
comfortable with Alvin playing in this room while we talked in the adjoining
observation room, so that we could keep an eye on him and talk freely.
During the clinical interview with Alvins grandmother, she confirmed the
information from the case notes detailing Alvins significant history of neglect
and his symptoms of oppositional defiant disorder (being noncompliant, easily annoyed, and quick to anger, and having frequent temper tantrums). She
described some continuing concern about his unresponsiveness to her, and in
particular his refusal to let her hug him or show affection, as well as extreme irritation and bossiness toward his sister whenever she tried to join in his play or touch
his things. Alvins grandmother also elaborated on Alvins refusal to do what
she asked, which involved severe temper tantrums in response to her direction,
often lasting for as long as an hour or until she withdrew her demand. However,
she proudly reported that since coming to live with her, 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.
Our initial assessment plan was to evaluate Alvins intellectual functioning
to rule out intellectual disability. He willingly followed the therapist to the testing room, but he refused to sit at the table. Despite the many different strategies
that were employed to engage him in formal testing, Alvins oppositional behavior escalated. He tested many limits by repeatedly crawling under and jumping
up from under the table, and then he progressed to more aggressive behaviors,

Tailoring Parent-Child Interaction Therapy

throwing papers off the table and attempting to rip pages from the test booklet. We thought it might be necessary to treat Alvins behavior problems before
adequate intellectual testing could be accomplished.
We continued with the assessment, administering standardized questionnaire
measures to evaluate both (a) Alvins broadband psychological functioning, using
the Behavior Assessment System for Children, Version 2 (BASC-2; Reynolds &
Kamphaus, 2004) and (b) his grandmothers parenting stress, using the Parenting
Stress Index, Short Form (PSI-SF; Abidin, 1995). Results from the BASC-2 indicated clinically significant externalizing behavior problems, with highest scores
on subscales of aggression and conduct problems, and subclinical elevations on
activities of daily living, including the subscales of adaptability and social skills.
Internalizing behavior problems were rated in the average range. On the PSI-SF,
Alvins grandmothers scores were at the 35th percentile on the Parent Distress
subscale, at the 70th percentile on the Parent-Child Dysfunctional Interaction
subscale, and at the 85th percentile on the Difficult Child subscale. The information from these instruments provided initial hypotheses for our diagnostic formulation, including Alvins primary presentation of anger and defiance as well as
his diminished interpersonal and adaptive functioning. The testing information
also reflected the grandmothers distress over Alvins behaviors and the quality
of their relationship.
While Alvins grandmother completed these questionnaires, the therapist
played with Alvin and collected informal observations of his behavior. When
invited to play with cars, Alvin was immediately excited and eagerly pulled them
out of the toy box. The therapist joined him by the cars and described his play.
Although Alvin didnt make eye contact with the examiner, he created stories
about the cars and continued his stories enthusiastically in response to the therapists comments. The therapist told Alvin that she had to step out for a minute
to check on his grandmother. He then made eye contact and asked, Are you
leaving me? Despite reassurance, Alvin stood and approached the therapist and
continued to repeat statements such as When are you coming back? and Are
you coming back? Alvins grandmother had fi nished her questionnaires and
returned with the therapist to the playroom. When they entered, Alvin ran up to
the therapist and hugged her legs, and then described his car game to her in an
animated manner, without acknowledging the presence of his grandmother.
After a break, we introduced the three DPICS-IV standard situations that we
would use to observe the interactions between Alvin and his grandmother. For
the fi rst 5-minute observation, we asked the grandmother to let Alvin lead the
play in the low-demand, child-led play situation. Alvin sat at the opposite end of
the play table from his grandmother and again played enthusiastically with the
cars. His grandmother asked him many questions about his play, but Alvin did
not respond to her inquiries. When his grandmother asked if she could play with
the cars, too, Alvin responded, No, theyre for the other lady.
In the second DPICS-IV situation, called parent-led play, we asked the grandmother to choose the play activity. She asked Alvin if he would like to draw with
the crayons, and he said, I need to put the cars through the carwash first. The

Childhood Disorders

grandmother responded, Okay, thats good. Then can we draw? and Alvin said,
The cars have to get dry. You draw it. He responded to most of her commands
with countercommands during this 5-minute observation.
In the fi nal, high-demand situation, cleanup, Alvins grandmother was asked
to have Alvin put the toys away by himself. After asking him once if he would like
to clean up the toys, 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. She continued
to suggest ideas that might get Alvin to help, but when she became more insistent,
Alvin started screaming and throwing the toys at the toy box across the room.
The DPICS-IV data indicated that the grandmothers primary verbalizations
in all three situations were questions (including indirect commands (e.g., Would
you like to . . . ), acknowledgments (e.g., okay), and unlabeled praises (e.g.,
good). Each of these brief verbalizations was repeated very frequently, stated
warmly, and suggested highly permissive parenting. Her praise and positive
attention occurred both when she approved and when she disapproved of Alvins
behavior. He did not comply with any of his grandmothers indirect commands.

Epidemiological and Contextual Considerations for Case Formulation


The results of the psychological evaluation showed consistent evidence of oppositional and defiant behaviors across interview, BASC-2, and behavioral observations of Alvins response to high-demand situations, suggesting a diagnosis of
oppositional defiant disorder (ODD). 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, Burke, Lahey, Winters, & Zera, 2000).
On the PSI-SF, his grandmothers results were within the normal range except
on the Difficult Child scale, suggesting that her distress was limited to concerns
about his behavior.
In our observations of Alvins responses to the therapist and his grandmother,
it was evident that Alvin also engaged in excessive familiarity with relative strangers and was often unforthcoming with his grandmother. 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; American Psychiatric
Association [DSM-IV-TR], 2000).
To diagnose RAD, it is necessary to rule out intellectual delay and pervasive
developmental disorder. Because Alvin demonstrated with the therapist the ability to engage in appropriate social conversation and to initiate eye contact, combined with his history of normal speech and motor development and the absence
of stereotyped behaviors, we were able to rule out a diagnosis of pervasive developmental disorder. Despite our inability to complete intellectual testing, we felt
comfortable ruling out intellectual disability at this time, based on the BASC-2
results of Alvins adaptive behaviors and our observations of his current developmental skills. There are neither psychometrically sound studies examining

Tailoring Parent-Child Interaction Therapy

the diagnostic accuracy of an attachment disorder among maltreated children


nor any evidence-based assessment instruments for this diagnosis (Chaffi n et al.,
2006). In addition, there is little systematically gathered epidemiological information on the prevalence, incidence, or natural course of RAD that could be
used to confirm our diagnosis (Chaffi n et al., 2006; Hanson & Spratt, 2000).

Case Formulation
At the conclusion of the evaluation, we provided brief feedback to Alvins grandmother. We first commented that it was good she came in to seek help for Alvins
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. 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,
Alvin had perhaps learned that caregivers could be more unpredictable and inconsistent in meeting his needs than unfamiliar adults, 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, 2003).

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. There are at
least five evidence-based parent training interventions for disruptive behavior
in preschool-age children (Eyberg, Nelson, & Boggs, 2008). Among these treatments, 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, 2004), and for this reason it was
considered for Alvins treatment. Although there is no intervention that has been
identified as empirically supported for treating RAD, PCIT meets the American
Professional Society on the Abuse of Children (APSAC) task force guidelines for
treating children with attachment problems (Chaffin et al., 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. The APSAC guidelines further indicate
that the interventions should be short-term, should involve the primary caregiver,
and should focus on increasing parental sensitivity. For these reasons, we selected
PCIT as the treatment we would use in this case (Eyberg & Funderburk, 2011).
PCIT outcome studies evidence increases in positive parenting skills and
decreases in disruptive child behavior (Zisser & Eyberg, 2010) and physical reabuse rates (Chaffin et al., 2004; Thomas & Zimmer-Gembeck 2011, 2012). The conceptual foundation of PCIT is based broadly in the developmental and behavioral

Childhood Disorders

literature. PCIT is based on Baumrinds (1966, 1991) developmental theory, which


holds that authoritative parentinga combination of nurturance, good communication, and behavioral regulationproduces optimal child mental health
outcomes. By providing caregivers with the skills to attend selectively to child
behavior, the caregiver also learns to be more sensitive to the child, to respond
with greater warmth, and to become more emotionally available, thus creating a
more secure caregiverchild attachment and reducing parent stress (Eisenstadt,
Eyberg, McNeil, Newcomb, & Funderburk, 1993; Fussell, Nzi, & Eyberg, 2012).
In PCIT parents learn authoritative parenting skills during two sequential
phases of treatment. In the first phase, parents learn to follow their childs lead
in play by providing attention to positive child behavior, combined with active
ignoring of negative child behavior, to create an empathic, nurturing parent-child
interaction called the child-directed interaction (CDI). During the second phase
of PCIT, called the parent-directed interaction (PDI), parents learn to direct
their childs behavior when necessary and to provide consistent consequences.
PCIT is a performance-based intervention in which the caregivers skills and the
childs behaviors are monitored weekly to guide progress through treatment and
to determine when treatment ends. The caregivers report of the childs behavior,
using the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), and
behavioral observation of the caregivers treatment skills, using the DPICS-IV,
are assessed at the beginning of each session. The results of these measures are
graphed weekly and are reviewed with the caregivers at the end of each session.

Alvins Treatment
At the feedback session, we established the plan for Alvins treatment. Because
Alvin was in a temporary guardianship arrangement with his grandmother, it
was important to explore the stability of this placement. If there were a possibility of reunification with his biological mother, it would be important to involve
her in treatment to establish the primary attachment relationship with the anticipated permanent caregiver. The grandmother informed us that Alvins long-term
placement plan was adoption by his grandmother due to the unstable psychological condition of his biological mother. As a result, the decision was made to
proceed with PCIT including only Alvin and his grandmother. 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. We arranged to see Alvin
in a satellite clinic at their community center for treatment.
The following week, Alvins grandmother attended the fi rst PCIT session, the
CDI teaching session, alone. In this session, caregivers learn to follow the childs
lead in play with positive attention, expressing approval and enjoyment of the
childs ideas, behaviors, and activities by describing and praising the childs positive play behaviors and by reflecting (paraphrasing) the childs comments during
play. At the same time, caregivers learn to avoid intrusive verbal behaviors such

Tailoring Parent-Child Interaction Therapy

as questions, commands, and criticism, which can give attention to and increase
negative child behaviors. Through the behavioral mechanisms of modeling and
differential social attention, many negative child behaviors drop away during the
CDI, and the parent-child play begins an upward cycle of mutually reinforcing
and responsive interactions. In the CDI teaching session, the therapist demonstrates the individual skills of the CDI, role-plays the skills with the parents, and
describes the emotional and behavioral effects of each skill on the child. Near the
end of the session, when reviewing the kinds of toys that work best when practicing the skills at home, the grandmother mentioned that Alvin did not have many
toys besides his tricycle and football. The therapist described some ways to make
toys out of household items, 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.
All subsequent sessions in the CDI phase of treatment are called CDI coaching sessions. In these sessions, the caregiver and child practice the CDI skills
together in the playroom while the therapist observes and coaches the caregiver
from an observation room. The coaching sessions begin with a 5- to 10-minute
check-in when the therapist and caregivers review the CDI homework and the
childs behavior during the previous week. The therapist then has the caregiver
begin practicing the CDI with the child while the therapist codes the interaction
from an observation room. By coding, or tallying, the frequency of the caregivers
skills during a 5-minute observation, the therapist can assess the progress made
since the previous session and can determine which skills to focus on during
coaching. When coaching the CDI, the therapist initially focuses on following the
caregivers lead, commenting positively on the parents use of the new skills, just
as the caregiver follows the childs lead in the CDI. One of the most effective kinds
of coaching statements is a short, labeled praise, such as Nice description! or
Excellent behavior to praise, after the caregiver uses a CDI skill. Coaching in
CDI becomes slightly more directive after one or two coaching sessions, when
caregivers are comfortable with the procedure. For example, a therapist might
suggest that the caregiver praise a particular behavior (e.g., You could praise
him for sharing with you) to help caregivers notice cooperative behaviors.
At the first CDI coaching session, we reviewed the PCIT homework sheet (Eyberg
& Funderburk, 2011; see Figure 1.1), which showed that Alvins grandmother had
practiced all seven days since the teaching session. To reinforce the importance of
daily homework practice, the therapist took time to discuss all of the comments that
Alvins grandmother had written and to praise the good toy and activity choices she
had come up with, which included building towers with food cans from the pantry.
During observation of the CDI interaction, the grandmother increased her use of
labeled praises from zero at the pretreatment assessment to five and decreased her
questions from 53 to 20, although she continued her indiscriminate use of unlabeled
praise. Alvin directed more of his play talk to his grandmother during this observation than at the pretreatment assessment. He remained distant from his grandmother,
though, by moving toy animals across the room to play there with them. When coaching in this session, it can be tempting to give corrective feedback, but we maintained
the focus on the grandmothers positive use of the skills while ignoring mistakes. Our

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 1.1.

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. When reviewing
the observation data with Alvins grandmother at the end of the session, rather than
commenting that she still asked many questions during the play, we emphasized her
improvement in decreasing questions, as well as our observation that Alvin spoke to
her somewhat more this week. She mentioned that Alvin had started talking to her
more at home also. The therapist pointed out the connection between this change and
the grandmothers consistent homework practice and commented that her practice
seemed to be reflected on her ECBI graph as well. When discussing homework for
the next week, Alvins grandmother decided to focus on increasing her reflections of
Alvins speech because he seemed to enjoy it during coaching.
Alvins grandmother continued to practice homework daily, and at the second
CDI coaching session she described continued improvements in his behavior at
home, including fewer temper tantrums during the week. During the 5-minute

Tailoring Parent-Child Interaction Therapy

11

coding, she demonstrated improvement in the frequency of her reflections, but her
questions remained high and she often did not seem aware of asking a question.
Alvin continued to increase the frequency of comments he directed to his grandmother about the play. His grandmother joined Alvin to play on the floor, and he
did not move away. However, she shifted uncomfortably while sitting on the floor,
and it seemed that her discomfort was affecting her ability to focus on the treatment skills. Before coaching began, the therapist entered the playroom to praise the
grandmother for following Alvins 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. The grandmother agreed, and Alvin helped her move the toys. The therapist
prompted his grandmother to praise him for playing with her at the table.
While in the room, the therapist told the grandmother that reducing questions
would be a focus of todays coaching. 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, to help the grandmother become more
aware of them. The grandmother expressed enthusiasm, and the plan was made for
the therapist to signal by saying question, after which the grandmother would
attempt to restate the question as a statement. During subsequent coaching, the
grandmother increasingly caught her own questions mid-stream or before.
When Alvin and his grandmother came to the third CDI coaching session,
his grandmother was beaming. She reported that Alvin had gotten ready for bed
without a temper tantrum for the last three days, and Alvin said to the therapist,
I went to bed fast! with a big smile on his face. The therapist asked the grandmother what she thought had contributed to this change, and the grandmother
mentioned that she had been praising Alvin for getting ready quickly each time
he did it. The therapist pointed out that the grandmother had used a positive
opposite praise (i.e., going to bed quickly) instead of focusing on the problem
behavior (i.e., getting ready slowly) and that she had used one of the best kinds of
praise to help Alvin change his behavior.
During the DPICS-IV observation of their interaction, Alvins grandmother
was catching most of her questions, restating them as CDI skills, and she had also
increased her labeled praises to 5. Still, she continued to use the unlabeled praise
good indiscriminately in response to many of Alvins comments, including
comments he made that were bossy or that contradicted something she had done,
such as telling her to put a toy in a different place than she had. Even though Alvin
continued to tell his grandmother what to do, he sat closer to her, and his directions were stated more matter-of-factly than with anger. 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, like sharing. The therapist also coached the grandmother to ignore
Alvins bossy statements, often by praising her for staying quiet (good ignoring)
before she had the chance to say good. After coaching for only a few minutes,
Alvins grandmother dramatically increased her labeled praise of Alvins positive opposite behaviors, and Alvin became increasingly engaged with his grandmother in play. Notably he was asking nicely more often for his grandmother to
join his play in a particular way, rather than telling her what to do.

12

Childhood Disorders

Alvin and his grandmother arrived 10 minutes late to the fourth CDI coaching session, and his grandmother appeared distraught. During the check-in, she
described losing her social security check and began to elaborate on the consequences of losing this check. 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. This interaction illustrates another common trap that the therapist avoided.
Instead of using the session time to process the distressing event or attempting to
help the grandmother problem-solve a solution, the therapist found a way to refocus the grandmother on the session goals and avoid derailing the childs progress.
The grandmothers CDI skills had continued to improve during the previous
week and during in-session coaching. Her improved mood at the end of the session may have helped her work more effectively with the social worker, who was
able to obtain emergency funding.
In the fifth CDI coaching session, 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. During coding and coaching,
the therapist observed that Alvins grandmother had to ignore negative and bossy
statements more often than in recent sessions. When she scored the ECBI, she also
noted that Alvins behavior problems had increased, and although they were still
below the clinical range, they were noticeably higher than they had been the week
before. This pattern on the ECBI graph often reflects a decrease in homework practice. During the review of the ECBI graph, the therapist described this pattern to
the grandmother and used motivational enhancement strategies to facilitate the
grandmothers commitment to resuming special time practice sessions each day.
Alvins grandmother said that Alvin had asked to have special time a few times,
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.
At the sixth CDI coaching session, Alvins grandmothers skills had greatly
improved from previous weeks, and she had almost achieved the CDI mastery criteria. 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. The
warmth of the interaction was qualitatively improved as wellthey laughed together
in session, and Alvin rested his head on his grandmothers shoulder when she told
him she was proud of how polite he was being. Alvin did not pull away when she put
her arm around him. The grandmothers ECBI score had reached the criterion level
for treatment termination, 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. The therapist pointed out that she was very close to mastery of the CDI skills
and that her description of Alvins behavior on the ECBI placed his behavior well
into the normal range at this point in treatment already. The therapist discussed the
importance of thinking about her and Alvins progress towards meeting their treatment goals in order to re-evaluate their treatment plan during the next session.
As the therapist had anticipated, during the seventh CDI coaching session,
Alvins grandmother met mastery criteria for the CDI skills. Her ECBI ratings of

Tailoring Parent-Child Interaction Therapy

13

Alvins behavior at home continued to be within the average range for children
his age, and she continued to report confidence in managing his few remaining
behavior problems. Because she was able to manage his behavior adequately with
positive attention and active ignoring, moving on to the PDI phase of treatment
was not obligatory. The therapist considered potential advantages and disadvantages of this second phase for Alvin and his grandmother, in which caregivers
learn to set fair but fi rm limits and to follow through on their rules with a timeout consequence for noncompliance, in addition to praise for compliance. For
children with ODD who have not experienced consistent limit-setting and followthrough, the time-out procedure is usually emotionally distressing initially. With
the recent, still developing attachment relationship between Alvin and his grandmother, the therapist decided to recommend not moving into the PDI phase of
PCIT. The therapist discussed these issues with Alvins grandmother, who agreed
and added that she felt that she and Alvin had met their treatment goals and were
ready to graduate. 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 also let the grandmother know
that she could contact her before their scheduled follow-up call if she had any
concerns about Alvins behavior.

Review of General Therapy Process


Many nonspecific issues common across all treatments were exemplified in the
case of Alvin and his grandmother (Eyberg, in press). Dealing with adherence
issues was evidenced by the therapists response to homework noncompliance
in the fi fth CDI coaching session. The therapist pointed out the correspondence between practice and progress that can be seen weekly on the ECBI graph,
enhancing the grandmothers motivation to complete homework consistently (see
Figure 1.2). This case also illustrated ways in which the therapist was able to avoid
common mistakes that can harm the therapeutic alliance or therapy progress.
For example, when the grandmother arrived at the fourth CDI coaching session
in distress regarding her fi nances, the therapist validated her concerns, but maintained focus on the established treatment goals. Consideration of cultural factors
in this case were highlighted by the therapists sensitivity to the caregivers socioeconomic situation, as shown by holding sessions at an easily accessible facility in
the grandmothers community to reduce fi nancial burden. 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.
Highly important process issues arise when addressing treatment termination
and relapse prevention. In this case, the therapist critically evaluated with the
grandmother the need for further treatment once the identified treatment goals
were achieved. A concrete plan was established for maintaining gains, and a follow-up call was scheduled to monitor progress and prevent relapse.

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 Grandmothers Weekly Ratings of Alvins Behavior Problems


during Treatment on the Eyberg Child Behavior Inventory (ECBI)

FIGURE 1.2.

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. In all evidence-based treatments, the pretreatment
assessment is essential to the process of tailoring treatment effectively. A diagnosis of ODD often occurs with comorbid disorders, and complex contextual factors are present in many families of children with ODD (Knock, Kazdin, Hirpi,
& Kessler, 2007). A comprehensive multimethod assessment provided information on three important aspects of this case that guided our treatment selection
and planning. The childs history of maltreatment and his diagnosis of ODD led
us to select PCIT as an appropriate evidence-based treatment. In considering the
relatively uncommon diagnosis of RAD, we sought guidance from the literature.
The recommendation that treatment be grounded in both behavioral and attachment theories also suggested that PCIT would be an appropriate fit.
Observational data provided key information on the childs attachment behaviors and the grandmothers permissive parenting style for the considerations in
tailoring coaching during treatment. These observations were supported by the
additional standardized questionnaires completed by the primary caregiver. One
strategy used in coaching with this case was to increase the grandmothers positive verbal attention to the childs initially limited conversation. A second coaching strategy was to increase the selectivity and specificity of the grandmothers
praise to the child, which more effectively conveyed her approval while enhancing the childs trust in her as a safe and nurturing caregiver. As mutual security in the relationship increased, the child became less insistent on remaining
in control of their interactions and gradually began accepting the grandmothers

Tailoring Parent-Child Interaction Therapy

15

suggestions for play. The grandmother became more open to coaching recommendations to ignore inappropriate behavior and, as a result, she was able to
use differential social attention effectively to manage her grandsons behavior,
setting in motion a positive reinforcement cycle. Treatment was completed when
the grandmothers CDI skills reached mastery level, enabling her to manage and
maintain the childs behavior within normal limits for disruptive behavior. 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, 2003) and for the childs 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.

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Chadwick Center on Children and Families. (2004). Closing the quality chasm in
child abuse treatment: Identifying and disseminating best practices. San Diego, CA:
Author.
Chaffi n, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova,
T., . . . Bonner, B.L. (2004). Parent-child interaction therapy with physically abusive
parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical
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Chaffi n, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., et al. (2006). Report
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16

Childhood Disorders

Eyberg, S. M., & Funderburk, B.W. (2011). Parent-child interaction therapy protocol.
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Eyberg, S. M., & Pincus, D. B. (1999). Eyberg child behavior inventory and SutterEyberg student behavior inventory: Professional manual. Odessa, FL: Psychological
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COMMENTARY

Patrick C. 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, the
paper reflects the remarkable potency and flexibility of PCIT. On the other hand,
it reflects the clinical acumen and interpersonal dexterity of the clinicians who
reported the case. We will discuss both of these aspects below.
We both came into contact with PCIT-related material during graduate school,
although at dramatically different points in time. My (Friman) initial contact
was during my first year in graduate school (1980) when I was assigned a highly
relevant reading (Peed, Roberts, & Forehand, 1977). Stacy Shaws 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). As a review of the relevant literature shows, Mark Roberts contributed
significantly to the early empirically derived knowledge base that has contributed to PCIT (e.g., Roberts, Hatzenbueler, & Bean, 1981; Roberts, McMahon,
Forehand, & Humphreys, 1978), and PCIT is, arguably, the most widely used and
empirically supported approach to disruptive behavior in young children in the
history of child psychology. But there are two other sources that are worth mentioning here; both are remarkable, but for different reasons.
The fi rst is a now legendary woman whom we did not have the opportunity
to meet, Constance Hanf. She was a professor at the Oregon Health Sciences
University (OHSU), where she had a tremendous impact on child clinical psychology. Specifically, she formulated the fi rst two-stage parent training protocol,
which remains the basis for many of the behavioral parent training protocols in
existence today, including PCIT. Hanfs influence is rather remarkable given that
her work was never published. Her name appears on only one conference presentation and two unpublished manuscripts (Hanf, 1969; Hanf, 1970; Hanf & Kling,
1973). Instead, her influence appears to be primarily derived through the interns
and postdoctoral fellows whom she trained at the OHSU. Dr. Hanfs students
read like a Whos Who of child clinical psychology (e.g., Rex Forehand, Sheila
Eyberg, Russell Barkley), and it is they and their students (e.g., Cheryl McNeil,
Carolyn Webster-Stratton) who went on to refi ne, test, and ultimately disseminate her approach.

18

Childhood Disorders

The second name that deserves special attention here is the second author
of the source document for these remarks, Sheila Eyberg. As noted above, Dr.
Eyberg is one of several prominent psychologists who trained at the OHSU with
Dr. Hanf. Dr. Eyberg herself went on to produce one of the more rigorous, generative, and creative lines of systematic replication in the field of applied child psychology (e.g., Eyberg et al., 2001; Eyberg & Matarazzo, 1980; Eyberg & Robinson,
1982). Dr. Hanf appears to have introduced the concept. Dr. Eyberg has evolved it
into the best-known empirically supported approach to child disruptive behavior
in this country, perhaps in the world. We could say more about the contributions
of these two remarkable people but space forbids elaboration.
This brings us to the target chapter by Nzi and Eyberg: it is the latest addition to the large body of literature that persuasively reveals the effectiveness
and durability of PCIT. 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.phhp.
ufl.edu/Literature.htm for a comprehensive list of PCIT literature). For these
reasons, 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. Nzi 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. They are: Helping the Noncompliant Child (Forehand & McMahon, 1981),
The Incredible Years (Webster-Stratton & Reid, 2003), Parent Management
Training Oregon Model (Patterson, Reid, Jones, & Conger, 1975), and Positive
Parenting Program (Sanders, 1999) (see Eyberg, Nelson, & Boggs, 2008, for a
more detailed description of empirical support). In the case described by Nzi
and Eyberg, 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, 2004).
In addition to the aptness of the treatment selection, there are several other virtues of the target chapter, but four are particularly noteworthy. The fi rst involves
the clinical presentation of the participating child. The literature on reactive
attachment disorder (RAD) is mostly descriptive, not wholly empirical, and the
portion devoted to treatment is quite small. This paper provides clinicians with
a practical conceptualization of RAD-associated treatment goals and a userfriendly guide for related treatment techniques. Although admittedly without an
empirical basis, 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.
The second involves the extent to which the authors adapted to a highly
complex set of socioeconomic conditions. Specifically, there were three potential barriers to success in this caseethnicity, socioeconomic status (SES), and
generational differenceand all three were bridged successfully. Of the three,
the most difficult in our experience has been generational difference. That is,

Tailoring Parent-Child Interaction Therapy

19

establishing adherence to parent training treatment requirements is difficult


enough when working with a parent, but when working with a grandparent the
difficulties multiply. This is especially true when the therapist is quite young. It
is perhaps even more difficult when the therapist does not have a family of his
or her own. Whether this is the case with the fi rst author, we cannot say, but we
suspect that Nzi was significantly younger than her client. Despite the potential
difficulties posed by this barrier and the others we have mentioned, the therapist (we assume it was Nzi) obtained excellent compliance, which is almost
certainly a testament to her skills as a therapist, but even more important, is a
testament to the compelling nature of PCIT. Practical barriers such as transportation difficulty and serious fi nancial problems are also difficult and can
waylay even the most experienced therapist. In this case, the therapist successfully addressed the grandmothers transportation and fi nancial needs without
distracting from the pursuit of an effective therapeutic application. Balancing
in-session demands is often tricky, and, like the therapist in this case, we have
found that having good social worker and community agency referrals can be
a session saver.
A third virtue involves a strategic modification to the conventional form
of PCIT, which usually involves a version of time-out. Because of the special
clinical presentation of the child involved (history of abuse, neglect, RAD), 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.
Moreover, the treatment goals had been reached, making the more invasive disciplinary procedures unnecessary. We also speculate that for a child affl icted with
RAD, consequential detachment could function as a reinforcer. For all of those
reasons, placing emphasis on the child empowerment version of the therapy may
be just what the doctor ordered, so to speak. And given the outcome, that appears
to have been the case here.
The fourth virtue brings us back to Drs. Hanf and Eybergs tremendous contributions to the treatment of childhood conduct problems from a social learning
perspective. Specifically, both emphasize objective data collection, particularly
through behavioral observation techniques, which are a somewhat unique staple of parent training from a social learning perspective. Again, Dr. Hanf seems
to have introduced the concept and Dr. Eyberg has cemented it as a standard
of practice. We cannot say enough about the value of objective data in clinical
practice and appreciate the comments on its use, from the assessment of Alvins
presenting problem and treatment progress to the assessment of Alvins grandmothers skill acquisition.
In closing, we both believe this is an excellent case report for the reasons mentioned above. Specifically, it is one more tribute to the power of PCIT. And, more
specifically, it indicates that PCIT can be adapted to cross generational, ethnic,
and socioeconomic lines and can be modified to fit special diagnostic characteristics. Thank you very much for inviting our opinion.

20

Childhood Disorders

References
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abuse treatment: Identifying and disseminating best practices. San Diego, CA:
Author.
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Patterson, G. R., Reid, J. B., Jones, R. R., & Conger, R. E . (1975). A social learning
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parental instruction-giving on child compliance. Behavior Therapy, 9, 793798. doi:
10.1016/S0005-7894(78)80009-4
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doi:10.1016/S0005-7894(81)80109-8
Sanders, M. R. (1999). 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. Clinical Child and Family Psychology Review, 2,
7190. doi:10.1023/A:1021843613840

Tailoring Parent-Child Interaction Therapy

21

Webster-Stratton, C., & Reid, M. (2003). The incredible years parents, teachers, and
children training series: A multifaceted treatment approach for young children with
conduct problems. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 224240). New York: Guilford. doi:0.1111/j.14753588.2007.00475.x

RESPONSE

Amanda M. Nzi and Sheila M. Eyberg

In their assumptions that the first author of our case study is a graduate student,
young, not yet a parent, and Alvins therapist, the commentators are 4 for 4.
We thank them for their comments on this case. I (Eyberg) also want to acknowledge Nzis clinical acumen. A fourth-year graduate student at the time, Nzi had
completed her clinical coursework and practica, had treated over 20 PCIT cases
before working with Alvin, and recently received the departmental award for
psychotherapy skill. PCIT is a difficult treatment to conduct, and Alvins presentation was challenging. This case study indeed demonstrates Nzis skill, experience, and talent.
In this response, I (Eyberg) wish fi rst to clarify a historical assumptions in
the commentary. Unfortunately, I was not a student of Constance Hanf. I was a
clinical psychology intern at the University of Oregon Medical School (UOMS)
in the internship program directed by Arthur Wiens. 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. As the commentators note, Hanf mentored several UAF interns and postdocs who subsequently developed treatments
influenced by her mentorship (Barkley, Cunningham, Forehand). Although I was
not able to observe Hanfs work due to her sabbatical the year that I was an intern
(19711972), I learned about it from my internship mentor, H. Elizabeth King.
Along with the writings of Diana Baumrind (1967), Virginia Axline (1947), and
Gerald Patterson (e.g., Patterson & Gullion, 1968), Hanfs work (1969) contributed importantly to the development of PCIT during my internship and residency
at UOMS (see Funderburk & Eyberg, 2010; Eyberg & Matarazzo, 1975). King
moved to Georgia and published the fi rst studies of Hanf-influenced treatment
with Forehand (Forehand & King, 1974; Forehand, King, Peed, & Yoder, 1975).
Since that time, generations of students have researched and refined the early
treatments influenced by Hanf.
Second, we wish to emphasize our clinical approach to the case of Alvin. As
Friman and Shaw suggest, this case provides an illustration of the flexibility of
the evidence-based, manualized treatment protocols for children. Alvins treatment followed the PCIT protocol with fidelity, while tailoring standard elements
to meet the unique needs of this family. Tailoring refers to changes in the delivery

Tailoring Parent-Child Interaction Therapy

23

style of therapy elements and components to accommodate the individual sensibilities of each family, without altering the procedures themselves (Eyberg, 2005),
and it occurs with every family in treatment. In the case of Alvin, moving the toys
to the table and focusing on attachment concerns during coaching are two examples of this approach. The decision to end treatment after CDI is another example
of tailoring, based on our knowledge that Alvins disruptive behavior was rated
within normal limits by his grandmother, that she had mastered the CDI skills,
and that her skills markedly changed the quality of interaction between the two.
Her skillful application of contingent attention during the CDI was sufficient to
manage the behavior problems that Alvin presented. Typically, caregivers opt to
continue on to PDI to learn ways to apply contingent attention in the discipline
interaction. In Alvins case, however, the therapist and the grandmother decided
that continuing to PDI was not the best course of action at this time.
There is no evidence to suggest that a CDI-only protocol would be suitable
for the entire RAD population, and we do not recommend such an adaptation at this time. In contrast to tailoring treatments for the individual family, 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; Eyberg, 2005). 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, such as greater acceptability in the new population (or greater
effectiveness). Decades of research have documented the effectiveness of ESTs,
and it is important to maintain the integrity of these treatments for the best
clinical outcomes. 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.

References
Axline, V. (1947). Play therapy. Boston: Houghton Miffl in.
Baumrind, D. (1967). Child care practices anteceding three patterns of preschool behavior. Genetic Psychology Monographs, 75, 4388.
Eyberg, S. M. (2005). Tailoring and adapting parent-child interaction therapy to new
populations. Education and Treatment of Children, 28, 197201.
Eyberg, S. M., & Matarazzo, R. (1975, April). Efficiency in teaching child management
skills: Individual parent-child interaction training versus group didactic training. Paper
presented at the meeting of the Western Psychological Association, Sacramento.
Forehand, R., & King, H. E. (1974). Pre-school childrens non-compliance: Effects of
short-term behavior therapy. Journal of Community Psychology, 2, 4244.
Forehand, R., King, H. E., Peed, S., & Yoder, P. (1975). Mother-child interactions:
Comparison of a noncompliant clinic group and a non-clinic group. Behavior
Research and Therapy, 13, 7984.

24

Childhood Disorders

Funderburk, B. W., & Eyberg, S. M. (2010). History of parent-child interaction therapy. In J. Norcross (Ed.). History of Psychotherapy: Continuity and Change (2nd ed.,
pp. 415420). Washington, DC: American Psychological Association.
Hanf, C. (1969). A two-stage program for modifying maternal controlling during motherchild (M-C) interaction. Paper presented at the meeting of the Western Psychological
Association, Vancouver, BC, Canada.
Patterson, G. R., & Gullion, M. E. (1968). Living with children: New methods for parents
and teachers. Champaign, IL: Research Press.

{2}

Attention Deficit/Hyperactivity Disorder


(ADHD)
Kevin M. 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.
Since age 15, Pat has had multiple legal infractions, including several substancerelated charges. (His most recent legal charge, driving while impaired, prompted
the current referral.) At the time of referral, Pat was living with his mother, was
employed part-time as a pizza delivery person, and was not currently enrolled in
college. He was not engaged in any type of treatment at the time of referral. Pat
was diagnosed with attention deficit/hyperactivity disorder (ADHD) at age 7.
The case of Pat represents a fairly typical case of a young adult who was diagnosed with ADHD in childhood. This case may or may not be applicable to those
individuals who were initially diagnosed with ADHD during adulthood.

Pat: Childhood
Pat was born full-term, the product of a planned pregnancy. He attained his
developmental milestones in an age-appropriate fashion. As a toddler, Pat
was described as an active child who had a great imagination. With peers,
he was described as bossy and could be stubborn; nonetheless, he had a keen
interest in social relations and was described as a social butterfly. At home, Pat
could be oppositional and/or defiant, but his mother reported that he responded
very well to point systems and other strategies rooted in operant conditioning.
During early elementary school, Pats teachers had concerns regarding his
abilities to exert self-control and complete tasks. Negative peer exchanges, often
escalating to aggression, became more common in 2nd grade (age 7). At the
request of his school, Pat was referred for a mental health evaluation. His parents
were still married at the time of this evaluation; while his mother was concerned
about his behaviors and difficulties with authority, his father was less concerned

26

Childhood Disorders

and believed that many of Pats difficulties were a function of a poor childteacher match. Based upon the evaluation, Pat was diagnosed with ADHD,
combined type, and oppositional defiant disorder (ODD).
In addition to the standard psychiatric evaluation, the school district also completed a psychoeducational evaluation. Results from that evaluation documented
that Pat had above average intellectual potential (Wechsler Intelligence Scales for
Children III [WISC-III], Full Scale IQ = 119) with especially strong perceptual/
spatial skills (WISC-III Perceptual Organization Skills standard score = 130).
Pats academic attainment was similarly described as above average for age. The
school appropriately concluded that Pats difficulties at school were not a function of a learning disability.
While a combined psychosocial and pharmacological treatment plan was recommended by the mental health professional, Pats parents did not wish to medicate their son. His parents did, however, enroll him in a social skills treatment
group. In addition, Pat and his parents also participated in family therapy aimed
at improving family functioning.
Pat completed the social skills group with limited improvement. In fact, his
mother reported that Pat learned new ways to be devious by observing other
children in the group. In addition, family therapy was discontinued after several
months due to increasing confl ict between Pats parents. Much of the confl ict
between his parents was attributed to Pat and his difficulties.
For the remainder of elementary school, Pat was not engaged in any type of
ADHD or mental health treatment. While he continued to excel academically,
his behavior and peer relationships at school both continued to be impaired.

Pat: Early Adolescence


Pat attended a new school for 5th grade, after having completed K4th grades
at the same elementary school. This transition brought with it new teachers and
some new students. (While Pat did not switch school districts, the middle school
was fed by several different elementary schools.) These new faces and the transition proved to be very difficult for Pat. Within the fi rst month of school, Pats
parents were getting almost daily phone calls from his school regarding disruptive behaviors. Academically, despite having made strong progress in elementary
school, Pats grades slipped considerably in middle school. He was having great
difficulties managing the increased independence that was expected from a middle school student (e.g., changing classes, planning for assignments). It was also
at this time that his parents marriage dissolved and his mother fi led for divorce,
seeking and being awarded uncontested sole custody of Pat.
As a function of Pats escalating disruptive behaviors and weaker school performance, as well as the stresses associated with the divorce, his mother sought
to once again enroll Pat in some form of mental health treatment. Pat was once
again diagnosed with ADHD and ODD; once again, a combined treatment program was recommended to his mother. His school was considering moving Pat

Attention Deficit/Hyperactivity Disorder (ADHD)

27

to an alternative classroom that would be better suited to manage his disruptive


behaviors. Possibly frightened by this possibility, Pats mother discussed the use
of medication with his pediatrician. Pat was prescribed methylphenidate (initially
5 mg BID, then titrated to 10 mg BID). At the urging of Pats school psychologist,
his mother also participated in a parenting class offered at a local mental health
clinic. Finally, his pediatrician also recommended that Pat participate in therapy
with a local psychologist.
His mother reported that Pat instantly responded to the medication and was
almost like a different boy. His teachers also noted the improvement, and his
grades reflected their impressions. Pat went from a C student to an A student,
largely as a function of simply completing and turning in all of his homework
assignments. His mother was also learning more effective ways to manage Pat at
home behaviorally; she implemented a point system with a response cost component. His therapist reported that Pat was more vocal about his feelings toward his
father and was learning new, more adaptive methods to manage his anger.
While the improvements in Pats functioning were exciting, his mother was
also increasingly concerned about his poor appetite and problems getting to
sleep. In addition, his mother was concerned about his mood swings in the
late afternoon when he was coming off his stimulant medication. Pat lost several
pounds during the second half of his 5th grade year. At the urging of his pediatrician, his mother did not continue to give Pat his methylphenidate during the summer. His mother reported that many of his disruptive behaviors returned during
the summer, although she also reported that he was somewhat more manageable
than before.
At the beginning of 6th grade, and unhappy with the continued side effects
of the methylphenidate, Pats mother discussed alternative medication options
with his pediatrician. Pat was prescribed mixed amphetamine salts (5 mg BID,
then titrated to 10 mg BID). This medication similarly helped Pat exert better
self-control and had fewer side effects. Nonetheless, even with the medication,
his mothers improved parenting skills (as a function of completing her parenting class) and his continued biweekly therapy, Pat continued to have difficulties in school, both academically and socially. A review of his 6th, 7th, and 8th
grade report cards all shared the same trends: bright boy who could be doing
much better if he applied himself; focuses more on social activities than school
work; disorganized; late for class; disrespectful to authority, and so on.
Academically, Pats cumulative averages were generally in the low 80s (C) with
considerable between- and within-subject variability.

Pat: Late Adolescence


High school again brought another change in school and with it new teachers,
new students, and new expectations. As in his first year of middle school, Pat did
not do well with the transition; his mother was getting almost daily phone calls
about his behavior at school. In October of his 9th grade year, Pat was found to

28

Childhood Disorders

have marijuana in his school locker. Along with a three-day suspension from
school, he was required to participate in a substance abuse education program
administered through the county. Pat also continued to be prescribed mixed
amphetamine salts, but he was reportedly inconsistent in his adherence. There
was also concern that Pat was diverting his stimulant medications to friends.
Thus, a decision was made in February of his 9th grade year to try atomoxetine
(initially 10 mg, then titrated up to 40 mg). While Pat was reported to have initially responded well to the atomextine, over time, he and his mother were unsure
if the medication was helping. Thus, at the end of his 9th grade year, he discontinued his atomoxetine.
Pat and his mother both reported that he continued to use marijuana throughout high school. His mother was far more concerned about his marijuana use
than Pat; he insisted that the marijuana helped [me] relax. Pats friends were
also regular marijuana users and were involved in other antisocial activities (e.g.,
shoplifting, egging houses, etc.).
In 10th grade, Pat had his fi rst romantic relationship and sexual activity. Pat
reported that he dated his first girlfriend for approximately three months, and
that the relationship ended when Pat cheated on her with another classmate.
Pat also reported having unprotected sex with both girls.
Academically, Pat continued to earn low C grades across all subjects, and
concerns continued to be raised about his poor academic motivation. He did not
receive any ancillary supports, as it was felt that he could do the work if he
wanted to.
At the end of 10th grade, Pat decided that he no longer needed therapy and
discontinued his biweekly therapy sessions. He also refused to take any ADHD
medications. Thus, for both 11th and 12th grades, Pat had completely untreated
ADHD. His academic performance and behavior at school dropped appreciably.
Concerns were raised about Pat not being able to graduate unless significant
improvements occurred. He attended summer school for two subjects (History,
English) between 11th and 12th grades. He had weekly disciplinary referrals, most
often for insubordination, with the occasional peer conflict resulting in aggression. No drug charges were recorded during these two years, although Pat commented that he frequently attended school high from morning marijuana use.
Pats general trend was to wait until May to turn it on academically. With
his native intelligence, Pat was able to get by and to eventually graduate high
school. Pat graduated 341st in a class of 404 students. There was a general consensus from all of his teachers that he was capable of much more. His mother,
however, was simply pleased to have her son graduate high school, commenting,
There were many days which I thought he would not do it.
To no ones surprise, Pat had no interest in attending college. Instead, he looked
for work and held several part-time jobs at local restaurants as a dishwasher. He
often grew dissatisfied with the job and either quit or was asked to leave within
the fi rst few months. Pat eventually began working as a pizza delivery person,
a job that he seemed to enjoy more. His coworkers were also regular marijuana
users. Pat also began to experiment more with alcohol during this time period.

Attention Deficit/Hyperactivity Disorder (ADHD)

29

Pats uncle, who was an instructor at a community college several hours away,
began to have more considerable discussions with him about giving school
another try. While Pat continued to express disinterest in school, he made a
seemingly impulsive decision (two weeks before classes started) to matriculate at
the community college and to live on campus.
Two days after his 19th birthday, Pat left home for the fi rst time and moved
into his dormitory room. Pat had a roommate whom he did not know, yet the two
quickly became fast friends, sharing an interest in music, technology, and marijuana. Within two weeks, Pat was no longer attending classes and was partying
quite often. Pat was found to have marijuana in his dorm room, was placed on
disciplinary probation, and was asked to attend counseling. Pat did well socially
at community college, yet when he attained a 0.8 GPA, his mother refused to
have him return for the spring semester. Pat still refers to his community college
experience as the best three months of my life.
Pat returned home, lived with his mother, and resumed his job at the pizza restaurant. The relationship between Pat and his mother had soured considerably,
such that his mother began taking an antidepressant. Pat continued his lifestyle
and had several girlfriends during this time period. In an attempt to improve
their relationship, his mother allowed one of his friends to move into their home.
After living with them for several months, the friend had sexual relations with
Pats girlfriend. Pat became so enraged that he punched a brick fireplace, breaking several bones and requiring surgery to repair his hand. Pat continued to use
marijuana (almost daily) and was drinking alcohol excessively.
Several months before his 21st birthday, Pat left work at the pizza shop with
friends and went to a local bar. Pat and his friends all had fake IDs and were able
to order mixed drinks. Pat left the bar and was stopped by a police officer on the
drive home. One of Pats friends had oxycontin pills on his person and hastily
threw the pills into the car glove box. When the officer searched the car and found
the pills, the friend refused to acknowledge that the pills were his possession. Pat
was arrested for driving while impaired and possession of a narcotic. Pat spent
the night in jail, and his friends were escorted home by the police.
Pat was found guilty of DWI and was court-ordered to substance abuse treatment. Once the substance abuse therapy was completed, his mother encouraged
the substance abuse therapist to suggest to the judge that Pat be mandated to
continue with ADHD-focused treatment (her words). The judge (who reportedly has a daughter with ADHD) agreed, mandating Pat to enter ADHD-focused
treatment. This is around the time that I first meet Pat.

Key Principles/Core Knowledge


ADHD is one of the most prevalent (~5% of the childhood population [APA,
2000]), wellresearched, and validated childhood psychiatric disorders (Goldman,
Genel, Bezman, & Slanetz, 1998). Once considered exclusively a childhood condition (Hill & Schoener, 1996), much research suggests that ADHD persists into

30

Childhood Disorders

adolescence and adulthood for roughly 60% of the population (Barkley, Murphy,
& Fischer, 2007; Faraone, Biederman, & Mick, 2006; Mannuzza, Klein, Bessler,
Malloy, & LaPadula, 1993).
ADHD is a highly heritable condition (average heritability index = .76;
Faraone et al., 2005). 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, Biederman, & Milberger, 1994). The same
holds true in adult ADHD; offspring of parents with ADHD are more likely to
have ADHD themselves (Biederman et al., 1995; Manshadi, Lippmann, ODaniel,
& Blackman, 1983). For example, Biederman et al. (1995) found a 57 percent prevalence of ADHD among children of ADHD adults, much higher than the 15 percent prevalence of ADHD among siblings of ADHD children.
Pediatric ADHD commonly co-occurs with multiple psychiatric disorders,
including mood, anxiety, and disruptive behavioral disorders (Angold, Costello,
& Erkanli, 1999; Biederman, Newcorn, & Sprich, 1991). Likewise, adult ADHD
is also associated with comorbid mood, anxiety, and substance use disorder diagnoses (Barkley et al., 2007; Biederman et al., 1993; Borland & Heckman, 1976;
Heiligenstein, Conyers, Berns, & Miller, 1998; Murphy & Barkley, 1996; Shekim,
Asarnow, Hess, Zaucha, & Wheeler, 1990; Thomson et al., 2005).
By defi nition, inattentive and/or overactive and impulsive symptoms have to
impair the childs functioning in two or more domains to meet the criteria of
the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision; DSM-IV-TR). In children, educational, social, and family domains are
often functionally impaired by ADHD symptoms (MTA Collaborative Group,
1999). Significant functional impairment in educational, marital, interpersonal,
occupational, and motor vehicle operation realms is common in adult ADHD
(Murphy & Barkley, 1996; Schubiner et al., 2000; G. Weiss, Hechtman, Milroy, &
Perlman, 1985; Wilens & Dodson, 2004). In fact, Barkleys longitudinal research
indicates that ADHD in adults is a more impairing disorder than many other disorders (e.g., anxiety disorders, mood disorders, etc.) across multiple domains of
major life activities, especially educational and occupational functioning, money
management, and management of daily responsibilities (Barkley et al., 2007).
ADHD TREATMENTS

There are ample data in the pediatric ADHD literature to support the efficacy
of stimulant medications (MTA Collaborative Group, 1999). Approximately
70% of children with ADHD will demonstrate a therapeutic response to stimulant medications (for reviews, see Biederman et al., 1996; Faraone, 2003). The
adult ADHD data (Biederman et al., 1995; Biederman, Faraone, Monuteaux,
Bober, & Cadogen, 2004) are strikingly similar and suggest that the majority
(74%) of adults with ADHD will demonstrate a therapeutic response to stimulant
medications.
The same pharmacological agents that are efficacious in the pediatric ADHD
literature have also been demonstrated to be effective in adults with ADHD.

Attention Deficit/Hyperactivity Disorder (ADHD)

31

Methylphenidate, amphetamines, and lisdexamfetamine are stimulants that are


FDA approved. Atomoxetine is a non-stimulant that is FDA approved for managing ADHD. Both the stimulants and atomoxetine improve core symptoms of
hyperactivity, inattention, and impulsivity (Adler et al., 2008; Spencer et al., 2005;
Spencer et al., 1998).
Adults with ADHD are more likely to require poly-pharmacy than is the case
for childhood ADHD (Adler, Reingold, Morrill, & Wilens, 2006; M. Weiss &
Hechtman, 2006; Wender, Wolf, & Wasserstein, 2001). While the stimulants and
atomoxetine are more commonly prescribed for ADHD, bupropion, modafi nil,
and desipramine have also been described as efficacious for managing adult
ADHD (Biederman et al., 1996; Taylor & Russo, 2000; Wilens et al., 2005) and
may be used as second-line agents. Bupropion has demonstrated efficacy in open
(Wender & Reimherr, 1990) and controlled (Kuperman et al., 2001; Wilens et al.,
2005) studies and may be particularly efficacious in adults with ADHD who have
comorbid mood disorders (Daviss et al., 2001).
In addition to pharmacotherapy, and similar to managing ADHD in children, a psychosocial treatment component is generally recommended (Dodson,
2005). Neither cognitive behavioral therapy (CBT) nor cognitive therapy has
much research support in pediatric ADHD (Abikoff & Gittelman, 1985; Baer &
Nietzel, 1991; Bloomquist, August, & Ostrander, 1991; DuPaul & Eckert, 1997;
Dush, Hirt, & Schroeder, 1989). For example, meta-analyses of CBT for children
with ADHD have typically reported the effect sizes to be less than one-third a
standard deviation (Baer, 1991). Due to its limited efficacy with children, CBT
was not included in the NIMH Multimodal Treatment Study of Children with
ADHD (MTA) treatment protocols.
Although CBT has not been demonstrated to be efficacious in children with
ADHD, there are reasons to be optimistic that CBT may be more efficacious in
adults with ADHD. For example, CBT is generally more effective in adolescents
relative to preadolescents (Holmbeck, Greenley, & Franks, 2003). Similarly, in
the adult ADHD literature, there is some evidence that CBT is efficacious for
reducing functional impairments in patients also being treated with stimulants
(Safren et al., 2005; Safren et al., 2010).

Assessment Strategy
At the time of referral, 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.
After a failed attempt at college, Pat had been living with his mother for several
years and was employed part-time as a pizza delivery person. He was not engaged
in any form of treatment and was quite opposed to any treatment, psychosocial
or pharmacological, stating, I have been on just about every ADHD medication
there is. I hate them all.
Given that he was living with his mother, I asked both Pat and his mother
to attend the intake assessment. I structured the intake assessment so that I

32

Childhood Disorders

met with Pat and his mother together for approximately 45 minutes. Meeting
together allowed me to collect information regarding Pats history and also to
observe the relationship between Pat and his mother. Whenever working with
a young adult such as Pat, if possible, I attempt to gain collateral information
from a parent. In my experience, young adults with ADHD are rather poor
historians.
During the initial 45-minute interview, it became clear that Pat and his mother
had a negative relationship. This is not to say that Pats mother was not appropriately concerned for her son nor to infer that Pat and his mother did not have a
good emotional bond. Rather, the negative relationship can be better characterized as a push-pull relationship; Pat perceived his mother as a nag who was
always on [my] back. Conversely, his mother perceived Pat as lazy, unmotivated and selfish. She pushes him; he pulls away.
During this initial 45-minute interview, it also became evident to me that Pats
mother quite possibly also had ADHD, although she had not been diagnosed
with the disorder. At the time of referral, Pats mother had been prescribed an
SSRI (selective serotonin reuptake inhibitor) for mood/anxiety concerns, most of
which she attributed to Pat.
Pats parents had divorced when he was 11 years old. His father continued
to live near Pat and his mother yet did not have regular contact with either. In
addition, neither Pat nor his mother had a positive relationship with Pats father.
Given both of these facts (limited involvement, negative relationship), a decision
was made not to invite Pats father to the intake assessment or involve him in
treatment.
After spending some time with Pat and his mother, his mother was asked
to go the waiting room to complete several behavioral rating scales commonly
used by our clinic to gather collateral information. These scales include the
Adult Behavior Checklist (Achenbach, 2007), World Health Organization Adult
ADHD Scale (ASRS; Kessler et al., 2005) and Impairment Rating Scale (Fabiano
et al., 2006). These scales were chosen for adults with ADHD; different scales are
employed for children and adolescents with ADHD.
While his mother was completing the rating scales, Pat was interviewed using
the structured clinical interview for DSM-IV disorders (SCID; First, Spitzer,
Gibbon, & Williams, 1997). Based upon the SCID, Pat met formal DSM-IV
diagnostic criteria for substance abuse (marijuana, alcohol) and a mood disorder, not otherwise specified. Our program also supplements the SCID with the
ADHD module from the Schedule for Affective Disorders and Schizophrenia for
School-Age Children, Present and Lifetime Version (K-SADS-PL; Kaufman et
al., 1997). (The K-SADS-PL is used because the SCID does not have an ADHD
module.) Based upon his report, Pat also met DSM-IV diagnostic criteria for
ADHD, combined type, both past and present diagnoses. This entire interview
took approximately 90 minutes. At the conclusion of this two-hour appointment,
a feedback session was scheduled for the following week. Both Pat and his mother
were encouraged to attend the feedback session.

Attention Deficit/Hyperactivity Disorder (ADHD)

33

During the feedback session, diagnostic impressions were provided and a


treatment plan was described. Pat met formal DSM-IV diagnostic criteria for
ADHD, substance abuse, and mood disorder, not otherwise specified. Given
that Pat had been cleared by his substance abuse program and was not deemed
to need further services, our treatment plan was to include both a pharmacological and psychosocial treatment component geared more toward his ADHD
diagnosis. While his mother was very excited and hopeful about the proposed
treatment plan, Pat was less enthusiastic yet stated, What choice do I have? I
dont think any.
After the feedback session, I also spoke privately to Pats mother via telephone
to follow up with her about my own observation that she may indeed have ADHD
herself. His mother reported that all of [my] friends say the same thing. Given
my therapeutic relationship with Pat, I referred her to another local clinician who
specializes in ADHD for a diagnostic evaluation.

Epidemiological Considerations
I have been working with Pat (and occasionally with Pat and his mother conjointly) for just over one year. We have had 34 sessions together, meeting weekly
in the beginning of therapy (for roughly the fi rst three months) and then biweekly
thereafter. Our program is a research program, and we collect a wide variety
of data at the initial evaluation (see above). Nonetheless, one did not need the
vast amount of data to reliably conclude that Pat continues to meet criteria for
ADHD. In many ways, Pat is a rather prototypical young adult who was diagnosed with ADHD in childhood.
In addition to his ADHD diagnosis, Pat met also formal DSM-IV diagnostic criteria for substance abuse (marijuana, alcohol) and a mood disorder, not
otherwise specified. Pat was referred to our team psychiatrist, who prescribed
extended release bupropion (100 mg initially, then titrated up to 200 mg). Pats
mother was referred to another local clinician who specializes in ADHD and
was indeed diagnosed with ADHD herself. She was prescribed extended release
methylphenidate by her primary care physician. She was also counseled to keep
the methylphenidate in a secure place, lest Pat have any ideas about diverting /
misusing his mothers medication.

Case Formulation
My initial case formulation was that Pat had ADHD and comorbid substance
abuse diagnoses and likely had many subthreshold dysthymic mood symptoms. I
believe that my diagnoses were evidence based because they relied on structured,
valid, and reliable assessment instruments as well as collateral report. In my eyes,
this was a relatively straightforward diagnosis, especially in light of the many

34

Childhood Disorders

previous assessments that Pat has had, as well as the clear chronic nature of his
impairing symptoms.
PSYCHOSOCIAL INTERVENTION: OVERVIEW

The psychosocial intervention was the cognitive behavioral treatment for adult
ADHD developed by Safren et al. (Safren et al., 2005; Safren et al., 2010). The
Safren et al. CBT model involves components of motivational interviewing, practice, review, and repetition of learned skills and is composed of three core modules, in addition to three optional modules. Pat received all six modules (core plus
optional modules).
The fi rst four-session core module involved psychoeducation about ADHD
as well as training in organization and planning skills. The second three-session
core module focused on Pat learning skills to reduce distractibility. The third core
module used cognitive restructuring strategies described by Beck (1995), modified to account for an ADHD population. This module was our longest module
and we spent far more sessions (11 sessions) in this module than in the original
Safren et al. manual. The Safren et al. (2005) optional modules were also completed. These modules included sessions focused on reducing procrastination,
improving communication skills (e.g., reducing interruptions, improving active
listening, etc.) and improving anger/frustration management. Again, given Pats
history, more time was spent in the improving anger/frustration management
modules than originally proposed by Safren et al.
Handouts describing the topics covered were provided to Pat at the conclusion of each session. The handouts were provided in an attempt to encourage
generalizability of the strategies to the real-world. In addition to relying on Pat
for information regarding his functioning and application of the skills, periodic
conversations with Pats mother were also included.
INITIAL SESSIONS

While the Safren et al. module begins with direct intervention aimed at improving organization and planning, a common starting point for my work with
young adults is increasing motivation. Stated another way, part of my job is
convincing the young adult that there is a problem. While this may be a clinical reality for many mental health workers, this is a very common phenomenon
for those of us who work in the ADHD field. In fact, many authors have commented on the positive illusory bias (PIB), which reflects an overestimation
of perceived abilities relative to actual level of ability and competence (Canu &
Carlson, 2007; Hoza, Waschbusch, Pelham, Molina, & Milich, 2000; Owens,
Goldfi ne, Evangelista, Hoza, & Kaiser, 2007). In other words, the individual
with ADHD views things as better than they really are. This has patent connections to motivation (or lack thereof) for therapy: If you do not perceive
that there is a problem, why would anything need to be changed? Thus, much
of my initial work with Pat consisted of applying motivational interviewing

Attention Deficit/Hyperactivity Disorder (ADHD)

35

techniques and concepts in an attempt to move him toward sensing a need for
change. It certainly helped when his girlfriend at the time broke up with him,
citing his anger and jealousy as primary reasons. These real-world gifts
became a means to enhance motivation, albeit in a slower fashion than I would
have liked.
SAFREN ET AL. CORE MODULES

Once some motivation for change had been established, we began the Safren et
al. core modules. As a general rule, my goal is to have the young adult and I
talk roughly the same amount (i.e., Pat talks for 50%, I talk for 50%). Directing
the session is a general practice in most forms of cognitive behavioral therapy
(Blagys & Hilsenroth, 2002), yet working with individuals with attention lapses
has taught me to nurture a great amount of conversational give-and-take rather
than long, one-sided discussions. This style is present throughout my work with
the individual with ADHD, not only during the initial sessions.
The fi rst module in the Safren et al. protocol focuses on psychoeducation
about ADHD. In our program, we focus on describing ADHD from a biopsychosocial perspective. 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. The organizational and planning skills components include very concrete interventions such as having Pat
purchase a planner. 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). We stress the importance of having a planner, not a calendar. Other organizational strategies are covered, including the importance of
doing things in a routine fashion (e.g., always putting your keys in the same place,
always charging your cell phone before you go to sleep at night, etc.). This module
with Pat accounted for four sessions, which, in my experience, is fairly typical for
young adults with ADHD.
The second Safren et al. module focused on lessening distractions. We focused
on breaking larger tasks down into smaller chunks, using timers or alarms to
help monitor time, estimating how long a task will take and then assessing [his]
estimate, and keeping a list in [his] front pocket to help him write down a task
rather than interrupting [his] ongoing task. These strategies were covered over
the course of three sessions. Considerable motivational interviewing continued
to be a prominent focus of the sessions.
The third module was our longest module to date; consisting of 11 sessions,
we covered errors in thinking using a structured sheet providing the most common errors in thinking based upon Becks work. Pat was asked to identify which
errors he makes more regularly. In addition, his mother was consulted for her
perspective on what she observes and/or hears from Pat. The concept of simple
awareness of the automatic errors in thinking was covered first. After enhancing his awareness of his own self-talk, we focused on fighting back against the
thoughts using cognitive restructuring techniques.

36

Childhood Disorders

At this point, I had been working with Pat in therapy for approximately four
months, and we had held 20 sessions. Pat had missed one appointment and had
been late to two others. Over the course of the fi rst 20 sessions (predominantly
weekly), Pat had gradually become more verbal and engaged in therapy. He also
appeared to be having a therapeutic response to the bupropion. Nonetheless,
attention problems persisted (especially being easily distracted). Thus, a decision
was made by our program psychiatrist to start lisdexamphetamine (initially 30
mg, then titrated to 50 mg).
While Pat reported limited changes in his real-world functioning, his mother
was reporting far more optimistic progress. She reported that she and Pat were
arguing far less often and that Pat was less emotionally impulsive and more
responsible (e.g., Pat did laundry last week. I did not even know that he knew
how to do laundry.). Having a young adult and parent (or spouse) disagree about
the efficacy of treatment is not uncommon in my experience. Moreover, the direction of the difference is not consistent across cases.
SAFREN ET AL. OPTIONAL MODULES

Reducing procrastination and improving communication skills (e.g., reducing


interruptions, improving active listening, etc.) were each covered in two sessions. In addition to the core Safren et al. strategies for reducing procrastination,
the concept of how we advertise activities, tasks, and so on, 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. The improving
communication skills module involved a great deal of role-playing various scenarios. In addition, we walked through the hospital one day with the expectation
that Pat would initiate and sustain conversations with strangers in the hospital.
(He seemed to enjoy this task immensely.)
The final Safren et al. optional module focused on improving anger/frustration
management. This was a challenge initially, as Pat had made progress such that his
frustration level was less than it had been nine months prior. However, once again, a
real-world change (another girlfriend breakup) helped bring the need for anger management back into focus. While Pat was able to very clearly describe how he should
manage his anger, Pat continued to have difficulties managing his anger. Thus, his
poor anger management was not a knowledge deficit, but more of a performance
deficit. While we continued to role-play anger management strategies and focus on
very concrete strategies (e.g., recognizing when is or is not a good time to have an
argument), Pat continues to struggle to effectively manage his anger. In my opinion,
and while not specific to ADHD, Pats poor anger management abilities are his most
enduring symptom, sadly seeming recalcitrant to my best interventions.
NONSPECIFIC FACTORS

A considerable amount of clinical attention was devoted to the nonspecific factors


of therapy, especially establishing a strong therapeutic alliance and promoting

Attention Deficit/Hyperactivity Disorder (ADHD)

37

optimism and hope for change. The fi rst several weeks of therapy were simply
focused on establishing rapport with Pat and attempting to connect with him,
relying heavily on motivational interviewing techniques such as empathetic
responding, providing feedback, and providing choices. As mentioned previously, Pat was not especially pleased to be in therapy and had participated in
many previous psychological therapies. 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. I explicitly avoided arguments with Pat
and attempted to roll with resistance rather than confronting him.
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. Given that Pat did not really see a need for change, I
once again relied heavily on motivational interviewing techniques to attempt to
lessen Pats ambivalence toward therapy.
POTENTIAL PROBLEMS

Missed appointments and arriving late to appointments are very common in


adults with ADHD. Thus, 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, the person is automatically discharged).
Given that Pat was court-ordered to treatment, he was well aware that discharge
would not be in his best interest.
Lack of commitment should be almost assumed in those that are court-ordered
for treatment. Thus, right from the start, motivational interviewing techniques
were heavily integrated into my treatment with Pat.
Using the Impairment Rating Scales (IRS; Fabiano et al., 2006) as our standard metric for assessing clinical response, Pat has modestly improved his functioning. (We have modified the IRS to include a self-report version for adults.)
In both the Parent and Self versions, reporters are instructed to rate the severity
of the young adults 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).
At the beginning of treatment (34 sessions ago), Pats mother rated him as
having an average of 4.6 on the assessed domains (relationship with peers, relationship with parents, self-esteem, occupational functioning, influence on family functioning, and overall impairment). At this point in therapy, Pats mother
rated him as having an average of 3.0 on the assessed domains. (Pats ratings
are 3.0 and 1.9, respectively.) Thus, from both perspectives, Pat is functioning
better. However, a IRS rating of 3.0 does not represent normal functioning.
Likewise, 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), Pat continues to have the same job (pizza delivery) and loses
his temper quite frequently with coworkers.

38

Childhood Disorders

The goal for Pat moving forward is to help him continue to navigate the
transition to adulthood. The transition to adulthood is defined by young adults
themselves as accepting responsibility for ones self, gaining autonomy and
independence, and becoming fi nancially independent (Arnett & Taber, 1994;
Shanahan, 2000). In many ways, these attributes and qualities are often very difficult for individuals like Pat who have been diagnosed with ADHD. For example, Pat has talked previously about moving out of his mothers home, enrolling
at a local community college, and requesting a promotion at work. At this point,
none of the above has come to fruition or, frankly, has even begun to head in that
direction.
If the above mentioned data did not suggest that Pat was improving, I would
not continue to press ahead with the Safren modules. Rather, I would take a step
back and rely more heavily on motivational interviewing techniques. I would also
attempt to engage more of Pats natural social supports (mother, girlfriend, etc.)
in the context of therapy.

Ethical Considerations
The issue of confidentiality/privacy need always be considered for young adults
who are not functioning like young adults. Thus, at the beginning of treatment,
I attempt to secure release of information in order to be in ongoing contact with
parents or others who may function like parents (e.g., uncles, supervisors, teachers). 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. I certainly respect the wishes of those who do
not wish to release information to parents, yet in my work with young adults with
ADHD, this is a relative rarity. (In fact, it is usually the parents who refer the
young adult for treatment in the fi rst place.)

Common Mistakes to Avoid


The most fundamental mistake that I attempted to avoid was assuming that Pats
childhood diagnosis was still his adult diagnosis. By having a very structured and
intensive assessment process, we attempt to avoid rubber stamping diagnoses
simply based on what childhood condition may have been diagnosed.
Another common mistake that I attempted to avoid in treatment was passively
reinforcing Pats marijuana use. Each time that Pat discussed his marijuana use, I
quickly shifted into motivational interviewing techniques, attempting to get him
to lessen his ambivalence toward his marijuana smoking.
Relapse prevention needs to be included in any treatment plan for a young
adult with ADHD and comorbid substance abuse. ADHD itself is often defi ned
by inconsistencies in performance and functioning. Thus, setbacks along the way
are almost a guarantee. Having this mind-set has helped me to be curious, not

Attention Deficit/Hyperactivity Disorder (ADHD)

39

furious when the inevitable relapse occurs. Continuing to reinforce previously


learned skills (e.g., using planners, keeping a list, etc.) has also helped to lessen
relapses.
Misconceptions that some may have about CBT include viewing the therapy
as a mechanical cookbook approach. While this approach may be true for
some CBT practitioners, I wholeheartedly believe that there is much art to the
practice of CBT. Knowing when to push forward, step back, and digress from the
manual are all learned with CBT experience. By no means do I consider myself a
master clinician in CBT; nonetheless, over the years in which I have been practicing CBT, I have become much more aware of the art that is involved in practicing
competent CBT. Basic issues such as the pacing of the session, tone of voice, and
digression from the manual by providing analogies, metaphors, and so on, all
figure heavily into my CBT practice. Nonetheless, at the core of my CBT practice
remains the science.
In conclusion, I view Pat as a rather prototypical young adult who was diagnosed with ADHD as a child. Certainly, there are less impaired young adults
with ADHD who do not require the level of intervention that Pat has received.
I certainly could have chosen these young adults to describe (and made myself
out to be a better clinician than I may actually be). However, the decision to
present Pat was quite easy for me; I believe that Pat represents both the challenges
of treating this population, as well as the clear need for treating this population.
In my opinion, ADHD is not the relatively benign condition that the media often
portrays.

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COMMENTARY

Russell A. Barkley

Dr. Antshel describes an interesting and relatively typical case of a young adult
referral in which ADHD has been previously diagnosed. Pats history of repetitive
antisocial behavior and occasional contacts with the legal authorities is, sadly,
relatively commonplace in children with ADHD followed to adulthood (Barkley,
Murphy, & Fischer, 2008; Satterfield, Faller, Crinella, Schell, Swanson, & Homer,
2007). This is particularly so for driving offenses, where available research shows
teens and adults with ADHD to be at high risk for a variety of adverse outcomes
(Barkley & Cox, 2007). Consequently, 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, including the use of medication while driving.
As in this case, 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, at least to the patients loved ones,
if not to the patient himself. And while ADHD, conduct disorder (CD; antisocial behavior), and psychopathy are distinct yet interrelated disorders/constructs
(Pardini, Obradovic, & Loeber, 2006), and most cases of ADHD do not become
adult psychopaths (Fowler, Langley, Rice, Whittinger, Ross et al., 2009), there
is a greater likelihood of psychopathy in teens and adults with ADHD than is
the case in the general population, especially if they had manifested symptoms
of childhood conduct problems (Waschbusch & Willoughby, 2008). Given the
strong contribution of psychopathic traits to persistence of antisocial behavior
into and through adulthood (Fowler et al., 2009; Lynam, 1998) and the substantial genetic and neurological contributions to psychopathy (Blair, Peschardt,
Budhani, Mitchell, & Pine, 2006), clinicians need to be on the alert for its existence in cases such as Pats, as it may bode for an even poorer outcome than would
ADHD or CD alone. It may also increase the risk of harm to family members and
others attempting to intervene with the patient. Thus it might have been useful in
this case to screen for such traits using rating scales for this purpose.
Clinicians also need to appreciate the high risk that such cases of ADHD/
antisocial behavior have for current and later drug use and abuse. This was
clearly the case for Pat, starting in early adolescence. My own longitudinal study
of children with ADHD followed to age 21 suggests that while earlier conduct

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, ADHD was associated with later drug-related activities, such as possession, sale, and use of illegal drugs and theft, even after controlling for earlier CD
(Barkley, Fischer, Smallish, & Fletcher, 2004). And once drug use was initiated,
it interacted over time with antisocial behavior such that each exacerbated the
other. That Pat should show some affi nity for the use and abuse of marijuana is
also not uncommon. 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, tobacco, and marijuana than does the general population
or control groups (Barkley et al., 2008). Hence the need for substance use treatment programs is likely to be part of the treatment package recommended for
such cases, as it was for Pat. And while not mentioned in Pats case history, those
using marijuana are likely to be using tobacco and typically started with the latter drug fi rst (Barkley et al., 2008), perhaps because the individual may fi nd some
therapeutic benefit from the nicotine and thus may be self-medicating his or her
ADHD (Kollins, McClerman, & Fuemmeler, 2005).
The limited or nonexistent insight of Pat into his current problems, history of
ADHD, and need for current treatment is a common occurrence. For instance,
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; the majority saw themselves as not having the disorder and grossly
underreported their symptoms (Barkley et al., 2008). As evidence of this fact, we
found that the correlation between parent and patient report at age 21 was just
.21 and at age 27 was just .43. 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, and thus parent reports were considered
more valid (Barkley, Fischer, Fletcher, & Smallish, 2002). This striking disparity between parental reports and self-reported information in someone not selfreferred for an evaluation of ADHD is commonplace, despite the patient having
been diagnosed as a child. It supports the commendable practice by Dr. 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, 2004).
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, particularly when oppositional defiant disorder and conduct
problems exist in the patient (Johnston & Mash, 2001; Edwards, Barkley et al.,
2001). In such cases, father absence is more common or, if a father is present
within the family unit, disengagement from the teen and even from the marriage
may be likely, in my experiencethis was certainly the case with Pats father
and removes one source of potential constructive influence from this situation.
In such families, as Dr. Antshel ably discusses, the likelihood of ADHD in one
or both parents is significant as a consequence of the striking heritability of the

Attention Deficit/Hyperactivity Disorder (ADHD)

45

ADHD trait(s). Clinicians should follow Dr. Antshels 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. The parents ADHD may well interfere with not only the current
adjustment of the patient but also with efforts to implement treatment programs
(Sonuga-Barke, Daley, & Thompson, 2002) for which the parent may have some
direct or indirect responsibilities. Further evaluation of and treatment for the
parents ADHD, as was initiated in this case, is likely to prove beneficial not only
for Pats mother but also for the treatment plan created for Pat as well.
That a mild mood disorder, such as demoralization or dysthymia, was evident
in Pats case, and clearly noticeable in his irritability with his mother and the
examiner, is likewise not surprising. 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., 2008). The linkage may arise, in part, from shared genetics between the disorders (Faraone &
Biederman, 1997), as well as the common comorbidity between ADHD, CD, and
depression (Angold, Costello, & Erkanli, 1999). Should the patients demoralization have arisen as a consequence of his repeated failures and impairments in
major life activities associated with his ADHD, it may well respond to management with ADHD medications. This is not likely to be the case for more serious
mood disorders, such as major depression, for which separate treatments may be
necessary.
The limited or nonexistent benefit of earlier treatments during childhood for
ADHD on adolescent and young adult outcomes, as evident in Pats case, is also
relatively typical in the small literature that has examined the issue (Barkley et al.,
2008; Molina, Hinson, Swanson, Arnold, Vitiello et al., 2009). This is not because
treatments given in childhood do not have beneficial effects on childrens ADHD
or domains of impairmentclearly they do. It is more likely due to the termination of these treatments over time, as was seen in Pats case, 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.
The lesson here seems to be that for treatment to improve adolescent and young
adult outcomes, it must be sustained through adolescence to young adulthood,
as would be the case with any chronic medical condition such as diabetes. That is
easier said than done with adolescents, as was clear in Pats case. His resistance to
taking medication as an adolescent and his later begrudging acceptance of it as a
young adult are also quite typical, in my own experience. 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.
Also noteworthy in Pats history and current adjustment is his limited educational attainment, despite above average intelligence and absence of a specific learning disability. Numerous longitudinal studies, including my own, have
repeatedly documented the adverse impact of ADHD on eventual educational

46

Childhood Disorders

attainment; 3040% of childhood cases do not complete high school, and perhaps just 510% complete a college degree program (Barkley et al., 2008). 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, as well as on
their upward advancement in their chosen occupation.
A few comments on the approach to assessment used by Dr. Antshel seem
in order. 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, as was done here, is essential for establishing that the patient
has met these aspects of diagnostic criteria for ADHD (McGough & Barkley,
2004; Murphy & Gordon, 2006). Several rating scales, besides the Adler scale
used here, have acceptable norms and are available for documenting DSM-IV
symptoms of ADHD in adults (Barkley, 2011a; Conners, Erhardt, & Sparrow,
1998). Also noteworthy was the attempt by Dr. Antshel to broadly screen for
potential impairment in major domains of life activities, in this case adapting
the child impairment scale initially developed by Fabiano. Symtom severity does
not equate directly to related levels of impairment, requiring that impairment be
assessed separately and specifically in such cases, rather than just inferring such
from the severity of the ADHD symptoms (Gordon, Antshel, Faraone, Barkley,
Lewandowski et al., 2006; Lewandowski, Lovett, & Gordon, 2009). Problematic
with the Childrens Impairment Scale, however, 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. 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, 2011b) that now would be a
more appropriate alternative.
Given that adults with ADHD often have associated deficits in various
domains of executive functioning (EF; Barkley et al., 2008; Hervey, Epstein,
& Curry, 2004), I also encourage clinicians to incorporate some assessment of
these functions in the evaluation of adults with ADHD. While this has been
traditionally done using psychometric EF test batteries, such tests often fail to
detect the difficulties in EF associated with ADHD, with just 2550% falling in
the impaired range on these tests (Barkley & Murphy, 2011; Biederman, Petty,
Fried, Black, Doyle et al., 2008; Biederman, Petty, Fried, Fontanella, Doyle et
al., 2006). Moreover, such tests have low or no ecological validity. This is to say
that they correlate poorly, if at all, 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, 2011c; Barkley & Fischer, 2011; Barkley & Murphy,
2011; Barkley & Murphy, 2010). As a result, I do not recommend that clinicians
waste their time with such a time-consuming psychometric test battery approach
in cases of adult ADHD. More useful, economical, convenient, and ecologically
valid is the use of rating scales of EF in daily life activities, such as the Deficits
in Executive Functioning Scale (Barkley, 2011d) or Behavior Rating Inventory
of Executive Functioning, Adult Version (Roth, Isquith, & Gioia, 2005). Note,
however, that the latter scale may have the potential to over-identify EF deficits

Attention Deficit/Hyperactivity Disorder (ADHD)

47

in view of its relatively super-normal and technologically, psychiatrically, and


medically fi ltered normative sample. Rating scales have greater utility than tests
in predicting impairment (Barkley & Fischer, 2011; Barkley & Murphy, 2010),
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. Such scales indicate that 8698% of adults with ADHD are
impaired in one or more domains of EF in daily life, such as self-organization
and problem-solving, self-management to time, self-motivation, self-discipline,
and self-regulation of emotions (Barkley, 2011c). Another advantage to such EF
rating scales and those noted earlier for adult ADHD and impairment is their
convenience for monitoring response to interventions, as was done in Pats case,
using the ADHD and impairment ratings.
Dr. Antshel commendably elected to use the most evidence-based interventions for Pats ADHD, these being medication and cognitive behavioral treatment (CBT). Medications remain a mainstay, empirically based treatment for
child and especially adult ADHD (see Prince, Wilens, Spencer, & Biederman,
2006) and so returning Pat to medication was a wise choice in this case, even
if the patient complied grudgingly. Medications will likely be required for the
management of 7080% or more of adult cases, in my opinion, whether to treat
the ADHD or, as often is the case in over 80% of adults with ADHD (Barkley
et al., 2008), to treat their comorbid disorders. While annoying side effects certainly exist with these medications, and their side effect profi le clearly depends
on whether stimulants (methlphenidate, amphetamine), nonstimulants (atomoxetine), or anti-hypertensives (guafacine XR, clonidine XR [FDA approved
only for children to date]) are utilized, 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. The most common side
effects (3050% or more of cases) for the stimulants are typically loss of appetite
for midday meals primarily, along with insomnia, both of which tend to be more
problematic for child than adult cases of ADHD. Some modest temporary cessation of gains in growth in children may occur, but these have not been documented to continue into late adolescence or adulthood. Perhaps 25% or fewer
cases complain of stomachaches or headaches in conjunction with stimulant use.
From 1025% of cases do not respond to the starting medication type or delivery
system (pills, OROS pump, time release pellets, skin patch, or pro-drug) and may
require switching to alternative delivery systems or medications before a good
therapeutic effect is obtained. About 35% of cases may not be able to tolerate
any dose of these medications.
The CBT program by Safren and colleagues (Safren, Perlman, Sprich, &
Otto, 2005) implemented with Pat is a fi ne intervention for adult ADHD with
an increasing evidence base (Knouse & Safren, 2010). Several similar programs
that also have an evidence base are available for conducting CBT with adults
with ADHD (Ramsay & Rostain, 2007; Solanto, 2010). All CBT programs focus
on training adults in strategies to compensate for their deficits in executive functioning in daily life, such as difficulties with time management, organization,

48

Childhood Disorders

problem-solving, emotional self-control, and so on, as noted above. 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. 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, and follow through on, the treatment
procedures than if they are off medicationa point with which I agree. Ramsay
and Rostain strongly encourage a combined intervention as well. The Solanto
program has been studied with patients being off medication and has had some
success as well, but it is not clear whether more improvement might have been evident had patients also been on an ADHD medication. 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,
this would seem to be the best approach for now, with both children and adults
with ADHD, when both are availablesomething not usually the case in rural
areas of the United States.
Besides such feedback counseling about the disorder following the evaluation,
ADHD medications, and the manual-based CBT interventions, some counseling
of the teen or young adult with ADHD, along with his or her parents or guardians,
is in order concerning other major domains of increased risk in major life activities associated with ADHD at these ages, as well as possible means to address the
risks (Barkley & Benton, 2010; Ramsay, 2010). While little or no research exists
on the best treatments for various impairments, some commonsense advice can
still be offered. These impairments include not only the driving problems noted
above, but also the penchant for risky sexual behavior and adolescent pregnancy
(Barkley, Fischer, et al., 2006; Flory, Molina, Pelham, Gnagy, & Smith, 2006),
occupational difficulties, money management problems, and increased health
risks such as excess use of legal substances, psychosomatic symptoms, obesity,
bulimia (in ADHD females), and cardiovascular disease (Barkley et al., 2008).
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, 2006; Barkley & Benton, 2010; Pera, 2009; Sarkis & Klein,
2010; Tuckman, 2007), given the plethora of such information in these sources,
much of which may not be science-based.
My remarks and caveats notwithstanding, Dr. Antshel has selected a fi ne
case, representative of the typical referral that one is likely to encounter in seeing young adults for evaluation and management of ADHD. His approach to the
evaluation, counseling, and management of the case is commendable, empirically based, and an exemplar to other clinicians.

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RESPONSE

Kevin M. Antshel

I am grateful to Dr. Barkley not only for his astute and insightful commentary
but also to have the opportunity to respond. Dr. Barkley is a veritable ADHD
encyclopediathere is no one, in my estimation, who knows the ADHD literature better than Dr. Barkley. It is a great honor to have someone so knowledgeable about ADHD comment on my clinical work.
As Dr. Barkley clearly delineates, ADHD in adulthood is very rarely diagnosed without a comorbid condition. Substance abuse is one common comorbid
condition, and Pat was required to complete a substance abuse treatment program with continuing monitoring of his substance use. Thus, my focus was more
on the ADHD and associated impairments. However, I continued to frankly discuss Pats substance use and the associated impairments. While I would not say
that his marijuana use was the primary focus of our treatment, his marijuana use
was an almost weekly discussion. My experience with Pat regretfully suggests
that even with random drug tests, it is possible to continue to use marijuana yet
pass drug tests.
Dr. Barkley refers to the limited insight of those with ADHD. While not all
individuals with ADHD have limited insight into their own functioning, a sizable
number of those with ADHD may demonstrate a positive illusory bias. That
is, individuals with ADHD may report that they are functioning better than they
may actually be. As one parent of a high school student with ADHD recently told
me, There is no one more surprised when he sees his report card than my son.
He thought he was doing fi ne. I guess his teachers think otherwise. Although
improved, Pat continues to have a relative lack of insight into his functioning; for
this reason, ongoing contact with collaterals such as his mother have become part
of my work with Pat.
Dr. Barkley also astutely points out the relatively limited number of instruments that currently exist to assess functional impairments in adults. 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), at the
time that I began working with Pat, these instruments were not available. I could
not agree with Dr. Barkley more when he asserts that the focus should move
well beyond symptoms and focus far more on functioning. The current move in
ADHD pharmacological intervention studies is also in this direction.

Attention Deficit/Hyperactivity Disorder (ADHD)

53

Finally, Dr. Barkley also correctly notes that adults with ADHD may be
impaired in their application of executive functioning skills. It is not uncommon for an adult with ADHD to score very well on psychological tests designed
to measure executive functioning, such as the Wisconsin Card Sorting Test or
Stroop Color Word test, yet remain functionally impaired in the real world by
his or her poor planning and limited attention regulation skills. (Our clinic is
currently in the process of moving away from these psychological tests as routine
for our adult patients.) Again, Dr. Barkley has suggested several self-report and
collateral report measures that we are currently considering.
In sum, I thank Dr. Barkley for his insightful commentary and agree with all
of his excellent observations and suggestions. Treating individuals with ADHD,
while undeniably challenging, can also be very rewarding. 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.

{3}

Behavior Analytic Treatment of Behavioral


Excesses and Deficits of Autism:
The Case of Jorge
W. Larry Williams, Ashley E. Greenwald, and Holly
A. Seniuk

Case History
INITIAL REFERRAL AND INTAKE

At his initial intake, Jorge (note: a pseudonym is used here and some facts
have been altered in this chapter to protect client confidentiality), an 8-year-old
Hispanic male, diagnosed with autistic disorder (autism), presented with high
rates of noncompliance and whining, limited communication, and he did not
interact with the behavior analysts. Jorge had been referred for treatment by a
service coordinator at one of the states regional centers. The referral indicated
that Jorge was nonverbal, engaged in noncompliant and screaming behaviors,
would not feed himself, and was not toilet trained. Jorges 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 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.
Upon subsequent home observations, Jorge appeared to be very energetic and
he enjoyed playing alone and preferably outdoors. Jorge was observed to have an
excellent imitative repertoire (i.e., he could imitate simple words) and was able
to follow simple instructions (i.e., turn off the light). When he needed assistance with something, Jorge would walk up to an adult, take him or her by the
hand, and use gestures to communicate his wants and needs. If his needs were
not adequately met, Jorge would begin to whine and cry, occasionally escalating
into screaming. Upon prompting, Jorge would imitate the exact words that were
said. For example, when his mother would say, Jorge, do you need help? and
Jorge would respond, Jorge, do you need help? When any academic work was

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

55

presented, Jorge would laugh, turn away from the work, and attempt to elope
from the table, or place his feet on the table and push his chair backward.
Activities of daily living were not a part of Jorges skill repertoire. Jorges
parents reported that they bathed and clothed him, daily. When observed at
mealtime, 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. Jorge was
observed, however, to independently drink juice. With regard to toileting, his
parents indicated that Jorge showed no interest in using the toilet although they
had attempted to teach him many times. It was reported that Jorge would void in
his diaper and provide no indication of needing to be changed.
BRIEF PERSONAL HISTORY

Jorge was raised in a lower-middle class community in the northwestern United


States. At the time of treatment, Jorge lived with his two parents and 12-year-old
sister, Carmen. Jorges family was originally from Mexico and had strong familial relationships and valued hard work and success. Jorge and his family were
predominately Spanish-speaking, although his older sister, Carmen, was fluent in
both Spanish and English. Jorge was spoken to in Spanish at home.
Jorge received a diagnosis of autism at age 3 years, 5 months. We noted that
a common diagnostic instrument for autism, such as the Autism Diagnosis and
Observation Scale (ADOS) (Lord, Rutter, DiLavore, & Risi, 1989), had not been
administered, nor was another standard tool, the Gilliam Autism Rating Scale
(GARS) (Gilliam, 1995). At the time of his diagnosis, his family was unfamiliar with the diagnosis and attempted to access services. However, given their
socioeconomic status and limited knowledge of the diagnosis, they were unsure
of what services Jorge needed. Jorge began speech therapy at age 5, along with
music therapy using classical music piped through state-of-the-art headphones.
Jorges family reported little to no academic or self-help gains since receiving his
diagnosis. Jorge attended a strategies program at his local elementary school for
skill acquisition and behavior management. The strategies program is designed
specifically for children on the autism spectrum and follows a national curriculum model, including basic learning skills (i.e., imitation and matching); upon
mastery of the basic skills, students progress into more advanced interpersonal
skills (i.e., socialization and conversation).

Epidemiological Considerations
Autism spectrum disorder (ASD), first identified by Kanner (1943) as a social
learning or psychiatric condition, is more currently understood to be a significant
neurodevelopmental disorder (Filipek, Accardo, Baranek, Cook, Dawson, et al.,
1999; Vismara & Rogers, 2010). As described by Granpeesheh, Dixon, Tarbox,
Kaplan, & Wilke (2009) with reference to the Diagnostic and Statistical Manual
of Mental Disorders (American Psychiatric Association, 2000):

56

Childhood Disorders

Autism spectrum disorder (ASD) has become the commonly used term
for all diagnoses falling within the pervasive developmental disorders,
including autistic disorder (299.00), pervasive developmental disorder not
otherwise specified (PDD NOS) (299.80), Aspergers disorder (299.80),
Retts disorder (299.80), and childhood disintegrative disorder (299.10).
ASD is characterized by deficits in 2 or more areas of functioning, including impaired language development, impaired social development, and
the presence of excessive and stereotyped repetitive behaviors or interests.
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. The most
recent estimate of the prevalence of autism among children in the United
States, released by the Centers for Disease Control and Prevention based
on 2002 data, is approximately 1 in 150. (2009, p. 163)
More recently, ASD prevalence has been reported at one in 110 or even one in 70
children (Centers for Disease Control, 2009, pp. 120).

Behavioral Principles Relevant to Addressing Jorges Behaviors


Fifty or so years of research in applied behavior analysis (ABA; e.g., see Journal
of the Experimental Analysis of Behavior; Journal of Applied Behavior Analysis)
have been based on behavioral processes studied in the experimental psychology areas of learning and motivation. These are the principles of reinforcement
(positive and negative), extinction, punishment, stimulus control, and generalization (Martin & Pear, 2011). A basic tenet of behavior analysis is that all public
(e.g., motor, consumatory, language) and private (e.g., cognition, self-talk, emotion, problem-solving), human performance is considered to be behavior, and all
behavior, whether adaptive or maladaptive, is functional.
In addition to the processes involved in neuro-reflexive or classical conditioning, fundamental to ABA is the process of operant behavior discovered by E. L.
Thorndike and, later, B. F. Skinner (1938; 1953) that the consequences of behavior
either strengthen or weaken its future occurrence. Behavior that is followed by
the occurrence of functional consequences (subjectively, the addition of positive
events or the removal of aversive events) will be strengthened. Similarly, 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).
For these reasons, behavior analysts regularly conduct preference assessments
in order to utilize events and activities that actually function as reinforcers,
thereby increasing adaptive behaviors engaged in by the child. These processes
occur in constantly changing physiological and social contexts under external
environmental and internal physiological conditions that can be learned (e.g., at
school, home, car, playing) and unlearned (e.g., morning without breakfast, with
headache, medications starting to have effect) and are referred to as motivating establishing or abolishing operations (MEO, MAO; Michael, 2004). These

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. Specific antecedent events, referred to as
discriminative stimuli, cue or prompt us that a specific behavior will result in a
specific outcome. 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, and are described as appropriate or inappropriate stimulus
control.

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,
Berberich, Perloff, & Schafer, 1966; Lovaas, Koegel, Simmons, & Long, 1973;
Lovaas, Schreibman, Koegel, & Rehm, 1971). These initial reports described the
first applications of the behavioral principles outlined above (such as reinforcement, extinction, discrimination training, shaping, fading, chaining, etc.) in the
teaching of basic language and social skill repertoires and the reduction of selfstimulatory, self-injurious, and oppositional behaviors in children diagnosed
with autism. These and other behavior analysts also began to describe specific
attention and discrimination phenomena related to a diagnosis of autism (e.g.,
overselectivity, where a single component of a multiple-component event will gain
control over a behavior, as opposed to many or all components in normal children). Over time, 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; Lovaas & Smith, 1989)
and more recently replicated by many others (Howard, Sparkman, Cohen, Green,
& Stanislaw, 2005; Perry et al., 2008; Perry et al., 2011; Remington et al., 2007;
Smith, Groen, & Wynn, 2000). One lesson learned throughout this development
was the somewhat obvious fact that the earlier intervention could be started (e.g.,
23 years old), the higher was the likelihood that a child would no longer engage
in autistic behaviors. The above studies also showed that after early intensive
treatment, approximately 50 percent of cases were indistinguishable from their
typically developing peers. Thus, while early intervention is ideal, it was not surprising to see large-scale behavioral changes in Jorge, even at the age of 7.
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. 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.e., self-stimulatory behavior or aggression)
and deficits (i.e., communication and social skills) (DSM-IV-TR, 2000). However,
maximum effects have been observed when intervention can be started as early
as possible. This evidence-based approach is in stark contrast to many reported
interventions that claim treatment outcomes but are not described sufficiently

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Childhood Disorders

to be replicated or are shown to be erroneous by subsequent studies (Jacobson,


Foxx, & Mulick, 2005).

Assessment
A variety of assessments were conducted to evaluate the potential function(s) of
target problem behaviors, Jorges discrimination abilities, and his current repertoire of adaptive living skills. Additionally, baseline data were collected on
all behaviors targeted for both acquisition and reduction, as identified by the
parents. Baseline data collection and analysis are a critical part of behavioral
assessment and treatment procedures, as they allow for the verification and identification of current levels of behavior, the assessment of the functional causes
of those behaviors, and an evaluation comparison measure of the effectiveness
of later treatment procedures. Baseline data serve as a control against which
the effects of specific independent variables are objectively evaluated (Cooper,
Heron, & Heward, 2007).
FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA)

Indirect assessment
First, an interview was conducted with Jorges parents to identify problem behaviors in which he currently engaged, and under what circumstances those behaviors were likely to occur. Jorges parents reported that he did not engage in any
severe problem behaviors except for the occasional whine. It was reported that at
times he would come out of his room and whine for no apparent reason. 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. Finally, it was reported
that during mealtime Jorge would often refuse to eat. Given this information, it
was determined that during mealtimes, when Jorge should normally be relatively
hungry, the behaviors targeted for reduction would be whining (any instance of
whining or crying), noncompliance (any instance of repetitive laughter, nonresponsiveness, and putting his feet on the table during task time), and food refusal (any
instance of Jorge not eating food when it was presented to him during mealtime).
Jorges parents also reported that he was not currently toilet-trained and wore
a diaper at all times. Additionally, 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. 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; Cooper et al., 2007), appropriate toileting, independent eating, and compliance to reasonable instructions.

Direct assessment
Direct observation consisted of antecedent-behavior-consequence (ABC) recording (Bijou, Peterson, & Ault, 1968). During this assessment, whining behavior

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

59

was observed, as well as the conditions under which the behavior occurred and
the specific consequences that followed each occurrence of behavior. An ABC
analysis involves the recording of the events that precede a behavior, the behavior itself, and the events following the behavior, yielding an overall description
of the patterns of occurrence and outcomes for that behavior (Cooper, Heron, &
Heward, 2007). 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. This behavior also frequently
occurred when Jorge was denied access to a preferred activity (i.e., going outside). These results indicated that whining was maintained by both escape from
demand and access to preferred activities/items.
Direct observation also indicated that Jorge frequently engaged in noncompliance, defi ned as repetitive laughter and/or putting his feet on the table when
presented with an academic task. This laughter and putting his feet on the table
would often last up to 5 minutes and was difficult to interrupt or redirect. ABC
contingency analysis determined that this behavior was likely maintained by
escape from demand.
SKILL ASSESSMENTS

Preference assessment
A formal paired-stimuli preference assessment (Fisher, Piazza, Bowman,
Hagopian, Owens, & Slevin, 1992) was conducted with Jorge, using toys to determine which toys would potentially function as reinforcers. For this assessment,
his parents were asked which toys Jorge typically enjoyed playing with. 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
toys were then rank-ordered, based on how many times he had selected the item.
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. The results of this assessment indicated that Jorges most highly
preferred toys were a ball, play dough, and a toy airplane. A formal preference
assessment was not conducted using leisure activities. However, it was observed
that Jorge enjoyed playing outdoors and with video games.

Assessment of Basic Learning Abilities


The Assessment of Basic Learning Abilities (ABLA) developed by Kerr,
Meyerson, 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, prevocational, and vocational skills.
It consists of six levels that are hierarchically ordered by difficulty (Martin, Yu,
& Vause, 2004).
The fi rst level is a simple motor task in which the individual is required to place
a piece of foam into a container. The second level is a position discrimination in

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Childhood Disorders

which the individual is required to put a piece of foam into the container on the
right. 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. 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, and when given
a yellow cylinder the correct response is to put it into the yellow can; the positions
of the red box and yellow can are randomly rotated. 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, drawn-out fashion, and to
put the foam in the red box when the tester says red box in a fast, high-pitched
tone. 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, with the exception that the positions of the red box and
yellow can rotate randomly between trials (Vause, Martin, & Yu, 2007).
Jorge was able to pass all levels of the ABLA. This indicated that Jorge was
able to perform auditory-visual conditional discriminations. The implications
of these results were that Jorge had the prerequisite skills to respond to vocal
instructions. Additionally, these results indicated that Jorge has the prerequisite
skills to learn to communicate through the use of spoken language.

Assessment of Basic Learning and Language Skills


The Assessment of Basic Learning and Language Skills (ABLLS-R) was originally developed by James W. Partington and Mark L. Sundberg in 1998 and
was revised in 2006 by Partington. The ABLLS-R (Partington, 2006) is based on
Skinners 1957 book Verbal Behavior, which proposes that language consists of
behavior influenced primarily through reinforcement, and that establishing and
maintaining the motivation to learn is a critical component of teaching an individual to acquire language. This assessment measures an individuals ability to
perform a variety of tasks in the domains of basic learner skills, academic skills,
self-help skills, and motor skills.
Jorge performed well in the areas of cooperation and reinforcer effectiveness,
vocal imitation, and spontaneous vocalizations, completing most of the tasks in
each section independently. However, he did not perform as well in the areas
of visual performance, receptive language, motor imitation, requests, labeling,
and intraverbals (when a verbal stimulus evokes a verbal response that does not
have point-to-point correspondence with the stimulus; Skinner, 1957). Jorge was
unable to perform most of the skills in each of these areas. The results of this
assessment provided the basis for the development of protocols to teach language
skills not already in Jorges repertoire.

Case Formulation
Given the results of the ABLA and ABLLS-R, the behavior analysts found it
imperative to focus on vocal language acquisition first. It was clear that Jorge had

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

61

very limited functional communication abilities, and therefore mand training


(Skinner, 1957) was the initial recommendation to the family. Additionally, based
on the results of the FBA, it was decided that functional communication training (FCT) would serve to increase communication as well as decrease whining
and noncompliant laughter. 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. During FCT,
problem behavior is typically placed on extinction (Tiger, Hanley, & Bruzek,
2008). Finally, the behavior analysts determined that it was also highly important to focus efforts on increasing independent eating, given concerns regarding
malnutrition.
The behavior analyst met with the family and explained the assessment results
and the initial treatment recommendations. 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. The parents were asked to select three goals for their child during the
6-month intervention. The goals selected by the family were increasing communication, independent eating, and independence. Since the first two goals would
be encompassed by the behavior analysts initial recommendations, the notion of
independence was discussed further and it was agreed upon that independence
would come from increasing communication, increasing independent eating, and
also from toilet training. The family and the behavior analysts therefore agreed
that functional communication training, mand training, and independent eating
protocols would begin immediately, as they were the top priorities for the family
and were found to be clinically necessary. It was agreed upon that toilet training
would be the third intervention attempted, once progress was made with communication and eating.
Additionally, after the ABLLS-R assessment results were completed, it was
concluded that Jorge would benefit from several academic interventions. The
behavior analysts approached the school to discuss some skill deficits and recommended areas to target for improvement. However, the school was not receptive
to the behavior analysts suggestions, given that they had a regimented autism
curriculum in place that was approved by the school district. The behavior analyst therefore provided the assessment results and several recommendations to
the family if they were to receive any private tutoring.

Intervention Planning
COMMUNICATION

Functional communication training


Based on the results of the FBA, it was determined that avoidance of task demands
was maintaining the noncompliant laughter. It was therefore decided that appropriate communication would replace noncompliance and whining. FCT involves

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Childhood Disorders

a differential reinforcement procedure in which appropriate responses are taught


and reinforced, while problem behavior is placed on extinction (Tiger, Hanley, &
Bruzek, 2008). The procedure used was outlined as follows: Jorge was asked to sit
at a table to work on an academic task. Using a prompting hierarchy, Jorge was
immediately prompted to ask for a break. Upon a correct response of break,
Jorge was allowed to scoot away from the worktable for 10 seconds. When time
was up, Jorge was again asked to complete an academic task. Upon engaging
in noncompliance, Jorges feet were immediately removed from the table and he
was redirected to the academic task. Once the response break was adequately
conditioned, 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.

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. Additionally, per parent request of independence, it was important to teach
Jorge to use socially appropriate communication to request things that he wanted
or needed. In accordance with FCT, 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. As with FCT, problem behavior was placed on extinction. The procedure used was outlined as follows: Jorge was given a preferred item
to engage/play with (i.e., a ball, movie, pictures). After about 10 seconds of access
to the preferred item or activity, the item was removed from Jorge. The consultant
would give Jorge a full verbal prompt (i.e., say ball) and wait for him to say the
word. If Jorge repeated the words say ball he was immediately told no and
the prompt was provided again, say ball. If Jorge continued to say, say ball, a
longer pause was inserted between the two words in the prompt (i.e., say . . . ball).
As soon as Jorge engaged in the correct response, ball, the ball was immediately
given to him followed by praise (i.e., good job! and a pat on the back). This
teaching was done in a discrete trial format (Martin & Pear, 2011) in which Jorge
was given multiple discrete opportunities to rehearse the new mand.
EATING INTERVENTION

The goal of this intervention was to increase Jorges independent eating and
reduce the need for parent spoon-feeding or prompting during mealtime. Based
on the result of the preference assessment, it was determined that a preferred
movie would be used as a reinforcer for independent consumption of food. 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 family was instructed to not spoon-feed Jorge or provide
him with any prompts to eat, but instead to allow him the opportunity to eat
on his own. Jorge was positioned at the dinner table such that he could see the
television within his view. Jorges parents were given the remote control and

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

63

every time that Jorge took a bite of his food, his favorite movie was momentarily
turned on for him to watch. After consumption of food (defi ned as swallowing),
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, the movie was
paused. The movie was turned on again as soon as Jorge put another bite of
food or sip of juice to his lips. If 20 seconds of not consuming any food or drink
elapsed, Jorges family was instructed to give him a gestural prompt by pointing
to his food.
TOILET TRAINING

A rapid method for toilet training (Azrin & Foxx, 1974) was used to meet the
clinical need of this case. 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, fluid loading, and overcorrection procedures. To begin this intervention, the behavior analysts sat down with
the family and explained the recommended procedures. The family agreed that
they were comfortable with the procedures, and a weekend was selected in which
all immediate family members would be home with the behavior analysts to help
support the process.
Initially, the family was asked to collect data on Jorges elimination schedule by
conducting diaper checks every 30 minutes over the span of 5 days. As per the results
of the preference assessment, a highly preferred toy was selected for toilet training
and was stored out of Jorges sight until the intervention weekend began. Jorges
family purchased several pairs of underwear for Jorge, which he helped select.
On the fi rst day of the intervention, Jorge was given unlimited access to many
preferred fluids and was prompted to take a sip every few minutes, a process
called fluid loading. This component was used to ensure that Jorge would need
to urinate frequently, allowing for more opportunity for success and teaching.
Digital timers were used to place toileting on a 15-minute schedule in which
Jorge was required to say, potty, and then sit on the toilet for 5 minutes or until
elimination occurred. If any elimination occurred while on the potty, Jorge was
praised and provided with 5 minutes of access to his preferred toy identified for
use during toilet training. If Jorge had an accident, an overcorrection procedure
was used in which Jorge was provided with a statement of disapproval, made to
clean up the area of his accident, and change his own clothes. This procedure is
called an overcorrection procedure, given that the response effort for accidents is
exaggerated to make the clean-up event exhaustive and slightly aversive (Cooper,
Heron, & Heward, 2007).
These procedures continued for two days, after which Jorge was consistently
eliminating in the toilet. The toileting schedule timings were slowly lengthened
and fluid loading was discontinued, such that Jorge was independently toileting
himself on his own schedule. Formally programmed positive reinforcement for
appropriate toileting was discontinued after one week. Jorge remained in pullups training pants overnight until he no longer was having overnight accidents.

64

Childhood Disorders

Addressing Nonspecifics
The model used for the treatment of this case was one of parent training and inhome consultation. The purpose of the parent training was to provide parents
with the skills necessary to implement the protocols developed by the behavior analysts. It should be noted that the most effective behavioral treatment for
autism has been early childhood intensive training. 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, 1967, 1987). Given the lack of resources in the community in which
the family lived, intensive intervention was not available at the time of Jorges
original diagnosis. Additionally, Jorges sister, Carmen, was also involved in the
training sessions and attended all meetings with the behavior analysts. Including
Carmen in the process allowed for another individual to implement protocols, as
well as the maintenance of consistency across all family members.
The first step in this process was building rapport with the family. Given that
the parents had previously experienced a lack of success with other treatment programs, it was important that they trusted the behavior analysts and the programs
that were developed. 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. Furthermore, the behavior analysts avoided the use of technical terms and communicated with the parents at a level with which they were comfortable. Finally, 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.
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. Foxx (1996) stated that in the case of successful behavioral intervention programs, 10% is knowing what to do; 90% is getting
people to do it (p. 230). This allows for consistency across environments to enhance
the likelihood that the intervention will be successful and durable (Forehand &
Atkeson, 1977). Therefore, the behavior analysts contacted other individuals in the
community who were providing other forms of treatment for Jorge, including Jorges
teachers at school, as well as his speech and language pathologist.

Potential Treatment Obstacles


Many obstacles may arise in the treatment of any individual. One of the most
common difficulties faced by behavior analysts who conduct in-home consultation is inconsistency across family members. The behavior analysts in this case
were fortunate that the family worked together as a unit, and inconsistency across
family members was minimal. 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.

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

65

To address the issue of inconsistency, the behavior analysts observed each of the
family members implementing each of the protocols and provided corrective
feedback. Additionally, inconsistency was addressed at meetings between family
members and the behavior analysts.
Another barrier commonly faced when conducting behavioral consultation
work is inconsistency or lack of collaboration among treatment providers for
the individual. Foxx (1996) suggested that often a program will fail because its
success depends on the consultant convincing people to carry out the program.
Unfortunately, after numerous attempts to meet with Jorges teacher, we were
not successful in establishing a meeting. The teacher was resistant to accepting
academic suggestions because the school was following a model that had been
approved by the school district. This is not an uncommon scenario, 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, 1996).
In addition to collaboration and implementation barriers, the behavior analysts in the case of Jorge faced challenges at the more basic level. For example,
as is common in many behavior analytic interventions, there was difficulty in
fi nding appropriate reinforcers. 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, 2004, p. 30). In this case, edible
reinforcers were automatically excluded due to food refusal. Therefore, other
potential reinforcers were sought out. This limited the amount of items that could
be used as reinforcers for Jorge. Limited reinforcers can cause problems for treatment, as strong reinforcers are a critical part of any intervention. In this case,
preferred items were identified through a preference assessment, but when treatment was not initially successful, the behavior analysts decided to reexamine the
effectiveness of the reinforcers being used.
Once items have been shown to be effective reinforcers, lack of success of an
intervention may be due to other factors. This was the case during toilet training.
The original protocol was not effective at first, so the behavior analysts met with
the family to discuss modifications. The lack of effectiveness of the video game
technology as a reinforcer was eliminated on the basis that Jorge would seek out
the game. The difficulty was that Jorge was not urinating in the toilet and thus
was not contacting reinforcement. Therefore, the behavior analysts and the family decided to use a more intensive intervention. The behavior analysts had Jorge
remain in the bathroom until he began to urinate. Once he began to urinate, he
was immediately placed on the toilet and allowed access to the video game. This
modification proved to be highly effective.

When Treatment Was Not Working


PROBLEMS WITH COMMUNICATION

One obstacle encountered during mand training was that Jorge would repeat
arbitrary words such as say. For example, following the prompt Say, ball,

66

Childhood Disorders

Jorge would repeat, say ball. Additionally, Jorges parents were prompting
him to say ball, please. After noting that Jorge would use the words say ball
please to request the ball, the behavior analysts had to meet with the family
and request that only one-word mands (i.e., ball) were taught initially and that
arbitrary words such as please were left out. A prompt fading procedure was
used in which the discriminative stimulus, say was spoken softer and with a
longer pause prior to the mand, until no prompts were needed. Additionally, a
differential reinforcement procedure was used in which only the response ball
was reinforced and not say ball or say ball please. This alternative procedure
helped to break the inappropriate verbal chain of words and assisted in teaching
Jorge his fi rst functional word, ball, as well as many other subsequent items
and activities.
PROBLEMS WITH EATING

After several successful meals in which Jorge ate independently, it was noted that
Jorge was only eating fi nger foods (i.e., quesadillas, hot dog, chips). When provided with foods that required a spoon (i.e., yogurt or applesauce), it was observed
that Jorge would refuse to eat them, even though parental report indicated that
he had previously eaten those foods. A modification to the protocol was made to
include spoon-only foods during certain meals, in which the same protocol was
used to reinforce independent eating with a preferred movie. Some additional
teaching was required to get Jorge to hold the spoon, scoop the food, and bring
food to his lips. After several meals with spoon foods only, the behavior analysts
were able to provide a variety of fi nger and spoon foods for Jorge at each meal.
A second concern that arose during mealtime was the duration of time that it
took Jorge to consume the foods. Jorge had traditionally spent an hour or more
at the dinner table while his parents tried various strategies to feed him. During
the intervention, Jorge spent about 45 minutes per meal while independently eating. The protocol was modified again to shape continuous eating during a meal,
instead of eating and pausing after swallowing bites. The total mealtime was
reduced from 45 minutes to 25 minutes.
PROBLEMS WITH TOILET TRAINING

Even with the 15-minute scheduled toilet time and overcorrection procedure for
accidents, Jorge had still not had a successful elimination on the toilet during the
fi rst 7 hours of the toilet training intervention. Up to that point, he had 8 accidents
and no successful eliminations on the toilet. At that point, the behavior analysts
modified the protocol and kept Jorge in the bathroom. A portable DVD player
was brought into the bathroom, and then Jorge and the behavior analyst watched
movies in the bathroom during the time between sits on the toilet. Scheduled sits
continued as usual. However, as soon as Jorge began voiding in his underwear,
the behavior analyst quickly escorted him onto the potty to fi nish his elimination
in the toilet. At that time, Jorge was praised and the successful elimination on

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

67

the toilet was reinforced with the highly preferred toy item. Following that initial
elimination and contact with the reinforcer, Jorge continued voiding in the toilet
during the scheduled sit time, and remaining in the bathroom during breaks was
no longer necessary.

Ethical Considerations
CONSULTATION MODEL: IS IT ETHICAL?

A primary consideration in the consultation model implemented in Jorges 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. However, given the limited availability of services in the area and the limited financial resources that the family
was able to contribute to ABA treatment, it was concluded that some support
would be better than no support.
Additionally, the consultation model included a rigorous parent-training component in which both parents and, in this case, a sibling were trained in the basics
of behavior support, including skill acquisition and behavioral reduction strategies. In this case, the behavior analysts were able to work with the family to set
obtainable goals, facilitate the implementation of plans, model appropriate supports, and provide technical assistance over a period of 4 months, enough time
to ensure that the family could implement the clinical recommendations with
fidelity. 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.
USE OF PUNISHMENT

Punishment is defi ned as a consequence that decreases the likelihood of the


behavior occurring in the future (Cooper, Heron, & Heward, 2007). Punishment
has historically been a controversial topic in the science of behavior analysis.
However, 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,
or for a behavior in which other less intrusive interventions have been demonstrated to be ineffective (Baily & Burch, 2005). In the treatment of Jorge, the
only time that punishment was used was during the overcorrection procedure
for accidents during toilet training. Ethical consideration was given prior to its
use; however, the behavior analysts felt that it was necessary to use the procedure, 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. Given these issues, as well as the health concerns of
Jorges school, the behavior analyst approached the family and received consent to use the punishment procedure during toilet training. The procedure was
carefully monitored, was implemented only by the behavior analysts, and was

68

Childhood Disorders

needed only during the fi rst day of toilet training; on subsequent days it was
discontinued.

Common Treatment Mistakes to Avoid


Numerous common mistakes should be avoided when designing and implementing behavioral interventions. The fi rst common mistake, briefly mentioned above,
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. A common mistake in behavioral treatment is to assume that the intervention is not working.
However, it is possible that the items chosen as reinforcers may not actually be
functioning as such (Higbee et al., 2000). In this type of situation, it is important to systematically verify that the putative reinforcers are functioning as such.
Reinforcer assessments are useful in this sort of a situation (Cooper et al., 2007).
In the case of Jorge, the behavior analysts assessed the effectiveness of potential reinforcers by using the identified preferred items during mand training and
assessing the data. Upon observing increases in behavior, it was established that
the preferred item was in fact functioning as a reinforcer. In such cases, reinforcers should be assessed systematically through a reinforcer assessment to ensure
their effectiveness and to avoid mistakenly modifying a 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. 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., 2007). A motivating operation is an environmental variable that a) alters the reinforcing effectiveness of some stimulus, object,
or event; and b) alters the current frequency of all behaviors that have been reinforced by that stimulus, object, or event (p. 699).
This is of importance in any intervention designed to promote acquisition of
a behavior, particularly in the case of teaching manding. In the case of Jorge, the
items that were being used for mand training were a ball, a movie, and pictures.
Family members were asked to restrict access to these items during times in which
mand training was not being implemented. As mentioned previously, a mand is
a verbal operant that is under the functional control of a motivating operation.
Therefore, by restricting Jorges access to these items it was more likely that a
motivating operation would be in place during training sessions, increasing the
effectiveness of the protocol. It should be noted that access to video game technology was also restricted to toilet-training sessions for the same reason.
Another common mistake made by behavioral consultants is not basing an
intervention on the function of the behavior, or basing it on the incorrect function. Functional behavior assessments (FBA) should be conducted prior to the
development of any intervention. An FBA will provide important information
regarding both antecedents related to the problem behavior that, if altered, may
reduce the motivating operation for problem behavior, as well as information

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

69

regarding the source of reinforcement for the behavior, which can then be eliminated (Cooper et al., 2007). If an intervention is designed that does not match the
function of the behavior, it is unlikely that it will be successful in reducing the
behavior. However, there are cases in which the function is difficult to identify
or is incorrectly identified. In such situations, it is important to reexamine the
function of the behavior and make appropriate modifications. Moreover, over the
course of time, functions of behavior are likely to change. Lerman et al. (1994)
stated that an intervention may lose its effectiveness over time due to the function of the problem behavior changing. Behavioral assessment and intervention
are ongoing processes in which data analysis and monitoring are highlighted. It
is important to monitor the data closely in order to detect changes that may be a
result of changing environmental variables.
Data analysis is arguably the most important part of behavioral interventions.
Data are the results of measurement, usually in quantified form (Johnston &
Pennypacker, 1993, p. 365). The information gained from data provides necessary insight into the success or failure of an intervention. Given that behavior is
dynamic and behavior change is an ongoing process, behavior analysis is a field in
which all decisions are based on data (Cooper et al., 2007). A common mistake is
to make programmatic changes without regard to the data; in such cases, where
decisions are not guided by data, the programs are likely to fail.

Overcoming Regression/Relapse
Regression and relapse are important considerations in any treatment regimen.
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. Behavioral consultation is designed to provide temporary treatment in which the effects will maintain
once consultation is removed. Behavior analysts program interventions to prevent regression and relapse through the use of generalization and maintenance
techniques. Stokes and Baer (1977) argued that for a treatment to be effective it
must occur over time, persons, and settings; this is called generalization. Behavior
analysts use a variety of methods to specifically program for generalization, such
as introducing natural maintaining contingencies and using many exemplars. It is
important that this process be considered one of importance and not something
that just occurs (Stokes & Baer, 1977).
Other methods used to prevent relapse and regression in the case of Jorge were
the use of parent training and referral to other services. During parent training
sessions, families were taught the basic principles of behavior analysis as well
as the importance of data monitoring. The parent training was important, as it
provided the family with the basic skills to be able to respond appropriately to
new problem behaviors that may arise, as well as to use what they have learned
to teach new skills. Follow-up was conducted 4 months following the closing session, and the parents reported that Jorge had continued to eat independently and
use the toilet independently, and that his verbal language continued to increase.

70

Childhood Disorders

In addition to providing families with basic skills in behavior analysis through


formal training, it also provides them with the knowledge to be more informed
consumers of autism services. It is common in low- 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, Ellis,
McLaurin, Daniels, & Morrisey, 2007). This may result in the use of services that
are not empirically supported and may ultimately be ineffective. Jorges 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.

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, Jorges family was trained on how to provide teaching and behavior support to their autistic son. Anecdotally, the family reported
that they felt as if the behavior analysts had awoken Jorge from autism. In other
words, the family felt accomplished and empowered in learning new strategies to
teach their son, who was once assumed to be un-teachable. It was observed that
the family was engaging in daily teaching interactions with Jorge, even on days
when the behavior analyst was not in the home.
At the beginning of treatment, Jorge had some words that were occasionally
used functionally, but were often used inappropriately to request items that he
later refused, or during echolalic responding. By the end of treatment, Jorge
engaged in over 50 functional words, all of which he was able to use appropriately
to request items or talk about items and events in his environment (see Figure 3.1).
Jorge was also taught to eat independently without spoon-feeding or continual
prompting from his parents (see Figure 3.2). By the end of the intervention, Jorge

Date

Functional Communication Training. Each data point represents the number of


words considered mastered at each of the dates.

FIGURE 3.1.

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

10 11 12 13 14 15 16 17 18 19 20 21
Session

FIGURE 3.2. Independent Eating Treatment. The open circle data stream indicates the
number of verbal or gestural prompts that were necessary for Jorge to self-feed over training
sessions. The solid square data stream indicates the number of times the video had to be
turned off due to Jorges cessation of eating.

was able to eat a meal independently within 20 minutes, using a spoon correctly,
as needed. Finally, Jorge was taught to independently toilet himself using the
toilet in his home. By the end of the first day, Jorge was engaging in successful
urination eliminations on the toilet (see Figure 3.3). Accidents were seen during
the fi rst three days but by the fourth day were no longer occurring. Jorge held
his bowels (often common during initial toilet training) during the fi rst five days;
upon consultation with the pediatrician, he was given a laxative and was successful in having bowel movements on the toilet after seven days. 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 3.3. Cumulative Occurrence over The First Five Days of Training Sessions of
Prompted and Independent Toilet Urinations and Accidents and BMs.

72

Childhood Disorders

toilet were needed for just over two weeks, 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, would simply go himself.

The Art of Behavior Analysis


While applied behavior analysis is based on scientific principles (Baer, Wolf, &
Risley, 1968), there is certainly an art to the delivery of services in behavior analysis. Relating particularly to the treatment of childhood autism, often the behavior analyst must work with the parents just as much as the behavior analyst works
with the individual child, especially in a consultation model. Speaking with and
relating to parents of a child with a debilitating condition often takes a certain
level of fi nesse and compassion. Additionally, parents often look to the behavior
analyst with hope of recovery from autism. This can be a challenge for the behavior analyst to explain that there is no promise of recovery and that, instead,
the behavior analyst will work to reduce behavioral excesses and to increase
skills to overcome behavior deficits associated with autism. Behavior analysis is
widely accepted as a treatment for autism; however, it must be made clear that the
strength of behavior analysis is overcoming the behavioral excesses and deficits.
Once those behaviors are changed, the diagnosis, defi ned by the occurrence of
these behaviors, may be modified or removed.
Shaping (Martin & Pear, 2011) is also a procedure that may be considered as
much an art as a science. While shaping involves using the empirically established scientific principles of reinforcement and extinction from the experimental
analysis of behavior, the decision to stop reinforcement of a particular amount or
strength of a behavior, to await variations in the behavior, and then to reinforce
those new levels of the response in applied behavior analysis is often left up to
the clinicians acumen. For example, there is no written rule that dictates when
the sound of a verbal operant is correct, but rather the behavior analyst, acting
as the listener, must decide which responses to reinforce and which to extinguish.
In the treatment case of Jorge, the art of shaping was used to reinforce successive
approximations to spoon-feeding, to duration of time during meals, to successful
approximations of speech during mand training, and to successful approximations to independent toileting. While there is an abundance of research on each
of these topics, 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.

Cultural Factors to Consider in Providing Treatment


There are often cultural concerns that arise during the treatment of autism, specifically pertaining to the treatment of children with respect to how the parent

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

73

was raised. 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. Given that autism
is classified in part by behavioral excesses (often aberrant behavior), 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. Often, what the parents consider to be punishment does not function
as punishment at all, but rather reinforces the problem behavior. For example, 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.g., go to your room). However, with regard to function
of behavior, escape-maintained problem behavior (behavior that is reinforced
by the postponement or removal of requests to engage in a certain behavior, or
the removal of environmental cues that signal the introduction of less desirable
activities) is actually strengthened by the time-out procedure, while the parent is
using what is thought to be discipline.
Perhaps one of the more obvious cultural factors to consider is the language
barrier that occasionally arises, as was the case in the treatment of Jorge. In this
case, initially a translator was brought in to assist in communication between
the behavior analysts and the family. Additionally, when there are two languages
being spoken in the household, 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.
A fi nal identified cultural barrier is differences of opinion of alternative treatments of autism. There are many documented treatments in autism, including
speech therapy, occupational therapy, physical therapy, sensory integration
therapy, play therapy, music therapy, chelation, gluten-casein-free diet, equine
therapy, acupuncture, and so on. Although many of these therapies have been
demonstrated to be helpful in the treatment of autism, many have not been.
Though applied behavior analysis is currently considered best practice in evidence-based treatment of autism (Vismara & Rogers, 2010), sometimes there are
barriers to its use as a treatment in certain communities.

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Baer, D. M., Wolf, M. W., & Risley, T. R. (1968). Some current dimensions of applied
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Baily, J. S., & Burch, M. R. (2005). Ethics for behavior analysts. Mahwah, NJ: Lawrence
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Bijou, S.W., Peterson, R. F., & Ault, M. H. (1968). A method to integrate descriptive
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Jacobson, J., Foxx, R. M., & Mulick, J. A. (2005). Controversial therapies for developmental disabilities: Fad, fashion and science in professional practice. Mahwah, NJ:
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Johnston, J. M. & Pennypacker, H. S. (1993). Strategies and tactics of human behavioral
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Kerr, N., Meyerson, L., & Flora, J. A. (1977). The measurement of motor, visual, and
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Lerman, D. C., Iwata, B. A., Smith, R. G., Zarcone, J. R., & Vollmer, T. R. (1994).
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Lord, C. Rutter, M. DiLavore, P. C., & Risi, S. (1989). Autism diagnostic observation
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COMMENTARY

Michael E. Kelley

Willams, Greenwald, and Seniuk provide a systematic description of a case study


involving one individual who exhibited symptoms consistent with a diagnosis
of autism. 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. In a sense, 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, teachers, and caregivers. On the
other hand, one of the confusing aspects of autism is that several individuals
diagnosed with autism may present with very different symptoms. Specifically,
some individuals may engage in vocal speech, while others may not. Some individuals may establish specific routines or repetitive behaviors that are difficult to
compete with, and others may not. Some individuals may seek out some social
interaction; others may tolerate social interaction, at best, while others will purposely avoid social interaction. Some individuals may develop significant food
selectivity. There are several other possible symptom clusters that might covary
among individuals diagnosed with autism. Simply considering the above potential symptom presentations, 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.
Williams et al. clearly show the difficulty in assessing and treating the core
and associated deficits and excesses of autism. They also clearly show (with their
single-subject data collection) the power of behavioral techniques and procedures for collecting data, establishing hypotheses, testing hypotheses, generating
function-based treatments, and making objective, data-based decisions about the
adequacy of an assessment or treatment. 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. For example, functional behavioral assessment (FBA) typically begins withand I emphasize begins with some sort of
indirect assessment procedures. Those procedures may include interviews, rating
scales, and instruments that are specifically designed to provide the practitioner
with information about the individuals behavior. 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.g., convert a parents

78

Childhood Disorders

description of an aggressive child to specific instances of what does and does


not count as aggression), to develop hypotheses about the function of those
behaviors, and to develop a plan for upcoming assessment. The plan will be influenced by myriad variables, including many aspects of family life, and so on, that
can only be obtained through indirect assessment.
The next step in the process involves direct assessment, which is described so
well in this chapter. Williams et al. began with antecedent-behavior-consequence
(ABC) recording (Bijou, Peterson, & Ault, 1968). ABC recording provides details
about the circumstances that preceded and followed the occurrences of target
behavior. There are several advantages to ABC recording. First, ABC recording produces a permanent product that aids in generating hypotheses about the
function of behavior. Second, ABC recording may help one to detect certain patterns in the environment (e.g., that problem behavior is likely to occur when the
mothers attention is diverted).
There are also some significant limitations to ABC recording. ABC recording does not provide information about the overall context in which the problem
behaviors occurred. Consider the example above. Lets say that a child engaged
in 10 instances of aggression, and all 10 instances were preceded by diverted
attention and were followed by reprimands. This might seem like fairly clear
evidence that attention diversion is motivating and attention delivery is maintaining aggression. If attention was only diverted 10 times, a one-to-one relationship would exist between the attention diversion and aggression; if attention
was only available contingent on aggression, a one-to-one relationship would
exist between aggression and attention. However, what if attention was actually
diverted an additional five times, and aggression did not occur on those five occasions? What if attention was diverted 100 times, and aggression did not occur on
those occasions? We would be far less confident about the relationship between
attention diversion and problem behavior. There is a growing literature on conditional probabilities that can help guide the practitioner in this area (e.g., Borrero,
Woods, Borrero, Masler, & Lesser, 2010; Lerman & Iwata, 1993; McKerchar &
Thompson, 2004; Pence, Roscoe, Bourret, & Ahearn, 2009; Vollmer, Borrero,
Wright, Van Camp, & Lalli, 2001). Specifically, this line of research helps practitioners to collect and analyze data such that the likelihood of a contingent relationship between events can be judged. The primary difference between ABC
recording and conditional probabilities is the exclusion or inclusion of the background context in which the behavior occurs.
Williams et al. conducted skills assessments next. I thought it was interesting
that the preference assessment was placed under skills assessment, because preference assessment results typically guide the practitioners use of stimuli as potential reinforcers. From a teachers perspective, it might seem daunting to have to
establish specific preferences for each individual. However, the literature clearly
supports several conclusions. First, preference assessments help to select the best
candidates for potential reinforcers. Second, there are several procedural variations to choose among, and it is likely that practitioners will find them reasonable
to use and helpful during assessment and treatment. Finally, the use of tools like

Behavior Analytic Treatment of Behavioral Excesses and Deficits of Autism

79

the Assessment of Basic Learning Abilities (ABLA; Kerr, Meyerson, & Flora,
1977) and the Assessment of Basic Learning and Language Skills (ABLLS-R) is
critical, because apparati such as these specifically guide skill development. The
other option available is to simply guess at a starting point, which is obviously a
crude and inefficient way to establish a baseline from which to begin teaching.
All of the procedures up to this point are designed to place a practitioner
in the best possible position to develop an effective treatment. The next section of the chapter, Intervention Planning, discusses the integration of the
previous assessments and their application to treatment development. One
procedure that readers may fi nd conspicuously absent is the use of functional
analysis (Iwata, Dorsey, Slifer, Bauman, & Richman, [1982]1994). 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, function-based treatments
(Mace, 1994). In Jorges case, treatment (functional communication training,
or FCT; Carr & Durand, 1985) was implemented, based on the results of the
FBA. An FBA may include a functional analysis, but in this case (as in many
cases), it did not. The feeding intervention was also put in place without the
information provided by a functional analysis. Later in the chapter, Williams et
al. describe problems with treatment, and Jorges manding and eating behavior
remained resistant to treatment. I wondered if the treatments may have been
more robust if they had been informed by the results of functional analyses.
I suspect that this would true, particularly for Jorges eating behavior. Consider
the data generated by Piazza et al. (2003). In their study, 10 of the 15 functional
analysis outcomes were interpretable. Of those 10 functional analyses, 9 out of
10 (90%) suggested that inappropriate mealtime behavior was maintained, at
least in part, by negative reinforcement in the form of escape from or avoidance
of eating. These data were congruent with previous research on treatment of
eating disorders with children with developmental disabilities. That is, 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. In Jorges case, Williams et al. arranged access to preferred stimuli
contingent on compliance, with constitutes differential reinforcement of alternative behavior (DRA). Unfortunately, to date, there are no studies showing
that positive-reinforcement-based treatments are useful for escape-maintained
problem behavior (including refusal) during mealtimes, at least not when escape
extinction is not a part of the treatment.
In the remainder of the chapter, Williams et al. address common mistakes to
avoid, relapse, an evaluation of their data, the art of behavior analysis, and cultural considerations (to which the authors alluded earlier in the chapter). Each of
these discussion points provide excellent rules of thumb for practitioners to follow when developing treatment plans with clients. From a scientific standpoint,
it is critical to maintain clear and consistent operational defi nitions, data collection procedures, and (not mentioned by the authors) assessment of interobserver
agreement. The data must guide the practitioner for selection of preferred stimuli

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Childhood Disorders

and to judge whether assessment and treatment procedures are producing the
desired information and outcome.

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Pence, S. T., Roscoe, E. M., Bourret, J. C., & Ahearn, W. H. (2009). Relative contributions of three descriptive methods: Implications for behavioral assessment. Journal
of Applied Behavior Analysis, 42, 425446.
Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Patel, M. R., Katz , R. M., Sevin,
B. M., Gulotta, C. S., & Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 36, 187204.
Vollmer, T. R., Borrero, J. C., Wright, C. S., Van Camp, C., and Lalli, J. S. (2001).
Identifying possible contingencies during descriptive analyses of severe behavior disorders. Journal of Applied Behavior Analysis, 34, 269287.

RESPONSE

W. Larry Williams, Ashley E. Greenwald, and


Holly A. Seniuk

Kelley raises some excellent points with regard to the overall treatment of autism.
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 agree that the case of Jorge was a classic
case of treatment of autism, with many behavioral excesses and deficits present
prior to treatment.
The major criticism posed by Kelley was that of the absence of a functional
analysis (Iwata, Dorsey, Slifer, Bauman, & Richman, [1982]1994). We support
Kelleys argument that a functional analysis is considered best practice with
regard to establishing a functional relationship between behavior and environmental contingencies. However, there are several limitations to the functional
analysis (e.g., Vollmer, Marcus, Ringdahl, & Roane, 1995), the most relevant to
this case being the limitation of time commitment in conducting a functional
analysis. In the case of Jorge, the difficulty with the manding intervention as a
result of echolalic behavior was easily resolved by fading the word say. Given
that no social contingencies were altered during instances of echolalia, it was
assumed that the behavior was automatically maintained, and an intervention
was immediately used to correct the inappropriate behavior. Although it may
have been acceptable to conduct a functional analysis here, in the interest of
time and resources, the clinicians decided to forgo the analysis and implement an
intervention. Had the intervention failed, a functional analysis would have been
implemented to determine the maintaining variables before attempting another
intervention. Additionally, this echolalic behavior was not harmful to Jorge or to
others, and therefore there was minimal risk in attempting an intervention prior
to a direct empirical demonstration of function.
With regard to the eating intervention, Kelley makes a strong argument for
escape- maintained behavior and the demonstrated use of escape extinction in
the literature for feeding problems. This escape-maintained behavior was not the
case with Jorge. Instead, it was observed that Jorge would readily accept food
when fed, but that he lacked motivation to feed himself. The use of differential

82

Childhood Disorders

reinforcement of alternative behavior (DRA) during Jorges mealtime proved to


be an effective intervention to increase independent eating.
Kelleys commentary reminds practitioners of the need for thorough justification for the use of empirically demonstrated interventions in the treatment of
autism. 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. Kelley makes an
excellent point when he notes that data must guide the practitioner in selecting
interventions to produce desired outcomes. 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. Without the use of evidence-based treatment, parents
are cautioned that resources may be wasted, and most important, time may be
lost in the race against autism.

References
Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1994).
Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27,
197209.
Vollmer, T. R., Marcus, B. A., Ringdahl, J. E., & Roane, H. S. (1995). Progressing from
brief assessments to extended experimental analysis in the evaluation of aberrant
behavior. Journal of Applied Behavior Analysis, 28, 561576.

{ PART II }

Mood Disorders

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{4}

Treatment of Depression
Patricia J. Robinson

There a number of popular myths about depression, and these myths have a
substantial impact on the health care services that people with symptoms of
depression receive. First, therapists and patients alike may think that depression is abnormal or out of the ordinary. However, in order for something to be
abnormal it must occur rarely, and this is not the case with depression. Clinical
research fi ndings indicate that one in ten people in America suffer from some
sort of depression every year (Kessler et al., 2005). A second myth concerns the
inevitability of depression as a response to difficult life circumstances. While
most people experiencing symptoms of depression report some form of loss or
personal setback, many do not experience depression so severe as to warrant
intensive treatment and instead fi nd a way to keep calm and carry on. A third
myth about depression is that it is associated with experiencing emotions, when
in fact it is more about becoming numb to emotions. Sadness is a part of our
human birthright, much like our other basic emotions, and, when permitted, it
flows in and out of our awareness throughout the day. Indeed, there are many
things in life that should trigger sadness, such as loss of a loved one or a job and
economic hardship.
That depression is purely a biological illness is a fourthand important
myth. While the World Health Organization, the body responsible for defi ning
and describing disease states, does not currently recognize depression as a disease, pharmaceutical companies promote this notion in marketing medications
to health care providers and patients. 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, and they are
not trained to market their findings.
Results from research studies conducted independent of pharmaceutical
companies influence suggest that depression is not a purely biological illness.
Specifically, the work of Paykel (Paykel, 2006) and colleagues suggests that cognitive behavioral therapy is more effective than medicine in preventing future
episodes of depression. Additionally, there is growing evidence that cognitive and

86

Mood Disorders

behavioral interventions may produce very rapid improvements in depression


(Kelly, Roberts, & Ciesla, 2005). It is also important to note that patients prefer
cognitive behavioral treatments to medications (Mynors-Wallis et. al., 2000).
When we look closely at these myths and research findings, we are more prepared to treat with intention and to understand the waters we are swimming in.
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. As this case demonstrates, it is important to understand not only the patients response to difficult
life circumstances, but also the patients response to that response, so to speak.
In the case of depression, that response typically involves avoidance of sad and
angry feelings, and the avoidance may occur both within the skin (experiential
avoidance, in which psychologically distressing thoughts, feelings, sensations, and
memories are avoided) and outside the skin (behavioral avoidance, 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, provide access to social reinforcement, and shape new behaviors). When
life circumstances overwhelm a persons ability to cope, a period of withdrawal,
rest, and request of support from others may be adaptive. 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 patients ability to cope in the first place.
Depression is a common problem; one in ten among us are prone to responding to hardships in life by using avoidance strategies and forgetting to reengage.
The learning history of the subject of this case study resulted in her experience of
this vulnerability. Ruby had suffered several episodes of depression prior to the
one described here. This chapter offers therapists contextual behavior therapy
strategies for use with people who are vulnerable to clinical depression, who get
trapped in their mind, and who struggle with struggling. Treatment of Ruby is
offered in a primary care clinic. This is the setting where most depressed patients
seek help and where increasing numbers of behavioral health providers are working (Robinson, Gould, & Strosahl, 2011; Robinson & Reiter, 2007). Treatment
formulation is based on six core processes of psychological flexibility derived
from acceptance and commitment therapy (ACT) theory (Hayes, Strosahl &
Wilson, 1999; Hayes & Strosahl, 2004; Hayes, Strosahl, & Wilson, 2011) and
found to be effective in clinical research studies (Bach & Hayes, 2002; Dahl,
Wilson, & Nilsson, 2004; Forman, Herbert, Moitra, Yeomans, & Geller, 2007;
Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007; Gifford, Kohlenberg, Hayes,
Antonuccio, Piasecki, et al., 2004; Hayes, Wilson, Gifford, Bissett, Piasecki, et al.,
2004; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Lundgren, Dahl, Yardi, &
Melin, 2008; McCracken & Eccleston, 2003; Zettle & Rains, 1989). These clinical
methods are derived in part from basic scientific research in the field of relational
frame theory (RFT) (Blackledge, 2003; Hayes, Barnes-Holmes, & Roche, 2001;
Torneke, 2011). In the recommended approach, the therapist assists the patient
with making gains in psychological flexibility, the goal of ACT, and moving

Treatment of Depression

87

from the depression trap toward a vital life (see Strosahl & Robinson, 2008, for
intervention materials and protocols).

Ruby
Ruby is a 64-year-old married mother. She lives in a rural area with her dog and
her husband of 18 years. 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. She and her husband had planned
to pursue art-related hobbies and to lead a slower paced, more contemplative
life in this pastoral setting, but they had significant fi nancial problems during
their fi rst year on the farm and had to pursue a plan B. Her husband, Albert,
was the author of plan B, and he believed that they could create and work in a
home business for a 10-year period and then retire. Ruby went along with the plan
reluctantly. 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. The
idea was to grow tomatoes and peppers and other ingredients to make a secret
family recipe for barbecue sauce, to prepare the sauce in their home, and to sell
it both locally and on the Internet. Ruby had worked for many years as an office
manager, and she anticipated the many details and hours of hard work needed to
create and implement a business plan. They argued about how soon their returns
would be realized, and, in the end, they both agreed to enter the new business.
Shortly after the launch, 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. While it entailed a 100-mile commute, he reasoned that he could spend
the workweek at his brothers house, as he lived near the company where Albert
planned to work. He reasoned that he wouldnt need to spend money on lodging,
and his salary would fund the cost of starting the barbecue business; he would
spend weekends with Ruby. Ruby was saddened by Alberts decision, as she had
hoped for a more intimate relationship at this phase of their marriage. She didnt
complain to Albert, reasoning that she should be happy that Albert had a chance
to bring in some money. Albert was her second husband, and they had married
in their forties. He had been married twice previously and had two children. They
had met at work and pursued their relationship in a secretive fashion for years
before tying the knot.
In her fi rst marriage, Ruby gave birth to one child and adopted one child. Her
daughter, the birth child, lived in another state and was happily married and
working long hours at her job. David, her adopted son, lived in the city where she
and Albert had lived previously. David had struggled intermittently with polysubstance abuse and heroin addiction since his high school years. While David
had participated in methadone treatment, had stable housing, and had worked
for years at a time, he continued to have relapses into using street drugs. Over the
years, Ruby had come to anticipate Davids relapses and to brace herself. Over
the past month, David had asked Ruby for a loan several times, explaining that

88

Mood Disorders

he and his wife were a little short. Ruby worried that this was a signal of his
return to street drugs, and she worried about him, his wife, and their seven-yearold son. She always slept much worse when she worried about David, and she
rarely talked with Albert about her concerns, as he was fed up with David.
After Albert started his new job, Ruby worked to optimize production of the
barbecue sauce; this involved managing personnel issues with their two full-time
employees, as well as completing all of the office tasks. She was also responsible
for managing their home fi nances, and she felt pangs of panic when she saw day
after day that money was going out and not coming in. Albert did not come home
every weekend as planned, as he was exhausted at the end of the week. During
this challenging year, Ruby and Albert often argued when he did come home.
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. He was sometimes critical of Ruby for
not being a better housekeeper. Ruby admittedly struggled with organizing the
personal and office space areas of the home. She was frustrated with not having
had the time to even unpack all the boxes from their move. The less organized
her home and workspace become, the more she wanted to retreat to her bedroom
with her dog and just maintain. She was irritable with Albert, and then critical
of herself for not being more organized, thoughtful, and supportive.
Rubys constant companion was her mixed-breed dog. Fiesty was 9 years old
and suffered from arthritis in her back legs. Ruby enjoyed walking Fiesty, even
though it required her to walk at a slower pace and for a shorter distance than she
would have liked. Prior to Fiestys decline over the past two years, Ruby had walked
her at a brisk pace and found that it helped her to feel calm and optimistic.
While only a distant memory, Rubys intention in moving to a rural area was
to have time for painting and writing. Shed hoped to find a reading group, take
painting lessons, study Spanish, and learn yoga. At the point when she sought
care, she was socially isolated and didnt even have time to visit with the neighbors. When she remembered her dreams about her retirement years, she felt sad
and told herself to buck up and play the hand shed been dealt. Ruby doesnt
hear that this message is often delivered in the voice of her long-deceased mother,
and instead experiences it as mandate.
At night, she reviews the frustrating and overwhelming activities of the day
and anticipates an uncontrollable tomorrow. She continues to take Prozac, having restarted it about a year ago and as a pattern of intermittent use over the
past 10 years or so. She experienced benefit at times but with a decrease in
sexual interest. Given increasing fatigue in the morning and the lack of energy to
persevere, Ruby decided to ask her family physician for help. She had established
care with Dr. Marks shortly after moving to the area, and he assumed responsibility for her blood pressure and arthritis medications. He also encouraged her
to walk 3045 minutes daily and to reduce salt in her diet. He was also the prescriber for her anti-depressant.
A psychiatrist had originally prescribed Prozac for Ruby. After her divorce,
she had experienced depression and sought help. She took the medicine and

Treatment of Depression

89

went for a dozen or so visits to discuss her family of origin and the failure of
her marriage. She had begun to feel better and had stopped the counseling. She
was unclear about the cause of depression, but felt it was probably a mix of bad
genes and a failure of character. To her knowledge, there were no counselors
in the smallest town near her home, and she knew that she could not afford the
time to go 20 miles to the next largest city. Moreover, she didnt know if her current insurance coverage would cover counseling or psychiatric care.
Ruby scheduled a visit with Dr. Marks to ask his advice about how to get
things under control. She briefed him on her stresses, and he already knew something of her history of depression. 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. He explained that Dr. Peterson was a behavioral health consultant
and often had good ideas about how to work with stress. Dr. Marks also said
he was concerned about Rubys blood pressure. 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. Dr. Peterson was able to
see Ruby for a 30-minute initial visit immediately after her visit with Dr. Marks.

Assessment
As was standard for Dr. Peterson, her consultation visit began with a description
of her services (see Box 4.1) and completion of the Duke Health Profi le. These initial activities may be completed in 5 minutes or less (90 seconds for the introduction and 180210 seconds for completion and scoring of the Duke). Dr. Petersons
job description defines her work as consultative (rather than psychotherapeutic)
and as a primary care service (rather than specialty mental health service). It also
orients the patient to the structure of the visit, so that the patient is able to participate actively. The Duke Health Profi le is a 17-item measure of health-related
quality of life. The normative sample was that of primary care patients. Use of
the Duke is congruent with the strengths-based approach that Dr. Peterson uses
in primary care behavioral health visits. 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. In her chart notes and her feedback to
the patient, she reports scores on three Function Scale Scores: Physical Health,
Mental Health, and Social Health. These scores range from 0 to 100; higher scores
indicate better functioning.
BOX 4.1.

Behavioral Health Consultant Introduction

Hello, Id like to tell introduce myself and explain what I do here in the clinic. I
am a behavioral health consultant and a psychologist. 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. I work as a

(continued)

90

Mood Disorders

BOX 4.1 (Continued)

consultant to you and to your doctor and I write my chart note in the medical
chart. I have the same reporting responsibilities concerning risk or danger as
other providers in the clinic.
Our visit today will take about 2025 minutes. First, Ill ask a lot of questions, trying to get a snapshot of your life right now and, then, we will focus on
the problem that you and your doctor have concerns about. After about 15 minutes, 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. Do you have any questions?
If not, lets start with having your respond to the Duke Health Profi le; its a
measure of health-related quality of life.

After her introduction and completion of the Duke, Dr. Peters obtained
a snapshot of Rubys present life context in about five minutes by asking a
series of questions. The Life, Work, Play, and Health Tool (Robinson, Gould, &
Strosahl, 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, conversational manner, which is usually experienced as supportive of relationship development by patients. Organized into four
areas, these questions include:
1. 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. Work
Do you work? Study?
If yes, what is your work?
Do you enjoy it?
If not working, are you looking for work?
If not working and not looking for a job, how do your support
yourself?
3. Play
What do you do for fun? For relaxation?
What do you do to connect with people in your neighborhood or
community?
4. Health
Do you use tobacco products, alcohol, 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. Marks and to Ruby, Dr. Peterson
focused her assessment on the referral problem identified by Dr. Marks and

Treatment of Depression

91

Rubysymptoms of depression and, from Rubys point of view, trying to get


things under control. To obtain an understanding of the way in which these
symptoms were functioning in Rubys life, Dr. Peterson completed a brief functional analysis. The Three Ts and Workability Tool (Robinson, Gould, & Strosahl,
2011) offers a structure that helps the behavioral health consultant strike a balance between thoroughness and brevity, so important to informing timely skill
training and development of an engaging and meaningful behavior change plan.
Three T and Workability questions are organized into four areas and include a
variety of questions in each area.
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, how long does it last?
2. 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. Trajectory
Is it here all the time or is it episodiccomes and goes? Whats the problem been like over timesometimes better and sometimes worse? Has
it been getting better or worse over time? How about recentlybetter
or worse in the past month?
4. Workability
What have you done to cope with the problem? Did it work, 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, Dr. Peterson shifted the interview to behavior change
planning. Box 4.2 is the resulting chart note for the first visit.
As can be seen in the Plan section of the chart note, Dr. Petersons efforts
to help Ruby approach her life and all of its stresses with greater psychological flexibility built upon Rubys strengths: her history of a meditation practice,
along with a current interest in meditation and yoga, and her organizational and
planning skills. In an effort to create a more powerful context for goal setting,
Dr. Peterson introduced the idea of setting goals in a value context. To help Ruby
clarify her values and connect with them, Dr. Peterson used the You won the
lottery and . . . exercise.
Lets say that you won the lottery, and you have decided to go on the vacation of a lifetime. You are somewhere over the Pacific Ocean, and your
captain comes on the overhead PA to announce, Our plane is having

92

Mood Disorders

BOX 4.2.

Dr. Petersons Chart Note of Initial Visit with Ruby

Subjective: Ruby is a 64-year-old married mother of two adult children. She


lives with her husband of 18 years in their home of two years. They have a home
business, and the husband works weekdays in a city 100 miles away. She enjoys
short walks with her dog, but fi nds little time for vigorous exercise or pleasurable
activities (such as writing and painting). No specific relaxation activities, but has
tried meditation in past. Prior to onset of fi nancial problems, patient had wanted
to learn Spanish and study yoga. Has hypertension and arthritis; takes medicine
as prescribed. Stresses include fi nances, work responsibilities, family problems
(increased confl ict with husband, adopted son with history of drug problems).
Drinks about 4 glasses of wine weekly. Does not use tobacco products. Drinks
34 cups of green tea daily.
Patient rates trying to get control of symptoms of depression as an 8 on
a 110 scale where 10 is a very big problem. These symptoms have become
increasingly problematic over the past 23 months, and patient is most concerned about her difficulties with concentration, her irritability, and a sense of
dread about the next day. Patient has had similar periods and started intermittent use of Prozac over 10 years ago. Experiences little benefit from it at present
but wants to continue just in case I might feel worse if I stopped. To solve current problems, patient has tried making lists and setting small goals (two skills
encouraged by a previous therapist). Walking the dog, talking with neighbors,
and watching movies also helps sense of calm.
Objective: Patient is alert and oriented. Mood is dysthymic. No SI / HI.
Assessment: Symptoms of depression in the context of multiple life stresses
(fi nancial, social, family, work)
Completed the Duke Health Profi le (a measure of health-related quality of
life) at todays visit. Results included three scores: Physical Health 40, Mental
Health 50, Social Health 40 (scores range 0100; higher scores indicate better
functioning).
Plan: Recommendations to patient
1. Set up meditation area in bedroom and practice 5 minutes every morning
2. Use values statement generated in todays visit to guide selection of 1 home
organizing, 1 work, and 2 social activities for the day during a morning
planning activity
3. Try yoga class
Recommendations to PCP / Follow-up Plan
1. Support patient in above
Patient to follow up with BHC in 12 weeks

difficulties and we will be making a water landing. Everyone is expected to


survive; we need for you to follow instructions carefully. . . . You follow the
instructions, and your life jacket supports you in swimming to a deserted
island. The island has things you can eat and you quickly fi nd a little cave
to sleep in. You realize that you will survive and that eventually someone

Treatment of Depression

93

will fi nd you, as you have a flare and will send it off when a plane comes
near the island.
After a couple of weeks, your loved ones back home come together to
talk about your life. They hope that youll be coming back, but they dont
know and they want to share their thoughts and memories about you. One
by one, they take turns talking about who you were to them and what they
thought you stood for. What is it that you hope your husband would say?
What do you hope that your daughter would say? Your son, David?
This was Rubys response to the exercise.
I hope that my husband would say that I was a smart businesswoman, fair
and honest, able to call it as I saw it. And of course that I was a loving partner willing to be close even in tough times.
I hope that my children would say I believed in them, encouraged them
to make the world a better place, that I was a good listener.
In debriefi ng this exercise, Dr. Peterson and Ruby talked about the workability
of the strategies shed been using to get control. 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, proactive problem solving.

Case Conceptualization
From the acceptance and commitment therapy point of view, three processes
are at work when people get stuck in the depression trap. These include (1) trying to feel good, (2) avoiding painful experiences, and (3) ignoring life results.
Figure 4.1 provides a brief summary of how Rubys coping efforts mapped to
these three processes. First, Ruby was swimming in the feel good agenda that
is pervasive in todays society. This agenda suggests that we should feel happy
and that if we are not happy, then something must be wrong with us. Implicit in
the feel good agenda are rules that we should follow in order to be happy, such
as be a good wife, and you will be happy; be a good mother, and you will be
appreciated and experience joy; buck up, smile, and the world will smile with
you. 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. What is consistent among humans is the fact that our learning histories
predict our pursuit of rules and stories perfectly. Our rules about life and our
stories about self are subtle, and we often dont see them, much as we might have
trouble realizing that we are seeing through sunglasses if we wear sunglasses all
the time for years.
Ruby was also avoiding painful experiences. In talking with Dr. Peterson, she
readily dismissed her feelings about her marriage and her sons ongoing health
problems (Oh, Im used to it), as well as her disappointment with not pursuing

94

Mood Disorders
Ruby avoided experience of the
frustration and sadness she felt
about having interesting and
enjoyable activities in her life.
She avoided having conflict with
her husband.
Avoid Painful
Experiences

Try to Feel
Good

Compression
Depression

Ignore Life
Results

The Depression Trap


Ruby tried to be happy,
be grateful, be a good wife,
to not complain.
FIGURE 4.1.

Ruby ignored the fact that her daily


activities did not bring her a sense
of vitality and purpose, and, in fact,
brought her sadness, exhaustion, and
resentment.

Case Conceptualization Tool: The Depression Trap

her planned life directions related to learning and creativity (It doesnt matter; its impossible anyway). 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; theres no point in making
trouble, and he isnt going to change anyway).
In ACT, we talk about a water line; below the water line, we swim in our
rules and stories and dont notice them; above the water line, we can see our private experiences for what they arestories, sensations, emotions. Given Rubys
difficulties with swimming above the water line, her ability to learn from her
direct experience with her life choices was limited. She couldnt 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. Further, she planned to follow the rule of take the medicine
and youll feel better, even while saying to Dr. Peterson that it didnt 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. Overall, Ruby felt pushed
around by life, victimized, limited, and, in many ways, resigned to a life of quiet
desperation. Without the ability to experience more contact with the present
moment, she was unable to learn from her direct experience. Without guidance
and support, she might continue to live life according to unseen and unexamined

Treatment of Depression

95

rules. Dr. Petersons mental conceptualization of Rubys situation helped her to


formulate ideas about what interventions might help Ruby develop greater psychological flexibility.
From the ACT perspective, six core processes are important to psychologically
flexible responding (see Figure 4.2). Since patients typically have strengths in some
areas, the therapist may use a patients strengths in one area to build strengths
in other processes. Since the six core processes are not mutually exclusive, and,
indeed, overlap in many ways, patients often make gains in processes not targeted
in an intervention. Dr. Peterson saw Rubys previous experience with meditation
(an activity that supports experience of the present moment, 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). Additionally,
she saw Rubys 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). Dr.
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, and social activities consistent with her values (process 3). In
follow-up visits, 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, 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 didnt matter) (process 4). In

1.
Contact the Present
Moment
2.
Define Your Values

6.
Accept What You
Cannot Change and
Focus on Action

Psychological
Flexibility & Vitality
5.
Learn to Let Go of
Distressing Thoughts/Feelings
and Name Unworkable Rules

3.
Make Commitments,
Keep Commitments

4.
Hold Your Self-Story
Lightly & Become a
Mind-Watcher
FIGURE 4.2.

Six Core Processes of Psychological Flexibility and Vitality

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Mood Disorders

providing ACT-consistent interventions, therapists dance around the six core


processes in an effort to help the patient more flexibly pursue workable solutions;
workable means that the solutions contribute to the patients sense of vitality
(whether symptoms improve, worsen, or stay the same).

Intervention Development: Course of Treatment


Ruby was seen for a total of seven visits over the course of a year, and Figure 4.3
provides a graph of her Duke scores at all visits. Her collaboration with Dr.
Peterson and Dr. Marks can perhaps be best conceptualized in three phases.
Through their close collaboration, Dr. Peterson and Dr. Marks were able to
amplify each others interventions, and, as Dr. Marks indicated an interest in
ACT, Dr. Peterson provided him with information on ACT designed for primary
care providers (see Robinson, Gould, & Strosahl, 2011; Strosahl & Robinson,
2009; Robinson, 1996; Robinson, Wischman, & Del Vento, 1996). They had
worked together for six years using the Primary Care Behavioral Health model to
develop their collaborative program (see Robinson & Reiter, 2007, for a guide to
implementing the Primary Care Behavioral Health model).
PHASE ONE

Engagement
Ruby returned for a second visit within two weeks and reported some success with
the planned interventions. She had also made additional changes that seemed to
help her, including restarting a diary-writing habit from the past. 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 4.3.

Rubys Duke Health Profile Scores

Visit 6

Visit 7

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97

husband had agreed to have two special meals when he was home for a weekend,
and each would cook one. She had taken to walking several times a week with
a neighbor she had met while walking her dog. Over the course of the following
six weeks, Ruby returned for three additional visits at the clinic, two with Dr.
Peterson and one with Dr. Marks. The work with Dr. Peterson focused on Rubys
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. Dr. Marks
supported Rubys work with Dr. Peterson. While her blood pressure was under
better control, he wanted to see if she could improve it further by working more
intentionally on sleep quality. He recommended that she complete an online cognitive behavioral program designed to improve sleep hygiene skills. She agreed
and found some of the ideas helpful.
PHASE TWO

During months three through five, Ruby had three visits with Dr. Peterson and
one with Dr. Marks. Her work with Dr. Peterson focused on her identification
and naming of unworkable rules. For example, Rubys 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 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. Through her journal, she was able to
make contact with the psychological pain she felt concerning her sons 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.
Rather than dreading a call from him, 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. When Dr. Peterson made a brief mention of personal assertive statements, Ruby bought a book online about it and
skimmed it.
PHASE THREE

Rubys last contact with Dr. Peterson was seven months after her initial visit. She
dropped by after a medical visit with Dr. Marks to let Dr. Peterson know that she
and her husband had decided to shut down the home business and that they were
busy selling leftover product, equipment, and so on. While he was continuing to
work away from home, he had changed his schedule to allow for three days per
week at home. She was taking a yoga class and had been looking on-line at senior
volunteer opportunities. Her dog had passed away, and her husband had bought
her a new dog, and the puppy liked to walk at a brisk pace two or three times

98

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every day. She continued to walk with her neighbor on some days, and the neighbor had invited her to join a womens book club. She continued to feel sad about
her son at times, 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. Dr. Peterson congratulated her on her progress, and
together they made a brief summary of the changes that had been most helpful
to Ruby. Dr. Peterson agreed to place this summary in the medical chart where
Dr. Marks could support it, and Ruby agreed to place it in her journal where she
could review it when she needed to.

Important Issues
In this section, we will consider potentially important concerns that therapists
may encounter in providing care to patients like Ruby. Perhaps the first concern
for most therapists is the selection of a therapeutic approach. While some therapists would select cognitive restructuring or behavioral activation, I selected ACT
because language plays an important role in the generation and maintenance of
depression symptoms. ACT provides a unique perspective on language, and it is
based on the basic science of relational frame theory. There are other possible
concerns that therapists face in providing treatment to the large and growing
group of patients with symptoms of depression, and the case of Ruby provides a
basis for addressing these.
THERAPY PROBLEMS

Therapists are often frustrated by problems such as missed appointments and


patient lack of commitment. In providing care to Ruby, the therapist is working in the Primary Care Behavioral Health model. This model is formed around
building patients access to therapy at the time of need. Since about half of Dr.
Petersons appointments were same-day, Ruby could access care when it was convenient and important for her. Dr. Peterson did not need constructs like lack of
commitment, as her job description by definition was to provide care in response
to patient motivation, day by day.
WHAT IF THERAPY DOESNT WORK

Sadly, therapy doesnt always work at all times for all patients. 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. Of course, other possibilities
might include helping Ruby connect with a behavioral health provider working
in a traditional model of care, where appointments are longer and treatment is
manual-based. Referring primary care patients to specialty mental health care is
a difficult decision, as many will decline and some who say they will go ultimately

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99

do not. If therapy doesnt work in primary care, it is good to offer the patient
more intensive care but to keep the door open in primary carepatients do tend
to vote with their feet.
ETHICAL CONSIDERATIONS

The most significant ethical consideration for Dr. Peterson concerned doing no
harm to Ruby. 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.
COMMON MISTAKES

Assuming that medications will solve the problems faced by a person with symptoms of depression is a somewhat common mistake, but less so today than in
previous years. To avoid making this mistake, it is important for therapists to
obtain information about the effectiveness of medication treatments for depression from studies not sponsored by pharmaceutical companies. A good guideline
is to note the sponsor of the article before reading the article. That being said, it is
important to be opensome patients with symptoms of depression find medications helpful and some do not. Ideally, therapists will know the evidence, make
it available to patients, and listen carefully to the patient preferences and patient
report of direct experience.
RELAPSE PREVENTION AND TERMINATION

In the Primary Care Behavioral Health model, the therapist works as a consultant
to the primary care provider. A consultant does not have a caseload, so the idea
of termination does not apply. 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. 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.
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, as well as
other mental health problems, is to gain a better understanding of the patients
worldview. 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. We need to respect these, even though we do not
understand them. Ruby believed in silence, in meditation, and Dr. Peterson used
this to enhance treatment outcomes.

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Mood Disorders
THE ART OF RUBY

The art of Ruby was in the dance she did with Dr. Peterson and Dr. Marks. It
wasnt planned or guided by any set of rules or guidelines for dancing, and it was
life changing. Rubys dance is ongoing, and she knows that she has several partners who will welcome her the next time she wants to learn a few new flexibility
movespsychologically speaking.

References
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to
prevent the rehospitalization of psychotic patients: A randomized controlled trial.
Journal of Consulting and Clinical Psychology, 70(5), 11291139.
Blackledge, J. T. (2003) An introduction to relational frame theory: Basics and applications. The Behavior Analyst Today, 3(4), 421433.
Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and
the treatment of persons at risk for long-term disability resulting from stress and pain
symptoms: A preliminary randomized trial. Behavior Therapy, 35(4), 785801.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and
cognitive therapy for anxiety and depression. Behavior Modification, 31(6), 772799.
Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M.,
Rasmussen-Hall, M. L., & Palm, K. M. (2004). Acceptance-based treatment for
smoking cessation. Behavior Therapy, 35, 689705.
Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving
diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Clinical and Consulting Psychology, 75(2),
336343.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory:
A post-Skinnerian account of human language and cognition. New York: Kluwer
Academic/Plenum Publishers.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance
and commitment therapy: Model, processes and outcomes, Behavior Research and
Therapy, 44(1), 125.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999) Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011) Acceptance and commitment therapy: The practice and process of mindful change. New York: Guilford Press.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Bissett, R., Piasecki, M., Batten, S. V., Byrd,
M., & Gregg, J. (2004). A preliminary trial of twelve-step facilitation and acceptance
and commitment therapy with polysubstance-abusing methadone-maintained opiate
addicts. Behavior Therapy, 35, 667688.
Kelly, M. A. R., Roberts, J. E., and Ciesla, J. A. 2005. Sudden gains in cognitive behavioral treatment for depression: When do they occur and do they matter? Behaviour
Research and Therapy, 43(6):703714.

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Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E.
(2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in
the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6),
593602.
Lundgren, T., Dahl, J., Yardi, N., & Melin L. (2008). Acceptance and commitment therapy and yoga for drug-refractory epilepsy: A randomized controlled trial. Epilepsy
and Behavior, 13(1), 102108.
McCracken, L. M., & Eccleston, C. (2003). Coping or acceptance: What to do about
chronic pain? Pain, 105(12), 197204.
Mynors-Wallis, L. M., Gath, D. H., Day, A., and Baker, F. 2000. Randomised controlled
trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. British Medical Journal 320(7226):2630.
Paykel, E. S. 2006. Cognitive therapy in relapse prevention in depression. International
Journal of Neuropsychopharmacology 10(1):131136.
Robinson, P. J., Gould, D., & Strosahl, K. D. (2011). Real behavior change in primary care.
strategies and tools for improving outcomes and increasing job satisfaction. Oakland,
CA: New Harbinger.
Robinson, P. J., & Reiter, J. T. (2007). Behavioral consultation and primary care: A guide
to integrating services. New York: Springer Science + Media.
Robinson, P. (1996). Living life well: New strategies for hard times. Reno, NV: Context
Press.
Robinson, P., Wischman, C., & Del Vento, A. (1996). Treating depression in primary care:
A guide for mental health and primary care providers. Reno, NV: Context Press.
Strosahl, K., & Robinson, P. (2008). The acceptance and mindfulness workbook for depression. Oakland, CA: New Harbinger.
Strosahl, K., & Robinson, P. (2009). Teaching acceptance and commitment therapy: A
guide for primary care providers. New Contextual Psychotherapies. Melbourne, AU.
Torneke, N. (2011). Learning RFT: An introduction to relational frame theory and its clinical applications. Oakland, CA: New Harbinger.
Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York:
Free Press.
Zettle, R. D., & Rains, J. (1989). Group cognitive and contextual therapies in treatment
of depression. Journal of Clinical Psychology, 45(3), 438445.

COMMENTARY

Olga V. Obraztsova and Lauren B. Alloy

When thinking about effective treatments for depression, it is likely that the first
two modalities that come to mind are antidepressant medications or a traditional
50-minute therapy hour. The reality, however, is that most individuals suffering
with depression never make it as far as receiving adequate treatment for their
symptoms, if they receive any treatment at all (Young et al., 2001). However, this
case study provides an example of the fact that it is possible to deliver effective,
empirically supported treatment within the context of a primary care setting that
is not simply based on medication management. Furthermore, this case study is
representative of a newer movement that seeks to deliver therapy in novel ways.
For example, 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, and studies have shown that these interventions,
especially when augmented with therapist support, can be effective in reducing
depressive symptoms (Spek et al., 2007).
In any discussion of therapy as a treatment for depression, it is always important
to consider if there are any advantages of choosing one therapy orientation over
another. In fact, 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). The ACT camp holds
that this therapy is a new, revolutionary approach to treatment that could replace
CBT (Hayes et al., 2006). Critics of this view believe that the skills taught in ACT
are not incompatible with traditional CBT approaches, and that there is nothing dramatically different about ACT (Hofman & Asmundson, 2008). Indeed, it
would be interesting to understand why Rubys treatment providers chose ACT
as their treatment orientation and why they believed it might be particularly efficacious for Ruby. 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. However, from the description of
the treatment procedure, it does not appear that language work was the focus of
Rubys treatment. In fact, this speaks to a criticism of ACT in that the techniques
used in treatment are not specifically linked to the philosophical and theoretical

Treatment of Depression

103

basis for the therapy (Hofman, 2008). There has been growing evidence that ACT
is an effective treatment for a variety of mental health issues, but what does the
empirical evidence say about the merits, if any, of one treatment modality over
another? A meta-analysis of existing treatment studies has shown that ACT is
superior to treatment-as-usual, but showed no differences in outcome when compared to traditional CBT, especially for treatment of depression (Powers, Zum
Vrde Sive Vrding, & Emmelkamp, 2009). However, this is a burgeoning area of
research, and there have been only a handful of studies to date that have used this
head-to-head comparison between these two therapy modalities.
The question that arises out of these studies, however, is whether it is important
to look for the unique aspects of these two therapies. Researchers have identified a
variety of common factors, that is, the aspects of therapy, such as the therapeutic
alliance between the client and therapist or client engagement in treatment, that
are shared by different therapy orientations. In fact, these common factors can
predict improvements seen in the clients regardless of the treatment implemented
(Castonguay et al., 1996). This is not to say that all therapies are exactly the same,
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, previous research has shown that improvements shown
as a result of therapy are mediated by different mechanisms, depending on the
treatment modality (Hayes, 2008). For example, individuals receiving cognitive
therapy showed improvements in observing and describing their experiences,
whereas those who received ACT showed changes in experiential avoidance,
acting with awareness, and acceptance (Forman et al., 2007). Unfortunately,
the clinicians did not collect this information from Ruby, so it is unclear if these
cognitive changes were responsible for her improvements, or if it was something
else entirely. A close examination of the interventions developed by her treatment
team reveals that they were based in large part on the principles of behavioral
activationthat is, encouraging Ruby to engage in more pleasurable activities
that may have fallen by the wayside during her life transitions.
Behavioral activation is an important shared component of both CBT and
ACT. Furthermore, research has shown that behavioral activation itself, even
without a cognitive component, is an effective treatment for depression on par
with traditional cognitive therapy (Mazzucchelli, Kane, & Rees, 2009; Dobson
et al., 2008). It is likely that engaging in positive life activities was associated with
Rubys improvements in mood. 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, real cases such as this one remind us that there
are myriad factors at work that influence outcomes. There is, however, another
real possibility that changes in Rubys external circumstances, rather than anything specific to the therapeutic intervention itself, were what produced improvements in her mood above and beyond those due solely to treatment. After all,
as clinical trials comparing medication, therapy, or a placebo as treatments for
depression have shown, a number of cases will show some improvement over time
even without the presence of an active intervention (e.g., DeRubeis et al., 2005).

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More specifically, the case description shows that Ruby experienced a variety of
life changes, such as the shutting down of her business and changes in her husbands work schedule, between her therapy appointments that resulted in some
positive changes to her situation. Without a doubt, treatment never occurs in a
vacuum, and in Rubys case, it was probably an interaction of events that were
dependent on and independent of her behavior that produced mood changes.
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. There is a steady movement toward openness to
integrating different techniques and modes of administering therapy. Ruby is not
a unique casethere are a multitude of people whose lives are too hectic to make
a commitment to therapy, and this approach is indicative of the reality that help
is available to them as well. At the same time, however, each case is unique, and it
is difficult to assess whether the approach used to treat Rubys depression would
work for individuals with a more severe or chronic case of depression.

References
Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996).
Predicting the effect of cognitive therapy for depression: A study of unique and common factors. Journal of Consulting and Clinical Psychology, 64(3), 497504.
DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon,
R. M., et al. (2005). Cognitive therapy vs medications in the treatment of moderate to
severe depression. Archives of General Psychiatry, 62(4), 409416.
Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling, K. B., Kohlenberg, R. J., Gallop,
R. J., et al. (2008). Randomized trial of behavioral activation, cognitive therapy,
and antidepressant medication in the prevention of relapse and recurrence in major
depression. Journal of Consulting and Clinical Psychology, 76(3), 468477.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A
Randomized controlled effectiveness trial of acceptance and commitment therapy
and cognitive therapy for anxiety and depression. Behavior Modification, 31(6),
772799.
Hayes, S. C. (2008). Climbing our hills: A beginning conversation on the comparison of
acceptance and commitment therapy and traditional cognitive behavioral therapy.
Clinical Psychology: Science and Practice, 15(4), 286295.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance
and commitment therapy: Model, processes and outcomes. Behaviour Research and
Therapy, 44(1), 125.
Hofmann, S. G. (2008). Acceptance and commitment therapy: New wave or morita therapy? Clinical Psychology: Science and Practice, 15(4), 280285.
Hofmann, S. G., & Asmundson, G. J. G. (2008). Acceptance and mindfulness-based
therapy: New wave or old hat? Clinical Psychology Review, 28(1), 116.
Mazzucchelli, T., Kane, R., & Rees, C. (2009). Behavioral activation treatments for
depression in adults: A meta-analysis and review. Clinical Psychology: Science and
Practice, 16(4), 383411.

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Powers, M. B, Zum Vrde Sive Vrding, M. B., & Emmelkamp, P. M. G. (2009).


Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and
Psychosomatics, 78(2), 7380.
Spek, V., Cuijpers, P. I. M., Nyklicek, I., Riper, H., Keyzer, J., & Pop, V. (2007).
Internet-based cognitive behaviour therapy for symptoms of depression and anxiety:
A meta-analysis. Psychological Medicine, 37(3), 319328.
Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (2001). The quality of care for
depressive and anxiety disorders in the United States. Archives of General Psychiatry,
58(1), 5561.

RESPONSE

Patricia J. Robinson

Perhaps the most important issue in the thoughtful commentary provided by


Obraztsova and Alloy is that of clinician choice in treatment selection. Many factors influence the decision-making process, and the evidence for possible treatment approaches, the training background of the clinician, and the feasibility of
implementation are heavy-hitters. Other factors include patient preference and
the context of care. In the case of Ruby, Drs. Peterson and Dr. Marks selected
ACT for all of these reasons and more.
While ACT is a relatively new form of cognitive behavioral therapy (CBT), there
is already promising research on its application to problems that commonly occur
(many co-morbidly with depression) in the primary care setting (Hayes, Strosahl, &
Wilson, 1999). Compared with usual-care patients with diabetes, diabetic patients
receiving a four-hour ACT intervention had better self-reported diabetes management and significant improvement in Hemoglobin A1C measurement (Gregg,
Callaghan, Hayes, & Glenn-Lawson, 2007). ACT is also likely to be helpful to
depressed patients who engage in health risk behaviors such as smoking (Gifford,
Kohlenberg, Hayes, Antonuccio, Piasecki, et al., 2004) and those who experience
problems with chronic pain and disability behavior (McCracken & Eccleston,
2003; Dahl, Wilson, & Nilsson, 2004), as well as substance abuse (Hayes, Wilson,
Gifford, Bissett, Piasecki, et al., 2004). One of the first randomized control trials of ACT concerned depressed patients (see Zettle & Hayes, 1986), and one of
the first randomized control trials conducted in primary care behavioral health
treatment of depression included ACT interventions (for detailed information, see
Robinson, Wischman, & Del Vento, 1996; Robinson, 1996). Finally, 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, Zum, Vorde, Sive Vording, & Emmelkamp, 2009), including
anxiety (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).
ACT is also included on the evidence-based treatments list provided by the
American Psychological Association Division 12. Specifically, ACT has moderate support for depression treatment and strong support for treatment of pain
(http://www.div12.org/PsychologicalTreatments/treatments.html). Additionally,
the Substance Abuse and Mental Health Services Administration (SAMHSA), a

Treatment of Depression

107

division of the Department of Health and Human Services, provides a National


Registry for Evidenced-based Programs and Practices (NREPP) to help providers make informed decisions about treatment approaches. NREPP lists ACT
as an empirically supported method (http://174.140.153.167/ViewIntervention.
aspx?id+191). The NREPP review includes not only evaluation of an approachs
evidence base, but also the extent to which the approach can be implemented and
disseminated. Research evidence for ACT was scored at 3.325 out of 4, and ACT
dissemination efforts received a perfect score of 4.0 on a 4.0 scale.
Dr. Peterson had attended both basic and advanced trainings in ACT and
was familiar with both the APA Division 12 list and the NREPP resource. She
preferred ACT because of the ease with which she could disseminate it. ACT is
a trans-diagnostic approach, which means, as the evidence suggests, that the
same basic procedures work well with a variety of diagnoses. Equipped with
a conceptual framework and a set of basic tools, she could help patients with
different problems make gains in psychological flexibility. She was not tied to
20 or 30 treatment manuals characteristic of earlier cognitive behavior therapy
approaches, each of which targeted a specific diagnosis, such as generalized
anxiety disorder or major depression. She did not need to ponder which treatment manual to use fi rst when patients presented with more than one problem
(e.g., depression and anxiety, or insomnia and depression). 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. Dr. 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. Peterson. Dr. Marks and other
primary care providers, including nursing staff, 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.
For Ruby, ACT offered Dr. Peterson tools for addressing clearly cognitive
(as well as behavioral) problems that predisposed her to recurrent depression.
Ruby was fused with unrecognized rules and with self-stories that led her to
an inflexible pursuit of unworkable strategies. The ACT approach helped Ruby
develop a new relationship with her unworkable rules and self-stories and, with
her new perspective, 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. Marks sees 2030 patients per day, and about half of them have psychological problems. Dr. Peterson sees 10+ patients per day, and all have psychological problems. Many of Drs. Mark and Petersons patients want help but face
many barriers to consistent participation in treatment. ACT supports a focus
on the patients pursuit of a meaningful life and offers front-line providers like
Drs. Marks and Peterson a set of tools that address processes that promote psychological flexibility, when patients are ready and requesting help. They use the
Duke to assess improvement, and this helps them track health-related quality of

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Mood Disorders

life over the course of a patients life. They could certainly use the Acceptance
and Action Questionnaire to assess process factors associated with treatment.
However, measurement comes down to choosing the most pertinent and most
time-effective approaches, 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, I recommend that readers study Joseph Ciarrochi and
Ann Baileys book, A CBT-Practitioners Guide to ACT: How to Bridge the Gap
between Cognitive Behavioral Therapy and Acceptance and Commitment Therapy.
There are a variety of ACT fi rst-reads available from New Harbinger Publishing
Company, and reading is a good way to begin to bring ACT ideas into play in
treating depression, whatever your practice setting.

{5}

Psychiatric Treatment of Bipolar Disorder:


The Case of Janice
Jeffrey J. Rakofsky and Boadie W. Dunlop

Case History
PRESENTING COMPLAINTS

Janice, a 30-year-old married Caucasian woman, presented to our university


clinic seeking a new psychiatrist to manage her bipolar illness. She had moved to
the Southeast due to her husbands job relocation three months ago, and had few
social contacts in her new city. 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, including sleeping up to 12 hours per night,
a loss of interest in some activities, feelings of worthlessness, and low energy.
She denied experiencing inappropriate sadness, but endorsed experiencing daily
mood elevations above her euthymic mood state, associated with concomitant
bursts of energy, racing thoughts, and goal-directed activity that would last for
a few hours. She denied all other symptoms of mania during these brief periods
and would sink back into the feelings of low interest, self-esteem, and energy. The
depressive symptoms were negatively affecting both her marriage and her work.
She had no wishes to be dead, nor any thoughts of suicide or her own death.
Janice reported experiencing her fi rst and only full manic episode four years
ago, which lasted approximately one month. During that time, her mood was
euphoric, she became easily distractible, and her energy increased, despite sleeping only three hours per night. She endorsed psychotic-grandiose thoughts,
believing that she could read other peoples minds and feeling overly confident
about her abilities. Her thoughts were racing with ideas, leading her to engage in
a variety of activities, including cleaning her house, running long distances, and
writing novels. Some of her behavior during that time was reckless and impulsive,
such as driving far above the speed limit and spending $400 in one day (more
money than she could afford to spend, as she was a student at the time).

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The patient denied ever hearing voices commenting about her or commanding her to act in a specific way, nor had she ever seen images or figures that were
apparent only to her. She denied ever feeling like others were spying on her, following her, or conspiring against her.
Janices alcohol intake was moderate. She reported drinking no more than
three drinks per night and denied that this has ever caused problems with her
social or work roles. She denied current use of illicit drugs, and had last used
marijuana four years ago. Her use at that time had been quite heavy and preceded
her manic episode by several months. This resulted in a diagnosis of cannabis
dependence, a decline in her school grades, and caused her psychotherapist to
terminate her therapy.
Janices physical health was challenged by having polycystic ovarian syndrome
(PCOS), an endocrine disorder causing menstrual irregularities, increased body
hair, insulin resistance (with associated impaired glucose tolerance), ovarian
cysts, and elevated levels of androgens, such as testosterone. Additionally, recent
blood work indicated mildly elevated levels of thyroid stimulating hormone, suggesting possible hypothyroidism.
At the time of her evaluation, Janice was taking divalproex (Depakote ER)
1,500 milligrams (mg) nightly for control of bipolar disorder. Although she had
been on this dose for one year, her blood level of this medication had never been
measured. To combat her depressive symptoms, she was also taking 300 mg daily
of venlafaxine XR, a serotonin-norepinepherine reuptake inhibitor, approved for
the treatment of major depressive disorder and several anxiety disorders.

Brief Personal History


Janice grew up as an only child to Italian-American parents living in the
Midwest. For several years during her adolescence, her father would come
home after a night of drinking and molest her while she was sleeping. During
the day, his temper would rage, and on occasion he hit her hard enough to leave
bruises on her arm. These experiences continued to affect her into her adulthood, as she reported occasional nightmares and flashbacks of his hands on
her, avoidant and hypervigilant behaviors, and a dramatic startle in response
to loud stimuli.
Her father, paternal grandfather, and a maternal cousin had all been diagnosed
with bipolar disorder, while her mother, maternal grandmother, five maternal
aunts, and one uncle all had been diagnosed with depression. Janice had her first
major depressive episode at age 17 and subsequently experienced three more episodes. She had been hospitalized twice, 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. She denied ever attempting
to end her life, but used to engage in self-mutilating behaviors, including burning, cutting, and choking, in an effort to control emotional pain and as forms of
self-punishment.

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Janice earned a masters degree in social work at age 26. However, tragedy
struck when she had her fi rst manic episode upon completion of graduate school.
At the time of her evaluation in our clinic, she had still not embarked on a career
in social work. Instead, she had worked as a waitress in a local restaurant, though
this work was not intellectually challenging and she was highly fearful of her
male coworkers who chastised her loudly when she made errors. Her marriage
of two years is a source of strength. Her husband has also been diagnosed with
bipolar disorder, and she believes he understands the struggles that she faces.
She has not had children and has no interest in becoming a parent yet. Among
her hobbies, she enjoys competing in triathalons and running long distances. She
reported no history of legal problems.

Key Principles
Bipolar disorder is a mood disorder characterized by a history of mania, hypomania, or mixed episodes along with mood episode recurrences over time (American
Psychiatric Association, 2000). A manic episode includes an elevated or irritable
mood lasting at least one week, along with increases in the speed of thoughts, distractibility, speech, self-esteem, energy, goal-directed activity, and risky behavior. These episodes often will cause major impairment for patients, resulting in
medical or psychiatric hospitalization, incarceration, 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. 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.
Bipolar spectrum disorders affect approximately 5% of the population, with
bipolar type I comprising 1% (Merikangas et al., 2007). The bipolar spectrum
includes type I illness, which requires patients to have experienced at least one
manic or mixed episode; type II illness, which requires at least one hypomanic
episode and one major depressive episode; and bipolar NOS, which includes
several bipolar variants, such as patients with ultra-rapid cycling or those with
recurrent hypomanic episodes without intercurrent depression. Unlike major
depression, lifetime prevalence rates of bipolar type I are similar between the
sexes (Merikangas et al., 2007). However, females tend to be overrepresented
among type II bipolar patients (Baldassano, et al., 2005) and among those with
rapid cycling (Schneck et al., 2004). Fifty percent of bipolar patients have experienced early childhood trauma in the form of physical or sexual abuse (Brown,
McBride, Bauer, & Williford, 2005).
Twenty percent of bipolar patients are rapid cyclers, meaning that they have
had four or more mood episodes in the previous 12 months (Schneck et al., 2004).
Within this group are severe rapid cyclers who experience 10 or more episodes
within a 12-month period, ultra-rapid cyclers who experience four or more mood
episodes within the past month, and ultra-ultra rapid cyclers (also known as
ultradian cyclers) who experience four or more mood episodes within a week

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(Kramlinger & Post, 1996). Ultra- and ultra-ultra rapid cycling episodes are
defined by mood-episode symptom criteria but not duration criteria. Janice can
be considered an ultra-ultra rapid cycler currently, because she is experiencing
daily cycling between states of hypomania and depression, even though this rate
of cycling did not occur until she was started on antidepressant medication.
Factors associated with increased cycling include antidepressant use (Schneck
et al., 2008), female gender (Schneck et al., 2004), bipolar type I, illicit drug
use, and early childhood trauma (Kupka et al., 2005). An association between
hypothyroidism and current rapid cycling has been proposed, though studies on
the topic are confl icting and are confounded by the gender composition and lithium use between study samples (Kupka, Luckenbaugh, Post, Leverich, & Nolen,
2003). Unresolved residual symptoms from a previous episode increase the risk
for subsequent episode recurrence (Perlis et al., 2006).
Medications with an indication for the treatment of bipolar disorder include
the mood stabilizers: lithium, divalproex, carbamazepine, and lamotrigine. Some
second generation antipsychotics, including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone, also have indications for the treatment of
various mood components of bipolar disorder. Mood stabilizers, such as divalproex, are effective in treating bipolar depression (Smith et al., 2010) and may
have some benefit in treating rapid cycling (Calabrese & Delucchi, 1990). For the
treatment of mania and long-term maintenance of bipolar disorder, divalproex
dosage is guided by serum concentrations drawn more than 12 hours after the
last dose, with a target of 50100 micrograms per milliliter (mcg/ml). However,
there is no established effective serum concentration of divalproex for the treatment of bipolar depression. Clinicians typically up-titrate the divalproex dosage
until reaching blood levels close to 100 mcg/ml, as this strategy was found to be
most effective when treating acute mania (Allen, Hirschfeld, Wozniak, Baker, &
Bowden, 2006).
There are few predictors of response to specific medications in bipolar disorder, and those that exist were discovered with post hoc analyses. Lithium
responders tend to experience full inter-episode recovery, have mood congruent psychotic features, are nonrapid cycling, have a positive family history of
lithium responsiveness, and have a mania-depression-euthymia episode pattern
(Maj, Del Vecchio, Starace, Pirozzi, & Kemali, 1984; Maj, Pirozzi, & Starace,
1989; Pfennig et al., 2010). Patients with mixed episodes tend to respond better
to divalproex than lithium (Swann et al., 1997). With few predictors empirically
studied, treatment selection remains trial and error.
The causes of bipolar disorder are unknown, though there is a strong genetic
risk, demonstrated by twin studies with identical twin concordance rates ranging from 4075% compared with fraternal twin concordance rates ranging from
611% (Kieseppa, Partonen, Haukka, Kaprio, & Lonnqvist, 2004), and heritability estimates as high as 85% (McGuffi n et al., 2003). The genetic contribution to
the illness-phenotype may be a deficit in cellular resilience in the face of external
stressors. Neurotrophic, anti-apoptotic and glucocorticoid signaling cascades
have been implicated, all of which affect cellular plasticity and cell survival

Psychiatric Treatment of Bipolar Disorder: The Case of Janice

113

(Hunsberger, Austin, Chen, & Manji, 2009). Stress sensitization as a result of


early life trauma and episode sensitization resulting from multiple mood episode
recurrences may worsen the course of illness, leading to more treatment resistance, increased rates of rapid cycling, and more psychiatric comorbidity (Post,
Leverich, Xing, & Weiss, 2001).

Assessment Strategy
To establish a diagnosis of bipolar illness, the clinician must assess for current
or previous symptoms of mania or hypomania. Actively manic patients are more
likely than depressed patients to present to an emergency room, and are often
transported against their will by family members or law-enforcement officers.
They are less likely to present to an outpatient clinic, as they typically are not
bothered by their manic symptoms and therefore are less driven to seek help.
Hypomanic patients are also not likely to present to a provider, as they are neither
bothered by their symptoms nor causing much concern to those around them.
The opposite is true for bipolar depressed patients, who are much more likely to
present to an outpatient clinic. In order to diagnose bipolar disorder in the outpatient setting, 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. This can be challenging to elicit from a depressed patient
during his or her initial assessment. As a result, up to 40% of assessed patients
with bipolar disorder are misdiagnosed as having unipolar depression (Ghaemi,
Sachs, Chiou, Pandurangi, & Goodwin, 1999). Over one-third of patients will
wait 10 years before being accurately diagnosed with bipolar disorder after
their fi rst psychiatric assessment (Hirschfeld, Lewis, & Vornik, 2003). Reasons
for this diagnostic delay include lack of insight during previous manic episodes
(Ghaemi, Stoll, & Pope, 1995), mood-state congruent recall-bias (Watkins, Vache,
Verney, Muller, & Mathews, 1996), and lack of significant impairments during a
hypomanic episode, which affect a patients ability to remember previous hypomanias. To avoid this error, initial evaluations should be performed with family members of the patient in the room, to enhance detection of episodes in the
patients life that were consistent with mania or hypomania. When interviewing
Janice, no family members were available to accompany her to the interview.
Thankfully, Janice was able to recall an episode of mania. However, in the event
that she could not do so, but endorsed illness characteristics typical of bipolar
illness (two or more short depressive episodes, family history of mania, onset of
illness before 30 years of age) (Angst et al., 2011), the clinician should consider
interviewing family members over the phone, with the patients permission.
Most clinicians will rely on a clinical, nonstructured interview to assess for
bipolar illness. However, screening tools and structured or semi-structured interviews are used as well. Some commonly used screening tools include the Mood
Disorders Questionnaire (MDQ), a self-report form that has high specificity but
poor sensitivity among community samples, leading to many missed cases of

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bipolar illness (Hirschfeld & Vornik, 2004). The Hypomania Checklist (HCL-32),
another self-report form, has high sensitivity and moderate specificity when
used among clinical samples of bipolar disorder and major depressive disorder
patients. However, it does not distinguish between bipolar type I and II (Angst
et al., 2005). 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.
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, Spitzer, Gibbon, & Williams, 2002). Though quite cumbersome
to be used in its entirety for clinical practice, it provides helpful probe and follow-up questions for each manic symptom. The SCIDs structured approach
to interviewing provides a significant advantage over traditional, unstructured
interviews. For example, traditional interviews may omit questions about each
possible manic symptom, missing opportunities to help the patient recall an earlier episode if one ever occurred. However, a limitation of the SCID is that if
a clinician strictly adheres to its Past Manic/Hypomanic Episode algorithm,
manic symptom questions will not be asked if the patient answers no to the
screening questions, which emphasize previous episodes of euphoria or irritability. Episodes of increased energy and activity level, rather than previous episodes of a particular mood state, may be easier for a patient to recall years later.
Thus, structured interview questions with additional clinical probes provide the
optimal approach to evaluation for possible bipolar symptoms. Useful additional
probes for bipolar illness include:
1. Did you ever have a period of time when you were feeling so full of energy,
more than normal for you, that you could go several nights with less sleep?
2. Did you ever have a period of time when you were more active and productive than normal for you, getting involved in more activities, starting
more projects (regardless of their completion), or becoming abnormally
super-focused on a single project?
3. Did you ever have a period of time when you were feeling so good about
yourself, more than normal for you, that you felt invincible, overly confident, or arrogant?
Early in an interview, it is very helpful to identify a period of euthymia for the
patient. By euthymia, we mean a period of at least two consecutive months during which the patient had no symptoms of depression or mood elevation. This
can be explored by asking patients to identify a time in their life when they felt
the most under control and contented, and experienced stable interpersonal
relationships. More specifically, it should be a time when they were sleeping
their normal amount (may vary between 6 and 10 hours, depending on the
person), were motivated to pursue their goals, and were not getting into confl icts
with others, either due to irritability or by being too talkative or intrusive with
others. 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.

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115

Having identified the presence of bipolar illness, other factors become important for treatment planning. These factors include clarifying current episode status (depression vs. mania vs. mixed vs. euthymic state), subtype (I vs. II vs. not
otherwise specified), rapid cycling status (none, rapid, severe-rapid, ultra, ultraultra), prognositc variables (age of onset of illness, comorbid medical illnesses,
concurrent substance use, early childhood trauma), and prior medication trials.
Assessment should not be considered complete simply by identifying bipolar
illness. Lifetime comorbid anxiety disorders are prevalent at a rate of 51%; posttraumatic stress disorder (PTSD), in particular, occurs in 17.2% compared with
7.8% in the general population (Simon et al., 2004). Substance use disorders have
been found in 60% of bipolar patients and are higher than in any other Axis I sample (Chengappa, Levine, Gershon, & Kupfer, 2000). Polycystic ovarian syndrome
(PCOS) has been associated with bipolar illness, with rates varying between 6 and
41% among bipolar women taking valproate. The individual contributions of valproate and bipolar pathophysiology to the risk for PCOS are unclear (Reynolds,
Sisk, & Rasgon, 2007). Thyroid disease is more common among women than men
with bipolar disorder. Although this difference is expected given higher rates of
thyroid disease among women compared to men in the general population, one
study found that the rate of thyroid disease for bipolar women was four times
higher than in the general population (Baldassano et al., 2005).

Differential Diagnosis
Illnesses such as schizoaffective disorder-bipolar type, substance-induced mood
disorder, mood disorder secondary to a general medical condition, posttraumatic
stress disorder, and borderline personality disorder may have a clinical presentation similar to bipolar disorder and should be ruled out as an explanation for
the patients current clinical presentation. Patients with schizoaffective disorder
will demonstrate psychotic symptoms even when free of mood episodes, whereas
bipolar patients only experience psychosis during mood episodes. By defi nition,
a bipolar patient cannot also have schizoaffective disorder. However, over time,
a patient originally considered to have bipolar disorder could develop psychotic
symptoms in the absence of a mood episode, at which point their diagnosis would
change to schizoaffective disorder, bipolar type.
Substance-induced mood disorder can be differentiated by the use of known
manic-inducing substances (cocaine, stimulants, corticosteroids) just before the
onset of the mania with a resolution of manic symptoms within 30 days after
cessation of substance use. 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. Additionally, 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.
For Janice, her cannabis use preceded her fi rst manic episode, but the episode
persisted long after the use had ended. Use of anxiolytic substances (e.g. alcohol,

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benzodiazepines, cannabis) prior to the onset of a full manic episode is common,


as patients may try to self-medicate against troubling symptoms of an emerging
episode.
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, such as seizures, suggesting a nonpsychiatric illness. However, a bipolar patient can also have episodes produced by otherwise
clinically silent medical conditions, such as a brain tumor or a stroke.
Posttraumatic stress disorder (PTSD) is an under-recognized condition that is
often mistaken for bipolar disorder, and vice versa. These two conditions also commonly co-occur in the same individual and may share neurobiological substrates
(Rakofsky, Ressler, & Dunlop, 2012). Patients with PTSD may be easily misdiagnosed as having bipolar disorder, as these patients often present with intense
irritability and decreased sleep, suggestive of dysphoric mania. PTSD patients
commonly have high levels of goal-directed activity, but this activity serves to
suppress intrusive thoughts and memories related to their trauma, whereas in
mania the high levels of activity typically reflect a sense of being driven to achieve
goals for their perceived high value. Unlike manic patients, PTSD patients do not
experience feelings of grandiosity. Although patients with either condition may
endorse experiencing racing thoughts, the content of these thoughts in PTSD is
usually limited to anxious worries, rather than exciting ideas or plans as in bipolar disorder. Finally, a history of traumatic events, the presence of other typical
PTSD symptoms, and the presence of insomnia rather than a decreased need for
sleep can help distinguish these two conditions.
Borderline personality disorder, with its characteristic mood lability, may also
be misdiagnosed as bipolar disorder. Important clues to differentiating this condition from bipolar disorder are:
1. Mood-state changes in response to feared or actual abandonment, in
contrast to untriggered or non-abandonment related mood episodes.
2. Impulsive behaviors intended to control others behavior or provide emotional self-soothing rather than arising from the grandiose-invincibility
component of mania.
3. Profound self-hatred above and beyond what would be expected during an
episode of depression.
4. Mood-state elevation, triggered by a positive event (e.g., falling in love),
that occurs in the absence of other typical manic symptoms (decreased
need for sleep, hyperactivity, racing thoughts, flight of ideas, rapid speech,
etc).
It is important to note that a patient can have both borderline personality or
PTSD and bipolar disorder, an unsurprising outcome given the early trauma that
many bipolar patients experience and the impairments in emotional regulation
that are central to these conditions. Janice, although displaying earlier episodes
of self-injurious behavior, does not meet full criteria for borderline personality
disorder. She is able to maintain a healthy relationship with her husband and can

Psychiatric Treatment of Bipolar Disorder: The Case of Janice

117

tolerate extended separations from him when he travels for work. She demonstrates a solid sense of self, values, and goals, and her impulsive behaviors were
limited to her single manic episode. Although she had a history of self-injurious
behaviors, they occurred as a means of escape from the memories and feelings
when her PTSD symptoms were at their worst.

Case Formulation
Janice meets criteria for bipolar disorder, type I. She is currently in a subsyndromal depressed mood episode, alternating with hypomanic symptoms on a
daily basis. Divalproex in combination with venlafaxine has helped to reduce the
intensity of her depression, though she is still symptomatic, and it is unclear if the
divalproex dose is fully optimized. Her use of an antidepressant, especially one
that interacts with two neurotransmitter systems (serotonin and norepinepherine) may be contributing to the constant cycling into hypomania. Additionally,
her elevated thyroid-stimulating hormone level, indicating inadequate peripheral
thyroid hormone levels, may exacerbate the cycling as well, along with some of her
remaining depressive symptoms. The sexual trauma that she suffered as an adolescent may have affected her developing brains reward-processing circuits and
hypothalamic-pituitary-adrenal axis, ultimately affecting mood regulation and
making her more likely to experience mood cycling as an adult. Additionally, the
childhood trauma is likely to negatively affect her long-term prognosis (Leverich,
et al., 2002).
Janice is at very high risk for psychiatric affective illness, given the significant
family history of bipolar disorder on her fathers side of the family and the family history of unipolar depression on her mothers side of the family. This high
predisposition (which is probably largely genetic), in combination with experienced environmental stressors (early childhood trauma), may have given rise to
the phenotypic expression of her bipolar illness. Her parents contribution to her
illness can be conceptualized in two ways. First, Janice likely inherited multiple
risk alleles for mood disorders. Second, her parents own psychiatric illnesses
provided the psychosocial context for the emergence of her illness at age 17. The
physical and emotional abuse committed by her parents could have occurred
during the heights of their own depression or mania, leading them to act impulsively, aggressively, or to be neglectful of the patients welfare.
In addition to her bipolar illness, Janice suffers from PTSD, stemming from
her childhood sexual molestation. Her current bipolar medication regimen,
though helpful for some with PTSD, is providing her minimal benefit for this
comorbid condition. Although she has had psychotherapy in the past, she has
never had exposure therapy, the only psychotherapy for which the Institute of
Medicine found sufficient evidence to suggest efficacy in the treatment of PTSD
(Institute of Medicine [IOM]. 2008). This therapy utilizes imaginal and in-vivo
exposure, requiring patients to retell their trauma in detail during therapy sessions and to approach the people, places, and activities that they have avoided

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Mood Disorders

following the trauma. Over time, patients habitutate to the distressing memories,
decrease avoidance of trauma reminders, and where appropriate, replace expectations of danger to cues in their environment with expectations of safety (Cukor,
Olden, Lee, & Difede, 2010).
Like so many others with comorbid bipolar disorder and PTSD, she also developed substance dependence with marijuana, though to her credit she has been
able to maintain sobriety for several years. However, she still consumes alcohol,
which can present many problems for her: increasing her risk for relapse back
into marijuana use, increasing her risk for developing a dependence to alcohol,
and potentially worsening the course of her bipolar illness.
Psychologically, she suffers from painful intrusive memories and nightmares
of her father abusing her. She fi nds it difficult to trust men and is quite fearful of them, as revealed by her workplace experience. This fear makes it hard
for her to go to work, which reinforces her sense of self as being incompetent.
Perhaps internalizing a belief that she is a bad person or tainted by the trauma
she endured, she resorted to self-mutilating behaviors, although again she has
managed to resist these urges over the last few years. She credits her marriage and
medications for this improvement. 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. However, her unwillingness to take on a social work job reflects a fear
of failure that her unpredictable bipolar mood symptoms have reinforced.
Socially, 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. However, her lingering depressive symptoms are
causing tension between the two of them. His bipolarity could be an additional
burden, affecting her stability should he develop a mood episode recurrence.
Additionally, because both she and her husband have the illness, there is a high
likelihood that future progeny will also develop bipolar disorder symptoms or
attention deficit/hyperactivity disorder (Birmaher et al., 2010). This could also
increase the emotional burden on the patient, as she would have to care for children requiring close parental supervision and frequent medical contact. She is
removed from her family of origin geographically and no longer maintains contact with her father. Having recently moved to a new city, she has few friends or
social supports but is using her recreational interests as a way to meet new people.
She is not part of any support or self-help groups. Although she is employed,
her work performance is affected by her fatigue and loss of interest. She worries
appropriately that she may be fired and without income, increasing her level of
stress.

Treatment Planning
The two most important targets for Janices treatment planning were to eliminate
the remaining depressive symptoms and the constant cycling. Her divalproex
level was 86 mcg/ml, so we increased her dose from 1,500 mg to 1,750 mg daily.

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. We chose this slow taper to avoid a worsening of her depression and to
avoid venlafaxine discontinuation effects, such as rebound anxiety and depression, headaches, fatigue, and electrical zap sensations. 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. Divalproex
is teratogenic, causing serious neural tube defects during the fi rst week after conception, and thus before a woman becomes aware of her pregnancy. Janice was
strongly counseled to remain on her birth control pill and to discuss any plans
about pregnancy before attempting to conceive. 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.
To address the PTSD symptoms and also to provide adjunctive bipolar support, she was referred to a therapist who specializes in working with bipolar
patients. We wanted to avoid antidepressants and benzodiazepines, two medication classes used to treat PTSD symptoms, given her bipolarity and her history
of substance dependence. Her therapist employed elements of interpersonal and
social rhythm psychotherapy (IPSRT), a therapy with proven benefits in bipolar
disorder when initiated during acute episodes (Frank et al., 2005). This treatment helps patients to improve mood regulation by encouraging them to keep
regular hours of sleep, waking, eating, and exercise. Expected future stressors
were managed by using problem-solving techniques to avoid any threat to social
rhythms and to enhance interpersonal effectiveness. Additionally, her therapist
utilized elements of exposure therapy once the patients mood cycling was under
better control. This part of the therapy entailed repeated sessions with Janice
emotionally engaging and sharing highly detailed memories of her father molesting her, while simultaneously applying newly learned breathing and relaxation
techniques.
For her alcohol use, we provided psychoeducation, explained her risks of
dependence, marijuana relapse, and worsening of her course of illness. She was
also encouraged to attend Narcotics Anonymous meetings, given her previous
history with marijuana dependence.
With these changes in place, the cycling resolved and the patient also reported
an improvement in her symptoms. However, two weeks after coming off venlafaxine, she relapsed into a full depressive episode. Lithium carbonate, another
mood stabilizer (with a target blood level of 0.81.0 mEq/L) was added to her
regimen and optimized to a blood level of 1.0 mEq/L. Once again, her depression fully resolved. However, over the next several months on the combination of
divalproex and lithium, she gained 15 pounds. Despite her participation in triathlons and her daily exercise schedule, she was unable to lose the added weight.
Without consultation with her psychiatrist, she self-tapered off the divalproex
and quickly began to lose the weight she had gained earlier. Two months later,
she relapsed into yet another depressive episode. Believing that divalproex had
contributed to her fatigue and was partly to blame for her weight gain, she was

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Mood Disorders

strongly opposed to restarting it. Given its weight-neutral properties and data
demonstrating improvement in depression when added to lithium, the anticonvulsant lamotrigine was started (van der Loos, et al., 2009). It was slowly titrated
to 200 mg over six weeks to avoid the risk of developing Stevens-Johnson syndrome, a life-threatening, exfoliative rash. With this combination of lithium and
lamotrigine, she maintained a euthymic state for several months.

Nonspecific Factors in Treatment


With all patients, developing the therapeutic alliance is necessary. This is even
more crucial when treating a patient who has both bipolar illness and PTSD
stemming from early childhood trauma (Rakofsky, Levy, & Dunlop, 2011). The
medications used in the treatment of bipolar illness cause both nuisance and
serious side effects. Anecdotally, 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. A patient with early childhood trauma and
PTSD symptoms may have difficulty trusting physician-authority figures who
attempt to provide reassurance about these medications. If the therapeutic alliance is weak, the patient may reject the physicians recommendations. She may
be unwilling to try these medications and thereby deprive herself of potentially
gaining better control of her bipolar illness.
Given her experience of being victimized and forced to do others bidding as
a child, it was important to encourage Janices 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. When she reported that she had self-tapered off divalproex and expected
her doctor to be infuriated with her, she was gently reminded that ultimately the
medications she takes are her own choice, and that her doctor would not be upset
by her decision to stop taking divalproex. 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, so she can be fully informed of the risks of
tapering. This reinforced the therapeutic alliance by establishing the physicians
role as a nonpunitive, expert-consultant, willing to support the patients broad
goals of achieving better illness control with minimal medication side effects.
Understanding the patients treatment goals is also part of strengthening the
therapeutic alliance. This patients specific goals included fi nding a medication
regimen that would improve her depressive symptoms without worsening her
cycling or causing physical side effects. As with all bipolar patients, it was important to remind Janice that fi nding the right medication or combination of medications is a trial-and-error process. By doing this, her expectations were framed
appropriately. 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.

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. In Janices case, one
of the motivations behind the self-tapering of divalproex may have been to test
the physicians resolve or to reenact the early childhood trauma that involved an
angry and sadistic male authority figure. If this is the case, she may engage in
other behaviors that may affect the stability of her illness.
Underreporting of mood symptoms is another common problem. If Janice
believed that she had to please her physician in order to maintain his positive
regard, or if she believed that more medications with weight-gain risks would be
added, she might have been inclined to underreport the true intensity or number
of her depressive symptoms. To manage these possibilities, she was reminded frequently that although she is a patient, she still makes the fi nal decisions regarding
her treatment. The physicians role is to guide her and to provide expertise to help
her meet her goal of reduced illness burden.
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. The plan was to optimize the current mood stabilizer
that she was taking and taper her off the antidepressant she had been prescribed.
Trials with other mood stabilizers, including lithium and lamotrigine, followed
due to a relapse. If treatment was still not effective, adding other medications
such as atypical antipsychotics, pramipexole, or electroconvulsive therapy would
have been options to consider, depending on the nature of the persisting symptoms. Reassessment of the biopsychosocial formulation would also be warranted
if poor treatment response continued. Perhaps a neurological or endocrinological condition, or a comorbid psychiatric illness, such as an eating disorder or substance abuse, undetected at the initial patient interview, might explain treatment
refractoriness. Perhaps her substance use has escalated, leading to increased
mood destabilization. Further consultation with her therapist at this point would
strengthen the psychiatrists psychological formulation of the patient and would
help to explain her lack of improvement.

Ethical Considerations
Treatment of psychiatric conditions always requires pause for ethical reflection.
Here, Janice is requesting help with her depressive symptoms and cycling, so the
decision to treat is straightforward. Management of bipolar disorder with psychotherapy alone is ineffective, so medication is clearly justified. More difficult
ethical considerations arise when hypomanic or manic patients refuse medication
that will reduce their elevated mood state. In those cases, the autonomous wishes
of the individual confl ict with the paternalistic goals of the clinician, who wishes

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to prevent harm, or at least improve functioning. Current legal standards allow


patients to refuse treatment unless they present an imminent risk of hurting
themselves or others, or are clearly unable to provide basic care for themselves.
However, situations often arise in which patients are not in dire circumstances,
but their behavior and judgment are impaired to the point that they appear likely
to enter dangerous situations in the future. These points in treatment are particularly challenging when concerned family fervently wish for an intervention to be
made, but the patient refuses, due to limited insight or dissatisfaction with previous treatment experiences. Because the patient is the one who must swallow the
medication, forcing treatment on all but the most disordered patients is typically
an ineffective approach, regardless of the ethical reasons justifying the intervention. Thus, the ideal approach is to maintain a strong therapeutic alliance and
agree to disagree about the need to use medication. Keeping an open line of communication and expressing concern and support, despite refusal of treatment,
provide an opportunity for the patient to acquire greater insight over time, and
perhaps to become more open to interventions.
Another challenging ethical consideration emerges from the interplay between
psychiatric symptom control and deleterious physical consequences of medications. Most of the effective medications for bipolar disorder cause weight gain,
lithium frequently interferes with thyroid and kidney function (the latter, when
dosed inappropriately), and divalproex may contribute to PCOS, as in Janices
case. Antipsychotics may contribute to metabolic problems such as diabetes and
dyslipidemias (Dunlop, Sternberg, Phillips, Andersen, & Duncan, 2003). 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). Thus, full ethical decision making about
maintaining long-term treatment in order to prevent mood episodes requires full
and frank discussion with patients. It requires a consideration of the patients past
mood episodes and the degree of impairment and distress they produced. 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, through education about diet, exercise, appropriate laboratory
testing, and collaboration with the patients primary care physician. For Janice,
the distress from her condition was significant enough to warrant maintenance
treatment. However, we respected her concerns about weight gain and explored
alternative medications. Only time will reveal whether her current medication
plan is sufficient to maintain her euthymia.

Common Mistakes to Avoid


It is easy to go astray in treating bipolar disorder, as errors can easily arise at many
steps along the treatment path. First, errors in diagnosis can occur frequently,

Psychiatric Treatment of Bipolar Disorder: The Case of Janice

123

even among experienced clinicians. Hypomanic symptoms can be mistaken for


anxiety, as patients will often describe these mood elevated states as being revved
up, like being in an anxious state (Rakofsky & Dunlop, 2011). Promiscuity and
impulsive spending that occur during states of interpersonally triggered dysphoria may also be interpreted as symptoms of hypomania or mania, rather than
behaviors characteristic of borderline personality.
Second, given that depressive symptoms are so prominent over the course of
illness for most patients, it can be difficult to resist adding antidepressants to a
patients regimen to treat symptoms of depression and anxiety. For some patients
with bipolar type II disorder with prominent depressive or anxious symptoms,
treatment with a selective serotonin reuptake inhibitor (SSRI) antidepressant
may be effective with little risk for manic mood induction, but greater caution
is required for bipolar type I patients (Amsterdam & Shults, 2010). Additionally,
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. More subtly, 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.
Medication side effects can also lead to non-adherence if patients are not warned
ahead of time of their possible occurrence, or if they feel as if their concerns
are dismissed by physicians. Although some side effects are unavoidable, failure
to empathize with the patients trade-off between improved illness stability and
increased physical side effects can drive a wedge between the patient and doctor.

Looking Forward: Focus on Relapse Prevention


Close follow-up is the key to preventing mood episode relapses, as it permits early
detection and treatment of break-through symptoms. Upon remission from her
mood episode, Janice had appointments with her psychiatrist at monthly intervals. As her stability increased, visit frequency was reduced to 6-week, then
8-week intervals. Additionally, her weekly psychotherapy visits also helped to
monitor for symptoms of relapse. As part of her psychotherapy, she and her therapist continued to monitor her social rhythms and anticipate upcoming stressors
that could disrupt her social rhythms and mood states. Medication adherence
was encouraged by the therapist asking about any recent medication changes or
problems with the medications, and urging the patient to contact her psychiatrist
before her next appointment if troublesome side effects emerged. 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. Substance use may lead to forgetting to take medications
and an overall worsening course of illness. She will need to be regularly asked
about her substance use and her attendance at Narcotics Anonymous meetings.
Assuming that her current stability persists, the greatest period of relapse
risk will occur if/when she decides to conceive children. Although they are less

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teratogenic than divalproex, both lamotrigine and lithium may also cause structural anomalies to a developing fetus (Burt & Rasgon, 2004). This may lead a
bipolar woman to stop taking her medications upon discovering that she is pregnant or while in the planning stages of pregnancy. Mood recurrences are highly
likely and occur faster among bipolar women who discontinue their medications
during pregnancy. This is especially true for those with a history of rapid cycling
(Viguera et al., 2007). If Janice decides to have children, she will have to make
the difficult choice of either continuing medications that will protect her from a
mood episode recurrence but may affect fetal development, or discontinuing her
medications and putting herself and fetus at risk for the dangers associated with
a mood episode recurrence. The advantages and disadvantages of this choice
should be discussed at length with her psychiatrist and psychotherapist, and close
follow-up with her providers should occur throughout her pregnancy and shortly
after delivery.

Author Note
Confl icts of interest and sources of funding: None of the authors received any
direct support for conducting this research. Dr. Dunlop is supported by a K23
award (K23MH086690). Over the past three years, Dr. Rakofsky has received
research support from AstraZeneca and Novartis. Dr. Dunlop has received
research support from AstraZeneca, Evotec, Forest, Glaxo-Smith-Kline, Ono
Pharmaceuticals, Pfi zer, Takeda and Wyeth. He has also served as a consultant
to BMS, Imedex and MedAvante.

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COMMENTARY

W. Edward Craighead and Anjana Muralidharan

Background
In the case study, Psychiatric Treatment of Bipolar Disorder: The Case of
Janice, Rakofsky and Dunlop describe the successful treatment of a patient
with a complicated history of bipolar disorder. They first provide an excellent
descriptive, clinical information regarding the background and scientific fi ndings
relevant to treatment of this disorder. This information is important for several
reasons. First, psychoeducation is a critical part of all evidence-based somatic
and psychosocial treatments; thus, it is essential that the person providing treatment have command of this information in order to educate the patient. In addition to educating the patient about the disorder, effective intervention includes a
coherent and compelling rationale for the treatmenta treatment that usually
is long-term and requires adherence to a prescribed regimen of medications and
psychosocial therapies.
As was the case with Janice, bipolar disorders (BP) are marked by the frequent
presence of comorbid disorders, chief among which are substance use disorders,
borderline personality disorder, and anxiety disorders such as posttraumatic
stress disorder (PTSD). Because the interventions for BP are fairly disorderspecific, it is essential to obtain an appropriate differential diagnosis. It is particularly difficult to distinguish between BP II diagnosis, borderline personality
disorder, and PTSD because the life experiences (e.g., trauma) may be similar and
the emotional dysregulation associated with each of the disorders can be quite
similar. Nevertheless, the treatment of choice for each of these disorders differs,
so distinguishing BP as a separate disorder is essential to efficacious treatment
outcomes. Of course, the disorders may indeed be comorbid in the sense of relatively independent but co-occurring, so each may require separate and independent treatment.
As a part of the overview, the role of the family in BP is nicely described, pointing to both the possible role of genetic vulnerabilities and interpersonal interactions, particularly when another BP individual (e.g., a parent) is present. Familial
information is important for both the BP individual and family members. It
matters directly in the presentation of the treatment rationale, and it matters
in understanding how family members may best be involved in the therapeutic

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129

process. It seems highly likely that Janice was biologically vulnerable to mood
disorders given that her fathers family had multiple instances of BP and several
members of her mothers family suffered from major depressive disorder (MDD).
This vulnerability, coupled with her abuse, rendered Janice vulnerable to BP
when faced with stressful situations.
Janices treatment team is to be commended for utilizing another positive and
overarching aspect of treating BP; namely, they employed a multifaceted, interdisciplinary approach to her treatment, including treatment by an endocrinologist, a psychiatrist, and a psychotherapist. As noted by the authors, BP may be
related to other diseases (e.g., thyroid disorder, polycystic ovary syndrome), 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.

Assessment
One of the most important aspects of this case study is the thoroughness of the
assessment. This is nicely demonstrated by the clinical use of the SCID interview. Utilizing such a semi-structured format prevents the inadvertent oversight
of important problems and symptoms, while at the same time not burdening the
practicing clinician and the patient with the unnecessary elements of the SCID.
Equally important, the authors suggest several supplementary questions designed
primarily to help with differential diagnoses.
It is important to think of additional idiosyncratic questions that might be
relevant to an individual patient, depending on the life-history information that
emerges. One particularly relevant area has to do with family history of BP versus
MDD. This is essential because approximately one-third of BP patients present
with depression in their initial episode of the disorder (Hirschfeld, Lewis, &
Vornik, 2003; Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994). Having
this information at hand, the treating physician can make a more effective decision regarding the types of medication that can best be employed. With Janice,
there were clear indications of BP, but with a fi rst-episode patient, the distinction
between BP depression and MDD depression is usually less clear.
The use of some post-test and follow-up measures (e.g., a longitudinal measure
such as the LIFE interview, Keller et al., 1987) could have strengthened the confidence in the treatment outcomes.

Medication Treatments
The medication interventions demonstrate the expertise of the treatment team.
Even though there is emphasis on trial and error in the use and evaluation of
medications employed, it is important to note that this is informed trial and
error. For example, even though the psychiatrist continued the use of divalproex,
he knew the serum levels needed to be evaluated and monitored. The adjustment

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in the dosage levels resulting from the information regarding low serum levels
seems to have produced an enhanced treatment effect. When the team added
lithium (LI) to the treatment regimen, the blood levels were again monitored in
order to determine effective dosing levels. Although this is the standard for such
treatments, levels frequently are not drawn and LI adherence suffers as a result.
Indeed, insufficient dosage contributes to ineffective treatment and non-adherence because side effects are felt but the ameliorative effects of the treatment are
not obtained. Obviously, 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.
The treatment team employed an expert-consultant or collaborative model
for their intervention rather than an authoritative approach. Although fostering collaboration with the patient in making clinical decisions has been widely
suggested, there are patient characteristics that moderate its utility. For example, greater levels of collaboration produce greater adherence among reactant
patients whereas a more authoritative approach produces better results with less
reactant patients (Madsen, McQuaid, & Craighead, 2009). Even though collaboration is generally indicated, it can on occasions be contraindicated if it
does not match the expectations of the patient. The collaborative approach of the
expert-consultant model was successfully employed in Janices treatment and
it was skillfully demonstrated and exemplified by the response to the self-taper
of divalproex.

Psychotherapy Intervention
There are two major ways in which psychotherapy helps the BP patient: medication adherence, and changes in the psychological state and coping mechanisms
of the individual. In this case study, the treatment team encounters a common
occurrence in the treatment of bipolar disorder: medication non-adherence.
Rates of non-adherence with mood stabilizers in mood disorder patients range
from 1852%. Although it is difficult to predict which patients are likely to be
non-adherent to medications, one significant predictor is a past history of medication non-adherence (Scott & Pope, 2002). In the case of Janice, communicating
with her previous treatment providers during the assessment phase might have
revealed a previous pattern of medication non-adherence, indicating that a discussion of this topic earlier in the intervention may have been helpful.
Given the high rates of non-adherence, Ramirez-Basco and Rush (2005) suggest a frank discussion of medication compliance at the beginning of treatment
with every bipolar patient. They recommend an assessment of intrapersonal,
social, interpersonal, and cognitive barriers to compliance, as well as a detailed
compliance contract outlining how the patient will overcome these barriers. In
addition to unpleasant side effects, attitudes and beliefs about mental illness and
medication are predictors of medication non-adherence. It is important to communicate to patients that full adherence can be difficult to achieve, and to engage

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131

in open discussion of what is likely to interfere. This preemptive discussion is an


opportunity to prevent medication non-adherence before it interferes in treatment (Ramirez-Basco & Rush, 2005).
Janices treatment team is to be commended for using an evidence-based psychotherapeutic intervention: interpersonal and social rhythm therapy (IPSRT;
Frank et al., 2005; Miklowitz et al., 2007). IPSRT was augmented with exposure
therapy, particularly for the comorbid PTSD. Exposure therapy is a highly effective intervention; however, it is essential that the therapist be trained in its use
and the parameters associated with its success. Otherwise, negative outcomes
may result from inappropriate use of this intervention (e.g., resensitization to the
earlier trauma). 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, 2007).
In addition to the individual psychotherapy that Janice received, she and
her husband may have benefited from family-focused therapy for bipolar disorder, a treatment that includes psychoeducation about bipolar illness, communication skills training, and problem-solving skills training (Miklowitz, 2008).
There are several reasons that this treatment may have been helpful for Janice.
First, her husband also had a diagnosis of BP, so learning about the illness may
have been doubly beneficial for the couple. Second, Janices relationship with
her husband was identified as a source of support; providing them with communication skills to buttress this strength may have positively impacted her
course of illness. Finally, family-focused therapy has been found to be particularly helpful with symptoms of bipolar depression, whereas medications seem
to have a greater effect on manic phases of the disorder (Simoneau, Miklowitz,
Richards, Saleem, & George, 1999). Given that Janice struggled foremost with
depressive symptoms, which are not always well controlled by mood-stabilizing
medication, a family-focused approach may have had a positive impact on her
symptoms.
Finally, it would be useful to know how the psychotherapy was managed
during the post-acute treatment phase. 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.
In summary, Rakofsky and Dunlop did a masterful job of treating this individual with BP disorder. Even though the case was quite complicated with comorbid disorders, they were persistent in following the best evidence available in
the treatment sequence. They maintained a consistent strategy throughout the
course of treatment, and the results indicate that this individual enjoyed a much
more satisfying quality of life as a result of the treatment.

Author Note
The writing of this manuscript was supported in part by NIH/NIMH Grant 1
RO1-MH 080880 awarded to W. Edward Craighead.

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References
Frank, E., Kupfer D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A.
M., . . . Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm
therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62,
9961004.
Hirschfeld, R. M., Lewis, L., & Vornik, L. A. (2003). 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. Journal of
Clinical Psychiatry, 64(2), 161174.
Keller, M. B., Lavori, P. W., Friedman, B., Nielsen, E., Endicott, J., & McDonaldScott, P. A. (1987). The longitudinal interval follow-up evaluation: A comprehensive method for assessing outcome in prospective longitudinal studies. Archives of
General Psychiatry, 44, 540548.
Lish, J. D., Dime-Meenan, S., Whybrow, P. C., Price, R. A., & Hirschfeld, R. M. (1994).
The National Depressive and Manic-depressive Association (DMDA) survey of
bipolar members. Journal of Affective Disorders, 31(4), 281294.
Madsen, J. W., McQuaid, J. R., & Craighead, W. E. (2009). Working with reactant
patients: Are we prescribing nonadherence? Depression and Anxiety, 26(2), 129134.
Miklowitz , D. J. (2008). Bipolar disorder: A family-focused treatment approach (2nd ed.).
New York: The Guilford Press.
Miklowitz , D. J., & Craighead, W. E. (2007). Bipolar disorders. In P. E. Nathan &
J. M. Gorman (Eds.), A guide to treatments that work (3rd ed., pp. 309322). New
York: Oxford University Press.
Miklowitz , D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Wisniewski, S. R.,
Kogan, J. N., . . . Sachs, G. S. (2007). Psychosocial treatments for bipolar depression:
A 1-year randomized trial from the Systematic Treatment Enhancement Program.
Archives of General Psychiatry, 64(4), 419426.
Ramirez-Basco, M., & Rush, A. J. (2005). Cognitive-behavioral therapy for bipolar disorder (2nd ed.). New York: The Guilford Press.
Scott, J., & Pope, M. (2002). Nonadherence with mood stabilizers: Prevalence and predictors. Journal of Clinical Psychiatry, 63, 384390.
Simoneau, T., Miklowitz, D., Richards, J., Saleem, R., & George, E. (1999). Bipolar disorder and family communication: Effects of a psychoeducational treatment program.
Journal of Abnormal Psychology, 108(4), 588597.

RESPONSE

Jeffrey J. Rakofsky and Boadie W. Dunlop

Drs. Craighead and Muralidharan provide a thoughtful analysis of our chapter,


and make several important suggestions that we address in this response. First,
they identify that use of post-test and follow-up measures may serve to strengthen
confidence in the treatment. Incoporating scales longitudinally to track patient
wellness over time is indeed a helpful tool. Unlike unipolar depression, for
which validated patient-rated scales such as the Quick Inventory of Depressive
Symptoms, Self-Report (QIDS-SR) (available for free at http://www.ids-qids.
org), and the Beck Depression Inventory can track symptom severity over time,
bipolar disorder lacks such instruments. A clinician-rated measure that we have
implemented in our bipolar clinic is the Clinician Global Improvement-Severity
(CGI-S) scale, a seven-item scale that condenses the patients symptom burden
and impairment in important life domains to a single-digit number (17) representing the status of his or her overall condition. 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. During Janices last
several clinic visits, her CGI-S scores ranged from 1 to 2, indicating minimal
symptom burden and role dysfunction, and an effective treatment regimen with
enduring impact. Follow-up measures and post-test assessments can also provide
value through ensuring diagnostic accuracy. 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,
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 second suggestion was to communicate with Janices previous treatment
providers to determine if there was a history of medication non-adherence,
because prior medication non-adherence may predict future non-adherence. We
agree with this practice and often do engage in such communications if the clinical situation suggests this potential risk. During Janices initial evaluation she
was forthcoming and knowledgeable about her treatment and psychiatric history, which made contacting her prior provider seem less urgent. However, it is
possible that important information had been forgotten by the patient, despite

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her intention to be as forthcoming as possible. Support staff, when available, can


be very helpful in tracking down prior treatment records.
Drs. Craighead and Muralidharan also suggest offering Janice family-focused
psychotherapy as another psychotherapy modality. We agree with this recommendation, though point out that, just as with interpersonal and social rhythm
therapy and prolonged exposure therapy, it is often difficult to fi nd experienced
therapists trained in these modalities. Because of our affi liation with an academic center, these options are readily available; this may be different for providers practicing in less urban settings. A web site managed by the American
Association of Marriage and Family Therapists, which can be used to identify
therapists trained in FFP, is: http://www.therapistlocator.net.
Finally, Janices post-acute treatment phase therapy focused on helping her
manage job-related stress, which represented a significant risk factor for mood
episode relapse. She has recently gained employment as a salesperson, which she
fi nds to be more satisfying than waitressing, and her supervisors are more supportive than her managers at the restaurant. However, getting paid mostly by sales
commission, she must contend with the unpredictability of the economy and the
whims of consumers as she tries to earn an income for her family. Similar to the
ups and downs of her illness, she is learning how to weather the good days and the
bad that commission-based jobs, such as hers, entail. 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.

{ PART III }

Anxiety Disorders

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{6}

Panic Disorder with Agoraphobia: A Case


Illustration with Treatment Decisions Informed
by Clinical Science
Julia R. Craner, Geoffrey L. Thorpe, K. Lira Yoon, and
Sandra T. Sigmon

Annie is a 36-year-old Caucasian American who lives with her husband of 14


years. As a teenager she began experiencing occasional panic attacks, which
became more severe and frequent in her senior year of college. She describes these
attacks as a sudden need to escape, accompanied by dry mouth, heart palpitations, weakness in her arms, and racing thoughts. She also fears losing control or
going crazy. Her fi rst significant panic attack occurred while she was studying at
the college library. She felt severe anxiety and a sudden urge to leave. After that,
she noticed that these attacks became more frequent, and she became very afraid
of having another panic attack.
For the past several years, Annie has avoided situations that may provoke
anxiety or panic-like physical sensations. For example, she avoids crowds at concerts, sporting events, and shopping malls. In these places, she is concerned about
what she will do if she has feelings of panic, and the potential embarrassment that
her panic might cause. She also avoids situations where it would be embarrassing
if she started to have severe anxiety (e.g., a social event with strangers, or formal
gatherings). She relies on her husband to accompany her to stores or places where
she feels uncomfortable. She is extremely anxious whenever she is separated from
her husband; she is afraid that if she becomes anxious and he is not around, she
will not be able to handle it. For instance, once she was at a friends house and
began to feel weak, as if she might pass out. Anxious that she might faint, she
immediately called her husband to pick her up. Her anxiety has put a significant
amount of strain on their relationship, because he is unable to be out late with
friends or leave town for business. Her husband is supportive, but Annie worries
about the impact that her panic is having on their relationship.

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Anxiety Disorders

Annie has also experienced several nocturnal panic attacks that have awoken
her in the middle of the night. Her heart beats rapidly and she feels shaky, with
intense anxiety. Fear of this happening makes nighttime anxiety-provoking for
her; she has difficulty falling asleep, and also wakes up several hours earlier than
she would like, because she cannot get back to sleep after her husband has left
for work.
In addition to acute anxiety, Annie experiences generalized worry about many
areas of her life. She worries excessively about family members, her job, fi nances,
and making decisions about her future. She also has intense fears about nosebleeds. She worries that if she had a nosebleed with a large amount of blood, she
might start to feel faint. If she has a nosebleed or sees someone with a nosebleed,
she begins to feel anxious and may have a panic attack.
Annie is particularly sensitive to many physical sensations and environmental cues because of their association with anxiety. She is sensitive to bright
lights, which make her feel dizzy. She is keenly aware of any physical sensations that do not have an obvious cause. If she begins to feel flushed or shaky
during her daily routine, this sensation might lead to a panic attack. She also
has a long history of significant premenstrual exacerbation of her anxiety due
to associated physical sensations, such as bloating. She dreads getting her
period, because she expects that she will experience more anxiety and panic.
Annie is sensitive to environmental cues, such as time of day, and experiences
increased anxiety in the morning, 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.
Annie has taken Zoloft for many years and also uses Xanax on rare occasions. She does not like Xanax because it makes her feel out of it and she worries about becoming addicted. However, she keeps it on hand for occasional use,
and feels comforted that she has that option if she feels that her anxiety is out of
control.
Annie has no significant medical history. Her mother and sister experience
clinical depression and also tend to worry, but there is no other known family
history of anxiety or panic. Annie grew up in a rural area, and she describes her
childhood as very sheltered. Her parents were very protective and she was quite
dependent on them growing up. She married her high school boyfriend. Now, she
doubts her ability to function independently and second-guesses herself often.
Primarily, she doubts her ability to handle her anxiety on her own, particularly
without her husband present.
Although Annie did not report any significant depressed mood or loss
of interest, she did report feeling down and discouraged following panic
attacks. She also feels frustrated with herself for letting her anxiety get out
of control.
Annie has attended counseling on several previous occasions for a few sessions each time, but did not fi nd talking about her anxiety helpful. Presently, 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.

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 Annies functioning and quality of life.
She reported no history of developmental difficulties, medical problems, alcohol or drug abuse, or traumatic events. In response to questions about current
difficulties, Annie reported that her main concern was her panic attacks, which
are very distressing to her. Thus, the primary focus of treatment was on panic
attacks.

STRUCTURED INTERVIEW

Because Annie reported difficulties with panic and anxiety, the Anxiety Disorders
Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994), a
structured diagnostic interview, was administered. Annie met criteria for panic
disorder with agoraphobia (PDA). She reported panic attacks, sometimes out of
the blue, accompanied by seven severe symptoms, and severe anxiety about having another panic attack. Her severe symptoms include heart palpitations, shaking, shortness of breath, nausea, dizziness, feelings of unreality, and fear of going
crazy. More mild to moderate symptoms include sweating, chills, fear of dying,
fear of doing something uncontrolled, and feeling a lump in her throat. She also
experiences situational avoidance and needs her husband to accompany her in
anxiety-provoking situations.
In addition to PDA, Annie also reported many symptoms consistent with generalized anxiety disorder. She reported excessive worries with fatigue, difficulty
concentrating, irritability, and muscle tension. Importantly, her worries are about
several areas of her life, not exclusively related to panic attacks. Furthermore,
Annie met criteria for a specific phobia, other type, related to her extreme fear
of nosebleeds. As Annie fears nosebleeds in general, rather than just the associated physiological sensations or panic symptoms resulting from encountering
blood, this is not best accounted for by her diagnosis of PDA.

FUNCTIONAL ANALYSIS

Situational antecedents for Annies panic attacks include being in crowds or in


situations where escape might be difficult, and in anxiety-provoking situations
without her husband. Internal antecedents include worrying about future panic
attacks, and physical sensations resembling panic attacks. Being with her husband reduces the likelihood of experiencing panic attacks, as well as being busy
at work or with other activities. Thoughts preceding panic attacks include fear
of being unable to cope if she starts to feel anxious, as well as thinking that there
might be something terrible wrong with her, that she might faint, or that she
might have a nosebleed if she starts to panic. She attempts to cope by escaping

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Anxiety Disorders

the situation, seeking out her husband, or taking Xanax. Dreading encountering
such situations in the future, she anxiously anticipates them. Increasing dependence on her husband typically follows episodes of panic and anxiety.

SELF-REPORT MEASURES

Beck Depression Inventory II (BDI-II): Annie completed the BDI-II (Beck, Steer, &
Brown, 1996), a self-report assessment questionnaire designed to measure current
depressive symptomatology. Her score of 18 suggests that she is mildly depressed.
She endorsed moderate levels of indecisiveness and concentration difficulty.
Beck Anxiety Inventory (BAI): Annie also completed the BAI (Beck & Steer,
1993), a self-report measure designed to assess anxiety symptoms. Annies score
of 34 is indicative of severe anxiety. She endorsed moderate symptoms of feeling unable to relax, fear of the worst happening, dizziness or lightheadedness,
heart pounding or racing, unsteadiness, feeling terrified, feeling nervous, having
feelings of choking, feeling shaking, fear of losing control, fear of dying, feeling
afraid, and abdomen discomfort.

SELF-MONITORING

Continuous self-monitoring of panic and anxiety is important in assessment and


treatment because it is more accurate than retrospective recall, which tends to
overestimate panic frequency and intensity (Craske & Barlow, 2008). Annie was
asked to complete a panic attack record and daily ratings of mood and anxiety.
However, she did not experience a panic attack during the first eight weeks of
treatment. On her daily mood record, Annie reported her average daily anxiety,
depression, and anxiety about panic about 25% of the time for the first several
weeks of treatment.

Overview of Treatment
TREATMENT APPROACH

The main treatment protocol used was Mastery of Your Anxiety and Panic, 4th
edition (MAP-4; Barlow & Craske, 2007; Craske & Barlow, 2006). The MAP-4
treatment protocol includes psychoeducation, breathing retraining, relaxation training, cognitive restructuring, interoceptive exposure, and in vivo
exposure. Interventions for Annies nocturnal panic attacks were drawn from
the cognitive-behavioral protocol evaluated by Craske, Lang, Aikins, and
Mystkowski (2005).

Session 1
The fi rst component of treatment involved orienting Annie to therapy. The therapist and Annie made a plan to focus on panic symptoms first. This would involve

Panic Disorder with Agoraphobia

141

learning about panic and anxiety, and then learning strategies to manage and
cope with these symptoms. It was explained that cognitive behavioral therapy
(CBT) for PDA should involve weekly sessions with between-session readings and
homework. Treatment began with following a specific protocol (MAP-4), but it
was discussed that treatment would also be flexible, based on her needs.
Next, psychoeducation for PDA was introduced. The nature of panic disorder
and agoraphobia were presented, as well as symptoms and prevalence. Biological
and psychological factors leading to panic disorder were also discussed, as well
as the potential role of stress. Annie told the therapist that she recognized having
many of the beliefs that were suggested as contributing to panic disorder (e.g.,
believing that panic attacks are harmful and inevitable, spending a lot of time
worrying about future panic attacks). She also noticed that these attacks tended
to occur more often during times of stress.
Unhelpful coping methods (i.e., avoidance, distraction, safety signals) were
introduced in relation to contributing factors to PDA. Annie stated that she
attempts to avoid situations that make her feel anxious, and that she relies on her
husband as a safety person to help her feel more comfortable.

Session 2
Session 2 focused on self-monitoring. It was explained that monitoring is an
important part of treatment in order to gain in-the-moment assessment of panic,
anxiety, and mood, and to help recognize patterns. Homework assignments
included completing a record for any panic attacks, and a daily mood record to
track anxiety, mood, and apprehension about panic attacks.

Session 3
In session 3, negative cycles of panic and agoraphobia were introduced. It was
explained that anxiety is a normal human emotion, but that it can become problematic when it occurs in the absence of threat. Panic disorder was explained as
a cycle that begins with a trigger, such as a physical symptom resembling panic,
which is perceived as threatening. In turn, this causes more sensations of anxiety,
which can lead to a panic attack. Annie noted that when she starts to feel panicky, she gets wound up and has a hard time calming herself down because she
fears that the anxiety will escalate into a panic attack.
Annie was asked to identify thoughts, behaviors, and physical sensations that
she experiences when she feels anxious or has a panic attack. She said that she
would sometimes have thoughts that she might faint, or that if she has to escape
the situation it would be difficult to explain this to others. She also reports thinking that whatever trigger she is experiencing might be part of a panic attack.
Common behaviors include trying to steady herself to prepare for a panic
attack, leaving the situation if she is in public, and contacting her husband
immediately. She recognized many physical symptoms as being part of her panic
attacks, most notably heart palpitations, racing thoughts, and nausea. These
physical sensations, thoughts, and behaviors were discussed in terms of being
part of a negative cycle.

142

Anxiety Disorders

Annie completed a step-by-step analysis of a recent panic attack. She noticed


that after feeling dizzy on waking up in the morning, she started to feel scared
and to think that this might be a panic attack. Then, her thoughts began to race
and she started to feel shaky. She began to worry that she might get sick, and
feared that she would not be able to contact her husband if she had a panic attack,
which intensified the feelings and she began to panic. Afterward, she called her
husband for comfort and called in sick for work that day. She told the therapist
that she could see how her reactions ended up increasing her panic, which made
the possibility of panic attacks in the future more frightening.

Session 4
During this session, the therapist reviewed common mistaken beliefs about panic
attacks, such as that one will have a heart attack, faint, or lose control. The
physiology of panic was discussed, and it was emphasized that panic attacks are
not physically dangerous, but beliefs that they are make them more frightening.
Annie noted that she often fears that there is something medically wrong with
her when she feels unusual physical sensations, such as thinking that a headache
could be a brain tumor. She also reported that when she panics, she starts to
worry that she might faint or embarrass herself in public.

Sessions 5 and 6
Sessions 5 and 6 focused on breathing retraining and relaxation. The therapist
discussed how hyperventilation is related to panic attacks, either as a trigger or
concomitant. Annie was taught how to control her breathing with slow abdominal breathing. Homework included practicing abdominal breathing every day.
At session 6, Annie reported that she had been practicing abdominal breathing when she felt anxious, and that it had been helpful in those situations. 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.
Progressive muscle relaxation training was introduced in session 6. The 15
muscle group relaxation training, which involves alternately tensing and relaxing
various muscle groups, was practiced in session. Annie reported that she was able
to achieve a state of deep relaxation, and she agreed to practice breathing and
relaxation daily over the next week.

Sessions 79
Annie reported uneven success with relaxation and breathing practice. The therapist emphasized the importance of continuing practice, and they problem-solved
ways to incorporate practice into Annies daily routine.
At this point, treatment shifted toward cognitive skills. Over the next three
sessions, the therapist asked Annie to identify thoughts that she has when she
feels anxious or panicky. First, the therapist introduced the concept of automatic thoughts, and how they might contribute to anxiety. Specifically, it was
discussed that when someone thinks that a negative event is more likely to

Panic Disorder with Agoraphobia

143

happen than it actually is, this thought can increase anxiety. Annie noted that
she often has thoughts that she is going to faint, even though this has actually
never happened as a result of having a panic attack. It was also explained that
thinking that relatively benign events are catastrophic can also increase anxiety
and panic. 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.
Next, the therapist discussed skills that may be used to reason with these anxious thoughts. Annie worked on identifying realistic probabilities for events and
putting her thoughts in perspective. For example, Annie noted that the probability of actually fainting while panicking would be less than 1%. 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. She also related
that if some of the things that she feared actually did happen (e.g., a nosebleed),
that she would be able to deal with it and it would not be a catastrophe. She also
worked on positive coping self-statements. Annie wrote these down on a note
card to have with her when she feels anxious. For example, she wrote: I dont
need an explanation in order to deal with this symptom.
The therapist and Annie also discussed some of her beliefs regarding her medication. Annie reported that when she wakes up in the middle of the night due to
anxiety, she is able to fall back asleep quickly if she takes a Xanax, despite her
recognition that it probably takes a half hour for the medication to actually take
effect. The therapist pointed out to Annie that she is able to calm down before the
Xanax begins working.
Annie was given homework to practice identifying automatic anxious thoughts
and to reason with these thoughts, as well as reading her coping statements.

Sessions 1012
Sessions 10 through 12 involved in-session exposure for panic symptoms. First,
a rationale was presented for exposure, using the explanation provided in the
MAP-4 manual. Annie was told how panic disorder and agoraphobia can result
from conditioning, and that repeated exposure to feared stimuli can result in
decreased anxiety through increasing a sense of mastery, realizing that panic
symptoms do not result in dangerous consequences, and developing a new set of
associations through conditioning.
During the fi rst exposure session, Annie performed several symptom-inducing
exercises, such as hyperventilating, breath holding, and head shaking. Annie
listed the symptoms that each exercise produced (e.g., dizziness), and then rated
the intensity of the symptoms, her anxiety, and the similarity between the sensation and panic symptoms. After trying the exercises, the only one that caused
significant anxiety for Annie was hyperventilating. For this exercise, Annie
rated the intensity at a 6 out of 8, anxiety at a 5 out of 8, and similarity to panic
symptoms at a 4 out of 8. This was the only exercise that produced significant
anxiety for Annie, and as such it was the only exercise used for interoceptive
exposure.

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Anxiety Disorders

At home and during the next session, Annie practiced the hyperventilation
exercise. She noted that her anxiety decreased beginning with the second exposure practice, because she knew what to expect. At the second exposure session, Annie rated her anxiety at a 2 out of 8. This progress was encouraging to
Annie.
The therapist discussed with Annie that the various symptom-inducing exercises did not significantly increase her anxiety in session. As a result, the treatment plan shifted to include out-of-session exposure.

Sessions 1316
The next focus of therapy was to practice exposure exercises in real-life situations. As the in-session exposure exercises were generally unsuccessful at increasing Annies anxiety, she was asked to try these exercises at home, fi rst with and
then without her husband present. She again reported that these exercises did not
increase her anxiety level, which she stated was because she knew that she was
causing the sensation.
The therapist suggested that exposure might be more effective for Annie if she
began to face situations that she has been avoiding. Annie made an agoraphobia
hierarchy, rating her level of anxiety for each situation. She rated not being able
to get in touch with her husband by phone at a 3 out of 8, going to a large store
by herself at a 4, waking up with her husband gone at a 6, staying somewhere
overnight without her husband at a 6, and being home with her husband gone at
a 7 out of 8.
Over the next several sessions, Annie began to practice exposing herself to
these situations. First, Annie and the therapist reviewed coping skills and positive self-statements. Annie chose an exercise from her hierarchy to practice during the week. The fi rst exposure task that Annie attempted was to go to the store
by herself twice during the week for a half hour. At the next session, she reported
that the activity was reduced to a 2 or 3 out of 8 for anxiety, and that she also did
not feel a strong need to avoid it. After the next session, Annie took a trip to visit
a friend overnight. She reported a significant amount of anxiety before the trip,
anticipating that she would feel anxious while driving there, and that she would
not be able to sleep at night without her husband there. However, Annie reported
that she only felt mild anxiety during the trip, and that she was able to sleep well.
She reported feeling more confident in her ability to handle her anxiety and to
attempt more situations independently. Next, Annie practiced staying in bed in
the morning when her husband left for work, a daily event that she associated
with increased anxiety and panic. She did this several times and reported that her
anxiety decreased each time.
During this phase of therapy, Annie had the fi rst panic attack that she had
since beginning therapy. She started to feel dizzy one morning while driving to
work, and this triggered a panic attack. She reported that she pulled off the road
for a couple of minutes, and that she was able to calm herself down without calling her husband, and went to work as she usually would. Annie noted that she
was feeling that she was making progress with her anxiety.

Panic Disorder with Agoraphobia

145

Session 17
During this session, Annie brought her husband with her to therapy. Annie
wanted her husband to be included in what she was working on in therapy, especially with regard to her exposure practice at home. The therapist emphasized
to Annies husband the importance of being supportive but not enabling, and
suggested ways in which he could be Annies teammate at home. For example,
it was suggested that if Annie asked her husband to accompany her to the store
or another anxiety-provoking place, he could ask her if she really needed him to
come, or if it might be better if she went by herself. In addition, when Annie calls
her husband when feeling anxious, it was suggested that rather than immediately
reassuring her, he could remind her to use some of her coping skills. Both Annie
and her husband noted that they were encouraged by Annies progress and were
motivated to continue treatment.

Sessions 1820
Annie arrived at the next session in a state of distress. During the past week, she
had had a series of intense panic attacks, to the extent that she had not felt any
effect from the Xanax. This began with several nocturnal panic attacks. After
this, Annie reported fear of going to sleep, and anxiety and panic before bedtime
in anticipation of having to go to sleep. She reported up to a dozen panic attacks
in the course of four days. Annie reported feeling extremely discouraged and
having thoughts that her panic would never end. She felt unable to control her
anxiety, and she was concerned that she was going crazy.
The therapist worked with Annie on looking at her panic attacks step-by-step.
Annie recognized that after the fi rst panic attack, she stopped using her coping
strategies, and began to dwell on her fear of having more panic attacks. She also
noted that her expectation of having more panic attacks ended up increasing her
anxiety and panic. 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. Annie agreed that she was feeling like a failure
and that she was back at square one. They discussed that where she was now in
terms of her anxiety was different from when she started treatment, for example,
by emphasizing the positive things that she had accomplished. 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.
Annies case is ongoing, and it is estimated that she will continue to see the
therapist for another 1015 sessions. She has shown marked improvement in several areas, particularly in being willing to encounter anxiety-provoking situations and to use coping strategies such as relaxation and self-talk when feeling
anxious. She has also increased her ability to deal with panic-like symptoms
without having them escalate into a full-blown panic attack. She also reports
feeling better able to function independently without relying on her husband to
accompany her in many situations. However, Annie continues to have a significant amount of generalized anxiety, and she reports continued anxiety related to
nosebleeds. Therefore, Annie and the therapist constructed a treatment plan to

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Anxiety Disorders

continue developing skills and pursuing exposure exercises related to PDA, while
moving forward in treatment to target other areas of concern (i.e., generalized
anxiety, phobia). Nocturnal panic attacks will continue to be targeted specifically (Craske et al., 2005).

Key Principles/Core Knowledge


Clinicians draw from a broad professional knowledge base in case formulation and treatment. Knowledge of psychopathology is important in developing an assessment strategy. It is important to assess for the presence of
coherent syndromes that, if identified, can lead clinicians to focus the assessment more precisely. Pragmatically, this begins with identifying the key areas
of distress or impairment associated with the clients concerns. In Annies
case, the distressing symptoms included emotional, cognitive, and behavioral
elements. The chief emotion was anxiety, both generalized and in the form
of panic attacks. Panic attacks occurred during sleep, when the cues (if any)
were difficult to determine. In waking life, a strong situational element had
developed. Annie also reported a fear of fear pattern in which somatic sensations associated with anxiety had become terrifying in their own right, and
there was a social component in that she feared embarrassment if she were to
leave a public place during a panic attack. Cognitive features were evident in
Annies fears that she was losing control or going crazy. Behavioral aspects
were her tendency to escape from feared situations and the development of an
avoidance pattern.
Controlled studies have validated particular interventions for PDA, designed
to reduce emotional distress and to encourage greater mobility while helping the
client abandon efforts to escape or avoid situations. This addresses sources of
impairment and potential handicap directly. Because Annies concerns fit a PDA
formulation, we were able to draw from a corpus of well-researched treatment
techniques to address the critical elements.
Interventions for agoraphobic avoidance based on the exposure principle
have been validated in randomized, controlled clinical trials and in studies
using single-case experimental designs. These procedures include the combination of systematic desensitization plus real-life practice (Gelder, Bancroft, Gath,
Johnston, Mathews, & Shaw, 1973); imaginal flooding plus real-life practice
(Emmelkamp, 1974; Gelder et al., 1973); graduated real-life practice with feedback
and praise from therapists contingent upon incremental gains (Agras, Leitenberg,
Barlow, & Burlington, 1968; Leitenberg, Agras, Thompson, & Wright, 1968); and
client-initiated, home-based graduated real-life practice (Mathews, Teasdale,
Munby, Johnston, & Shaw, 1977; Mathews, Gelder, & Johnston, 1981). Imaginal
flooding has been shown to be more effective than systematic desensitization
(Boulougouris, Marks, & Marset, 1971). Exposure in vivo and imaginal floodingconfrontive, prolonged exposure to real and imagined feared situations
have produced the most rapid therapeutic gains (Emmelkamp & Wessels, 1975;

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Hazlett-Stevens & Craske, 2009b; Marks, Berlin, Gournay, & Noshirvani, 1980;
Mathews, Johnston, Lancashire, Munby, Shaw, & Gelder, 1976).
Panic control treatment consists of exposure to somatic cues, cognitive
restructuring, and breathing retraining (Hazlett-Stevens & Craske, 2009a; Rapee
& Barlow, 1991; Street & Barlow, 1994). A large-scale outcome study by Barlow,
Craske, Cerny, and Klosko (1989) confi rmed the efficacy of panic control treatment, and the therapeutic benefits persisted for at least two years following treatment (Street & Barlow, 1994).
Following a structured treatment protocol that has been studied in clinical
trials and has been found effective is strongly recommended (Barlow, 1996).
Clinicians adapt specific techniques to the unique situation of the client, but stop
short of substituting their impressions and hunches about how to proceed for
fidelity to a well-researched, manualized treatment. Traditional clinical skills
come into play when the clinician explains the rationale for treatment, develops
a treatment plan in collaboration with the client, and encourages him or her to
trust the protocol and follow the recommended treatment exercises. Negotiating
with the client about specific goals and their relative priorities is important. The
clinician is called upon to act as morale-booster, supportive coach, and collaborative problem-solver.

Assessment Strategy
Annie presented a variety of specific concerns. 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, social, occupational, educational, and other activities. It was also essential
to identify patterns, syndromes, or disorders in need of immediate treatment or
more elaborate assessment studies. Panic disorder typically includes a fear of
unfamiliar bodily sensations that can evoke concerns about medical emergencies. Complicating this, many clients first encounter panic attacks following an
experience resulting from an actual medical condition (e.g., feeling faint because
of low blood sugar, dizziness following an inner ear infection, or depersonalization related to intoxication by illicit drugs). It is, thus, imperative to rule out any
medical conditions that might resemble symptoms of panic attacks before proceeding with treatment of PDA (e.g., asthma, hypoglycemia, hyperthyroidism,
Cushings syndrome, pheochromocytoma, and hypoparathyroidism; Hecker &
Thorpe, 1992, Appendix A). Failing to identify a treatable condition, or neglecting to recommend a needed medical consultation, could fall below acceptable
standards of professional practice. In Annies case, she saw her family physician
and, upon his recommendation, had several tests performed prior to beginning
treatment: a complete metabolic panel, an evaluation of thyroid function, and a
test of hormone levels.
The self-report measures used in Annies initial assessment were developed
using classical test theory techniques, resting upon established criteria for

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reliability, validity, and standardization. In the standardization sample of 500


mental health outpatients, the internal consistency of the BDI-II was alpha =
.92, and in 26 outpatients retested after one week the test-retest stability was r
= .93. In 87 outpatients the correlation between BDI-II and Revised Hamilton
Psychiatric Rating Scale for Depression scores was r = .71. Thus the BDI-II shows
acceptable psychometric characteristics (Beck et al., 1996).
The BAI scores of 393 outpatients with various anxiety disorders (Beck &
Steer, 1990) indicated satisfactory internal consistency (alpha = .94), test-retest
stability after one week (r = .75), and concurrent validity with other inventories
(e.g., with both components of the State-Trait Anxiety Inventory: Trait r = .58;
State r = .47).
Instruments based on classical test theory rest on the often untested assumption
that items have equal weight in contributing to the aggregate score. Alternative
approaches involve selecting only the most discriminating items and scaling them
for difficulty in order to produce briefer, more efficient tests (Bond & Fox, 2007;
Chang & Reeve, 2005; Johnston, Johnston, Wilkes, Burns, & Thorpe, 1984).
Annie and her therapist compiled an idiographic anxiety hierarchy to delineate
specific problems and provide structure for treatment. Scaling is easily achieved
when a hierarchy item is viewed as a mini-test; when Annie drives to a large store
by herself, reaching the store guarantees, of course, that she also reached every
intermediate location along the way.

Epidemiological Considerations
Life-time prevalence estimates for panic disorder approach 5%. Panic disorder
without agoraphobia is three or four times more common than the PDA syndrome. In mental health outpatient settings, 95% of clients who present with agoraphobia meet criteria for PDA, though in samples from the general community,
half of those with agoraphobia have panic disorder (Kessler, Chiu, Jin, Ruscio,
Shear, & Walters, 2006; Thorpe, Sigmon, & Yoon, 2012).
The lifetime prevalence rate for PDA is estimated as 1.1%. The base rates for
those medical conditions that can create symptoms similar to those of PDA are
beyond the standard knowledge base for psychology, but accepted practice is to
encourage the client to seek a medical consultation in order to assess for such
conditions.
A host of questions could arise. Could the central problems stem from seizure
activity? Could it even be a factitious presentation in which, for obscure reasons,
the client seeks to present a fabricated symptom picture? Could Annies various symptoms be viewed as offshoots of an across-the-board, 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. In formulating Annies

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case, we considered the facts that in outpatient mental health settings the base
rates for epilepsy (Picot, Baldy-Moulinier, Daurs, Dujols, & Crespel, 2008) and
factitious symptom presentations (Catalina, Macias, & Cos, 2008; Eastwood &
Bisson, 2008) are typically low, and that medical test results indicated that Annie
was in good health.

Initial Case Formulation


Annie was diagnosed with PDA, generalized anxiety disorder (GAD), and specific phobia, blood-injury-injection type. One issue that arose in case conceptualization involved diagnosing comorbid disorders. There is a large overlap among
symptoms of PDA, GAD, and specific phobia, such as the experience of anxiety,
worry, and panic, as well as symptoms of avoidance of feared stimuli. However,
because Annie worried excessively about many different areas of her life, apart
from their relationship to panic or symptoms of panic or agoraphobia, and these
worries caused distress and impairment above and beyond that related to PDA,
she met separate criteria for GAD. Similarly, Annie met criteria for specific phobia
because, despite the observation that nosebleeds occasionally cause her to panic
and she fears that nosebleeds may result in panic-like symptoms, she also fears
others nosebleeds, and for other reasons apart from those relating to her PDA.

Development of an Intervention Model


Studies have shown that standardized interventions for panic disorder drawn
from well-researched, published protocols produce outcomes comparable
to, and often surpassing, those resulting from the application of individually
focused treatment plans, despite clinicians understandable concerns about the
need to address each clients unique circumstances (Barlow, 1996; Brown, Beck,
Newman, Beck, & Tran, 1997; Wilson, 1996). 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. Components
of the MAP-4 protocol that guided Annies treatmentcognitive restructuring,
applied relaxation, and exposure to interoceptive and external cuesare on the
list of well-established techniques among the empirically supported treatments
(Chambless & Ollendick, 2001; Forsyth, Fus, & Acheson, 2009).
Alternatively, the therapist could have used acceptance and commitment therapy
(ACT; Hayes, Strosahl, & Wilson, 1999). ACT revises conditioning language into a
newer terminology that emphasizes the verbal classes that denote anxiety-provoking
situations. Research by ACT practitioners has shown that clients who avoid rather
than enter challenging situations tend to develop additional anxiety symptoms.
Behavioral avoidance, as well as trying to suppress upsetting feeling states, promotes
continued anxiety rather than relief from distress (Hayes et al., 1999). Although ACT

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has support in the treatment of anxiety disorders, the MAP-4 has received empirical
support specifically for PDA, and was thus chosen in this case.

Dealing with Nonspecifics


Although the scientific evidence supports using standard treatment protocols
that have been validated by research, therapists find opportunities to employ
their general clinical skills when helping their clients to overcome demoralization and to increase their motivation for treatment. Clinicians will also use their
skill and judgment in adapting specific elements of the protocol to the specifics
of the clients presentation. For example, Annie feared breathlessness but not
feelings of unreality. Thus, the therapist asked Annie to confront panic elements
therapeutically by practicing voluntary hyperventilation rather than staring at a
spot on a wall, an exercise that has been shown to produce symptoms of depersonalization or derealization (Craske & Barlow, 2006).
Nonspecific aspects of treatment include the clients initial expectations. One
of us treated a PDA client whose initial expectations of therapy had been unusually low. She had previously had months of therapy with a psychodynamic clinician who had focused entirely on the clients adjustment and relationship issues
in childhood and had not attended to present difficulties with driving away from
home and dealing with panic attacks. On returning with the new therapist from
an early treatment session that had involved driving back and forth across a local
highway bridge, the client stated that she now felt that she had been cheated by
the former therapist. The issue was not that psychodynamic therapy had necessarily been objectionable in itself, but rather that it was the former therapists
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.
Like other psychotherapists, effective cognitive behavioral therapists show
competence in relationship skills (Spruill et al., 2004). Research has shown that
clients who rated their cognitive behavioral therapists as respectful and understanding made greater progress than those who did not. Establishing a positive and productive professional relationship between client and therapist is an
important component of psychotherapy, but in CBT the relationship itself is not
viewed as the central mechanism of change. In CBT for PDA specifically, better
client outcomes were seen when therapists emphasized empathy and warmth in
the early sessions, and took a directive stance once the goals and methods of
therapy had been established and agreed upon (Key & Craske, 2004; Thorpe,
McMillan, Owings, & Dawson, 2008).

Strategies for Dealing with Problems


Annie occasionally arrived late for appointments and missed one altogether
without prior notice. In a subsequent session, she expected the therapist to make

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a significant issue of this, because a former therapist had spent an entire session attempting to uncover the meaning of her tardiness. The current therapist
briefly registered disappointment that they would have less time than expected to
work on the treatment plan, but quickly moved on to address the days topics. It
turned out that Annie was punctual from that point on. 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.
In motivational interviewing, therapists set the scene for clients to acknowledge the extent of their difficulties and to increase their engagement in and
commitment to treatment. This is achieved not by a confrontational approach
in which therapists attempt to browbeat their clients into compliance, but
instead by a nonthreatening, receptive attitude, acknowledging the difficulties involved and supporting clients as they struggle with their mixed feelings
about tackling their problems constructively (Levensky, Kersh, Cavasos, &
Brooks, 2009).
Several stumbling blocks had to be addressed in the course of Annies treatment. Initially, she began symptom-inducing exposure exercises in session, ranking their anxiety-provoking potential and similarity to panic. However, despite
attempting a variety of similar exercises over several sessions, Annie did not
report any significant anxiety as a result of engaging in these activities, with the
exception of hyperventilation. She also felt that these exercises were very different from what she experienced when panicking, because she was deliberately
producing them, and she knew what was causing the symptom. As a result of
being unable to significantly increase Annies anxiety to a level sufficient to produce effect from exposure, the therapist suggested to her that she begin to try
real-life (in vivo) exposure practice. This was a successful shift in treatment,
as Annie began to practice exposing herself to a variety of feared situations,
such as being home without her husband, visiting a friend alone overnight, and
going to shopping malls alone. She reported feeling more confident in her ability to handle anxiety-provoking situations, as well as attempting more activities
independently.
A significant challenge in Annies treatment occurred after approximately
17 treatment sessions. As noted earlier, Annie had a series of intense panic attacks,
up to a dozen in the course of a few days, resulting in sleep disturbance and avoidance of feared situations. For several weeks following, Annie had elevated anxiety and panic. The therapist worked with Annie to review the skills and strategies
that she had developed to deal with her panic attacks. The panic episode was
analyzed step-by-step, and the therapist and Annie worked to discover how her
thoughts and behaviors continued the series of panic attacks, and when she could
have used particular strategies (e.g., challenging anxious thoughts, relaxation)
to stop the escalation of panic. They also discussed the improvements she had
made, and tried to put this episode in the perspective of a stumbling block, rather
than a sign that Annie was a failure or that her anxiety was completely out of her
control.

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Ethical Considerations
The primary ethical directive was to provide competent treatment consistent
with accepted standards of professional practice. This is not as straightforward
a requirement as we might wish, because the profession of clinical psychology
does not follow a standard paradigm for psychotherapy. However, if the goal
is to reduce the clients distress and impairment as efficiently as possible, it is
inevitable that we would draw from those empirically supported interventions
that demonstrably help clients attain those objectives. Collaboration with the client in agreeing upon the goals and methods of the proposed treatment plan is an
essential fi rst step.
The clinician who treated Annie was a doctoral candidate whose clinical work
was being supervised by a licensed psychologist. The therapist informed the client at the outset that she was working under supervision, and supplied the name
of the supervisor.
Presenting an actual case, as we did in this chapter, raises the important ethical issues of confidentiality and disclosures. In the Ethics Code of the American
Psychological Association (2002), Standard 4.07 requires that in their published
writings psychologists do not disclose personally identifiable information on a
client without disguising it, unless the client has given written consent. We satisfied
that requirement by altering significant details of the case, such as the clients name,
age, and elements of her personal history and symptom presentation, and by including some information drawn from our experience with other clients with PDA. Thus
every clinical issue that we have cited has been presented by an actual client, though
Annie combines the features and characteristics of several of them.

Common Mistakes to Avoid in Treatment


Clinicians whose primary work setting is in higher education and research may
be vulnerable to talking too muchfor example, by adopting a lecturing style
when providing the rationale for recommended treatment interventions. This
may inhibit questioning from the client, interfere with appropriate back-and-forth
communication, and even give the impression that the therapist, as an expert, is
responsible for effecting all the needed changes.
To return to the topic of motivational interviewing, in early sessions with
Annie the therapist adopted this approach by asking the client to give her
thoughts and views on the proposed interventions. The intent was to encourage
Annie to contribute to the intended collaborative atmosphere (Sobell & Sobell,
2003). Preferably the therapist will adopt the role of coach or advisor as the client works on acquiring the needed skills. Traditional therapeutic postures such
as conveying empathy could, if overdone, interfere with the therapists role in
encouraging practice, giving feedback on progress, and problem-solving with the
client when difficulties arise. The preferred therapist attitude would be supportive, yet disciplined.

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153

Relapse Prevention
Annies case is still ongoing and, thus, we have not dealt with issues of relapse or
termination. In cognitive behavior therapy for anxiety disorders, the primary
task of termination involves relapse prevention strategies (Hazlett-Stevens,
2008, p. 326). Future difficulties are anticipated by careful preparation through
psychoeducation before active treatment ends. Specific plans for continued
self-initiated practice following treatment termination are agreed upon. 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, self-initiated treatment
(Thorpe et al., 2008).
It is important for cognitive behavioral therapists not to neglect the interpersonal aspects of treatment termination. Ending the professional relationship
successfully involves encouraging the client to question unhelpful assumptions
(e.g., that problems must be resolved perfectly before we terminate), to accept
and adopt the role of being his or her own therapist, and to address constructively
with the therapist the emotions raised by the ending of the relationship (Ochoa
& Muran, 2008).

The Art of This Case


There were some issues in trying to modify exposure exercises so that Annie could
realistically enact them between sessions, and so that they actually evoked anxiety similar to her real-life panic attacks. For example, Annie reported significant
anxiety in sleeping in the morning after her husband had gone to work, and typically got out of bed at the same time as him, despite the fact that this was several
hours earlier than she needed to wake up for work. It would have been impossible
to cause Annie to sleep in the morning after her husband has gone to work, so
instead, she practiced staying in bed until her preferred time to get up.
The most salient cultural factors had to do with Annies rural location and
the relative absence of such urban amenities as high-rise buildings, elevators,
and public transportation. Treatment was adapted to her setting and, despite the
rural environment, 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, social gatherings, and sports events.

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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. In the sections
that follow, we comment on the clinical science supporting the clinical choices
that were made, as well as the clinical science supporting additional choices that
could have been made or were not fully discussed. Our comments are structured
in the same format as the review.

Case Description
The case of Annie, a 36-year-old Caucasian American, nicely captures the phenomenology of panic and agoraphobia. The onset followed an initial unexpected
panic attack during Annies time as a college student, and subsequently developed into a full-fledged panic disorder with agoraphobic avoidance behavior.
The case description includes comorbidity with generalized anxiety disorder,
characterized by excessive worry about a number of different areas of life,
along with comorbidity of a phobia of nosebleeds. The issue of comorbidity is
appropriate, since panic disorder with agoraphobia often presents with comorbid anxiety and depressive disorders (Brown, Campbell, Lehman, Grisham, &
Mancill, 2001; Kessler, Chiu, Demler, Merikangas, & Walters, 2005). The case
description indicates signs of typical interoceptive sensitivity to physical sensations observed in panic disorder (Craske & Barlow, 2006) as well as overreliance
on safety signals in the form of her husband and Xanax (Craske & Barlow, 2006).
Furthermore, the background experiences, such as having a sheltered and overly
protective upbringing and perhaps an overprotective parenting style, are consistent with the literature showing that overprotective parenting is characteristic
of parents who have children who are anxious (Rapee & Murrell, 1988). Other
risk factors for panic disorder with agoraphobia include history of respiratory
disturbance, early exposure to familial violence and abuse, medical illnesses in
self and family, and high levels of temperamental neuroticism and beliefs that
symptoms of anxiety are harmful (i.e. anxiety sensitivity) (Roy-Byrne, Craske,
& Stein, 2006).

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Assessment
The assessment strategy includes a clinical interview and a structured interview, followed by a thorough functional analysis, self-report measures, and self-monitoring.
Overall, this represents an adequate assessment strategy; reliance on the Anxiety
Disorders Interview Schedule (Di Nardo, Brown, & Barlow, 1994) for differential
diagnosis is very appropriate and consistent with the evidence-based literature showing enhanced inter-rater reliability using such semi-structured interviews. Of note,
however, is the comorbid diagnosis of specific phobia of nosebleeds. References are
made to this fear of nosebleeds as being a specific phobia, other type that is independent of panic disorder. It is stated that while certain aspects of the fear of nosebleeds do pertain to panic disorder, in that fears of feeling faint are core to the panic
disorder fears, other unrelated fears warrant an independent diagnosis. However, it
is never clearly stated what those other unrelated fears, which would lead to an independent diagnosis of fear of nosebleeds, would be. Furthermore, it would appear
that if there is an independent diagnosis, it would pertain to fear of blood, which
would more accurately be categorized as a blood-injection-injury type of phobia.
The functional analysis clearly describes the situational antecedence to the
panic attacks that will subsequently become a target of exposure therapy, along
with the internal antecedence, such as the physical sensations. The analysis also
includes Annies husband as being a factor, although greater clarification of his
role as a safety signal that warrants targeting in treatment should have been garnered from this functional analysis. That aside, the functional analysis continues
to adequately describe the role of thoughts, behaviors, and physical sensations
in a typical fear of fear cycle. The self-report measures that were selected
include the Beck Depression Inventory and the Beck Anxiety Inventory. While
these instruments can be useful in gauging levels of anxiety and depression, they
are not specific to panic disorder. Recommended measures that will specifically
target features of panic disorder, thereby providing a gauge of severity at any
given time as well as providing an index of change with treatment, include (1)
the Anxiety Sensitivity Index (Reiss, Peterson, Gursky, & McNally, 1986), (2) the
Body Sensations Questionnaire and the Agoraphobia Cognitions Questionnaire
(Chambless, Caputo, Bright, & Gallagher, 1984), and (3) the Chambless Mobility
Inventory (Chambless, Caputo, Jasin, Gracixy, & Williams, 1985). (For a complete review of recommended measures, see Keller & Craske, 2008.)
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, but of course is also central to the process of cognitive
behavioral therapy as it encourages a scientific observer perspective.

Overview of Treatment
The overview of the treatment is based on the Craske and Barlow (2006) Mastery of
Your Anxiety and Panic, 4th edition, manual, which has been empirically tested in

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159

a number of different studies with slightly different versions. The main difference
between the manualized treatment, which has been studied in various efficacy
trials, and the way in which it was implemented in the current case is the number
of sessions. Most efficacy trials involve 1216 treatment sessions, whereas in this
case, the case description is described through session 20, with an estimated additional 1015 sessions still to be completed. This raises the empirical question of
the appropriate number of treatment sessions for completing cognitive behavioral
therapy for panic disorder. There are a number of empirical investigations that
pertain to this issue. First, brief treatments have been shown to have some effect,
including up to six sessions of cognitive behavioral therapy alongside expert psychotropic medication recommendations (Roy-Byrne et al., 2005) (although, in
that study, there was also a beneficial effect from continuing phone call follow-up
sessions over the subsequent few months; Craske et al., 2006). There are also studies showing that week-long intensive treatments are effective. There is further
evidence regarding sudden gains at the start of treatment being predictive of
superior outcome at follow-up (Clerkin, Teachman, & Smith-Janik, 2008). Thus,
the question is whether the same results could have been achieved in this case
over a shorter duration. As it is, the treatment was spread out so that the earlier
sessions focused on one specific skill at a time, and, as noted below, the introduction of exposure therapy to situations that were fear-producing was delayed some
time. Certainly for the purpose of cost-effectiveness, briefer treatments are more
valuable, although clinical law often dictates longer treatments with more severe
levels of agoraphobia and with comorbid personality disorders.
Sessions 5 and 6 of this particular treatment focused on both breathing
retraining and relaxation training. However, the empirical evidence regarding the benefits of breathing retraining and relaxation training are somewhat
mixed. First, 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.g. Meuret, Wilhelm, Ritz, & Roth, 2003).
Second, the safety signal perspective has been raised as a potential downside
to breathing retraining in particular, since focusing on controlling the breath
may serve as a way of avoiding facing the physical symptoms (Craske, Rowe,
Lewin, & Noriega-Dimitri, 1997). Third, recent evidence suggests that the way in
which breathing retraining has been done in the panic control therapy protocol,
which is to use slow abdominal breathing, may actually exacerbate hyperventilatory symptoms in individuals who have irregular or hypercapnic breathing
(Meuret, Wilhelm, Ritz, & Roth, 2003). For this reason, Meuret and colleagues
have developed a capnometry-assisted breathing training protocol, involving
biofeedback of exhaled CO2 levels, which has shown to be promising for panic
disorder (Meuret & Ritz, 2010). Fourth, in this case, both breathing retraining
and relaxation training were included, and it is unclear why both were used, as
usually one or the other would be chosen. The evidence for relaxation training
for panic disorder, again, is mixed, with some fi ndings showing that it does not
add significant benefit (Siev & Chambless, 2007), whereas other fi ndings show
that applied relaxation, wherein relaxation is used as a coping skill for facing

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anxiety-provoking situations, has been shown to be as effective as cognitive therapy for panic disorder (Ost, Westling, & Hellstrom, 1993).
Sessions 7 through 9 focused on cognitive restructuring. Again, there has been
some debate in the literature about the role of cognitive restructuring. For example, some suggest that cognitive therapy does not add significantly to the benefits of exposure therapy (See Bouchard, Gauthier, LaBerge, French, Pelletier,
& Godbout, 1996 for review). On the other hand, other studies have shown that
cognitive therapy alone is effective for panic disorder (see Bouchard et al. for
review). It is this issue regarding the benefits of cognitive restructuring that have
led to more interest in alternative treatment approaches, such as acceptance
and commitment therapy, which do not engage in restructuring of thoughts, but
rather attempt to distance, or to teach people to distance themselves from their
thinking.
Sessions 11 and 12 focused on interoceptive exposure to bodily sensations.
Apparently, since little anxiety was induced after the fi rst occasion, interoceptive exposure was discontinued. However, use of more idiosyncratic interoceptive exercises tailored specifically to this particular set of fears, such as fears of
bright lights or of feeling flushed or shaky or faint, may have yielded higher levels of anxiety. Examples might have been staring at bright lights or pictures of
nosebleeds to generate sensations of faintness or lightheadedness. Furthermore,
although the interoceptive exercises failed to induce significant discomfort in session, they may well have induced discomfort in agoraphobic situations. 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). This concept is based on the basic science approach of deepened extinction, which has been shown to benefit extinction learning (Rescorla,
2006).
It is noteworthy that the in vivo exposure to feared situations did not begin
until session 13, which represents approximately 3 months from starting treatment. As noted earlier, this represents a lengthy period of time, and certainly
different from what is typically done in treatment outcome trials. Unfortunately,
there is little description of the way in which in vivo exposure was conducted. The
latest science of exposure therapy emphasizes the importance of weaning safety
signals and safety behaviors, such as weaning reliance on the Xanax, and conducting exposure in ways that are designed to enhance inhibitory learning, which
in this case would mean enhancing the learning that the physical symptoms of
panic, or panic itself, are not threatening. (For a review of these issues, see Craske
et al., 2008.) There may have been an overemphasis on fear reduction throughout
the exposure therapy, which, as we have argued elsewhere, may serve as a safety
signal, particularly in the case of panic disorder, where the experience of fear is
the element that is most dreaded.
In session 17, the husband attended therapy sessions. This is a useful technique for the reasons specified in the chapter, but nonetheless, 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

Panic Disorder with Agoraphobia

161

about the nature of the panic disorder, the nature of the treatment, and can
become a coach in the application of cognitive and somatic coping skills and
the practice of exposure therapy. Furthermore, 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.
In session 18, there is a description of an upsurge of the occurrence of panic
attacks and the failure of Xanax to have any ameliorating effects. If anything,
this may illustrate the downside of continuous reliance upon Xanax, which may
have been better weaned as an inappropriate safety signal earlier in the treatment.
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. That being said, the experience of panic attacks
during treatment is not necessarily a bad thing, as it can be regarded as a valuable
learning experience.
References were made to nocturnal panic attacks as being an area to target in
future treatment sessions. However, the empirical literature demonstrates that
nocturnal panic attacks function very similarly to daytime panic attacks, most
often representing a fear of bodily sensations that occur as one is waking from
sleep. There is good evidence that involving interoceptive exposure centered on
the nocturnal panic attacks themselves is effective, such as by alarm sounds that
are set at random intervals throughout the night to elicit abrupt arousal-induced
awakening from sleep. Although the chapter notes that there are a lack of cues
for panic attacks during sleep, the evidence suggests that physiological cues are
likely to be significant triggers (Tsao & Craske, 2003).
Finally, 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 1020 years. Meta-analyses such as those
conducted by Hofmann and Smits in 2008, Norton and Price in 2007, and Tolin
in 2010 would include some of those studies. Reference to alternative therapies,
such as acceptance and commitment therapy, is somewhat overstated, since there
is a lack of more than one randomized controlled trial for the treatment of anxiety disorders.

References
Bouchard, S., Gauthier, J., LaBerge, B., French, D., Pelletier, M.H., & Godbout, C.
(1996). Exposure vs. Cognitive Restructuring in the Treatment of Panic Disorder
with Agoraphobia.Behavior Research & Therapy, 34, 213224.
Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001).
Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a
large clinical sample. Journal of Abnormal Psychology, 110(4), 585599.
Chambless, D. L., Caputo, G. C., Bright, P., Gallagher, R. (1984). Assessment of fear
of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic

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Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52(6),


10901097
Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracixy, E. J., Williams, C. (1985). The
mobility inventory for agoraphoba. Behavior Research and Therapy, 23(1), 3544.
Clerkin, E. M., Teachman, B. A., Smith-Janik, S. B. (2008). Sudden gains in group
cognitive-behavioral therapy for panic disorder. Behavior Research and Therapy,
46(11), 12441250.
Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and panic: Therapist
guide (4th ed.). New York: Oxford University Press.
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker,
A. (2008). Optimizing inhibitory learning. Behavior Research and Therapy, 46(1),
527.
Craske, M. G., Roy-Byrne, P., Stein, M. B., Sullivan, G., Hazlett-Stevens, H., Bystritsky,
A., & Sherbourne, C. (2006). CBT intensity and outcome for panic disorder in a primary care setting. Behavior Therapy 37(2), 112119.
Craske, M. G., Rowe, M., Lewin, M., & Noriega-Dimitri, R. (1997). Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. British Journal of Clinical Psychology, 36, 8599.
Di Nardo, P., Brown, T. A., Barlow, D. H. Anxiety disorders interview schedule, 4th ed.
(ADIS-IV). New York: Oxford University Press, 1994.
Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult
anxiety-disorders: A meta-analysis of randomized placebo-controlled trials. Journal
of Clinical Psychiatry, 69(4), 621632.
Keller, M. B., & Craske, M. G. (2008). Panic disorder and agoraphobia. In Hunsley, J., &
Mash, E. J. (Eds.) A guide to assessments that work (pp. 229253). New York: Oxford
University Press.
Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005).
Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National
Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 61727.
Meuret, A. E., & Ritz, T. (2010). Hyperventilation in panic disorder and asthma:
Empirical evidence and clinical strategies. International Journal of Psychophysiology,
78(1), 6879.
Meuret, A. E., Wilhelm, F. H., Ritz, T., Roth, W. T. (2003) Breathing training for treating panic disorder: Useful intervention or impediment? Behavior Modification, 27,
731754.
Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult cognitive-behavioral
treatment outcome across the anxiety disorders. Journal of Nervous and Mental
Disease, 195(6), 521531.
Ost, L., Westling, B. E., & Hellstorm, K. (1993). Applied relaxation, exposure in vivo
and cognitive methods in the treatment of panic disorder with agoraphobia. Behavior
Research and Therapy, 31(4), 383394.
Rapee, R. M., & Murrell, E. (1988) Predictors of agoraphobic avoidance. Journal of
Anxiety Disorders, 2, 203217.
Rescorla, R. A. (2006). Deepened extinction from compound stimulus presentation.
Journal of Experimental Psychology: Animal Behavior Processes, 32(2), 135144.
Reiss, S., Peterson, R., Gursky, M., & McNally, R. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 18.

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Roy-Byrne, P. P., Craske, M. G., & Stein, M. B. (2006). Panic disorder. Lancet, 368,
10231032. Roy-Byrne, P., Craske, M. G., Stein, M. B., Sullivan, G., Bystritsky, A.,
Katon, W., Golinelli, D., & Sherbourne, C. D. (2005). A randomized effectiveness
trial of cognitive-behavioral therapy and medication for primary care panic disorder.
Archives of General Psychiatry, 62, 290298.
Siev, J., & Chambless, D. L. (2007). Specificity of treatment effects: Cognitive therapy
and relaxation for generalized anxiety and panic disorders. Journal of Consulting and
Clinical Psychology, 75(4), 513522.
Tolin, D.F. (2010). Is cognitive-behavioral therapy more effective than other therapies?:
A meta-analytic review. Clinical Psychology Review, 30(6), 710720.
Tsao, J. C. I., & Craske, M. G. (2003). Reactivity to imagery and nocturnal panic attacks.
Depression and Anxiety: Special Issue: Panic and sleep disorders, 18(4), 205213.

RESPONSE

Julia R. Craner, Geoffrey L. Thorpe, K. Lira Yoon,


and Sandra T. Sigmon

In this short section, we will respond to the commentary on the evidence basis for
our treatment approach of panic disorder with agoraphobia for Annie. Overall,
we found the commentary to be insightful and thorough. We appreciate the
observations that there are different choices that can be made when making decisions based on clinical research. However, we would like to take this opportunity
to clarify a few points with regard to the treatment approach.
Concerning differential diagnosis for comorbid disorders, Annie was diagnosed with panic disorder with agoraphobia, generalized anxiety disorder, and
specific phobia blood-injection-injury type. The diagnosis of specific phobia in
addition to panic disorder with agoraphobia is based on several considerations.
First, even though Annie has fears that if she gets a nosebleed she will lose a
significant amount of blood, which may make her feel faint and lead to either
medical consequences or a panic attack, this is only one aspect of her fear of
nosebleeds. Annie also fears that other people will get nosebleeds around her,
that she will see people in movies getting nosebleeds, that if others are injured
they will get a nosebleed, and that the nosebleeds will lead to catastrophic medical consequences. Notably, by her report, these are fears of the nosebleeds themselves, rather than the anxiety symptoms that they elicit. In addition to intense
fears of nosebleeds, she reported significant avoidance behavior, such as avoiding
watching sports games, and making sure to keep a humidifier running in the
house to avoid nosebleeds due to dryness. She reported that she does not fear
blood in general; for example, she does not have fears related to getting her blood
drawn. For these reasons, we believe that Annie meets criteria for specific phobia. However, if her fears of nosebleeds were confined to the physical symptoms
or anxiety experienced in response to having or seeing a nosebleed, this would fit
better with her primary diagnosis of panic disorder with agoraphobia. Annie also
met criteria for generalized anxiety disorder, given that she has excessive worries
about a wide array of situations, such as finances and relationship issues, not only
panic and agoraphobic experiences.
The commentary was quite correct in noting that efficacy studies for panic disorder indicate that 1216 sessions are generally effective. There are many benefits
of brief treatment, including cost-effectiveness. However, manualized treatment

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165

must often be individualized to meet idiosyncratic client needs. Clinicians utilizing empirically supported treatments (ESTs) are charged with the task of providing effective psychotherapy while making accommodations for unexpected
events, additional issues that come up, and comorbid diagnoses. Often, cases arise
in practice in which a clinician has to decide whether to forge ahead or slow down,
depending on what the client presents with. For example, a client who misses multiple sessions, does not complete homework assignments, or has difficulty with
comprehension may require treatment to be delivered over a longer period of time
to address these issues as they arise. Considering that Annie meets criteria for
three separate anxiety disorders, and that she experienced a significant stumbling
block when she had several escalating panic episodes during treatment, we feel that
additional sessions are appropriate for her. The research literature indicates that
when clinicians are presented with complex cases, such as comorbid diagnoses,
ESTs may need to be modified (Ruscio & Holohan, 2006). Randomized controlled
trials of ESTs typically use more homogeneous samples than those that confront
clinicians in practice (Greenberg & Watson, 2006). Research indicates that clients
seen in private practice often require a greater number of sessions to receive treatment benefit, particularly those with comorbid diagnoses (Stirman & DeRubis,
2006). One type of modification strategy in treating comorbid diagnoses involves
delivery of multiple ESTs (Ruscio & Holohan, 2006), and this is the approach that
was taken when planning the future number of sessions with Annie.
Finally, with regard to the sequence of treatment, the approach that was chosen included breathing retraining, relaxation training, and cognitive restructuring. Although some studies have indicated that these aspects of treatment may
not be essential, there has been empirical support for the treatment manual chosen, which contains these components (Craske & Barlow, 2006). Therefore, the
choice to follow a manual with demonstrated research support is the rationale
for including these components. It is possible that had treatment followed a more
aggressive course in beginning exposure sessions earlier without the above components, treatment could have been briefer without compromising effectiveness.
However, based on the clinical experience with the client, she found these strategies, particularly diaphragmatic breathing, to be extremely helpful in dealing
with anxiety. Regarding mechanisms of action, researchers have indicated that
breathing retraining may work not through reduction of hyperventilation, but
through distraction and/or increasing sense of control (Craske & Barlow, 2008).
Furthermore, several research studies have indicated that progressive muscle
relaxation, whether essential to treatment or not, is helpful in relieving anxiety
symptoms in both patients with panic disorder and generalized anxiety disorder
(Conrad & Roth, 2007).
Utilization and dissemination of empirically supported treatments is a critical
topic in psychotherapy and psychotherapy research. Thus, it is important to discuss
the actual applications of such treatments in everyday clinical settings with a heterogeneous group of clients, as well as different choices that could have been made
during this process. This practice enhances both research and clinical outcomes
and is a valuable step toward increasing the effectiveness of psychotherapy.

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References
Conrad, A., & Roth, W. T. (2007). Muscle relaxation therapy for anxiety disorders: It
works but how? Journal of Anxiety Disorders, 21(3), 243264.
Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and panic: Therapist
guide (4th ed.). New York: Oxford University Press.
Craske, M. G., & Barlow, D. H. (2008). Panic disorder and agoraphobia. In D. Barlow
(Ed.) Clinical handbook of psychological disorders (4th ed., pp. 164). New York: The
Guilford Press.
Greenberg, L. S., & Watson, J. C. (2006). Change process research. In J. Norcross, L.
Beutler, & R. Levant (Eds.) Evidence-based practices in mental health. Washington,
DC: American Psychological Association.
Ruscio, A. M., & Holohan, D. R. (2006). Applying empirically supported treatments to
complex cases: Ethical, empirical, and practical considerations. Clinical Psychology:
Science and Practice, 13(2), 146162.
Stirman, S. W., & DeRubeis, R. J. (2006). Research patients and clinical trials are frequently representative of clinical practice. In J. Norcross, L. Beutler, & R. Levant
(Eds.) Evidence-based practices in mental health. Washington, DC: American
Psychological Association.

{7}

Treatment of Complex PTSD: The Case of a


Torture Survivor
Richard A. Bryant and Angela Nickerson

Hakim is a 36-year-old Iraqi Shiite Muslim who was granted refugee status in
Australia in 2001 after fleeing Iraq in 2000. Hakim was arrested in late 1999 and
was held in an Iraqi prison for a period of four months. Throughout this time he
was tortured on numerous occasions, sometimes daily, for weeks at a time. His
torture experiences included being beaten with cables, burned with cigarettes,
and hung naked by his hands. His toes were broken with wooden bludgeons and
his toenails were removed with pliers. Electric cables were attached to his genitals
and electric shocks administered. He was kept in solitary confi nement, on a starvation diet, for a period of three weeks. Throughout his imprisonment, 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. His wife and four children were regularly visited by the Mukhabarat
(Iraqi secret police) and were harassed and intimidated. Following his release
from prison, Hakim fled Iraq, crossing the border into neighboring Iran. From
there, he traveled by airplane to Malaysia, before enlisting the services of people
smugglers to travel fi rst to Indonesia, then Australia. He endured a dangerous
boat trip across treacherous seas to Australiaa trip renowned for boats sinking
with asylum seekers on board. Upon his arrival in Australia, Hakim was held
in a detention center for seven months. Following his release, he was granted a
three-year temporary protection visa (TPV), which he still held at the time of
treatment. Due to the restriction of rights and access to services associated with
TPV status, Hakim was unable to apply to bring his wife and four children to
Australia. Further, he was ineligible for employment assistance and access to
English classes. At the time of treatment, Hakim was living with his cousins
family in a one-bedroom apartment. He relied on his cousin for food, lodging,
and fi nancial support. Hakim had sporadic telephone contact with his wife and
children.

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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 individuals 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
cousins 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 individuals 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).
Hakims 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. Hakims profound sense of
hopelessness led him to feel highly pessimistic about his future, and he believed

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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 Hakims 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 ggen & 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,

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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 Hakims 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 Hakims treatment. Hakims 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 Hakims 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 Hakims 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 Shiite interpreter at
Hakims request.

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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 6292% (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 Hakims
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

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(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
cousins 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. Hakims 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 Hakims
belief that he could not cope with negative emotions served to exacerbate his fear
and sadness and acted as another form of avoidance.
Hakims 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. Hakims 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 Hakims 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 Hakims 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 Allahs will.
Hakims 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

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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 Hakims 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 Hakims
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 Hakims PTSD symptoms.
There were some concerns regarding how Hakims 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 Hakims 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 Hakims alcohol use may also be exacerbated following exposure therapy. The potential consequences for Hakims 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 Hakims 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

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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 Hakims 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 individuals 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

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Hakims 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 Hakims 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 Hakims 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
Hakims 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.
Hakims 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

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isolation. In treatment, a hierarchy of feared situations was constructed by which


Hakim rated each situation in terms of the distress he expected it to induce. This
ranged from reading the newspaper (expected distress: 3/10) to going to a shopping mall alone (expected distress: 10/10). At the end of each session, Hakim and
the therapist jointly identified a feared situation to which he would expose himself prior to the next session. The activity, the duration, and the absence of safety
behaviors were carefully operationalized. The exposure was then evaluated during the next treatment session. For example, Hakim had been very physically
active prior to his torture experiences in Iraq. His physical injuries had prevented
him from being able to engage in physical exercise for a long time, and further,
he was fearful that the pain associated with the physical activity would trigger
trauma memories and that he would be unable to cope. Following a number of
sessions of imaginal exposure therapy, the distress associated with the memories
had lessened somewhat, and Hakims confidence in his ability to cope with the
distress had increased. It was decided jointly by the therapist and Hakim that
he would begin to go for short walks. Following the session, Hakim went for a
15-minute evening walk around the block with his cousin. At the next session,
Hakim reported that he had felt considerably anxious during the experience, but
that this anxiety decreased relatively quickly and he was able to have a conversation with his cousin. In this way, Hakim was able to reengage in physical exercise,
to learn that he could cope with previously feared situations and trauma memories, and to have social contact with his cousin outside the home. This process
was continued with a number of feared situations on Hakims hierarchy.
Cognitive therapy was considered to be a key aspect of Hakims treatment. As
with many torture survivors, Hakim harbored strong feelings of guilt and shame
following his torture experiences, in which he had been forced to name other people from his religious community, who were then imprisoned and interrogated.
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.g., crying, screaming, begging). It became apparent throughout therapy that
these experiences had fundamentally challenged Hakims self-conceptthat he
no longer felt that he was a person of value. Key related cognitions included I
am a weak person, I should have acted like a man, I have destroyed my familys honor. Hakims experiences had also transgressed his basic beliefs about
humankind and justice in the world. Whereas previously Hakim seemed to have
believed that people were generally good, he now harbored thoughts such as
Most people are evil, Terrible things always happen to good people, while bad
people are rewarded, and I cant trust anyone.
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, not least because the extreme trauma that
survivors have experienced offers much evidence to support negative beliefs
about other people and the world, which can be overwhelming. It was of key
importance when working with Hakim to acknowledge that these cognitions
were completely understandable, considering the experiences he had endured. It

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must be noted that, overall, success in restructuring these thoughts was relatively
limited in Hakims case. In an attempt to assist Hakim in evaluating his behavior
under circumstances of torture more realistically, psychoeducation was provided
about the nature and purpose of torture. 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. Further, the fact that torture was intended to cause emotions such as guilt,
shame, and humiliation provided further incentive for Hakim to challenge these
interpretations, to avoid providing the torturers with the satisfaction of having
achieved their goals.
Difficulties were also encountered in challenging Hakims beliefs about humankind and justice. Throughout the last several years, Hakim had been exposed
to extreme violence and cruelty, which appeared to have shattered underlying
cognitive frameworks about the world and humankind. Attempts were made
throughout the therapeutic process to assist Hakim in gathering evidence about
the world that contradicted his beliefs about malevolence and injustice. For
example, by spending time with family and friends, and slowly meeting new people in Australia, Hakim was able to see that not all people were evil. However, for
the most part, Hakims negative beliefs about humankind and justice remained
intact throughout therapy. 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. The pros and cons of ascribing
to these beliefs were identified and weighed. While Hakim could identify several
pros associated with his cognitions (e.g., not trusting people means that they are
less likely to be able to hurt me, focusing on injustice means I will be better prepared when it happens again), he was also able to see several negative aspects
associated with thinking in this way, particularly in the context of social relations. However, overall, changes in cognitions about the world and other people
were minimal throughout treatment. To assist in the management of ruminating,
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. 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 Allahs eyes; he often stated that he believed
that Allah tested his followers by giving them difficulties, and so by adhering to
the treatment strategies he was directly honoring Allah.
An important component of Hakims treatment focused on the reestablishment of social connections and goal-setting for the future. As previously indicated, Hakim was extremely socially isolated, 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, which led him to avoid other people and abandon previously
held social networks such as the religious community. The way in which Hakims

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social isolation was maintaining his psychological symptoms was discussed in


therapy and, following a reduction in fear of trauma memories and associated
avoidance, plans were made whereby Hakim would be exposed to other people.
For example, a local torture and trauma service held an Iraqi mens cooking
group, which Hakim joined toward the end of therapy. Hakim also continued to
go for walks with his cousin and his cousins friends, which allowed him to engage
in social interaction outside the environment of the apartment. This also served
as behavioral activation to combat Hakims symptoms of depression and lack of
interest in daily activities.
Goal-setting was also implemented as a therapeutic strategy to assist Hakim in
planning for the future. Following the development of the narrative that chronicled Hakims history to date, additional sheets of paper were attached to Hakims
time line to represent his future. Goals for the future were then developed jointly
with Hakim, ranging in magnitude from small (e.g., reading a book) to medium
(e.g., attending English classes) to large (e.g., fi nding employment), drawing on
the strengths and interests that had been identified throughout the time line process. Step-by-step plans were then formulated to assist Hakim in working toward
these goals. The fi nal aspect of Hakims treatment comprised relapse prevention,
in which a plan to continue therapy gains was developed, warning signs were
identified, and strategies for managing recurring symptoms were discussed.
Overall, Hakims treatment was moderately successful. By the end of treatment, Hakims reexperiencing symptoms had decreased markedly, as had the
extent to which he avoided feared internal and external stimuli. Hakim also
reported improved mood, increased interest in daily activities, and greater hope
for the future. However, at the end of treatment, Hakim still met clinical criteria for major depressive disorder. He was still preoccupied with issues of injustice, although he was much better able to manage his anger reactions and other
negative emotional responses. While Hakim was able to recognize that he had
behaved in an entirely understandable way in the torture situations, he still harbored strong feelings of shame and guilt about his behavior, in addition to negative global beliefs about humankind and the world.

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. As previously noted, Hakim had considerable difficulty
with trusting other people, as is common in survivors of torture and severe interpersonal trauma. This was particularly salient when he perceived a person to be
in a position of authority, such as the therapist. Furthermore, Hakims 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. It was
difficult for Hakim to admit to and discuss these feelings, and it was extremely

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important to the therapeutic relationship that these be normalized. The nature


of the torture that Hakim had experienced, including sexual torture (the attaching of electrodes to his genitalia and the administration of electric shocks), had
resulted in deep and lasting feelings of humiliation in Hakim, who was understandably initially reluctant to disclose these experiences to the female therapist
and female interpreter. This further highlights the importance of inquiring as to
the clients preferences in terms of demographics of the interpreter. Hakim had
specifically requested a female interpreter from the same religious group as he;
it is possible that, if the interpreter had been male, he may have not been willing to discuss this experience at all, and one of the most salient traumas would
have remained unexplored. Overall, it was necessary to take the time to build a
trusting therapeutic relationship with Hakim prior to exposure therapy, which he
considered the most distressing component of treatment.

Therapy Problems
What were your strategies for dealing with therapy problems (missed apt, distortions, lack of commitment etc.)?
One factor that presented challenges to the treatment process was Hakims noncompliance with appointment times and between-session tasks. On a number of
occasions, Hakim failed to attend treatment sessions without informing the therapist prior to the session. Further, there were several instances in which Hakim
did not complete assigned between-session tasks, particularly in relation to in
vivo exposure. This was conceptualized by the therapist as a form of avoidance
of talking about distressing subjects or engaging with trauma memories. At the
beginning of the intervention, the importance of committing to the treatment was
emphasized; it was acknowledged that there would be times that Hakim would not
feel like attending treatment sessions, or completing required tasks, and that these
should be discussed openly in therapy. Further, differences between this program
and other types of treatment (e.g., medical, casework) were emphasized, and a
commitment to engage in treatment as much as possible was elicited from Hakim.
This had been established from the beginning of treatment, but it was necessary
to discuss this again at several points throughout the therapy, while normalizing
Hakims desire to avoid treatment, yet reiterating the rationale for the intervention
strategies and reminding him of his initial commitment to therapy.
Ongoing stressors were important aspects that also had the potential to influence the intervention. At the time of treatment, Hakim held a TPV, and thus his
access to services was greatly restricted. He relied on his cousin for fi nancial support, was unable to seek employment, and was not able to sponsor his wife and
children to come to Australia. Understandably, these issues were of considerable
concern to Hakim, and he often considered them to be of greater priority than his
PTSD and other psychological symptoms. These concerns were frequently exacerbated during therapy because of media reports of asylum seekers in detention

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centers in Sydney attempting suicide or rioting in the facilities; this media coverage fueled Hakims anxieties.
At the beginning of treatment, the scope of the psychological service that could
be offered was explained to Hakim, and differences between this treatment and
other services (e.g., medical, casework) were outlined. Contact was made (with his
permission) with the caseworker who was managing Hakims resettlement process. Fifteen minutes were designated at the start of each therapy session to review
Hakims weekoften, 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. 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.

Problems
WHEN THERAPY IS NOT WORKING

What would you have done if therapy wasnt working like you thought it would?
It was possible that Hakim may not have responded to exposure-based therapy
at all. We have had other torture survivors who cannot tolerate the distress of
exposure, or even the anticipation of exposure therapy. In these cases, we attempt
a behavioral experiment in which we explicitly ask the patient to outline his or
her fears and expectations of exposure. We then contract with the patient that he
or she will do a single session of exposure; the goal is to test whether the feared
outcome of doing exposure does actually occur. Patients are reassured that it
will then be their decision to proceed or not with the treatment. In these cases,
we typically conduct a very brief form of the trauma narrative so as to convey
to the patient that they can manage the distress, and then strongly endorse their
strength in managing these memories. Many patients can tolerate exposure if (a)
they are initially given some experience of mastery, (b) they feel that they have the
control to terminate it whenever they wish, and (c) they understand that experiencing some distress is actually an indication of progress.

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, considering Hakims current situation. At the time of
treatment, Hakim held a TPV, which was a temporary visa issued by the Australian
government affording Hakim three years of asylum in Australia. At the end of this
three-year period, Hakim was required to reapply for refugee status; if this was
granted, he would hold another TPV. If the visa application was denied, Hakim
may have been deported to Iraq. Accordingly, Hakim was extremely worried

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about the possibility of being returned to his country of origin, where he believed
he would once again be incarcerated and tortured, and possibly killed, as a result
of fleeing to Australia. As exposure therapy comprises exposure to memories of
past traumatic events, it was likely that the reliving of these memories would trigger thoughts about possible traumatic events that Hakim may endure in the future,
exacerbating fears that Hakim already harbored. This likelihood underscores the
need for the therapist to explain clearly to Hakim the rationale for using exposure,
and that although it would ease the distress of the trauma memories, it would not
necessarily solve his anxieties about his family in Iraq. By emphasizing mastery of
the recall of these memories, rather than the extinction of all anxiety associated
with past traumas and current fears for family, therapy was able to repeatedly
point Hakim in the direction of having a degree of control over his state. In this
context, it is worth noting that several studies undertaken with individuals in insecure circumstances, including refugee camps (Neuner et al., 2008; Neuner et al.,
2004), as well as case studies with asylum seekers (Basoglu, Ekblad, Baarnhielm,
& Livanou, 2004; Neuner et al., 2010), suggest that trauma-focused treatments may
be useful in reducing symptoms of PTSD in these groups when they emphasize the
role of mastery. As Hakim was not at immediate risk of being sent back to Iraq, it
was deemed appropriate to proceed with exposure-based therapy while carefully
monitoring Hakims level of distress. While he initially reported an increase in
thoughts about possible future traumatic events in Iraq, following the completion
of the exposure component of treatment, Hakim evidenced both reduced reexperiencing symptoms related to past trauma and reduced thoughts associated with
possible future negative events.

Common Mistakes
What common mistakes did you work to avoid in treatment?
It is important to note that the implementation of trauma-focused therapy, particularly with survivors of extreme violence, will elicit high levels of distress,
especially in the early stages. One common mistake in clinical practice is to discontinue this treatment component at this point for fear that it is worsening the
individuals symptoms and resulting in retraumatization. As exposure therapy
involves the suspension of many avoidance behaviors and deliberately entertaining the memories, it is to be expected that there will be an initial increase in
PTSD symptoms following early exposure-based sessions. Accordingly, Hakim
reported that, following the fi rst two sessions of imaginal exposure therapy, he
experienced more intrusive memories and nightmares than he had previously.
His instinct was then to reinstate avoidance behaviors, by avoiding thinking
about the trauma or engaging in any activities that might trigger reminders of the
traumatic events. Prior to the commencement of exposure therapy, the therapist
worked with Hakim to ensure that he fully understood the rationale underlying
exposure therapy, and informed him that he could expect to experience increased

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intrusive symptoms following initial exposure therapy sessions and that these
would begin to decrease fairly quickly. Following early exposure sessions, the
therapist reiterated the rationale for treatment and reminded Hakim that this
was an expected (and important) part of the healing process. Hakim was able
to continue with the treatment, and his distress and reexperiencing symptoms
reduced over time.
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. Nearly each week
Hakim would arrive at the session with marked, and usually justified, concerns
about events that were occurring to him or those he knew back in Iraq. In the
interest of attending to the patients immediate needs, it is tempting for clinicians
to focus on these matters, but this can disrupt attention to core strategies that
are needed to initiate recovery from the effects of the trauma. 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, it was decided that time
be allocated to discussing these current mattersbut this was firmly limited in
order to ensure that exposure and cognitive restructuring were achieved. Patients
can quickly learn that by raising other matters, therapy attention can be diverted
away from trauma-related strategies, which can then become an avoidant technique. By explaining to the patient the benefits of dealing with the core problem of PTSD, the therapist can both recognize ongoing issues and give adequate
therapy time to trauma-focused strategies.

Relapse Prevention and Termination


How did you deal with relapse prevention and termination?
Termination was a salient consideration in Hakims case, particularly due to the
strong therapeutic alliance that had been developed across the course of treatment. Hakim was relatively socially isolated in Australia, and had great difficulty
trusting people in positions of authority, 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. When it
became apparent that Hakims PTSD symptoms were improving considerably,
the therapist addressed the issue of termination. Together, Hakim and the therapist agreed that a gradual reduction of session frequency would be the most
beneficial way to end treatment, while allowing Hakim to check in regularly
with the therapist regarding any difficulties that he was experiencing with the
therapeutic skills. Prior to the tapering off of sessions, relapse prevention was
also addressed with Hakim. The trajectory of recovery was discussed (including
the difference between a short-term lapse and a long-term relapse), early warning
signs of increased symptom intensity were jointly developed, and strategies for
managing symptoms learned in treatment were reiterated.

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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. 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, see Nicholl & Thompson, 2004;
Nickerson, et al., 2011; Palic & Elklit, 2010; Schweitzer, Buckley, & Rossi, 2002),
there have been few treatment trials specifically evaluating the efficacy of treatments for torture survivors (Bichescu, Neuner, Schauer, & Elbert, 2007; Carlsson,
Mortensen, & Kastrup, 2005; Halvorsen & Stenmark, 2010; Tol et al., 2009). 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, 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., 2002; Cloitre et al., 2010).
Although some commentators argue that exposure-based therapies are not
appropriate for this form of trauma survivor, we drew on the major change mechanisms identified in treatments that work, and considered how they could be best
applied to assist Hakim. The roles of extinction learning, cognitive restructuring,
emotion regulation, behavioral activation, and enhancing mastery were all core
factors that needed to be enhanced if Hakim was to address his traumatic past.
The manner in which these were delivered required flexibility and therapeutic
creativity. For example, we used a time line that allowed Hakim to contextualize
both his traumatic experiences and positive experiences in his life overall; importantly, 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. Motivational interviewing and cognitive restructuring were also undertaken in the context of his
religious beliefs, such as framing his attempts at tolerating distress and adhering
to treatment as a sign of him honoring Allah.

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. Torture occurs in a specific context, often
in circumstances that include mass violence and the collapse of institutions that
provide an organizing framework for society. The purpose of torture is often
to instill terror in the community at large, in addition to extracting a confession or serving as punishment. However, the circumstances in which torture
occurs, including the factors underlying political or religious violence are specific
to individual settings. Thus, it is of key importance that the therapist has some

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knowledge of the situation from which the client has fled, including the main
actors and the nature of the confl ict.
Further, the culture of the individual who is seeking treatment is likely to
have a significant effect on the manner in which his or her psychological symptoms manifest and the way in which they are interpreted by the client and
members of the clients community. For example, in Hakims culture, a great
emphasis was placed on male strength and fortitude, and thus his behavior
under torture was a great source of shame and guilt to him, as he felt that he
had not acted as a man should. Further, Hakims humiliation at the sexual
torture he had endured was very salient. 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. This may also vary according to the
gender of the client and the therapist. Thus, knowledge of the clients culture
prior to the commencement of therapy is highly advantageous for managing
such issues during treatment.

Conclusion
The case of Hakim highlights that torture survivors, like other victims of prolonged trauma, can benefit from evidence-based therapy. If the clinician adheres
to evidence-informed change mechanisms and adapts them in ways that meet the
specific needs of the patient, while also building on their capacities, it is likely
that treatment gains will be achieved.

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COMMENTARY

Barbara O. Rothbaum

Richard Bryant and Angela Nickerson describe the case of Hakim, a 36-yearold Iraqi Shiite Muslim who fled Iraq in 2000 and was granted refugee status in
Australia in 2001. They describe multiple presenting problems including PTSD,
depression, alcohol abuse (although this was never formally diagnosed in the
case presentation), anger, physical pain caused by injuries sustained during the
torture, social isolation, and familial stressors. This is a heart-wrenching case,
punctuated by multiple injustices and misfortunes. Hakims PTSD is likely exacerbated by his psychosocial circumstances, including his separation from his wife
and four children, probable fears about their safety, restrictions of visa status and
resulting dependence on his cousin, and stressful living conditions with limited
resources. These circumstances would be highly stressful for any mammal.
Their approach to treating Hakim and describing that treatment are theory-driven and empirically driven, especially by what is known about torture
survivors. Within this context, they used a case conceptualization approach:
forming hypotheses about the nature of his difficulties and designing treatment
to address these difficulties. They assessed for PTSD as a primary presenting
complaint both due to his history and the referral question. They also assessed
for depression, which was important, as his depression and inactivity and hopelessness seemed to account for significant dysfunction and often co-occur with
PTSD (Foa, Hembree, & Rothbaum, 2007). 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. They were sensitive to
cultural factors, such as ensuring that the assessment was undertaken in a manner that avoided an interrogatory style of questioning, even in the therapy room
setting, using a large, bright room with windows to differentiate it from his cell.
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, but that
also served as behavioral activation exercises, getting him more physically and
socially active and engaged.
The therapist was able to point out that Hakims behavior served as a self-fulfi lling prophecy to help educate him that he needed to change his behavior. This
is an excellent example of using cognitive as well as exposure principles in the
treatment of PTSD (Foa, Hembree, & Rothbaum, 2007). It is very commendable

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that the therapist operationalized safety behaviors and instructed the patient in
in vivo exposures, especially without safety behaviors. It is also commendable
that the therapist used the patients religious beliefs in therapy. In this case, they
were directly relevant, as he was abducted and tortured because of his religious
beliefs. I have found that religion often plays a role in the maintenance of PTSD
symptoms. Sometimes patients are angry with God for what happened; sometimes they lose faith in God (e.g., How could God have allowed this to happen?). Sometimes, the event strengthens faith (e.g., God spared me for a reason
so it is up to me to discover what it is.). But I have often seen therapists shy away
from religious beliefs due to their discomfort. In this case, it was very fruitful, as
his difficulties were reframed as serving Allah. The authors describe a very nice
intervention, essentially setting up a behavioral experiment when patients are
too fearful about their reactions to exposure, although it was not necessary with
this case.
Others have found that victims of political torture have displayed less PTSD
than would be expected (Basoglu et al., 1997; Basoglu et al., 1994), 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. However, in Hakims case, he
was tortured for his religious beliefs. He also continues to fear for his wife and
children, and likely feels inadequate that he cannot protect them. His self-statements sound reminiscent of patients who have experienced what have been called
moral injuries, and therefore these would need to be addressed.
In general, the behavioral aspects of this case were exceptionally well conceptualized and administered. Although it may be a tautology because the patient
did not improve as much in his cognitions (guilt, blame), it seems that maybe
some other cognitive behavioral techniques also could have been applied. I have
become convinced lately that the majority of the empirically supported cognitive behavioral treatments for PTSD (e.g., CPT, PE) really have more in common
than they have differences; they just emphasize different aspects or mechanisms.
I think it is imperative for trauma survivors to be able to think about their experience, their behavior, and their future differently than before treatment. I hypothesize that to be able to modify these thoughts, they need to go thereto be
able to expose themselves in detail to what happened. Often, merely by doing
that repeatedly, the error of their beliefs becomes apparent. By avoiding thinking about what happened, they cannot hope to modify these beliefs. Exposure
therapies emphasize the importance of exposure, 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 patients beliefs are often challenged and certain realizations are made explicit. Cognitive processing therapy
(CPT) emphasizes cognitive restructuring and stuck points (Resick & Schnicke,
1993). Eye movement desensitization and reprocessing (EMDR) emphasizes the
saccadic eye movements during exposure (Shapiro, 1995). All of these approaches
aim to have patients change their dysfunctional beliefs about the traumatic event
and modify their behavior, and all involve going there to some extentvisiting
the aspects of the trauma to evaluate these fears and beliefs. The authors could

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have used any of these empirically supported treatments for Hakim but made
their decisions based on his case conceptualization.
When patients feel particularly guilty and responsible for the outcomes of the
traumatic event(s), I fi nd it is often useful to help distribute responsibility for the
outcomes. In this case, Hakim did in fact disclose the names of religious friends
and colleagues to the torturers. I agree with the approach of the authors, using
exposure and cognitive techniques to help the patient understand the context
and the realities of the situation, that is, torture is designed to elicit information and these emotional responses. But I also think that Hakim needs to fi nd
some acceptance of himself for his actions, and for this, more Socratic questioning may be useful, listing all those responsible for his situation and ascribing
responsibility to them all. It also may be useful to continue the questioning to
ask him what he thought would have happened had he not disclosed names. It
may be that the torture would have escalated, resulting in more physical impairment, and possibly even his death. If he feels helpless now in regard to taking
care of his family, at least there is still hope, whereas if he were more physically
disabled or murdered, there would be no hope of helping them. It also might be
useful to ask the patient how he needs to think about it differently, for example,
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,
especially when using exposure therapy for PTSD patients: (1) The patient gets
distressed; the therapist gets distressed; and they terminate exposure. What this
teaches the patient is that he was right to avoid the memory and all reminders,
and that if he becomes too distressed, he cannot tolerate it. By holding their feet
to the fi re, patients learn that they can tolerate the distress, it lessens as exposure continues, nothing terrible happens, the therapist has faith in their ability
to handle it, the therapist will not collude in their avoidance, and then, that they
can trust the therapist. (2) The therapist fails to identify safety behaviors during
in vivo exposures. It is important to figure out the perfect exposure and what
exactly you are exposing the patient to. For example, some of our veterans from
the wars in Iraq and Afghanistan with PTSD often ride public transportation for
an exposure. For some, listening to music might be a distraction from the exposure, but for others, listening to music would mean that they could not monitor
the environment, and that would be a better exposure. (3) The therapist misses
the core fear. In the case of Hakim, it seems that his reaction to some of the torture was the crux of the issue. As the authors mention, if they had missed that,
they would have missed an important component of his treatment. The fact that
he did not improve as much as hoped on some dimensions makes me wonder if
he still withheld some important information. (4) The therapist attends to red
herrings presented at the beginning of the session and doesnt get the agenda
covered. Patients with PTSD often have chaotic lives and can be upset. I will
conceptualize it for patients that if I think their PTSD is primary, the best thing I
can do for them is deliver the treatment that I think will have the most impact for
them, and it is my job to keep us focused on the goal. I will acknowledge the issue

Treatment of Complex PTSD: The Case of a Torture Survivor

193

and its impact, and if there is time, I will address these issues at the end of the
session. The therapist must be sensitive, yet fi rm. It is heartening that the authors
did not fall prey to any of these common mistakes.
As a critique, the authors emphasize Hakims inability to tolerate distress and
use this as justification for providing him with a stepped approach ( la Cloitre et
al., 2010), starting with a skills-building phase before exposure techniques were
implicated. However, it is not clear if this was necessary or served to delay his treatment and possibly made his treatment more difficult, as it was conducted with an
interpreter. Only PTSD and depression seem to have been formally diagnosed.
The authors do not mention if the patient likely met criteria for borderline personality disorder, in which case the teaching of distress tolerance skills has been
empirically supported (Linehan, 1993). I am not exactly sure what distinguishes
this case as complex PTSD. That termed is used often lately (e.g., Linehan,
1993), and it is not always clear what makes a case complex, as PTSD is not a simple
disorder in and of itself. Other more minor comments include the points that no
pre/post assessment results were reported, no follow-up was reported, no details
were provided on whether the imaginal exposures were tape-recorded and the
patient was instructed to listen to them as homework. In summary, Drs. Bryant
and Nickerson present a lovely case steeped in both empirically supported treatment and individual case conceptualization. They hardly mention the complication that an interpreter causes and describe an ecologically valid and culturally
sensitive approach. Oftentimes, we clinical researchers are criticized that such an
approach is not possible, and the authors have presented a case in which it was. It
appeared to be a complicated case, yet it became simpler by taking it apart. The
therapist was fi rm in not allowing the patient to avoid and maintain his dysfunctional patterns. She demonstrated deliberate human kindness and caring, both
in his new culture, and by a person in a position of authority, and with an interpreter who was of the same culture and religion. It is impressive that the patient
had a choice of demographic and social characteristics of his interpreter. 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. His good fortune and the beneficence of others, including the Australian
society, sets up a stark contrast with the torturers.

References
Basoglu, M., Mineka, S., Paker, M., Aker, T., Livanou, M., & Gok, S. (1997). Psychological
preparedness for trauma as a protective factor in survivors of torture. Psychological
Medicine, 27(6), 14211433.
Basoglu, M., Paker, M., Paker, O., Ozmen, E., Marks, I., Incesu, C., . . . Sarimurat, N.
(1994). Psychological effects of torture: A comparison of tortured with nontortured
political activists in Turkey. American Journal of Psychiatry, 151(1), 7681.
Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson,
C. L., . . . Petkova, E. (2010). Treatment for PTSD related to childhood abuse: A

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randomized controlled trial. American Journal of Psychiatry, 167(8), 915924. doi:


appi.ajp.2010.09081247 [pii] 10.1176/appi.ajp.2010.09081247
Foa, E. B., Hembree, E. & Rothbaum, B. O. (2007). Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences, therapist guide. New York:
Oxford University Press.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press.
Resick, P. A., & Schnicke, M. (1993). Cognitive processing therapy for rape victims: A
treatment manual. Interpersonal Violence: The Practice Series. London: Sage
Publications.
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford.

RESPONSE

Richard A. Bryant and Angela Nickerson

Barbara Rothbaums commentary on Hakims treatment provides a valuable perspective on this case, highlighting a variety of conceptual, empirical, and clinical
issues. While we are unable to comment on all of these important points due to
space limitations, we will address some of the most pertinent below.
Dr. Rothbaum commented that the self-statements used by Hakim may be
seen as sequelae of moral injuries; indeed, the moral injury concept provides a useful framework within which to conceptualize the effects of gross
human rights violations on Hakims worldview. The concept of moral injury,
recently employed to explain the impact of war experiences that transgress
combatants deeply held moral beliefs, expectations, and values (Litz et al.,
2009), 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. Torture is an experience characterized by human degradation and violation, and has great potential to shatter fundamental beliefs of
victims about themselves, the world, and humanity, using methods designed
to infl ict maximum psychological harm (McIvor & Turner, 1995; Silove, 1996).
The cognitive effects of such experiences may manifest in (often realistically)
negative assumptions and expectations about humankind and the world in
general. The potential for traumatic events to dramatically alter beliefs and
cognitions is well-documented through cognitive models of PTSD (e.g., Ehlers
& Clark, 2000). Furthermore, posttraumatic changes to ones worldview, for
example fundamental challenges to beliefs that assist the individual to make
sense of the world, such as justice (Lerner, 1980) and human benevolence
(Janoff-Bulman, 1992), may substantially influence the way in which the individual navigates the external world and relates to others. This can be seen in
the case of Hakim, who evidenced generally negative beliefs and expectations
about the surrounding world and others (people are generally bad and cant
be trusted, there is no justice in the world), manifesting in negative behaviors such as social withdrawal and alcohol abuse, which lent further cognitive
evidence in support of these beliefs.
Dr. Rothbaum also made the excellent suggestion that techniques focusing
on the distribution of responsibility may have been useful with Hakim. In other
cases of torture and refugee trauma, we have found that patients often benefit

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from discussions concerning trauma-related responsibility and control. As Dr.


Rothbaum suggested, it may have been constructive, in the current case, to
explore responsibility regarding the consequences of torture, including Hakims
actions, thoughts, and feelings. Assisting Hakim to realize that the torturers
were responsible for these outcomes may have alleviated some of the guilt he felt.
Further, this process may have helped Hakim to recognize that these outcomes
represent some of the core goals of torture, which is designed to infl ict psychological damage. This may then have provided further motivation for Hakim to
alleviate feelings such as shame, humiliation, and guilt, to prevent the torturers
from succeeding in their purpose.
Dr. Rothbaum posited that Hakim may have been withholding certain information throughout the course of therapy, precluding the full processing of the
events to which he had been exposed. This may indeed be the case; Hakims
shame and guilt, combined with his suspicion of others, rendered the therapeutic relationship of key importance in this case. Although the relationship was
an important aspect of treatment (and likely therapeutic in itself), it is certainly
possible that there were elements of his experiences that Hakim was unwilling to
disclose, which may have prevented Hakim from going there and hampered the
effectiveness of the treatment strategies.
Dr. Rothbaum also raises the issue of complex PTSD, 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. There are
solid justifications for both approaches. Many torture survivors lack emotionregulation skills, which is the defi ning feature of complex PTSD (Bryant, 2010).
Although we do not have the benefit of evidence concerning the defi ning clinical
features of torture-related PTSD and its treatment, 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. As
augmented exposure therapy that prepares the patient with emotion-regulation
skills has been shown to be effective, it seems a logical approach (Cloitre et al.,
2010). However, Dr. Rothbaum makes a cogent point in suggesting that we may
have delayed the most effective component of treatment. It is common for PTSD
patients to express concern about exposure therapy. However, as soon as they
have mastered their first experience of it, there is enormous relief and significant
motivation to proceed. This fi rst session of exposure is often a powerful behavioral experiment that can quickly teach patients, even one with emotion dysregulation problems, that they can master the memories. This knowledge provides
disconfirming information of many of patients fears and doubts about recovery.
The problem at the outset of therapy is that one never knows how a person will
respond to treatment. In the case of Hakim, we were very aware of other torture survivors who have not responded positively to their initial exposure session and have balked at proceeding. We should also add that we have proceeded
with exposure with such patients and they have enjoyed rapid symptom relief.
Perhaps we should have commenced exposure sooner, but even in hindsight it
is sometimes difficult to know. The most important point is that it is critical to

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.

References
Bryant, R. A. (2010). The complexity of complex PTSD. American Journal of Psychiatry,
167(8), 879881.
Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L.,
et al. (2010). Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry, 167(8), 915924.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
Behaviour Research and Therapy, 38(4), 319345.
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma.
New York: Free Press.
McIvor, R. J., & Turner, S. W. (1995). Assessment and treatment approaches for survivors of torture. British Journal of Psychiatry, 166, 705711.
Lerner, M. J. (1980). The belief in a just world. New York: Plenum.
Litz , B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., et al. (2009). Moral
injury and mora repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695706.
Silove, D. (1996). Torture and refugee trauma: Implications for nosology and treatment
of posttraumatic syndromes. International Review of Psychiatry, 2, 211232.

{8}

Treatment of Social Anxiety Disorder: A Case


Complicated by Panic Disorder
Milena Stoyanova and Debra A. Hope

Social anxiety disorder, the excessive fear of being humiliated and embarrassed
in social situations (American Psychiatric Association, 2000), is the fourth most
common psychiatric disorder after major depressive disorder, alcohol abuse, and
specific phobia. Recent prevalence rates suggest that 12.1% of people are affected
by social anxiety disorder at some point in their lives (Kessler et al., 2005). A
twelve-month prevalence rate of 6.8% demonstrates that social anxiety disorder is
the second most prevalent disorder after specific phobia (Kessler, Chiu, Demler,
& Walters, 2005). Social anxiety has an early age of onset (Schneier, Johnson,
Hornig, Liebowitz, & Weissman, 1992), with reliable diagnoses being reported as
early as 6 years of age (Bgels et al., 2010). 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., 1994) and rate their
quality of life significantly lower than individuals without social anxiety (Safren,
Heimberg, Brown, & Holle, 1997).

Epidemiological Considerations
Despite the high prevalence rate and life impairments, most people with social
anxiety disorder do not seek treatment unless they have developed another
disorder (Schneier et al., 1992). In fact, approximately 6390% of people with
social anxiety disorder meet criteria for at least one other comorbid diagnosis (Ruscio, Brown, Chiu, Sareen, Stein, & Kessler, 2008), and social anxiety
disorder appears to have an earlier age of onset relative to the comorbid conditions (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996). The most common comorbid diagnoses among individuals with social anxiety disorder in
community samples are other anxiety disorders, followed by mood disorders

Treatment of Social Anxiety Disorder

199

and alcohol or substance use disorders (Magee et al., 1996; Ruscio et al., 2008;
Schneier et al., 1992).
The efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder has been well established. Specifically, cognitive behavioral group therapy
(CBGT; Heimberg & Becker, 2002) was more effective than an educational supportive treatment (Heimberg et al., 1990; Heimberg et al., 1998) and pill placebo (Heimberg et al, 1998). The treatment gains were maintained at a five-year
follow-up (Heimberg, Mueller, Holt, Hope, & Liebowitz, 1992). Furthermore, the
effectiveness of CBT in a group format for the treatment of social anxiety disorder has also been demonstrated in community clinics (McEvoy, 2007) and private
practice (Gaston, Abbott, Rapee, & Neary, 2006). The more recently developed
individual version of the treatment used with the present case (Hope, Heimberg,
Juster, & Turk, 2000; Hope, Heimberg, & Turk, 2010a) was more efficacious than
a wait-list control group, with treatment gains being maintained at three-month
follow-up (Ledley et al., 2009). Effect sizes for within-session change in the active
treatment across 6 of 7 key measures were large (median Cohens d = 2.52). Across
studies, typically 7580% of participants receiving the cognitive behavioral treatment are classified as responders, meaning that they have made clinically significant change, and, in many cases, their symptoms have reduced to a subclinical
level.
While the effectiveness of CBT interventions for the treatment of social anxiety has been well established, factors such as comorbid conditions that may complicate treatment have been less discussed in the literature. While the presence
of a comorbid mood disorder has been associated with greater interference and
symptom presentation at pre- and post-treatment, the rate of improvement did
not differ based on presence or absence of comorbid condition (Erwin, Heimberg,
Juster, & Mindlin, 2002; Turner, Beidel, Wolff, Spaulding, & Jacob, 1996). In a
different study, the presence of depression resulted in lower treatment response
(Chambless, Tran, & Glass, 1997). Less is known about how a comorbid anxiety
disorder impacts treatment response. However, a more complex symptom presentation may pose challenges for the clinician. This chapter will illustrate the use
of specific treatment strategies, guided by a case formulation approach, to aid in
resolving treatment challenges for social anxiety.

The Case of Andy


Andy was a 38-year-old European American man who initially contacted a university training clinic for problems with anger. (Identifying details, including the
name, have been modified in order to protect the clients anonymity. Written consent was obtained from the client for inclusion of his de-identified information in
this chapter.) Specifically, he reported being easily angered by others and stated
that his feelings of anger exacerbated when he was around large groups of people.
Andy also described experiencing physical symptoms, such as pounding heart,

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sweating, and hyperventilating, when around people. Given Andys anxiety symptoms and concerns about being around people, he was referred to the Anxiety
Disorders Clinic for a more thorough evaluation of his anxiety presentation.
During the second meeting, the Anxiety Disorders Interview Schedule for
DSM-IV (ADIS-IV; Brown, Di Nardo & Barlow, 1994) was administered. He
described experiencing anxiety in social situations since he was a child and stated
that the anxiety intensified when he was in high school, when he noticed becoming more concerned about doing or saying something that might embarrass
him in front of his peers. He identified a number of social situations as anxietyprovoking, such as parties, participating at meetings, speaking with unfamiliar
people, dating situations, talking to authority figures, initiating and maintaining conversations, and being assertive. 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, which has
been reported in up to 84% of individuals with social anxiety disorder (Barlow
et al., 1985). Aside from the expected panic attacks, Andy described experiencing unexpected panic attacks in various situations, such as while driving, at the
grocery store, at restaurants, at the airport, and when home alone. He described
that the unexpected panic attacks had been more recent, beginning within the
previous year. 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 other physical symptoms, such
as sweating, shortness of breath, stomach distress, lightheadedness, feelings of
unreality, and fears of fainting, dying, or doing something uncontrolled. Andy
described experiencing four to five full panic attacks and 12 to 15 limited symptom attacks (12 symptoms only) in the previous month. Andy reported being
extremely concerned about his panic attacks and worried about future ones. He
engaged in distracting activities if a panic felt imminent. He stated that he would
avoid leaving his house, going to restaurants, going out with his friends, or just
being out in public. As a result, Andy described an increase in arguments with
his girlfriend, which resulted in her moving out and ultimately prompted him to
seek treatment. Although anger was the initial complaint, it was not seen as the
primary problem, as Andys outbursts and irritability resulted from his intense
fears of embarrassing himself in front of others. Thus, the underlying concern
was related to his social fears, whereas anger was the response elicited when a
situation was perceived as threatening but unavoidable. In addition to social anxiety and panic disorder, Andy described depressive symptoms consistent with
dysthymic disorder, described further below.

Assessment Strategy
The initial assessment was completed over two sessions. During his initial
visit, Andy described anger problems as his primary reason for seeking therapy. The ADIS-IV was completed to further assess his anxiety concerns and

Treatment of Social Anxiety Disorder

201

was also administered at post-treatment. The ADIS-IV is a semi-structured


clinician-administered interview that assesses for anxiety disorders, mood disorders, substance use, and somatoform disorders. In addition to providing a
DSM-IV-TR (American Psychiatric Association, 2000) diagnostic impression,
the interviewer gives a Clinician Severity Rating (CSR) for each diagnosis to
illustrate the degree of impairment and distress resulting from each disorder,
using a scale that ranges from 0 (none) to 8 (very severe), where a score of 4 or
above meets the clinical threshold for a DSM-IV diagnosis. The ADIS-IV was
conducted at pre- and post-treatment by a trained clinician who did not act as
the therapist.
To further assess Andys social anxiety, panic symptoms, and depressed
mood, he completed the Brief Fear of Negative Evaluation (BFNE; Leary, 1983),
the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986),
and the Beck Depression Inventory II (BDI-II, Beck, Steer, & Brown, 1996) prior
to beginning treatment and at every other session. The BFNE is a 12-item questionnaire that assesses for fear of negative evaluation. 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. The measure, adapted from the original
Fear of Negative Evaluation (FNE; Watson & Friend, 1969), has demonstrated
good test-retest reliability and strong internal consistency (Leary, 1983). The
Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986) is a
16-item questionnaire that measures discomfort with anxiety relevant symptoms,
more specifically assessing for beliefs about somatic or danger consequences of
anxiety. ASI total scores range from 0 to 64, with higher scores indicating greater
anxiety sensitivity. The ASI has demonstrated excellent psychometric properties,
including good test-retest reliability (Reiss, Silverman, & Weems, 2001) and high
internal consistency (Peterson & Reiss, 1992). The BDI-II is a 21-item self-report
questionnaire designed to measure level of depressed mood over the past two
weeks, and it has demonstrated excellent internal consistency and test-retest reliability (Beck et al., 1996; Sprinkle et al., 2002). Scores range from 0 to 63, with
higher scores indicating more severe depressive symptoms.
To monitor Andys progress, he completed the Social Anxiety Session Change
Index (SASCI; Hayes, Miller, Hope, Heimberg, & Juster, 2008) weekly, starting
with session 8. This is a four-item measure assessing a respondents subjective
improvement related to social situations since the beginning of therapy, using
a scale from 1 (much less) to 4 (not different) to 7 (much more). A total score is
obtained by summing all items, with scores ranging from 4 to 28. A score of 16
indicates no change since starting treatment, scores of 4 to 15 suggest improvement in symptoms, and scores of 17 to 28 indicate deterioration. Additionally, 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, PaSCI). The same scoring is applied as the SASCI. Additionally,
a Fear and Avoidance Hierarchy, a list of feared situations, was constructed
(Barlow & Craske, 2006; Hope et al., 2010a). After generating a list of 10 feared
situations, a rating was provided for each situation to indicate level of anxiety

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Anxiety Disorders

and degree of avoidance, using a scale ranging from 0 (no anxiety; no avoidance)
to 8 (extreme anxiety; complete avoidance). Anxiety and avoidance ratings were
collected during the tenth and last treatment session.
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, indicating that his symptoms related to
social interactions and the experiencing of unexpected panic attacks were both
markedly disturbing and disabling. As noted above, cued panics in social situations are a common presentation of social anxiety disorder (Barlow et al., 1985).
The presence of clinically significant uncued panics is less common, occurring in
only 3% of individuals with social anxiety disorder in one recent study (Brown,
Campbell, Lehman, Grisham, & Mancill, 2001; but see also Sanderson, DiNardo,
Rapee, & Barlow, 1990). His initial BFNE score of 46 indicated that he experienced a moderately elevated fear of negative evaluation, which was consistent
with his self-report but somewhat lower than expected. Andys score of 37 on the
ASI also confi rmed his apprehension about panic-like symptoms, which was consistent with his reported fear of experiencing physical sensations. Additionally, a
diagnosis of dysthymic disorder with a CSR of 4 was assigned, which was consistent with his BDI-II score of 25.

Case Formulation
In general, Andy demonstrated hypersensitive reactions to external and internal
experiences. He has been nervous in social settings since he was a child, 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. Andy became
increasingly concerned about other students opinions of him and often avoided
speaking in class or interacting with others between class periods. The frequent
avoidance of social interactions maintained Andys belief that he would not be
able to initiate and sustain friendships because of how he acted around people.
He often avoided social gatherings due to anxiety, which ultimately affected his
relationship with his girlfriend. Soon after she moved in with him, they began
having more frequent arguments related to their social life and Andys avoidance
of social events. Although they had been dating for several years, Andy never
told his girlfriend about the anxiety because he was worried that she might think
badly of him and leave him. The stress of the relationship appeared to have exacerbated his anxiety. While his fear of negative evaluation intensified due to their
frequent arguments, Andy also became apprehensive about physical sensations
in his body. He began to associate bodily symptoms such as lightheadedness,
dizziness, detached feelings, and chest pain with fainting, having a heart attack,
and doing something uncontrolled. Andy tried to manage his worries about the
physical implications of panic attacks by avoiding various activities that induced
sensations similar to panic, leading to further arguments with his girlfriend. The
avoidance and distracting behaviors further contributed to his belief that the

Treatment of Social Anxiety Disorder

203

sensations were dangerous and harmful to his body. Furthermore, he began to


isolate himself from close friends and family and frequently experienced days
when he was depressed. Andys symptoms worsened after his girlfriend decided
to move out (a few months before he initiated treatment), and he reported having
more frequent panic attacks. Although they were still romantically involved at the
beginning of treatment, he attributed the separation to his anxiety, which further
reinforced his view of inadequacy and intensified his fears of negative evaluation.
The worsening of his symptoms prompted him to ultimately seek treatment.

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. As
the anxiety disorders share common elements such as fear/panic, anticipatory
anxiety, and avoidance (Barlow, 2002; Barlow, Allen, & Choate, 2004; Craske,
1999, 2003), the general principles of CBT (psychoeducation, cognitive restructuring, and exposure) were tailored to specific symptoms as outlined in Managing
Social Anxiety: A Cognitive Behavioral Therapy Approach (Hope, Heimberg, &
Turk, 2010a) and Mastery of Your Anxiety and Panic (MAP-4; Barlow & Craske,
2006) treatment protocols.
Given the complexity of the case, the first three sessions were spent on developing a shared rationale for treatment and agreement on the tasks and goals of
therapy, both of which are associated with positive treatment outcomes (Frank &
Frank 1993, Horvath, Del Re, Flckiger, & Symonds, 2011). 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, which revealed significant anxiety difficulties. A functional analysis was used to determine the relationship between his
anxiety and recent anger difficulties. As we discussed the history of his symptom
presentation and examined the chain of events leading up to specific times when
he felt angry, 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. Once it was agreed that the anxiety was triggering his
irritability (e.g., insisting on leaving social events, leaving a restaurant after noticing physical sensations), the next step was to determine which anxiety disorder to
address in treatment fi rst. 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. However, Andy displayed some difficulties differentiating between panic and social anxiety. Since most of his panic attacks
occurred in social settings, he had difficulty identifying whether the threat was
social evaluation or the physical sensations. Finally, rather than trying to identify
which treatment to do fi rst, the therapist focused on identifying which symptoms
were more distressing to Andy on a daily basis, consistent with the guidelines outlined by the American Psychological Association (APA Presidential Taskforce on

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Anxiety Disorders

Evidence-Based Practice, 2006) emphasizing the importance of including clients


preferences in treatment planning. While Andys ultimate goal for treatment was
to reduce his social anxiety, he fi rst wanted to focus on panic symptoms and the
associated worry due to the discomfort they produced. This was consistent with
the overall treatment plan, 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. Thus, therapist and client decided to do a
hybrid of both social anxiety and panic disorder treatment, while initially focusing on reducing the frequency of and worry associated with panic attacks.
Sessions 4 through 7 focused on psychoeducation about the nature and
treatment of anxiety disorders to lay the groundwork for the overall treatment. Education about the three components of anxiety physical sensations,
thoughts, and behaviors was presented, and examples from both social and
panic-related situations were discussed. Self-monitoring of symptoms was
introduced, and the difference between subjective and objective monitoring
was described. Given that Andy experienced both anxiety related to social situations and unexpected panic attacks, 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). Andy practiced completing a Panic Attack Record form (see Barlow & Craske, 2006, for
template) in session based on a recent panic attack in which he described the
triggers, whether the attack was expected or unexpected, rated maximum fear
using a 010 scale, checked off symptoms that he experienced, and documented
thoughts and behaviors. A second monitoring form was introduced to allow
Andy to track his anxiety about social interactions, worry about panic attacks,
and depressed mood.
Though Andy stated that he had completed his homework after it was introduced, at the next session he indicated that he had forgotten to bring the paperwork. The therapist and client discussed his anxiety and panic attacks without
having his monitoring forms present; he was to continue monitoring and to bring
forms for both weeks to the following session. When he again arrived without the
paperwork, the therapist decided to explore reasons underlying the homework
noncompliance.

Strategies for Handling Homework Noncompliance


The therapist used the procedures from the treatment to address the problem
of homework noncompliance. First, the therapist returned to the homework
rationale, emphasizing the importance of monitoring to not only understand
his experiences but also to help monitor treatment progress. Potential barriers
were explored, and during this discussion Andy revealed that the reason for not
having the monitoring form was because of heightened anxiety. Using the three
components system of anxiety, 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

Treatment of Social Anxiety Disorder

205

will laugh at me), his physical sensations (heart racing, sweating, shortness of
breath), and behaviors (not completing the homework). Problem solving was used
to improve homework compliance, 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. While this strategy facilitated avoidance to some degree, the goal at this
point was to get the homework completed; the avoidance piece would be discussed later in treatment when Andy was ready to make it an exposure. This
discussion further confirmed that social anxiety was affecting treatment and thus
needed to be addressed as well.

Continuing the Course of Treatment


After addressing the homework problems, the normal course of treatment was
resumed. Information about the physiology underlying social anxiety and panic
was presented. The main concepts conveyed were (1) a biopsychosocial model
of the etiology of anxiety (focusing on biological, psychological, and stressful
life experiences as they affect the development of social anxiety and panic), (2)
the protective function of panic and anxiety, and (3) myths and mistaken beliefs
about panic symptoms. While he described always being a shy person, he recalled
several specific incidents in high school (e.g., being criticized for his spelling and
other students laughing while he read in class) that contributed to the expression
of his social anxiety. The fight-or-flight system was discussed in more detail to
illustrate the protective function of panic. In comparison to most clients, there
was more extensive focus on the fight component, as it was relevant to Andys
experience (i.e., his anger). 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. At
the end of the educational component, the therapist reviewed the rationale behind
the main components of treatmentcognitive restructuring, breathing retraining, homework, and exposures (in session and outside session)to address social
anxiety and panic attacks.
During session 8, breathing retraining (see Barlow & Craske, 2006, for details)
was introduced as a coping skill that teaches clients how to breathe through
their diaphragm rather than chest muscle. The session began with a discussion
about breathing and the changes in breathing that were experienced during panic
attacks. Given that overbreathing appeared to contribute to his panic attacks,
learning to regulate his breathing was the next step. Education about normal
breathing, the effects that anxiety and fear have on breathing, and the physiology
related to hyperventilation were presented. 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.g., playing in a dart tournament, walking into a restaurant alone), rather than use it to eliminate uncomfortable sensations and anxiety.
The diaphragmatic breathing was formally practiced in session, and Andy was
instructed to practice the skill daily on his own.

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Anxiety Disorders

Session 9 and 10 focused on establishing a Fear and Avoidance Hierarchy.


Andy and his therapist collaboratively generated a list of anxiety-provoking situations incorporating both situations relevant to social anxiety and panic. Several
dimensions were considered while generating the list to allow for a more accurate
depiction of his anxiety and avoidance levels (e.g., alone or with others, number
of people, proximity to an exit). Andy rated his anxiety and avoidance for each
situation. Table 8.1 provides Andys Fear and Avoidance Hierarchy.
Session 11 focused on a discussion of unhelpful ways of dealing with anxiety,
such as relying on safety signals or distractions. Andy identified his safety signals
(objects that he believed provided safety) as being with familiar people, having
access to his own car, and carrying a cell phone at all times. He identified several
safety behaviors and distractions, including waiting for friends before walking
into a restaurant, only speaking to familiar people, acting busy when he is at the
store so that he does not have to interact with the store staff, and looking for the
exit sign when he entered a store. 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. 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. During our discussion of safety
TABLE 8.1.

Andys Fear and Avoidance Hierarchy


Situation

1
2

5
6
7
8
9
10

YMCA, health club


Play darts while
others watch
(being the center of
attention)
Going to a party
alone, meeting
friends there
Crowded place
(grocery store,
mall, sports game,
concert)
Karaoke (just going)
Restaurant with 6 or
more friends
Going to a party
with friends
Movie theater, sitting
in the middle row
Initiate a
conversation
Going to store and
asking questions

Anxiety

Avoidance

Pre-treatment

Post-treatment

Pre-treatment
8

Post-treatment
2

Note. Ratings are 0 to 8, with higher ratings indicating greater anxiety and avoidance. Since Andy was initially
introduced to the panic monitoring forms that utilize a 08 point scale, the same scale was kept for the hierarchy even
though the Hope et al. (2010a) manual uses a 0100 point scale.

Treatment of Social Anxiety Disorder

207

signals and distracting behaviors, it became apparent that the diaphragmatic


breathing had become a safety signal (Taylor, 2001) because Andy was using it
to escape feared physical sensations that he continued to believe were harmful if
allowed to continue. Given that the breathing retraining was counterproductive
and may not be essential for a good treatment outcome (Schmidt et al., 2000),
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.
Sessions 12 though 17 focused on teaching Andy cognitive restructuring skills.
First, the relationship between thoughts, feelings, and behaviors was reviewed
with an emphasis on how thoughts affect emotions. Automatic thoughts, or
irrational thoughts about the self, others, and the future (Beck, Rush, Shaw,
& Emery, 1979), were fi rst identified. Andys automatic thoughts were explored
using the downward arrow technique (Beck, 1995), which was described as the
further exploration of ones thoughts by identifying what he was afraid of in a
given situation, followed by further careful questioning of what he pictured happening as a result, and so on. Andys automatic thoughts had themes typical of
both social anxiety and panic: They will think Im a fool and I will have a
heart attack. After assisting Andy in identifying his automatic thoughts, the
therapist and client proceeded to recognizing logical errors in his thinking and
challenging his automatic thoughts. 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). Examples of disputing questions
included, Do I know for certain that ____ will happen? or What evidence do
I have that (the opposite) is true? or Whats 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.
Though he had a good understanding of how his thoughts affect his emotions,
Andy seemed to struggle with identifying automatic thoughts and often reported
them in the form of a question. For example, while recalling recently having dinner with friends, 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
Im an idiot) to aid in the cognitive restructuring process. The most common
thinking errors for Andy were mind reading, catastrophizing, fortune-telling,
and disqualifying the positive. Using the disputing questions to challenge his
automatic thoughts, Andy was able to generate rational responses for social anxiety (Even if Im nervous, 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. After trying to resolve the problem without success, 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, as recommended in Hope and colleagues (2010b). Andys
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.

208

Anxiety Disorders

At the beginning of session 17, Andy appeared more relaxed and described using
the self-statements generated during the previous session to play darts with two
friends, a previously avoided anxiety-provoking situation. Andy was praised for
initiating exposures on his own, and his experience was further explored, focusing
on his anxiety in anticipation of, during, and toward the end of the game. Overall,
he described that while his anxiety was elevated at the beginning, he noticed a
gradual reduction during the game and even described enjoying the experience.
Andy was eager to continue outside-session exposures and described several social
events during the upcoming holiday season. Additionally, the therapist and client
reviewed the role of avoidance in maintaining his anxiety and discussed how to
effectively manage his panic and anxiety, focusing on using the exposures to help
Andy learn that his feared catastrophic outcome was not likely to occur.
Session 18 focused on reviewing Andys anxiety and exposure practices over
the holiday season. Overall, he reported engaging in less avoidance than he had in
the past, and his anxiety had been manageable. He indicated that he had enjoyed
the holiday season and described several planned and spontaneous social activities that he had attended. He seemed encouraged by his experience and planned
to continue outside-session exposures on his own and review them in session.
Sessions 19 through 23 focused on exposure. Given that Andy had already initiated in vivo exposures on his own, his outside-session practices were reviewed
at the beginning of each session and modifications were made as needed. In session 19, Andy described an upcoming darts tournament, which he had previously avoided due to panic and social anxiety. He described his passion for the
game but stated that he had only been able to play darts alone or with his closest
friends, who offered some safety. After a discussion in session, he decided to
officially register for the tournament as he saw it as a good opportunity to practice facing his fears. Given Andys reliance of avoidance behaviors in the past,
he was praised for his efforts to face his fears and overcome his social anxiety.
The purpose of exposure was reviewed, and the goal of learning something new
(that what he was most worried about was not likely to happen) was reiterated.
An emphasis was placed on tolerating the anxiety and fear, while not focusing on
immediate symptom reduction, which would be achieved with repeated practice.
Some time was devoted to preparing for his upcoming tournament and possible barriers, and unhelpful ways of dealing with anxiety (avoidance, distraction)
were discussed. Prior to leaving session, Andy appeared comfortable and ready
to face this very challenging in vivo exposure.
During the next session (session 20), Andy reviewed his experiences during the
darts tournament. He described feeling elevated anxiety in anticipation of the
event and admitted to considering escaping. However, he described generating
a self-statement (Even if we lose, its not the end of the world), which helped
him stay in the situation. 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. After Andy described his successful exposure, we discussed what he learned from the experience, focusing on managing
the intensity of anxiety and staying in the situation. He described that he had

Treatment of Social Anxiety Disorder

209

accomplished his goal of playing in the tournament (rather than being focused on
winning), and how it was going to help him overcome his fear of negative evaluation. Although Andys team won the fi rst round in the tournament, the therapist
and client discussed the possibility of losing, as this is a realistic possibility in any
competition. The conversation focused on what the goal of the exposure was (stay
in the situation despite fear and anxiety), and what it would mean if they lost.
Andy concluded that losing is part of life and stated that it would not be that bad.
At this point, 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, while in-session focus shifted to panic
sensations.
Although he described worrying less about panic attacks (because he knew
that they were not harmful), it also appeared that the physical symptoms continued to cause him discomfort and distress. Thus, 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, 2006). 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, interceptive exposures to the symptoms of dizziness and lightheadedness were identified
(staring at self in mirror, spinning while standing, and straw breathing) and were first
practiced in session and followed by daily homework practices. Andy reported that
the interoceptive exposures were helpful and reduced his fears of physical symptoms in casual conversations and other social events. Andy missed the following
five weeks of treatment, claiming a busy work schedule. To keep him engaged in
treatment, the therapist encouraged him to continue practicing his exposures and
to continue monitoring during the weekly brief phone conversations.

Strategies for Handling Poor Attendance and Partial Relapse


Sessions 24 through 27 focused on exploring the recent break from therapy and
restarting treatment. Since his self-report questionnaires revealed that his social
anxiety, worry about panic, and depression were elevated relative to the previous session (see Figures 8.2, 8.3, and 8.4), 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. The therapist followed the recommended steps proposed by Persons
(2008) to address non-adherence behavior: assess, conceptualize, and intervene.
After gentle questioning (without being judgmental or blaming), Andy revealed
that he was experiencing several stressors (relationship problems, fi ling taxes,
heavier work load, and fi nancial difficulties), which might have affected completion of self-monitoring and exposure homework. The therapist presented this
return in symptoms as an opportunity to examine how avoidance affected Andys
anxiety and depression over the last five weeks. Also, this incident was used to
illustrate the difference in anxiety levels when Andy was actively working on his

210

Anxiety Disorders

anxiety versus when he began to avoid more. Andy was encouraged to resume his
exposure practices, which he reported doing right away. His symptoms began to
improve immediately, which further motivated Andy to continue exposure. The
therapist also used this opportunity to stress the importance of continuing exposures even after treatment is terminated.
Attention was then turned to his recent stressors and how they may have exacerbated his anxiety. Although initially resistant, Andy soon revealed experiencing more confl icts with his girlfriend. It was decided to spend session 28 focusing
solely on his relationship difficulties. A functional assessment of the arguments
revealed that Andys decrease in social anxiety symptoms and increased comfort with being more assertive were changing the relationship. Andy had come
to believe that his girlfriend was in the relationship primarily for fi nancial support. 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. He asked her to leave and ended the relationship. Later, he
expressed feelings of guilt and described an increase in depressive symptoms.
His experiences were normalized given the recent break-up, and his goals for the
relationship were reviewed. During a telephone conversation scheduled between
sessions, he stated that he felt happier and described spending more time with his
friends and attending more social events, which he found helpful.

Relapse Prevention and Termination


Session 29 focused on a review of Andys progress, challenges encountered,
and skills learned in treatment. Andy reported that his mood had continued to
improve since the recent break-up. Key take-home points from treatment were
discussed, followed by relapse prevention. Andy re-rated items on his Fear and
Avoidance Hierarchy (see Table 8.1). His scores demonstrated a decrease in his
ratings. Overall, Andy reported that facing his fears, whether they concerned
social situations or physical sensations, helped him to learn that they were not
dangerous. Furthermore, he described feeling happier than when he started
treatment. Andy indicated that the treatment helped him become more assertive
to deal with the unhealthy relationship and to feel more comfortable around his
friends. He had already begun to expand his social circle and participate in more
social events. Andy and his therapist developed a plan for the next few months,
focusing on continued exposure to maintain gains made in treatment.

Session-by-Session and Post-Treatment Assessment


Andys session-by-session scores on the SASCI and PaSCI are displayed in
Figure 8.1. His scores demonstrated that his social anxiety and panic symptoms
started to improve after session 8, with a relapse at session 28, as described above.
His change score improved by the last session.

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 8.1. 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, which is a decrease
from his initial CSR of 6; a CSR of 3 for his social anxiety disorder, which was
also initially a 6. A CSR of 3 was assigned to his dysthymic disorder (decrease of 1
point), demonstrating that depressive symptoms were no longer clinically severe.
Overall, the CSRs at post-treatment demonstrated that Andys symptoms associated with panic, social anxiety, and depression had dropped to a subclinical level
(a CSR of a 3 or less). This change on the CSR would have classified Andy as a
responder in one of the treatment outcome studies described earlier.
Also, self-report measures administered post-treatment demonstrated
improvement in symptom presentation. Specifically, Andys fear of physical sensations associated with anxiety as measured by the ASI decline over time to 12
(from an initial score of 37), indicating that he was significantly less concerned
about his physical sensations (see Figure 8.2). His scores on the BFNE dropped
to 37 (from an initial pre-treatment score of 46), which indicated that his fear of
negative evaluation declined during treatment but remained slightly above the
reported mean scores for controls (Weeks et al., 2005). A more comprehensive
40

ASI Score (0-64)

35
30
25
20
15
10
5
0

FIGURE 8.2.

11

13

15

17

19

21

23

Bi-weekly Scores on the Anxiety Sensitivity Index (ASI)

25

27

29 post

212

Anxiety Disorders
48

BFNE Score (12-60)

44
40
36
32
28
24
20
pre
FIGURE 8.3.

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 8.3. Andys depressive symptoms on the BDI-II reduced from a moderate range (25) to a mild range (18) at the
end of treatment (see Figure 8.4).
Overall, these results indicate that Andy responded well to treatment. His ratings from week to week were more variable than often seen, perhaps because of
ongoing stressors, particularly from the relationship. His symptoms related to
social anxiety and panic decreased substantially after treatment, especially on
the Fear and Avoidance Hierarchy, ADIS-IV, and ASI. Additionally, symptoms
of depression, which were not directly targeted in treatment, also decreased.

Importance of Principles from Basic Science for This Case


This case required a thorough understanding of the nature of social anxiety and
panic, as well as the core principles underlying exposure-based interventions. The

35

BDI Score (0-63)

30
25
20
15
10
5
0
pre
FIGURE 8.4.

11

13

15 17
Session

19

22

24

26

27

Bi-weekly Scores on the Beck Depression Inventory-II (BDI-II)

29

post

Treatment of Social Anxiety Disorder

213

complexity of the case prevented the application of a single standardized protocol. The case formulation was guided by knowledge of the psychopathology of
social anxiety and its often earlier onset relative to 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. Recognizing Andys
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.

Nonspecific Factors in Therapy


Psychotherapy has often been considered the sum of nonspecific and specific
factors. Nonspecific factors often refers to common factors across all psychotherapies, such as the therapeutic alliance and having a shared rationale and
treatment goals (e.g., Frank & Frank, 1993; Horvath et al., 2011). In this case,
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. Given the clients initial conceptualization of his problem as anger,
it took some time to arrive at a shared rationale. 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.

Alternative Strategies to Consider


Although not a prototypical course of cognitive behavioral treatment for anxiety, treatment in this case relied on established procedures for treating social
anxiety and panic. If these strategies had not been successful, three primary
alternate strategies would have been considered. One possibility would have
been a referral for pharmacotherapy for the social anxiety and panic. There is
an established body of literature of the efficacy of certain medications for both
disorders (see Blanco et al., 2003; van Apeldoorn et al., 2008). Medication could
have been added to the current treatment or considered on its own. Andy was
not on medication when he came to the clinic and preferred not to take it, but he
may have felt differently if treatment had been less successful. Another possible
treatment approach would have been to return to the original conceptualization
of the problem as one of anger, as fi rst put forth by the client, and to treat the
anger directly. Finally, in the background of treatment was the clients ongoing
problematic relationship with his girlfriend. This relationship was the focus of
treatment in session 28 but was in the background throughout, and confl ict with
her was an important impetus for Andy to seek treatment initially. It is possible
that a treatment approach that focused on his interpersonal relationships might
have been a viable alternative.

214

Anxiety Disorders

Ethical Considerations
The primary ethical consideration in this case was to provide the client with true
informed consent for treatment. As noted above, the therapist and client initially
had different conceptualizations of the case. Therefore, Andys true informed
consent required that he understand why the therapist believed that anxiety, not
anger, was the primary problem and why the recommended treatment was a reasonable approach. Cognitive behavioral treatments require clients to engage in
difficult therapeutic exposures, which can be quite uncomfortable. Clients must
understand why they will be asked to face these challenges and must freely choose
to undertake them.

Avoiding Common Mistakes


Even while drawing from two primary CBT protocols, 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.
First, the therapist took time to arrive at a shared rationale before launching into
treatment procedures. Second, the therapist addressed homework noncompliance (not bringing in paperwork) early in treatment and accepted a good shortterm solution, even though it involved some avoidance behavior. Third, breathing
retraining was dropped when it became a safety behavior. Fourth, no in-session
exposures for social anxiety were conducted. About the time that the therapist
planned to initiate in-session exposures, the client began self-initiating in vivo
exposures, which were quite successful. Therefore, the therapist and client agreed
to use session time to plan and debrief in vivo exposures. For this particular client, appropriate in vivo opportunities were readily available, which is not always
the case for more socially isolated clients. Fifth, formal cognitive restructuring
was curtailed, as the client was not able to use it effectively on his own. In-session
discussion of exposures utilized cognitive techniques (e.g., therapist guiding
Andy to notice that predicted feared outcomes had not occurred) without the use
of formal terminology. Finally, the clients life stressors, particularly the romantic relationship that was in the background of much of therapy, became a focus of
sessions at key times, particularly in session 28.

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, and such individuals make up most participants in treatment outcomes
studies (Hays, 1995). Cases described elsewhere describe adaptations to treatment for social anxiety with recent immigrants (Weiss, Singh & Hope, 2011), a
man coming to understand his sexual orientation as gay (Walsh & Hope, 2010),

Treatment of Social Anxiety Disorder

215

an African American woman (Fink, Turner, & Beidel, 1996), and an interdisciplinary intervention for a woman with associated speech difficulties (Laguna,
Healey, & Hope, 1998).

The Art of Therapy, Conclusions, and Clinical Implications


The present case demonstrated the effectiveness of CBT for the treatment of
social anxiety complicated by recent onset of uncued panic. 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, the more recent uncued panic
attacks were quite distressing to the client. Typically in our clinic, we treat such
cases sequentially, focusing first on a protocol for one disorder and then moving to a second if needed. In this case, given the clients difficulties differentiating between his experiences, perhaps due in part to the overlap in symptoms
across social anxiety and panic (panic attacks, anticipatory anxiety, worry, and
avoidance behavior), we focused on a more integrated approach, using cognitive behavioral techniques from established protocols for both social anxiety and
panic disorder, based on a case formulation.
The so-called art of therapy involved the therapists creative development and application of a case formulation, grounded in the empirical literature. Guiding the collection of self-monitoring data to develop the rationale
and attending carefully to the clients application of the treatment procedures
produced an ideographic treatment experience with a sound scientific basis that
resulted in a positive outcome.
Our approach was successful at reducing symptoms related to social anxiety
and panic, as well as depressive symptoms, although the latter were not directly
targeted in treatment. 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, Abel,
& Newman, 1995; Brown, Anthony, & Barlow, 1995; Norton, Hayes, & Hope,
2004), providing support for the similarities among the anxiety and mood
disorders.
In addition to high comorbidity among the anxiety and mood disorders
(Brown et al., 2001; Kessler et al., 1998), there is considerable evidence that the
anxiety disorders share a core vulnerability, namely negative affectivitythe
sensitivity to experience negative emotions even without the presence of aversive
events or stressors (Watson & Clark, 1984). 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, 2005; Erickson,
Janeck, & Tallman, 2007) and for a broader range of emotional problems
anxiety, depression, somatoform, and dissociative disorders (Unified Protocol;
see Barlow et al., 2004). Thus, it appears that using a transdiagnostic treatment
approach may become more common in the near future.

216

Anxiety Disorders

This case further demonstrated the importance of continuing to engage the


client in treatment, which may at times be complicated by homework noncompliance or continued avoidance behavior. Problematic behavior that may interfere with treatment should be addressed right away using non-confrontational
approaches. Although we have illustrated an idiographic approach to treatment,
the decision-making process was always based on science, using evidence-based
approaches combined with ongoing assessment of adherence and progress.

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COMMENTARY

Richard M. McFall

Stoyanova and Hope report their year-long, 29-session treatment experience with
Andy, a 38-year-old European American client suffering from social anxiety disorder, complicated by the comorbid symptoms of panic disorder and poor anger
management. The authors present a chronological account of their intervention
and conclude that their treatment was successful, citing summary data from several measures in support of this claim. They attribute their successful outcome
to their reliance on a creative combination of empirically established treatment
procedures (described as CBT), principles from basic science (described only
vaguely), and nonspecific factors (not well defi ned).
Reading this case, I kept wondering what, if anything, we might take away to
help us treat similar cases more cost-effectively in the future. 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, so many choice
points and potential decisionstypically governed mostly by inexplicable clinical intuitionsthat well never really know why the therapists did what they did,
or what would have happened if the therapists had made different choices. Once
the outcome is known, of course, we always can offer post hoc explanations, as
though we actually know what caused what; in fact, however, there invariably are
so many competing and confl icting forces at play (for example, this clients failure
to provide homework data, or his unstable romantic relationship, to name just
two) that interpreting cause and effect is impossible in a single case.
As skeptical scientists, we must ask: What might have happened if the therapists had taken a different fork in the road at each juncture? Well never know,
of course, which is exactly the problem with case studies. Indeed, skeptics might
go further and ask, Should we even consider Andys outcome to be a good one,
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, which isnt available in this case, such questions are moot.
Nevertheless, these questions stand as silent cautions against the common temptation to draw inferences with confidence.
Indeed, when I look at Andys outcome data, I am not ready to concede that
Andy benefited significantly from the treatment, or that his treatment moved him
into the normal range of functioning. His data are characterized by considerable

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instability, with dramatic ups and downs all across the 29 sessions. To their credit,
the therapists persevered until Andy seemed better; however, if the therapists
were determined to continue treatment until Andy seemed better, and stopped
only when he did, 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. That is, perhaps the therapists simply stopped their treatment precisely
at a point when the client was doing better than usual, in the course of his random ups and downs, thereby unintentionally capitalizing on the instability of his
symptoms and incorrectly overestimating the treatments impact. This cant be
ruled out.
The main take-away message for me, in case studies such as this, is that one
needs to be highly skeptical of any strong inferences. Moreover, the therapists
should be the fi rst to critique their own interpretations and decisionsfrom the
beginning to the end of their intervention. The case study then becomes a source
of hypotheses, not a basis for interpretation.
In the beginning, for example, Stoyanova and Hope decided that Andys problem was that he demonstrated hypersensitive reactions to external and internal experiences. Does this formulation tell us anything that we didnt already
know about Andy, 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, the therapists decided to spend the first three
sessions developing a shared rationale for treatment and agreement on the tasks
and goals of therapy. Might the treatment outcome have been more dramatic
and rapid, for instance, if the therapists had moved quickly to use exposure
procedures?
Several early sessions were devoted to analyzing, interpreting, and dealing
with the clients failure to provide homework data. 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 Meehls papers about the limited circumstances under which
it is best to use clinical judgment, rather than sticking to a formula.)
Essentially, all case studies are fi lled with such tantalizing conundrums. We
dont really know, in this particular case, why the therapists chose the path they
did, at each point; what other options were considered; or what would have happened if they had chosen differently. These uncertainties limit the information
value of this report, and all such case studies, in my view. Reading a case study
is like reading a novel. It is interesting, because it deals with the human condition; but it is a one-of-a-kind experience, as viewed through the eyes of a narrator
with a unique perspective on the events. Though interesting, it contributes little
to our scientific understanding of psychological phenomena. Science la Karl
Popperis a process of homing in on truth by systematically eliminating plausible rival hypotheses. Case studies dont offer much help of this kind.

RESPONSE

Debra A. Hope and Milena Stoyanova

McFall raises a number of points in his comments on our chapter describing the
treatment of Andy. 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; (2) it is not known how successful treatment would have been had the
therapist made different choices, including about how quickly to start and stop
the intervention or how to handle homework noncompliance; and (3) the formulation offered little additional information. We will respond to each in turn.
First, we agree with McFall that one cannot draw scientific conclusions from
case studies, but they can be useful for raising hypotheses. This function largely
applies to new areas of scientific inquiry, and as such does not describe treatment for social anxiety disorder, which has been extensively researched since
it was called neglected more than 25 years ago (Liebowitz, Gorman, Fyer, &
Klein, 1985). 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. Stepping outside the confi nes of a clinical trial, we sought to describe how
a highly expert clinician with a strong scientific orientation applies the research
literature to a relatively complex, multi-problem case. The primary purpose was
not to demonstrate the efficacy of the treatment, ruling out competing hypotheses for change, but rather to illustrate a scientific approach to clinical work that
draws on research on basic psychopathology, nonspecific treatment factors, and
clinical trials.
The nature of the case report requires that the clinician report, as best he
or she can, why decisions were made at various points. It is impossible to know
if the best choices were made or even whether these were the most important
decisions to report. What is important is that, whenever possible, the scientific
literaturenot a discredited theory, conventional clinical wisdom, or therapists
instinctwas used to guide the decision. As noted by McFall, we could have
attempted to start exposure right away, rather than spending three sessions seeking a shared understanding of the problem. However, in this particular case, we
had no time constraints, as one has in a time-limited clinical trial, and having a
shared rationale and goals accounts for a significant portion of variance across
numerous studies (e.g., Horvath, Del Re, Flckiger, & Symonds, 2011). Exposure-

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based therapies are challenging for clients, and strategies that enhance motivation, including that the treatment is appropriate, can have a positive impact on
treatment engagement (e.g., Buckner & Schmidt, 2009). Similarly, 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.g., Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010).
This is especially true when it appears that the noncompliance is simply a sample
of the problem for which the client sought treatment. Certainly when psychopathology interferes with treatment, addressing the interference itself is consistent
with treatment goals.
Finally, McFall questioned the added value of the case formulation that the client demonstrated hypersensitive reactions to external and internal experiences.
The client did not articulate this formulation on his own, and another therapist
might have offered a formulation relating the presenting problems primarily to
the dysfunctional romantic relationship, or to childhood maternal bonding experiences, for example. 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. We would argue that such a strategy is not modal strategy employed in clinical practice.

References
Buckner, J. D., & Schmidt, N. B. (2009). A randomized pilot study of motivation enhancement therapy to increase utilization of cognitivebehavioral therapy for social anxiety. Behaviour Research and Therapy, 47, 710715. doi:10.1016/j.brat.2009.04.009
Horvath, A. O., Del Re, A. C., Flckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 916. doi:10.1037/a0022186
Liebowitz , M. R., Gorman, J. M., Fyer, A. J., & Klein, D. F. (1985). Social phobia: Review
of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729736.
Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The
relationship between homework compliance and therapy outcomes: An updated
meta-analysis. Cognitive Therapy and Research, 34, 429438. doi:10.1007/s10608-0109297-z

{9}

Psychological Treatment of ObsessiveCompulsive Disorder: The Case of Cassie


Jonathan S. Abramowitz and Brittain Mahaffey

At her initial evaluation, Cassie (note: a pseudonym is used here, and some facts
have been altered in this chapter to protect client confidentiality), a 29-year-old
Caucasian female in her first year as a graduate student, described the presence
of unwelcome, yet recurrent and distressing, intrusive thoughts. These included
unwanted impulses to yell curse words during classes, when at the library, or
other quiet places such as plays or other performances. When in the presence
of knives, she also experienced unwanted impulses to stab others. Although
Cassie was highly deliberate, conscientious, and had never committed any violent behavior, she worried that these intrusions meant that a dark part of her
wanted to do such things, and that it was a matter of time before she lost control.
She ruminated, for example, about how she could simply yell a curse word with
relatively little effort.
Cassie described constantly trying to dismiss these unwanted thoughts from
her mind. She had mental rituals involving the repetition of positive phrases (e.g.,
Im good. Im good. Im good) to undo the bad thoughts. She also analyzed
the possible meanings of her thoughts over and over, trying to reassure herself
that they were senseless. When not anxious, Cassie could recognize that these
thoughts were meaningless and were probably not going to lead to any inappropriate behaviors; that is, she had good insight into the senselessness of her obsessivecompulsive disorder (OCD) symptoms. During anxious episodes, however, this
recognition would elude her and she would resort to using rituals to calm herself.

Case History
BRIEF PERSONAL HISTORY

Cassie was raised in an upper-middle-class community in the northeastern


United States. She considered herself religious with strong moral values. Her

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relationship with her parents and younger sister had always been very close. She
reported outstanding school achievement and participation in numerous extracurricular activities. Cassie graduated from a Christian college and was pursuing
a graduate degree in exercise physiology. She also reported satisfaction with her
social life and denied previous abuse of alcohol or drugs.
Cassie reported that her obsessional problems began six years prior, when
she heard a story on the news about a boy who had killed his parents in their
sleep. Shortly thereafter, Cassie began having thoughts about doing this to
her parents. Finding these thoughts troubling, she tried dismissing them, only
to fi nd that she could not do so. Her inability to rid herself of these thoughts
then led her to fear that, 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. She reported no desire to commit harm or do any of the things
featured in her unwanted thoughts. Cassie began avoiding situations that triggered her intrusive thoughts, which gradually began to interfere with her daily
functioning.

Psychological Principles Relevant to Understanding Cassies OCD


Symptoms
Three research-supported psychological principles are relevant to understanding Cassies OCD symptoms: (a) Becks (1976) cognitive specifi city hypothesis,
(b) Wegners ironic process model of thought suppression, and (c) Mowrer
(1958) and Dollard and Millers (1950) avoidance learning model, which is
based on the principles of classical and operant conditioning. Becks cognitive
specificity model of emotion posits that psychological distress is the result of
dysfunctional thoughts and beliefs about situations and experiences. Research
with individuals with OCD (e.g., Rachman & Hodgson, 1980) demonstrates
that obsessional anxiety results from catastrophic beliefs about normally
occurring, senseless intrusive thoughts. 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.
The vast majority of the people, however, experience the same sorts of intrusions from time to time, yet do not misinterpret them as harmful or significant
(e.g., Rachman & de Silva, 1978).
The distress that results from the misinterpretation of intrusive thoughts leads
to urges to control or reduce this distress, fi rst and foremost by using thought
suppression or distraction techniques (Purdon, 2004). Yet attempts at thought
control usually fail because searching for the to-be-suppressed target thought
ironically results in having such thoughts (Wegner, Schneider, Carter, & Wright,
1987). Moreover, the person also becomes hypersensitive to (constantly vigilant
for signs of) the to-be-suppressed thought, leading to more thought occurrences.
When the very intrusion that the person is trying to dismiss becomes more frequent, it leads to a secondary misappraisal (e.g., Even when I try to get rid of

Psychological Treatment of Obsessive-Compulsive Disorder

227

this thought, it keeps coming back. This must mean I am truly a bad person; e.g.,
Tolin, Abramowitz, Hamlin, Foa, Synodi, 2002).
Mental rituals, phobic avoidance, and other neutralizing strategies, such as
analyzing the meaning of unwanted thoughts or trying to seek assurance that
they are unimportant, sometimes results in a temporary decrease in obsessional
anxiety (de Silva, Shafran, & Menzies, 2003). Yet even if brief, this outcome negatively reinforces the mental rituals, causing them to become habitual (Dollard &
Miller, 1950; Mowrer, 1958). Moreover, when catastrophic consequences do not
occur, and anxiety is (temporarily) relieved, the individual mistakenly attributes
this to the rituals and avoidance (i.e., a near miss), further consolidating this as
a strategy for dealing with upsetting intrusive thoughts. Rituals and avoidance
behavior also prevent the person from learning that intrusive thoughts are not
dangerous or significant in the first place. This ensures that the mistaken beliefs
described above remain intact, completing a self-perpetuating vicious cycle
(Rachman, 1997, 1998).

Assessment Strategy
While there is merit to diagnostic assessment to rule in or out possible differential
diagnoses, it is the idiographic cognitive-behavioral functional assessment that
contributes most to the successful treatment of obsessive-compulsive symptoms.
This assessment, which aims to elucidate the factors that maintain the obsessional problem, is guided by the theoretical principles described in the previous section and informs the treatment plan (as discussed later in this chapter).
It begins with the collection of detailed information about the form and content
of the intrusive obsessional thoughts themselves. Next, the external triggers
situations and stimuli associated with unwanted intrusionsare assessed. Cassie
reported that using knives (particularly when others are nearby), reading or hearing about violent crimes, and being in quiet places such as libraries and performances provoked obsessional thoughts.
The patients beliefs and interpretations of the intrusive thoughts are also
assessed. These cognitions form the basis for the obsessional anxiety and the
urge to avoid and perform rituals. They can be measured using psychometrically
validated self-report instruments designed for this purpose, such as the Obsessive
Beliefs Questionnaire and Interpretation of Intrusions Inventory (Obsessive
Compulsive Cognitions Working Group, 2005), as well as through clinical interviewing. For example, Cassie reported being concerned that she would impulsively act on her unwanted thoughts. She also believed that it was immoral even
to think about harming others.
Assessment also involves collecting detailed information about the persons
responses to the obsessional thoughts and anxiety. What does he or she do to
try to control the intrusions, reduce anxiety, and prevent feared disastrous consequences? It is important to understand the patients beliefs about how these
behaviors work. For example, Cassie explained that the ritual of mentally

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repeating Im good helped to dismiss unwanted thoughts and to keep her reassured that she wasnt the kind of person who would do such terrible things. She
believed that if she didnt perform this ritual, it increased her chances of losing
control and acting out.
To this end, lists of avoided circumstances are developed (e.g., knives, going
to church, plays, libraries, and other quiet places, in Cassies case). 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. The details of these behaviors, and their function, should be carefully
assessed. Cassie described several types of rituals. First, she reported testing
herself when she had urges to yell curse words in public places. This involved
sub-vocally whispering the curse word to make sure she could resist the urge
to say it louder. Cassie also described mentally reasoning about the possibility that she would commit the acts she obsessed about. Cassie said that on
some occasions she spent up to three hours engaged in this type of analyzing.
Indeed, such rituals have no natural terminus, and thus often lead to further
obsessions and distress. Finally, Cassie reported often trying to rid her mind of
her unwanted thoughts, using distraction or simply telling herself not to think
about it.
Assessment also included a clinical interview and self-report measure of OCD
symptoms (the Dimensional Obsessive-Compulsive Scale [DOCS]; Abramowitz
et al., 2010) and depression (Beck Depression Inventory [BDI]; Beck et al., 1996),
since Cassie had reported difficulties with mood and anhedonia. For the purposes of monitoring progress through the course of treatment, Cassies 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).
Avoidance: The degree to which Cassie was avoiding situations associated
with unpleasant intrusive thoughts was rated from 0 (never avoids) to 8 (invariably avoids).
Neutralizing (rituals): Daily time spent performing neutralizing behaviors
(e.g., rationalizing the meaning of unpleasant thoughts) was assessed on a scale
from 0 (none) to 8 (30 times or over 2 hours per day).

Case Formulation
Cassies difficulties were conceptualized using the evidence-based psychological principles described earlier (also see Abramowitz, 2006; Rachman, 1997;
Salkovskis, 1996). Assessment data were used to test hypotheses about the validity
of this conceptualization. Cassies intrusive thoughts, however unpleasant, were
considered normal stimuli that occur in 90% of the population (Rachman & de
Silva, 1978). Her anxiety associated with such thoughts was considered a result of
misinterpretations of the thoughts presence and significance (e.g., the thoughts

Psychological Treatment of Obsessive-Compulsive Disorder

229

mean I am an evil person). Cassies thought suppression attempts and avoidance of situations that triggered the intrusive thoughts were viewed as methods to
prevent or control intrusions and related distress. Rituals and neutralizing were
conceptualized as methods of escape from intrusive thoughts already in progress,
as well as methods to prevent feared disastrous consequences (e.g., I will lose
control and yell curse words). Yet because thought suppression, avoidance, and
rituals were sometimes effective in temporarily reducing distress, Cassie resorted
to them whenever intrusions occurred, and they became compulsive. In the
long term, these strategies prevented Cassie from discovering that her intrusive
thoughts were senseless and were not foreboding of inappropriate behavior. Her
anxiety-driven attempts to suppress the obsessions merely led to greater attention to the thoughts, preoccupation, and increased thought frequency. Thus,
Cassies subjective resistance to the thoughts was actually serving to maintain
her obsessional problem.
Cassie reported depressive symptoms, yet assessment suggested that these
symptoms were secondary to her obsessional complaints. That is, she was
depressed about the obsessional intrusions and distress, and the toll they had
taken on her functioning. Cassie had not experienced depressive symptoms until
her OCD symptoms began to intensify over the last few years.

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, and that resistance to such thoughts is not only unnecessary, but maladaptive (e.g., Rachman, 2003). 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, indeed,
mistaken. 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, (b) cognitive therapy targeting mistaken beliefs
about intrusive thoughts, (c) exposure, and (d) response prevention (for a review,
see Abramowitz, 2006).
Since Cassies OCD symptoms are conceptualized as a fear of intrusive
thoughts, the primary component of treatment is exposure therapy. Foa and
Kozak (1986) suggested that the reduction of pathological fear requires confrontation with the feared stimulus, along with presentation of corrective information. In this case, corrective information consists of learning that disastrous
consequences do not occur. Repeated and prolonged exposure to situations that
evoke intrusive thoughts (i.e., situational or in vivo exposure), as well as to the
thoughts themselves (i.e., imaginal exposure), will help Cassie to discover that
such thoughts are not threatening. Exposure is thought to weaken the misappraisal of such intrusions and thereby to weaken fear responses to such thoughts

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(Foa & Kozak, 1986). Response prevention, another necessary ingredient, entails
refraining from rituals and neutralizing, since these behaviors would foil exposure and would ensure that dysfunctional beliefs about intrusive thoughts remain
intact, as discussed previously.
Accordingly, following her initial intake assessment, Cassies treatment began
with two information-gathering/psychoeducational sessions during which rapport was built, the functional assessment was conducted, and Cassies therapist
introduced the cognitive behavioral model of OCD. The treatment techniques
were also explained, and Cassie was given a rationale for their use. During the
second session, a hierarchy of situations and intrusive thoughts for exposure was
collaboratively developed. Next, cognitive therapy was introduced in session 3,
during which Cassie learned techniques for logically disputing and challenging
her mistaken beliefs about the significance and meaning of intrusive thoughts
(e.g., Wilhelm & Steketee, 2006). Following the introduction of cognitive techniques, Cassie and the therapist considered alternative ways of thinking about
her obsessional thoughts that were consistent with the conceptualization of OCD
symptoms. Graded exposure (moving up the hierarchy at the patients pace) and
response prevention were begun during session 5. During sessions 5 through 15,
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.e., habituation). She also practiced gradually confronting
situations that she had been avoiding because they triggered her obsessions (e.g.,
church services, libraries, knives). Repeated and prolonged (e.g., until anxiety
was reduced by at least 50%) exposure was both practiced in-session and assigned
between sessions. For example, Cassie was instructed to go out to dinner with
a friend and to hold her knife while thinking about stabbing her acquaintance.
Rituals and neutralizing strategies identified in the functional assessment were
also targeted for either immediate or gradual fading. Treatment lasted 16 sessions
(session 16 focused on relapse prevention) and was conducted weekly.

Nonspecific Factors in Treatment


Nonspecific factors play a role in all forms of treatment for psychological problems, cognitive-behavioral therapy for OCD being no exception. Although there
is scientific evidence that the specific techniques of exposure, response prevention, and cognitive therapy are efficacious over and above nonspecific variables
(e.g., Lindsay, Crino, & Andrews, 1997), it is important to take advantage of these
factors since they are inexorably linked to psychological therapies. For example,
Cassie sought out treatment from a recognized expert in the treatment of OCD.
She therefore likely had expectations of improving merely because her provider
was an expert. The therapist acknowledged that these nonspecific factors were
likely present, coming across as confident and conveying strong beliefs about the
efficacy of the intervention. The therapeutic relationship was also an important
emphasis. The therapist recognized that a strong working alliance was necessary

Psychological Treatment of Obsessive-Compulsive Disorder

231

to cultivate the trusting relationship that Cassie would require before she would
engage in exposure therapy techniques, which are anxiety-provoking.

Potential Treatment Obstacles


Two potential obstacles arose during Cassies treatment. 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. Because of her strict religious
upbringing, Cassie felt that it was morally wrong to purposely think thoughts
about harming others. She believed that this was in direct violation of the Bible,
and she worried that such sinful behavior would offend God. Cassie decided that
she would need to speak with her pastor to gain his permission before trying
exposure. Consequently, the therapist asked Cassie whether she frequently sought
reassurance from her pastorwhich Cassie indicated that she did. Many strictly
religious individuals with OCD engage in such behavior, 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. It turned out that, on numerous occasions, Cassie had already asked her pastor about her intrusive thoughts
and had been told (on numerous occasions) not to be worried about these intrusions. Cassies therapist therefore dealt with this situation by asking Cassie what
she thought her pastor would say about doing exposure, given his past responses.
Cassie was able to recognize that he would think it was all right. Thus, the therapist helped Cassie to rely on her own judgment, as opposed to needing to ask
others for reassurance.
The second obstacle that arose during treatment was that Cassie became
afraid that the anxiety provoked during exposures might harm her. Specifically,
she was worried about the physiological signs of anxiety, 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). Cassies 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, and increased breathing, to get more oxygen into her body. Once Cassie understood that the purpose
of anxiety (fight/fl ight) was to protect her from harm, she felt more comfortable
allowing herself to engage in exposure exercises.

When Therapy Is Not Working


Once each week, in addition to obtaining Cassies subjective report regarding her
progress, the therapist asked Cassie to rate her fear of the intrusive thoughts, the
intensity and frequency of her avoidance behavior, and the severity of her neutralizing rituals. Once Cassie began completing exposure exercises on a daily basis,
these ratings indicated that Cassie was improving. However, not all patients show

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such improvement. When this is the case, it is important to consider possible


explanations. Usually, failure to make treatment gains can be attributed to one
(or more) of the following problems.
PROBLEMS WITH THE TREATMENT PLAN

One possibility is that the exposure hierarchy is missing key items. That is, if
patients do not confront circumstances and intrusive thoughts that match closely
with their actual fears, and do not do so in multiple contexts, mistaken beliefs
about obsessional thoughts and situations can persist, leading to an ineffective treatment program. Thus, the therapist should inquire about whether the
exposure exercises that comprise the treatment plan are well-matched with the
patients actual fears. If they are not, then the treatment hierarchy will need to be
adjusted. Perhaps important anxiety-provoking elements have been overlooked,
and additional assessment is needed. Perhaps the patient has difficulty articulating his or her fears. These difficulties can be easily overcome provided the
therapist is constantly assessing to make sure each exposure item has a purpose
and matches the patients obsessional fear. To this end, involving the patient in
developing the exposure hierarchy is critical.
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). It is therefore not surprising that many patients cut corners or complete exposure inadequately, especially when practicing between
sessions (without therapist supervision). Examples include (a) conducting brief,
as opposed to prolonged, exposures in which the patient avoids becoming very
fearful; (b) failing to confront the key anxiety-provoking elements of an exposure
situation; and (c) performing neutralizing rituals immediately before, during,
or after the exposure. Before doing some of her exposures, for example, Cassie
prayed to God to prevent her from acting on unwanted violent thoughts. Thus,
when this exposure task evoked little anxiety (unexpectedly), Cassies therapist
inquired about any rituals that she had performed to control her anxiety. 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, and the gradual decrease
in anxiety that occurs naturally with time. When it is clear that exposure is being
implemented improperly (e.g., little or no anxiety is provoked), 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

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233

of uncertainty (Abramowitz et al., 2011). 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, sinful person, or not?). As with
performing compulsive rituals such as washing and checking or, in Cassies
case, mental neutralizing, excessive reassurance-seeking (e.g., asking questions repeatedly, scouring information, etc.) interferes with the treatment of
OCD because it prevents direct exposure to the actual feared situation, which
involves being uncertain about the consequences. Patients with OCD must
learn to reduce their fears of uncertainty and compulsive urges to attain certainty. When therapy is not progressing as expected, it is likely that patients are
obtaining reassurancebe it in an obvious way (e.g., asking the same questions
to the same person), or more subtly (e.g., asking similar questions to different
people).
Unnecessary reassurances of safety impinge on the match between the
patients fear and the exposure situation and reinforce the excessive need for such
an opinion in everyday life (which is not practical). 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. Cassie desired to speak with her pastor before conducting exposure to sinful thoughts. Although the therapist was able to help Cassie
see that such a consultation was unnecessary, in some instances it may be useful to allow a single consultation visit with an expertfor instance, if doing so
would prevent the patient from dropping out of treatment. However, the therapist
should supervise such a consultation to ensure that excessive reassurance seeking
does not take place.
Some patients are particularly persistent at questioning the therapist to try
to gain assurance of safety and have difficulty resisting this behavior, even during exposure exercises. In such instances, the first inclination may be to ease the
patient by guaranteeing her that she is not in any danger. However, this undermines the goal of teaching patients to live with acceptable levels of risk and
uncertainty. On the other hand, it is not necessary to try to convince the patient
that she is indeed putting herself at high risk for negative consequences. The most
preferable response uses a compassionate approach, focusing on how exposures
are designed to evoke uncertainty for the patient. It is often useful to explain to
patients that although exposure exercises present low risk, there can never truly
be an absolute guarantee of safety. A general rule that therapists can keep in
mind is that questions about risk in a given situation should be answered only
once. Additional attempts to gain assurance should be pointed out to the patient
and addressed in an empathic way, such as:
It sounds like youre feeling uncomfortable and are searching for a guarantee right nowthats your obsessional doubting. Since I have already
answered that question, it would not be helpful for you if I answered it
again. The best way to stop the obsessional doubts is for you to work on
tolerating the distress and uncertainty. How can I help you to do that?

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Reassurance seeking can also be more subtle, such as a patient making a statement about a homework exposure they are planning (Im going to go into the
church and purposely think about curse words) and then scrutinizing the therapists facial expression for signs of concern. In such instances, the therapist should
inquire of the patient as to whether the statement constituted assurance seeking,
and then revisit the rationale for not providing such assurances.
FAMILY ACCOMMODATION

Finally, when cognitive behavioral therapy for OCD is not working as expected,
it is important to determine whether family members at home are, unwittingly,
interfering with treatment progress by accommodating OCD symptoms. For
example, if a patients family has been helping the OCD sufferer avoid certain
situations out of concerns that the patient might become overly anxious or hostile, such OCD symptom accommodation will impede progress with exposure,
which aims to allow the patient opportunities to confront obsessional anxiety
and avoided situations. Similarly, if family members have been providing reassurance or assisting with other rituals, the therapist should convey the reasons
for ending this behavior (i.e., by reviewing the cognitive behavioral model of
OCD and the rationale for exposure-based therapy) to the family. It is best for
the patient and family to come to an agreement (perhaps in a session with the
therapists arbitration) about how requests for assurances and help with rituals
will be managed going forward.

Ethical Considerations
EXPOSURE THERAPY: IS IT ETHICAL?

Despite the well-established benefits of exposure therapy, a major concern


expressed by professionals and the lay public alike is that this treatment is
unethical because it is harmful to patients. Indeed, patients temporarily experience anxiety and fear during exposure, which is intuitively the opposite of what
a treatment for anxiety problems would be expected to include. Yet the available
research evidence demonstrates that exposure therapy is safe and tolerable, carrying minimal risk of harming patients (Olatunji, Deacon, & Abramowitz, 2009).
In fact, given its well-established effectiveness, we assert that it may be unethical to fail to consider exposure therapy in favor of less effective or unsubstantiated treatments. This is not to say that there are no risks in conducting exposure
therapy; indeed, it may place patients at greater risk than do other forms of psychological treatment. Yet, by taking issues of danger and risk into consideration
when conducting exposure, clinicians can significantly decrease the probability
of harm.
It is unfortunate that ethical concerns related to maintaining proper boundaries may prevent some therapists from employing exposure therapy when indicated (Richard & Gloster, 2007). Effective exposure often requires accompanying

Psychological Treatment of Obsessive-Compulsive Disorder

235

consenting patients on field trips outside the office (i.e., temporarily crossing a
boundary), which some view as problematic because this might increase the probability of inappropriate, unethical, and harmful boundary violations (Gabbard,
1994). Yet, as authors have pointed out (Olatunji, Deacon, & Abramowitz, 2009),
this practice is not inherently unethical and provides patients with an opportunity to confront their actual fears, rather than representations of their fears. Still,
therapists should be aware that confidentiality can be compromised when exposure occurs outside the office. This issue should be discussed with the patient as
part of the informed consent process. In cases where this is a significant concern
for the patient, various strategies may be employed to minimize the likelihood
that confidentiality will be compromised.
WORKING WITH STRICTLY RELIGIOUS PATIENTS

Conducting exposure and response prevention with religious patients, such as


Cassie, presents a number of additional ethical challenges. Deciding on the specific situations for exposure is one delicate issue. Instructions to flagrantly violate
religious laws are neither appropriate nor necessary to reduce fears of committing
religious sins. Exposure should entail situations that evoke doubts and uncertainty about sin, but that are not actual violations. As an analogous situation,
consider an OCD patient with the obsession that her food might be contaminated
with mold. Her pathological anxiety involves uncertainty over whether or not
her food is contaminated, not what to do when there is clearly mold growing on
her food. Therefore, rather than actually eating food with mold, exposure would
involve taking acceptable risks such as eating food that is one day past its sell
by date.
It is also important for therapists to help religious patients come to understand that the purpose of exposure is to help engender healthy religiosity, as
opposed to the use of religious rituals merely to reduce excessive fear of having committed sins. Many individuals with this presentation of OCD also view
God as petulant, easily angered, and vengeful (Abramowitz, 2008), which is
inconsistent with most religious doctrines. According to most religions, people
have not sinned unless they (a) intentionally decide to do things that they know
are evil (e.g., murder someone) and (b) remain remorseless. Therefore, Cassies
unwanted thoughts would not be considered violations by most religious authorities. 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.e., have faith, even though there is no actual confi rmation) that
God understands the nonintentional nature of the thoughts and does not require
reassurance.
Informing patients that, for centuries, 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. Indeed, training manuals for pastoral counselors specifically recommend suggesting that people with such fears purposely

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act contrary to their moral scruples (Chiarrocchi, 1995). Specific guidelines


include (a) emulating conscientious people, even if doing so might violate the
rule in question, (b) allowing oneself to purposely evoke impure thoughts,
and (c) disavowing oneself of repetitive confessions and redundant prayer (Jones
& Adleman, 1959). Chiarrocchis (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.

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. One of these is
the tendency to use cognitive therapy and exposure to try to challenge the validity
of the obsessional thoughts per se, as opposed to the patients misinterpretation
of the thoughts. The second is allowing the patient to use cognitive therapy as a
form of reassurance-seeking ritual. These missteps are described in this section,
and information is provided about how they may be dealt with.

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.g., the impulse to yell curse words in a library)
rather than challenging the patients faulty beliefs and interpretations of the
thoughts (e.g., I have to be extra careful because I am a sinful person who
could lose control and act badly at any time). Intuitively, the obsession itself
seems like a good target for cognitive therapy because it is both a cognition
and foremost on the patients list of complaints. It is also usually illogical. Yet,
from a Beckian perspective, obsessional intrusions are considered the event
or stimulus about which the patient has dysfunctional beliefs. It is these
beliefs that require modification if treatment is to be successful. Because most
patients already recognize their obsessions as irrational, directly challenging the validity of these thoughts will likely have only a transient therapeutic
effect. Moreover, such challenges could turn into reassurance-seeking rituals or maladaptive neutralization strategies used in response to the particular
obsession (as we discuss further below).
The best way to avoid challenging obsessions is to ensure that intrusive
thoughts are differentiated from misinterpretations and appraisals of obsessions.
Because both are cognitive events, disentangling them can be tricky. However,
this can be clarified if the therapist considers the unwanted intrusive thought not
as the cognitive basis of distress itself, but rather as a stimulus about which the
person has automatic thoughts and interpretations.

Psychological Treatment of Obsessive-Compulsive Disorder

237

WHEN COGNITIVE THERAPY BECOMES A RITUAL

As mentioned above, 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. For example, after
learning about the conceptual model discussed above, Cassie at fi rst began ritualistically repeating the phrase obsessional thoughts are normal to reduce
anxiety associated with her obsessions. Moreover, she felt that she had to repeat
this phrase three times perfectly before she could stop the ritual. 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. Cassies therapist, aware of this tendency, recognized Cassies behavior as an OCD symptom
rather than an appropriate cognitive intervention. In general, therapists can
reduce the chances that cognitive therapy techniques will become rituals by
avoiding the provision of guarantees. For example, rather than telling patents
that they probably wont act out their thoughts, it is better to explicitly say
that the probability of acting on obsessional thoughts, while acceptably low, is
not zero.
Freeston and Ladouceur (1999) suggest that if the patient repeats the same
cognitive analysis, uses it in a stereotypic way, or requires increasing efforts to
reduce distress, it means that such material is being used for the purposes of
neutralizing. In contrast, 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, taking risks). For
example, Cassie was taught how to use her cognitive challenges to think less catastrophically about her intrusive thoughts, and then to engage in an exercise (e.g.,
holding a knife while sitting close to the therapist) to demonstrate that her feared
consequences were unlikely.

Termination and Relapse Prevention


ASSESSING TREATMENT OUTCOME

In addition to informally assessing progress, evaluation of treatment outcome


should include re-administration of any self-report and interview symptom
measures. At treatment termination, Cassies therapist asked her to provide current ratings of her fear of intrusive thoughts, severity of avoidance behavior, and
frequency of neutralizing. Cassie also completed the BDI and DOCS. Like most
patients, Cassie reported some residual OCD symptoms. Her score of 8 on the
DOCS and 5 on the BDI, however, indicated that she had made good progress
(pre-treatment scores were DOCS = 26; BDI = 27). Her therapist emphasized
that normal obsessions and rituals are a part of everyday life for most people,
so such experiences will never be completely absent. However, treatment helped
Cassie respond to obsessional stimuli in new healthy ways. Cassie was also told

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that distress and functional impairment could be minimized with continued


practice of the skills learned in treatment.
CONTINUING CARE

Although Cassie was ready to end her course of treatment and continue working on her own to manage her residual OCD symptoms, some patients desire
additional treatment. 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. Such individuals
might be referred for supportive psychotherapy to help manage existing OCD
symptoms. Attending a support group, such as that run by a local affi liate of
the International Obsessive Compulsive Disorder Foundation (www.ocfoundation.org), if available, is another good option. If residual OCD symptoms are
minimal, yet there is concern about possible relapse, follow-up sessions can
be considered (relapse prevention programs for OCD are described elsewhere
[e.g., Hiss, Foa, & Kozak, 1994]). Alternatively, a less formal strategy involving telephone calls and less frequent (perhaps monthly) appointments could be
undertaken.
PREPARING FOR STRESSORS

Cassies therapist explained that Cassie should expect to experience residual


OCD symptoms from time to time. Often, these are triggered by increased life
stress, such as in the midst of occupational or family confl ict, following a death
or illness in the family, or around the time of childbirth. Cassies therapist helped
Cassie to identify potential high risk periods during which she could ready
herself to apply the techniques learned in therapy if necessary.

Conclusions
The treatment program used to help Cassie was based on a conceptualization
of OCD symptoms (i.e., obsessional thinking) that identifies two distinct phenomena: (a) intrusive thoughts or ideas that evoke anxiety, and (b) mental or
behavioral rituals performed to reduce anxiety. This conceptualization involves
empirically supported psychological phenomena and processes (e.g., intrusive
thoughts, thought suppression, coping mechanisms to reduce anxiety) that have
their basis in normal human behavior and cognition, rather than implicating
some cognitive deficit or brain dysfunction. This assumption of normality, which
can (and should) be demonstrated to patients, is often reassuring to individuals
who fear that their OCD is a brain disease. Providing a clear and compelling
model of OCD and rationale for treatment to patients is extremely important for
successful treatment. Patients who have a conceptual model for understanding
their own difficulties, as well as knowledge of how and why exposure works to

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239

decrease these problems, are much more likely to comply with the often challenging treatment instructions.

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Rachman, S. (2003). The treatment of obsessions. New York: Oxford University Press.
Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research
and Therapy, 16, 233248.
Rachman, S., & Hodgson, R. (1980). Obsessions and compulsions. Englewood Cliffs, NJ:
Prentice-Hall.
Richard, D. C. S., & Gloster, A. T. (2007). Exposure therapy has a public relations
problem: A dearth of litigation amid a wealth of concern. In D. C. S. Richard & D.
Lauterbach (Eds), Comprehensive handbook of the exposure therapies (pp. 409425).
New York: Academic Press.
Salkovskis, P. M. (1996). Cognitive-behavioral approaches to the understanding of
obsessional problems. In R. M. Rapee (Ed.), Current controversies in the anxiety disorders (pp. 3350). New York: Guilford Press.
Tolin, D. F., Abramowitz, J. S., Hamlin, C., Foa, E. B., & Synodi, D. S. (2002). Attributions
for thought suppression failure in obsessivecompulsive disorder. Cognitive Therapy
and Research, 26(4), 505517.
Wegner, D. M., Schneider, D., Carter, S. R., and White, T. L. (1987). Paradoxical effects
of thought suppression. Journal of Personality and Social Psychology, 53, 513.
Wilhelm, S., & Steketee, G. S. (2006). Cognitive therapy for obsessive-compulsive disorder:
A guide for professionals. Oakland, CA: New Harbinger.

COMMENTARY

Deborah C. Beidel

Cassies treatment illustrates the very effective use of cognitive behavior therapy
to treat obsessive-compulsive disorder (OCD). The authors did an excellent and
thorough diagnostic assessment. Often, novice therapists initiate treatment too
quickly, without a comprehensive understanding of all of the factors that may
play a role in the etiology and maintenance of the disorder. For example, Cassie
may have come in saying, I am afraid of knives. Without a thorough diagnostic assessment, a therapist may have considered this statement to represent
a specific phobia and may not have probed further, thereby neglecting Cassies
fear of losing control and hurting her family. Of course, the authors of this case
were experts in the treatment of OCD and spent the time necessary to adequately
understand Cassies clinical presentation and to design an appropriate treatment
strategy. Another area of agreement was the use of cognitive behavioral treatment (CBT). As illustrated by this commentary, there are many variations in how
exposure therapy may be implemented, 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. In the most severe cases, both CBT and medication may be necessary.
Another area of agreement was the use of homework assignments, in addition to
clinic treatment sessions. OCD is a complex and severe disorder, and once weekly
clinic sessions will not produce the desired treatment outcome. Again, 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, but there is agreement that homework assignments are
critical to positive treatment outcome.
Cassies case history is quite typical of people with OCD. Early adulthood is
a common age of onset for this disorder. If I were interviewing Cassie, I would
have pressed her for the specific circumstances in her life at the time when she
pinpointed the onset of her fears. 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 usbut not everyone who heard that story developed OCD. As her therapist,
I would have wondered, Why that thought at that time? Often the etiology
of OCD is related to the presence of certain stressful life events such as marriage, the birth of a child, a new job, or a move away from home (Rachman &

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Hodgson, 1980). Basic conditioning studies suggest that people with higher levels
of general physiological arousal more easily acquire fears when presented with
fear-conditioning paradigms. Thus, 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), Cassie may have been at higher risk for acquiring a fear
of behaving in an uncontrollable manner. 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. Addressing current
environmental stressors will enhance the efficacy of the immediate intervention.
Furthermore, once symptoms are eliminated, it is often necessary to teach the
patient general stress management strategies to guard against relapse or reoccurrence. Therefore, understanding the factors that played a role in the frank onset
of the disorder can be critical to maintaining treatment gains.
I would be most interested in personal factors that increased the likelihood
that Carrie would develop a disorder. Family history would be an important but
complicated area to investigate. A family member with OCD could indicate (a)
the presence of a genetic predisposition that made her more likely to develop
this disorder, or (b) the presence of a learning history, whereby Cassie might
have observed her parents or other relatives being overly worried and concerned
whenever they heard about traumatic or violent events. Finally, I would want to
know if Cassie had other ritualistic behaviors, perhaps at a sub-syndromal level
that had been heretofore undetected. Given the severe and chronic nature of this
disorder, a thorough clinical interview is necessary in order to develop a comprehensive treatment program; neglect of these factors represents one of the most
common reasons for incomplete treatment or relapse.
Cassies treatment involved creating a hierarchy of situations and intrusive
thoughts. This commonly used and highly effective approach is known as graduated exposure. An alternative strategy is intensive exposure, or flooding. Both
approaches involve engineering situations or events that allow patients to confront their fears. Whereas graduated exposure allows the patient to confront his
or her fears in a controlled fashion, flooding immediately immerses the patient in
the situation/event at the top of the hierarchy. Both approaches are efficacious,
and often it is a matter of therapist time and patient motivation when deciding
whether to use a graduated or hierarchical approach. In Cassies case, because
her obsession could not be reproduced in real life, flooding would have involved
creating an imaginal scene where she would imagine that she actually acted on
her thoughtsspecifically, Cassie would have been asked to imagine that she lost
control and killed her parents with a knife. She would have been asked to graphically imagine walking into her parents room and stabbing them, over and over
again, until they were dead, confronting the fear that she had to be an evil person
because only an evil person would commit such a horrific act. Carries 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.
Flooding is based on an extinction model of learning that states that behavior change occurs as a result of repeated presentations of unreinforced events

Psychological Treatment of Obsessive-Compulsive Disorder

243

(Baum, 1970). From a strictly behavioral conceptualization, Cassies flooding


scene would include exposure to the physiological arousal, cognitive distress, 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). During any
one session, the increase in anxiety followed by a decrease to baseline is known
as within session habituation. Over a number of treatment sessions, the repeated
presentation of this exact same scene produces a pattern where, as the number
of presentations (sessions) increases, the peak anxiety elicited by the scene lessens and the time it takes for the arousal to return to baseline decreases. When
Cassie can imagine stabbing her parents while they sleep without the elicitation
of anxious distress, she would show between session habituation, indicating that
her obsessions had been successfully treated.
It is important to note that for within and between session habituation to
occur, 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, 1980). Thus, behaviors such as cognitive avoidance (e.g.,
shifting attention away from perceived threat cues to non-feared environmental
elements), cognitive restructuring, or engaging in any type of avoidance behavior
(e.g., doing rituals in her head, imagining that she is not really stabbing her parents but stabbing the mattress; Clark, 1999; Parrish, Radomsky, & Dugas, 2008),
and attempts to physically or mentally escape (Barlow, 2002; Foa & Kozak, 1986;
Mobini, & Grant, 2007) must be avoided. Such distractions are considered to
interfere with the learning process that underlies extinction and undermine its
effectiveness (Clark, 1999; Foa, Huppert, & Cahill, 2006; Foa & Kozak, 1986;
Hofmann, 2007, 2008; Sloan & Telch, 2002). Therefore, unlike a more graduated approach, treating Cassie with flooding would not include specific attention to cognitive restructuring. From the standpoint of a standard behavioral
approach, cognitions are considered a form of behavior and, as noted above,
would be included as part of the flooding scene. For flooding as well as graduated
exposure, homework assignments represent an integral ingredient in exposure
treatment for all modalities. Homework refers to exposure exercises that Carrie
would carry out between weekly sessions to generalize in-session treatment gains
(Huppert, Roth Ledley, & Foa, 2006).
The decision to use a graduated or intensive approach often depends on therapist and patient factors. Flooding sessions are often at least 90 minutes in length,
a time frame not always appropriate for many clinical settings. On the other
hand, because there is no need to proceed up a hierarchy, symptom reduction
is often achieved in a shorter period of time with the need for fewer sessions.
Patients are sometimes resistant to floodinghowever, a confident therapist and
a clearly explained rationale of the science behind the procedure will engage
cooperation. In many instances, the patients imagination of what occurs in the
flooding session is far more extreme than the situation presented by the therapist.
Furthermore, both flooding and graduated approaches require the therapist to
accompany patients to actual places that are currently avoideda therapy component known as in vivo exposure. In Cassies case, I would have accompanied

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her to church and stayed with her until her anxiety dissipated. In many instances,
therapists direct patients to do these assignments on their own. However, patients
are often unable to complete those assignments on their own (at least initially),
leading them to conclude that behavior therapy does not work. As Cassies
treatment plan illustrates, confronting actual fears is an important element of the
treatment plan.
The case description does not indicate if, after reduction of immediate obsessions and compulsions, Cassies treatment was discontinued or if there was a
second phase to the treatment. As noted, depending upon Cassies personal predispositions, additional anxiety management strategies may be needed. For example, is she a person with high trait anxiety and therefore more likely to be reactive
to specific life events? Are there overwhelming environmental factors, such as limited economic resources or specific family stressors, that contribute to feelings of
general anxiety or worry? Because we know that these factors can create stress, it is
imperative that they be considered. If they exist for Cassie, I would continue to see
her to provide her with general anxiety management strategies, such as relaxation
training, a regular program of exercise, or problem-solving skills, all designed to
reduce her general level of distress and therefore reduce the likelihood of relapse.

References
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and
panic (2nd ed.). New York: Guilford Press.
Baum, M. (1970). Extinction of avoidance responding through response prevention
(flooding). Psychological Bulletin, 74, 276284.
Clark, D. M. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour
Research and Therapy, 37, S5S27.
Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An
update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 324). New York: The Guilford Press.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective
information. Psychological Bulletin, 99, 2035.
Hofmann, S. G. (2007). Enhancing exposure-based therapy from a translational research
perspective. Behaviour Research and Therapy, 45, 19872001.
Hofmann, S. G. (2008). Cognitive processes during fear acquisition and extinction in
animals and humans: Implications for exposure therapy of anxiety disorders. Clinical
Psychology Review, 28, 200211.
Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior
therapy for anxiety disorders. Journal of Psychotherapy Integration, 16, 128139.
Mobini, S., & Grant, A. (2007). Clinical implications of attentional bias in anxiety disorders: An integrative literature review. Psychotherapy: Theory, Research, Practice,
Training, 44, 450462.
Parrish, C. L., Radomsky, A. S., & Dugas, M. J. (2008). Anxiety-control strategies: Is
there room for neutralization in successful exposure treatment? Clinical Psychology
Review, 28, 14001412.

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245

Rachman, S. J., & Hodgson, R. J. (1980). Obsessions and compulsions. Engelwood Cliffs,
NJ: Prentice Hall.
Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided
threat reappraisal on fear reduction during exposure: An experimental investigation.
Behaviour Research and Therapy, 40, 235251.

RESPONSE

Jonathan S. Abramowitz and Brittain Mahaffey

In her commentary on our case description of Cassie, Dr. Beidel very thoughtfully raises a number of important points regarding the treatment of obsessivecompulsive disorder (OCD). And we agree with all of them. Dr. Beidel, however,
raises two issues in particular that we wish to comment on further: (a) the origins
of obsessional fears, and (b) the use of distraction in exposure therapy.

Etiological Factors and Cognitive Behavioral Therapy


As Dr. Beidel points out, it is interesting to speculate about the possible factors that
might increase ones vulnerability to developing an anxiety disorder such as OCD.
Obsessional fears, like other forms of fear, can be learned in three ways (including
combinations of these): (a) through personal experiences (e.g., becoming very ill after
using a public toilet), (b) vicariously (e.g., watching or hearing about someone else
becoming ill from a public toilet), and (c) through the transmission of information
regarding threat (e.g., reading statistics about germs and illnesses found on public
toilets; Rachman, 1977). There might also be biological or genetic factors that set
the stage for these learning experiences to really affect the individual. We typically
explain to patients that OCD is caused by some combination of biological/genetic
and learning/environmental factorsmuch like how cold air and moisture are both
required to produce a blizzard. It is also likely that the combination of factors is different for different OCD sufferers. Accordingly, it is notoriously difficult to pinpoint
the precise factors that might have led to the development of OCD symptoms for
someone like Cassie. 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. As a result, we do not spend much time trying to unravel the patients history
or understand factors that might play a role in the onset of OCD symptoms. Rather,
we prefer to use session time to develop and implement the treatment plan.
All of this notwithstanding, we occasionally do work with OCD patients who
describe conditions that are hard to deny as etiological factors. One example is
a man with intrusive sexual obsessional thoughts about one of his male friends.
Although the patient was happily married without any history of homosexual
encounters, he worried that his unwanted images of this mans penis meant that he

Psychological Treatment of Obsessive-Compulsive Disorder

247

was gay and would be damned to hell by God. As a result, he engaged in compulsive praying and reassurance seeking regarding his true sexuality. On interview,
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. He also reported having learned through similar channels that God
knows all of your thoughts, and that one can sin by thinking immoral things. Yet,
even in this rather clear instance, the possibility that his religious upbringing contributed to the OCD symptoms was discussed merely as a possibility. Indeed, the
majority of religious individuals do not suffer with obsessions and compulsions.

Distraction versus distraction


Dr. Beidel also raises the important issue of distraction affecting habituation of
anxiety during exposure therapy. Indeed, 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, Foa, &
Steketee, 1982, 1986). Accordingly, we encourage patients to focus on, rather than
distract themselves from, the exposure stimulus. However, 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. Thus, we might
shift the topic of conversation or help the patient to engage in some sort of routine
activity (e.g., writing e-mails, 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, Look at you! Youve got bathroom germs on
your hand but youre putting on makeup, or Youre driving on a street crowded
with pedestrians, and youre listening to your favorite song! to reinforce that
the patient can manage the situation and obsessional anxiety better than was
thought. Regularly asking questions such as How are you feeling now? What
are you telling yourself? Whats 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, even while patients engage in other activities.
Thus, while deliberate distraction that functions as an escape from anxiety and
a disruption from the obsession is likely to hinder the effects of treatment, judicious use of distractions in the therapy sessionas well as repeatedly reminding
the patient of what he or she is exposed tocan help the patient better achieve
mastery over the obsessive fears. We also agree with Dr. Beidel that it is important to assess for cognitive avoidance, which the patient might use to reduce anxiety, but which cannot be directly observed.

Reference
Rachman S. (1977). The conditioning theory of fear-acquisition: A critical examination.
Behaviour Research Therapy, 15, 375387.

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{ PART IV }

Psychotic Disorders and Organic


Brain Syndromes

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{ 10 }

The Initial Evaluation and Treatment of


Schizophrenia and Related Psychotic Disorders
Belinda McIntosh and Michael T. Compton

Despite advances in treatment approaches over the past few decades, schizophrenia and related psychotic disorders (e.g., schizophreniform disorder, schizoaffective disorder) continue to represent a class of disorders that are a leading
challenge facing mental health clinicians today. Schizophrenia is among the top
ten causes of disability in the world (Murray et al., 1996). Affected individuals
typically experience substantial impairments in personal, occupational, and
social functioning. The impact of these deficits can be catastrophic for the individuals as well as their families and communities. The lifetime prevalence of
schizophrenia has been estimated at roughly 1% (Perala et al., 2007; Saha et al.,
2005). Schizophrenia has a higher prevalence in men than women, with a ratio of
about 1.4:1 (Aleman et al., 2003), and there is some evidence for an increased risk
of schizophrenia at higher latitudes (Saha et al., 2006). In addition to the epidemiological variability of schizophrenia, there is much heterogeneity in the way in
which persons with schizophrenia present. Such heterogeneity in illness features
(e.g., positive symptoms, negative symptoms, disorganization, neurocognitive
deficits) is likely underpinned by heterogeneity in etiology and pathophysiology,
which are areas of active research pursuits.

Epidemiology and Key Principles


Patients with schizophrenia and related psychotic disorders are identified at varying stages of illness, describe different modes of onset, and are seen in a multitude
of treatment settings. They can present with an array of comorbid medical (Carney
et al., 2006; Lyketsos et al., 2002), psychiatric, and substance use (Kavanagh et
al., 2002; Koskinen et al., 2009, 2010; Margolese et al., 2004; Regier et al., 1990;
Volkow, 2009) conditions. Social, cultural, economic, and demographic factors
add further layers of complexity to the presentation (Strakowski et al., 1997) and
must be considered in the diagnostic formulation. Because accurate diagnosis is

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fundamental to planning treatment, care must be taken to consider all of these


variables when assessing an individual presenting with psychotic symptoms.
Patients with schizophrenia and related psychotic disorders typically come to
clinical attention after psychotic symptoms are manifested. However, functional
impairment due to premorbid declines in academic and social functioning, as
well as prodromal symptoms, is often present long before the onset of psychosis.
Such was the case with Mr. M. The following section details his initial presentation, along with the ensuing work-up, course of treatment, and clinical outcome.
This case illustrates the complexity of making a diagnosis of schizophrenia in
a patient who presents with a vague history, nonspecific symptoms, substance
use, and potential psychiatric comorbidity. In this case, as with many, although
schizophrenia was high on the list of differential diagnoses from early on, months
passed before this diagnosis could be confi rmed.

Case History
PRESENTING COMPLAINTS

Mr. M. is a 22-year-old single male college student and part-time employee at


a coffee shop, who presented to the outpatient mental health clinic with complaints of feeling very depressed, being unable to get out of bed, and feeling
stressed. He also complained of difficulty remembering things and concentrating at work. He reported sleeping 16 hours or more per day, which sometimes
caused him to miss work and school. He could not provide a time line for these
symptoms, but stated that the previous two weeks had been particularly difficult. He was recently reprimanded by his supervisor at work for tardiness and
absenteeism. He voiced concern that he may have attention deficit/hyperactivity
disorder (ADHD) and complained of inattentiveness, distractibility, impulsivity, and fidgeting. He specifically requested stimulant medication for ADHD.
He described a long history of vacillating between high self-confidence and
very low self-confidence. Mr. M. reported occasional feelings of sadness and
described recent and worsening anhedonia. He denied excessive worry, muscle
tension, appetite changes, and all other depressive and anxious symptoms. He
also denied grandiosity, paranoia, and any perceptual disturbances. Occasional
headaches, lightheadedness, and difficulty breathing were the only physical
symptoms reported.

ADDITIONAL PERSONAL HISTORY

His past psychiatric history was unremarkable. In fact, this was his fi rst encounter with a mental health practitioner. He did not recall having any problems with
depression, anxiety, mania, or psychosis earlier in life. He stated that in the past
his teachers and parents remarked that he might have ADHD, though he was
never formally tested, diagnosed, or treated.

Treatment of Schizophrenia and Related Psychotic Disorders

253

He reported significant substance use, which included alcohol and marijuana.


He began consuming alcohol at the age of 17. At the time of presentation, he
was drinking one-quarter to one-third liters of rum at least twice per week. He
smoked marijuana occasionally over the previous two years at a rate of about
twice per month.
Obtaining Mr. M.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.
Otherwise, his medical history was unremarkable. He was not taking any medications at the time of the initial visit. Family history was significant only for
unspecified anxiety disorders in two second-degree relatives.
Psychosocial history revealed that he was born in Brazil but immigrated to
the United States with his family at the age of 12. Details of his birth and early
childhood development were unremarkable, based on his report. He described
some difficulty making friends upon moving to the United States and starting
middle school. He denied any history of physical abuse, but stated that he was
teased by peers for having a foreign accent. He did fairly well in school, earning
average to above-average grades through middle and high school. He described
feelings of alienation from peers beginning in the 11th grade. He reported having
many acquaintances but no close friends. He has never had a significant romantic
relationship. After graduating from high school, he began attending a four-year
college. However, after two years there, he was expelled due to poor academic
performance. At the time of presentation, he was enrolled at the local community
college, worked part-time, and lived alone in an apartment near campus.

Assessment Strategy
The clinicians approach to assessing Mr. M. involved consideration of his presenting complaints, examined within the context of any prevailing medical,
familial, substance abuse, and social issues. Once obtained, the initial history
was used to guide the rest of the assessment. Key goals of the assessment included
making a provisional diagnosis, ruling out potentially confounding diagnoses,
and establishing a baseline level of symptoms, functioning, and overall health
against which treatment response could be gauged.
MENTAL STATUS EXAM

In addition to obtaining presenting complaints, past medical, psychiatric, social,


and substance abuse history, the clinician observed the patient during the clinical interview, thereby acquiring significant additional clinical information.
Mental status examination on the initial visit was obtained during the course of
a 60-minute in-person diagnostic interview conducted in the clinicians office.
Mr. M. presented as a young man of average height and build who appeared his
stated age. He was alert and was oriented to person, place, time, and situation.
Eye contact was poor. He was cooperative with the interview, but his responses,

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Psychotic Disorders and Organic Brain Syndromes

though lengthy, were often vague (impoverished content of speech). He was quite
talkative and exhibited normal rate, volume, and tone of speech. Psychomotor
agitation was evident in that he shifted often in his seat. Mood was reported as
stressed. Affect was incongruent and somewhat odd. He smiled inappropriately throughout the interview. Thought process was mostly linear and logical,
but at times he was circumstantial. For example, when asked about his current
peer relationships, 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. In general, he
was overly inclusive of detail. There were rare instances of tangential thinking
and on one occasion he made a loose association. He said, I was picked on in
school. I have a problem with my knee. He denied paranoia and did not demonstrate overtly delusional thinking. He did, however, come across as somewhat
grandiose, frequently making references to being unusually smart and capable
of thinking in ways that most people cannot. In fact, he talked about reading
other peoples thoughts as a means of entertaining himself. He admitted that this
sounded odd, but he described it as a thought exercise rather than a special power.
He denied any suicidal or violent ideation. Insight and judgment were deemed to
be limited. Impulse control was observed to be fair, based on his ability to tolerate the structure of the interview, remain seated for an extended period, and await
the completion of the clinicians questions and comments before responding.
CONSIDERATION OF DIFFERENTIAL DIAGNOSIS

After gathering history from the patient and performing a mental status examination, the clinician gave thought to potential differential diagnoses. At the end
of the initial encounter with Mr. M., diagnostic considerations included a broad
array of possibilities from the following categories: anxiety disorder, mood disorder, ADHD, personality disorder, psychotic disorder, and substance use disorder.
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. Differential diagnoses when evaluating first-onset psychosis typically
include bipolar disorder, psychotic depression, schizophreniform disorder, schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder,
substance-induced psychotic disorder, and psychoactive substance intoxication
or withdrawal (Del-Ben et al., 2010). In cases of older individuals and persons
with medical problems, psychotic disorder due to a general medical condition,
dementia, and delirium must also be considered.
In order to narrow the list of differential diagnoses in the case of Mr. M., the
clinician conducted a thorough review of symptoms through a diagnostic interview guided by the Diagnostic and Statistical Manual of Mental Disorders, 4th
edition (DSM IV-TR; American Psychiatric Association, 2000) criteria. Based
on this review and consideration of the history, particularly the cognitive complaints, decline in functioning, increased alcohol and marijuana intake, and social
withdrawal, the potential Axis I diagnoses included prodromal schizophrenia,

Treatment of Schizophrenia and Related Psychotic Disorders

255

ADHD, alcohol abuse, cannabis abuse, and substance-induced mood disorder.


Given the mild thought disorder and odd thinking, and considering the concomitant social and academic dysfunction, cognitive decline, and sleep disturbance,
the clinician arrived at the provisional diagnosis of prodromal schizophrenia.
The clinician incorporated medical, psychological, social, 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,
work, and academics
Axis V:
Global Assessment of Functioning (GAF) = 55
The clinician was, unfortunately, unsuccessful in gaining any collateral history
on this initial visit, as Mr. M. was estranged from his parents and was reluctant
to allow the clinician to contact his coworkers. As with many such evaluations,
unraveling Mr. M.s diagnosis would require additional visits.
ASSESSMENT OF RISKS AND SAFETY

Besides establishing a provisional diagnosis, it was also important on Mr. M.s


fi rst visit to determine whether there were any acute safety issues requiring immediate attention. In this case, there were no indications that he posed an imminent
risk of causing harm to himself or others. He also demonstrated sufficient capacity to care for himself in his existing surroundings. These conclusions provided
the basis for the decision to begin Mr. M.s treatment on an outpatient basis.
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, onset characteristics and duration of those symptoms, the extent of impairment in functioning,
and predisposing and precipitating factors. This information is derived from
a thorough review of the patients past psychiatric, medical, developmental,

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Psychotic Disorders and Organic Brain Syndromes

substance use, social, and family history, as well as a mental status examination.
Frequently, assessment of a patient continues beyond the initial visit and includes
gathering more details by obtaining collateral history from other sources, such as
family and peers, and doing a variety of cognitive, psychological, and biological
tests when indicated. Key questions guiding the ongoing assessment originate
from the developing differential and provisional diagnoses.
During subsequent visits, the mental status examination was repeated. As
time passed, Mr. M.s complaints about cognitive symptoms progressed (e.g.,
problems with concentration and memory, and difficulties getting [his] thoughts
together). He also reported lack of interest and motivation, stating that he had
lost his fi re.
LABORATORY TESTS AND NEUROIMAGING

In order to exclude potential medical causes for his reported decline in cognitive functioning, the clinician ordered a comprehensive metabolic panel, complete blood count, and tests of thyroid function, all of which were determined to
be within normal ranges. A urine drug screen was negative. Despite the lack of
evidence favoring brain imaging as part of the diagnostic workup for fi rst-episode psychosis, brain magnetic resonance imaging (MRI) was completed, which
revealed no abnormalities.
PSYCHOLOGICAL AND NEUROCOGNITIVE TESTING

The clinician referred Mr. M. for testing to assess his current level of psychological and neurocognitive functioning and to determine whether or not there
were any cognitive deficits, perceptual problems, or maladaptive personality
features. Among the tests administered by the psychologist were the Minnesota
Multiphasic Personality Inventory 2 and the Wechsler Adult Intelligence Scale
III. Of note, there is little data to support the use of the MMPI in determining a
differential diagnosis, though it can be helpful in understanding personality profi les. The conclusion from this testing was that Mr. M. was a person of average
intellectual ability who likely suffers from an attention deficit disorder with specific deficits in processing ability, who also possesses schizoid personality traits.
There was a slight elevation on the paranoia scale of his Minnesota Multiphasic
Personality Inventory 2, but it did not rise to a level of clinical relevance. One
recommendation on the basis of these fi ndings might be to consider treatment
with a psychostimulant.
Incidentally, since testing results were not available for a couple of weeks, the
clinician had had the opportunity to observe Mr. M. as his symptoms unfortunately continued to evolve. He denied using any substances during this time, and
subsequent drug screens were negative. Over time, increasing signs of suspiciousness, odd and restricted affect, and illogical thinking became evident. For example, he began to express concern about being the subject of police surveillance
based on a minor traffic violation that had occurred the previous year. By the

Treatment of Schizophrenia and Related Psychotic Disorders

257

time the testing results were available, the clinician had become highly concerned
that Mr. M. was experiencing the onset of a psychotic disorder and, as such, was
reluctant to prescribe a stimulant. The clinician recommended a trial of an atypical antipsychotic, which Mr. M. refused. As is not uncommon in the initial stages
of treatment engagement, Mr. M. did not return to the clinic for three months
and was unable to be reached. When he returned to the clinic three months later,
he was floridly psychotic, expressing bizarre persecutory delusions and reporting
nearly constant auditory hallucinations. At that point, the clinician felt certain
that his initial symptoms had represented the prodromal phase of schizophrenia
or a related psychotic disorder.
On this visit, during which Mr. M. presented with frank psychotic symptoms,
he allowed the clinician to contact his family. By then, he had lost his job, was
no longer enrolled at the community college, and had moved back to his parents home. His mother and father expressed concern that he appeared to them
depressed and withdrawn. They stated that he was not maintaining his personal hygiene or contributing to the household. He was also observed holding
conversations while no one else was present and pacing at times, especially during these episodes of talking to himself. The clinician met with his mother, father,
and adolescent sister and observed that Mr. M.s tone toward his parents was at
times hostile and at best indifferent. During this family meeting, it became clear
that the family knew very little about schizophrenia or about mental illnesses in
general.

Relevant Aspects of the Early Pre-Treatment Course of


Psychotic Disorders
The schizophrenia prodrome, defi ned as the time from onset of behavioral and
psychological changes to the onset of frank psychotic symptoms (e.g., hallucinations, delusions), has been well characterized. It involves impairments in attention, concentration, drive, sleep, and mood. Suspiciousness, social withdrawal,
and deterioration in role functioning are common (Compton et al., 2010; Larson
et al., 2010; Yung et al., 1996). Indeed, after extended time in treatment, with
improved insight and a fi rmly established rapport, Mr. M. described having an
awareness of progressive losses in cognitive functioning and consequent academic decline over the preceding two years. Even before the onset of prodromal
features, individuals who later develop psychotic disorders commonly experience
a subtle and gradual decline in both academic and social functioning during the
premorbid period. In retrospect, Mr. M.s reports of difficulties in middle and
high school are consistent with those of many young people who later develop
schizophrenia.
For Mr. M., although the prodrome had lasted at least two years, the onset of
psychotic symptomsthe evolution from intermittent, vague perceptual anomalies to frank hallucinations, and the emergence of persecutory delusions from
initial suspiciousnesscomprised approximately four months. Included within

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Psychotic Disorders and Organic Brain Syndromes

these recent months, in this case, is another critical interval that has been referred
to as duration of untreated psychosis (Compton et al., 2011; Compton et al.,
2008; Oliveira et al., 2010), or the period that occurs after that onset of psychosis and before treatment is sought or initiated. 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., 2005; Perkins et al.,
2005). Secondary prevention, or early detection and treatment, can be promoted
through efforts to reduce the duration of untreated psychosis. Engaging families
is of utmost importance, given that families commonly initiate treatment seeking (though that was not the case for Mr. M.). The familys level of awareness,
openness to education about the illness, and willingness to support the treatment plan are critical factors to consider in treatment planning and determining
prognosis.
As this case demonstrates, the assessment of schizophrenia and related psychotic disorders is a multifaceted and sometimes protracted endeavor. Patients
presenting with an exacerbation of multi-episode schizophrenia are often more
easily identified as having schizophrenia than are first-episode patients. Though
psychological and neurocognitive testing and brain imaging were included in Mr.
M.s assessment, such tests are not always performed on first-episode patients and
are not required in order to make the diagnosis of a psychotic disorder.
INITIAL CASE FORMULATION

In formulating this case, the clinician considered positive and negative fi ndings
from the history (reported by patient and family), mental status examination,
psychological and neurocognitive testing, and medical tests. Guided by DSM-IV
diagnostic criteria, the patients symptomsand the evolution of those symptoms over timewere considered to make a firm diagnosis of schizophrenia, paranoid type. In ruling out an affective psychotic disorder, the clinician considered
the relative lack of affective symptoms, the predominance of auditory hallucinations, and anhedonia. In a study differentiating affective psychoses from schizophrenia, anhedonia and hallucinations were more specific for schizophrenia than
other markers (Gelber et al., 2004).
Ruling out a primary substance use disorder and a substance-induced psychotic disorder was crucial given the patients history of marijuana use. 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. This allowed the clinician to rule out the possibility that the psychotic symptoms were directly induced by the physiological effects of a psychoactive substance. His early substance abuse, which began in high school, may have
been spurred by an attempt to self-medicate some of the emerging symptoms,
such as anhedonia and dysphoria, which characterized his prodromal state.
The clinician also considered that the age at onset of prodromal and psychotic
symptoms were consistent with the typical course of schizophrenia. Given the

Treatment of Schizophrenia and Related Psychotic Disorders

259

relatively early age at onset and the insidious course, impairment in affect and
functioning, reported cognitive decline, and lack of insight on the part of the
patient and the family, the initial prognosis was relatively poor. Of note, although
the patient and his family were initially highly resistant to accepting the diagnosis of schizophrenia, they agreed to a trial of antipsychotic medication.

Treatment Planning
Both pharmacologic treatment and psychosocial interventions are indicated in
the treatment of schizophrenia. In keeping with the established guidelines for the
treatment of fi rst-episode nonaffective psychosis using second-generation antipsychotic agents, Mr. M. was started on risperidone 2 milligrams (mg) at bedtime.
Mr. M. and his family wanted to avoid hospitalization, expressing a strong preference for a trial of outpatient treatment. Despite starting risperidone, Mr. M.
was admitted to a crisis stabilization unit a week later, after becoming verbally
aggressive at home. In this inpatient setting, he admitted to having taken high
doses of stimulant medication along with the risperidone. He stated that he felt
too slowed down by the risperidone and thought that the stimulant would help
with his thinking. Although this development raised the suspicion of stimulant
abuse possibly leading to the development of psychosis, over time, the primacy
of psychostimulants contributing to the development of psychosis was not borne
out. While in the crisis stabilization unit, 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, family therapy, ongoing pharmacotherapy,
social and vocational skills training, substance abuse counseling, and cognitive
behavioral therapy were core parts of the treatment program. Mr. M. received
treatment in outpatient, inpatient, and partial hospitalization settings at varying
points depending on the nature of his symptoms and his ability to engage in the
process.

Assessment
As exemplified by Mr. M.s assessment, the initial evaluation of a potential psychotic disorder requires a multipronged approach. Of course, obtaining all relevant aspects of the history, supplemented with collateral reports and any prior
psychiatric records, is a necessary first step. Much of the remaining assessment
pertains to excluding medical causes of psychosis and identifying any medical,
psychiatric, and substance abuse comorbidities. Furthermore, given that antipsychotic agents will be started, the initial medical evaluation serves as a baseline
for future comparisons in terms of potential side effects of the chosen pharmacologic agents, especially movement abnormalities and metabolic side effects
(Freudenreich et al., 2009). Thus, the baseline physical and neurological examination is crucial.

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Psychotic Disorders and Organic Brain Syndromes

Commonly ordered laboratory tests include basic metabolic markers, complete blood counts, inflammatory markers (e.g., erythrocyte sedimentation rate
and antinuclear antibody), thyroid stimulating hormone, ceruloplasmin, and
vitamin B12, as well as testing for neurosyphilis and human immunodeficiency
virus. Additional tests may be warranted, depending on the clinical picture, family history, and epidemiological/environmental considerations (Freudenreich et
al., 2009).
During the initial evaluation, an electroencephalogram is commonly done
to rule out temporal lobe epilepsy if clinical features are consistent with this.
Neuroimaging, using either computed tomography or magnetic resonance imaging, is also commonly performed. Although the need for routinely conducted
neuroimaging during the first-episode evaluation continues to be debated
(Compton et al., 2009; McKay et al., 2006), specific fi ndings from such scans (e.g.,
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). Finally, testing for chromosome 22q11 deletion (velo-cardio-facial syndrome) may be warranted if certain
clinical and morphologic features are present (Murphy et al., 2001). This genetic
syndrome, characterized by variable phenotypes such as cleft palate, congenital
heart anomalies, and immune disorders (Shprintzen et al., 2005), is associated
with a lifetime prevalence of psychosis of approximately 25 times that of the general population (Hodgkinson et al., 2001).

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., 2010) and the American
Psychiatric Association (Rose, 1997). They include pharmacologic and psychosocial interventions aimed at reducing symptoms and fostering recovery in patients
with schizophrenia and related psychotic disorders. Pharmacologic treatment
of schizophrenia includes antipsychotic medications as well as a number of
adjunctive agents for treating associated symptoms and side effects. Psychosocial
interventions include psychoeducation, family therapies, assertive community
treatment, supported employment, supportive housing, social skills training, and
cognitive behavioral therapy for psychosis. Integrated substance abuse treatment
is indicated in many patients with schizophrenia who present with concurrent
substance abuse or dependence.
PHARMACOLOGIC TREATMENT OF SCHIZOPHRENIA

Pharmacologic treatment of psychosis in schizophrenia calls for the use of antipsychotic medications. The fi rst-generation antipsychotic medications exert therapeutic effect through blockade of dopamine D2 receptors. However, such agents

Treatment of Schizophrenia and Related Psychotic Disorders

261

can cause significant extrapyramidal side effects, as well as diverse side effects
related to their effects at other receptor types. The second-generation antipsychotic agents similarly antagonize dopamine receptors but also block serotonin
5HT2A receptors.
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, 2010; Rose, 1997).
In contrast, the Schizophrenia Patient Outcomes Research Team (PORT) recommendations give no preference to second- over fi rst-generation antipsychotic
agents (Buchanan et al., 2010). Both guidelines suggest consideration of factors
such as current symptoms, history of past medication response, susceptibility
to certain side effects, relevant medical history, history of adherence, and costeffectiveness in deciding on an antipsychotic medication. The recently published
guidelines are influenced by conclusions from two large studies of antipsychotic
effectiveness, the Clinical Antipsychotic Trials of Intervention Effectiveness
(CATIE) and the Cost Utility of the Latest Antipsychotics in Schizophrenia
Study (CUtLASS).
CATIE was a large National Institute of Mental Health (NIMH)funded
pragmatic comparison of the effectiveness of fi rst- and second-generation
antipsychotic medications. In this study, patients were randomized to one of
the then-available second-generation antipsychotic medications (olanzapine,
quetiapine, risperidone, and ziprasidone), or to the fi rst-generation antipsychotic
perphenazine (Lieberman et al., 2005). The primary outcome measure was time
to discontinuation of randomized treatment. The study revealed substantial discontinuation rates overall; 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, at 64%. The other second-generation
antipsychotics demonstrated no significant advantage over perphenazine, in
terms of time to discontinuation. Metabolic side effects were greatest with olanzapine. The rates of extrapyramidal side effects were relatively low in all groups
(Lieberman et al., 2005).
The CUtLASS trial compared quality of life in 227 patients living in the
United Kingdom who, due to inadequate response or adverse effects, were randomized to a trial of a different antipsychotic medication. They were randomized
to receive either a fi rst- or second-generation antipsychotic, with the specific
agent being chosen by the treating physician. Participants were blindly rated on
measures of social and vocational functioning and overall quality of life at 12, 26,
and 56 weeks post-randomization. This study revealed no difference in outcome
between the fi rst- and second-generation antipsychotic treatment groups (Jones
et al., 2006).
Though prior studies suggest that second-generation antipsychotics are superior to fi rst-generation agents in preventing relapse, the current recommendations
support the use of either first- or second-generation antipsychotic medications
(with the exception of clozapine) as fi rst-line agents for the treatment of acute

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Psychotic Disorders and Organic Brain Syndromes

psychosis in patients with prior episodes of psychosis (Buchanan et al., 2010).


Olanzapine is not recommended as first-line in treating psychosis in first-episode
patients (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., 2007). Clozapine is recommended for people with schizophrenia whose psychotic symptoms have not responded sufficiently to two adequate
trials of other antipsychotics. The recommended dose is 300 to 800 mg daily
(Buchanan et al., 2010). Though studies demonstrate that clozapine is more effective than other antipsychotics in the treatment of positive and negative symptoms
of schizophrenia (Lieberman et al., 2003a; Lieberman et al., 2003b), it remains an
option only for treatment-refractory patients because of the risk of agranulocytosis, weight gain, metabolic side effects, and other adverse events.
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. First-episode patients show heightened responsiveness to the therapeutic effects of antipsychotic agents, as well as increased
sensitivity to side effects and adverse events. The recommended dosage range for
fi rst-generation antipsychotics is typically expressed in terms of chlorpromazine
(CPZ) equivalents and is considered to be 3001,000 mg CPZ equivalents for an
exacerbation of multi-episode schizophrenia and 300500 mg CPZ equivalents
for fi rst-episode patients (Buchanan et al., 2010). 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., 2010). For treatment of first-episode psychosis
in treatment-responsive schizophrenia, the recommended dosage generally falls
within the lower half of the therapeutic range.
The benefits of continuation of treatment with an antipsychotic agent beyond
the acute phase of schizophrenia are well established. People with schizophrenia
who, through treatment with an antipsychotic agent, experience sustained relief of
psychotic symptoms should be offered maintenance treatment to prevent relapse
(Buchanan et al., 2010). Long-acting injectable formulations currently exist for
several fi rst- and second-generation agents. Some patients prefer a monthly or
semi-monthly injection over the daily use of oral medications, and some evidence
suggests improved outcomes associated with long-acting injectables.
Treatment with antipsychotic agents requires close monitoring for side effects
and adverse events. Abnormal involuntary movements are common consequences of the use of high-potency antipsychotic agents such as haloperidol and
fluphenazine; these involuntary movements can include akathisia, acute dystonia, parkinsonism, and tardive dyskinesia. Low-potency antipsychotics such a
chlorpromazine and thioridazine, though less likely to cause movement abnormalities, are associated with elevated risk for cardiac arrhythmias, hepatotoxicity, metabolic abnormalities, weight gain, orthostatic hypotension, and sedation.
Metabolic abnormalities, including elevated glucose, lipid profi le alterations,

Treatment of Schizophrenia and Related Psychotic Disorders

263

and insulin resistance, are common in certain second-generation antipsychotic


agents and some low-potency fi rst-generation agents. Olanzapine and clozapine
are more likely than other second-generation antipsychotic agents to cause weight
gain and glucose elevation, followed by quetiapine and risperidone, which demonstrate an intermediate effect on weight and glucose metabolism (Newcomer,
2005). Aripiprazole and ziprasidone have not been shown to cause significant
weight gain or metabolic effects (Newcomer, 2005). Paliperidone is a second-generation antipsychotic drug that was approved for treatment of schizophrenia in
2006. Since then, three new antipsychotic medications, lurasidone, iloperidone,
and asenapine, were approved by the Food and Drug Administration between
2009 and 2010 (Citrome, 2011). Comparative studies of their metabolic effects are
underway.
When treating psychotic symptoms in a patient with schizophrenia using a
fi rst-generation antipsychotic agent, current recommendations do not support the
use of prophylactic antiparkinsonian agents to reduce the risk of extrapyramidal
side effects (Kreyenbuhl et al., 2010). The decision to start an antiparkinsonian
agent should be made on an individual basis, when considering such factors as
prior history of extrapyramidal symptoms, patient preference, and characteristics of the chosen antipsychotic medication (Buchanan et al., 2010). First-episode
patients are more susceptible to extrapyramidal symptoms when treated with
high-potency fi rst-generation antipsychotics (Buchanan et al., 2010).
The use of adjunctive medications in treating associated psychiatric symptoms in individuals with schizophrenia is common in clinical practice. Current
guidelines support the use of rapidly acting benzodiazepines, in conjunction
with antipsychotic agents, for the management of acute agitation in persons with
schizophrenia (Buchanan et al., 2010). However, many other common adjunctive medication strategies are not supported by the current recommendations.
Given insufficient evidence of the efficacy of adding lithium or an anticonvulsant
to treat residual psychotic symptoms, their use is not routinely recommended.
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. This practice of antipsychotic polypharmacy is not supported by evidence to date and is not included in the PORT treatment recommendations (Buchanan et al., 2010) or the APA guidelines for the treatment of
schizophrenia.
THE PSYCHOSOCIAL TREATMENT OF SCHIZOPHRENIA

Recommended psychosocial treatments for schizophrenia include individual,


family, and community-based interventions. Studies show significant improvements in symptom reduction and functional outcome when psychosocial interventions are integrated with pharmacologic management. Current evidence-based
psychosocial treatments that are recommended for the treatment of people
with schizophrenia include assertive community treatment (ACT), supported
employment, social skills training, cognitive behavioral therapy, family therapy

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Psychotic Disorders and Organic Brain Syndromes

(including family psychoeducation), and psychosocial interventions for weight


management and substance abuse (Dixon et al., 2010).
ACT should be offered to people with schizophrenia who are homeless or at
high risk of hospitalization (Dixon et al., 2010). ACT consists of a multidisciplinary team that includes a medication prescriber, frequent patient contact, low
patient-to-staff ratios, and outreach to patients in the community. ACT reduces
rates of hospitalization and homelessness in people with schizophrenia and
related psychotic disorders (Coldwell et al., 2007).
Family therapy, including the use of multifamily groups, is effective at improving treatment adherence (Pitschel-Walz et al., 2006), preventing relapse, and
reducing family burden (Pfammatter et al., 2006). Family interventions are recommended for people with schizophrenia who have ongoing contact with family
members. Critical components of effective family interventions include psychoeducation (Bauml et al., 2006), crisis management, supportive therapy, 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., 2010; Pfammatter et al., 2006).
Cognitive behavioral therapy is effective in reducing positive and negative
symptoms of schizophrenia (Turkington et al., 2008) and improving functional
outcome. For these reasons, current guidelines support the use of individual and
group-based cognitive behavioral therapy for the treatment of schizophrenia
(Lecomte et al., 2008; Wykes et al., 2008).
Current guidelines for the treatment of schizophrenia also call for offerings in
the area of environmental support (Kreyenbuhl et al., 2010). People with schizophrenia often benefit from additional support in the areas of housing, employment, and education. 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., 2010; Lehman
et al., 2004). Supported employment, which integrates psychiatric and vocational
services, improves the acquisition and maintenance of competitive employment
(Cook et al., 2005). Though the current guidelines do not yet include recommendations for supported education or supportive housing, these interventions are
clearly beneficial for many patients with schizophrenia.
Current guidelines also recommend psychosocial interventions for weight
management, smoking cessation, and substance abuse treatment in individuals with psychotic disorders. Obesity and smoking, common in patients with
schizophrenia, are high-impact modifiable risk factors that can lead to significant medical morbidity and premature death. In fact, morbidity and mortality
rates are persistently elevated among individuals with schizophrenia compared
to the general population. Interventions aimed at reducing these two risk factors
in patients with schizophrenia could improve overall health outcomes for these
patients (Goff et al., 2005). With the proliferation of prescriptions for secondgeneration antipsychotic medications over the past decade, weight management
has become increasingly important. Current guidelines suggest that clinicians
should implement a psychosocial intervention of at least three months duration

Treatment of Schizophrenia and Related Psychotic Disorders

265

for patients with schizophrenia who are overweight or obese (Dixon et al., 2010).
According to the guidelines, such interventions should include nutritional counseling, behavioral management, and weight monitoring.
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., 2010). The optimal duration of treatment has not yet been determined,
though even brief interventions have been shown to improve substance abuse and
psychiatric outcomes in patients with schizophrenia (Graeber et al., 2003).
Though studies of psychosocial interventions to improve treatment adherence
have yielded mixed results, close attention to those environmental and psychoeducational strategies that may improve adherence to treatment are critically
important.

Discussion
NONSPECIFIC FACTORS IN TREATMENT

Nonspecific variables, including patient and clinician factors, have the potential
to significantly affect treatment adherence, thereby influencing outcome. In this
case, the fact that the clinician was relatively young may have contributed to the
establishment and maintenance of a therapeutic rapport. Mr. M. demonstrated
an oppositional orientation toward his parents and other authority figures prior
to and during treatment. On the contrary, his attitude toward the clinician was
much more amiable. This was maintained throughout treatment. The clinician
strove to preserve the rapport by making continual efforts to join with the patient,
using a patient-centered approach to treatment. The patient-centered approach
includes prioritization of the patients own stated goals in treatment (Tempier et
al., 2010). In this case, even though much of the treatment was aimed at decreasing psychotic symptoms, the clinician consistently demonstrated interest in alleviating Mr. M.s primary complaints of depression, stress, excessive sleeping, and
difficulty with thinking. These considerations informed the selection of pharmacologic and psychosocial interventions. Potential treatments were discussed with
the patient in terms of his own stated goals, thus facilitating a sense of collaboration between the patient and the provider.

TREATMENT OBSTACLES

In schizophrenia, some potentially significant obstacles to treatment are tied


to symptomatology. As Mr. M.s illness progressed, his functional impairment
(due to negative symptoms and disorganization) led to unemployment and loss
of health insurance. Financial difficulty and challenges obtaining transportation
limited the frequency of his follow-up visits. The clinicians response to missed
appointments was to discuss them in terms of Mr. M.s own recovery goals. For

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Psychotic Disorders and Organic Brain Syndromes

example, he was reminded that by keeping his appointments, he would be less


likely to require hospitalization, which would adversely affect his ability to maintain employment.
Another barrier to treatment was Mr. M.s and his familys relative lack of
knowledge about mental disorders. Early in treatment, this posed a significant
obstacle because they were hesitant to agree to a trial of antipsychotic medication. As his symptoms progressed, the family became more supportive of such
interventions. The clinician paid sustained attention to developing a trusting
relationship with the patient while providing psychoeducation to the patient and
family.
WHEN THERAPY IS NOT EFFECTIVE

Unfortunately, in the treatment of schizophrenia, there are many instances of


inadequate response to treatment. In treating Mr. M., the clinician made the
patient and family aware of the risks, benefits, and alternatives to the chosen treatment as part of the process of gaining informed consent. Treatment response was
measured at follow-up visits by clinical interview. Whenever treatment response
is inadequate, it is important to consider possible explanations, including but not
limited to inadequate dosage, non-adherence, substance use (including nicotine),
and environmental stress.
ETHICAL CONSIDERATIONS

Obtaining true informed consent for treatment from a psychotic patient can be
challenging. However, any patient, regardless of psychotic symptoms, who can
demonstrate and articulate reasonable understanding of his or her illness, as
well as the risks, benefits, and alternatives to the proposed treatment, has the
capacity to provide or withhold such consent. Given the potential for significant
metabolic, movement, and other side effects with antipsychotic medications,
informed consent is crucial. At the same time, weighing the costs of the illness
against the costs of the treatment, it can be tempting for clinicians to provide less
information about potential risks of the medications, especially when working
with a patient or family who are already skeptical or reluctant about initiating
treatment.
Involuntary hospitalization presents a specific ethical dilemma frequently
encountered by clinicians who treat patients with schizophrenia. The laws
governing involuntary hospitalization vary across the United States. In the
case of Mr. M., initially there was no evidence that he was at imminent risk
of harming himself or others; therefore there were insufficient grounds for
admitting him to the hospital against his will. This changed after he became
verbally aggressive and threatening at home. When deciding on involuntary
hospitalization, 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.

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 patients delusional system, prematurely engaging in
exploratory or insight-oriented therapy, failing to address comorbid substance
abuse problems on an ongoing basis, failing to engage the family (for patients
who have significant and ongoing contact with family members), and failing to
continually reassess suicide risk. In the case of Mr. M., substance abuse and family support were significant modifiable prognostic factors to which the clinician
paid close attention.

RELAPSE PREVENTION

Because the course of schizophrenia is commonly chronic, treatment of schizophrenia is typically a lifelong undertaking. Available pharmacologic agents serve
to reduce symptoms rather than bring about a cure. Pharmacologic and psychosocial interventions help to improve and preserve functioning over the life span
of persons diagnosed with schizophrenia and related psychotic disorders. Once
remission from psychotic symptoms is achieved, relapse prevention becomes a
significant priority in treatment. Since relapse prevention is intricately linked to
treatment adherence, approaches that enhance treatment adherence are likely to
decrease the risk of relapse. Such interventions include psychoeducation, peer
support, and abstinence from alcohol, marijuana, and other substances.

Conclusions
This chapter has reviewed key principles in the initial evaluation and treatment
of schizophrenia and related psychotic disorders, including assessing the patient,
making a case formulation, and developing an intervention plan. In the case of
Mr. M., evidence-based practices were integrated within the recovery model
(Frese et al., 2001) to increase the likelihood of positive treatment outcomes.
Challenges with non-adherence were explored in individual treatment and group
therapy. The treatment plan was continually reassessed and adjusted to accommodate Mr. M.s changing needs and capabilities. Adjustments to pharmacotherapeutic and psychosocial interventions to decrease the burden of the treatment
itself resulted in improved adherence to all treatment modalities.
The treatment of schizophrenia is often a long-term undertaking. The course
of treatment can, at any point, be influenced by multiple variables, including
patient, cultural, and societal factors. Stigma is one example of the latter, which
is known to be associated with poor treatment engagement; of note, schizophrenia is probably the most stigmatized of all health conditions. Non-adherence is a
frequently encountered barrier to effective treatment intervention. While adherence is important, the treatment plan must also be adaptable. A fi xed treatment
plan, or one that is not frequently reviewed, is essentially flawed and is likely to

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Psychotic Disorders and Organic Brain Syndromes

engender increased risk of non-adherence. Treatment plans that take into account
the fact that patients operate within a complex psychosocial landscape, which is
susceptible to change, are inherently superior.

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COMMENTARY

Alan S. Bellack

McIntosh and Compton have done an excellent job of describing the onset of
schizophrenia in a young person. They aptly represent the subtle disease process
that unfolds over time, making differential diagnosis difficult, if not impossible,
at a circumscribed point in time. As is the case with many young persons, Mr.
M expressed a number of vague complaints, with a common denominator of a
gradual decline in functioning, especially increasing social isolation, and declining performance at school or work. The confounding and potentially exacerbating role of drugs and alcohol is also characteristic and frequently complicates the
diagnostic picture.
The authors also provide a sound overview of evidence-based treatments that
should be considered. 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.
The section on polypharmacy should be mandatory reading for the legions of
community providers who persist in the belief that polypharmacy is appropriate,
despite the lack of supporting evidence. It is clear that many individuals are not
responsive to antipsychotics and that many others are only partially responsive.
However, 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 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, combining several psychosocial treatments and pharmacotherapy. However, due to space constraints,
this section was necessarily too brief to give the reader an adequate sense of the
richness and sophistication of current psychosocial treatments. 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. For example, my colleagues and I have published book-length
manuals on Social Skills Training (Bellack et al., 2004) and an empirically supported behavioral treatment for substance abuse (Bellack, Bennett, & Gearon,
2007). Becker and Drake (2003) published a monograph on Individual Placement

Treatment of Schizophrenia and Related Psychotic Disorders

273

and Support, the most widely researched approach to supported employment.


A manual for implementing McFarlanes Multiple Family Group Treatment for
working with the families of people with serious mental illness was also published
as a book (McFarlane, 2002). Unfortunately, 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. In contrast
to Mr. M., few consumers with schizophrenia actually receive evidence-based
psychosocial treatments and state-of-the-art pharmacotherapy.
The case summary of Mr. M. is an example of the complexity of assessing and
treating young persons with symptoms of serious mental illness. Nonetheless,
several questions are raised by the summary, and some additional points warrant consideration. The justification for the provisional prodromal schizophrenia diagnosis is not entirely clear, given the background clinical information
provided. Mr. M. was not exhibiting hallucinations or delusions and reportedly
manifested minimal thought disorder (some poverty of content, tangentiality, and
one example of a loose association). The decline in social and school functioning
was certainly suggestive of an invidious process, and the diagnosis turns out to
have been correct over succeeding months, but the clinical report makes it seem
as if the interviewer was more prescient than analytical. It was nice to see the
metabolic and blood work conducted, but the justification for the MRI, MMPI,
and WAIS was similarly unclear If there was some question about cognitive
impairment, a brief neuocognitive battery or a screening instrument such as the
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS;
Randolph, 1998) would have been more appropriate than an MRI, and at best
there is minimal data to support the use of the MMPI in differential diagnosis.
The section on assertive community treatment (ACT; Stein & Santos, 1998)
was somewhat surprising, given that Mr. M. is a young person with recent onset
of illness. As noted by the authors, ACT is an evidence-based treatment that can
be an extremely helpful component of a comprehensive approach for assisting
people with serious mental illness. However, it is not a treatment per se. Rather,
it is a case management strategy that employs small, interdisciplinary teams to
provide comprehensive services where the patient resides, whether at home, in
shelters, or on the street for homeless persons. As such, its use is limited to highly
impaired, chronic patients who are unable or unwilling to come to the clinic for
care. ACT is both too costly and too intrusive for use with younger, fi rst-episode
persons. Moreover, it could be iatrogenic by promoting dependency and fostering
chronicity.
Concern about fostering chronicity is especially important in the care of
younger and fi rst-episode cases. McIntosh and Compton clearly highlight the
goal of preventing psychotic exacerbations and relapse, including the risk associated with extended periods of untreated psychosis. However, they do not address
the equally important goal of preventing early illness from evolving into chronic
disability. For many individuals with schizophrenia and related serious mental
illnesses, chronicity is the central component of the illness, not symptomatology.
This syndrome includes inability to work or engage in gainful activities, to engage

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in rewarding social interactions and maintain close relationships with others, to


care for oneself and to manage ones illness, and to suffer from self-stigma (negative, maladaptive beliefs about the nature of mental illness and ones responsibility for being ill).
Prevention of chronicity is a primary goal of most first episode programs
(e.g., Amminger et al., in press; Bertelsen et al., 2008). Emphasis is placed on
helping the young person resume normative social activities, return to school or
work, and avoid the harmful effects of self-stigma and hopelessness. McIntosh
and Compton note the use of supportive employment (SE), 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, including pharmacotherapy, may be structured (Nuechterlein
et al., 2008). Importantly, 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.
A related goal for most young persons is resumption of normative social relationships. As was the case with Mr. M., many persons suffering from schizophrenia gradually lose contact with peers and become socially isolated. Consequently,
social skills training (SST), another evidence-based treatment. has been shown
to be very helpful when tailored for the needs of younger persons. The Danish
OPUS program is an excellent example of how SST can be incorporated into a
program for recent-onset persons (Bertelsen et al., 2008).
As in the case of supported employment, McIntosh and Compton accurately
note the potential value of social skills training (SST). However, it should be
emphasized that there are important clinical differences between the application of these strategies with fi rst-episode and more chronic persons. 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). Importantly, 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. Treatment content and
structure need to be adjusted accordingly (Ramsay et al., 2008). Many chronic
persons are used to coming to community mental health clinics multiple times
per week and participating in diverse treatment groups. Treatment providers and
other patients are often their primary social contacts. Many younger persons will
not come to treatment multiple times per week, and attending groups with older,
more chronic patients can be demoralizing and can provide unwanted modeling
of chronic behaviors and expectations. Consequently, many innovative programs
for younger persons have developed geographically and structurally distinct
centers with a greater emphasis on technology (e.g., computer- and smart phone
driven strategies) as well as the aesthetics and lifestyle of younger persons. Peter
McGorrys program in Melbourne is a prototype for these innovative approaches
(Cotton et al., 2011; Amminger et al., in press).
Two other issues discussed in the chapter merit comment. 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

Treatment of Schizophrenia and Related Psychotic Disorders

275

et al., 2010). 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. That is clearly a critical decision for the
clinician. However, the reader should be aware that suicidal risk must be assessed
on an ongoing basis. While there are no evidence-based practices for dealing with
suicidal risk in young persons, there are a number of emerging strategies, and this
is an issue of considerable interest in the field.
The fi nal point pertains to substance use. 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. However, this issue warrants greater
attention with Mr. M. It can generally be assumed that people with schizophrenia
underestimate their use of substances. Given that Mr. M. reports regular use of
a considerable amount, it would be prudent to revisit this issue once a good relationship has been established. Whether or not he is using alcohol to self-medicate,
as suggested by the authors, alcohol abuse is a serious problem that contributes to
non-adherence to mental health treatment and may itself exacerbate symptoms
and increase disability.
In sum, McIntosh and Compton have done an excellent job of describing a typical case of early-onset schizophrenia, including the pernicious decline in functioning. They aptly describe treatment options and underscore the importance of
multidisciplinary treatment approaches that continue over time. Conversely, the
discussion did not sufficiently emphasize some of the unique issues associated
with treating younger persons, especially in regard to preventing the development of chronic disability. While not necessarily germane to the task of outlining
appropriate assessment and care, it should be underscored that state of the art
practices, as described here, are rarely available in the community. Many younger
persons often start out receiving care paid for by their parents private insurance,
but they quickly spend down lifetime limits and are supported by Medicaid or
(less frequently) Medicare. 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.

References
Amminger, G. P., Henry, L. P., Harrigan, S. M., Harris, M. G., Alvarez-Jimenez, M.,
Herrman, H., Jackson, H. J., & McGorry, P. D. (in press). Outcome in early-onset schizophrenia revisited: Findings from the Early Psychosis Prevention and
Intervention Centre long-term follow-up study. Schizophrenia Research.
Becker, D. R., & Drake, R. E. (2003). A working life for people with severe mental illness.
New York: Oxford University Press.
Bellack, A. S., Bennett, M. E., & Gearon, J. S. (2007). Behavioral treatment for substance
abuse in people with serious and persistent mental illness. New York: Routledge Press.
Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social skills training for
schizophrenia: A step-by-step guide (2nd ed.). New York: Guilford Press.

276

Psychotic Disorders and Organic Brain Syndromes

Bertelsen, M., Jeppesen, P., Petersen, L., Thorup, A., hlenschlger, J., Le Quach, P.,
Christensen, T.., Krarup, G., Jrgensen, P., & Nordentoft, M. (2008). 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.
Archives of General Psychiatry, 65, 762771.
Cotton, S. M, Luxmoore, M., Woodhead, G., Albiston, D. D., Gleeson, J. F., & McGorry,
P. D. (2011). Group programmes in early intervention services. Early Intervention in
Psychiatry, 5, 259266.
McFarlane, W. R. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: Guilford Press.
Melle, I., Johannessen, J. O., Friis, S., Haahr, U., Joa, I., Larsen, T. K., Opjordsmoen, S.,
Rund, B. R., Simonsen, E., Vaglum, P., & McGlashan, T. (2010). Course and predictors of suicidality over the fi rst two years of treatment in fi rst-episode schizophrenia
spectrum psychosis. Archives of Suicide Research, 14, 158170.
Nuechterlein, K. H., Subotnik, K. L., Turner, L. R., Ventura, J., Becker, D. R., & Drake,
R. E. (2008). Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment.
Psychiatric Rehabilitation Journal, 31, 2008, 340349.
Ramsay, C. E., Broussard, B., Goulding, S. M, Cristofaro, S., Hall, D., Kaslow, N.J,
Killackey, E., Penn, D., & Compton, M. T. (in press). Life and treatment goals of individuals hospitalized for fi rst-episode nonaffective psychosis. Psychiatry Research.
Randolph, C. (1998). Repeatable Battery for the Assessment of Neuropsychological Status.
San Antonio, TX: The Psychological Corporation.
Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe
mental illness. New York: W. W. Norton.

RESPONSE

Belinda McIntosh and Michael T. Compton

Dr. Bellacks commentary highlights a number of important points in the assessment and treatment of patients with schizophrenia and related psychotic disorders. He emphasizes that, although many patients with schizophrenia receive
pharmacotherapeutic and psychosocial treatments in keeping with the spirit of
the recommendations, often the treatments being applied are not evidence-based.
Dr. Bellack stresses that there are a number of manualized psychosocial treatments to guide clinicians wishing to provide evidence-based supported employment, social skills training, and substance abuse treatment. 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.
Dr. 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. In
this case, the clinician determined that the odd thinking (the idea that Mr. M.
could read others thoughts and that his mind worked in ways that other peoples
did not) lay somewhere on a continuum between mildly grandiose, non-psychotic
thinking and overt delusions. Considered within the context of social and academic dysfunction, cognitive decline, and sleep disturbance, the odd thinking
provided grounds for conceptualizing all the signs and symptoms parsimoniously
under a single diagnosis. Among the diagnoses under consideration, prodromal
schizophrenia was the only one that captured all the presenting symptoms. Yet,
as rightly recognized by Dr. Bellack, the presentation falls short of meeting the
usual defi nition for the schizophrenia prodrome. In this case, the presence of
attenuated psychotic symptoms, such as transient auditory hallucinations, would
have bolstered the provisional diagnosis.
Dr. 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. He also points out that assertive community treatment and some other psychosocial treatments are geared
toward the more chronically ill patient with schizophrenia. Indeed, fi rst-episode
patients like Mr. M. benefit from treatment that promotes developmentally
appropriate advancement in social, occupational, and academic functioning.

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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 declineit 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


Alzheimers 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. Marilyns daughter, Betty, contacted NSCS coaches at
that time for assistance. During the assessment, it was discovered that Marilyns
change in behavior was due to pain related to a broken tooth. The tooth was
repaired, and Marilyns behavior returned to baseline. Once Marilyns 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 Marilyns daughter in
response to the facilitys request that Betty relocate Marilyn to another facility
because her crying was disruptive to other residents and staff. Direct care staff
reported that Marilyns 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 fathers death. Betty reported concerns about her mothers
health because the frequency and intensity of her mothers 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.

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Background
Marilyn had lived in the facility for one year and was well liked by staff. According
to her daughters 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 Marilyns 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 NCSCs 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 mothers 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 Marilyns dementia and that Betty needed to look for another facility for
Marilyn.

Medical Status
Marilyns 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 Marilyns 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

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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 Marilyns presentation, facility staff reported that
this was Marilyns 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 Marilyns 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 persons 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.
Alzheimers 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, Parkinsons
disease, frontotemproal dementia, and normal pressure hydrocephalus, account
tor the remaining 13% (Plassman et al., 2007). AD affects an individuals 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 members needs
(Pinquart & Srensen, 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

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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
3258% (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

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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 individuals 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 individuals social and physical environment results in
a reduction of behavioral problems and a decreased risk of excess disability
(Ayalon, Gum, Feliciano, & Aren, 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

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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 Marilyns 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 Marilyns cognitive
status. The MMSE is a quick assessment of cognitive functioning, with scores
ranging from 030 (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
Marilyns 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 Marilyns 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 Marilyns nurse care managers to inquire
whether medical assessments had been conducted to rule out conditions such as

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pain, infection, or medication reactions that could contribute to the precipitous


decline in Marilyns 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 Marilyns
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 Marilyns crying behavior were conducted by NCSC coaches to determine if environmental factors were contributing to Marilyns 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 Marilyns 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 Marilyns 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, Marilyns 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

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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
Marilyns 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 Marilyns dementia.

Initial Case Formulation


NCSC coaches hypothesized that Marilyns 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 Marilyns inability
to self-report discomfort. This hypothesis was informed by the contextual model
and Marilyns history of similar behavioral changes associated with tooth pain.
Marilyns 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
Marilyns 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 Marilyns crying that they were aware that urinary tract infections cause

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changes in mental status. If nursing staff were aware of this phenomenon, the
question emerges of why it took NCSC coaches inquiring about the specific date
of Marilyns last urinalysis to intervene and result in the proper assessment and
treatment of Marilyns urinary tract infection. We would argue that the medical
models view of behavioral challenges as symptoms of dementia contributes to
this misattribution, or heuristic error, in explaining behavior change in persons
with dementia. Kahneman and Tversky (1972) describe heuristics as subjective
probability judgments. Heuristics are cognitive shortcuts or rules that a person
follows in making decisions. 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, 1974).
Nursing staff had decided that Marilyns crying was due to her dementia getting worse and that she was grieving her father. This conclusion constituted a
representative heuristic error. Representative heuristics involve a choice made
because it reflects the salient features of the process by which it is generated
(Kahneman & Tversky, 1972, p. 430). Behavioral problems are often incorrectly conceptualized as a consequence of the progression of dementia, even
though behavioral problems are not part of the dementia diagnostic criteria (see
American Psychiatric Association, 2000), vary widely in incidence across persons
with dementia, and can be reduced or eliminated in the absence of any change
in the underlying neurological disorder (see Ayalon, Gum, Feliciano, & Aren,
2006; Buchanan & Fisher, 2002; Burgio & Stevens, 1999; Gitlin et al., 2010; Yury
& Fisher, 2007).
Behavioral disturbances in persons with dementia, as in this case, are often
a sign of an adverse event such as medication side effects, infection, pain, or an
overwhelming environment. Because of the heuristic that behavioral problems
are part of the progression of dementia, these secondary issues can go undetected
and untreated, leading to excess disability and unnecessary suffering on the part
of the person with dementia. It is ironic that a biological perspective of behavioral change in dementia (i.e., that it is the result of neuropathology) can lead to
a lack of medical assessment and intervention of true medical issues (pathology), such as the UTI. The nursing staffs decision that the crying was related to
dementia led to a lack of proper medical assessment, which resulted in Marilyn
suffering with a urinary tract infection longer than necessary and receiving sedating medication to reduce the crying. The sedating medication reduced Marilyns
ability to communicate her discomfort even more than the resulting change to
her mental status caused by the urinary tract infection itself. One could surmise
that Marilyn was suffering from extra excess disabilityexcess disability caused
by the urinary tract infection and excess disability caused by the high doses of
sedating medication.
If nursing staff had approached Marilyns change in behavior from the contextual model, Marilyns urinary tract infection may have been identified and
treated earlier, reducing her suffering and preventing the excess disability.
Once it was determined that the UTI was causing the behavior changes, the
intervention model was out of the scope of the NCSC coaches and within the

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scope of her medical team. The antibiotic treatment was the necessary intervention to combat the UTI and behavior changes secondary to the infection. A
behavioral modification intervention was not considered because the descriptive
assessment did not give evidence to environmental factors, possibly causing the
behavioral change.

Nonspecific Factors
Caregiver coaches worked closely with Betty in assessing Marilyn. Betty and
her primary coach had strong rapport due to the previous incident of Marilyns
tooth pain and ongoing caregiver support provided by the NCSC. Betty made
several statements expressing gratitude to the coaches. She displayed increased
assertiveness (e.g., advocating for her mother with facility staff), following the
direct instruction and guided practice that she had experienced through her
coaching.
Facility staff members were initially less amenable to NCSC coaches, often
displaying frustrated behavior that NCSC coaches were investigating Marilyns
case. Staff members often made statements to NCSC coaches that Marilyns
dementia had gotten worse and that she needed to move to a more restrictive
facility. NCSC coaches responded by continuing to advocate to rule out excess
disability, but consistently displaying warm and respectful behavior toward facility staff. Alliance with specific staff grew stronger over this time period, especially after the UTI was diagnosed.

Ethical Considerations
The inaccurate assumptions by staff about Marilyns behavior led to a severe
UTI being untreated for several days, at the same time that high doses of sedating
medication were given to control her crying behavior. The untreated UTI caused
Marilyn discomfort and distress that could have been avoided or at least lessened
by proper, timely assessment and treatment. As mentioned above, these types
of medications are associated with several risks, such as increased falls, confusion, stroke, and death. Marilyn was given the sedating medication to control her
crying behavior. Antibiotic medication for the UTI was administered long after
acute behavior changes were observed by the staff. 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.
The facilitys request to Betty to move Marilyn due to her crying behavior also
carries ethical implications. Betty contacted the state ombudsmans office after
the UTI was treated and Marilyns behavior returned to baseline. The ombudsmans office conducted an investigation and intervened to prevent the facility
from expelling Marilyn.

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Relapse Prevention
NCSC coaches continued to provide caregiver coaching services to Betty, and
undergraduate students continued to visit Marilyn as part of the companionship
program. Assessment of Marilyns adaptive behavior and crying behavior was
ongoing as a part of these services. NCSC services are typically terminated after
the individual with dementia dies. Marilyn died four months after this incident;
in those four months, one other UTI was discovered by staff, based on similar
behavior changes, and was treated in a more timely manner.

The Art of This Case


The art of this case lies in a conceptualization of dementia care based in a
contextual model. This conceptualization considers factors such as changes in
environment, changes in the persons ability to communicate, and changes in the
persons ability to recognize sensations in assessing behavioral problems before
making the assumption that the behavior is simply due to the dementia. As this
case illustrates, making the assumption that behavior problems are due to inevitable dementia-related decline can lead to inappropriate treatment and/or a lack
of treatment of treatable medical problems. While it seems extreme, this case is
not unique. In the several years that the NCSC has been operating, several similar situations have been encountered across settings.

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COMMENTARY

Ann M. Steffen and Nika R. 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. 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. Despite already knowing the importance of good dementia care,
we are impressed with this coincidence and the urgency experienced by families
in these situations. This commentary highlights some of the points made by the
authors of the case study. We also hope to extend our discussion to review some
of the skills needed for working with older adults in a variety of settings, with
implications for empirically supported practice and professional development.
All clinical work is rooted in an initial conceptualization. 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, Drossel, Ferguson, Cherup, & Sylvester, 2008). Diagnoses offer
some information, but they must be accompanied by a focus on the relationships
between behaviors and environments for a specific person. In her case, Marilyns
diagnosis functioned both as a deterrent (i.e., leading to staff misattributing her
crying to the normal progression of dementia) and a key to understanding specific concerns (i.e., the centrality of behavior as communication in dementia).
We are struck by how common this is; while looking to psychiatric diagnoses to
provide us with information, these same diagnoses can also misdirect if accepted
too readily as a causal explanation. Understanding physical and mental health
conditions that are common among older adults is important, but we also need
to develop an individualized formulation for each specific case. The contextual
approach helps us to do that.
In the case of Marilyn, her undiagnosed urinary tract infection resulted in
discomfort, over-medication, excess disability, and the risk of discharge to an
unknown new facility. Such a discharge/transfer is complicated and difficult for
both patients and their families. She was placed in serious risk of other problems, and the daily quality of life was disrupted for her and her daughter Betty.
The staff at her care facility had a previous example of a physical condition
(i.e., a broken tooth) that had resulted in Marilyn displaying excess crying. As
is true for many of our clients, they had difficulty generalizing this experience

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to her newest incident of distress. This case study demonstrates the importance
of dementia-specific education, training, and ongoing support for professionals
in a variety of disciplines, not just in long-term care environments (Logsdon,
McCurry, & Teri, 2007; Steffen, 2007).
The presence of a dementing illness increases the risk for delirium and excess
disability due to physical health concerns. In community, acute, and long-term
care settings, delirium in dementia patients is unrecognized up to 50% of the time
and can be deadly (Inouye, 2006). As difficult as it was for facility staff members
to see Marilyns crying as conveying more than a progression of her illness, they
had daily experiences with her over a relatively long period. It is even more challenging for medical staff in acute hospital settings to recognize signs of delirium
and excess disability in dementia patients. For Marilyn, 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.
An initial diagnosis, such as dementia, thus is not the endpoint of assessment but
rather the beginning.
The contextual approach frames challenging behaviors as communication;
problems serve important functions that merit attention. Attention means
assessment. In the case of Marilyn, this contextual approach helped to defi ne
assessment questions, leading to the ultimate question: If crying functions
adaptively, 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.
Mental health professionals working in traditional office settings may doubt the
feasibility of descriptive behavioral assessments/monitoring. This case study
offers the creative solution of undergraduate companions who were available to
monitor both specific adaptive behaviors (e.g., smiling, eye contact, engaging in
conversation) and the targeted problem behavior (i.e., crying). Other sources of
monitoring include the development of simple forms and instructions for family,
designated volunteers who are already familiar with the setting, and care staff.
Even when textbook perfect functional analyses of behavior are not possible, there are certainly good enough strategies to determine whether problem
behaviors are linked to specific environments or are occurring across multiple
life domains. Behavioral assessments for individuals with dementia are possible,
and the literature provides us with resources to help (Fisher et al., 2008; McCurry
& Drossel, 2011). 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.
Along with knowledge of assessment and dementia-specific issues, working
with older adults often involves attention to medications. Mental health professionals must help families communicate with prescribing physicians, and they
may need to collaborate with medical staff in administering drugs. Marilyns
case makes this clear in several dramatic ways. She was harmed by the increased
use of medications to manage her behavioral symptoms of crying (American
Academy of Neurology Ethics and Humanities Subcommittee, 1996), as well as

A Contextual Approach to Dementia Care in Alzheimers Disease

295

by the absence of antibiotics needed for her UTI. Her PRN Ativan was observed
to have negative effects on her alertness and behavior, but could have also led
to a fall, fractured hip, decreased mobility, and ultimately to respiratory problems and death. 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. 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, 2008).
The NCSC coaches were also effective because of their consultation/liaison
skills; this included knowledge of the nursing home organizational structure and
mechanisms for communication and treatment planning. Each setting is different, but some basic issues generalize for all of us. 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, 2011).
Issues of cultural diversity also influence clinical work with older adults and their
care providers. Patterns of demographic changes in the United States and abroad
make it clear that we will be assessing and treating clients, as well as working with
health care professionals, from an increasing variety of ethnic and cultural backgrounds (Hinrichsen, 2006; Laidlaw & Pachana, 2009). Our attention to diversity
will help us understand how these might influence assessment, treatment, and
consultation approaches (Lau & Kinoshita, 2006).
In summary, this case study highlights a number of issues related to conceptualization, assessment, consultation/liaison, and professional development. 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., 2002) or exposure to Medicare and Medicaid policies and practices (Hartman-Stein & Georgoulakis, 2008; Hinrichsen 2010). Those interested
in exploring additional sources of professional development should be encouraged by the growing volume of resources for clinicians (APA, 2004; www.apa.
org/pi/aging; Karel, Knight, Duffy, Hinrichsen & Zeiss, 2010; Pachana, Knight,
Karel, & Beck, 2008) and supervisors/educators (Hinrichsen, Zeiss, Karel, &
Molinari, 2010; Knight, Karel, Hinrichsen, Qualls, & Duffy, 2009). As the e-mail
from our colleague reminded us, there are many individuals like Marilyn and
Betty who need our attention and help.

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